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  5. Burden of Digestive Diseases in the United States Report

Burden of Digestive Diseases in the United States Report

James E. Everhart, M.D., M.P.H., Editor

National Institute of Diabetes and Digestive and Kidney Diseases
National Institutes of Health
United States Department of Health and Human Services

Copyright Information
All material appearing in this report is in the public domain and may be reproduced or copied without permission: citation as to source, however, is appreciated.

Suggested Citation
[Author(s). Chapter title. In:] Everhart JE, editor. The burden of digestive diseases in the United States. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 2008; NIH Publication No. 09-6443 [pp. – ].

Table of Contents

  1. FOREWORD
  2. Acknowledgements
  3. ALL DIGESTIVE DISEASE
  4. GASTROINTESTINAL INFECTIONS
  5. VIRAL HEPATITIS
  6. DIGESTIVE CANCERS
  7. CANCER OF THE ESOPHAGUS
  8. CANCER OF THE STOMACH
  9. CANCER OF THE SMALL INTESTINE
  10. CANCER OF THE COLON AND RECTUM
  11. PRIMARY LIVER CANCER
  12. CANCER OF THE BILE DUCTS
  13. CANCER OF THE GALLBLADDER
  14. CANCER OF THE PANCREAS
  15. HEMORRHOIDS
  16. GASTROESOPHAGEAL REFLUX DISEASE
  17. FUNCTIONAL INTESTINAL DISORDERS
  18. PEPTIC ULCER DISEASE
  19. APPENDICITIS
  20. ABDOMINAL WALL HERNIA
  21. INFLAMMATORY BOWEL DISEASE
  22. DIVERTICULAR DISEASE
  23. LIVER DISEASE
  24. GALLSTONES
  25. PANCREATITIS
  26. INDICATIONS AND OUTCOMES OF GASTROINTESTINAL ENDOSCOPY
  27. COSTS OF DIGESTIVE DISEASES
  28. APPENDICES
  29. ICD and SEER Codes
  30. Summary of Surveys Used in The Burden of Digestive Diseases in the United States
  31. Methodology for Tables and Figures
  32. Index of Tables and Figures

Foreword

Digestive diseases include a wide spectrum of disorders affecting the oropharynx and alimentary canal, liver and biliary system, and pancreas. These disorders have diverse causes, including congenital and genetic anomalies, acute and chronic infections, cancer, adverse effects of drugs and toxins, and, in many cases, unknown causes. Some conditions, such as foodborne diarrheal diseases, are so common as to be considered a universal life experience, while many others are relatively uncommon or rare. The impact of these diseases ranges from the inconvenience of a transient diarrheal disease causing missed time from school or work, to chronic and debilitating illnesses requiring continuous medical care, or, all too frequently, to dreaded conditions such as pancreatic cancer that are usually fatal.

During the 20th century, there were dramatic changes in the incidence, prevalence, and overall impact of digestive diseases in the United States that were the result of many factors, including improved sanitation and an improved food supply; numerous research discoveries that led to the development of new drugs, vaccines, diagnostic tests, and minimally invasive procedures; and an economic and health care system capable of providing these advances to the majority of the population. Continued progress in improving the health welfare of the population of the United States requires a continued investment in digestive disease research, public health initiatives, the health care system, and the education of the general public about how to improve their health. Accurate descriptive statistical information is one of the most basic types of information required by those engaged in activities aimed at improving digestive health, including researchers, administrators, public officials, professional and patient-based organizations, and the general public.

In 1994, the National Institutes of Health (NIH) sponsored a publication, Digestive diseases in the United States: epidemiology and impact, that has served as a reference to meet these needs; the report had a limited update in 2001.1, 2 Because of continuing changes in the incidence and prevalence of digestive diseases, important changes in health care, such as the emphasis on outpatient care whenever possible, and the availability of new statistical resources, the time is right to generate a new report to capture the impact of digestive diseases in the United States. In addition, congressional report language accompanying the Fiscal Year 2005 appropriations bills in the House and Senate for Labor-Health and Human Services-Education and Related Agencies called for the creation of an advisory committee, the National Commission on Digestive Diseases, and tasked it with addressing the burden of digestive diseases and developing a long-range research plan. The resulting research plan from this charge, Opportunities and challenges in digestive diseases research: recommendations of the National Commission on Digestive Diseases, outlines a broad and ambitious agenda aimed at improving the health of the nation for digestive diseases through research; the research plan can be accessed on the Opportunities & Challenges in Digestive Diseases Research page. The NIH sponsored the current report on the burden of digestive diseases to serve not only as a needed statistical reference, but also as a companion volume to inform research goals recommended in the Commission’s research plan.

Close examination of this report will reveal many interesting and provocative pieces of statistical information about trends in various digestive diseases. As outlined in the report, for any specific disease condition, there are numerous limitations on the types of data that can be obtained in the diverse and decentralized U.S. health care system. Despite the many limitations of the statistical information, there are several certainties. In spite of a century of progress, the burden of digestive diseases in numerical terms remains staggering in the United States; the numbers, however, convey in only a limited way the suffering of and impact on the millions of individuals affected. In addition, the limitations of the report and the statistical data mandate a strong digestive disease research effort aimed at improving health in the United States through pursuit of the many recommendations of the Commission’s research plan, improving our ability to capture needed statistical and epidemiological information, and spurring fundamental improvements in the health care system.

Stephen P. James, M.D.
Chair, National Commission on Digestive Diseases
Director, Division of Digestive Diseases and Nutrition
National Institute of Diabetes and Digestive and Kidney Diseases
National Institutes of Health
U.S. Department of Health and Human Services

References

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Acknowledgements

I wish to thank the following individuals for making this report possible: Danita Byrd-Holt, Constance Ruhl, Bryan Sayer, Sanee Maphungphong, Beny Wu, Laura Fang, Laura Spofford, Polly Gilbert, Julie Kale, and Katherine Merrell of Social & Scientific Systems, Inc., for programming, production of tables and figures, text and cover graphic design, copyediting, and production of the final report; Daniel Westbrook and Douglas Brown of Georgetown University for analysis of the cost of digestive diseases; David Lieberman and Nora Mattek of the Clinical Outcomes Research Initiative (CORI) for the national endoscopy data; Dedun Ingram at the National Center for Health Statistics for advice on age-adjustment; and Robert Kloos at Ohio State University for advice on recovery times from surgery.

James E. Everhart, M.D., M.P.H., Editor
National Institute of Diabetes and Digestive and Kidney Diseases
National Institutes of Health
U.S. Department of Health and Human Services

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CHAPTER 1

All Digestive Diseases

James E. Everhart, M.D., M.P.H.

For systematic coding, mortality and health care statistics rely on disease classification systems, of which the International Classification of Diseases (ICD) is the world standard. The diagnostic codes traditionally used for digestive diseases primarily code for chronic conditions that are neither infectious nor malignant. In the current ICD edition (ICD-10), these include K20 through K93 in chapter “K” (Appendix 1). Other digestive diseases of public health significance and of particular interest to practitioners and researchers are coded in other chapters: Intestinal Infectious and Parasitic Diseases (A00–A09); Viral Hepatitis (B15–B19); Malignant Neoplasms of Digestive Organs (C15–C26); Hemorrhoids (I84); Esophageal and Gastric Varices (I85, I86.4); Maternal Disorders (Digestive) Related to Pregnancy (O21–O22); Conditions (Digestive) Originating in the Perinatal Period (P53, P54, P57, and P59); Digestive System Disorders of Fetus and Newborn (P75–P78, P92); and Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q39–Q45). For some of these groups of conditions, there were enough national data for individual sections in this report. For others, they and many other digestive system disorders were grouped under "other digestive diseases," so that a more complete impact of the total burden of digestive diseases could be estimated.

ICD-9 codes were used for mortality 1979–1998, and ICD-10 codes have been used subsequently, which has been noted on figures of mortality trends. As of the publication of this report, the United States had yet to switch from ICD-9-CM (Clinical Modification) to ICD-10 codes for coding morbidity, despite the publication of the newer edition in 1992. Therefore, all morbidity information from 1979 through 2005 was from ICD‑9-CM.

In 2004, there were an estimated 72 million ambulatory care visits with a first-listed diagnosis of a digestive disease and more than 104 million visits with an all-listed diagnoses, which equated to a rate of 35,684 visits per 100,000 U.S. population (Table 1). In other words, for every 100 U.S. residents, there were 35 ambulatory care visits at which a digestive disease diagnosis was noted. Visits were common for all age groups, with the highest rate among persons age 65 years and older. Age-adjusted rates were comparable for blacks and whites and were 20 percent higher for females than for males.

Digestive diseases were common all-listed diagnoses at hospital discharge in 2004 as well as first-listed diagnosis (Table 1). There were approximately 4.6 million discharges of patients with digestive disease as first-listed diagnosis and 13.5 million discharges as all-listed diagnoses. With a rate of all-listed diagnoses of 4,608 per 100,000, there were nearly five overnight hospital stays per 100 U.S. residents that included a discharge diagnosis of at least one digestive disease. These rates were nearly as high among children as among middle-aged adults and were higher in these two age groups than among younger adults. The highest rate was among persons age 65 years and older. In contrast to their ambulatory care visits, blacks had higher rates of hospitalization than did whites. Comparable or lower age-adjusted rates of ambulatory care visits among blacks, yet higher rates of hospitalization, were a common finding for a number of digestive diseases. Women had a 10 percent higher age-adjusted rate than men.

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown in Figure 1 by 3-year periods (except for the first period, which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Age-adjusted rates increased during this period by one-third, from 26.4 per 100 population to 35.3 per 100 population. This trend in increased rates of ambulatory care visits started at least as early as 1985, when there were 22.4 digestive disease diagnoses per 100 population.3 Rates of all-listed hospitalization with a digestive disease diagnosis fell between 1983 and 1988, a pattern that occurred for all hospitalizations in the United States. Hospitalization rates were stable for the next 10 years before rising to a rate in 2004 equal to the previous peak rate in 1982. The age-adjusted percent increase between 1998 and 2004 was 35 percent. This overall increase was the net of diagnoses whose rates increased and diagnoses whose rates decreased. The largest contributor to the increase was “other digestive diseases”—those conditions that do not have separate chapters in this report. The largest individual disease contributions to the increase were made by gastroesophageal reflux disease (GERD), with an increase over this period of 376 per 100,000 population; viral hepatitis C, with 79 per 100,000; chronic constipation, with 62 per 100,000; intestinal infections, with 41 per 100,000; and pancreatitis, with 23 per 100,000. Except for pancreatitis, each of these diagnoses was more likely to be listed as a secondary discharge diagnosis than as the first-listed diagnosis.

The recent increase in overnight hospital stays with a diagnosis of digestive disease is surprising for two reasons. A few common conditions were known to have declined as reasons for overnight hospitalizations, notably peptic ulcer disease (due to decreased frequency) and gallstones (due to shift to same-day surgery). Of greater significance was the modest rate of increase of hospital discharges for all diseases (from 11,569 per 100,000 in 1998 to 13,104 per 100,000 in 2004, a 13.3 percent increase) relative to the larger increase for digestive diseases. In 1998, 25.3 percent of all hospital discharges had a diagnosis of digestive diseases; this increased to 30.1 percent in 2004. Thus, rates of hospitalizations with digestive disease diagnoses increased both absolutely and as a proportion of all hospitalizations.

In 2004, there were more than 236,000 deaths in the United States with a digestive disease as the underlying cause (Table 2), which represented 9.8 percent of all deaths. A disproportionately lower proportion of deaths from digestive diseases occurred among children (4.1 percent) and a higher proportion occurred among middle-aged adults (15.1 percent). There was no major variation in the distribution of deaths from digestive disease as a proportion of all deaths by race or sex. However, blacks had a 29 percent higher death rate than whites, and men had a 53 percent higher rate than women.

There were 2 million years of potential life lost (YPLL) prior to age 75 years due to digestive diseases, representing 8.5 years per death with digestive disease as an underlying cause. Digestive diseases were more frequently listed as underlying cause than as contributing cause, mainly due to the large effect of deaths from cancer, which was usually listed as underlying cause. There was a gradual decline in digestive disease mortality between 1979 and 2004, both as underlying (18.2 percent) and as underlying or other cause (20.3 percent) (Figure 2). There have been many contributions to this decline, but the greatest determinant was the decrease in digestive disease cancer mortality by 19.8 percent as underlying cause and 24.0 percent as underlying or other cause.

The 10 costliest prescription drugs from retail pharmacies for digestive diseases, according to the 2004 Verispan database (Appendix 2), are shown in Table 3. Dominating the prescription market at 50.7 percent of total number of prescriptions and 77.3 percent of total cost were five proton pump inhibitors, which were mainly prescribed for GERD. The other costliest medications were mesalamine (for inflammatory bowel disease), ranitidine (another anti-acid agent), tegaserod [for irritable bowel syndrome (IBS) and constipation], and ribavirin and peginterferon alfa_2a (for hepatitis C). A deficiency of the drug data is lack of information on nonprescription medications, complementary and alternative medications, infusions, and drugs administered in the hospital.

Summary data for individual digestive diseases are shown in Table 4, ordered by underlying cause of death and type of disease. Five diseases each caused more than 10,000 deaths. These were liver disease and four cancers, led by colorectal cancer. Two common causes of death were transmissible infectious diseases: gastrointestinal (GI) infections and viral hepatitis C. Chronic viral hepatitis is also believed to be a significant contributor to liver and bile duct cancers, which accounted for more than 11,000 deaths.

The YPLL prior to age 75 years is the addition of the number of years prior to age 75 at which deaths occur.

A death at age 55 years, for example, contributes 20 YPLL, while a death at age 75 years contributes none. Malignancies were responsible for 6 of the top 10 digestive diseases that contributed the most to YPLL (Table 4). Liver disease was the second leading cause of death (after colorectal cancer), but contributed the greatest number of YPLL. Also among the 10 leading causes of YPLL were hepatitis C and pancreatitis.

The distribution of burden of medical care for digestive diseases is notably different from mortality from digestive diseases. The six leading diseases with diagnosis noted at ambulatory care visits were GERD, chronic constipation, abdominal wall hernia, hemorrhoids, diverticular disease, and IBS. At least three of these (GERD, constipation, and IBS) are largely caused by disordered function of the GI tract, and diverticular disease also may be in part a consequence of dysfunction. The six most common digestive diseases diagnoses on hospital discharge records were GERD, diverticular disease, liver disease, constipation, gallstones, and peptic ulcer disease. The main difference between the records for hospital discharge diagnoses and ambulatory care diagnoses was the high numbers of diagnoses with liver disease and peptic ulcer disease, which can be life-threatening, and gallstones, which are a common reason for surgery. Because GERD and constipation should rarely lead to hospitalization, it must be assumed that when listed on discharge, they either contributed to the reason for hospitalization or were listed in thousands of discharges simply because they were so common.

References

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Table 1. All Digestive Diseases: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
10,951 18,010 15,170 24,948 331 544 2,321 3,817
AGE (Years)
15–44
21,348 16,967 28,749 22,848 1,112 884 2,401 1,908
AGE (Years)
45–64
21,430 30,314 32,434 45,880 1,362 1,926 3,489 4,935
AGE (Years)
65+
18,342 50,483 28,437 78,268 1,779 4,897 5,313 14,622
Race
White
59,506 24,317 85,798 34,953 3,526 1,412 10,242 4,108
Race
Black
8,733 24,076 13,339 37,784 531 1,655 1,702 5,142
Sex
Female
39,531 25,827 59,553 38,648 2,545 1,592 7,593 4,753
Sex
Male
32,540 23,017 45,236 32,159 2,023 1,483 5,909 4,335
Total 72,071 24,543 104,790 35,684 4,591 1,563 13,533 4,608

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Figure 1. All Digestive Diseases: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Rates increased slightly from 26.4 per 100 population in 1992-1993 to 27.8 per 100 population in 1997-1999, and then more sharply to 35.3 per 100 population in 2003-2005. The trend in hospitalization rates was U-shaped. The rate in 1979 was 37.6 per 1000 population and remained relatively stable until 1983. From 1983 to 1988, rates fell to 29.6 per 1000 population. Rates were stable for the next 10 years before rising to 39.5 per 1000 population in 2004, equal to the previous peak rate in 1982.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. All Digestive Diseases: Number and Age-Adjusted Rates of Deaths, Years of Potential Life Lost (to Age 75), and Digestive Disease as a Percentage of All Deaths by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying Cause Digestive Disease As Percent of All Death Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
1,612 2.7 118.2 4.1 2,908 4.8
AGE (Years)
15–44
11,036 8.8 397.3 6.9 17,915 14.2
AGE (Years)
45–64
66,806 94.5 1,263.8 15.1 92,862 131.4
AGE (Years)
65+
156,706 431.3 228.2 8.9 252,709 695.5
Race
White
200,834 77.0 1,579.4 9.8 313,055 119.7
Race
Black
27,812 99.5 340.2 9.7 42,514 152.7
Sex
Female
111,264 63.6 723.3 9.2 177,811 100.7
Sex
Male
124,900 97.1 1,284.2 10.6 188,596 149.1
Total 236,164 80.4 2,007.5 9.8 366,407 124.8

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Figure 2. All Digestive Diseases: Age-Adjusted Rates of Death in the United States, 1979–2004

There was a gradual decline in mortality between 1979 and 2004, both as underlying cause and as underlying or other cause. Underlying-cause mortality per 100,000 decreased from 95.0 in 1979 to 77.8 in 2004. All-cause mortality per 100,000 decreased from 151.4 in 1979 to 120.6 in 2004.
Source: Vital Statistics of the United States

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Table 3. All Digestive Diseases: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Lansoprazole 20,989,993 15.5% $3,104,963,208 25.2%
Esomeprazole 19,458,740 14.3 2,845,665,944 23.1
Pantoprazole 11,716,033 8.6 1,408,222,345 11.4
Rabeprazole 8,019,431 5.9 1,135,819,908 9.2
Omeprazole 8,582,644 6.3 1,038,622,087 8.4
Mesalamine 2,448,971 1.8 468,426,719 3.8
Ranitidine 13,171,338 9.7 319,418,374 2.6
Tegaserod 1,618,699 1.2 238,030,688 1.9
Ribavirin 221,035 0.2 229,351,616 1.9
Peginterferon alfa-2a 131,001 0.1 191,754,177 1.6
Other 49,378,593 36.4 1,351,443,116 11.0
Total 135,736,478 100.0% $12,331,718,182 100.0%

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Table 4. Burden of Selected Digestive Diseases in the United States, 2004

Source: a Vital Statistics of the United States
b National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS)
c Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

DIGESTIVE DISEASE Deaths, Underlying Causea Years of Potential Life Lost to Age 75 Yearsa Ambulatory Care Visits, All-Listed Diagnosisb Hospital Discharges, All-Listed Diagnosisc
All Digestive Disease 236,164 2,007,500 104,790,000 13,533,000
All Digestive Cancer 135,107 945,200 4,198,000 726,000
Colorectal Cancer 53,226 333,000 2,589,000 255,000
Pancreatic Cancer 31,800 206,800 415,000 68,000
Esophageal Cancer 13,667 113,800 372,000 44,000
Gastric Cancer 11,253 84,200 141,000 31,000
Primary Liver Cancer 6,323 72,400 63,000 33,000
Bile Duct Cancer 4,954 32,900 17,000
Gallbladder Cancer 1,939 10,900 6,000
Cancer of the Small Intestine 1,115 9,300 9,000
Liver Disease 36,090 559,100 2,398,000 759,000
All Viral Hepatitis 5,393 101,800 3,510,000 475,000
Hepatitis C 4,595 87,500 2,747,000 419,000
Hepatitis B 645 11,800 729,000 69,000
Hepatitis A 58 800 10,000
Gastrointestinal Infections 4,396 12,800 2,365,000 450,000
Peptic Ulcer Disease 3,692 19,700 1,473,000 489,000
Pancreatitis 3,480 42,800 881,000 454,000
Diverticular Disease 3,372 8,600 3,269,000 815,000
Abdominal Wall Hernia 1,172 6,900 4,787,000 372,000
Gastroesophageal Reflux Disease 1,150 6,000 18,342,000 3,189,000
Gallstones 1,092 4,400 1,836,000 622,000
All Inflammatory Bowel Disease 933 9,100 1,892,000 221,000
Crohn’s Disease 622 7,000 1,176,000 141,000
Ulcerative Colitis 311 2,000 716,000 82,000
Appendicitis 453 5,000 782,000 325,000
All Functional Intestinal Disorders 423 2,500 11,648,000 1,241,000
Chronic Constipation 137 900 6,306,000 700,000
Irritable Bowel Syndrome 20 0 3,054,000 212,000
Hemorrhoids 14 200 3,275,000 306,000

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CHAPTER 2

Gastrointestinal Infections

James E. Everhart, M.D., M.P.H.

Most GI infections are self-limited and do not come to medical attention, although they are both extremely common and disruptive of daily activities, including school and work. GI infections are caused by viral and bacterial pathogens, but the minority that are most severe and for which causative agents are found are typically bacterial. The ICD-9 and ICD-10 codes match well, except for nonspecified organisms. The most significant differences are that Intestinal Infections Due to Other Organisms (008) and Ill-Defined Intestinal Infections (009) in ICD-9 were replaced by Other Bacterial Intestinal Infections (A04), Other Bacterial Foodborne Intoxications (A05), and Viral and Other Specified Intestinal Infections (A08) in ICD-10. Here is a breakdown of the codes for GI infections:

  ICD-9 ICD-10
Cholera 001 A00
Typhoid and Paratyphoid 002 A01
Other Salmonella 003 A02
Shigellosis 004 A03
Other Food Poisoning 005
Other Bacterial Intestinal Infections A04
Other Bacterial Foodborne Intoxications A05
Amebiasis 006 A06
Other Protozoal Intestinal Diseases 007 A07
Intestinal Infections Due to Other Organisms 008
Viral and Other Specified Intestinal Infections A08
Ill-Defined Intestinal Infections 009
Diarrhea and Gastroenteritis of Presumed Infectious Origin A09
All GI Infections 001–009 A00–A09

As shown in Table 1, in 2004, more than half of ambulatory care visits for GI infections occurred in those under the age of 15 years. When first-listed, the rate in this age group (1,930 per 100,000 population), was at least 4 times that of any other age group. Age-adjusted rates were 45.7 percent higher among whites than blacks and 18.1 percent higher among females than males. Relative to the frequency of ambulatory care visits, hospitalizations were uncommon. In contrast to those in ambulatory care, persons over age 65 years had both the highest number and rate of hospitalizations, and blacks had rates similar to those of whites. GI infections were considerably more often a secondary diagnosis (272,000) than first-listed diagnosis (178,000). The rate of age-adjusted hospitalizations with a diagnosis of GI infections increased by 92.8 percent between 1979 (76.1 per 100,000) and 2004 (146.7 per 100,000) and by 43.3 percent between 1992 (102.4 per 100,000) and 2004 (Figure 1).

In 2004, there were 4,396 deaths with a GI infection listed as the underlying cause (Table 2). The large majority of these deaths occurred among persons age 65 years and older. The death rate among whites was 50 percent higher than that among blacks, and the rates were similar among females and males. Similar patterns were seen for GI infections as either underlying or contributing cause. Because the majority of deaths occurred in the elderly, the YPLL prior to age 75 years was small, less than 3 years per death. In recent years, there has been a remarkable increase in deaths from GI infections (Figure 2). Over the 20-year period between 1979 and 1999, the age-adjusted underlying cause mortality rate doubled from 0.21 per 100,000 to 0.42 per 100,000. But in the 5 years from 1999 to 2004, the rate more than tripled to 1.44 per 100,000. About two-thirds of the more recent increase is due to one bacterial cause, Clostridium difficile, which is coded under Other Bacterial Intestinal Infections as A04.7.

MEDICATIONS

The costliest prescriptions filled at retail pharmacies for GI infections in 2004, according to the Verispan database (Appendix 2), are shown in Table 3. Most were antimicrobial agents, such as ciprofloxacin, or they affected GI motility, such as promethazine. An estimated 938,000 outpatient prescriptions were filled.

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Table 1. Gastrointestinal Infections: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
1,174 1,930 1,222 2,010 47 77 83 137
AGE (Years)
15–44
579 460 672 534 31 25 65 51
AGE (Years)
45–64
266 377 311 440 34 47 86 122
AGE (Years)
65+
109 301 159 439 66 183 215 593
Race
White
1,800 785 1,994 867 140 57 359 144
Race
Black
225 529 253 595 16 46 48 151
Sex
Female
1,142 796 1,279 888 107 67 261 160
Sex
Male
986 684 1,085 752 71 52 188 142
Total 2,128 725 2,365 805 178 61 450 153

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Figure 1. Gastrointestinal Infections: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 increased from 676 in 1992-1993 to 817 in 2003-2005. Hospitalizations per 100,000 increased from 76.1 in 1979 to 101 in 2000, and then more sharply to 147 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. Gastrointestinal Infections: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
32 0.1 2.3 40 0.1
AGE (Years)
15–44
49 0.0 1.9 97 0.1
AGE (Years)
45–64
353 0.5 6.0 577 0.8
AGE (Years)
65+
3,962 10.9 2.6 6,345 17.5
Race
White
4,104 1.5 10.7 6,552 2.5
Race
Black
241 1.0 1.6 422 1.6
Sex
Female
2,746 1.5 6.4 4,257 2.3
Sex
Male
1,650 1.4 6.4 2,802 2.4
Total 4,396 1.5 12.8 7,059 2.4

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Figure 2. Gastrointestinal Infections: Age-Adjusted Rates of Death in the United States, 1979–2004

In recent years, there has been an exponential increase in deaths. Over the 20-year period between 1979 and 1999, underlying-cause mortality per 100,000 doubled from 0.21 to 0.42. But in the 5 years from 1999 to 2004, the rate more than tripled to 1.44 per 100,000. The trend in all-cause mortality per 100,000 was similar, increasing from 0.36 in 1979 to 0.82 in 1999 to 2.32 in 2004.
Source: Vital Statistics of the United States

Table 3. Gastrointestinal Infections: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Vancomycin 14,507 1.5% $28,375,011 62.9%
Promethazine 346,794 37.0 5,985,173 13.3
Ciprofloxacin 126,523 13.4 5,132,893 11.4
Metronidazole 184,090 19.6 2,986,288 6.6
Loperamide 112,285 12.0 865,924 1.9
Diphenoxylate 122,042 13.0 832,096 1.8
Levofloxacin 7,325 0.8 483,046 1.1
Acidophilus/Bulgaricus 20,432 2.2 275,062 0.6
Ciprofloxacin-Betaine Combination 1,215 0.1 109,988 0.2
Prochlorperazine 2,927 0.3 26,326 0.1
Other 67 0.0 5,788 0.0
Total 938,207 100.0% $45,077,595 100.0%

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CHAPTER 3

Viral Hepatitis

James E. Everhart, M.D., M.P.H.

The primary forms of viral hepatitis in the United States are hepatitis A, B, and C (see ICD codes in Appendix 1). Hepatitis A is common and can be serious or even lethal. It does not have a chronic form. Hepatitis B can cause both acute and chronic disease, whereas acute hepatitis C is often asymptomatic, and its burden is predominantly due to chronic disease.

HEPATITIS A

Although the infection is common, hepatitis A is infrequently recognized in the ambulatory care or hospital setting. It was too infrequent to appear in the office-based sample of the National Ambulatory Medical Care Survey (Table 1). Hospitalization rates declined by about 75 percent between 1979 and 1993, and remained relatively stable through 2004. An effective vaccine to prevent infection was introduced in the 1990s, but it has not had a noticeable effect on reducing hospitalizations (Figure 1). Mortality from hepatitis A was rare, with fewer than 100 deaths per year (Table 2). Unlike recently stable rates of hospitalizations, the death rate from viral hepatitis A was halved between 1999 and 2004 (Figure 2).

HEPATITIS B

Viral hepatitis B is a more significant disease than hepatitis A. In the United States, infections were most commonly recognized between ages 15 and 44 years, and hospitalizations with the diagnosis occurred across the age range of adults (Table 3). Rates of both ambulatory care visits and hospitalizations with hepatitis B were higher among blacks than whites and among males than females. Hepatitis B was rarely the first-listed hospital diagnosis. There has been a vaccine available for hepatitis B since the 1980s, but the rates of both ambulatory care and hospitalizations have increased markedly since 1999 (Figure 3). This increase has been attributed to increased rates of immigration of chronic carriers of hepatitis B virus. Although not a common cause of death, viral hepatitis B resulted in about 10 times as many deaths as hepatitis A (Table 4). The majority of deaths with hepatitis B as either underlying or contributing cause occurred in middle age, between age 45 and 64 years. As with other forms of infections, hepatitis B was more often listed as a contributing than as an underlying cause. Deaths from hepatitis B increased between 1979 and 1994, but mortality steadily declined thereafter, in spite of (or perhaps related to) the increased rates of medical care (Figure 4). As an underlying cause, rates in 2004 were similar to those in 1979, but as a contributing cause, rates were considerably higher in 2004 than they had been 25 years earlier. Age-adjusted mortality was higher among blacks than whites.

HEPATITIS C

The hepatitis C virus was discovered in 1989, and tests for it soon followed. Most prior cases of non-A, non-B hepatitis are believed to have been viral hepatitis C. In both the outpatient and inpatient setting, more than half the cases were in persons ages 45–64 years (Table 5). Rates were at least twice as high among blacks as whites and among males as females. Viral hepatitis C was rarely the first-listed diagnosis at hospital discharge, but was frequently listed as a secondary diagnosis. As a result, only 2.6 percent of hospital discharge diagnoses for hepatitis C listed it as the first-listed diagnosis. Where hepatitis C was not the first-listed diagnosis, the most common underlying (first-listed) causes were chronic liver disease and its sequelae (10.4 percent), mood disorders (4.5 percent), cellulitis (3.8 percent), complications of procedures (2.6 percent), pneumonia (2.5 percent), and HIV (2.4 percent). The majority of hospitalizations, however, appeared to be unrelated to hepatitis C, suggesting that the diagnoses may appear as a result of testing for hepatitis C, rather than as consequences of hepatitis C. Blacks and men had the highest age-adjusted rates.

Both outpatient and inpatient diagnoses have greatly increased since hepatitis C received its own ICD code in the early 1990s (Figure 5). The number of hospitalizations prior to 1992 was too small to provide estimates. Much of the increase can be attributed to increasing recognition of the disease. There was also the introduction of antiviral therapy that required frequent patient monitoring. It is not clear how much of the increase can be attributed to the consequences of disease burden due to longstanding infection.

In 2004, 85 percent of hepatitis-related deaths were from viral hepatitis C. Hepatitis C was listed as a contributing cause of death more often than as the underlying cause (Table 6). About two-thirds of deaths occurred between the ages of 45 and 64 years. Age-adjusted death rates among blacks were nearly twice those of whites, and males had more than double the death rate of females. Hepatitis C contributed a high number of YPLL before the age of 75 years (87,500), because of the large number of deaths and because few deaths are attributed to the disease after age 75. This number placed hepatitis C as the fifth leading digestive disease cause of YPLL, behind esophageal cancer and ahead of gastric cancer. In keeping with the growing identification and long-term consequences of the disease, mortality rates increased rapidly from 1990 to 2004 (Figure 6). (The few deaths recorded prior to 1990 were for non-A, non-B viral hepatitis.) Of note, the mortality rate for hepatitis C as underlying cause leveled off beginning in 2001 and as underlying or contributing cause in 2002.

ALL VIRAL HEPATITIS

The burden of all viral hepatitis primarily reflected that of hepatitis B in past years and, more recently, hepatitis C (Tables 7 and 8, Figures 7 and 8). For example, 97.5 percent of the YPLL prior to age 75 years due to viral hepatitis was a result of hepatitis B (11.6 percent) or hepatitis C (85.9 percent).

