Article Versions
Export Article
Cite this article
  • Normal Style
  • MLA Style
  • APA Style
  • Chicago Style
Research Article
Open Access Peer-reviewed

Trends in Hospitalizations for Celiac Disease in the United States

Eric P. Borrelli
International Journal of Celiac Disease. 2017, 5(4), 150-154. DOI: 10.12691/ijcd-5-4-5
Published online: November 24, 2017

Abstract

Celiac disease is a severe autoimmune disease that results in patients having an intolerance to gluten. Patients that have celiac disease and ingest gluten can have gastrointestinal related adverse effects. There is currently no cure or treatment for celiac disease outside of a diet consisting of strict adherence to a 100% gluten free diet. However, adherence to a strict gluten free diet is difficult and patients may consume food that is cross-contaminated with gluten which can cause adverse effects that can lead to medical treatment or hospitalizations. Currently, there is only limited published data detailing hospitalizations for celiac disease in the United States. This study analyzed trends in hospitalizations for celiac disease in the United States by utilizing the National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project net (HCUPnet) using the primary diagnosis code 579.0 celiac disease. The study analyzed total discharges, length of stay for hospitalizations from 1995-2014, as well as mean cost per hospitalizations from 2006-2014. Total number of hospital discharges for celiac disease was trending upward from 1995 to 2014 varied from a low of 391 discharges in 1996 to a high of 1405 in 2010. The mean length of stay varied from a high of 8.69 days in 1996 to a low of 4.88 days in 2014. The mean cost per hospitalization varied from a high of $11,510 in 2013 to a low of $9,247 in 2014. Until there is a cure or therapeutic treatments available, celiac disease will continue to cause hospitalizations and contribute to the cost of healthcare in the United States.

1. Introduction

Celiac disease (CD) is a severe autoimmune disease that causes patients to have an intolerance to gluten. Several studies have indicated that in the United States, around 0.5 to 1 percent of the population has CD 1, 2, 3. Although the median age of diagnosis of CD is around 50 years old, studies indicate there is a similar number of patients diagnosed below the age of 18 compared to patients above the age of 65 4, 5, 6. There are many potential symptoms associated with CD and some of the most common include diarrhea, weight loss, and abdominal pain 7. Malabsorption of important nutrient such as vitamin b12, calcium, and iron is common and along with the diarrhea and weight loss may be some of the reasons that patients with CD have growth issues and tend to be short in stature 7, 8, 9, 10. Evidence supports the theory that CD can be hereditary and occurs in patients who have Human Leukocyte Antigens (HLA) HLA-DQ2 and HLADQ8 haplotypes 11, 12, 13. In severe cases, CD can lead to digestive cancers which can be fatal 14. There is increasing evidence that patients with celiac disease are at a higher risk of having additional autoimmune diseases such as Hashimoto’s thyroiditis, Grave’s disease, type 1 diabetes mellitus (T1DM), inflammatory bowel disease (IBD) and Crohn’s disease 15, 16, 17, 18. There is currently no cure for CD. As of now, there is also no currently approved therapeutic medication for CD, however, there are some therapeutic agents currently in clinical trials. The only therapy available for CD is a strict adherence to a 100% gluten free diet 19. Compliance with a strict gluten free diet can be difficult as foods can be contaminated with traces of gluten in the process of preparing. Even some products like prescription or over-the-counter (OTC) medications may contain gluten and result in adverse reactions and events. In some instances, these adverse reactions may require medical treatment and/or hospitalizations. Several studies have been completed trying to analyze the cost burden of CD 20, 21, 22. One study in the United States analyzed the cost of hospitalizations for CD for the year of 2014 and discovered that the mean cost per hospitalization was $9,247 and the national aggregate cost was $7,413,355 20. There is limited data analyzing the cost and description of hospitalizations in the United States for CD. This study tried to analyze and describe the recent trends of hospitalizations for CD in the United States.

