OBJECTIVE—The goal of this study was to estimate the excess hospitalizations, hospital days, and inpatient costs attributable to diabetes in Andalusia, Spain (37 hospitals, 7,236,459 inhabitants), during 1999 compared with those without diabetes.

RESEARCH DESIGN AND METHODS—This study was an analysis of all hospital discharges. Those with an ICD-9-CM code of 250 as either the main or secondary diagnosis were considered to have been admissions of individuals with diabetes. An estimate of costs was applied to each inpatient admission by assigning a cost weight based on the diagnostic-related group (DRG) related to each admission.

RESULTS—A total of 538,580 admissions generated 4,310,654 hospital bed-days and total costs of €940,026,949. People with diabetes accounted for 9.7% of all hospital discharges, 13.8% of total stays, and 14.1% of the total cost. Of the total cost for individuals with diabetes (€132,509,217), 58.3% were excess costs, of which 47% was attributable to cardiovascular complications and 43% to admissions for comorbid diseases. Individuals 45–75 years of age accounted for 75% of the excess costs. The rate of admissions during the study year was 145 per 1,000 inhabitants for individuals with diabetes compared with 70 admissions per 1,000 inhabitants for individuals without diabetes.

CONCLUSIONS—The costs arising from hospitalization of individuals with diabetes are disproportionate in relation to their prevalence. For those aged ≥45 years, cardiovascular complications were clearly the most important factor determining increased costs from diabetes.

Diabetes is one of the most important public health problems worldwide. An estimated 300 million individuals will have the disease by the year 2025 (1). Prevalence studies in Spain corroborate this trend (2). Studies of the costs associated with diabetes show that the direct burden resulting from its treatment is very high in relation to its prevalence (38).

From 30 to 50% of expenses arising from diabetes correspond to indirect costs, with the rest corresponding to the direct cost of health care (3,6,9). Studies in Spain, Europe, and the U.S. generally agree that most direct costs are due to inpatient care of the associated chronic complications of diabetes (39).

Care of individuals with diabetes generates a disproportionate use of hospital resources relative to the prevalence of diabetes (1012). The greatest impact on hospital stay and expense is from hospitalizations for chronic complications, especially cardiovascular complications (8,12).

Data published in Spain on hospital costs generally came from small- or medium-sized hospitals (1012), or they were calculated from theoretical estimates based on prevalence studies (7) or from smaller samples of patients from the primary care setting only (4,8). Very few European studies, and none in Spain, have focused their hospitalization data of individuals with diabetes to estimate the excess cost. Moreover, those that have have carried out population-based analyses using low populational prevalence data for diabetes (13). In this study, we estimated the excess costs attributable to hospitalization of individuals with diabetes using a population-based analysis in Andalusia, a region in Southern Spain with >7 million inhabitants, using up-to-date prevalence data for diabetes.

Andalusia has its own health care service under the Andalusian Consejería de Salud. The population of Andalusia is 7,236,459 inhabitants, with health care provided to >98% of these individuals (14). We analyzed all admissions during 1999 to all the hospitals under the jurisdiction of the Consejería de Salud (5 first-level regional centers, 9 second level, and 18 local). The only admissions excluded were those of newborns. The study population was stratified by age into the following groups: <15 years, 15–44 years, 45–75 years, and >75 years.

The diagnoses and procedures of all hospital discharges were coded in accordance with the ICD-9-CM. All hospital discharges that included diagnostic category 250 as the main or secondary medical diagnosis (in any of its 10 sections) were considered to refer to individuals with diabetes. The remaining hospital discharges not classified under diagnostic category 250 were considered to relate to treatment of individuals without diabetes.

All hospitalization episodes were classified according to the diagnostic-related group (DRG) derived from the corresponding ICD-9-CM codes and translated by the All Patients DRGs software (vol. 12, 1996). Each diabetic subject was further classified into the following mutually exclusive groups based upon reported DRG (Table 1): 1) acute complications, 2) chronic complications of diabetes, and 3) other comorbid conditions (all remaining hospitalizations). The specific conditions considered to be chronic complications of diabetes and the associated DRGs were based on those published by the American Diabetes Association and in other relevant peer-reviewed literature (6,10,15) (Table 1).

