NASH in US estimated to cost more than $175 billion over next 2 decades
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Based on the current number of cases of non-alcoholic steatohepatitis in the United States, more than $175 billion will be spent on managing and treating the disease, two-thirds being spent in those with obesity and NASH, according to a presentation.
“Based on data from meta-analysis, modeling and global burden of disease or GBD, the global burden of NASH is driven by the growing epidemic of obesity and type 2 diabetes,” Zobair M. Younossi, MD, MPH, chairman of the department of medicine at the Inova Fairfax Medical Campus in Virginia, said during his presentation at The Liver Meeting Digital Experience. “The growing prevalence of obesity and related NASH is projected to cause substantial clinical and economic burden in the United States over the next 2 decades.”
Younossi and colleagues used a discrete-time Markov model to simulate outcomes for a hypothetical cohort of NASH patients in the U.S. aged older than 20 years, stratifying cohorts by age and presence of obesity along the projections data for 2019 to 2040 along with published literature.
The model included nine health states and three absorbing death states in each year with defined transition probabilities. Researchers used data from various sources such as the National Health and Nutrition Examination III to adjust transition probabilities and they were then rescaled. Estimated costs included inpatient, outpatient, professional services, emergency department and drug costs.
Younossi reported that 4.48% of the U.S. population (n = 11.2 million) had NASH in 2019 and of those with NASH, 70.1% had obesity.
From 2019 to 2040, he estimated that those classified as having obese NASH will have higher mortality when compared to non-obese NASH in all-cause mortality at 74.85% vs. 62.52% and cardiac-specific death at 28.26% vs. 8.51%. Liver-specific mortality, though, was slightly lower in the obesity group.
“This has been shown ... that patients who are not obese with NASH may have more aggressive disease,” Younossi said, also noting it is still an ongoing debate.
In the obese NASH cohort, the model showed 31,947 liver transplants; 817,269 years of decompensated cirrhosis; and 491,212 years of hepatocellular carcinoma. The non-obese NASH cohort showed just 11,154 liver transplants; 293,151 years of decompensated cirrhosis; and 147,479 years of HCC.
Lastly, Younossi estimated costs for obese NASH to be $126,765,231,245 vs. $48,837,960,130 for the non-obese NASH cohort. At all age timepoints, NASH with obesity cost more than non-obese NASH, with both cohorts increasing with age. Younossi noted that drug costs were not calculated as there are no currently approved drugs to treat NASH.
“These data should inform providers, payers, policy makers and other stakeholders to address the growing burden of NASH in the U.S.,” Younossi said.
Perspective
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Jamile’ Wakim-Fleming, MD, FACG, FAASLD
Fatty liver disease occurs in about 70% of individuals who have obesity. NASH is the advanced form of fatty liver disease, and it occurs in about 5% of patients with fatty liver translating into a prevalence of more than 11 million people. Once NASH develops, the progression to the more advanced form, that is cirrhosis and its complications such as liver failure, liver cancer and death, or liver transplantation becomes imminent.
Obesity is rising in the United States and worldwide for men, women and children. Obesity, fatty liver disease/NASH and insulin resistance are interlinked. Each of these entities may drive the other two in its direction. As rates of obesity rise, so do rates of the other two conditions. Liver transplantation related to fatty liver disease is taking the lead among all other causes of liver transplantation and the resources associated with it.
In this seminal study performed by Younossi and colleagues and accepted for oral presentation late abstract submission at The Liver Meeting 2021, the authors set out to study the economic burden of NASH in individuals with NASH and obesity. They used the discrete Markov predictive model to estimate costs projected into 2040 based on 2019 fee schedule obtained from the Center for Medicare and Medicaid Services. Their results show that the estimated NASH with obesity cohort will experience at least five times more liver transplants and years of decompensated cirrhosis and seven times more in years of hepatocellular carcinoma than individuals with NASH without obesity. Expected costs were estimated at greater than $161 billion for NASH with obesity vs. more than $30 billion for NASH without obesity.
These findings highlight the burden of NASH with obesity and should alert clinicians as well as policy makers to tackle it and allocate budget resources as well as resources to implement appropriate preventive measures accordingly.
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Younossi ZM. Burden of illness and economic impact of nonalcoholic steatohepatitis (NASH) in the United States according to the presence of obesity. Presented at: The Liver Meeting Digital Experience; Nov. 12-15, 2021 (virtual meeting).
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