Register-based studies of healthcare costs

The economic burden of diseases in the Nordic countries: A systematic review

BACKGROUND

Economic burden studies can provide insights into the drivers leading to increasing healthcare costs. It can also provide a more holistic view of how diseases impact the welfare of patients and their families. Having concrete estimates of the economic burden across multiple diseases can help policymakers determine which diseases are economically more burdensome. This study aimed to review and summarise comprehensively economic burden studies across multiple diseases in the Nordic countries between 2000 and 2020.

METHODS

According to the 2020 PRISMA statement, a systematic literature review was conducted in PubMed, CINAHL, Academic Search Premier and Global Health databases using key terms related to the economic burden of any disease in Denmark, Finland, Greenland, Iceland, Norway and Sweden. Grey literature was also reviewed.

RESULTS

A total of 10,050 potential titles and abstracts were identified and screened, and 254 full-text papers that met the inclusion criteria were evaluated by two independent reviewers. Of these, 119 articles were included in a qualitative synthesis. Twenty-nine had clearly defined comparison groups, thus able to attribute the costs to the disease. Large variations concerning methodology and cost components were noted. Across diseases, the economic burden ranged from EUR 1668 per patient annually for chronic obstructive pulmonary disease to EUR 93,041 for multiple sclerosis. However, estimates varied widely, even within each disease.

CONCLUSIONS

Our review highlights the need for more comparable economic burden studies. Future studies should focus on applying robust methodology and homogeneous cost-reporting methods to inform policymakers about which diseases are economically more burdensome.

Healthcare costs associated with opportunistically identifiable vertebral fractures

PURPOSE

Vertebral fractures (VFs) are often available on radiological imaging undertaken during daily clinical work, yet the healthcare cost burden of these opportunistically identifiable fractures has not previously been reported. In this study, we examine the direct healthcare costs of subjects with vertebral fractures available for identification on routine CT scans.

METHODS

Thoracolumbar vertebral fractures were identified from 2000 routine CT scans. Subjects with VF on the scan were matched 1:2 against subjects with no VF on the scan, and similarly in a 1:3-ratio against a general population cohort. We excluded those subjects who received treatment with osteoporosis medication(s) in the year prior to baseline. Direct healthcare costs, identified from the national Danish registers, were accrued over up to 6 years of follow-up, and reported per day at risk and per year.

RESULTS

In subjects undergoing a CT scan, costs were initially high, yet declined over time. Comparing subjects with prevalent vertebral fracture (n = 321) against those subjects with no vertebral fracture (n = 606), mean total healthcare costs per day at risk was numerically higher in the first three years after baseline, while healthcare costs per year were similar between the cohorts. No differences reached statistical significance. When compared to the general population cohort, costs were significantly higher in the vertebral fracture cohort.

CONCLUSION

Subjects with vertebral fractures available for identification on routine CT scans incur substantially higher healthcare costs than matched subjects representing the general population, and numerically, albeit non-significantly, higher healthcare costs per day at risk in the short term, as compared to subjects with no visible VF on the CT scan.

The effects of pantoprazole vs. placebo on 1-year outcomes, resource use and employment status in ICU patients at risk for gastrointestinal bleeding: a secondary analysis of the SUP-ICU trial

PURPOSE

Patients in intensive care units (ICUs) are at risk of stress-related gastrointestinal (GI) bleeding and stress ulcer prophylaxis (SUP), including proton pump inhibitors, is widely used in the attempt to prevent this. In this secondary analysis of Stress Ulcer Prophylaxis in Intensive Care Unit (SUP-ICU) trial, we assessed 1-year outcomes in the pantoprazole vs. placebo groups.

METHODS

In the SUP-ICU trial, 3298 acutely admitted ICU patients at risk of GI bleeding were randomly allocated, stratified for site, to pantoprazole or placebo. In this secondary analysis, we assessed clinically important GI bleedings in ICU and 1-year mortality, health care resource use (e.g. readmission with GI bleeding, use of home care and general practitioner), health care costs, and employment status for the Danish participants using registry data.