Rates of hospitalization for individuals with and without diabetes were calculated for each age-group by dividing the number of hospitalizations by the respective population at risk. The relative risk of hospitalization was estimated by dividing the rate of hospitalization of individuals with diabetes by the rate of hospitalization of individuals without diabetes. We used the prevalence data of diabetes in the general population published for the different populations in Spain (2,16). The following prevalence data were used: <15 years of age (0.1% of the general population), 15–44 years (0.85% of the general population), 45–75 years (7% of the general population), and >75 years (17% of the general population).

Estimation of costs

A specific financial control system has been established by the Consejería de Salud based on the DRG of the patient. An estimate of costs was applied to every inpatient admission by assigning a cost weight based on the DRG related to each admission. In 1999, the cost of one DRG point was €1,357. The sum of all such cost weights was calculated for each age-group and disease type according to the DRG for both diabetes- and non–diabetes-related admissions. The results are expressed in euros.

Determination of excess hospitalization, stays, and costs

The excess numbers of admissions, hospital days, and costs generated by individuals with diabetes were calculated by estimating the expected value, based on admission indexes, the mean stay, and the hospital costs in individuals without diabetes for each group studied. These were then subtracted from the observed findings for individuals with diabetes (13). These calculations were made for the total number of admissions and for each of the different groups studied classified according to the DRG and age.

Table 2 summarizes the overall and age-grouped results of the demographic data for admissions, stays, and costs generated. Of the 538,580 admissions, 52,454 corresponded to individuals with diabetes. The total number of admissions generated 4,310,654 bed-days (596,851 for individuals with diabetes) and total costs of €940,026,949 (€132,509,217 for individuals with diabetes). The mean cost per admission was €2,526 for individuals with diabetes and €1,661 for individuals without diabetes.

Of the total cost generated by hospitalization of individuals with diabetes (€132,509,217), 58.3% (€77,206,772) was directly attributable to the presence of diabetes (excess costs). Figure 1 specifies the percentages attributable to the excess costs in relation to the total cost generated by hospitalization of individuals with diabetes. Figure 2 shows the percentage contribution by age-group to the excess costs generated by hospitalization of individuals with diabetes.

Table 3 details, for the total group and for each of the age-groups studied, the distribution of admissions, stays, and costs of the individuals with diabetes as well as the expected and the excess costs for each of the diagnostic subgroups studied. The main determinant factors in the €132,509,217 generated by hospitalization of individuals with diabetes were admissions for cardiovascular complications (€46,083,642 [34.8% of the total], of which €36,304,002 [27.4% of the total] were directly attributable to diabetes) and diabetes comorbid conditions (€74,931,013 [56.5% of the total], of which €33,240,356 [25.1% of the total] were directly attributable to diabetes).

The rate of admissions during the study year was 145 per 1,000 inhabitants for individuals with diabetes compared with 70 admissions per 1,000 inhabitants for individuals without diabetes. The rates of admission per age-group for individuals with diabetes versus individuals without diabetes were 468 vs. 45 admissions per 1,000 inhabitants (<15 years of age), 95 vs. 59 admissions per 1,000 inhabitants (15–44 years of age), 230 vs. 88 admissions per 1,000 inhabitants (45–75 years of age), and 234 vs. 161 admissions per 1,000 inhabitants (>75 years of age).

This study shows that individuals with diabetes have a high risk of hospital admission compared with individuals without diabetes. There was a notable increase in all age-groups in stays and a disproportionate cost associated with the diagnosis. Almost 60% of all hospital costs for hospitalization of people with diabetes were excess costs, either due to chronic or acute diseases related with complications, especially those related with the cardiovascular system, or to the increased expense associated with admission for other comorbid diseases not related with diabetes. In absolute terms, it was the age-group of 45- to 75-year-old individuals who contributed most (75%) to the excess costs (Fig. 2).

The rates of hospitalization for individuals with diabetes were clearly above those of individuals without diabetes in all age-groups; this is in agreement with other studies (6,10,15). The reasons for the excess admissions (and subsequent costs) in the various age-groups were well differentiated (Table 3). In individuals <45 years of age, this was mainly due to hospitalizations for decompensation of their diabetes. In the other two age-groups (>45 years), cardiovascular complications were the most important diabetes-related factors determining increased costs.

