Continuous glucose monitoring (CGM) has become one of the biggest success stories in modern diabetes care. NHS access has expanded dramatically, international guidelines increasingly recommend the technology and manufacturers continue investing billions in smaller, smarter and more accurate sensors. A newly published correspondence in The Lancet Diabetes & Endocrinology has now reopened a debate that many healthcare systems believed had largely been settled: does wider CGM adoption always represent good value?
For readers in the UK, the discussion may sound familiar.
Before CGM became widely available through the NHS, NICE examined not only whether sensors improved glucose management but whether their higher upfront cost could be justified over the long term. Rather than comparing the cost of sensors with blood glucose test strips alone, the assessment considered whether improved glucose control could reduce severe hypoglycaemia, diabetic ketoacidosis (DKA), hospital admissions and the long-term complications that account for a significant proportion of diabetes-related healthcare spending.
NICE ultimately concluded that, for defined groups of people with diabetes, the expected clinical and economic benefits justified wider NHS funding. That decision has helped transform diabetes care across the UK over the past decade.
The correspondence published this week argues that the calculation may be very different in low and middle-income countries (LMICs), where healthcare budgets are far more constrained and access to diabetes technology remains limited.
Although the authors do not dispute the clinical benefits of CGM, they question whether the evidence currently available is sufficient to justify substantially higher ongoing costs in resource-limited healthcare systems. It does, however, mark one of the clearest public challenges in recent years to the momentum behind wider CGM adoption. Rather than asking whether CGM works, the correspondence asks a different question: at what point does expanding access stop representing good value for healthcare systems?
Reopening the economic debate
The correspondence responds to a recent randomised controlled trial reporting improvements in HbA1c among people with type 2 diabetes using CGM.
While acknowledging those findings, the authors argue that clinical effectiveness alone should not determine whether healthcare systems continue expanding access. Instead, they believe affordability, infrastructure and long-term value deserve far greater attention, particularly in countries where healthcare resources are limited.
Using India as an example, they estimate that Abbott's FreeStyle Libre 2 Plus costs approximately ₹100,000 (around £800) over a 32-week period. By comparison, twice-daily self-monitoring of blood glucose (SMBG) is estimated to cost around ₹11,000 (around £88) over the same timeframe.
In their view, that order-of-magnitude difference makes widespread CGM adoption difficult to justify for many lower-income healthcare systems.
The correspondence also notes that insulin therapy is used by only a minority of people living with diabetes in many LMICs. The authors argue this limits how broadly the findings of the original trial can be applied across the wider diabetes population and question whether the conclusions should automatically support wider rollout.
Looking beyond the cost of a sensor
Cost is only one aspect of the argument.
The correspondence highlights several practical barriers that could influence the real-world effectiveness of CGM in lower-income settings. Many current systems rely on smartphones for data visualisation, trend analysis and alerts, yet smartphone ownership, digital literacy and access to reliable digital infrastructure cannot be assumed across all populations.
The authors suggest these challenges may reduce some of the behavioural advantages associated with continuous glucose data, particularly where users are unable to engage fully with the technology.
They also question whether some of the behavioural improvements reported in the original study are likely to persist over time. Improvements in physical activity and dietary behaviour were more apparent after 16 weeks than after 32 weeks, leading the authors to suggest that continuous feedback may initially encourage behaviour change before its impact begins to diminish.
Finally, they argue that more long-term evidence is needed to establish whether relatively modest improvements in HbA1c ultimately translate into meaningful reductions in complications such as kidney disease, cardiovascular disease and vision loss.
The NHS reached a different conclusion
The correspondence inevitably invites comparison with the UK's own experience.
When NICE evaluated wider NHS access to CGM, the economic assessment extended far beyond the cost of replacing blood glucose test strips with sensors. It considered whether better glucose management could reduce emergency treatment for severe hypoglycaemia, lower the incidence of DKA, decrease hospital admissions and reduce the long-term burden of diabetes complications.
In other words, the question was not whether CGM cost more than finger-prick testing. It was whether investing more in monitoring today could reduce healthcare spending tomorrow.
That broader health economic approach helped underpin the expansion of NHS-funded CGM, despite the technology carrying significantly higher upfront costs.
The Lancet correspondence does not argue that this approach was wrong. Instead, it questions whether equivalent long-term economic evidence currently exists for healthcare systems with substantially lower resources, different patient populations and far tighter healthcare budgets.
A debate extending beyond diabetes
The timing of the correspondence is notable.
CGM is no longer expanding only within diabetes care. Abbott's Lingo, Dexcom's Stelo and other biosensors are introducing continuous glucose monitoring to people interested in nutrition, exercise and metabolic health, while manufacturers continue investing heavily in next-generation sensing platforms.
As access widens and new markets emerge, questions around affordability, long-term outcomes and value for money are likely to become increasingly prominent.
The correspondence is unlikely to alter the continued expansion of CGM in countries where funding is already well established. However, it highlights a debate that is likely to shape future healthcare policy. As CGM becomes available to larger patient populations and new consumer markets, healthcare systems may increasingly ask not only whether the technology improves outcomes, but whether expanding access continues to represent the most effective use of finite healthcare resources.
For Abbott, Dexcom and the wider diabetes technology industry, the next phase of adoption may depend not only on producing smaller and more accurate sensors, but also on generating robust long-term evidence that broader use continues to deliver measurable clinical and economic value across different healthcare systems.
|
Understanding the paper This article reports on a Correspondence published in The Lancet Diabetes & Endocrinology. Correspondence articles are not new clinical trials. Instead, they provide expert commentary, critique or discussion of previously published research. In this case, the authors are responding to a recent randomised controlled trial examining the use of continuous glucose monitoring (CGM) in people with type 2 diabetes. Their correspondence raises questions about the cost-effectiveness and wider implementation of CGM in low and middle-income countries. The views expressed are those of the correspondence authors and form part of the normal scientific debate that follows publication of important research. |
Reference: https://www.thelancet.com/journals/landia/article/PIIS2213-8587(26)00153-1
Leave a comment (all fields required). Please note, we are unable to respond to individual comments posted here.