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Reviews/Commentaries/Position Statements
REPORT FROM THE AMERICAN DIABETES ASSOCIATION

Economic Costs of Diabetes in the US in 2002
AMERICAN DIABETES ASSOCIATION

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OBJECTIVE — Diabetes is the fifth leading cause of death by disease in the US Diabetes also contributes to higher rates of morbidity–people with diabetes are at higher risk for heart disease, blindness, kidney failure, extremity amputations, and other chronic conditions The objectives of this study were 1 to estimate the direct medical and indirect productivity-related costs attributable to diabetes and 2 to calculate and compare the total and per capita medical expenditures for people with and without diabetes RESEARCH DESIGN AND METHODS — Medical expenditures were estimated for the US population with and without diabetes in 2002 by sex, age, race/ethnicity, type of medical condition, and health care setting Health care use and total health care expenditures attributable to diabetes were estimated using etiological fractions, calculated based on national health care survey data The value of lost productivity attributable to diabetes was also estimated based on estimates of lost workdays, restricted activity days,
prevalence of permanent disability, and mortality attributable to diabetes RESULTS — Direct medical and indirect expenditures attributable to diabetes in 2002 were estimated at 132 billion Direct medical expenditures alone totaled 918 billion and comprised 232 billion for diabetes care, 246 billion for chronic complications attributable to diabetes, and 441 billion for excess prevalence of general medical conditions Inpatient days 439, nursing home care 151, and office visits 109 constituted the major expenditure groups by service settings In addition, 518 of direct medical expenditures were incurred by people 65 years old Attributable indirect expenditures resulting from lost workdays, restricted activity days, mortality, and permanent disability due to diabetes totaled 398 billion US health expenditures for the health care components included in the study totaled 865 billion, of which 160 billion was incurred by people with diabetes Per capita medical expenditures totaled 13,243 for people with diabetes and 2,560 for people without diabetes When adjusting for differences in age, sex, and race/ethnicity between the population with and without diabetes, people with diabetes had
medical expenditures that were 24 times higher than expenditures that would be incurred by the same group in the absence of diabetes CONCLUSIONS — The estimated 132 billion cost likely underestimates the true burden of diabetes because it omits intangibles, such as pain and suffering, care provided by nonpaid caregivers, and several areas of health care spending where people with diabetes probably use services at higher rates than people without diabetes eg, dental care, optometry care, and the use of licensed dietitians In addition, the cost estimate excludes undiagnosed cases of diabetes Health care spending in 2002 for people with diabetes is more than double what spending would be without diabetes Diabetes imposes a substantial cost burden to society and, in particular, to those individuals with diabetes and their families Eliminating or reducing the health problems caused by diabetes through factors such as better access to preventive care, more widespread diagnosis, more intensive disease management, and the advent of new medical technologies could significantly improve the quality of life for people with diabetes and their families while at the same time potentially
reducing national expenditures for health care services and increasing productivity in the US economy Diabetes Care 26:917932, 2003

This report was prepared by Paul Hogan, Tim Dall, and Plamen Nikolov of the Lewin Group, Inc, Falls Church, Virginia Address correspondence and reprint requests to Matt Petersen, American Diabetes Association, 1701 N Beauregard St, Alexandria, VA 22311 E-mail: mpetersen@diabetesorg Abbreviations: ADA, American Diabetes Association; BLS, Bureau of Labor Statistics; CMMS, Centers for Medicare and Medicaid Services; GHPS, Group Health of Puget Sound; MEPS, Medical Expenditure Panel Survey; NHIS, National Health Interview Survey; PVFE, present value of future earnings; SSDI, Social Security Disability Insurance A table elsewhere in this issue shows conventional and Systeme International SI units and conversion factors for many substances

iabetes cost the US an estimated 132 billion in 2002 in medical expenditures and lost productivity Across the components of the health care system included in this study, per capita direct medical expenditures for the 121 million people diagnosed with diabetes in the US are more than double the expenditures of
otherwise similar people without diabetes A total of 92 billion in direct medical expenditures are attributable to diabetes Diabetes is associated with higher rates of lost work time, disability, and premature mortality The resulting economic loss to the US economy in 2002 alone is estimated to be 40 billion This cost estimate documents the extraordinary national economic burden of diabetes Even so, such estimates do not account for the losses attributable to pain and suffering incurred by people with diabetes, as well as to families and friends of those with diabetes The prevalence of diabetes increases with age and is higher among certain racial and ethnic minority populations The growth, aging, and increasing racial and ethnic diversity of the US population portends a substantial increase in the size of the population with diabetes If diabetes prevalence rates remained constant over time, controlling for age, sex, race, and ethnicity, then based on Census Bureau population projections 1, the number of people diagnosed with diabetes could increase to 145 million by 2010 and to 174 million by 2020 The projected increase in the number of people with diabetes suggests that the
annual cost in 2002 dollars of diabetes could rise to an estimated 156 billion by 2010 and to 192 billion by 2020 The actual cost in future years could be higher if the cost of health care outpaces the overall cost of living, or if the growing problem of obesity increases the prevalence of type 2 diabetes This national cost estimate represents an increase from estimates reported in earlier studies, reflecting the growing prevalence of diabetes in the US and the increasing cost of health care services Comparison of national cost estimates across studies is complicated by differ917

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ences in the cost components included in each study, the continuing growth and aging of the US population, and changes over time in the cost of health care services The previous American Diabetes Association ADA study on the cost of diabetes estimated the national cost of diabetes in 1997 to be 98 billion 2 Documenting the national economic impact of diabetes can inform priority setting in health care research and delivery, including prevention, diagnosis, and treatment of diabetes Unless specifically noted, this study uses prevalence-based
cost-of-illness methods similar to the approach used by ADA 2,3 The following is an overview of the research design and methods used for this study, a discussion of important findings, and a summary of the implications of these findings, limitations of the study, and suggestions for future research RESEARCH DESIGN AND METHODS — The approach used to estimate the cost of diabetes follows, to the extent possible, the approach used in previous studies of the cost of diabetes and, in particular, ADAs previous cost estimate 2 This approach has found acceptance in the general cost-of-disease literature Deviations from the approach used previously by ADA 2 are noted and occur in some instances when the exact approach used in the earlier study could not be determined or when new data sources and analytical tools enable improvements to past approaches Below is a summary of the approach used to estimate 1 the size of the population with diabetes, 2 health care use and total health care expenditures attributable to diabetes, and 3 the value of lost productivity attributable to diabetes Estimating the size of the population with diabetes This national cost estimate is based on an estimate of
121 million people in the US in 2002 who have been diagnosed with diabetes This estimate of the magnitude of the diabetic population represents an increase of 1 million 9 from year 2000 estimates and an increase of 18 million 17 from year 1997 estimates Based on results from the 2000 Census, it appears that during the period of 1990 2000, the US population grew faster than projected by the Census Bureau The actual
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US population in 2000, based on the 2000 Census, exceeded the Census Bureaus pre-2000 projections of the US population in 2000 by 68 million individuals [or 24 of the total population] One implication is that pre-2000 estimates of the number of people with diabetes in the US were biased downward because the sample weights used in surveys such as the National Health Interview Survey NHIS were based on Census Bureau population estimates It is based on self-reported prevalence of diabetes only; therefore, it does not account for the considerable number of people with diabetes who are unaware that they have the disease or do not report it Indeed, the ADA estimates that as many as one-third of people with diabetes are unaware that they have the disease Further, this
estimate excludes women with gestational diabetes This cost estimate is based on prevalence rates derived from the combined 1998, 1999, and 2000 files of the NHIS Combining 3 years worth of NHIS files created larger samples with which to estimate separate prevalence rates for each of 12 age-groups by sex and by four race/ ethnicity designations The 12 age categories are 0 17, 18 24, 2529, 30 34, 3539, 40 44, 45 49, 50 54, 5559, 60 64, 65 69, and 70 years The four race/ethnicity categories are Hispanic, non-Hispanic white, non-Hispanic black, and non-Hispanic other The NHIS collects data on 43,000 households of more than 106,000 people annually The combined files for 1998 2000 create a sample of more than 320,000 people People with diabetes are identified using the survey question that asks whether the survey participant has been told by a doctor that he or she has diabetes other than gestational diabetes Responses to the question are coded as yes, no, borderline, and no response People responding yes are coded as having diabetes People responding borderline are not counted as having diabetes in this analysis As shown in Figs 1 and 2, diabetes prevalence rates increase with age
Prevalence rates vary substantially by race and ethnicity They are higher for Hispanics and non-Hispanic blacks than for nonHispanic whites Furthermore, the rates for other populations ie, Asian Americans, American Indians, Pacific Islanders, etc are similar to those of non-Hispanic

