How has diabetes care in the U.S. changed over time?


This collection of charts and a related brief explore trends in health outcomes, quality of care, and treatment costs for people with diabetes and related endocrine disorders. 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 disease. 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 has been a reduction in complications due to diabetes and improvement in disease management, but diagnosis rates and spending continue to grow.

Diabetes is among the 10 leading causes of death in the United States


Diabetes is an endocrine system disease 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 1 diabetes, formerly called juvenile diabetes, is usually diagnosed in children and young adults when the body does not produce insulin. There is no way to prevent type 1 diabetes, and proper management includes daily injections of insulin and monitoring blood glucose levels. Gestational diabetes occurs when there is not enough insulin created to support the pregnancy and happens in about 9.2% of pregnancies according to an analysis by the Centers for Disease Control and Prevention. A diagnosis of gestational diabetes can create complications for both mother and child. Type 2 diabetes is the most common and accounts for about 90%-95% of diagnosed diabetes in adults. It occurs when the body does not use insulin properly causing blood glucose levels to rise.

The mortality rate for diabetes in the U.S. rose between 1990-2002 but has been declining since 2003


The U.S. has higher mortality rates due to diabetes than the average comparable country.  The mortality rate in the U.S. rose nearly 23% between 1990 and 2002 and then decreased about 19% between 2002 and 2010. The average comparable country reduced mortality by about 16% between 1990 and 2010.

Crude and age-adjusted rates of diagnosed diabetes have been steadily increasing


The crude and age-adjusted diagnosis rates have increased about 84% and 55% respectively from 1997 to 2014. Crude rates are influenced by the age distribution in a given population making them useful for targeted community interventions to decrease diabetes diagnosis. Age-adjusting rates ensures the annual trends can be attributed to actual changes in diabetes incidence instead of changes in age distribution. 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.

Diagnosed diabetes has been increasing among people ages 45-74


Diabetes diagnosis rates are highest among people ages 45-64 and 65-74 and have increased by about 58% and 50% respectively from 1997 to 2014. The likelihood of developing and being diagnosed with type 2 diabetes does increase with age, but while the rates are much lower, there has also been a 50% increase in diagnosis among people aged 0-44 in the same time period.

Blacks and Hispanics have higher than average rates of diagnosed diabetes


Diagnosis rates are increasing more rapidly among Whites and Asians, but blacks and Hispanics continue to have higher than average rates of diagnosed diabetes. From 1997-2014 diagnosis increased among blacks, and Hispanics by 32% and 45% respectively, compared to 65% for Whites and 72% for Asians.

U.S. disease burden for endocrine diseases has increased nearly 15% in the past 2 decades


Aside from mortality and diagnosis rates, another way to measure the effect diabetes has on health is to look at the burden of disease, which takes into account both years of life lost due to premature death as well as years of productive life lost to poor health or disability. Using a measure called Disability Adjusted Life Years (DALYs), the Institute for Health Metrics and Evaluation finds that endocrine diseases (including diabetes) are the sixth leading cause of disease burden in the U.S. Endocrine diseases occur when any of the eight major glands found in the body produce too little or too much of a particular hormone. In the U.S., diabetes is the most common endocrine disease. For a given population, DALYs are calculated by summing the Years of Life Lost (YLL) prematurely and the Years Lived with Disability (YLD, which are weighted). 

For each of the disease categories with improvements in age-standardized DALYs, the improvement has come primarily from a reduction in the years of life lost (as opposed to a reduction in the year lived with disability). The 15% increase for endocrine diseases falls within the confidence intervals for the DALYs rate in 1990.

Adults with diabetes have increasingly reported poor mental and physical health


Health related quality of life measures the number of days during a 30 day period that a person felt poor mental or physical health or an inability to perform usual activities. The percentage of adults with diabetes reporting poor mental health, poor physical health, and an inability to do usual activities has increased from 1994-2011. In a similar time period, adults with diabetes experienced a larger increase in the percentage of adults experiencing poor mental health and an inability to do usual activities than the general population.

Rates of diabetes complications in the U.S. have decreased significantly from 1990-2010


Since 1990, the age-standardized rates of diabetes complications has dropped anywhere between 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.

The U.S. hospitalization rate for uncontrolled diabetes is lower than in comparable countries, and higher for diabetes complications


Hospital admissions for diabetes can arise when prevention services are either not being delivered or adhered to. Uncontrolled diabetes occurs when there is a hospital admission for type 1 or 2 diabetes without any mention of short or long term complications. Admission for diabetes complications occurs when the patient with type 1 or 2 diabetes has long or short term diabetes complications such as amputation, cardiovascular disease, and blindness. 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.

