Outcomes of liver transplantation by insurance types in the United States.

OBJECTIVES: The outcomes of liver transplantation may vary according to socioeconomic factors such as insurance coverage. The aim of this study was to assess the association between the type of insurance payer and outcomes of liver transplant candidates and recipients in the United States. STUDY DESIGN: This was a retrospective cohort study of a national database. METHODS: The US Scientific Registry of Transplant Recipients was used to select adults (≥18 years) wait-listed for liver transplantation in the United States (2001-2017); patients were followed until March 2018. RESULTS: There were 177,862 liver transplant candidates with payer and outcomes data: The mean (SD) age was 54.1 (10.4) years, 64% were male, 39% had chronic hepatitis C with or without alcoholic liver disease (ALD), 19% had ALD alone, 17% had nonalcoholic steatohepatitis, and 16% had hepatocellular carcinoma. Fifty-nine percent were primarily covered by private insurance, 21% by Medicare, and 16% by Medicaid. After listing, 56% eventually received transplants (mean wait time of 229 days) and 22% dropped off the list. In multivariate analysis, adjusted for demographic and clinical factors, being covered by Medicare (odds ratio [OR], 0.81; 95% CI, 0.78-0.84) or Medicaid (OR, 0.76; 95% CI, 0.73-0.79) was independently associated with a lower chance of receiving a transplant (reference: private insurance). Posttransplant mortality was 11.6% at 1 year, 20.1% at 3 years, 26.8% at 5 years, and 41.6% at 10 years. Having Medicare (adjusted hazard ratio [aHR], 1.24; 95% CI, 1.17-1.31) or Medicaid (aHR, 1.14; 95% CI, 1.06-1.21) was independently associated with higher posttransplant mortality (P <.001) but not with the risk of graft loss (P >.05). CONCLUSIONS: Liver transplant candidates covered by Medicare or Medicaid have poorer wait-list outcomes and higher posttransplant mortality.

Changes in the Global Burden of Chronic Liver Diseases From 2012 to 2017: The Growing Impact of NAFLD.

BACKGROUND AND AIMS: Chronic hepatitis B virus (HBV), hepatitis C virus (HCV), nonalcoholic fatty liver disease (NAFLD), and alcohol-associated liver disease (ALD) are main causes of chronic liver disease. We assessed the global incidence, mortality, and disability-adjusted life-years (DALYs) related to chronic liver disease (primary liver cancer [LC] and cirrhosis). APPROACH AND RESULTS: We obtained data from the 2017 Global Burden of Disease study. In 2017, there were 2.14 million liver-related deaths (2.06-2.30 million), representing an 11.4% increase since 2012 (16.0% increase in LC deaths; 8.7% increase in cirrhosis deaths). LC and cirrhosis accounted for 38.3% and 61.7%, respectively, of liver deaths (LC and cirrhosis deaths were related to HBV [39% and 29%], HCV [29% and 26%], ALD [16% and 25%], and NAFLD [8% and 9%]). Between 2012 and 2017, age-standardized incidence rate, age-standardized death rate (ASDR), and age-standardized DALY rate increased for LC from 11.1 to 11.8, 10.1 to 10.2, and 250.4 to 253.6 per 100,000, respectively. Although age-standardized incidence rate for cirrhosis increased from 66.0 to 66.3, ASDR and age-standardized DALY rate decreased from 17.1 to 16.5 and 532.9 to 510.7, respectively. The largest increase in ASDR for LC occurred in Eastern Europe (annual percent change [APC] = 2.18% [0.89%-3.49%]), whereas the largest decrease occurred in high-income Asia Pacific (APC = -2.88% [-3.58 to -2.18%]). ASDR for LC-NAFLD and ALD increased annually by 1.42% (1.00%-1.83%) and 0.53% (0.08-0.89), respectively, whereas there were no increases for HBV (P = 0.224) and HCV (P = 0.054). ASDR for cirrhosis-NAFLD increased (APC = 0.29% [0.01%-0.59%]) but decreased for ALD (APC = -0.44% [-0.78% to -0.40%]), HCV (APC = -0.50% [-0.81% to -0.18%]), and HBV (APC = -1.43% [-1.71% to -0.40%]). CONCLUSIONS: From 2012 to 2017, the global burden of LC and cirrhosis has increased. Viral hepatitis remains the most common cause of liver deaths, and NAFLD is the most rapidly growing contributor to liver mortality and morbidity.

