Canadian trends in spending on liver hospitalizations and transplants: 2004–2020
Abstract
Background:
The incidence and prevalence of liver disease are increasing and contribute to significant morbidity and mortality. In Canada, more than 3 million people live with liver diseases, accounting for approximately 2% of all hospitalizations. However, it remains unclear how much liver hospitalizations cost the Canadian health care system. Thus, this study estimates the cost of liver-related hospitalization across Canada.
Methods:
We conducted a population-based, retrospective study using acute inpatient admission data for liver-related hospitalizations obtained from the Canadian Institute for Health Information. We calculated the total and the average nominal spending for liver hospitalizations nationally from April 1, 2004, to March 31, 2020, based on fiscal year (FY). In addition, we stratified the average liver hospitalization spending based on age and sex group.
Results:
Canada spent $947 million on liver-related hospitalizations in FY2019, a 145% growth in spending from FY2004. The average liver disease–related hospitalization was estimated to be $17,506 in FY2019. Within the sub-group analysis, the age group <30 showed the highest average cost per hospitalization at $21,776; however, there was no significant difference in cost between males and females. Across the different provinces in FY2019, Alberta experienced the highest average spending per hospitalization at $23,150, whereas Ontario had the lowest spending at $15,712.
Conclusions:
Liver-related hospitalizations are associated with high spending that is increasing nationally with variations across provinces and territories. Our results are of great use for economic evaluations of novel interventions in the future.
Introduction
Liver diseases (eg, viral hepatitis and non-alcoholic fatty liver disease) are important causes of morbidity and mortality and account for approximately 2 million deaths annually worldwide (1). In Canada, more than 3 million people live with liver diseases annually, contributing to approximately 2% of all hospitalizations across the country (4). Existing studies establish a severe and increasing burden of liver disease. Still, there is limited information on the cost of liver hospitalizations and transplants in Canada and how this varies across different provinces and territories (6). Accurate up-to-date cost estimates for economic evaluations are critical for effective policy-making. Furthermore, since Canada is committed to the World Health Organization’s viral hepatitis elimination target by 2030, there are a number of micro-elimination interventions currently in development (2). Thus, it will be important to provide cost estimates for hospitalization and liver transplants, as they will be important for economic evaluations of those interventions. Since current costs associated with liver hospitalization are poorly understood, this study aims to estimate the cost and trend of hospitalizations of chronic liver patients and liver transplants across Canada.
Methods
We conducted a retrospective, population-based study of the cost of liver-related hospitalizations and transplants in Canada from April 1, 2004, to March 31, 2020. The aggregate-level data from the Discharge Abstract Database (DAD), which records all inpatient hospital admissions across Canada, were obtained from the Canadian Institute for Health Information (CIHI) using ICD-10 diagnostic codes for liver-associated hospitalizations (Supplemental Table 1). The diagnosis codes were not specifically limited to liver-associated admissions, but it was possible for liver disease to occur during the hospitalizations as well.
We reported the annual costs of hospitalization nationally and for each province in Canada. We calculated the total and the average spending for liver hospitalizations nationally from 2004 to 2020 based on fiscal year (FY). Each fiscal year starts from April of the previous year to March of next year. Further, the average cost per hospitalization was compared for the year FY2004 and FY2019 nationally and for each province. Costs are reported as nominal annual costs; however, for a sensitivity analysis, we inflated the annual costs before 2020–2021 values using the all-items consumer price indexes (7). Liver hospitalization cost data were unavailable for Quebec and excluded from the study. Also, data for the Atlantic provinces and territories were reported collectively due to small sample sizes. A secondary analysis was performed on liver transplants, excluding Saskatchewan, Manitoba, Quebec, and the territories due to no available data.
The average cost of liver hospitalization and transplants were stratified by age (ie, age <30, age 30–49, age 50–64, age ≥65) and sex (ie, male and female) annually by fiscal year. We used ICD-10 diagnostic codes for liver-associated transplantations (Supplemental Table 2).
