Assessing the Effect of Including Social Costs in Economic Evaluations of Diabetes-Related Interventions: A Systematic Review

Figures & data

Figure 1 PRISMA flowchart of the search strategy.

Table 1 Descriptive Information on the Selected Studies (n = 47)

First Author & Publication Year	Diabetes Type	Intervention Type	Country and Currency	Discount Rate (Costs/Outcomes)	Time Horizon	Costs Included	Method Used for Calculating Social Costs
Broekhuizen (2018)^Citation32	Gestational diabetes mellitus	Health education or behaviour	United Kingdom, Ireland, Austria, Poland, Italy, Spain, Denmark, Belgium, and the Netherlands (2012€)	n.a./n.a.	48 weeks	Healthcare costs: primary and secondary healthcare, medication, travel costs Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
De Wit (2018)^Citation34	Diabetes mellitus type 1 or type 2	Health education or behaviour	The Netherlands (2015€)	n.a/n.a.	6 months	Healthcare costs: hospital admissions, outpatient visits and calls, emergency room visits, ambulance transfers, medication and medical supply usage Social costs: productivity losses and informal care	Productivity losses: friction cost method (paid - absenteeism and presenteeism - and unpaid work) Informal care: n.a.
Ericsson (2018)^Citation35	Diabetes mellitus type 2	Pharmaceutical	Sweden (2015SEKs)	3%; 3%	40 years	Healthcare costs: anti-hyperglycaemic treatment and other treatment costs, diabetes-related complications Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Breeze (2017)^Citation31	Diabetes	Health education or behaviour	UK (2014/15£)	1.5%, 1.5%	Lifetime	Healthcare costs: direct health care costs, intervention and HbA1c testing costs Social costs: productivity losses	Productivity losses: friction cost approach (paid time - absenteeism)
Jendel (2017)^Citation40	Diabetes mellitus type 1	Medical device/pharmaceutical	Sweden (2015SEKs)	3%; 3%	Lifetime	Healthcare costs: intervention costs (insulin sensor), self-monitoring of blood glucose strips, diabetes-related complications Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Landstedt-Hallin (2017)^Citation44	Diabetes mellitus type 1	Medical device/pharmaceutical	Sweden (2015SEKs)	3%; 3%	Lifetime	Healthcare costs: direct health care costs financed by tax payments and co-payments Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Roze (2017)^Citation49	Diabetes mellitus type 1	Medical device	Denmark (2015DKK)	3%; 3%	Lifetime	Healthcare costs: direct medical costs due to diabetes-related complications, intervention costs (blood glucose self-testing) Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Slangen (2017)^Citation55	Diabetes mellitus type 2	Surgical	Netherlands (2012€)	4%; 1.5%	12 months	Healthcare costs: specialist doctor, surgery, laboratory tests, revisions, paramedical visits, follow-up visits, medication, inpatient admission costs Social costs: productivity losses and informal care costs	Productivity losses: friction cost method (paid time - absenteeism) Informal care: opportunity cost method
Farshchi (2016)^Citation73	Diabetes mellitus type 2	Pharmaceutical	Iran (2012US$)	n.a/n.a.	48 weeks	Healthcare costs: laboratory, medications, clinician visits, inpatient, non-medical costs Social costs: productivity losses	Productivity losses: n.a.
Haig (2016)^Citation66	Diabetes mellitus type 1 or type 2	Medical procedure, pharmaceutical	Canada (2013CAN$)	5%; 5%	Lifetime	Healthcare costs: treatment and monitoring visits, complications, treatment costs Social costs: productivity losses and informal care costs	Productivity losses: n.a. Informal care: n.a.
Kolu (2016)^Citation43	Diabetes mellitus type 2	Health education intervention	Finland (2015€)	Not specified	7 years	Healthcare costs: primary care doctor, specialist doctor, nursing, physiotherapist, medication, inpatient admission costs Social costs: productivity losses and informal care costs	Productivity losses: human capital approach (paid time - absenteeism costs) Informal care: opportunity cost method (paid time)
