Chapter 14: Gastroesphageal Reflux Disease

The Burden of Digestive Diseases in the United States

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

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)

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

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%
Share

This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by the NIDDK is carefully reviewed by NIDDK scientists and other experts.