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HCV Health Services Utilization "Large",
Increasing Healthcare Burden......new study
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"We sought to characterize healthcare utilization by individuals infected with HCV in the US, examining adult (≥ 18 years) outpatient, ED and inpatient visits among individuals with HCV diagnosis for the period 2001-2010......Annual inpatient charges among HCV-infected persons with a liver-related complication totaled $463 million for the younger cohort, $5.8 billion for the baby boomer cohort and $1.3 billion for the older cohort........Inpatient stays totaled 2.8 million days and cost over $15 billion annually. Non-whites, uninsured individuals, and individuals receiving publicly funded health insurance were disproportionately affected in all healthcare settings.......Individuals with HCV infection were large users of healthcare resources; incurring over 2.3 million outpatient, 73,000 ED, and 475,000 in patient hospital stays annually.Our findings highlight the challenges of and opportunities for improved care of individuals with HCV infection.......Discharges with HCV and no liver-related complication were disproportionately black, underinsured, from the Northeast Census region, composed of residents from ZIP codes in the lowest quartile for household income, and admitted with a primary diagnosis of mental disorder......The findings of our study highlight the urgency of expanding HCV detection and initial care nationally.......Most alarming is the increase in inpatient utilization, suggesting that the progression of HCV-related liver disease will create an increasing healthcare burden over the coming decades......because a significant percentage of HCV infections remain undiagnosed, our findings will underestimate the true burden of HCV infection in the US.The current analysis provides the best data available regarding the national impact of HCV.......we may have under-detected the number of healthcare encounters, particularly in the outpatient and ED settings. Our study describes the number of healthcare visits by HCV-infected individuals, but does not indicate the prevalence of the disease in the US populations. Furthermore, we did not analyze comorbid diseases, which may have led to increased healthcare visits by HCV-infected individuals.........HCV screening is inexpensive and reliable, with evolving treatment strategies making HCV an imminently curable disease.......Coordinated screening efforts are paramount in order to detect the disease at its earliest stages, maximizing opportunities for early treatment and prevention of major health sequelae. Early detection and treatment are viable and essential strategies for reducing HCV mortality and healthcare burden. Given the known healthcare utilization disparities and those observed in our study, limiting HCV screening and treatment to traditional settings will fall short of current needs and increasing rates of HCV-related cirrhosis and hepatocellular carcinoma. Ongoing health care reform changes must expand opportunities for HCV screening and treatment to all persons, regardless of insurance status, to achieve success similar to that seen with HIV through the Ryan White Care Act."
Our objective was to determine the characteristics of the outpatient, ED and in patienthealthcare utilization by persons with HCV infection in the US.
In conclusion, individuals with HCV infection were large users of outpatient, ED and inpatient health services in the US, with resource use highest and increasing in the baby boomer cohort. These observations illuminate the public health burden of HCV infection in the US.
Individuals with HCV infection are large users of outpatient, ED, and inpatient health services. Resource use is highest and increasing in the "baby boomer" generation. These observations illuminate the public health burden of HCV infection in the US......Most alarming is the increase in inpatient utilization, suggesting that the progression of HCV-related liver disease will create an increasing healthcare burden over the coming decades......Furthermore, because a significant percentage of HCV infections remain undiagnosed, our findings will underestimate the true burden of HCV infection in the US.The current analysis provides the best data available regarding the national impact of HCV......Because of the limited number of diagnoses collected by each data set, we may have under-detected the number of healthcare encounters, particularly in the outpatient and ED settings.....Furthermore, we did not analyze comorbid diseases, which may have led to increased healthcare visits by HCV-infected individuals.
This analysis provides current national perspectives of the burden of HCV infection upon the US healthcare system. Individuals with HCV infection were large users of healthcare resources; incurring over 2.3 million outpatient, 73,000 ED, and 475,000 in patient hospital stays annually.Our findings highlight the challenges of and opportunities for improved care of individuals with HCV infection.
Annual inpatient charges among HCV-infected persons with a liver-related complication totaled $463 million for the younger cohort, $5.8 billion for the baby boomer cohort and $1.3 billion for the older cohort.
Discharges with HCV and no liver-related complication were disproportionately black, underinsured, from the Northeast Census region, composed of residents from ZIP codes in the lowest quartile for household income, and admitted with a primary diagnosis of mental disorder.
