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Chang, Lui, Matsoyan, Safaee, Aryan, and Ames: Comparative Review of the Socioeconomic Burden of Lower Back Pain in the United States and Globally

Abstract

Internationally, the United States (U.S.) cites the highest cost burden of low back pain (LBP). The cost continues to rise, faster than the rate of inflation and overall growth of health expenditures. We performed a comprehensive literature review of peer-reviewed and non– peer-reviewed literature from PubMed, Scopus, and Google Scholar for contemporary data on prevalence, cost, and projected future costs. Policymakers in the U.S. have long attempted to address the high-cost burden of LBP through limiting low-value services and early imaging. Despite these efforts, costs (~$40 billion; ~$2,000/patient/yr) continue to rise with increasing rates of unindicated imaging, high rates of surgery, and subsequent revision surgery without proper trial of non-pharmacologic measures and no corresponding reduction in LBP prevalence. Globally, the overall prevalence of LBP continues to rise largely secondary to a growing aging population. Cost containment methods should focus on careful and comprehensive clinical assessment of patients to better understand when more resource-intensive interventions are indicated.

INTRODUCTION

Approximately 5% of the United States (U.S.) population consumes 50% of all healthcare spending. A portion of this high-cost minority are individuals with chronic low back pain (LBP) [1]. Internationally, the U.S. cites having the highest cost burden of LBP is consistent with having the highest national health expenditure overall [2]. In 2013, spinal conditions consisting of both neck and back pain, accounted for the third highest national health spending after only diabetes and ischemic heart disease [3]. The cost continues to rise along with a growing prevalence. In 2016, nearly 10% (31.6 million people) of the U.S. population reported suffering from chronic LBP [4]. Globally, the age-standardized point prevalence is similar, around 8.2% [5]. Between 1997 and 2005, total national expenditure of adults with spine problems increased 65% after adjusting for inflation and faster than the rate of growth of overall health expenditures [6].

1. Theoretical Framework for Understanding the Cost of Care

This review comprises of 3 sections: (1) an overview of the socioeconomic burden of LBP in the U.S., (2) cost burden globally divided geographically and by level of development, and (3) cost burden of LBP compared to other chronic diseases in the U.S. For domestic data, relevant literature and statistics for each section were gathered first through government- or government-affiliated databases (Healthcare Cost and Utilization Project, Centers for Medicare & Medicaid Services, Centers for Disease Control and Prevention), then a focused literature search of academic and nonacademic databases (MEDLINE, Embase, Web of Science, Google Scholar), including nonprofit domestic economic thinktanks for more updated statistics. Search terms for cost statistics included, “socioeconomic [AND] LBP,” “cost [AND] LBP,” “spending [AND] LBP,” “economic* [AND] LBP,” and “healthcare costs [AND] LBP;” for disease burden statistics, search terms included “prevalence [AND] LBP,” “incidence [AND] LBP,” and “burden [AND] LBP.” For statistics on international practices in the management of LBP, search terms were a combination of the prior terms with the country’s name. For example, for the cost of LBP in Korea, the following search term was used: “‘Korea’ [AND] ‘LBP’ [AND] ‘cost.’” The same formula was used for cost and prevalence statistics for every country and region. Authors selected the literature by first using publicly accessible domestic and international government databases with updated data then using nongovernment-based sources to supplement missing data. Inconsistencies were resolved to default on data from government-based databases.

1) Framework

To compare the cost of LBP care per capita across countries of different sizes. The following equation was used.
P(i,t)=TruePrevalance(i,t)*Diagnosis(i,t)*C(i,t)=TurePrevalance(i,t)*Diagnosis(i,t)*(Cost0 f NonSurgicalCare+Prob0 f Imaging*Cost0 f Imagining+Prob0 f Surgery*Cost0 f Surgery+Prob0 f PT*Cost0 f PT)
where,
  • - P(i,t) is the per capita cost of LBP treatment in country i in year t

  • - TruePrevalance captures true prevalence in the population

  • - Diagnosis is the probability to be diagnosed given back pain (not all sick people seek care or are being diagnosed)

  • - C(i,t) is the cost per diagnosed patient

  • - Other variables are self-explanatory and are conditional on the positive diagnosis

All costs are reported in US$2021. Domestic costs were converted to US$2021 using the Consumer Price Index for All Urban Consumers as reported by the US Bureau of Labor Statistics for the July of the respective year to July of 2021. The midyear (July 1st) Consumer Price Index index was chosen as the period closest reflecting global pre-COVID-19 pandemic real Gross Domestic Product trends in attempt to attenuate the drastic economic effects experienced due to the pandemic [7-9].
Per capita costs for international studies were calculated by dividing the total national annual cost by the national annual population size as reported by the World Bank for that year. This amount was then converted to US$2021 using the same methodology described above.
All ensuing costs are given in US$2021.

