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The Economic and Clinical Burden of Non-alcoholic Fatty Liver Disease (NAFLD) in the United States and Europe
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Hepatology accepted article Aug 20 2016
Zobair M. Younossi* 1, Deirdre Blissett4, Robert Blissett4, Linda Henry2, Maria Stepanova2, Youssef
Younossi2, Andrei Racila2, Sharon Hunt3, Rachel Beckerman4
1Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, VA
2Center for Outcomes Research in Liver Disease, Washington, D.C.
3Betty and Guy Beatty Center for Integrated Research, Inova Health Systems, Falls Church, VA
4Maple Heath Group, LLC, New York, NY
Non-alcoholic fatty liver disease (NAFLD) is a major cause of chronic liver disease. There is uncertainty around the economic burden of NAFLD. We constructed a steady-state prevalence model to quantify this burden in the United States of America (USA) and Europe (EU).
METHODS: Five models were constructed estimating burden of NAFLD in the USA and 4 European countries. Models were built using a series of interlinked Markov chains, each representing age increments of the NAFLD and the general population. Incidence and remission rates were calculated by calibrating against real-world prevalence rates. The data was validated using a computerized disease Model called DisMod II. NAFLD patients transitioned between nine health states (nonalcoholic fatty liver, non-alcoholic steatohepatitis (NASH), NASH-fibrosis, NASH-compensated cirrhosis, NASH-decompensated cirrhosis, hepatocellular carcinoma, liver transplantation, post-liver transplant and death). Transition probabilities were sourced from the literature, systematic review and was calibrated against real-world data. Utilities were obtained from NAFLD patients using SF-6D. Costs were sourced from the literature and local fee schedules.
RESULTS: In the USA, over 64 million people are projected to have NAFLD, with annual direct medical costs of about $103 bn [$1,613 per patient (PP)]. In EU-4 countries [Germany, France, Italy and United Kingdom], there are ∼52 million people with NAFLD with an annual cost of about 35 billion (from 354 to 1,163 PP). Costs are highest in patients aged 45-65. The burden is significantly higher when societal costs are included.
The analysis quantifies the enormity of the clinical and economic burden of NAFLD, which will likely increase as incidence of NAFLD continues to rise. This article is protected by copyright. All rights reserved.
In addition to direct annual cost of NAFLD, there is also a societal cost related to the loss of QALYs due to NAFLD and its complications. By assigning a monetary value to societal costs and adding these to the annual direct cost of NAFLD for the USA and EU-4, the total annual cost of NAFLD can be estimated at $292.19 billion and 227.84 billion, respectively. Furthermore, these cost calculations do not take into account other indirect costs of NAFLD which are related to work productivity loss and its economic impact.
Treatment costs were not included in this model, as, unlike for viral hepatitis and other etiologies of chronic liver disease, there are currently no effective therapies approved for the treatment of NAFL or NASH. However, as there are a significant number of therapies currently under investigation [52], this may substantially change the cost burden of NAFLD in the future.

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