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. 2015 Oct 29;33(7):877–885. doi: 10.1111/dme.12965

Societal costs of diabetes mellitus in Denmark

C Sortsø 1,2,, A Green 1,3, P B Jensen 3, M Emneus 1
PMCID: PMC5061106  PMID: 26414087

Abstract

Aim

To provide comprehensive real‐world evidence on societal diabetes‐attributable costs in Denmark.

Methods

National register data are linked on an individual level through unique central personal registration numbers in Denmark. All patients in the Danish National Diabetes Register in 2011 (N = 318 729) were included in this study. Complication status was defined according to data from the Danish National Hospital Register. Diabetes‐attributable costs were calculated as the difference between costs of patients with diabetes and the expected costs given the annual resource consumption of the diabetes‐free population.

Results

Societal costs attributable to diabetes were estimated to be at least 4.27 billion EUR in 2011, corresponding to 14,349 EUR per patient‐year. A twofold higher healthcare resource usage was found for patients with diabetes as compared with the diabetes‐free population. Attributable costs, grouped according to different components, were 732 million EUR for primary and secondary care services, 153 million EUR for pharmaceutical drugs, 851 million EUR for nursing services, 1.77 billion EUR in lost productivity and 761 million EUR for additional costs. A steep increase in diabetes‐attributable costs was found for patients with major complications compared with patients without complications across all cost components. For attributable healthcare costs this increase was estimated to be 6,992 EUR per person‐year after controlling for potential confounders.

Conclusions

Nearly half of the total costs of patients with diabetes can be attributed directly to their diabetes. The majority of costs are incurred among patients with major complications pointing to the importance of secondary preventive efforts among patients with diabetes.

What's new?

  • Real‐world evidence on the attributable costs of diabetes is calculated from individual register data and categorized according to complication progression.

  • The study shows evidence of twofold higher healthcare resource usage in patients with diabetes compared with the diabetes‐free population.

  • The societal diabetes‐attributable costs of diabetes in Denmark 2011 were estimated to be ˜ 4.27 billion EUR, corresponding to 14,349 EUR per patient year.

  • Nearly 60% of diabetes‐attributable costs were ascribed to the 25% of patients with major complications.

  • Steep gradients of increasing costs with increasing complications were evidenced across all cost components.


What's new?

  • Real‐world evidence on the attributable costs of diabetes is calculated from individual register data and categorized according to complication progression.

  • The study shows evidence of twofold higher healthcare resource usage in patients with diabetes compared with the diabetes‐free population.

  • The societal diabetes‐attributable costs of diabetes in Denmark 2011 were estimated to be ˜ 4.27 billion EUR, corresponding to 14,349 EUR per patient year.

  • Nearly 60% of diabetes‐attributable costs were ascribed to the 25% of patients with major complications.

  • Steep gradients of increasing costs with increasing complications were evidenced across all cost components.

Introduction

Globally, healthcare systems are facing the challenge of an exponential increase in the prevalence of chronic diseases 1. This puts a heavy economic burden on society as new successful but costly treatments lead to an increase in care for more people as life expectancy increases.

With ~ 371 million people diagnosed globally 2 and evidence of rapidly increasing prevalence 3, 4, 5, 6, diabetes mellitus is one of the most burdensome chronic diseases. Diabetes is associated with shorter lifetime, reduced quality of life and economic burdens on the patient and society as a result of healthcare, pharmaceutical drugs, nursing, reduced labour market participation and premature mortality 1, 7, 8, 9, 10.

We aimed to present new evidence of the relationship between costs of patients with diabetes, with and without complications, compared with the diabetes‐free population based on data from all relevant national registers in Denmark 11. Categorizing patients according to their complication progression into no complications, minor complications and major complications, is a novel method intended to inform decision‐makers of a complex problem in an intuitive and easily interpretable way. Our results provide an economic rationale for secondary prevention, which is important to recognize with increasing numbers of patients with the chronic condition of diabetes. Furthermore, the results may contribute to an awareness among decision‐makers regarding the allocation of budgets which can impede shifts of resources between sectors.

Subjects and methods

Study population

Denmark offers unique opportunities for register‐based research in epidemiology and healthcare 11. The present study is part of a large‐scale register‐based observational investigation, the Diabetes Impact Study 2013, investigating the epidemiological, health economic and socio‐economic aspects of diabetes in Denmark.

