The evidence documenting the large—and at least partly avoidable—economic burden of type 2 diabetes has grown rapidly in the past 13 years. |
Many studies documenting the economic costs of type 2 diabetes in low- and middle-income countries (LMICs) have emerged, providing a first picture of the economic impact of diabetes in poorer countries, whereas the evidence on the labour market effects in LMICs remains scarce. |
Costs of diabetes, as well as its adverse labour market effects, increase over time and with disease severity, indicating that early investments into prevention and disease management may be particularly worthwhile. |
COI studies in particular did not rigorously account for potential biases in their estimation, suggesting that cost-effectiveness studies that make use of these estimates might under- or overestimate the value for money of the respective intervention or drug. |
1 Introduction
2 Methods
2.1 Search Strategy
2.2 Inclusion and Exclusion Criteria
2.3 Data Extraction and Analysis
3 Results
3.1 Cost-of-Illness (COI) Studies on Type 2 Diabetes
3.1.1 Number of Studies
3.1.2 Regional Distribution
3.1.3 Data Sources
3.1.4 Variation in Costing Approaches
3.1.5 Study Perspective
3.1.6 Costing Components
3.1.7 Cost Estimates of Diabetes Using a Prevalence Approach
High-income countries | Low- and middle-income countries | |||||||
---|---|---|---|---|---|---|---|---|
Sum-all medical costs | Sum-diagnosis specific | RB/matching | Own survey | Sum-all medical costs | Sum-diagnosis specific | RB/matching | Own survey | |
Min | 1,117 | 907 | 264 | 1,495 | 242 | 662 | 443 | 456 |
Max | 11,917 | 9,346 | 8,306 | 5,585 | 4,129 | 4,672 | 1,136 | 3,401 |
N
| 25a
| 19a
| 18 | 3 | 27a
| 5a
| 2 | 10 |
Estimate | Standard error | |
---|---|---|
Constant | 2,133 | 1773.922 |
GDP per capita ($) | 0.045** | 0.017 |
Estimation approach | ||
Sum-all medical | Ref. | |
Sum-diagnosis-specific | −413.880 | 528.766 |
RB/matching | −719.868 | 526.896 |
Survey | −689.806 | 671.020 |
At least four costing components | 702.966* | 403.968 |
USA study | 3,111.067*** | 533.534 |
Year of study | ||
<1995 | Ref. | |
1995–1999 | −1,744.799 | 1632.498 |
2000–2004 | −816.647 | 1586.966 |
2005–2009 | −1,021.685 | 1592.595 |
2010–2014 | −2,744.739 | 1839.689 |
Study representative | −598.670 | 409.070 |
Complications | 666.803 | 414.727 |
R-squared adj. | 0.559 | |
N
| 70 |
3.1.8 Direct and Indirect Costs of Diabetes
3.1.9 Studies Using the Incidence Approach
References | Country | Time horizon | Population | Approach | Results |
---|---|---|---|---|---|
[52] | Canada | 1992–2001 | Incidence T2D pts from Saskatchewan Health’s administrative database in Canada | Sum-all medical | Highest total healthcare costs at year of diagnosis with CAN$7,343 ($7,635), then increased from a low of CANS$3,880 ($4,034) 3 years after diagnosis to CAN$4,441 ten years thereafter ($4,618) |
[19] | Colombia | 32 years | Hypothetical average Columbian T2D pt | Sum-all medical | Total lifetime costs (32-year period) of average diabetes pt, including direct and indirect costs, 57.565 million Colombian pesos ($54,351) |
[21] | Germany | 1995–2003 | Newly diagnosed T2D pts from randomly drawn practices across Germany | Sum-all medical | €1,288 ($1,635) for the first treatment year after diabetes diagnosis and increased to €3,845 ($4,880) in the 7th year |
[73] | USA | 1997–1998 | Women employed by nationwide operating company and hypothetical women above age 64 receiving Medicare | RB/matching | $282,973 incremental lifetime direct healthcare costs, using incidence-based, steady-state methodology |
3.1.10 Country-Level Costs Prediction Studies
References | Country | Population | Approach | Time horizon | Results |
---|---|---|---|---|---|