RESULTS

1. The Socioeconomic Burden of LBP in the U.S.

1) Sources of high spending: frequent ambulatory visits, surgery, imaging

A major driver of the high-cost burden of LBP in the U.S. is higher rates of surgery and frequent and often initial visits to medical specialists (and the associated interventions) instead of primary providers. Sixty-one percent of the $22.9 billion of total medical spending to address LBP in 2016 was spent on ambulatory visits [1,4]. LBP accounted for 2% of all (or 2.63 million) emergency department visits in 2006 [10,11]. Nearly 67% of these patients were admitted and 10% receiving computed tomography (CT) or magnetic resonance imaging (MRI), 3 times higher than imaging rates in 2002 [10,12]. One in 4 patients who received primary care for LBP received imaging while 1 in 3 patients in the Emergency Department received imaging [11].
Within the first 90 days of beginning sick-leave, on average 32% of patients with LBP undergo surgery in the U.S. compared to 6% in other highly developed countries like Sweden [13]. The same trend rings true over time with 92% of U.S. patients receiving surgery within the first year compared to 75% in countries like Germany [13].
Not only is surgery an earlier therapeutic option in the U.S., but the rate of surgical intervention also continues to rise particularly fusions for degenerative spinal diseases. Between 2004 and 2015, the volume of elective lumbar fusions in the U.S. increased 62.3% (from 60.4 to 79.8 fusions per 100,000 U.S. adults). Amongst those older than 65 years old, the volume increased more drastically, from 98.3 to 170.3 per 100,000 from 2004 to 2015 [6]. The market for lumbar fusions continues to grow 18%–20% annually with fusion as the standard for treating common lumbar pathologies which do not typically involve instability, like lumbar stenosis despite few studies demonstrating definitive clinical superiority of fusion over nonfusion decompression [14,15].
One proven driver of this increase in surgery is imaging overuse which may lead to faulty attribution of pain to an imaging abnormality, particularly as most imaging abnormalities are incidental findings in asymptomatic patients [16]. Although surgery is not the most widespread intervention it is the costliest, averaging $51,500 per admission and exceeding $10 billion in aggregate in 2015 [6]. In another study, while only 1.2% of patients with newly diagnosed LBP received surgery, surgery accounted for almost 30% of the total 12-month costs of the entire cohort [3].
The American College of Physicians (ACP) has developed clinical guidelines for primary care physicians and Emergency Department physicians seeing a patient for the first time with LBP [17]. ACP guidelines urge against imaging within 30 days of diagnosis and before trying nonsurgical treatments. Deviations from these guidelines are common and costly—responsible for an additional $373 million annually [3]. In a recent study, patients who received imaging (lumbar CT, MRI, or radiograph) within 30 days of diagnosis had double the 12-month costs of those treated under guidelines even after stratifying by imaging modalities [3]. Use of MRIs as the first intervention within 30 days of the LBP diagnosis led to an 8-fold increased risk of spine surgery [18]. Furthermore, Lurie et al. found that 22% of the regional variation in spine surgery rates can be explained by variation in the rate of advanced spine imaging (CT and MRI), a trend that has been true over time and across regions [19,20]. Notably, advanced imaging is twice as predictive of surgery than the regional density of spine surgeons, hospitals in which spine surgery is performed, or socioeconomic or insurance status [21]. Thankfully, the rate of guideline deviance has decreased over the past decade [3].
One of the most common nonsurgical treatments is prescription medications, which contributed 15% of the direct medical costs in 2007 [22]. In 2008, there was a 50% increase in narcotic prescriptions concomitant with a 50% decrease in acetaminophen prescriptions [23]. The prescription of opioids has been linked with worse pain, functioning including higher doses being directly associated with prolonged work disability, catastrophizing and depression [18,24,25]. This has also contributed to the increase in substance abuse disorders and deaths due to overdose. While clinicians are increasingly wary of prescribing narcotics for chronic LBP, opioids remain the most frequently prescribed medication for LBP [26].

2) Indirect cost burden twice as large due to lost productivity

However high the direct cost, the indirect cost of LBP is at least twice as high [4]. An estimated 149 million workdays are lost annually due to LBP, accounting for 5% of lost workdays from any cause. A major cause of LBP and thus lost workdays is occupation-related LBP from high-risk industries such as lumber retailing, gas extraction, and nursing. Occupation-related LBP was responsible for 101.8 million (68%) of lost workdays due to LBP [18]. Occupations with the highest prevalence of LBP include health care providers, farmers, fishers, and forestry workers [27].

2. The Socioeconomic Burden of LBP Globally

1) LBP: leading source of global disability since 1990

Since the global burden of disease study was published in 1990, LBP has been a leading cause of years lived in disability (YLD) [28-30]. In 2017, about 580 million people worldwide reported having LBP, with an incidence of 250 million responsible for 64 million YLD annually. In the Western population, 70%–85% will develop LBP at one point in life, 60% will continue to report LBP 1 year later, and 10%–15% will have chronic LBP [31-33]. Due to a growing global population, the age-standardized point-prevalence of LBP has decreased in most countries (-2.1%). However, overall number of cases has increased nearly 20% between 2007 and 2017 [5,29]. Prevalence is highest among those 80+ years old. Nevertheless, YLD is highest among those 45–49 years old because of the significance of disability on quality of life at a working age. Causes of this absolute rise in prevalence include increased longevity, obesity and psychiatric illness in developed countries. In emerging economies, additional causes include rapid industrialization with a growing working population and increasingly sedentary lifestyles [5,29,34-36].
Accurate cost comparisons across international studies remains elusive as studies adopt varying methodologies for calculating costs. Regardless, a few systematic reviews have attempted to explore geographic differences [5,37,38]. The findings from these reviews and more recent studies are summarized by their respective geographic region in Table 1 and Figs. 1 and 2.

2) LBP in high-income North America and Australia

The age-standardized mean prevalence of LBP in the US and Canada is 10.71% (95% confidence interval, 10.06–11.39), the 7th highest prevalence globally since 1990 [5]. In Canada, emergency department visits for LBP has increased to 3.2% of all visits, only 9% of which are truly attributable to nerve impingement [39]. Disease and treatment regimen has also evolved with increasing incidences of LBP due to “sequelae of previous back surgery” which was claimed 26 times more in 2007 than 2000 [40]. Utilization of instrumented lumbar surgeries more than doubled between 1993 and 2012 with the annual procedure rate among those older than 80-year old increasing 7.6-fold [40]. The same is true in Australia. Between 2003 and 2013 the rate of 3+ level or 2+ approach spinal fusion grew 400%, simple fusion grew 115%, while decompression grew 16% for the treatment of spinal stenosis despite minimal evidence of their marginal benefit over decompression alone [41].
Despite a notably distinct healthcare financing system, Canada, like the U.S., has dramatically increased the rate of surgical intervention to address LBP [40,42]. This cost burden is only worsened by postsurgical complications, suggesting potential overmedicalization of a multifactorial pain syndrome.

