Research Proposal: Nursing Interventions to Decrease complications of Diabetes
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journal of
health global
The cost of diabetes in Latin America and the Caribbean in 2015: Evidence for decision and policy makers
Alberto Barcelo1, Armando Arredondo2, Amparo Gordillo–Tobar3, Johanna Segovia1, Anthony Qiang4
1 University of Miami, Miller School of Medicine, Miami, Florida, USA
2 National Institute of Public Health, Cuernavaca, Mexico
3 World Bank, Washington D.C., USA 4 McMaster University, Hamilton, Canada
Correspondence to: Armando Arredondo National Institute of Public Health Av. Universidad 655 Cuernavaca, México Phone–Fax: 0052777 3293062 Email: armando.arredondo@insp.mx
Background The financial implications of the increase in the prev- alence of diabetes in middle–income countries represents one of the main challenges to health system financing and to the society as a whole. The objective of this study was to estimate the econom- ic cost of diabetes in Latin America and the Caribbean (LAC) in 2015.
Methods The study used a prevalence–based approach to estimate the direct and indirect costs related to diabetes in 29 LAC countries in 2015. Direct costs included health care expenditures such as medications (insulin and oral hypoglycemic agents), tests, consul- tations, hospitalizations, emergency visits and treating complica- tions. Two different scenarios (S1 and S2) were used to analyze di- rect cost. S1 assumed conservative estimates while S2 assumed broader coverage of medication and services. Indirect costs includ- ed lost resources due to premature mortality, temporary and per- manent disabilities.
Results In 2015 over 41 million adults (20 years of age and more) were estimated to have Diabetes Mellitus in LAC. The total indirect cost attributed to Diabetes was US$57.1 billion, of which US$ 27.5 billion was due to premature mortality, US$16.2 billion to perma- nent disability, and US$ 13.3 billion to temporary disability. The total direct cost was estimated between US$ 45 and US$ 66 billion, of which the highest estimated cost was due to treatment of com- plications (US$ 1 616 to US$ 26 billion). Other estimates indicated the cost of insulin between US$ 6 and US$ 11 billion; oral medica- tion US$ 4 to US$ 6 billion; consultations between US$ 5 and US$ 6 billion; hospitalization US$ 10 billion; emergency visits US$ 1 billion; test and laboratory exams between US$ 1 and US$ 3 mil- lion. The total cost of diabetes in 2015 in LAC was estimated to be between US$ 102 and US$ 123 billion. On average, the annual cost of treating one case of diabetes mellitus (DM) in LAC was estimat- ed between US$ 1088 and US$ 1818. Per capita National Health Expenditures averaged US$ 1061 in LAC.
Conclusions Diabetes represented a major economic burden to the countries of Latin America and the Caribbean in 2015. The esti- mates presented here are key information for decision–making that can be used in the formulation of policies and programs to achieve greater efficiency and effectiveness in the use of resources for dia- betes prevention in the 29 countries of LAC.
Electronic supplementary material: The online version of this article contains supplementary material.
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The cost of diabetes mellitus (DM) was estimated at US$ 65 billion in 2000 in Latin America and the Ca- ribbean (LAC) [1]. This burden was attributed to lost productivity due to mortality and disability, as well as direct medical costs caused by treating diabetes and its long–term complications.
The financial implications of the increase in the prevalence of diabetes in middle–income countries, rep- resents one of the main challenges to be solved by health systems and society as a whole. DM is one of the top global public health concerns because of the increased morbidity and mortality among affected individuals. An estimated 415 million people suffer from diabetes globally in 2015 and this number is expected to reach the 642 million mark by 2040 [2]. This will increase direct health expenses as well as premature deaths and disability to unprecedented levels unless effective preventive and control strategies are implemented.
DM presents a global public health challenge, particularly among middle and low–income countries, where 80% of those with the disease live. Diabetes management is complex because it demands continu- ous care involving many services, tests, and medications, owing to the detrimental effect of chronic hy- perglycemia on organs and tissues.
According to the 2012 World Health Organization (WHO) National Capacity Survey for Non Commu- nicable Diseases (NCD) Prevention and Control, 95% of countries in the Americas reported having DM policies or action plans. However, the capacity to prevent and control diabetes may be limited. In fact, only one third of the countries reported having operational evidence–based guidelines or protocols [3]. Population–based surveys and clinical series from many of the countries of LAC indicated that most peo- ple with diagnosed DM do not achieve treatment goals [4–9], increasing the risk of premature mortality and disabilities.
The objective of this study was to estimate the economic cost of diabetes in LAC in 2015. This study in- tends to update a previous estimate of the cost of diabetes in LAC for 2000 [1].
METHODS
This study used a prevalence–based approach that includes direct and indirect costs caused by diabetes. Adult (20 and more years of age) diabetes prevalence data for 2015 were used to estimate the direct and indirect costs related to diabetes in 29 LAC countries (Latin America: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Uruguay and Venezuela; English Caribbean: Bahamas, Barbados, Belize, Grenada, Guyana, Jamaica, Saint Lucia, Suriname and Trinidad & Tobago). Estimates included people with both type 1 and type 2 diabetes. The protocol for this project was reviewed and ap- proved by the Committee on Health Research of the National Council of Science and Technology of Mex- ico. Patient records information was anonymized and de–identified prior to analysis.
Data
Direct costs included insulin and oral hypoglycemic agents, consultations, A1c tests, lipid profiles, micro albuminuria test, hospitalizations, emergency visits and treating complications. A “bottom–up” approach was used for direct cost estimation.
Indirect costs included lost resources due to mortality, as well as temporary and permanent disabilities. These were estimated using the human capital approach, which applies the present value of future earn- ings to estimate the burden of mortality and disability [10].
LAC demographic data for 2015 [11] were combined with prevalence data for 2015 from the Interna- tional Diabetes Federation (IDF) to estimate the population with diabetes by age and gender for each country. Countries were classified using the World Bank GDP per capita classification [12] in low–income countries (US$ 1035 or less), lower middle–income countries (US$ 1036 to US$ 4085), upper middle– income countries (US$ 4086 to US$ 12 615), and high–income countries (US$ 12 616 or more) [13]. The most recent National Health Expenditures (NHE) for each country were obtained from the Pan American Health Organization (PAHO) basic data indicators [14]. NHE for Puerto Rico was not available.