In absolute terms, the main factor contributing to the excess costs generated by diabetes was related to admissions for cardiovascular complications (almost 50% of the estimated excess). This occurred in all age-groups, although it was especially marked in individuals from 45–75 years of age, the data being similar to those reported by us and others (4,6,12,13,17). The fact that our findings are similar to data from other countries, both European and American, with different health care systems reinforces the validity of the data and emphasizes the universal role of diabetes in increasing health care costs. Two factors explain this. First, the risk of admission due to cardiovascular disease in individuals with diabetes is clearly greater in all age-groups studied; our data are similar to or even higher than those of others (13,17,18). Second, admissions of individuals with diabetes due to cardiovascular disease are more complex and prolonged than admissions of individuals without diabetes (from 1 to 3.4 days longer, depending on the age-group), thereby generating greater consumption of resources. Patients who have macrovascular complications cause a notable increase (at least twofold) in the direct annual costs resulting from their care, with greater increases among the younger patients (4,19,20).

Individuals with diabetes who are >50 years old and who also have the metabolic syndrome, i.e., almost 90% of this group, are those who most often have cardiovascular disease, whereas this disease is hardly present in individuals with diabetes but without the metabolic syndrome (21). In our study, it was not possible to determine the main cause of the increase in admissions for cardiovascular disease or its associated costs (whether they were due to diabetes itself or to the associated disease). Nevertheless, it seems clear that reducing the costs associated with diabetes requires aggressive control of the other components of the metabolic syndrome (obesity, blood pressure, or dyslipidemia) as well as intensifying the treatment of diabetes. This should result in notable long-term savings in both monetary terms and possibly also in terms of improved quality of life, although it probably means greater short-term expenses (5,8,22). A more aggressive treatment of diabetes in hospitalized patients (especially those admitted for cardiovascular disease) with the aim of achieving optimum metabolic control is also effective at reducing morbidity and mortality and, consequently, the associated expenses (23).

Patients with diabetes have a clear increase in the number of hospitalizations, the number of hospital days, and the costs associated with admission for comorbid diseases not related with diabetes. This had important economic repercussions in all the age-groups, as it accounted for 43% of the excess costs. The presence of diabetes may increase the incidence and severity of other diseases, leading to hospitalization, a longer mean stay, and more hospital complications. The increase in the number of visits to health care centers by individuals with diabetes also results in more admissions. For certain diseases, therefore, the presence of diabetes tends to increase the likelihood of hospital admission or of receiving more aggressive therapy (10,15).

Our study, however, is not without limitations. First, our estimation of costs largely depended on prevalence figures for diabetes. Nevertheless, we decided to use age values similar to other recent studies in our area (2,16). These figures are much higher than those used by others (7,13) but are probably nearer the actual figures. Lower figures would have resulted in possibly even higher figures for excess costs. Second, the system of cost assignment was based on DRGs that were not designed for individuals with diabetes (who have longer mean stays than individuals without diabetes) and which simplify primary and secondary diagnoses (with the corresponding loss of information in older individuals with diabetes, who usually have more comorbid diseases). Third, it has been shown, both in our area (24) and in other countries (25), that undercoding of hospital diabetes can be very high (from 20 to 61% of all individuals with diabetes), which would result in underestimation of the costs (24,26).

In conclusion, our study demonstrated that almost 60% of costs generated by hospitalization of individuals with diabetes (in a large sample of hospitals from southern Spain) are specifically attributable to the disease itself. Hospitalizations for cardiovascular complications and increased costs associated with hospitalization of individuals with diabetes for other unrelated diseases were notable. The optimal management of blood glucose, blood pressure, and lipid concentrations and the early detection and management of existing complications should possibly result in an important reduction of the excess costs associated with hospitalization of individuals with diabetes. For those individuals age ≥45 years, cardiovascular complications were clearly the most important factor determining increased costs from diabetes.

Figure 1—

Proportion corresponding to the excess cost compared with the total cost generated by hospitalization of individuals with diabetes (total and by age-group).

