A systematic review of the economic burden of diabetes mellitus: contrasting perspectives from high and low middle-income countries

Figures & data

Figure 1. PRISMA diagram of systematic review on diabetes cost of illness.

Figure 2. Yearly review of publication data.

Figure 3. Geographical representation of Reviewed Data. *AUS: Australia. Other: No Specific region.

Figure 4. Different methods are used for the estimation of diabetes cost of illness. *SUM: Sum of all Medical costs, RB: Regression Bias, SDS: Sum diagnosis-specific, WTP: Willingness to pay.

Table 1. Cost components of patients reporting data average reporting data (USD).

	Country	Diabetes Type	Outpatient Per-Visit	Visits Per-Year	Medicine Per-Year	Inpatient Per-Year
LMICs	Nigeria (Suleiman and Festus (2015), Fadare et al. (2015))	T2DM	5.97	26.88	522.85	-
	Bangladesh (Afroz et al., (2019), Shetty et al., (2021))	T1DM, T2DM	-	24.00	195.00	-
	Iran (Davari et al., 2016, Javanbakht et al., 2011)	T2DM	56.94	85.05	225	551
	China (Bloom et al. (2014), Bao et al. (2017), Huang et al. (2016))	T2DM	-	-	255.95	215
	Ghana (Quaye et al. (2011), Amon and Aikins (2017))	-	-	-	-	-
HICs	No data was reported from patients.

Table 2. Average Reporting Data (USD) Outpatient Cost Components from records.

	Country	Diabetes type	Outpatient Per visit	Visits Per-year	Medicine Per-year	Inpatient Per-year
LMICs	Thailand (Chatterjee et al. (2011))	T1DM, T2DM	3.99	28	996	2651
	China (Dahal et al. (2022), Bloom et al. (2014))	T2DM	47	-	1764	2885
	Vietnam (Le et al. (2017))	-	-	-	292	1052
	Brazil (Bahia et al. (2019), Borges et al. (2014), Toscano et al. (2018))	T2DM	-	-	1036	1772
	Argentina (Elgart et al. (2014))	T2DM	22	-	239	1407
HICs	Canada (Anja and Laura (2017))	-	24	395	400	5500
	Germany (Ulrich et al. (2016))	T1DM, T2DM	11	545	220	4978
	Italy (Marcellusi et al. (2016))	T2DM	33	555	1278	4964
	USA (Bommer et al. (2017))	–	50	1000	7884	9581
	Finland (Arffman et al. (2020))	T2DM	22	550	417	3912

Table 3. Prevalence-based study direct expenses by estimation technique and financial status in USD.

	HICs				LMICs
	SAM	SDS	RB/M	Survey	SAM	SDS	RB/M	Survey
Min	620	720	1187	1895	240	232.5	465	645
Max	1930	2640	4750	4234	960	1550	3750	8755
N	4^a	3^a	3^a	3 ^a	2^a	4^a	7 ^a	6^a

* ^a= various countries are included, SAM = Sum all medical cost, SDS = Sum diagnostic specific, RB = Regression based, HICs = high income countries, LMICs = lower-middle income countries.

Figure 5. Annual cost/patient in high-income countries.

Figure 6. Annual cost/patient in lower-middle-income Countries.

Table 4. Per patient medication cost per annum.

Country	Settings	Diabetes Type	Annual Per Medication cost per patient in USD
			Analogue Insulin	NPH Insulin	Insulin	Metformin	Glibenclamide	Oral Medication	Antidiabetic	CVD medication
Argentina (Elgart et al. (2014))	HC	T2DM	–	398	655	102	115	226	519	–
Brazil (Bahia et al., 2019)	SC	T2DM	985	687	758	–	–	201	–	355
Mexico (Barquera et al., 2013)	SC	T2DM	–	544	945	–	–	287	–	–
China (Palmer et al. (2012), Bloom et al. (2014))	HC	T1DM, T2DM	–	–	240	72	141	–	–	240
Vietnam (Le et al. (2017))	SC	T2DM	–	–	91	–	–	380	–	–
India (Sathyanath et al. (2022), Todorova et al. (2012), Akari et al. (2013), Bloom et al. (2014))	SC	T2DM	–	–	18	–	–	–	4	27
USA (Bommer et al. (2017), Bommer et al. (2018), Association (2013))	HC	T1DM, T2DM	35	–	100	–	–	–	–	50
Germany (Sun et al. (2022), Ulrich et al. (2016), Köster et al. (2011))	HC	T1DM, T2DM	–	1501	1025	–	–	492	–	544
Iran (Javanbakht et al. (2011))	–	–	–	–	80	–	–	–	–	–
Canada (Anja and Laura (2017))	HC	T2DM	1589	–	1256	–	–	520	–	–
Italy (Bruno et al. (2012), Marcellusi et al. (2016))	SC	T1	–	–	147	–	–	–	–	–
Taiwan Chen et al. (2016)	HC	–	–	–	613	–	–	–	–	–