Five sources of original country data were used to produce estimates:
1. Commercial prices reported to the NCD Management National Capacity survey for chronic diseases in LAC [15] were obtained for tests, medications, and medical services. Prices were updated in 2015 by
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contacting health professionals and diabetes associations in each country. The PAHO database contains prices for insulin, oral medication, testing and services for 26 out of the 29 countries [15]. When a specific price for one country was not available we used an average price for countries of the same sub region (English Caribbean, Central or South America). The price list is available in Online Supple- mentary Document.
2. The Sentinel Surveillance (ViCen) questionnaire was completed for a random sample of 1 899 patients in clinics in six countries (Bolivia, Chile, El Salvador, Guatemala, Honduras and Nicaragua). This sur- vey explored health care utilization along with the presence of DM and diabetes–related long–term complications. The ViCen questionnaire was produced by PAHO in collaboration with the IDF and was used in previous research in Brazil [16,17].
3. A clinical record database of 51 795 patients from Chile was used to calculate the prevalence of chron- ic complications (retinopathy, nephropathy, cardiovascular disease, neuropathy and peripheral vascu- lar disease) [18]. This database was also used to produce estimates of permanent disability by age and sex adjusted by diabetes duration.
4. A database from the National Institute of Public Health (NIPH) in Mexico was used to estimate the cost of cases with and without long–term diabetes complications. The NIPH database provided an estima- tion of how much higher was the cost of cases with each long–term diabetes complication as compared to treating cases without complications [19].
5. The Barbados Eye Study (BES) is a cohort study funded by the National Eye Institute. It is a nation- ally representative cohort of 4709 Barbados–born citizens, ages 40 to 84 years and selected by simple random sampling. BES used Relative Risk Ratios (RR), based on the hazard ratios estimated from the Cox Proportional Hazard Model. RR was calculated comparing mortality for people with and without diabetes by age and gender using 9–year follow–up data (1997–2002) [20].
Direct costs
Two analyses were conducted separately to calculate direct cost. These analyses are identified as Scenario 1 (S1) and Scenario 2 (S2). S1 and S2 differ in estimations for the use of medication and the cost increase related to treatment of diabetes chronic complications. S1 contains conservative estimates while S2 as- sumes broader coverage of medication and services. Assumptions for S1 and S2 are described below. A sensitivity analysis was conducted to compare results of the cost for S1 and S2.
Medication
Insulin. The annual total cost of insulin (TCI) for the 29 LAC countries was estimated as follows:
TCI = NIU × CI × IC (1)
where NIU is the number of insulin users, CI is the cost of insulin per unit in each country, and IC is the number of insulin unit consumption per year.
Patterns of insulin use might be different in each country. Population based research indicated that among people with diabetes insulin use ranged from 2% in Chile [4] and 29% in Costa RicaRica [7]. Due to the paucity of information regarding the heterogeneity in the use of insulin use, we estimated two different proportion of insulin use: 10% (S1) and 20% (S2) of the diabetes population of each country.
Insulin consumption was assumed at 10 000 IU per person per year, as previously used by Phillips and Salmeron [21] and used in our previous analysis also [1]. The commercial cost of insulin in each country was taken from the PAHO database price list [15].
Oral hypoglycemic agents. The annual total cost of oral medications (TCO) for the 29 countries studied was estimated as follows.
TCO = NOU × CO × OC (2)
where NOU is the number of oral medication users, CO is the cost of oral medications (metformin) in each country extracted from the PAHO database, and OC is the estimated number of pills consumed per person each year.
The proportion of people taking oral medication varies from 90% in Cuba [22] to 50% in Belize [7]. As the proportion of people with diabetes taking oral medication might vary among countries two different
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assumptions were applied. We assumed that 50% or 80% of people with diabetes were taking oral med- ication for S1 and S2, respectively. The per capita consumption of metformin each year was estimated at 1 500 tablets. Prices of Metformin 800 mg were taken from the PAHO database [15].
Consultations and hospitalizations
The total number of consultations and hospitalizations in the general population of each country was ob- tained from the PAHO basic indicator database [14]. These consultations and hospitalizations were con- sidered to be due to general causes not related to diabetes.
The ViCen survey showed that people with diabetes made 3.5 times more medical visits and had 7 times more hospitalizations than people without diabetes [16]. In addition, the ViCen study showed that length of stay for those with diabetes was 1.9 days longer than those without diabetes [16]. The numbers of medical visits and hospitalization per inhabitants in each country were multiplied by factors of 2.55 and 6, respectively, which represented the excess number of visits and hospitalizations due to diabetes [6,7]. The estimated number of people with diabetes was then multiplied by these products. In the case of hos- pitalizations, we obtained the total number of hospital days by multiplying the number by the average of length of stay in each country reported to the PAHO basic indicator database [14], and then increased by the fraction of 0.9 which was the excess number of days attributed to diabetes reported by patients to the ViCen study [16]. The costs of consultations and per–day hospitalization were obtained from PAHO’s price list [15]. The cost of services, procedures or treatment was not included due to the paucity in coun- try–specific data.
The annual total cost of consultations (TCC) was estimated as follows:
TCC = [(NC × CC) × COC] × DM (4)
where NC is the number of consultations per year, CC is the average cost of a general medicine consulta- tion in each country, COC is the average cost of a consultation with an ophthalmologist in each country, and DM is the number of people under care. It was assumed that, across the region, 55% of those with DM were treated by a health care providers.
The annual total cost of hospitalizations (TCH) was estimated as follows:
TCH = NH × LH × CH × DM (5)
where NH is the annual number of hospitalizations, LH is the length of stay, CH is the average cost of a hospitalization, and DM is the number of those with diabetes who were at risk of being hospitalized. It was assumed that the total number of those with DM was at risk of being hospitalized.