whites among females but are higher than the rates for non-Hispanic whites among males Applying these prevalence rates to the size of the US population in each demographic group, as determined by the 2000 Census and projected to 2002 using Census Bureau estimates, produced the estimate of 121 million people diagnosed with diabetes If diabetes prevalence rates within a demographic group remained constant over time, then, based on Census Bureau population projections 1, the size of the population with diabetes will grow to 145 million by 2010 and to 174 million by 2020 Table 1 Whereas the US population is projected to increase by 17 between 2002 and 2020, the size of the population diagnosed with diabetes is projected to increase by 44 due, in large part, to the increase in the size of the elderly population and the increasing racial and ethnic diversity of the US population Changing demographic
characteristics will contribute to an increase in the overall prevalence rate for diagnosed cases of diabetes from 42 in 2002 to a projected 52 in 2020 The number of Hispanics and other minority populations diagnosed with diabetes is projected to double between 2002 and 2020, whereas the number of non-Hispanic blacks and non-Hispanic whites diagnosed with diabetes is projected to increase by 50 and 27, respectively Although there is no projected increase in the total number of people under age 45 years diagnosed with diabetes between 2002 and 2020, the projected increases for populations aged 45 64 and 65 years are 48 and 56, respectively Health resource use attributable to diabetes In addition to receiving health care services for medical conditions directly related to diabetes, people with diabetes are at greater risk for neurological disease, peripheral vascular disease, cardiovascular disease, renal disease, endocrine/ metabolic complications, ophthalmic disease, and other chronic complications compared with individuals without diabetes A portion of health care use associated with these medical conditions is attributable to diabetes The general principle for estimating the cost
of diabetes in this analysis is
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American Diabetes Association

Figure 1–Proportion of female population with confirmed diabetes in 2002

straightforward Health care use attributable to diabetes is determined by a comparison of the health care use patterns of individuals with and without diabetes, controlling for differences between the two populations in demographic characteristics that are potentially correlated with the use of health care services eg, age, sex, and race/ethnicity Three limitations of the source data, however, increase the complexity of the analysis design and calculations These limitations are 1 absence of a single data source for all estimates, 2 small sample sizes for some items of interest, and 3 underreporting of diabetes as a comorbidity The implications of these limitations and how we have addressed these limitations are summarized below

No single source of data Because no single data source representative of the US population contains all of the information necessary to estimate the health care cost of diabetes, it is necessary to draw upon multiple data sources Among some of these sources are differences
in definitions for identi-

fying people with diabetes and differences in levels of detail to categorize types of patient visits One source of complete data required to estimate direct medical expenditures attributable to diabetes is claims from Group Health of Puget Sound GHPS This data source contains a diabetic flag in a disease registry, but the GHPS sample might not be representative of health care use patterns and costs for the entire US population The Medical Expenditure Panel Survey MEPS is closest to a single, nationally representative source of data in that it 1 identifies people with diabetes-related conditions, 2 measures health care use, and 3 provides cost information However, MEPS is limited by the small sample size Small sample sizes for some items of interests Disaggregating the US population by age, sex, race, and ethnicity requires relatively large sample sizes to obtain reliable estimates of differences in use patterns by diabetes status when analyzing specific medical conditions associated with diabetes The number

of identified people with diabetes who participated in the most recent MEPS is insufficient to obtain reliable estimates of health care use for
some chronic complications associated with diabetes and in some health care settings The use of alternative data sources, such as the National Ambulatory Medical Care Survey, increases sample size but is hindered by the third major limitation– underreporting of diabetes as a comorbidity Underreporting of diabetes as a comorbidity The literature reports that there is significant underreporting of diabetes as a comorbidity in health care databases Unless the attending physician lists diabetes as a comorbidity on the patients medical record, the health care services provided to that patient are not linked to diabetes Sources such as GHPS and MEPS allow one to identify whether a person has been diagnosed with diabetes but, as discussed above, their representativeness is often questioned in the case of GHPS or they have insufficient sample size
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Figure 2–Proportion of male population with confirmed diabetes in 2002

These data limitations are addressed as follows First, the study uses an eclectic approach that combines findings from empirical analysis of multiple data sources with findings reported in the literature Second,
for several national surveys completed annually, multiple years worth of data are pooled to increase sample size Third, similar to previous studies, this study uses an attributable risk methodology to estimate use of health care services that can be attributed to diabetes The attributable risk methodology estimates the odds of having a particular medical condition by diabetes status, then combines these odds with estimates of the proportion of the population with diabetes to calculate an etiological fraction The etiological fraction represents an estimate of the proportion of health care services for a particular medical condition that is attributable to diabetes The etiological fraction is calculated based on the following:
Ei P P Ri Ri 1 1 1

where Ei is the fraction of health care use for medical condition i that is attributable to diabetes, P represents the diabetes prevalence rate, and Ri is the relative risk of disease i ie, the odds ratio for people

with diabetes compared with people without diabetes Combining odds ratios estimated using the MEPS with diabetes prevalence rates estimated using the NHIS creates

Table 1–Projections of the US population diagnosed with
diabetes in millions Increase from 2002 to 2020 17 44 24 107 27 50 100 48 40 0 48 56

2002 Total population Diagnosed with diabetes Overall diabetes prevalence rate Race/ethnicity Hispanic Non-Hispanic white Non-Hispanic black Non-Hispanic other Sex M F Age years 45 4564 65 288 121 42 14 81 20 06 58 63 21 52 48

2010 307 145 47 20 91 25 09 71 74 20 70 55

2020 335 174 52 29 103 30 12 86 88 21 77 75

Census Bureau 1 population projections adjusted using calibration factors that align Census Bureau projections for the year 2000 with actual Census 2000 counts

