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Epidemiology of Alcohol-Related Liver and Pancreatic Disease in the United States

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Epidemiology of Alcohol-Related Liver and Pancreatic Disease in the United States ORIGINAL INVESTIGATION Epidemiology of Alcohol-Related Liver and Pancreatic Disease in the United States Alice L. Yang, MD; Shweta Vadhavkar, MS; Gurkirpal Singh, MD; M. Bishr Omary, PhD, MD Background: The epidemiology of acute alcoholic pan- hospital discharges per 100 000 persons for AP plus AH creatitis (AP), chronic alcoholic pancreatitis (CP), acute were 1.8; and for CP plus CH, 0.32. There were higher alcoholic hepatitis (AH), and chronic alcoholic hepati- male to female ratios for AH and CH, and less so for AP tis with cirrhosis (CH) alone or in combination is not well and CP. A markedly higher frequency of AP (63.5) and described. To better understand alcohol-related liver and CP (11.3) was seen among blacks than among whites (AP, pancreas effects on and associations with different eth- 29.6 and CP, 5.1), Hispanics (AP, 27.1 and CP, 3.7), nic groups and sexes, we analyzed the trends of AP, CP, Asians (AP, 12.8 and CP, 1.4), and American Indians (AP, AH, CH, AP plus AH, and CP plus CH in the United States. 15.5 and CP, 2.3). This higher frequency remained stable between 1994 and 2004. Overall case fatality steadily de- Methods: We examined discharge records from the Na- creased in all categories, but remains highest in CH tionwide Inpatient Sample, the largest representative (13.6%) with similar racial distributions. sample of US hospitals. Hospital discharges, case- fatality, and sex and race contributions were calculated Conclusions: In the United States, AP is the most com- from patients with discharge diagnoses of AP, CP, AH, mon discharge diagnosis among alcohol-related liver or CH, AP plus AH, or CP plus CH between 1988 and 2004. pancreas complications, while CH has the highest case fatality rate and male to female ratio. Blacks have the high- Results: The distribution of overall hospital discharges est frequency of alcohol-related pancreatic disease. per 100 000 persons between 1988 and 2004 was as fol- lows: AP, 49.2; CP, 8.1; AH, 4.5; and CH, 13.7. Overall Arch Intern Med. 2008;168(6):649-656 HE ASSOCIATION BETWEEN homogeneous population in Northern Eu- alcohol intake and pancre- rope or Asia,1,3-5,8 while 2 recent studies atic and liver diseases is specifically focused on acute pancreatitis well documented. The 4 (of all causes) in California or the United major pancreas- and liver- States.9,10 Studies in Europe and Japan re- Trelated clinical entities precipitated by al- ported that cofactors such as ethnicity, cohol intake are acute pancreatitis (AP), smoking, diet, genetic make-up, cyto- chronic pancreatitis (CP), acute alco- kines, and other inflammatory mediators holic hepatitis (AH), and chronic alco- are associated more frequently with either holic hepatitis with cirrhosis (CH).1-5 Dis- alcoholic pancreatic or liver disease.8,11,12 ability-adjusted life years, as an indirect To our knowledge, no large studies have assessment of disease burden in the United analyzed the prevalence or trends of these States, places alcohol as the fifth leading diseases in the racially diverse US popu- disease burden among men, after ische- lation, although some studies have exam- mic heart disease, road traffic accidents, ined incidence rates in Europe. For ex- bronchopulmonary cancers, and human ample, the incidence of AP in Europe is immunodeficiency virus.6 Furthermore, rising for reasons that are not well under- Author Affiliations: 1998 hospital-related US costs for these al- stood.13 Department of Medicine, cohol-related diseases were between $0.6 Limited data on CP are available for the Division of Gastroenterology billion and $1.8 billion.1 In terms of gas- United States, but in Europe the inci- and Hepatology, Veterans Affairs trointestinal and liver disease burden, al- dence rate ranges from 1.6 new cases per Palo Alto Health Care System coholic liver disease was the seventh lead- year per 100 000 population in Switzer- and Stanford University ing gastrointestinal cause of death in the land to 23 cases per year per 100 000 in (Drs Yang, Singh, and Omary), 7 5 and Institute of Clinical United States in 2001. Finland. With regard to alcohol-related Outcomes Research and Most previous epidemiologic studies of liver disease, few studies have addressed Education (Ms Vadhavkar and alcohol-related pancreatic and liver dis- acute alcoholic hepatitis in limited US sub- Dr Singh), Palo Alto, California. ease have analyzed cases in an ethnically populations focusing on trends in alco- (REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 6), MAR 24, 2008 WWW.ARCHINTERNMED.COM 649 ©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 holic cirrhosis incidence and mortality.1,3 It is unclear why Census Bureau contained data for the