Recognizing Cirrhosis as a Public Health Burden: Cost of Care Tops COPD, Heart Failure

New research is shedding light on the financial magnitude of cirrhosis care, especially for patients with decompensated cirrhosis, relative to the costs associated with heart failure (HF) and chronic obstructive pulmonary disease (COPD).1

Leveraging claims data from the UnitedHealth Group (UHG) for patients enrolled in Medicare Advantage plans, the study found the per-patient cost of cirrhosis care exceeded that of HF and COPD by 21.7% and 55.0%, respectively, suggesting the importance of focusing public health interventions on reducing the progression to cirrhosis and promoting guideline-adherent care for those who have developed cirrhosis.1

According to the US Centers for Disease Control and Prevention, 4.5 million adults in the United States have been diagnosed with liver disease. Cirrhosis is estimated to affect about 1 in 400 US adults, although the actual number may be higher because many people with cirrhosis are not diagnosed, especially in its early stages where symptoms may not yet be present.2,3

“Cirrhosis prevalence is increasing, yet costs associated with its chronic, complex care are poorly understood,” Filip Obradović, MSc, a research assistant and PhD candidate at Northwestern University, and colleagues wrote.1

To characterize the costs of care for patients with cirrhosis compared to those with HF and COPD, investigators conducted a retrospective, longitudinal cohort study using UHG claims data for patients enrolled in non-health maintenance organization (HMO) Medicare Advantage plans between January 1, 2011, and December 31, 2020.1

Cirrhosis, HF, and COPD were all identified based on ICD-9 and ICD-10 codes. Patients with cirrhosis were further categorized into 5 mutually exclusive groups by etiology: metabolic dysfunction-associated steatohepatitis (MASH); alcohol-associated cirrhosis (ETOH), including alcohol-associated liver disease and MetALD; hepatitis C virus (HCV); biliary; and ‘other’.1

For the purpose of analysis, cost was defined as the total amount paid by the insurer and patient, taking the healthcare sector cost perspective, and included inpatient medical, emergency medical, pharmacy, and other costs. Average costs were adjusted for inflation to 2021 United States dollars using the Bureau of Labor Statistics consumer price index to adjust for inflation between 2011 and 2020.1

All months of coverage for all included patients under non-HMO Medicare Advantage plans were analyzed from the index month until the end of observation, defined as disenrollment, transplant, or the end of the cohort study period on December 31, 2020.1

In total, the cohort included 93,308 patients with cirrhosis. The mean age was 69.6 years and 48.0% of participants were female with a mean Charlson Comorbidity Index of 8.9. The most common cirrhosis etiologies were MASH (37.7%), ETOH (22.1%), and HCV (21.6%). Additionally, 67.0% of patients had decompensated cirrhosis at inclusion or became decompensated during observation.1

The study also included 355,520 patients with HF and 318,949 patients with COPD who were, on average, 6.3 and 3.3 years older, were more frequently female (54.0% and 55.2%), with lower Charlson Comorbidity Indices (7.7 and 6.6), respectively.1

Results showed total costs for cirrhosis were $3,032.00 per patient-month, including $1,250.70 (41.3%) for inpatient medical costs; $87.60 (2.9%) for emergency medical costs; $950.60 (31.4%) for other medical costs; and $743.10 (24.5%) for outpatient pharmacy costs. Investigators noted total patient-month costs were $3,969.30 for decompensated cirrhosis and $1,749.60 for compensated cirrhosis.1

The total cost for HF was $2,491.60 per patient-month, including $2,024.30 for medical costs and $467.30 for pharmaceutical costs. For COPD, the total cost was $1,955.60, including $1,497.50 for medical costs and $458.20 for pharmaceutical costs per patient-month.1

Compared to patients with HF, investigators noted patients with cirrhosis had 21.7% greater overall costs, 13.1% greater medical costs, and 59.0% higher pharmaceutical costs per patient-month. Additionally, compared to patients with COPD, patients with cirrhosis had 55.0% greater overall costs, 52.8% greater medical costs, and 62.2% greater pharmaceutical costs per patient-month.1

Analyses limited to patients with decompensated cirrhosis revealed the monthly cost of care was 59.3% greater than patients with HF and 103.0% greater than patients with COPD.1

Investigators outlined multiple limitations to these findings, including the lack of generalizability to patients insured by other payors or with traditional Medicare fee-for-service coverage only; the potential inaccuracies of ICD-9 and ICD-10 codes for cirrhosis diagnoses; the inability to differentiate which costs were specific to particular conditions; and the exclusion of denied services from the cost calculation, which could result in cost underestimation.1

“Focusing public health interventions on the reduction of progression to cirrhosis and progression of cirrhosis to decompensation will not only significantly improve health outcomes but also significantly decrease the financial burden of cirrhosis,” investigators concluded.1

References

1. Obradović F, Vitello DJ, Hasjim NJ, et al. Comparing the cost of cirrhosis to other common chronic diseases: A longitudinal study in a large national insurance database. Hepatology. doi:10.1097/HEP.0000000000001206
2. US Centers for Disease Control and Prevention. Chronic Liver Disease and Cirrhosis. National Center for Health Statistics. November 6, 2023. Accessed January 14, 2025. https://www.cdc.gov/nchs/fastats/liver-disease.htm
3. National Institutes of Health. Cirrhosis. Liver Disease. June 2023. Accessed January 14, 2025. https://www.niddk.nih.gov/health-information/liver-disease/cirrhosis/definition-facts