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Figure 3–Etiological fractions, adjusted for race/ethnicity, sex, and finer age-groupings CVD, cardiovascular disease; GMC, general medical conditions; PVD, peripheral vascular disease; OCC, other chronic complications

separate etiological fractions for the medical conditions listed in Fig 3 for each demographic group modeled This figure combines etiological fractions across the 12 age-groups by race/ethnicity and sex to present etiological fractions for the population aged 45, 45 64, and 65 years The etiological fractions vary substantially
by age to reflect the changing prevalence of diabetes and differences in the prevalence of specific medical conditions by age For example, for the populations aged 45, 45 64, and 65 years, the proportions of all health care use associated with neurological disease that is attributable to diabetes are 6, 10, and 5, respectively The medical condition with the highest etiological fractions is cardiovascular disease, where the proportions of all health care visits attributable to diabetes for individuals aged 45, 45 64, and 65 years are 16, 20, and 17, respectively Although not reported here, the etiological fractions vary substantially by race
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and ethnicity, with the fractions generally higher for Hispanics and non-whites compared with non-Hispanic whites This finding is consistent with past research that shows ethnic disparities in both diabetes prevalence rates and the rates of diabetic complications 4 Table 2 summarizes the data sources used to analyze each component of the cost analysis and summarizes the unit cost estimates Sources of health care use data include the 1998 2000 files of the National Ambulatory Medical Care Survey,
the 1998 2000 files of the National Hospital Ambulatory Medical Care Survey, the 1999 National Inpatient Sample, the 1999 National Nursing Home Survey, and the 1998 and 2000 files of the National Home and Hospice Care Survey For each of these files, the primary diagnosis is used to classify the health care visit or inpatient day into one of nine medical condition classifications: 1 diabetes without complications, 2 one of the seven chronic medical conditions above

ie, neurological disease, peripheral vascular disease, cardiovascular disease, renal disease, endocrine/metabolic complications, ophthalmic disease, and other chronic complications, or 3 neither 1 nor 2, in which case the visit is classified as a general medical condition See the APPENDIX for a list of diagnosis codes used to categorize visits and hospital inpatient days by medical condition Health care use rates for each of the nine conditions in each health delivery setting are estimated by patient age, sex, and race/ethnicity Combining these use rates with etiological fractions and estimates of population size for each demographic group produces national estimates of health care use attributable to diabetes for each
medical condition The 1998 MEPS is the primary source for most estimates of the per-unit price of health care services Price estimates are based on actual payment for services, not charges Price estimates from other
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Table 2–Source of health resource use and price estimates Unit price 2002 dollars 2,385 169 160 452 247 561 47 89 107

Cost component Institutional care Hospital day Nursing home day Outpatient care Office-based physician encounter Emergency department visit Ambulance service Hospital outpatient and free-standing ambulatory surgical center visit Outpatient medication Home health visit Hospice care day Indirect costs Lost workday Restricted activity day Premature mortality lost lifetime earnings Permanent disability lost annual earnings Supplies Insulin use supplies include glucose monitoring supplies, insulin delivery supplies, and insulin and average annual cost of use

Source of use data 1999 NIS 1999 NNHS 19982000 NAMCS 19982000 NHAMCS 19982000 NHAMCS 19982000 NHAMCS 19982000 NAMCS, 19982000 NHAMCS 1998, 2000 NHHCS, 19982000 NHIS 1998, 2000 NHHCS

Source of price data 1998 MEPS Kiplinger 5 1998 MEPS 1998 MEPS AAA 1998 MEPS 1998 MEPS 1998 MEPS Hospice
Association of America 6 BLS BLS BLS BLS

19982000 NHIS 19982000 NHIS Social Security Administration 7 2002 Social Security Administration Data 8 19982000 NHIS, 2002 The Source Prescription Audit, LifeClinic 9, 10, Fertig et al 11, Frost and Sullivan 12 19982000 NHIS, Luna and Feinglos 16, 2002 The Source Prescription Audit, CDC 17, NIDDK 18

168 67 116,928 42,462

2002 Red Book 13, 2002 The Source Prescription Audit, Scott-Levin, 2002 AllegroMedical et al 14, 2002 MiniMed 15 2002 Red Book 13

1,778

Use of oral agents and average annual cost of use

666

American Ambulance Association AAA estimate of the national average cost for a basic life support transport, adjusted to 2002 dollars; actual estimate varies by age-group and sex; estimated annual cost per user CDC, Centers for Disease Control and Prevention; NAMCS, National Ambulatory Medical Care Survey; NHAMCS, National Hospital Ambulatory Medical Care Survey; NHHCS, National Home and Hospital Care Survey; NIS, National Inpatient Sample; NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases; NNHS, National Nursing Home Survey

sources are used when such information is readily available for more recent years or
when price estimates from the MEPS appear unreliable eg, because of small sample sizes in the MEPS All price estimates for health care services are adjusted to 2002 dollars using the medical component of the consumer price index The unit prices represent averages across all patients irrespective of diabetes status or reason for visit neonatal inpatient stays were omitted from the calculation of average cost per day To the extent that the unit price is higher when diabetes is a comorbidity, or that inpatient days and outpatient visits tend to be more expensive
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for the medical complications associated with diabetes, the average unit cost might underrepresent the true unit cost for services attributable to diabetes Estimates of the average annual cost of supplies for people using insulin and oral agents were calculated using cost data from The Source Prescription Audit, the 2002 Red Book 13, pharmaceutical companies, and suppliers of devices used by people taking insulin Based on prevalence rates computed using the combined 1998 2000 files of NHIS and estimates of the population in 2002, the estimated number of people using oral agents for diabetes and the estimated number
of

people using insulin are 75 and 39 million, respectively The percentage of people using insulin and oral agents varies substantially by age, reflecting the increasing proportion of cases involving type 2 diabetes among the population with diabetes in older age brackets Not all people with diabetes use either insulin or oral agents, especially among the younger age brackets Productivity foregone People with diabetes are at greater risk of temporary incapacity defined as lost workdays and bed days, permanent disability, and premature mortality The peDIABETES CARE, VOLUME 26, NUMBER 3, MARCH 2003

