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Hospitalizations And Costs Associated With Hepatitis C And Advanced Liver Disease Continue To Increase - HCV/Aging Hospitalizations/Costs Tripled in 6 Years
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"increase in the rate of hospitalizations associated with hepatitis C is striking"......"suggest that hepatitis C is a public health problem"......."During the study period the number of hospitalizations for which hepatitis C was the principal diagnosis more than tripled, from 20,963 in 2004-05 to 64,867 in 2010-11"......."estimated nationwide charges from the 663,114 hospitalizations principally caused by advanced liver disease totaled $69.4 billion during 2010-11 (an average of $34.7 billion per year),"
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Health Economics/Cost Effectiveness: AASLD: Projected Health and Economic Impact of Hepatitis C on the United States Medicare System From 2010 to 2024 - (11/17/14)......"We estimated that between 2010 and 2024, an additional 1,027,066 individuals with chronic HCV would enter the Medicare system.......Of the cumulative 1,823,298 individuals with chronic HCV currently in or entering Medicare from 2010-2024, with NT we forecast that 661,060 (36.2%) would die from HCV or other causes while in a diagnosed state of DCC, HCC, or transplant/post-transplant......Treatment with all-oral new HCV drugs reduced deaths in these states by 126,163 and increased undiscounted QALYs by 7,692,906.......Treatment, especially treatment with interferon free, all oral regimens could substantially reduce morbidity and mortality from HCV within Medicare. Because of the large proportion of Medicare patients that enter the program in advanced stages of disease, treatment prior to Medicare entry is likely to be more effective in mitigating the health consequences of HCV.....costs with treatment- $68.8 bill
Health Economics/Cost Effectiveness: AASLD: AASLD: Health Economics/Cost-Effectiveness - (11/21/14)
65th Annual Meeting of the American Association for the Study of Liver Diseases (100 reports)
Boston, MA Nov 7-11 2014
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HCV, Aging Number of Hospitalizations & Hospitalizations Costs Tripled from $0.9 to $3.5 Bill....impetus for national programs of testing and linkage to care......With.....more effective and curative therapies for hepatitis C......especially ...patients with....advanced liver disease or... failed with previous treatment, the growth in hospitalizations and deaths resulting from chronic hepatitis C can be slowed substantially......newer-generation pharmaceuticals have largely been found to be cost-effective.......The high rates of hospitalization and the morbidity burden associated with hepatitis C, along with the rapidly evolving availability of effective new hepatitis C therapies, are an impetus for national programs of testing and linkage to care......Large health care payers such as Medicare and private insurance companies must consider the costs of providing access to hepatitis C therapies, which could exceed $84,000 per patient, as well as the benefits of such treatments, which could include forgone ambulatory services and hospital stays associated with advanced and end-stage liver disease sequelae......
".....large cohort of people infected with hepatitis C is aging and developing severe liver disease.....Most patients were born in the period 1945-65......hepatitis C is a public health problem and has been growing in magnitude in recent years: rapidly increasing nationwide trend in morbidity attributable to hepatitis C and advanced liver disease related to hepatitis C in the United States, increased morbidity related to hepatitis C was associated with large and increasing medical costs......The total charge of hospitalizations principally caused by hepatitis C reached $3.5 billion in 2010-11 and more than tripled during the study period (291 percent). Increased costs were also observed for diagnoses of advanced liver disease (44 percent)......A recent study also investigated the burden of hepatitis C in the health care system and reported the inpatient burden to be greater than $15 billion annually.......The apparent shifting to Medicare for insurance by the aging cohort of people infected with hepatitis C is an important finding for health care policy makers. During the study period, the proportion of hepatitis C hospitalizations paid for by private insurance decreased, and the proportion paid for by Medicare increased by 5 percentage points, from 28.7 percent to 33.9 percent (Exhibit 3). As the baby boomers age, they are more likely to leave health plans provided by their employers and private insurance companies, replacing those plans with Medicare coverage.