Results
Liver hospitalizations
Nationally, spending on hospitalization increased by 145% between FY2004 and FY2019 ($387 million to $947 million) (Figure 1 and Table 1; values accounting for inflation can be found in Supplemental Figure 1). The average national cost was $11,428 per hospitalization in FY2004 and reached a peak of $17,506 per hospitalization by FY2019. By FY2019, the age group <30 had the highest average cost per hospitalization at $21,776, whereas the age group 30–49 had the lowest average cost at $16,250. Spending between the two sex groups did not differ. Provincially, Alberta had the highest average cost per hospitalization in FY2004 and FY2019 at $13,756 and $23,150, respectively (Figure 2; values accounting for inflation can be found in Supplemental Figure 2). Conversely, the territories had the lowest average cost per hospitalization in FY2004 at $6,346, whereas Ontario had the lowest average cost per hospitalization in FY2019 at $15,712.
| Sex | Age, y | ||||||
|---|---|---|---|---|---|---|---|
| Average cost ($) | Male | Female | <30 | 30–49 | 50–64 | 65+ | |
| National | 17,507 | 17,356 | 17,713 | 21,776 | 16,250 | 17,388 | 17,639 |
| British Columbia | 18,819 | 16,985 | 17,447 | 23,647 | 15,708 | 16,555 | 17,867 |
| Alberta | 23,151 | 23,655 | 22,479 | 32,695 | 21,235 | 23,306 | 22,502 |
| Saskatchewan | 16,778 | 16,909 | 16,641 | 12,245 | 17,830 | 16,648 | 16,991 |
| Manitoba | 20,648 | 19,810 | 21,567 | 21,203 | 16,855 | 19,711 | 23,218 |
| Ontario | 15,713 | 15,560 | 15,931 | 19,148 | 14,576 | 15,364 | 16,012 |
| Atlantic Provinces | 17,822 | 17,031 | 18,931 | 19,516 | 14,399 | 18,445 | 18,295 |
| Territories | 16,059 | 17,545 | 14,189 | 10,533 | 12,133 | 17,503 | 19,997 |
Figure 2: Average cost for liver-related hospitalizations by province and territories, 2004/2005 versus 2019/2020 (non-inflation adjusted)
BC = British Columbia; AB = Alberta; SK = Saskatchewan; MB = Manitoba; ON = Ontario; AP = Atlantic Provinces (New Brunswick, Nova Scotia, Prince Edward Island); TE = Territories (Northwest Territories, Yukon, Nunavut)
Note: Quebec did not report spending data
Liver transplants
Across Canada, spending on liver transplants increased by 108% between FY2004 and FY2019 ($19.1 million to $39.7 million). The average national cost for each liver transplant was $66,305 in FY2004 and reached a peak of $107,536 in FY2013. In FY2019, the age group <30 had the highest average liver transplant cost at $149,737, whereas the other three groups had comparable costs ranging from $74,914 to $77,904. Further, in FY2019, females generally had a higher average liver transplant cost of $100,139, and males averaged $78,274. Between British Columbia, Alberta, and Ontario, the liver transplant spending in FY2004 was $220,425, $116,993, and $58,806, respectively. By FY2019, the average liver transplant cost decreased in British Columbia to $170,641 and increased in Alberta and Ontario to $143,237 and $71,779, respectively.
Discussion
By the end of the 16-year study period, the national cost of liver-related hospitalizations was close to $1 billion a year by FY2019, which represents 1.2% of the national hospital expenditure and is on the rise (3). Notably, the average national cost of liver hospitalization in 2019 ($17,506) was double the amount of the current health care spending per capita in Canada ($7,932). However, this varied across provinces and territories (3). These results further highlight the importance of improving care for those living with liver diseases and developing interventions to help prevent future hospitalization.
All provinces showed a significant increase in hospitalization costs over the study period, with variation among provinces. Specifically, Alberta’s spending on liver hospitalizations was 1.5 times higher than Ontario’s in FY2019. These variations could be related to differences in health care resources in each province (eg, better screening and follow-ups), the stage of diagnosis and disease severity of patients who enter the hospital, or the age of the population (5). These results prompt further investigation into the variation among provinces for the potential of shared learnings.
The results offer important insights into the current trajectory of the cost of liver-related hospitalization and transplants but also can be used to establish current benchmarks of costs in the care of those living with liver diseases. Specifically, these hospitalization and transplant costs can be used for future economic evaluations and cost-effectiveness analysis models to generate economic evidence for emerging interventions, as well as planning future budgets. For example, if a new treatment becomes available in the future, predictive economic models can be based on the spending information from this study. Thus, after the treatment is released into the market, it can support health policymakers in making informed decisions as to whether an intervention is cost-saving or not.