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cuniary value of lost productivity is calculated based on the average earnings of the person whose productivity is foregone Bureau of Labor Statistics BLS estimates of year 2001 annual earnings by age and sex for the civilian noninstitutional population are used to estimate the average cost per day of missing work, the average cost per year of permanent disability, and the loss of expected lifetime earnings resulting from premature mortality 19,20 Earnings estimates for 2001 are inflated to 2002 dollars using the overall consumer price index Lost workdays
and bed days The economic impact of temporary incapacity due to diabetes can be measured by both workdays lost and number of bed days, because both capture physical limitation due to diabetes that results in lost productivity These data are obtained from the NHIS, in which respondents report workdays lost and bed days during the previous year due to illness Lost workdays are defined as days in which a person misses work at a job or business because of diabetes or diabetes-related injury excluding maternity leave Bed days are defined as days in which a person is kept in bed more than half of the day because of diabetes or diabetes-related injury including days while an overnight patient at a hospital Lost workdays are subtracted from bed days to prevent overcounting if a person has both a lost workday and a bed day An estimate of workdays lost due to diabetes is found by comparing average days lost by diabetes status for each agegroup and by sex Controlling for age, men with diabetes have 31 more lost workdays and 79 more bed days per year, on average, than men without diabetes Women with diabetes had 06 more lost workdays and 81 more bed days, on average, than women without
diabetes However, these estimates likely underestimate lost workdays to the extent that men and women with diabetes are less likely to be in the labor force than men and women without diabetes The pecuniary value of a workday is defined as average earnings for the person incurring the lost workday Average earnings differ by age-group and sex, but the average earnings for people with diabetes who are between the ages of 18 and 64 is estimated at 168 per day Following the approach used by Yassin et al 21, the
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cost per bed day is defined as 40 of the cost of a lost workday Disability People with diabetes are at greater risk for amputations, loss of vision, and other physical problems that can limit their earning potential or preclude them from gainful employment Ideally, estimating lost earnings would entail comparing the average earnings of all people with diabetes to the average earnings of people without diabetes, controlling for differences in demographic characteristics and other factors that affect earning potential but that are unrelated to diabetes A comparison of gross average earnings would capture both differences in labor
force participation patterns and the possibility that an individual with diabetes will be in a lower-paying job Unfortunately, there are no recent data that provide reliable information with which to estimate average earnings by diabetes status while controlling for demographic and other factors affecting earning potential Consequently, following the approach previously used by the ADA 2, data from the Social Security Administration are used to estimate the prevalence of total number of permanently disabled workers attributable to diabetes The Social Security Disability Insurance SSDI program provides benefits to disabled workers and their spouses or children whether or not they are disabled, retired workers and their dependent family members, and survivors of deceased workers Individuals aged 18 64 years who receive SSDI benefits are included in the estimate of lost productivity attributed to diabetes-related disability The Social Security Administration Office of Research, Evaluation, and Statistics compiles information on the total number of people with disabilities by specified condition Therefore, using information on the number of disabled workers as a percentage of the
total number of beneficiaries from Table 1 in the Annual Statistical Report on the Social Security Disability Insurance Program, 2000, we adjusted the Social Security Administration data to reflect the number of disabled workers by specified condition As of January 2002, there were an estimated 122,000 people aged 18 64 years receiving SSDI benefits where diabetes is listed as the primary basis of disability and another 109,000 people aged

18 64 years receiving SSDI benefits where diabetes is listed as the secondary basis of disability This study attributes to diabetes 100 of the cases where diabetes is the primary basis of disability and 50 of the cases where diabetes is the secondary basis of disability The number of cases where diabetes is a contributing factor to the disability, but where diabetes is not listed as the primary or secondary diagnosis, was unavailable Also, the number of unemployed people with diabetes who are not receiving SSDI but who would be employed in the absence of diabetes is unknown An estimated 176,475 person-years of permanent disability in 2002 are attributable to diabetes Each case of permanent disability results in an average lost earnings of
42,462 per year The national cost estimate excludes the cost to family and friends caring for a person with permanent disabilities attributable to diabetes Mortality Data from the 1998 Multiple Cause of Death File 22 were used to determine the total number of deaths attributable to diabetes The file reports causes of death, along with economic, geographic, and demographic information for deaths of all US citizens occurring within the US Mortality-related productivity costs are the estimated value of lost future earnings from paid market and unpaid household labor resulting from premature death due to diabetes or diabetes-related diseases The estimated loss in annual earnings is based on estimates of the proportion of the population in the labor force, estimates of annual mean earnings from the BLS, and estimates of the mean value of housekeeping services The estimated value of lost housekeeping services for individuals not in the labor force is 40 of average earnings for people of similar age and sex who are in the work force and 20 of annual earnings for individuals in the labor force Estimates of the present value of lifetime future earnings are based on human capital
methodology, which assumes that earnings reflect the contribution workers make to the value of goods and services and that the present value of expected future earnings is an estimate of the value of human capital 23 The mortality-related productivity loss estimate incorporates both the number and timing of premature deaths attributable to diabetes
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Table 3–Health care use attributable to diabetes in the US, by age and type of service, 2002 in thousands Age years Type of service Institutional care Hospital inpatient days Nursing home days Outpatient care Office-based physician encounters Emergency department encounters Hospital outpatient and freestanding ambulatory surgical center encounters Home health visits Hospice care days 45 2,183 15,141 11,555 334 46 4564 5,802 32,805 16,718 971 2,399 65 8,927 34,406 34,365 3,478 3,467 Total 16,912 82,352 62,638 4,782 5,912

tions proportion of total use attributable to diabetes, and Table 6 shows the proportion of total US use attributable to diabetes Examination of these three tables reveals the following trends:

1,493 48

5,899 430

36,820 4,616

44,212 5,094

Using 2001 earnings estimates from the Bureau of Labor
Statistics, we updated the present value of future earnings PVFE estimates from Haddix et al 24 The PVFE for 2002, including unpaid household work, was estimated assuming a 4 real discount rate The average PVFE estimate for all diabetes-attributed mortality cases is 116,928, although the actual cost estimate differs by age and sex RESULTS Health resource use attributable to diabetes From estimates of per capita health care use and the size of the population, by demographic group, this study estimates total health care use for each demographic group Applying the etiological fractions for the corresponding demographic groups results in estimates of health resource use attributable to diabetes Table 3 shows estimated health care

use by type of service aggregated into three broad age-groups The attributable health care use due to diabetes is greatest for the population aged 65 years, despite this population having slightly fewer people with diabetes than the population aged 45 64 years For instance, officebased physician encounters attributable to diabetes for peop le over age 65 years is more than double the office-based physician encounters for people between 45 and 64 years Use of
emergency department, home health, and hospice care services is also substantially higher for the population over age 65 years compared with the population between age 45 and 64 years and the population under age 45 years Tables 4 6 provide information on health care use attributable to diabetes by medical condition and type of service Table 4 shows total use of services by type of medical condition attributable to diabetes, Table 5 shows each medical condi-

Most of the health care use attributable to diabetes is for the treatment of general medical conditions, ie, visits or inpatient days where the primary diagnosis is neither diabetes nor one of the seven chronic complications analyzed For example, 63 of hospital inpatient days attributable to diabetes fall under the category of general medical conditions Of the seven chronic complications analyzed, cardiovascular disease accounts for the largest proportion of health care use attributable to diabetes For example, in 2002, an estimated 4 million hospital inpatient days were attributable to diabetes where the primary diagnosis is related to cardiovascular disease This constitutes 24 of total hospital days attributable to
diabetes and 19 of total US inpatient days when the primary diagnosis was related to cardiovascular disease Diabetes accounts for a sizable increase in the use of health care services An estimated 18 of home health visits in the US are attributable to diabetes Approximately 15 of nursing home services and 14 of hospice care services in the US are attributable to diabetes

Health care expenditures attributable to diabetes Health care expenditures attributable to diabetes are those costs incurred by the population with diabetes above what

Table 4–US health care use attributable to diabetes by medical condition in thousands Chronic complications

Service Institutional care Inpatient days Nursing home days Outpatient care Physician office visits Emergency visits Hospital outpatient visits Home health visits Hospice care days

