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Reviews/Commentaries/ADA Statements

Economic Costs of Diabetes in the U.S. in 2007

  1. American Diabetes Association
  1. Address correspondence and reprint requests to Matt Petersen, American Diabetes Association, 1701 N. Beauregard St., Alexandria, VA 22311. E-mail: mpetersen{at}diabetes.org
Diabetes Care 2008 Mar; 31(3): 596-615. https://doi.org/10.2337/dc08-9017
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Article Figures & Tables

Figures

  • Tables
  • Figure 1—
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    Figure 1—

    Rate of health resource use by men with diabetes relative to men without diabetes for visits/days where heart failure is the primary diagnosis.

  • Figure 2—
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    Figure 2—

    Percent of category expenditures associated with diabetes. See appendix for diagnosis codes for each category of complications.

  • Figure 3—
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    Figure 3—

    Average hospital length of stay (ALOS) when diabetes is a secondary diagnosis.

  • Figure 4—
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    Figure 4—

    Age distribution of deaths associated with diabetes.

  • Figure 5—
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    Figure 5—

    Net present value of future lost earnings from premature death.

  • Figure 6—
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    Figure 6—

    Rate ratios for inpatient care where the primary diagnosis code is a general medical condition: males. A ratio of 1.0 means that per capita hospital admissions (or days) for people with diagnosed diabetes is the same as the per capita admissions (or days) for people without diabetes.

Tables

  • Figures
  • Table 1—

    U.S. population (in thousands) and percent of U.S. population with diabetes, 2007

    Total U.S. populationWith diagnosed diabetesWith undiagnosed diabetesTotal with diabetes*
    Total population*301,73617,4865.8%6,6402.2%24,1268.0%
    Race/ethnicity
        Non-Hispanic white199,09111,4035.7%4,5202.3%15,9238.0%
        Non-Hispanic black37,0022,7757.5%6991.9%3,4749.4%
        Non-Hispanic other20,1011,0765.4%3171.6%1,3936.9%
        Hispanic45,5412,2314.9%1,1042.4%3,3357.3%
    Sex
        Male148,7448,5435.7%3,1132.1%11,6567.8%
        Female152,9928,9435.8%3,5282.3%12,4718.2%
    Age (years)
         <1873,8781570.2%350.1%1920.3%
        18–3470,3739641.4%6691.0%1,6332.3%
        35–4443,3561,6863.9%1,1742.7%2,8606.6%
        45–5443,8383,4437.9%1,3273.0%4,77010.9%
        55–5918,2352,30712.7%7564.1%3,06316.8%
        60–6414,3232,26115.8%7755.4%3,03621.2%
        65–6910,6901,87917.6%8508.0%2,72925.5%
        ≥7027,0424,78817.7%1,0553.9%5,84321.6%
    Insurance
        Private169,8867,0574.2%3,0181.8%10,0755.9%
        Government91,7948,9979.8%2,8913.1%11,88813.0%
        Uninsured40,0551,4323.6%7311.8%2,1635.4%
    • Source: Combined information from the 2004–2006 NHIS, 2004 NNHS, 1999–2004 NHANES, and the U.S. Census Bureau population estimates for 2007.

    • *

      ↵* Numbers do not necessarily sum to totals because of rounding.

  • Table 2—

    Average cost ($) per medical event, by complication, 2007

    Medical eventDiabetesChronic complications
    General medical
    NeurologicalPeripheral vascularCardiovascularRenalMetabolicOphthalmicOther
    Hospital inpatient day*†1,8532,3632,2263,2251,8722,1562,4081,7182,188
    Outpatient visit†331487714577592295753403745
    Emergency visit†6967988116805765941,613636701
    Physician office visit†132160199151169118182162162
    • Source:

    • *

      ↵* 2004 NIS;

    • †

      ↵† 2003–2005 MEPS. Estimates adjusted to 2007 dollars.

  • Table 3—

    Average cost per medical event, 2007

    Medical eventUnit cost ($)
    Prescription (excluding insulin and oral agents)*72
    Oral agents (per user per year)*697
    Insulin (per insulin user per year)*751
    Diabetic supplies (per person with diabetes per year)*, a102
    Home health visits (cost per person per day of use)*, a204
    Hospice care day†147
    Nursing facility day‡ (excluding food and rent) b131 (120)
    Other medical supplies (excess cost per person with diabetes per year)*, a
    Glasses/contacts5.57
    Ambulance services5.92
    Orthopedic items5.52
    Hearing devices9.02
    Prosthesis4.09
    Bathroom aids1.52
    Medical equipment7.09
    Disposable supplies10.85
    Alterations/modifications7.10
    Other0.14
    • Source:

    • *

      ↵* 2003–2005 MEPS;

    • †

      ↵† Hospice Association of America 2006.