HC = Health Care, SC = Social Setting, T2DM = Type 2 Diabetes Mellitus, CVD = Cardiovascular Disease, NPH = Neutral Protamine Hagedorn

Appendix Table 1: Country coding for Data Evaluation.

Country	Country Code	Country2	Country Code 3	Country4	Country Code 5	Country6	Country Code 7
Ecuador	ECU	Brazil	BRA	France	FRA	8 Western	EUR
El Salvador	SLV	Canada	CAN	Germany Guatemala Guyana	DEU GTM GUY	Taiwan	TWN
35 Developing	LMIC	Chile	CHL	Haiti	HTI	Thailand	THA
Argentina	ARG	China	CHN	Honduras	HND	JAM countries	Jamaica
Australia	AUS	Colombia	COL	Hong Kong	HKG	Japan	JPN
Bahamas	BHS	Costa Rica	CRI	India	IND	Latin America and Caribbean	LAC
Barbados	BRB	Cuba	CUB	Iran, Islamic	IRN	Mexico	MEX
Belgium	BEL	Czech Republic	CZE	Ireland	IRL	The Netherlands	NLD
Bolivia	BOL	Denmark	DNK	Israel	ISR	Nicaragua	NIC
Norway	NOR	Switzerland	CHE	Italy	ITA	Nigeria	NGA
Pakistan	PAK	Dominican Republic	DOM	Serbia	SRB	Venezuela	VEN
Panama	PAN	Trinidad and Tobago	TTO	United Arab Emirates	UAE	United Kingdom	UK
Paraguay	PRY	USA	USA	WHO African Region	AFR	Spain	ESP
Peru	PER	Uruguay	URY	The Bahamas, Barbados,	CARICOM	Sudan	SDN
						Sweden	SWE