.........Hospitalizations Doubled in 2004-05 vs 2010-11.......rate of those hospitalizations per 100,000 people increased from 4.76 to 13.81, a relative percent change of 190 percent.......nationwide charges for hospitalizations [Tripled] with hepatitis C as the principal diagnosis increased from $0.9 billion during 2004-05 to $3.5 billion relative percent change of 291 percent.......estimated nationwide charges from..... advanced liver disease totaled $69.4 billion during 2010-11 (an average of $34.7 billion per year), which resulted in a relative percent change of 44 percent when compared with 2004-05.......The proportion of people with Medicare increased from 28.7 percent in 2004-05 to 33.9 percent in 2010-11, while the proportion of those with private insurance declined from 28.6 percent to 22.7 percent.............
"This article investigates the recent trends in hospitalizations and costs associated with hepatitis C and advanced liver disease. We used representative data sets that recorded inpatient care discharges and patient characteristics during the period 2004-11........The increase in the rate of hospitalizations associated with hepatitis C is striking, with a relative percent change of 190 percent in the period 2004-11......During the same period, rates of hospitalizations principally for hepatitis B and for alcoholic cirrhosis of the liver, the other two main etiologies for advanced liver disease, were stable or declined......our data provide evidence for a rapidly increasing nationwide trend in morbidity attributable to hepatitis C and advanced liver disease related to hepatitis C in the United States. This is consistent with the trends observed during the period 1998-2003.27 These findings suggest that hepatitis C is a public health problem and has been growing in magnitude in recent years.......The increased morbidity related to hepatitis C was associated with large and increasing medical costs. The total charge of hospitalizations principally caused by hepatitis C reached $3.5 billion in 2010-11 and more than tripled during the study period (291 percent). Increased costs were also observed for diagnoses of advanced liver disease (44 percent)."
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At The Crossroads: How Will Medicare Grapple With Hep C?
By Kristin Gourlay
http://ripr.org/post/crossroads-how-will-medicare-grapple-hep-c
My recent story about the high cost of new hepatitis C treatments focused on the difficulty of deciding who gets these new drugs now and who has to wait. That's because, while new drugs like Sovaldi and Harvoni (both made by Gilead) promise to cure a lot of people, they're so expensive we simply couldn't afford to treat everyone who's infected right now. I looked at how Rhode Island's Medicaid agency is grappling with this question, by restricting treatment to patients with the most advanced liver disease, and placing some other requirements on patients, such as being drug free for at least six months prior to being approved for treatment.
All the experts I've been speaking with for this series tell me that Medicaid covers a disproportionate number of people infected with hepatitis C; it's a disease, in many ways, of the disenfranchised. But it's also been called the disease of a generation, baby boomers - people born between 1945 and 1965 (and if that's you, get tested!). They'll soon age into Medicare.
The costs of not treating hepatitis C could mount as well. In the same issue of Health Affairs, another analysis found hospitalizations from untreated hepatitis C tripled between 2004 - 2011.
And that's a challenge the program will have to deal with sooner rather than later, one that's been overlooked in the discussion about the high cost of new hepatitis C treatments, said Tricia Neuman, senior vice president of the Kaiser Family Foundation and director of the program on Medicare policy.
Neuman says the concern is that Medicare will soon have to bear even more of the cost of treating hepatitis C. She penned an analysis in the journal Health Affairs, recently, and I caught up with her about her findings.
"There are an estimated 350,000 people on Medicare with hepatitis C," Neuman told me. "Medicare is encouraging people to get tested for hepatitis c. And as baby boomers age onto Medicare, if they haven't been treated and cured before they've aged on to the program, there will be even more people on Medicare with hepatitis C."
Costing billions of dollars, depending on how many get treated. What's more, the federal government is not allowed to negotiate drug discounts for Medicare. Not so with Medicaid, which gets an automatic 23 percent discount. And the VA recently negotiated a 44 percent discount on the drugs from Gilead.
So Neuman thinks Medicare could be facing some tough decisions soon.
She estimated that if a certain percentage of boomers gets treated while on Medicare, the new drugs could cost between $2 - $6 billion dollars.
