Update on the management of cirrhosis - focus on cost-effective preventative strategies

Abstract

Cirrhosis is a chronic liver disease stage that encompasses a variety of etiologies resulting in liver damage. This damage may induce secondary complications such as portal hypertension, esophageal variceal bleeding, spontaneous bacterial peritonitis, and hepatic encephalopathy. Screening for and management of these complications incurs substantial health care costs; thus, determining the most economical and beneficial treatment strategies is essential. This article reviews the economic impact of a variety of prophylactic and treatment regimens employed for cirrhosis-related complications. Prophylactic use of β-adrenergic blockers for portal hypertension and variceal bleeding appears to be cost-effective, but the most economical regimen for treatment of initial bleeding is unclear given that cost comparisons of pharmacologic and surgical regimens are lacking. In contrast, prophylaxis for spontaneous bacterial peritonitis cannot be recommended. Standard therapy for spontaneous bacterial peritonitis includes antibiotics, and the overall economic impact of these medications depends largely on their direct cost. However, the potential development of bacterial antibiotic resistance and resulting clinical failure should also be considered. Nonabsorbable disaccharides are standard therapies for hepatic encephalopathy; however, given their questionable efficacy, the nonsystemic antibiotic rifaximin may be a more cost-effective, long-term treatment for hepatic encephalopathy, despite its increased direct cost, because of its demonstrated efficacy and prevention of hospitalization. Further studies evaluating the cost burden of cirrhosis and cirrhosis-related complications, including screening costs, the cost of treatment and maintenance therapy, conveyance to liver transplantation, liver transplantation success, and health-related quality of life after transplantation, are essential for evaluation of the economic burden of hepatic encephalopathy and all cirrhosis-related complications.

Keywords: cost; hepatic encephalopathy; lactulose; maintenance of remission; rifaximin.

Figure 1

Trends in hospital discharges and in-hospital cost for cirrhosis from 2002 to 2010. Notes: *ICD-9-CM diagnosis codes 571.2, 571.5, 571.6; all listed diagnoses. In general, the number of hospital discharges for cirrhosis (International Classification of Diseases, Clinical Modification, Ninth Edition codes 571.0–571.9) tended to increase from 1993 to 2010. Discharges were associated with a disproportionately large increase in in-hospital charges. Data with permission from HCUPnet.

Figure 2

Increase trend in hepatic encephalopathy admissions since 2004, with 21% during the period of 2009 to 2010. Notes: Data calculated using ICD-9-CM codes 291.2 (alcoholic dementia, not elsewhere classified), 348.30 (encephalopathy, not otherwise specified), and 572.2 (hepatic coma); includes all listed discharge diagnoses. Abbreviations: HE, hepatic encephalopathy; ICD, International Classification of Diseases.

Figure 3

In-hospital cost (in US dollars) and duration of hospital stay for patients discharged with hepatic encephalopathy (International Classification of Diseases, Clinical Modification, Ninth Edition code, 572.2) or portal hypertension (International Classification of Diseases, Clinical Modification, Ninth Edition code, 572.3) from 2004 to 2010. Notes: *Data calculated using ICD-9-CM codes 291.2 (alcoholic dementia, not elsewhere classified), 348.30 (encephalopathy, not otherwise specified), and 572.2 (hepatic coma); includes all listed discharge diagnoses. For patients with hepatic encephalopathy or portal hypertension, the mean duration of hospital stay decreased during this period, although in-hospital charges continued to increase. Data with permission from HCUPnet. Abbreviations: HE, hepatic encephalopathy; ICD, International Classification of Diseases.