Striking differences were noted between HCV inpatient discharges with and without liver-related complications. HCV inpatient discharges without a liver-related diagnosis were disproportionately black and underinsured, and with a primary ICD-9 code diagnosis of mental disorder. From 2001 to 2010, this group revealed a significant and steady rise in proportion to all hospital discharges for the younger and baby boomer cohorts. These findings highlight the burden of mental health disorders, which includes substance abuse and psychiatric illnesses, within this HCV-infected population. This suggests that efforts to successfully link and treat this population might require significant resources to stabilize both drug and alcohol addiction and psychiatric illness
We sought to characterize healthcare utilization by individuals infected with HCV in the US, examining adult (≥ 18 years) outpatient, ED and inpatient visits among individuals with HCV diagnosis for the period 2001-2010......Individuals with HCV infection were responsible for over 2.3 million outpatient, 73,000 ED, and 475,000 inpatient visits annually. Persons in the baby boomer cohort accounted for 72.5%, 67.6%, and 70.7% of care episodes in these settings, respectively. While the number of outpatient visits remained stable during the study period, inpatient admissions among HCV-infected baby boomers increased by over 60%. Inpatient stays totaled 2.8 million days and cost over $15 billion annually. Non-whites, uninsured individuals, and individuals receiving publicly funded health insurance were disproportionately affected in all healthcare settings.
The findings of our study highlight the urgency of expanding HCV detection and initial care nationally. HCV screening is inexpensive and reliable, with evolving treatment strategies making HCV an imminently curable disease.Recent advances in HCV treatment with direct-acting antivirals (DAAs) have transformed the care of this previously incurable disease.[20-22] Coordinated screening efforts are paramount in order to detect the disease at its earliest stages, maximizing opportunities for early treatment and prevention of major health sequelae.[23-25] Early detection and treatment are viable and essential strategies for reducing HCV mortality and healthcare burden. Given the known healthcare utilization disparities and those observed in our study, limiting HCV screening and treatment to traditional settings will fall short of current needs and increasing rates of HCV-related cirrhosis and hepatocellular carcinoma. Ongoing health care reform changes must expand opportunities for HCV screening and treatment to all persons, regardless of insurance status, to achieve success similar to that seen with HIV through the Ryan White Care Act.
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National Estimates of Healthcare Utilization by Individuals with Hepatitis C Virus Infection in the United States
Clinical Infectious Diseases Advance Access published June 9, 2014
James W. Galbraith1, John P. Donnelly1, Ricardo Franco2, Turner Overton2, Joel B. Rodgers1, Henry E. Wang1
1Department of Emergency Medicine, University of Alabama at Birmingham, AL, USA 2Department of Medicine, Division of Infectious Disease, University of Alabama at Birmingham, AL, USA
Abstract
BACKGROUND. Hepatitis C virus (HCV) infection is a major public health problem in the United States (US). While prior studies have evaluated HCV-related healthcare burden, these studies examined a single treatment setting and did not account for the growing "baby boomer" population (individuals born 1945-1965).
METHODS. Data from the National Ambulatory Medical Care Survey (NAMCS), the National Hospital Ambulatory Medical Care Survey (NHAMCS), and the Nationwide Inpatient Sample (NIS) were analyzed. We sought to characterize healthcare utilization by individuals infected with HCV in the US, examining adult (≥ 18 years) outpatient, ED and inpatient visits among individuals with HCV diagnosis for the period 2001-2010. Key subgroups included persons born before 1945 (older), between 1945 and 1965 (baby boomer), and after 1965 (younger).
RESULTS. Individuals with HCV infection were responsible for over 2.3 million outpatient, 73,000 ED, and 475,000 inpatient visits annually. Persons in the baby boomer cohort accounted for 72.5%, 67.6%, and 70.7% of care episodes in these settings, respectively. While the number of outpatient visits remained stable during the study period, inpatient admissions among HCV-infected baby boomers increased by over 60%. Inpatient stays totaled 2.8 million days and cost over $15 billion annually. Non-whites, uninsured individuals, and individuals receiving publicly funded health insurance were disproportionately affected in all healthcare settings.
CONCLUSIONS. Individuals with HCV infection are large users of outpatient, ED, and inpatient health services. Resource use is highest and increasing in the "baby boomer" generation. These observations illuminate the public health burden of HCV infection in the US.
