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Supplements Importance of Selecting the Appropriate Therapy for Inflammatory Bowel Disease in the Managed Care E

Report: Economic Implications of Inflammatory Bowel Disease and Its Management

Foram Mehta, MS, RPh
Crohn’s disease and ulcerative colitis, the 2 most common inflammatory bowel diseases (IBDs), are chronic conditions with periods of exacerbation and remission. Patients with IBD experience clinical gastrointestinal (GI) symptoms, as well as the emo-tional burden that accompanies chronic conditions characterized by reduced quality of life and ability to work. With estimates of direct and indirect costs ranging between $14.6 and $31.6 billion in 2014, there is a significant healthcare burden associated with IBD. Although treatment expenses make up a significant portion of the cost of IBD, studies show that inappropriate treatment, lack of adherence to therapeutic regimens, or suboptimal treatment increase the cost burden. Costs for IBD include hospitalizations, the eventual need for surgery due to disease complications, and physician visits. The staggering economic burden of IBD makes early diagnosis, coupled with effective treatment at onset, imperative. Therefore, management of IBD must evolve beyond symptom control and toward sus-tained control of GI inflammation as measured by endoscopic, radiologic, and laboratory parameters.Treatment advances have made deep remission a realistic target for some people with IBD. However, achieving deep remission requires a shift in the man-agement paradigm of IBD, encouraging individualized treatment with biologics that focuses less on treating symptoms and more on preventing potential disease progression. Although expensive at onset, this man-agement strategy may ultimately lead to decreased rates of surgeries and hospitalizations, potentially yielding lower long-term costs for treatment.


     Inflammatory bowel disease (IBD) is a term applied to a group of idiopathic, chronic conditions that are characterized by inflammation of the gastrointestinal (GI) tract and a progressive course, which includes periods of exacerbations and remissions.1,2 The 2 most common IBDs are Crohn’s disease (CD) and ulcerative colitis (UC); both are distinguished by a dysregulated immune response. However, CD is typified by inflammation throughout the digestive tract, whereas UC is limited to the large intestine.3,4 Approximately 1.17 million individuals in the United States currently have IBD,

and the total number of patients with IBD increases by approximately 70,000 each year.1,2

Impact on Patients

     Patients with IBD may experience a range of emo-tional responses to the unexpected GI exacerbations,2 which can be painful, inconvenient, and embarrassing. Severe chronic conditions such as IBD can lead patients to feel anger or anxiety and can elevate stress, which, in turn, may cause flare-ups. The chronicity and progres-sive nature of the disease has been shown to increase disability, as well as reduce quality of life (QOL) and ability to work.5

     Although the onset of IBD can occur at any age, the peak age for CD onset is 20 to 30 years, coinciding with the beginning of an individual’s prime working years.5,6 The peak age for UC is between 30 and 40 years.5 The relentlessness of the illnesses, especially during periods of exacerbations, negatively affects various aspects of the patient’s QOL, including their daily living, social and sexual lives, ability to work, and self-perception and body image.5,7 Studies have shown that QOL worsens in association with disease severity, with lower QOL scores in patients with active disease compared with patients in remission.8,9

Economic Burden of IBD

     The painful flare-ups of CD and UC cause a substantial economic burden on the healthcare system, includ-ing both direct and indirect expenditures. IBD ranks as 1 of the 5 most expensive GI disorders despite its being the lowest in prevalence among the list of GI disorders.10 Based on pharmacoeconomic data from 2004 to 2008, the Crohn’s & Colitis Foundation of America (CCFA) extrapolated cost data to the current prevalence estimates of CD and UC, and determined the total annual financial burden of IBD in the United States to be $14.6 to $31.6 billion in 2014.2,6,11,12 However, recent longi-tudinal data and reimbursement information for CD indicate that total costs may significantly exceed these earlier estimates.13

     After 30 years of disease, up to one-third of patients with UC will require surgery. Approximately  70% of patients with CD eventually require surgery, and 30% of these patients will experience recurrence within 3 years.2 With an estimated 1.9 million physician visits, IBD was the eighth leading diagnosis for GI disorders in outpatient clinic visits in 2009,14 an increase from a 2004 report that estimated IBD as the primary cause in 1.36 million physician visits.15,16 Additionally, in 2009, IBD was the first-listed discharge diagnosis in over 100,000 hospitalizations—a 37% increase from discharge diagnoses in 2000. These hospitalizations resulted in 569,918 total hospital days, with a mean cost of $32,965 and aggregate costs of over $1 billion.14 A year later, in 2010, the National Hospital Discharge Survey showed that the number of hospitalizations due to IBD more than doubled to 208,000.18 However, hospitalizations make up only a portion of the costs associated with IBD.