Among Medicare Patients With Hepatocellular Carcinoma, Non-alcoholic Fatty Liver Disease is the Most Common Etiology and Cause of Mortality.

GOALS: The main purpose of this study was to assess the recent trends in mortality and health care utilization of hepatocellular carcinoma (HCC) among Medicare population in the United States. BACKGROUND: The incidence of HCC is increasing in the United States. MATERIALS AND METHODS: Data were obtained for a sample of Medicare beneficiary from 2005 to 2014. Diagnosis of HCC and etiology of liver disease were based on ICD-9 codes. Temporal trends in HCC rates, clinical, demographical and utilization parameters were analyzed by joinpoint regression model. RESULTS: Study cohort included 13,648 Medicare recipients with HCC (mean age: 70.0 y, 62.8% male and 76.0% white). Non-alcoholic fatty liver disease (NAFLD) was the most common cause of HCC in the inpatient (32.07%) and outpatient (20.22%) followed by hepatitis C virus (HCV) (19.2% and 9.75%, respectively). Between 2005 and 2014, HCC rate per 100,000 Medicare recipients increased from 46.3 to 62.8 [average annual percentage change (AAPC) =3.4%, P<0.001]. Rate of HCV-HCC increased from 6.18 to 16.54 (AAPC=11.8%, P<0.001) while the NAFLD-HCC increased from 9.32 to 13.61, P<0.001). Overall 1-year mortality decreased from 46.2% to 42.1% (AAPC=-1.7%, P=0.004). Total charges increased from $67,679 to $99,420 (AAPC=5.1%, P<0.001) for inpatients and from $11,933 to $32,084 (P<0.001) for outpatients. On comparison of patients with hepatitis B virus-HCC, those with NAFLD-HCC (odds ratio: 1.87, P<0.001) had higher risk of mortality. On comparison of patients with hepatitis B virus-HCC, those with HCV-HCC had higher charges (percent change: 24.33%, 95% confidence interval: 1.02%-53.02%, P=0.040). CONCLUSIONS: Although HCC rates are increasing, the overall mortality is decreasing. NAFLD is the most important cause of HCC and an independent predictor of HCC in the outpatient setting for Medicare patients with HCC.

Resource Utilization and Outcomes of Medicare Recipients With Chronic Hepatitis B in the United States.

GOALS: To assess the outcomes and resource utilization of chronic hepatitis B (CH-B) among Medicare beneficiaries. BACKGROUND: CH-B is highly prevalent among immigrants from endemic areas. Although incidence of CH-B is stable in the United States, CH-B patients have become Medicare eligible. STUDY: We used the inpatient and outpatient Medicare database (2005 to 2014). Adult patients with CH-B diagnosis were included. One-year mortality and resource utilization were assessed. Independent associations with resource utilization and mortality were determined using multivariate analysis. RESULTS: Study cohort included 18,603 Medicare recipients with CH-B. Between 2005 and 2014, number of Medicare beneficiaries with CH-B increased by 4.4% annually. The proportion of beneficiaries with CH-B who were whites decreased while those who were Asians increased (P<0.05). Furthermore, 7.4% of CH-B Medicare cohort experienced decompensated cirrhosis, 2.9% hepatocellular carcinoma (HCC) and 11.9% 1-year mortality. Although the number of inpatients with CH-B remained stable, the number of outpatient encounters increased. Annual total inpatient charges increased from $66,610 to $94,221 while these charges for outpatient increased from $9257 to $47,863. In multivariate analysis, age [odds ratio (OR), 1.05; 95% confidence interval (CI), 1.04-1.05], male gender [OR, 1.24 (95% CI, 1.12-1.38)], decompensated cirrhosis [OR, 3.02 (95% CI, 2.63-3.48)], HCC [OR, 2.64 (95% CI, 2.10-3.32)], and higher Charlson comorbidity index [OR, 1.24 (95% CI, 1.21-1.27)] were independently associated with increased 1-year mortality. HCC and higher Charlson comorbidity index were also associated with higher inpatient and outpatient charges, and inpatient length of stay (all P<0.001). CONCLUSIONS: CH-B infection has been rising in Medicare population and is responsible for significant mortality and resource utilization.

