( 5,6 ) and ranks ninth as a global cause of death ( 7 ) . deaths from diabetes are on the increase worldwide ( 7 ) but are decreasing in the u.s . the growing prevalence of diabetes imposes a substantial financial burden on affected individuals and their families , communities , and country ( 2,3 ) . globally , at least $ 548.5 billion was spent on diabetes - related expenditures ( 9 ) , and in the u.s . , direct medical costs associated with diabetes were $ 176 billion in 2012 ( 1,3 ) . this is almost double to eight times the direct medical cost of other chronic diseases : $ 32 billion for copd in 2010 ( 10 ) , $ 93 billion for all cancers in 2008 ( 11 ) , $ 21 billion for heart failure in 2012 ( 12 ) , and $ 43 billion for hypertension in 2010 ( 13 ) . in the u.s . , total economic cost of diabetes rose by 41% from 2007 to 2012 ( 2 ) . furthermore , individuals with diabetes spend about $ 7,900/year on diabetes - related medical expenditures ( 2 ) ; high rates of inpatient hospitalization and diabetes - related complications account for a major part ( 1416 ) . studies examining the cost of diabetes and its related complications exist ( 2,1622 ) . however , the majority has studied either just a single year or one part of health care expenditures , such as out - of - pocket expenditures or cost trends in a managed care setting . in this study adults with diabetes from 2002 to 2011 using a novel cost estimation methodology and a nationally representative survey . the cost methodology used in this study addresses the probability of observing a zero versus positive medical expenditure and a generalized linear model ( glm ) was estimated conditional on having a medical expenditure . adults aged > 17 years from 2002 to 2011 using the medical expenditure panel survey household component ( meps - hc ) . the meps provides nationally representative estimates of health care use , expenditures , sources of payment , and health insurance coverage for the u.s . civilian noninstitutionalized population ( 23 ) . the panel design of the survey includes five rounds of interviews covering two full calendar years and provides data for examining person - level changes in selected variables such as expenditures and health status ( 23 ) . the meps has a complex design that includes clustering , stratification , and multistage and disproportionate sampling with oversampling of minorities ( 24 ) . the 20022011 costs were adjusted to 2014 dollar value using the consumer price index obtained from the bureau of labor statistics ( 25 ) . we combined 10 years of data because they have a common variance structure necessary to ensure compatibility of our variables within the complex sample design ( 26 ) . additionally , pooled data increase the sample size and the precision of the estimates for the diabetes subpopulation and aid the evaluation of trends in health care expenditures over time ( 27 ) . we adjusted the analytic sampling weight variable by dividing with the number of years pooled . the sum of these adjusted weights represents the average annual population size for the pooled period . our study accounts for the sampling weights , clustering , and stratification design to estimate the nationally representative aggregate for unadjusted and adjusted health care expenditures in individuals with diabetes in the u.s . the dependent variable was total direct health care expenditures for the calendar year for each individual , including out - of - pocket payments and payments by private insurance , medicaid , medicare , and other sources ( 23 ) . medical expenditures include office - based medical provider , hospital outpatient , emergency room ( er ) , inpatient hospital ( including zero night stays ) , pharmacy , dental , home health care , and other medical expenditures ( 23 ) . the primary independent variable was self - reported diabetes measured as a yes response to the question ,  have you ever been diagnosed with diabetes ?  all covariates used for this analysis were based on self - report . we included the comorbidities as binary indicators based on a positive response to the question ,  have you ever been diagnosed with hypertension , stroke , emphysema , joint pain , arthritis , or asthma ?  cardiovascular disease ( cvd ) indicates a positive response to a question ,  have you ever been diagnosed with coronary heart disease , angina , myocardial infarction , or other heart diseases ?  