That doesn't paint the full picture, though. The costs of not treating hepatitis C could mount as well. In the same issue of Health Affairs (October 2014's issue about the rising cost of specialty pharmaceuticals), another analysis found hospitalizations from untreated hepatitis C tripled between 2004 - 2011. Seventy seven percent of those hospitalized were boomers. If you look at total charges for hospitalizations in which the primary diagnosis was hepatitis C, total spending is up to $3.5 billion a year. But if you look at total spending on hospitalizations for advanced liver disease (cirrhosis, for example), the primary cause of which is hepatitis C, spending is up to $70 billion a year.
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Hospitalizations And Costs Associated With Hepatitis C And Advanced Liver Disease Continue To Increase
Health Affairs October 2014
Fujie Xu, Xin Tong, and Andrew J. Leidner, CDC
"The increase in the rate of hospitalizations associated with hepatitis C is striking, with a relative percent change of 190 percent in the period 2004-11......During the same period, rates of hospitalizations principally for hepatitis B and for alcoholic cirrhosis of the liver, the other two main etiologies for advanced liver disease, were stable or declined......our data provide evidence for a rapidly increasing nationwide trend in morbidity attributable to hepatitis C and advanced liver disease related to hepatitis C in the United States. This is consistent with the trends observed during the period 1998-2003.27 These findings suggest that hepatitis C is a public health problem and has been growing in magnitude in recent years.......The increased morbidity related to hepatitis C was associated with large and increasing medical costs. The total charge of hospitalizations principally caused by hepatitis C reached $3.5 billion in 2010-11 and more than tripled during the study period (291 percent). Increased costs were also observed for diagnoses of advanced liver disease (44 percent).......During the study period the number of hospitalizations for which hepatitis C was the principal diagnosis more than tripled, from 20,963 in 2004-05 to 64,867 in 2010-11 (Exhibit 1). All of these hospitalizations had one or more liver diseases listed among the secondary diagnoses. During the same period the nationwide rate of those hospitalizations per 100,000 people increased from 4.76 to 13.81, a relative percent change of 190 percent-that is, relative to the amount of hospitalizations in 2004-05, there were almost two times more hospitalizations in 2010-11......
.......When we combined the increases in per hospitalization charge and number of hospitalizations (Exhibit 1), we estimated that the total nationwide charges for hospitalizations with hepatitis C as the principal diagnosis increased from $0.9 billion during 2004-05 (20,963 hospitalizations at $42,415 per hospitalization) to $3.5 billion (64,867 hospitalizations at $53,626 per hospitalization) during 2010-11. This was a relative percent change of 291 percent. Similarly, the estimated nationwide charges from the 663,114 hospitalizations principally caused by advanced liver disease totaled $69.4 billion during 2010-11 (an average of $34.7 billion per year), which resulted in a relative percent change of 44 percent when compared with 2004-05.....
........Strong trends were seen among proportions of payer types (Exhibit 3). The proportion of people with Medicare increased from 28.7 percent in 2004-05 to 33.9 percent in 2010-11, while the proportion of those with private insurance declined from 28.6 percent to 22.7 percent."
"When we looked at the secondary diagnoses of advanced liver disease among hospitalizations associated with hepatitis C, we found that the proportions of most liver diseases increased significantly (Exhibit 3)." [from Jules: liver cancer, esophageal & other vatical bleeding almost doubled, portal hypertension doubled, nonalcoholic cirrhosis increased from 39.4 to 49.7]
Abstract
Disease burden models have predicted worsening morbidity of liver disease caused by hepatitis C in the United States. The aim of this study was to determine the trend in hospitalizations caused by hepatitis C and advanced liver disease. We analyzed data for the period 2004-11 from the Nationwide Inpatient Sample, the largest nationwide all-payer hospital inpatient care database. Hospitalization rates for hepatitis C per 100,000 people increased significantly from 4.76 in 2004-05 to 13.81 in 2010-11-an increase of 190 percent. Hospitalization rates for advanced liver disease also increased, particularly for hepatorenal syndrome (93 percent) and portal hypertension (62 percent). Hepatitis C was the principal diagnosis for 64,867 hospitalizations in 2010-11, resulting in a total charge of $3.5 billion. We found nationwide trends in increasing morbidity and medical costs for advanced liver disease associated with hepatitis C. Our findings suggest that hepatitis C is a public health problem and has been growing in magnitude in recent years. Stakeholders and policy makers should implement both recommended screenings for people born in the period 1945-65 and more effective treatment for hepatitis C, which have the potential to reverse the rising morbidity and costs of hepatitis C.
