1TR002541); serving on advisory boards for Amgen, AstraZeneca, Baxter Healthcare, Bayer AG, Boehringer Ingelheim, Cytokinetics, and Relypsa; and participating on clinical end point committees for studies sponsored by Novartis and the National Institutes of Health. Dr van Meijgaard is an employee of GoodRx. Dr Mehra reported receiving travel support and consulting fees, paid to Brigham and Women's Hospital, from Abbott; fees for serving on a steering committee from Medtronic and Janssen (Johnson & Johnson); fees for serving on a data and safety monitoring board from Mesoblast; consulting fees from Portola, Bayer, and Triple Gene; and fees for serving as a scientific board member from NuPulseCV, Leviticus, and FineHeart. Dr Mehra also reported receiving personal fees from Baim Institute for Clinical Research and Roivant. Dr Joseph reported receiving grants from Novartis, Amgen, Otsuka, and Kowa and is a consultant for Novartis. No other disclosures were reported. Additional Contributions:We acknowledge Diane Li, BA, and Amanda Nguyen, PhD, employees of GoodRx, who assisted with curation and analysis of the data. They did not receive additional financial compensation for these contributions.Disclaimer: These analyses are based on a representative sample of US pharmacy claims and not based on GoodRx transactions.

IMPORTANCE One factor associated with the rapidly increasing clinical and economic burden of chronic liver disease (CLD) is inpatient health care utilization. OBJECTIVE To understand trends in the hospitalization burden of CLD in the US.

OBJECTIVES: Alcoholic liver disease (ALD) prevalence, particularly the subset with advanced liver disease, is not well defined. Herein, we aim to provide a comprehensive assessment of ALD epidemiology across the spectrum of disease severity and across different settings using 3 unique US databases. METHODS: We performed a retrospective, observational study of US adults with ALD using 2001–2016 National Health and Nutrition Examination Survey (NHANES), 2007–2014 Nationwide Inpatient Sample (NIS), and 2007–2017 United Network for Organ Sharing (UNOS) registry. ALD in the NHANES was defined using clinical laboratory data and self-reported alcohol use, among which fibrosis-4 score of >2.67 defined stage ≥3 fibrosis. Alcoholic cirrhosis (AC) in the NIS was identified using International Classification of Diseases, Ninth Revision codes. ALD in the UNOS was identified using UNOS coding. RESULTS: From 2001–2002 to 2015–2016, the overall weighted ALD prevalence was stable from 8.8% to 8.1% (P = 0.102), whereas the proportion of ALD with stage ≥3 fibrosis increased from 2.2% (95% CI: 0.4–4.0) to 6.6% (95% CI: 2.0–9.9; P = 0.007) (NHANES). From 2007 to 2014, the number of hospitalizations among patients with AC per 1,000 increased by 32.8%, and the proportion of hospitalizations among the patients with AC with ≥3 cirrhosis complications increased from 11.6% in 2007 to 25.8% in 2014 (P trend < 0.0001) (NIS). From 2007 to 2017, the total number of adults with ALD listed for liver transplant increased by 63.4% and the proportion with concurrent hepatocellular carcinoma increased by 178% (UNOS). DISCUSSION: Among these 3 US databases, consistent observations of increasing ALD severity emphasize the urgent need for greater awareness about the consequences of unhealthy alcohol use and interventions aimed specifically at addressing alcohol use disorders.

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Background and aims: Disparities in timely referral to liver transplantation (LT) evaluation persist. We aim to examine race/ethnicity and insurance-specific differences in the Model for End-Stage Liver Disease (MELD) score at time of waitlist (WL) registration and its impact on WL survival. Methods: We retrospectively evaluated U.S. adults listed for LT using 2005-2018 United Network for Organ Sharing LT registry. Multiple linear regression methods examined factors associated with MELD at listing, and Fine-Gray competing risks regression were used to analyze WL mortality. Results: Among 144,163 WL registrants (median age = 56 years, 65.3% male, 56.4% private insurance, 23.3% Medicare, 15.7% Medicaid), mean WL MELD at listing was higher in African Americans versus non-Hispanic whites (2.57 points higher, 95%CI: 2.40-2.74, P < 0.001). Compared with patients with private insurance, adjusted mean WL MELD was higher among those with no insurance, Medicare, or Medicaid (P < 0.001 for all). After correcting for differences in MELD at listing, Asians had lower risk of WL death versus non-Hispanic whites (subhazard ratio (SHR): 0.92, 95% CI: 0.86-1.00, P = 0.04), but no difference was observed in African Americans or Hispanics. Compared with patients with private insurance, higher risk of WL death was observed in patients