race / ethnicity groups were categorized as non - hispanic white ( nhw ) , non - hispanic black ( nhb ) , and hispanic / other race . education was coded as less than high school ( grade 11 ) , high school , and college or more ( grade 13 ) . marital status was coded as married , nonmarried ( divorced , separated , or widowed ) , and never married . sex was coded as female versus male , and age was coded as 1844 , 4564 , and 6585 years . metropolitan statistical area was coded as yes versus no at end of the year ( 31 december ) . health insurance was coded in three categories : private , public only , and uninsured at all times in the year . income level was defined as a percentage of the poverty level and coded as poor or negative income ( < 100% ) , low income ( 100 to < 200% ) , middle income ( 200 to < 400% ) , and high income ( 400% ) . calendar year was coded in five categories : 2002/2003 , 2004/2005 , 2006/2007 , 2008/2009 , and 2010/2011 for the pooled data . we followed manning and mullahy s recommendation of a two - part general linear model that allows for mixed discrete - continuous variables ( 29 ) . a probit model was first estimated for the probability of observing a zero versus positive medical expenditure , and then a glm was estimated conditional on having a positive medical expenditure ( 3032 ) . the model addresses the zero concentration as well as the positive skewness of expenditures ( 33 ) and allows users to calculate incremental effects and standard errors from the two parts of the model ( 30 ) . population was ensured by taking into account the complex design of the meps via sampling weight , variance estimation stratum , and primary sampling unit ( clustering ) . the weighted model was used to estimate trends in medical expenditures in adults with diabetes and the adjusted burden of medical expenditures for individuals with diabetes on the u.s . we adjusted for sociodemographic factors ( age , sex , race , marital status , education , health insurance , metropolitan statistical area , region , and income level ) and comorbidities ( hypertension , cvd , stroke , emphysema , joint pain , arthritis , and asthma ) . a modified park test ( 27,29,30 ) was used to verify that poisson distribution ( coefficient of  = 0.8 ) with a log link was the best - fitting glm to get consistent estimation of coefficients and incremental effects of medical expenditures . the variance inflation factor for all predictors used in the two - part model ranged from 1.0 to 1.8 , indicating no multicollinearity problems . the f test for the model indicated that the model was significant . all analyses used person - level weights and were performed using stata 13 . adults aged > 17 years from 2002 to 2011 using the medical expenditure panel survey household component ( meps - hc ) . the meps provides nationally representative estimates of health care use , expenditures , sources of payment , and health insurance coverage for the u.s . civilian noninstitutionalized population ( 23 ) . the panel design of the survey includes five rounds of interviews covering two full calendar years and provides data for examining person - level changes in selected variables such as expenditures and health status ( 23 ) . the meps has a complex design that includes clustering , stratification , and multistage and disproportionate sampling with oversampling of minorities ( 24 ) . the 20022011 costs were adjusted to 2014 dollar value using the consumer price index obtained from the bureau of labor statistics ( 25 ) . we combined 10 years of data because they have a common variance structure necessary to ensure compatibility of our variables within the complex sample design ( 26 ) . additionally , pooled data increase the sample size and the precision of the estimates for the diabetes subpopulation and aid the evaluation of trends in health care expenditures over time ( 27 ) . we adjusted the analytic sampling weight variable by dividing with the number of years pooled . the sum of these adjusted weights represents the average annual population size for the pooled period . our study accounts for the sampling weights , clustering , and stratification design to estimate the nationally representative aggregate for unadjusted and adjusted health care expenditures in individuals with diabetes in the u.s . the dependent variable was total direct health care expenditures for the calendar year for each individual , including out - of - pocket payments and payments by private insurance , medicaid , medicare , and other sources ( 23 ) . medical expenditures include office - based medical provider , hospital outpatient , emergency room ( er ) , inpatient hospital ( including zero night stays ) , pharmacy , dental , home health care , and other medical expenditures ( 23 ) . the primary independent variable was self - reported diabetes measured as a yes response to the question ,  have you ever been diagnosed with diabetes ? we included the comorbidities as binary indicators based on a positive response to the question ,  have you ever been diagnosed with hypertension , stroke , emphysema , joint pain , arthritis , or asthma ? cardiovascular disease ( cvd ) indicates a positive response to a question ,  have you ever been diagnosed with coronary heart disease , angina , myocardial infarction , or other heart diseases ?  