An estimated 2.7 million people in the United States have chronic hepatitis C.1 These people are at risk for progressive hepatic fibrosis and cirrhosis, which can lead to portal hypertension, ascites, gastrointestinal bleeding, hepatic encephalopathy, and liver cancer.2
The majority of people infected with hepatitis C were born between 1945 and 1965.3,4 Largely because of the aging of this birth cohort, disease burden models predict a substantial increase over the next thirty years in the morbidity associated with liver disease and hepatitis C.5,6 Deaths and liver transplants as a result of hepatitis C have increased,7,8 and a trend of increasing liver-related hospitalizations has been observed in recent years.9 These hospitalizations have considerable costs6,9 and-in the absence of interventions that are more cost-effective than current practices-will continue to contribute to the projected vast economic burden of hepatitis C.6 With the implementation of recommended screening3 and treatment10,11 for hepatitis C in the United States, its growing burden can be reduced.12
Unfortunately, chronic hepatitis C is not widely acknowledged as an urgent public health issue. This lack of awareness becomes particularly apparent when the levels of diagnosis, evaluation, and treatment related to hepatitis C are examined. About 50 percent of people infected with hepatitis C remain undiagnosed.13,14 Many people who might otherwise qualify for therapy have not been tested and identified.15 In a large, multicenter cohort study, only 18 percent of the population predicted to be infected had evidence of any treatment for hepatitis C.13
However, therapeutic agents for hepatitis C are advancing rapidly and are more effective at curing hepatitis C quickly-often within twelve weeks-with few side effects.16⇓-18 A cure of hepatitis C after treatment is associated with reductions in all-cause mortality, not just mortality resulting from liver disease.19
This article investigates the recent trends in hospitalizations and costs associated with hepatitis C and advanced liver disease. We used representative data sets that recorded inpatient care discharges and patient characteristics during the period 2004-11.
Study Data And Methods
Using diagnosis and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) (for a list of the codes, see online Appendix A),20 we identified hospitalizations for which the principal diagnosis was either hepatitis C or advanced liver disease in the Nationwide Inpatient Sample (NIS) and State Inpatient Database (SID) annual data sets for the period 2004-11. For our trend analysis of hospitalizations related to hepatitis C, we also examined hospitalizations that were principally for advanced liver disease but whose secondary diagnoses included hepatitis C.
Nationwide Inpatient Sample
The NIS is drawn annually from the administrative databases of a nationally representative sample of hospitals.21,22 The NIS is the largest nationwide all-payer hospital inpatient care database available in the United States. It is maintained as part of the Healthcare Cost and Utilization Project (HCUP), which is sponsored by the Agency for Healthcare Research and Quality.
The NIS is a stratified sample of approximately 20 percent of all US community hospitals. Five characteristics are used to select the hospitals: location (rural or urban), hospital size, region, teaching status, and ownership. The NIS includes all discharges from sampled hospitals, providing information on five to eight million discharges from an average of 1,000 hospitals each year. Discharges are captured regardless of payer status-that is, patients with Medicare, Medicaid, private insurance, or no insurance are all included.
State Inpatient Database
The SID is also maintained by HCUP.23 Similar to the NIS, it includes inpatient discharge abstracts regardless of payer status.24 The SID captures over 90 percent of all annual US hospital discharges.24 For our state-specific analyses, we chose California, Florida, and Michigan because their populations were the largest, and because data from them were available for the entire study period.
Scope And Outcomes Of Interest
We estimated national hospitalization rates and costs from the NIS during the period 2004-11. In addition to hospitalization rates associated with hepatitis C, we calculated hospitalization rates associated with hepatitis B because hepatitis B is an important cause of liver disease. In addition, we provided rates of hospitalizations associated with HIV as a comparison.