General Peripheral medical Diabetes Neurological vascular Cardiovascular Renal Metabolic Ophthalmic Other conditions 856 25,296 9,930 309 1,357 16,924 121 460 7,948 652 65 47 1,077 39 313 941 336 31 49 1,000 9 4,084 12,628 13,064 690 1,367 6,973 698 410 2,600 980 166 111 803 52 16 107 1,171 4 93 33 1 5 9 1,502 19 109 77 0 89 161 175 41 16 103 0 10,680 32,663
34,826 3,456 2,763 17,221 4,175

Total 16,912 82,352 62,638 4,782 5,912 44,212 5,094

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Table 5–Share of total US health care use attributable to diabetes by medical condition Chronic complications

Service Institutional care Inpatient days Nursing home days Outpatient care Physician office visits Emergency visits Hospital outpatient visits Home health visits Hospice care days
Data are

General Peripheral medical Diabetes Neurological vascular Cardiovascular Renal Metabolic Ophthalmic Other conditions Total 5 31 16 6 23 38 2 3 10 1 1 1 2 1 2 1 1 1 1 2 0 24 15 21 14 23 16 14 2 3 2 3 2 2 1 0 0 2 0 2 0 0 0 0 2 0 2 0 0 1 0 0 1 0 0 0 63 40 56 72 47 39 82 100 100 100 100 100 100 100

would be expected if this population did not have diabetes Of the estimated 918 billion in health care expenditures attributable to diabetes, 476 billion 52 is for services provided to people 65 years of age An estimated 316 billion 34 is for services provided to people age 45 64 years, whereas the remaining 126 billion 14 is for services provided to people under age 45 years Table 7 Home and hospice care expenditures
attributable to diabetes are incurred primarily by the population 65 years of age Table 8 shows estimates of attributable health care expenditures by medical condition and type of service Expenditures for health care events with a primary diagnosis of uncomplicated diabetes and diabetes-related supplies are estimated to be 232 billion for 2002, which accounts for 25 of all health care attributable expenditures At over 44 billion or 48 of

total attributable expenditures, general medical conditions comprise the largest component of expenditures attributable to diabetes Together, the seven chronic conditions associated with diabetes account for the remaining 27 of attributable expenditures, with cardiovascular disease being the single largest contributor Total US expenditures for health care services analyzed in this study are estimated at 865 billion Table 9, which is 58 of the total US health care expenditures of approximately 15 trillion in 2002 25 Centers for Medicare and Medicaid Services [CMMS] estimated national health care expenditures of 13 trillion in the year 2000, which is adjusted to 2002 using CMMSs projection of an 8 increase in annual cost of health care services in
the US resulting from rising medical costs and an increased use of services Cost components not included in this analysis include such things as

school-based and public health clinics, dental care, podiatric care, optometry care and vision products with the exception of ophthalmology services, which are included, research, over-the-counter medicines, and other areas CMMS estimates expenditures in 2000 to be 60 billion for dental care, 44 billion for government public health activities, and 44 billion for investment ie, research and construction Martin et al 26 estimate expenditures in 1998 to be 16 billion for vision products and other medical durables eg, hearing aides, medical equipment rentals, etc and 122 billion for over-the-counter medicine and sundries This analysis focuses on those areas where health care use patterns have been shown to differ by diabetes status Therefore, it is unknown what portion of the remaining 42 of US health care costs can be attributed to diabetes Compo-

Table 6–Proportion of total US health care use attributable to diabetes for various conditions Chronic complications

Service Institutional care Inpatient days Nursing home days Outpatient care
Physician office visits Emergency visits Hospital outpatient visits Home health visits Hospice care days

General Peripheral medical Diabetes Neurological vascular Cardiovascular Renal Metabolic Ophthalmic Other conditions Total 100 100 100 100 100 100 100 7 15 8 7 9 7 5 8 12 6 7 8 9 9 19 19 20 20 22 19 19 10 20 8 7 8 12 10 13 13 14 13 14 7 11 8 0 6 17 12 9 0 3 4 2 1 1 3 0 8 9 5 4 4 11 13 9 15 7 4 7 18 14

Data are Differences across service types in the proportion of total health care use attributable to diabetes occur because the etiological fraction for a particular medical condition differs by demographic group, and the demographic characteristics of patients receiving services differ by type of service

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Table 7–Health care expenditures attributable to diabetes in the US, by age and type of service, 2002 in millions of dollars Age years Type of service Institutional care Hospital inpatient days Nursing home days Outpatient care Office-based physician encounters Emergency department encounters Hospital outpatient and free-standing ambulatory surgical center encounters Home health visits Hospice care days Other
expenditures Ambulance services Outpatient medication Oral agents Insulin and delivery supplies Total 45 5,207 2,552 1,851 151 26 133 5 28 756 533 1,355 12,596 4564 13,838 5,528 2,678 439 1,345 524 46 40 1,991 2,318 2,891 31,640 65 21,293 5,798 5,505 1,572 1,944 3,273 492 77 2,769 2,157 2,745 47,626 Total 40,337 13,878 10,033 2,162 3,315 3,930 543 146 5,516 5,009 6,991 91,861

nents of the health care system not analyzed in this study, but where health care use patterns might differ by diabetes status include dentistry, podiatry, optometry, and licensed dietitians It is known, for example, that people with diabetes are at higher risk for periodontal disease than the general population, but these data are not incorporated here Thus, it is likely that this estimate of health care costs attributable to diabetes underestimates the true amount Of the health care components analyzed, more than 1 in 10 spent on health care services in the US is attributable to diabetes Expenditures attributable to diabetes are greatest for hospital

inpatient stays 403 billion, followed by nursing home care 139 billion and visits to physician offices 10 billion The cost of oral agents to lower blood
glucose, insulin, and insulin-related supplies totaled approximately 12 billion Diabetes is responsible for a substantial proportion of total US expenditures for certain health care services, eg, 18 of home health expenditures, 15 of nursing home expenditures, and 14 of hospice care expenditures The estimated cost to provide health care services to people with diabetes exceeded 160 billion in 2002 for those components of the health care system included in this study This includes costs

attributable to diabetes as well as non diabetes-related costs Although people with diagnosed diabetes comprise only slightly more than 4 of the US population, of the components of the health care system included in this study, almost 1 of every 5 spent on health care in the US is for a person with diabetes Because the prevalence of type 2 diabetes increases with age, the population with diabetes tends to be older compared with the population without diabetes Consequently, people with diabetes incur a substantial proportion of long-term care services For example, more than 1 in 4 spent for nursing home, home health, and

Table 8–Health care expenditures attributable to diabetes, by medical
condition and type of service, 2002 in millions of dollars Nursing home days 4,263 1,339 159 2,128 438 18 2 27 5,504 13,878 Home health visits 1,504 96 89 620 71 3 7 9 1,531 3,930 Hospice care days 13 4 1 74 6 0 0 0 445 543

Medical condition Diabetes Neurological symptoms Peripheral vascular disease Cardiovascular disease Renal complications Endocrine/metabolic complications Ophthalmic complications Other complications General medical conditions Total