Figure 1—

Proportion corresponding to the excess cost compared with the total cost generated by hospitalization of individuals with diabetes (total and by age-group).

Close modal
Figure 2—

Percentage contribution according to age of the excess costs generated by hospitalization of individuals with diabetes.

Figure 2—

Percentage contribution according to age of the excess costs generated by hospitalization of individuals with diabetes.

Close modal
Table 1—

Groups of hospital discharges based on DRG

DRGs
Acute complications 294, 295 
Chronic complications  
    Neurological 007, 008, 016–019, 045, 034, 035, 045, 531, 533 
    Ophthalmological 036, 037, 039, 042, 046, 047, 534, 535 
    Cardiovascular 014, 015, 106–114, 119–125, 127, 128, 130–134, 140–145, 285, 478, 479, 796, 797, 532, 543, 544, 549, 550, 808 
    Musculoskeletal and skin 225–227, 244, 245, 268–273, 563, 564 
    Genitourinary 302, 316, 317, 325, 326, 331, 332, 341, 568, 569 
Comorbidity All remaining hospitalizations 
DRGs
Acute complications 294, 295 
Chronic complications  
    Neurological 007, 008, 016–019, 045, 034, 035, 045, 531, 533 
    Ophthalmological 036, 037, 039, 042, 046, 047, 534, 535 
    Cardiovascular 014, 015, 106–114, 119–125, 127, 128, 130–134, 140–145, 285, 478, 479, 796, 797, 532, 543, 544, 549, 550, 808 
    Musculoskeletal and skin 225–227, 244, 245, 268–273, 563, 564 
    Genitourinary 302, 316, 317, 325, 326, 331, 332, 341, 568, 569 
Comorbidity All remaining hospitalizations 
Table 2—

Demographic characteristics, hospital care resources, and costs in individuals hospitalized with and without diabetes

Individuals with diabetesIndividuals without diabetes
Total admissions among the different age-groups* 52,454 (9.7) 486,126 (90.3) 
    <15 years 615 (1) 59,459 (99) 
    15–44 years 2,793 (1.3) 204,483 (98.7) 
    45–75 years 33,428 (16.5) 169,447 (83.5) 
    >75 years 15,618 (22.9) 52,737 (77.2) 
Sex   
    Men 25,241 (44.3) 215,538 (48.1) 
    Women 27,213 (55.7) 270,589 (51.9) 
Total bed-days* 596,851 (13.8) 3,713,803 (86.2) 
Mean length of stay among the different age-groups (days) 11.4 7.6 
    <15 years 6.6 4.4 
    15–44 years 8.2 5.6 
    45–75 years 11.6 10.0 
    >75 years 11.7 11.8 
Total inpatient cost among the different age-groups* €132,509,217 (14.1) €807,517,732 (85.9) 
    <15 years €723,055 (1) €68,862,789 (99) 
    15–44 years €4,885,394 (1.9) €248,984,696 (98.1) 
    45–75 years €85,421,739 (19) €364,297,480 (81) 
    >75 years €41,479,029 (24.9) €125,372,767 (75.1) 
Individuals with diabetesIndividuals without diabetes
Total admissions among the different age-groups* 52,454 (9.7) 486,126 (90.3) 
    <15 years 615 (1) 59,459 (99) 
    15–44 years 2,793 (1.3) 204,483 (98.7) 
    45–75 years 33,428 (16.5) 169,447 (83.5) 
    >75 years 15,618 (22.9) 52,737 (77.2) 
Sex   
    Men 25,241 (44.3) 215,538 (48.1) 
    Women 27,213 (55.7) 270,589 (51.9) 
Total bed-days* 596,851 (13.8) 3,713,803 (86.2) 
Mean length of stay among the different age-groups (days) 11.4 7.6 
    <15 years 6.6 4.4 
    15–44 years 8.2 5.6 
    45–75 years 11.6 10.0 
    >75 years 11.7 11.8 
Total inpatient cost among the different age-groups* €132,509,217 (14.1) €807,517,732 (85.9) 
    <15 years €723,055 (1) €68,862,789 (99) 
    15–44 years €4,885,394 (1.9) €248,984,696 (98.1) 
    45–75 years €85,421,739 (19) €364,297,480 (81) 
    >75 years €41,479,029 (24.9) €125,372,767 (75.1) 

Data are n (%).