Lian (2016)^Citation74	Diabetes	Screening	China (2009HK$)	3.5%; 3.5%	n.a.	Healthcare costs: staff time costs, co-payment intervention cost, capital costs, follow-up and treatment costs Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Nguyen (2016)^Citation75	Diabetes mellitus type 2	Screening	Singapore (2015 Singapore$)	3%; 3%	Lifetime	Healthcare costs: screening, follow-up visits, laser treatment, transportation costs Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Roussel (2016)^Citation48	Diabetes mellitus type 2	Pharmaceutical	France (2013€)	3%; 3%	Lifetime	Healthcare costs: diabetes medications, self-monitoring of blood glucose, concomitant medications and diabetes-related complications costs Social costs: productivity losses	Productivity losses: n.a. (paid time - absenteeism)
Roze (2016)^Citation53	Diabetes mellitus type 1	Medical device, pharmaceutical	United Kingdom (2013£)	3.5%; 1.5%	Lifetime	Healthcare costs: treatment costs (strips, lancets, transmitter and glucose sensors) and diabetes-related complication costs Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Roze (2016)^Citation52	Diabetes mellitus type 1	Medical device, pharmaceutical	France (2014€)	4%; 4%	Lifetime	Healthcare costs: treatment costs (strips, lancets, transmitter and glucose sensors) and diabetes-related complication costs Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Roze (2016)^Citation50	Diabetes mellitus type 1	Pharmaceutical	Netherlands (2013€)	4%; 1.5%	Lifetime	Healthcare costs: treatment costs (strips, lancets, transmitter and glucose sensors) and diabetes-related complication costs Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Brown (2015)^Citation61	Diabetes mellitus type 1 or type 2	Pharmaceutical	US (2012US$)	3%; 3%	14 years	Healthcare costs: disease management and treatment costs, complications and adverse events costs, insurer costs Social costs: productivity losses and informal care costs	Productivity losses: human capital approach (paid time)
Cutino (2015)^Citation62	Diabetes mellitus type 1 or type 2	Medical device	US (2014US$)	Not specified	15 years	Healthcare costs: study drug costs, administration and monitoring costs, concomitant treatments, adverse events Social costs: informal care costs	Informal care: opportunity costs (paid time)
Huetson (2015)^Citation38	Diabetes mellitus type 2	Pharmaceutical	Norway (2012NOKs)	4%; 4%	45 years	Healthcare costs: disease management and treatment costs, complications costs Social costs: productivity losses	Productivity losses: human capital approach (paid time)
Roze (2015)^Citation51	Diabetes mellitus type 1	Medical device	Sweden (2011SEKs)	3%; 3%	Lifetime	Healthcare costs: intervention costs and diabetes-related complications costs (cardiovascular, renal, acute events, eye disease and other) Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Kiadaliri (2014)^Citation42	Diabetes mellitus type 2	Pharmaceutical	Sweden (2014SEKs)	n.a/n.a.	Lifetime	Healthcare costs: drugs, self-monitoring blood glucose test strips and lancets, diabetes-related complications costs, treatment side effects costs Social costs: productivity losses	Productivity losses: human capital approach
Png (2014)^Citation76	Diabetes mellitus type 2 and prediabetes	Health education or behaviour - Pharmaceutical	Singapore (2012US$)	3%; 3%	3 years	Healthcare costs: outpatient care, laboratory tests and medications Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Steen-Carlsson & Persson (2014)^Citation57	Diabetes mellitus type 2	Pharmaceutical	Sweden (2013SEKs)	n.a/n.a.	Lifetime	Healthcare costs: preventive treatment, micro- and macrovascular complications costs Social costs: productivity losses	Productivity losses: human capital approach
Tsiachristas (2014)^Citation58	Diabetes mellitus type 2	Management program intervention	Netherlands (2012€)	n.a/n.a.	12 months	Healthcare costs: GP, nurse practitioner, nurse, dietician, physiotherapist, podiatrist, lifestyle coach, medical specialists in outpatient clinics etc., hospital admissions and admission days, and medication use Social costs: productivity losses	Productivity losses: friction cost method (paid time - absenteeism)
