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Costs of Hepatitis C
J. Paul Leigh, PhD;
Christopher L. Bowlus, MD;
Bruce N. Leistikow, MD, MS;
Marc Schenker, MD, MPH
Arch Intern Med. 2001;161:2231-2237.
ABSTRACT
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Objective To estimate the direct and indirect costs of the hepatitis C virus (HCV)
in the United States in 1997.
Design Aggregation and analysis of national data sets collected by the National
Center for Health Statistics, the Health Care Financing Administration, and
other government bureaus and private firms. To estimate costs, we used the
human capital method, which decomposes costs into direct categories, such
as medical expenses, and indirect categories, such as lost earnings and lost
home production. We consider HCV that results in chronic liver disease separate
from HCV that results in primary liver cancer.
Results We estimate $5.46 billion as the cost of HCV in 1997. Costs are split
as follows: 33% for direct and 67% for indirect costs. Hepatitis C virus that
results in chronic liver disease contributes roughly 92% of the costs, and
HCV that results in primary liver cancer contributes the remaining 8%. The
total estimate of $5.46 billion is conservative, because we ignore costs associated
with pain and suffering and the value of care rendered by family members.
Conclusions To our knowledge, only one estimate of the annual costs of HCV in the
1990s has appeared in the literature, $0.6 billion. However, that estimate
was not supported by an explanation of the methods. Our estimate, which relies
on detailed methods, is nearly 10 times the original estimate. Our estimate
of $5.46 billion is on a par with the cost of asthma ($5.8 billion [1994]).
INTRODUCTION
THE HEPATITIS C virus (HCV) was identified in 1988 and has received
increasing attention from physicians and researchers ever since. Because HCV
has only been recently identified, national statistics are difficult to obtain.
Initial estimates suggested that the annual mortality due to chronic liver
disease (CLD) from HCV was between 8000 and 10 000.1
Recent work2 has assumed 8000 to be the more
reasonable estimate. An initial estimate of the prevalence of HCV based on
the anti-HCV antibody was 3.9 million persons.3
However, more recently, Alter et al4 estimate
the prevalence of active HCV infection at 2.7 million persons. Whereas the
incidence of the disease has been decreasing, the overall prevalence is large,
roughly 4 times as large as that of the human immunodeficiency virus.5 Sixty-five percent of persons with an HCV infection
are aged 30 to 49 years. The highest rates of new infections are among persons
aged 20 to 39 years.6 It is the single most
common reason for liver transplantations in the United States.5
Risk factors include sharing of contaminated needles by drug users, multiple
sex partners, employment as a health care worker, receipt of a blood transfusion
any time before 1988, and, more generally, poverty, low educational attainment,
and having been divorced or separated.4
Several studies7-10
have investigated the cost-effectiveness and cost-benefits of various therapies
for hepatitis C. A MEDLINE search from January 1, 1988, through September
30, 1999, did not uncover a single published cost-of-illness study in the
United States for which the main purpose was to estimate the cost of this
disease. A study by Wong et al2 in October
2000 estimated the future mortality, morbidity, and costs for the years 2010
to 2019. But, as we will show, the strengths of the Wong et al study are in
forecasting mortality and morbidity, not cost. In any case, they do not provide
an estimate of current costs. A Centers for Disease Control and Prevention
fact sheet3 indicates a cost of $600 million
in 1991 dollars, excluding transplantation. But the method underlying that
estimate does not appear on the fact sheet. It is unfortunate that a reliable
defensible estimate of the cur rent cost apparently does not exist. Costs
have become a critical variable in the debate on medical care.
Our purpose in this study is to generate estimates of costs that incorporate
the best methods from prior studies. We use standard methods with some simple
improvements, eg, we adjust for the high per-day hospital costs for HCV. As
a result, our estimates may be compared with estimates for other diseases.
MATERIALS AND METHODS
In this section, we address the unique features of this disease, indicate
how we count cases, and describe how we estimate costs.
GENERAL DESCRIPTION
Brief descriptions of HCV and treatments are available.5, 7-8
Roughly 15% to 45% of persons with HCV spontaneously eliminate the virus.8 Most of the remaining 55% to 85% develop chronic hepatitis
but show no symptoms until the development of end-stage liver disease. The
natural history of chronic HCV infection is variable and remains controversial.