Clinical and Economic Burden of Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis.

Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease with an increasing global prevalence associated with tremendous clinical, economic, and health-related quality-of-life burden. Clinically, NAFLD is considered the liver manifestation of metabolic syndrome. However, diagnosing NAFLD presents significant challenges due to the limited noninvasive and accurate diagnostic tools available to not only accurately diagnose nonalcoholic steatohepatitis but also to stage hepatic fibrosis, the major predictor of long-term outcomes, including mortality.

Demographics, Resource Utilization, and Outcomes of Elderly Patients With Chronic Liver Disease Receiving Hospice Care in the United States.

OBJECTIVES: Hospice offers non-curative symptomatic management to improve patients' quality of life, satisfaction, and resource utilization. Hospice enrollment among patients with chronic liver disease (CLD) is not well studied. The aim of tis tudy is to examine the characteristics of Medicare enrollees with CLD, who were discharged to hospice. METHODS: Medicare patients discharged to hospice between 2010 and 2014 were identified in Medicare Inpatient and Hospice Files. CLDs and other co-morbidities were identified by International Classification of Diseases-ninth revision codes. Generalized linear model was used to estimate regression coefficients with P-values. Logistic regression was used to calculate odds ratios and 95% confidence intervals. RESULTS: A total of 2,179 CLD patients and 34,986 controls without CLD met the inclusion criteria. Non-alcoholic fatty liver disease, alcoholic liver disease, and hepatitis C virus (HCV) were the most frequent cause of CLD. CLD patients were younger (70 vs. 83 years), more likely to be male (57.7 vs. 39.3%), had longer hospital stay (length of stay, LOS) (19.4 vs. 13.0 days), higher annual charges ($175,000 vs. $109,000), higher 30-day re-hospitalization rates (51.6 vs. 34.2%), and shorter hospice LOS (13.7 vs. 17.7 days) than controls (all P<0.001). Presence of HCV and congestive heart failure were the strongest contributors to increased total annual costs (34% and 31% higher, P<0.001), increased total annual LOS (26% and 43% higher, P<0.001), and increased 30-day readmission risk (2.20 and 2.19 times, respectively). CONCLUSIONS: Patients with CLD have longer and costly hospitalizations before hospice enrollment as compared with patients without CLD. It was highly likely that these patients were enrolled relatively late, which could potentially lead to less benefit from hospice.

Independent Predictors of Mortality and Resource Utilization in Viral Hepatitis Related Hepatocellular Carcinoma.

INTRODUCTION: Hepatitis B (HBV) and C viruses (HCV) are important causes of hepatocellular carcinoma (HCC). Our aim was to assess mortality and resource utilization of patients with HCC-related to HBV and HCV. MATERIAL AND METHODS: National Cancer Institute's Surveillance, Epidemiology and End Results (SEER)-Medicare linked database (2001-2009) was used. Medicare claims included patient demographic information, diagnoses, treatment, procedures, ICD-9 codes, service dates, payments, coverage status, survival data, carrier claims, and Medicare Provider Analysis and Review (MEDPAR) data. HCC related to HBV/HCV and non-cancer controls with HBV/HCV were included. Pair-wise comparisons were made by t-tests and chi-square tests. Logistic regression models to estimate odds ratios (ORs) with 95% confidence intervals (CIs) were used. RESULTS: We included 2,711 cases of HCC (518 HBV, 2,193 HCV-related) and 5,130 non-cancer controls (1,321 HBV, 3,809 HCV). Between 2001-2009, HCC cases related to HBV and HCV increased. Compared to controls, HBV and HCV patients with HCC were older, more likely to be male (73.2% vs 48.9% and 57.1% vs. 50.5%), die within one-year (49.3% vs. 20.3% and 52.2% vs. 19.2%), have decompensated cirrhosis (44.8% vs. 6.9% and 53.9% vs. 10.4%) and have higher inpatient ($60.471 vs. $47.223 and $56.033 vs. $41.005) and outpatient charges ($3,840 vs. $3,328 and $3,251 vs. $2,096) (all P < 0.05). In two separate multivariate analyses, independent predictors of one-year mortality were older age, being male and the presence of decompensated cirrhosis. CONCLUSIONS: The rate of viral hepatitis-related HCC is increasing. Mortality and resource utilization related to HBV and HCV-related HCC is substantial.