Ericsson (2013)^Citation36	Diabetes mellitus type 1 or type 2	Pharmaceutical	Sweden (2012 SEKs)	n.a/n.a.	1 year	Healthcare costs: insulin costs, needles, self-monitoring blood glucose test strips and lancets costs, general practitioner (GP) visit, GP home visit, and emergency department visit Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Saha (2013)^Citation54	Diabetes	Physical exercise plus nutritional recommendations	Sweden (2012US$)	3%; 3%	85 years	Health care costs: medical treatment costs, costs for institutional health care, pharmaceuticals Social costs: productivity losses and informal care costs	Productivity losses: human capital approach (paid time due to morbidity) Informal care: opportunity cost method (non-paid time) and replacement cost method
De Salas-Cansado (2012)^Citation33	Diabetes	Pharmaceutical	Spain (2006€)	n.a/n.a.	12 weeks	Healthcare costs: drug and non-drug treatments, medical visits, hospitalizations and diagnostic tests Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism and presenteeism)
Kamble (2012)^Citation69	Diabetes mellitus type 1	Medical device	United States (2010US$)	3%; 3%	60 years	Healthcare costs: costs of glucose meters and test strips, lancets, insulin, and provider time to obtain annual treatment costs, costs of insulin pumps, transmitters, sensors, insertion devices and other pump suppliers Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Oostdam (2012)^Citation46	Gestational diabetes	Non-pharmaceutical (exercise intervention)	Netherlands (2009€)	n.a/n.a.	32 weeks	Healthcare costs: visits to healthcare providers, medication Social costs: productivity losses and informal care costs	Productivity losses: human capital approach (paid time - absenteeism) and friction cost method (paid time - absenteeism) Informal care: n.a.
Smith-Palmer (2012)^Citation56	Diabetes mellitus type 2	Pharmaceutical	Sweden (2010SEKs)	3%; 3%	Lifetime (40 years)	Healthcare costs: diabetes-related complications costs, medications, self-monitoring blood glucose tests costs, treatment costs Social costs: productivity losses	Productivity losses: human capital approach
Greeley (2011)^Citation64	Diabetes mellitus type 1	Screening	United States (2008US$)	3%; 3%	10, 20 and 30 years	Healthcare costs: medications, test strips, complications costs Social costs: informal care costs	Informal care: n.a. (paid time)
Kasteng (2011)^Citation41	Diabetes mellitus type 1 or type 2	Pharmaceutical	Sweden (2009SEKs)	3%; 3%	Lifetime	Healthcare costs: intervention drug costs, complications costs Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Kuo (2011)^Citation70	Diabetes mellitus type 1 or type 2	Care delivery	United States (2010US$)	3%; 3%	20 years	Healthcare costs: endocrinologist, registered/certified nurse or diabetes educator, exercise physiologist, medical assistant, rotated staff, laboratory tests, physician office hours, complications costs Social costs: productivity losses	Productivity losses: human capital approach (paid time)
Patel (2011)^Citation47	Diabetes mellitus type 1	Health education or behaviour	United Kingdom (2006£)	n.a/n.a.	1 year	Healthcare costs: hospital inpatient and outpatient services, primary care services, other community-based services, social services, medications, insulin-related equipment, other equipment and adaptations and intervention costs Social costs: productivity losses and informal care costs	Productivity losses: n.a. (paid time - absenteeism and presenteeism - and non-paid time) Informal care: n.a.