RESULTS

Among the 2099 Danish participants, 2092 had data in the registries; 1045 allocated to pantoprazole and 1047 to placebo. The number of clinically important GI bleedings in ICU was 1.9 percentage points [95% CI 0.3-3.5] lower in the pantoprazole group vs. the placebo group, but none of the 1-year outcomes differed statistically significantly between groups, including total health care costs (€1954 [- 2992 to 6899]), readmission with GI bleeding (- 0.005 admissions [- 0.016 to 0.005]), 1-year mortality (- 0.013 percentage points [- 0.051 to 0.026]), and employment (- 0.178 weeks [- 0.390 to 0.034]).

CONCLUSION

Among ICU patients at risk of GI bleeding, pantoprazole reduced clinically important GI bleeding in ICU, but this did not translate into a reduction in 1-year mortality, health care resource use or improvements in employment status.

Economics of mental well-being: a prospective study estimating associated health care costs and sickness benefit transfers in Denmark

BACKGROUND

Previous literature has examined the societal costs of mental illness, but few studies have estimated the costs associated with mental well-being. In this study, a prospective analysis was conducted on Danish data to determine 1) the association between mental well-being (measured in 2016) and government expenditure in 2017, specifially healthcare costs and sickness benefit transfers.

METHODS

Data stem from a Danish population-based survey of 3,508 adults (aged 16 + years) in 2016, which was linked to Danish registry data. A validated scale (WEMWBS) was used for the assessment of mental well-being. Costs are expressed in USD PPP. A two-part model was applied to predict costs in 2017, adjusting for sociodemographics, health status (including psychiatric morbidity and health behaviour), as well as costs in the previous year (2016).

RESULTS

Each point increase in mental well-being (measured in 2016) was associated with lower healthcare costs ($- 42.5, 95% CI = $- 78.7, $- 6.3) and lower costs in terms of sickness benefit transfers ($- 23.1, 95% CI = $- 41.9, $- 4.3) per person in 2017.

CONCLUSIONS

Estimated reductions in costs related to mental well-being add to what is already known about potential savings related to the prevention of mental illness. It does so by illustrating the savings that could be made by moving from lower to higher levels of mental well-being both within and beyond the clinical range. Our estimates pertain to costs associated with those health-related outcomes that were included in the study, but excluding other social and economic outcomes and benefits. They cover immediate cost estimates (costs generated the year following mental well-being measurement) and not those that could follow improved mental well-being over the longer term. They may therefore be considered conservative from a societal perspective. Population approaches to mental health promotion are necessary, not only to potentiate disease prevention strategies, but also to reduce costs related to lower levels of mental well-being in the non-mental illness population. Our results suggest that useful reductions in both health care resource use and costs, as well as in costs due to sick leave from the workplace, could be achieved from investment in mental well-being promotion within a year.

The cost burden of Crohn's disease and ulcerative colitis depending on biologic treatment status - a Danish register-based study

Background

Patients diagnosed with inflammatory bowel disease may be treated with biologics, depending on several medical and non-medical factors. This study investigated healthcare costs and production values of patients treated with biologics.

Methods

This national register study included patients diagnosed with Crohn’s disease (CD) and ulcerative colitis (UC) between 2003 and 2015, identified in the Danish National Patient Register (DNPR). Average annual healthcare costs and production values were compared for patients receiving biologic treatment or not, and for patients initiating biologic treatment within a year after diagnosis or at a later stage. Cost estimates and production values were based on charges, fees and average gross wages.

Results

Twenty-six point one percent CD patients and ten point seven percent of UC patients were treated with biologics at some point in the study period. Of these, 46.4 and 45.5 % of patients initiated biologic treatment within the first year after diagnosis. CD and UC patients treated with biologics had higher average annual healthcare costs after diagnosis compared to patients not treated with biologics. CD patients receiving biologics early had lower production values both ten years before and eight years after treatment initiation, compared to patients receiving treatment later. UC patients receiving biologics early had lower average annual production values the first year after treatment initiation compared to UC patients receiving treatment later.

Conclusions

CD and UC patients receiving biologic treatment had higher average annual healthcare costs and lower average annual production values, compared to patients not receiving biologic treatment. The main healthcare costs drivers were outpatient visit costs and admission costs.

Cost Burden of Crohn's Disease and Ulcerative Colitis in the 10-Year Period Before Diagnosis-A Danish Register-Based Study From 2003-2015

BACKGROUND

The diagnostic delay in inflammatory bowel disease (IBD) is well known, yet the costs associated with diagnoses before IBD diagnosis have not yet been reported. This study explored societal costs and disease diagnoses 10 years before Crohn's disease (CD) and ulcerative colitis (UC) diagnosis in Denmark.