Inpatient days 2,043 1,096 746 9,740 977 38 11 212 25,473 40,337

Office visits 1,591 104 54 2,093 157 188 241 28 5,578 10,033

Outpatient visits 761 26 27 767 62 52 61 9 1,549 3,315

Emergency visits 140 29 14 312 75 2 9 19 1,562 2,162

Other 12,916 52 31 1,892 92 126 92 14 2,447 17,662

Total 23,231 2,748 1,121 17,626 1,879 426 422 318 44,091 91,861

Includes ambulance services, outpatient medications, oral agents, insulin, and supplies

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Table 9–Total health care expenditures by diabetes status, 2002 in millions of dollars and of US total Population with diabetes Attributable to diabetes Cost component Hospital inpatient Nursing home Physicians
office Hospital outpatient Emergency Outpatient medication Home health Hospice care Ambulance services Insulin and delivery supplies Oral agents Total health care costs Millions of dollars 40,337 13,878 10,033 3,315 2,162 5,516 3,930 543 146 6,991 5,009 91,861 of US total 9 15 7 7 4 9 18 14 5 100 100 11 Incurred by people with diabetes Millions of dollars 76,245 25,860 18,433 5,911 4,424 9,636 6,230 1,020 281 6,991 5,009 160,041 of US total 18 28 13 12 9 15 28 26 10 100 100 19 Population without diabetes 354,970 millions of dollars 67,915 118,484 42,330 44,952 55,074 15,873 2,960 2,433 NA NA 704,991 US total 431,216 millions of dollars 93,775 136,917 48,240 49,375 64,710 22,103 3,981 2,714 6,991 5,009 865,032

hospice care is spent to provide services to someone with diabetes Dividing health care expenditures by the size of the population with and without diabetes creates estimates of per capita expenditures Table 10 On average, people with diabetes incurred approximately 13,243 in health care expenditures in 2002 across the health care components included in this study People without diabetes incurred approximately 2,560 in expenditures, for a ratio of 5 to 1 This comparison is
slightly higher than ratios estimated by ADA 2 and Rubin et al 27, who found a four-

fold difference in average annual health care expenditures for people with diabetes compared with others However, this ratio somewhat overstates the impact of diabetes on per capita costs because the demographic composition of the population with diabetes differs substantially from the demographic composition of the population without diabetes The population with diabetes tends to be older, on average, than the population without diabetes We derived an age-adjusted annual per capita expenditure of 5,642 to control for differences in demographic char-

acteristics of the population with diabetes compared with the nondiabetic population, yielding a ratio of 24-to-1 for health care expenditures among people with and without diabetes This ratio prevails, roughly, across cost components, ranging from a high of 27 to 1 for home health services to a low of 2 to 1 for emergency services Indirect costs attributable to diabetes At an annual cost of 75 billion, more than 176,000 cases of permanent disability in 2002 are attributable to diabetes

Table 10–Annual per capita health care expenditures by
diabetes status, 2002 Unadjusted Cost component Hospital inpatient Nursing home Physicians office Hospital outpatient Emergency Home health Hospice Ambulance services Outpatient medication Insulin delivery supplies Oral agents Total health care costs With diabetes 6,309 2,140 1,525 489 366 516 84 23 797 579 414 13,243 Without diabetes 1,289 247 430 154 163 58 11 9 202 NA NA 2,560 Ratio with to without diabetes 49 87 35 32 22 89 79 26 39 NA NA 52 Without diabetes 2,971 991 695 215 187 190 39 11 341 NA NA 5,642 Adjusted Ratio with to without diabetes 21 22 22 23 20 27 21 21 23 NA NA 24

Adjusted to reflect demographic composition of the population with diabetes

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Table 11–Morbidity costs attributable to diabetes, 2002 Value of lost productivity billions of dollars 52 05 02 16 75

Cause of permanent disability Diabetes Cardiovascular disease Renal disease Other diagnoses Total

Attributed disability cases 121,893 12,110 3,887 38,584 176,475

of total attributed cases 69 7 2 22 100

Table 11 This cost estimate represents a sizeable decrease from the cost of disability in the 1998 report 2, which used the present value of
lost lifetime earnings to estimate the cost of disability We use average annual lost earnings, estimated at 42,462 per case, to represent the productivity loss associated with the disability Disability cases where diabetes is listed as the primary cause accounts for more than two-thirds of total cases attributed to diabetes Cases where cardiovascular disease is listed as the primary cause of disability accounts for 7 of all cases attributed to diabetes The estimated number of deaths attributable to diabetes is derived from instances where the primary cause of death is diabetes, renal disease, cerebrovascular disease, or cardiovascular disease The etiological fractions used to estimate health care use attributable to diabetes are applied to the estimates of the number of deaths– by age, sex, race/ethnicity, and primary cause of death–to estimate deaths attributable to diabetes Estimated lost years of life are based on comparing timing of premature death to life expectancy 28 In 2002, an estimated 186,000 deaths were attributable to diabetes Table 12 An estimated 19 of all deaths for which cardiovascular disease is listed as the primary cause of death are attributed to diabetes,
and this accounts for 108,000 58 of all deaths attributable to diabetes This finding is consistent with the major findings of a study by DeStefano and Newman 29, which finds that coronary heart disease is the leading cause of mortality among people with diabetes DeStefano and Newman find that for younger people ie, men under age 45 years and women under age 55 years, people with diabetes had a 13-fold greater risk of coronary heat disease mortality
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than people without diabetes when controlling for other coronary heart disease risk factors The Centers for Disease Control and Prevention reports that adults with diabetes have heart death rates that are two to four times higher than those of adults without diabetes 30 An estimated 2,000 deaths with renal disease as the primary cause are attributed to diabetes Geiss et al 31 found that ageadjusted renal mortality rates for people with diabetes are more than 25 times the rates for people without diabetes National cost of diabetes Combining estimates of health care expenditures and productivity losses attributable to diabetes yields an estimate of the national cost of diabetes Table 13 In 2002, the estimated cost of diabetes was
approximately 132 billion, of which approximately 92 billion 70 was additional health care expenditures and 40 billion 30 was lost productivity due to disability and early mortality Institutional care ie, hospital inpatient care and nursing home care was the largest component of health care costs and comprised 41 of the national cost of diabetes Outpatient care, at 20 billion in

2002, comprised 15 of the national cost of diabetes At 175 billion, the cost of outpatient medication and supplies comprised 13 of the national cost of diabetes As the US population grows in size, ages, and becomes more racially and ethnically diverse, the size of the population diagnosed with diabetes will grow, even if current patterns in diabetes prevalence remain unchanged Using current diabetes prevalence rates applied to Census Bureau population projections, the national cost of diabetes could grow to 156 billion by 2010 in 2002 dollars and to 192 billion by 2020 Fig 4 Direct medical costs could increase from 92 billion in 2002 to 138 billion in 2020, whereas indirect costs from lost productivity could increase from 40 billion in 2002 to 54 billion in 2020 The actual future cost of diabetes is likely
to be substantially higher than these projected amounts if the prevalence of diabetes continues to grow– especially for type 2 diabetes, which is correlated with the growing problem of obesity in the US– even after controlling for changing demographic characteristics CONCLUSIONS — H e a l t h c a r e spending in 2002 for people with diabetes is more than double what spending would be without diabetes This costs the US economy an estimated 92 billion in higher health care expenditures Lost productivity attributed to diabetes resulting from lost workdays, lost home services, permanent disability, and premature mortality is estimated at 40 billion Compared to people without diabetes, people with diabetes and their families bear a disproportionate share of health care expenditures