Estimates of the progression of HCV to cirrhosis range from 2% to more than
50%.8 Roughly 1% to 5% of persons will develop
primary liver cancer (PLC).
Treatment for 6 or 12 months with interferon alfa-2b and ribavirin is
recommended for persons with HCV. It is expensive ($5000 per year) and can
produce adverse effects such as flulike symptoms and fatigue.
Within any year, roughly 3.1% of persons with cirrhosis (whether they
have HCV or not) will receive a liver transplant.7
Liver transplantation costs more than $200 000, and the subsequent yearly
care is also quite expensive.9 Approximately
4000 people (most without HCV) receive a liver transplant every year.10
EPIDEMIOLOGICAL FEATURES
We used the prevalence of HCV and CLD to estimate deaths and costs associated
with HCV. Prevalence may overstate disease burden given that there is a downward
trend in incidence. But for patients with HCV, there is an upward trend in
morbidity and mortality.2 An alternative method—using
incidence—creates greater problems. Using incidence would necessitate
forecasting the future course of disease, treatment, and cost. Most cost-of-illness
studies11-14
have preferred the prevalence method precisely because it allows analysis
of reliable data that are available and requires fewer forecasting assumptions
than the incidence method.
Mortality due to HCV has been estimated at 8000 to 10 000 deaths
per year.3 This range is regarded as a little
high, so that recent analyses2 have used 8000
as the preferred point estimate. We, too, will use 8000 as our preferred point
estimate and allow a lower bound of 7000 and an upper bound of 10 000.
Estimates of the contribution of HCV to hepatocellular carcinoma (HCC)
differ considerably between populations. Between 11% and 52.5% of patients
in the United States with HCC are anti-HCV seropositive.15
Case-control studies suggest that 11% to 20% of HCC cases in the United States
can be attributed to HCV. Based on these studies,15
we estimate that 30% of HCC-related deaths are due to HCV.
Primary liver cancer included HCC and other cancers, such as hepatoblastomas
and cholangiocarcinomas. For those younger than 20 years, HCC accounts for
only 33% of PLCs, whereas in adults, 90% of PLCs are due to HCC.16
ECONOMICS
Costs are estimated using the human capital cost-of-illness method,
whereby 2 broad categories are constructed: direct and indirect costs. Within
the direct category, there are medical expenses and administrative expenses.
Medical costs include payments to hospitals, physicians, drug companies, nursing
homes, and vendors of medical supplies. Insurance administration includes
the cost of processing claims, prosecuting fraud, managing financial accounts,
paying bills, advertising, sales commissions, rate credits, dividends, and
profits or losses. The administrative expenses are in turn split into administration
for medical and administration for indemnity (disability) insurance.
Indirect costs include lost wages, lost fringe benefits, and lost home
production. Lost wages are meant to capture not just the hardship on the person
and family without the wages but the cost to the economy in terms of lost
output. Lost fringe benefits are included for the same reason. The total economic
loss is assumed to be what is required for the business to attract a qualified
person to the job. This would include wages and fringe benefits. Home production
includes time costs of child care, making home repairs, preparing meals, and
so on.
General discussions of advantages and disadvantages of the human capital
cost-of-illness method are available.17-20
We will omit that discussion herein and simply note that despite its weaknesses,
the human capital cost-of-illness method is the most popular method for estimating
the costs of any illness or injury.