METHODS

This national register study included patients diagnosed between 2003 and 2015 identified in the Danish National Patient Registry (NPR) and controls who were individually matched on age and sex from the general population. Societal costs included health care services, prescription medicine, home care services, and labor productivity loss. Prediagnostic hospital contact occurring before CD or UC diagnosis was identified using the NPR. Average annual costs per individual were calculated before the patient's first CD or UC diagnosis. A 1-sample t test was then applied to determine significance in differences between cases and controls.

RESULTS

Among CD (n = 9019) and UC patients (n = 20,913) the average societal costs were higher throughout the entire 10-year period before the diagnosis date compared with the general population. The difference increased over time and equaled €404 for CD patients and €516 for UC patients 10 years before diagnosis and €3377 and €2960, respectively, in the year before diagnosis. Crohn's disease and UC patients had significantly more diagnoses before their CD and UC diagnosis compared with the general population.

CONCLUSIONS

Compared with the general population, the societal costs and number of additional diagnoses among CD and UC patients were substantially higher in the 10-year period before diagnosis.

Extraintestinal Manifestations and Other Comorbidities in Ulcerative Colitis and Crohn Disease: A Danish Nationwide Registry Study 2003-2016

Background

Extraintestinal manifestations (EIMs) in inflammatory bowel disease (IBD) may be a frequent complication to an underlying abnormal immune response. This study investigated the occurrence of EIMs in Crohn disease (CD) and ulcerative colitis (UC) patients using population-based data in Denmark from 2003 to 2016.

Methods

In this national registry-based study, incident CD and UC patients between 2003 and 2015 were matched on age and gender with non-IBD controls and followed until 2016. The selected EIMs for this study included 51 different diagnoses divided into biological systems of diseases, which were tested for differences in the timing and occurrence of EIMs.

Results

The study cohort included 10,302 patients with CD and 22,144 patients with UC. The highest risk of patients experiencing EIM/comorbidities for the first time before their IBD diagnosis was in the skin and intestinal tract systems. For CD, the odds ratio of having an EIM before or after IBD diagnosis, as compared with controls, was significant in the skin, intestinal tract, hepatopancreatobiliary, musculoskeletal, ocular, renal, and respiratory systems. For UC, the risks were similar before and after UC diagnosis, apart from the nervous system where the odds ratio was significantly higher before the diagnosis of UC, and significantly lower after diagnosis for diseases in the ocular system.

Conclusions

EIMs in CD and UC patients may also precede their IBD diagnosis. These findings may indicate a significant diagnostic delay of CD and UC, and the occurrence of known EIMs should prompt physicians to look for patients possibly having underlying IBD.

Treatment patterns for biologics in ulcerative colitis and Crohn's disease: a Danish Nationwide Register Study from 2003 to 2015

Background: The choice of treatment for Crohn's disease (CD) and ulcerative colitis (UC) depends among other factors, disease severity. Patients with moderate-to-severe disease should be prescribed biologic response modifiers (biologics), according to guidelines. This study aims to explore the treatment patterns of patients diagnosed with CD and UC between 2003 and 2015 that were treated with biologics in Denmark between the years 2003 and 2016.Methods: This national register study included patients diagnosed between 2003 and 2015, identified in the Danish National Patient Registry. Biologic therapies available during the study period were infliximab, adalimumab, vedolizumab and golimumab. The share of patients initiating and receiving biologic treatment in each year was estimated. Additionally, the time from IBD diagnosis to first biologic treatment and time between treatments was calculated.Results: Among 10,302 CD patients and 22,144 UC patients, 28.5% of CD patients and 11.3% of UC patients received treatment with biologics during the study period, with an increasing trend in the number of patients initiating treatment with biologics each year. About 46% of CD patients and 45% of UC patients received their first biologic treatment within the first year after IBD diagnosis. About 57-68% of CD and UC patients received treatment with their second line biologic within 2 months of the last treatment of their first line.Conclusions: The number of patients initiating biologic treatments after diagnosis increased throughout the study period. Most patients diagnosed with CD and UC are receiving biologic treatments relatively soon after their diagnosis.