ICD-9-CM diagnostic or procedure codes (Appendix A)20 were used to identify hospitalizations associated with hepatitis C, advanced liver disease such as liver cancer, hepatitis B, and HIV. This analysis focused on hospitalization rates calculated from principal diagnosis codes. Because there was only one principal diagnosis for each hospitalization, the hospitalizations included in our analyses were put in one of four mutually exclusive categories: hepatitis C, hepatitis B, HIV, or any of ten specific diagnoses of advanced liver disease.
Typically there were multiple secondary diagnoses for each hospitalization. To better estimate the burden of hospitalizations related to hepatitis C, we combined hospitalizations with hepatitis C as the principal diagnosis with those that had advanced liver disease as the principal diagnosis and also listed hepatitis C among the secondary diagnoses.
Empirical Approach
The unit of analysis was the hospital discharge. We excluded hospital discharge records from the NIS and SID if the patient was younger than age eighteen at hospital admission. Patient characteristics included age, race or ethnicity, and first listed payment source. Hospital characteristics included geographic region and status as a teaching hospital. Discharge-specific characteristics included the charge or cost for the hospitalization, in-hospital death, the principal diagnosis or procedural code, and whether hepatitis C was listed as a secondary diagnosis.
National estimates were obtained by using individual discharge sampling weights. The weighted number of hospitalizations at the national or state level each year was then divided by the corresponding national (or state) population count based on the midyear (July) US census population estimates tabulated by HCUP.25
The ratio of the estimated number of hospitalizations to the estimated population count is the hospitalization rate. To adjust costs incurred in earlier years to 2011 US dollars, we used the Personal Consumption Expenditure index for hospital services26 (for inflation rates, see Appendix B).20 We computed changes during the period 2004-11 in hospitalization rates and average charge per hospitalization by comparing estimates for 2004-05 with those for 2010-11.
We estimated orthogonal polynomial coefficients both to summarize patient characteristics and to test hypotheses for trends over time across categories of patient characteristics. All statistical analyses were conducted using SAS 9.3-callable SUDAAN.
Because this study relied on existing data that were publicly available, it was exempt from review by an Institutional Review Board.
Limitations
Our findings must be interpreted in light of some limitations.
First, some amount of the trends in hospitalization rates that we observed may be the result of changes in coding practice. Increased awareness of hepatitis C might have led to coding changes that increased the use of hepatitis C as the principal diagnosis for hospitalizations caused by advanced liver disease in more recent years.
Second, the number of states contributing data to the NIS has increased, which could introduce bias as the nationwide sample changed over time. From 2004 to 2011 the number of participating states increased from thirty-seven to forty-six. However, we found no evidence that people in the states newly added to the sample were more or less likely to have had hospitalizations for hepatitis C and liver disease than people in the states sampled before 2004. Furthermore, the stability of the proportions of patients from different regions suggests that any sampling bias attributable to geographic area was limited.
Finally, the unit of the analysis was the hospital discharge, not the patient. If a single patient had multiple hospital admissions in any one-year period, readmissions were counted as new hospitalizations. This could mean that if a small number of patients account for a large number of hospitalizations, this small number of patients could become overly influential in estimating the means and could distort the distribution of patient characteristics.
Study Results
National Trends
During the study period the number of hospitalizations for which hepatitis C was the principal diagnosis more than tripled, from 20,963 in 2004-05 to 64,867 in 2010-11 (Exhibit 1). All of these hospitalizations had one or more liver diseases listed among the secondary diagnoses. During the same period the nationwide rate of those hospitalizations per 100,000 people increased from 4.76 to 13.81, a relative percent change of 190 percent-that is, relative to the amount of hospitalizations in 2004-05, there were almost two times more hospitalizations in 2010-11.
Similar, though less dramatic, trends were observed for a number of advanced liver diseases, including liver cancer (Exhibit 1). Only modest changes in hospitalization rates were observed for liver transplant and hepatic encephalopathy. Interestingly, hospitalization rates for esophageal and other variceal bleeding and rates associated with cirrhosis of the liver (both alcoholic and without mention of alcohol) declined during the study period.