3) LBP in Europe: Netherlands, Belgium, Sweden

The highest per capita direct cost was reported in 2002 from the Netherlands at 8,533€ ($410)—US$2021 calculated from foreign currency using the historical exchange rate average in the year reported. Then the historic US equivalent is covered to US$2021 using the US Bureau of Labor’s Consumer Price Index published annual inflation rate—per capita [43]. Costs were highly variable depending on level of care and referral patterns. Specialist care for back pain cost significantly more than those treated at a primary care setting (4,875€ vs. 2,365€ or $6,045 vs. $2,932, p< 0.001). General practitioner referrals also accumulated lower costs relative to those referred by a specialist (1,569€ vs. 3,018€ or $1,946 vs. $3,742, p< 0.05) [44]. Among all patients, LBP was managed as follows: 88% treated with exercise therapy, 53% with opioids, and only 26% patients treated with surgical intervention [44]. LBP alone was responsible for 25% of all drug costs for musculoskeletal pathology with an average of 2 medications per patient with chronic lower back pain [45].
In Sweden, surgery and specialist care are responsible for a quarter each of all direct costs for LBP in Sweden, similar to the US where surgery is responsible for 22% of all direct costs [46,47]. The landscape of medical costs for LBP has changed as treatment regimens evolve. In a recent Belgian study, LBP was responsible for 55% of all transcutaneous electrical nerve stimulation units and 60% of intrathecal pumps [48].
Across the continent, the indirect cost of absenteeism varies widely, ranging from 38%–85% of all costs [48,49]. In Sweden, each episode of LBP results in on average 51 days of absenteeism, equivalent to 2,753€ ($3,436) [49]. Cost of illness comparisons between the U.S. and European countries is difficult as most U.S. studies take the perspective of private insurance. Any cost reduction over time may be due to true cost containment efforts or costs merely shifted to another payer.
Lumbar fusion surgery popularity grows not only in the U.S. but around the world though at a different pace. In Finland, as the rate of lumbar decompressions doubled between 1997 and 2017 from 33 to 77 per 100,000 person-years, the rate of lumbar fusions tripled from 9 to 30 per 100,000 person-years [50]. Norway likewise experienced a faster growth in the rate of complex lumbar surgeries, the majority of which were fusions (13.6 to 21 per 100,000 inhabitants), than simple lumbar surgeries (64.3 to 88.9 per 100,000) between 1999 and 2013. Females and adults between 60 and 74 years old made up the most frequent and fastest growing complex lumbar surgery demographic [51]. So while the U.S. reports the fastest growth in the total number of lumbar fusions performed year over year, rate of growth per 100,000 inhabitants in Europe currently outpaces the U.S.

4) LBP in Asia: Korea, Japan, China

In Asia, high-income countries had the highest burden of LBP (age-standardized point prevalence: 13.16 [11.74–14.73]) whereas lower-income East Asia had the lowest of all regions globally (3.92 [3.46–4.37]) likely due to high population density [5,29].
In Korea, duration of pain was the major direct cost determinant consistent with findings from other high-income countries. Fifty-one percent of insurance claims for back pain was for pain lasting less than 6 months accounting for 10% of total costs due to LBP compared to the 6% of claims for pain lasting longer than 2 years which was responsible for 30% of costs [52].
In Japan, chronic LBP affects an estimated 1.5 million people, accounting for nearly one-third of patients with chronic pain [53]. While no difference was found in costs per ER visits or hospitalization, chronic LBP patients sought their provider seven times more than age, sex, body mass index, Charlson Comorbidity Index, and smoking status-matched controls leading to an incremental cost of $1,230 per person and a national direct cost burden of $24.4 billion [53]. Unlike in other developed countries, loss of productivity in Japan due to chronic LBP is largely due to presenteeism, or decreased productivity while being present at work. Like in other high-income countries, the socioeconomic burden of LBP is significantly worsened by psychiatric comorbidities [54–56]. Depression and anxiety is associated with higher pain, lower quality of life, increased productivity loss, and increased healthcare utilization in patients with chronic LBP [57,58]. This recognition has shifted Japanese health policy makers towards addressing chronic LBP as a holistic pain to be treated with cognitive behavioral treatment, exercise, and sleep hygiene [59].
Since 1990, China has seen a gradual decline in point prevalence of LBP nationwide attributed to an improving primary care system as the YLD due to LBP increased 23% between 1990 and 2016 due to the population growth and increased longevity [60].

5) LBP in emerging economies: Sub-Saharan Africa, India, Brazil

Known risk factors like height and fat distribution in high-income populations have no relationship to LBP in lower income populations [61].
In Sub-Saharan Africa, after degenerative spine disease, spinal infections are the second leading cause of LBP with tuberculosis responsible for nearly 80% of symptomatic infections [62]. Human immunodeficiency virus is the cause cited for 84% of lower back spondyloarthropathies and the third leading cause of LBP [63].
Multiple studies have examined the occupational hazards affecting men and women of lower economic status in urban India [64-66]. For men in Southern India, lack of educational attainment is a significant risk factor for LBP [61]. For working women, the high incidence of LBP (70%–80%) has been attributed to a combination of prolonged hours in suboptimal working positions, occupational monotony, and inadequate income—highlighting the complex biopsychosocial model underpinnings of chronic pain [65]. Prevalence of LBP among rural housewives in India is likewise high (83%) though the economic burden to society is significantly lower due to reduced access to healthcare and lower wages [67].
In countries with rapidly expanding economies, like Brazil, the epidemiology of LBP looks increasingly like those of higher income countries. In 2016, two-third of government spending on spinal disorders was spent on LBP. The direct cost impact is growing secondary to high utilization of healthcare services, procedural interventions, and imaging [34].
Treatment and prevention of chronic LBP in lower-income regions varies significantly from those in higher-income countries due to the prevalence of preventable communicable diseases and occupational hazards while countries with rapidly growing economies are beginning to demonstrate the same overmedicalization seen in high-income countries.

3. Socioeconomic Burdens of Major Chronic Diseases in the U.S.

While neither the costliest nor the most prevalent chronic disease, chronic back pain has one of the highest cost per person [4]. An aging population and increased longevity will only exacerbate the socioeconomic burden of these chronic diseases, in particular LBP, in the next few decades. Findings are summarized in Table 2 and Fig. 3.

4. Relative Cost of Major Chronic Diseases in Other High-Income Countries

Across high-income countries, LBP is one of, if not the costliest chronic disease per case. Between cardiovascular disease, dementia, stroke and diabetes, LBP is responsible for the highest per capita cost in Sweden. In the Netherlands and the U.S., the per capita cost of LBP ranks second only to diabetes. Both diabetes and LBP carry growing cost burdens associated with sedentary lifestyles and rising obesity rates. The cost per capita of LBP and major chronic diseases is presented in Table 3.