Societal costs attributable to Crohn's disease and ulcerative colitis within the first 5 years after diagnosis: a Danish nationwide cost-of-illness study 2002-2016

Objective: There is little information on cost-of-illness among patients diagnosed with Crohn's disease (CD) and ulcerative colitis (UC) in Denmark. The objective of this study was to estimate the average 5-year societal costs attributable to CD or UC patients in Denmark with incidence in 2003-2015, including costs related to health care, prescription medicine, home care and production loss.Materials and methods: A national register-based, cost-of-illness study was conducted using an incidence-based approach to estimate societal costs. Incident patients with CD or UC were identified in the National Patient Registry and matched with a non-IBD control from the general population on age and sex. Attributable costs were estimated applying a difference-in-difference approach, where the total costs among individuals in the control group were subtracted from the total costs among patients.Results: CD and UC incidence fluctuated but was approximately 14 and 31 per 100,000 person years, respectively. The average attributable costs were highest the first year after diagnosis, with costs equalling €12,919 per CD patient and €6,501 per UC patient. Hospital admission accounted for 36% in the CD population and 31% in the UC population, the first year after diagnosis. Production loss exceeded all other costs the third-year after diagnosis (CD population: 52%; UC population: 83%).Conclusions: We found that the societal costs attributable to incident CD and UC patients are substantial compared with the general population, primarily consisting of hospital admission costs and production loss. Appropriate treatment at the right time may be beneficial from a societal perspective.

Societal costs of venous thromboembolism and subsequent major bleeding events: a national register-based study

Aims

Detailed evidence on the societal costs of venous thromboembolism (VTE), i.e. deep vein thrombosis (DVT) and pulmonary embolism (PE), and of subsequent major bleeding events, e.g. intracranial and gastrointestinal bleedings, is limited. The objective was to estimate the average 3-year societal event costs attributable to VTE and subsequent major bleedings in Denmark.

Methods and results

Based on nationwide Danish registers, each incident patient diagnosed with VTE in the period from 2004 to 2016 was identified and matched with four non-VTE patients by nearest-neighbour propensity score matching. For bleeding patients, the reference cohort was VTE patients without bleedings. Event costs in terms of VTE, DVT, PE, and major bleedings in VTE patients were measured by the ‘difference-in-actual-cost’ method within 3 years after the incidence. Societal costs included healthcare costs (primary care, hospital, and prescription medicine), municipality home care services, and production loss. The study population included 74 137 VTE incident patients (DVT: 43 099; PE: 31 038), and 4887 VTE patients with a major bleeding within 3 years from VTE diagnosis. The 3-year attributable societal VTE event costs were 40 024 EUR (DVT: 34 509 EUR; PE: 50 083 EUR) with 53% of these costs appearing in the first incident year. Similar results for major bleedings were 51 168 EUR with 46% of these costs appearing in the first incident year.

Conclusion

The societal costs of VTE and subsequent major bleedings are substantial and ought to be considered. Estimated costs of events may be informative in evaluating the impact of preventive interventions targeting VTE and subsequent major bleedings.

Long-term medical costs of Alzheimer's disease: matched cohort analysis

OBJECTIVES

Medical costs associated with Alzheimer's disease (AD) are characterised by uncertainty and are often presented in a format unsuitable for decision modelling. We set out to estimate long-term medical costs attributable to AD compared to the general population for use in decision modelling.

METHODS

We used multiple logistic regressions to generate propensity scores to match 26,951 incident cases of AD with 26,951 people without AD, identified from Danish hospital and medication registries. Costs were available for up to 11 years for each individual, representing costs for 10 years before and 5 years after diagnosis. Generalised estimating equations were employed to investigate the effect of having AD on primary care, medication, hospital and total costs in the matched cohort. We also explored the impact of other socio-economic and demographic factors on healthcare costs.

RESULTS

We report costs by year to diagnosis, from 10 years before to 5 after. AD was associated with significantly higher costs, driven by medication and hospital costs, especially around the time of diagnosis. Mean total medical cost was €4996 higher for AD than for the control group in year of diagnosis, after which primary and hospital costs decreased to pre-diagnostic levels. AD had higher attributable primary care costs in years preceding diagnosis.

CONCLUSIONS

Reporting AD-attributable costs by year to diagnosis can be useful for use in decision modelling. Medical costs attributed to AD are driven by diagnostic procedures and medication, and the impact of AD on medical costs may not be as high or prolonged as previously suggested.