The costs of hospitalizations related to DM and for general causes were calculated separately. Only the excess cost attributed to DM was included in the direct cost calculation. The cost of one day hospital stay was taken from the PAHO’s price list [15]. This cost does not include any service or procedure. This cost is assumed to be conservative since it is well known that most cases of diabetes would require specific services and specialized care which are usually more expensive.
The average cost of a general and ophthalmologist medical visit per country was taken from the PAHO database [15].
The cost of medical visits related to DM and for general causes were calculated separately; only the excess cost estimated for those consultations attributed to DM was included in the direct cost calculation. The cost of consultation to a general practitioner in each country was taken from PAHO’s price list [15] and was used as a proxy for all DM medical consultations because country specific prices for specialist visits (except for ophthalmologist) were not available. This cost does not include any additional procedures, it includes only a consultation with a physician.
Testing
The annual total cost of examinations (TCE) for the 29 countries was estimated as follows:
TCE = (A1c × Lipid + EKG + Rx + Protein) × DM (3)
where A1c is the cost of a glycated hemoglobin test, Lipid is the cost of a lipid profile, EKG is the cost of an electrocardiogram, Rx is the cost of a chest x–ray, protein is the cost of a urine protein test, and DM is the total population with diabetes.
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It was assumed that each person with DM was tested once a year with lipid profile, one electrocardio- gram, one chest x–ray, and one urine protein test. The number of A1c test was assumed to be 1 per year for S1 and 3 per year for S2.
Emergency visits
The annual total cost of emergency visits (TCEV) was estimated as follows:
TCEV = NEC × CEV × DM (6)
where NEC is the average annual number of emergency visits, CEV is the average cost of an emergency visit in each country taken from the PAHO price list, and DM is the total number of people with diabetes in each country.
The ViCent survey showed that those with diabetes made 1.4 emergency visit per year while those with- out diabetes reported 0.9 visits per year [16]. The estimated number of people with diabetes was multi- plied by 1.4 to estimate the number of emergency visit. The cost of an emergency department visit in each country was obtained from the PAHO’s price list [15].
The emergency cost does not include the cost of any procedure, it includes only the cost of being seen by a physician in an emergency department. The cost of emergency visits due to general causes was dis- counted. Only emergency visits attributed to diabetes (0.5 per person per year) were included.
Complications
This study included the cost of the following complications: cardiovascular disease, nephropathy, neu- ropathy, peripheral vascular disease and retinopathy. It also included the costs of dialysis, hemodialysis, photocoagulation and treating foot–related problems.
Three steps were used to estimate the cost of complications. First, the weighted probability of major com- plications from the Chilean QUALIDIAB [18] database were applied to the diabetes population to obtain the number of persons with each complication per country. Second, we estimated the cost of regular care for uncomplicated cases of DM for each country. We made different assumptions for regular care for S1 and S2. Population based surveys showed wide variation in the proportion of cases of diabetes under care in different countries. Therefore, we made different assumptions for the two scenarios. For S1 regular care for uncomplicated cases one visit to an ophthalmologist, one A1c, one lipid profile, one urine protein test, one electrocardiogram and one chest x–ray for 55% of the population with diabetes. This was a conserva- tive estimate that was based on protocols available in some of the participating countries. For S2 regular care for uncomplicated cases included one visit to an ophthalmologist, three A1c, one lipid profile, one urine protein test, one electrocardiogram and one chest x–ray for 85% of the population with diabetes.
Available data from Chile [1], Brazil [17], and Mexico [19] showed that the ratio of expenditure per per- son with diabetes and chronic complications to persons with diabetes without complications was vari- able. Because of the heterogeneity of health care provision and medical costs across countries, for each complication a lower (S1) and higher (S2) ratio was used to produce two separate estimates. Among the three sources, we selected the lowest estimated cost ratio (S1) and an average of the other two estimates (S2). The ratio used for these calculations were retinopathy 1.09 and 1.86; neuropathy 1.08 and 1.58; Peripheral Vascular Disease 1.06 and 1.81; Cardiovascular Disease 1.23 and 1.86; and Nephropathy 1.76 and 2.96 for S1 and S2 respectively.
Third, we applied the excess of cost of treating (consultations, medications and other procedures) for each complication as per S1 and S2 cost ratio using the cost estimates for uncomplicated cases in each coun- try as per previous calculation.
The total cost of consultations for retinopathy (TCCR) was estimated as follows:
TCCR = [(NCR × CC) + COC] × DM × PVR (7)
where TCCR is the annual cost of consultations for those with diabetes retinopathy, NCR is the number of consultations per person with DM–related retinopathy, and PVR is the prevalence of retinopathy.
The total cost of consultations for other (TCCO) DM–related complications was estimated as follows:
TCCO = iI
[(NCC i × CC) + COC] × DM × PV
i (8)
where TCCO is the annual cost of consultations for those with DM and long–term complications other than retinopathy, NCC is the number of consultations per person with a DM–related complication other
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than retinopathy, PV is the prevalence of the complication, and i represents the four complications stud- ied, excluding retinopathy.
The total cost of consultations for complications (TCCC) of those with DM–related complications was estimated as follows:
TCCC = TCCR + TCCO (9).
The total cost of hospitalizations related to complication (TCHC) was estimated as follows:
TCHC = iI
NHC i × LHC
i × CH × DM × PV
i (10)
where TCHC is the annual cost of hospitalizations for those with DM–related complications, NHC is the number of hospitalizations by person with DM–related complications, LHC is the length of a patient’s hospital stay, CH is the average cost of a hospitalization per person, PV is the prevalence of complications, and i is the set of complications studied.
The used age–weighted probability for each long–term complication was 1.09 for retinopathy, 1.23 for CVD, 2.35 for nephropathy, 1.08 for neuropathy, and 3.35 for PVD [18].
Indirect costs
Mortality costs
Mortality costs were estimated by multiplying the number of DM–related deaths by age range and gender by the number of years of productive life lost (YPLL) for each age by the country GDP per capita. A three percent discount was applied.
