Burden of NAFLD is growing, and EDs are bearing the brunt

An increasing number of cases of nonalcoholic fatty liver disease (NAFLD) is contributing to the growing number of patients with liver disease (LD) seen in emergency departments (EDs) in the United States. The first study to document changes in the types, frequency, and outcomes of LD cases seen in EDs appears in the Journal of Clinical Gastroenterology.

The researchers found that during a 7-year period, the annual number of ED admissions with LD increased by about 65,000, and patients admitted and diagnosed with LDs had higher mortality compared with patients without LD.

Using data from the National Inpatient Survey database and codes from ICD-9, researchers led by Zobair M. Younossi, MD, MPH, Betty and Guy Beatty Center for Integrated Research, Falls Church, VA, analyzed trends in ED admissions among patients with LD between 2005 and 2011. They focused on hepatitis C virus (HCV) and hepatitis B virus (HBV) infection, alcoholic liver disease (ALD), hepatocellular carcinoma (HCC), and NAFLD.

The researchers examined the association between ED admissions among patients with LDs and outcomes such as mortality, length of stay, and hospital costs using a matched cohort of 1,083,210 LD cases and an equal number of controls. In 2005, 123,873 cases of LD were seen in EDs, which increased to 188,501 in 2011 (P < 0.0001).

Although the combined number of all LD cases increased, the proportion of patients with HCV, HBV, or ALD seen in the ED remained relatively stable from 2005 to 2011 (41.6% vs 38.2%, 3.7% vs 2.8%, and 41.4% vs 38.5%, respectively). However, the proportion of NAFLD diagnoses doubled from 6.0% to 11.9% during this period.

In fact, NAFLD was the only LD that showed an increase in the rate of in-hospital mortality over time: 59 cases (0.80%) in 2005 compared with 256 (1.13%) in 2011 (P=0.0925).

The rate of in-hospital mortality decreased for patients with HBV, HCV, and ALD during the study period, but was still higher than for controls. “Further research is required to fully understand this finding and its significance in terms of LD treatment and health care utilization,” the authors wrote.

An increase in the proportion of patients discharged to home health care was a common trend. From 2005 to 2011, the percentage of patients with HCV discharged to home health care increased from 27.77% to 31.14% (P=0.0005). For patients with HBV, it rose from 26.71% to 31.85% (P=0.0325), and for patients with NAFLD, from 17.86% to 21.88% (P < 0.0001).

Results also showed a general trend in increased hospital costs and decreased length of inpatient stay for all ED admissions, although these findings did not reach statistical significance. Matched univariate analysis showed overall lower hospital costs for most LD patients compared with controls. While costs decreased over time for HCC patients, costs increased for those with NAFLD ($7,002 to $7,872). “This may be indicative of the availability of effective early treatment for HCC and no treatment being available for NAFLD,” the authors reasoned.

Currently, NAFLD affects approximately 30% of the US population—including almost 11% of adolescents. Although the natural history of NAFLD is not well established, it is correlated with obesity and type 2 diabetes mellitus.

As these conditions continue to increase, the number of diagnosed NAFLD cases is expected to grow as well. According to the authors, these data “add to the growing body of evidence that the clinical and economic burden of NAFLD is increasing.” They called for the development of a national policy to address the growing burden of NAFLD.