COMMENTARY

Neglecting Hemorrhoids Comes at a Cost

David A. Johnson, MD

Disclosures

June 07, 2019

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

Orphan diseases are defined as those that affect ≤ 200,000 in a nationwide population. By those standards, hemorrhoids is not a true orphan disease. However, recent evidence suggests that it may meet this designation by being substantially underserved.

Billion-Dollar Burden

In a very well-designed epidemiologic analysis,[1] Dr Robert Sandler and colleagues at the University of North Carolina studied the burden and costs of outpatient hemorrhoids in the United States. In a cross-sectional study using the MarketScan Commercial Claims and Encounters Database for 2014, they analyzed data from approximately 19 million individuals ranging in age from 18 to 64 years (a non-Medicare group), which was used to extrapolate representative cost estimates for the US employer-insured population.

Taking the primary diagnosis of hemorrhoids and looking at the payments for prescription medications, physician encounters, and facility costs, which were then put through a validated and weighted adjustment, they estimated that it was associated with approximately $770 million annualized costs in the United States. When they took this a step further and analyzed hemorrhoids as a secondary rather than a primary diagnosis, that number ballooned up to approximately $2.5 billion.

This represents a considerable economic burden. When you consider that it only looked at the employed population and didn't include the cost of over-the-counter medications, this number certainly would go up considerably.

It's also notable that this was performed in a non-Medicare age group. The authors acknowledge that epidemiologic studies show that hemorrhoidal problems increase with age, as well as estimates that the prevalence of hemorrhoids will go up in the next decade by 25% in the Medicare population.[2] Therefore, these costs will continue to escalate.

These authors also didn't include inpatient costs. Only about 3.3%-4.0% of patients get hospitalized for hemorrhoids,[1] so I think the additional financial burdens here are probably relatively minor.

By Overlooking Hemorrhoids, Are We Turning It Into an Orphan Disease?

Regardless, these escalating costs represent a real disease burden that the field of healthcare economics needs to start considering and addressing. Despite this, the authors point out that in the last quarter of a century, there's been no National Institutes of Health funds directed toward this disease. We don't have validated patient-related outcomes for it.

What we do have are a number of effective medical therapies we can deliver, particularly in the office, although we are currently not sufficiently doing that. That contributes to the economic burden of repetitive exposures, with patients coming back to us.

The study's authors and the writer of an accompanying editorial[3] both highlight that this is equivalent to what we'd say is an orphan disease, given that it's underfunded and underattended to by gastroenterologists. When I reflect on my 35-plus years out of fellowship, we were never taught about perianal disease, in particular hemorrhoidal treatments to offer these patients. This is something we need to clearly start thinking about. The authors suggest that this represents an opportunity for orphan disease funding, but also for addressing with our patients and for looking to make effective interventions.

This is a disease process that is very much dismissed by most of us, yet we now know that its economic burden is considerable, if not astronomical, if not given specific attention. We need to pay closer attention to making a definitive intervention. We need to start talking to patients about hemorrhoids and related symptoms (pain, bleeding, itching, fecal leakage). Funding needs to be directed in this area given its significant disease and economic burden.

Although hemorrhoids may not technically be an orphan disease, it's perhaps been orphaned by our inattention. If we don't discuss and address this, I'd ask you what are we leaving behind? (No pun intended.) Talk to your patients and ask the right questions. I think you'll be surprised at what a difference you can make with the presently available effective therapies.

I'm Dr David Johnson. Thanks for listening.

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