Complications due to diabetes have improved, while diagnosis rates and spending continue to grow

Compared to similar countries, the United States has higher rates of mortality for most of the leading causes of death, and generally performs worse on a variety of quality indicators. Diabetes and endocrine diseases are no exception. There has been a reduction in complications due to diabetes and improvement in disease management, but diagnosis rates and spending continue to grow.

Endocrine diseases occur when any of the eight major glands in the endocrine system produce too little or too much of a particular hormone. In the U.S., diabetes is the most common endocrine diseases. Diabetes is caused when the body is unable to create enough insulin to break down blood sugar. It is among the 10 leading causes of death in the U.S. and can cause serious health complications such as early mortality, blindness, kidney failure, lower-extremity amputations, and heart disease. There are three types of diabetes: type 1, type 2, and gestational diabetes. Type 2 diabetes is the most common and accounts for about 90%-95% of diagnosed diabetes in adults.

Mortality rates due to diabetes rose from 1990 to 2002, but have fallen again to the 1990 level.  In contrast, the average mortality rate due to diabetes across comparable countries (those with above median GDP and GDP per capita in at least one of the past 10 years) has fallen by about 16% over the period.

The age-adjusted diabetes diagnosis rates have increased about 55% from 4 per 100 population in 1997 to 6.2 in 2014. It is also important to note that the Centers for Disease Control and Prevention (CDC) estimate that about “1 of 4 people with diabetes are unaware they have diabetes” because they have not been diagnosed.

Another way to assess health outcomes is to look at disease burden, which encompasses both premature death and years lived with poor health or disability. Using a measure called Disability Adjusted Life Years (DALYs), the Institute for Health Metrics and Evaluation finds that disease burden due to diabetes and other endocrine diseases has increased about 15% between 1990 and 2013. The percentage of adults with diabetes reporting poor mental health, poor physical health, and inability to do usual activities has also increased from 1994 to 2011.

Diabetes Management and Complications

Diabetes management includes, among other things, healthy eating, exercise, monitoring blood glucose levels, periodic doctor visits, and adhering to prescribed medications. Proper management is important for reducing complications such as cardiovascular disease, amputations, and blindness due to diabetes. From 1994-2010, the percentage of adults receiving dilated eye exams and visiting a doctor annually for diabetes care have shown little improvement. Diabetics self-monitoring blood glucose daily has increased about 78% from 1994-2010. The rate of diabetes patients receiving an annual foot exam has increased about 40% over the same time period.

Since 1990, the age-standardized rates for diabetes complications have decreased 28% to 68% depending on the type of complication. Preventive health care and controlling risk factors are among the reasons for a decline in diabetes complications.

Hospital admissions for diabetes and diabetes complications can arise when prevention services are either not being delivered or adhered to. Hospital admission rates in the U.S. are higher than in comparable countries for complications due to diabetes. However, the U.S. has lower rates of hospitalization for uncontrolled diabetes than comparably wealthy countries do on average.

While the U.S. has not improved mortality and diagnosis rates for diabetes, there has been some reduction in hospitalization for complications due to diabetes.

The Cost of Treating Diabetes in the U.S.

Treatment of diabetes is expensive. Between 2010 and 2015, diabetes injectable prescription costs increased. Humulin, for example, experienced the largest price increase (380%), jumping from $15 to $72. Victoza increased 77% and NovoLog increased 125%. The monthly price of Glumetza tablets increased 500% between June 2014 and 2015. The price further increased 50% in July 2015.

In addition to high drug prices, people with a current or prior diagnosis of diabetes face higher average out-of-pocket costs than people without a diagnosis. Average out-of-pocket spending for people who had ever had a diabetes diagnosis was $1,259 in 2013, compared to an average of $661 who had never been diagnosed with diabetes. In 2012, the U.S. spent $138 billion on the treatment of diabetes and other endocrine diseases, according to estimates by the Bureau of Economic Analysis.  This represents nearly 7% of total medical services spending on disease treatment ($1.9 trillion). On a per capita basis, the U.S. spends about $440 per year to treat endocrine diseases (including diabetes), up from $192 in 2000.  This represents the total cost of treating endocrine diseases divided by the total population in the U.S.

A recent study found that patients with type 2 diabetes are more likely to adhere to prescribed medication when they have lower co-payments. As a result, their overall medical costs are lower. Patients with higher Medicare pharmacy costs were also more likely to be highly adherent to prescribed medication and had about one third of the overall medical expenses than patients with higher out-of-pocket-costs for prescriptions who were less adherent.