Economic burden of cirrhosis in Catalonia: a population-based analysis

Timely Albumin Infusion May Improve Resource Utilization in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis is a life-threatening complication of cirrhosis that can increase healthcare utilization. The impact of albumin administration timing on hospital resource utilization and its optimal timing is unclear, despite its efficacy in improving survival for cirrhosis patients with spontaneous bacterial peritonitis. A retrospective study was conducted to evaluate the influence of the timing of albumin administration on the length of stay and total hospital cost for patients with cirrhosis and spontaneous bacterial peritonitis who require fluid resuscitation. The study utilized de-identified data from Cerner Health Facts® data. Adult inpatients with a diagnosis of cirrhosis and SBP receiving ≥1 antibiotic and fluid resuscitation between January 1, 2009, and April 30, 2018, were included and stratified by albumin administration timing: ≤24 hours from hospital admission ("timely albumin") or >24 hours of admission or no albumin ("non-timely albumin"). We used a Kaplan-Meier curve with log-rank test to evaluate the association between timing of albumin administration and time to hospital discharge and a generalized linear model to examine the association between albumin timing and total hospital costs. We identified 1,308 hospitalizations, of which 301 contained valid cost data. The timely albumin group had a median time to discharge of 6.95 days compared to 7.78 days in the non-timely group (p = 0.02). Cost model showed that receiving timely albumin incurred 16% lower costs (p = 0.027) than patients in the non-timely albumin group. Timely albumin administration with an antibiotic regimen may shorten the length of stay and lower costs, thereby reducing hospital resource utilization in patients with cirrhosis and spontaneous bacterial peritonitis requiring fluid resuscitation.

Impact of major osteoporotic fractures on the use of healthcare resources in Catalonia, Spain

OBJECTIVES

To estimate the impact of first major osteoporotic fractures (MOF) on health resource use and healthcare expenditures in people aged ≥50 years in Catalonia, Spain.

DESIGN

Observational, retrospective study. The Catalan Health Surveillance System (CHSS) registry was used to obtain sociodemographic, clinical and expenditure data from all public centres in Catalonia (Spain).

SETTING AND PARTICIPANTS

Males and females aged ≥50 years who sustained a first major osteoporotic fracture between January 1, 2018, and December 31, 2020.

METHODS

Data on admissions to the emergency department, hospitalization and skilled nursing facilities, primary and specialized care visits, nonemergency medical transport, outpatient rehabilitation and pharmacy prescriptions were retrieved for each patient. Monthly and yearly mean usage rates, expenditure in euros (€) and incremental costs one and two years after fracture were calculated.

RESULTS

There were 64,403 patients with first MOF: 47,555 females and 16,848 males with a mean age (standard deviation) of 76.5 (12.0) years. The average annual expenditure increased from €4564 in the year before to €12,331 in the year following a hip fracture. For forearm fractures, the expenditure increased from €2511 to €4251, for vertebral fractures from €4146 to €6659, for pelvic fractures from €4442 to €7124, for humerus fractures from €3058 to €5992, and for multiple fractures from €4598 to €12,028. The average cost for overall fractures experienced a 110.3 % increase. The leading cause of health expenditure in the year following MOF was hospital admission. Expenditure in the second year post-fracture returned to pre-fracture levels. The use of some healthcare resources, especially visits to emergency services, increased in the prefracture month. Male sex, older age and high previous comorbidities were associated with a higher expenditure.

CONCLUSIONS

In people with a first MOF, healthcare expenditure doubled during the first-year post-facture, mostly in relation to inpatient care. The healthcare resource use increased during the previous month. This increase could potentially be attributed to the worsening of pre-existing comorbidities.

Economic impact of inflammatory bowel disease in Catalonia: a population-based analysis

Background

Inflammatory bowel disease (IBD) has a major economic impact on healthcare costs.

Objectives

The aim of this study was to evaluate the current healthcare expenditure associated with IBD in a population-wide study in Catalonia.

Design

Retrospective observational study.

Methods

All patients with IBD included in the Catalan Health Surveillance System (CHSS) were considered eligible. The CHSS compiles data on more than 7 million individuals in 2020 (34,823 with IBD). Data on the use of healthcare resources and its economic impact were extracted applying the International Classification of Diseases, 10th revision, Clinical Modification codes (ICD-10-CM codes). Health expenditure, comorbidities, and hospitalization were calculated according to the standard costs of each service provided by the Department of Health of the Catalan government. The data on the IBD population were compared with non-IBD population adjusted for age, sex, and income level. IBD costs were recorded separately for Crohn's disease (CD) and ulcerative colitis (UC).