Direct Costs

     Direct medical costs include expenses for hospitaliza-tions, physician services, prescription drugs, OTC drugs, skilled nursing care, diagnostic procedures, and other healthcare services.11 In a study estimating the direct costs (based on insurance claims) in the United States, includ-ing inpatient, outpatient, and pharmaceutical services, Kappelman and colleagues estimated the overall annual direct costs of IBD treatment to be greater than $6.3 billion in 2004.11 Based on current prevalence, extrapolated estimated costs in 2014 would be $11 to $28 billion.2

     In 2004, CD was responsible for more than 800,000 first-listed ambulatory care visits (first-listed refers to the primary diagnosis), and more than 1 million all-listed visits (all-listed refers to any diagnosis other than the first-listed diagnosis).16 Comparatively, UC was the primary cause of 500,000 ambulatory care visits and about 700,000 all-listed visits in the same year.

     For hospital discharges, CD was the first-listed diagnosis for 57,000 stays; it was also mentioned as an additional diagnosis in another 100,000 discharges. Hospitalizations for UC were less common, with 35,000 first-listed discharge diagnoses and 82,000 all-listed diagnoses.16 (See trends in Figures 1A16 and 1B16) These numbers increased in 2010 when hospital discharges numbered 187,000 for CD and 107,000 for UC.17 An assessment of healthcare resource utilization and costs from 2003 to 2013 of privately insured US employees with UC showed that, compared with controls, patients with UC had substantially higher baseline hospitaliza-tion rates (16.9% vs 6.2%), emergency department visits (31.1% vs 22.0%), and prescription drug use (95.3% vs 72.0%). Overall, adjusted total direct costs were also substantially higher for patients with UC than their counterparts without ($15,548 vs $4812).18

     The impact of IBD on overall costs per patient has been evaluated individually and collectively for CD and UC. In patients with CD, an analysis of longitudinal data and health insurance claims data between 2011 and 2013 showed the mean health-plan paid cost per member per year was $18,637.13 In patients with UC, a retrospective analysis of administrative data from 2004 to 2009 of 100 self-insured US employers revealed that mean annual all-cause total healthcare costs (inpatient, outpatient, and pharmacy claims) for patients with UC were $3821.44 higher than the matched control group (P <.001).19 In a longitudinal analysis of data from the Medical Expenditure Panel Survey from 1996 to 2011, researchers examined healthcare expenditures of patients with CD or UC20 and calculated annual mean expendi-tures per person were $10,364 for CD and $7827 for UC. These were significantly greater than the expenditures for individuals without IBD ($4314; P <.05). IBD-related costs were less for privately insured ($8014) compared with publicly insured patients ($18,067, P <.05). Inpatient care was the leading cost category; however, privately insured patients had higher costs for outpatient care, office-based care, and prescribed medicines.20 A systematic review showed that treatment of CD cost almost 2 to 4 times as much in the United States as it did in other Western countries.21,22 An analysis of data from the MarketScan database from 1999 to 2005 showed similar differences in cost for patients with UC in the United States compared with other Western countries.6,21

Indirect Costs

     Indirect costs are the value of lost earnings or productivity; they may include the value of leisure time lost.6 One study focused on the cost of IBD based solely on missed work days: Although the absence burden for employees with CD was not significantly different from matched controls, employ-ees with CD did have a 2.5 times higher probability of receiving short-term disability benefits in

the 12 months after diagnosis compared with controls (19.8% vs 7.3%, respectively; P <.01). The burden of short-term disability costs was $972 for people with CD; it was 2.5 times higher for those with the disease ($1627 per patient) compared with controls ($655 per patient) (P <.01).6 Employees with UC were 2.5 times more likely than controls to receive short-term disability benefits in the 12 months after diagnosis (15.4% vs 6.1%, respectively; P <.01). Based on data from the MarketScan database (1999-2005), the average cost burden for patients with UC was $1386 per year compared with $522 for controls—a difference of $864 per patient with UC per year (P <.01).6 A later study, which used data from 100 self-insured US employers from 2004 to 2009, detected no differences in

all-cause absenteeism costs (P = .834) or mean-annual all-cause short-term disability costs for patients with UC compared with matched controls (P = .283).19 However, cost data from 2003 to 2013 of privately insured US employees with UC show that, compared with controls, patients with UC had substantially higher adjusted total indirect costs ($4125 vs $1961).18

Changing Cost-Drivers

     The increase in cost in IBD treatment over the past decade may be attributed to the changing cost-drivers in disease management. An economic analysis of data from 2004 shows that nonsurgical hospitaliza-tions resulted in 20% of the total direct costs for either disease.11 Outpatient services were responsible for 33% and 35% of direct costs, while pharmacy utilization was responsible for 35% and 28% of direct costs for CD and UC, respectively.11 However, a more recent study of health-plan paid costs paid between 2011 and 2013 for CD suggests that inpatient care costs account for 23% of the total CD-attributable costs and pharmacy utilization constitutes 45.5%, which is almost twice as much as the inpatient costs (Figure 213).

     When all medications prescribed for IBD, including those not approved for IBD, were considered, mesala-mine was the most costly and most frequently prescribed medication for CD and UC in 2004.11,15 It was one of several oral aminosalicylates prescribed, accounting for 37% of all prescription costs for CD and almost 50% of all prescription costs for UC.15 At least 2 claims for oral aminosalicylates were reported for 39% of patients with CD and 43% of patients with UC.11

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