While type 1 diabetes is growing at a moderate rate in the overall population, Factors contributing to this increase in prevalence of diabetes include: …
Global Forum for Health Research
Forum 8, Mexico City, November 2004
Economical aspects of diabetes care
Stephan Björk, Senior Adviser, Stakeheldur Relations, Starpasdin Relations,
Novo Nordisk A/S, Denmark
Increasing prevalence
While type 1 diabetes is growing at a moderate rate in the overall
population, type 2 diabetes is experiencing an explosive growth rate
Although essentially all people with type 1 diabetes are appropriately
diagnosed, it is estimated that presently more than half of people with
type 2 diabetes are unaware they have diabetes Factors contributing to
this increase in prevalence of diabetes include:
General population growth
Aging population
Increase in the number of diagnosed patients
More aggressive diabetes screening in the population at large
General trend in the Western world of a lifestyle with fatty foods and
less exercise
Adoption of the Western lifestyle in countries with historically low
incidence of diabetes, especially newly developed countries
According to the most recent research conducted by the International
Diabetes Federation IDF some 194 million people worldwide, or 51 of the
adult population, have diabetes
If nothing is done to slow the epidemic,
this number is expected to exceed 333 million, or 63 by 2025[1]
The direct annual cost of treatment is at least 153 billion international
dollars and may even exceed 286 billion a year[2], [3] To put this into
context, diabetes costs nine times more than asthma, and almost two thirds
of cancer spending[4],[5],[6]
This exceptional strain on healthcare budgets is set to increase as the
number of cases of diabetes continues to increase The World Health
Organisation WHO estimates that by the year 2030, the number of people
with diabetes will have reached 370 million[7] The cost of treating these
sufferers will mushroom to between 213 and 396 billion international
dollars a year by 2025, eating up as much as 40 percent of some countries
health budgets2
Health impact
In both type 1 and type 2 diabetes, chronically high levels of glucose in
the bloodstream can progressively damage nerves and small blood vessels
microvascular complications, increasing the risk of complications
statistics below are based on data from economically developed
countries13:
Blindness Diabetes is the leading cause of new cases of
blindness and
visual disability in adults in economically developed societies
Findings suggest that, after 15 years of having the condition, 2 of
people with diabetes become blind and 10 develop severe visual
impairment
Kidney disease Diabetes is the leading cause of end-stage renal
disease, accounting for about one-third of new cases
Nerve disease and amputations About 70 of people with diabetes have
some degree of nerve damage which, when severe, can lead to lower limb
amputation Diabetes is the leading cause of non-traumatic lower limb
amputations
In addition to these complications, people with type 2 diabetes often have
high levels of blood lipids and cholesterol, making their risk of heart
disease and stroke macrovascular complications two to four times higher
than the risk in people without diabetes
Healthcare costs
Diabetes is one of the costliest health problems in the world Few accurate
cost figures are available for individual countries, and comparisons are
difficult to make because healthcare systems and costs vary from country to
country However, the International Diabetes Federation IDF estimates
direct costs of diabetes to be
approximately 6 of the total health budget
of economically developed countries Their estimate, based on data from
1995, assumes that diabetes affects 6 of the population, on average, and
that the overall cost of healthcare for someone with diabetes is 25 times
more than for a person without the condition Total direct costs of
diabetes are highest in the US, Japan, Germany, and France: 60 billion,
1694 billion, 1067 billion and 73 billion US dollars, respectively2
The American Diabetes Association ADA has compiled more precise and
detailed cost figures for the US, based on data from 1997 [8],[9] They
estimate the direct costs of diabetes in the US to be 441 billion dollars
This includes costs for controlling blood glucose 77 billion dollars,