DISCUSSION

1. Why Does LBP Cost so Much in the U.S.? A Healthcare Pricing Issue

The high cost of LBP in the U.S. is in proportion to its high national healthcare costs, not the population’s health status. While the U.S. boasts the highest obesity rates, the prevalence of LBP in the U.S. is similar to other high-income countries [68]. Furthermore, Papanicolas et al. [69] found that population health factors at large (smoking, drinking, obesity) were not responsible for the substantially higher healthcare costs of the U.S. Instead, the high price of healthcare, in particular physician and hospital services, pharmaceuticals, and diagnostic testing in the U.S. drives the high cost of chronic disease [70]. Across surgical specialties ranging from obstetrics, general surgery, and orthopedic surgery, surgeries in the U.S. are more expensive and thus more lucrative than other comparable countries. For example, the cost of a knee replacement is 53% more expensive in the U.S. than Switzerland and 77% more expensive than Australia [71]. The higher rate and revenue of performing spine surgery and other high-margin procedures like caesarean deliveries and angioplasties account for a fifth of the difference in healthcare cost per capita between the U.S. and other high-income countries! [72]
Another possible cause of the U.S.’ disproportionate spending on LBP is its well-known litigious nature, which may predispose to overutilization of indisputable clinical evidence such as imaging. The U.S. performs many more CT scans (278.5 per 1,000 people, in 2019) than any other country. Iceland, which ranks second, performs 234 CT scans per 1,000 people and Korea, third, 228 per 1,000 people [73]. The price of scans is also higher in the U.S. with a the nearly 10-fold difference in CT per capita cost between the U.S. and the Netherlands ($220 vs. $23, respectively) [72]. Emanuel et al. notes that 7% of the cost difference between the U.S. and Netherlands is due to imaging [72].

2. The Future of LBP in the U.S.

The fastest growing segment of the U.S. population are people aged 60 years and older, from 962 million 2017 to 2.1 billion in 2050. In the U.S., 2 out of every 3 adult male over 60 years old reports having LBP in the past year [74]. A critical subdivision of the elderly population are those older than 65, a population particularly prone to the complications of LBP (depression, falls, etc.). Superaging populations like Japan where those over 65 years old outnumber those under 18 face the economic crisis of a simultaneously decreasing labor force and increasing public sector demands on health care [75,76]. By 2034, the U.S. too is projected to become a superaging population [77].
Considering these impending demographic challenges, adherence to evidence-based management of LBP can help safeguard from wasteful healthcare spending. A 2018 Lancet series highlights global recommendations on the management of acute and chronic LBP summarized in Table 4 [17,28,30,78-80]. A seriously underutilized tool—patient education and reassurance—is the first line therapy for both acute and chronic LBP.

CONCLUSION

The cost of LBP will continue to rise in the U.S. and other high-income countries largely due to an aging population becoming an ever-greater public budget strain. This urges discernment of the cost-contributors and inefficiencies in the clinical and health system-wide management of chronic LBP. Respecting guidelines for imaging and surgical management and cautious referrals to specialists for the first visit would be reasonable initial approaches to managing a complex biopsychosocial issue like chronic pain.

NOTES

Conflict of Interest

The authors have nothing to disclose.

Funding/Support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author Contribution

Conceptualization: MMS, CA; Formal analysis: DC, AL; Investigation: DC, AL, AM; Methodology: DC, MMS, CA; Project administration: DC, MMS; Writing – original draft: DC, AL; Writing – review & editing: DC, AL, MMS, CA, HA.

Fig. 1.
Prevalence, direct cost and indirect cost of low back pain for select high-income countries. The relative prevalence, direct and indirect cost (US$2021), and direct and indirect cost per person (US$2021) are depicted for the United States (U.S.), Japan, Korea, Netherlands, Sweden, and Canada by colored ribbons with their associated rank. For example, the U.S. has the highest prevalence, annual direct cost, direct cost/person, and annual indirect cost and therefore the orange ribbon has both the widest and topmost ribbon for those categories. However, Sweden has the highest indirect cost per person and likewise, the purple ribbon is the widest and surpasses the orange for indirect cost per person. The referenced article is listed under each country. For countries with more than one referenced article, asterisks help differentiate from which article the prevalence and/or cost data originated.
ns-2448372-186f1.jpg
Fig. 2.
Global age-standardized prevalence of low back pain (LBP) by region in 1990 and 2017. Average age-standardized prevalence percentage of LBP by geographic region and gender in 1990 and 2017 represented as black lines and colored bars, respectively, based on the global burden of disease studies. For 2017 estimates, the male average is marked by blue bars; female average by pink; male and female averages depicted in purple. The lower and upper uncertainty level markers are marked by vertical dashes. Regional percent changes between 1990 to 2017 and the male and female average regional rankings in 1990 and 2017 are listed in the right three columns, respectively.
ns-2448372-186f2.jpg
Fig. 3.
Relative per capita cost of major chronic diseases in the United States (U.S.). The direct, indirect, and total cost per capita of major chronic diseases in the U.S. are depicted by horizontal bars. Per capita costs were calculated by dividing the respective cost by the U.S. population size in the year for which the cost data was collected as sourced from the World Bank. LBP, low back pain.
ns-2448372-186f3.jpg
Table 1.
Prevalence, direct, and indirect cost of low back pain in high-income countries (US$2023)
Country Study (FA, year) Cost collection year Overall prevalence Annual direct cost (million) Direct cost/capita* Annual indirect cost (million) Indirect cost/capita
US Shmagel et al. [81] 2016 20.1% (31.6 million), working age
Waters & Graf [4] 2018 2016 $78,700 $244 $445,800 $1,379
Canada Beaudet et al. [40] 2013 2007 1.4%–3.2% (519,000–1,200,000), recurrent LBP $31.6 $0.91
Netherlands Boonen et al. [43] 2005 2002 20%–50% (3.3–8.2 million) $31.0–77.2 ($8,342/patient) $2.00–4.98 $18,000–46,000 ($5,640/patient) $1,128–2,867
Sweden Olafsson et al. [49] 2018 2011 15%–30% (1.52–3.04 million) $496.5 ($2,237/LBP episode) $52.54 $961.7 ($3,788/LBP episode) $2,986
Korea Ahn et al. [82] 2016 2011 15.3% (7.7 million) $1,885 $37.39
Hyeong et al. [52] 2005 1997 $40,192 (workers’ compensation) $875
Japan Sadosky et al. [83] 2015 20%–25% (25.5–31.8 million)
Montgomery et al. [53] 2017 2011 $27,500 $216.43 $12,193 ($14,677/patient) $95.80

LBP, low back pain.