MEDICATIONS

The costliest prescriptions filled at retail pharmacies for viral hepatitis in 2004, according to the Verispan database (Appendix 2), are shown in Table 9. An estimated 637,000 outpatient prescriptions were filled, but these were represented by few drugs, which were prescribed exclusively for hepatitis B (adefovir and lamivudine) or hepatitis C (ribavirin and peginterferon). When used to treat hepatitis C, ribavirin was nearly always used with interferon. For a full course of therapy, each of the medications in Table 9 would have required multiple prescriptions.

Table 1. Hepatitis A: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
0 1 0 1
AGE (Years)
15–44
1 1 3 3
AGE (Years)
45–64
0 1 4 5
AGE (Years)
65+
0 1 2 6
Race
White
2 1 7 3
Race
Black
0 0 2 4
Sex
Female
1 1 5 3
Sex
Male
1 1 5 3
Total 2 1 10 3

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Figure 1. Hepatitis A: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)

The number of ambulatory care visits during the time period was too small to provide estimates. Hospitalizations per 100,000 declined from 6.51 in 1979 to 1.67 in 1993, and remained relatively stable through 2004 when the rate was 1.30.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. Hepatitis A: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
6 0.0 0.2 13 0.0
AGE (Years)
45–64
27 0.0 0.6 61 0.1
AGE (Years)
65+
25 0.1 0.0 55 0.2
Race
White
48 0.0 0.7 101 0.0
Race
Black
7 0.0 0.1 20 0.1
Sex
Female
28 0.0 0.3 57 0.0
Sex
Male
30 0.0 0.5 72 0.0
Total 58 0.0 0.8 129 0.0

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Figure 2. Hepatitis A: Age-Adjusted Rates of Death in the United States, 1979–2004

The death rate was halved between 1999 and 2004. From 1979 through 1999, it was relatively stable. Underlying-cause mortality per 100,000 was 0.07 in 1979, 0.05 in 1999, and decreased to 0.02 in 2004. All-cause mortality per 100,000 was 0.09 in 1979, 0.10 in 1999, and decreased to 0.04 in 2004.
Source: Vital Statistics of the United States

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Table 3.Hepatitis B: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
385 306 2 1 26 21
AGE (Years)
45–64
277 392 1 2 33 47
AGE (Years)
65+
0 1 9 26
Race
White
242 98 2 1 40 16
Race
Black
183 510 1 3 19 55
Sex
Female
122 83 1 1 26 17
Sex
Male
607 418 2 1 43 29
Total 448 152 729 248 4 1 69 23

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Figure 3. Hepatitis B: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). The rates of both ambulatory care visits and hospitalizations have increased markedly since 1999. Ambulatory care visits per 100,000 rose from 88.4 in 1992-1993 to 247 in 2003-2005. Hospitalizations per 100,000 rose from 6.79 in 1979 to 12.2 in 1999, and then to 18.1 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 4. Hepatitis B: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
1 0.0
AGE (Years)
15–44
115 0.1 4.2 291 0.2
AGE (Years)
45–64
346 0.5 7.1 962 1.4
AGE (Years)
65+
184 0.5 0.5 441 1.2
Race
White
424 0.2 7.6 984 0.4
Race
Black
124 0.4 2.5 390 1.2
Sex
Female
174 0.1 2.7 428 0.3
Sex
Male
471 0.3 9.1 1,267 0.9
Total 645 0.2 11.8 1,695 0.6

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Figure 4. Hepatitis B: Age-Adjusted Rates of Death in the United States, 1979–2004

Deaths increased between 1979 and 1994, but steadily declined thereafter. Underlying-cause mortality per 100,000 rose from 0.12 in 1979 to 0.44 in 1994 and then fell to 0.21 in 2004. All-cause mortality per 100,000 rose from 0.18 in 1979 to 0.81 in 1994 and then fell to 0.56 in 2004. As an underlying cause, rates in 2004 were similar to those in 1979, but as a contributing cause, rates were considerably higher in 2004 than they had been 25 years earlier.
Source: Vital Statistics of the United States

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Table 5. Hepatitis C: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
0 0
AGE (Years)
15–44
382 304 791 628 2 2 127 101
AGE (Years)
45–64
918 1,298 1,603 2,268 7 10 248 351
AGE (Years)
65+
353 970 1 4 43 118
Race
White
1,110 451 1,828 742 9 3 298 120
Race
Black
235 662 739 2,122 2 5 99 286
Sex
Female
514 331 925 604 4 3 161 105
Sex
Male
974 677 1,823 1,261 7 4 258 176
Total 1,487 506 2,747 936 11 4 419 143

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Figure 5. Hepatitis C: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Both outpatient and inpatient diagnoses have greatly increased since the early 1990s. Ambulatory care visits per 100,000 rose from 116 in 1992-1993 to 914 in 2003-2005. The number of hospitalizations prior to 1992 was too small to provide estimates. Hospitalizations per 100,000 rose from 7.69 in 1992 to 120 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 6. Hepatitis C: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
2 0.0 0.1 3 0.0
AGE (Years)
15–44
547 0.4 18.6 1,445 1.1
AGE (Years)
45–64
3,062 4.3 66.1 7,590 10.7
AGE (Years)
65+
984 2.7 2.7 2,253 6.2
Race
White
3,712 1.4 71.0 8,771 3.4
Race
Black
718 2.2 14.2 2,111 6.4
Sex
Female
1,625 1.0 26.8 3,448 2.2
Sex
Male
2,970 2.0 60.8 7,844 5.3
Total 4,595 1.6 87.5 11,292 3.8

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Figure 6. Hepatitis C: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality rates increased rapidly from 1990 to 2004. (Few deaths were recorded prior to 1990.) Underlying-cause mortality per 100,000 rose from 0.03 in 1990 to 1.50 in 2004, while all-cause mortality per 100,000 rose from 0.04 in 1990 to 3.68 in 2004. The mortality rate as underlying cause leveled off beginning in 2001 and as underlying or contributing cause in 2002.
Source: Vital Statistics of the United States

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Table 7. All Viral Hepatitis: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
1 1 1 2
AGE (Years)
15–44
627 499 1,174 933 6 5 150 119
AGE (Years)
45–64
1,118 1,582 1,914 2,708 10 14 271 383
AGE (Years)
65+
399 1,099 2 6 53 147
Race
White
1,260 509 2,101 852 14 6 330 133
Race
Black
315 869 919 2,625 3 9 113 326
Sex
Female
620 404 1,071 703 8 5 185 121
Sex
Male
1,356 936 2,439 1,685 11 7 290 198
Total 1,977 673 3,510 1,195 19 6 475 162

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Figure 7. All Viral Hepatitis: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Both outpatient and inpatient rates have greatly increased since the early 1990s. Ambulatory care visits per 100,000 rose from 230 in 1992-1993 to 1,171 in 2003-2005. The hospitalization rate per 100,000 was 18.3 in 1979 and remained stable through 1992, after which it increased to 138 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital AmbulatoryMedical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002,2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 8. All Viral Hepatitis: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
3 0.0 0.2 9 0.0
AGE (Years)
15–44
684 0.5 23.7 1,674 1.3
AGE (Years)
45–64
3,477 4.9 74.7 8,249 11.7
AGE (Years)
65+
1,229 3.4 3.2 2,723 7.5
Race
White
4,254 1.7 80.4 9,538 3.7
Race
Black
866 2.6 17.1 2,401 7.3
Sex
Female
1,872 1.2 30.5 3,850 2.4
Sex
Male
3,521 2.4 71.3 8,806 6.0
Total 5,393 1.8 101.8 12,656 4.3

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Figure 8. All Viral Hepatitis: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality increased slightly prior to 1990, after which it rose more rapidly. Underlying-cause mortality per 100,000 increased from 0.36 in 1979 to 0.66 in 1990 and then to 1.76 in 2004. All-cause mortality per 100,000 increased from 0.46 in 1979 to 0.98 in 1990 and then to 4.13 in 2004. The mortality rate as underlying cause leveled off beginning in 2001 and as underlying or contributing cause in 2002.
Source: Vital Statistics of the United States

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Table 9. All Viral Hepatitis: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Ribavirin 221,035 34.7% $229,351,616 40.0%
Peginterferon alfa-2a 131,001 20.5 191,754,177 33.5
Peginterferon alfa-2b 64,398 10.1 84,943,979 14.8
Adefovir 86,784 13.6 43,120,493 7.5
Lamivudine 134,657 21.1 23,580,159 4.2
Total 637,875 100.0% $572,750,424 100.0%

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CHAPTER 4

Digestive Cancers

James E. Everhart, M.D., M.P.H.

The Surveillance, Epidemiology, and End Results (SEER) program provides considerable information on cancer burden not available for other digestive diseases. SEER statistics used in this report are number of cases and incidence in 2004, and the time trends for incidence and 5-year survival following diagnosis between 1979 and 2004. The codes used by ICD-9, ICD-10, and SEER are listed in Appendix 1.

ALL DIGESTIVE SYSTEM CANCERS

In 2004, approximately 233,000 persons were diagnosed with digestive system cancers (Table 1), which represented 18 percent of all cancers and was second only to genital system cancers for the most commonly affected organ system. Two-thirds of digestive system cancers occurred among persons age 65 years and older. The median age of diagnosis was 70 years, compared with 67 years for all cancers (PDF, 28KB) . Age-adjusted rates were highest among non-Hispanic blacks and lowest among American Indians. Males had slightly higher rates than females. Age-adjusted incidence declined by 13.2 percent between 1979 and 2004, with the entire decline coming after 1986 (Figure 1). Survival for all cancers and for individual cancers was calculated as absolute survival. Other reports may calculate survival relative to the general population with the same age and sex distribution, which would result in higher apparent survival. The same trends, however, would be seen for either approach. Five-year survival increased an absolute 6 percent to 34.6 percent; thus, for every 100 persons diagnosed with a digestive system cancer in 1999, 6 more survived at least 5 years longer than did those diagnosed 20 years earlier.

There were approximately 3.5 million ambulatory care visits for first-listed digestive system cancer in 2004 and 4.2 million all-listed visits. The elderly, whites, and males had the highest rates of ambulatory care visits (Table 2). Among all hospital discharges with digestive system cancers, about half were first-listed. The main demographic difference between ambulatory care diagnoses and hospital diagnoses was that blacks had a higher age-adjusted rate of hospital diagnoses. Rates of ambulatory care visits for digestive system cancers did not change appreciably over the period 1992–2004, but hospitalizations rates declined by 13.6 percent over that period (Figure 2).

In 2004, there were approximately 135,000 deaths due to digestive system cancers (Table 3), which represented 24 percent of all cancers and were second only to respiratory system cancers as cause of death due to cancer. As underlying cause, digestive system cancers constituted 57.2 percent of all digestive disease deaths. Death rates among persons 65 years and older were 5 times that of those aged 45–64 years. Age-adjusted death rates were higher among blacks and men. There were 945,000 YPLL due to digestive system cancer, the large majority occurring among males. Death rates from digestive system cancer declined steadily between 1979 and 2004 by an overall 19.8 percent (Figure 3).

MEDICATIONS

The costliest prescriptions filled at retail pharmacies for digestive system malignancies in 2004, according to the Verispan database (Appendix 2), are shown in Table 4. An estimated 879,000 outpatient prescriptions were filled. The costliest agents were either anti-neoplastic agents, such as capecitabine, or nonspecific pain and anti-nausea medications, such as fentanyl. Because the prescriptions were filled at retail pharmacies and do not capture all the settings where anti-cancer treatment is prescribed, this table both underestimates the number of prescriptions and likely misses many of the drugs used to treat digestive system malignancies. Medications are not shown for the individual malignancies in the following chapters.

Table 1. All Digestive Cancers: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Demographic Characteristics Number of Cases Incidence per 100,000 Unadjusted Incidence per 100,000 Age-Adjusted
AGE (Years)
Under 15
293 0.5
AGE (Years)
15–44
10,927 9.1
AGE (Years)
45–64
78,215 111.6
AGE (Years)
65+
154,886 452.8
RACE/ETHNICITY
Non-Hispanic White
191,668 99.6 83.5
RACE/ETHNICITY
Non-Hispanic Black
26,748 78.3 109.0
RACE/ETHNICITY
Hispanic
15,921 39.3 81.8
RACE/ETHNICITY
Asian/Pacific Islander
8,914 72.4 84.4
RACE/ETHNICITY
American Indian/Alaska Native
1,009 54.5 75.0
Sex
Female
109,058 74.7 70.0
Sex
Male
123,967 88.7 105.1
Total 233,239 81.6

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Figure 1. All Digestive Cancers: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 decreased from 99.6 in 1979 to 86.5 in 2004, with the entire decline coming after 1985. Five-year survival increased from 28.6 percent in 1979 to 34.6 percent in 1999, the last year for which it could be calculated.
Source: Surveillance, Epidemiology, and End Results (SEER) Program

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Table 2. All Digestive Cancers: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
1 1 5 7
AGE (Years)
15–44
110 87 145 115 19 15 47 37
AGE (Years)
45–64
1,293 1,829 1,537 2,174 115 163 257 364
AGE (Years)
65+
2,034 5,600 2,472 6,805 200 550 418 1,149
Race
White
3,149 1,235 3,771 1,479 263 102 572 222
Race
Black
240 802 313 1,040 40 141 89 307
Sex
Female
1,740 1,081 2,218 1,375 167 100 374 226
Sex
Male
1,741 1,309 1,980 1,485 168 128 351 267
Total 3,481 1,185 4,198 1,429 335 114 726 247

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Figure 2. All Digestive Cancers: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Rates of ambulatory care visits did not change appreciably over the period, but hospitalization rates declined since the early 1990s. Ambulatory care visits per 100,000 were 1,032 in 1992-1993 and 1,395 in 2003-2005. Hospitalizations per 100,000 increased from 224 in 1979 to 260 in 1984, remained relatively stable through 1992, and then declined to 216 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 3. All Digestive Cancers: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
43 0.1 3.0 57 0.1
AGE (Years)
15–44
3,972 3.2 142.7 4,549 3.6
AGE (Years)
45–64
35,968 50.9 648.1 41,599 58.8
AGE (Years)
65+
95,123 261.8 151.5 114,984 316.5
Race
White
113,468 43.5 737.8 136,231 52.2
Race
Black
16,907 62.2 161.7 19,587 72.3
Sex
Female
61,515 35.4 346.5 74,315 42.7
Sex
Male
73,592 57.9 598.7 86,876 68.8
Total 135,107 46.0 945.2 161,191 54.9

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Figure 3. All Digestive Cancers: Age-Adjusted Rates of Death in the United States, 1979–2004

Death rates declined steadily between 1979 and 2004. Underlying-cause mortality per 100,000 decreased from 55.6 in 1979 to 44.6 in 2004. All-cause mortality per 100,000 decreased from 69.9 in 1979 to 53.1 in 2004.
Source: Vital Statistics of the United States

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Table 4. All Digestive Cancers: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Capecitabine 77,376 8.8% $76,943,103 53.6%
Fentanyl 80,768 9.2 21,519,990 15.0
Oxycodone 92,577 10.5 20,027,456 14.0
Hydromorphone 371,312 42.2 16,110,590 11.2
Oxycodone/Acetaminophen 215,506 24.5 4,516,077 3.1
Morphine 17,890 2.0 3,690,323 2.6
Gemcitabine 379 0.0 361,858 0.3
Hydrocodone/Acetaminophen 4,285 0.5 249,901 0.2
Bevacizumab 18 0.0 45,962 0.0
Cetuximab 15 0.0 27,876 0.0
Other 18,557 2.0 14,683 0.0
Total 878,683 100.0% $143,507,819 100.0%

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CHAPTER 5

Cancer of the Esophagus

James E. Everhart, M.D., M.P.H.

The two forms of esophageal cancer are squamous cell carcinoma, which occurs in the upper two-thirds of the esophagus, and adenocarcinoma, which occurs in the lower part of the esophagus. Because the epidemiology of the two cancers is quite different, the SEER results are presented separately. Other national data sources do not differentiate as well, and those data therefore are combined.

In 2004, the majority (67 percent) of new cases of esophageal squamous cell cancer occurred among persons 65 years and older (Table 1) and occurred most often among non-Hispanic blacks and males (61 percent). The incidence declined over 25 years to 2004, when it was about half the rate of 1979 (Figure 1). Five-year survival remained poor, but improved from about 3 percent to 12 percent over that period.

Esophageal adenocarcinoma had a younger age distribution than most other digestive system cancers, but the majority of cases (63 percent) still occurred at age 65 years and older (Table 2). Non-Hispanic whites and males had by far the highest risk. These race and sex differences were greater than for any other common digestive tract cancer. During the 25 years of observation, the incidence of esophageal adenocarcinoma increased more rapidly than any other common malignancy, rising approximately fivefold between 1979 and 2004 (Figure 2). Five-year survival remained poor, but had increased from less than 5 percent to more than 15 percent.

Combining the two esophageal cancers (Table 3 and Figure 3) obscures their dynamic differences. For example, incidence of all esophageal cancer increased modestly over the period, but in 1979, adenocarcinoma was about one-eighth as frequent as squamous cell carcinoma, whereas by 2004, adenocarcinoma had the higher incidence. These combined data can, however, be useful for comparison with other national data. In 2004, there were an estimated 372,000 ambulatory care visits and 44,000 hospital diagnoses for esophageal cancer; rates of ambulatory care visits were moderately higher among persons age 65 years and older (Table 4). There were only sufficient numbers of ambulatory care visits for whites and males to show in the table. Hospitalizations occurred predominantly among persons age 65 years and older. During the 25 years of reporting, the rates of hospitalization remained relatively stable, in keeping with the overall incidence figures (Figure 4). Ambulatory care visits were too uncommon to discern a trend.

Esophageal cancer was a frequent cause of cancer death, ranking third in 2004 among digestive system cancers (after colorectal and pancreatic cancer) and was responsible for more than 13,000 deaths (Table 5) and 113,000 YPLL prior to age 75 years. Cancers of the gastroesophageal junction and cardia accounted for 4.6 percent of these deaths (see Chapter 6, Cancer of the Stomach). In keeping with the SEER data, death rates were highest among persons age 65 years and older, blacks (modestly more than whites), and males. Death rates increased between 1979 and 2004, but not during the last 6 years of that period.

Table 1. Esophageal Squamous Cell Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Demographic Characteristics Number of Cases Incidence per 100,000 Unadjusted Incidence per 100,000 Age-Adjusted
AGE (Years)
Under 15
AGE (Years)
15–44
94 0.1
AGE (Years)
45–64
1,655 2.4
AGE (Years)
65+
3,093 9.0
RACE/ETHNICITY
Non-Hispanic White
3,183 1.7 1.4
RACE/ETHNICITY
Non-Hispanic Black
1,108 3.2 4.4
RACE/ETHNICITY
Hispanic
263 0.7 1.4
RACE/ETHNICITY
Asian/Pacific Islander
210 1.7 2.0
RACE/ETHNICITY
American Indian/Alaska Native
Sex
Female
1,771 1.2 1.2
Sex
Male
2,828 2.0 2.4
Total 4,612 1.6

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Figure 1. Esophageal Squamous Cell Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 declined from 3.09 in 1979 to 1.81 in 2004. Five-year survival improved from 3.48 percent in 1979 to 11.7 percent in 1999, the last year for which it could be calculated.
Source: Surveillance, Epidemiology, and End Results (SEER) Program

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Table 2. Esophageal Adenocarcinoma: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Demographic Characteristics Number of Cases Incidence per 100,000 Unadjusted Incidence per 100,000 Age-Adjusted
AGE (Years)
Under 15
AGE (Years)
15–44
198 0.2
AGE (Years)
45–64
2,420 3.5
AGE (Years)
65+
3,996 11.7
RACE/ETHNICITY
Non-Hispanic White
6,553 3.4 2.9
RACE/ETHNICITY
Non-Hispanic Black
143 0.4 0.5
RACE/ETHNICITY
Hispanic
268 0.7 1.4
RACE/ETHNICITY
Asian/Pacific Islander
54 0.4 0.5
RACE/ETHNICITY
American Indian/Alaska Native
Sex
Female
942 0.6 0.6
Sex
Male
5,318 3.8 4.5
Total 6,309 2.2

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Figure 2. Esophageal Adenocarcinoma: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 increased rapidly from 0.66 in 1979 to 2.61 in 2004. Five-year survival increased from 5.08 percent in 1979 to 15.8 percent in 1999, the last year for which it could be calculated.
Source: Surveillance, Epidemiology, and End Results (SEER) Program

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Table 3. All Esophageal Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Demographic Characteristics Number of Cases Incidence per 100,000 Unadjusted Incidence per 100,000 Age-Adjusted
AGE (Years)
Under 15
AGE (Years)
15–44
367 0.3
AGE (Years)
45–64
4,712 6.7
AGE (Years)
65+
8,411 24.6
RACE/ETHNICITY
Non-Hispanic White
11,572 6.0 5.1
RACE/ETHNICITY
Non-Hispanic Black
1,394 4.1 5.5
RACE/ETHNICITY
Hispanic
638 1.6 3.4
RACE/ETHNICITY
Asian/Pacific Islander
299 2.4 2.9
RACE/ETHNICITY
American Indian/Alaska Native
Sex
Female
3,186 2.2 2.1
Sex
Male
9,605 6.9 8.1
Total 12,863 4.5

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Figure 3. All Esophageal Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 increased modestly from 4.42 in 1979 to 5.17 in 2004. Five-year survival increased from 3.47 percent in 1979 to 13.3 percent in 1999, the last year for which it could be calculated.
Source: Surveillance, Epidemiology, and End Results (SEER) Program

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Table 4. All Esophageal Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
1 1 2 2
AGE (Years)
45–64
215 304 217 308 8 11 17 25
AGE (Years)
65+
138 379 150 413 11 30 25 69
Race
White
343 131 361 139 16 6 36 14
Race
Black
2 8 6 19
Sex
Female
5 3 10 6
Sex
Male
244 170 261 184 15 11 34 26
Total 354 120 372 127 20 7 44 15

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Figure 4. All Esophageal Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 were 71.0 in 1992-1993 and 120 in 2003-2005, but were too uncommon to discern a trend. During the 25 years of reporting, the rate of hospitalizations remained relatively stable, at around 15 per 100,000.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 5. All Esophageal Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
371 0.3 12.9 388 0.3
AGE (Years)
45–64
4,650 6.6 82.6 4,929 7.0
AGE (Years)
65+
8,646 23.8 18.4 9,610 26.4
Race
White
11,850 4.6 94.6 12,953 5.0
Race
Black
1,561 5.5 17.0 1,696 6.0
Sex
Female
3,063 1.8 18.5 3,361 2.0
Sex
Male
10,604 8.1 95.4 11,566 8.9
Total 13,667 4.7 113.8 14,927 5.1

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Figure 5. All Esophageal Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

Death rates increased between 1979 and 2004, but not during the last 6 years of that period. Underlying-cause mortality per 100,000 rose from 3.91 in 1979 to 4.50 in 2004. All-cause mortality per 100,000 rose from 4.37 in 1979 to 4.92 in 2004.
Source: Vital Statistics of the United States

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CHAPTER 6

Cancer of the Stomach

James E. Everhart, M.D., M.P.H.

SEER includes cancers of the gastroesophageal junction and gastric cardia with gastric cancer. Over the period 1979 to 2004, the incidence of cancers of the gastroesophageal junction and cardia approximately doubled, resulting in an increase in the proportion of gastric cancer at these sites from 14.9% in 1979 to 30.4% in 2004. However, for medical care and vital statistics, these sites were included with esophageal cancer.

In 2004, the stomach was the third most common anatomical site for digestive system cancer, after the colon/rectum and the pancreas. Cancer of the stomach, gastric cancer, had an older age distribution than did other GI cancers, with 68 percent of cases having occurred at age 65 years or older (Table 1). Median age of diagnosis was 71 years (PDF, 28KB) . Asians and Hispanics had the highest age-adjusted incidence rates; non-Hispanic whites had the lowest rate. The incidence of gastric cancer, as reflected by mortality rates, has been declining for more than 70 years in the United States. Between 1979 and 2004, the incidence declined more than one-third (Figure 1).

During that period, 5-year survival following diagnosis increased by 50 percent.

Ambulatory care visits and hospital discharges with gastric cancer were relatively insubstantial (Table 2). Hospitalization rates declined more rapidly than the incidence rate (Figure 2). Because gastric cancer now has somewhat better survival than other digestive system cancers, it was only the fourth leading cause of death among these cancers. Seventy percent of deaths with gastric cancer as the underlying cause occurred at age 65 years or older (Table 3). The large majority of deaths listed gastric cancer as the underlying cause. Age-adjusted mortality rates were more than twice as high among blacks as whites and nearly twice as high among men as women. If cancer of the gastroesophageal junction were included among gastric cancer, the number of deaths would have increased 5.6 percent to 11,883 in 2004. Reflecting the declining incidence rate and longer survival, the age-adjusted mortality rate of gastric cancer declined by 49 percent between 1979 and 2004 (Figure 3), the most rapid decline for any major digestive system cancer.

Table 1. Gastric Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Demographic Characteristics Number of Cases Incidence per 100,000 Unadjusted Incidence per 100,000 Age-Adjusted
AGE (Years)
Under 15
AGE (Years)
15–44
1,292 1.1
AGE (Years)
45–64
6,610 9.4
AGE (Years)
65+
14,617 42.7
RACE/ETHNICITY
Non-Hispanic White
14,224 7.4 6.2
RACE/ETHNICITY
Non-Hispanic Black
2,727 8.0 11.4
RACE/ETHNICITY
Hispanic
2,425 6.0 12.3
RACE/ETHNICITY
Asian/Pacific Islander
1,419 11.5 13.8
RACE/ETHNICITY
American Indian/Alaska Native
123 6.6 9.1
Sex
Female
8,579 5.9 5.5
Sex
Male
12,888 9.2 11.1
Total 21,519 7.5

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Figure 1. Gastric Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 declined from 12.0 in 1979 to 7.64 in 2004. Five-year survival increased from 12.5 percent in 1979 to 18.1 percent in 1999, the last year for which it could be calculated.
Source: Surveillance, Epidemiology, and End Results (SEER) Program

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Table 2. Gastric Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
1 1 3 2
AGE (Years)
45–64
5 7 10 14
AGE (Years)
65+
107 295 10 29 19 52
Race
White
99 40 11 4 21 8
Race
Black
3 11 6 21
Sex
Female
7 4 14 8
Sex
Male
59 44 9 7 17 13
Total 137 47 141 48 17 6 31 11

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Figure 2. Gastric Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 declined from 66.8 in 1992-1993 to 48.2 in 2003-2005. Hospitalizations per 100,000 declined from 20.1 in 1979 to 9.28 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 3. Gastric Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
573 0.5 20.7 585 0.5
AGE (Years)
45–64
2,809 4.0 51.8 2,942 4.2
AGE (Years)
65+
7,871 21.7 11.7 8,734 24.0
Race
White
8,494 3.3 58.0 9,271 3.6
Race
Black
2,008 7.5 18.7 2,177 8.1
Sex
Female
4,791 2.8 32.9 5,197 3.0
Sex
Male
6,462 5.2 51.3 7,064 5.7
Total 11,253 3.8 84.2 12,261 4.2

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Figure 3. Gastric Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

The mortality rate declined rapidly between 1979 and 2004. Underlying-cause mortality per 100,000 decreased from 7.27 in 1979 to 3.72 in 2004. All-cause mortality per 100,000 decreased from 8.10 in 1979 to 4.05 in 2004.
Source: Vital Statistics of the United States

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CHAPTER 7

Cancer of the Small Intestine

James E. Everhart, M.D., M.P.H.

Cancer of the small intestine is often considered rare, but in 2004, there were more than 5,000 new cases diagnosed (exclusive of intestinal lymphomas), or about a third the total number of esophageal cancers or primary liver cancers, and more than the number of gallbladder cancers. Slightly more than half of patients were diagnosed at age 65 years or older (Table 1), with a median age of 67 years (PDF, 28KB) , making this the digestive system cancer with the second youngest age of onset (after primary liver cancer). Nevertheless, rates were highest among the elderly and among blacks and males.

Age-adjusted incidence for cancer of the small intestine increased by 73 percent between 1979 and 2004 (Figure 1). Lack of awareness of the magnitude of this increase may be a reason for the perception that it remains a rare cancer. Over the same period, 5-year survival improved modestly, from about 33 percent to about 41 percent. National medical care systems do not adequately capture outpatient or inpatient visits (Table 2), although rates of hospital discharges have tended to increase in recent years (Figure 2). The number of hospitalizations prior to 1988 was too small to provide estimates.

Because of its relatively high survival rate, there were only 1,115 deaths from cancer of the small intestine in 2004, and fewer than 10,000 YPLL prior to age 75 years (Table 3). The majority of deaths occurred among persons age 65 years and older. Death rates were higher for blacks than whites and for males than females, reflecting the incidence rates. Age-adjusted death rates changed little between 1979 and 2004 (Figure 3).

Table 1. Cancer of the Small Intestine: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Demographic Characteristics Number of Cases Incidence per 100,000 Unadjusted Incidence per 100,000 Age-Adjusted
AGE (Years)
Under 15
AGE (Years)
15–44
407 0.3
AGE (Years)
45–64
1,987 2.8
AGE (Years)
65+
2,889 8.4
RACE/ETHNICITY
Non-Hispanic White
4,298 2.2 1.9
RACE/ETHNICITY
Non-Hispanic Black
756 2.2 3.0
RACE/ETHNICITY
Hispanic
295 0.7 1.4
RACE/ETHNICITY
Asian/Pacific Islander
107 0.9 1.0
RACE/ETHNICITY
American Indian/Alaska Native
Sex
Female
2,357 1.6 1.5
Sex
Male
2,703 1.9 2.2
Total 5,065 1.8

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Figure 1. Cancer of the Small Intestine: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 increased from 1.08 in 1979 to 1.87 in 2004. Five-year survival improved modestly, from 36.8 percent in 1979 to 41.4 percent in 1999, the last year for which it could be calculated.
Source: Surveillance, Epidemiology, and End Results (SEER) Program

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Table 2. Cancer of the Small Intestine: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
0 0 1 1
AGE (Years)
45–64
2 3 3 5
AGE (Years)
65+
3 9 5 14
Race
White
5 2 7 3
Race
Black
1 3 1 5
Sex
Female
3 2 4 3
Sex
Male
3 2 5 4
Total 6 2 9 3

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Figure 2. Cancer of the Small Intestine: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With Any‑L‑Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)

The number of ambulatory care visits during the period was too small to provide estimates. The number of hospitalizations prior to 1988 was too small to provide estimates. Rates of hospital discharges per 100,000 have tended to increase in recent years from 1.55 in 1988 to 2.37 in 2004.
Source: Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 3. Cancer of the Small Intestine: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
55 0.0 2.0 59 0.0
AGE (Years)
45–64
329 0.5 6.0 358 0.5
AGE (Years)
65+
731 2.0 1.4 838 2.3
Race
White
908 0.3 6.9 1,021 0.4
Race
Black
175 0.6 2.1 194 0.7
Sex
Female
523 0.3 4.3 588 0.3
Sex
Male
592 0.5 5.0 667 0.5
Total 1,115 0.4 9.3 1,255 0.4

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Figure 3. Cancer of the Small Intestine: Age-Adjusted Rates of Death in the United States, 1979–2004

Death rates changed little between 1979 and 2004. Underlying-cause mortality per 100,000 was 0.39 in 1979 and 0.37 in 2004. All-cause mortality per 100,000 was 0.47 in 1979 and 0.41 in 2004.
Source: Vital Statistics of the United States

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CHAPTER 8

Cancer of the Colon and Rectum

James E. Everhart, M.D., M.P.H.