The number of DM–related deaths was calculated by multiplying the number of deaths for all causes, by the population attributable–fraction (PAF), which was estimated as follows:
PAF = P(RR–1)/1 + [P(RR–1)] (11)
where P is the prevalence of DM and RR is the relative risk of death from the disease.
The Barbados Eye Study (BES) is a cohort study that includes RR obtained from the Barbados Eye Study, which contained information from a cohort of people with diabetes. The RR used were Men 40–49 = 3.4 (1.2–9.3); 50–59 = 2.0 (1.0–3.7); 60–64 = 3.2 (2.2–4.7) and Women 40–49 = 2.8 (1.2–6.4); 50–59 = 4.4 (2.4–8.3); 60–64 = 2.3 (1.1–1.9) (19). YPLL were included for individuals dying between the ages of 40 and 64 years. Only deaths estimated to occur between the ages of 40 and 79 years of age were included. YPLL between the ages of 40 and 64 years of ages were calculated since the age of retiring was assumed to be 65 years of age. 95%–Confidence intervals were calculated by applying lower and higher estimates for the OR of original BES data [19].
Disability costs
Permanent disability. The total proportion of people with disability was estimated at 4.2% of the total target population. After discounting cases considered to be related to general causes, we estimated that 3.2% of the target population was disable due to diabetes. Estimates for other diseases and diabetes re- lated disability by age and gender were obtained by applying research results from Gomez de Moura et al [23] to Brazil’s national statistics [24]. The probability of diabetes related disability by age and gender was applied to the Chilean database and adjusted throughout a logistic regression by diabetes duration and the presence of chronic diabetes complications that would prevent people to remain in the workforce. These complications were blindness, amputations, strokes and infarction. The age–and–gender specific estimates were multiplied by the number of people with diabetes by age and gender to obtain the num- ber of disabled due to diabetes. We used these estimates to calculate the number of discounted years of productive life lost (YPLL) before the age of 65 years. Only one year of income lost per person was in- cluded. GNP per capita for each country was used as a proxy for lost productivity in 2015. The cost of permanent disability was estimated by multiplying the per capita GNP by the number of YPLL.
Temporary disability. Only absenteeism was included as cost of temporary disability. The lack of infor- mation on other aspects of temporary disability such as bed days due to illness or care takers and others were not included. Temporary disability costs were calculated by multiplying the number of economi- cally active people with DM by age and gender between the ages of 20 and 64 years, by the number of days lost due to disability by national annual GDP per capita (divided by 365) as a proxy of potential in-
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come per day. The number of people that were economically active in each country was calculated by discounting the unemployed as per data published by the World Bank [12]. The number of lost produc- tive days was calculated with data from the ViCen survey [16]. The estimated number of lost days for general causes not related to DM was subtracted from the total lost days. Thus, the number of lost days included were only the excess number attributed to DM.
All costs estimates are presented in 2015 US dollars (US$).
95%–CI for permanent/ temporary disability as well for indirect cost, were calculated by using bootstrap analysis with 1000 replications of age–and–gender specific estimates.
All analysis were performed using SPSS 24 (IBM Analytics, Armonk, New York, USA) and Stata 12 (Stata- Corp, College Station, Texas, USA).
RESULTS
Over 41 million people were estimated to have DM throughout LAC in 2015. From the total in LAC of those with DM, approximately 97% lived in Latin America (Central–South America, Mexico and the Span- ish Caribbean) and 2% in the English Caribbean. Overall, among components of indirect cost, US$ 27.5 billion was attributed to diabetes related premature mortality, US$ 16.2 billion to permanent disability, and US$ 13.3 billion to temporary disability. The total indirect cost was US$ 57.2 (US$ 54.9–60.4) bil- lion (Table 1).
Table 2 presents estimates of the cost of medication as well as exams and consultations for scenario 1 (S1) and scenario 2 (S2). Overall 4 to 6 million people with diabetes were estimated to use insulin with an estimated cost between US$ 6.9 to US$ 11.6 billion. The number of oral medication users was esti- mated between 19.7 and 33.5 million with an estimated cost of US$ 11 to US$ 18 million. The total cost of medication was estimated to be between US$ 11 to US$ 18 million. This shows how sensitive is direct cost to coverage, in particular the number of insulin or oral medication users.
The total number of hospitalization (Table 3) was 36 746 from which more than 18 thousand were esti- mated to be attributed to diabetes causing a burden of more than US$ 10 billion. The estimated number of emergency visit was more than 95 thousand with an estimated cost of more than US$ 1 billion.
Table 1. Data on those with diabetes mellitus (DM) and estimated indirect costs in Latin America and the Caribbean, 2015
Item LatIn amerIca engLIsh carIbbean totaL Populations 20–79 (×103) 315 188 2598 317 786
Total No. of people with diabetes (×103) 41 022 554 41 576
Mortality:
No. of deaths 1 364 376 22 137 1 386 513
Deaths related to diabetes (40–64 years) 313 205 4897 318 102
YPLL 2 044 418 30 214 2 074 633
Cost (US$×106) 27 280 305 27 585
95% CI (US$×106) 8 066–47 905 90–570 8157–48 475
Permanent disability:
Total No. of people with permanent disability 1 389 057 17 407 1 406 464
YPLL due to DM 1 016 571 26 557 1 043 128
Cost in 1 year (US$×106) 15 863 342 16 205
95% CI (US$×106) 15 115–16 702 316–517 15 450–17 037
Temporary disability:
Estimated DM employed population (20–64) 31 463 016 409 686 31 872 702
No. of days missed of work general causes 665 563 904 8 306 850 673 870 754
No. of days missed of work due to DM 309 631 903 3 864 491 313 496 394
YPLL 847 567 10 588 858 154
Cost (US$×106) 13 212 179 13 391
95% CI (US$×106) 12 773–13 735 170–191 12 944–13 906
Indirect cost (US$×106) 56 355 826 57 181
95% CI (US$×106) 54 045–59 565 799–992 54 881–60 411
YPLL – years of productive life lost; CI – confidence interval
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More than 4 million people with diabetes were estimat- ed to have retinopathy and cardiovascular diseases re- spectively, while more than 3 million were estimated to have neuropathy and more than 2 million were estimat- ed to suffer from nephropathy or peripheral vascular dis- ease, respectively (Table 4).
