Abstract

Background/Objectives: Diabetes-related stigma decreases treatment motivation. While subjective financial burden is a known barrier, the impact of actual medical costs on stigma remains unclear. We investigated the relationship between annual outpatient medical costs (total and out-of-pocket) and stigma in type 2 diabetes to explore whether this association might be more closely related to direct financial hardship or underlying treatment complexity. Methods: In a cross-sectional study, we evaluated stigma in 232 outpatients using the Kanden Institute Stigma Scale (KISS). Patients scoring ≥20 formed the high stigma group (n = 59). Annual medical costs were extracted from electronic hospital claims. We examined associations between medical costs and high stigma using multivariable logistic regression and restricted cubic spline (RCS) models. Results: Adjusted for sex and age, higher total medical cost (per 10,000 JPY/year) was significantly associated with high stigma (odds ratio [OR] = 1.03, 95% confidence interval [CI]: 1.01–1.05, p < 0.01). However, this significance was attenuated after additionally adjusting for HbA1c and antidiabetic agent count (OR = 1.02, 95% CI: 1.00–1.04, p = 0.05). RCS analysis confirmed this dose–response association disappeared upon adjusting for treatment intensity. Notably, out-of-pocket costs showed no significant association with high stigma in any fully adjusted models (OR = 1.03, 95% CI: 0.95–1.11, p = 0.45). Conclusions: While total medical costs are associated with high stigma, the attenuation of this relationship after adjusting for clinical factors suggests that this association may be closely intertwined with the psychosocial burden of treatment complexity, such as polypharmacy and insulin injections, rather than acting solely through direct economic pain from out-of-pocket expenses. Clinicians should prioritize shared decision-making to mitigate psychological distress when intensifying treatment.

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