For this report, cancers of the colon and rectum were combined (see Appendix 1 for ICD codes). Together, these cancers were responsible for an estimated 55 percent of all digestive system cancers diagnosed in 2004. In 72.5 percent of cases, the colon was the anatomical site. By themselves, colon cancer would be the most common digestive system cancer, and rectal cancer the second most common. Therefore, trends in colorectal cancer largely determine trends in digestive system cancers as a whole.

Two-thirds of new cases of colorectal cancer were among those age 65 years or older (Table 1). Among the major racial-ethnic groups, non-Hispanic blacks had the highest rate, followed by non-Hispanic whites. American Indians had the lowest rates, with Hispanics and Asians intermediate. Age-adjusted rates were about one-third higher among males than females. Colorectal cancer incidence has been falling for the past 20 years, declining by 27.1 percent from 1985 to 2004 (Figure 1). The proportion of newly diagnosed patients who survived for at least 5 years has climbed steadily since 1979.

Colorectal cancer is the digestive system malignancy with the most reliable data on medical care (Table 2). In 2004, there were an estimated 2.6 million ambulatory care visits for persons with colorectal cancer. Most visits were among persons age 65 years and older and among women. Blacks had two-thirds the age-adjusted rate of whites. Visit rates were similar for males and females. For hospitalizations, colorectal cancer was more often listed as a first-listed diagnosis than as a secondary diagnosis. Hospitalization rates were disproportionately higher among the 65 years and older group. Age-adjusted rates were higher for blacks than for whites and for males than for females. Hospitalization rates declined from the early 1980s through 1995, and subsequently increased slightly (Figure 2).

Colorectal cancer was the leading cause of death related to the digestive system, accounting for 22.5 percent of deaths (Table 3). Because the median age of death for colorectal cancer was 75 years (PDF, 28KB) , colorectal cancer accounted for a smaller proportion of YPLL to digestive diseases (16.6 percent), second to liver disease. Because of declining incidence and improved survival, death rates declined 34.8 percent between 1979 and 2004. This decline accelerated during the latter part of that period (Figure 3).

Table 1. Colorectal Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Demographic Characteristics Number of Cases Incidence per 100,000 Unadjusted Incidence per 100,000 Age-Adjusted
AGE (Years)
Under 15
AGE (Years)
15–44
6,019 5.0
AGE (Years)
45–64
41,467 59.2
AGE (Years)
65+
87,872 256.9
RACE/ETHNICITY
Non-Hispanic White
111,509 58.0 48.5
RACE/ETHNICITY
Non-Hispanic Black
14,251 41.7 58.6
RACE/ETHNICITY
Hispanic
7,370 18.2 38.1
RACE/ETHNICITY
Asian/Pacific Islander
4,089 33.2 38.6
RACE/ETHNICITY
American Indian/Alaska Native
477 25.8 35.8
Sex
Female
64,080 43.9 41.1
Sex
Male
65,069 46.5 55.7
Total 129,189 45.2 47.5

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Figure 1. Colorectal Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 was 62.4 in 1979; between 1985 and 2004 it declined from 66.3 to 48.3. Five-year survival climbed steadily from 40.5 percent in 1979 to 48.8 percent in 1999, the last year for which it could be calculated.
Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Table 2. Colorectal Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
56 45 83 66 7 6 14 11
AGE (Years)
45–64
721 1,021 875 1,238 47 66 80 113
AGE (Years)
65+
1,321 3,636 1,627 4,477 97 268 160 441
Race
White
1,892 747 2,323 915 118 45 195 76
Race
Black
127 426 177 601 17 59 30 107
Sex
Female
1,134 705 1,456 902 76 45 127 75
Sex
Male
969 736 1,133 856 76 58 127 98
Total 2,103 716 2,589 882 151 52 255 87

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Figure 2. Colorectal Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 have been relatively stable during the period at 791 in 1992-1993 and 880 in 2003-2005. Hospitalization rates per 100,000 declined from 118 in 1979 to 72.3 in 1995, and subsequently increased slightly to 82.8 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 3. Colorectal Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
1 0.0 0.1 2 0.0
AGE (Years)
15–44
1,608 1.3 58.3 1,654 1.3
AGE (Years)
45–64
12,262 17.3 219.9 13,056 18.5
AGE (Years)
65+
39,355 108.3 54.9 48,188 132.6
Race
White
45,340 17.3 263.0 53,979 20.6
Race
Black
6,592 24.7 57.7 7,446 28.2
Sex
Female
26,512 15.1 142.8 31,153 17.5
Sex
Male
26,714 21.5 190.2 31,747 25.9
Total 53,226 18.1 333.0 62,900 21.4

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Figure 3. Colorectal Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

Death rates declined between 1979 and 2004. This decline accelerated during the latter part of that period. Underlying-cause mortality per 100,000 decreased from 27.3 in 1979 to 17.8 in 2004. All-cause mortality per 100,000 decreased from 32.1 in 1979 to 21.0 in 2004.
Source: Vital Statistics of the United States

CHAPTER 9

Primary Liver Cancer

James E. Everhart, M.D., M.P.H.

The major malignant neoplasm of the liver is liver cell cancer (hepatocellular carcinoma). Also included in this category in this report are the rare malignancies of hepatoblastoma and angiosarcoma as well as other primary specified and unspecified liver carcinomas. Intrahepatic bile duct carcinoma is included among bile duct cancers (see Appendix 1 for ICD codes).

In 2004, primary liver cancer occurred at an earlier age than any other digestive system cancer, with 50 percent of cases being diagnosed under the age of 65 years (Table 1). Hepatoblastoma, although the most common liver neoplasm among children, had minimal influence on this association because of its rarity. Incidence was lowest among non-Hispanic whites, intermediate among non-Hispanic blacks and Hispanics, and highest among Asians and American Indians. Males had more than 3 times the age-adjusted incidence of females.

The incidence of primary liver cancer rose modestly between 1979 and 1988 (14.5 percent) and more rapidly subsequently (90 percent over the period 1988–2004) (Figure 1). Liver cancer was one of the most lethal digestive system cancers, although 5-year survival did increase nearly fourfold during this period, albeit to only 8 percent.

Medical care visits and hospitalizations for liver cancer were too infrequent in 2004 to make firm statements about them. Hospitalization discharge rates (Table 2) had a demographic pattern similar to incidence rates (Table 1), with the highest rates among patients age 65 years and older, blacks, and males. Hospitalization rates more than doubled from 1984 to 2004 (Figure 2), also in keeping with the increase in incidence.

Death rates increased with age, but not as markedly as in other digestive system cancers (Table 3). Age-adjusted death rates were higher among blacks and males. Because of its increasing incidence and poor survival, primary liver cancer has contributed an increasing number and proportion of deaths, although it accounted for only 4.7 percent of all deaths from digestive system cancers in 2004. Because of the relatively early age of onset, it accounted for a higher proportion of YPLL due to digestive system cancers (7.7 percent). As with incidence, mortality rate increased, although not as quickly. The mortality rate increased 75 percent between 1979 and 2004 (Figure 3).

Table 1. Primary Liver Cancer: Number of Cases and Incidence Rate by Age, Race/Ethnicity, and Sex, 2004

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Demographic Characteristics Number of Cases Incidence per 100,000 Unadjusted Incidence per 100,000 Age-Adjusted
AGE (Years)
Under 15
165 0.3
AGE (Years)
15–44
856 0.7
AGE (Years)
45–64
7,863 11.2
AGE (Years)
65+
8,093 23.7
RACE/ETHNICITY
Non-Hispanic White
9,507 4.9 4.2
RACE/ETHNICITY
Non-Hispanic Black
2,244 6.6 8.3
RACE/ETHNICITY
Hispanic
1,894 4.7 9.0
RACE/ETHNICITY
Asian/Pacific Islander
1,414 11.5 12.9
RACE/ETHNICITY
American Indian/Alaska Native
151 8.2 10.0
Sex
Female
4,350 3.0 2.8
Sex
Male
11,827 8.5 9.4
Total 16,260 5.7

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Figure 1. Primary Liver Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 rose modestly from 2.56 in 1979 to 2.93 in 1988 and then more rapidly to 5.56 in 2004. Five-year survival increased from 2.38 percent in 1979 to 8.12 percent in 1999, the last year for which it could be calculated.
Source: Surveillance, Epidemiology, and End Results (SEER) Program

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Table 2. Primary Liver Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
0 1 2 3
AGE (Years)
15–44
1 1 2 2
AGE (Years)
45–64
6 9 15 21
AGE (Years)
65+
6 17 14 39
Race
White
10 4 25 10
Race
Black
2 7 5 14
Sex
Female
4 3 9 6
Sex
Male
10 7 23 17
Total 63 21 14 5 33 11

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Figure 2. Primary Liver Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The number of ambulatory care visits during the period was too small to provide estimates, except for 2003-2005 when the rate was 21.0 per 100,000. Hospitalizations per 100,000 increased from 3.02 in 1979 to 9.58 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 3. Primary Liver Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
33 0.1 2.3 34 0.1
AGE (Years)
15–44
243 0.2 9.1 250 0.2
AGE (Years)
45–64
2,781 3.9 53.9 3,069 4.3
AGE (Years)
65+
3,266 9.0 7.2 3,567 9.8
Race
White
4,742 1.8 49.8 5,204 2.0
Race
Black
944 3.1 14.7 1,021 3.4
Sex
Female
1,522 0.9 12.0 1,666 1.0
Sex
Male
4,801 3.5 60.4 5,254 3.9
Total 6,323 2.2 72.4 6,920 2.4

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Figure 3. Primary Liver Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

The mortality rate increased between 1979 and 2004. Underlying-cause mortality per 100,000 rose from 1.19 in 1979 to 2.08 in 2004. All-cause mortality per 100,000 rose from 1.33 in 1979 to 2.27 in 2004.
Source: Vital Statistics of the United States

CHAPTER 10

Cancer of the Bile Ducts

James E. Everhart, M.D., M.P.H.

For this report, intrahepatic and extrahepatic bile duct cancers were combined (see Appendix 1 for ICD-9 and ICD-10 codes). Substantial differences between them are noted.

In 2004, 22 percent of bile duct cancer was coded intrahepatic and 45 percent extrahepatic; nearly all the remainder did not have a location specified. Rates were much higher in the oldest age group, with 74 percent of cases occurring at age 65 or older. Age-adjusted rates were highest among Hispanics and Asians (Table 1). Males had a higher rate and slightly higher number of cases than females. Incidence increased modestly between 1979 and 2004 (about 22 percent), all of which could be accounted for by an increase in the incidence of intrahepatic bile duct cancer. Five-year survival did not improve and was about 10 percent for the entire period (Figure 1). There were too few outpatient or inpatient diagnoses to draw inferences about medical care (Table 2), but hospitalization rates were relatively constant at about 5 per 100,000 U.S. population (Figure 2).

Because of low survival, bile duct cancer mortality was similar to incidence. As underlying cause, there were 4,954 deaths in 2004 and nearly 33,000 YPLL prior to age 75 years (Table 3). Rates were highest in the oldest age group. Age-adjusted mortality rates were slightly higher for whites and for males. Death rates for bile duct cancer rose 39 percent between 1979 and 2004 (Figure 3).

Table 1. Bile Duct Cancer: Number of Cases and Incidence Rate by Age, Race/Ethnicity, and Sex, 2004

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Demographic Characteristics Number of Cases Incidence per 100,000 Unadjusted Incidence per 100,000 Age-Adjusted
AGE (Years)
Under 15
AGE (Years)
15–44
266 0.2
AGE (Years)
45–64
1,655 2.4
AGE (Years)
65+
4,569 13.4
RACE/ETHNICITY
Non-Hispanic White
4,859 2.5 2.1
RACE/ETHNICITY
Non-Hispanic Black
523 1.5 2.1
RACE/ETHNICITY
Hispanic
519 1.3 2.8
RACE/ETHNICITY
Asian/Pacific Islander
332 2.7 3.3
RACE/ETHNICITY
American Indian/Alaska Native
Sex
Female
3,051 2.1 2.0
Sex
Male
3,133 2.2 2.7
Total 6,186 2.2

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Figure 1. Bile Duct Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 increased from 1.85 in 1979 to 2.27 in 2004. Five-year survival was around 10 percent for the entire period through 1999, the last year for which it could be calculated.
Source: Surveillance, Epidemiology, and End Results (SEER) Program

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Table 2. Bile Duct Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
0 0 1 1
AGE (Years)
45–64
2 3 5 7
AGE (Years)
65+
6 17 11 30
Race
White
7 3 14 5
Race
Black
1 3 1 5
Sex
Female
4 3 8 5
Sex
Male
5 4 9 7
Total 9 3 17 6

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Figure 2. Bile Duct Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)

The number of ambulatory care visits during the period was too small to provide estimates. Hospitalization rates during the period were relatively constant at about 5 per 100,000.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 3. Bile Duct Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
2 0.0 0.1 3 0.0
AGE (Years)
15–44
143 0.1 5.2 148 0.1
AGE (Years)
45–64
1,245 1.8 21.9 1,308 1.9
AGE (Years)
65+
3,564 9.8 5.7 3,855 10.6
Race
White
4,348 1.7 27.6 4,657 1.8
Race
Black
366 1.4 3.4 401 1.5
Sex
Female
2,554 1.5 15.1 2,711 1.6
Sex
Male
2,400 1.9 17.8 2,603 2.1
Total 4,954 1.7 32.9 5,314 1.8

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Figure 3. Bile Duct Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

Death rates rose between 1979 and 2004. Underlying-cause mortality per 100,000 increased from 1.18 in 1979 to 1.64 in 2004. All-cause mortality per 100,000 increased from 1.33 in 1979 to 1.76 in 2004.
Source: Vital Statistics of the United States

CHAPTER 11

Cancer of the Gallbladder

James E. Everhart, M.D., M.P.H.

About 3,000 cases of gallbladder cancer were estimated to have occurred in 2004 (Table 1). Gallbladder cancer was the only digestive system malignancy that occurred predominantly among women (nearly twice the age-adjusted rate of men) and was one of the few nongenital cancers that had a female predominance. It was predominantly a diagnosis of the elderly, with a median age of diagnosis of age 73 years (PDF, 28KB) , the highest of any digestive system cancer. Age-adjusted rates were too low to draw inferences about ethnic differences in risk. Incidence of gallbladder cancer declined by 42.2 percent from 1979 to 1997, and was then stable through 2004 (Figure 1). Five-year survival increased modestly to about 9 percent. Outpatient and inpatient data were too sparse to draw inferences, except that the rate of hospitalization with gallbladder cancer declined substantially until the mid-1990s and has been stable since (Figure 2).

Because of low survival, gallbladder cancer mortality was similar to incidence. As underlying cause, there were nearly 2,000 deaths in 2004 and just under 11,000 YPLL prior to age 75 years (Table 3), which reflects the older age at which gallbladder cancer occurred. Rates were 6.8 times as high in the oldest age group (65 years and older) as among those ages 45–64 years. Age-adjusted mortality rates were higher for blacks than whites, and for females than males. The death rate for gallbladder cancer declined by 47 percent between 1979 and 2004 (Figure 3). Because gallstones are the major recognized risk factor for gallbladder cancer, it is of interest that there was a similar decline (56.1 percent) in gallstone disease-related mortality over that period.

Table 1. Gallbladder Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Demographic Characteristics Number of Cases Incidence per 100,000 Unadjusted Incidence per 100,000 Age-Adjusted
AGE (Years)
Under 15
AGE (Years)
15–44
79 0.1
AGE (Years)
45–64
850 1.2
AGE (Years)
65+
2,257 6.6
RACE/ETHNICITY
Non-Hispanic White
2,129 1.1 0.9
RACE/ETHNICITY
Non-Hispanic Black
356 1.0 1.5
RACE/ETHNICITY
Hispanic
348 0.9 1.9
RACE/ETHNICITY
Asian/Pacific Islander
142 1.2 1.4
RACE/ETHNICITY
American Indian/Alaska Native
Sex
Female
2,180 1.5 1.4
Sex
Male
867 0.6 0.8
Total 3,034 1.1

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Figure 1. Gallbladder Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 declined from 1.84 in 1979 to 1.07 in 1997, and was then stable through 2004. Five-year survival increased modestly from 7.84 percent in 1979 to 9.64 percent in 1999, the last year for which it could be calculated.
Source: Surveillance, Epidemiology, and End Results (SEER) Program

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Table 2. Gallbladder Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
0 0
AGE (Years)
45–64
1 1 1 2
AGE (Years)
65+
2 6 4 11
Race
White
2 1 5 2
Race
Black
0 1 1 2
Sex
Female
2 1 4 2
Sex
Male
1 1 2 1
Total 3 1 6 2

Return To Table Of Contents

Figure 2. Gallbladder Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)

The number of ambulatory care visits during the period was too small to provide estimates. Hospitalizations per 100,000 declined substantially from 5.05 in 1979 to 1.35 in 1992 and have been stable since with a rate of 1.86 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 3. Gallbladder Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
41 0.0 1.5 44 0.0
AGE (Years)
45–64
422 0.6 7.1 443 0.6
AGE (Years)
65+
1,476 4.1 2.3 1,585 4.4
Race
White
1,600 0.6 8.5 1,715 0.7
Race
Black
227 0.9 1.6 239 0.9
Sex
Female
1,343 0.8 7.4 1,422 0.8
Sex
Male
596 0.5 3.5 650 0.5
Total 1,939 0.7 10.9 2,072 0.7

Return To Table Of Contents

Figure 3. Gallbladder Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

The death rate declined between 1979 and 2004. Underlying-cause mortality per 100,000 decreased from 1.22 in 1979 to 0.64 in 2004. All-cause mortality per 100,000 decreased from 1.34 in 1979 to 0.69 in 2004.
Source: Vital Statistics of the United States

CHAPTER 12

Cancer of the Pancreas

James E. Everhart, M.D., M.P.H.

In 2004, 71 percent of newly diagnosed pancreatic cancers were among persons age 65 years and older (Table 1). Age at diagnosis was higher than for most other digestive system cancers, with the median being 72 years and 40 percent diagnosed at age 75 years or older (PDF, 28KB) .

Incidence rates were highest among the elderly, non-Hispanic blacks, and males. Age-adjusted incidence was relatively stable from 1979 to 2004, being essentially the same in the first and last year (Figure 1). Survival from pancreatic cancer is the poorest of any major cancer, digestive system or otherwise. Nevertheless, 5-year survival increased modestly from 2 percent among persons diagnosed in 1979 to 3.8 percent among persons diagnosed in 1999.

In 2004, there were an estimated 415,000 ambulatory care visits for pancreatic cancer and 68,000 hospital discharges with a diagnosis of pancreatic cancer (Table 2). Hospitalization rates were highest among the elderly and age-adjusted rates were higher for blacks and males. While ambulatory care visits appear to have increased from 1992 through 2004, hospital discharge rates were stable from 1979 through 2004 (Figure 2).

Because of low survival, pancreatic cancer mortality was essentially the same as incidence in 2004. As underlying cause, there were 31,800 deaths in 2004 (third highest of all digestive diseases) and more than 200,000 YPLL prior to age 75 years (also third highest of all digestive diseases) (Table 3). Rates were highest in the oldest age group. Age-adjusted mortality rates were higher for blacks and for males. Death rates for pancreatic cancer remained steady between 1979 and 2004 (Figure 3).

Table 1. Pancreatic Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Demographic Characteristics Number of Cases Incidence per 100,000 Unadjusted Incidence per 100,000 Age-Adjusted
AGE (Years)
Under 15
AGE (Years)
15–44
878 0.7
AGE (Years)
45–64
9,513 13.6
AGE (Years)
65+
21,681 63.4
RACE/ETHNICITY
Non-Hispanic White
25,873 13.5 11.2
RACE/ETHNICITY
Non-Hispanic Black
3,614 10.6 15.2
RACE/ETHNICITY
Hispanic
1,929 4.8 10.4
RACE/ETHNICITY
Asian/Pacific Islander
947 7.7 9.2
RACE/ETHNICITY
American Indian/Alaska Native
99 5.3 8.1
Sex
Female
15,709 10.8 10.0
Sex
Male
14,853 10.6 12.7
Total 30,560 10.7

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Figure 1. Pancreatic Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 was relatively stable from 1979 to 2004, being essentially the same in the first and last years at 11.5. Five-year survival increased modestly from 2.03 percent in 1979 to 3.76 percent in 1999, the last year for which it could be calculated.
Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Table 2. Pancreatic Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
1 1 2 2
AGE (Years)
45–64
154 218 162 229 12 16 23 33
AGE (Years)
65+
230 634 251 690 21 59 43 119
Race
White
383 148 409 158 28 11 55 21
Race
Black
4 15 8 30
Sex
Female
214 129 237 144 17 10 34 20
Sex
Male
173 124 178 128 17 13 34 26
Total 386 132 415 141 34 12 68 23

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Figure 2. Pancreatic Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 appear to have increased from 32.9 in 1992-1993 to 137 in 2003-2005. Hospitalizations per 100,000 were stable at 22.8 in 1979 and 20.8 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 3. Pancreatic Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
1 0.0
AGE (Years)
15–44
596 0.5 20.6 606 0.5
AGE (Years)
45–64
8,407 11.9 147.9 8,656 12.2
AGE (Years)
65+
22,796 62.7 38.2 23,825 65.6
Race
White
27,247 10.5 167.8 28,323 10.9
Race
Black
3,681 13.7 31.9 3,848 14.3
Sex
Female
16,004 9.2 83.3 16,602 9.6
Sex
Male
15,796 12.4 123.5 16,487 12.9
Total 31,800 10.8 206.8 33,089 11.3

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Figure 3. Pancreatic Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

Death rates remained steady between 1979 and 2004. Underlying-cause mortality per 100,000 was 10.6 in 1979 and 10.5 in 2004. All-cause mortality per 100,000 was 11.4 in 1979 and 10.9 in 2004.
Source: Vital Statistics of the United States

CHAPTER 13

Hemorrhoids

James E. Everhart, M.D., M.P.H.

Hemorrhoids are classified as diseases of the circulatory system by ICD-9 and ICD-10 (Appendix 1), but are much more often diagnosed and treated by digestive disease specialists than by those with a primary interest in the circulatory system. Therefore, burden data for hemorrhoids are presented in this report. Hemorrhoids are subclassified by anatomical location (internal or external) and whether they are complicated with bleeding, prolapse, strangulation, or ulceration. Hemorrhoids are common, and their treatment is primarily in the ambulatory care setting. In 2004, there were an estimated 2 million ambulatory care visits with hemorrhoids as first-listed diagnosis and 3.2 million visits at which hemorrhoids were an all-listed diagnoses (Table 1), which made hemorrhoids the fourth or fifth leading outpatient digestive system diagnosis (after GERD, abdominal wall hernia, and functional disorders, and essentially tied with diverticular disease). Visit rates were highest among persons age 65 years and older and among whites. Age-adjusted rates were similar for males and for females. Most hospitalizations for hemorrhoids are for surgery, which is performed most often as same-day surgery; thus, the number of hospitalizations for hemorrhoids was small relative to the number of ambulatory care visits (Table 1). As opposed to rates of ambulatory care visits, age-adjusted hospitalization rates were higher for blacks than whites. Hemorrhoids were most often listed as a secondary diagnosis (87 percent).

Age-adjusted ambulatory care visits for hemorrhoids declined slightly between the periods of 1992–1993 and 2003–2005 (Figure 1). The rate of visits in this latter period was about 20 percent lower than in the early 1980s, continuing a trend in declining outpatient visits that began in the 1960s.4 Overnight hospitalizations with hemorrhoids listed as a diagnosis declined by about 60 percent from 1981 to 1994, and were relatively stable for the following 10 years. As a first-listed hospital diagnosis, hemorrhoids declined much more: from about 70 per 100,000 in 1979 to 13 per 100,000 in 2004.5

Death from hemorrhoids has always been exceedingly rare (Table 2 and Figure 2). There was a substantial decline from 1980 through 2004 in hemorrhoids noted as a diagnosis on death certificates.

Nearly 2 million prescriptions for hemorrhoids were filled at retail pharmacies in 2004, according to Verispan (Appendix 2), with topical medications such as pramoxine (pramocaine) and hydrocortisone and stool softeners such as psyllium most often prescribed (Table 3). Most persons with hemorrhoids do not seek medical care and are self-treated using nonprescription medications similar to those listed in Table 3; thus the totals in this table were a small portion of the number and cost of medications used to treat hemorrhoids.6

References

Table 1. Hemorrhoids: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
1 1
AGE (Years)
15–44
716 569 1,131 899 8 7 57 46
AGE (Years)
45–64
915 1,294 1,331 1,883 13 19 96 136
AGE (Years)
65+
387 1,065 790 2,174 16 45 152 418
Race
White
1,819 724 2,915 1,161 29 11 245 96
Race
Black
145 421 234 656 6 19 45 150
Sex
Female
944 621 1,745 1,132 19 12 179 110
Sex
Male
1,092 751 1,531 1,061 19 14 127 95
Total 2,036 693 3,275 1,115 38 13 306 104

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Figure 1. Hemorrhoids: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 declined slightly from 1,122 in 1992–1993 to 1,093 in 2003–2005. Hospitalizations per 100,000 declined from 139 in 1979 to 52.3 in 1994, and were relatively stable through 2004 when the rate was 59.9.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. Hemorrhoids: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
2 0.0 0.1 5 0.0
AGE (Years)
45–64
8 0.0 0.2 22 0.0
AGE (Years)
65+
4 0.0 0.0 30 0.1
Race
White
9 0.0 0.1 42 0.0
Race
Black
2 0.0 0.0 9 0.0
Sex
Female
3 0.0 0.0 21 0.0
Sex
Male
11 0.0 0.2 36 0.0
Total 14 0.0 0.2 57 0.0

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Figure 2. Hemorrhoids: Age-Adjusted Rates of Death in the United States, 1979–2004

Deaths declined substantially from 1980 through 2004. Underlying-cause mortality per 100,000 decreased from 0.01 in 1979 to less than 0.01 in 2004. All-cause mortality per 100,000 decreased from 0.07 in 1979 to 0.02 in 2004.
Source: Vital Statistics of the United States

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Table 3. Hemorrhoids: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Pramoxine/Hydrocortisone 336,508 16.9% $19,424,146 45.1%
Hydrocortisone 989,521 49.8 14,852,947 34.5
Hydrocortisone/Lidocaine 98,928 5.0 6,288,920 14.6
Docusate 511,791 25.7 1,672,743 3.9
Hydrocodone/Acetaminophen 15,223 0.8 437,436 1.0
Oxycodone/Acetaminophen 2,550 0.1 116,818 0.3
Psyllium 7,715 0.4 80,312 0.2
Polycarbophil 14,496 0.7 43,635 0.1
Bismuth subgallate/Zinc oxide/Balsam 4,099 0.2 42,819 0.1
Ibuprofen/Hydrocodone 858 0.0 25,637 0.1
Other 4,296 0.2 39,848 0.0
Total 1,985,985 100.0% $43,025,261 100.0%

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CHAPTER 14

Gastroesophageal Reflux Disease

James E. Everhart, M.D., M.P.H.

In 2004, GERD was by far the most frequently first-listed digestive system condition at ambulatory care visits (Table 1), constituting 17.5 percent of all digestive system diagnoses. There were at least 6 outpatient visits with a GERD diagnosis listed per 100 persons in the United States. GERD was a common diagnosis in all age groups, although the highest rate was for those age 65 years and older. Age-adjusted ambulatory care visit rates were higher among blacks than whites and were similar for females and males. As the first-listed diagnosis, hospitalizations with GERD were not especially common relative to the frequency of outpatient visits. However, GERD was the first-listed diagnosis on only 5 percent of hospital discharges on which it was mentioned. As a result, GERD was the most common digestive system disease noted at hospital discharge and was found on 23.5 percent of hospitalizations at which a digestive system condition was listed at discharge. The pattern by race and sex of rates of hospitalization with a diagnosis of GERD were similar to the rates of ambulatory care visits. About half of all hospital diagnoses were recorded at age 65 years and older.

Rates of both all-listed ambulatory care visits and hospital discharges increased several-fold from the early 1990s to 2004 (Figure 1). Among other digestive system diseases, only viral hepatitis C saw a similar increase in medical care, but much of that increase was a result of the fact that hepatitis C was not recognized as a disease with its own ICD code until 1992. The increases in medical care for GERD began at least as early as the mid-1970s.7 Between 1975 and 2004, the rate of all-listed ambulatory care visits for GERD increased approximately 2,000 percent. It was in the mid-1970s that better means to diagnose (flexible endoscopes) and treat (histamine-2 receptor blockers) became available, both of which stimulated recognition of the condition. Nevertheless, it is quite unlikely that all the increases in GERD-related statistics can be attributed solely to increased recognition.

Despite not being considered a fatal disease, GERD was listed as the underlying cause of more than 1,000 deaths in 2004 (Table 2), 83 percent of which occurred among persons age 65 years and older. GERD was much more often listed as a contributing cause of death, with the large majority at age 65 years and older. Mortality rates differed little by race and sex. Rates of GERD as a first-listed or contributing cause of death increased by 115 percent from 1979 to 2004, with the majority of the increase occurring during the last 9 years of that period (Figure 2).

More than 60 million prescriptions for GERD were estimated to have been filled at retail pharmacies in 2004 (Table 3), representing 48 percent of all prescriptions for digestive system disorders and more than 50 percent of their cost. The large majority of prescriptions and their cost were for proton pump inhibitors, which were the five most commonly prescribed and costliest medications. Because over-the-counter medications were not included in this tabulation, the total medication cost may have been considerably higher.

References

Table 1. Gastroesophageal Reflux Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
693 1,139 1,504 2,473 20 33 110 182
AGE (Years)
15–44
2,083 1,656 4,064 3,230 28 22 463 368
AGE (Years)
45–64
2,463 3,484 6,961 9,847 53 75 1,050 1,486
AGE (Years)
65+
1,611 4,433 5,813 15,999 58 159 1,565 4,307
Race
White
5,567 2,267 14,964 6,002 122 49 2,513 987
Race
Black
1,028 2,872 2,603 8,075 21 65 342 1,107
Sex
Female
3,388 2,209 10,624 6,733 87 54 1,936 1,183
Sex
Male
3,462 2,462 7,718 5,506 71 51 1,252 937
Total 6,849 2,332 18,342 6,246 158 54 3,189 1,086

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Figure 1. Gastroesophageal Reflux Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Rates of both ambulatory care visits and hospital discharges increased several-fold from the early 1990s to 2004. Ambulatory care visits per 100,000 rose from 2,036 in 1992-1993 to 6,146 in 2003-2005. The hospitalization rate per 100,000 was 152 in 1979 and remained relatively stable through 1992, after which it increased to 734 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. Gastroesophageal Reflux Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
18 0.0 1.3 106 0.2
AGE (Years)
15–44
43 0.0 1.6 228 0.2
AGE (Years)
45–64
135 0.2 2.5 1,034 1.5
AGE (Years)
65+
954 2.6 0.6 6,669 18.4
Race
White
1,033 0.4 4.7 7,273 2.7
Race
Black
97 0.4 1.1 649 2.5
Sex
Female
653 0.3 2.2 4,470 2.4
Sex
Male
497 0.4 3.8 3,567 3.0
Total 1,150 0.4 6.0 8,037 2.7

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Figure 2. Gastroesophageal Reflux Disease: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality rates as a first-listed or contributing cause of death increased from 1979 to 2004, with the majority of the increase occurring during the last 9 years of that period. Underlying-cause mortality rates rose only slightly. Underlying-cause mortality per 100,000 was 0.28 in 1979 and 0.37 in 2004. All-cause mortality per 100,000 rose from 1.22 in 1979 to 1.88 in 1995 to 2.63 in 2004.
Source: Vital Statistics of the United States

Table 3. Gastroesophageal Reflux Disease: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Lansoprazole 14,233,183 22.0% $2,187,235,735 28.4%
Esomeprazole 14,250,281 22.1 2,180,756,920 28.4
Pantoprazole 9,995,074 15.5 1,224,174,329 15.9
Rabeprazole 5,954,447 9.2 914,472,545 11.9
Omeprazole 6,630,268 10.3 840,514,740 10.9
Ranitidine 8,771,688 13.6 202,788,663 2.6
Famotidine 1,527,991 2.4 51,413,838 0.7
Metoclopramide 2,326,992 3.6 34,416,702 0.4
Nizatidine 187,276 0.3 26,124,573 0.3
Sucralfate 112,698 0.2 11,892,069 0.2
Other 622,786 0.8 15,976,940 0.2
Total 64,612,684 100.0% $7,689,767,054 100.0%

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CHAPTER 15

Peptic Ulcer Disease

James E. Everhart, M.D., M.P.H.