Table 12–Mortality costs attributable to diabetes, 2002 Deaths attributed to diabetes thousands 72 2 4 108 186 Value of lost productivity millions of dollars 10,622 273 305 10,358 21,558

Primary cause of death Diabetes Renal disease Cerebrovascular disease Cardiovascular disease Grand total

of total US deaths 100 6 12 19 NA

Total lost years thousands 1,080 31 54 1,357 2,522

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

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Table 13–Total cost of diabetes, 2002 Total cost attributable to diabetes millions of dollars 91,861 54,215 40,337 13,878 20,130 10,033 2,162 146 3,315 3,930 543 17,516 5,516 6,991 5,009 39,810 4,503 6,256 21,558 7,494 131,672 Components proportion of total cost 70 41 31 11 15 8 2 0 3 3 0 13 4 5 4 30 3 5 16 6 100

Cost component Health care expenditures Institutional care Hospital inpatient care Nursing home care Outpatient care Physician office-based care Emergency care Ambulance services Hospital outpatient care Home healthcare Hospice care Outpatient medication and supplies Outpatient medication Insulin and delivery supplies Oral agents Indirect costs due to lost productivity Lost work days Restricted activity days Mortality Permanent disability Total cost

diabetes are categorized with the nondiabetic population If per capita use of health care services is greater for people with undiagnosed diabetes than for people without diabetes, the health care costs attributable to diabetes will be
underestimated Future research might investigate the cost of diabetes in these areas omitted from the present analysis The estimated national cost of diabetes was calculated using prevalence-based cost-of-illness methods with data from 1998 through 2002 For some components of the cost estimate eg, the cost of supplies, multiple data sources were analyzed and the results were compared to ensure robust results One change from the approach used in ADAs 1998 study was to combine multiple years of national health use databases to increase sample size and allow for finer disaggregation of the US population– both of which would improve the accuracy of the findings, because the prevalence of diabetes and the use of health care services varies substantially by age-group, sex, and race/ ethnicity Greater disaggregation also allows for more accurate projections of the national cost of diabetes in future years as the US population grows, ages, and becomes more racially and ethnically diverse However, if lifestyle trends in the US such as the growing problem of obesity increase diabetes prevalence rates, future costs could grow in excess of those extrapolated based on current prevalence rates
Although this study includes the same cost components of ADAs 1998

Cost component percentages do not necessarily sum to category totals because of rounding

This cost estimate is conservative and likely understates the true burden of diabetes for the following reasons:

This estimate omits the cost of intangibles such as pain and suffering, the cost of care provided by informal caregivers, and administrative costs of insurers The cost components included in this analysis account for only 58 of the estimated 15 trillion in US health care expenditures in 2002 For example, over-the-counter medications and sundries, which Martin et al 26 estimate at 122 billion in 1998, are omitted from the cost estimate Whereas the areas of health care expenditures analyzed are those where health care use patterns have been shown to differ by diabetes status, there are several areas omitted from the analysis where people with diabetes probably use services at higher rates than people without diabetes, eg, dental care, optometry care, and the use of licensed dietitians The average price per health service used could differ by diabetes status If health care conditions classified as general medical
conditions eg, pneumonia are more severe for people

with diabetes than without diabetes, then the cost estimate would be too low The study controls for differences in health care use attributable to diabetes, eg, the number of hospital inpatient days, but does not control for differences in mix of health care professionals seen eg, if people with diabetes are more likely to see a specialist instead of a primary care physician In this study, people with undiagnosed

Figure 4–Projected impact of changing demographic characteristics on the national cost of diabetes: 20022020 in 2002 billions of dollars

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study 2, the change in estimated diabetes-attributed costs between 1997 and 2002 for some cost components reflects a refinement in the cost estimates as opposed to an actual change in true costs As discussed previously, the 1998 study estimated disability-related costs at 325 billion in 1997, compared with the current study, which estimates disabilityrelated costs at 75 billion Much of the decrease in attributed costs is the result of using foregone expected annual expenditures instead of foregone expected lifetime
earnings to estimate the pecuniary cost of lost productivity, which may have been an inadvertent overstatement in the previous report This large decrease in attributed costs is offset by substantially higher cost estimates for certain health care components such as nursing home care, home health care, and physician officebased care One factor contributing to the large increase in attributed cost for nursing home care is the higher estimated cost per day in nursing homes 169 per day used in this study vs 79 per day [97 per day in 2002 dollars] used in the 1998 study This study estimates a much higher cost of home health care services, with an estimated 18 of total US home health care services costs attributed to diabetes compared with an estimated 02 of the total US cost of home health care services attributed to diabetes in the 1998 study Martin et al 26 estimated national expenditures of approximately 30 billion for home health care in 1997, compared with the estimate of 19 billion in the 1998 report 2 Eliminating or reducing the health problems caused by diabetes through factors such as better access to preventive care, more widespread diagnosis, more intensive disease
management, and the advent of new medical technologies could significantly improve the quality of life for people with diabetes and their families, while at the same time potentially reducing national expenditures for health care services and increasing productivity in the US economy In conclusion, the cost of diabetes, both direct medical expenditures and the costs of foregone productivity, is estimated to have been 132 billion in 2002 This represents a substantial cost burden to society and, in particular, to those in930

APPENDIX
Chronic complications of diabetes Neurological symptoms Myasthetic syndromes in diseases classified elsewhere amyotrophy Other specified idiopathic peripheral neuropathy Mononeuritis of upper and lower limbs Arthropathy associated w/neurological disorders Charcots arthropathy Peripheral autonomic neuropathy Polyneuropathy in diabetes Neuralgia, neuritis, and radiculitis, unspecified Diabetes with neurological complications Occlusion of cerebral arteries Hemorrhagic stroke Late effects of cerebrovascular disease Occlusion of stenosis of pre-cerebral arteries Other and ill-defined cerebrovascular disease Acute, but ill-defined, cerebrovascular disease
Transient ischemic attack Peripheral vascular disease Atherosclerosis Embolism and thrombosis, structure of artery Other peripheral vascular disease Other disorders of circulatory system Phlebitis and thrombophlebitis, portal vein thrombosis, and thrombolism and venous thrombolism Other venous embolism and thrombolism Varicose veins of lower extremities Gangrene and amputations Chronic ulcer of skin Cardiovascular disease Aortic and other aneurysms Hypotension Angina Conduction disorders and cardiac dysrhythmias Atherosclerotic cardiovascular disease Cardiomegaly Cardiomyopathy Other acute and subacute forms of ischemic heart disease Heart failure Diabetes w/peripheral circulatory disorders Myocardial degeneration Myocardial infarction Other chronic ischemic heart disease Hypertension Renal Complications Infections of kidney Other disorders of bladder Cystitis Renal sclerosis, unspecified Glomerulonephritis, nephrotic syndrome, nephritis, nephropathy Proteinuria ICD-9 MEPS codes 3581 3568 354, 355 7135 3371 3572 7292 2506 434 430432 438 433 437 436 435 440 444, 4471 443 459 451, 452