[42] | Australia | Australian population | Sum-diagnosis specific | 2000–2051 | If age- and sex-specific prevalence remains unchanged → 2.5-fold increase; if age- and sex-specific prevalence allowed to change as well → 3.4-fold increase |
[16] | Canada | Canadian population | Sum-all medical costs | 2000–2016 | 1.7-fold increase |
[17] | Canada | Four Alberta Health and Wellness databases | Sum-all medical costs | 2008–2035 | 2.4-fold increase |
[80] | China | In patients and outpatients in 20 hospitals | Own survey | 2007 and 2030 (projection) | Increase from $73 billion in 2007 to $132 billion in 2030 (1.8-fold increase) |
3.2 The Impact of Diabetes on Employment Chances and Productivity
References | Survey year | Country | Age (years) | Effect on employment | |
---|---|---|---|---|---|
Males | Females | ||||
[103] | 1999–2000 | Australia | >24 | Exogenous: 10.8 % point reduction to be in labour force; endogenous: 7.1 %points reduction; test indicates endogeneity | Exogenous: 10 % points to be in labour force; endogenous: 9 % points reduction; test indicates endogeneity |
[102] | 2001, 2004–2005 | Australia | 18–64 | 50–64: 11.5 % points less likely to be in labour force; 18–49: 3.9 % points less likely; all effects increase when other chronic diseases are present | No significant effect for diabetes alone; significant negative effect if other chronic diseases are present |
[100] | 1998 | Canada | 15–64 | Exogenous: 19 % points less likely to be employed; endogenous: not significant and positive; test indicates endogeneity | Exogenous: 17 % points less likely to be employed; endogenous: not significant and positive and test indicates exogeneity |
[124] | 1983–1990 | Canada | 18–64 | With complications two times less likely to be in labour force; no significant effect on employment for those in labour forcea
| |
[71] | 1992–1993 | Sweden | >24 | 14.2 % points higher retirement rate (22.9 vs. 8.7)a
| |
[125] | 2004 | Sweden, Denmark, The Netherlands, Germany, Austria, Switzerland, France, Italy, Spain, Greece | 50–65 | For whole dataset: no effect of diabetes on being unemployed, but increased OR of 1.33 on being retired. No information on effects by countrya
| |
[101] | 2005 | Taiwan | 45–64 | Exogenous: 9 % points less likely to be employed; endogenous: 19 % points less likely to be employed; test on whole sample indicates endogeneity | Exogenous: 11 % points less likely to be employed, endogenous: not significant and negative |
[98] | USA | >44 | Exogenous: 7.4 % points less likely to be employed; endogenous: 10.6 % points less likely but test indicates exogeneity | Exogenous: 7.5 % points less likely to be employed; Endogenous: no significant effect found; test indicates endogeneity | |
[99] | 2006 | USA | >19 at diagnosis | Exogenous: 25.2 % less likely to be employed; Endogenous: 45.1 % less likely to be employed | |
[108] | 1992–2000 | USA | 51–61 | More likely to be retired in 1992 (adjusted OR 1.3). Over 8 years follow-up spent 0.14 incremental years in retirementa
| |
[105] | 1996–1997 | USA | >44 | 7.5 % Points less likely to be employed | No significant effect on employment chances found |
[110] | 2008 | USA | 35–64 | Diabetes negatively related to employment (5 % points reduction); better diabetes management (A1c) positively affects employment probabilities; A1c lowering of 10 % increases employment probability by 0.44 % points | No significant effect on employment chances found |
[126] | 1992, 1994 | USA | 51–61 | 9 % Points less likely to work without complications controlled for, with complications controlled for 7.1 % points less likely | 5.9 % Points less likely to work without complications controlled for, with complications controlled for 4.4 % points less likely but not significant |
[127] | 1997–2005 | USA | 20–44 and 45–64 | 20–44: proportion with work limitations 3.1 % higher; 45–64: proportion not working is 8.1 % higher; the proportion work disabled is 3.4 % higher; proportion with work limitations is 5.7 % higher (all vs. similar age group without diabetes)a