*

Percent compared with the total number of inpatients in each age-group.

Percent compared with the total number of patients in each group (diabetes and no diabetes).

Table 3—

Distribution of hospital admissions, hospital days, and costs for individuals with diabetes compared with the expected values for the total number of patients by age-group

Hospital admissions
Hospital days
Costs (euros)
ActualExpectedExcessPercent excessRelative risk*ActualExpectedExcessPercent excessActualExpectedExcessPercent excess
All age-groups              
    Acute complications 2,557 — 2,557 9.4 — 22,333 — 22,333 6.7 3,252,095 — 3,252,095 4.2 
    Neurological 869 341 528 1.9 3.3 13,572 4,562 9,010 2.7 3,520,710 1,285,427 2,235,283 2.9 
    Ophthalmological 1,349 936 413 1.5 2.8 5,180 2,959 2,221 0.7 1,652,065 1,097,048 555,017 0.7 
    Cardiovascular 17,174 4,114 13,060 48.2 8.1 195,650 40,105 155,545 46.9 46,083,642 9,779,640 36,304,002 47.0 
    Musculoskeletal and skin 429 374 55 0.2 1.1 5,482 2,661 2,821 0.8 869,272 630,864 238,408 0.3 
    Genitourinary 954 383 571 2.1 3.8 9,808 3,359 6,449 1.9 2,200,419 818,808 1,381,611 1.8 
    Comorbidity 29,122 19,220 9,902 36.6 1.3 345,026 211,279 133,747 40.3 74,931,013 41,690,657 33,240,356 43.1 
    Total 52,454 25,369 27,085 100 2.1 597,051 264,925 331,926 100 132,509,217 55,302,444 77,206,773 100 
Individuals >75 years of age              
    Acute complications 508 — 468 10.5 — 5,130 — 5,130 9.3 686,392 — 686,392 4.3 
    Neurological 273 143 130 2.7 1.9 5,245 2,517 2,728 1,367,902 704,349 663,553 4.2 
    Ophthalmological 333 495 −162 — 0.7 1,101 1,405 −304 — 401,409 575,244 −173,835 — 
    Cardiovascular 5,300 2,182 3,118 64.7 2.4 59,057 21,904 37,153 67.6 15,175,988 5,497,688 9,678,299 61.3 
    Musculoskeletal and skin 103 109 −6 — 0.9 1,495 1,061 434 0.8 236,100 208,682 27,418 0.2 
    Genitourinary 285 193 92 1.9 15 3,508 1,834 1,674 580,265 362,398 217,867 1.4 
    Comorbidity 8,816 7,680 1,136 23.6 1.1 107,002 98,846 8,156 14.8 23,030,973 18,330,398 4,700,575 29.7 
    Total 15,618 10,802 4,816 100 1.45 182,538 127,567 54,971 100 41,479,029 25,678,759 15,800,270 100 
Individuals 45–75 years of age              
    Acute complications 861 — 468 4.2 — 8,838 — 8,838 3.3 1,163,354 — 1,163,354 2.0 
    Neurological 561 187 374 1.8 7,913 1,934 5,979 2.3 2,057,431 556,342 1,501,088 2.6 
    Ophthalmological 964 432 532 2.6 2.2 3,719 1,502 2,217 0.9 1,178,520 510,584 667,936 1.2 
    Cardiovascular 11,643 1,899 9,744 47.1 6.1 134,187 17,970 116,217 44.7 30,348,995 4,218,306 26,130,689 45.1 