INTRODUCTION
Hepatitis C virus (HCV) infection poses a major and growing public health problem. Anestimated 3.2 million Americans are currently living with chronic HCV infection.[1]_ENREF_1HCV infection is particularly prevalent in the "baby boomer" population (those born between 1945 and 1965). Prior studies estimate that 3.3% of baby boomers are HCV-antibody positive, and this birth cohort accounts for up to 75% of all United States (US) HCV infections.[2]Additionally, 43-85% of baby boomers are unaware of their HCV infection status.[3-5]Chronic HCV infection remains the leading cause of chronic liver disease, hepatocellular carcinoma, and liver transplantation.[6] In 2007, mortality from HCV eclipsed that of the Human Immunodeficiency virus (HIV) in the US and is expected to rise over the coming decades.[7]
While much is known about the disease course of individuals with HCV infection, little is known about their collective impact upon the US healthcare system.Prior studies of HCV healthcare utilization have been limited to single centers or treatment settings.[8, 9]Because the chronic nature of HCV may result in healthcare utilization in outpatient, Emergency Department(ED) and inpatient settings, efforts to estimate the national healthcare burden of HCV must account for all three treatment arenas. Few studies describe the comparative rates or patterns of healthcare utilization by HCV individuals in these settings. This information is particularly important given HCV primarily affect the "baby boomer" generation.[10]
Our objective was to determine the characteristics of the outpatient, ED and in patienthealthcare utilization by persons with HCV infection in the US.
Selection of Participants
We studied adult (≥ 18 years) patients with a diagnosis of HCV infection. We defined the population as individuals with outpatient, ED or inpatient diagnoses consistent with HCV infection. While the outpatient and ED data contained up to three diagnoses, the inpatient data included up to 25 diagnoses. International Classification of Diseases, 9th Revision(ICD-9) diagnosis codes for HCV included 70.41, 70.44, 70.51, 70.54, 70.70, 70.71, V02.62.
We stratified all HCV individuals into three birth cohorts: "older"(individuals born before 1945), "baby boomer" (those born between 1945 and 1965), and "younger" (those born after 1965). We additionally classified visits and discharges as involving a liver-related complication if they had diagnoses of chronic liver disease or cirrhosis (ICD-9: 571), liver abscess and sequelae of chronic liver disease (572), other disorders of the liver (573), ascites (789.5), esophageal varices (456.00-456.21), hepatocellular carcinoma (155.0 and 155.2), or hepatorenal syndrome (674.8).[13]
RESULTS
Characteristics of Outpatient Visits
Among 824 million annual adult outpatient visits from 2001-2010, individuals with HCV infection accounted for 2.29 million (0.28%; 95% CI 0.22-0.34).Baby boomers accounted for almost three-fourths of outpatient visits by HCV-infected individuals. (Table 1)Compared to non-HCV baby boomer visits, HCV-infected visits were disproportionately male (69.9% vs 40.0%; p<0.001), black (29.5% vs 11.4%; p<0.001), and insured by Medicaid (25.9% vs 7.0%; p<0.001). (Table 2)Over the 10-year study period, there was no change in the percentage of outpatient visits for HCV(trend p-value 0.182). (Figure 1)Liver-related complications occurred in 3.5%, 7.6% and 10.0% of the younger, baby boomer and older cohorts, respectively.
Characteristics of Emergency Department Visits
Among 90 million annual adult ED visits, individuals with HCV infection accounted for 72,138 (0.08%; CI0.07-0.10).Baby boomers accounted for 67.7% of ED visits by HCV-infected persons. (Table 1) Compared to non-HCV baby boomer visits, HCV-infected ED visits were disproportionately male (62.1% vs 46.9%; p<0.001), of Hispanic ethnicity (19.4% vs 10.6%; p=0.011), and insured by Medicaid (42.1% vs 16.8%; p<0.001). (Table 2)There were no trends in the percentage of ED visits for HCV among baby boomers(trend p-value 0.519). (Figure 1)The proportion of visits with a liver-related complication was smallest for the younger cohort (5.2%).
For the others, the proportion was elevated, with 16.6% of the baby boomer cohort and 26.3% of the older cohort having a complication.
Characteristics of Inpatient Discharges
Among 31.8 million annual adult inpatient discharges, HCV-infected persons accounted for 475,224 (1.5%; CI 1.4-1.5).The baby boomer cohort accounted for 70.7% of inpatient discharges among HCV-infected persons. (Table 1) Inpatient discharge for HCV increased by 60% for the baby boomer cohort, rising from 2.6 % in 2001 to 4.2% in 2010 (trend p-value <0.001). (Figure 2A) Compared to non-HCV baby boomer discharges, those with HCV infection were disproportionately male (66.1% vs 47.1%; p<0.001), insured by Medicaid (35.1% vs 16.0%; p<0.001) and residents in the lowest median household income quartile (39.8% vs 29.9%; p<0.001). (Table 2) The proportion of discharges with a liver-related complication was smallest for the younger cohort (13.6%; CI 12.8-14.3) and elevated for the others, with 34.5% (CI 33.7- 35.3) of the baby boomer and 40.5% (CI 39.5-41.4) ofthe older cohort having a complication.