The study population was identified from the Danish National Diabetes Register, adjusted for shortcomings 12, resulting in a period prevalence of n = 318,729. Person‐time was quantified as number of person‐years, defined as 365 person‐days (n = 297,378). Patient data were combined with data from the Danish National Patient Register 13, the Danish National Prescription Registry 14, the Danish National Health Service Register 15, the Danish Civil Registration System 16 and registers at Statistics Denmark. Municipal statements were used where register data were not available. Data were linked between registers using the unique Danish Personal Identification Number, assigned to each Danish citizen 16.

Analysis

Person‐time was stratified by gender and current age (in 5‐year age intervals) into three complication status groups: no complications, minor complications and major complications. Documentation on diagnoses and procedural codes across complication status groups can be found in Table S1.

The cost of illness framework was applied with a societal cost perspective, including both direct and indirect costs, but excluding intangible costs such as psychosocial effects 10, 17. The analytical time window was the calendar year, 2011. Costs (market values excluding value added tax) 17) were defined as opportunity costs valued as alternative forgone use. The following cost components were evaluated on an individual person level from national register data: 1) healthcare services in primary and secondary care including ambulant treatment and emergency room visits; 2) nursing services in own home/assisted facilities and nurse home visits; 3) pharmaceutical drug consumption; and 4) lost productivity including lower annual income, absenteeism and premature mortality, calculated using the human capital approach 17. Additional cost components (prevention, education, psychological assistance, use of self‐monitoring of blood glucose appliances, insulin pumps, medical appliances, patients’ (and informal care givers’) own time and depreciation of capital) were conservatively estimated from Statistics Denmark data and the literature. The measurement of cost components is shown in Table S2.

Attributable costs measure the excess costs of patients with diabetes’ total healthcare consumption compared with the annual resource consumption of the diabetes‐free population, stratified according to gender and age. This approach means that our attributable cost estimates reflect the cost of care of patients with diabetes including issues not directly associated with diabetes, and not solely the cost of diabetes care. This was applied because earlier studies document that adding up diabetes‐specific diagnoses/services underestimates the attributable costs compared with a case–control method 18, 19.

For healthcare services, patients with diabetes were compared with the diabetes‐free population (n = 5,261,714 in 2011) stratified by gender and 5‐year age groups. For pharmaceutical drugs, nursing and the labour market, comparisons were made between patients with diabetes and a matched cohort of the diabetes‐free population, consisting of five control subjects per patient with diabetes, matched by age, gender and residence at date of diagnosis (n = 1,462,872). As a result of data limitations from source registers, some cost components were calculated per person (pharmaceutical drugs, nursing, productivity loss) and some per person‐years (healthcare costs). In calculations across the different sectors, person‐years were applied.

Direct associations between cost components and complication status groups were explored in a multivariate linear regression analysis, controlling for potential confounders (gender, age, highest attained education level, ethnicity, year of death and region of residence). The dependent variables were: total and attributable healthcare cost (EUR per person‐years) in primary and secondary care; total net pharmaceutical drug costs; and total costs for home nursing (EUR per year) in 2011, defined per group according to the independent variables. The definitions of these variables are given in Table S3. T‐tests were performed and the significance valued at the 1% level.

Costs were further analysed according to first ascertainment source in the Danish National Diabetes Register as we have previously seen that up to 20% of registrants in the Danish National Diabetes Register are included only as a result of frequent blood glucose measurements and may not have diabetes 12.

Results

Estimates for total and attributable costs and costs per person‐year across cost components, gender and complication status groups are shown in Tables 1, 2, 3. Estimates excluding possible ‘false‐positive’ patients are shown in Tables S4 and S5. All cost estimates are presented in Euro (EUR).

Table 1.

Total diabetes resource use (total costs) and costs per person‐year for the entire diabetes population according to complication status and gender