2. Methods

To evaluate the trends in hospitalizations in the U.S. for CD, an analysis of the United States National Inpatient Sample (NIS) was conducted utilizing the Healthcare Cost and Utilization Project Net (HCUPnet) 23. The primary diagnosis code of 579.0, celiac disease, for the years 1995-2014 was examined in the analysis. The Agency for Healthcare Research and Quality (AHRQ) is a federal agency within the United States Department of Health and Human Services (HHS). AHRQ sponsors HCUP and HCUPnet. HCUPnet is a free online query system available to the public that provides information and statistics on hospitalizations and emergency room visits in the United States 24. The outcomes examined in the analysis annually were total number of discharges, mean length of stay (LOS) in days, and mean cost per hospitalization in U.S. dollars. The cost per hospitalization is only available via HCUPnet starting in the year 2006, therefore, the analysis of annual mean cost had to be adjusted to the timeframe of 2006-2014. All costs were adjusted to 2014 United States dollars using the Gross Domestic Product (GDP) health expenditure price index 25.

3. Results

3.1. Trends in Number of Discharges

The time frame from 1995-1998, which was the first four years that we measured, had the four lowest numbers of annual discharges for CD (Table 1). There were 476 discharges in 1995, 391 discharges in 1996, 510 discharges in 1997, and 476 discharges in 1998 (Figure 1). The number of annual discharges then rose every year over the course of seven-year span from 2000-2006 with 667 discharges in 2000 and 1286 discharges in 2006. In 2010, there were 1,405 discharges which was the most of any year during this 20-year span. The following four years resulted in an annual decrease each subsequent year with there being 1,151 discharges in 2011, 1,015 discharges in 2012, 985 discharges in 2013, and 805 discharges in 2014.

3.2. Trends in Length of Stay

The length of stay for hospitalizations for CDhas decreased over the 20-year span from what was first looked at in 1995 compared to where it ended in 2014 (Figure 2). The length of stay was highest during the first five years analyzed from 1995-1999. The length of stay per hospitalization per year during this time frame was 7.76 days in 1995, 8.69 days in 1996, 7.97 days in 1997, 8.37 days in 1998, and 8.02 days in 1999 with the year of 1996 having the highest mean length of stay out of any year during this 20-year span. The length of stay decreased every year over a seven-year span from 1998-2004 with length of stay decreasing to 5.32 days in 2004. The length of stay rose each of the next two years to 6.67 days in 2005 and 6.82 days in 2006. Then, over another seven-year span from 2006-2012, the length of stay decreased every year to 5.32 days per hospitalization in 2012. The length of stay rose in 2013 to 5.85 days before decreasing to its lowest value during the 20-year span of 4.88 days in 2014.

3.3. Trends in Mean Cost

The mean cost per hospitalization was similar between the nine years after being adjusted to 2014 U.S. dollars (Table 2). The costs varied between a low of $9,427 in 2014 and a high of $11,510 in 2013 (Figure 3). The rest of the years the mean cost per hospitalization varied by less than $1,000 ($9,543 to $10,506).

4. Discussion

This study tried to describe the trend in number of hospital discharges for CD in the United States over a twenty-year period and the trends in mean cost of hospitalization in the U.S. over a 9-year period. The number of hospitalizations for CD was trending upward from the beginning of the study timeframe of 1995 until 2010. After 2010, the trend for hospitalizations has been decreasing. The increasing trend until 2010 supports previous studies which indicate the increasing prevalence and diagnosis of CD in the United States and north America 26. This study indicates that the LOS for CD has been trending downward from the beginning of the study timeframe until the end (1995-2014). This increase of diagnosis may be due to several factors such as improvement of physician awareness of CD, advancement in diagnostic technology, and/or environmental and dietary factors 1, 26, 27, 28, 29. The increase in physician awareness may also lead to earlier the diagnosis, and therefore the sooner the treatment can begin which would lead to a shortee hospitalization stay. Outside of the fluctuation in mean hospital costs between 2013 and 2014, the mean costs per hospitalization stayed constant with little variation. Evidence shows that LOS and cost per hospitalization go together and if there was a decrease in LOS, cost would expect to decrease as well 20, 24, 30, 31, 32. For this study, although LOS trended downward, costs stayed relatively the same. Further research is needed to analyze what may have caused the deviation from the norm.