Outcomes trends for acute myocardial infarction, congestive heart failure, and pneumonia, 2005-2009.

OBJECTIVES: The CMS core conditions-acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia-are a focus of hospital quality reporting and its value-based purchasing program. The study's purpose was to assess national trends of in-hospital mortality and resource utilization for these core measures. STUDY DESIGN: A time series study using outcomes from the 5 yearly cycles of the Nationwide Inpatient Sample (2005-2009). METHODS: Stratum-specific χ2 test for independence (binary or categorical parameters) or t test for a contrasted mean (continuous parameters) were used to identify parameters that changed significantly over time (in-hospital mortality, length of stay, cost, charges, severity of illness, diagnoses per case, procedures per case). Multiple logistic and linear regression models were used to identify factors associated with in-hospital deaths, hospital charges, and length of stay (LOS). RESULTS: In-hospital mortality decreased for AMI, CHF, and pneumonia. LOS was unchanged for CHF, but decreased for AMI and pneumonia. Average inflation-adjusted charges per case increased for all 3 conditions, while the average inflation-adjusted cost per case decreased for CHF and remained stable for AMI and pneumonia. The proportion of patients with extreme disability and extreme likelihood of dying, as defined by All-Patient-Refined Diagnosis Related Group, increased for all 3 diagnoses. The number of diagnoses and procedures were independently associated with LOS, cost, and charges for all 3 conditions. CONCLUSIONS: Many measures of quality of inpatient care and resource utilization for CMS core conditions improved despite increases in patient complexity and risk of mortality. Further research is necessary to determine the exact causes of these improvements.

Resource utilization and survival among Medicare patients with advanced liver disease.

BACKGROUND: The prevalence of advanced liver disease and its complications may be on the rise within the Medicare population. The study aim was trend assessment for prevalence, mortality and resource utilization of patients with advanced liver disease. METHODS: A retrospective, cross-sectional design was used to analyze a national sample of non-institutionalized Medicare in/outpatients from 2005 to 2009. Cases were ascertained by International Classification of Diseases, 9th Edition. Outcomes were overall mortality (within 1 year) and resource utilization [hospital length of stay (LOS/days) and institutional costs to Medicare]. Multivariate analyses were used to estimate the odds ratios for mortality predictors; linear regression was used for resource utilization predictors. RESULTS: A total of 21,913 beneficiaries with advanced liver disease were identified in the Medicare inpatient and outpatient administrative data sets from 2005 to 2009. Over 70 % of the beneficiaries with advanced liver disease died during study time period with 17 % dying while hospitalized. Predictors of mortality were: admission to the intensive care unit (ICU) and increasing Charlson Comorbidity Index. Predictors for increased LOS and cost were: ICU admission and having a thoracentesis procedure (both indicators of the levels of illness). CONCLUSIONS: Advanced liver disease and its related complication are increasing in the Medicare population and are associated with very high mortality. Further study is warranted to understand the drivers of the increased prevalence of advanced liver disease for earlier identification and treatment.

Trends in outpatient resource utilizations and outcomes for Medicare beneficiaries with nonalcoholic fatty liver disease.