Appendix Table 2: Cost of Illness of Diabetes

Ref.	Horizon	Country	Sample size	Population	Perspective	Approach	LCU	Aggregate costs (mill. $)				Per capita costs
[35]	2002- 2003	35 LMIC	121051	General pop.	Patient	RB/M	$				3 at 50th percentile to 157 at 95th percentile	3.40 at 50th percentile to 178 at 95th percentile
[59]	NA	Various Arab countries	NA	General pop.	Healthc. system	SAM	US$				US$529j
[82]	2009- 2010	CHN	1232 (diabetes), 1201 (no diabetes)	General pop.	Healthc. system	RB/M	RMB				4135 (3.38 times greater than controls)	1136 (3.38 times greater than controls)
[57]	2008- 2035	CAN	147498 with diabetes	Four Alberta Health and Wellness databases	Healthc. system	SAM	CAD		5934 (2007); 20032 (2035)		4563	4023
[31]	2010	MEX	Whole pop.	Population demanding services at Mexican healthcare institutions for T2D	Societal	SAM	MXN	1066	470	596	4016	485	5090	610
[95]	NA	TWN	16094	Elderly with DM in Taiwan	Healthc. system	SAM	TWD		51		111982	6338
[55]	2007	USA	7514 with diabetes	US pop. with positive healthcare expenditures in survey	Healthc. system	SAM	USD				11167	11917
[89]	2005- 2010	FIN	1890 with T2D	People with T2D in two cities in Finland	Healthc. system	SDS	EUR				1038	1087
[43]	2009	POL	Whole pop	All Polish diabetes patients	Healthc. system	SDS	EUR	3396	1910	1486
[51]	2000- 2007	POL	320000 (2000) to 275000 (2007)	T2DM	Healthc. system	RB/M	EUR		17299 (2000), 25614 (2007)		2400 (2000), 2605 (2007)	3493 (2007), 3218 (2000)
[85]	2000- 2009	GHA	not given, only DM patients stated (30472)	T2DM	Healthc. system	RB/M	GHC		21230 (2000), 26226 (2009)		2779 (2000), 2611 (2009)	3471 (2000), 3261 (2009)
[56]	2006	ITA	311979	People with DM at 22 local health districts	Healthc. system	RB/M	EUR				2589	3296
[47]	2003- 2004	ITA	33792 (diabetes) and 863123 (no diabetes)	Turin pop.	Healthc. system	RB/M	EUR				2465 (3361 (diabetes), 896 (no diabetes)	3328 (4537 (diabetes), 1210 (no diabetes)
[94]	2005	USA	32052	American Indians in and around Phoenix, Arizona	Healthc. system	RB/M	USD				5542	6282
[3]	2009	IRN	4500	Diabetes patients from Tehran and Fars province	Societal	Survey	IRR	9611	5187	4420	8358592	2142	8578816	2199
[10]	2008	THI	475	Diabetes patients treated in district hospital	Societal	Survey	THB				17638	1082	10569	649
[63]	2015-2016	BAN	496	Diabetes Patient Bangladesh	Patient	Survey	TKK	314	283	31	283	31
[59]	2014	SAR	88	T1DM	Societal	Survey	SAR	27915			19852–32856
[49]	2011-12	IND	219	T2DM	Societal	Survey	INR	1347	1322	25
[39]	2009	THI	1035	T2DM	Societal	Survey	THB	1184	701	483
[40]	2009	GHN	588	T2DM	Societal	Survey	GHC	1132	1048	84
[71]		22 Countries	156 625	T2DM	Healthc. system	Survey	USD
[74]	2007 & 2011	2 countries	330	T2DM	Societal	Survey	USD	281(Solomon), 747(Nauru)
[76]	2006-2011	CHN	62 523	T2DM	Healthc. system		RMB	7996.11(Hospitalization) 41,875(Complication)
[75]		CHL	257	T2DM	Healthc. system		USD	182.61
[76]	2013	NIG	129	T2DM	Societal		NGN		1,096,668
[80]	2009-2010	BRZ	209	T2DM	Societal		BRZ	1851	1020	831
[70]	2011	ARG	774	T2DM	Healthc. system		USD	13930.9 Wo/C 20850 W/C	3143 Wo/C 6851 W/C	10787.9 Wo/C 13999.6 W/C
[77]	2011	IRN	2898	T2DM			IRR	155.8
[80]	2009-2011	CHN	5543	T2DM			RMB		2780
[67]		NIG	35	Diabetes patients in out-patient clinic in Nigeria	Patient	SDS	NGN				29366	662
[84]		FRA	1250300	General pop.	Societal	SAM	EUR	16547	1130	15416	597	904	8145	12330
[26]		BNG	35	Diabetes patients in out-patient clinic in Nigeria	Patient	SDS	TKK				29366	662
[85]		RUS	Whole pop.	General pop. using public healthcare institutions	Societal	SAM	RUB	532 (2005)	234 (2005)	297 (2005)	1467 (2005)	263 (2005)	1852 (2005)	331 (2005)
[84]		AFR	1223 with T2D	People with DM	Healthc. system	SAM	USD				7100 (undiscounted per year over 10 year period)	9072 (undiscounted per year over 10 year period)
[82]		VTM	517	People with DM in Veitnam	Societal	SDS	EUR				2560	4690	1844	3379
[83]		BRA	20757185 (in 1998), 21089859 (in 1999)	People with DM in National Health Insurance	Healthc. system	SDS	BRZ				62617 (1998), 60775 (1999)	3499 (1998), 3396 (1999)
[81]		GHA	311979	People with DM at 22 local health districts	Healthc. system	RB/M	GHC				2589	3296
[76]		IND	498	Diabetes patients in out-patient clinics in northern Taiwan	Societal	WTP	INR			4003			68118	4004
[73]		SUR	35	Diabetes patients in out-patient clinic	Patient	SDS	NGN				29366	662
[55]		GER	254100	General pop.	Societal	SAM	EUR	1410	509	901	14580	2003	25801	3545
[75]	2013	MYS	267300	General pop.	Societal	SAM	MYR	2830	1104	1727	873	4129	1366	6460

Suleiman, I. A., & Festus, J. A. (2015). Cost of illness among diabetes mellitus patients in Niger Delta, Nigeria. Journal of Pharmaceutical Health Services Research, 6(1), 53–60.