    • ‡

      ↵‡ Average of cost for semi-private room and private room per the Genworth Financial 2007 Cost of Care Survey (http://longtermcare.genworth.com/comweb/consumer/pdfs/long_term_care/Cost_Of_Care_Survey.pdf). Note:

    • a

      ↵a Cost estimate varies by age and sex.

    • b

      ↵b An estimated 38% of the cost per day in a nursing home is for food and rent. For long-term residents, we exclude from the cost estimates expenses for room and board that would still have been incurred if the person were living at home. Estimates are adjusted to 2007 dollars.

  • Table 4—

    Health resource use (in millions of units) in the U.S., by diabetes attribution and cost component, 2007

    Health resourcePopulation with diabetes
    Incurred by population without diabetesU.S. total*
    Attributed to diabetes
    Incurred by people with diabetes
    Units% of U.S. totalUnits% of U.S. total
    Institutional care
        Hospital inpatient days24.31340.722145.7186.4
        Nursing/residential facility days56.110140.625433.3573.9
    Outpatient care
        Physician's office visits64.77137.614822.1959.7
        Emergency visits5.6511.510104.4115.9
        Hospital outpatient and freestanding ambulatory surgical center visits5.7610.91281.792.7
        Home health visits27.413.846.023.2152.7198.8
        Hospice care days0.2<19.61181.591.1
        Retail prescriptions175.38359.6171,762.02,121.6
    • *

      ↵* Numbers do not necessarily sum to totals because of rounding.

  • Table 5—

    Health resource use attributed to diabetes in the U.S., by age and type of service, 2007 (in thousands)

    Health resourceAge (years)
    Total*
    < 4545–64≥ 65
    Institutional care
        Hospital inpatient days2,1157,58614,56224,262
        Nursing/residential facility days1,26911,10343,68756,059
    Outpatient care
        Office-based physician visits7,35326,55230,80864,713
        Emergency visits1,4991,9842,0845,567
        Hospital outpatient and freestanding ambulatory surgical center visits1,3072,5351,8885,730
        Home health visits08,93918,44927,388
        Hospice care days422165192
        Retail prescriptions15,18171,29588,841175,317
    • *

      ↵* Numbers do not necessarily sum to totals because of rounding.

  • Table 6—

    Health resource use attributed to diabetes in the U.S., by medical condition (in thousands)

    Health resourceDiabetesChronic complications
    General medical conditionsTotal*
    Neuro-logicalPeripheral vascularCardio-vascularRenalMetabolicOphthalmicOther
    Hospital inpatient days8281,3181,2216,4461,75582151,87110,72624,262
    Office-based physician visits21,9312,3861,4056,6351,9054034,9341,44323,67264,713
    Emergency visits336173535922292272803,8745,567
    Hospital outpatient and freestanding ambulatory surgical center visits2,544154189549147271731731,7735,730
    • *

      ↵* Numbers do not necessarily sum to totals because of rounding.

  • Table 7—

    Share of total attributed health resource use, by medical condition

    Health resourceDiabetesChronic complications
    General medical conditionsTotal*
    Neuro-logicalPeripheral vascularCardio-vascularRenalMetabolicOphthalmicOther
    Hospital inpatient days35527700844100
    Office-based physician visits344210318237100
    Emergency visits63111400570100
    Hospital outpatient and freestanding ambulatory surgical center visits443310303331100
    • *

      ↵* Numbers do not necessarily sum to totals because of rounding.

  • Table 8—

    Proportion of total health resource use attributed to diabetes in the U.S. by medical condition

    Health resourceDiabetesChronic complications
    General medical conditionsTotal
    NeurologicalPeripheral vascularCardio-vascularRenalMetabolicOphthalmicOther
    Hospital inpatient days10026363435512744713
    Office-based physician visits100261811154191337
    Emergency visits1002212199419745
    Hospital outpatient and freestanding ambulatory surgical center visits100272410114181426
  • Table 9—

    Health care expenditures in the U.S., by diabetes status and type of service, 2007 (in millions of dollars and % of U.S. total)