5. Conclusion

Over a twenty-year period, the number of hospitalizations in the United States for CD was trending upward from 1995 until the year 2010 which they started trending downward until 2014. The LOS for hospitalization in the U.S. for CD was trending downward from 1995 until 2014. Mean costs per hospitalization for CD stayed fairly constant for a 7-year period of 2006 through 2012 until they considerably increased in 2013, then came back down in 2014 to the previous range. Further research is needed to analyze the cost burden of CD on the United States healthcare system. With no approved medication treatments or cures, CD will continue to cause hospitalizations and contribute to the cost of healthcare in the United States.

Statement of Competing Interests

The author has no financial funding or conflict of interest to disclose.

List of Abbreviations

CD: Celiac disease; GI: gastrointestinal; T1DM: Type 1 Diabetes Mellitus; IBD1: irritable dowel disease; NIS: National Inpatient Sample; HCUP: Healthcare Cost and Utilization Project; AHRQ: Agency for Healthcare Research and Quality; HHS: Health and Human Services; LOS: length of stay; GDP: Gross domestic product

References

[1]  Fasano A, Berti I, Gerarduzzi T, Not T, Colletti RB, Drago S, Elitsur Y, Green PH, Guandalini S, Hill ID, Pietzak M, Ventura A, Thorpe M, Kryszak D, Fornaroli F, Wasserman SS, Murray JA, Horvath K. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med. 2003 Feb 10; 163(3): 286-92.
In article      View Article  PubMed
 
[2]  Dubé C, Rostom A, Sy R, Cranney A, Saloojee N, Garritty C, Sampson M, Zhang L, Yazdi F, Mamaladze V, Pan I, Macneil J, Mack D, Patel D, Moher D. The prevalence of celiac disease in average-risk and at-risk Western European populations: a systematic review. Gastroenterology. 2005 Apr; 128(4 Suppl 1): S57-67
In article      View Article  PubMed
 
[3]  Rubio-Tapia A, Ludvigsson JF, Brantner TL, Murray JA, Everhart JE. The prevalence of celiac disease in the United States. Am J Gastroenterol. 2012 Oct; 107(10): 1538-44.
In article      View Article  PubMed
 
[4]  Patel D, Kalkat P, Baisch D, Zipser R. Celiac disease in the elderly. Gerontology. 2005; 51(3): 213-4.
In article      View Article  PubMed
 
[5]  Rashtak S, Murray JA. Celiac Disease in the Elderly. Gastroenterology clinics of North America. 2009; 38(3): 433-446.
In article      View Article  PubMed
 
[6]  Murray JA, Van Dyke C, Plevak MF, Dierkhising RA, Zinsmeister AR, Melton LJ. Trends in the identification and clinical features of celiac disease in a North American community, 1950-2001. Clin Gastroenterol Hepatol. 2003; 1(1): 19-27.
In article      View Article  PubMed
 
[7]  Gujral N, Freeman HJ, Thomson AB. Celiac disease: Prevalence, diagnosis, pathogenesis and treatment. World Journal of Gastroenterology: WJG. 2012; 18(42): 6036-6059.
In article      View Article  PubMed
 
[8]  Green PH, Lebwohl B, Greywoode R. Celiac disease. J Allergy Clin Immunol. 2015May; 135(5): 1099-106.
In article      View Article  PubMed
 
[9]  Elli L, Branchi F, Tomba C, et al. Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity. World Journal of Gastroenterology: WJG. 2015; 21(23): 7110-7119.
In article      View Article  PubMed
 
