The consequences of cirrhosis in America.

In the evolution of liver disease, the phase between the development of cirrhosis and the development of complications, termed decompensated cirrhosis, is often prolonged, with a reported median survival of 12 years [1]. The development of cirrhotic complications (variceal bleeding, overt encephalopathy, infection, cancer, renal failure, ascites and hepatic hydrothorax) has immediate implications as it relates to the utilization of health care; moreover, such complications herald the larger risk of future clinical deterioration [2]. Development of any one of these complications denotes a turning point in the life of the cirrhotic patient. Hospitalization for a decompensation event markedly changes the median survival of the cirrhotic patient to \2 years [3]. Quality-of-life and mobility decline followed by a progressive rise of healthcare expenditures. Individuals with compensated and decompensated cirrhosis have significantly worse health status, have more comorbid conditions and have a greater use of healthcare services including hospital visits, nursing homestays and physician visits compared to an age-matched patients without cirrhosis [4]. Rakowski et al. [4] reported the profound functional disability in cirrhotics as it relates to activities of daily living. Cirrhotics receive double the informal caregiving hours compared with age-matched non-cirrhotics leading to monetary loss due to medications, medical fees, home health costs and missed wages by patients and relations. Bajaj et al. [5] observed that hepatic encephalopathy is associated with a significant decline in employment status and financial status and significant increase in caregiver burden which rose with Model EndStage Liver Disease score. The prevalence of cirrhosis in the USA is expected to increase, attributed largely to an aging hepatitis C birth cohort and the rising incidence of nonalcoholic steatohepatitis [6]. In the face of heightened Medicare utilization by the baby boomers, the direct cost of managing chronic liver disease—even excluding hepatitis C therapy—exceeds US $1.4 billion annually [7]. The clinical hepatologist, in turn, strives toward minimizing the emergency room visits, prolonged hospitalizations and costly therapeutic interventions that characterize this complex patient population. In this issue of Digestive Diseases and Sciences, Otgonsuren et al. [8] focus on how to better understand the economic and medical outcomes of Medicare patients who suffer from decompensated cirrhosis. This timely study highlights the impact of complications of chronic liver disease in the growing Medicare population. The findings include a high rate of death over 1 year after evidence of decompensation, with a 70 % overall death rate within 1 year following a decompensation event. Despite an improvement in mortality over the study period, the study additionally reflects a significant overall cost increase from 2005 to 2010, coinciding with an increase in the rates of spontaneous bacterial peritonitis and bleeding esophageal varices. Additionally, there was an 11 % increase in ICU stays, which represented a major driver of costs. In an attempt to determine the highest relevant predictors of mortality, the authors identified older age, a higher comorbidity index and male gender as major influences. While these factors are not surprising, the authors interestingly identified hepatocellular carcinoma (HCC) as a major predictor of cost as well as mortality. This finding adds to a growing body of literature documenting that the incidence of HCC is growing at an alarming rate in the S. R. Jafri S. C. Gordon (&) Department of Gastroenterology and Hepatology, Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit, MI 48302, USA e-mail: sgordon3@hfhs.org