 Google Scholar

Fadare, J., Olamoyegun, M., & Gbadegesin, B. (2015). Medication adherence and direct treatment cost among diabetes patients attending a tertiary healthcare facility in Ogbomosho, Nigeria. Malawi Medical Journal, 27(2), 65–70. https://doi.org/10.4314/mmj.v27i2.7

 PubMed Web of Science ®Google Scholar

Afroz, A., et al. (2019). Type 2 diabetes mellitus in Bangladesh: A prevalence based cost-of-illness study. BMC Health Services Research, 19(1), 1–12. https://doi.org/10.1186/s12913-019-4440-3

 PubMed Web of Science ®Google Scholar

Shetty, A., et al. (2021). Health-related quality of life among people with type 2 diabetes mellitus–A multicentre study in Bangladesh. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 15(5), 102255. https://doi.org/10.1016/j.dsx.2021.102255

 PubMed Web of Science ®Google Scholar

Davari, M., Boroumand, Z., Amini, M., Aslani, A., & Hosseini, M., et al. (2016). The direct medical costs of outpatient cares of type 2 diabetes in Iran: A retrospective study. International Journal of Preventive Medicine, 7, 72. https://doi.org/10.4103/2008-7802.181758

 PubMedGoogle Scholar

Javanbakht, M., et al. (2011). Cost-of-illness analysis of type 2 diabetes mellitus in Iran. PLoS One, 6(10), e26864. https://doi.org/10.1371/journal.pone.0026864

 PubMed Web of Science ®Google Scholar

Bloom, D. E., et al. (2014). The macroeconomic impact of non-communicable diseases in China and India: Estimates, projections, and comparisons. The Journal of the Economics of Ageing, 4, 100–111. https://doi.org/10.1016/j.jeoa.2014.08.003

 Google Scholar

Bao, X., et al. (2017). Hospitalization costs and complications in hospitalized patients with type 2 diabetes mellitus in Beijing, China: 中国北京市 2 型糖尿病住院患者费用与并发症的关系分析. Journal of Diabetes, 9(4), 405–411. https://doi.org/10.1111/1753-0407.12428

 PubMed Web of Science ®Google Scholar

Huang, Y., et al. (2016). Economic burden in Chinese patients with diabetes mellitus using electronic insurance claims data. PloS One, 11(8), e0159297.

 PubMed Web of Science ®Google Scholar

Quaye, E., Akweongo, P., & Aikins, M. (2011). PDB33 cost of diabetes management to Cocoa clinics in Ghana. Value in Health, 14(7), A477. https://doi.org/10.1016/j.jval.2011.08.1336

 Web of Science ®Google Scholar

Amon, S. K., & Aikins, M. K. S. (2017). Economic burden of type 2 diabetes mellitus complications among patients in the eastern region of Ghana: A descriptive cross-sectional cost-of-illness study. Diabetes Manag, 7(5), 367–376.

 Google Scholar

Chatterjee, S., et al. (2011). Cost of diabetes and its complications in Thailand: A complete picture of economic burden. Health & Social Care in the Community, 19(3), 289–298. https://doi.org/10.1111/j.1365-2524.2010.00981.x

 PubMed Web of Science ®Google Scholar

Dahal, P. K., et al. (2022). Economic evaluation of health behavior interventions to prevent and manage Type 2 diabetes mellitus in Asia: A systematic review of randomized controlled trials. International Journal of Environmental Research and Public Health, 19(17), 10799. https://doi.org/10.3390/ijerph191710799

 PubMed Web of Science ®Google Scholar

Le, N. T. D., Dinh Pham, L., & Quang Vo, T. (2017). Type 2 diabetes in Vietnam: A cross-sectional, prevalence-based cost-of-illness study. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 10, 363–374. https://doi.org/10.2147/DMSO.S145152

 PubMed Web of Science ®Google Scholar

Bahia, L. R., et al. (2019). Economic burden of diabetes in Brazil in 2014. Diabetology & Metabolic Syndrome, 11(1), 1–9. https://doi.org/10.1186/s13098-019-0448-4

 PubMedGoogle Scholar

Borges, N. B., Ferraz, M. B., & Chacra, A. R. (2014). The cost of type 2 diabetes in Brazil: Evaluation of a diabetes care center in the city of São Paulo, Brazil. Diabetology & Metabolic Syndrome, 6(1), 1–10. https://doi.org/10.1186/1758-5996-6-122

 PubMedGoogle Scholar

Toscano, C. M., et al. (2018). Annual direct medical costs of diabetic foot disease in Brazil: A cost of illness study. International Journal of Environmental Research and Public Health, 15(1), 89. https://doi.org/10.3390/ijerph15010089

 PubMed Web of Science ®Google Scholar

Elgart, J. F., et al. (2014). Direct and indirect costs associated to type 2 diabetes and its complications measured in a social security institution of Argentina. International Journal of Public Health, 59(5), 851–857. https://doi.org/10.1007/s00038-014-0604-4

 PubMed Web of Science ®Google Scholar

Anja, B., & Laura, R. (2017). The cost of diabetes in Canada over 10 years: Applying attributable health care costs to a diabetes incidence prediction model. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice, 37(2), 49.

