Burden of Gastrointestinal Disease in the United States

2012 Update

Anne F. Peery; Evan S. Dellon; Jennifer Lund; Seth D. Crockett; Christopher E. Mcgowan; William J. Bulsiewicz; Lisa M. Gangarosa; Michelle T. Thiny; Karyn Stizenberg; Douglas R. Morgan; Yehuda Ringel; Hannah P. Kim; Marco Dacosta Dibonaventura; Charlotte F. Carroll; Jeffery K. Allen; Suzanne F. Cook; Robert S. Sandler; Michael D. Kappelman; Nicholas J. Shaheen

Disclosures

Gastroenterology. 2012;143(5):1179-1187. 

In This Article

Results

Symptoms and Diagnoses

The leading GI symptoms prompting an outpatient clinic visit in 2009 are listed in Table 1. Abdominal pain is the most common GI symptom with an estimated 15.9 million visits in 2009. Other leading symptoms at outpatient visits were diarrhea, constipation, vomiting, and nausea.

The most common physician diagnoses for GI disorders in outpatient clinic visits in 2009 are listed in Table 2. Gastroesophageal reflux was the most frequent outpatient diagnosis with almost 9 million visits in 2009. Abdominal pain, gastroenteritis and dyspepsia, constipation, abdominal wall hernia, and diverticular disease followed in frequency.

Quality of Life

The impact of select GI diseases and symptoms on quality of life, overall work productivity, and activity impairment are detailed in Supplementary Table 1. In all diseases and symptoms for all outcomes except colorectal cancer, we found worse quality of life and significantly more work and activity impairments compared with population norms. In this survey, participants with a history of colorectal cancer are likely to be cancer survivors, and these individuals demonstrate better mental health, but worse physical health, than population norms.

Hospitalizations

The most common inpatient principal GI discharge diagnoses from 2009 are detailed in Table 3. Acute pancreatitis was the most common single GI diagnosis and cost an estimated 2.6 billion dollars per year in inpatient costs. Combined diverticular disease (diverticulitis and hemorrhage) was actually more common than acute pancreatitis and also cost an estimated 2.6 billion dollars per year. Clostridium difficile infection discharges increased 237% since 2000 and account for a proportion of inpatient mortality similar to GI hemorrhage (Figure 1A).

Figure 1.

Panel A: Number of annual hospital discharges with a principal diagnosis of Clostridium difficile infection, 1993–2009, from the National Inpatient Sample. Panel B: Time trends in endoscopy procedure rates in commercially insured patients in the United States, 2000–2009. Upper GI endoscopy included esophagogastroduodenoscopy, upper endoscopic ultrasound, and enteroscopy. Lower GI endoscopy included colonoscopy, flexible sigmoidoscopy, lower endoscopic ultrasound, and pouch/stoma endoscopy.

Statistics for select GI and hepatology-related discharge diagnoses not among the top 100 discharge diagnoses are detailed in Table 3. Chronic liver disease and viral hepatitis were associated with 6% mortality and cost an estimated $1.8 billion per year in inpatient cost. Hospitalizations for nonalcoholic fatty liver disease have increased 97% since 2000. Inflammatory bowel disease and functional/motility disease both cost almost $1 billion per year in inpatient costs.

The most common inpatient GI and hepatology-related discharge diagnoses among any listed diagnoses from 2009 are detailed in Supplementary Table 2. Esophageal reflux (4.4 million), obesity (1.7 million), and constipation (1 million) were the most common discharge diagnoses.

Cancer

GI cancer incidence, mortality, and 5-year survival are detailed in Table 4. An estimated 147,308 people were diagnosed with colorectal cancer in the United States in 2008. When diagnosed with localized disease, 5-year survival is 90%. Esophageal, pancreatic, and liver cancer are less common but are associated with 5-year survival of less than 40% even when diagnosed at an early stage.

Mortality

In 2009, there were a total of 2,437,163 deaths in the United States with 245,921 attributable to an underlying GI cause (10%). The leading GI causes of death are presented in Table 5. Colorectal cancer remains the leading GI cause of mortality followed by pancreatic and hepatobiliary neoplasms. Clostridium difficile is now the ninth leading GI cause of death, increasing from 2195 deaths in 2002 to 7251 in 2009, a 230% absolute increase.

In 2009, there were 30,558 deaths in the United States attributed to chronic liver disease and cirrhosis, representing the 12th leading cause overall. Malignant neoplasms of the liver and biliary tree represent the most frequent cause of hepatic and biliary mortality, followed by cirrhosis/fibrosis, alcoholic liver disease, and chronic hepatitis C virus infection (Table 5). Mortality rates associated with each of these causes of death have increased since 2002, whereas the rates attributable to acute and chronic hepatitis B and primary biliary cirrhosis have remained stable.

Endoscopic Utilization

There were an estimated 6.9 million upper, 11.5 million lower, and 228,000 biliary endoscopies performed in the United States in 2009 based on Thompson Reuters MarketScan commercial (Thompson Reuters, New York, NY), Medicare, and Medicaid databases. The estimated total outpatient cost was $32.4 billion. Upper endoscopies were estimated at $12.3 billion, lower endoscopies $19.2 billion, and ERCP $900 million. The estimated average costs for all upper endoscopies, lower endoscopies, and ERCPs were $1775, $1672, and $3899, respectively. The estimated average total cost for EGD alone (either diagnostic or with biopsy) was $685. The estimated average total cost for colonoscopy alone (either with biopsy or with polypectomy) was $1013.

The trends in endoscopic volume in commercially insured patients in the United States between 2000 and 2009 are detailed in Figure lB. We found a 54% and 17% increase in all upper and lower GI endoscopy, respectively, but a 16% decrease in ERCP.

Additionally, the trends in endoscopic volume in Medicare Part B in the United States between 2000 and 2010 are detailed in Table 6. Overall, there was also a significant increase in the performance of endoscopic procedures in Medicare recipients over the last decade. Colonoscopy is consistently the most commonly performed procedure with over 3.3 million colonoscopies performed in Medicare beneficiaries in 2010. Whereas the use of magnetic resonance cholangiopancreatography (MRCP) was significantly lower than that of ERCP in 2000, there has been a nearly 8-fold increase in its use, making it more than twice as common as ERCP in 2010. EUS utilization has increased 6-fold in the last 10 years.

A total of 785,302 colonoscopies, 34,884 flexible sigmoidoscopies, 448,888 EGDs, 16,980 ERCPs, and 13,374 EUSs was recorded in CORI's National Endoscopic Database from 2005 to 2010. The most common indications for upper endoscopy were reflux symptoms (24%), dysphagia (20%), evaluation for any GI bleeding symptom (19%), and abdominal pain or bloating (18%) (Supplementary Table 3). The most common indications for colonoscopy were routine screening examinations (32%), evaluation of any GI bleeding symptom (22%), and surveillance for adenomatous polyps (18%) (Supplementary Table 4).

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