Peptic ulcers are coded by anatomical location (stomach, duodenum, gastrojejunum, and unspecified), chronicity, and by complication (hemorrhage or perforation). The ICD codes that cover peptic ulcers are shown in Appendix 1. In 2004, there were about 700,000 ambulatory care visits with peptic ulcer as the first-listed diagnosis and an equal number in which it was a secondary diagnosis (Table 1). Ambulatory care rates increased with increasing age, were higher for blacks than for whites, and were higher among women. When listed at hospital discharge, peptic ulcer was the first-listed diagnosis 37 percent of the time.

The frequency of outpatient and inpatient care declined for peptic ulcer disease (Figure 1), which continued a pattern that began in the 1970s, if not before.8 Within 12 years, age-adjusted ambulatory care visit rates with a peptic ulcer diagnosis declined 68 percent, and within 25 years, hospital discharge rates declined 51 percent.

Peptic ulcer was coded as the underlying cause among 3,692 deaths in 2004 and other cause among an additional 4,604 deaths (Table 2). Nearly 80 percent of these deaths occurred among persons age 65 years and older. Age-adjusted death rates were similar for blacks and whites and were higher for males than females. Between 1979 and 2004, mortality from peptic ulcer as underlying cause declined 62.6 percent and as underlying or other cause by 68.8 percent (Figure 2). This continued at least a century of decline in peptic ulcer mortality.9 Much of the decline in the medical significance of peptic ulcer has been attributed to the decline of Helicobacter pylori, which is a causative agent. This effect has likely been accelerated by the widespread adoption of acid suppressive medications (Table 3) and eradication of H. pylori infection by antimicrobial agents. Although antimicrobial agents are important for treatment of peptic ulcer disease, they do not appear among the most commonly used drugs, perhaps because of their short-term self-limited use. The high use of acid suppressant therapy does not differentiate indications for treatment from prophylaxis.

References

Table 1. Peptic Ulcer Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
1 2 2 4
AGE (Years)
15–44
251 199 472 375 23 19 61 48
AGE (Years)
45–64
164 233 472 668 53 75 142 201
AGE (Years)
65+
295 812 525 1,444 104 285 283 780
Race
White
420 171 926 371 134 52 361 141
Race
Black
71 251 149 491 21 70 65 218
Sex
Female
389 242 898 574 92 55 259 154
Sex
Male
323 230 575 408 89 68 229 176
Total 712 243 1,473 501 181 62 489 166

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Figure 1. Peptic Ulcer Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). The frequency of outpatient and inpatient care declined for peptic ulcer disease. Ambulatory care visits per 100,000 decreased from 1,535 in 1992-1993 to 493 in 2003-2005. Hospitalizations per 100,000 decreased from 287 in 1979 to 140 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. Peptic Ulcer Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
7 0.0 0.5 9 0.0
AGE (Years)
15–44
118 0.1 4.3 221 0.2
AGE (Years)
45–64
646 0.9 12.1 1,331 1.9
AGE (Years)
65+
2,921 8.0 2.7 6,733 18.5
Race
White
3,221 1.2 14.9 7,183 2.7
Race
Black
368 1.3 4.3 849 3.2
Sex
Female
1,995 1.1 7.4 4,287 2.3
Sex
Male
1,697 1.4 12.3 4,009 3.3
Total 3,692 1.3 19.7 8,296 2.8

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Figure 2. Peptic Ulcer Disease: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality declined between 1979 and 2004. Underlying-cause mortality per 100,000 decreased from 3.24 in 1979 to 1.21 in 2004. All-cause mortality per 100,000 decreased from 8.71 in 1979 to 2.72 in 2004.
Source: Vital Statistics of the United States

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Table 3. Peptic Ulcer Disease: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Drug Prescription (#) Prescription Retail Cost Cost
Lansoprazole 1,341,444 26.7% $177,496,893 34.2%
Pantoprazole 1,128,002 22.5 123,697,885 23.9
Esomeprazole 680,009 13.6 85,753,825 16.5
Lansoprazole/Amoxicillin/Clarithromycin 130,482 2.6 40,749,140 7.9
Omeprazole 333,879 6.7 30,663,736 5.9
Rabeprazole 204,602 4.1 27,175,479 5.2
Ranitidine 727,492 14.5 13,039,236 2.5
Nizatidine 89,340 1.8 9,185,345 1.8
Sucralfate 157,770 3.1 5,342,588 1.0
Famotidine 135,865 2.7 3,072,170 0.6
Other 89,023 1.8 2,394,483 0.4
Total 5,017,908 100.0% $518,570,780 100.0%

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CHAPTER 16

Functional Intestinal Disorders

James E. Everhart, M.D., M.P.H.

Included in this chapter are separate entries on chronic constipation and irritable bowel syndrome (IBS). Other functional conditions that were either too uncommon or too nonspecific were functional diarrhea, neurogenic bowel and megacolon not elsewhere described, anal spasm, and other specified and unspecified functional intestinal disorders. These are included in the section All Functional Intestinal Disorders.

CHRONIC CONSTIPATION

In 2004, constipation was frequently noted at ambulatory care visits either as a first-listed diagnosis (3.1 million visits) or all-listed diagnoses (6.3 million visits) (Table 1), which made it the second most common ambulatory care diagnosis, after GERD. Persons under age 15 years had the highest number of visits for chronic constipation and nearly as great a rate as persons age 65 years and older. The number of ambulatory care visits for the younger age group was equal to that of intestinal infections (Chapter 2). Chronic constipation and GI infections were the two most common reasons for ambulatory care visits among children. Rates of visits with a chronic constipation diagnosis were also higher for blacks and for females. Hospitalizations with chronic constipation were uncommon, with first-listed diagnoses only 1–2 percent of ambulatory care visits. All-listed diagnoses of chronic constipation were more common—about one-tenth the rate of all-listed ambulatory care diagnoses. After many years of stable rates of medical care statistics for chronic constipation, there was a surge in both ambulatory medical care visits and hospitalizations between 1992 and 2004 (Figure 1), with more than a doubling of rates of ambulatory care diagnoses and nearly a fourfold increase in rates of hospital discharge diagnoses. The rate of ambulatory visits began to increase at least as early as 1985, when there were approximately 500 per 100,000 population.10

Mortality from chronic constipation is, of course, rare (Table 2). Nevertheless, in keeping with the increase in medical care, there was an increase in constipation as either underlying cause or underlying or other cause between 1989 and 2004 (Figure 2).

According to the Verispan database of retail pharmacy prescriptions (Appendix 2), in 2004, nearly half of all medications prescribed for chronic constipation were for the laxative polyethylene glycol (Table 3). Tegaserod (Zelnorm®), a medication for women with irritable bowel syndrome and constipation, was not as commonly prescribed, but was nearly as costly. Other medications were primarily stool softeners or motility agents. These data did not capture the very large number of nonprescription medications purchased for constipation.

IRRITABLE BOWEL SYNDROME

In 2004, there were 3 million ambulatory care visits with IBS noted as a diagnosis, and slightly more than half were first-listed diagnoses (Table 4). Unlike constipation, which was common among children, rates of visits with IBS increased with age only in later adulthood. Whites had more than twice the age-adjusted rate of visits as blacks. The rate of visits among females was more than 4 times that of males—the largest sex difference for any digestive disease. IBS was rarely noted as first-listed diagnosis on hospital discharge, but was much more commonly coded as a secondary diagnosis. The age, race, and sex patterns for all-listed discharge diagnosis were similar to ambulatory care diagnoses.

Age-adjusted rates of ambulatory care visits with an IBS diagnosis fell by about 20 percent between 1992–1993 and 2003–2005 (Figure 3), although the rate in the latest period was similar to rates in 1981, 1982, and 1985.11 In contrast, rates of hospital discharges with a diagnosis of IBS fell in the mid-1980s, leveled off through the mid-1990s, and then increased by 81 percent between 1999 and 2004. IBS as underlying or contributing cause of death was exceedingly rare (Table 5), and trend data were not meaningful (Figure 4).

According to the Verispan database of retail pharmacies, in 2004, tegaserod (Zelnorm®) contributed much to the cost of IBS and was the third most widely prescribed drug (Table 6). The anticholinergic drugs hyoscyamine and dicyclomine were the most commonly prescribed drugs.

ALL FUNCTIONAL INTESTINAL DISORDERS

As a group of conditions, functional disorders were common reasons for outpatient visits, such that there were estimated to be more than 11 million ambulatory care visits noting these diagnoses in 2004 (Table 7), or about 4 visits per every 100 persons in the United States. Eighty percent of these visits were for either chronic constipation or IBS. Hospitalizations for functional disorders were uncommon, but they did commonly appear as an all-listed diagnoses. Recent increases in diagnoses with a mention of functional disorders on ambulatory care visits and hospital discharge were almost entirely due to increased rates of diagnoses of constipation (Figure 5). Chronic constipation and IBS accounted for 73.5 percent of these diagnoses. Functional disorders were coded as an underlying cause of death for 423 persons in 2004, and listed as a contributing cause for 1,766 persons (Table 8). The death rate with mention of functional intestinal conditions was stable from 1979 to 1999, when the change to ICD-10 coding resulted in a 19 percent increase that was likely a coding artifact (Figure 6).

According to the Verispan database of retail pharmacies, in 2004, there were estimated to be more than 13 million prescriptions filled at retail pharmacies at a cost of nearly three-quarters of a billion dollars (Table 9). Nearly one-third of this cost was for tegaserod (Zelnorm®). Other agents were primarily for pain, including several acid-blocking agents, or for constipation.

References

Table 1. Chronic Constipation: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
1,175 1,933 2,127 3,497 5 8 32 53
AGE (Years)
15–44
601 478 1,397 1,110 6 5 106 84
AGE (Years)
45–64
492 696 1,112 1,572 8 11 164 231
AGE (Years)
65+
880 2,423 1,671 4,599 18 50 399 1,097
Race
White
2,582 1,064 5,057 2,100 28 11 534 209
Race
Black
430 1,011 990 2,620 5 15 98 322
Sex
Female
1,955 1,267 4,050 2,655 23 14 434 260
Sex
Male
1,194 866 2,256 1,657 14 11 266 206
Total 3,149 1,072 6,306 2,148 37 13 700 238

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Figure 1. Chronic Constipation: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). After many years of stable rates of medical care for chronic constipation, there was a surge in both ambulatory medical care visits and hospitalizations between 1992 and 2004. Ambulatory care visits per 100,000 increased from 876 in 1992-1993 to 2,151 in 2003-2005. The hospitalization rate per 100,000 was 36.1 in 1979 and remained stable through 1992, after which it increased to 154 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. Chronic Constipation: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
3 0.0 0.2 6 0.0
AGE (Years)
15–44
11 0.0 0.5 22 0.0
AGE (Years)
45–64
10 0.0 0.2 54 0.1
AGE (Years)
65+
113 0.3 0.1 500 1.4
Race
White
129 0.1 0.8 527 0.2
Race
Black
7 0.0 0.1 48 0.1
Sex
Female
98 0.1 0.4 381 0.3
Sex
Male
39 0.0 0.5 201 0.1
Total 137 0.0 0.9 582 0.2

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Figure 2. Chronic Constipation: Age-Adjusted Rates of Death in the United States, 1979–2004

There was an increase in mortality rates as either underlying cause or underlying or other cause between 1989 and 2004. Underlying-cause mortality per 100,000 was 0.01 in 1979, 0.02 in 1989, and rose to 0.04 in 2004. All-cause mortality per 100,000 was 0.06 in 1979, 0.08 in 1989, and rose to 0.19 in 2004.
Source: Vital Statistics of the United States

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Table 3. Chronic Constipation: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Polyethylene Glycol 3350 2,462,873 46.0% $78,006,220 43.8%
Tegaserod 487,989 9.1 62,696,997 35.2
Lactulose 1,234,865 23.1 29,190,969 16.4
Docusate® 1,087,397 20.3 7,481,476 4.2
Methylcellulose 13,221 0.2 219,099 0.1
Magnesium Hydroxide 40,991 0.8 176,097 0.1
Psyllium 10,634 0.2 172,225 0.1
Senna® 4,085 0.1 139,618 0.1
Bisacodyl 10,271 0.2 57,569 0.0
Malt Extract 535 0.0 37,774 0.0
Other 3,432 0.0 66,635 0.0
TOTAL 5,356,293 100.0% $178,244,679 100.0%

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Table 4. Irritable Bowel Syndrome: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
0 1 1 2
AGE (Years)
15–44
724 575 1,169 929 8 6 61 48
AGE (Years)
45–64
363 514 979 1,384 5 7 73 103
AGE (Years)
65+
469 1,290 792 2,179 4 11 77 213
Race
White
1,459 593 2,803 1,138 15 6 180 72
Race
Black
212 534 1 4 12 36
Sex
Female
1,322 867 2,531 1,649 14 9 177 112
Sex
Male
283 201 523 373 4 2 35 26
Total 1,605 547 3,054 1,040 18 6 212 72

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Figure 3. Irritable Bowel Syndrome: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 fell from 1,240 in 1992-1993 to 1,032 in 2003-2005. In contrast, rates of hospital discharges fell in the mid-1980s, leveled off through the mid-1990s, and then increased between 1999 and 2004. The hospitalization rate per 100,000 was 91.2 in 1979 and remained stable through 1983, after which it decreased to 31.6 in 1990 and remained stable until 1999, and from there it increased to 54.8 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 5. Irritable Bowel Syndrome: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
7 0.0
AGE (Years)
45–64
1 0.0 0.0 21 0.0
AGE (Years)
65+
19 0.1 0.0 188 0.5
Race
White
19 0.0 0.0 210 0.1
Race
Black
1 0.0 0.0 5 0.0
Sex
Female
16 0.0 0.0 164 0.1
Sex
Male
4 0.0 0.0 52 0.0
Total 20 0.0 0.0 216 0.1

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Figure 4. Irritable Bowel Syndrome: Age-Adjusted Rates of Death in the United States, 1979–2004

IBS as underlying or contributing cause of death was exceedingly rare and trend data were not meaningful.
Source: Vital Statistics of the United States

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Table 6. Irritable Bowel Syndrome: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Tegaserod 1,101,880 18.6% $171,155,138 58.1%
Hyoscyamine 1,574,929 26.5 34,810,797 11.8
Dicyclomine 1,317,179 22.2 20,669,937 7.0
Glycopyrrolate 222,748 3.8 19,877,577 6.7
Clidinium/Chlordiazepoxide 731,965 12.3 11,525,984 3.9
Diphenoxylate 372,133 6.3 7,711,178 2.6
Pantoprazole 45,496 0.8 7,384,419 2.5
Omeprazole 76,680 1.3 5,384,300 1.8
Esomeprazole 38,526 0.6 4,546,806 1.5
Methscopolamine 70,911 1.2 4,393,505 1.5
Other 383,137 6.3 7,201,054 2.4
TOTAL 5,935,584 100.0% $294,660,695 100.0%

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Table 7. All Functional Intestinal Disorders: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
1,347 2,215 2,384 3,921 10 17 48 79
AGE (Years)
15–44
1,710 1,359 3,256 2,588 29 23 248 197
AGE (Years)
45–64
1,127 1,594 2,700 3,820 30 42 341 483
AGE (Years)
65+
1,762 4,851 3,308 9,104 45 124 603 1,660
Race
White
5,039 2,057 9,690 3,980 86 35 944 373
Race
Black
633 1,513 1,391 3,702 16 54 169 546
Sex
Female
3,886 2,518 7,778 5,074 76 47 808 496
Sex
Male
2,059 1,484 3,871 2,815 39 29 432 328
Total 5,945 2,025 11,648 3,967 115 39 1,241 423

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Figure 5. All Functional Intestinal Disorders: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Rates of both ambulatory care visits and hospitalizations have increased in recent years. Ambulatory care visits per 100,000 rose from 2,732 in 1992-1993 to 3,955 in 2003-2005. Hospitalizations per 100,000 decreased from 195 in 1979 to 131 in 1990 and then rose to 299 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 8. All Functional Intestinal Disorders: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
6 0.0 0.4 27 0.0
AGE (Years)
15–44
21 0.0 0.9 106 0.1
AGE (Years)
45–64
49 0.1 0.9 335 0.5
AGE (Years)
65+
347 1.0 0.2 1,721 4.7
Race
White
381 0.1 1.9 1,941 0.7
Race
Black
36 0.1 0.5 214 0.8
Sex
Female
266 0.1 0.9 1,297 0.7
Sex
Male
157 0.1 1.6 892 0.7
Total 423 0.1 2.5 2,189 0.7

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Figure 6. All Functional Intestinal Disorders: Age-Adjusted Rates of Death in the United States, 1979–2004

The death rate was stable from 1979 to 1999, when the change to ICD-10 coding resulted in an increase. Underlying-cause mortality per 100,000 was 0.12 in 1979 and 0.14 in 2004. All-cause mortality per 100,000 was 0.53 in 1979 and 0.72 in 2004.
Source: Vital Statistics of the United States

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Table 9. All Functional Intestinal Disorders: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Tegaserod 1,618,699 11.6% $238,030,688 32.0%
Lansoprazole 695,616 5.0 85,935,464 11.6
Polyethylene glycol 3350 2,647,099 19.0 84,291,600 11.3
Esomeprazole 395,269 2.8 64,101,386 8.6
Pantoprazole 592,957 4.3 60,350,131 8.1
Hyoscyamine 1,787,325 12.8 40,443,459 5.4
Lactulose 1,278,184 9.2 30,168,691 4.1
Rabeprazole 303,450 2.2 29,843,464 4.0
Omeprazole 303,450 1.7 23,755,697 3.2
Glycopyrrolate 242,494 1.7 20,706,229 2.8
Other 4,114,833 29.6 65,854,357 8.9
Total 13,914,807 100.0% $743,481,166 100.0%

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CHAPTER 17

Appendicitis

James E. Everhart, M.D., M.P.H.

Being an acute surgical condition, appendicitis was not especially common at ambulatory care visits, but did account for an estimated 600,000 first-listed ambulatory care visits (Table 1), which was as frequent as those for ulcerative colitis or pancreatitis. Visit rates were nearly equal across age groups up to age 65. Rates were higher among blacks and males. Hospital discharges more accurately reflected disease occurrence. In 2004, there were an estimated 325,000 hospitalizations with a diagnosis of appendicitis, of which 91.7 percent were first-listed diagnosis. This proportion of first-listed diagnoses was higher than that of any other digestive disease and changed little over 20 years.12 Discharge rates did not differ markedly by age. The rate among whites was twice that of blacks, while the rate for males was 20 percent greater than that for females.

Rates of ambulatory care visits increased from 1992–1993 to 2003–2005, but the more significant trends were for hospital discharges (Figure 1). Hospitalizations with a diagnosis of appendicitis declined from 1979 through 1995, continuing a decline that began at least in 1965, if not earlier.13 Between 1995 and 2004, the trend reversed, such that there was a 34 percent increase in the rate of hospital discharges with a diagnosis of appendicitis.

Deaths from appendicitis were uncommon in 2004, with the large majority occurring at age 65 years and older, indicating a high case-fatality rate among older persons (Table 2). Mortality rates from appendicitis continued a many-year decline until 1991 (Figure 2). From 1991 onward, rates remained stable.

Because appendicitis is a surgical condition requiring hospitalization, prescriptions filled at retail pharmacies captured through the Verispan database (Appendix 2) were not frequent nor necessarily representative of the medications used in this condition. In 2004, there were an estimated 315,000 such medications prescribed, at a retail cost of $5.6 million. More than 98 percent of these medications were for pain relievers, with the rest for antimicrobial agents.

References

Table 1. Appendicitis: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
106 174 163 267 61 101 63 103
AGE (Years)
15–44
358 284 458 364 156 124 169 134
AGE (Years)
45–64
133 188 150 212 58 83 65 93
AGE (Years)
65+
21 59 26 72
Race
White
469 200 607 260 232 99 253 107
Race
Black
139 355 18 45 21 53
Sex
Female
260 179 372 258 126 86 144 98
Sex
Male
341 232 410 279 164 112 172 118
Total 601 205 782 266 298 101 325 111

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Figure 1. Appendicitis: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 increased from 189 in 1992–1993 to 269 in 2003–2005. Hospitalizations per 100,000 declined from 129 in 1979 to 87.5 in 1995. Between 1995 and 2004, the trend reversed such that the rate increased to 117 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. Appendicitis: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
21 0.0 1.4 33 0.1
AGE (Years)
15–44
31 0.0 1.4 45 0.0
AGE (Years)
45–64
97 0.1 1.9 168 0.2
AGE (Years)
65+
304 0.8 0.3 516 1.4
Race
White
378 0.1 3.7 646 0.2
Race
Black
59 0.2 1.0 90 0.3
Sex
Female
200 0.1 1.4 341 0.2
Sex
Male
253 0.2 3.6 421 0.3
Total 453 0.2 5.0 762 0.3

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Figure 2. Appendicitis: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality rates declined until 1991, after which they remained stable. Underlying-cause mortality per 100,000 decreased from 0.35 in 1979 to 0.16 in 1991 and was 0.15 in 2004. All-cause mortality per 100,000 decreased from 0.63 in 1979 to 0.32 in 1991, and was 0.25 in 2004.
Source: Vital Statistics of the United States

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CHAPTER 18

Abdominal Wall Hernia

James E. Everhart, M.D., M.P.H.

Abdominal wall hernias (AWH) are coded by their anatomical location (direct and indirect inguinal, femoral, and umbilical, plus other or unspecified) and subcoded by complication (obstruction, with or without gangrene) in ICD-10. Coding was different in ICD-9, which had an odd combination of location and complication (Appendix 1). However, the individual codes match up fairly well between the two editions.

The large majority of AWH are inguinal hernias, which frequently occur as a result of incomplete closure of the inguinal canal in male infants. Hence, there was a substantial number of ambulatory care visits among children and more than twice the rate among males as females in 2004 (Table 1). However, among adults, the rate of visits increased progressively with age. Whites had a higher rate than blacks. Rates have not changed appreciably since 1975.14 AWH was the third leading cause of ambulatory care visits in 2004, after GERD and constipation. Rates of hospital discharges with AWH were higher among blacks and there was little difference by sex.

The definitive treatment of AWH is by surgical repair. Because most repairs no longer require overnight hospitalization, the rate of hospitalizations has declined substantially, largely over a 10-year period between 1983 and 1993 (Figure 1). This decline was mostly accounted for by substantial reduction in the number of direct hernia repairs among males.15 The same decline did not occur among females, which may account for the similar discharge rates between males and females.

In 2004, more than 1,000 persons died with AWH as the underlying cause (Table 2). The large majority of deaths occurred among persons age 65 years and older. Mortality rates were similar for whites and blacks and for males and females. Mortality rates declined between 1979 and the mid-1990s for AWH as underlying cause and more substantially as underlying or other cause (Figure 2). Mortality rates were then stable through 2004.

Because AWH is primarily a surgical condition, prescriptions filled at retail pharmacies captured through the Verispan database (Appendix 2) may not have captured the extent and nature of medication use for these conditions. In 2004, there were an estimated 3.7 million retail prescriptions filled, at a cost of $59.5 million. More than 97 percent of these prescriptions were for analgesics, with the rest for antimicrobial agents.

References

Table 1. Abdominal Wall Hernia: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
160 264 417 685 5 8 24 40
AGE (Years)
15–44
1,113 885 1,278 1,016 29 23 65 52
AGE (Years)
45–64
1,492 2,111 1,804 2,552 60 84 124 176
AGE (Years)
65+
976 2,686 1,288 3,545 69 189 158 435
Race
White
3,347 1,348 4,223 1,703 130 51 290 115
Race
Black
287 858 437 1,275 17 54 47 142
Sex
Female
1,056 681 1,526 987 86 54 194 121
Sex
Male
2,686 1,902 3,261 2,317 75 56 177 132
Total 3,742 1,274 4,787 1,630 163 55 372 127

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Figure 1. Abdominal Wall Hernia: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 increased from 1,340 in 1992-1993 to 1,607 in 2003-2005. The rate of hospitalization has declined substantially, largely over a 10-year period between 1983 and 1993. Hospitalizations per 100,000 decreased from 391 in 1979 to 111 in 1995 and then remained stable through 2004 when the rate was 110.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. Abdominal Wall Hernia: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
10 0.0 0.7 21 0.0
AGE (Years)
15–44
43 0.0 1.6 70 0.1
AGE (Years)
45–64
197 0.3 3.8 384 0.5
AGE (Years)
65+
922 2.5 0.8 1,624 4.5
Race
White
1,015 0.4 5.3 1,815 0.7
Race
Black
133 0.5 1.5 246 0.9
Sex
Female
670 0.4 3.2 1,132 0.6
Sex
Male
502 0.4 3.7 967 0.8
Total 1,172 0.4 6.9 2,099 0.7

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Figure 2. Abdominal Wall Hernia: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality rates declined between 1979 and the mid-1990s as underlying cause and more substantially as underlying or other cause, and were then stable through 2004. Underlying-cause mortality per 100,000 decreased from 0.61 in 1979 to 0.39 in 2004. All-cause mortality per 100,000 decreased from 1.68 in 1979 to 0.83 in 1991, and was 0.69 in 2004.
Source: Vital Statistics of the United States

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CHAPTER 19

Inflammatory Bowel Disease

James E. Everhart, M.D., M.P.H.

The two inflammatory bowel diseases (IBD) are Crohn’s disease (also known as regional enteritis) and ulcerative colitis (UC). Adding the data for the two results in the number of ambulatory care visits, hospital discharge diagnoses, and deaths for all IBD. (Tables and figures also are shown for all IBD, but not discussed.) Most care for these chronic diseases occurs in the outpatient setting, with hospitalizations reserved for complications that might require surgery. Mortality is relatively uncommon, such that death due to GERD is more common than death due to IBD. The significant suffering from IBD is not captured well in such statistics.

CROHN’S DISEASE

In 2004, Crohn’s disease resulted in more than 800,000 first-listed ambulatory care visits and more than 1 million all-listed visits (Table 1). Although Crohn’s disease affects both children and older adults, more than 80 percent of visits were among young and middle-aged adults. Visits were most common among whites, and there were similar rates for males and females. Crohn’s disease was the first-listed diagnosis at 57,000 hospital discharges and was mentioned as another diagnosis on nearly 100,000 other discharges. Rates increased modestly with age among adults and were higher for whites and females.

Age-adjusted rates of ambulatory care visits increased from 1992–1993 through 2003–2005 by 74 percent (Figure 1), continuing a trend that began at least as early as 1985, when the rate of office-based visits was 185 per 100,000 population.16 Rates of hospitalization were relatively stable from 1979 through the early 1990s, but then increased modestly. Crohn’s disease was uncommonly listed as the underlying cause of death in 2004, and more often as a contributing cause (Table 2). Rates increased with age and did not differ greatly by race or by sex. Between 1979 and 2004, mortality for Crohn’s disease as underlying cause changed little, but as underlying or other cause increased by 53 percent (Figure 2).

According to the Verispan database of prescriptions filled at retail pharmacies (Appendix 2), mesalamine was the costliest and most frequently prescribed medication for Crohn’s disease (Table 3), although not approved for this condition. Mesalamine was one of several nonspecific anti-inflammatory agents prescribed. The exception was infliximab, a monoclonal antibody for which there was a considerable cost for the modest number of prescriptions.

ULCERATIVE COLITIS

In 2004, there were about one-half million first-listed ambulatory care visits for UC and about 700,000 all-listed visits (Table 4). Visit rates were highest among young adults, and women had almost twice the rate of men. Visits were not frequent enough among other groups to provide reliable data. Hospitalizations were relatively uncommon, with 35,000 first-listed discharge diagnoses and 82,000 all-listed diagnoses.

Ambulatory care rates for UC may have increased between 1992–1993 and 2003–2005 (Figure 3), but not nearly as much as for Crohn’s disease. Hospitalization rates with a discharge diagnosis of UC were relatively stable for many years, as far back as 1970, but then increased 67 percent in just 5 years, 1999–2004.17 UC was uncommonly listed as the underlying cause of death in 2004, and more often as a contributing cause (Table 5). Mortality rates did not change between 1979 and 2004, except for a sharp drop in 1999, the year that ICD-10 was instituted for mortality coding (Figure 4).

According to the Verispan database of prescriptions filled at retail pharmacies, mesalamine and its prodrug balsalazide accounted for the majority of prescriptions and three-quarters of the prescription cost for UC (Table 6). Comparing Crohn’s disease and UC, the number of prescriptions and their costs were very similar, as were the actual drugs prescribed. The major difference was that UC was treated with fewer drugs. A significant limitation of the drug data is a lack of information on infusion biologics, which have become an important and expensive treatment for IBD.