Treating chronic complications caused an estimated bur- den between US$ 16.2 and US$ 26.5 billion for S1 and S2 respectively. Cardiovascular disease was the costliest complication with an estimated burden between US$ 5.6 and US$ 8.2 billion followed by retinopathy (US$ 3.5 to US$ 6.4 billion), nephropathy (US$ 2.9 to US$ 4.6 bil- lion), neuropathy (US$ 2.1 to US$ 3.7 billion) and pe- ripheral vascular disease (US$ 2 to US$ 3.4 billion) (Ta- ble 5).
Among countries of LAC (Table 6) the highest direct cost was estimated for Brazil (between US$ 17.5–US$ 23.8 billion); while the lowest was estimated for Grena- da (between US$ 4.0–US$ 6.6 billion). The highest per capita cost was estimated for Puerto Rico, US$ 2764– 4949 and the lowest for Peru US$ 445–821 (S2).
On average, the annual cost of treating one case was be- tween US$ 1088 and US$ 1818. Countries of LAC ex-
pended in health an average of US$ 1063, with the highest among reported by Cuba (US$ 2280) and the lowest by Guyana (US$ 361). On average, NHE were notably lower among low income countries (US$ 508 per capita) and the highest among higher income countries (US$ 1063). Average expending on dia- betes was close to average NHE for S1 and notably higher for S2. On average, among lower–middle in- come countries, NHE (US$ 508) was notably lower than the per capita cost of care for people with dia- betes assuming either S1 (US$ 1014) or S2 (US$ 1832)
Table 2. Direct cost of diabetes mellitus (DM) by in Latin America and the Caribbean (LAC) sub–region, 2015
Item LatIn amerIca engLIsh carIbbean totaL S1 S2 S1 S2 S1 S2
Medication:
No. of insulin users (×103) 3869 6550 184 364 4054 6915
No. of oral medication users (×103) 18 851 32 046 898 1 527 19 749 33 573
Cost of insulin (US$×106) 6671 10971 324 640 6995 11611
Cost of oral medication (US$×106) 3811 6479 218 370 4029 6849
Total cost of medication (US$×106) 10 482 17 450 542 1 010 11 024 18 460
Cost of exams (US$×106) 1252 2584 128 274 1380 2859
Consultations:
Total no. consultations (×103) 266 169 321 546 13 538 15 605 279 708 337 151
DM related causes (×103) 101 523 156 899 3 789 5 856 105 312 162 755
Cost DM related causes (US$×106) 4872 6536 196 270 5068 6806
Table 3. Cost of hospitalizations and emergency visit among those with diabetes in Latin America and the Caribbean in 2015
Item LatIn amerIca engLIsh carIbbean totaL Total No. of hospitalization (×103) 34 747 1998 36 746
Diabetes–related causes (×103) 17 462 832 18 294
Total days 135 834 7 843 143 677
No. days (DM related causes) 66 691 3177 69 868
Cost DM related (US$×106) 10 025 309 10 334
No. emergency visits 91 277 4349 95 626
Cost (US$×106) 1036 22 1059
DM – diabetes mellitus
Table 4. Estimated number (×103) of people with diabetes and chronic complications in Latin America and the Caribbean, 2015
compLIcatIons LatIn amerIca
engLIsh carIbbean
totaL
No. person with retinopathy 4671 223 4894
No. person with cardiovascular disease 4496 214 4711
No. person with nephropathy 2306 110 2416
No. person with neuropathy 3421 163 3584
No. person with peripheral vascular disease 2254 107 2362
Table 5. The cost (US$×106) of diabetes complications in Latin America and the Caribbean, 2015
cost LatIn amerIca engLIsh carIbbean totaL S1 S2 S1 S2 S1 S2
Cost of retinopathy 3345 6097 166 347 3511 6444
Cost of cardiovascular disease 5435 7870 235 396 5670 8266
Cost of nephropathy 2755 4434 147 258 2902 4692
Cost of neuropathy 2028 3560 107 208 2134 3768
Cost of peripheral vascular disease 1949 3686 90 1891 2040 3418
Total cost of complications 15 511 25 204 746 1 384 16 257 26 588
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The total cost of diabetes in LAC was estimated to be between US$ 103 and US$ 124 billion in 2015. The highest cost was estimated for Brazil between US$ 37 and US$ 43 billion while the lowest cost was esti- mated for Grenada between US$ 39 and US$ 42 million (Table 7).
Table 8 presents a summary of detailed explanations of all components, sources of the data, estimations and the corresponding cost result.
DISCUSSION
The estimated number of people with DM in countries of LAC soared from 15 million in 2000 to 41 mil- lion in 2015, – a 2.7–fold increase in 15 years. In 2015, the economic burden of diabetes was estimated to be between US$ 103 and US$ 124 billion, which represents a 6 to 7–fold increase in the total cost, 4 to 6–fold increase in direct medical, as well as a 8–fold increase in indirect costs compared to the previ- ously estimated costs for 2000 [1].