Valentine (2011)^Citation60	Diabetes mellitus type 2	Pharmaceutical	Switzerland (2008€)	3%; 3%	Lifetime	Healthcare costs: medications and treatment costs, complications costs Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Valentine (2011)^Citation59	Diabetes mellitus type 1	Pharmaceutical	Sweden (2006SEKs)	3%; 3%	50 years	Healthcare costs: diabetes-related complications costs, pharmacy costs Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Huang (2010)^Citation68	Diabetes mellitus type 1	Diagnostic - Medical device	United States (2008US$)	n.a/n.a.	Lifetime	Healthcare costs: intervention´s technology and treatment costs, standard glucose monitoring costs, routine office visits, after-hours clinic visits, emergency room visits, 911 calls, and hospitalizations Social costs: productivity losses and informal care costs	Productivity losses: human capital approach (paid time - absenteeism and presenteeism) Informal care: opportunity cost method (paid time)
Ismail (2010)^Citation39	Diabetes mellitus type 2	Non-pharmacological intervention	United Kingdom (2005/06£)	n.a./n.a.	1 year	Healthcare costs: hospital inpatient and outpatient services, primary care services, other community-based services, social services, medications, insulin-related equipment, other equipment and adaptations and the cost of the interventions Social costs: productivity losses and informal care costs	Productivity losses: human capital approach (paid and non-paid time) Informal care: opportunity cost method (paid and non-paid time)
Gschwend (2009)^Citation37	Diabetes mellitus type 1	Pharmaceutical	Belgium, France, Germany, Italy and Spain (2006€)	Belgium 3% costs, 1.5% benefits; France 3% both; Germany 5% both; Italy 3% both; Spain 6% both	Lifetime	Healthcare costs: diabetes-related complication costs, medication (insulin) and needles and devices for self-monitoring of blood glucose Social costs: productivity losses	Productivity losses: human capital approach
Lindgren (2007)^Citation45	Diabetes mellitus type 2	Health education or behaviour	Sweden (2003€)	3%; 3%	n.a.	Healthcare costs: intervention costs, physician visits, nutritionist visits, training sessions, travel time, diabetes-related complications costs Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Valentine (2006)^Citation72	Diabetes	Pharmaceutical	United States (2002US$)	3%; 3%	35 years	Healthcare costs: treatment, diabetes-related complications, medication costs Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Eddy (2005)^Citation63	Diabetes	Health education or behaviour	United States (2000US$)	3%; 3%	30 years	Healthcare costs: hospital admissions and emergency department visits, office and clinic visits, tests and discrete procedures, medications and ongoing programs Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism and presenteeism)
Herman (2005)^Citation67	Diabetes mellitus type 2	Health education intervention - Pharmaceutical	United States (2000US$)	3%; 3%	Lifetime	Healthcare costs: intervention costs, diabetes-related complication costs, physician visits, hospitalizations Social costs: productivity losses	Productivity losses: n.a.
Rosen (2005)^Citation71	Diabetes	Pharmaceutical	United States (2003US$)	3%; 3%	Lifetime	Healthcare costs: intervention costs, diabetes-related complication costs, ongoing costs of care, medication costs Social costs: productivity losses and informal care costs	Productivity losses: n.a. Informal care: n.a.
The Diabetes Prevention Program Research Group (2003)^Citation65	Diabetes mellitus type 2	Pharmaceutical - Health education or behaviour	United States (2000US$)	3%; 3%	3 years	Healthcare costs: intervention costs, side effects of the intervention, care outside the prevention program (hospital, emergency room, urgent care, and outpatient services; telephone calls to health care providers; and prescription medications), travel costs Social costs: productivity losses	Productivity losses: human capital approach (paid time - absenteeism)
Almbrand (2000)^Citation30	Diabetes mellitus type 1 or type 2	Pharmaceutical	Sweden (1999€)	3%; 3%	Lifetime	Healthcare costs: medication costs, hospitalizations, post-hospital discharge costs, diagnostic and monitoring procedures and tests, and outpatient visits Social costs: productivity losses	Productivity losses: human capital approach (paid time)