Results

Prevalence of comorbidities was higher in patients with IBD than in those without. The risk of hospitalization was twice as high in the IBD population. The overall healthcare expenditure on IBD patients amounted to 164M€. The pharmacy cost represents the 60%. The average annual per capita expenditure on IBD patients was more than 3.4-fold higher (IBD 4200€, non-IBD 1200€). Average costs of UC were 3400€ and 5700€ for CD.

Conclusion

The risk of comorbidities was twice as high in patients with IBD and their use of healthcare resources was also higher than that of their non-IBD counterparts. Per capita healthcare expenditure was approximately 3.4 times higher in the population with IBD.

Trial registration

The study was not previously registered.

An Economic Analysis of Transjugular Intrahepatic Portosystemic Covered Stent Shunt for Variceal Bleeding and Refractory Ascites in a Spanish Setting

INTRODUCTION

The primary aim is to estimate the cost-effectiveness of transjugular intrahepatic portosystemic stent shunt (TIPSS) in two indications from a Spanish perspective. Firstly, as pre-emptive treatment for patients with acute variceal bleeding (indication 1) compared with endoscopic band ligation plus drug therapy. Secondly, to treat refractory ascites (indication 2) compared with large volume paracentesis.

METHODS

A two-state (alive and dead) Markov model was developed to capture the costs and health impact for the two indications over a 2-year time horizon with monthly cycles. In the alive state, patients could experience adverse event(s), associated with costs and disutility, such as recurrent variceal bleeding, ascites, and hepatic encephalopathy. Discount rates of 3% for utilities and costs and a cost-effectiveness threshold of €25,000 per QALY were applied.

RESULTS

In the base case analysis, TIPSS was estimated to be cost-effective as a pre-emptive treatment for indication 1 (incremental cost and QALYs of - €230 and 0.211, respectively). TIPSS also remained cost-effective (€16,819/QALY) in a conservative scenario analysis, conducted with an alternate source for clinical parameters. The key drivers of the outcomes were survival for the comparator arm, mean band ligation outpatient procedures, and TIPSS treatment costs. TIPSS was estimated to dominate the comparator for indication 2 (incremental cost and QALYs of - €25,687 and 0.531, respectively). The key drivers of the outcomes were monthly paracentesis sessions and cost per inpatient stay for those undergoing paracentesis.

CONCLUSIONS

TIPSS is likely to be a cost-effective and a cost-saving treatment in patients with cirrhosis in indications 1 and 2, compared with standard treatments. The analyses estimate clinical benefits along with reduced healthcare costs from avoided downstream resource consumption.

Epidemiology of major osteoporotic fractures: a population-based analysis in Catalonia, Spain

PURPOSE

The aim of this study was to estimate the incidence of major osteoporotic fractures in Catalonia, Spain, in 2018 and 2019 and their association with age, sex, income, climate and a set of comorbidities.

METHODS

Data on age, sex, smoking, alcohol abuse, comorbidities (obesity, Parkinson's disease, arthritis, chronic kidney disease, hepatic cirrhosis, diabetes, chronic obstructive pulmonary disease, dementia, cerebrovascular disease, hyperthyroidism, multiple myeloma and epilepsy) and income levels in people aged ≥ 50 years with a new diagnosis of major osteoporotic fractures in 2018 and 2019 were collected from the Catalan Health Surveillance System (CHSS). Climatological variables were obtained from the Catalan Meteorological Service. Incidence rates were estimated for five major osteoporotic fractures (MOF). Associations between osteoporotic fractures and age, sex, income, comorbidities and climate variables were ascertained through multilevel generalized linear model analysis (Poisson's regression).

RESULTS

There were 60,671 MOF. The annual incidence rate per 1000 persons/years at risk (PYAR) was 10.6 (3.1 for hip, 2.3 for distal forearm, 2.2 for vertebrae, 1.7 for pelvis and 1.5 for proximal humerus). Female sex, older age, lower income, smoking, alcohol abuse and some common comorbidities were associated with a higher incidence of MOF while obesity was a protective factor.