Health care cost consequences of using robot technology for hysterectomy: a register-based study of consecutive patients during 2006-2013

The objective of this study is to examine the costs attributable to robotic-assisted laparoscopic hysterectomy from a broad healthcare sector perspective in a register-based longitudinal study. The population in this study were 7670 consecutive women undergoing hysterectomy between January 2006 and August 2013 in public hospitals in Denmark. The interventions in the study were total and radical hysterectomy performed robotic-assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy (TLH), or open abdominal hysterectomy (OAH). Service use in the healthcare sector was evaluated 1 year before to 1 year after the surgery. Tariffs of the activity-based remuneration system and the diagnosis-related grouping case-mix system were used for valuation of primary and secondary care, respectively. Costs attributable to RALH were estimated using a difference-in-difference analytical approach and adjusted using multivariate linear regression. The main outcome measure was costs attributable to OAH, TLH, and RALH. For benign conditions RALH generated cost savings of € 2460 (95% CI 845; 4075) per patient compared to OAH and non-significant cost savings of € 1045 (95% CI -200; 2291) when compared with TLH. In cancer patients RALH generated cost savings of 3445 (95% CI 415; 6474) per patient when compared to OAH and increased costs of € 3345 (95% CI 2348; 4342) when compared to TLH. In cancer patients undergoing radical hysterectomy, RALH generated non-significant extra costs compared to OAH. Cost consequences were primarily due to differences in the use of inpatient service. There is a cost argument for using robot technology in patients with benign disease. In patients with malignant disease, the cost argument is dependent on comparator.

Health service use among children with and without eczema, asthma, and hay fever

BACKGROUND

Atopic diseases, for example, eczema, asthma, and hay fever, are among the most common chronic diseases of childhood. Knowledge on health service use among children with atopic disease is limited. This study aimed to investigate the total use and costs of health services for children with and without eczema, asthma, and hay fever in a Danish general population.

METHODS

We conducted a health survey with four complete birth cohorts from the City of Copenhagen. Individual questionnaire data on eczema, asthma, and hay fever for children aged 3, 6, 11, and 15 years were linked to register information on use and costs of health services and prescribed medication and parental education. In total 9,720 children participated (50.5%).

RESULTS

We found increased health service use (number of additional consultations per year [95% confidence interval]) among children with current eczema symptoms (1.77 [1.29-2.26]), current asthma symptoms (2.53 [2.08-2.98]), and current hay fever symptoms (1.21 [0.74-1.67]), compared with children without these symptoms. We also found increased use of prescribed medication and most subtypes of health services. Current asthma symptoms and current eczema symptoms, but not current hay fever symptoms, increased the health service costs with at least €300 per year per child.

CONCLUSION

Children with eczema, asthma, and hay fever used health services and prescribed medication more than children without these diseases.

Health care and social care costs of pneumonia in Denmark: a register-based study of all citizens and patients with COPD in three municipalities

Background

Pneumonia is a frequent lung infection and a serious illness, which is often diagnosed among patients hospitalized with acute exacerbations of COPD. The aim of this study was to estimate the attributable costs due to pneumonia among patients hospitalized with pneumonia compared to a matched general population control group without pneumonia hospitalization.

Methods

This study includes citizens older than 18 years from three municipalities (n=142,344). Based on national registers and municipal data, the health and social care costs of pneumonia in the second half of 2013 are estimated and compared with propensity score-matched population controls.

Results

The average health care costs of 383 patients hospitalized with pneumonia in the second half of 2013 were US$34,561 per patient. Among pneumonia patients with COPD, the costs were US$35,022. The attributable costs of patients with pneumonia compared to the population control group for the 6-month period were US$24,155 per case. Overall, the attributable costs for the 383 pneumonia cases amounted to US$9.25 million. Subgroup analyses showed that costs increased with age. The attributable costs due to pneumonia were highest among the 18–59-year-old and the 70–79-year-old patients. This difference is likely to reflect an increased risk of mortality among the pneumonia patients. Men have higher costs than women in the pneumonia group.

Conclusion

The costs of pneumonia are considerable. In three Danish municipalities, the attributable costs due to pneumonia were US$24,155 per case or US$64,992 per 1,000 inhabitants in the second half of 2013. Similar high health care and social care costs were found for pneumonia patients with COPD – the largest group having pneumonia episodes. The municipalities are responsible for 49% of the costs, while a closer focus on the prevention of pneumonia may be advisable, eg, starting with citizens having COPD.

