In industrialized countries, about a quarter of the medical expenditures for diabetes is spent for the control of elevated blood sugar. Another quarter goes to treat long-term complications (largely cardiovascular disease), and half is consumed by the additional general medical care that accompanies diabetes and diabetic complications, including intensified efforts to prevent cardiovascular and microvascular complications 1 . In these countries, persons with major complications of diabetes incur much higher medical care expenditures than persons without major complications 2 3 4 5 . For example, published estimates of expenditures for diabetic foot ulceration not requiring amputation range from USD993 to USD30,724 (1998 USD) 10 . Expenditures for ulceration requiring amputation are even higher, USD16,488 to USD60,215 (1998 USD) 10 . Total expenditures of diabetic foot ulceration and amputation totalled USD10.9 billion in 2001 10 6 . Due to amounts like these, in the USA, acute hospitalization consumes 44% of diabetes-attributable expenditures, followed by outpatient care (22%), drugs and supplies (19%), and nursing home care (15%) 7 . Similar proportions are reported from other high-income countries such as Finland 11 .
In middle-income countries, a higher proportion of expenditures — half — goes for blood sugar control, which is essential for the prevention of acute life-threatening hyperglycaemia. The remainder is split between general medical care and chronic complications 8 . In Latin America and the Caribbean, anti-hyperglycaemic drugs alone are believed to account for about half of all spending 8 . In Bangladesh, even among patients with diabetes sampled from a tertiary diabetes care hospital, 52% of annual medical care expenditures were consumed by drugs 12 . These data confirm anecdotal reports from IDF member associations indicating that most persons in these countries do not receive a great deal of medical care once complications appear, and many may not survive acute hyperglycaemic crises to develop longer term sequellae.
It is significant to note that diabetes increases medical care expenditures even before it is diagnosed. Researchers in the USA found that persons destined to have diabetes incurred an extra USD1,205 per year (1993 USD) during the eight years preceding diagnosis 13 . In 2004 dollars, this adds up to USD14,896 over all eight pre-diagnosis years. Increased utilization before diagnosis has also been reported from the United Kingdom 9 .
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