References

Table 1. Crohn’s Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
2 3 3 5
AGE (Years)
15–44
405 322 505 401 33 26 64 51
AGE (Years)
45–64
304 430 455 644 15 21 44 63
AGE (Years)
65+
7 18 30 82
Race
White
729 299 1,050 425 46 19 117 48
Race
Black
6 15 12 34
Sex
Female
462 315 665 444 32 22 84 55
Sex
Male
385 266 512 369 24 16 57 40
Total 847 288 1,176 401 57 19 141 48

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Figure 1. Crohn’s Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 increased from 227 in 1992–1993 to 395 in 2003–2005. The hospitalization rate per 100,000 was 22.9 in 1979 and remained relatively stable through 1990, after which it increased modestly to 35.8 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. Crohn’s Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
1 0.0 0.1 2 0.0
AGE (Years)
15–44
70 0.1 2.8 137 0.1
AGE (Years)
45–64
195 0.3 3.7 473 0.7
AGE (Years)
65+
356 1.0 0.5 973 2.7
Race
White
573 0.2 6.0 1,473 0.6
Race
Black
44 0.1 0.9 102 0.3
Sex
Female
371 0.2 3.5 886 0.5
Sex
Male
251 0.2 3.6 699 0.5
Total 622 0.2 7.0 1,585 0.5

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Figure 2. Crohn’s Disease: Age-Adjusted Rates of Death in the United States, 1979–2004

Between 1979 and 2004, mortality as underlying cause changed little, but as underlying or other cause increased. Underlying-cause mortality per 100,000 was 0.16 in 1979 and 0.21 in 2004. All-cause mortality per 100,000 rose from 0.34 in 1979 to 0.52 in 2004.
Source: Vital Statistics of the United States

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Table 3. Crohn’s Disease: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Mesalamine 701,941 37.4% $180,555,504 69.0%
Mercaptopurine 182,978 9.7 29,004,965 11.1
Azathioprine 369,377 19.7 19,433,538 7.4
Budesonide 75,949 4.0 17,236,094 6.6
Prednisone 420,924 22.4 6,931,980 2.7
Sulfasalazine 112,215 6.0 4,230,607 1.6
Infliximab 986 0.1 2,072,089 0.8
Balsalazide 5,260 0.3 1,382,994 0.5
Methylprednisolone 6,615 0.4 337,040 0.1
Olsalazine 2,123 0.1 319,852 0.1
Total 1,878,368 100.0% $261,504,663 100.0%

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Table 4. Ulcerative Colitis: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
1 2 2 3
AGE (Years)
15–44
205 163 16 13 29 23
AGE (Years)
45–64
10 14 24 34
AGE (Years)
65+
8 23 27 75
Race
White
435 173 582 230 29 12 70 28
Race
Black
3 8 6 18
Sex
Female
306 201 483 308 19 12 45 28
Sex
Male
232 162 16 11 37 27
Total 513 175 716 244 35 12 82 28

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Figure 3. Ulcerative Colitis: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 increased from 231 in 1992–1993 to 241 in 2003–2005 (with a dip to 190 in 1994-1996). The hospitalization rate per 100,000 was 16.9 in 1979 and remained relatively stable for many years until 1999, but then increased to 26.5 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 5. Ulcerative Colitis: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
2 0.0
AGE (Years)
15–44
17 0.0 0.7 65 0.1
AGE (Years)
45–64
56 0.1 1.0 166 0.2
AGE (Years)
65+
238 0.7 0.3 757 2.1
Race
White
291 0.1 1.7 930 0.4
Race
Black
18 0.1 0.3 54 0.2
Sex
Female
168 0.1 0.9 502 0.3
Sex
Male
143 0.1 1.1 488 0.4
Total 311 0.1 2.0 990 0.3

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Figure 4. Ulcerative Colitis: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality rates did not change between 1979 and 2004, except for a sharp drop in 1999, the year that ICD-10 was instituted for mortality coding. Underlying-cause mortality per 100,000 was 0.22 in 1979, decreased to 0.11 in 1999, and was 0.10 in 2004. All-cause mortality per 100,000 was 0.48 in 1979, decreased to 0.36 in 1999, and was 0.33 in 2004.
Source: Vital Statistics of the United States

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Table 6. Ulcerative Colitis: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Mesalamine 1,080,775 49.5% $177,226,718 65.0%
Balsalazide 213,951 9.8 57,138,781 20.9
Sulfasalazine 464,152 21.3 19,986,261 7.3
Olsalazine 57,143 2.6 9,955,396 3.6
Prednisone 350,182 16.1 4,821,998 1.8
Budesonide 15,419 0.7 3,733,906 1.4
Total 2,181,622 100.0% $272,863,060 100.0%

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Table 7. All Inflammatory Bowel Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
3 6 5 8
AGE (Years)
15–44
543 432 710 564 49 39 92 73
AGE (Years)
45–64
486 688 677 958 25 35 68 96
AGE (Years)
65+
446 1,227 15 41 56 155
Race
White
1,163 472 1,631 654 76 31 185 75
Race
Black
236 764 9 23 18 51
Sex
Female
768 516 1,148 752 51 34 127 82
Sex
Male
592 410 744 531 40 28 93 66
Total 1,359 463 1,892 644 92 31 221 75

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Figure 5. All Inflammatory Bowel Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 increased from 458 in 1992–1993 to 636 in 2003–2005. The hospitalization rate per 100,000 was 39.4 in 1979 and remained relatively stable through 1990, after which it increased to 61.7 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 8. All Inflammatory Bowel Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
1 0.0 0.1 4 0.0
AGE (Years)
15–44
87 0.1 3.5 202 0.2
AGE (Years)
45–64
251 0.4 4.8 636 0.9
AGE (Years)
65+
594 1.6 0.7 1,729 4.8
Race
White
864 0.3 7.7 2,399 0.9
Race
Black
62 0.2 1.1 156 0.5
Sex
Female
539 0.3 4.3 1,386 0.8
Sex
Male
394 0.3 4.7 1,185 0.9
Total 933 0.3 9.1 2,571 0.9

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Figure 6. All Inflammatory Bowel Disease: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality remained stable between 1979 and 2004. Underlying-cause mortality per 100,000 was 0.38 in 1979 and 0.31 in 2004. All-cause mortality per 100,000 was 0.82 in 1979 and 0.85 in 2004.
Source: Vital Statistics of the United States

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CHAPTER 20

Diverticular Disease

James E. Everhart, M.D., M.P.H.

Under ICD-10, diverticular disease is coded by anatomical site (small intestine, large intestine, both, or unspecified), although nearly all disease occurs in the large intestine, and by complication (perforation, abscess, or peritonitis). Under ICD-9, complications are not listed, but would presumably fall under diverticulitis, which is not a code under ICD-10.

In 2004, diverticular disease was the fifth most common reason for ambulatory care visits, after GERD, constipation, abdominal wall hernia, and hemorrhoids. Diverticular disease is generally considered a disease of the elderly, a belief that is consistent with medical care statistics (Table 1). Rates of ambulatory care visits increased with age, such that half of all visits for diverticular disease were for persons age 65 years and older. Age-adjusted rates were 18 percent higher among whites than blacks and 49 percent higher among women than men. Among digestive diseases, diverticular disease was also one of the most common reasons for hospitalization, with 313,000 first-listed and 815,000 all-listed diagnoses. Rates of hospitalization by demographic groups were similar to those of ambulatory care visits, although blacks had a higher rate than whites.

Ambulatory care visits with a diagnosis of diverticular disease increased about 18 percent between 1992–1993 and 2003–2005 (Figure 1). The rate of hospitalizations with a diagnosis of diverticular disease declined from 1982 until 1989, as it did for other digestive diseases. After several years of minimal change, rates began to increase slightly at the end of the 1990s, rising 16.4 percent between 1996 and 2004.

Diverticular disease was listed as the underlying cause of death among about 58 percent of certificates on which it was listed (Table 2). Nearly 90 percent of underlying cause of deaths occurred among persons age 65 years and older, resulting in an average of only 2.5 YPLL prior to age 75 per death. Age-adjusted death rates were modestly higher among whites and females. Mortality rates as underlying cause of death declined steadily by a total of 35 percent from 1980 through 2004 (Figure 2), which continued a decline begun in 1970 or earlier.18

In 2004, there were an estimated 2.8 million prescriptions at a cost of $100 million filled at retail pharmacies for diagnosis of diverticular disease (Table 3), according to the Verispan database (Appendix 2). All 10 costliest medications were for either antimicrobial agents (ciprofloxacin being the costliest and most common) or pain-relievers, led by morphine.

References

Table 1. Diverticular Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
280 222 329 261 39 31 59 47
AGE (Years)
45–64
622 879 1,239 1,753 101 142 212 299
AGE (Years)
65+
947 2,607 1,686 4,641 173 477 544 1,498
Race
White
1,609 627 2,878 1,115 252 99 668 258
Race
Black
143 481 264 945 30 110 79 291
Sex
Female
1,284 785 2,109 1,293 181 108 493 288
Sex
Male
580 434 1,160 865 131 99 321 251
Total 1,864 635 3,269 1,113 313 107 815 278

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Figure 1. Diverticular Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 increased from 919 in 1992–1993 to 1,082 in 2003–2005. Hospitalizations per 100,000 declined from 272 in 1979 to 179 in 1988. There was minimal change until the end of the 1990s when rates began to increase slightly to 214 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. Diverticular Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
39 0.0 1.4 58 0.0
AGE (Years)
45–64
306 0.4 5.1 505 0.7
AGE (Years)
65+
3,027 8.3 2.1 5,238 14.4
Race
White
3,084 1.2 7.2 5,308 2.0
Race
Black
243 1.0 1.1 410 1.7
Sex
Female
2,299 1.2 4.2 3,867 2.1
Sex
Male
1,073 0.9 4.4 1,934 1.7
Total 3,372 1.1 8.6 5,801 2.0

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Figure 2. Diverticular Disease: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality rates declined steadily from 1980 through 2004. Underlying-cause mortality per 100,000 decreased from 1.64 in 1979 to 1.10 in 2004. All-cause mortality per 100,000 declined from 3.82 in 1979 to 1.90 in 2004.
Source: Vital Statistics of the United States

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Table 3. Diverticular Disease: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Ciprofloxacin 563,520 20.2% $32,814,344 32.7%
Morphine 788,714 28.3 22,240,858 22.2
Levofloxacin 221,943 8.0 20,204,227 20.2
Metronidazole 745,223 26.7 11,416,565 11.4
Amoxicillin/Clavulanate 125,629 4.5 6,411,362 6.4
Hydrocodone/Acetaminophen 187,977 6.7 1,640,576 1.6
Oxycodone/Acetaminophen 47,534 1.7 1,190,000 1.2
Cephalexin 36,199 1.3 715,276 0.7
Ibuprofen/Hydrocodone 15,994 0.6 703,984 0.7
Moxifloxacin 5,577 0.2 611,465 0.6
Other 51,210 1.7 2,281,170 2.3
Total 2,789,520 100.0% $100,229,827 100.0%

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CHAPTER 21

Liver Disease

James E. Everhart, M.D., M.P.H.

There are many causes of liver disease, and the underlying cause is not always clear from administrative data sets. Thus, this report does not break out cause-specific liver disease other than viral hepatitis and hepatocellular carcinoma. Because ICD-10 does not separate acute from chronic liver disease, ICD-9 codes for acute and chronic liver disease were combined to achieve consistency for time trend data (Appendix 1).

In 2004, liver disease was the ninth leading diagnosis at ambulatory care visits, with 2.4 million visits (Table 1). If combined with the 3.5 million visits with a diagnosis of viral hepatitis, then liver disease would have been the third leading diagnosis, after GERD and chronic constipation. All-listed visit rates for liver disease were highest at age 45–64 years. Age-adjusted rates were higher for blacks than whites and slightly higher among females. When listed as a hospital discharge, liver disease was first-listed diagnosis on only 24.4 percent of records. In 2004, liver disease was the third leading diagnosis on hospital discharge records, after only GERD and diverticular disease. Combined with 475,000 viral hepatitis diagnoses, liver disease would have been the second leading diagnosis, with 1.2 million. Rates increased with age and were higher among blacks and males. The rates of age-adjusted ambulatory care visits increased steadily between 1992–1993 and 2003–2005 (Figure 1), in contrast to the 1970s and 1980s, when they were relatively constant.19 Hospitalization rates were stable through the 1970s and fell throughout the 1980s, as was true for many other diseases.20 Between 1999 and 2004, the rate of hospitalization with a diagnosis of liver disease increased by more than a third.

In 2004, there were 36,000 deaths with liver disease listed as underlying cause, which was half the number of deaths with liver disease listed as underlying or other cause (Table 2). Among all digestive diseases, liver disease was the second leading cause of death, after colorectal cancer. Death from liver disease was most common among persons aged 45–64 years, although the mortality rate from liver disease was highest at age 65 years and older. As a result of the large number of deaths occurring at an early age, the YPLL prior to age 75 years was higher than for any other digestive disease. Mortality rates were slightly higher among whites than blacks, and were nearly twice as high among males. Beginning in 1970, through 2004, mortality from liver disease declined slowly but steadily (Figure 2).21 Between 1979 and 2004, liver disease mortality fell 30 percent. This rate of decline would have been halved had deaths from viral hepatitis been included.

According to the Verispan database of retail pharmacy prescriptions (Appendix 2), only three drugs (spironolactone, lactulose, and furosemide) were commonly prescribed for liver disease in 2004, for a total of 731,000 prescriptions at a cost of $16 million (Table 3). Spironolactone constituted 80 percent of both the number of prescriptions (583,000) and their cost ($12.8 million).

References

Table 1. Liver Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
2 2 9 14
AGE (Years)
15–44
346 275 490 389 35 28 153 122
AGE (Years)
45–64
665 941 1,374 1,944 102 144 365 517
AGE (Years)
65+
358 986 503 1,385 47 129 233 640
Race
White
1,122 446 1,903 749 149 59 596 236
Race
Black
198 654 289 912 21 63 96 292
Sex
Female
796 512 1,282 815 73 46 327 206
Sex
Male
577 394 1,116 762 112 78 432 305
Total 1,373 468 2,398 816 185 63 759 259

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Figure 1. Liver Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 increased from 560 in 1992–1993 to 789 in 2003–2005. Hospitalizations per 100,000 fell from 204 in 1979 to 160 in 1988. They remained relatively stable through 2000, after which they increased to 217 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. Liver Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
146 0.2 10.7 491 0.8
AGE (Years)
15–44
4,169 3.3 146.4 7,851 6.2
AGE (Years)
45–64
18,154 25.7 367.6 35,259 49.9
AGE (Years)
65+
13,620 37.5 34.4 29,486 81.2
Race
White
31,041 12.1 462.8 61,685 24.1
Race
Black
3,784 11.8 72.8 8,547 27.1
Sex
Female
13,385 8.2 178.9 27,503 16.8
Sex
Male
22,705 16.2 380.2 45,588 32.8
Total 36,090 12.3 559.1 73,091 24.9

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Figure 2. Liver Disease: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality declined slowly but steadily between 1979 and 2004. Underlying-cause mortality per 100,000 decreased from 16.9 in 1979 to 11.9 in 2004. All-cause mortality per 100,000 decreased from 32.6 in 1979 to 24.0 in 2004.
Source: Vital Statistics of the United States

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Table 3. Liver Disease: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Spironolactone 583,486 79.8% $12,838,400 80.0%
Lactulose 115,294 15.8 3,006,568 18.7
Furosemide 32,450 4.4 208,205 1.3
Total 731,230 100.0% $16,053,173 100.0%

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CHAPTER 22

Gallstones

James E. Everhart, M.D., M.P.H.

Gallstones (cholelithiasis) are coded with or without complications (choledocholithiasis, cholangitis, cholecystitis). Cholecystitis (inflammation of the gallbladder) without the presence of gallstones was not included (Appendix 1).

In 2004, there were an estimated 1.8 million ambulatory care visits with a diagnosis of gallstones, most of which were for gallstones as a first-listed diagnosis (Table 1). Visit rates increased with age, although only modestly after age 65 years. Age-adjusted rates for any visits were 18 percent higher among whites than blacks and 162 percent higher for females than males, which is in keeping with the known risks for gallstones. Gallstones ranked fifth among digestive diseases in all-listed discharge diagnoses in 2004. However, this was an underestimate of the actual hospital burden, because most hospitalizations with gallstones were for cholecystectomy, of which a high proportion were performed laparoscopically without overnight stay and, therefore, not included in hospitalization statistics.22 Based on hospitalization rates prior to this shift in hospital care, gallstones would have ranked first among digestive diseases in first-listed diagnoses and second in all-listed (the first being GERD). Hospitalization rates with mention of gallstones increased with age, were similar for blacks and whites, and were 58 percent higher for women than men. Over time, rates of ambulatory care visits were relatively stable (Figure 1), but increased from the 1980s by at least 20 percent.23 Hospitalization rates dropped by 40 percent in 2004 from their peak in 1991, because of the aforementioned change in hospital care.

Case-fatality rates for gallstones were low in 2004, but there were still more than 1,000 deaths with gallstones listed as underlying cause (Table 2), because the condition is so common and complications can be severe. The large majority of deaths occurred among persons age 65 years and older. Thus, there were only about 4 Y YPLL prior to age 75 years per death with gallstones as the underlying cause. Age-adjusted death rates differed little by race and by sex. Mortality rates fell between 1979 and 2004 by 56 percent for gallstones as underlying cause and by 71 percent as underlying or other cause (Figure 2). This was the greatest rate of decline for any common digestive disease, continuing a pattern from at least 1950, when more than 5,000 persons had gallstones listed as underlying cause of death.24

According to the Verispan database of retail pharmacy prescriptions (Appendix 2), in 2004, the total number of prescriptions for gallstones was 1.65 million at a retail cost of $18.6 million. Analgesics constituted more than 99 percent of these prescriptions.

References

Table 1. Gallstones: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
2 4 4 6
AGE (Years)
15–44
443 352 651 518 119 95 179 142
AGE (Years)
45–64
522 739 734 1,039 106 150 180 255
AGE (Years)
65+
321 883 411 1,132 124 341 259 713
Race
White
1,041 421 1,516 615 278 112 490 195
Race
Black
127 369 179 521 34 102 63 198
Sex
Female
932 604 1,358 882 235 151 406 256
Sex
Male
367 260 478 336 114 85 214 162
Total 1,299 442 1,836 625 352 120 622 212

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Figure 1. Gallstones: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 were relatively stable from 1992-1993 when they were 675 through 2003-2005 when they were 614. The hospitalization rate per 100,000 was 307 in 1979 and was relatively stable through 1991, after which it dropped to 189 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. Gallstones: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
1 0.0
AGE (Years)
15–44
31 0.0 1.1 75 0.1
AGE (Years)
45–64
137 0.2 2.6 276 0.4
AGE (Years)
65+
924 2.5 0.6 1,803 5.0
Race
White
960 0.4 3.3 1,883 0.7
Race
Black
90 0.3 0.7 199 0.8
Sex
Female
648 0.3 2.0 1,256 0.7
Sex
Male
444 0.4 2.4 899 0.8
Total 1,092 0.4 4.4 2,155 0.7

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Figure 2. Gallstones: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality rates fell between 1979 and 2004, more sharply for underlying or other causes than for underlying cause alone. Underlying-cause mortality per 100,000 declined from 0.82 in 1979 to 0.36 in 2004. All-cause mortality per 100,000 declined from 2.45 in 1979 to 0.71 in 2004.
Source: Vital Statistics of the United States

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CHAPTER 23

Pancreatitis

James E. Everhart, M.D., M.P.H.

Pancreatitis is coded as acute or chronic, and the two are grouped together in this chapter, although acute pancreatitis has the greater burden of medical care and mortality.25 In 2004, there were 475,000 ambulatory care visits as first-listed diagnosis and 881,000 visits as all-listed diagnoses (Table 1). Rates of visits with pancreatitis as all-listed diagnoses increased moderately with age. Age-adjusted rates were 25 percent higher among blacks than whites and 52 percent higher among females than males. Pancreatitis was the seventh most commonly noted digestive disease diagnosis on hospitalization, just after peptic ulcer disease. Hospitalization rates increased with age and were 88 percent higher among blacks and 11 percent higher among males. Rates of both ambulatory care visits and hospitalizations with pancreatitis increased from the 1980s to 2004 (Figure 1). In particular, the rate of hospital discharges with a pancreatitis diagnosis increased 62 percent between 1988 and 2004.

In 2004, pancreatitis was the eleventh most common underlying cause of death from digestive diseases and the fifth most common nonmalignant cause, just after peptic ulcer disease. More than half of deaths occurred among persons age 65 years and older (Table 2).

Pancreatitis ranked eighth among all digestive diseases in YPLL prior to age 75, with about 43,000 years or 12.3 years per death. Death rates increased with age and were higher among blacks than whites and men than women. Mortality rates fell slightly from 1979 to 2004 (Figure 2), with the rate for underlying cause having fallen 15 percent over this 25-year period.

According to the Verispan database of retail pharmacy prescriptions (Appendix 2), in 2004, the total number of prescriptions for pancreatitis was approximately 766,000 at a retail cost of roughly $88.6 million (Table 3). Pancreatic enzyme replacements constituted 60.3 percent of the prescriptions and 84.8 percent of the cost. All the other prescriptions were analgesics or antiemetic agents.

References

Table 1. Pancreatitis: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
3 5 5 8
AGE (Years)
15–44
153 121 304 241 99 78 152 120
AGE (Years)
45–64
219 310 354 500 104 147 171 242
AGE (Years)
65+
101 279 222 611 72 197 127 349
Race
White
396 160 721 294 194 78 318 128
Race
Black
77 213 129 368 46 136 81 241
Sex
Female
306 199 545 355 136 87 228 145
Sex
Male
169 116 336 234 140 100 226 161
Total 475 162 881 300 277 94 454 155

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Figure 1. Pancreatitis: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 increased from 241 in 1992-1993 to 296 in 2003-2005. The hospitalization rate per 100,000 was 84.7 in 1979 and was relatively stable through 1988, after which it increased to 134 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

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Table 2. Pancreatitis: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
15 0.0 1.0 26 0.0
AGE (Years)
15–44
467 0.4 17.8 888 0.7
AGE (Years)
45–64
1,044 1.5 21.0 2,222 3.1
AGE (Years)
65+
1,953 5.4 3.0 4,005 11.0
Race
White
2,838 1.1 31.7 5,739 2.2
Race
Black
557 1.8 9.7 1,210 4.0
Sex
Female
1,549 0.9 13.0 3,239 1.9
Sex
Male
1,931 1.5 29.8 3,903 3.0
Total 3,480 1.2 42.8 7,142 2.4

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Figure 2. Pancreatitis: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality rates fell slightly from 1979 to 2004. Underlying-cause mortality per 100,000 declined from 1.36 in 1979 to 1.15 in 2004. All-cause mortality per 100,000 declined from 3.21 in 1979 to 2.36 in 2004.
Source: Vital Statistics of the United States

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Table 3. Pancreatitis: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Amylase/Lipase/Protease 343,519 44.8% $54,085,858 61.1%
Pancrelipase 118,277 15.4 21,041,841 23.8
Hydrocodone/Acetaminophen 171,121 22.3 6,524,330 7.4
Oxycodone/Acetaminophen 76,199 9.9 3,970,182 4.5
Oxycodone 25,097 3.3 2,629,763 3.0
Promethazine 20,846 2.7 184,599 0.2
Codeine/Acetaminophen 8,808 1.1 89,625 0.1
Acetyl Salicylic Acid/Oxycodone 964 0.1 30,971 0.0
Meperidine 1,139 0.1 21,709 0.0
Prochlorperazine 394 0.0 3,834 0.0
Total 766,364 100.0% $88,582,712 100.0%

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CHAPTER 24

Indications and Outcomes of Gastrointestinal Endoscopy

Constance E. Ruhl, M.D., Ph.D.; and James E. Everhart, M.D., M.P.H.

Through diagnosis and management, endoscopy plays a role in nearly all GI diseases as well as a crucial role in clinical research. It is estimated that more than 20 million GI endoscopies are performed yearly in the United States.26 There is no single national endoscopic database that can provide accurate population-based information on the absolute number of GI endoscopies and their indications and diagnostic outcomes. To remedy this important gap in knowledge on the burden of GI disease, data were obtained from the Clinical Outcomes Research Initiative’s (CORI) National Endoscopic Database (NED). For more than 10 years, this project has collected and analyzed computerized endoscopic records gathered from diverse endoscopic practices throughout the United States. Pediatric procedures are not represented, and the participating sites are overrepresented by veteran and military facilities. Nevertheless, the patterns of endoscopy in NED have been shown to be quite similar to that of a national sample of the Medicare population and may well be applicable to the United States as a whole.27 There is no independent confirmation of the indications and diagnoses reported by the endoscopist on the endoscopy record, although the report is frequently included in the medical record and used for billing.

For this report, endoscopic data were obtained for the period 2001–2005. The number of patients receiving the various endoscopic procedures, along with the practices and practice sites where the procedures were conducted, is shown in Table 1. Of the 885,593 procedures performed during this period, 61.2 percent were colonoscopies, 30.6 percent were esophagogastroduodenoscopies (EGD), 6.3 percent were flexible sigmoidoscopies, 1.0 percent were endoscopic retrograde cholangiopancreatography (ERCP), and 0.8 percent were endoscopic ultrasonographies (EUS). Colonoscopy, flexible sigmoidoscopy, and EGD were primarily performed within community or health maintenance organization (HMO) practices in hospital or ambulatory surgery centers. The more specialized procedures of ERCP and EUS were more likely to have been performed in academic centers and almost exclusively in the hospital. Age 50–59 years was the peak age group for all the procedures. There was some ethnic variation in likelihood of receiving a particular procedure, relative to all procedures. Non-Hispanic whites were more likely to have undergone colonoscopy (85.9 percent) and EUS (86.9 percent), non-Hispanic blacks (13.3 percent) and Asian-Pacific Islanders (2.2 percent) flexible sigmoidoscopy, and Native Americans (6.0 percent) and Hispanics (12.4 percent) ERCP. Excluding Veterans Affairs (VA) facilities, the majority of procedures were performed on women.

Of the 101 sites providing data to NED during 2001–2005, 36 did so throughout the 5-year period. At these “stable” sites, the total number of procedures increased by 34.1 percent from 2001 to 2005, but trends differed by procedure (Figure 1). Colonoscopy increased 63.4 percent, partly at the expense of flexible sigmoidoscopy, which decreased by 60.0 percent. EGD increased by 20.3 percent. The frequency of each of these procedures peaked at age 50–59 years, but more so for colonoscopy (Figure 2). At the stable sites, the growth in colonoscopy from 2001 to 2005 was concentrated among this age group and to a lesser extent among persons ages 60–69 years (Figure 3). The number of colonoscopies among other age groups changed little. In contrast, the number of sigmoidoscopies at stable sites declined appreciably among persons ages 40–79 years, but most among those ages 50–79 (Figure 4).

The distribution of indications for all colonoscopies and sigmoidoscopies is shown in Table 2. Because there could be more than one indication for a procedure, the totals of the percentages exceeded 100 percent. Broadly speaking, surveillance and symptoms were more often listed as indications for colonoscopy than for sigmoidoscopy, while screening was a more frequent indication for sigmoidoscopy than for colonoscopy. Suspected bleeding was the most common indication for colonoscopy (29.7 percent), followed by screening of persons at routine risk of colorectal cancer (21.6 percent), surveillance of adenomatous polyps (13.5 percent), and screening for persons with a family history of colorectal cancer (12.1 percent). These most common indications for colonoscopy indicate that concern over possible colorectal cancer was the predominant reason for colonoscopy. The same statement can be made for sigmoidoscopy, except that a high percentage (47.4 percent) were performed for persons at routine risk of colorectal cancer.

The findings among persons who had colonoscopies or sigmoidoscopies are shown in Table 3. The most interesting group is the column of colonoscopic findings among persons at routine risk only, among whom findings should not have been influenced by symptoms or other indications for the procedure. As long as all abnormalities were recorded, these may be considered the prevalence of such findings in the general population. Common but benign conditions such as diverticulosis and hemorrhoids may not have been recorded if a more serious problem was diagnosed. Notably, 21.0 percent of examinations were normal and 6.4 percent found a polyp of at least 1 centimeter or a suspected malignancy. Figure 5 demonstrates colonoscopic findings among persons at routine risk according to age group. Diverticulosis, the most common finding, steadily increased in prevalence from age 50–59 years to age 80 years and older, at which point it was found on 71.4 percent of examinations. Increasing in prevalence with age, but not as quickly as diverticulosis, were polyps of all sizes and number, and hemorrhoids. The prevalence of normal examinations fell from 36.2 percent at age 20–39 years to 10.2 percent at 80 years and above. There was a higher prevalence of polyps among men than women at routine risk (Figure 6), but no other particular differences by sex. Hemorrhoids were more common among Hispanics, but no other racial or ethnic differences were evident (Figure 7).

In contrast to the uneven increase in utilization of colonoscopy across age groups, EGD use increased modestly across all age groups at stable sites (Figure 8). The indications for EGD at all NED sites are shown in Table 4. These indications were not mutually exclusive and included groupings of symptoms, notably alarm symptoms (weight loss, vomiting, or bleeding) and bleeding (anemia, iron deficiency, melena, hematemesis, hematochezia, positive fecal occult blood test, or suspected upper GI bleed). The most common indications for EGD were reflux symptoms (28.3 percent), alarm symptoms (27.7 percent), dysphagia (20.5 percent), signs of bleeding (20.4 percent), and abdominal pain or bloating (20.1 percent). More than 40 percent of examinations had normal findings (Table 5). The most common diagnostic abnormalities were mucosal abnormality, hiatal hernia, and esophageal inflammation, each of which is characteristic of GERD. The next three most common diagnoses, stricture/stenosis, Barrett’s esophagus, and ulcer, can be consequences of GERD. Combining these diagnoses, it can be inferred that the large majority of abnormal findings on EGD are associated with GERD.

ERCP findings from 2001–2005 are shown in Table 6. Because there were fewer than 10,000 ERCP reports from relatively few centers, the generalizability of the results is questionable. Also, some important information appeared in free text fields in the report, making interpretation more difficult. Nevertheless, it appeared that ductal abnormalities and obstruction to flow were the most common findings on ERCP, and that one-third of examinations were normal. EUS was performed too infrequently and at too few sites to present information on either indication or results.

