Patients with Cushing’s syndrome—hypercortisolemia from any etiology—manifest a multitude of debilitating physical, metabolic, and psychiatric symptoms. Cushing’s disease (CD)—hypercortisolemia resulting from an adrenocorticotropic hormone-secreting pituitary adenoma— is the cause of about 70% of spontaneous Cushing’s syndrome cases. CD occurs more frequently in women, with most cases found in patients aged 25 to 45.
Although relatively uncommon, CD has been associated with significant mortality and morbidity. Central obesity, wasting of the extremities, hair loss, facial hirsutism, acne, and easy bruising or fragile skin are among the most common patient complaints. Among the more serious comorbidities associated with CD are:
Osteoporosis with pathologic fractures.
Immunosuppression with frequent infections.
Hypertension, diabetes, and cardiac disease.
Psychiatric illness, especially depression.
While surgery to remove the adenoma is successful in 65% to 90% of cases and many associated comorbidities improve with resolution of the hypercortisolemia, the medical and psychological effects of CD may persist after the hypercortisolemia has resolved.
A Closer Look at the Economic Burden of Cushing’s Disease
In the September 2011 issue of Endocrine Practice, my colleagues and I had a study published for which we explored the healthcare costs of CD, including its comorbidities, and whether successful treatment improved the economic impact of the disease. Using administrative health insurance data, we compared healthcare resource use and costs among patients with CD with those of patients with non-functioning pituitary adenomas (NFPA) and population controls (PC) without pituitary disease. The prevalence of comorbidities and changes in medical costs were analyzed in patients with CD before and after surgical treatment and compared with controls.
We found that coding for insurance claims demonstrated comorbidities of the same type and distribution that endocrinologists would expect to see in patients with CD, based on clinical criteria. As expected, these comorbidities—as manifested in the CD claims—appeared to be significantly more common in patients with CD than in either of the other patient groups.
Our analysis also demonstrated that inpatient admissions, physician office visits, outpatient hospital visits, and emergency room visits were higher among CD patients for each year analyzed when compared with NFPA and PC patients. Those with CD required more pharmacologic treatment and had higher associated pharmacy costs when compared with the other two groups. At each of these healthcare delivery sites and during each year studied, the costs associated with CD were four times higher than those associated with NFPA or PC.
Successful Cushing’s Disease Treatment Matters
A key finding in our investigation, however, was that the effect of the costs attributed to CD appeared to be ameliorated with successful treatment of the disease. For those who did not achieve surgical remission, postoperative total costs more than doubled when compared with preoperative total costs; inpatient costs, pharmacy costs, and outpatient costs all increased after unsuccessful treatment. When surgery was successful, outpatient costs decreased significantly. Overall and inpatient costs were also reduced with successful surgery.
The increased mortality risk and comorbidities of CD require aggressive treatment on clinical grounds. Our study indicates that aggressive management is cost-effective and decreases the overall healthcare burden associated with the disease.
Readings & Resources (click to view)
Swearingen B, Wu N, Chen SY, et al. Health care resource use and costs among patients with Cushing disease. Endocr Pract. 2011;17:681-690. Available at: http://aace.metapress.com/content/0661770073618n3k/.
Tritos NA, Biller BM, Swearingen B; Medscape. Management of Cushing disease. Nat Rev Endocrinol. 2011;7:279-289.
Valassi E, Biller BM, Swearingen B, et al. Delayed remission after transsphenoidal surgery in patients with Cushing’s disease. J Clin Endocrinol Metab. 2010;95:601-610.
Biller BM, Grossman AB, Stewart PM, et al. Treatment of adrenocorticotropin-dependent Cushing’s syndrome: a consensus statement. J Clin Endocrinol Metab. 2008;93:2454-2462.
Swearingen B, Biller BM, Barker FG 2nd, et al. Long-term mortality after transsphenoidal surgery for Cushing disease. Ann Intern Med. 1999;130:821-824.
Moore D, Adi Y, Connock M, Bayliss S. Clinical effectiveness and cost-effectiveness of pegvisomant for the treatment of acromegaly: a systematic review and economic evaluation. BMC Endocr Disord. 2009;9:20.
Sherlock M, Ayuk J, Tomlinson JW, et al. Mortality in patients with pituitary disease. Endocr Rev. 2010;31:301-342.
Barahona MJ, Sucunza N, Resmini E, et al. Persistent body fat mass and inflammatory marker increases after long-term cure of Cushing’s syndrome. J Clin Endocrinol Metab. 2009;94:3365-3371.