BACKGROUND AND AIM: Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease. The objective of this study was to describe the recent trend of health care resource utilization and short-term mortality of Medicare beneficiaries with NAFLD. METHODS: This study utilized data from a random sample of national outpatient claims of Medicare beneficiaries (2005 to 2010) who sought outpatient care for NAFLD. RESULTS: This study included 29,528 patients who sought outpatient care for NAFLD from 2005 to 2010. The annual number of patients increased consistently from 3585 in 2005 to 6646 in 2010. The prevalence of studied comorbidities including cardiovascular disease, diabetes, hyperlipidemia, and hypertension also increased significantly. At the same time, the mean yearly charge and the mean yearly payment increased significantly from $2624±$3308 and $561±$835 in 2005 to $3608±$5132 and $629±$1157 (P<0.05), respectively. The observed mortality rate remained stable around 2.84% (P=0.64). After adjusting for the other covariates, the total number of outpatient visits and all the comorbidities considered were the most determinant factors for yearly charge and yearly payment (P<0.0001). Overall mortality was associated with age, gender, number of outpatient visits, diabetes, and hyperlipidemia. CONCLUSIONS: The number of outpatient visits because of NAFLD rose between 2005 and 2010. Short-term mortality rates remained stable throughout the study period, whereas total annual charges and payments increased.

Clinical outcomes and resource utilisation in Medicare patients with chronic liver disease: a historical cohort study.

OBJECTIVE: The aim of this study is to assess recent trends in health resource utilisation and patient outcomes of Medicare beneficiaries with chronic liver disease (CLD). SETTING: Liver-related mortality is the 10th leading cause of death in the USA, and hepatitis C virus (HCV) and obesity-related non-alcoholic fatty liver disease are the major causes of CLD. As the US population ages and becomes more obese, the impact of CLD is expected to become more prominent for the Medicare population. PARTICIPANTS: This is a retrospective cohort study of Medicare beneficiaries with a diagnosis of CLD based on inpatient (N=21 576; 14 977 unique patients) and outpatient (N=515 990; 244 196 patients) claims from 2005 to 2010. PRIMARY AND SECONDARY OUTCOME MEASURES: The study outcomes included hospital length of stay (LOS) and inpatient mortality as well as inpatient and outpatient inflation-adjusted payments. RESULTS: Between 2005 and 2010, there was an annual decrease in LOS of 3.17% for CLD-related hospitalisations. Risk-adjusted in-hospital mortality decreased (OR 0.90, 95% CI 0.87 to 0.94), while short-term postdischarge mortality remained stable (1.00, 0.98 to 1.03). Inpatient per-claim payment increased from $11 769 in 2005 to $12 347 in 2010 (p=0.0006). Similarly, the average yearly payments for outpatient care increased from $366 to $404 (p<0.0001). This change in payment was observed together with a consistent decrease in the proportion of beneficiary-paid amount (25.4-20%, p<0.0001) as opposed to Medicare-paid amount (73.1-80%, p<0.0001). The major predictors of higher outpatient payments were younger age, Asian race or Hispanic ethnicity, living in California, and having more diagnoses and outpatient procedures per claim. The predictors of inpatient spending also included younger age, location and the number of inpatient procedures. CONCLUSIONS: Length of inpatient stay and inpatient mortality among Medicare beneficiaries with CLD decreased, while inpatient and outpatient spending increased.

The inpatient economic and mortality impact of hepatocellular carcinoma from 2005 to 2009: analysis of the US nationwide inpatient sample.

BACKGROUND: Hepatocellular carcinoma (HCC) is an important complication of cirrhosis. Our aim was to assess the inpatient economic and mortality of HCC in the USA METHODS: Five cycles of Nationwide Inpatient Sample (NIS) conducted from 2005 to 2009 were used. Demographics, inpatient mortality, severity of illness, payer type, length of stay (LoS) and charges were available. Changes and associated factors related to inpatient HCC were assessed using simple linear regression. Odds ratios and 95% CIs for hospital mortality were analysed using log-linked regression model. To estimate the sampling variances for complex survey data, we used Taylor series approach. SAS(®) v.9.3 was used for statistical analysis. RESULTS: From 2005 to 2009, 32,697,993 inpatient cases were reported to NIS. During these 5 years, primary diagnosis of HCC increased from 4401 (2005), 4170 (2006), 5065 (2007), 6540 (2008) to 6364 (2009). HCC as any diagnosis increased from 68 per 100,000 discharges (2005) to 99 per 100,000 (2009). However, inpatient mortality associated with HCC decreased from 12% (2005) to 10% (2009) (P < 0.046) and LoS remained stable. However, median inflation-adjusted charges at the time of discharge increased from $29,466 per case (2005) to $31,656 per case (2009). Total national HCC charges rose from $1.0 billion (2005) to $2.0 billion (2009). In multivariate analysis, hospital characteristic was independently associated with decreasing in-hospital mortality (all P < 0.05). Liver transplantation for HCC was the main contributor to high inpatient charges. Longer LoS and other procedures also contributed to higher inpatient charges. CONCLUSIONS: There is an increase in the number of inpatient cases of HCC. Although inpatient mortality is decreasing and the LoS is stable, the inpatient charges associated with HCC continue to increase.

