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DIRECT TREATMENT COSTS OF CIRRHOSIS IN THE BRAZILIAN PUBLIC
HEALTHCARE SYSTEM: A 2008-2012 RETROSPECTiVE ANALYSIS
Andre Morais , Luis André Magno
1
1
1. Janssen Farmaceutica, Sao Paulo, Brazil
PGI10
ObjectiveS:
To estimate the direct healthcare costs associated with cirrhosis from a brazilian public payer
perspective (SUS).
MethodS:
Between 2008 and 2012, 2.933 patients received hospital care for cirrhosis and treatment for
HCV with a total cost of R$ 19 million, transplant-associated costs accounted for R$ 15 million,
or 77% of total costs. Patients with cirrhosis without HCV G1 treatment reached 105.285 in the
same period and 57.553 received HCV G1 care.
Figure 1: Number of patients hospitalized for cirrhosis and receiving HCV G1 treatment in the SUS.
A retrospective study of a public claims database (DATASUS) was used to assess direct healthcare
costs associated with cirrhosis between 2008 and 2012. Patients with cirrhosis were identified
based on ICD-10 codes for cirrhosis (K70.3, K71.7, K74.3-K74.6). The retrospective analysis
considered both inpatient costs and outpatient treatment costs of patients during the 4 year
time frame. Medication costs were defined as a weighted average during the period of analysis
considering official government price lists available at www.comprasnet.gov.br. A sub analysis
was carried out for cirrhotic patients with hepatitis C (HCV) treatment, defined according to
patients that received treatment with peg-interferon with ribavirin (PR).
120.082
ConclusionS:
Organ transplant accounts for the majority of hospital healthcare costs in cirrhosis patients in
the Brazilian public healthcare system. Considering patients with HCV treatment and cirrhosis,
the average cost per patient was around 78% higher than the general cirrhosis patient
INTROduction
Patients
with
cirrhosis
hospital care
+ HCV
treatment
Patients with
cirrhosis*
received
hospital care
Results:
Between 2008 and 2012, 120,082 patients were hospitalized for the ICD codes of cirrhosis (49%
of patients accounted by ICD K746) with a total treatment cost of R$ 404 million, 68% accounting
for transplant (R$ 276 million), 30% for outpatient procedures (R$ 121 million), 2% for surgical
procedures (R$ 6 million) and the remainder for exams and diagnostics. Patients were hospitalized
for an average of 10,1 days per year, with an average cost of R$ 2,806 (R$2.149- R$ 3,757) per
hospitalization event and R$ 3.378 (R$ 2.523-4.579) per patient. The average cost for transplant
was R$ 52.912 (R$43.304-70.274). Between 2008 and 2012 2.933 patients were hospitalized for
cirrhosis having received treatment for HCV with a total cost of R$ 19 million. The average inpatient
cost for HCV-cirrhosis patients was R$ 4,999 for 11,2 days of hospitalization. Organ transplantsassociated costs accounted for R$ 15 million, 77% of total costs, with an average cost of R$ 67,319
per transplant.
2.933
57.553
Patients with
HCV G1**
*Defined by ICD codes
**Received HCV treatment with peginterferon and ribavirin (PR)
The average inpatient cost for HCV-cirrhosis patients was R$ 4,999, 78% higher compared to
cirrhotic patients without HCV G1 treatment. (Table 4) HCV G1 cirrhotic patients had an average
cost of R$ 67,319 per liver transplant, about 27% higher than cirrhotic patients without HCV G1.