race / ethnicity groups were categorized as non - hispanic white ( nhw ) , non - hispanic black ( nhb ) , and hispanic / other race . education was coded as less than high school ( grade 11 ) , high school , and college or more ( grade 13 ) . marital status was coded as married , nonmarried ( divorced , separated , or widowed ) , and never married . sex was coded as female versus male , and age was coded as 1844 , 4564 , and 6585 years . metropolitan statistical area was coded as yes versus no at end of the year ( 31 december ) . health insurance was coded in three categories : private , public only , and uninsured at all times in the year . income level was defined as a percentage of the poverty level and coded as poor or negative income ( < 100% ) , low income ( 100 to < 200% ) , middle income ( 200 to < 400% ) , and high income ( 400% ) . calendar year was coded in five categories : 2002/2003 , 2004/2005 , 2006/2007 , 2008/2009 , and 2010/2011 for the pooled data . the dependent variable was total direct health care expenditures for the calendar year for each individual , including out - of - pocket payments and payments by private insurance , medicaid , medicare , and other sources ( 23 ) . medical expenditures include office - based medical provider , hospital outpatient , emergency room ( er ) , inpatient hospital ( including zero night stays ) , pharmacy , dental , home health care , and other medical expenditures ( 23 ) . the primary independent variable was self - reported diabetes measured as a yes response to the question ,  have you ever been diagnosed with diabetes ? we included the comorbidities as binary indicators based on a positive response to the question ,  have you ever been diagnosed with hypertension , stroke , emphysema , joint pain , arthritis , or asthma ?  cardiovascular disease ( cvd ) indicates a positive response to a question ,  have you ever been diagnosed with coronary heart disease , angina , myocardial infarction , or other heart diseases ?  race / ethnicity groups were categorized as non - hispanic white ( nhw ) , non - hispanic black ( nhb ) , and hispanic / other race . education was coded as less than high school ( grade 11 ) , high school , and college or more ( grade 13 ) . marital status was coded as married , nonmarried ( divorced , separated , or widowed ) , and never married . sex was coded as female versus male , and age was coded as 1844 , 4564 , and 6585 years . metropolitan statistical area was coded as yes versus no at end of the year ( 31 december ) . health insurance was coded in three categories : private , public only , and uninsured at all times in the year . income level was defined as a percentage of the poverty level and coded as poor or negative income ( < 100% ) , low income ( 100 to < 200% ) , middle income ( 200 to < 400% ) , and high income ( 400% ) . calendar year was coded in five categories : 2002/2003 , 2004/2005 , 2006/2007 , 2008/2009 , and 2010/2011 for the pooled data . we followed manning and mullahy s recommendation of a two - part general linear model that allows for mixed discrete - continuous variables ( 29 ) . a probit model was first estimated for the probability of observing a zero versus positive medical expenditure , and then a glm was estimated conditional on having a positive medical expenditure ( 3032 ) . the model addresses the zero concentration as well as the positive skewness of expenditures ( 33 ) and allows users to calculate incremental effects and standard errors from the two parts of the model ( 30 ) . population was ensured by taking into account the complex design of the meps via sampling weight , variance estimation stratum , and primary sampling unit ( clustering ) . the weighted model was used to estimate trends in medical expenditures in adults with diabetes and the adjusted burden of medical expenditures for individuals with diabetes on