For the younger cohort, median charges differed between non-HCV discharges ($12,559; IQR 7,777-21,973) and those with HCV ($15,832; 8,763-31,394). For the baby boomer cohort, median charges were similar between non-HCV ($21,540; 11,696-41,509) and HCV ($22,364;11,920-44,619). The greatest difference in median charge was observed for the older cohort, with non-HCV ($23,484; 12,627-45,053) substantially lower than HCV ($28,873; 15,385-56,315). There were modest increases in median inpatient charge for HCV-infected discharges in the baby boomer and older cohorts. (Figure 3) However, these increases were smaller than those observed for non-HCV discharges.
Diagnosis Subgroup Analysis
Between 2001 and 2010, there were large increases in the percentage of all baby boomer cohort discharges with HCV and a liver-related complication (Figure 2B; trend p <0.001) and HCV with no liver-related complication (Figure 2C; trend p <0.001). The percentage of liver-related complications among HCV discharges increased for the baby boomer and younger cohorts, but decreased for the oldercohort. (Figure 2D) The percentage of non-HCV discharges having a liver-related complication increased from 2001 to 2010 for all age groups. (Figure 2E)
Among all adult inpatient discharges, charges and length of stay were greatest for discharges with a liver-related complication, regardless of HCV status. (Table 3) Annual inpatient charges among HCV-infected persons with a liver-related complication totaled $463 million for the younger cohort, $5.8 billion for the baby boomer cohort and $1.3 billion for the older cohort.
Temporal trends in charges did not vary substantially by diagnosis group. (Supplementary Figure 1) Discharges with HCV and no liver-related complication were disproportionately black, underinsured, from the Northeast Census region, composed of residents from ZIP codes in the lowest quartile for household income, and admitted with a primary diagnosis of mental disorder. (Table 3) We observed similar patterns for ambulatory medical care visits in the outpatient or ED setting. (Supplementary Table 1)
DISCUSSION
This analysis provides current national perspectives of the burden of HCV infection upon the US healthcare system. Individuals with HCV infection were large users of healthcare resources; incurring over 2.3 million outpatient, 73,000 ED, and 475,000 in patient hospital stays annually.Our findings highlight the challenges of and opportunities for improved care of individuals with HCV infection.
As expected, our study affirmed the disproportionate use of healthcare resources by HCV-infected baby boomer cohort, accounting for approximately 1.7 million outpatient visits, 49,000 ED visits, and 336,000 inpatient discharges annually. However, there were other important observations that highlight the challenges of providing healthcare to this subset. For example, while the rates of outpatient and ED visits by HCV baby boomer cohort remained stable from 2001-2010, the corresponding rates of inpatient discharge increased by over 60%. Compared with outpatient and ED settings, a larger percentage of discharges involved a liver-related complication. Among the baby boomer cohort, discharges with a liver complication were a substantial economic burden, totaling nearly $6 billion annually. At the current rate, in 10 years, HCV baby boomers may account for up to 912,000 annual hospitalizations,with acuity likely to increase given the underlying progressive liver disease and high comorbidity burden among these patients.[17]
The increase in inpatient discharges relative to outpatient visits is also potentially worrisome. While not indicated by our data, these findings may signal the inability of these individuals to access outpatient care and treatment to prevent the progression of HCV-related liver disease. These observations could also represent the results of delayed HCV detection, with individuals not presenting for care until after developing symptomatic end stage liver disease or other severe sequelae. We also identified a very low percentage of HCV-related visits in rural settings; while potentially suggesting regional disparities in HCV prevalence, these findings may also indicate a lack of suitable HCV care resources outside of metropolitan areas.