Cost item Total costs (EUR) Total cost per person‐years (EUR)
ALL C0 C1 C2 ALL C0 C1 C2
Healthcare costs 1,638,237,935 553,933,413 319,439,149 764,865,373 5,509 3,361 5,508 10,257
Women 741,592,485 302,682,783 139,460,753 299,448,949 5,140 3,445 5,670 9,409
Men 896,645,450 251,250,630 179,978,396 465,416,424 5,857 3,265 5,388 10,889
Primary care 221,176,905 110,599,788 42,068,988 68,508,128 744 671 725 919
Women 113,618,643 63,234,638 19,779,391 30,604,615 787 720 804 962
Men 107,558,262 47,365,151 22,289,598 37,903,514 703 616 667 887
Secondary care 1,417,061,030 443,333,624 277,370,161 696,357,244 4,765 2,690 4,782 9,339
Women 627,973,841 239,448,145 119,681,362 268,844,335 4,352 2,725 4,866 8,447
Men 789,087,188 203,885,480 157,688,799 427,512,910 5,154 2,650 4,721 10,002
Pharmaceutical drug costs 255,799,680 102,638,292 62,354,493 90,806,895 860 623 1,075 1,218
Women 124,231,968 56,257,489 28,124,315 39,850,163 861 640 1,143 1,252
Men 131,567,712 46,380,803 34,230,178 50,956,732 859 603 1,025 1,192
Nursing costs 1,913,057,725 486,635,500 319,986,457 1,106,435,768 6,433 2,953 5,517 14,838
Women 1,181,279,919 347,648,931 197,983,759 635,647,229 8,187 3,957 8,050 19,973
Men 731,777,784 138,986,589 122,002,705 470,788,491 4,780 1,806 3,652 11,015
Nursing home 850,952,193 211,354,084 128,233,596 511,364,513 2,862 1,282 2,211 6,858
Women 537,556,556 151,368,523 82,046,366 304,141,667 3,726 1,723 3,336 9,556
Men 313,395,637 59,985,561 46,187,229 207,222,847 2,047 780 1,383 4,848
Nursing in own home 682,300,980 207,788,535 123,110,097 351,402,347 2,294 1,261 2,123 4,713
Women 421,328,648 149,028,783 75,136,381 197,163,484 2,920 1,696 3,055 6,195
Men 260,972,332 58,759,753 47,973,716 154,238,863 1,705 764 1,436 3,609
Home nurse in own home 379,804,552 67,492,881 68,642,764 243,668,907 1,277 410 1,183 3,268
Women 222,394,715 47,251,626 40,801,011 134,342,079 1,541 538 1,659 4,221
Men 157,409,815 20,241,275 27,841,759 109,326,781 1,028 263 833 2,558
Productivity loss 1,770,021,767 584,202,697 360,442,062 825,377,008 5,952 3,545 6,214 11,069
Women 550,569,259 245,373,990 101,862,861 203,332,408 3,816 2,793 4,142 6,389
Men 1,219,452,507 338,828,707 258,579,201 622,044,600 7,965 4,403 7,741 14,553
Lost income 912,272,022 413,992,645 184,680,345 313,599,033 3,068 2,512 3,184 4,206
Women 317,068,466 190,042,378 47,083,003 79,943,085 2,198 2,163 1,914 2,512
Men 595,203,557 223,950,267 137,597,342 233,655,947 3,888 2,910 4,119 5,467
Lost productivity in 2011 as a result of premature mortality 32,477,477 3,584,403 5,659,401 23,233,674 109 22 98 312
Women 8,209,904 884,182 1,901,945 5,423,777 57 10 77 170
Men 24,267,574 2,700,221 3,757,456 17,809,896 159 35 112 417
Lost productivity in 2011 as a result of premature deaths before 2011 723,048,722 122,775,598 144,419,340 455,853,784 2,431 745 2,490 6,113
Women 187,784,170 35,195,124 44,329,134 108,259,911 1,302 401 1,802 3,402
Men 535,264,552 87,580,474 100,090,205 347,593,872 3,496 1,138 2,996 8,132
Absence 102,223,545 43,850,051 25,682,976 32,690,518 344 266 443 438
Women 37,506,720 19,252,307 8,548,779 9,705,634 260 219 348 305
Men 64,716,826 24,597,745 17,134,197 22,984,884 423 320 513 538
Total additional costs 1,096,979,996 285,846,918 193,084,112 618,048,966 3,689 1,734 3,329 8,288
Women 499,242,465 152,580,215 81,802,942 264,859,308 3,460 1,737 3,326 8,322
Men 597,737,531 133,266,704 111,281,170 353,189,657 3,904 1,732 3,331 8,263
Education, prevention, psychological assistance etc. 23,510,431 13,124,212 4,710,462 5,675,757 79 80 81 76
Women 11,433,432 7,005,481 1,995,657 2,432,294 79 80 81 76
Men 12,076,999 6,118,731 2,714,805 3,243,462 79 80 81 76
SMBG and pumps 66,392,321 38,767,809 13,283,599 14,340,912 223 235 229 192
Women 32,467,058 20,693,596 5,627,794 6,145,668 225 236 229 193
Men 33,925,263 18,074,213 7,655,806 8,195,243 222 235 229 192
Medical appliances 57,486,656 0 0 57,486,656 193 0 0 771
Women 24,635,388 0 0 24,635,388 171 0 0 774
Men 32,851,268 0 0 32,851,268 215 0 0 769
Patients’ and informal care givers’ time 345,542,010 183,886,084 66,482,029 95,173,897 1,162 1,116 1,146 1,276
Women 167,107,269 98,155,258 28,166,096 40,785,915 1,158 1,117 1,145 1,282
Men 178,434,741 85,730,825 38,315,933 54,387,982 1,166 1,114 1,147 1,272
Depreciation 604,048,579 50,068,814 108,608,022 445,371,743 2,031 304 1,873 5,973
Women 263,599,318 26,725,880 46,013,396 190,860,043 1,827 304 1,871 ½5,997
Men 340,449,260 23,342,934 62,594,626 254,511,701 2,224 303 1,874 5,955
Total for all cost items 6,674,097,103 2,013,256,821 1,255,306,273 3,405,534,010 22,443 12,216 21,643 45,670
Women 3,096,916,097 1,104,543,408 549,234,630 1,443,138,059 21,465 12,572 22,331 45,345
Men 3,577,180,985 908,713,433 706,071,649 1,962,395,903 23,365 11,809 21,137 45,912