After we adjusted for inflation, the average per hospitalization charge for hepatitis C and all types of liver disease increased during the study period (Exhibit 1). The greatest increases were observed for hepatorenal syndrome and liver transplant. The smallest increase was for cirrhosis of the liver without mention of alcohol.
When we combined the increases in per hospitalization charge and number of hospitalizations (Exhibit 1), we estimated that the total nationwide charges for hospitalizations with hepatitis C as the principal diagnosis increased from $0.9 billion during 2004-05 (20,963 hospitalizations at $42,415 per hospitalization) to $3.5 billion (64,867 hospitalizations at $53,626 per hospitalization) during 2010-11. This was a relative percent change of 291 percent. Similarly, the estimated nationwide charges from the 663,114 hospitalizations principally caused by advanced liver disease totaled $69.4 billion during 2010-11 (an average of $34.7 billion per year), which resulted in a relative percent change of 44 percent when compared with 2004-05.
We calculated the rates of three types of hospitalizations: those for which hepatitis C was the principal diagnosis, those for which advanced liver disease was the principal diagnosis and hepatitis C was a secondary diagnosis, and the first two types combined (Exhibit 2). During the study period the most dramatic increase occurred in rates of hospitalization for which the principal diagnosis was hepatitis C, which rose from 5.0 to 14.4 per 100,000 people. The rates of both types of hospitalizations combined also increased, from 29.9 to 34.5 per 100,000 people.
Characteristics Of Patients Hospitalized Because Of Hepatitis C
Exhibit 3 presents the characteristics of patients hospitalized with hepatitis C as the principal diagnosis; all of these patients also had secondary diagnosis codes indicating liver disease. The share of people in the 1945-1964 birth cohort increased during the study period, from 68.7 percent of hospitalized patients in 2004-05 to 77.3 percent in 2010-11. The proportion of males also increased.
The racial and ethnic characteristics of the patient population did not change significantly during the study period: It remained predominantly white (Exhibit 3). The regional distribution did not change either, with patients were more likely to be from the South and West than from the Northeast or the Midwest throughout the study period.
Strong trends were seen among proportions of payer types (Exhibit 3). The proportion of people with Medicare increased from 28.7 percent in 2004-05 to 33.9 percent in 2010-11, while the proportion of those with private insurance declined from 28.6 percent to 22.7 percent.
When we looked at the secondary diagnoses of advanced liver disease among hospitalizations associated with hepatitis C, we found that the proportions of most liver diseases increased significantly (Exhibit 3). However, the proportion of in-hospital deaths remained relatively constant during the study period.
Hospitalization Trends Associated With Hepatitis C, Hepatitis B, And HIV
For comparison, we present hospitalization rates associated with hepatitis C, hepatitis B, and HIV during the study period (Exhibit 4). When we looked at the trends based on the data from three states-California, Florida, and Michigan (data not shown)-we found that they were largely consistent with national trends.
During the study period the annual rate of hospitalizations associated with HIV declined nationally and in all three states. In contrast, the hospitalization rate associated with hepatitis C uniformly increased. The hospitalization rate associated with hepatitis B changed only slightly.
Discussion
The increase in the rate of hospitalizations associated with hepatitis C is striking, with a relative percent change of 190 percent in the period 2004-11. This dramatic increase is part of a larger trend that we observed among hospitalizations with hepatitis C listed as either the principal diagnosis or as one of the secondary diagnoses when liver disease was listed as the principal diagnosis. We also observed increases in hospitalization for advanced liver disease sequelae, particularly hepatorenal syndrome, portal hypertension, ascites, and liver cancer. During the same period, rates of hospitalizations principally for hepatitis B and for alcoholic cirrhosis of the liver, the other two main etiologies for advanced liver disease, were stable or declined.
Taken together, our data provide evidence for a rapidly increasing nationwide trend in morbidity attributable to hepatitis C and advanced liver disease related to hepatitis C in the United States. This is consistent with the trends observed during the period 1998-2003.27 These findings suggest that hepatitis C is a public health problem and has been growing in magnitude in recent years.