Direct Costs
Our "top-down" approach to estimating direct costs is similar to those
of Rice11 and Leigh13
and colleagues. Estimates rely on a ratio involving hospital days multiplied
by national estimates of medical spending (see upcoming equation). This hospital
day ratio acts as an anchor in the estimation of all direct costs. Hospitalization
data are highly regarded, are collected annually, and are standardized within
the same definition (days in the hospital), thus permitting comparisons across
diseases. Similar data are not available for drug use or most other categories
of spending, such as medical durable products (eg, wheelchairs). Moreover,
hospitalizations are the most expensive (broad) category of medical care,
contributing to 40% of medical costs.21 Physicians'
services are second at 22%.21 Other cost studies11, 13 assume that spending on all other
direct costs is proportional to days in the hospital. This assumption is controversial
for hepatitis C. Interferon, ribavirin, and especially liver transplantations
are expensive. We will adjust for this expense as indicated with our inpatient
and outpatient categories. Our adjustments represent an improvement over prior
cost studies.11-14
Our top-down approach begins with an estimate of national expenditures
on medical care—$1035 billion ($1.035 trillion) or 13.6% of the gross
domestic product in 1996.21 This year (1996)
was the latest year available with critical information on out-of-pocket expenses,
insurance administration, and dental services. We update these figures with
a medical care inflation factor. This $1.035 trillion is equivalent to spending
$3633 per person. Medicare and Medicaid (including Medi-Cal) contributed 20.0%
and 14.7%, respectively; other third-party government spending contributed
11.4%; and direct out-of-pocket expenditures contributed 17.6%. The remainder,
36.3%, was contributed by private health insurance and health maintenance
organizations. This $1035 billion ($1.035 trillion) in health care expenditures
included payments for hospitalizations, physician visits, nursing home care,
drugs, medical supplies, and dental services, among others. Also included
are public health care expenditures, such as the construction of hospitals
and offices, government public health activities, and research, and some estimate
of program administration and net cost of health insurance. We include public
health care expenditures on the grounds that without hepatitis C, some portion
of these public expenditures would not be necessary. We did not include the
Levit et al21 estimate of the last category—"program
administration and net cost of public health insurance"—in our calculations,
however. We believe the Levit et al estimate to be too low. The Levit et al
estimate is $60.9 billion. This would be the equivalent of roughly 6.3% of
expenditures [$60.9/($1035 - $60.9) = 0.0625]. Studies22-24
have shown that administrative costs can add an additional 45% to the total
cost of medical care. Danzon23 has been especially
critical of the low estimates for Medicare and Medicaid. For example, she
argues that private insurers allow fewer fraudulent claims than government
insurers. Ferreting out fraudulent claims requires administrative resources,
however. The overall result, in her view, is that the private sector provides
more medical care to patients who need it and less to those committing fraud
when compared with government-provided care. Another example pertains to buffer
funds that private insurance companies require. These are captured in premiums.
For any given year, however, they may or may not be paid out as benefits.
These buffer funds are sometimes viewed as wasteful administration. They are
not. Governments do not require buffer funds since they can rely on raising
taxes. The increase in taxes to shore up the Medicare Hospital Insurance trust
fund was a case in point.23 For both of these
reasons and others,22-24
the "true" administrative costs of Medicare and Medicaid are higher than the
costs that Levit et al suggest. The estimate of Cutler24
of 15% appears to be the most reliable and has been used in previous analyses.13, 25 As a result, we will exclude the
$60.9 billion (6.3%) but include a 15% administrative expense to our calculations.
We also exclude dental services ($47.6 billion), reasoning that HCV
should not influence dental costs. We, therefore, use the following formula
to begin our calculations: [($1035.1 - $60.9) - $47.6] = $926.6
billion.
Our analysis is divided into 2 parts: one for CLD and another for PLC.
In the description of methods that follows, we will use CLD as the example.
The same methods are applied to PLC.
Using the National Hospital Discharge Survey,26
we first calculate the total number of days spent in the hospital by the number
of patients with a principal diagnosis of CLD and cirrhosis (International Classification of Diseases, Ninth Revision code 571).
We use the code for liver disease rather than the code for hepatitis C (International Classification of Diseases, Ninth Revision
code 70), because the latter code is underrecorded on hospital records.4 But we do not use the 1997 hospital days for liver
disease "as is" (600 000). We only use 31.78% of 600 000, or 190 680.
This 0.3178 is the ratio of hepatitis C–related deaths (n = 8000) (Alter1 suggested 8000-10 000, and we selected 8000)
to liver disease–related deaths (n = 25 175). These total days
of hospitalization for hepatitis C, 190 680, we attribute to hospital
days resulting from hepatitis C. This 190 680 is then divided by total
hospital days for all diseases and injuries in the United States in 1997 (190 668/157 458 000
= 0.0012109) (additional data available from the authors). This percentage
(0.12109%) is then multiplied by $971 billion (1997 dollars), which equals
$1.1758 billion. Finally, we account for disease-specific inpatient and outpatient
adjustments. The procedure is displayed in the following equation:
Med$CLD = $971 x [(0.3178 x CLDDays)/TotalDays] + Inpatient
Adjustment + Outpatient Adjustment,
where Med$CLD is our estimate of the medical
dollars spent for hepatitis C due to CLD; CLDDays,
the number of days in the hospital attributed to CLD; and TotalDays, the number of days in the hospital attributed to all diseases
and injuries in the United States.