    Cost componentPopulation with diabetes
    Population without diabetesU.S. total*
    Attributed to diabetes
    Total incurred by people with diabetes
    Dollars% of U.S. totalDollars% of U.S. total
    Institutional care
        Hospital inpatient58,3441496,97423332,902429,875
        Nursing/residential facility7,4861018,5252556,69275,217
    Outpatient care21,739
        Physician's office9,89768,06514132,984154,723
        Emergency department3,87057,8791073,38181,446
        Ambulance services1035370181,7262,096
        Hospital outpatient2,98546,7701060,05466,824
        Home health5,586149,3912331,14940,546
        Hospice28<11,4111110,62212,033
        Podiatry27319408281,0281,437
    Outpatient medications and supplies
        Insulin3,7331003,733100NA3,733
        Diabetic supplies1,7831001,783100NA1,783
        Oral agents8,5861008,586100NA8,586
        Retail prescriptions12,692826,03517127,562153,597
        Other equipment and supplies89052,7141416,90119,615
    Total*116,25711205,09220834,3791,051,505
    • *

      ↵* Numbers do not necessarily sum to totals because of rounding.

  • Table 10—

    Health care expenditures attributed to diabetes in the U.S., by age group and type of service, 2007 (in millions of dollars)

    Cost componentAge (years)
    Total*
    <4545–64≥65
    Institutional care
        Hospital inpatient4,55118,44735,34658,344
        Nursing/residential facility1661,5275,7937,486
    Outpatient care
        Physician's office1,1133,9824,8029,897
        Emergency department1,0471,3841,4383,870
        Ambulance services47921103
        Hospital outpatient6451,3121,0282,985
        Home health01,8233,7635,586
        Hospice132428
        Podiatry1458202273
    Outpatient medications and supplies
        Insulin7881,5641,3813,733
        Diabetic supplies2178597071,783
        Oral agents9674,1633,4568,586
        Retail prescriptions1,0995,1616,43212,692
        Other equipment and supplies77448365890
    Total*10,68940,81064,758116,257
    • *

      ↵* Numbers do not necessarily sum to totals because of rounding.

  • Table 11—

    Annual per capita health care expenditures attributed to diabetes by age group 2007

    Cost componentAge (years)
    Total*
    <4545–64≥65
    Institutional care
        Hospital inpatient1,6212,3035,3023,337
        Nursing/residential facility59191869428
    Outpatient care
        Physician's office397497720566
        Emergency department373173216221
        Ambulance services11036
        Hospital outpatient230164154171
        Home health0228564319
        Hospice0042
        Podiatry573016
    Outpatient medications and supplies
        Insulin281195207214
        Diabetic supplies77107106102
        Oral agents344520518491
        Retail prescriptions392644965726
        Other equipment and supplies27565551
    Total*3,8085,0949,7136,649
    • *

      ↵* Numbers do not necessarily sum to totals because of rounding.

  • Table 12—

    Health care expenditures attributed to diabetes in the U.S., by medical condition for select settings, 2007 (in millions of dollars)

    SettingDiabetesChronic complications
    General medical conditionsTotal*
    Neuro-logicalPeripheral vascularCardio-vascularRenalMetabolicOphthalmicOther
    Hospital inpatient1,5353,1152,71920,7903,285176363,21523,47358,344
    Physician's office2,8993822791,004323488992333,8309,897
    Emergency department2341384340313213111782,7173,870
    Hospital outpatient84275135317878130701,3212,985
    • *

      ↵* Numbers do not necessarily sum to totals because of rounding.

  • Table 13—

    Annual per capita health care expenditures by diabetes status, 2007

    Cost componentWith diabetesUnadjusted
    Age-sex adjusted
    Attributed to diabetes
    Without diabetesRatio with to without diabetesWithout diabetesRatio with to without diabetes
    Institutional care
        Hospital inpatient5,5461,1714.72,2092.53,337
        Nursing/residential facility1,0591995.36311.7428
    Outpatient care
        Physician's office1,2434682.76771.8566
        Emergency department4612581.82401.9221
        Ambulance services2163.5151.46
        Hospital outpatient and freestanding ambulatory surgical center3872111.82161.8171
        Home care5511105.02322.4319
        Hospice careNANANANANA2
        Podiatry2346.583.016
    Outpatient medications and supplies
        Insulin214NANANANA214
        Diabetic supplies102NANANANA102
        Oral agents491NANANANA491
        Retail prescriptions1,4894493.37632.0726
        Other equipment and supplies155592.61041.551
    Total*$11,744$2,9354.0$5,0952.3$6,649
    • *

      ↵* Numbers do not precisely sum to totals because of rounding.