the u.s . population . we adjusted for sociodemographic factors ( age , sex , race , marital status , education , health insurance , metropolitan statistical area , region , and income level ) and comorbidities ( hypertension , cvd , stroke , emphysema , joint pain , arthritis , and asthma ) . a modified park test ( 27,29,30 ) was used to verify that poisson distribution ( coefficient of  = 0.8 ) with a log link was the best - fitting glm to get consistent estimation of coefficients and incremental effects of medical expenditures . the variance inflation factor for all predictors used in the two - part model ranged from 1.0 to 1.8 , indicating no multicollinearity problems . the f test for the model indicated that the model was significant . all analyses used person - level weights and were performed using stata 13 . as shown in table 1 , significant differences in diabetes status were found by time , specific demographic characteristics , and comorbid conditions . diabetes was more likely in nhb and hispanics / other race , 45 years of age , men , married and nonmarried , high school , publicly insured , rural and southern dwellers , and poor , low , and middle income earners . individuals with diabetes were more likely to have all comorbidities examined , and diabetes prevalence appeared to increase in 2006/2007 , 2008/2009 , and 2010/2011 . the total mean unadjusted direct expenditures for individuals with diabetes increased from $ 11,667 ( 95% ci 10,97012,363 ) in 2002/2003 to $ 12,802 ( 11,76713,835 ) in 2004/2005 , and then declined continuously to $ 11,751 ( 11,05412,448 ) in 2010/2011 ( table 2 and fig . total mean unadjusted medical expenditures for individuals without diabetes increased continuously from $ 4,651 ( 4,4074,896 ) in 2002/2003 to $ 5,528 ( 5,2935,763 ) in 2010/2011 . relative to individuals without diabetes ( $ 5,058 [ 4,9495,166 ] ) , individuals with diabetes had more than double ( $ 12,180 [ 11,77512,586 ] ) the unadjusted pooled mean expenditures over the 10-year period examined ( table 2 ) . unadjusted means of total health care and health care service expenditures by diabetes status inpatient , hospital inpatient ; outpatient , hospital outpatient . * level of significance p < 0.05 . , the unadjusted inpatient expenditures rose initially from $ 4,014 ( 95% ci 3,4574,573 ) in 2002/2003 to $ 4,183 ( 3,4884,879 ) in 2004/2005 , and then decreased continuously to $ 3,443 ( 2,9843,904 ) through 2010/2011 ( table 2 and fig . individuals without diabetes had declining inpatient hospital expenditures from 2002/2003 ( $ 1,444 [ 1,2391,650 ] ) through 2008/2009 ( $ 1,378 [ 1,2671,489 ] ) but then increased in 2010/2011 ( $ 1,632 [ 1,4701,796 ] ) , exceeding 20022009 levels . as shown in table 2 , prescription medicine expenditures increased from 2002/2003 through 2006/2007 ( $ 3,298 to $ 3,709 ) and then decreased slightly from 2006/2007 through 2010/2011 ( $ 3,709 to $ 3 , 601 ) but remained higher than 2002/2003 levels . trends in office - based and hospital outpatient expenditures were similar ; 2010/2011 expenditures were higher than 2002/2003 and 2006/2007 ; however , 2004/2005 and 2008/2009 expenditures were the peak years . er expenditures rose from 2002/2003 through 2008/2009 and peaked at $ 383 ( 95% ci 244522 ) and then fell to $ 351 ( 303400 ) in 2010/2011 but remained higher than pre-2008 levels . although er expenditures in individuals without diabetes rose throughout the 10 years examined , the levels never reached the lowest er expenditure year for people with diabetes . trends in home health expenditures decreased from 2002/2003 through 2010/2011 among people with diabetes but showed no trend in people without diabetes . after adjusting for relevant covariates as well as time , individuals with diabetes had $ 2,558 ( 95% ci 2,2662,849 ) significantly higher expenditures compared with those without diabetes ( table 3 ) . being female , high school graduate , urban resident , and publicly insured were significantly associated with higher total health care expenditures . nhb or hispanic / other race , nonmarried , never married , uninsured , residence in the south , and low , middle , or high income were significantly associated with lower total health care expenditures . adjusted mean expenditures were significantly higher by $ 433 ( 95% ci 140726 ) in 2004/2005 , $ 373 ( 88660 ) in 2006/2007 , and $ 342 ( 53631 ) in 2010/2011 ( table 3 ) . two - part regression model : incremental effects of health care expenditures by diabetes status among u.s . adults accounting