Chapter 15: Peptic Ulcer Disease

The Burden of Digestive Diseases in the United States

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

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)

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

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

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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