* Direct and indirect costs reported as costs per person based on the national population size as reported by the World Bank during study period reported.

Table 2.
Cost of major chronic diseases in the United States (US$2023)
Disease Study (FA, year) Cost data collection year Overall prevalence Annual direct cost (billion, US$2021) Direct cost/person (US$2021) Annual indirect cost (billion, US$2021) Indirect cost/person (US$2021) Annual total cost (billion, US$2021) Total cost/person (US$2021)
Low back pain Soni [22] 2010 2007 27,000,000 $43.02 $142.91 - - - -
Katz [84] 2006 NA - - - $88 - - -
Shmagel et al. [81] 2016 2016 31,600,000 - - - - - -
Waters & Graf [4] 2018 2016 31,573,940 $78.69 $243.63 $445.84 $1,380.32 $524.54 $1,830.25
Stroke Virani et al. [85] 2020 2015 790,000 $31.95 $99.53 $19.98 $62.25 $51.93 $161.79
Waters & Graf [4] 2018 2016 8,794,418 $62.40 $193.30 $64.01 $198.19 $126.45 $441.21
Benjamin et al. [86] 2017 2017 8,794,418 - - - - - -
Dementia Plassman et al. [87] 2007 2002 3,400,000 (70-year projection) $148.46 $515.50 $292.86 $1,016.88 $441.30 $1,532.39
Waters & Graf [4] 2018 2016 5,619,500 $221.62 $686.14 $98.22 $304.10 $319.85 $1,116.03
Alzheimer Association* 2017 2017 5,619,500 - - - - - -
Cardiovascular disease Nichols et al. [88] 2010 2005 128,000,000 (2020 projection) $178.83 $604.18 $312.96 $1,057.30 $491.79 $1,661.47

NA, not available.

* Prevalence includes only those diagnosed with Alzheimer disease.

Table 3.
Relative per capita cost of major chronic diseases in select high-income countries (US$2023)
Country LBP CVD CVD: LBP Dementia Dementia: LBP Stroke Stroke: LBP Diabetes Diabetes: LBP
US $1,830.25 (Waters & Graf [4] 2018) $1,407.78 (Virani et al. [85] 2020) 0.769 $1,117.84 (Waters & Graf [4] 2018) 0.611 $441.93 (Waters & Graf [4] 2018) 0.241 $2,114.94 (Waters & Graf [4] 2018) 1.168
Canada $0.81* (Beaudet [40] 2013) $1,059.57 (Tarride et al. [89] 2019) NA $251.18 (Østbye et al. [90] 1994) NA $199.94 (Goeree et al. [91] 2005) NA $296.44 (Dawson et al. [92] 2002) NA
Netherlands $330.71 (Lambeek et al. [93] 2011) $0.61 (Wilkins et al. [94] 2017) 1.63 × 10-3 $307.72 (Koopmanschap et al. [95] 1998) 0.824 $180.57 (Struijs et al. [96] 2006) 0.484 $509.00 (Peters et al. [97] 2017) 1.390
Sweden $379.79 (Ekman et al. [45] 2005) $0.26 (Wilkins et al. [94] 2017) 6.06 × 10-4 $363.02 (Wimo et al. [98] 1997) 0.847 $341.32 (Terént et al. [99] 1994) 0.796 $157.38 (Henriksson et al. [100] 1998) 0.367
Korea $147.28 (Lee et al. [76] 2019) $157.12 (Chang et al. [101] 2012) 0.945 $85.79 (Suh et al. [102] 2006) 0.516 $172.70 (Cha [103] 2018) 1.040 $422.95 (Oh et al. [104] 2021) 2.54
Japan $318.50 (Montgomery et al. [53] 2017) $157.54 (Gochi et al. [105] 2018) 0.438 $1,336.91 (Sado et al. [106] 2018) 3.720 $0.12 (Urakami et al. [107] 2019) 3.45 × 10-4

LBP, low back pain; CVD, cardiovascular disease.

* Direct cost per person. No total cost of LBP in Canada.

Not reported as there was no available total of LBP in Canada.

Includes only the total cost of ischemic heart disease.

Table 4.
International evidence-based guidelines on the management of LBP [78-82]
Level of treatment Acute LBP Chronic LBP
First-line Remaining active Remaining active
Education/reassurance Education/reassurance
Exercise therapy
Cognitive behavioral therapy
Second-line Spinal manipulation Spinal manipulation
Massage Massage
Acupuncture Acupuncture
NSAIDs Yoga
Superficial heat Midfulness-based exercises
Interdisciplinary rehabilitation
NSAIDs
SNRI
Surgery
 - Discectomy for herniated disc
 - Laminectomy for spinal stenosis
Limited use where indicated Exercise therapy Opioids*
Cognitive behavioral therapy Epidural glucocorticoid injection for herniated disc
Skeletal muscle relaxants
Opioids*
Insufficient evidence Yoga Superficial heat
Mindfulness-based exercises Skeletal muscle relaxants
Interdisciplinary rehabilitation Antiseizure medications
SNRI Surgery (spinal fusion for nonradicular LBP with degenerative disc findings)
Antiseizure medications
Surgery
 - Discectomy for herniated disc
 - Laminectomy for spinal stenosis
 - Spinal fusion for non-radicular LBP with degenerative disc findings
Not recommended Epidural glucocorticoid injection for herniated disc Paracetamol
Systemic glucocorticoids
Paracetamol

LBP, low back pain; NSAID, nonsteroidal anti-inflammatory drugs; SNRI, selective norepinephrine reuptake inhibitor.

* Use with caution.

REFERENCES

1. Clewley D, Rhon D, Flynn T, et al. Health seeking behavior as a predictor of healthcare utilization in a population of patients with spinal pain. PLoS One 2018;13:e0201348.
crossref pmid pmc
2. World Health Organization Global Health Expenditure database. Current health expenditure per capita (current US$). Geneva (Switzerland): World Health Organization; 2021.