    Musculoskeletal and skin 307 244 63 0.3 1.3 3,835 1,500 2,335 0.9 600,652 389,338 211,314 0.4 
    Genitourinary 613 182 431 2.1 3.4 5,809 1,461 4,348 1.7 1,364,925 427,033 937,892 1.6 
    Comorbidity 18,479 9,810 8,669 41.9 1.9 223,133 102,986 120,147 46.2 48,707,862 21,318,638 27,389,225 47.2 
    Total 33,428 12,754 20,674 100 2.6 387,234 127,353 259,882 100 85,421,739 27,420,240 58,001,499 100 
Individuals 15–44 years of age              
    Acute complications 720 720 69.2 — 5,037 — 5,037 37.9 860,756 — 860,756 31.3 
    Neurological 34 10 24 2.3 3.4 414 106 308 2.3 94,158 23,333 70,825 2.6 
    Ophthalmological 52 43 4.2 360 51 309 2.3 72,136 10,996 61,140 2.2 
    Cardiovascular 224 32 192 18.5 2,361 226 2,135 16.1 545,278 61,850 483,428 17.6 
    Musculoskeletal and skin 18 20 −2 — 0.9 150 95 55 0.4 31,263 31,008 255 0.0 
    Genitourinary 56 48 4.6 6.7 491 61 430 32 255,229 28,163 27,066 8.3 
    Comorbidity 1,689 1,674 15 1.5 14,209 9,202 5,007 37.7 3,026,573 1,979,162 1,047,411 38.1 
    Total 2,793 1,753 1,040 100 1.59 23,022 9,741 13,281 100 4,885,394 2,134,513 2,750,881 100 
Individuals <15 years of age              
    Acute complications 468 — 468 84.3 — 3,328 — 3,328 87.7 541,593 — 541,593 82.8 
    Chronic complications 1.1 47 19 28 0.7 15,857 6,473 9,384 1.4 
    Comorbidity 138 56 81 14.7 2.5 682 245 437 11.5 165,605 62,459 103,146 15.8 
    Total 615 60 555 100 10.3 4,057 264 3,794 100 723,055 68,932 654,123 100 
Hospital admissions
Hospital days
Costs (euros)
ActualExpectedExcessPercent excessRelative risk*ActualExpectedExcessPercent excessActualExpectedExcessPercent excess
All age-groups              
    Acute complications 2,557 — 2,557 9.4 — 22,333 — 22,333 6.7 3,252,095 — 3,252,095 4.2 
    Neurological 869 341 528 1.9 3.3 13,572 4,562 9,010 2.7 3,520,710 1,285,427 2,235,283 2.9 
    Ophthalmological 1,349 936 413 1.5 2.8 5,180 2,959 2,221 0.7 1,652,065 1,097,048 555,017 0.7 
    Cardiovascular 17,174 4,114 13,060 48.2 8.1 195,650 40,105 155,545 46.9 46,083,642 9,779,640 36,304,002 47.0 
    Musculoskeletal and skin 429 374 55 0.2 1.1 5,482 2,661 2,821 0.8 869,272 630,864 238,408 0.3 
    Genitourinary 954 383 571 2.1 3.8 9,808 3,359 6,449 1.9 2,200,419 818,808 1,381,611 1.8 
    Comorbidity 29,122 19,220 9,902 36.6 1.3 345,026 211,279 133,747 40.3 74,931,013 41,690,657 33,240,356 43.1 
    Total 52,454 25,369 27,085 100 2.1 597,051 264,925 331,926 100 132,509,217 55,302,444 77,206,773 100 
Individuals >75 years of age              
    Acute complications 508 — 468 10.5 — 5,130 — 5,130 9.3 686,392 — 686,392 4.3 
