As detailed above, the toll of gastrointestinal and liver disease on the U.S. population is extensive. Using the most comprehensive statistical resources available, we present a broad and detailed picture of the current challenges facing these patients and our specialty. Several trends merit special mention.
The toll of C. difficile
infection is large and becoming more prominent. C. difficile
hospitalizations have increased by 237% since 2000. This finding is consistent with the documented increase in C. difficile
incidence in the United States.13–15
In-hospital mortality attributable to C. difficile
is estimated at 4%, which is comparable to the 30 day estimate of 6%.16
is now the 9th
leading gastrointestinal cause of death.
We also found that C. difficile infection was associated with marked impairment in quality of life and capacity for activity. These data may actually represent an under-estimate of the association of this infection with diminished quality of life, given that some proportion of the participants in the NHWS had resolved disease. Whether those with resolved disease also have impaired quality of life and activity impairment is unknown.
Hospitalizations for morbid obesity increased by 314% since 2000. While the prevalence of obesity between 1998 and 2008 was relatively stable, the prevalence of morbid obesity has increased significantly.17
Bariatric surgical procedures also increased, from 13,000 in 1998 to more than 100,000 in 2003, and this may account for some portion of the observed trend.18
Reflux symptoms remain the most common indication for upper endoscopy, and gastroesophageal reflux disease the most common principal gastroenterology-related diagnosis in the primary care setting. Barrett’s esophagus accounted for almost a half million visits in 2009. An estimated 3.3 million Americans have a diagnosis of Barrett’s esophagus.19
Most (90%) patients with Barrett’s esophagus have nondysplastic disease.20
Guidelines generally recommend that patients with nondysplastic disease undergo endoscopic surveillance every three to five years. Given the large number of subjects with Barrett’s, these examinations represent a substantial commitment of resources.
An estimated 147,308 people were diagnosed with colorectal cancer in the United States in 2008. Colorectal cancer continues to be the number one cause of GI-related mortality. Colorectal cancer accounts for more than half of all GI cancer diagnoses and a third of GI cancer-related deaths.
There is no single national endoscopic database to estimate the prevalence and cost of endoscopy. We generated our estimates using a mix of public and private databases. Total outpatient cost for gastrointestinal endoscopy in 2009 was $32.4 billion. Our estimate is higher than a previous estimate1
and suggests that the cost of gastrointestinal endoscopy is not well characterized. Our estimate is likely a more accurate approximation because we utilized health care claims data from 35 million people in a mix of public and private databases and standardized the estimates of procedures performed to the US population based on census data.
We estimated that 6.9 million upper, 11.5 million lower, and 228,000 biliary endoscopies were performed in the United States in 2009. A survey published in 2000 estimated that 5 million flexible sigmoidoscopies and 4 million colonoscopies were performed that year in the United States.21
A second survey in 2002 estimated that approximately 2.8 million flexible sigmoidoscopies and 14.2 million colonoscopies were performed.22
No recent estimates on upper endoscopies or biliary endoscopies have been published. Our data demonstrate that ERCP volume has increased more slowly than that of other endoscopic procedures. Concurrently, the use of MRCP has increased dramatically, perhaps due to the expanded role of MRCP in the diagnosis of pancreaticobiliary disorders and the decreased use of ERCP for purely diagnostic indications.
Our findings should be viewed in light of the strengths and limitations of the databases from which we gathered the data. NAMCS data are based on office-based physician visits and do not reflect other important sources of ambulatory care including the emergency department, urgent care and federal facilities. The strength of NAMCS is that the diagnoses and patient symptoms are extracted from the medical record using a standardized procedure. The NHWS is an Internet based survey. Diagnoses are not verified and it is possible that those who respond are systematically different then those who do not complete the survey. Despite these limitations, NHWS is a large nationally representative sample comparable with the National Heath Interview Survey.7
Not all states contribute to NIS. Cost estimates are approximated from charges and do not include physician fees. Regardless, NIS is the largest all-payer inpatient data source in the United States and contains charge information on all patients. SEER data represents 18 areas of the country. While the data are weighted to approximate national estimates they are not statistically representative. SEER data are verified and data are estimated to be 99 percent complete from contributing sites. The National Vital Statistics System is a complete accounting of deaths in the United States but is dependent on the accuracy of death certificates, and coding of death certificates may be erroneous. Inpatient endoscopic procedure costs could not be isolated from other hospital-associated costs and were excluded from this analysis. CORI data are based on voluntary participation and are not nationally representative. . Finally, our ability to detect conditions that cause substantial burden of disease depends on codes that may be imprecise, poorly used, or non-existent. Non-alcoholic fatty liver disease, for example, is prevalent but is newly recognized and therefore poorly captured with codes. For this reason, updated reports will be needed as more recent data becomes available.
In summary, we present a comprehensive and current estimate of the toll of gastrointestinal and liver diseases in the U.S. Payers, policymakers, 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.