Recent trends in inpatient mortality and resource utilization for patients with stroke in the United States: 2005-2009.

BACKGROUND: The aim of the study is to evaluate recent trends in mortality, length of stay, costs, and charges for patients admitted to the US hospitals with the principal diagnosis of stroke. METHODS: This was a retrospective temporal trends study using data from the Nationwide Inpatient Sample from 2005 to 2009. RESULTS: During the study period, there were 2.7 million hospital admissions with the diagnosis of stroke in the United States (470,000 intracerebral hemorrhage, 130,000 subarachnoid hemorrhage, and 2.1 million ischemic strokes). In-hospital mortality decreased from 10.2% in 2005 to 9.0% in 2009 (26.0%-23.0%, 23.4%-23.1%, and 6.0%-5.1% for the stroke subtypes, respectively), the average length of stay decreased from 6.3 days to 5.9 days (5.6-5.2 days for ischemic stroke, remained the same for hemorrhagic stroke), and the average number of 1.3 ± 0.1 procedures per admission remained the same. The proportion of patients with major or extreme severity of illness increased from 39.2% to 47.0% (P < .0001). After adjustment for inflation, the average total charge per admission increased from $36,215 to $46,518 (P < .0001), whereas the average cost of treatment remained the same. Higher treatment cost is associated with lower in-hospital mortality after adjustment for demographic, hospital-related, and clinical confounders (odds ratio = .968 [.965-.970] per each extra $1000). CONCLUSIONS: Between 2005 and 2009, in-hospital mortality for patients hospitalized with stroke improved despite increasing severity of illness. At the same time, the average charge for hospitalization increased by 28% despite unchanged cost of treatment and shorter length of stay.

In-hospital mortality and economic burden associated with hepatic encephalopathy in the United States from 2005 to 2009.

BACKGROUND & AIMS: Hepatic encephalopathy (HE) is a major complication of cirrhosis that causes substantial mortality and utilization of resources. METHODS: We analyzed 5 cycles of the Nationwide Inpatient Sample, conducted between 2005 and 2009, to determine national estimates of incidence, prevalence, inpatient mortality, severity of illness, and resource utilization for inpatients with HE. RESULTS: The yearly inpatient incidence of HE ranged from 20,918 (2005) to 22,931 (2009) (P = .2226), comprising approximately 0.33% of all hospitalizations in the United States. Over the 5-year period of analysis, mortality of inpatients with HE remained relatively stable, at 14.13%-15.61% (P = .062); however, the proportion of patients with major and extreme severity of illness increased (P < .0001). The average length of inpatient stay increased from 8.1 to 8.5 days (P = .019). The average total inpatient charges increased from $46,663 to $63,108 per case (P < .0001). Furthermore, total national charges related to HE increased from $4676.7 million (2005) to $7244.7 million (2009). In multivariate analysis, independent predictors of inpatient mortality included the number of diagnoses per admission (odds ratio [OR] = 1.022; 95% confidence interval [CI], 1.016-1.029 per diagnosis), number of procedures per admission (OR = 1.192 per procedure; 95% CI, 1.177-1.208), and major or extreme severity of illness (OR = 3.16; 95% CI, 2.84-3.50). The most important predictors of cost, charge, and length of stay were admission to a large, urban hospital; use of Medicaid or Medicaid as the payer; major or extreme severity of illness; number of diagnoses at discharge; and procedures per admission (P < .05). CONCLUSIONS: Resource utilization increased from 2005 to 2009 for patients discharged from US hospitals with the diagnosis of HE. The inpatient mortality rate, however, remained stable, despite a trend toward more severe disease.