  • Table 14—

    Indirect costs attributed to diabetes, 2007

    Cost componentProductivity lossTotal cost attributable to diabetes ($ billions)Proportion of indirect costs (%)
    Work days absent15 million days2.64
    Reduced performance at work120 million days20.034
    Reduced productivity days for those not in labor force6 million days0.81
    Permanent disability445,000 people, 107 million days7.914
    Mortality284,000 deaths26.946
    Total58.2100
  • Table 15—

    Annual productivity loss per person with diabetes by cause, 2007

    SexAgeAbsenteeismPresenteeismReduced productivity for those not in labor forceUnemployment from disabilityPremature mortality
    Male<18————4,306
    18–34221,458179363,366
    35–44992,883107284,476
    45–544932,688726524,468
    55–593602,1961093153,081
    60–641811,5171318061,822
    65–6986721—274569
    70+45378—146284
    Female<18————2,070
    18–3450844217431,095
    35–44471,378141,2161,456
    45–542401,310704491,388
    55–591791,09390491994
    60–647260480492642
    65–6927228—448140
    70+17140—74116
  • Table 16—

    Mortality costs attributed to diabetes, 2007

    Primary cause of deathTotal U.S. deaths (thousands)Deaths attributed to diabetes
    Deaths (thousands)% of total U.S. deathsValue of lost productivity (millions of dollars)
    Diabetes7777100.09,520
    Renal disease432557.42,116
    Cerebrovascular disease1555937.63,849
    Cardiovascular disease73912316.511,417
    Grand totalNA*284NA*26,902
    • *

      ↵* Grand total comprises mortality for reasons other than diabetes, renal disease, cerebrovascular disease, and cardiovascular disease.

  • Table A1—

    Summary of data sources

    Data source and descriptionUsed to estimate/analysisStrengths and limitations
    National Health Interview Survey (NHIS): combined 2004–2006 surveys to increase sample size.Diabetes diagnosed prevalence by age, sex, and race/ethnicity Prevalence of insulin and oral agents use Impact of diabetes on employment/hours worked Activity limitation and restriction+Large sample size +Contains employment-related information −Diabetes status self-reported of whether ever been told by physician you have diabetes −Excludes institutionalized population where diabetes is overrepresented
    National Health and Nutrition Examination Survey (NHANES): combined the three biannual surveys (1999–2000, 2001–2002, and 2003–2004) to increase sample size.Verify diagnosed prevalence Estimate undiagnosed prevalence+Contain both self-reported and lab test–identified diabetic persons −Excludes institutionalized population where diabetes is overrepresented
    Medical Expenditure Panel Survey (MEPS): combined 2003–2005 surveys to increase sample size.Average cost per physician office, outpatient, and emergency visit and outpatient prescription Average annual expenditures for podiatry, home health, insulin, oral agents, diabetes-related supplies use and cost, other medical equipment and supplies+Rich source of health resource use and cost information −Relatively small sample size per year −Contains only three-digit diagnosis codes; many chronic conditions of diabetes require four-digit codes to identify −Excludes institutionalized population where diabetes is overrepresented
    National Ambulatory Medical Care Survey (NAMCS): combined 2003–2005 surveys to increase sample size.National number of physician office visits by medical condition(using primary diagnosis code) Average number of scripts written per visit+Larger sample size than MEPS +Contains five-digit diagnosis codes to identify chronic conditions of diabetes −Visits are the unit of observations, with incomplete information on patients (including whether they have diabetes)
    National Hospital Ambulatory Medical Care Survey (NHAMCS): combined 2003–2005 surveys to increase sample size.National number of hospital outpatient and emergency visits by medical condition (using primary diagnosis code)+Same as for NAMCS −Same as for NAMCS
    Average number of scripts written per visit
    Nationwide Inpatient Sample (NIS): used 2004–2005 surveys.National number of hospital inpatient days for diabetes and comorbidities of diabetes (using primary diagnosis)+Same as for NAMCS −Same as for NAMCS
    Cost per inpatient day calculated using hospital-specific cost-to-charge ratios
    National Home and Hospice Care Survey (NHHCS): used 2000 data.Hospice care use (also validate home health)+Same as for NAMCS −Same as for NAMCS
    National Nursing Home Survey (NNHS): used 2004 data.Nursing facility use+Same as for NAMCS −Same as for NAMCS
    Ingenix MCURE databaseCalculate age-sex specific relative rate ratios for each medical condition for hospital inpatient days, emergency visits, and ambulatory visits (physician office and hospital outpatient combined)+Large sample size −All medical records can be linked for the year to identify people with diabetes based on whether they have any diabetes diagnosis code during the year −Lacks detailed data on health behavior found in MEPS
  • Table A2—