[10]  Esmaeilzadeh A, Ganji A, Goshayeshi L, Ghafarzadegan K, Afzal Aghayee M, MosanenMozafari H, Saadatniya H, Hayatbakhs A, Ghavami Ghanbarabadi V. Adult Celiac Disease: Patients Are Shorter Compared with Their Peers in the General Population. Middle East J Dig Dis. 2016 Oct; 8(4): 303-309.
In article      View Article  PubMed
 
[11]  Book L, Zone JJ, Neuhausen SL. Prevalence of celiac disease among relatives of sib pairs with celiac disease in U.S. families. Am J Gastroenterol. 2003 Feb; 98(2): 377-81.
In article      View Article  PubMed
 
[12]  Rahmoune H, Boutrid N, Amrane M, Bioud B. Triggering agents for transient celiac disease. Internat J Celiac Dis. 2017 Aug; 5 (3): 127-128.
In article      View Article
 
[13]  Rubio-Tapia A, Van Dyke CT, Lahr BD, Zinsmeister AR, El-Youssef M, Moore SB, Bowman M, Burgart LJ, Melton LJ, 3rd, Murray JA. Predictors of family risk for celiac disease: a population-based study. Clin Gastroenterol Hepatol. 2008; 6: 983-7.
In article      View Article  PubMed
 
[14]  Aomari A, Firwana M, Benelbarhdadi I, Ajana FZ. Celiac disease and cancers in Morocco. Internat J Celiac Dis. 2017 Aug; 5 (3): 108-110.
In article      View Article
 
[15]  Sur LM, Floca E, Sur G, Rednic S. Serological and genetic evidence of Celiac Disease in Juvenile arthritis and rheumatoid arthritis. Internat J Celiac Dis. 2016 Aug; 4 (3) 82-83.
In article      View Article
 
[16]  Zwolińska-Wcisło M, Rozpondek P, Galicka-Latała D, Mach T. [Clinical symptoms variety in adults with celiac disease]. PrzeglLek. 2010; 67: 1325-1328.
In article      PubMed
 
[17]  Tankova L, Gerova V, Getsov P, Penkov N, Taneva G, Terziev I, Nakov R. The association of Crohn’s Disease, Celiac Disease, and Selective Ig 1a 1deficiency. Internat J Celiac Dis. 2016 Feb; 4 (1) 30-33.
In article      View Article
 
[18]  Ch’ng CL, Jones MK, Kingham JGC. Celiac Disease and Autoimmune Thyroid Disease. Clinical Medicine & Research. 2007; 5(3): 184-192.
In article      View Article  PubMed
 
[19]  Chou R, Bougatsos C, Blazina I, Mackey K, Grusing S, Selph S. Screening for Celiac Disease: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2017 Mar 28; 317(12): 1258-1268.
In article      View Article  PubMed
 
[20]  Borrelli EP. Inpatient hospital costs for celiac disease in the United States in 2014. Internat J Celiac Dis. 2017 Aug; 5 (3): 111-114.
In article      View Article
 
[21]  Long KH, RubioO-Tapia A, Wagie AE, et al. The economics of celiac disease: a population-based study. Alimentary pharmacology & therapeutics. 2010; 32(2): 261-269.
In article      View Article  PubMed
 
[22]  Violato M, Gray A, Papanicolas I, Ouellet M. Resource Use and Costs Associated with Coeliac Disease before and after Diagnosis in 3,646 Cases: Results of a UK Primary Care Database Analysis. Singh SR, ed. PLoS ONE. 2012; 7(7): e41308.
In article      View Article
 
[23]  HCUPnet. Healthcare Cost and Utilization Project (HCUP). 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://hcupnet.ahrq.gov/ Accessed September 5, 2017.
In article      View Article
 