The hospital days ratio in the equation assumes that all hospital days
have equal costs, regardless of the disease (ie, circulatory disease, cancer,
hepatitis C, or asthma). It also assumes that all nonhospital (outpatient)
costs are proportional to hospital days. Since this simple method has been
so widely used in the past,11, 13
we will apply it to data on hepatitis C. However, we will make adjustments
to reflect the higher costs that are unique to medical care for hepatitis
C. The inpatient and outpatient adjustments are unique to this study and,
we believe, an improvement over prior methods.
The Agency for Health Care Policy and Research27
maintains cost data per disease per hospital day on a Web site and in its
Research Note Series. We calculate that, on average, a hospital day for hepatitis
C resulting in CLD costs 111.91% of the typical hospital day for all diseases
and injuries. That is, hepatitis C resulting in CLD is roughly 12% more expensive
than average. We multiply the 0.1191 by the percentage of total US medical
costs attributed to hospitalizations and nursing home care (less program administration
and dental care, 0.47). The product (0.1191 x 0.47), is then multiplied
by the following: $971 x [(0.3178 x CLDDays)/TotalDays] (ie, the first half of the equation).
We refer to this procedure as the inpatient care adjustment (additional data
available from the authors).
An outpatient adjustment using physician visits was problematic. Reliable
physician visit data are not available on hepatitis C, CLD, or PLC from the
authoritative Ambulatory Care Visits series of the National Center for Health
Statistics.28 We, therefore, assume that all
spending other than that on hospital and nursing home care would be proportional
to the ratio of hospital days for hepatitis C to all hospital days, and to
the higher per-day cost of hepatitis C hospitalizations. In our preferred
point estimate, we essentially assume that physician visits are proportionately
as expensive as hospital costs for hepatitis C resulting in CLD (additional
data available from the authors). In the sensitivity analysis, we allow an
alternative assumption that outpatient costs are 20% rather than 12% more
than medical costs associated with hospitalizations for CLD (additional data
available from the authors).
The equation estimates do not account for the administrative costs,
however. To obtain administrative costs, we subtract out-of-pocket expenses
from national estimates and then apply our 15% administrative estimate (additional
data available from the authors).
Indirect Costs
Indirect mortality costs capture wages, fringe benefits, and home production
for years of life lost due to early death. Indirect morbidity costs capture
the same 3 categories for persons who have not died. Indirect mortality costs
are estimated using a standard present value equation (data available from
the authors). The present value equation uses age-, sex-, and disease-specific
mortality data from the National Center for Health Statistics, Vital Statistics
Division, and life table estimates,29-31
combined with earnings and labor force participation data from the US Bureau
of Labor Statistics' Employment and Earnings32 (additional data available from the authors).
Finally, we calculate national disease-specific ratios for morbidity
costs to mortality costs from Rice et al.11
For CLD, we use the digestive disease estimates. For PLC, we use all cancer
estimates (additional data available from the authors). In our sensitivity
analysis, we use a morbidity to mortality cost ratio from an acquired immunodeficiency
syndrome cost study during the 1980s.14
RESULTS
EPIDEMIOLOGICAL FEATURES
Table 1 presents the results
for CLDs (including cirrhosis) and PLC. Our estimates of deaths by age and
sex appear in the first 3 columns of Table
1 for HCV resulting in CLD. We estimate 5168 male deaths and 2832
female deaths, for a total of 8000. For HCV resulting in PLC, we estimate
1002 male deaths and 444 female deaths, for a total of 1446. The total for
both sexes and diseases is 9446.
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Table 1. Total HCV-Related Deaths in 1997 Due to CLD and PLC*
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COSTS
We calculated the direct costs of hepatitis C due to CLD and the indirect
mortality costs due to CLD. We also calculated the indirect morbidity and
mortality costs for PLC (data available from the authors). Table 2 combines the more important estimates from these calculations.