for relevant covariates ( adjusted to 2014 dollars ) primary outcome variable in this model is total health care expenditures . * * * level of significance p  0.01 . * * level of significance p  0.05 . based on the average yearly estimate , unadjusted total direct health care expenditures for adults with diabetes in the u.s . population were approximately $ 218.6 billion / year and adjusted total incremental expenditures were approximately $ 46 billion / year . as shown in table 1 , significant differences in diabetes status were found by time , specific demographic characteristics , and comorbid conditions . diabetes was more likely in nhb and hispanics / other race , 45 years of age , men , married and nonmarried , high school , publicly insured , rural and southern dwellers , and poor , low , and middle income earners . individuals with diabetes were more likely to have all comorbidities examined , and diabetes prevalence appeared to increase in 2006/2007 , 2008/2009 , and 2010/2011 . the total mean unadjusted direct expenditures for individuals with diabetes increased from $ 11,667 ( 95% ci 10,97012,363 ) in 2002/2003 to $ 12,802 ( 11,76713,835 ) in 2004/2005 , and then declined continuously to $ 11,751 ( 11,05412,448 ) in 2010/2011 ( table 2 and fig . total mean unadjusted medical expenditures for individuals without diabetes increased continuously from $ 4,651 ( 4,4074,896 ) in 2002/2003 to $ 5,528 ( 5,2935,763 ) in 2010/2011 . relative to individuals without diabetes ( $ 5,058 [ 4,9495,166 ] ) , individuals with diabetes had more than double ( $ 12,180 [ 11,77512,586 ] ) the unadjusted pooled mean expenditures over the 10-year period examined ( table 2 ) . unadjusted means of total health care and health care service expenditures by diabetes status inpatient , hospital inpatient ; outpatient , hospital outpatient . , the unadjusted inpatient expenditures rose initially from $ 4,014 ( 95% ci 3,4574,573 ) in 2002/2003 to $ 4,183 ( 3,4884,879 ) in 2004/2005 , and then decreased continuously to $ 3,443 ( 2,9843,904 ) through 2010/2011 ( table 2 and fig . individuals without diabetes had declining inpatient hospital expenditures from 2002/2003 ( $ 1,444 [ 1,2391,650 ] ) through 2008/2009 ( $ 1,378 [ 1,2671,489 ] ) but then increased in 2010/2011 ( $ 1,632 [ 1,4701,796 ] ) , exceeding 20022009 levels . as shown in table 2 , prescription medicine expenditures increased from 2002/2003 through 2006/2007 ( $ 3,298 to $ 3,709 ) and then decreased slightly from 2006/2007 through 2010/2011 ( $ 3,709 to $ 3 , 601 ) but remained higher than 2002/2003 levels . trends in office - based and hospital outpatient expenditures were similar ; 2010/2011 expenditures were higher than 2002/2003 and 2006/2007 ; however , 2004/2005 and 2008/2009 expenditures were the peak years . er expenditures rose from 2002/2003 through 2008/2009 and peaked at $ 383 ( 95% ci 244522 ) and then fell to $ 351 ( 303400 ) in 2010/2011 but remained higher than pre-2008 levels . although er expenditures in individuals without diabetes rose throughout the 10 years examined , the levels never reached the lowest er expenditure year for people with diabetes . trends in home health expenditures decreased from 2002/2003 through 2010/2011 among people with diabetes but showed no trend in people without diabetes . after adjusting for relevant covariates as well as time , individuals with diabetes had $ 2,558 ( 95% ci 2,2662,849 ) significantly higher expenditures compared with those without diabetes ( table 3 ) . being female , high school graduate , urban resident , and publicly insured were significantly associated with higher total health care expenditures . nhb or hispanic / other race , nonmarried , never married , uninsured , residence in the south , and low , middle , or high income were significantly associated with lower total health care expenditures . adjusted mean expenditures were significantly higher by $ 433 ( 95% ci 140726 ) in 2004/2005 , $ 373 ( 88660 ) in 2006/2007 , and $ 342 ( 53631 ) in 2010/2011 ( table 3 ) . two - part regression model : incremental effects of health care expenditures by diabetes status among u.s . adults accounting for relevant covariates ( adjusted to 2014 dollars ) primary outcome variable in this model is total health care expenditures . * * * level of significance p  0.01 . * * level of significance p  0.05 . based on the average yearly estimate , unadjusted total direct health care expenditures for adults with diabetes in the u.s . population were approximately $ 218.6 billion / year and adjusted