Early psychosocial intervention in Alzheimer's disease: cost utility evaluation alongside the Danish Alzheimer's Intervention Study (DAISY)

OBJECTIVE

To assess the cost utility of early psychosocial intervention for patients with Alzheimer's disease and their primary caregivers.

DESIGN

Cost utility evaluation alongside a multicentre, randomised controlled trial with 3 years of follow-up.

SETTING

Primary care and memory clinics in five Danish districts.

PARTICIPANTS

330 community-dwelling patients and their primary caregivers.

INTERVENTION

Psychosocial counselling and support lasting 8-12 months after diagnosis and follow-up at 3, 6, 12 and 36 months in the intervention group or follow-up only in the control group.

MAIN OUTCOME MEASURES

The primary outcome measure was the cost of additional quality-adjusted life years (QALYs). Costs were measured from a societal perspective, including the costs of healthcare, social care, informal care and production loss. QALYs were estimated separately for the patient and the caregiver before aggregation for the main analysis.

RESULTS

None of the observed cost and QALY measures were significantly different between the intervention and control groups, although a tendency was noted for psychosocial care leading to cost increases with informal care that was not outweighed by the tendency for cost savings with formal care. The probability of psychosocial intervention being cost-effective did not exceed 36% for any threshold value. The alternative scenario analysis showed that the probability of cost-effectiveness increased over the range of threshold values used if the cost perspective was restricted to formal healthcare.

CONCLUSIONS

A multifaceted, psychosocial intervention programme was found unlikely to be cost-effective from a societal perspective. The recommendation for practice in settings that are similar to the Danish setting is to provide follow-up with referral to available local support programmes when needed, and to restrict large multifaceted intervention programmes to patients and caregivers with special needs until further evidence for cost-effectiveness emerges.

TRIAL REGISTRATION

The study was registered in the Clinical Trial Database as ISRCTN74848736.

Costs of traffic injuries

OBJECTIVE

The aim of this study was to analyse the socioeconomic costs of traffic injuries in Denmark, notably the healthcare costs and the productivity costs related to traffic injuries, in a bottom-up, register-based perspective.

METHOD

Traffic injury victims were identified using national emergency room data and police records. Victims were matched with five controls per case by means of propensity score, nearest-neighbour matching. In the cohort, consisting of the 52 526 individuals that experienced a traffic injury in 2000 and 262 630 matched controls, attributable healthcare costs were assessed using Danish national healthcare registers. Productivity costs were computed using duration analysis (Cox regression models). In a subanalysis, cost per severe traffic injury was computed for the 12 995 individuals that experienced a severe injury.

RESULTS

The socioeconomic cost of a traffic injury was €1406 (2009 price level) in the first year, and €8950 over a 10-year period. Per 100 000 population, the 10-year cost was €6 565 668. A severe traffic injury costs €4969 per person in the first year, and €4 006 685 per 100 000 population over a 10-year period. Victims of traffic injuries are younger and generally worse off, compared to the general population.

CONCLUSIONS

Prevention of traffic injuries could result in societal savings. The bottom-up, register-based approach renders more precise figures for these savings. The socioeconomic profile of injury victims differs from that of the general population on most parameters.

The Cost of Diabetes-Related Complications: Registry-Based Analysis of Days Absent from Work

The aim of this study was to estimate the annual number of days absent from work associated with diabetes-related complications. Registry data were obtained for 34,882 individuals aged 18–70 years with hospital-diagnosed diabetes (ICD-10 codes: E10–E14) identified from a large national sample (40% of the Danish population) with 6 years of hospital utilisation data. The occurrence of a complication was defined as a hospital admission with a specified diagnosis or procedure code. Data on sickness episodes with municipal subsidy were retrieved for each individual. Days absent from work attributable to complications were defined as the estimated difference in absence days between individuals with and without the specified complication and were estimated for the first and subsequent years after the initial episode of the recorded complication. Angina pectoris, ischaemic stroke, and heart failure were the three most frequent complications in the population. Heart failure, amputation, renal disease, and peripheral vascular disease were on average associated with more than three-month additional absence from work during the first and subsequent years. Leg ulcers and neuropathy were associated with more days absent from work during the first year than in subsequent years. Diabetes complications are associated with a substantial number of additional days absent from work. The avoidance of these complications would benefit both patients and society.