Data presented here tends to be conservative and may underestimate the real cost of diabetes. This anal- ysis included the best information available, however, there is a lack of information on the cost of proce-
Table 6. Total and per capita direct cost of diabetes mellitus (DM) and national health expenditures by country and GDP group, Latin America and the Caribbean, 2015
Lower–mIddLe Income natIonaL heaLth expendItures (us$)
s1 (Lower) s2 (hIgher) Direct costs (US$×106)
Per capita costs (US$)
Direct costs (US$×106)
Per capita costs (US$)
Bolivia 420 263.4 677 483.8 1244
El Salvador 565 353.2 1084 665.0 2040
Guatemala 462 1054.3 1385 1943.1 2552
Guyana 361 26.9 540 44.9 901
Honduras 428 464.4 1388 855.9 2559
Nicaragua 445 301.1 1091 512.0 1856
Paraguay 874 301.8 931 542.0 1673
Sub–total 508† 2765.1 1014† 5046.7 1832†
Upper–middle income:
Argentina 862 1741.1 1010 3026.3 1756
Belize 487 20.9 728 32.5 1133
Brazil 1318 17 492.5 1227 23 825.7 1672
Colombia 962 2928.3 961 5367.5 1761
Costa Rica 1390 292.1 1047 521.6 1870
Cuba 2280 562.4 551 937.7 919
Dominican Republic 581 317.2 627 470.6 930
Ecuador 1042 1144.8 1379 1753.1 2112
Grenada 758 4.0 580 6.6 957
Jamaica 476 311.7 1538 509.3 2513
Mexico 1091 10 659.1 930 14 246.8 1243
Panama 1678 361.7 1568 605.8 2627
Peru 656 560.7 455 1010.7 821
Saint Lucia 721 8.3 625 13.9 1044
Suriname 947 26.2 625 41.9 1001
Venezuela 950 1773.6 831 2865.3 1343
Sub–total 1012† 38 204.6 918† 55 235.3 1481†
Higher–income:
Bahamas 1818 48.5 1345 2021
Barbados 1198 31.7 928 50.8 1487
Chile 1717 1354.9 987 2054.2 1496
Puerto Rico* 1009.1 2764 1806.6 4949
Trinidad & Tobago 1822 190.2 1356 289.4 2063
Uruguay 1792 97.4 618 129.4 821
Sub–total 1669† 2731.8 1333† 4403.3 2140
Total 1063† 43 701.5 1088† 64 685.3 1818†
* National Health Expenditures (NHE) figure for Puerto Rico was not available.
†Average.
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Table 7. Direct, indirect and total cost of diabetes mellitus (DM) by country and GDP, Latin America and the Caribbean, 2015
Lower–mIddLe Income: IndIrect costs (us$×106)
s1 (Lower) s2 (hIgher) Direct costs (US$×106)
Total costs (US$×106)
Direct costs (US$×106)
Total costs (US$×106)
Bolivia 358 264 622 485 843
El Salvador 245 355 601 667 912
Guatemala 523 1059 1582 1948 2471
Guyana 44 28 72 46 90
Honduras 180 467 648 859 1039
Nicaragua 110 307 417 518 628
Paraguay 229 305 534 546 774
Sub–total 1690 2786 4476 5068 6757
Upper–middle income:
Argentina 1740 1771 3511 3057 4796
Belize 21 22 42 33 54
Brazil 19 052 18 271 37 323 24 605 43 656
Colombia 2805 3087 5892 5527 8331
Costa Rica 286 298 584 527 814
Cuba 1590 581 2170 956 2545
Dominican Republic 464 328 792 481 946
Ecuador 742 1187 1929 1795 2537
Grenada 35 4 39 7 42
Jamaica 239 328 567 526 765
Mexico 17 240 10 835 28 075 14 423 31 663
Panama 344 364 708 608 952
Peru 1209 571 1780 1021 2230
Saint Lucia 11 9 20 14 26
Suriname 51 27 78 43 94
Venezuela 6062 1800 7862 2891 8953
Sub–total 51 890 39 483 91 373 56 514 108 404
Higher–income:
Bahamas 70 50 120 75 145
Barbados 40 33 73 52 92
Chile 2224 1430 3654 2129 4353
Puerto Rico 440 1035 1475 1832 2272
Trinidad & Tobago 315 199 514 298 613
Uruguay 512 105 617 137 649
Sub–total 3601 2852 6453 4523 8125
Total 57 181 45 121 102 302 66 105 123 286
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dures and services. Therefore, these costs were not included in the amount attributed to consultations, emergency visits, hospitalizations or visits to ophthalmologists. On the other hand the frequency of test- ing and consultations, may vary widely among countries. The cost of medications and care might have variations depending on purchasing capacity and government policies. Because of that, two different sce- narios were prepared. For S1 and S2, lower and higher coverage for medication, testing and service as well as cost for treating diabetes complications respectively were assumed. These different estimates re- sulted in very different direct cost estimates for scenario 1 and scenario 2. Keeping constant indirect costs, the observed variation of the total cost of diabetes reflects the sensitivity to different assumption for each component such as medication and care for complications. Scenario 2 is 31 percent costlier than scenar- io 1. Sensitivity is also clearly related to the cost of medication. For example If all other cost assumptions are kept as established for S1 and S2, and the cost of insulin is reduced to US$ 4.20 per vial, it would re- sult in cutting direct cost in 50% and the per capita cost of diabetes care by 35% (data not shown).
The proportion of direct and indirect cost was 44% and 56% for S2 and 54% and 46% for S1 respective- ly. These variations are driven by the difference in access to care and the cost of complications assumed for S1 and S2. These results are consistent with previous research, for example, an African study calcu- lated direct medical cost at 43% and indirect cost at 56% [25] similar to our proportion in S1; while the ADA estimates indicated a higher proportion of direct cost at 72% and lower proportion of indirect cost
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Table 8. The cost of diabetes in Latin American and the Caribbean in 2015
IndIrect cost source cost (us$) Number of people with DM
41 576 396. Estimated by the Diabetes Atlas
Permanent disability Number of persons with diabetes with permanent disability: 1 043 128. Estimated by multiplying the eco- nomically active diabetes population in each country by the proportion of people with permanent disabil- ity by age and gender. These proportions were calculated by estimating the proportion of people receiving benefits due to diabetes by age and gender in Brazil, adjusted by diabetes duration and the prevalence of chronic disabling diabetes complication in the Chilean database (those with amputations, Chronic Kidney Disease (CKD), blindness, cerebrovascular disease and infarctions), approximate 33.5% of the total popula- tion with diabetes.
Cost calculated by multiplying years lost to disability by annual country GNP per capita. Cost of permanent disability in one year.
16 204 846 613
Temporary disability The estimated number of person with diabetes in the labor force was estimated by discounting the unem- ployed (according to each country unemployment rate published by the World Bank) among those in work- ing ages (20–64 y of age): 31 872 702. Number of sick days related to diabetes 10.5 days per person per year as per results of the ViCen survey.