Table 2 presents the total
of direct plus indirect costs. We estimate total costs at $5.46 billion. Roughly
33% of that ($1.80 billion) is for direct costs and roughly 67% ($3.66 billion)
is for indirect costs. Within CLD, direct costs are $1.66 billion (33%) and
indirect costs are $3.37 billion (67%), for a total of $5.03 billion. Within
PLC, direct costs are $0.14 billion (32%) and indirect costs are $0.29 billion
(68%), for a total of $0.43 billion. Chronic liver disease contributes 92%
and PLC contributes 8% to the total.
Table 3 presents our sensitivity
analysis. Several key assumptions are addressed. The first assumption pertains
to the CLD-related death range of 8000 to 10 000, suggested by Alter.1 We selected 8000 as our preferred amount and assumed
a lower range of 7000. However, if 7000 applies, our total cost estimate,
combining CLD and PLC, would fall to $4.8 billion. This represents a decrease
of 12% from our preferred $5.46 billion. If, on the other hand, 10 000
rather than 8000 applies, our total cost estimate would increase to $6.7 billion,
some 23% above $5.46 billion. These results appear in the first 2 rows of Table 3.
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Table 3. Sensitivity Analysis*
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The second assumption pertains to the percentage of PLCs caused by HCV.
Our preferred percentage is 30%, suggested by DiBisceglie15
and roughly midway between 11.0% and 52.5%. Suppose instead we choose 11.0%.
Our estimated total costs, combining CLD with PLC, would be $5.19 billion.
This represents roughly a 5% decrease from our preferred amount of $5.46 billion.
A 52.5% assumption would yield an estimate of $5.78 billion, roughly 6% above
our preferred estimate. These results are in rows 3 and 4 of Table 3.
Another assumption is that the average earnings of US workers are applied
to calculate lost earnings for people with HCV or for those who died of HCV.
Hepatitis C disproportionately affects people of low socioeconomic status.
Although ethical concerns can be raised if we place a low value ($0) on the
years of life lost for some people based on the circumstances of their lives,33 suppose we allow indirect costs to be reduced by
10%. Our new estimate for total costs, combining CLD with PLC, is $5.09 billion,
which represents a decrease of roughly 7% from our preferred estimate (row
5 of Table 3).
Row 6 of Table 3 allows
for an outpatient adjustment ($0.0504 billion) based on ambulatory care visits.
Row 6 assumes outpatient costs are 20% more than the ratio of hospital days
for HCV to hospital days for all other diseases and conditions. Row 7 of Table 3 allows for morbidity to be calculated
based on acquired immunodeficiency syndrome costs during the 1980s. This acquired
immunodeficiency syndrome adjustment generates the largest effect: a 16% decrease
below the preferred estimate.
If all of the cost-reducing assumptions are applied, then our estimate
would be $3.35 billion. This represents a 39% decline from the preferred estimate.
All of the cost-increasing assumptions suggest an upper bound of $7.08 billion.
Our range is, therefore, $3.35 billion to $7.08 billion, with $5.46 billion
being the best point estimate. We believe it is extremely unlikely that HCV
costs less than $3.35 billion.
COMMENT
OTHER STUDIES
Since its identification in 1988, HCV has attracted increasing attention
from physicians, researchers, and the public. Yet a literature search through
September 30, 2000, did not uncover a single study with the primary aim of
estimating the national cost of HCV. The only estimate that was cited ($600
million in 1991) appears on a Centers for Disease Control and Prevention fact
sheet on hepatitis C without any citation or discussion.3
Our preferred estimate of $5.46 billion is more than 9 times this $0.6 billion
estimate.
In October 2000, Wong et al2 published
a study on the future burden (years 2010-2019) of HCV. We believe our methods
provide a more accurate estimate of the total costs of HCV. Wong et al focus
attention on mortality, morbidity, and treatment costs, not total costs. Our
cost methods rely on national estimates for bed days, physician visits, and
total dollars spent. Their methods rely on estimates from a single university
hospital. In addition, they use marginal costs, whereas we use average costs.
Marginal costs ignore fixed (equipment) costs. But fixed costs can be significant,
especially for liver transplantation. Cost-of-illness studies11, 13-14
that measure the overall burden of disease use average and total costs, not
marginal costs. Marginal costs are appropriate for cost-effectiveness studies,
and these are precisely the studies that Wong et al rely on to generate their
cost estimates. Wong et al do not mention the costs of administration. They
do mention that they explicitly ignored "overhead." This is critical. With
the rise of managed care, these costs have become increasingly important.
