Expert comments

Comments on this technology were invited from clinical experts working in the field and relevant patient organisations. The comments received are individual opinions and do not represent NICE's view.

Two of the 3 experts were familiar with or had used the physical device version of this technology before.

Level of innovation

Two experts stated that this technology is innovative because it can automate daily insulin dosage recommendations, which is not feasible through current healthcare professional input. Two experts said that currently people have infrequent dose adjustment advice at 6‑ or 12‑monthly clinic reviews with a specialist diabetes nurse. One expert said that in between reviews people can make some additional adjustments to their insulin dosing, based on advice from a diabetes nurse. However, HbA1c often remains elevated or gradually increases. One expert said that there is a lack of educational support for using and titrating insulin in those with type 2 diabetes. One expert said that there is good evidence to show that patient adjustment of insulin dosing after appropriate education can lead to better glycaemic control compared with periodic contact with healthcare professionals. They said that this app could help support people with effective insulin titration for a variety of insulin regimens, but the supporting evidence is limited.

One expert said that d‑Nav is a way to allow frequent insulin dose adjustment and the resultant HbA1c improvement, without affective staff resources. They stated that d‑Nav could replace the current standard of insulin dose optimisation. This would allow clinic reviews to be less frequent and would allow more time to focus on other areas of diabetes management. Another expert said that help and support from healthcare professionals would still be needed to ensure safe and continued use of the technology.

Potential patient impact

Two experts said that this technology could benefit most patients using insulin for type 2 diabetes who need good glycaemic control. All experts said that the main benefit is improved glycaemic control and the resultant reduction in diabetic complications. One expert said that making insulin dosing easier would also be better for patients. One expert said that through using the technology, people learn more about their relationship between eating and insulin requirements and become more knowledgeable about their type 2 diabetes and insulin therapy. One expert acknowledged that people would need to be able to afford a smartphone and have internet access, which is an equality consideration. They would also need to be feel confident in using technology.

Potential system impact

One expert said that the technology can reduce the burden on primary care and secondary care diabetes teams. By improving the glycaemic control for many patients, the technology can reduce the complications associated with diabetes. This would reduce the number of people who need additional, and potentially more invasive, treatments or procedures. One expert agreed that the technology could reduce reliance on healthcare professionals for insulin titration as well as reduce the number of referrals to secondary care and hospital outpatient visits. Another expert agreed but said that there are still some d‑Nav users who need additional support and encouragement to use the service consistently and safely, which leads to more support and healthcare professional interactions.

All experts said that the use of the d‑Nav technology would lead to cost savings in the NHS. This would be as a result of reductions in the cost of other drugs used and from a reduction in costs because of complications and morbidity from poorly controlled diabetes.

One expert said that no additional clinical facilities are needed as the d‑Nav technology comes with a support team to support the patient in using the device. All experts said that patients and healthcare professionals need training in how to use the device. One expert said that this would include training for healthcare professionals on setup and how to use the web-based services to monitor usage, set limits and reset insulin dosages. All experts said that clinicians also need guidance on who the technology would be appropriate for. One expert noted that additional costs would be incurred for staff training and patient education. One expert said that additional work is needed to set up an insulin titration support service and that patients would need initial and ongoing support to use the technology safely and successfully.

General comments

One expert said that the device is simple and straightforward to use. They have seen a wide range of people who have been able to use it successfully. However, they stated that some healthcare professionals may find it hard to understand how a device or algorithm can adjust insulin dose, meaning reassurance is needed. One expert said that patient selection is very important because they need to be able to understand the technology and the dosage guidance it gives. They said the technology would be for those who would benefit from an HbA1c score less than 53 mmol/litre who have good hypoglycaemic awareness.

One expert said that although there was a randomised controlled trial done in the US, further evidence is needed in the form of long‑term comparative studies in the UK to show that the technology is better than standard care.

One expert who uses the physical device said that moving to the d‑Nav phone app would improve usability and reduce the workload associated with the physical device such as setup, resets, device replacements and provision of test strips. However, they were concerned whether people will enter blood glucose readings into the app because the glucose meter is built into the physical device.