CONCLUSIONS

MOF are frequent in the adult Catalan population, especially in older women and people on low incomes. Hip fracture is the most frequent, followed by forearm and vertebral fractures. Smoking, alcohol abuse and some comorbidities were associated with an increased incidence of fracture.

Use of healthcare resources and drug expenditure before and after treatment of chronic hepatitis C with direct antiviral agents

The aim of this study was to analyse the impact of treating chronic hepatitis C (CHC) with direct-acting agents (DAA) on the use of healthcare resources. We included all patients treated with DAA for CHC from January 2015 to December 2017 in Catalonia whose medical records from 12 months before to 24 months after treatment were available. Data were obtained from the Catalan Health Surveillance System. A total of 12,199 patients in Catalonia were treated with DAA for CHC. Of these, 11.3% had no-minimal fibrosis (F0-F1), 24.0% had moderate fibrosis (F2), 50.3% had significant fibrosis or cirrhosis (F3-F4), and 14.4% had decompensated cirrhosis. Use of healthcare resources decreased from the pre-treatment period to the post-treatment period for the following: hospital admissions due to complications of cirrhosis, from 0.19 to 0.12 per month per 100 patients (RR 0.57; 95% CI 0.47-0.68); length of hospital stay, from 12.9 to 12.2 days (RR 0.93; 95% CI 0.91-0.94); outpatient visits, from 65.0 to 49.2 (RR 0.75; 95% CI 0.74-0.75); and number of medication containers per patient per month, from 13.9 to 12.5 (RR 0.837; 95% CI 0.835-0.838). However, the number of invoices for antineoplastic treatment increased after DAA treatment, especially for patients with high morbidity or advanced fibrosis stage. In conclusion, a decrease in health resource use was seen in CHC patients treated with DAA, as measured by length of hospital stay, number of admissions due to cirrhosis complications, outpatient visits and overall drug invoicing. However, use of antineoplastic drugs increased significantly, especially in patients with cirrhosis and high morbidity.

Direct medical costs of non-alcoholic fatty liver disease in Catalonia at the hospital level: a retrospective multicenter study

Background: The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing worldwide, which is expected to correlate with significant medical and social costs. This study aimed to evaluate the clinical and economic burden of NAFLD in Catalonia at the hospital level.Methods: Records of all patients diagnosed with NAFLD and treated in Catalan hospitals between the year 2007 and 2018 were extracted from a patient-level healthcare database.Results: Admission files of 24,172 individual patients were obtained. High comorbidity rates were found across age groups, with a mean Charlson Comorbidity Index of 5.1. In-hospital mortality rate increased over the study period, and was associated to a higher comorbidity rate. Disease complexity was increased in this patient group, which is associated with larger medical costs. The mean annual cost per patient was €4073, with a total annual direct medical cost of €27,370,827. The greatest portion of costs was attributed to surgical interventions (€14,429,336).Conclusions: The high level of comorbidity and disease complexity in this patient group versus the general population is expected to correlate with a more intensive use of medical resources and costs. This study provides novel data to inform resource allocation and disease management decisions at the regional level.

A cohort study on long-term exposure to air pollution and incidence of liver cirrhosis

Cirrhosis is an advanced liver disease affecting millions of people worldwide, involving high healthcare costs. Despite experimental evidence suggesting a possible role of airborne pollutants in liver diseases, epidemiological studies are lacking. We aimed at investigating the association between exposure to air pollutants and incidence of cirrhosis in a large population-based cohort in Rome.

Methods

We used an administrative cohort established from the 2001 census. We included all adults of 30 years of age or older who were free of cirrhosis, resulting in a study population of over 1.2 million subjects. Follow-up of the subjects ended on 31 December 2015. We ascertained incident cases of cirrhosis from regional mortality and hospital discharge registries using a validated algorithm. We assessed exposure of the subjects to PM₁₀, PM coarse, PM_2.5, PM_2.5 absorbance, NO₂, NOx, and PM metal components at their residential address using Land Use Regression models. We used Cox regression models, adjusted for relevant covariates, to estimate the association between air pollution exposure and cirrhosis incidence.