total incremental expenditures were approximately $ 46 billion / year . our findings show that compared with individuals without diabetes , individuals with diabetes had significantly higher health expenditures from 2002 to 2011 and the bulk of the expenditures came from hospital inpatient and prescription expenditures . trends in total direct health care expenditures among adults with diabetes increased initially but then declined from 2004/2005 through 2010/2011 . people with diabetes had more than two times higher total direct health care expenditures compared with people without diabetes . hospital inpatient stay , prescription medicine , and office - based visit were 2.6 , 3.4 , and 1.9 times higher in people with diabetes , respectively , compared with people without diabetes . other factors associated with increased health care cost in the u.s . were age 45 years , high school degree , public insurance status , urban dwellers , and presence of comorbidities , whereas being minority , unmarried ( non- and never married ) , uninsured , residence in the south , and low , middle , or high income earners were associated with decreased cost . existing studies ( 2,20,21 ) on the cost of diabetes have examined 13-year periods or studied limited categories of health care expenditures . this study has several major contributions : 1 ) the ability to examine trends in cost using a nationally representative survey ; 2 ) the use of multiple cost categories , including inpatient , outpatient , prescription medications , dental , er , and home health expenditures ; 3 ) the use of a novel cost methodology that addresses the limitation of prior studies and provides ways of evaluating incremental cost ; 4 ) the inclusion of a variety of comorbidities so that the effect observed is an independent effect of diabetes ; 5 ) the use of a pooled analysis that provides a large sample size ; and 6 ) the inclusion of unadjusted cost estimates that reflect the actual cost accrued by people with diabetes over time . our study is comparable to the few studies that have examined the medical cost of diabetes ( 2,20 ) . a study by the american diabetes association including institutionalized people and indirect costs and using multiple data sources reports that people with diabetes have 2.3 times higher expenditures ( $ 13,700 per year in 2012 ) compared with individuals without diabetes . our pooled estimate of $ 12,180 was similar to this study but we did not include institutionalized adults , which could explain the difference in estimates . in a managed care organization study ( 20 ) , the adjusted direct medical cost of type 2 diabetes was $ 2,465 , which is somewhat consistent with our findings of $ 2,558 . another study observed annual medical spending of approximately $ 13,966 in people with diabetes similar to our study ( 19 ) . office - based and hospital outpatient expenditures , which are both outpatient services , accounted for 19 and 8% of health care expenditures among people with diabetes , respectively . the trends observed in outpatient services remain unclear ; one hypothesis could be that after the recession in 2007 , unemployment may have led to decreased access to care and health care use . however , this is unlikely because one would expect a concurrent increase in inpatient expenditures from poor diabetes outcomes and complications . it is also unclear why inpatient expenditures increased from $ 4,014 in 2002/2003 to $ 4,183 in 2004/2005 , and then decreased continuously to $ 3,443 through 2010/2011 . this could be explained by decreasing rates of potentially preventable hospitalizations for conditions such as diabetes ( 15 ) and implementation of medicare part d. studies suggest implementation of medicare part d had a positive impact on health care cost by reduced nondrug medical spending , especially inpatient and skilled nursing facility care ( 34 ) , increased antihypertensive and antilipemic drug use ( 35,36 ) , and increased medication possession ratios among adults with diabetes ( 37 ) . our findings of a decline in inpatient and total expenditures post  part d implementation in 2006 for individuals with diabetes are consistent with the literature . other possible explanations for the decline in inpatient expenditures include macroeconomic issues ( the economic decline may have prevented people from utilizing care regardless of need ) , better diabetic medications and medication adherence , disease management programs , implementation of quality of care standards ( better physician care ) , and