C0, no complications; C1, minor complications; C2, major complications; SMBG, self‐monitoring of blood glucose.

Table 2.

Diabetes attributable costs and attributable costs per person‐year for the diabetes population according to complication status and gender

Cost item Total attributable cost (EUR) Total attributable cost per person‐year (EUR)
ALL C0 C1 C2 ALL C0 C1 C2
Healthcare costs 731,520,509 93,151,921 146,557,644 491,810,944 2,460 565 2,527 6,595
Women 307,076,026 56,324,754 65,757,805 184,993,467 2,128 641 2,674 5,813
Men 424,444,483 36,827,167 80,799,839 306,817,477 2,772 479 2,419 7,178
Primary care 23,775,938 8,071,606 4,630,869 11,073,463 80 49 80 149
Women 9,466,709 3,358,214 2,032,360 4,076,136 66 38 83 128
Men 14,309,229 4,713,392 2,598,509 6,997,327 93 61 78 164
Secondary care 707,744,571 85,080,316 141,926,775 480,737,481 2,380 516 2,447 6,447
Women 297,609,317 52,966,541 63,725,445 180,917,331 2,063 603 2,591 5,685
Men 410,135,255 32,113,775 78,201,329 299,820,150 2,679 417 2,341 7,015
Pharmaceutical drug costs 153,372,738 51,151,437 43,493,499 58,727,802 516 310 750 788
Women 68,729,716 25,830,792 18,958,706 23,940,218 476 294 771 752
Men 84,643,022 25,320,645 24,534,793 34,787,584 553 329 734 814
Nursing costs 851,426,972 44,157,419 138,412,494 668,857,059 2,863 268 2,386 8,970
Women 530,191,480 55,119,865 94,574,667 380,496,948 3,675 627 3,845 11,956
Men 321,235,491 ‐10,962,446 43,837,827 288,360,111 2,098 ‐142 1,312 6,746
Nursing home 271,179,210 ‐22,733,872 29,375,665 264,537,417 912 ‐138 506 3,548
Women 214,979,658 8,249,313 31,006,921 175,723,425 1,490 94 1,261 5,521
Men 56,199,552 ‐30,983,185 ‐1,631,255 88,813,992 367 ‐403 ‐49 2,078
Nursing in own home 307,899,167 47,914,035 59,025,923 200,959,210 1,035 291 1,018 2,695
Women 180,996,612 39,487,891 36,882,579 104,626,142 1,254 449 1,500 3,287
Men 126,902,555 8,426,144 22,143,344 96,333,067 829 110 663 2,254
Home nurse in own home 272,348,594 18,977,256 50,010,906 203,360,433 916 115 862 2,727
Women 134,215,210 7,382,661 26,685,167 100,147,381 930 84 1,085 3,147
Men 138,133,384 11,594,594 23,325,738 103,213,051 902 151 698 2,415
Productivity loss 1,770,021,767 584,202,697 360,442,062 825,377,008 5,952 3,545 6,214 11,069
Women 550,569,259 245,373,990 101,862,861 203,332,408 3,816 2,793 4,142 6,389
Men 1,219,452,507 338,828,707 258,579,201 622,044,600 7,965 4,403 7,741 14,553
Lost income 912,272,022 413,992,645 184,680,345 313,599,033 3,068 2,512 3,184 4,206
Women 317,068,466 190,042,378 47,083,003 79,943,085 2,198 2,163 1,914 2,512
Men 595,203,557 223,950,267 137,597,342 233,655,947 3,888 2,910 4,119 5,467
Lost productivity in 2011 due to premature mortality 32,477,477 3,584,403 5,659,401 23,233,674 109 22 98 312
Women 8,209,904 884,182 1,901,945 5,423,777 57 10 77 170
Men 24,267,574 2,700,221 3,757,456 17,809,896 159 35 112 417
Lost productivity in 2011 due to premature deaths before 2011 723,048,722 122,775,598 144,419,340 455,853,784 2,431 745 2,490 6,113
Women 187,784,170 35,195,124 44,329,134 108,259,911 1,302 401 1,802 3,402
Men 535,264,552 87,580,474 100,090,205 347,593,872 3,496 1,138 2,996 8,132
Absence 102,223,545 43,850,051 25,682,976 32,690,518 344 266 443 438
Women 37,506,720 19,252,307 8,548,779 9,705,634 260 219 348 305
Men 64,716,826 24,597,745 17,134,197 22,984,884 423 320 513 538
Total additional costs 760,778,770 257,979,629 132,635,083 370,164,058 2,558 1,565 2,287 4,964
Women 352,528,414 137,705,130 56,192,816 158,630,468 2,443 1,567 2,285 4,984
Men 408,250,356 120,274,499 76,442,267 211,533,590 2,667 1,563 2,288 4,949
Education, prevention, psychological assistance etc. 23,510,431 13,124,212 4,710,462 5,675,757 79 80 81 76
Women 11,433,432 7,005,481 1,995,657 2,432,294 79 80 81 76
Men 12,076,999 6,118,731 2,714,805 3,243,462 79 80 81 76
SMBG and pumps 66,392,321 38,767,809 13,283,599 14,340,912 223 235 229 192
Women 32,467,058 20,693,596 5,627,794 6,145,668 225 236 229 193
Men 33,925,263 18,074,213 7,655,806 8,195,243 222 235 229 192
Medical appliances 57,486,656 0 0 57,486,656 193 0 0 771
Women 24,635,388 0 0 24,635,388 171 0 0 774
Men 32,851,268 0 0 32,851,268 215 0 0 769
Patients’ and informal care givers’ time 345,542,010 183,886,084 66,482,029 95,173,897 1,162 1,116 1,146 1,276
Women 167,107,269 98,155,258 28,166,096 40,785,915 1,158 1,117 1,145 1,282
Men 178,434,741 85,730,825 38,315,933 54,387,982 1,166 1,114 1,147 1,272
Depreciation 267,847,352 22,201,524 48,158,993 197,486,835 901 135 830 2,648
Women 116,885,267 11,850,795 20,403,270 84,631,202 810 135 830 2,659
Men 150,962,085 10,350,729 27,755,723 112,855,634 986 135 831 2,640
Total for all cost items 4,267,120,755 1,030,643,103 821,540,781 2,414,936,871 14,349 6,254 14,164 32,386
Women 1,809,094,895 520,354,532 337,346,855 951,393,509 12,539 5,923 13,716 29,894
Men 2,458,025,860 510,288,571 484,193,927 1,463,543,362 16,055 6,631 14,495 34,241