Table 2 Incremental Costs, QALYs and ICURs from the Healthcare Payer/Provider and the Societal Perspective in the Estimations That Changed Results or Conclusions After the Inclusion of Social Costs

Estimation Number		Healthcare Payer/Provider Perspective				Societal Perspective				Perspectives Comparison	Threshold Value
	Authors and Publication Year	∆Costs	∆QALYs	ICUR (Cost/QALY)	Authors´ Conclusions	∆Costs	∆QALYs	ICUR (Cost/QALY)	Authors´ Conclusions	Do the Conclusions Change? (YES/NO)
2	Broekhuizen et al (2018)^Citation32	−23	−0.003	7667	The intervention is more cost-effective than usual care	653	−0.003	−241,959	The intervention is dominated by usual care	YES	€10,000–24,400
4	de Wit et al (2018)^Citation34	−197	−0.0008	247,388	The intervention is less cost-effective than usual care	708	−0.0008	−888,936	HypoAware is dominated by usual care	NO, but when social costs are included, the intervention is dominated	€20,000
5	de Wit et al (2018)^Citation34	−197	−0.001	23,130	The intervention is less cost-effective than usual care	708	−0.001	−83,112	The intervention is dominated by usual care	NO, but when social costs are included, the intervention is dominated	€20,000
10	Breeze et al (2017)^Citation31	0	0.0001	0	The intervention is more cost-effective than doing nothing	−0.02	0.0001	−200	The intervention dominates doing nothing	NO, but when social costs are included, the intervention becomes cost-saving	£20,000
15	Breeze et al (2017)^Citation31	0	0.0001	0	The intervention is more cost-effective than doing nothing	−0.01	0.0001	−100	The intervention dominates doing nothing	NO, but when social costs are included, the intervention becomes cost-saving	£20,000
18	Jendel et al (2017)^Citation40	350,484	1.067	328,476	The intervention is more cost-effective than the comparator	268,899	1.067	252,014	The intervention is more cost-effective than the comparator	YES	SEKs 300,000
26	Slangen et al (2017)^Citation55	16,569	0.22	75,314	The intervention is more cost-effective than the comparator	21,226	0.22	96,481	The intervention is less cost-effective than the comparator	YES	€80,000
28	Haig et al (2016)^Citation66	9849	0.4	24,494	The intervention is more cost-effective than the comparator	−18,993	0.4	−47,483	The intervention dominates the comparator	NO, but when social costs are included, the intervention becomes cost-saving	CAN$ 50,000
29	Haig et al (2016)^Citation66	11,471	0.32	36,414	The intervention is more cost-effective than the comparator	−11,114	0.32	−34,731	The intervention dominates the comparator	NO, but when social costs are included, the intervention becomes cost-saving	CAN$ 50,000
37	Roze et al (2016)^Citation52	35,801	1.187	30,163	The intervention is less cost-effective than the comparator	31,884	1.187	26,863	The intervention is more cost-effective than the comparator	YES	€30,000
39	Brown et al (2015)^Citation61	56,366	0.9981	56,445	The intervention is more cost-effective than the comparator for threshold values > $56,500	−30,807	0.9981	−30,866	The intervention dominates the comparator	NO, but when social costs are included, the intervention becomes cost-saving	$50,000–100,000
40	Cutino et al (2015)^Citation62	18,880	0.1288	146,584	The intervention is less cost-effective than the comparator	5015	0.1288	38,948	The intervention is more cost-effective than the comparator	YES	$50,000
41	Cutino et al (2015)^Citation62	13,548	0.1288	105,186	The intervention is less cost-effective than the comparator	−1367	0.1288	−10,613	The intervention dominates the comparator	YES	$50,000
44	Roze et al (2015)^Citation51	415,106	0.76	545,005	The intervention is less cost-effective than the comparator	279,962	0.76	367,571	The intervention is more cost-effective than the comparator	YES	SEKs 500,000
47	Kiadaliri (2014)^Citation42	−1912	0.15	−12,747	The intervention dominates the comparator	5936	0.15	39,573	The intervention is more cost-effective than the comparator	NO, but when social costs are included, the intervention is no longer costs-saving	SEKs 500,000
51	Png et al (2014)^Citation76	281	0.01	21,065	The intervention is more cost-effective than the comparator	−19,915	0.01	−1,991,500	The intervention dominates the comparator	NO, but when social costs are included, the intervention becomes cost-saving	$53,000
91	Valentine et al (2011)^Citation60	1023	0.15	6820	The intervention is more cost-effective than the comparator	−346	0.15	−2307	The intervention is more cost-effective than the comparator	NO, but when social costs are included, the intervention becomes cost-saving	€40,000–60,000
92	Valentine et al (2011)^Citation59	26,144	0.53	49,328	The intervention is more cost-effective than the comparator	−80,113	0.53	−151,157	The intervention is more cost-effective than the comparator	NO, but when social costs are included, the intervention becomes cost-saving	SEKs 100,000–400,000
102	Lindgren et al (2007)^Citation45	1673	0.2	8365	The intervention is more cost-effective than the comparator	−1853	0.2	−9265	The intervention dominates the comparator	NO, but when social costs are included, the intervention becomes cost-saving	Not determined
104	Eddy et al (2005)^Citation63	22,737	0.159	143,000	The intervention is less cost-effective than the comparator	9969	0.159	62,698	The intervention is more cost-effective than the comparator	YES	$100,000

Note: ∆ Stands for incremental.

Figure 2 Incremental Cost-Utility Ratios from the healthcare perspective. For ease of comparison, results are shown in additional euros per additional QALY, applying the euro-currency exchange rates of the year of each record. The values were not updated to any base year since the efficiency thresholds applied as a usual reference are usually kept constant over several years. In this sense, and to facilitate the interpretation of the results of both panels, two vectors were drawn with the values of €30,000/QALY and €50,000/QALY since they are frequently cited thresholds in the economic evaluation literature.

Figure 3 Incremental Cost-Utility Ratios from the societal perspective. For ease of comparison, results are shown in additional euros per additional QALY, applying the euro-currency exchange rates of the year of each record. The values were not updated to any base year since the efficiency thresholds applied as a usual reference are usually kept constant over several years. In this sense, and to facilitate the interpretation of the results of both panels, two vectors were drawn with the values of €30,000/QALY and €50,000/QALY since they are frequently cited thresholds in the economic evaluation literature.

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