References

Table 1. Characteristics of Endoscopy Sites and Persons Undergoing Endoscopic Procedures, 2001–2005

EGD = Esophagogastroduodenoscopy; ERCP = Endoscopic retrograde cholangiopancreatography; EUS = Endoscopic ultrasonography; VA = Department of Veterans Affairs
Source: National Endoscopy Database/Clinical Outcomes Research Initiative

  Colonoscopy EGD Flexible Sigmoidoscopy ERCP EUS
Number of Patients 542,650 270,957 55,708 9,333 6,945
Number of Practices 76 77 72 40 23
Number of Sites 101 101 96 44 25
Site CHARACTERISTICS (Percentage)
TYPE OF ENDOSCOPY SITE Community/HMO 78.1 72.8 58.5 40.1 2.9
TYPE OF ENDOSCOPY SITE Academic 11.3 14.6 16.6 41.1 66.5
TYPE OF ENDOSCOPY SITE VA/Military 10.6 12.6 24.9 18.8 30.6
TYPE OF FACILITY Office 1.7 2.7 1.1 < 0.1 0
TYPE OF FACILITY Hospital 40.9 49.7 51.3 96.7 100
TYPE OF FACILITY Ambulatory Surgery Center 57.4 47.6 47.7 3.3 < 0.1
PATIENT CHARACTERISTICS (Percentage)
AGE (Years) 20–29 1.7 4.6 5.6 9.2 2.3
AGE (Years) 30–39 4.0 9.4 8.6 10.3 5.3
AGE (Years) 40–49 11.7 17.4 12.2 14.1 13.1
AGE (Years) 50–59 32.9 23.1 34.6 19.3 24.3
AGE (Years) 60–69 25.6 19.5 19.8 16.5 24.1
AGE (Years) 70–79 18.4 17.5 13.6 18.3 22.8
AGE (Years) 80+ 5.9 8.6 5.6 12.4 8.1
Race/Ethnicity Non-Hispanic White 85.9 81.3 78.2 72.0 86.9
Race/Ethnicity Non-Hispanic Black 6.4 7.3 13.3 7.5 5.0
Race/Ethnicity Asian/Pacific Islander 1.5 2.0 2.2 1.8 1.8
Race/Ethnicity American Indian/ Alaska Native 0.8 1.2 0.9 6.0 0.4
Race/Ethnicity Multiracial Non-Hispanic 0.2 0.2 0.6 0.3 0.3
Race/Ethnicity Hispanic 5.3 8.0 4.8 12.4 5.6
Sex Female 49.6 51.4 41.0 52.0 40.7
Sex Male 50.4 48.6 59.0 48.0 59.3
Sex (Excluding VA/Military) Number of Patients 485, 085 236, 848 41,839 7,577 4,819
Sex (Excluding VA/Military) Female 54.3 57.2 52.7 61.1 51.6
Sex (Excluding VA/Military) Male 45.8 42.8 47.3 38.9 48.4

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Figure 1. Number of Endoscopic Procedures at Stable Sites (N=36) by Year, 2001–2005

The number of procedures is shown for colonoscopy, EGD, and flexible sigmoidoscopy. The number of colonoscopies increased from 37,510 in 2001 to 61,301 in 2005. The number of sigmoidoscopies decreased from 8,243 in 2001 to 3,301 in 2005. The number of EGDs increased from 23,695 in 2001 to 28,505 in 2005.
Source: National Endoscopy Database/Clinical Outcomes Research Initiative
EGD = Esophagogastroduodenoscopy

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Figure 2. Number of Endoscopic Procedures by Age, 2001–2005

The number of procedures is shown for colonoscopy, EGD, and flexible sigmoidoscopy for 10-year age groups from 20-29 through 70-79 and for 80+ years. The frequency of each of these procedures peaked at age 50–59 years, but more so for colonoscopy. The number of colonoscopies increased from 9,120 among 20-29 year olds to 63,202 among 40-49 year olds, and more sharply to 178,405 among 50-59 year olds; it then decreased to 31,730 among 80+ year olds. The number of EGDs increased from 12,422 among 20-29 year olds to 62,544 among 50-59 year olds, and then decreased to 23,168 among 80+ year olds. The number of sigmoidoscopies increased from 3,099 among 20-29 year olds to 19,300 among 50-59 year olds, and then decreased to 3,094 among 80+ year olds.
Source: National Endoscopy Database/Clinical Outcomes Research Initiative
EGD = Esophagogastroduodenoscopy

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Figure 3. Number of Colonoscopies at Stable Sites (N=36) by Age and Year, 2001–2005

The growth in colonoscopy from 2001–2005 was concentrated among persons aged 50-59 years and to a lesser extent, among 60–69 year olds. The number of colonoscopies among other age groups changed little. The number of colonoscopies increased between 2001 and 2005 as follows: among 50-59 year olds, from 10,695 to 22,342; among 60-69 year olds, from 9,581 to 16,472; among 70-79 year olds, from 8,015 to 9,984; among 40-49 year olds, from 4,729 to 6,276; among 80+ year olds, from 2,315 to 3,135; and among 20-39 year olds, from 2,175 to 3,092.
Source: National Endoscopy Database/Clinical Outcomes Research Initiative

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Figure 4. Number of Flexible Sigmoidoscopies at Stable Sites (N=36) by Age and Year, 2001–2005

The number of sigmoidoscopies declined appreciably among persons age 40–79 years, but most among those age 50–79. The number of sigmoidoscopies decreased between 2001 and 2005 as follows: among 50-59 year olds, from 2,935 to 992; among 60-69 year olds, from 1,962 to 676; among 70-79 year olds, from 1,333 to 447; among 40-49 year olds, from 834 to 386; among 20-39 year olds, from 841 to 580; and among 80+ year olds, from 338 to 220.
Source: National Endoscopy Database/Clinical Outcomes Research Initiative

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Table 2. Indications for Colonoscopy and Flexible Sigmoidoscopy, 2001–2005

1 Indication categories are not mutually exclusive.
2 Bleeding group = one or more of the following symptoms: anemia or iron deficiency, positive fecal occult blood test, hematochezia, melena.
3 Irritable bowel syndrome cluster = one or more of the following symptoms: diarrhea; constipation; abdominal pain/bloating; change in bowel habits, excluding surveillance of, or established Crohn’s disease or ulcerative colitis; weight loss; and bleeding (anemia or iron deficiency, positive fecal occult blood test, hematochezia, melena).
Source: National Endoscopy Database/Clinical Outcomes Research Initiative

  PERCENTAGE1
INDICATION Colonoscopy (N=542,650) Flexible Sigmoidoscopy (N=55,708)
SURVEILLANCE
Surveillance of Adenomatous Polyps
13.5 2.4
SURVEILLANCE
Surveillance of Colorectal Cancer
2.0 1.0
SURVEILLANCE
Surveillance of Ulcerative Colitis
0.9 1.0
SURVEILLANCE
Surveillance of Crohn’s Disease
0.6 0.4
SURVEILLANCE
Established Crohn’s Disease
0.2 0.2
SURVEILLANCE
Established Ulcerative Colitis
0.2 0.6
SCREENING
Routine Risk Only
21.6 47.4
SCREENING
Family History of Colorectal Cancer
12.1 1.0
SCREENING
Family History of Polyps
2.8 0.3
SYMPTOMS
Bleeding Group2
29.7 21.7
SYMPTOMS
Irritable Bowel Syndrome Cluster3
18.2 15.0
SYMPTOMS
Hematochezia
17.9 20.4
SYMPTOMS
Abdominal Pain/Bloating
9.1 5.4
SYMPTOMS
Diarrhea
7.6 9.9
SYMPTOMS
Positive Fecal Occult Blood Test
7.2 0.7
SYMPTOMS
Change in Bowel Habits
7.1 1.6
SYMPTOMS
Anemia
5.7 0.9
SYMPTOMS
Constipation
5.4 4.5
SYMPTOMS
Weight Loss
1.6 0.5
SYMPTOMS
Melena
0.7 0.2
SYMPTOMS
Iron Deficiency Without Anemia
0.3 < 0.1
FOLLOWUP OF DIAGNOSIS
Polyp Found on Flexible Sigmoidoscopy
1.5 0.2
FOLLOWUP OF DIAGNOSIS
Abnormal Study
1.0 1.2
FOLLOWUP OF DIAGNOSIS
History of Non-Gastrointestinal Cancer
0.8 0.3
FOLLOWUP OF DIAGNOSIS
Suspected Inflammatory Bowel Disease
0.5 0.6
FOLLOWUP OF DIAGNOSIS
Polyp Found on Barium Enema
0.2 0.1
FOLLOWUP OF DIAGNOSIS
Polyp Found on Previous Colonoscopy
0.2 0.4
OTHER 6.5 11.5

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Table 3. Colonoscopy Findings in the Total Population and Persons at Routine Risk Only, and Flexible Sigmoidoscopy Findings, 2001–2005

1 Finding categories are not mutually exclusive.
AVM = arteriovenous malformation
Source: National Endoscopy Database/Clinical Outcomes Research Initiative

FINDING Percentage1 Colonoscopy Total Population (N=542,650) Percentage1 Colonoscopy Routine Risk Only (N=117,422) Percentage1 Flexible Sigmoidoscopy (N=55,708)
Diverticulosis 42.8 45.0 22.3
Hemorrhoids 39.6 34.2 31.7
Polyp 35.9 37.4 16.2
Normal Exam/No Findings 17.6 21.0 30.5
Polyp > 9mm/Suspected Malignant Tumor 7.6 6.4 3.4
Multiple Polyps 7.2 7.2 2.8
Mucosal Abnormality-Colitis 5.2 1.4 7.8
Tumor 1.2 0.4 0.9
Angiodysplasia (AVM) 1.1 0.7 0.3
Other Finding 9.8 6.6 12.1

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Figure 5. Colonoscopy Findings in Persons at Routine Risk by Age, 2001–2005

Diverticulosis, the most common finding, steadily increased in prevalence from age 50-59 years to age 80 years and older. Increasing in prevalence with age, but not as quickly as diverticulosis, were polyps of all sizes and number, and hemorrhoids. The prevalence of diverticulosis was 30.9 percent among 20-39 year olds and remained relatively stable through age 50-59 years when it was 32.6 percent; it then increased to 71.4 percent at age 80 years and older. The prevalence of a polyp increased from 18.8 percent among 20-39 year olds to 38.3 percent among 80+ year olds. The prevalence of hemorrhoids increased from 32.2 percent among 20-39 year olds to 35.9 percent among 80+ year olds. The prevalence of normal examinations fell from 36.2 percent at age 20–39 years to 10.2 percent at 80 years and above. The prevalence of a polyp >9 mm/suspect malignant tumor increased from 2.7 percent among 20-39 year olds to 8.8 percent among 80+ year olds, while that of multiple polyps increased from 1.3 percent among 20-39 year olds to 6.9 percent among 80+ year olds. The prevalence of a diagnosis of mucosal abnormality-colitis was low, ranging from 1.3 at age 60-69 years to 2.7 at age 40-49 years.
Source: National Endoscopy Database/Clinical Outcomes Research Initiative

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Figure 6. Colonoscopy Findings in Persons at Routine Risk by Sex, 2001–2005

There was a higher prevalence of polyps among men than women at routine risk, but no other particular differences by sex. The prevalence for men and women, respectively, was as follows: for diverticulosis, 46% and 44%; for hemorrhoids, 33% and 36%; for a polyp, 43% and 31%; for normal exam/no findings, 19% and 24%; for a polyp >9mm/suspected malignant tumor, 8% and 5%; and for multiple polyps, 9% and 5%.
Source: National Endoscopy Database/Clinical Outcomes Research Initiative

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Figure 7. Colonoscopy Findings in Persons at Routine Risk by Race/Ethnicity, 2001–2005

Hemorrhoids were more common among Hispanics, but no other racial or ethnic differences were evident. The prevalence for non-Hispanic whites, non-Hispanic blacks, and Hispanics, respectively, was as follows: for diverticulosis, 46%, 38%, and 43%; for hemorrhoids, 33%, 34%, and 48%; for a polyp, 38%, 36%, and 30%; for normal exam/no findings, 21%, 24%, and 19%; for a polyp >9mm/suspected malignant tumor, 6%, 7%, and 5%; and for multiple polyps, 8%, 6%, and 5%.
Source: National Endoscopy Database/Clinical Outcomes Research Initiative

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Figure 8. Number of Esophagogastroduodenoscopy (EGD) Procedures at Stable Sites (N=36) by Age and Year, 2001–2005

EGD use increased modestly across all age groups. The number of EGDs increased between 2001 and 2005 as follows: among 50-59 year olds, from 5,649 to 7,126; among 60-69 year olds, from 4,702 to 5,923; among 70-79 year olds, from 4,539 to 4,734; among 40-49 year olds, from 4,099 to 4,702; among 20-39 year olds, from 2,887 to 3,705, and among 80+ year olds, from 1,819 to 2,315.
Source: National Endoscopy Database/Clinical Outcomes Research Initiative
EGD = Esophagogastroduodenoscopy

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Table 4. Indications for Esophagogastroduodenoscopy (EGD) (N=270,957), 2001–2005

1 Indication categories are not mutually exclusive.
2 Alarm symptoms = weight loss, vomiting, bleeding cluster.
3 GERD = reflux symptoms, excluding dysphagia and surveillance of Barrett’s esophagus.
4 Dyspepsia/abdominal pain = dyspepsia and/or abdominal pain/bloating, excluding reflux symptoms; dysphagia; and surveillance of Barrett’s esophagus.
5 Bleeding cluster = any of the following indications: anemia, iron deficiency without anemia, melena, hematemesis, hematochezia, positive fecal occult blood test, suspected upper gastrointestinal bleed.
Source: National Endoscopy Database/Clinical Outcomes Research Initiative

INDICATION PERCENTAGE1
SURVEILLANCE
Surveillance of Barrett’s Esophagus
3.1
SURVEILLANCE
Surveillance of Gastric Ulcer
1.0
SURVEILLANCE
Surveillance of Varices
0.9
SURVEILLANCE
Surveillance of Helicobacter Pylori
0.3
SURVEILLANCE
Surveillance of Duodenal Ulcer
0.2
SURVEILLANCE
Surveillance of Gastric Polyps
0.2
SCREENING
Screening for Barrett’s Esophagus
1.5
SCREENING
Screening for Varices
0.9
SYMPTOMS
Reflux Symptoms/Heartburn
28.3
SYMPTOMS
Alarm Symptoms2
27.7
SYMPTOMS
GERD3
22.3
SYMPTOMS
Dyspepsia/Abdominal Pain4
21.6
SYMPTOMS
Dysphagia
20.5
SYMPTOMS
Bleeding Cluster5
20.4
SYMPTOMS
Abdominal Pain/Bloating
20.1
SYMPTOMS
Anemia
10.5
SYMPTOMS
Dyspepsia
9.7
SYMPTOMS
Nausea
6.7
SYMPTOMS
Vomiting
4.9
SYMPTOMS
Melena
4.6
SYMPTOMS
Weight Loss
4.0
SYMPTOMS
Chest Pain
3.9
SYMPTOMS
Hematemesis
2.8
SYMPTOMS
Diarrhea
2.4
SYMPTOMS
Early Satiety
1.3
SYMPTOMS
Hematochezia
0.9
SYMPTOMS
Anorexia
0.8
SYMPTOMS
Odynophagia
0.7
SYMPTOMS
Pulmonary Symptoms
0.7
SYMPTOMS
Iron Deficiency Without Anemia
0.5
SYMPTOMS
Malabsorption
0.2
SYMPTOMS
Feeding Refusal
0.1
FOLLOWUP OF DIAGNOSIS
Positive Fecal Occult Blood Test
2.7
FOLLOWUP OF DIAGNOSIS
Suspected Upper Gastrointestinal Bleed
2.5
FOLLOWUP OF DIAGNOSIS
Abnormal Study/Exam/Results
2.1
FOLLOWUP OF DIAGNOSIS
Therapeutic Intervention
1.2
FOLLOWUP OF DIAGNOSIS
Evaluation of Suspected Varices
0.8
FOLLOWUP OF DIAGNOSIS
Suspected Barrett’s Esophagus
0.4
FOLLOWUP OF DIAGNOSIS
Family History of Cancer
0.3
FOLLOWUP OF DIAGNOSIS
Prior Upper Gastrointestinal Cancer
0.2
FOLLOWUP OF DIAGNOSIS
Gastrointestinal Symptoms in Immunocompromised Host
0.1
FOLLOWUP OF DIAGNOSIS
Personal History of Other Upper Gastrointestinal Condition
0.1
FOLLOWUP OF DIAGNOSIS
Evaluation of Crohn’s Disease
< 0.1
Other 8.4

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Table 5. Esophagogastroduodenoscopy (EGD) Findings (N=270,957), 2001–2005

1 Finding categories are not mutually exclusive.
Source: National Endoscopy Database/Clinical Outcomes Research Initiative

FINDING PERCENTAGE1
Normal Exam 41.5
Mucosal Abnormality 38.8
Hiatal Hernia 33.4
Esophageal Inflammation 17.8
Stricture/Stenosis 9.9
Barrett’s Esophagus 6.7
Ulcer 6.3
Polyp 4.5
Varices 2.8
Prior Surgery 2.6
Foreign Body/Retained Food 2.1
Nodule 2.0
Anatomical Deformity 1.0
Tumor 0.9
Arteriovenous Malformation 0.9
Healed Ulcer 0.5
Other Finding 18.0

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Table 6. Endoscopic Retrograde Cholangiopancreatography (ERCP) Findings (N=9,333), 2001–2005

1 Finding categories are not mutually exclusive.
Source: National Endoscopy Database/Clinical Outcomes Research Initiative

FINDING PERCENTAGE1
Ductal Dilation 37.2
Normal Exam 34.6
Stones 25.9
Stricture/Stenosis 18.1
Filling Defect 8.5
Duodenal Diverticulum 5.7
Stent 4.6
Leak/Extravasation 3.1
Irregularity 2.3
Tumor 1.5
Pancreas Divisum 1.0
Pancreatitis 0.7
Extrinsic Compression 0.5
Pancreatic Pseudocyst 0.4
Cholangitis 0.3
Other Finding 28.2

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CHAPTER 25

Costs of Digestive Diseases

Constance E. Ruhl, M.D., Ph.D.; Bryan Sayer, M.H.S.; Danita D. Byrd-Holt, B.B.A.; and Douglas M. Brown, Ph.D.

This chapter provides the estimated costs of digestive diseases in the United States for 2004, the last year for which data were available from all sources used in this analysis. Direct medical costs included expenditures for hospital services, physician services, prescription drugs, over-the-counter drugs, nursing home care, home health care, hospice care, and outpatient endoscopy. Indirect costs of morbidity and mortality associated with digestive diseases were also calculated.

The costs of digestive diseases were estimated using the human capital approach.28, 29 Costs under the human capital method include the value of resources used for medical care (direct costs) and those forgone due to time lost from work and leisure (indirect costs). To calculate direct costs, billed charges are used as an imperfect surrogate for the sum of all the resource payments used in the production of patient services for which data are unavailable. For hospital facilities, costs obtained from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS) (Appendix 2) were converted from total charges using cost-to-charge ratios based on hospital accounting reports from the Centers for Medicare & Medicaid Services.

Where possible, an attempt was made to provide cost estimates by ICD codes for each digestive disease with a substantial economic impact. Digestive disease definitions were based on ICD-9-CM codes for health care and ICD-10 codes for mortality, as listed in Appendix 1.

The methodology used to derive cost estimates for digestive diseases is briefly described here. More detail is to be made available at a National Institutes of Health Web site. A conservative approach was taken toward estimation of economic costs. A limitation of this approach is an underestimate of indirect costs related to work loss from digestive diseases not related to medical care (discussion follows).

DIRECT COSTS

Direct costs represent charges for hospital services, physician services, prescription drugs, over-the-counter drugs, nursing home care, home health care, hospice care, and outpatient endoscopy.

Hospital facility costs and physician charges for hospital and ambulatory care include only non-Federal hospitals and physicians, and, therefore, underestimate the total costs of hospital care and ambulatory care for digestive diseases in the United States. (Federal hospitals and physicians include those of the armed services, Department of Veterans Affairs, and the Indian Health Service.) Approximately 10 percent of care in the United States is provided by non-reported hospitals and physicians.

Hospital facility costs (Table 2, column 2) were taken from the 2004 HCUP NIS, a representative sample of hospital discharges from non-Federal hospitals in the United States (Appendix 2). Some hospital facility costs were assumed to be associated with problems other than the first-listed diagnosis. Therefore, 80 percent of inpatient facility charges were allocated to the primary diagnosis (or 100 percent if no secondary diagnoses were present). The remaining 20 percent was allocated to the secondary diagnoses in proportion to the number of secondary diagnoses. For example, if there were three secondary diagnoses, each one received one-third of 20 percent of these costs. If two of the three secondary diagnoses were digestive diseases, then those two each received one-third of 20 percent of the total, and the other one-third was not included, because it was associated with a nondigestive disease.

Total hospital facility costs were $40.6 billion. Facility charges for first-listed diagnoses were 86 percent of the total hospital charges. Diseases costing more than $1 billion (in descending order) were gallstones, abdominal wall hernia, diverticular disease, pancreatitis, colorectal cancer, appendicitis, liver disease, GERD, and peptic ulcer disease.

Physician hospital charges (Table 2, column 3) include those for performing procedures and those for patient visits (rounds). Data on number of hospital discharges with a diagnosis of each digestive disease, as well as length of stay and procedures performed at those visits, were taken from the 2004 HCUP NIS. Because no national estimates were available for the average price charged by physicians per procedure, Medicare reimbursement rates were used. These rates are locality-specific; therefore, we used the average of the regional reimbursement rates weighted by the population density of each region. As in the calculation of hospital facility costs, 80 percent of physician procedure charges were allocated to the primary diagnosis and 20 percent to secondary diagnoses.

To estimate physician visit charges, Medicare reimbursement rates were used. It was assumed that for each first-listed diagnosis there was one physician visit per day in the hospital, and that when a digestive disease was a secondary diagnosis, an average of one visit per hospitalization by a second physician would have occurred for each secondary digestive disease diagnosis.

Two surgical procedures, laparoscopic cholecystectomy (ICD-9-CM procedure code 51.23) and inguinal herniorrhaphy (ICD-9-CM 53.0–53.1), are frequently performed as ambulatory surgery. For each of these procedures, the number of ambulatory surgeries was estimated as the difference between the total number of surgeries (inpatient and outpatient) in 1996, the last year for which ambulatory surgery data were available, and the number of inpatient surgeries in 2004. Facility charges were approximated as the average charge for a 1-day overnight hospitalization for the same procedure. Physician charges were estimated by Medicare reimbursement rates. The total cost of ambulatory laparoscopic cholecystectomies was estimated to be $2.0 billion, and the total cost of ambulatory herniorrhaphies was estimated to be $2.5 billion. These costs were included in hospital and physician hospital costs for gallstone disease and abdominal wall hernia, respectively, in Table 2.

Additional costs that could not be distributed among individual digestive diseases were from services provided by primarily hospital-based specialties: anesthesiology, radiology, and pathology. Their costs were estimated by multiplying the amount of collection for professional charges for each specialty by the number of physicians involved in patient care for each specialty.30, 31 Anesthesiology costs included those for certified nurse anesthetists.32 The cost attributable to digestive diseases was estimated as 12 percent of total costs for each specialty; 12 percent was based on the average calculation from the HCUP NIS of the proportion of all hospital discharges, all hospital facility costs, and all physician hospital costs attributed to digestive diseases.

Total physician charges associated with hospital services for digestive diseases were $14.7 billion. Procedures performed at the hospital (including anesthesiology costs) accounted for $5.5 billion and physician hospital visits for $5.2 billion (remaining costs were attributed to radiologists, pathologists, and ambulatory herniorrhaphy and cholecystectomy). Procedures performed for first-listed diagnoses were 85 percent of the total procedure charges. Visits made for first-listed diagnoses were 42 percent of the total visit charges, while consultant fees for secondary diagnoses accounted for the remainder. GERD, gallstones, and abdominal wall hernia had the highest physician fees.

Ambulatory care costs (Table 2, column 4) consist of physician fees for office visits plus any extra charges for procedures performed in their offices. Data on number of ambulatory visits with a diagnosis of each digestive disease and services provided at those visits were taken from the 2004 National Ambulatory Medical Care Survey (NAMCS) and the 2004 National Hospital Ambulatory Medical Care Survey (NHAMCS), representative samples of office-based and hospital-based, respectively, non-Federal physicians in the United States (Appendix 2). Only the primary diagnosis was used for ambulatory care estimates. Medicare reimbursement rates were used to estimate physician visit fees and procedure charges.

Total ambulatory care costs (excluding ambulatory surgery) were $16.0 billion. Procedures performed on outpatients constituted 50 percent of this amount. Abdominal wall hernia, GERD, chronic constipation, gallstones, and diverticular disease were the largest contributors to ambulatory costs.

Expenditures for prescription drugs written by physicians during an office visit (Table 2, column 5) were derived using national data for 2004 collected by Verispan (Appendix 2). They were based on first-listed diagnoses only. For some digestive diseases, numbers were too small to produce reliable estimates.

The total cost of prescription drugs was $12.3 billion. Over half of this cost ($7.7 billion) was associated with drugs prescribed for GERD. Peptic ulcer disease, hepatitis C, IBS, and IBD were major contributors to the remaining drug cost.

Nursing home costs (Table 2, column 6) were estimated using data from the 2004 National Nursing Home Survey (NNHS) (Appendix 2). Home health care costs (Table 2, column 7) and hospice care costs (Table 2, column 8) were estimated using data from the 2000 National Home and Hospice Care Survey (NHHCS) (Appendix 2). Expenditures for home health and hospice care were inflated to estimate 2004 costs. For both surveys, costs were calculated using the average daily rate and the length of stay and were allocated among primary and secondary diagnoses using an 80-20 split. For some digestive diseases, data were unavailable.

Nursing home costs totaled $3.3 billion. The conditions making the largest contributions to these costs were GERD, chronic constipation, diverticular disease, peptic ulcer disease, and colorectal cancer.

Home health care costs totaled $3.1 billion. The conditions making the largest contributions to these costs were colorectal cancer, Crohn’s disease, and pancreatic cancer. Hospice care costs totaled an additional $1.9 billion, with the largest contributors to cost being colorectal, pancreatic, and gastric cancers.

Two additional categories of direct costs could not be distributed among individual digestive diseases: outpatient endoscopy and over-the-counter drugs (Table 2). Endoscopic procedures performed among outpatients are inadequately captured by the NAMCS and the NHAMCS. To estimate costs of outpatient endoscopy, national estimates of the number of colonoscopies and flexible sigmoidoscopies (performed in 2002) were obtained from the Survey of Endoscopic Capacity (SECAP), conducted by the Centers for Disease Control and Prevention and adjusted to 2004 levels based on trends in the CORI (Appendix 2).33 The number of EGDs was estimated using the ratio of EGDs to colonoscopies from CORI. From these totals, the numbers accounted for in the outpatient and inpatient data are subtracted, leaving the total number of procedures missed by those data. Medicare reimbursement rates were used to estimate these additional endoscopy charges. Outpatient endoscopy costs were estimated to be $3.7 billion.

An estimate of expenditures for over-the-counter drugs (for GERD, constipation, and diarrhea) was obtained from retail trade data provided by the Consumer Healthcare Products Association.34 These costs represent sales to major pharmacy markets, excluding Walmart. Adding Walmart’s share, estimated to be 10 percent of sales in this market, yields an estimated total of $2.1 billion.

The total direct cost of digestive diseases in the United States in 2004 was estimated to be $97.8 billion (Table 2). Hospital facility costs and physician hospital costs accounted for 57 percent. Over $85 billion of this total could be assigned to individual digestive diseases. The remaining $12.1 billion, which could not be allocated to individual diseases, represented unassigned outlays for hospital-based physicians, outpatient endoscopy, and over-the-counter drugs. The 10 most significant digestive diseases in terms of direct costs in 2004 were (in descending order) GERD, gallstones, AWH, colorectal cancer, diverticular disease, peptic ulcer disease, pancreatitis, liver disease, appendicitis, and chronic constipation. These 10 diseases cost $42.8 billion, which represented 44 percent of total costs, or 50 percent of expenditures assigned to individual diseases. Neoplasms accounted for $8.4 billion, or 10 percent of the direct costs assigned to individual diseases.

INDIRECT COSTS

Indirect costs comprise the implicit value of forgone earnings or production due to (1) consumption of hospital or ambulatory care, (2) premature death, and (3) additional work loss associated with acute and chronic digestive diseases. Indirect costs also include the value of leisure time lost due to morbidity and mortality.

To determine forgone earnings and leisure due to hospital stays, ambulatory care visits, and death, data were obtained from the U.S. Department of Commerce, Bureau of Labor Statistics, Employment and Earnings. For each age group, the average wage paid, including benefits, and the average employment rate (as a proxy for the probability that a person would have been working) were used. For children under 15 years of age, the costs of forgone earnings and leisure due to hospitalization or physician office visits were those of adults who were assumed to have accompanied the children. In calculating indirect costs, 100 percent of costs were attributed to the first-listed diagnosis.

Indirect costs due to hospital stays (Table 3, column 2), were estimated by obtaining data from the 2004 HCUP NIS on number of days hospitalized by condition and age. For this calculation, it was assumed conservatively that patients would spend twice the equivalent number of days at home recuperating as spent in the hospital.

The total indirect cost due to hospital stays was $5.8 billion. Pancreatitis, liver disease, diverticular disease, and gallstones were the most significant causes of lost wages during hospital stays.

Indirect costs due to ambulatory visits (Table 3, column 3) were estimated in a similar manner to those for hospital stays, except for the assumption that the average visit took 1 hour and 50 minutes away from work or leisure.35

The total indirect cost due to ambulatory visits was $1.9 billion. The largest contributors to this cost were GERD and AWHs.

Indirect costs of lost earnings and leisure due to premature death (Table 3, column 4) were estimated using the number of deaths in 2004 and the projected future lifetime earnings, benefits, and leisure for men and women to age 75, based on age at death.36 The expected lifetime value was discounted to the present using a 4 percent annual discount rate; 100 percent of costs were attributed to the underlying cause of death.

The total indirect cost due to mortality was $32.8 billion. Liver disease was the costliest condition at $10.2 billion. Because of their high fatality rate, digestive tract malignancies accounted for a large proportion of the mortality costs (46 percent).

A major source of indirect costs that could not be assigned to individual digestive diseases was the cost of work and leisure loss from acute and chronic conditions that did not result in a physician outpatient visit or hospitalization. An estimate of the total number of days lost was obtained from the Medical Expenditure Panel Survey (MEPS) (Appendix 2) and converted to dollars using the age- and sex-specific rates of forgone earnings. Losses captured by inpatient and outpatient encounters are subtracted from this total. The resulting indirect cost of conditions not resulting in medical care or death was estimated at $3.6 billion. In contrast, the cost estimate for work loss days in 1985 from acute gastroenteritis alone was $4.1 billion.37 In MEPS, any acute condition that resulted in work loss was obtained by self-report of that condition, which is a concern for self-limited illnesses that do not require visits to a health care provider.

The total indirect cost of digestive diseases in the United States in 2004 was estimated at $44.0 billion (Table 2). Almost three-quarters of this cost was due to mortality, and one-fourth was from work loss due to medical care or illness. Liver disease, colorectal cancer, and pancreatic cancer resulted in the greatest indirect costs.

The total estimated cost of digestive diseases, including direct and indirect, in the United States in 2004 was $141.8 billion (Table 1). Direct costs accounted for 69 percent of the total. The majority of costs (88 percent of direct and 92 percent of indirect) was assigned to specific digestive diseases. In total cost, the most costly diseases were liver disease ($13.1 billion), GERD ($12.6 billion), colorectal cancer ($9.5 billion), gallstones ($6.2 billion), and AWH ($6.1 billion).

Our cost calculations have limitations: (1) Hospital facility costs and physician charges for hospital and ambulatory care include only non-Federal hospitals and physicians, and, therefore, underestimate the total cost of hospital care and ambulatory care for digestive diseases in the United States. (2) Physician costs for procedures were based on Medicare reimbursement rates, which may differ from (i.e., be lower than) rates of other payers. (3) Physician costs for inpatient and outpatient visits were based on Medicare reimbursement rates, which may differ from (i.e., be lower than) rates of other payers. (4) Over-the-counter drug data did not include all categories of digestive disease drugs. (5) Indirect costs of acute and chronic conditions that did not result in medical care did not include data for all digestive diseases. (6) Indirect costs do not include work loss due to disability, for which we have no data. Consequently, the true cost of digestive diseases in the United States is underestimated.

