Abstract
We read with great interest the article titled “Burden of Coeliac Disease in Germany: Real-World Insights from a Large Retrospective Health Insurance Claims Database Analysis” from Bokemeyer et al. 1 The authors conducted a retrospective case-control study using claims data, analyzing a large and representative database that provides valuable insights into the economic burden of celiac disease (CeD). The CeD diagnosis was defined by at least one inpatient or two outpatient diagnostic codes within four quarters (irrespective of the calendar year) during the 5-year study period. Controls (non-CeD patients) were matched in a ratio of 5:1. Healthcare resource utilization (including hospitalizations, outpatient visits, and medication use) and healthcare costs (outpatient services, inpatient services, outpatient pharmaceuticals, sick leaves, and aids and remedies) were compared between CeD patients and controls. The results showed that CeD patients incur considerably higher healthcare resource utilization and costs compared to matched controls, primarily due to increased hospitalizations.
However, some further limitations of the study should be considered. The analyzed population is mainly represented by adults (roughly 75%), and it also accounts for 10.6% of people over 67 years. First, there is no distinction between newly diagnosed patients and those with a diagnosis that dates back decades. Differentiating new diagnoses from established cases is important, as newly diagnosed patients may incur higher costs due to the initial diagnostic process, educational support for adherence to a gluten-free diet, and closer follow-up care during the early stages. Conversely, patients with a long-standing diagnosis may require fewer interventions and generate lower costs, should they strictly comply with the gluten-free diet. Recent studies have highlighted differences in healthcare resource utilization between newly diagnosed and established CeD patients, noting that those in the early diagnosis phase typically require more visits, tests, and treatments.2,3 Furthermore, the study could also explore the potential role of comorbidities, which may differ between newly diagnosed and long-term CeD patients. This distinction could significantly alter the findings and provide a more detailed understanding of the economic impact of CeD.
Secondly, the study considered all causes of hospitalization without examining the relationship between CeD and the condition requiring medical services. Costs might be much higher for CeD diagnoses among adults, especially if the suspicion for CeD is raised following a complication of the disease (i.e., osteoporosis-related fractures and infertility). It is not known the number of diagnoses of CeD that were established during hospitalizations for other causes, and it will be somewhat informative to gather some data on this. Moreover, differentiating the conditions that lead to hospitalization and identifying their correlation with CeD would enable a more precise understanding of the indications for which medications are prescribed. This could yield more reliable data on the portion of healthcare expenses related to medications prescribed to CeD patients.
As regards prescriptions for functional gastrointestinal disorders, it will be of note to highlight the temporal relationship between CeD diagnosis and prescriptions, as this could either inform us on the misdiagnosis of CeD or on the real necessity of treating functional disorders or residual symptoms in patients with CeD. Moreover, with such a large and representative database available, stratifying costs by age could help identify the groups with the highest expenses. This approach would facilitate more targeted interventions, particularly for the prevention and treatment of those most affected. 4
It could be interesting to evaluate the personal expenditures of CeD patients, in addition to the costs borne by the healthcare system. As gluten-free alternatives can be a significant financial burden, understanding out-of-pocket expenses could provide valuable insights into the economic challenges faced by patients.
In conclusion, while the study makes an important contribution to understanding the economic burden of CeD, we believe that distinguishing between newly diagnosed and long-standing patients, as well as identifying the conditions leading to hospitalization and stratifying for age groups, would improve the accuracy of the findings. If these are addressable only in future research, we look forward to seeing such studies to shape newer policies and interventions for CeD.