Number of years lost due sick days: 858 154. Cost calculated by multiplying years of productivity lost by GNP per capita.
13 391 123 563
Mortality Estimated number of all causes deaths: 1 386 513.
Calculated by the Population Attributable Fraction using OR obtained from the BES study.
Estimated number of deaths among those with diabetes: 318 102 (173 532–461 789).
Estimated number of years lost due to premature mortality: 2 074 633. Years lost before age 65 y with a 3% discount rate. Cost calculated by multiplying years lost to premature mortality in each country by annual GNP per capita.
27 585 053 690
Indirect cost total 57 181 023 866
Direct cost
Insulin Scenario 1: Proportion of people with diabetes using insulin: 10%.
Insulin consumption per year: 10 000 units per person
Number of insulin users: 4 053 699. Cost of insulin in each country obtained from the PAHO database. 66 995 221 314
Scenario 2: Proportion of people with diabetes using insulin: 20%.
Insulin consumption per year: 10 000 units per person
Number of insulin users: 6 914 458. Cost of insulin in each country obtained from the PAHO database. 11 611 301 234
Oral medication Scenario 1: Oral medication consumption per year: 1500 tablets of Metformin. Users 50% of the diabetes population
Oral medication users: 19 748 788. Cost of metformin in each country obtained from the PAHO database. 44 028 574 000
Scenario 2: Oral medication consumption per year: 1500 tablets of Metformin. Users 80% of the diabetes population
Oral medication users: 33 572 940. Cost of metformin in each country obtained from the PAHO database. 6 848 575 800
Consultations Scenario 1: Estimated that 50% of people were followed by health services.
Estimated number of consultations related to DM per year for people with diabetes: 105 312 278. Number of consultations per inhabitant from PAHO’s basic indicators. The ViCen survey indicated that people with diabetes had 3.5 more visits than those without diabetes. Visit for general causes were subtracted. The num- ber of consultations due to diabetes was multiplied by the estimated number of people with diabetes in each country. The cost of consultations per country was obtained from the PAHO database.
5 067 964 481
Scenario 2: Estimated that 85% of people were followed by health services. Estimated number of consulta- tions related to DM per year for people with diabetes: 162 755. Number of consultations per inhabitant from PAHO’s basic indicators. The ViCen survey indicated that people with diabetes had 3.5 more visits than those without diabetes. Visit for general causes were subtracted. The number of consultations due to diabe- tes was multiplied by the estimated number of people with diabetes in each country. The cost of consulta- tions per country was obtained from the PAHO database.
6 805 773 280
Hospitalizations Scenario 1–2: Total number of DM hospitalizations per year for people with diabetes: 18 293 614. The Vi- Cen survey indicated that people with diabetes were hospitalized 7 times and hospital stay was 1.9 d longer than those without diabetes. Number of hospital discharges per inhabitant for the general population from the PAHO basic indicator database was used to estimate the excess hospital days due to diabetes in each country. Cost of one hospital day in each country obtained from the PAHO database.
10 333 828 105
Emergency visits Scenario 1–2: Total number of DM emergency visit per year for people with diabetes: 95 625 710; estimated number of diabetes related emergency visits 95 626. The ViCen survey indicated that people with diabetes had 1.4 more emergency visit than those without diabetes.
Number of emergency visits per inhabitant for the general population from the PAHO basic indicator data- base was used to estimate the excess emergency visits due to diabetes in each country. Only visits assumed to be related to diabetes were included in cost calculation. Cost of an emergency visit in each country ob- tained from the PAHO database.
11 058 606 746
Test and laboratory exams
Scenario 1: Includes the cost of one A1c, one lipid profile, one albuminuria test, one EKG, and one X Ray for 50% of the diabetes population of each country. Cost of items in each country obtained from the PAHO database.
1 379 772 482
Scenario 2: Includes the cost of three A1c, one lipid profile, one albuminuria test, one EKG, and one X Ray for 50% of the diabetes population of each country. Cost of items in each country obtained from the PAHO database.
2 858 452 553
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at 28% [26] because of the well–known high cost of many medical services and procedures in the Unit- ed States. The Brazilian study estimated the direct and indirect cost at 63% and 37%, respectively [17]. But the difference in the proportion of direct and indirect cost can be also due to the inclusion of differ- ent items in the study, real differences in the cost of procedures and medications, as well as differences in access to care.
On average, health care cost was estimated at US$ 1088–1819 per capita with wide ranges from US$ 4979 (S2) in Puerto Rico to US$ 540 (S1) in Guyana. The ADA [26] study estimated the per capita cost of diabetes at US$ 7900 [21] in the US, which was much higher than the cost reported in this study for LAC. In Africa, this figure varied from US$ 2144.3 to US$ 11 431.6 depending on the country’s Gross National Income [25]. Interestingly, there were substantial differences in the items included in the North American, African and this current LAC study. The ADA [26] and the African [25] studies both included diabetes supplies, in addition the ADA [26] study included home care; those items were not included in the present study.
Our results for per capita direct cost was consistent to previous research in the region such as those pub- lished for Brazil [17], Argentina [27], and the South–Central America (SACA) Region [27]. The Brazilian study estimated the direct per capita cost to be US$ 1334 [17], which is close to the US$ 1227–1 672 we estimated for Brazilian persons with diabetes. The Argentine study [27] estimated the quarterly direct per capita cost of DM in a social security institution at US$ 904.60 and US$ 1841.80 Argentine pesos for DM cases with and without chronic complications, respectively. These figures translate into US$ 1796.82 (without chronic complications) and US$ 2037.89 (with chronic complications) per year. These estima- tions are closed to estimations reported in this study for Argentina (US$ 1010–1773) [27]. De Rocha Fer- nandes et al. [28] calculated health care cost for the IDF–SACA region between US$ 1155 and US$ 2024 for 2014, which overlap to our results for the same region of IDF at US$ 1136–1711 (data not shown).
A big gap was observed between NHE and the cost of diabetes care especially among lower income coun- tries. This gap, as suggested by Arredondo et al [29] in Mexico, may result in out of pocket expenses in some cases [25] or the avoidance of necessary services because of economic constrains in others.