Also, they do not properly account for fringe benefits or home production.
Despite these criticisms, we believe that the Wong et al study is valuable,
especially in forecasting morbidity and mortality.
Our $5.46 billion estimate is significant. It is comparable to the national
costs of asthma, $5.8 billion in 1994,12 and
rheumatoid arthritis,34 $7.1 billion in 1994
(assuming that rheumatoid arthritis contributes 11% to the total cost of arthritis).
Although not of the same magnitude, the hepatitis C estimate can be compared
with the cost of the human immunodeficiency virus ($30 billion in 199235), epilepsy ($11.1 billion in 199536),
chronic obstructive pulmonary disease ($23.9 billion in 199337),
and cancer ($107 billion in 199438). Perhaps
more significant, none of these diseases are forecasted to increase their
burden as rapidly as hepatitis C. The Centers for Disease Control and Prevention
predicts that HCV-related mortality might double or triple within the next
10 to 20 years.3
LIMITATIONS
There are several limitations to our study. First, disease-related deaths
and hospital days were counted as occurring in 1997. However, the exposures
leading to the deaths and hospitalizations could have occurred 20 or 30 years
before the death or hospitalization. But the same argument applies to all
other cost-of-illness studies, even those that use the incidence method. Thus,
our estimates are still comparable to others.
Second, we did not adjust for current employment status in the present
value of earnings tables. We merely adjusted for the labor force participation
rate. In doing so, we undervalued the earnings of those employed. That is,
those employed are not a random sample of all persons in the labor market.
Those employed probably had better lifetime employment prospects than all
persons in the labor force. All persons in the labor force included those
persons unemployed. This limitation suggests that we underestimated costs.
Third, we ignored pain and suffering costs and quality-of-life issues.
It is difficult to estimate costs for these, however. Lawsuits involving nonfatal
injuries almost always involve some payment for pain and suffering. A rule
of thumb frequently cited in the courts is that pain and suffering costs equal
3 to 4 times the medical expenses and lost wages.39
This would mean adding another roughly $15 to $20 billion to our costs.
We did not include the costs of family caregivers' time or the costs
of health problems that occur among caregivers. These costs are undoubtedly
large but are difficult to estimate. McFloyd and Flanagan40
document the deleterious psychological consequences on spouses who provide
care. One highly regarded study41 estimated
family (so-called informal) caregiving to be equal to 20% of direct costs.
A 20% figure would add an additional $0.45 billion to our combined estimate.
We indirectly adjusted for the high cost of liver transplantations,
interferon, and ribavirin, with inpatient and outpatient adjustment factors
based on the increased cost of hospitalization for CLD and PLC. We believe
that outpatient costs may have been underestimated given the high drug costs.
In addition, we assume that outpatient costs are proportional to mortality.
This is also likely to be an underestimate as outpatient costs are also related
to the identification and treatment of HCV-infected asymptomatic individuals.
An alternative calculation (in the sensitivity analysis, row 6 of Table 3) added another $0.05 billion, assuming
all outpatient costs are 20% higher for patients with HCV than for all others.
We also excluded indirect costs involving costs to employers for hiring
and training new workers to replace those who die or experience long absences.
Despite the limitations, there are merits to our approach. Apart from
a few improvements, we use a standard cost-of-illness method. This allows
comparisons to other disease and injuries. Some methods we introduce improve
on prior cost-of-illness estimates. First, we exclude dental services in our
macro top-down calculations. Second, we make adjustments for average costs
for inpatient and outpatient care for HCV. Last, we do not rely on National
Center for Health Statistics' estimates for "program administration," ie,
administration costs. These have been sharply criticized by economists.22-24 Moreover, the National
Center for Health Statistics' estimates ignore insurance administration for
indemnity (disability) benefits.
In conclusion, our study estimates the national cost of HCV to have
been $5.46 billion in 1997. Because the incidence of this disease is decreasing,
because more people with HCV are expected to experience symptoms in the next
10 to 20 years, and because medical care for HCV is rapidly improving, these
cost figures will need to be reassessed in the future.
AUTHOR INFORMATION
Accepted for publication February 22, 2001.