Striking differences were noted between HCV inpatient discharges with and without liver-related complications. HCV inpatient discharges without a liver-related diagnosis were disproportionately black and underinsured, and with a primary ICD-9 code diagnosis of mental disorder. From 2001 to 2010, this group revealed a significant and steady rise in proportion to all hospital discharges for the younger and baby boomer cohorts. These findings highlight the burden of mental health disorders, which includes substance abuse and psychiatric illnesses, within this HCV-infected population. This suggests that efforts to successfully link and treat this population might require significant resources to stabilize both drug and alcohol addiction and psychiatric illness
Across all settings, compared with HCV-seronegative patients, HCV individuals were predominantly Medicaid or Medicare beneficiaries. Furthermore, the percentage of individuals with private insurance in the baby boomer cohort was below 50%for all settings.These findings underscore that the increasing burden of funding HCV care will fall upon public resources. Inadequate health insurance coverage and poor access to regular health care have been extensively described as barriers to HCV screening and treatment. Stepanova, et al. revealed that a high proportion of persons infected with HCV have no insurance (38%) or have publicly funded health insurance (28%).[18] Uninsured HCV-positive individuals in the same study were more likely to use the hospital emergency room than any other type of health care. Efforts to reduce the impact of HCV must consider expansion of HCV screening and early treatment among the uninsured and medically underserved. Additionally, the explosion of new directly acting antiviral medications for the treatment of HCV will be useless without access for this large under-insured and uninsured cohort.[19]
Prior studies examining HCV healthcare burden have limitations.Tsui, et al. examined the NAMCS and NHAMCSOPD data from 1997 through 2005 and reported a high proportion of HCV related outpatient visits by the baby boomer cohort and disproportionate growth among non-whites and Medicaid recipients.[8]Moorman, et al. assessed the clinical impact of chronic HCV infection through a prospective cohort study from four participating health systems, confirming the prominence of this condition among baby boomers.[9] Grant, et al.also used national inpatient data characterize healthcare resource utilization by HCV individuals.[13] However, their study was limited to 1994-2001, while our study included 2001-2010 and reflects the most current estimates. We also included ED and outpatient encounters provided by NHAMCS.Our study extends upon these prior efforts, confirming increases in HCV-related healthcare burden among baby boomers. Most alarming is the increase in inpatient utilization, suggesting that the progression of HCV-related liver disease will create an increasing healthcare burden over the coming decades.
The findings of our study highlight the urgency of expanding HCV detection and initial care nationally. HCV screening is inexpensive and reliable, with evolving treatment strategies making HCV an imminently curable disease.Recent advances in HCV treatment with direct-acting antivirals (DAAs) have transformed the care of this previously incurable disease.[20-22]Coordinated screening efforts are paramount in order to detect the disease at its earliest stages, maximizing opportunities for early treatment and prevention of major health sequelae.[23-25]Early detection and treatment are viable and essential strategies for reducing HCV mortality and healthcare burden. Given the known healthcare utilization disparities and those observed in our study, limiting HCV screening and treatment to traditional settings will fall short of current needs and increasing rates of HCV-related cirrhosis and hepatocellular carcinoma. Ongoing health care reform changes must expand opportunities for HCV screening and treatment to all persons, regardless of insurance status, to achieve success similar to that seen with HIV through the Ryan White Care Act.
We recognize the limitations of the current analysis. NAMCS, NHAMCS and NIS are retrospective, probability sampled data sets. Recent studies have questioned the validity of the ambulatory medical care surveys.[26,27] However, the methodologies of NAMCS and NHAMCS are rigorous, and the data sets have been widely used in similar analyses for over 15 years.[28, 29]_ENREF_5NAMCS, NHAMCS, and NIS date sets only include visits to non-federally employed office-based practices and non-institutional general and short-stay hospitals (excluding Federal, military, and VA hospitals). Given these known limitations, the large HCV burden identified in this study likely underestimates the true US burden. Furthermore, because a significant percentage of HCV infections remain undiagnosed, our findings will underestimate the true burden of HCV infection in the US.The current analysis provides the best data available regarding the national impact of HCV.
While we were able to characterize collective outpatient, ED and inpatient utilization by HCV-infected individuals, we were not able to determine the care or outcomes of individual persons. NAMCS, NHAMCS, and NIS data represent visits and discharges, not unique individuals. Therefore, we could not control for or determine patterns of readmission. Because of the limited number of diagnoses collected by each data set, we may have under-detected the number of healthcare encounters, particularly in the outpatient and ED settings. Our study describes the number of healthcare visits by HCV-infected individuals, but does not indicate the prevalence of the disease in the US populations. Furthermore, we did not analyze comorbid diseases, which may have led to increased healthcare visits by HCV-infected individuals.
In conclusion, individuals with HCV infection were large users of outpatient, ED and inpatient health services in the US, with resource use highest and increasing in the baby boomer cohort. These observations illuminate the public health burden of HCV infection in the US.
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