    Neurological 273 143 130 2.7 1.9 5,245 2,517 2,728 1,367,902 704,349 663,553 4.2 
    Ophthalmological 333 495 −162 — 0.7 1,101 1,405 −304 — 401,409 575,244 −173,835 — 
    Cardiovascular 5,300 2,182 3,118 64.7 2.4 59,057 21,904 37,153 67.6 15,175,988 5,497,688 9,678,299 61.3 
    Musculoskeletal and skin 103 109 −6 — 0.9 1,495 1,061 434 0.8 236,100 208,682 27,418 0.2 
    Genitourinary 285 193 92 1.9 15 3,508 1,834 1,674 580,265 362,398 217,867 1.4 
    Comorbidity 8,816 7,680 1,136 23.6 1.1 107,002 98,846 8,156 14.8 23,030,973 18,330,398 4,700,575 29.7 
    Total 15,618 10,802 4,816 100 1.45 182,538 127,567 54,971 100 41,479,029 25,678,759 15,800,270 100 
Individuals 45–75 years of age              
    Acute complications 861 — 468 4.2 — 8,838 — 8,838 3.3 1,163,354 — 1,163,354 2.0 
    Neurological 561 187 374 1.8 7,913 1,934 5,979 2.3 2,057,431 556,342 1,501,088 2.6 
    Ophthalmological 964 432 532 2.6 2.2 3,719 1,502 2,217 0.9 1,178,520 510,584 667,936 1.2 
    Cardiovascular 11,643 1,899 9,744 47.1 6.1 134,187 17,970 116,217 44.7 30,348,995 4,218,306 26,130,689 45.1 
    Musculoskeletal and skin 307 244 63 0.3 1.3 3,835 1,500 2,335 0.9 600,652 389,338 211,314 0.4 
    Genitourinary 613 182 431 2.1 3.4 5,809 1,461 4,348 1.7 1,364,925 427,033 937,892 1.6 
    Comorbidity 18,479 9,810 8,669 41.9 1.9 223,133 102,986 120,147 46.2 48,707,862 21,318,638 27,389,225 47.2 
    Total 33,428 12,754 20,674 100 2.6 387,234 127,353 259,882 100 85,421,739 27,420,240 58,001,499 100 
Individuals 15–44 years of age              
    Acute complications 720 720 69.2 — 5,037 — 5,037 37.9 860,756 — 860,756 31.3 
    Neurological 34 10 24 2.3 3.4 414 106 308 2.3 94,158 23,333 70,825 2.6 
    Ophthalmological 52 43 4.2 360 51 309 2.3 72,136 10,996 61,140 2.2 
    Cardiovascular 224 32 192 18.5 2,361 226 2,135 16.1 545,278 61,850 483,428 17.6 
    Musculoskeletal and skin 18 20 −2 — 0.9 150 95 55 0.4 31,263 31,008 255 0.0 
    Genitourinary 56 48 4.6 6.7 491 61 430 32 255,229 28,163 27,066 8.3 
    Comorbidity 1,689 1,674 15 1.5 14,209 9,202 5,007 37.7 3,026,573 1,979,162 1,047,411 38.1 
    Total 2,793 1,753 1,040 100 1.59 23,022 9,741 13,281 100 4,885,394 2,134,513 2,750,881 100 
Individuals <15 years of age              
    Acute complications 468 — 468 84.3 — 3,328 — 3,328 87.7 541,593 — 541,593 82.8 
    Chronic complications 1.1 47 19 28 0.7 15,857 6,473 9,384 1.4 
    Comorbidity 138 56 81 14.7 2.5 682 245 437 11.5 165,605 62,459 103,146 15.8 
    Total 615 60 555 100 10.3 4,057 264 3,794 100 723,055 68,932 654,123 100 
*