References

Table 1. Direct, Indirect, and Total Costs of Digestive Diseases in the United States, 2004 ($ millions)

DIGESTIVE DISEASE Direct Costs Indirect Costs TOTAL
Gastrointestinal Infections $1,343.4 $392.5 $1,735.9
Hepatitis A 14.5 18.5 32.9
Hepatitis B 204.6 253.2 457.9
Hepatitis C 1,065.5 1,783.6 2,849.1
Other Viral Hepatitis 15.9 32.0 47.9
All Viral Hepatitis 1,300.5 2,087.3 3,387.8
Esophageal Cancer 597.3 1,975.4 2,572.6
Gastric Cancer 487.5 1,415.0 1,902.6
Cancer of Small Intestine 123.8 159.9 283.8
Colorectal Cancer 4,043.7 5,455.2 9,498.9
Primary Liver Cancer 261.2 1,318.6 1,579.8
Bile Duct Cancer 166.0 515.5 681.5
Gallbladder Cancer 66.6 150.6 217.2
Pancreatic Cancer 1,077.4 3,225.6 4,303.0
Other Digestive Cancers 1,618.0 1,490.9 3,108.9
All Digestive Cancer 8,441.5 15,706.7 24,148.2
Hemorrhoids 775.8 97.6 873.4
Gastroesophageal Reflux Disease 12,125.0 515.0 12,639.9
Peptic Ulcer Disease 2,599.9 518.7 3,118.6
Chronic Constipation 1,572.1 140.4 1,712.5
Irritable Bowel Syndrome 949.8 57.5 1,007.3
Other Functional Disorders 1,139.3 129.7 1,269.0
All Functional Intestinal Disorders 3,661.2 327.7 3,988.8
Appendicitis 2,310.6 356.3 2,666.8
Abdominal Wall Hernia 5,698.9 371.9 6,070.8
Crohn's Disease 1,071.0 227.9 1,298.9
Ulcerative Colitis 767.9 100.1 868.0
All Inflammatory Bowel Disease 1,838.9 328.0 2,166.9
Diverticular Disease 3,569.3 471.9 4,041.2
Liver Disease 2,532.0 10,563.0 13,095.0
Gallstones 5,763.6 406.2 6,169.7
Pancreatitis 2,546.2 1,187.1 3,733.3
Other Digestive Diseases 31,193.0 7,102.2 38,295.2
All Digestive Disease 85,699.7 40,432.0 126,131.7
Total Costs That Could Not Be Allocated to Specific Conditions 12,118.1 3,576.4 15,694.5
Total $97,817.9 $44,008.4 $141,826.3

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Table 2. Direct Costs of Digestive Diseases in the United States, 2004 ($ millions)

DIGESTIVE DISEASE Hospital(Non-Federal) Physician Hospital (Non-Federal) Ambulatory (Non-Federal) Prescription Drugs Nursing Home Home Health Care (2000) Hospice Care (2000) TOTAL
Gastrointestinal Infections $877.2 $145.4 $260.0 $45.1 $9.6 $6.2 - $1,343.4
Hepatitis A 10.9 2.6 0.9 - 0.1 0.0 - 14.5
Hepatitis B 48.3 16.8 71.8 66.7 - 0.4 0.6 204.6
Hepatitis C 206.9 95.8 241.8 506.0 - 12.7 2.3 1,065.5
Other Viral Hepatitis 8.9 1.5 3.7 - 0.6 0.9 0.4 15.9
All Viral Hepatitis 274.9 116.6 318.2 572.8 0.7 14.0 3.3 1,300.5
Esophageal Cancer 302.2 49.9 99.7 8.7 0.7 42.3 93.7 597.3
Gastric Cancer 234.8 39.0 35.1 18.4 6.0 24.4 129.8 487.5
Cancer of Small Intestine 92.8 17.2 4.2 - - 0.0 9.7 123.8
Colorectal Cancer 1,947.4 392.4 465.5 81.0 122.4 277.5 757.5 4,043.7
Primary Liver Cancer 151.7 24.9 26.5 - 33.0 - 25.1 261.2
Bile Duct Cancer 119.1 21.3 7.1 - - - 18.5 166.0
Gallbladder Cancer 31.5 6.3 8.4 - - 3.6 16.8 66.6
Pancreatic Cancer 403.7 71.0 76.3 33.3 12.4 105.9 374.8 1,077.4
Other Digestive Cancers 1,044.1 225.0 123.4 2.1 9.1 46.5 167.8 1,618.0
All Digestive Cancer 4,327.3 847.0 846.2 143.5 183.7 500.1 1,593.7 8,441.5
Hemorrhoids 196.7 79.6 447.3 43.0 7.4 1.8 - 775.8
Gastroesophageal Reflux Disease 1,527.4 774.8 1,391.1 7,689.8 641.9 82.4 17.6 12,125.0
Peptic Ulcer Disease 1,442.5 246.9 199.0 518.6 130.6 61.4 0.9 2,599.9
Chronic Constipation 297.5 154.4 627.3 178.2 254.6 59.0 1.0 1,572.1
Irritable Bowel Syndrome 113.8 50.9 467.2 294.7 19.6 3.3 0.4 949.8
Other Functional Disorders 429.6 111.8 217.7 270.6 88.6 16.3 4.7 1,139.3
All Functional Intestinal Disorders 840.9 317.0 1,312.2 743.5 362.8 78.7 6.2 3,661.2
Appendicitis 1,930.7 261.1 92.2 5.6 15.4 5.6 - 2,310.6
Abdominal Wall Hernia 3,527.6 541.9 1,496.4 59.5 22.2 49.8 1.6 5,698.9
Crohn's Disease 427.1 78.3 160.6 261.5 6.2 137.2 0.1 1,071.0
Ulcerative Colitis 296.3 58.1 113.7 272.9 6.4 20.5 0.1 767.9
All Inflammatory Bowel Disease 723.4 136.3 274.3 534.4 12.6 157.8 0.2 1,838.9
Diverticular Disease 2,239.0 421.2 553.8 100.2 181.8 71.0 2.2 3,569.3
Liver Disease 1,799.9 310.1 214.6 16.1 62.1 45.3 84.0 2,532.0
Gallstones 4,314.6 748.1 619.1 18.6 41.9 21.1 0.1 5,763.6
Pancreatitis 1,982.2 258.0 85.5 88.6 50.5 75.8 5.7 2,546.2
Other Digestive Diseases 14,630.3 3,285.8 7,875.6 1,752.6 1,552.5 1,885.6 210.6 31,193.0
All Digestive Disease 40,634.6 8,489.8 15,985.5 12,331.7 3,275.6 3,056.6 1,925.8 85,699.7
Total Costs That Could Not Be Allocated to Specific Conditions
Over-the-Counter Drugs 2,141.00
Outpatient Endoscopy 3,718.5 3,718.5
Hospital-Based Physicians 6,258.6 6,258.6
Total $97,817.9

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Table 3. Indirect Costs of Digestive Diseases in the United States, 2004 ($ millions)

DIGESTIVE DISEASE Hospital Stay Ambulatory Care Mortality TOTAL
Gastrointestinal Infections $165.6 $65.8 $161.1 $392.5
Hepatitis A 2.5 0.2 15.8 18.5
Hepatitis B 10.1 15.4 227.7 253.2
Hepatitis C 46.7 51.2 1,685.7 1,783.6
Other Viral Hepatitis 2.0 1.2 28.9 32.0
All Viral Hepatitis 61.3 68.0 1,958.0 2,087.3
Esophageal Cancer 41.8 9.1 1,924.5 1,975.4
Gastric Cancer 31.5 2.3 1,381.3 1,415.0
Cancer of Small Intestine 12.1 0.3 147.5 159.9
Colorectal Cancer 226.3 38.1 5,190.8 5,455.2
Primary Liver Cancer 22.5 2.3 1,293.8 1,318.6
Bile Duct Cancer 14.1 0.7 500.6 515.5
Gallbladder Cancer 3.5 1.1 146.1 150.6
Pancreatic Cancer 54.9 7.5 3,163.2 3,225.6
Other Digestive Cancers 148.5 6.4 1,336.0 1,490.9
All Digestive Cancer 555.3 67.7 15,083.7 15,706.7
Hemorrhoids 32.9 59.8 5.0 97.6
Gastroesophageal Reflux Disease 231.6 194.8 88.5 515.0
Peptic Ulcer Disease 181.8 16.3 320.6 518.7
Chronic Constipation 52.3 75.6 12.4 140.4
Irritable Bowel Syndrome 21.8 35.4 0.4 57.5
Other Functional Disorders 80.1 26.7 22.9 129.7
All Functional Intestinal Disorders 154.2 137.7 35.7 327.7
Appendicitis 264.1 19.6 72.5 356.3
Abdominal Wall Hernia 160.3 107.3 104.3 371.9
Crohn's Disease 84.8 25.1 118.1 227.9
Ulcerative Colitis 56.7 11.6 31.8 100.1
All Inflammatory Bowel Disease 141.5 36.6 149.9 328.0
Diverticular Disease 314.9 36.0 120.9 471.9
Liver Disease 345.2 38.2 10,179.6 10,563.0
Gallstones 303.4 32.1 70.7 406.2
Pancreatitis 398.2 13.0 775.9 1,187.1
Other Digestive Diseases 2,485.5 983.3 3,633.4 7,102.2
All Digestive Disease 5,795.9 1,876.2 32,759.8 40,432.0
Total Costs That Could Not Be Allocated to Specific Conditions Additional Work Loss 3,576.4
Total $44,008.4

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APPENDIX 1

ICD and SEER Codes

Table 1. International Classification of Diseases (ICD) Code Disease Definitions

Source: ICD-9-CM
ICD-9
ICD-10

DISEASE CODE DIGESTIVE DISEASE ICD-9-CM Codes for Morbidity ICD-9 Codes for Mortality (1979–1998) ICD-10 Codes for Mortality (1999–2004)
1 Gastrointestinal Infections 001–009 001–009 A00–A09
2 Hepatitis A 070.0, 070.1 070.0, 070.1 B15
3 Hepatitis B 1991–present: 070.42, 070.52; All Years: 070.2, 070.3 070.2, 070.3 B16, B17.0, B18.0, B18.1
4 Hepatitis C 1991–present: 070.41, 070.44, 070.51, 070.54, 070.7; Before 1991: 070.4, 070.5 070.4, 070.5 B17.1, B18.2
5 Other Viral Hepatitis 1991– present: 070.43, 070.49, 070.53, 070.59; All Years: 070.6, 070.9 070.6, 070.9 B17.2, B17.8, B18.8, B18.9, B19
2–5 All Viral Hepatitis
6 Esophageal Cancer 150, 151.0 150, 151.0 C15, C16.0
7 Gastric Cancer 151.1–151.9 151.1–151.9 C16.1–C16.9
8 Cancer of Small Intestine 152 152 C17
9 Colorectal Cancer 153, 154 153, 154 C18–C21
10 Primary Liver Cancer 155.0 155.0 C22.0, C22.2–C22.7
11 Bile Duct Cancer 155.1, 156.1–156.9 155.1, 156.1–156.9 C22.1, C24
12 Gallbladder Cancer 156.0 156.0 C23
13 Pancreatic Cancer 157 157 C25
14 Other Digestive Cancers 155.2, 158, 159.0, 159.8, 159.9, 196.2, 197.4–197.8 155.2, 158, 159.0, 159.8, 159.9, 196.2, 197.4–197.8 C22.9, C26.0, C26.8, C26.9, C45.1, C48.0–C48.8, C77.2, C78.4–C78.8
6–14 All Digestive Cancer
15 Hemorrhoids 455 455 I84
16 Gastroesophageal Reflux Disease 530.1–530.3, 530.81 530.1–530.3 K20, K21, K22.1, K22.2
17 Peptic Ulcer Disease 531–534 531–534 K25–K28
18 Chronic Constipation 564.0 564.0 K59.0
19 Irritable Bowel Syndrome 564.1 564.1 K58
20 Other Functional Disorders 536, 564.2–564.9 536, 564.2–564.9 K30, K31.0, K59.1–K59.9, K91.0, K91.1, K91.8
18–20 All Functional Disorders
21 Appendicitis 540–543 540–543 K35–K38
22 Abdominal Wall Hernia 550, 551.0–551.2, 551.8, 551.9, 552.0–552.2, 552.8, 552.9, 553.0–553.2, 553.8, 553.9 550, 551.0–551.2, 551.8, 551.9, 552.0–552.2, 552.8, 552.9, 553.0–553.2, 553.8, 553.9 K40–K43, K45, K46
23 Crohn’s Disease 555 555 K50
24 Ulcerative Colitis 556 556 K51
23–24 All Inflammatory Bowel Diseases
25 Diverticular Disease 562 562 K57
26 Liver Disease 570–573 570–573 K70–K76
27 Gallstones 574 574 K80
28 Pancreatitis 577.0, 577.1 577.0, 577.1 K85, K86.0, K86.1
29 Other Digestive Diseases 014, 017.8, 021.1, 022.2, 032.83, 040.2, 060, 072.3, 072.71, 075, 086.1, 091.1, 091.62, 095.2, 095.3, 098.7, 098.86, 099.52, 099.56, 112.84, 112.85, 120–129, 130.5, 176.3, 211, 230.1–230.9, 235.2–235.5, 239.0, 251.4–251.9, 271.3, 273.4, 275.0, 275.1, 277.01, 277.03, 277.1, 277.4, 279.01, 280.8, 281.0, 286.0–286.5, 286.7, 289.2, 306.4, 307.54, 307.7, 452, 453.0, 456.0–456.2, 530.0, 530.4–530.7, 530.82–530.89, 530.9, 535, 537, 538, 551.3, 552.3, 553.3, 557, 558, 560, 565–569, 575, 576, 577.2, 577.8, 577.9, 578, 579, 643, 646.7, 671.8, 750.3–750.9, 751, 772.4, 773.4, 774.2–774.7, 776.0, 777, 779.3, 782.4, 787, 789.0, 789.1, 789.3–789.9, 792.1, 793.3, 793.4, 793.6, 794.8, 862.22, 862.32, 863, 864, 868.02–868.04, 868.12–868.14, 935.1, 935.2, 936–938, 947.2, 947.3, 973, 988.1, 996.82, 996.86, 996.87, 997.4, V01.0, V02.0–V02.3, V02.6, V03.0, V03.1, V04.4, V05.3, V06.0, V10.00, V10.03–V10.09, V12.7, V16.0, V18.5, V42.7, V42.83, V42.84, V44.1–V44.4, V45.3, V45.72, V45.75, V45.86, V47.3, V53.5, V55.1–V55.4, V58.75, V59.6, V73.4, V74.0, V75.5–V75.7, V76.41, V76.5, E858.4, E870.7, E879.5, E943 014, 017.8, 021.1, 022.2, 040.2, 060, 072.3, 075, 086.1, 091.1, 095.2, 095.3, 098.7, 120–129, 130.5, 176.3, 211, 230.1–230.9, 235.2–235.5, 239.0, 251.4–251.9, 271.3, 273.4, 275.0, 275.1, 277.1, 277.4, 280.8, 281.0, 286.0–286.5, 286.7, 289.2, 306.4, 307.7, 452, 453.0, 456.0–456.2, 530.0, 530.4–530.9, 535, 537, 538, 551.3, 552.3, 553.3, 557, 558, 560, 565–569, 575, 576, 577.2, 577.8, 577.9, 578, 579, 643, 646.7, 671.8, 750.3–750.9, 751, 772.4, 773.4, 774.2–774.7, 776.0, 777, 779.3, 782.4, 787, 789.0, 789.1, 789.3–789.9, 792.1, 793.3, 793.4, 793.6, 794.8, 863, 864, 935.1, 935.2, 936–938, 947.2, 947.3, 973, 988.1, 997.4 A18.3, A21.3, A22.2, A51.1, A54.6, A56.3, A60.1, A74.8, A95, B25.1, B25.2, B26.3, B27, B46.2, B57.3, B58.1, B65–B83, B94.2, D00.1, D00.2, D01, D12, D13, D19.1, D20, D37.1–D37.9, D48.3, D48.4, D50.1, D51.0, D66, D67, D68.0–D68.4, D80.2, E16.3–E16.9, E73, E74.3, E80, E83.0, E83.1, E84.1, E88.0, F50.5, F98.1, I81, I82.0, I85, I86.4, I88.0, I98.2, K22.0, K22.3–K22.9, K23, K29, K31.1–K31.9, K44, K52, K55, K56, K60–K63, K65–K67, K81–K83, K86.2–K86.9, K87, K90, K91.2, K91.5, K91.9, K92, K93 O21, O22.4, O26.6, P53, P54.0–P54.3, P57, P59, P75–P78, P92.0, P92.1, Q39–Q45, R10.0, R10.1, R10.3, R10.4, R11–R15, R16.0, R16.2, R17–R19, R93.2, R93.3, R93.5, R94.5, S36.1–S36.9, T18.1–T18.9, T28.1, T28.2, T28.6, T28.7, T47, T62.0, T85.5, T86.4, Y53, Y60.7, Y84.5, Z11.0, Z11.6, Z12.0, Z12.1, Z20.0, Z20.5, Z22.0, Z22.1, Z22.5, Z23.0, Z23.1, Z24.3, Z24.6, Z27.0, Z43.1–Z43.4, Z46.5, Z52.6, Z80.0, Z83.7, Z85.0, Z87.1, Z90.3, Z90.4, Z93.1–Z94.4, Z98.0
1–29 Any Digestive Disease

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Table 2. Surveillance, Epidemiology, and End Results (SEER) Program Site Recodes With SEER Morphology
Codes (ICD-0-3) for Digestive Cancers

Source: Fritz A, Percy C, Jack A, Shanmugaratnam K, Sobin L, Parkin DM, Whelan S, eds. International Classification of Diseases for Oncology. 3rd ed. Geneva, Switzerland: World Health Organization; 2000

DIGESTIVE CODE CANCER SEER SITE RECODES (Morphology Codes in Parentheses)
1 Esophageal Cancer, Squamous Cell 21010 (805–808)
2 Esophageal Cancer, Adenocarcinoma 21010 (814–838)
3 Esophageal Cancer, Other 21010 (all other O codes)
1–3 Any Esophageal Cancer
4 Gastric Cancer 21020
5 Cancer of Small Intestine 21030
6 Colorectal Cancer 21041–21049, 21051, 21052, 21060
7 Primary Liver Cancer 21071
8 Bile Duct Cancer 21072, 21090
9 Gallbladder Cancer 21080
10 Pancreatic Cancer 21100
11 Other Digestive Cancers (Other Ill Defined) 21110, 21120, 21130
1–11 Any Digestive Cancer

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APPENDIX 2

Summary of Surveys Used in The Burden of Digestive Diseases in the United States

Constance E. Ruhl, M.D., Ph.D.; and Bryan Sayer, M.H.S.

National Ambulatory Medical Care Survey (NAMCS)

Sponsor

Ambulatory Care Statistics Branch
Division of Health Care Statistics
National Center for Health Statistics
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
3311 Toledo Road
Hyattsville, MD 20782
301-458-4600

Design

The National Ambulatory Medical Care Survey (NAMCS) is a continuing series of nationally representative sample surveys of office-based physicians in the United States. The survey includes all non-Federal office-based physicians who are primarily engaged in direct patient care. Anesthesiologists, pathologists, and radiologists are excluded. The design is a multistage stratified probability sample of geographically defined areas, physician practices within these areas, and patient visits within physician practices. Physicians are asked to complete a patient encounter form for a systematic sample of office visits occurring during a randomly assigned 1-week reporting period.

The study design is described in: National Center for Health Statistics, Bryant E, Shimuzu I. Sample design, sampling variance, and estimation procedures for the National Ambulatory Medical Care Survey. Hyattsville, Maryland: Public Health Service, 1988; DHHS Publication No. (PHS) 88-1382. (Vital and health statistics, Series 2, No. 108.)

Timeframe

Data were collected annually from 1974 through 1981, and in 1985; data have been collected annually since 1989. Data from 1992 through 2005 were used in this report.

Sample Size

Through 1981, the sample included 3,000 total physicians, about 1,925 responding physicians, and about 51,000 patient visits. The 1985 sample included about 5,000 total physicians, 2,900 responding physicians, and 70,000 patient visits. Beginning in 1989, the sample included 2,500 total physicians, about 1,600 responding physicians, and about 42,000 patient visits.

Content Relevant to Digestive Diseases

Demographic data, reason for visit, physician’s diagnostic and therapeutic services ordered or provided, diagnosis and disposition decision, and drugs prescribed are included. International Classification of Diseases (ICD) codes are given for the first four physician diagnoses. The reason for office visit is the principal reason given by the patient, which in the physician’s judgment is the most appropriate one. Two additional symptoms or other reasons for visit can be coded.

Strengths

The survey form is completed from provider records. Trend data are available for about 30 years. Visits can be compared with those of the National Health Interview Survey, in which the conditions are similarly defined. Since 1980, data have been collected on the number and names of specific drugs prescribed in office-based practice. The sample allows estimates for specific physician subspecialties. ICD codes are used for diagnoses.

Limitations

The sample is limited to office-based physicians, a group that has become a less inclusive source for ambulatory care. There may be more than one report per person, because the report reflects a visit rather than an individual. The sample size is small, so estimates of fewer than 200,000 are statistically unreliable. Because ambulatory care in Federal facilities is not included, ambulatory care rates based on the U.S. population are underestimates.

Availability of Data

Published data are found in the National Center for Health Statistics Vital and health statistics, Series 13 and in Advance data. Data are available for public use on the National Center for Health Statistics Web site in an easy-to-use form with input statements.

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National Hospital Ambulatory Medical Care Survey (NHAMCS)

Sponsor

Ambulatory Care Statistics Branch
Division of Health Care Statistics
National Center for Health Statistics
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
3311 Toledo Road
Hyattsville, MD 20782
301-458-4600

Design

The National Hospital Ambulatory Medical Care Survey (NHAMCS) is a continuing series of nationally representative sample surveys of physicians in hospital emergency departments and outpatient departments in the United States. The survey includes all non-institutional, non-Federal, general, and short-stay hospitals with at least six beds staffed for patient use. The design is a multistage stratified probability sample of geographically defined areas, hospitals within these areas, clinics within the outpatient departments and emergency service areas within the emergency departments of these hospitals, and patient visits to these clinics and emergency service areas. Physicians are asked to complete a patient encounter form for a systematic sample of visits occurring during a randomly assigned 4-week reporting period.

The study design is described in: National Center for Health Statistics, McCaig LF, McLemore T. Plan and operation of the National Hospital Ambulatory Medical Care Survey. Hyattsville, Maryland: Public Health Service, 1994; DHHS Publication No. (PHS) 94-1310. (Vital and health statistics, Series 1, No. 34.)

Timeframe

Data have been collected annually since 1992. Data from 1992 through 2005 were used in this report.

Sample Size

A fixed panel of 600 hospitals was selected for the sample. A special supplement of 66 hospitals was added in 2003 to increase reliability of emergency department estimates for rural and proprietary hospitals. In 1992, the sample included about 36,000 emergency department visits and about 35,000 outpatient department visits.

Content Relevant to Digestive Diseases

Demographic data, reason for visit, physician’s diagnostic and therapeutic services ordered or provided, diagnoses and disposition decision, drugs prescribed, types of health care professionals seen, causes of injury where applicable, expected sources of payment, and characteristics of the hospital such as type of ownership are included.

Strengths

This survey complements the NAMCS, to provide more complete data on ambulatory care. The survey form is completed from provider records. Trend data are available for more than 10 years. International Classification of Diseases (ICD) codes are used for diagnoses.

Limitations

There may be more than one report per person, because the report reflects a visit rather than an individual. The sample size is small, so estimates of fewer than 200,000 are statistically unreliable. Because ambulatory care in Federal facilities is not included, ambulatory care rates based on the U.S. population are underestimates.

Availability of Data

Published data are found in the National Center for Health Statistics Vital and health statistics, Series 13 and in Advance data. Data are available for public use on the National Center for Health Statistics Web site in an easy-to-use form with input statements.

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Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Sponsor

Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road, Suite 2000
Rockville, MD 20850
301-427-1364
866-290-HCUP

Design

The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS) is a database of hospital inpatient stays. It utilizes a stratified sample of hospitals drawn from the subset of hospitals in the States that make their data available to HCUP. Hospitals are stratified by region, location/teaching status, bed-size category, and ownership. All discharges from sampled hospitals are included. The 2004 HCUP NIS includes all discharges from more than 1,000 hospitals, an approximate 20 percent stratified sample of U.S. community hospitals. HCUP NIS data are weighted to represent the annual discharges from non-Federal hospitals in the United States.

Several revisions have been made to the HCUP NIS sampling design since its inception. First, the sampling frame changed over time as more States made their data available to HCUP. The 1988 HCUP NIS was drawn from a sampling frame of eight States, representing 31 percent of all hospital discharges in the United States. In contrast, the sampling frame in recent years included 37 States, representing 85 to 90 percent of all hospital discharges in the United States. Second, in 1998, the sampling method was changed to better reflect the cross-sectional population of hospitals. The hospital stratification variables were redefined, short-term rehabilitation facilities were dropped from the target universe, and sampling preference was no longer given to prior-year NIS hospitals.

Timeframe

Data have been collected annually since 1988. Data from 2004 were used in this report.

Sample Size

The sample size is approximately 8 million hospital stays each year.

Content Relevant to Digestive Diseases

Data for each hospital stay include patient demographics (gender, age, race, median income for ZIP Code), admission and discharge status, length of stay, total charges, expected payment source, up to 15 diagnoses and 7 surgical procedures coded using International Classification of Diseases (ICD)-9-CM codes, and hospital characteristics (ownership, size, teaching status).

Strengths

The HCUP NIS is the largest all-payer inpatient care database in the United States. Data are weighted to be nationally representative of non-Federal hospitals in the United States. The HCUP NIS is the only national hospital database containing charge information on all patients, regardless of payer.

Limitations

Not all States participate. Not all participating States collect data on race-ethnicity; in 2004, race-ethnicity data were not collected by 11 participating States: Georgia, Illinois, Kentucky, Maine, Minnesota, Nebraska, Nevada, Ohio, Oregon, Washington, and West Virginia. The charge information is for the facility only; no information on physician fees is available. Data on medications are not supplied, although medication costs are included in the charge total.

Availability of Data

Summary statistics are published by the Agency for Healthcare Research and Quality. An online database, HCUP-Net, allows users to generate certain statistics easily. Selected data sets can be purchased for analysis.

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National Hospital Discharge Survey (NHDS)

Sponsor

Hospital Care Statistics Branch
Division of Health Care Statistics
National Center for Health Statistics
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
3311 Toledo Road
Hyattsville, MD 20782
301-458-4321

Design

The National Hospital Discharge Survey (NHDS) is a continuing series of nationally representative sample surveys of hospitals in the United States. The survey includes all short-stay, non-Federal non-institutional hospitals having six or more beds for patient use and, before 1988, those in which the average length of stay for all patients was less than 30 days. In 1988, the scope was altered slightly to include all general and children’s general hospitals regardless of the length of stay. The design is a two-stage stratified probability sample of hospitals and discharges within hospitals. Beginning in 1985, two data collection procedures have been used: (1) a manual system in which data are abstracted from hospital records by the hospital staff or U.S. Census Bureau staff on behalf of the National Center for Health Statistics, and (2) an automated system in which machine-readable medical record data are purchased from commercial organizations, State data systems, hospitals, or hospital associations.

The study design is described in: National Center for Health Statistics, Dennison CF, Pokras R. Design and operation of the National Hospital Discharge Survey: 1988 redesign. Washington, D.C.: U.S. Government Printing Office, 2000; DHHS Publication No. (PHS) 2001-1315. (Vital and health statistics, Series 1, No. 39.)

Timeframe

Data have been collected annually since 1965. Data from 1979 through 2004 were used in this report.

Sample Size

Approximately 270,000 stays from about 500 hospitals each year constitute the sample.

Content Relevant to Digestive Diseases

Data in medical records for hospital discharges are collected for patient demographics (age, sex, race, ethnicity, and marital status), disposition, length of stay, expected source of payment, and for up to seven diagnoses and four surgical procedures coded to the International Classification of Diseases (ICD)-9-CM.

Strengths

The NHDS includes patients who die in the hospital and admissions from nursing homes, thereby producing more accurate estimates of utilization, diagnostic, and procedure data than those produced by household, self-reported interview surveys such as the National Health Interview Survey. Data are obtained directly from hospital records, thus minimizing underreporting. Data include up to seven discharge diagnoses and four procedure codes. ICD codes are used for diagnoses. Trend data are available for about 40 years.

Limitations

The data, which are based only on the factsheet of the hospital discharge record, may contain incomplete or inaccurate information, because there is no validation of condition. Extensive demographic and other health-related information is not available from hospital records. Recorded data reflect a discharge, not a person, so there may be more than one discharge per person for the same condition. Race is not coded on approximately 10 percent of records. Because hospitalizations in Federal facilities are not included, hospitalization rates based on the U.S. population are underestimates.

Availability of Data

Published data are found in the National Center for Health Statistics Vital and health statistics, Series 13 and in Advance data. Data are available for public use on data tapes, data diskettes, CD-ROMs and downloadable files from the National Center for Health Statistics Web site in an easy-to-use form with input statements.

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Vital Statistics of the United States: Multiple Cause-of-Death Data

Sponsor

Mortality Statistics Branch
Division of Vital Statistics
National Center for Health Statistics
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
3311 Toledo Road, 7th floor
Hyattsville, MD 20782
301-458-4666

Design

Multiple cause-of-death mortality data from the National Vital Statistics System provide mortality data by multiple cause of death for all deaths occurring within the United States. Each record in the microdata is based on information abstracted from death certificates filed in vital statistics offices of each State and the District of Columbia. Causes of death were coded according to the International Classification of Diseases (ICD)-9 for 1979 through 1998, and according to ICD-10, beginning in 1999.

The study design is described in: National Center for Health Statistics, Data systems of the National Center for Health Statistics. Hyattsville, Maryland: Public Health Service, 1981; DHHS Publication No. (PHS) 82-1318. (Vital and health statistics: Series 1, No. 16.)

Timeframe

Data have been collected annually since 1968. Data from 1979 through 2004 were used in this report.

Sample Size

The sample is a 100 percent count of deaths in the United States.

Content Relevant to Digestive Diseases

Demographic data (age, sex, race, residence) and underlying and contributing causes of death are included.

Strengths

A complete count of deaths in the United States is included, along with 18 diagnoses. Trend data are available for more than 35 years. For digestive diseases with high mortality rates, such as cirrhosis, death records are the most comprehensive data source. Mortality statistics may be the only reliable data source for uncommon fatal conditions. Annual age-adjusted mortality rates are useful for examining trends over time, assuming case-fatality rates do not change significantly. Mortality rates for diseases that are usually fatal are often used as estimates of incidence rates when the latter are not available.

Limitations

Quality is dependent on the accuracy of death certificates, which may vary, according to condition. Chronic diseases that contribute to mortality are frequently underreported.

Availability of Data

Published data are found in: National Center for Health Statistics. Vital statistics of the United States, Vol. II, Mortality, Parts A and B; National vital statistics reports; and Vital and health statistics, Series 20. Data are available for public use on the National Bureau of Economic Research Web site in an easy-to-use form with input statements.

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United States Population Estimates

Sponsor

Division of Population Projections
U.S. Census Bureau
From CDC Wonder
Centers for Disease Control and Prevention (CDC)
U.S. Department of Health and Human Services
1600 Clifton Road
Atlanta, GA 30333
404-639-3311
404-639-3534 and 800-311-3435 (public inquiries)

Design

The population estimates are mid-year (July 1) population counts by age, sex, and race. The counts are used with all national samples as the denominator for all estimates of rates. The year 2000 estimates are also used for age adjusting. These estimates are not used for cancer statistics from the Surveillance, Epidemiology, and End Results (SEER) program, which has its own population counts.

Timeframe

Estimates for 1979 through 2005 were used in this report.

Sample Size

The U.S. population is the sample.

Content Relevant to Digestive Diseases

Denominators are provided for calculating rate per 100,000 persons by age, race, and sex.

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Surveillance, Epidemiology, and End Results (SEER) Program

Sponsor

Cancer Statistics Branch
Surveillance Research Program
Division of Cancer Control and Population Sciences
National Cancer Institute
National Institutes of Health
U.S. Department of Health and Human Services
6116 Executive Boulevard
Suite 504, MSC 8316
Bethesda, MD 20892-8316
301-496-8510

Design

A total of 17 population-based registries in the United States provide data on all residents diagnosed with cancer and follow-up information on all previously diagnosed patients. Data are compiled twice a year. Cancer mortality data are obtained from vital statistics for the entire United States.

Timeframe

Data have been collected annually since 1975. Data from 1979 through 2004 were used in this report.

Sample Size

Surveillance, Epidemiology, and End Results (SEER) program data for trends are 100 percent counts from Atlanta, Georgia; Connecticut; Detroit, Michigan; Hawaii; Iowa; New Mexico; San Francisco/Oakland, California; Seattle/Puget Sound, Washington; and Utah. SEER data for 2004 are 100 percent counts from the 9 registries above, plus Los Angeles, California; San Jose-Monterey, California; Rural Georgia; the Alaska Native Tumor Registry; Greater California; Kentucky; Louisiana; and New Jersey. National Center for Health Statistics mortality data are 100 percent counts from the entire United States.

Content Relevant to Digestive Diseases

Data regarding cancer incidence and mortality, including current and projected trends, are collected for selected sites, such as esophagus, stomach, colon, rectum, liver, and pancreas. Demographic data include age, sex, and race.

Strengths

SEER data are verified for quality and completeness. Data are estimated to be 99 percent complete from the registry sites. Mortality data are 100 percent counts of the United States. Trend data are available for about 30 years.

Limitations

SEER data represent only 17 areas of the country (and only 9 for trend data). Although the data are weighted to provide national estimates, these data are not statistically representative of the United States. Accuracy of cause of death coding for some gastrointestinal cancers is unknown.

Availability of Data

Data are published by the National Cancer Institute. Certain statistics can easily be generated online. Selected data sets are available for analysis.