survival bias , meaning sicker people with diabetes may have died , leaving a healthier population who would have lower cost . it is important to note that these are potential explanatory factors that need to be confirmed in future studies . there is also some evidence to support the role of self - care and medication adherence on cost reduction . a study showed that diabetes self - management education and having a regular provider are associated with a high probability of seeking appropriate care and engaging in beneficial activities ( 6 ) , while another study among veterans with diabetes showed that inpatient costs can be saved ( by approximately $ 1 billion / year ) if nonadherent veterans became adherent ( 38 ) . policies investing in such interventions will improve health outcomes in people with diabetes and consequently prevent expensive hospital inpatient events . additionally , the creation of awareness and providing insightful education to affected individuals and health care providers are ways to curb this growing pandemic and its associated financial burden . first , individuals with diabetes as well as comorbidities were identified based on self - report , which could be subject to bias . however , self - reported chronic diseases have been shown to be reliable ( 39 ) , and also previous studies ( 2,21 ) have used similar data to estimate the prevalence of disease and cost . second , our estimates are likely lower than the actual cost of diabetes for the following reasons : 1 ) people with undiagnosed diabetes who account for 28% of the u.s . population ( 1 ) are not accounted for ; 2 ) we may have overcontrolled in the adjusted estimates , since cvd is a comorbidity of diabetes ; 3 ) meps does not include institutionalized individuals who are often very sick people , often die , and have higher expenditures ; 4 ) estimates from over - the - counter medications were not accounted for ; and 5 ) indirect costs such as work absenteeism , decreased productivity related to diabetes , or poor quality of life were not accounted for . third , even though we analyzed 10-year pooled data , our results should not be interpreted longitudinally . in conclusion , our findings show that compared with individuals without diabetes , individuals with diabetes had significantly higher health expenditures from 2002 to 2011 , and the bulk of the expenditures came from hospital inpatient and prescription expenditures . population , and based on the average yearly estimate , unadjusted total direct health care expenditures for diabetes in the u.s . population were $ 218.6 billion / year and the adjusted total expenditures were approximately $ 46 billion / year . these figures represent potential savings from interventions to improve prevention and management of diabetes in the u.s . civilian population .
objectivedirect medical cost of diabetes in the u.s . has been estimated to be 2.3 times higher relative to individuals without diabetes . 
 this study examines trends in health care expenditures by expenditure category in u.s . 
 adults with diabetes between 2002 and 2011.research design and methodswe analyzed 10 years of data representing a weighted population of 189,013,514 u.s . 
 adults aged 18 years from the medical expenditure panel survey . 
 we used a novel two - part model to estimate adjusted mean and incremental medical expenditures by diabetes status , while adjusting for demographics , comorbidities , and time.resultsrelative to individuals without diabetes ( $ 5,058 [ 95% ci 4,9495,166 ] ) , individuals with diabetes ( $ 12,180 [ 11,77512,586 ] ) had more than double the unadjusted mean direct expenditures over the 10-year period . 
 after adjustment for confounders , individuals with diabetes had $ 2,558 ( 2,2662,849 ) significantly higher direct incremental expenditures compared with those without diabetes . for individuals with diabetes , inpatient expenditures rose initially from $ 4,014 in 2002/2003 to $ 4,183 in 2004/2005 and then decreased continuously to $ 3,443 in 2010/2011 , while rising steadily for individuals without diabetes . 
 the estimated unadjusted total direct expenditures for individuals with diabetes were $ 218.6 billion / year and adjusted total incremental expenditures were approximately $ 46 billion / year.conclusionsour findings show that compared with individuals without diabetes , individuals with diabetes had significantly higher health expenditures from 2002 to 2011 and the bulk of the expenditures came from hospital inpatient and prescription expenditures .