Table 4: Average treatment costs for cirrhotic patients and cirrhotic patients treated for HCV G1
Cirrhotic
patients HCV+
Cirrhotic Patients
Cirrhosis is a chronic liver disease characterized by progressive inflammation of the liver leading
ultimately to liver failure and death. The main causes of cirrhosis include hepatitis B virus (HBV)
and hepatitis C virus (HCV) infection, alcoholic liver disease.1 Recent studies show that mortality
due to cirrhosis seemed to remain stagnant over past years in the USA and most of Europe
and has even increased in countries such as the UK.2 The WHO estimates that liver cirrhosis
accounts for 1.8% of all deaths in Europe (170,000 deaths per year).3
(N= 120.082)
(N= 2.933)
Cost/hospital stay
R$ 2,806
R$ 4,999
Cost/Patient
R$ 3,378
R$ 6,583
Transplant
R$ 52,912
R$ 67,319
Surgery
R$ 15,937
R$ 22,471
Clinical procedure
R$ 1,056
R$ 1,440
Other
R$ 336
R$ 250
Average length of stay (Days)
10.2
11.2
The overall cost of cirrhosis includes direct costs (drug and hospitalization costs) and indirect
costs (due to loss of work productivity and impact in the quality of life). A recent study
demonstrated that patients with HCV diagnosis and liver disease had higher healthcare resource
use and twice the costs compared to patients with liver disease and no HCV diagnosis.4
Unlike HBV infection, there is currently no vaccine available for HCV, and avoiding chronic liver
disease depends on HCV infection prevention and treatment. Recently approved treatments,
such as simeprevir and sofosbuvir, offer hihh chances of cure with few side effects. The objective
os this study was to estimate the direct healthcare costs of inpatient care for cirrhosis in patients
with and without a history of HCV in the brazilian public healthcare system.
METHODS
A retrospective study of a public claims database (DATASUS) was used to assess direct healthcare
costs associated with cirrhosis between 2008 and 2012. Patients with cirrhosis were identified
based on ICD-10 codes for cirrhosis (K70.3, K71.7, K74.3-K74.6). The retrospective analysis
considered both inpatient costs and outpatient treatment costs of patients during the 4 year
time frame. Medication costs were defined as a weighted average during the period of analysis
considering official government price lists available at www.comprasnet.gov.br. A sub analysis
was carried out for cirrhotic patients with hepatitis C (HCV) treatment, defined according to
patients that received treatment with peg-interferon with ribavirin (PR).
After the first month of treatment for HCV G1, 21% of patients were hospitalized for cirrhosis
with an additional 11% of patients receiving hospital care up to 12 months of treatment.
On average, patients with HCV had higher costs for treating cirrhosis compared to patients
without HCV treatment. Comparing the average cost of transplant, patients with HCV had 19%
higher costs than chirrotic patients without HCV treatment.
Table 5: Hospital costs of cirrhosis patients and cirrhosis patients with a history of HCV treatment in Brazil
Cirrhosis Control
RESuLTS
Between 2008 and 2012, 120.082 patients were hospitalized for the ICD codes of cirrhosis
(49% of patients accounted by ICD K746) with a total treatment cost of R$ 404 million, 68%
accounting for transplant (R$ 276 million), 30% for outpatient procedures (R$ 121 million), 2%
for surgical procedures (R$ 6 million) and the remainder for exams and diagnostics.
Total Cost (R$)
% Total Cost
Patients
Average cost (R$)
% Patients
Procedures
114.066.302
31%
101.398
1.125
96%
Transplant
248.711.946
67%
4.426
56.193
4%
Others
5.956.732
1,6%
391
15.235
1%
Table 1: Number of cirrhotic patients hospitalized per year
Patients
2008
TOTAL
2009
24,381
NEW
2010
23,958
–
2011
24,066
22,225
2012
24,112
21,912
21,725
23,565
TOTAL
2009
R$ 61,510,890
2010
R$ 69,898,765
2011
Total
(20082012)
2012
Total Cost (R$)
% Total Cost
Patients
Average cost (R$)
% Patients
Procedures
3.931.527
20%
2.731
1.440
93%
Transplant
14.944.868
77%
222
67.319
8%
Others
430.439
2,2%
33
13.044
1%
20,885
Table 2: Hospital costs of cirrhotic patients in the SUS
2008
Cirrhosis and HCV Patients
%
Figure 2: Number of patients hospitalized per year in the SUS
R$ 75,341,830 R$ 90,153,572 R$ 107,913,333 R$ 404,818,390
Total Hosp.