Relative risk of admission for individuals with diabetes compared with individuals without diabetes for each age-group and disease type.

This study was partly financed by a grant from the Consejería de Salud de la Junta de Andalucía (01/118) and by a grant from the Instituto de Salud Carlos III, RCMN (C03/08), Spain.

The authors thank Ian Johnstone for the English language version of the study.

1
King H, Aubert RE, Herman WH: Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections.
Diabetes Care
21
:
1414
–1431,
1998
2
Goday A, Delgado A, Díaz-Cadorniga F, de Pablos P, Vazquez JA, Soto E: Epidemiología de la diabetes tipo 2 en España.
Endocrinol Nutr
49
:
113
–126,
2002
3
Rubin RJ, Altman WM, Mendelson DN: Health care expenditures for people with diabetes mellitus, 1992.
J Clin Endocrinol Metab
78
:
809A
–809F,
1994
4
Jonsson B: Revealing the cost of type II diabetes in Europe.
Diabetologia
45
:
S5
–12,
2002
5
Olveira G, Carral F: Costes de la diabetes: una reflexión desde la situación asistencial en España.
Av Diabetol
16
:
121
–130,
2000
6
American Diabetes Association: Economic cost of diabetes in the U.S. in 2002.
Diabetes Care
26
:
917
–932,
2003
7
Hart WM, Espinosa C, Rovira J: El coste de la diabetes mellitus conocida en España.
Med Clin (Barc)
109
:
289
–293,
1997
8
Mata M, Antonanzas F, Tafalla M, Sanz P: The cost of type 2 diabetes in Spain: the CODE-2 study.
Gac Sanit
16
:
511
–520,
2002
9
Lopez-Bastida J, Serrano-Aguilar P, Duque-Gonzalez B: The social and economic cost of diabetes mellitus.
Aten Primaria
29
:
145
–150,
2002
10
Carral F, Olveira G, Salas J, García L, Sillero A, Aguilar M: Care resource utilization and direct costs incurred by people with diabetes in a Spanish hospital.
Diabetes Res Clin Pract
56
:
27
–34,
2002
11
Monereo S, Pavon I, Vega B, Elviro R, Duran M: Complicaciones de la diabetes mellitus: impacto sobre los costes hospitalarios.
Endocrinologia
46
:
55
–59,
1999
12
Carral F, Aguilar M, Olveira G, Mangas A, Domenech I, Torres I: Increased hospital expenditures in diabetic patients hospitalized for cardiovascular diseases.
J Diabetes Complications
17
:
331
–336,
2003
13
Currie CJ, Morgan CL, Peters JR: Patterns and costs of hospital care for coronary heart disease related and not related to diabetes.
Heart
78
:
544
–549,
1997
14
Anonymous:
Anuario Estadistico de Andalucia 1999
. Sevilla, Spain, Instituto de Estadistica de Andalucia,
2000
15
Ray N, Thamer M, Taylor T, Fehrenbach A, Ratner R: Hospitalization and expenditures for the treatment of general medical conditions among the U.S. diabetic population in 1991.
J Clin Endocrinol Metab
81
:
3671
–3679,
1996
16
Soriguer-Escofet F, Esteva I, Rojo-Martinez G, Ruiz de Adana S, Catala M, Merelo MJ, Aguilar M, Tinahones F, Garcia-Almeida JM, Gomez-Zumaquero JM, Cuesta-Munoz AL, Ortego J, Freire JM: Prevalence of latent autoimmune diabetes of adults (LADA) in Southern Spain.
Diabetes Res Clin Pract
56
:
213
–220,
2002
17
Glauber H, Brown J: Impact of cardiovascular disease on health care utilization in a defined diabetic population.
J Clin Epidemiol
47
:
1133
–1142,
1994
18
Massi-Benedetti M: The cost of diabetes type II in Europe: the CODE-2 Study.
Diabetologia
45
:
S1
–S4,
2002
19
Nichols GA, Brown JB: The impact of cardiovascular disease on medical care costs in subjects with and without type 2 diabetes.
Diabetes Care
25
:
482
–486,
2002
20
Brandle M, Zhou H, Smith BRK, Marriot D, Burke R, Tabaei BP, Brown MB, Herman WH: The direct medical cost of type 2 diabetes.
Diabetes Care
26
:
2300
–2304,
2003
21
Alexander CM, Landsman PB, Teutsch SM, Haffner SM: NCEP-defined metabolic syndrome, diabetes, and prevalence of coronary heart disease among NHANES III paricipants age 50 years and older.
Diabetes
52
:
1210
–1214,
2003
22
Klonoff D, Schwartz D: An economic analysis of interventions for diabetes.
Diabetes Care
23
:
390
–404,
2000
23
Van Den Berghe G, Mesotten D: Clinical potential of insulin therapy in critically ill patients.
Drugs
63
:
625
–636,
2003
24
Carral F, Olveira G, Aguilar M, Ortego J, Gavilán I, Domenech I, Escobar L: Hospital discharge records under-report the prevalence of diabetes in inpatients.
Diabetes Res Clin Pract
59
:
145
–151,
2003
25
Leventan CS, Passaro M, Jablonski K, Kass M, Ratner RE: Unrecognized diabetes among hospitalized patients.
Diabetes Care
21
:
246
–249,
1998
26
Ragnarson-Tennvall G, Apelqvist J, Eneroth M: The inpatient care of patients with diabetes mellitus and foot ulcers: a validation study of the correspondence between medical records and the Swedish Inpatient Registry with the consequences for cost estimations.
J Intern Med
248
:
397
–405,
2000

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.