This study was supported by grant R01 OH04006-01 from the National Institute
for Occupational Safety and Health, Atlanta, Ga.
We thank Roxanne Leary, BS, and Penny Walgenbach, BA, for providing
programming assistance.
Corresponding author: J. Paul Leigh, PhD, Center for Health Services
Research in Primary Care, Patient Services and Support Building, Suite 2500,
University of California at Davis Medical Center, Sacramento, CA 95817 (e-mail: jpleigh{at}epm.ucdavis.edu).
From the Center for Health Services Research in Primary Care (Dr Leigh)
and the Department of Internal Medicine (Dr Bowlus), University of California
at Davis Medical Center, Sacramento, Calif; and the Department of Epidemiology
and Preventive Medicine, School of Medicine, University of California at Davis
(Drs Leigh, Leistikow, and Schenker).
REFERENCES
| |
1. Alter MJ. Epidemiology of hepatitis C. Hepatology. 1997;26(suppl 1):62S-65S.
2. Wong JB, McQuillan GM, McHutchison JG, Poynard T. Estimating future hepatitis C morbidity, mortality, and costs in the
US. Am J Public Health. 2000;90:1562-1569.
FREE FULL TEXT
3. Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV)
infection and HCV-related chronic disease. MMWR Morb Mortal Wkly Rep. 1998;47(RR-19):1-39.
4. Alter MJ, Kruszon-Moran D, Nainan DV, et al. The prevalence of hepatitis C virus infection in the United States,
1988 through 1994. N Engl J Med. 1999;341:556-562.
FREE FULL TEXT
5. Rosenberg S, Tarre H. Tracking and treating Hep C infection. Bus Health. 1999;17:41-42.
PUBMED
6. National Institute on Drug Abuse. Hepatitis C: Community Drug Alert Bulletin. Bethesda, Md: US Dept of Health and Human Services, National Institutes
of Health; 2000.
7. Wong JB. Cost-effectiveness of treatments for chronic hepatitis C. Am J Med. 1999;107(suppl 6B):74S-78S.
8. Seeff LB. Natural history of hepatitis C. Am J Med. 1999;107(suppl 6B):10S-15S.
9. Showstack J, Katz PP, Lake JR, et al. Resource utilization in liver transplantation: effect of patient characteristics
and clinical practice. JAMA. 1999;281:1381-1386.
FREE FULL TEXT
10. Russell PS. Understanding resource use in liver transplantation. JAMA. 1999;281:1431-1432.
FREE FULL TEXT
11. Rice DP, Hodgson TA, Kopstein AN. The economic costs of illness: a replication and update. Health Care Financ Rev. 1985;7:61-80.
PUBMED
12. Smith DH, Malone DL, Lawsen KA, Okamoto LJ, Buttista C, Saunders WB. A national estimate of the economic costs of asthma. Am J Respir Crit Care Med. 1997;156:787-793.
FREE FULL TEXT
13. Leigh JP, Markowitz SB, Fahs MC, Shin SG, Landrigan PJ. Occupational injury and illnesses in the US: estimates of costs, mortality
and morbidity. Arch Intern Med. 1997;157:1557-1568.
ABSTRACT
14. Scitovsky AA, Rice DP. Estimates of the direct and indirect costs of acquired immunodeficiency
syndrome in the United States, 1985, 1987, and 1991. Public Health Rep. 1987;102:5-17.
ISI
| PUBMED
15. DiBisceglie AM. Hepatitis C and hepatocellular carcinoma. Hepatology. 1997;3(suppl 1):34S-38S.
16. Kaczynski J, Hannson G, Wallerstedt S. Incidence of primary liver cancer and aetiological aspects: a study
of a defined population from a low-endemicity area. Br J Cancer. 1996;73:128-132.
PUBMED
17. Rice DP, MacKenzie EJ, Miller TR, et al. Cost of Injury in the United States: A Report to
Congress. San Francisco: Institute for Health and Aging, University of California,
and Injury Prevention Center, Baltimore, Md: The John Hopkins University;
1989.
18. Kenkel DS. Cost-of-illness approach. In: Tolley G, Kenkel DS, Fabian R, eds. Valuing
Health for Policy: An Economic Approach. Chicago, Ill: Chicago University
Press; 1994.