Transplant
R$ 39,710,200
R$ 45,784,557
R$ 49,408,370 R$ 62,503,427 R$ 79,409,419
R$ 276,815,973
Transplant
68%
30.000
Clinical
Procedures
R$ 20,488,532
R$ 22,954,138
R$ 24,666,333 R$ 26,225,754 R$ 26,915,667
Surgery
R$ 1,303,082
R$ 1,146,275
R$ 1,256,418
Other
(eg. Diagnostics,
etc.)
R$ 1,401,082
R$ 1,565,150
R$ 121,250,424
30%
R$ 6,672,007
2%
25.000
24.381
23.958
24.066
24.112
23.565
20.000
15.000
R$ 9,076
R$ 13,796
R$ 10,708
R$ 23,309
R$ 23,098
R$ 79,987
0%
Cirrhotic patients were hospitalized for an average of 10,1 days per year, with an average cost
of R$ 2,806 (R$2.149- R$ 3,757) per hospitalization event and R$ 3.378 (R$ 2.523-4.579) per
patient. (Table 3)
10.000
5.000
917
1.000
1.028
1.094
1.130
2011
2012
0
2008
2009
2010
The average cost for transplant was R$ 52.912 (R$43.304-70.274).
DISCUSSION
Table 3: Average treatment costs and length of stay for cirrhotic patients
2008
2009
2010
2011
2012
Average
(20082012)
Cost/
hospital stay
R$ 2,149
R$ 2,457
R$ 2,607
R$ 3,059
R$ 3,757
R$ 2,806
Cost/Patient
R$ 2,523
R$ 2,918
R$ 3,131
R$ 3,739
R$ 4,579
R$ 3,378
Transplant
R$ 43,304
R$ 45,785
R$ 48,063
R$ 57,133
R$ 70,274
R$ 52,912
Surgery
R$ 18,353
R$ 13,979
R$ 15,705
R$ 16,881
R$ 14,766
R$ 15,937
Clinical
procedure
R$ 873
R$ 1,000
R$ 1,070
R$ 1,138
R$ 1,198
R$ 1,056
Other
R$ 303
R$ 383
R$ 275
R$ 364
R$ 355
R$ 336
Average length
of stay (Days)
10.4
10.1
10.1
10.0
10.1
10.2
Presented at the ISPOR 17th Annual European Congress, 8-12 November 2014, Amsterdam RAI, The Netherlands
Although HCV treatment was used as an indicator for HCV, many patients in the cirrhosis group
might also have HCV but were not eligible for treatment. Furthermore, identifying in a hospital
database patient with HCV treatment represents a bias for hospital costs, which will be more
easily identified. According to the label of HCV treatment with PegIFN should only be used
in mild cirrhotic patients (defined as Child-Pugh class according to five clinical criteria) and
according to the results there might be a delayed use of PR. Furthermore, around 50 million
Brazilians have private health insurance and have access to private hospital care. This study
does not account for these patients that might receive HCV treatment in the SUS but were
hospitalized in a private setting.
conclusion
Organ transplant accounts for the majority of hospital healthcare costs in cirrhosis patients in
the Brazilian public healthcare system. Considering patients with HCV treatment and cirrhosis,
the average cost per patient was around 78% higher than the general cirrhosis patient.
References:
1. Heidelbaugh JJ, Bruderly M. Cirrhosis and chronic liver failure: part I. Diagnosis and evaluation. Am Fam Physician. 2006;74:756-762. 2. Fedeli MD et al. Trends in mortality from chronic liver disease. Annals of Epidemiology
24 (2014) 522e526. 3.Zatonski WA, Sulkowska U, Manczuk M, Rehm J, Boffetta P, Lowenfels AB, et al. Liver cirrhosis mortality in Europe, with special attention to Central and Eastern Europe. Eur Addict Res 2010;16:193–201. 4.
McAdam-Marx C, et al. All-Cause and Incremental Per Patient Per Year Cost Associated with Chronic Hepatitis C Virus and Associated Liver Complications in the United States: A Managed Care Perspective. JMCP September
2011 Vol. 17, No. 7. 5. PEGASYS® (peginterferon alfa-2a) FDA Label. 2002.