[24]  Borrelli EP, Lee EYK. Hospitalization inpatient costs and demographics for amyotrophic lateral sclerosis in the U.S. from 2010-2014. Int J Recent Sci Res. 2017 July; 8 (7) 18203-18206.
In article      
 
[25]  U.S. Bureau of Economic Analysis. National Income and Product Account Tables, Table 1.1.4 Price Indexes for Gross Domestic Product. [September10, 2017]. http: //bea.gov/iTable/iTable.cfm?ReqID=9&step=1.
In article      View Article
 
[26]  Ludvigsson JF, Rubio-Tapia A, van Dyke CT, et al. Increasing incidence of celiac disease in a North American population. The American journal of gastroenterology. 2013; 108(5): 818-824.
In article      View Article  PubMed
 
[27]  Riddle MS, Murray JA, Porter CK. The Incidence and Risk of Celiac Disease in a Healthy US Adult Population. Am J Gastroenterol. 2012; 107: 1248-1255.
In article      View Article  PubMed
 
[28]  Welander A, Tjernberg AR, Montgomery SM, et al. Infectious disease and risk of later celiac disease in childhood. Pediatrics. 2010; 125: e530-e536.
In article      View Article  PubMed
 
[29]  Aggarwal S, Lebwohl B, Green PHR. Screening for celiac disease in average-risk and high-risk populations. Therapeutic Advances in Gastroenterology. 2012; 5(1): 37-47.
In article      View Article  PubMed
 
[30]  Glance LG, Stone PW, Mukamel DB, Dick AW. Increases in Mortality, Length of Stay, and Cost Associated With Hospital-Acquired Infections in Trauma Patients. Archives of Surgery (Chicago, Ill: 1960). 2011; 146(7): 794-801.
In article      View Article  PubMed
 
[31]  Puffer RC, Planchard R, Mallory GW, Clarke MJ. Patient-specific factors affecting hospital costs in lumbar spine surgery. J Neurosurg Spine. 2016; 24: 1-6.
In article      View Article  PubMed
 
[32]  Nicasio AM, Eagye KJ, Kuti EL, Nicolau DP, Kuti JL. Length of stay andhospital costs associated with a pharmacodynamic-based clinical pathway forempiric antibiotic choice for ventilator-associated pneumonia. Pharmacotherapy. 2010 May; 30(5): 453-62.
In article      View Article  PubMed
 

Published with license by Science and Education Publishing, Copyright © 2017 Eric P. Borrelli

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Eric P. Borrelli. Trends in Hospitalizations for Celiac Disease in the United States. International Journal of Celiac Disease. Vol. 5, No. 4, 2017, pp 150-154. http://pubs.sciepub.com/ijcd/5/4/5
MLA Style
Borrelli, Eric P.. "Trends in Hospitalizations for Celiac Disease in the United States." International Journal of Celiac Disease 5.4 (2017): 150-154.
APA Style
Borrelli, E. P. (2017). Trends in Hospitalizations for Celiac Disease in the United States. International Journal of Celiac Disease, 5(4), 150-154.
Chicago Style
Borrelli, Eric P.. "Trends in Hospitalizations for Celiac Disease in the United States." International Journal of Celiac Disease 5, no. 4 (2017): 150-154.
Share
[1]  Fasano A, Berti I, Gerarduzzi T, Not T, Colletti RB, Drago S, Elitsur Y, Green PH, Guandalini S, Hill ID, Pietzak M, Ventura A, Thorpe M, Kryszak D, Fornaroli F, Wasserman SS, Murray JA, Horvath K. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med. 2003 Feb 10; 163(3): 286-92.
In article      View Article  PubMed
 
[2]  Dubé C, Rostom A, Sy R, Cranney A, Saloojee N, Garritty C, Sampson M, Zhang L, Yazdi F, Mamaladze V, Pan I, Macneil J, Mack D, Patel D, Moher D. The prevalence of celiac disease in average-risk and at-risk Western European populations: a systematic review. Gastroenterology. 2005 Apr; 128(4 Suppl 1): S57-67
In article      View Article  PubMed
 
