Cirrhosis Complications, Health Care Utilization Linked to Greater Economic Burden

Fasiha Kanwal, MD, MSHS

Credit: Baylor College of Medicine

Findings from a recent study are providing novel insight into the longitudinal health care costs faced by patients with cirrhosis, highlighting a greater economic burden in the first year after diagnosis and among those with complications and comorbidities.¹

The retrospective cohort study leveraged patient data from the Veterans Affairs (VA) system and found the incremental cost of care for patients with cirrhosis ranged from $32,930 to $57,544 per patient per year, alluding to the potential cost-savings benefit of preventing cirrhosis-related complications.¹

Each year, about 26,000 deaths in the United States are attributed to cirrhosis, a progressive condition in which the continual development of scar tissue leads to irreversible liver damage. If diagnosed early and the underlying cause is treated, further damage can be limited. However, the cost of care from diagnosis to ongoing management is not well understood.²

“While many studies have examined other outcomes of patients with cirrhosis, few have quantified the costs required to deliver those outcomes, and even fewer in a longitudinal cohort that allows comparison with national averages,” Fasiha Kanwal, MD, MSHS, professor of medicine and chief of gastroenterology and hepatology at Baylor College of Medicine, and colleagues wrote.¹

To address this gap in research, investigators retrospectively collected data from the national VA Corporate Data Warehouse for patients with newly diagnosed cirrhosis who were seen at 130 VA hospitals from January 10, 2011, to September 30, 2015. For inclusion, patients were required to have ≥ 2 instances of cirrhosis or cirrhosis complications codes in the inpatient or outpatient settings, or ≥ 1 code for cirrhosis or complications with ≥ 1 filled prescription of spironolactone, rifaximin, or lactulose after a cirrhosis diagnosis.¹

Investigators used random sampling without replacement to identify a sex- and age-matched control cohort of individuals who did not meet cirrhosis criteria, matched to the cirrhosis cohort for gender, hospital, year of index visit, and age at index. For each patient with cirrhosis, investigators selected ≤ 4 controls.¹

All patients were followed up through 2019 to compare long-term costs and resource use between the groups. Investigators estimated incremental annual health care costs attributable to cirrhosis, both overall and in subgroups based on severity, cirrhosis complications, and comorbidity.¹

In total, 39,691 patients with cirrhosis and 138,964 matched controls were identified and retrospectively enrolled in the study. Among the cirrhosis cohort, the mean age was 62.3 (Standard deviation [SD], 10.5) years, 96.3% of patients were male, and 70.3% were White. The controls had a mean age of 61.9 (SD, 10.8) years, 97.0% were male, and 63.7% were White.¹

In the cirrhosis cohort, 16.7% of patients had significant multimorbidity, defined as Deyo index ≥ 3, 32.7% had depression, and 14.1% had anxiety. Of note, approximately 39.0% of the year 1 cohort had cirrhosis complications including ascites, hepatic encephalopathy, or varices, and 18% had AKI. Compared with matched controls, patients with cirrhosis were significantly more likely to be older, be of lower income status, have a higher burden of comorbidity, and have greater health care utilization within 1 year before cohort entry (all P <.0001).¹

After accounting for differences in age, gender, race/ethnicity, priority status, health insurance status, and baseline health care utilization, investigators noted the incremental first-year cost of caring for patients with cirrhosis was $45,839 (95% CI, $42,862–$48,817) but decreased to $35,029 (95% CI, $32,473–37,585) after additional adjustment of comorbidity, ranging from $14,216 to $17,629 in the subsequent 3 years.¹

Of note, cirrhosis complications accounted for most of these costs – investigators pointed out patients with cirrhosis had significantly more emergency department visits, primary care encounters, gastrointestinal encounters, and outpatient visits relative to controls (P <.0001).¹

They further noted development of decompensated cirrhosis resulted in a sharp increase in medical costs in the first year. The cost of managing patients with hepatic encephalopathy (year 1 cost, $50,080) was similar to that of managing patients with ascites (year 1 cost, $50,364), both of which were greater than the cost of managing patients with varices (year 1 cost, $20,488). The incremental cost was the greatest among patients with AKI (year 1 cost, $64,413), although patients with cirrhosis with significant multimorbidity were the costliest with year 1 incremental cost of $66,653.¹

Investigators were careful to acknowledge several potential limitations to these findings, including the use of VA-centric data, lack of consideration for care occurring outside of the VA and covered by non-VA health insurance, limited number of patients who received a liver transplant, and inability to account for social costs of cirrhosis beyond medical costs.¹

“We found that patients with cirrhosis had substantially higher health care costs than matched controls. The additional economic burden of cirrhosis was mostly related to cirrhosis complications and high inpatient utilization in the first year after diagnosis,” investigators concluded.¹ “Preventing progression to decompensation and programs focused on palliative care have the largest potential for cost saving and could serve as targets for improvement.”

References:

1. ^{Kanwal F, Nelson R, Liu Y, et al. Cost of Care for Patients With Cirrhosis. The American Journal of Gastroenterology 119(3):p 497-504,. doi:10.14309/ajg.0000000000002472}
2. ^{Mayo Clinic. Cirrhosis of the Liver. Diseases & Conditions. July 26, 2023. Accessed March 25, 2024. https://my.clevelandclinic.org/health/diseases/15572-cirrhosis-of-the-liver}