C0, no complications; C1, minor complications; C2, major complications; SMBG, self‐monitoring of blood glucose.

Table 3.

Total person‐years for the entire diabetes population according to complication status and gender

Person years All No complications Minor complications Major complications
Total 297,378 164,809 58,000 74,568
Women 144,281 87,860 24,595 31,826
Men 153,097 76,950 33,405 42,742

Healthcare

Total healthcare costs were estimated to be 1.64 billion Euro, corresponding to 5509 EUR per person‐year. On average, a patient with diabetes consumed approximately twice the healthcare resources compared with a diabetes‐free person (1.2, 1.8 and 2.8 times the healthcare resource use of a diabetes‐free person for patients with no, minor or major complications, respectively) with higher gradients found among younger patients as compared with the elderly, among male patients as compared with female patients, and for secondary care as compared with primary care. A patient going from no complications to minor or major complications incurred increased healthcare costs of 1782 and 7534 EUR per person‐year, respectively, even after controlling for potential confounders (Table S6).

The total attributable healthcare costs of diabetes were estimated to be 732 million EUR, divided between the no complication, minor complication and major complication groups as follows: 93, 147 and 492 million EUR, respectively. The greatest absolute cost burden was observed in the age group of 60–74 years, mainly because of the sheer volume of patients in these age groups.

Average attributable costs per person‐year for healthcare were 2460 EUR (2,128 EUR for women and 2,772 EUR for men). The costs for patients with minor complications were 4.5 times higher and for patients with major complications 12 times higher than for patients without complications. Patients with major complications, representing 25% of all patients, consumed almost 50% of total healthcare resources. Differences in attributable healthcare costs between a patient with no complications and a patient with minor or major complications of 1617 and 7388 EUR per person‐year, respectively, were found, after controlling for potential confounders (Table S7).