    Chronic complications of diabetes

    Chronic complications of diabetesICD-9 codes
    Neurological symptoms
        Myasthetic syndromes in diseases classified elsewhere (amyotrophy)358.1
        Other specified idiopathic peripheral neuropathy356.8
        Mononeuritis of upper and lower limbs354, 355
        Arthropathy associated w/neurological disorders (Charcot's arthropathy)713.5
        Peripheral autonomic neuropathy337.1
        Polyneuropathy in diabetes357.2
        Neuralgia, neuritis, and radiculitis, unspecified729.2
        Diabetes with neurological complications250.6
        Occlusion of cerebral arteries434
        Hemorrhagic stroke430–432
        Late effects of cerebrovascular disease438
        Occlusion of stenosis of pre-cerebral arteries433
        Other and ill-defined cerebrovascular disease437
        Acute, but ill-defined, cerebrovascular disease436
        TIAs435
    Peripheral vascular disease
        Atherosclerosis440
        Embolism and thrombosis, structure of artery444, 447.1
        Other peripheral vascular disease443
        Other disorders of circulatory system459
        Phlebitis and thrombophlebitis, portal vein throbosis and thrombolism and venous thrombolism451,452
        Other venous embolism and thrombolism453
        Varicose veins of lower extremities454
        Gangrene and amputations785.4, 885–887, 895–897
        Chronic ulcer of skin707
    Cardiovascular disease
        Aortic and other aneurysms441, 442
        Hypotension458
        Angina413
        Conduction disorders and cardiac dysrhythmias426–427
        ASCVD429.2
        Cardiomegaly429.3
        Cardiomyopathy425
        Other acute and subacute forms of ischemic heart disease411
        Heart failure428
        Diabetes w/peripheral circulatory disorders250.7
        Myocardial degeneration429.1
        Myocardial infarction410, 412
        Other chronic ischemic heart disease414
        Hypertension401–405
    Renal Complications
        Infections of kidney590
        Other disorders of bladder596
        Cystitis595
        Renal sclerosis, unspecified587
        Glomerulonephritis, nephrotic syndrome, nephritis, and nephropathy580–583
        Proteinuria791.0
        Renal failure and its sequelae584, 586, 588
        Other disorders of kidney and ureter593
        Urinary tract infection599.0
        Diabetes and renal complications250.4
        Chronic renal failure (ESRD)585
    Endocrine/metabolic complications
        Dwarfism-obesity syndrome259.4
        Glycogenosis and galactosemia271.0, 271.1
        Disorders of iron metabolism275.0
        Hypercholesterolemia272.0
        Hyperchylomicronemia272.3
        Hyperkalemia276.7
        Hypertriglyceridemia272.1
        Macroglobulinemia273.3
        Lancereaux's disease261
        Lipidoses272.7
        Other specified endocrine disorders259.8
        Other and unspecified hyperlipidemia272.4
        Mixed hyperlipidemia272.2
        Renal glycosuria271.4
    Ophthalmic complications
        Other retinal disorders362
        Vascular disorders of the iris and ciliary body364.0, 364.4
        Disorders of the optic nerve and visual pathways377
        Diabetes with ophthalmic complications250.5
        Cataract366
        Glaucoma365
        Visual disturbance, low vision, blindness368–369
    Other complications
        Bacteremia, bacterial infection, Coxsackie virus079.2, 790.7
        Candidiasis of skin and nails112.3
        Chronic osteomyelitis of the foot730.17
        Other and unspecified noninfectious gastroenteritis and colitis558.9
        Impotence of organic origin607.84
        Infective otitis externa380.1
        Degenerative skin disorders709.3
        Candidiasis of vulva and vagina112.1
        Cellulitis681, 682
        Diabetes with other specified manifestations250.8
        Diabetes with unspecified complication250.9
        Other bone involvement in disease classified elsewhere731.8
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Diabetes Care: 31 (3)

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March 2008, 31(3)
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Economic Costs of Diabetes in the U.S. in 2007
American Diabetes Association
Diabetes Care Mar 2008, 31 (3) 596-615; DOI: 10.2337/dc08-9017

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Economic Costs of Diabetes in the U.S. in 2007
American Diabetes Association
Diabetes Care Mar 2008, 31 (3) 596-615; DOI: 10.2337/dc08-9017
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