The Rising Costs of Alcohol-Associated Liver Disease in the United States

Abstract

Introduction: Alcohol-associated liver disease (ALD) is rising in the United States because of an increase in high-risk drinking, but population-level ALD cost is unknown. Our aim was to project the direct and indirect costs associated with ALD in the US population through 2040.

Methods: We used a previously validated microsimulation model of alcohol consumption and ALD with model parameters estimated from publicly available data sources, including the National Epidemiologic Survey Alcohol and Related Conditions-III, the Center for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research, the Bureau of Labor Statistics, and published studies informing the impact of alcohol consumption on ALD severity in the United States resident population. The simulated scenario included current and projected ALD-associated costs.

Results: From 2022 to 2040, the ALD is projected to cost $880 billion, $355 billion in direct healthcare-related costs, and $525 billion in lost labor and economic consumption. The annual cost of ALD is projected to increase from $31 billion in 2022 to $66 billion (118% increase) in 2040. Although the female population makes up 29% of these costs in 2022, by 2040 on a per annum basis, female costs would be 43% of the total annual expenditure.

Discussion: Increased consumption of alcohol in the US population, especially in females, will cause a steep rise in the economic burden of ALD in the United States. These findings highlight the need for planners and policymakers to plan for the increased impact of liver disease in the United States.

Figure 1:. State-transition model of the natural history of alcohol-related liver disease and drinking state

A patient is represented by the combination of a drinking state and disease state, shown here as circles and rectangles, respectively. States H1–H5 represent tunnel states to simulate healthy liver pre-drinking states. As individuals progress from H1 to H5 the risk of their first drink increases until they commence drinking. We simulate the following levels of alcohol consumption: never having consumed alcohol (denoted H1 – H5 in the model), abstinence, low-risk (< 3 drinks per day), medium risk (3-4 drinks per day), high-risk (4-7 drinks per day), and very high-risk states (> 7 drinks per day). After drinking commences, transitions occur between every drinking level (abstinence, low risk, medium risk, high risk, and very high-risk drinking). States C1 and C2 represent the naturally occurring range of liver susceptibility of individuals in the US population by age and sex to ALD. Individuals who drink can develop ALD. The natural history of ALD in the model is represented by fibrosis stages (F1–F4) and the darker blue stages represent various complications of decompensated cirrhosis. Patients could develop hepatocellular carcinoma or die from liver-related mortality or background mortality. Competing-cause mortality, the probability of dying from other causes both related and unrelated to alcohol use, exists in every state, but are not shown in our diagram for simplicity. Abbreviations: pre-drinking tunnel states (H1–H5), no fibrosis (F0), mild fibrosis (F1), moderate fibrosis (F2), septal fibrosis (F3), compensated cirrhosis (F4), hepatocellular carcinoma (HCC) Abbreviations: pre-drinking tunnel states (H1–H5), no fibrosis (F0), mild fibrosis (F1), moderate fibrosis (F2), septal fibrosis (F3), compensated cirrhosis (F4), hepatocellular carcinoma (HCC)

Figure 2:

Projected annual (A) and cumulative (B) cost in billions for alcohol-associated liver disease in the US from 2022 to 2040 Abbreviations: United States Dollars (USD)

Figure 3:

Annual (A) and cumulative (B) alcohol-associated liver disease costs by sex from 2022-2040 in the United States Abbreviations: United States Dollars (USD)

Figure 4:

Annual (A, C) and cumulative costs (B, D) for alcohol-associated liver conditions by age and sex

Figure 5:

Projected Alcohol sequelae cost: US 2022-2040 Abbreviations: mild fibrosis (F1), moderate fibrosis (F2), septal fibrosis (F3), hepatocellular carcinoma (HCC)