174, treating greater-than-normal rates of chronic complications 118
billion dollars, 268, and general medical conditions 246 billion
dollars, 558 On average, people with diabetes in the US incur nearly
four times as much in annual medical expenditures as compared to people
without diabetes: 10,071 dollars versus 2,669 dollars per person,
respectively3
Although even fewer assessments have been made of indirect costs those due
to lost
productivity, most estimates put them as high as or higher than
direct costs For example, indirect and direct costs of diabetes, in US
dollars, for the US, Mexico and Australia, respectively, are estimated to
be 541 billion and 441 billion, 330 million and 100 million, and 280
million and 371 million2 ADAs assessment of US indirect costs includes
lost productivity due to disability 371 billion dollars and premature
death 169 billion dollars3 ADA further estimates that, on average,
people with diabetes, age 18 to 64 years, missed 83 days of work compared
to 17 days per year for people without diabetes In the US in 1997, a
total of 159,719 deaths were attributable to diabetes, representing an
estimated loss of two million years of life
Controlling hyperglycaemia reduces complications
As high blood glucose levels are the root of most of the complications of
diabetes, maintaining glycaemic control is central to treatment Over the
years, a number of small studies have suggested that more intensive
therapy, to achieve tighter control of blood glucose levels, can prevent or
delay the onset of complications - and, therefore, decrease their
associated costs Compared to traditional
therapy, intensive therapy
involves more careful monitoring of blood glucose levels and administering
more frequent doses of insulin eg, three or more times per day and/or, in
the case of type 2 diabetes, oral antidiabetic drugs Two large, key
studies provided definitive proof that intensive therapy provides
significant health benefits over traditional therapy
The Diabetes Control and Complications Trial DCCT showed that, in type 1
diabetes, intensive therapy delayed the onset and slowed the progression of
microvascular complications[10] Risk reductions for various complications
ranged from 35 to 75 Improved glycaemic control was also associated with
reduced cardiovascular disease events, but the difference was not
statistically significant, possibly because the population studied was
young adults
More recently, the United Kingdom Prospective Diabetes Study UKPDS showed
similar benefits of intensive therapy for type 2 diabetes[11] Intensive
therapy with insulin and oral antidiabetic drugs decreased the risk of
retinopathy, nephropathy, and possibly neuropathy Overall, the rate of
microvascular complications decreased by 25
Recent research suggests that controlling the rise in blood
glucose
following a meal - post-prandial hyperglycaemia - is especially important
in reducing the higher risk of cardiovascular disease in individuals with
type 2 diabetes For example, a recent analysis of ten European studies
involving more than 22,000 people with type 2 diabetes showed that blood
glucose levels two hours after a standard glucose loading test predicted
cardiovascular disease mortality better than fasting plasma glucose
levels[12]
Similarly, the landmark DECODE analysis, based on 13 separate studies
involving more than 25,000 people with diabetes, showed two-hour post-
prandial glucose levels are as significant as systolic blood pressure in
predicting all-cause mortality, and are a better predictor of mortality
than fasting glucose levels in patients without a history of diabetes[13]
Cost versus the benefits of intensive therapy
Intensive glycaemic therapy costs more than traditional therapy: 4,000 to
5,800 US dollars, versus 1,700 dollars per year, respectively, according to
one estimate[14] Some researchers have examined whether the benefits are
worth the extra cost While there are some differences of opinion due to
differing assumptions in the health
economics analyses, most conclude that
the benefits are well worth the extra expenditure The conclusion from the
UKPDS for people with type 2 diabetes is that The additional costs of
intensive glucose control are largely offset by significant reduction in
the costs of treating complications of diabetes[15] For example, in
reviewing the literature, one group of researchers noted that intensive
