Healthcare resource utilization and costs among nonalcoholic fatty liver disease patients in Germany

Abstract

Background: Patients with nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are associated with progression to advanced liver diseases that include compensated cirrhosis, decompensated cirrhosis, liver transplantation, and hepatocellular carcinoma (HCC). This study characterized comorbidities, healthcare resource utilization (HRU), and associated costs among NAFLD patients in Germany.

Methods: German healthcare claims data between 2011 and 2016 were analyzed retrospectively. Adult patients diagnosed with NAFLD and/or NASH were categorized as NAFLD, NAFLD non-progressors, compensated cirrhosis, decompensated cirrhosis, liver transplant, or HCC. Within each stage, annual all-cause HRU and costs were measured during the pre- and post-index periods.

Results: Among 4,580,434 patients in the database, proportion of NAFLD was 4.7% (n=215,655). Of them, 36.8% were non-progressors, 0.2% compensated cirrhosis, 9.6% decompensated cirrhosis, 0.0005% liver transplant, and 0.2% HCC. Comorbidity rates were significantly higher in compensated cirrhosis, decompensated cirrhosis, and HCC compared with non-progressors (52.07%, 56.46%, 57.58% vs. 27.49% for cardiovascular disease; 77.13%, 76.61%, 83.47% vs. 54.89% for hypertension; 47.20%, 53.81%, 52.89% vs. 35.21% for hyperlipidemia; 49.88%, 36.67%, 48.21% vs. 20.38% for type 2 diabetes mellitus). The mean annual numbers of post-index outpatient visits and inpatient hospitalizations were significantly higher in patients with advanced liver diseases versus non-progressors. Mean annual costs were significantly higher among patients with advanced liver diseases (compensated cirrhosis, €10,291; decompensated cirrhosis, €22,561; liver transplant, €34,089; HCC, €35,910) than non-progressors (€3,818, P<0.001, except liver transplant cohort). This trend remained consistent after adjusting for baseline demographics and comorbidities.

Conclusions: NAFLD patients in Germany are grossly underdiagnosed and exert substantial healthcare resource use and economic burden, particularly those with advanced liver diseases. Optimal strategies for early identification and management are needed to prevent disease progression and limit the rising costs.

Keywords: Disease burden; Germany; advanced liver diseases; nonalcoholic fatty liver disease (NAFLD); nonalcoholic steatohepatitis (NASH).

Figure 1

Patient attrition. ^aExclusionary diagnoses include other liver etiologies [viral hepatitis (hepatitis A, B, C, D, E), toxic liver disease, autoimmune hepatitis, Wilson’s disease, Gaucher disease, lysosomal acid lipase deficiency, alcoholism including alcoholic liver disease, primary biliary/sclerosing cholangitis, or hemochromatosis] and human immunodeficiency virus infection. ^bNon-mutually exclusive groups of liver severity stages (since patients progressing to multiple liver severity stages were included in >1 group). CC, compensated cirrhosis; DCC, decompensated cirrhosis; HCC, hepatocellular carcinoma; ICD-10-GM, International Classification of Diseases, Tenth Edition, German Modification; InGef, Institut für angewandte Gesundheitsforschung; LT, liver transplant; NAFLD, nonalcoholic fatty liver disease; NASH, nonalcoholic steatohepatitis.

Figure 2

Selected baseline comorbidities. *P<0.05 for comparison with NAFLD non-progressors. ^†P<0.05 for comparison with compensated cirrhosis. CC, compensated cirrhosis; DCC, decompensated cirrhosis; HCC, hepatocellular carcinoma; LT, liver transplant; NAFLD, nonalcoholic fatty liver disease; NR, not reported (owing to small sample size).

Figure 3

Annual all-cause healthcare costs. *P<0.05 for pre-index vs. post-index. ^†P<0.05 for comparison with NAFLD non-progressors post-index. ^‡P<0.05 for comparison with compensated cirrhosis post-index. CC, compensated cirrhosis; DCC, decompensated cirrhosis; HCC, hepatocellular carcinoma; LT, liver transplant; NAFLD, nonalcoholic fatty liver disease.