Results

We observed 10,111 incident cases of cirrhosis, with a crude incidence rate of 67 × 100,000 person-years. Long-term exposure to all pollutants tested was significantly associated with cirrhosis, e.g., PM₁₀ (hazard ratios [HR], 1.05; 95% confidence interval [CI], 1.01-1.09, per 10 µg/m³ increments), PM coarse (HR, 1.11; 95% CI, 1.05-1.17, per 10 µg/m³ increments), PM_2.5 (HR, 1.08; 95% CI, 1.03-1.13, per 5 µg/m³ increments), and NO₂ (HR, 1.03; 95% CI, 1.02-1.05, per 10 µg/m³ increments). The associations were robust in secondary analyses.

Conclusions

Our findings suggest a possible contribution of air pollution to the development of cirrhosis.

Epidemiological Trend of Sepsis in Patients with Hospital Admissions Related to Hepatitis C in Spain (2000-2015): A Nationwide Study

Background: Hepatitis C virus (HCV) infection predisposes patients to other infectious diseases, such as sepsis. We aimed to analyze epidemiological trends of sepsis-related admissions, deaths, and costs in hospital admissions with chronic hepatitis C who had a hospital admission in Spain. Methods: We performed a retrospective study of all hospitalizations involving chronic hepatitis C in the Spanish Minimum Basic Data Set (MBDS) between 2000 and 2015. This period was divided into four calendar periods (2000–2004, 2005–2007, 2008–2011, and 2012–2015). Results: We selected 868,523 hospital admissions of patients with chronic hepatitis C over 16 years in the Spanish MBDS. Among them, we found 70,976 (8.17%) hospital admissions of patients who developed sepsis, of which 13,915 (19.61%) died during admission. We found an upward trend, from 2000–2003 to 2012–2015, in the rate of sepsis-related admission (from 6.18% to 10.64%; p < 0.001), the risk of sepsis-related admission (from 1.31 to 1.55; p < 0.001), and the sepsis-related cost per hospital admission (from 7198€ to above 9497€; p < 0.001). However, we found a downward trend during the same study period in the sepsis case-fatality rate (from 21.99% to 18.16%; p < 0.001), the risk of sepsis-related death (from 0.81 to 0.56; p < 0.001), and the length of hospital stay (LOHS) (from 16.9 to 13.9; p < 0.001). Moreover, the rate of bacterial Gram-positive and candidiasis infections decreased, while Gram-negative microorganisms increased from 2000–2003 to 2012–2015. Conclusions: Sepsis, in chronic hepatitis C patients admitted to the hospital, has increased the period 2000–2015 and has been an increasing burden for the Spanish public health system. However, there has also been a significant reduction in lethality and LOHS during the study period. In addition, the most prevalent specific microorganisms have also changed in this period.

Epidemiological trend of hepatitis C-related liver events in Spain (2000-2015): A nationwide population-based study

OBJECTIVE

Analysis the epidemiological trends of hospital admissions, intra-hospital deaths, and costs related to chronic hepatitis C (CHC) taking into account four major clinical stages [compensated cirrhosis (CC), end-stage liver disease (ESLD), hepatocellular carcinoma (HCC), and liver transplantation (LT)] in Spain.

METHODS

Retrospective study in patients with chronic hepatitis C and a hospital admission in the Spanish Minimum Basic Data Set from 2000 to 2015. Outcome variables were admission, death, length of hospital stay and costs.

RESULTS

A total of 868,523 hospital admissions with CHC (25.5% CC, 25.3% ESLD, 8.6% HCC, and 2.5% LT) were identified. Overall rates of admission and mortality increased from 2000-2003 to 2004-2007, but after 2008, these rates stabilized and/or decreased. An upward trend was found for hospitalization percentage in CC (from 22.3% to 30%; p < 0.001), ESLD (from 23.9% to 27.1%; p < 0.001), HCC (from 7.4% to 11%; p < 0.001), and LT (from 0.07% to 0.10%; p = 0.003). An upward trend was also found for case fatality rate, except in ESLD (p = 0.944). Gender and age influenced the evolution of hospitalization rates and mortality differently. The length of hospital stay showed a significant downward trend in all strata analyzed (p < 0.001). Cost per patient had a significant upward trend (p < 0.001), except in LT, and a decrease from 2008-2011 to 2012-2015 in CC (p = 0.025), HCC (p < 0.001), and LT (p = 0.050) was found.

CONCLUSION

The initial upward trend of the disease burden in CHC has changed from 2000 to 2015 in Spain, improving in many parameters after 2004-2007, particularly in the 2012-2015 calendar period.