Observed patterns in healthcare resource consumption are shown in Fig. 1 and may be summarized as follows: 1) gradients between complication status groups were especially marked for secondary care, where the largest costs also lay; 2) men consumed more resources in all secondary care services than women, whereas the opposite was true for primary care; and 3) attributable cost per person‐year decreased with age, mainly as a result of the diabetes‐free population experiencing an increase in cost with age.

Figure 1.

Figure 1

Total cost of secondary care for the diabetes‐free population (DKnoDM) and patients with diabetes (DM) by complication state (C0: no, C1: minor and C2: major) for (a) women and (b) men.

Pharmaceutical drugs

Pharmaceutical drug consumption amounted to 256 million EUR in 2011, corresponding to 860 EUR per person. Differences in the costs between no complications and minor and major complications, respectively, were 257 and 329 EUR per year, after controlling for potential confounders (Table S8). The pharmaceutical drug consumption of patients with diabetes was 2.5 times higher than that of the diabetes‐free population: 153 million Euro were found to be attributable to diabetes. Attributable costs per person‐year were 516 EUR (476 EUR for women and 553 EUR for men), and were 310, 750 and 788 EUR per person‐year for the no complication, minor complication and major complication groups, respectively. This shows a significant increase in pharmaceutical drug costs when patients progressed from uncomplicated diabetes to minor complications, whereas later progression to major complications did not impose a marked increase. For women, the increase from minor to major complications was 2% and for men 10%. The higher attributable costs among men were the result of differences in pharmaceutical drug consumption between genders in the control group, whereas consumption was approximately equal for each gender among patients with diabetes.

Attributable costs were highest among the young, and declined with age (Fig. 2). This pattern is mainly the result of patients with diabetes having more or less the same pharmaceutical drug consumption across age groups, whereas there was increasing consumption with age among the control subjects.

Figure 2.

Figure 2

Diabetes‐attributable cost for pharmaceuticals by age, gender and complication status (C0: no, C1: minor and C2: major).

Nursing

Costs for nursing for patients with diabetes in 2011 amounted to 1.91 billion EUR, corresponding to 6,433 EUR per person. Total attributable nursing costs amounted to 851 million corresponding to 2,863 EUR per person‐year (3,675 EUR for women and 2,098 EUR for men). When the attributable costs were divided between the no complication, minor complication and major complication groups, the costs were 268, 2,386 and 8,970 EUR, respectively, per patient. Attributable costs per patient hence increased 33‐fold when patients progressed from uncomplicated diabetes to diabetes with major complications.

The probability of living in a nursing home for patients with diabetes was 45% greater compared with the matched diabetes‐free population. For men (in particular those aged ≥ 75 years) negative attributable costs were evidenced, reflecting that men in these older age groups, who have no complications, use fewer nursing resources than aged‐matched men in the diabetes‐free population. Patients with diabetes received on average 50% more home nursing visits than the matched diabetes‐free population. The difference in total costs for home nursing between patients with no complications and those with minor and major complications were estimated to be 299 and 722 EUR per year, respectively, after controlling for potential confounders (Table S9).

Productivity

In total, the productivity loss amounted to 1.77 billion EUR, assuming patients with diabetes of working age earned the same income as the diabetes‐free population of the same age, gender and education level, died at the same age and had not experienced any excess days of absence attributable to disease.

Patients with diabetes on average received a lower annual gross income than matched control subjects after controlling for education level. This reflected that a higher percentage of control subjects had jobs requiring high‐level skills, e.g. almost twice as many control subjects held jobs in managerial positions, whereas patients with diabetes had a 22% higher unemployment rate and more than twice as many had retired early (12% compared with 5.4%). Differences in income level increased with education level and complication status group, with a maximum annual difference among patients with major complications belonging to the highest education level group of 25,229 EUR for men and 24,104 EUR for women in the age group 55–59 years. The annual difference in mean gross income according to age in four education level groups is shown for the no complications group, with men and women separately in Fig. 3.

Figure 3.

Figure 3

Annual difference in mean gross income according to age and education level for (a) women and (b) men with no diabetes complications.

