Natural history, risk prediction and cost of cirrhosis in insured Americans.

Cirrhosis is a leading cause of mortality in the United States (US), diagnosed in over 4 million people and results in over 40,000 deaths each year. One in ten patients with cirrhosis experience life-threatening decompensating events, such as ascites, hepatic encephalopathy (HE), gastrointestinal bleeding (GIB), or develop hepatocellular carcinoma (HCC). These events often result in hospitalization, disability, or even death. The challenge is to accurately predict those patients who are likely to develop decompensating events and are likely to die. Accurate risk stratification of persons with cirrhosis will allow for early identification and development of mitigating interventions in the future for those at highest risk. Several predictive models exist but none of them adequately answers this question. Furthermore, no longitudinal cost of care analyses and cost prediction has been performed in the US for persons with cirrhosis. The care of patients with cirrhosis is complex, often involving costly recurrent hospitalizations and procedures. In 2015, the hospital costs alone were reported to be $16.3 billion. Our proposed research will analyze national administrative health payer data available from UnitedHealth Group (UHG), which offers detailed information on diagnoses, procedures, laboratory tests, medications, in- and outpatient care, as well as standardized costs for each of these services for approximately 15% of 170 million commercially insured Americans, including 396,727 persons diagnosed with cirrhosis between 2011 and 2018. Such a large population-based cirrhosis cohort, which includes cost data, offers a unique and unprecedented opportunity to study disease progression and apply a multitude of traditional and novel methodologies to predict decompensation, death, and costs. Aim 1. To describe and examine different states of liver cirrhosis Aim 1.1: To describe different states of patients with cirrhosis and probability to move between the states Aim 1.2: To describe disease progressions through different states of liver cirrhosis (trajectories) Aim 1.3: To adjudicate potentially risk-relevant covariates by a specialized stakeholder panel Aim 2. To predict risk of decompensation and risk of death in patients with cirrhosis Aim 2.1: To model the risk of different cirrhosis stages or trajectories, conditional on observed patient covariates Aim 2.2: To merge administrative claims data with the National Death Registry and model the risk of death Aim 3: To ascertain and predict costs associated with care of patients with liver cirrhosis Aim 3.1: To ascertain standardized cost stratified by stage/trajectories and other covariates Aim 3.2: To model cost of care, conditional on observed patient covariates