The economic burden of Type 2 Diabetes by social determinants of health: A systematic review.

Clinical Snapshot

Key Findings

• P Value: Not reported

• Effect Size: In high out-of-pocket expense healthcare systems, Black and Hispanic ethnic backgrounds and rural residence were associated with lower direct healthcare costs, interpreted as reflecting constrained ability to pay rather than reduced clinical need. Lower indirect costs (lost productivity, absenteeism) were observed in unemployed and lower-income groups, likely reflecting reduced workforce participation rather than better health outcomes.

• Primary Outcome: Cost differences in T2DM treatment and management stratified by social determinants of health (education, income, employment, residency, ethnicity)

• Nnt Or Sensitivity: Percentage differences between lowest and highest SDH gradient ends were calculated where possible, but specific values are not reported in the abstract. No NNT, hazard ratios, or diagnostic accuracy statistics applicable.

• Confidence Interval: Not reported; no meta-analysis performed

Clinical Application

The review's findings are primarily policy-relevant rather than directly actionable at the individual clinician level. Clinicians can use these findings to inform targeted screening, proactive outreach, and care navigation for high-risk socioeconomic groups. Integration of SDH screening into T2DM management pathways (e.g., using validated tools such as the PRAPARE or AHC HRSN screening tools) is feasible in primary care settings. Australia's mixed public-private healthcare system presents a unique context. Medicare provides universal coverage for GP consultations and many T2DM-related services, and the PBS subsidises key diabetes medications including metformin, SGLT2 inhibitors (empagliflozin, dapagliflozin), GLP-1 receptor agonists (semaglutide, dulaglutide), and insulin formulations. However, significant cost disparities persist: rural and remote Australians face documented access barriers (AIHW data), Aboriginal and Torres Strait Islander peoples experience disproportionate T2DM burden and higher rates of complications, and out-of-pocket costs for allied health, CGM devices, and specialist care create financial barriers for lower-income patients. The RACGP's Standards for General Practice and the National Diabetes Strategy 2021–2030 explicitly acknowledge SDH as drivers of diabetes inequity. This review supports the policy direction of the National Diabetes Strategy but highlights the need for Australian-specific economic data stratified by SDH. The MBS chronic disease management items (CDM, GP Management Plans, Team Care Arrangements) and the NDSS provide structural supports, but uptake disparities by SDH remain a concern. Adults with T2DM across diverse socioeconomic backgrounds, particularly those from ethnic minority groups, rural areas, lower income brackets, lower educational attainment, or unemployment — populations at elevated risk of both T2DM and inadequate access to care

Abstract

BACKGROUND: The unequal distribution of resources in society generates social gradients that translate into health inequalities and differential use of health care resources and their costs. Non-medical factors such as employment, income, ethnicity and education impact the prevalence and treatment outcomes of patients with type 2 diabetes mellitus (T2DM); however, there is a scarcity of articles assessing the relationship between health inequalities and the economic costs of treatment. Therefore, we conducted a systematic review of published studies examining the cost differences of treating T2DM across social determinants of health (SDH). METHODS: We systematically searched MEDLINE, Embase, PsycINFO, EconLit, and NHS EED for original peer-reviewed articles that provided cost differences of treating T2DM by SDH: education, income, employment, residency and ethnicity. We grouped the studies by each SDH and calculated the percentage differences where possible between the lowest and highest ends of the gradient (education, income and employment). Residency was categorised as rural vs. urban and ethnicity as white or general population vs other ethnic minorities. RESULTS: We included 19 articles retrieved internationally from varying healthcare systems. Results were contextualised given the healthcare financing model. In countries with high out-of-pocket expenses, Black and Hispanic ethnic backgrounds and rural residence were associated with lower direct health care and costs likely to be determined by ability to pay rather than clinical need. Indirect costs such as lost productivity due to absenteeism were also lower in unemployed, and lower income groups. CONCLUSIONS: There are evident health disparities in the direct and indirect economic consequences of T2DM. The effect of decreased healthcare use and costs on treatment outcomes needs to be further explored to inform policies to ensure healthcare delivery is based on clinical need rather than socio-economic factors.

References

1. 1.Alarcón-Yaquetto, D. E., Stewart, R., Ismail, K., & Shearer, J. (2026). The economic burden of Type 2 Diabetes by social determinants of health: A systematic review. PLOS ONE. https://doi.org/10.1371/journal.pone.0354198