Diabetes: the cost of diabetes
As the number of people with diabetes grows worldwide, the disease takes an ever-increasing proportion of national health care budgets. Without primary prevention, the diabetes epidemic will continue to grow. Even worse, diabetes is projected to become one of the world’s main disablers and killers within the next twenty-five years. Immediate action is needed to stem the tide of diabetes and to introduce cost-effective treatment strategies to reverse this trend.
Diabetes: the size of the problem
A diabetes epidemic is underway. An estimated 30 million people world-wide had diabetes in 1985. By 1995, this number had shot up to 135 million. The latest WHO estimate (for the number of people with diabetes, world-wide, in 2000) is 177 million. This will increase to at least 300 million by 2025. The number of deaths attributed to diabetes was previously estimated at just over 800,000. However, it has long been known that the number of deaths related to diabetes is considerably underestimated. A more plausible figure is likely to be around 4 million deaths per year related to the presence of the disorder. This is about 9% of the global total. Many of these diabetes related deaths are from cardiovascular complications. Most of them are premature deaths when the people concerned are economically contributing to society. This situation is increasingly outstretching the health-care resources devoted to diabetes.
For WHO and the International Diabetes Federation (IDF), sponsors of World Diabetes Day, this increase can and must be prevented with the right measures.
What are the costs of diabetes?
- Because of its chronic nature, the severity of its complications and the means required to control them, diabetes is a costly disease, not only for the affected individual and his/her family, but also for the health authorities.
- Studies in India estimate that, for a low-income Indian family with an adult with diabetes, as much as 25% of family income may be devoted to diabetes care. For families in the USA with a child who has diabetes, the corresponding figure is 10%.
- The total health care costs of a person with diabetes in the USA are between twice and three times those for people without the condition. It was calculated, for example, that the cost of treating diabetes in the USA in 1997 was US$ 44 billion.
- In WHO’s Western Pacific region a recent analysis of health care expenditure has shown that: 16% of hospital expenditure was on people with diabetes. In the Republic of the Marshall Islands, this figure was 25%. 20% of “offshore expenditure” on health by Fiji was on diabetes related complications – instances where facilities for care were not available in Fiji, so patients had to travel elsewhere. These represent considerable sums for countries who can ill afford such massive expenditure on preventable conditions. The costs of diabetes affect everyone, everywhere, but they are not only a financial problem. Intangible costs (pain, anxiety, inconvenience and generally lower quality of life etc.) also have great impact on the lives of patients and their families and are the most difficult to quantify.
- The costs of diabetes affect everyone, everywhere, but they are not only a financial problem. Intangible costs (pain, anxiety, inconvenience and generally lower quality of life etc.) also have great impact on the lives of patients and their families and are the most difficult to quantify.
- Direct costs to individuals and their families include medical care, drugs, insulin and other supplies. Patients may also have to bear other personal costs, such as increased payments for health, life and automobile insurance.
- Direct costs to the healthcare sector include hospital services, physician services, lab tests and the daily management of diabetes – which includes availability of products such as insulin, syringes, oral hypoglycaemic agents and blood-testing equipment. Costs range from relatively low-cost items, such as primary-care consultations and hospital outpatient episodes, to very high-cost items, such as long hospital inpatient stays for the treatment of complications.
- Recent cost estimates, denied by similar methods to that quoted above for the USA, include those for Brazil (US$ 3.9 billion), Argentina (US$ 0.8 billion) and Mexico (US$ 2.0 billion). Each of these is an annual figure and is rising as diabetes prevalence increases. Overall, direct health care costs of diabetes range from 2.5% to 15% annual health care budgets, depending on local diabetes prevalence and the sophistication of the treatment available.
- For most countries, the largest single item of diabetes expenditure is hospital admissions for the treatment of long-term complications, such as heart disease and stroke, kidney failure and foot problems. Many of those are potentially preventable given prompt diagnosis of diabetes, effective patient and professional education and comprehensive long term care.
Costs of lost production (“indirect costs”)
- A number of diabetes patients may not be able to continue working or work as effectively as they could before the onset of their condition.
- Sickness, absence, disability, premature retirement or premature mortality can cause loss of productivity.
- Estimating the cost to society of this loss of productivity is not easy. However, in many cases where estimates have been made, these costs of lost production may be as great or even greater than direct health care costs. For example, the US estimate of direct costs of US$ 44 billion mentioned above needs to be set against an estimated US$ 54 billion of loss of productivity during the same year (1997). Combining the cost estimates for 25 Latin American countries suggests that costs of lost production may be as much as five times the direct health care cost. This may be because there is limited access to high quality care with, consequently, a high incidence of complications, disability and premature mortality. Families too, of course, suffer loss of earnings as a result of diabetes and its consequences.
- Pain, anxiety, inconvenience and other factors which decrease quality of life are intangible costs, which are just as heavy. Some activities may have to be foregone in favour of treatment, discrimination may be experienced in the workplace, obtaining jobs may be more difficult, and professional life may be shortened because of complications leading to early disability and even death.
- Personal relationships, leisure and mobility can also be negatively influenced. Diabetes treatment, particularly insulin injection and self-monitoring, can be time-consuming, inconvenient and uncomfortable.
Prevention and diabetes:
Effective prevention also means more cost-effective healthcare. This may be the prevention of the onset of diabetes itself (primary prevention) or the prevention of its immediate and longer-term consequences (secondary prevention).
- Primary prevention protects susceptible individuals from developing diabetes. It has an impact by reducing or delaying both the need for diabetes care and the need to treat diabetes complications. Reliable examples of this measure come from studies undertaken among susceptible groups in China. Lifestyle modifications (appropriate diet and increased physical activity and a consequent reduction of weight), supported by a continuous education programme, were used to achieve a reduction of almost two-thirds in the progression to diabetes over a six-year period. This type of measure is not easy, but is likely to be cost effective if it can be implemented on a population scale. It should be considered particularly in the poorest regions of the world where resources are severely limited. Similar results have also been achieved recently in Finland and the USA.
- Such preventive measures will have benefits above and beyond diabetes since improvements in diet and day-to-day physical activity will reduce obesity, cardiovascular disease and some cancers.
Secondary prevention includes early detection, prevention and treatment. Appropriate action taken at the right time is beneficial in terms of quality of life, and is cost-effective, especially if it can prevent hospital admission.
Secondary prevention measures:
- The treatment of high blood pressure and raised blood lipids, as well as the control of blood glucose levels, can substantially reduce the risk of developing complications and slow their progression in all types of diabetes.
- Another cost-saving strategy is the prevention of foot ulceration and amputation. Effective foot-care reduces both the frequency and length of hospital stays and the incidence of amputation in diabetes patients by as much as 50%.
- Screening and early treatment for retinopathy is also very cost-effective, given the devastating direct, indirect and intangible costs of blindness.
- Screening for protein in urine is another valid preventive measure to prevent or slow down the inevitable progression to kidney failure. Furthermore, there is evidence that screening for traces of protein is cost saving, as it allows even earlier intervention in the natural course of kidney disease.
- Measures to reduce the consumption of tobacco will also assist in the management of diabetes. Cigarette smoking has been found to be associated with poor control of blood glucose and it is also strongly causally related to hypertension and heart disease in people with diabetes as well as those without.
WHO and IDF are committed to working for access to high quality health care for people with diabetes wherever they live and for primary prevention to reduce the impact of diabetes and its complications in the future.