| |
[128] | 1990–1995 | USA | Unemployment rate for pts with diabetes was 16 % compared with 3 % among matched comparison groupa
| ||
[109] | 1989 | USA | >29 at diagnosis | 3.6 % less likely to be employed (exogenous), 12 % for those with complicationsa
| |
[104] | 1979–2010 | USA | >14 | Average reduction of employment probability of 28 % points; strongest employment penalty in first 5 years after diagnosis | Average reduction of employment probability of 36 % points; strongest employment penalty in first 15 years after diagnosis |
References | Survey year | Country | Age (years) | Effect on other productivity outcomes | |
---|---|---|---|---|---|
Males | Females | ||||
[124] | 1983–1990 | Canada | 18–64 | Effect on earnings only when complications are present: reduced to 72 % of total income of controlsa
| |
[106] | 2009, 2011 | China | Not given | 16.3 % decrease in annual income for newly diagnosed diabetics in 2011. Impact more significant for males and people with A1c levels between 8.0 % and 10.0 %, leading to a 22.0 % and 28.0 % decrease in annual income, respectively. Also effects are stronger for those in lower income quintiles | |
[129] | 1989–2007 | France | Males 40–50, females 35–50 in 1989 | 1.7 HR to transition from employed to disabled, 1.6 HR to be retired, 7.3 HR to be dead; between age 35 and 60 each person with diabetes lost 1.1 years of time in workforcea
| |
[130] | 2010–2013 | The Netherlands | 45–64 | Diabetes reduced work ability measured using WAI by 2 %. No significant effect on productivity was founda
| |
[71] | 1992–1993 | Sweden | >24 | 9.4 more sick daysa
| |
[107] | 1999 | UK | <65 | $1,744 lost earnings per year with diabetes; $2,609 for carers of people with diabetesa
| |
[99] | 2006 | USA | >19 at diagnosis | Exogenous: $3,118 loss in earnings per year, Endogenous: $21,392; Exogenous: 2 working hours less per week, no significant effect on missed workdays per year, endogenous: no significant effect on working hours or workdays missed | |
[108] | 1992–2000 | USA | 51–61 | Lost income of $50,004 from 1992 to 2000 per capita or $6,250 per year, for whole US population of same age $85.6 billion or $10.7 billion per year; people with diabetes more likely to have taken sick days in 1992 (adjusted OR 1.3)a
| |
[131] | 2002 | USA | Working age | No significant effect on work daysa
| |
[105] | 1996–1997 | USA | >44 | No significant effect on earnings | Women with diabetes earn 84 % less |
[110] | 2008 | USA | 35–64 | Wages reduced by 0.74 % due to diabetes; for every 10 % reduction in A1c wages rise by 0.62 %. A1c >8 was related to decreasing wages | No significant effect of diabetes on female earnings; no effect of blood sugar management for women, A1c levels just below 6 to just above 7 were related to lower wages |
[132] | 2005–2009 | USA | >16 | Lost earnings per year of $2,221a
| |
[126] | 1992, 1994 | USA | 51–61 | No significant effect on number of work days | 2.5 more lost workdays per year |
[128] | 1990–1995 | USA | 71 % of those with diabetes had an annual income of less than $20,000 compared with 59 % of the matched respondentsa
| ||
[109] | 1989 | USA | >29 at diagnosis | No significant effect on work days for T2D, for those with complications 3.2 days lost within 2 weeks | |
[133] | NA | USA | >45 | For every dollar of labour income lost by adults with diabetes, a further income reduction of $0.48 occurs in the community. Total output reduction for upper bound estimate is $300 million for the local economya
| |
[104] | 1979–2010 | USA | >14 | No general effect of T2D on wages; some evidence of wage penalty of about 18 % 6–10 years after diagnosis | No strong evidence found for wage penalty for females |