[3]  Rubio-Tapia A, Ludvigsson JF, Brantner TL, Murray JA, Everhart JE. The prevalence of celiac disease in the United States. Am J Gastroenterol. 2012 Oct; 107(10): 1538-44.
In article      View Article  PubMed
 
[4]  Patel D, Kalkat P, Baisch D, Zipser R. Celiac disease in the elderly. Gerontology. 2005; 51(3): 213-4.
In article      View Article  PubMed
 
[5]  Rashtak S, Murray JA. Celiac Disease in the Elderly. Gastroenterology clinics of North America. 2009; 38(3): 433-446.
In article      View Article  PubMed
 
[6]  Murray JA, Van Dyke C, Plevak MF, Dierkhising RA, Zinsmeister AR, Melton LJ. Trends in the identification and clinical features of celiac disease in a North American community, 1950-2001. Clin Gastroenterol Hepatol. 2003; 1(1): 19-27.
In article      View Article  PubMed
 
[7]  Gujral N, Freeman HJ, Thomson AB. Celiac disease: Prevalence, diagnosis, pathogenesis and treatment. World Journal of Gastroenterology: WJG. 2012; 18(42): 6036-6059.
In article      View Article  PubMed
 
[8]  Green PH, Lebwohl B, Greywoode R. Celiac disease. J Allergy Clin Immunol. 2015May; 135(5): 1099-106.
In article      View Article  PubMed
 
[9]  Elli L, Branchi F, Tomba C, et al. Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity. World Journal of Gastroenterology: WJG. 2015; 21(23): 7110-7119.
In article      View Article  PubMed
 
[10]  Esmaeilzadeh A, Ganji A, Goshayeshi L, Ghafarzadegan K, Afzal Aghayee M, MosanenMozafari H, Saadatniya H, Hayatbakhs A, Ghavami Ghanbarabadi V. Adult Celiac Disease: Patients Are Shorter Compared with Their Peers in the General Population. Middle East J Dig Dis. 2016 Oct; 8(4): 303-309.
In article      View Article  PubMed
 
[11]  Book L, Zone JJ, Neuhausen SL. Prevalence of celiac disease among relatives of sib pairs with celiac disease in U.S. families. Am J Gastroenterol. 2003 Feb; 98(2): 377-81.
In article      View Article  PubMed
 
[12]  Rahmoune H, Boutrid N, Amrane M, Bioud B. Triggering agents for transient celiac disease. Internat J Celiac Dis. 2017 Aug; 5 (3): 127-128.
In article      View Article
 
[13]  Rubio-Tapia A, Van Dyke CT, Lahr BD, Zinsmeister AR, El-Youssef M, Moore SB, Bowman M, Burgart LJ, Melton LJ, 3rd, Murray JA. Predictors of family risk for celiac disease: a population-based study. Clin Gastroenterol Hepatol. 2008; 6: 983-7.
In article      View Article  PubMed
 
[14]  Aomari A, Firwana M, Benelbarhdadi I, Ajana FZ. Celiac disease and cancers in Morocco. Internat J Celiac Dis. 2017 Aug; 5 (3): 108-110.
In article      View Article
 
[15]  Sur LM, Floca E, Sur G, Rednic S. Serological and genetic evidence of Celiac Disease in Juvenile arthritis and rheumatoid arthritis. Internat J Celiac Dis. 2016 Aug; 4 (3) 82-83.
In article      View Article
 
[16]  Zwolińska-Wcisło M, Rozpondek P, Galicka-Latała D, Mach T. [Clinical symptoms variety in adults with celiac disease]. PrzeglLek. 2010; 67: 1325-1328.
In article      PubMed
 
[17]  Tankova L, Gerova V, Getsov P, Penkov N, Taneva G, Terziev I, Nakov R. The association of Crohn’s Disease, Celiac Disease, and Selective Ig 1a 1deficiency. Internat J Celiac Dis. 2016 Feb; 4 (1) 30-33.
In article      View Article
 