Our results have some important limitations worth noting. First, the current study does not include spending information from Quebec. In addition, Nunavut’s spending data were not available and were estimated based on Northwest Territories and Yukon. Secondly, results were not adjusted for variation in population between provinces, although we stratified spending on liver hospitalizations and transplants by age and sex. Lastly, due to the nature of CIHI data, we are unable to further stratify hospitalization costs associated with specific liver diseases such as hepatitis B virus, hepatitis C virus, or non-alcoholic fatty liver disease.
Conclusion
Overall, our results highlight that the cost of liver hospitalization and transplant are high and continue to grow across Canada. Variation in spending exists among provinces in Canada, which needs to be further examined. These findings provide insights for future budgeting and policymaking in the health system.
Supplemental Material
canlivj-2022-0033_supplement1.pdf
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Registry and Registration No. of the Study/Trial:
N/A
Funding:
This study was funded by the Canadian Institutes of Health Research (CIHR). JR Guertin holds a Research Scholar award from the Fonds de recherche du Québec-Santé (FRQS).
Peer Review:
This manuscript has been peer reviewed.
Animal Studies:
N/A.
References
1.
Asrani SK, Devarbhavi H, Eaton J, Kamath PS. Burden of liver diseases in the world. J Hepatol. 2019;70(1):151–71.
2.
Binka M, Janjua NZ, Grebely J, et al. Assessment of treatment strategies to achieve hepatitis C elimination in Canada using a validated model. JAMA Network Open. 2020;3(5):e204192. Medline:
3.
Canadian Institute for Health Information. Health Expenditure Data in Brief; 2021. https://www.cihi.ca/sites/default/files/document/health-expenditure-data-in-brief-en.pdf (Accessed: June 1, 2022).
4.
Canadian Liver Foundation. Liver disease in Canada: a crisis in the making; 2013. https://www.liver.ca/wp-content/uploads/2017/09/Liver-Disease-in-Canada-E-3.pdf (Accessed: June 15, 2022).
5.
Hirode G, Saab S, Wong RJ. Trends in the burden of chronic liver disease among hospitalized US adults. JAMA Network Open. 2020;3(4):e201997. Medline:
6.
Roberts SB, Hansen BE, Shin S, et al. Internal medicine hospitalisations and liver disease: A comparative disease burden analysis of a multicentre cohort. Aliment Pharmacol Ther. 2021;54(5):689–98. Medline:
7.
Statistics Canada. Consumer Price Index, annual average, not seasonally adjusted [Internet]; 2022. https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1810000501. (Accessed: November 10, 2022).
Information & Authors
Information
Published In
Canadian Liver Journal
Volume 6 • Number 4 • December 2023
Pages: 407 - 411
Copyright
© Canadian Association for the Study of the Liver, 2023. This article is free to read to all interested readers, immediately upon publication. For their own personal use, users may read, download, print, search, or link to the full text. Manuscripts published in the Canadian Liver Journal are copyrighted to the Canadian Association for the Study of the Liver. Requests for permission to reproduce this article should be made to the University of Toronto Press using the Permission Request Form: https://canlivj.utpjournals.press/policies#_copyright or by email: [email protected].
History
Received: 21 November 2022
Accepted: 26 November 2022
Published ahead of print: 13 July 2023
Published online: 20 December 2023
Published in print: December 2023
Keywords:
Authors
Contributions:
Conceptualization, K Zhao, A Shakeri, P Graili, JR Guertin, W Wong, M Tadrous; Data Curation, M Tadrous; Funding Acquisition, M Tadrous; Investigation, K Zhao, A Shakeri, P Graili, JR Guertin, W Wong, M Tadrous; Methodology, K Zhao, A Shakeri, M Tadrous; Writing - Original Draft, K Zhao, A Shakeri, P Graili, JR Guertin, W Wong, M Tadrous; Writing - Review & Editing, K Zhao, A Shakeri, P Graili, JR Guertin, W Wong, M Tadrous.
Disclosures:
The authors have nothing to disclose.
Funding Information
Canadian Institutes of Health Research (CIHR)
Fonds de recherche du Québec-Santé (FRQS)
Funding: This study was funded by the Canadian Institutes of Health Research (CIHR). JR Guertin holds a Research Scholar award from the Fonds de recherche du Québec-Santé (FRQS).
Ethics Approval:
N/A
Informed Consent:
N/A
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Canadian Liver Journal 2023 6:4, 407-411
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