Aims Alcoholic hepatitis (AH) and alcoholic cirrhosis disproportionately affect ethnic minority and safety-net populations. We evaluate the impact of a hospital’s safety net burden (SNB) on in-hospital mortality and costs among patients with AH and alcoholic cirrhosis. Methods We performed a cross-sectional analysis of 2012–2016 National Inpatient Sample. SNB was calculated as percentage of hospitalizations with Medicaid or uninsured payer status. Associations between hospital SNB and in-hospital mortality and costs were evaluated with adjusted multivariable logistic regression and linear regression models. Results Among 21,898 AH-related hospitalizations, compared to low SNB hospitals (LBH), patients hospitalized in high SNB hospitals (HBH) were younger (44.4 y vs. 47.4 y, P &lt; 0.001) and more likely to be African American (11.3% vs. 7.7%, P &lt; 0.001) or Hispanic (15.4% vs. 8.4%, P &lt; 0.001). AH-related hospitalizations in HBH had a non-significant trend towards higher odds of mortality (OR 1.27, 95% CI 0.98–1.65, P = 0.07) and higher mean hospitalizations costs. Among 108,669 alcoholic cirrhosis-related hospitalizations, patients in HBH were younger (53.3 y vs. 55.8 y, P &lt; 0.001) and more likely to be African American (8.2% vs. 7.3%, P &lt; 0.001) or Hispanic (24.4% vs. 12.0%, P &lt; 0.001) compared to LBH. Compared to alcoholic cirrhosis-related hospitalizations in LBH, mortality was higher among medium SNB (OR 1.10, 95% CI 1.03–1.17, P = 0.007) and HBH (OR 1.07, 95% CI 1.00–1.15, P = 0.05). Mean hospitalization costs were not different by SNB status. Conclusions HBH hospitals predominantly serve ethnic minorities and underinsured/uninsured populations. The higher in-hospital mortality associated HBH particularly for alcoholic cirrhosis patients is alarming given its increasing burden in the USA.

Goals: The aim of this study was to understand the burden of nonalcoholic fatty liver disease (NAFLD) among hospitalized patients in the United States. Background: A major driver of the rapidly increasing US clinical and economic burden of NAFLD is attributed to inpatient health care resource utilization. Methods: We performed a cross-sectional study of the 2007 to 2014 Nationwide Inpatient Sample. A total of 481,122 hospitalizations in patients with NAFLD were identified using ICD-9 codes after excluding other etiologies of chronic liver disease. We analyzed survey-weighted annual trends in national estimates of hospitalizations in patients with NAFLD, stratified by metabolic comorbidities, cirrhosis, and other liver-related complications. Annual trends in total hospitalization charges were inflation adjusted to 2014 USD. Results: From 2007 to 2014, hospitalizations in patients with NAFLD increased by 83.4% (42,060 to 77,143, P<0.0001), and the proportion of total hospitalizations represented by patients with NAFLD increased by 104.4% (6.34 to 13.0 per 1000 hospitalizations). During this time, there was a 159% increase in total inpatient hospitalization charges in patients with NAFLD ($7.7 billion in 2007 to $19.9 billion in 2014, P<0.001). This increasing clinical and economic burden was observed across all metabolic comorbidities and liver complications evaluated among hospitalizations in patients with NAFLD. Conclusions: With the rising prevalence of NAFLD in the United States, the inpatient clinical and economic burden of NAFLD is also rapidly rising. In 2014, total estimated national hospitalization charges in patients with NAFLD reached nearly $20 billion, with metabolic comorbidities and liver-related complications being major contributors to this rising burden.