From the AGA Journals

Analysis Details the GI Disease Burden in U.S.

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A Substantial Burden

Digestive (GI and liver) diseases constitute a substantial and growing burden in the United States. As detailed in the report by Dr. Peery and colleagues, there were over 46 million outpatient encounters associated with the top 20 digestive disease diagnoses in 2009, with approximately 10% of deaths nationwide with an underlying digestive disease cause. The observed increased prevalence of hospitalizations for many diagnoses (e.g., a 14% increase with principal discharge diagnosis of chronic liver disease with viral hepatitis) and procedures (e.g., a 17% increase in lower GI endoscopies among commercially insured patients) between 2000 and 2009 is expected given population growth and aging. In addition, dramatic increases in hospitalizations associated with C. difficile and morbid obesity were also noted.

The report provides crucial information for diverse constituencies, including healthcare planners, clinicians and researchers. However, as acknowledged by the authors, there are some important caveats with respect to coverage or quality for some data sources to bear in mind when interpreting these results. This is particularly relevant for non-alcoholic fatty liver disease, which is likely underestimated because of well-known problems in diagnostic code specificity and use.

Several factors suggest that the prevalence and costs of digestive diseases will increase substantially during the next decade. These include: an aging population with the number of people aged 65 years or older projected to be greater than 54 million by 2020;the estimated tens of millions of individuals with newly available healthcare coverage as of 2014 as part of the Affordable Care Act; continued increases in obesity rates; and the recent CDC recommendation that all baby-boomers be screened for hepatitis C. This report will facilitate timely planning and also serve as benchmark to help measure the impact of these forces on the scope and burden of digestive diseases and their clinical management.

DONNA L. WHITE, PH.D., MPH, is an investigator in the Clinical Epidemiology and Outcomes Program in the Houston VA Health Services Research and Development Center of Excellence at the Michael E. DeBakey VA Medical Center, Houston. She also is an assistant professor in the department of medicine at Baylor College of Medicine, Houston.



Clostridium difficile contributes mightily to the overall burden of gastrointestinal disease in the United States and was associated with a 237% increase in hospitalizations in the last decade.

Researchers who examined the latest data on the nationwide toll of GI and liver disease also found a 314% rise in hospitalizations related to morbid obesity and a continuing national health burden exacted by reflux symptoms, Barrett’s esophagus, and colorectal cancer.

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"We compiled the most recently available statistics on GI symptoms, quality of life, outpatient diagnoses, hospitalizations, costs, mortality, and endoscopic utilization from a variety of publicly and privately held databases," Dr. Anne F. Peery of the University of North Carolina, Chapel Hill, and her colleagues reported in the November issue of Gastroenterology (doi:10.1053/j.gastro.2012.08.002).

"Payers, policy makers, clinicians, and others interested in resource utilization may use these statistics to better understand evolving disease trends, and the best way to meet the challenge of these diseases."

The findings are based on data for 2009, the most recent year for which complete information was available, from the National Ambulatory Medical Care Survey, sponsored by the U.S. Centers for Disease Control and Prevention; the United States National Health and Wellness Survey, sponsored by the private company Kantar Health; the Nationwide Inpatient Sample, sponsored by the Agency for Healthcare Research and Quality; the Surveillance, Epidemiology, and End Results database of the National Cancer Institute; the National Vital Statistics System, sponsored by the National Center for Health Statistics and the CDC; and the Thomson Reuters MarketScan’s databases of commercial, Medicare, and Medicaid records.

Among the findings:

C. difficile hospitalizations have increased 237% since 2000 and were associated with 4% in-hospital mortality. Now the ninth leading GI cause of mortality, with an absolute increase of 230% in the number of C. difficile–related deaths since 2002, the infection also markedly impairs quality of life and the capacity for work and other activities.

• Hospitalizations related to obesity remained relatively stable since 2000, but those associated with morbid obesity rose by 314%, and many were likely caused by the marked increase in bariatric surgery.

• Gastroesophageal reflux remains the most common GI-associated diagnosis in primary care, accounting for 9 million outpatient visits in 2009, and the most common GI-associated discharge diagnosis, with 4.4 million such diagnoses in 2009. Obesity was associated with 1.7 million discharge diagnoses and constipation with 1 million.

• Barrett’s esophagus accounted for almost half a million outpatient visits in 2009, when an estimated 3.3 million Americans had this diagnosis. Given that endoscopic surveillance is recommended every 3-5 years, Barrett’s contributes substantially to resource utilization.

• Colorectal cancer, with an estimated 147,000 patients diagnosed in 2008, accounts for more than half of all GI cancer diagnoses and continues to be the primary cause of GI-associated mortality. Pancreatic and hepatobiliary cancers are the next most frequently diagnosed GI cancers.

Courtesy CDC/Dr. Gilda Jones

Clostridium difficile infections [pictured] are now the ninth-leading GI cause of mortality.

• Of the approximately 2.5 million deaths in the United States in 2009, 10% were attributed to an underlying GI cause. Chronic liver disease and cirrhosis are the 12th leading causes of death in the country.

• The total outpatient cost for GI endoscopy in 2009 was estimated to be $32.4 billion, which is higher than previously published estimates. An estimated 6.9 million upper endoscopies, 11.5 million lower endoscopies, and 228,000 biliary endoscopies were performed in the United States in 2009.

• Chronic liver disease and viral hepatitis were associated with 6% mortality and cost an estimated $1.8 billion per year in inpatient cost.

• Hospitalizations for nonalcoholic fatty liver disease increased 97% since 2000.

This study was supported in part by the National Institutes of Health. No financial conflicts of interest were reported.

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