following races: white, pancreatic and/or liver disease is acquired and what de- black, Hispanic, Asian American/Pacific Islander, American In- termines the tissue predilection in a given individual. Some dian/Alaska Native. studies suggest that the coexistence of alcohol- associated pancreatic and liver disease is relatively com- HOSPITAL DISCHARGES AND mon,14,15 while others have noted infrequent involve- CASE-FATALITY DATA ment of the 2 organs simultaneously.16 In the present study, we use US national data on hos- The number of hospital discharges of each disease alone or in pital discharges to provide an up-to-date analysis of trends combination per 100 000 US residents overall and per year were in alcohol-related acute and chronic pancreatic and liver calculated for each racial and/or ethnic group and sex. The case- fatality data were obtained from the NIS and calculated as a per- diseases. We also examine the number of hospital dis- centage of all discharges. charge diagnoses of combined AP and AH and com- bined CP and CH. STATISTICAL ANALYSIS METHODS Statistical analyses were performed by accounting for the sur- vey design of the NIS database, using SAS 9.1 software (SAS DATABASE Institute, Cary, North Carolina). To define the numbers of hos- pitalized patients with specific diagnoses in different groups of The Nationwide Inpatient Sample (NIS) is the largest all- patients, we used an SAS PROC SURVEYFREQ statement that payer inpatient database in the United States and includes a strati- allowed calculation of the weighted frequency with the stan- fied random sample of hospitals that makes up approximately dard deviation (SD) using modified weights. We then calcu- 85% of all hospital discharges in the United States (www.hcup-us lated rates of hospital discharges and population-based case fa- .ahrq.gov/nisoverview.jsp). The sample includes community and talities per 100 000 population using the US Census Bureau general hospitals and academic medical centers. It is the only national population estimates. national hospital database with information on all patients, re- gardless of payer, including persons covered by Medicare, Med- RESULTS icaid, private insurance, and the uninsured. Data from NIS are available from 1988 to 2004, allowing for analysis of trends over The total number of discharges reviewed in the NIS be- time. For each hospital discharge, data include over 100 clini- cal and nonclinical variables for each hospital stay, such as pri- tween 1988 and 2004 was 608 584 037. The total num- mary and secondary diagnoses (up to 15) and primary and sec- ber of hospital discharges of AP (all causes) between 1988 ondary procedures (up to 15) using International Classification and 2004 was 2 999 516. Hospital discharges with diag- of Diseases, Ninth Revision (ICD-9) codes (www.cdc.gov/nchs noses of AP, CP, AH, CH, AP plus AH, or CP plus CH /icd9.htm), patient demographics (sex, age, race, median in- with 95% confidence intervals (CIs) per 100 000 US per- come, and zip codes), length of stay, and discharge status. sons per year for each year between 1988 and 2004 are shown in Figure 1A. From 1988 to 2004, the number PATIENT ELIGIBILITY of AP diagnoses per 100 000 persons has progressively increased, from 39.8 (95% CI, 37.3-42.2) to 65.0 (95% The study cohort included all hospital discharges in the NIS CI, 62.5-67.5), an increase of 63%, while the other clini- data system with 1 of the following primary ICD-9 discharge cal entities did not increase as much. The number of CH diagnoses: acute pancreatitis (577.0), chronic pancreatitis diagnoses per 100 000 persons changed from 11.9 (95% (577.1), acute alcoholic hepatitis (571.1), or alcoholic liver cir- CI, 11.0-12.8) in 1988 to 18.1 (95% CI, 16.8-19.4) in rhosis (571.2). The cohort also included patients who were di- 2004, a 52% rise. The rates per 100 000 persons of AH agnosed as having combined alcoholic AP and AH or CP and CH. All patients were discharged between 1988 and 2004. and CP diagnoses changed minimally, from 4.9 (95% CI, For the AP group, since there is no specific ICD-9 code for 4.4-5.3) to 4.2 (95% CI, 3.9-4.5) for AH and from 7.0 alcohol-related disease, those with a concurrent diagnosis of (95% CI, 7.2-7.8) to 8.1 (95% CI, 7.5-8.7) for CP acute cholecystitis (575.0), other cholecystitis (575.1), chole- (Figure 1A). The number of hospital discharge diag- cystitis unspecified (575.10), calculus of the gallbladder with noses of combined AP plus AH was much lower than that acute cholecystitis without/with obstruction (574.00-574.01), of each disease individually, but the number has nearly calculus of the gallbladder with other cholecystitis without/ doubled between 1988 and 2004, from 1.4 (95% CI, 1.2- with obstruction (574.10-574.11), calculus of the gallbladder 1.6) to 2.4 (95% CI, 2.2-2.6) cases per 100 000 persons without cholecystitis without/with obstruction (574.20- (Figure 1B).
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