Hospitalization for diabetic ketoacidosis is highest among those aged 0-44


Diabetic Ketoacidosis (DKA) is an acute, life-threatening condition caused by very high blood glucose levels. It occurs most often in patients with type 1 diabetes which is why it occurs in diabetics ages 0-44 at much higher rates, but patients with type 2 diabetes are also at risk if experiencing other complications such as infections, trauma, and cardiovascular issues. Hospitalization for DKA is highest among people ages 0-44, but has decreased about 39% from 1988-2009.

Average length of stay of hospital discharges with diabetes or diabetic ketoacidosis has been decreasing


The average length of hospital stays in the U.S. has decreased about 32% from 1988 to 2009. The average length of stay for people discharged from the hospital for diabetes or diabetic ketoacidosis (very high blood sugar) has decreased 39% and 40% respectively from 1988-2009. The decrease may be associated with a decrease in hospitalization and improved disease management.

Death rates for hyperglycemic crises have decreased among all age groups


Hyperglycemic crisis is caused by chronically high blood glucose levels and can lead to complications such as, stroke, heart attack, amputation, and kidney disease. It most often occurs in patients with type 1 diabetes, but patients with type 2 diabetes are also at risk if experiencing other complications or specific risk factors. Mortality rates due to hyperglycemic crisis have been decreased among all age groups from 1980 to 2009. Diabetics ages 75 and older experienced the largest decrease in mortality (89%), and those ages 65-74 decreased mortality about 87%. Treatment of hyperglycemic crisis has improved, but hyperglycemic crisis is underreported on death certificates which may contribute to the decline in reported mortality rates. One study of ICD-10 codes found that having multiple comorbidities was associated with exclusion of diabetes as a cause of death on a death certificate. This might explain a portion of the sharp decrease in hyperglycemic death rates in people ages 75+ since they are more likely to have additional comorbidities such as cancer and cardiovascular disease.

End-stage renal disease related to diabetes is highest among black men and women


End-stage renal disease (ESRD) signifies that the kidneys are barely or no longer functioning after about 10-20 years of chronic kidney disease. Without dialysis or a kidney transplant, ESRD leads to death.  ESRD related to diabetes is about 170% higher in black men than in White men and about 131% higher in black women than in White women. Hispanic men and women also experience ESRD at a disproportionately higher percentage, 60% and 56% respectively.

Foot and leg amputations due to diabetes are decreasing in the U.S. and comparable countries


Lower extremity amputations due to diabetes happen when large blood vessels are affected by hyperglycemia and impact blood circulation to the point of requiring amputation of lower extremities. Lower extremity amputations are higher in the U.S. than in comparable countries, however the U.S. is making significant progress as the rate of such amputations has decreased by 54% between 2006 and 2010.

More men than women with diabetes report using diabetes medication


Diabetes management includes, but is not limited to healthy eating, exercise, and monitoring blood glucose levels. Properly managing diabetes helps prevent complications that can lead to disability and sometimes death. Another piece of diabetes management is using proper medication and adhering to medications as prescribed. In 2011, about 85% of all adults diagnosed with diabetes reported use of diabetes medication. While men and women have similar rates of diabetes diagnosis, men have typically reported using diabetes medication more frequently than women.

Some diabetes injectable prescription costs have increased between 77% and 380% from 2010 – 2015


Medi-Span collects prescription drug pricing data to be used as a reference pricing index. It is an average of prices manufacturers provide to Medi-Span. According to Medi-Span, between 2010 and 2015, diabetes injectable prescription costs increased. Humulin 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% in one year


Medi-Span reports that the monthly price of Glumetza increased 500% between June 2014 and 2015. The price further increased 50% in July 2015.

Diabetic Medicare patients who are less adherent to prescribed medication have higher medical spending


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 highly adherent and had about a third of the overall medical expenses than patients with higher out-of-pocket-costs for prescriptions who were less adherent. 

Endocrine diseases, including diabetes, are a leading driver of medical services spending growth from 2000-2012


Diabetes accounted for 8.5% of medical services spending growth from 2000-2012. Treatments for ill-defined conditions, musculoskeletal disorders (which include back problems and arthritis) and circulatory diseases were the three largest contributors to overall health services spending growth over the 2000 – 2012 period.

Spending on endocrine diseases accounts for more than 7% of disease based health expenditures


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 more than 7% of total medical services spending on disease treatment ($1.9 trillion). The top five disease-based spending categories (ill-defined conditions, circulatory, musculoskeletal, respiratory, endocrine, and nervous system conditions) account for roughly half (51%) of all medical services spending by disease category.

On a per capita basis, the U.S. spends about $440 per year to treat endocrine diseases, up from $192 in 2000


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. 

Diagnosis with a serious or chronic health condition is associated with higher spending


People with a current or prior diagnosis of diabetes have higher spending on average than people without a diabetes diagnosis. Average health spending (including insurer claims and out-of-pocket costs) for people who had ever had a diabetes diagnosis was $12,913 in 2013, compared to an average of $4,349 who had never been diagnosed with diabetes.

People with a diagnosis of a serious or chronic health condition face higher average out-of-pocket costs


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.