453 454 7854, 885887, 895897 707 441, 442 458 413 426427 4292 4293 425 411 428 2507 4291 410, 412
414 401405 590 596 595 587 580583 7910 Continued on following page

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Appendix continued Chronic complications of diabetes Renal failure and its sequelae Other disorders of kidney and ureter Urinary tract infection Diabetes and renal complications Chronic renal failure end-stage renal disease Endocrine/metabolic complications Dwarfism-obesity syndrome Glycogenosis and galactosemia Disorders of iron metabolism Hypercholesterolemia Hyperchylomicronemia Hyperkalemia Hypertriglyceridemia Macroglobulinemia Lancereauxs disease Lipidoses Other specified endocrine disorders Other and unspecified hyperlipidemia Mixed hyperlipidemia Renal glycosuria Ophthalmic complications Other retinal disorders Vascular disorders of the iris and ciliary body Disorders of the optic nerve and visual pathways Diabetes with ophthalmic complications Cataract Glaucoma Visual disturbance, low vision, blindness Other complications Bacteremia, bacterial infection, Coxsackie virus Candidiasis of skin and nails Chronic osteomyelitis of the foot Other and unspecified noninfectious gastroenteritis and colitis Impotence of organic origin
Infective otitis externa Degenerative skin disorders Candidiasis of vulva and vagina Cellulitis Diabetes with other specified manifestations Diabetes with unspecified complication Other bone involvement in disease classified elsewhere
ICD-9, International Classification of Diseases, Ninth Revision

ICD-9 MEPS codes 584, 586, 588 593 5990 2504 585 2594 2710, 2711 2750 2720 2723 2767 2721 2733 261 2727 2598 2724 2722 2714 362 3640, 3644 377 2505 366 365 368369 0792, 7907 1123 73017 5589 60784 3801 7093 1121 681, 682 2508 2509 7318

4

5

6

7

8

9

10 11

12 13 14

15 16 17

dividuals with diabetes and their families Nevertheless, this estimate is conservative and probably underestimates the true cost of the disease
Acknowledgments — Support for this study was provided by ADA, the National Institute of Diabetes and Digestive and Kidney Diseases, and the ADA Industry Advisory Council

References 1 US Bureau of the Census: Population ProjectionsAvailablefromhttp://wwwcensus gov/population/www/projections/popproj html Accessed October 2002 2 American Diabetes Association: Economic consequences of diabetes mellitus in the US in 1997 Diabetes Care 21:296 309, 1998 3 American Diabetes
Association: Direct and

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Indirect Costs of Diabetes in the United States in 1992 Alexandria, VA, American Diabetes Association, 1993 Karter AJ, Ferrara A, Liu JY, Moffet HH, Ackerson LM, Selby JV: Ethnic disparities in diabetic complications in an insured population JAMA 287:2519 2527, 2002 Kiplinger Retirement Report Available from http://wwwkiplingercom/retreport/ archives/2000/September/living2htm Accessed October 2002 Hospice Association of America: Hospice Facts and Statistics Available from http:// wwwnahcorg/Consumer/hpcfactspdf Accessed October 2002 Social Security Administration: Annual Statistical Report on the Social Security Disability Insurance Program, 2000 The Office of Policy, Social Security Available from http://wwwssagov/statistics/di_asr/ 2000/indexhtml Accessed October 2002 Social Security Administration: Persons Receiving SSDI Benefits on the Basis of Disability, by Specified Disease, 2000 Washington, DC, The Office of Policy, Social Security, 2000 LifeClinic: Insulin Delivery Available from http://wwwlifecliniccom/focus/diabetes/ supply_syringesasp Accessed October 2002 LifeClinic Insulin Available from http:// wwwlifecliniccom/focus/diabetes/supply_
insulinasp Accessed October 2002 Fertig BJ, Simmons DA, Martin DB: Therapy for diabetes In Diabetes in America 2nd ed Harris MI, Cowie CC, Stern MP, Boyko EJ, Reiber GE, Bennett PH, Eds Washington, DC, US Govt Printing Office, 1995 NIH publ no 95-1468, p 519 540 Frost Sullivan: US Diabetes Delivery Systems Markets New York, Frost Sullivan, 2001 Red Book: Drug Topics Montvale, NJ, Medical Economics Company, 2002 AllegroMedical: Needles Syringes Available from http://wwwallegromedicalcom/ Home/Subcategoryasp?C 520S 3631 Accessed October 2002 MiniMed Test Strips Available from http: //wwwminimedstorecom/test-strips html Accessed October 2002 Luna B, Feinglos MN: Oral agents in the management of type 2 diabetes mellitus Am Fam Physician 63:17471756, 2001 Centers for Disease Control and Prevention: Diabetes Surveillance 1997 Atlanta, GA, US Department of Health and Human Services, 1997 National Institute of Diabetes and Digestive and Kidney Diseases: Diabetes in America 2nd ed Harris MI, Cowie CC, Stern MP, Boyko EJ, Reiber GE, Bennett PH, Eds Washington, DC, US Govt Printing Office, 1995 NIH publ no 951468

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19 US Census
Bureau: Detailed Income Tabulations from the CPS: Earnings by Sex and Age, 2001 Available from http://www censusgov/hhes/income/dinctabshtml Accessed October 2002 20 US Bureau of Labor Statistics: Household Data: Employment Status of the Civilian Noninstitutional Population by Age, Sex, and Race, 2001 Available from ftp://ftpbls gov/pub/specialrequests/lf/aat3txt Accessed October 2002 21 Yassin AS, Beckles GL, Messonnier ML: Disability and its economic impact among adults with diabetes J Occup Environ Med 44:136 142, 2002 22 Centers for Disease Control and Prevention: Public Use Data File Documentation: Multiple Cause of Death for ICD-9 1998 Data Atlanta, GA, US Department of

Health and Human Services, 2000 23 Becker G: Human Capital New York, National Bureau of Economic Research, 1975 24 Haddix AC, Teutsch SM, Shaffer PA, Dunet DO: Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation New York, Oxford University Press, 1996 25 Centers for Medicare and Medicaid Services: Chart Services, Chapter 1: US Health Care System Available from http:// cmshhsgov/charts/series/sec1pdf Accessed October 2002 26 Martin AB, Whittle LS, Levit KR: Trends in state health
care expenditures and funding: 1980 1999 Health Care Financ Rev 22:111140, 2001 27 Rubin RJ, Altman WM, Mendelson DN: Health care expenditures for people with diabetes mellitus, 1992 J Clin Endocrinol

Metab 78:809A 809F, 1994 28 Centers for Disease Control and Prevention: Life Expectancy Tables Available from http://wwwcdcgov/nchs/fastats/ pdf/47_13t3pdf Accessed October 2002 29 DeStefano F, Newman J: Comparison of coronary heart disease mortality risk between black and white people with diabetes Ethn Dis 3:145151, 1993 30 Centers for Disease Control and Prevention: National Diabetes Fact Sheet Available from http://wwwcdcgov/diabetes/ pubs/estimateshtm Accessed October 2002 31 Geiss LS, Herman WH, Teutsch SM: Diabetes and Renal Mortality in the United States Am J Public Health 75:13251326, 1985

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Source:oznet.ksu.edu