3. Kim LH, Vail D, Azad TD, et al. Expenditures and health care utilization among adults with newly diagnosed lowback and lower extremity pain. JAMA Netw Open 2019;2:e193676.
crossref pmid pmc
4. Waters H, Graf M. The costs of chronic disease in the U.S Santa Monica (CA), Milken Inst. 2018.

5. Wu A, March L, Zheng X, et al. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med 2020;8:299.
crossref pmid pmc
6. Martin BI, Mirza SK, Spina N, et al. Trends in lumbar fusion procedure rates and associated hospital costs for degenerative spinal diseases in the United States, 2004 to 2015. Spine (Phila Pa 1976) 2019;44:369-76.
crossref pmid
7. Harris B, Mehrotra N. Measuring the strength of the recovery. Washington, D.C: United States Department of the Treasury; 2022.

8. Labonte M, Weinstock LR. US economic recovery in the wake of COVID-19: successes and Challenges. Washington, D.C: Congressional Research Service; 2022.

9. Milesi-Ferretti GM. A most unusual recovery: how the US rebound from COVID differs from rest of G7. Washington, D.C: Brookings Institution; 2021.

10. Friedman BW, Chilstrom M, Bijur PE, et al. Diagnostic testing and treatment of low back pain in US emergency departments. A national perspective. Spine (Phila Pa 1976) 2010;35:1406-11.
pmid
11. Downie A, Hancock M, Jenkins H, et al. How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years. Br J Sports Med 2020;54:642-51.
crossref pmid
12. Drazin D, Nuño M, Patil CG, et al. Emergency room resource utilization by patients with low-back pain. J Neurosurg Spine 2016;24:686-93.
crossref pmid
13. Hansson TH, Hansson EK. The effects of common medical interventions on pain, back function, and work resumption in patients with chronic low back pain: a prospective 2-year cohort study in six countries. Spine (Phila Pa 1976) 2000;25:3055-64.
pmid
14. Kim P, Kurokawa R, Itoki K. Technical advancements and utilization of spine surgery--international disparities in trenddynamics between Japan, Korea, and the USA. Neurol Med Chir (Tokyo) 2010;50:853-8.
crossref pmid
15. Deyo RA, Gray DT, Kreuter W, et al. United States trends in lumbar fusion surgery for degenerative conditions. Spine (Phila Pa 1976) 2005;30:1441-5.
crossref pmid
16. Deyo RA. Diagnostic evaluation of LBP: reaching a specific diagnosis is often impossible. Arch Intern Med 2002;162:1444-7.
crossref pmid
17. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2017;166:514-30.
crossref pmid
18. Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med 2010;52:900-7.
crossref pmid
19. Verrilli D, Welch HG. The impact of diagnostic testing on therapeutic interventions. JAMA 1996;275:1189-91.
crossref pmid
20. Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine (Phila Pa 1976) 2003;28:616-20.
crossref pmid
21. Volinn E, Mayer J, Diehr P, et al. Small area analysis of surgery for low-back pain. Spine (Phila Pa 1976) 1991;17:575-81.
crossref
22. Soni A. Statistical brief #289. Back problems: use and expenditures for the U.S. adult population, 2007. Rockville, MD: Agency for Healthcare Research and Quality; 2010.

