The Economic Costs of Type 2 Diabetes: A Global Systematic Review

Till Seuring, Olga Archangelidi, Marc Suhrcke, Till Seuring, Olga Archangelidi, Marc Suhrcke

Abstract

Background: There has been a widely documented and recognized increase in diabetes prevalence, not only in high-income countries (HICs) but also in low- and middle-income countries (LMICs), over recent decades. The economic burden associated with diabetes, especially in LMICs, is less clear.

Objective: We provide a systematic review of the global evidence on the costs of type 2 diabetes. Our review seeks to update and considerably expand the previous major review of the costs of diabetes by capturing the evidence on overall, direct and indirect costs of type 2 diabetes worldwide that has been published since 2001. In addition, we include a body of economic evidence that has hitherto been distinct from the cost-of-illness (COI) work, i.e. studies on the labour market impact of diabetes.

Methods: We searched PubMed, EMBASE, EconLit and IBSS (without language restrictions) for studies assessing the economic burden of type 2 diabetes published from January 2001 to October 2014. Costs reported in the included studies were converted to international dollars ($) adjusted for 2011 values. Alongside the narrative synthesis and methodological review of the studies, we conduct an exploratory linear regression analysis, examining the factors behind the considerable heterogeneity in existing cost estimates between and within countries.

Results: We identified 86 COI and 23 labour market studies. COI studies varied considerably both in methods and in cost estimates, with most studies not using a control group, though the use of either regression analysis or matching has increased. Direct costs were generally found to be higher than indirect costs. Direct costs ranged from $242 for a study on out-of-pocket expenditures in Mexico to $11,917 for a study on the cost of diabetes in the USA, while indirect costs ranged from $45 for Pakistan to $16,914 for the Bahamas. In LMICs-in stark contrast to HICs-a substantial part of the cost burden was attributed to patients via out-of-pocket treatment costs. Our regression analysis revealed that direct diabetes costs are closely and positively associated with a country's gross domestic product (GDP) per capita, and that the USA stood out as having particularly high costs, even after controlling for GDP per capita. Studies on the labour market impact of diabetes were almost exclusively confined to HICs and found strong adverse effects, particularly for male employment chances. Many of these studies also took into account the possible endogeneity of diabetes, which was not the case for COI studies.

Conclusions: The reviewed studies indicate a large economic burden of diabetes, most directly affecting patients in LMICs. The magnitude of the cost estimates differs considerably between and within countries, calling for the contextualization of the study results. Scope remains large for adding to the evidence base on labour market effects of diabetes in LMICs. Further, there is a need for future COI studies to incorporate more advanced statistical methods in their analysis to account for possible biases in the estimated costs.

Figures

Fig. 1
Fig. 1
PRISMA [5] flowchart. COI cost of illness, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Fig. 2
Fig. 2
Number of cost-of-illness studies, by costing approach and income group. For LMICs, no WTP study is counted, because the only study [91] presenting a WTP estimate for an LMIC used primarily a different approach to estimate costs, and the WTP estimate was only presented additionally. Therefore, this study was not counted under WTP here. Two studies are counted twice as they give estimates for a sum-diagnosis specific and a RB/matching approach. LMIC low- to middle-income country, RB regression based, WTP willingness to pay
Fig. 3
Fig. 3
GDP to direct costs ratio by estimation approach. The line depicts the best fit based on the linear regression of direct costs on GDP per capita in international dollars. Refer to Table 7 for country abbreviations. For better visibility, the y-axis presenting per capita direct costs is expressed in log scale. GDP gross domestic product
Fig. 4
Fig. 4
Direct and indirect cost relation in studies estimating total costs of type 2 diabetes. The 45° line depicts the points where direct and indirect costs would be equal. Above the line, direct costs are higher than indirect costs and vice versa. For better visibility, both coordinate axes are expressed in log scale. Refer to Table 7 for country abbreviations

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