The total attributable difference in annual gross income was 912 million EUR. The main share (46%) of the total productivity loss was attributable to productivity losses among patients with no complications, because of the volume of people of working age. Lost productivity in 2011 as a result of premature death from diabetes was 32.4 million EUR calculated from 1,567 premature deaths corresponding to 52% of the total number of deaths among patients with diabetes of working age and to 1% of the total diabetes population in the working age group. Production foregone in 2011 as a result of premature deaths from diabetes encountered before 2011 (with production foregone as a result of the diabetes‐attributable deaths until the age of 69 years used as proxy estimate) was estimated to be 723 million EUR, and excess days of absence from work were estimated to be 102 million EUR in 2011.

Additional costs

Additional costs attributable to diabetes were estimated to be 761 million EUR corresponding to 2,558 EUR per person‐year.

Total attributable costs

The total costs of diabetes in Denmark in 2011 were estimated to be 6.67 billion EUR (22,443 EUR per person‐year), of which 4.27 billion EUR (14,349 EUR per person‐year) were attributable to diabetes. The relative distribution between cost components is shown in Fig. 4, and the absolute distribution is shown in the Figure S1.

Figure 4.

Figure 4

Relative distribution of the components of diabetes‐attributable costs.

The total diabetes‐attributable costs were divided between the no complication, minor complication and major complication groups as follows: 6,254, 14,164 and 32,386 EUR per person‐year, respectively (Fig. 5).

Figure 5.

Figure 5

Diabetes attributable costs according to complication status (C0: no complications; C1: minor complications; C2: major complications) and gender.

The relative distribution of total attributable costs according to complication status and number of person‐years showed that 25% of patients with diabetes consumed nearly 60% of attributable costs (Fig. 6).

Figure 6.

Figure 6

Relative distribution of person years (a) and diabetes attributable costs (b) according to complication status (C0: no complications; C1: minor complications; C2: major complications).

Discussion

We found that patients with diabetes consumed approximately twice the healthcare resources consumed by people without diabetes. This is less than that documented in earlier studies 20, indicating that the population with diabetes is becoming less resource‐demanding in the healthcare sector per person‐year, probably as a result of improvements in prognosis 21, 22. Compared with the diabetes‐free population, patients with diabetes incurred their resource use earlier in life, while later in life they required more specialized care. When patients with diabetes developed complications, the healthcare and nursing costs increased markedly. Men in particular used fewer healthcare services before complications, whereas later they were more likely than women to progress to major complications with a need for specialized care. We show a marked increase in healthcare costs with increasing complications, even after controlling for relevant confounders. These findings correspond to those of other studies, which document major costs related to diabetes complications 23, 24. This highlights the cost‐saving potential of preventing complications among patients with diabetes and hence the importance of secondary prevention. Acknowledging that more people are living for longer with diabetes because of prognosis improvements, and that these epidemiological trends cannot be turned around in the short or medium term 21, 22, the importance of prevention of expensive complications is highlighted. We found that patients’ morbidity characteristics were the most important predictors of diabetes‐attributable costs. Interestingly, however, the multivariate analysis, showed significant cost differences according to region of residence, education level and year of death. This latter finding indicates that the high attributable costs for younger patients with diabetes might, to some degree, be attributable to death per se, irrespective of the cause of death. This methodological issue should be further investigated. Likewise, underlying associations between patients’ characteristics and their morbidity patterns are important to investigate further in order to target prevention and treatment efforts. These issues will be dealt with in future work.

Regarding pharmaceutical drug consumption, the greatest increase in costs was found to be between patients with no complications and those with minor complications. Clinically, this might be explained by patients with minor complications being heavily medicated to prevent progression to major complications. Gender differences point to women being more proactive in receiving pharmaceutical drugs earlier in their diabetes (with fewer complications) than men. Nursing costs were found to be concentrated among patients with major complications, corresponding to recent structural changes in Denmark with respect to nursing services being offered. Patients with diabetes were more costly than the diabetes‐free population, in particular with respect to visits by a home nurse. Results clearly show evidence for different labour market patterns among patients with diabetes compared with the control subjects, and increasing loss in productivity among patients with diabetes was seen with an increase in complication levels. When controlling for education level, it was evident that the main extent of the income disparities could not be accounted for by the fact that the diabetes incidence was higher among people with lower income. We therefore expect the difference to be attributable to the influence of the ability of the person with diabetes to work, thus resulting in a lower annual income. Even though diabetes mainly affects older people in society, looking at patient volume, we show major costs to society as well as to the individual in relation to productivity.

The exclusion of patients registered in the Danish National Diabetes Register solely because of frequent blood glucose measurements (63,647 person‐years) 12 resulted in a reduction in patients with no complications. Total attributable costs were decreased by 9% (to 3.9 billion EUR), but attributable cost per person‐year increased. We conclude therefore that estimates for patients with no complications might be underestimated.