[18]  Ch’ng CL, Jones MK, Kingham JGC. Celiac Disease and Autoimmune Thyroid Disease. Clinical Medicine & Research. 2007; 5(3): 184-192.
In article      View Article  PubMed
 
[19]  Chou R, Bougatsos C, Blazina I, Mackey K, Grusing S, Selph S. Screening for Celiac Disease: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2017 Mar 28; 317(12): 1258-1268.
In article      View Article  PubMed
 
[20]  Borrelli EP. Inpatient hospital costs for celiac disease in the United States in 2014. Internat J Celiac Dis. 2017 Aug; 5 (3): 111-114.
In article      View Article
 
[21]  Long KH, RubioO-Tapia A, Wagie AE, et al. The economics of celiac disease: a population-based study. Alimentary pharmacology & therapeutics. 2010; 32(2): 261-269.
In article      View Article  PubMed
 
[22]  Violato M, Gray A, Papanicolas I, Ouellet M. Resource Use and Costs Associated with Coeliac Disease before and after Diagnosis in 3,646 Cases: Results of a UK Primary Care Database Analysis. Singh SR, ed. PLoS ONE. 2012; 7(7): e41308.
In article      View Article
 
[23]  HCUPnet. Healthcare Cost and Utilization Project (HCUP). 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://hcupnet.ahrq.gov/ Accessed September 5, 2017.
In article      View Article
 
[24]  Borrelli EP, Lee EYK. Hospitalization inpatient costs and demographics for amyotrophic lateral sclerosis in the U.S. from 2010-2014. Int J Recent Sci Res. 2017 July; 8 (7) 18203-18206.
In article      
 
[25]  U.S. Bureau of Economic Analysis. National Income and Product Account Tables, Table 1.1.4 Price Indexes for Gross Domestic Product. [September10, 2017]. http: //bea.gov/iTable/iTable.cfm?ReqID=9&step=1.
In article      View Article
 
[26]  Ludvigsson JF, Rubio-Tapia A, van Dyke CT, et al. Increasing incidence of celiac disease in a North American population. The American journal of gastroenterology. 2013; 108(5): 818-824.
In article      View Article  PubMed
 
[27]  Riddle MS, Murray JA, Porter CK. The Incidence and Risk of Celiac Disease in a Healthy US Adult Population. Am J Gastroenterol. 2012; 107: 1248-1255.
In article      View Article  PubMed
 
[28]  Welander A, Tjernberg AR, Montgomery SM, et al. Infectious disease and risk of later celiac disease in childhood. Pediatrics. 2010; 125: e530-e536.
In article      View Article  PubMed
 
[29]  Aggarwal S, Lebwohl B, Green PHR. Screening for celiac disease in average-risk and high-risk populations. Therapeutic Advances in Gastroenterology. 2012; 5(1): 37-47.
In article      View Article  PubMed
 
[30]  Glance LG, Stone PW, Mukamel DB, Dick AW. Increases in Mortality, Length of Stay, and Cost Associated With Hospital-Acquired Infections in Trauma Patients. Archives of Surgery (Chicago, Ill: 1960). 2011; 146(7): 794-801.
In article      View Article  PubMed
 
[31]  Puffer RC, Planchard R, Mallory GW, Clarke MJ. Patient-specific factors affecting hospital costs in lumbar spine surgery. J Neurosurg Spine. 2016; 24: 1-6.
In article      View Article  PubMed
 
[32]  Nicasio AM, Eagye KJ, Kuti EL, Nicolau DP, Kuti JL. Length of stay andhospital costs associated with a pharmacodynamic-based clinical pathway forempiric antibiotic choice for ventilator-associated pneumonia. Pharmacotherapy. 2010 May; 30(5): 453-62.
In article      View Article  PubMed