The total economic burden of diabetes among countries is highly driven by the size of the population, baring higher cost for countries with bigger population size such as Brazil, Mexico and Argentina. Per capita direct cost however, depends more on national prices of goods and services. Some of them have proven to be highly variable. The best example is the price of a vial of insulin, which price varied from US$ 78 in Puerto Rico to US$ 1.25 in Cuba (average price US$ 20). The Pan American Health Organiza- tion Strategy Fund (PAHO–SF) offers high quality medicine at affordable prices to countries of the Amer- icas [30]. For example, a vial of 100 ml of high quality insulin is offered by PAHO–SF at US$ 4.20 to Member States. Running our analysis replacing country specific prices for insulin and oral medication with PAHO–SF’s prices (plus 15%) in our data, resulted in cutting direct cost in 50% and the per capita cost of diabetes care by 35% (data not shown).
Table 8. Continued
IndIrect cost source cost (us$) Excess cost of complications
Scenario 1: The age–and–gender weighted probability of diabetes complications (cardiovascular disease 0.11, nephropathy 0.06, neuropathy 0.09, peripheral vascular disease 0.06 and retinopathy 0.12) was ob- tained from the Chilean QUALIDIAB database. The excess cost of each diabetes complication was applied to the cost of uncomplicated cases following results from the Mexican NIH database (excess cost of compli- cations: neuropathy 1.08; peripheral vascular disease 11.06; cardiovascular disease 1.23; nephropathy 11.76; retinopathy 1.09)
16 256 804 668
Scenario 2: The age–and–gender weighted probability of diabetes complications (cardiovascular disease 0.11, nephropathy 0.06, neuropathy 0.09, peripheral vascular disease 0.06 and retinopathy 0.12) was ob- tained from the Chilean QUALIDIAB database. The excess cost of each diabetes complication was applied to the cost of uncomplicated cases following results from the Mexican NIH database (excess cost of compli- cations: neuropathy 1.58; peripheral vascular disease 1.81; cardiovascular disease 1.86; nephropathy 2.96; retinopathy 1.86)
26 587 999 416
Direct cost total Scenario 1 45 120 771 799
Scenario 2 66 104 537 136
Total Cost of DM Scenario 1 102 301 795 665
Scenario 2 123 285 561 002
DM – diabetes mellitus, y – year
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Acknowledgements: The following individuals contributed with country–based data: Maltie Algoe, Dr Arias, Raul Aviles, Noël Barengo, Adelina Barrantes, Aracely Basurto Calderon, Gilda Benitez, Oscar Boggio, Imperia Brajkovich, Felicia Cańete, Roberto del Aguila, Eizabeth Duarte, Felix Escańo, Tomiris Estepan, Manodj Hin- dori, Nestor Alberto Huiman, Fadlo Fraige filho, Sebastian Laspiur, Olga Graciela López Mena, Esha Marhé, Enrique Medina Sandino, Viginia Molina, Carlos Olimpo Mendivil, Eduardo Palacios, Oris Ruiz, Gerardo So- lano, Maria Suniaga, Emilce Herrera, Josue Hernandez.
Funding: None.
Authorship declaration: AB, AG and AA researched data and wrote and edited the manuscript. AB, AA, JS and AQ researched data, performed statistical analysis, and wrote and edited the manuscript. AB, AA, AG, JS and AQ researched data and reviewed and edited the manuscript.
Competing interests: The authors have completed the Unified Competing Interest form at www.icmje.org/ coi_disclosure.pdf (available on request from the corresponding author) and declare no conflict of interest.
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Prevalence estimates in this paper are based on epidemiological studies on the frequency of DM prepared for the Diabetes Atlas [2]. It was assumed that 55% (S1) or 85% (S2) of the total number of cases received care; however, this proportion may vary widely from country to country. Furthermore, the proportion of cases receiving treatment may vary according to access to care, patient’s educational level, and the capac- ity of the health system.
Major limitations of this study include the lack of information on many issues which were replaced by assumptions that in many cases cannot be confirmed. That is the case of the proportion of cases receiv- ing services, the prevalence of diabetes chronic complications (approximations are based on one local study), and the proportion of people with permanent or temporary disability. In every case the best in- formation available was used to generate estimates for the missing information. The results of this study were consistent when compared, as discussed previously, to small number of research reports available in the medical literature on the subject from Argentina [27], Brazil [17] and the SACA Region [28]. It is, however, suggested that these results be considered with caution, since inaccuracy may occur when mak- ing similar assumption for many countries with different health and financial systems. All cost compo- nents were adjusted to the age–and–sex population estimates for each country, except for the proportion of cases receiving treatment or under care. The latest was not possible because of the lack of information on these issues. Finally, we used in our estimates commercial prices for services and medication for each country. This was done so because prices for government provided goods and services were not available in every country. It may be possible that these services and medications are available at lower subsidized prices in some of the countries. Prices of medication and services for each country depended on informa- tion provided by a wide variety of collaborators including government officials, member of diabetes or professional associations, health providers and other volunteers. Biases introduced by the observers could not be controlled in any possible way.
While providing comparable estimates of the cost of diabetes among countries, this paper alerts public health officials of the growing burden of DM in LAC. It provides arguments to reinforce needs to strength- en public policies that promotes health and diabetes prevention, such as those that discourage the con- sumption of junk food or sugary drinks and promote physical activity; as well as those focused on in- creasing access to diabetes care and supplies.
DM represents a major public health problem in LAC. Middle and low–income countries face a major challenge that not only affects their health system organization and financing, but also their economic growth. Buying medication from PAHO–SF instead of paying market prices may reduce the burden that diabetes care represents to countries and individuals. As the prevalence of DM is expected to increase in the near future, so will its toll on individuals, families and society as a whole.
CONCLUSIONS
The high economic burden of diabetes showed here has strong implications for the health systems and the economic grow of the nations of LAC. This burden is related to direct medical care but also to indi- rect cost caused by loss of productivity due to premature death and disability. Multi–sector public poli- cies could contribute to curve this treat on the long term.
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