The chosen approach with a 1‐year time window has its limitations, but it allowed a descriptive analysis of the population in this year 25. It would be advantageous to include more years to facilitate analysis of trends over time. Our data did not allow a distinction between Type 1 and Type 2 diabetes, which would be advantageous taking the different aetiology into consideration. Our findings across age groups indicate high attributable costs among children and teenagers, reflecting that the diabetes‐free population in these age groups consumes markedly less healthcare, nursing services and pharmaceutical drugs.

Categorizing patients according to their development of complications; i.e. no complications, minor complications and major complications, is a novel method within this field. We aimed to contribute to this field with an easily understandable outline of the cost pattern for a very complex disease, providing decision‐makers with the necessary guidance for future investments in diabetes.

The presented cost distributions by component and by complication status are presumably not only valid in a Danish setting but could be transferred to other countries and chronic diseases.

Based on all available data in Danish national health registers for all patients with diabetes in 2011, the costs attributable to diabetes were estimated to be at least 4.27 billion EUR, corresponding to 14,349 EUR per person‐year. We show a steep increase in attributable costs for patients with major complications compared with patients without complications across all cost components, also when potential confounders are controlled for. Our results underline the universal message of cost increases with increased complications, providing an economic rationale for secondary prevention.

Evidence of cost distributions within diabetes can guide future efforts in specific sectors, or targeted patient groups, based on expected cost savings.

Funding sources

This study was conducted by the Institute of Applied Economics and Health Research in cooperation with the Danish Diabetes Association and supported by a PhD programme from Centre of Health Economics Research, funded by The Danish Centre for Strategic Research in Type 2 Diabetes, DD2. A consortium of sponsors, from the pharmaceutical industry comprising Astra Zeneca/BMS, Novo Nordisk, Merck, Sanofi Aventis and Bayer, provided an unrestricted grant to the Institute of Applied Economics and Health Research for the conduct of this research. Neither the Danish Diabetes Association nor the consortium of sponsors from the pharmaceutical industry had any influence on the execution of the study

Competing interests

None declared.

Supporting information

Table S1. Grouping of diagnoses and interventions used for classifying hospital activities by complication status of relevance for diabetes, and with respect to diagnostic specificity for diabetes.

Table S2. Cost units and methods of calculation for cost components.

Table S3. Definition of variables included in the multivariate analysis

Table S4. Total diabetes‐attributable costs and attributable costs per person‐year for all diabetes patients, excluding patients included in the National Diabetes Register as a result of frequent blood glucose measurements.

Table S5. Distribution of person‐years by complication status and gender for all diabetes patients, excluding patients included in the National Diabetes Register as a result of frequent blood glucose measurements.

Table S6. Multivariate analysis of total healthcare costs (EUR per person‐year).

Table S7. Multivariate analysis of total attributable healthcare costs (EUR per person‐year).

Table S8. Multivariate analysis of total net pharmaceutical costs (EUR per year).

Table S9. Multivariate analysis of total costs for nursing in own home (EUR per year).

Figure S1 Absolute distribution of diabetes‐attributable costs by cost components.

Supplementary references.

Acknowledgements

This study was conducted on behalf of the Danish Diabetes Association and supported by a PhD program at Centre of Health Economics Research supported by the Danish Centre for Strategic Research in Type 2 Diabetes, DD2. We thank Mrs Sabrina I. Imeroski for editorial assistance.

Diabet. Med. 33, 877–885 (2016)

[The copyright line for this article was changed on 15 February 2016 after original online publication.]

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Table S1. Grouping of diagnoses and interventions used for classifying hospital activities by complication status of relevance for diabetes, and with respect to diagnostic specificity for diabetes.

Table S2. Cost units and methods of calculation for cost components.

Table S3. Definition of variables included in the multivariate analysis

Table S4. Total diabetes‐attributable costs and attributable costs per person‐year for all diabetes patients, excluding patients included in the National Diabetes Register as a result of frequent blood glucose measurements.

Table S5. Distribution of person‐years by complication status and gender for all diabetes patients, excluding patients included in the National Diabetes Register as a result of frequent blood glucose measurements.

Table S6. Multivariate analysis of total healthcare costs (EUR per person‐year).

Table S7. Multivariate analysis of total attributable healthcare costs (EUR per person‐year).

Table S8. Multivariate analysis of total net pharmaceutical costs (EUR per year).

Table S9. Multivariate analysis of total costs for nursing in own home (EUR per year).

Figure S1 Absolute distribution of diabetes‐attributable costs by cost components.

Supplementary references.


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