23. Mafi JN, Mccarthy EP, Davis RBD, et al. Worsening trends in the management and treatment of back pain HHS public access. JAMA Intern Med 2013;173:1573-81.
crossref pmid pmc
24. Franklin GM, Stover BD, Turner JA, et al. Early opioid prescription and subsequent disability among workers with back injuries: the disability risk identification study cohort. Spine (Phila Pa 1976) 2008;33:199-204.
pmid
25. Ashworth J, Green DJ, Dunn KM, et al. Opioid use among low back pain patients in primary care: Is opioid prescription associated with disability at 6-month follow-up? Pain 2013;154:1038-44.
crossref pmid pmc
26. Vogt MT, Kwoh CK, Cope DK, et al. Analgesic usage for low back pain: Impact on health care costs and service use. Spine (Phila Pa 1976) 2005;30:1075-81.
crossref pmid
27. Haiou Y, Haldeman S, Lu ML, et al. Low back pain prevalence and related workplace psychosocial risk factors: a study using data from the 2010 National Health Interview Survey. J Manipulative Physiol Ther 2016;39:459-72.
crossref pmid pmc
28. Buchbinder R, Van Tulder M, Öberg B, et al. Low back pain: a call for action. Lancet 2018;391:2384-8.
crossref pmid
29. James SL, Abate D, Abate KH, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 Diseases and Injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1789-858.
pmid pmc
30. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet 2018;391:2356-67.
crossref pmid
31. Itz CJ, Geurts JW, Van Kleef M, et al. Clinical course of nonspecific low back pain: a systematic review of prospective cohort studies set in primary care. Eur J Pain 2013;1:5-15.
crossref
32. Andersson GBJ. Epidemiological features of chronic lowback pain. Lancet 1999;354:581-5.
crossref pmid
33. Mutubuki EN, Beljon Y, Maas ET, et al. The longitudinal relationships between pain severity and disability versus health-related quality of life and costs among chronic low back pain patients. Qual Life Res 2020;29:275-87.
crossref pmid pmc pdf
34. Carregaro RL, Tottoli CR, da Silva Rodrigues D, et al. Low back pain should be considered a health and research priority in Brazil: lost productivity and healthcare costs between 2012 to 2016. PLoS One 2020;15:e0230902.
crossref pmid pmc
35. Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum 2012;64:2028-37.
crossref pmid
36. Hoy D, Brooks P, Blyth F, et al. The epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010;24:769-81.
crossref pmid
37. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 2008;8:8-20.
crossref pmid
38. Fatoye F, Gebrye T, Odeyemi I. Real-world incidence and prevalence of low back pain using routinely collected data. Rheumatol Int 2019;39:619-26.
crossref pmid pdf
39. Edwards J, Hayden J, Asbridge M, et al. The prevalence of low back pain in the emergency department: a descriptive study set in the Charles V. Keating Emergency and Trauma Centre, Halifax, Nova Scotia, Canada. BMC Musculoskelet Disord 2018;19:306.
crossref pmid pmc pdf
40. Beaudet N, Courteau J, Sarret P, et al. Prevalence of claimsbased recurrent low back pain in a Canadian population: a secondary analysis of an administrative database. BMC Musculoskelet Disord 2013;14:151.
crossref pmid pmc pdf
41. Machado GC, Maher CG, Ferreira PH, et al. Trends, complications, and costs for hospital admission and surgery for lumbar spinal stenosis. Spine (Phila Pa 1976) 2017;42:1737-43.
crossref pmid
42. Xu Y, Yen D, Whitehead M, et al. Use of instrumented lumbar spinal surgery for degenerative conditions: trends and costs over time in Ontario, Canada. Can J Surg 2019;62:393-401.
crossref pmid pmc
43. Boonen A, Van Den Heuvel R, Van Tubergen A, et al. Large differences in cost of illness and wellbeing between patients with fibromyalgia, chronic low back pain, or ankylosing spondylitis. Ann Rheum Dis 2005;64:396-402.
crossref pmid pmc
44. Dutmer AL, Schiphorst Preuper HR, Soer R, et al. Personal and societal impact of low back pain: the Groningen spine cohort. Spine (Phila Pa 1976) 2019;44:E1443-51.
pmid
45. Ekman M, Jönhagen S, Hunsche E, et al. Burden of illness of chronic low back pain in Sweden: a cross-sectional, retrospective study in primary care setting. Spine (Phila Pa 1976) 2005;30:1777-85.
pmid
46. Hansson EK, Hansson TH. The costs for persons sick-listed more than one month because of low back or neck problems. A two-year prospective study of Swedish patients. Eur Spine J 2005;14:337-45.
crossref pmid pmc pdf
47. Williams DA, Feuerstein M, Durbin D, et al. Health care and indemnity costs across the natural history of disability in occupational low back pain. Spine (Phila Pa 1976) 1998;23:2329-36.
crossref pmid
48. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000;84:95-103.
crossref pmid
49. Olafsson G, Jonsson E, Fritzell P, et al. Cost of low back pain: results from a national register study in Sweden. Eur Spine J 2018;27:2875-81.
crossref pmid pdf
50. Ponkilainen VT, Huttunen TT, Neva MH, et al. National trends in lumbar spine decompression and fusion surgery in Finland, 1997-2018. Acta Orthop 2021;92:199-203.
crossref pmid pmc
51. Grotle M, Småstuen MC, Fjeld O, et al. Lumbar spine surgery across 15 years: trends, complications and reoperations in a longitudinal observational study from Norway. BMJ Open 2019;9:28743.
crossref pmid pmc
52. Hyeong SK, Jae WC, Soung HC, et al. Treatment duration and cost of work-related low back pain in Korea. J Korean Med Sci 2005;20:127-31.
crossref pmid pmc
53. Montgomery W, Sato M, Nagasaka Y, et al. The economic and humanistic costs of chronic lower back pain in Japan. Clin Outcomes Res 2017;9:361-71.
crossref pdf
54. Sagheer MA, Khan MF, Sharif S. Association between chronic low back pain, anxiety and depression in patients at a tertiary care center. J Pak Med Assoc 2013;63:688-90.
pmid
55. Mirzamani SM, Sadidi A, Sahrai J, et al. Anxiety and depression in patients with lower back pain. Psychol Rep 2005;96(3 Pt 1):553-8.
crossref pmid pdf
56. Krishnan KRR, France RD, Pelton S, et al. Chronic pain and depression. II. Symptoms of anxiety in chronic low back pain patients and their relationship to subtypes of depression. Pain 1985;22:289-94.
crossref pmid
57. Tsuji T, Matsudaira K, Sato H, et al. The impact of depression among chronic low back pain patients in Japan. BMC Musculoskelet Disord 2016;17:447.
crossref pmid pmc pdf
58. Wada K, Arakida M, Watanabe R, et al. The economic impact of loss of performance due to absenteeism and presenteeism caused by depressive symptoms and comorbid health conditions among Japanese workers. Ind Health 2013;51:482-9.
crossref pmid pmc
59. Kikuchi S. The recent trend in diagnosis and treatment of chronic low back pain. Spine Surg Relat Res 2017;1:1-6.
crossref pmid pmc
60. Wu A, Dong W, Liu S, et al. The prevalence and years lived with disability caused by low back pain in China, 1990 to 2016: Findings from the global burden of disease study 2016. Pain 2019;160:237-45.
crossref pmid pmc
61. Mathew AC, Safar S, Anithadevi TS, et al. The prevalence and correlates of low back pain in adults: a cross sectional study from Southern India. Int J Med Public Heal 2013;3:342-6.
crossref
62. Mijiyawa M, Oniankitan O, Kolani B, et al. Low back pain in hospital outpatients in Lomé (Togo). Joint Bone Spine 2000;67:533-8.
crossref pmid
63. Njobvu P, McGill P, Kerr H, et al. Spondyloarthropathy and human immunodeficiency virus infection in Zambia. J Rheumatol 1998;25:1553-9.
pmid
64. Durlov S, Chakrabarty S, Chatterjee A, et al. Prevalence of low back pain among handloom weavers in West Bengal, India. Int J Occup Environ Health 2014;20:333-9.
crossref pmid pmc
65. Das B. An evaluation of low back pain among female brick field workers of West Bengal, India. Environ Health Prev Med 2015;20:360-8.
crossref pmid pmc pdf
66. Ahdhi G, Subramanian R, Saya G, et al. Prevalence of low back pain and its relation to quality of life and disability among women in rural area of Puducherry, India. Indian J Pain 2016;30:111.
crossref
67. Gupta G, Nandini N. Prevalence of low back pain in nonworking rural housewives of Kanpur, India. Int J Occup Med Environ Health 2015;28:313-20.
crossref pmid
68. ProCon.org. Global obesity levels [Internet] Britannica. 2020 [cited 2021 Aug 10]; Available from: https://obesity.procon.org/global-obesity-levels/.

69. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA 2018;319:1024-39.
crossref pmid
70. Anderson GF, Reinhardt UE, Hussey PS, et al. It’s the prices, stupid: why the United States is so different from other countries. Health Aff (Millwood) 2003;22:89-105.
crossref pmid
71. Kamal R, Cox C. How do healthcare prices and use in the U.S. compare to other countries? [Internet]. PETERSONKFF Health System Tracker. 2018 [cited 2021 Nov 22]; Available from: https://www.healthsystemtracker.org/chart-collection/how-do-healthcare-prices-and-use-in-the-u-scompare-to-other-countries/.

72. Emanuel EJ. The real cost of the US health care system. JAMA 2018;319:983-5.
crossref pmid
73. Steward C. Number of CT examinations in selected countries, 2019. New York: Statista Inc; 2021.

74. Marshall LM, Litwack-Harrison S, Makris UE, et al. A prospective study of back pain and risk of falls among older community-dwelling men. J Gerontol A Biol Sci Med Sci 2017;72:1264-9.
crossref pmid pmc
75. Uehara M, Ikegami S, Horiuchi H, et al. Prevalence and related factors of low back pain in the general elderly population: a Japanese cross-sectional study randomly sampled from a basic resident registry. J Clin Med 2021;10:4213.
crossref pmid pmc
76. Lee R, Mason A. Cost of aging slowing growth of population and labor force HHS public access. Financ Dev 2017;54:7-9.

77. An aging nation: projected number of children and older adults. Washington, D.C.: Census Bureau; 2017.

78. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018;391:2368-83.
crossref pmid
79. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J 2018;27:60-75.
crossref pmid pdf
80. National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. London: National Institute for Health and Care Excellence; 2016.

81. Shmagel A, Foley R, Ibrahim H. Epidemiology of chronic low back pain in us adults: data from the 2009-2010 National Health and Nutrition Examination Survey. Arthritis Care Res 2016;68:1688-94.
crossref pmid pmc
82. Ahn YJ, Shin JS, Lee J, et al. Evaluation of use and cost of medical care of common lumbar disorders in Korea: cross-sectional study of Korean Health Insurance Review and Assessment Service National Patient Sample data. BMJ Open 2016;6:e012432.
crossref pmid pmc
83. Sadosky AB, DiBonaventura M, Cappelleri JC, et al. The association between lower back pain and health status, work productivity, and health care resource use in Japan. J Pain Res 2015;8:119-30.
pmid pmc
84. Katz JN. Lumbar disc disorders and low-back pain: Socioeconomic factors and consequences. J Bone Joint Surg Am 2006;88 Suppl 2:21-4.
crossref pmid
85. Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics—2020 update: a report from the American Heart Association. Circulation 2020;141:e139-596.
pmid
86. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics’2017 update: a report from the American Heart Association. Circulation 2017;135:e146-603.
pmid pmc
87. Plassman BL, Langa KM, Fisher GG, et al. Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology 2007;29:125-32.
crossref pmid pmc pdf
88. Nichols G, Bell T, Pedula K, et al. Medical care costs among patients with established cardiovascular disease. Am J Manag Care 2010;16:e86-93.
pmid
89. Tarride JE, Lim M, DesMeules M, et al. A review of the cost of cardiovascular disease. Can J Cardiol 2009;25:e195-202.
crossref pmid pmc
90. Østbye T, Crosse E. Net economic costs of dementia in Canada. Can Med Assoc J 1994;151:1457-64.

91. Goeree R, Blackhouse G, Petrovic R, et al. Cost of stroke in Canada: a 1-year prospective study. J Med Econ 2005;8:147-67.
crossref
92. Dawson KG, Gomes D, Gerstein H, et al. The economic cost of diabetes in Canada, 1998. Diabetes Care 2002;25:1303-7.
crossref pmid pdf
93. Lambeek LC, Van Tulder MW, Swinkels ICS, et al. The trend in total cost of back pain in the netherlands in the period 2002 to 2007. Spine (Phila Pa 1976) 2011;36:1050-8.
crossref pmid
94. Wilkins E, Wilson L, Wickramasinghe K, et al. European cardiovascular disease statistics 2017. Brussels: European Heart Network; 2017.

95. Koopmanschap M, Polder J, Meerding W, et al. Cost of dementia in the Netherlands. The Economics of Dementia 1998;207-16.

96. Struijs J, van Genugten M, Evers S, et al. Future costs of stroke in the Netherlands: the impact of stroke services. Int J Technol Assess Health Care 2006;22:518-24.
crossref pmid
97. Peters ML, Huisman EL, Schoonen M, et al. The current total economic burden of diabetes mellitus in the Netherlands. Neth J Med 2017;75:281-97.
pmid
98. Wimo A, Jönsson L, Bond J, et al. The worldwide economic impact of dementia 2010. Alzheimers Dement 2013;9:1-11. e3.
crossref pmid pdf
99. Terént A, Marke LA, Asplund K, et al. Costs of stroke in Sweden. A national perspective. Stroke 1994;25:2363-9.
crossref pmid
100. Henriksson F, Jönsson B. Diabetes: the cost of illness in Sweden. J Intern Med 1998;244:461-8.
crossref pmid
101. Chang HS, Kim HJ, Nam CM, et al. The socioeconomic burden of coronary heart disease in Korea. J Prev Med Public Heal 2012;45:291-300.
crossref pmid pmc
102. Suh G, Knapp M, Kang C. The economic costs of dementia in Korea, 2002. Int J Geriatr Psychiatry 2006;21:722-8.
crossref pmid
103. Cha YJ. The economic burden of stroke based on South Korea’s National Health Insurance Claims Database. Int J Heal Policy Manag 2018;7:904.
crossref pmid pmc pdf
104. Oh SH, Ku H, Park KS. Prevalence and socioeconomic burden of diabetes mellitus in South Korean adults: a population-based study using administrative data. BMC Public Health 2021;21:548.
crossref pmid pmc pdf
105. Gochi T, Matsumoto K, Amin R, et al. Cost of illness of ischemic heart disease in Japan: a time trend and future projections. Environ Health Prev Med 2018;23:21.
crossref pmid pmc pdf
106. Sado M, Ninomiya A, Shikimoto R, et al. The estimated cost of dementia in Japan, the most aged society in the world. PLoS One 2018;13:e0206508.
crossref pmid pmc
107. Urakami T, Kuwabara R, Yoshida K. Economic impact of diabetes in Japan. Curr Diab Rep 2019;19:2.
crossref pmid pdf


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