The increased morbidity related to hepatitis C was associated with large and increasing medical costs. The total charge of hospitalizations principally caused by hepatitis C reached $3.5 billion in 2010-11 and more than tripled during the study period (291 percent). Increased costs were also observed for diagnoses of advanced liver disease (44 percent).
A recent study also investigated the burden of hepatitis C in the health care system and reported the inpatient burden to be greater than $15 billion annually.28 This cost estimate included all hospitalizations that listed hepatitis C as a principal or secondary diagnosis. When all hospitalizations that listed hepatitis C as a secondary diagnosis were included, even if the principal diagnosis was unrelated to hepatitis C or liver disease, the resulting cost estimate was much higher than ours.
The most probable explanation of the increasing rates of hospitalizations is that a large cohort of people infected with hepatitis C is aging and developing severe liver disease. This is supported by the patient characteristics shown in Exhibit 3. Most patients were born in the period 1945-65. This result is consistent with those of other studies of hospitalizations related to hepatitis C9 and the emerging literature that has been documenting the associated rising mortality rates.7
The increasing trend in liver disease could have many different causes, including a large number of hepatitis C infections that have not been diagnosed.13 Recent validation studies29 have shown that the ICD-9-CM codes for advanced liver disease that we used in our analysis-particularly the codes for liver transplant, liver cancer, variceal bleeding, and ascites-have high positive predictive values. This gives us confidence that our estimates are reasonable.
However, increased awareness of hepatitis C in the later part of our study period might have led to higher rates of testing for hepatitis C, and more prompt diagnosis of hepatitis C might have led to coding changes that favored listing hepatitis C as the principal cause of a hospitalization related to advanced liver disease. The decline in hospitalization rates characterized by liver disease as the principal diagnosis and hepatitis C as the secondary diagnosis contrasts with the increasing hospitalization rates characterized by hepatitis C as the principal diagnosis. The presence of these two diametrically opposed trends is consistent with changing coding practices.
A more detailed investigation into specific coding practices is beyond the scope of the current study. Nonetheless, when these two types of hospitalizations are combined (Exhibit 2), the overall trend is increasing. This suggests that morbidity related to hepatitis C is on the rise.
The apparent shifting to Medicare for insurance by the aging cohort of people infected with hepatitis C is an important finding for health care policy makers. During the study period, the proportion of hepatitis C hospitalizations paid for by private insurance decreased, and the proportion paid for by Medicare increased by 5 percentage points, from 28.7 percent to 33.9 percent (Exhibit 3). As the baby boomers age, they are more likely to leave health plans provided by their employers and private insurance companies, replacing those plans with Medicare coverage.
With the recent licensure by the Food and Drug Administration of more effective and curative therapies for hepatitis C,17,18 especially in the case of patients who have evidence of advanced liver disease or who had failed with previous treatment,30 the growth in hospitalizations and deaths resulting from chronic hepatitis C can be slowed substantially.31 Large health care payers such as Medicare and private insurance companies must consider the costs of providing access to hepatitis C therapies, which could exceed $84,000 per patient, as well as the benefits of such treatments, which could include forgone ambulatory services and hospital stays associated with advanced and end-stage liver disease sequelae.
Partly because of the expensive hospital visits and procedures that may be associated with hepatitis C and advanced liver disease, many newer-generation pharmaceuticals have largely been found to be cost-effective in recent modeling efforts.32,33 The high rates of hospitalization and the morbidity burden associated with hepatitis C, along with the rapidly evolving availability of effective new hepatitis C therapies, are an impetus for national programs of testing and linkage to care. Eventually, initiatives such as the recent Centers for Disease Control and Prevention's screening recommendations3 to identify people born in the period 1945-65 who are infected with hepatitis C may reverse the trend in hospitalizations associated with cirrhosis and end-stage liver disease.
Conclusion
This article has identified increasing trends in hospitalization rates resulting from hepatitis C and advanced liver disease in the period 2004-11. In addition to the rising rates of hospitalization, the average cost of the hospitalizations nationally increased 18-50 percent. Implementation of the recommended screening of people born in the period 1945-65 and of more effective treatment for hepatitis C in the United States has the potential to reverse the rising morbidity and costs from hepatitis C.
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