 PubMed Web of Science ®Google Scholar

Ulrich, S., et al. (2016). Cost burden of type 2 diabetes in Germany: Results from the population-based KORA studies. BMJ Open, 6(11), e012527. https://doi.org/10.1136/bmjopen-2016-012527

 PubMed Web of Science ®Google Scholar

Marcellusi, A., et al. (2016). The direct and indirect cost of diabetes in Italy: A prevalence probabilistic approach. The European Journal of Health Economics, 17(2), 139–147. https://doi.org/10.1007/s10198-014-0660-y

 PubMed Web of Science ®Google Scholar

Bommer, C., et al. (2017). The global economic burden of diabetes in adults aged 20–79 years: A cost-of-illness study. The Lancet Diabetes & Endocrinology, 5(6), 423–430. https://doi.org/10.1016/S2213-8587(17)30097-9

 PubMed Web of Science ®Google Scholar

Arffman, M., et al. (2020). FinDM database on diabetes in Finland.

 Google Scholar

Barquera, S., et al. (2013). Diabetes in Mexico: Cost and management of diabetes and its complications and challenges for health policy. Globalization and Health, 9(1), 1–9. https://doi.org/10.1186/1744-8603-9-3

 PubMedGoogle Scholar

Palmer, J., et al. (2012). PDB18 direct medical costs of diabetes mellitus in China: Annual cost of illness and long-term projections using a validated diabetes model. Value in Health, 15(7), A662. https://doi.org/10.1016/j.jval.2012.08.349

 Google Scholar

Sathyanath, S., Kundapur, R., Deepthi, R., Poojary, S. N., Rai, S., Modi, B., & Saxena, D. (2022). An economic evaluation of diabetes mellitus in India: A systematic review. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 16(11), 02641. https://doi.org/10.1016/j.dsx.2022.102641

 Web of Science ®Google Scholar

Todorova, L., et al. (2012). PDB21 direct medical costs of diabetes-related complications in India. Value in Health, 15(7), A662.

 Web of Science ®Google Scholar

Akari, S., Mateti, U. V., & Kunduru, B. R. (2013). Health-care cost of diabetes in South India: A cost of illness study. Journal of Research in Pharmacy Practice, 2(3), 114. https://doi.org/10.4103/2279-042X.122382

 PubMedGoogle Scholar

Bommer, C., et al. (2018). Global economic burden of diabetes in adults: Projections from 2015 to 2030. Diabetes Care, 41(5), 963–970. https://doi.org/10.2337/dc17-1962

 PubMed Web of Science ®Google Scholar

Association, A. D. (2013). Economic costs of diabetes in the US in 2012. Diabetes Care, 36(4), 1033–1046. https://doi.org/10.2337/dc12-2625

 PubMed Web of Science ®Google Scholar

Sun, H., et al. (2022). IDF diabetes atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Research and Clinical Practice, 183, 109119. https://doi.org/10.1016/j.diabres.2021.109119

 PubMed Web of Science ®Google Scholar

Köster, I., et al. (2011). Direct costs of diabetes mellitus in Germany–CoDiM 2000–2007. Experimental and Clinical Endocrinology & Diabetes, 119(06), 377–385. https://doi.org/10.1055/s-0030-1269847

 PubMedGoogle Scholar

Bruno, G., et al. (2012). Direct costs in diabetic and non diabetic people: The population-based Turin study, Italy. Nutrition, Metabolism and Cardiovascular Diseases, 22(8), 684–690. https://doi.org/10.1016/j.numecd.2011.04.007

 PubMed Web of Science ®Google Scholar

Chen, Y.-C., et al. (2016). Impact of pay-for-performance on mortality in diabetes patients in Taiwan: A population-based study. Medicine, 95(27), e4197. https://doi.org/10.1097/MD.0000000000004197

 PubMed Web of Science ®Google Scholar