19. Cook PJ, Ludwig L. Gun Violence: The Real Costs. New York, NY: Oxford University Press Inc; 2000.
20. Harwood HJ. The Economic Costs of Alcohol and Drug Abuse in the
United States, 1992. Bethesda, Md: US Dept of Health and Human Services, National Institutes
of Health, National Institute on Drug Abuse, Office of Science Policy and
Communications, National Institute on Alcohol Abuse and Alcoholism, Office
of Policy Analysis; 1998. NIH publication 98-4327.
21. Levit KR, Lazenby HC, Braden BR, et al. National health expenditures, 1996. Health Care Financ Rev. 1997;19:161-200.
ISI
| PUBMED
22. Thorpe KE. Inside the black box of administrative costs. Health Aff (Millwood). 1992;11:41-55.
FULL TEXT
| PUBMED
23. Danzon PM. Hidden overhead costs: is Canada's system really less expensive? Health Aff (Millwood). 1992;11:21-43.
FULL TEXT
| PUBMED
24. Cutler DM. A guide to health care reform. J Econ Perspect. 1994;8:13-29.
PUBMED
25. Leigh JP, Markowitz SB, Fahs MC, Landrigan PJ. Costs of Occupational Injuries and Illnesses. Ann Arbor: University of Michigan Press; 2000.
26. Owings MF, Lawrence L for the National Center for Health Statistics. Detailed diagnosis and procedures: National Hospital Discharge Survey, 1997. Vital Health Stat 13. 1999;145:1-157.
27. Agency for Healthcare Research and Quality (formerly the Agency for
Health Care Policy and Research). Clinical Classifications for Health Policy Research:
Hospital Inpatient Statistics. Rockville, Md: Agency for Healthcare Research and Quality; 1998.
HCUP-3 Research Note, publication 98-0049.
28. Schappert SM. Ambulatory care visits to physician offices, hospital outpatient departments
and emergency departments: United States, 1996. Vital Health Stat 13. 1998;134:1-37.
29. National Center for Health Statistics. Health, US, 1994. Hyattsville, Md: Public Health Service; 1995.
30. National Center for Health Statistics. Vital Statistics of the US, 1991: Mortality, Part
A. Vol 2. Washington, DC: Public Health Service; 1996:section 1.
31. National Center for Health Statistics, US Department of Health and
Human Services. Life Tables, Vital Statistics of the US, 1990. Vol 2. Washington, DC: National Center for Health Statistics, US
Dept of Health and Human Services; 1994:section 6. Publication 94-1104.
32. US Bureau of Labor Statistics. Employment and Earnings. Washington, DC: US Dept of Labor, US Government Printing Office;
1997.
33. Gold MR, Siegel JE, Russell LB, Weinstein ML. Cost-effectiveness in Health and Medicine. New York, NY: Oxford University Press Inc; 1996.
34. Yelin E, Callahan LF. The economic cost and social and psychological impact of musculoskeletal
conditions. Arthritis Rheum. 1995;38:1351-1362.
ISI
| PUBMED
35. Farnham PG. The economic costs of HIV/AIDS. In: Pogodzinski JM, ed. Readings in Public Policy. Cambridge, Mass: Blackwell Publishers; 1995.
36. Begley CE, Famulari M, Annegers FJ, et al. The cost of epilepsy in the US: an estimate from population-based clinical
and survey data. Epilepsia. 2000;41:342-351.
FULL TEXT
|
ISI
| PUBMED
37. Sullivan SD, Ramsey SD, Lee TA. The economic burden of COPD. Chest. 2000;117(suppl):5S-9S.
38. Brown ML, Hodgson TA, Rice DP. Economic impact of cancer in the US. In: Schottenfeld D, Fraumen JF, eds. Cancer Epidemiology
and Prevention. 2nd ed. New York, NY: Oxford University Press Inc;
1996:295-314.
39. Rodgers GB. Estimating jury compensation for pain and suffering in product liability
cases involving nonfatal personal injury. J Forensic Econ. 1993;6:251-262.
40. McFloyd VC, Flanagan CA. Economic Stress: Effects on Family Life and Child
Development. San Francisco, Calif: Jossey-Bass Inc; 1990.
41. Arno PS, Levine C, Memmott MM. The economic value of informal caregiving. Health Aff (Millwood). 1999;18:182-188.
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