therapy costs approximately 20,000 dollars and 16,000 dollars per quality
adjusted life year for type 1 and type 2 diabetes, respectively They
concluded that, from an economic perspective, this compares favourably with
pharmacological therapy for high-risk individuals with hypertension and
hypercholesterolaemia, and that health policy should foster the use of
intensive therapy for people with diabetes[16]
Unfortunately, despite the unequivocal demonstration of the benefits of
intensive therapy and the convincing cost-benefit analyses, intensive
therapy is not universally accepted by the healthcare system or available
to the majority of individuals with diabetes for a number of reasons[17]
Multiple daily insulin injections need adoption and compliance can be
difficult; further, intensive
therapy requires substantial time, effort,
commitment and communication for the patient and physician
Clearly, the benefits of intensive therapy must be more convincingly
communicated to healthcare professionals, managed care organisations and
individuals with diabetes New methods of administering therapy without
injections - such as inhaled insulin, which is currently in trials - also
hold the promise of making insulin therapy more convenient and less
intrusive, promoting greater compliance and more intensive treatment and,
in the end, decreasing the risk of diabetic complications and saving lives
———————–
[1] Diabetes Atlas, Second Edition, released August 2003 from the
International Diabetes Federation IDF
[2] The international dollar is a common currency unit that takes into
account differences in the relative purchasing power of various currencies
Figures expressed in international dollars are calculated using purchasing
power parities PPP, which are rates of currency conversion constructed to
account for differences in price levels between countries
[3] Diabetes Atlas - Second Edition published, International Diabetes
Foundation, August 2003
[4] American
Diabetes Association Economic costs of diabetes in the US
in 2002 Diabetes Care 2003 Mar;263:917-32
[5] Cancer Society Costs of cancer Web page Available at
http://wwwcancerorg
[6] American Heart Association Cardiovascular Disease Cost web page
Available at http://2161851125/presenterjhtml?identifier4475
[7] World Health Organisation http://wwwwhoint/hpr/gsfsdiabetesshtml
[8] American Diabetes Association Diabetes Facts and Figures
http://wwwdiabetesorg/ada/factsasp
[9] American Diabetes Association Economic consequences of diabetes
mellitus in the US in 1997 Diabetes Care 1998; 212:296-309
[10] Diabetes Control and Complications Trial Research Group The effect of
intensive treatment of diabetes on the development and progression of long-
term complications in insulin-dependent diabetes mellitus N Engl J Med
1993; 329:977-986
[11] UK Prospective Diabetes Study Group Intensive blood-glucose control
with sulphonylureas or insulin compared with conventional treatment and
risk of complications in patients with type 2 diabetes UKPDS 33 Lancet
1998; 352:837-853
[12] Kuizon D, Gordon SM Dolmatch BL Glucose Tolerance and
Cardiovascular Mortality: Comparison of fasting and 2-hour
diagnostic
criteria Arch Intern Med 2001, Feb 12; 1613:397-405
[13] The DECODE study group, European Diabetes Epidemiology Group; Diabetes
Epidemiology: Collaborative analysis Of Diagnostic criteria in Europe
Glucose tolerance and mortality: comparison of WHO and American Diabetes
Association diagnostic criteria Lancet 1999 Aug 21; 3549179:717-621
[14] Diabetes Control and Complications Trial Research Group Resource
utilization and costs of care in the diabetes control and complications
trial Diabetes Care 1995 Nov; 1811:1468-1478
[15] Gray A, Raikou M, McGuire A et al Intensive blood glucose control in
patients with type 2 diabetes: cost effectiveness in comparison with
conventional treatment In The Economics of Diabetes Care - An
international perspective, eds Williams, Tuomilehto Bjork Blackwell
Science 2000
[16] Herman WH, Dasbach EJ, Songer TJ Eastman RC The cost-effectiveness
of intensive therapy for diabetes mellitus Endocrinol Metab Clin North Am
1997 Sep; 263:679-695
[17] Cefalu WT, Skyler JS, Kourides IA, Landschulz WH, Balagtas CC, Cheng S-
L Gelfand RA, for the Inhaled Insulin Study Group Inhaled human insulin
in patients with type 2 diabetes mellitus brief
communication Arch
Intern Med 2001; 134:203-207
Source:nfid.org
