Systematic literature review of the economic burden of coeliac disease

The purpose of this systematic review was to assess the economic burden of CD in North America and Europe. Forty nine economic studies were identified that met the inclusion criteria. Thirty three studies were conducted in Europe but only 11 focussed on direct costs, with the majority of studies reporting on or modelling costs associated with screening and diagnosis. A small subset of studies focussed on indirect costs such as work absenteeism or school performance.  

In line with national guidance, identifying CD appears to be most cost-effective when tissue transglutaminase (TTG) testing is followed by endoscopy and biopsy to confirm the diagnosis. The cost per positive CD diagnosis of screening patients already undergoing upper gastrointestinal endoscopy for other indications such as anaemia or IBS were highly variable and ranged from 1300 Canadian dollars (in Canada) to more than 44,000 Euros (in the Netherlands). It should be noted that the models did not consider the costs of missing a true diagnosis.
 
It is clear that a diagnosed CD patient costs payers more than a matched control without CD, mostly due to outpatient care which accounts for two thirds of the costs. Direct annual excess costs to a US payer per diagnosed CD patient totalled 6000 US dollars more than for a person without CD. These estimates suggest that the excess costs of managing CD are more than those associated with managing other chronic conditions such as asthma or rheumatoid arthritis, but less than others such as diabetes. CD patients continue to use more healthcare than controls, even 4-5 years post diagnosis and initiation of a GFD. This usage relates mainly to outpatient services, although hospitalisation, emergency visits and medications are all used more commonly by people with CD. Mental and behavioural health are particularly important categories of outpatient care amongst CD patients, even for those with controlled disease, suggesting areas of unmet need.
 

Undiagnosed CD patients cost payers more than diagnosed patients. Undiagnosed patients are likely to incur costs related to CD symptoms and complications, even if these costs are not attributed to CD. These costs drop following diagnosis and adherence to the GFD. Patients visit primary care providers less often after diagnosis and miss fewer days from work or school. The exception to costs falling after diagnosis occurs in the UK, where GF foods have formerly been prescribed and reimbursed. However, following public consultation, NHS–England has restricted the prescription and reimbursement of GF foods to save costs. With this change, there will be an opportunity to study the effects on adherence among CD patients to a GFD without reimbursement, and whether this results in clinical consequences for the patients. It would also be interesting to assess whether subsequent higher costs to the payer for these clinical consequences would negate savings made by ending reimbursement for GF products.
 
The economic studies examined by this review addressed CD-related costs globally rather than those related to the many complications attributed to this disease, including infertility and cancer. Because CD itself is common, chronic, and treated only with a GFD, studies of costs related to the disease tend to focus on screening, diagnosis, and visits to outpatient clinicians. This explains why more studies have
been performed in Europe than is typical for an economic body of literature, without the need for a US healthcare claims database to assess direct costs of treatment. Complete analyses of the economics of CD will not include the full cost of this condition until the incidence of these complications and the associated costs to treat them are considered. Adding these downstream costs to economic models may suggest that some upstream expenses associated with earlier and more aggressive screening may be more cost effective
than is currently suggested.