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Verispan

Sponsor

Verispan
800 Township Line Road, Suite 125
Yardley, PA 19067
267-685-4300 (telephone)
267-685-4400 (fax)

Design

The Vector One®: National (VONA) is a national-level prescription and patient tracking service that provides data on the numbers of prescription drugs dispensed by retail pharmacies. Data on nearly half of retail prescriptions dispensed in the United States are collected each month and are projected to be nationally representative through methods that stratify by geography, pay type, and class of trade.

The Physician Drug & Diagnosis Audit (PDDA) collects national-level disease state and associated therapy data from more than 3,100 office-based physicians representing 29 specialties. Physicians report all patient activity during one typical workday each month. Data collected are projected by region and specialty to be nationally representative of office-based physicians.

Diagnosis data from the PDDA and prescription data from the VONA are utilized by the Factor Processor to segment the number of prescriptions, units dispensed, or retail sales by disease state or diagnosis, to estimate total number of prescriptions and total costs for specific diseases.

Timeframe

The PDDA was established in 1990. Data from 2004 were used in this report.

Sample Size

Each month, data are captured on approximately half of all retail prescriptions dispensed in the United States. More than 3,100 office-based physicians report all patient activity during 1 typical workday each month.

Content Relevant to Digestive Diseases

The database includes International Classification of Diseases (ICD) codes for physician diagnoses that can be used to generate data on drugs prescribed for specific digestive diseases of interest.

Strengths

Data are nationally representative. Drug data are available for specific diseases defined by ICD codes.

Limitations

Estimates of total numbers of prescriptions and total costs for specific diseases are based on a factoring method applying information on physician prescribing practices to pharmacy data, rather than direct measurement. Number of prescriptions written by physicians may not be equivalent to number of prescriptions filled. Retail value of drugs may not be equivalent to the cost actually paid by patients. Prescription drugs from mail-order pharmacies are not included. Over-the-counter medications are not included.

Availability of Data

Summary statistics can be purchased through a contract with Verispan.

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National Endoscopy Database (NED)/Clinical Outcomes Research Initiative (CORI)

Sponsor

Clinical Outcomes Research Initiative
3303 Southwest Bond Avenue, Suite 15C
Portland, OR 97239
888-786-2674 (toll-free telephone)
503-494-7401 (local telephone)
503 494-2699 (fax)
503-494-6522 (research services fax)

Design

U.S. endoscopy sites that voluntarily participate in the Clinical Outcomes Research Initiative (CORI) submit data on all endoscopic procedures performed at the sites.

Timeframe

CORI began in 1995 and is ongoing. Data from 2001 through 2005 were used in this report.

Sample Size

Currently, more than 275,000 procedure reports are received annually from 86 practice sites and more than 400 physicians in the United States. More than 1.7 million reports exist in the National Endoscopic Database (NED). Data used in this report came from 77 practices with 101 sites that performed a total of 542,650 colonoscopies, 270,957 esophagogastroduodenoscopies (EGD), 55,708 flexible sigmoidoscopies, 9,333 endoscopic retrograde cholangiopancreatographies (ERCP), and 6,945 endoscopic ultrasonographies (EUS), from 2001 through 2005.

Content Relevant to Digestive Diseases

Data collected include site and patient characteristics, indications for procedures, findings from procedures, completion rates, and unplanned event rates.

Strengths

The NED is the only U.S. national endoscopy database. Trends can be studied using data from a subset of “stable sites” that have participated for multiple consecutive years.

Limitations

Participation in CORI is voluntary; therefore, data from participating sites are not nationally representative.

Availability of Data

Through a contract with CORI, summary statistics can be purchased by persons outside the participating endoscopy sites.

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National Nursing Home Survey (NNHS)

Sponsor

Long-Term Care Statistics Branch
Division of Health Care Statistics
National Center for Health Statistics
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
3311 Toledo Road
Hyattsville, MD 20782
301-458-4747

Design

The National Nursing Home Survey (NNHS) is a continuing series of nationally representative sample surveys of nursing homes in the United States. The survey includes all nursing homes with at least three beds that are either certified (by Medicare or Medicaid) or have a State license to operate as a nursing home. The design is a two-stage stratified probability sample of nursing homes and of current residents, persons discharged (deceased or alive) in the past year, and staff members within nursing homes. Data on residents and discharges are collected by interviewing a nurse who obtains the needed information from the medical records and the next of kin. The redesigned 2004 survey was administered using a computer-assisted personal interviewing (CAPI) system.

The study design is described in: Shimizu I. The 1985 National Nursing Home Survey design. Proceedings of the section on survey research methods, 1986 Annual Meeting of the American Statistical Association. Chicago: American Statistical Association, 1987.

Timeframe

Data have been collected in 1973–74, 1977, 1985, 1995, 1997, 1999, and 2004. Data from 2004 were used in this report.

Sample Size

In 2004, 1,500 facilities were selected from a sampling frame of 16,628 nursing homes, and 1,174 facilities participated. A total of 14,017 residents were sampled from the responding facilities, and 13,507 participated.

Content Relevant to Digestive Diseases

Prevalence of chronic conditions by primary diagnosis, medications taken, functional status, receipt of services (medical, nursing, and therapeutic), discharge health status and length of stay by diagnosis, cost of providing care by diagnosed condition, and sources of payment are available. Information on fecal incontinence is specifically gathered. Also included are demographic characteristics of residents, health and functional status before nursing home admission, lifetime use of nursing home care, and amount of Medicaid spending. Ostomy patients and patients with alcohol abuse or dependence can be identified. Bowel and bladder incontinence was also recorded.

Strengths

The survey provides a source of health status data on the subgroup of the population residing in and discharged from all types of nursing homes for whom health care data are otherwise difficult to obtain. Primary and secondary diagnoses by International Classification of Diseases (ICD) code, which include the diseases of the digestive system, are available for residents at admission and discharge. Reasons for admissions from short-stay hospitals by selected diagnostic-related groups for age 70 years or older include esophagitis, gastroenteritis and miscellaneous digestive disorders, and gastrointestinal hemorrhage.

Limitations

Residents with a primary diagnosis of digestive disease make up a small percentage of the nursing home population. The survey is of limited use for examining specific conditions, which tend to be coded only broadly.

Availability of Data

Published data are found in the National Center for Health Statistics Vital and Health Statistics, Series 13 and in Advance data. Data are available for public use on the National Center for Health Statistics Web site in an easy-to-use form with input statements.

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National Home and Hospice Care Survey (NHHCS)

Sponsor

Long-Term Care Statistics Branch
Division of Health Care Statistics
National Center for Health Statistics
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
3311 Toledo Road
Hyattsville, MD 20782
301-458-4747

Design

The National Home and Hospice Care Survey (NHHCS) is a continuing series of surveys of home and hospice care agencies in the United States. The survey includes all agencies that are licensed or certified (Medicare or Medicaid). The design is a two-stage stratified probability sample of home health and hospice agencies and of current patients and discharges within agencies. Data are collected through personal interviews with administrators and staff.

The study design is described in: National Center for Health Statistics, Haupt BJ. Development of the National Home and Hospice Care Survey. Hyattsville, Maryland: Public Health Service, 1994; DHHS Publication No. (PHS) 94-1309. (Vital and health statistics, Series 1, No. 33.)

Timeframe

Data were collected in 1992, 1994, 1996, 1998, and 2000. Data from 2000 were used in this report.

Sample Size

In 2000, 1,800 agencies were selected from a sampling frame of 15,451 home health and hospice care agencies, and 1,425 agencies participated. The patient sample consisted of approximately 14,000 total patients, split between home health and hospice, and between current patients and discharged patients.

Content Relevant to Digestive Diseases

Admission and discharge diagnoses, referral and length of service, number of visits, patient charges, health status, reason for discharge, and types of services were provided.

Strengths

This survey provides a source of health status data on the subgroup of the population receiving care from, or discharged from, all types of home and hospice care agencies for whom health care data are otherwise difficult to obtain. Primary and secondary diagnoses by International Classification of Diseases (ICD) code, which include the diseases of the digestive system, are available for residents at admission and discharge.

Limitations

The exact coverage of the current patients is unclear. The weighted total may underestimate or overestimate the number of patients enrolled in a given year due to the rolling nature of the survey and the length of stay of patients. In addition, cost data represent billed amounts and not paid amounts.

Availability of Data

Published data are found in the National Center for Health Statistics Vital and health statistics, Series 13 and in Advance data. Data are available for public use on the National Center for Health Statistics Web site in an easy-to-use form with input statements.

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Medical Expenditure Panel Survey (MEPS)

Sponsor

Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road, Suite 2000
Rockville, MD 20850
301-427-1364

Design

The Medical Expenditure Panel Survey (MEPS) is a set of national surveys. The Household Component (HC) provides data from individual households and their members, which are supplemented by data from their medical providers. The HC collects data from a nationally representative subsample of households that participated in the prior year’s National Health Interview Survey (NHIS). The selected subsample undergoes several rounds of interviews during 2 full years of follow-up. A new sample of households is included in the survey each year.

The Medical Provider Component (MPC) surveys hospitals, physicians, home health care providers, and pharmacies identified by HC respondents to supplement and/or replace information received from the HC respondents.

The Insurance Component (IC), also known as the Health Insurance Cost Study, is a separate survey of a sample of private and public sector employers that collects data on employer-based health insurance plans.

Timeframe

Data have been collected annually since 1996. Data from 2004 were used in this report.

Sample Size

The 2004 HC surveyed 32,737 individuals from 13,018 families.

Content Relevant to Digestive Diseases

Data collected in the HC on each person in the household include demographic characteristics, health conditions, health status, use of medical services, charges and source of payments, access to care, satisfaction with care, health insurance coverage, income, and employment.

Data collected in the IC include the number and types of private insurance plans offered (if any), premiums, contributions by employers and employees, eligibility requirements, benefits associated with these plans, and employer characteristics.

Data utilized in the current report were from the HC and consisted of counts of the number of days of work missed due to illness, injury, or hospitalization.

Strengths

The sample is nationally representative of the U.S. population. Household data are supplemented by health care provider data. The survey includes data on number of days of work missed due to illness, injury, or hospitalization, which are unavailable from other data sources.

Limitations

Household data on medical conditions are by self-report.

Availability of Data

Summary data tables are published by the Agency for Healthcare Research and Quality on the MEPS Web site. An online database, MEPSnet, allows users to generate certain statistics easily. HC data files are available for public use. IC data files are not released publicly. MPC data files are not available for public release; information from these files is incorporated into the HC data files.

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APPENDIX 3

Methodology for Tables and Figures

Bryan Sayer, M.H.S.

This appendix provides information on the sources and computations for the tables and figures used in the chapters on digestive diseases.

I. Data Sources

The number of ambulatory care visits, hospital discharges, and deaths in the tables and figures came from four sources (see Appendix 2 for descriptions):

  1. Ambulatory care visits data in tables and figures came from the combined National Ambulatory Medical Care Survey (NAMCS)/National Hospital Ambulatory Medical Care Survey (NHAMCS) years 1992–2005.
  2. Data on hospital discharges in the figures came from the National Hospital Discharge Survey (NHDS), years 1979–2004.
  3. Hospital data in the tables came from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS) for the year 2004.
  4. Mortality data came from the National Vital Statistics System Multiple Cause Mortality data years 1979–2004, as prepared by the National Bureau of Economic Research.

For digestive cancers (Chapters 4–12), cancer incidence and survival were derived from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute (NCI). Data in the tables for 2004 came from the 17 registry sites that SEER used at that time. Data in the figures for 1979–2004 were from the nine sites in operation during the entire period. Population data corresponding to the definition of the SEER sites were provided by SEER.

II. Disease Definitions

Digestive diseases were coded into 1 of 29 digestive disease categories based on the International Classification of Diseases (ICD)-9 CM (Clinical Modification) code for morbidity, and either ICD-9 (1979–1998) or ICD-10 (1999–2004) for mortality. See Appendix 1 for the complete list of codes for each of the 29 diseases. The first-listed diagnosis was considered the primary diagnosis for tables and figures for primary digestive disease. All remaining diagnoses were considered secondary and were included under the category “All-Listed Diagnoses.” In the tables and figures for ambulatory care visits, hospital discharges, and mortality, diagnoses were counted only once under the all-listed category, irrespective of the number of actual diagnoses. For example, in the chapter on all digestive diseases, only one digestive disease diagnosis was counted, even though more than one could have been listed on a medical record or death certificate.

While the coding for digestive disease mortality is generally consistent between ICD-9 and ICD-10, the World Health Organization (WHO), which produces the ICD code definitions, advises that series are not necessarily comparable across versions of the ICD code book. This change was portrayed as a vertical line at 1999 on the mortality figures.

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III. Demographic Categories

For the purpose of calculating rates for the U.S. population, population data were derived from the national population estimates program of the U.S. Census Bureau and the Centers for Disease Control and Prevention (CDC). Population counts were specific for each of the demographic subgroups shown in the tables.

Demographic Subgroup Population Count, 2004
AGE (Years)
Under 15
60,806,159
AGE (Years)
15–44
125,824,714
AGE (Years)
45–64
70,692,944
AGE (Years)
65+
36,333,025
Race
White
238,285,011
Race
Black
38,608,953
Sex
Female
149,121,439
Sex
Male
144,535,403
Total 293,656,842

Race was coded as “White” or “Black”; or “Other,” if another category was specified. Missing race data were not considered “Other.” The HCUP NIS data combine Hispanic origin with race, so it was impossible to know whether Hispanics were white or black. In order not to undercount the totals, we assumed all Hispanics were white. As a result, discharges for whites were slightly overstated and for blacks slightly understated.

HCUP NIS data came from the individual States, and 11 States did not report race in 2004. To adjust for this limitation, we created a separate weight for race, based on the existing weight times the inverse of the proportion of each race in the States that did report race to the total for the United States. Note that these are counts of persons, based on the 2004 mid-year population estimate, and not the proportion of discharges. We did not report separate counts for “Other” race, because the definition in the HCUP NIS and the population counts may not be the same.

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IV. Age-Adjustment

Age-adjustment through direct standardization allowed for comparisons across race, sex, and time that were not influenced by differences in age distribution for the groups being compared. Year-specific population data in 19 age groups (PDF, 260KB), plus the National Center for Health Statistics (NCHS) standard year 2000 population, were used for age-adjusting. Age-specific rates were calculated for each of the 19 age groups (age 0, age 1–4, 5-year age groups through age 84, and age 85 and older), and the results were multiplied by the year 2000 standard population proportion in each of the age groups. These results then were summed to arrive at the age-adjusted population rate estimate. Further details can be found in Anderson and Rosenberg.38

V. Tables

Morbidity Estimates

1. Ambulatory Care Visits

Estimates in the tables for ambulatory care visits in 2004 were from combined NAMCS/NHAMCS files for the years 2003–2005. Multiple years were combined in order to have sufficient observations to meet the minimum threshold for reporting and for more stable estimates. The 3 years of data were averaged by dividing the sampling weight by 3, in accordance with the general instructions from NCHS. The combined file included visits to freestanding physician offices and physician offices at hospitals, and emergency room visits that did not result in an overnight stay in the hospital.

First-Listed Diagnosis

The primary diagnosis for an outpatient visit was the first diagnosis listed in the record. A visit was considered to have been for 1 of the 29 digestive diseases if the first of the diagnoses listed on the record fell into the subject category. Estimates for first-listed diagnosis for digestive diseases included the number of visits and the rate of visits per 100,000 of the population. The rate per 100,000 was the number of visits, not the number of individuals with a visit, divided by the number of persons (in 100,000s) in the population in the specific subgroup.

The weighted count of visits with a first-listed diagnosis of each of the digestive diseases was the count (in thousands) listed in the table under “Ambulatory Care Visits,” “First-Listed Diagnosis,” “Number in Thousands.” The “Rate per 100,000” was calculated by dividing the count of visits by the number of persons (in 100,000s) in the population in the specific subgroup.

All-Listed Diagnoses

Each outpatient record could have multiple diagnoses listed. A visit was considered to have been for a specific digestive disease if any of the diagnoses listed on the record fell into the subject category. Therefore, any individual record could be counted for more than one digestive disease. However, a given record was not counted more than once for a specific disease. For example, a record having the ICD-9-CM diagnostic codes of “001” and “002” was only counted once in the category of Gastrointestinal Infections. The weighted count of visits with all-listed diagnoses of each of the digestive diseases was the count (in thousands) listed in the table under “Ambulatory Care Visits,” “All-Listed Diagnoses,” “Number in Thousands.” The “Rate per 100,000” was calculated by dividing the count of visits by the number of persons in the population (in 100,000s) in the demographic subgroup.

2. Hospital Discharges

Hospital discharges were based on inpatient stays of at least 1 night. Emergency room visits that did not result in an admission to the hospital with an overnight stay were not counted. Data in the tables came from the 2004 HCUP NIS file of hospital discharges from participating States. Sampling weights inflated the discharges to the U.S. total, based on information from the American Hospital Association. Data in the figures showing age-adjusted hospital discharges over time were based on the NHDS, 1979–2004.

First-Listed Diagnosis

The primary diagnosis for a hospital discharge was the first diagnosis listed in the record. Inpatient estimates for first-listed diagnosis for digestive diseases included the number of discharges and the rate of discharges per 100,000 of the population. The weighted count of hospital discharges with a primary diagnosis of each of the digestive diseases was the count (in thousands) listed in the table under “Hospital Discharges,” “First-Listed Diagnosis,” “Number in Thousands.” The “Rate per 100,000” was the number of discharges, not the number of individuals with an inpatient stay, divided by the number of persons (in 100,000s) in the population in the specific subgroup.

All-Listed Diagnoses

Each hospital discharge record could have multiple diagnoses listed. A discharge was considered to have been for a specific digestive disease if any of the diagnoses listed on the record fell into the subject category. Therefore, any individual record could be counted for more than one digestive disease. As with ambulatory care visits, a given record was not counted more than once for a specific disease. For example, ICD‑9-CM diagnostic codes of “001” and “002” were only counted once in the category of Gastrointestinal Infections. The weighted count of hospital discharges with all-listed diagnoses of each of the digestive diseases was the count (in thousands) listed in the table under “Hospital Discharges,” “All-Listed Diagnoses,” “Number in Thousands.” The “Rate per 100,000” was calculated by dividing the count of hospital discharges by the number of persons in the population (in 100,000s) in the demographic subgroup.

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Mortality

Counts for 2004 for deaths from digestive disease were derived from the Multiple Cause-of-Death data files from the Division of Vital Statistics, CDC. These data are a complete accounting of all deaths in the United States (although not necessarily for all U.S. citizens). Cause of death is organized on a record axis, with a specific underlying cause of death and contributing causes for each decedent.

1. Underlying Cause of Death

The underlying cause of death was determined from the list of all causes on the death certificate by professional coders. Underlying cause is analogous to a first-listed diagnosis for morbidity. The “Number of Deaths” column for “Underlying Cause” was a count of the number of records in the file with each digestive disease as the underlying cause of death.

The “Rate per 100,000” column was determined by dividing the number of deaths with the underlying cause by the population (in 100,000s) in the demographic subgroup. The race- and sex-specific estimates were age-adjusted, while the age-specific rates and the total were not age-adjusted.

“Years of Potential Life Lost” assumed life expectancy of 75 years, had individuals not died before that age. Because age at death is reported in full years, we added 0.5 years to each age at death. Thus, for the purpose of calculating years of life lost, a person whose age at death was listed as 65 was counted as having been 65.5 years old. The age 65.5 represented the average age of all persons who died at age 65, and each contributed 9.5 years of potential life lost (75-65.5 = 9.5). The tables showed the total number of years of life lost to age 75 in thousands.

2. Underlying or Other Cause of Death

The record axis of the death certificate can contain up to 20 contributing causes in addition to the underlying cause. A recording of any of the 29 unique digestive diseases was noted for each of the 21 total possible causes, and any duplicate digestive diseases were eliminated. A death was attributed to one of the digestive diseases if any of the unduplicated digestive diseases were recorded. Therefore, a death could appear under more than one of the digestive diseases in the “Underlying or Other Cause” column of the tables. Unlike the underlying cause, only the “Number of Deaths” and the “Rate per 100,000” were shown for “Underlying or Other Cause.” “Years of Potential Life Lost” were irrelevant.

“Number of Deaths” (in 100,000s) was the count of all deaths that had the specified digestive disease listed in any position on the record axis. A death could appear under more than one disease if any of the diagnoses were listed; however, no death appeared more than once for a given disease.

The “Rate per 100,000” column was determined by dividing the number of deaths for underlying or other cause by the population (in 100,000s) in the demographic subgroup. The race- and sex-specific estimates were age-adjusted, while the age-specific rates and the total were not age-adjusted.

Cancer Incidence

Cancer incidence and 5-year survival rates in Chapters 4–12 were derived from SEER registry data. The registries did not cover the entire United States, nor necessarily represent the entire population. Instead, each registry covers a specific set of counties, usually statewide, across diverse sections of the country. (For more information on registries, see SEER.2, 3) Population counts used for rates and age-adjustment were also restricted to the counties covered by the registry. Only estimates based on unweighted counts of 17 or more cases were shown, following the reporting standard set by NCI.

Cancer incidence was estimated for the entire country from the rates for the 17 registries in 2004, multiplied by the 2004 U.S. population. This yielded an estimated number of new cases for the United States in 2004. The unadjusted and age-adjusted incidence rates were based only on the 17 registry areas. Unadjusted rates were calculated from the number of new cases in 2004 divided by the population in the demographic subgroup. Age-adjusted incidence rates were calculated from the age-specific rates within the demographic subgroup multiplied by the U.S. standard 2000 population as described in section IV. Age-Adjustment.

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VI. Figures

Morbidity Estimates

The figures showing trends in ambulatory care visits and hospital discharges for the period 1979–2004 used the all-listed diagnoses. The all-listed diagnoses were defined the same as for the tables. However, the data source for hospital discharges was the NHDS because HCUP NIS data were unavailable over the entire timeframe. Because of the smaller sample size for the ambulatory care surveys, estimates derived from NAMCS/NHAMCS files were 3-year averages, except for the 1992 estimates, which were averages of 1992 and 1993 data. This approach provided more stable estimates across time. The year 1992 was the starting point, because this was the first year of the NHAMCS. All rates were age-adjusted.

Mortality

The figures showing mortality data for the period 1979–2004 used the multiple cause-of-death data for each year. Because these were observed counts for the United States and not samples, they were not considered estimates. The age-adjusted mortality rates were shown for both underlying cause and underlying or other cause for the total population per year. The vertical line at 1999 represented the change from ICD-9 to ICD-10.

Cancer Incidence and 5-Year Survival

For digestive cancers (Chapters 4–12), the figures for age-adjusted cancer incidence and 5-year survival were derived from data obtained by the nine registries that SEER used through the entire period 1979–2004. Five-year survival was the proportion of those diagnosed in a given year who were still known to be alive 5 years later. Five-year survival ended at 1999, because it was impossible to know the 5-year status of patients diagnosed after that year. Absolute survival is shown in these figures, whereas SEER typically publishes relative survival. Relative survival takes into account the expected survival of the population as a whole and is higher than absolute survival, especially for cancers that concentrate in groups with high underlying mortality, such as the elderly.

References

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LIST OF TABLES AND FIGURES

1. All Digestive Diseases

Table 1. All Digestive Diseases: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. All Digestive Diseases: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 2. All Digestive Diseases: Number and Age-Adjusted Rates of Deaths, Years of Potential Life Lost (to Age 75), and Digestive Disease as a Percentage of All Deaths by Age, Race, and Sex in the United States, 2004
Figure 2. All Digestive Diseases: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 3. All Digestive Diseases: Costliest Prescriptions
Table 4. Burden of Selected Digestive Diseases in the United States, 2004

2. Gastrointestinal Infections

Table 1. Gastrointestinal Infections: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Gastrointestinal Infections: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 2. Gastrointestinal Infections: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Gastrointestinal Infections: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 3. Gastrointestinal Infections: Costliest Prescriptions

3. Viral Hepatitis

Table 1. Hepatitis A: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Hepatitis A: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)
Table 2. Hepatitis A: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Hepatitis A: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 3. Hepatitis B: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 3. Hepatitis B: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 4. Hepatitis B: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 4. Hepatitis B: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 5. Hepatitis C: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 5. Hepatitis C: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 6. Hepatitis C: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 6. Hepatitis C: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 7. All Viral Hepatitis: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 7. All Viral Hepatitis: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 8. All Viral Hepatitis: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 8. All Viral Hepatitis: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 9. All Viral Hepatitis: Costliest Prescriptions

4. Digestive Cancers

Table 1. All Digestive Cancers: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. All Digestive Cancers: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Table 2. All Digestive Cancers: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. All Digestive Cancers: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 3. All Digestive Cancers: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. All Digestive Cancers: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 4. All Digestive Cancers: Costliest Prescriptions

5. Cancer of the Esophagus

Table 1. Esophageal Squamous Cell Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Esophageal Squamous Cell Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Table 2. Esophageal Adenocarcinoma: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 2. Esophageal Adenocarcinoma: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Table 3. All Esophageal Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 3. All Esophageal Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Table 4. All Esophageal Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 4. All Esophageal Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 5. All Esophageal Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 5. All Esophageal Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

6. Cancer of the Stomach

Table 1. Gastric Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Gastric Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Table 2. Gastric Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Gastric Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 3. Gastric Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Gastric Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

7. Cancer of the Small Intestine

Table 1. Cancer of the Small Intestine: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Cancer of the Small Intestine: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Table 2. Cancer of the Small Intestine: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Cancer of the Small Intestine: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)
Table 3. Cancer of the Small Intestine: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Cancer of the Small Intestine: Age-Adjusted Rates of Death in the United States, 1979–2004

8. Cancer of the Colon and Rectum

Table 1. Colorectal Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Colorectal Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Table 2. Colorectal Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Colorectal Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 3. Colorectal Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Colorectal Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

9. Primary Liver Cancer

Table 1. Primary Liver Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Primary Liver Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Table 2. Primary Liver Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Primary Liver Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 3. Primary Liver Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Primary Liver Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

10. Cancer of the Bile Ducts

Table 1. Bile Duct Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Bile Duct Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Table 2. Bile Duct Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Bile Duct Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)
Table 3. Bile Duct Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Bile Duct Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

11. Cancer of the Gallbladder

Table 1. Gallbladder Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Gallbladder Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Table 2. Gallbladder Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Gallbladder Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)
Table 3. Gallbladder Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Gallbladder Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

12. Cancer of the Pancreas

Table 1. Pancreatic Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Pancreatic Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Table 2. Pancreatic Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Pancreatic Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 3. Pancreatic Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Pancreatic Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

13. Hemorrhoids

Table 1. Hemorrhoids: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Hemorrhoids: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 2. Hemorrhoids: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Hemorrhoids: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 3. Hemorrhoids: Costliest Prescriptions

14. Gastroesophageal Reflux Disease

Table 1. Gastroesophageal Reflux Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Gastroesophageal Reflux Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 2. Gastroesophageal Reflux Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Gastroesophageal Reflux Disease: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 3. Gastroesophageal Reflux Disease: Costliest Prescriptions

15. Gastroesophageal Reflux Disease

Table 1. Peptic Ulcer Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Peptic Ulcer Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 2. Peptic Ulcer Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Peptic Ulcer Disease: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 3. Peptic Ulcer Disease: Costliest Prescriptions

16. Functional Intestinal Disorders

Table 1. Chronic Constipation: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Chronic Constipation: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 2. Chronic Constipation: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Chronic Constipation: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 3. Chronic Constipation: Costliest Prescriptions
Table 4. Irritable Bowel Syndrome: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 3. Irritable Bowel Syndrome: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 5. Irritable Bowel Syndrome: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 4. Irritable Bowel Syndrome: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 6. Irritable Bowel Syndrome: Costliest Prescriptions
Table 7. All Functional Intestinal Disorders: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 5. All Functional Intestinal Disorders: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 8. All Functional Intestinal Disorders: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 6. All Functional Intestinal Disorders: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 9. All Functional Intestinal Disorders: Costliest Prescriptions

17. Appendicitis

Table 1. Appendicitis: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Appendicitis: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 2. Appendicitis: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Appendicitis: Age-Adjusted Rates of Death in the United States, 1979–2004

18. Abdominal Wall Hernia

Table 1. Abdominal Wall Hernia: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Abdominal Wall Hernia: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 2. Abdominal Wall Hernia: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Abdominal Wall Hernia: Age-Adjusted Rates of Death in the United States, 1979–2004

19. Inflammatory Bowel Disease

Table 1. Crohn’s Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Crohn’s Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 2. Crohn’s Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Crohn’s Disease: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 3. Crohn’s Disease: Costliest Prescriptions
Table 4. Ulcerative Colitis: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 3. Ulcerative Colitis: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 5. Ulcerative Colitis: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 4. Ulcerative Colitis: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 6. Ulcerative Colitis: Costliest Prescriptions
Table 7. All Inflammatory Bowel Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 5. All Inflammatory Bowel Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 8. All Inflammatory Bowel Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 6. All Inflammatory Bowel Disease: Age-Adjusted Rates of Death in the United States, 1979–2004

20. Diverticular Disease

Table 1. Diverticular Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Diverticular Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 2. Diverticular Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Diverticular Disease: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 3. Diverticular Disease: Costliest Prescriptions

21. Liver Disease

Table 1. Liver Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Liver Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 2. Liver Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Liver Disease: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 3. Liver Disease: Costliest Prescriptions

22. Gallstones

Table 1. Gallstones: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Gallstones: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 2. Gallstones: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Gallstones: Age-Adjusted Rates of Death in the United States, 1979–2004

23. Pancreatitis

Table 1. Pancreatitis: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Pancreatitis: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Table 2. Pancreatitis: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Pancreatitis: Age-Adjusted Rates of Death in the United States, 1979–2004
Table 3. Pancreatitis: Costliest Prescriptions

24. Indications and Outcomes of Gastrointestinal Endoscopy

Table 1. Characteristics of Endoscopy Sites and Persons Undergoing Endoscopic Procedures, 2001–2005
Figure 1. Number of Endoscopic Procedures at Stable Sites (N=36) by Year, 2001–2005
Figure 2. Number of Endoscopic Procedures by Age, 2001–2005
Figure 3. Number of Colonoscopies at Stable Sites (N=36) by Age and Year, 2001–2005
Figure 4. Number of Flexible Sigmoidoscopies at Stable Sites (N=36) by Age and Year, 2001–2005
Table 2. Indications for Colonoscopy and Flexible Sigmoidoscopy, 2001–2005
Table 3. Colonoscopy Findings in the Total Population and Persons at Routine Risk Only, and Flexible Sigmoidoscopy Findings, 2001–2005
Figure 5. Colonoscopy Findings in Persons at Routine Risk by Age, 2001–2005
Figure 6. Colonoscopy Findings in Persons at Routine Risk by Sex, 2001–2005
Figure 7. Colonoscopy Findings in Persons at Routine Risk by Race/Ethnicity, 2001–2005
Figure 8. Number of Esophagogastroduodenoscopy (EGD) Procedures at Stable Sites (N=36) by Age and Year, 2001–2005
Table 4. Indications for Esophagogastroduodenoscopy (EGD) (N=270,957), 2001–2005
Table 5. Esophagogastroduodenoscopy (EGD) Findings (N=270,957), 2001–2005
Table 6. Endoscopic Retrograde Cholangiopancreatography (ERCP) Findings (N=9,333), 2001–2005

25. Costs of Digestive Diseases

Table 1. Direct, Indirect, and Total Costs of Digestive Diseases in the United States, 2004 ($ Millions)
Table 2. Direct Costs of Digestive Diseases in the United States, 2004 ($ Millions)
Table 3. Indirect Costs of Digestive Diseases in the United States, 2004 ($ Millions)

Appendix 1. ICD and SEER Codes

Table 1. International Classification of Diseases (ICD) Code Disease Definitions
Table 2. Surveillance, Epidemiology, and End Results (SEER) Program Site Recodes With SEER Morphology Codes (ICD-0-3) for Digestive Cancers