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Cited by 438Antifungal resistance and susceptibilityFungal Infections and StudiesHealth Systems, Economic Evaluations, Quality of Life

Estimation of Direct Healthcare Costs of Fungal Diseases in the United States

Open access
Benedict, Kaitlin, Jackson, Brendan R, Chiller, Tom, Beer, Karlyn D·2019·Clinical Infectious Diseases
DOI 10.1093/cid/ciy776PMC PMC6409199
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Abstract

Background: Fungal diseases range from relatively minor superficial and mucosal infections to severe, life-threatening systemic infections. Delayed diagnosis and treatment can lead to poor patient outcomes and high medical costs. The overall burden of fungal diseases in the United States is challenging to quantify because they are likely substantially underdiagnosed. Methods: To estimate total national direct medical costs associated with fungal diseases from a healthcare payer perspective, we used insurance claims data from the Truven Health MarketScan® 2014 Research Databases, combined with hospital discharge data from the 2014 Healthcare Cost and Utilization Project National Inpatient Sample and outpatient visit data from the 2005–2014 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. All costs were adjusted to 2017 dollars. Results: We estimate that fungal diseases cost more than $7.2 billion in 2017, including $4.5 billion from 75,055 hospitalizations and $2.6 billion from 8,993,230 outpatient visits. Hospitalizations for Candida infections (n=26,735, total cost $1.4 billion) and Aspergillus infections (n=14,820, total cost $1.2 billion) accounted for the highest total hospitalization costs of any disease. Over half of outpatient visits were for dermatophyte infections (4,981,444 visits, total cost $802 million), and 3,639,037 visits occurred for non-invasive candidiasis (total cost $1.6 billion). Conclusions: Fungal diseas…

Integrity signals

Registry

Crossref · 10.1093/cid/ciy776

Cites

40 of 40 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

3 of 11 cited sources checked · 2 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Only 50% of invasive fungal diseases are diagnosed before death, according to autopsy studies.

    “For example, studies of autopsy reports suggest that only 50% of invasive fungal diseases are diagnosed before death [25].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [25] Dignani, 2014, Epidemiology of invasive fungal diseases on the basis of autopsy reports, F1000Prime Rep source
  • Interpretationcitation

    Other studies support the finding that mucormycosis consistently results in high average hospitalization costs (more than 100,000 dollars in this study) due to its severity and long length of stay.

    “Other studies also support our findings that mucormycosis, though a rare disease, consistently results in high average hospitalization costs (>$100,000 in this study) due to its severity and long length of stay [10, 22].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [10] Zilberberg, 2014, Hospital days, hospitalization costs, and inpatient mortality among patients with mucormycosis: a retrospective analysis of US hospital discharge data, BMC Infect Dis source
    • cites [22] Kontoyiannis, 2016, Prevalence, clinical and economic burden of mucormycosis-related hospitalizations in the United States: a retrospective study, BMC Infect Dis source

      The Discussion reports an average cost of $112,419 per mucormycosis-related hospital stay and describes substantial morbidity and mortality. It says prolonged stays, intensive care use, and severe underlying conditions *could* contribute to the high cost; the citing sentence states the cause more definitively. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.
  • Findingown data

    Dermatophyte infections had the lowest average outpatient visit costs (123 to 217 dollars).

    “Dermatophyte infections had the lowest average visit costs ($123–$217), and costs for vaginal candidiasis were also relatively low ($186–$287).”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.
  • Findingown data

    Average cost per hospitalization was generally highest for mucormycosis (106,655 to 112,849 dollars), invasive candidiasis (64,723 to 153,090 dollars), and uncommon and opportunistic mycoses (49,463 to 131,823 dollars).

    “Average cost per hospitalization varied by payment source, but were generally highest for mucormycosis ($106,655–$112,849), invasive candidiasis ($64,723–$153,090), and uncommon and opportunistic mycoses ($49,463–$131,823) (Table 2).”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.
  • Findingown data

    Of the non-invasive candidiasis visits, 792,057 (22%) were for candidiasis of an unspecified site.

    “Of those, 1,354,331 visits (37%) were for vaginal candidiasis (total cost $368 million), 782,522 visits (22%) were for oral candidiasis (total cost $335 million), and 792,057 visits (22%) were for candidiasis of an unspecified site.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.
  • May combine two claims. 16
  • Classified as probably not a substantial claim. 1

  • May combine two claims.

    Findingown data

    Of the non-invasive candidiasis visits, 782,522 (22%) were for oral candidiasis, with a total cost of 335 million dollars.

    “Of those, 1,354,331 visits (37%) were for vaginal candidiasis (total cost $368 million), 782,522 visits (22%) were for oral candidiasis (total cost $335 million), and 792,057 visits (22%) were for candidiasis of an unspecified site.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.

  • May combine two claims.

    Findingown data

    Aspergillus infections accounted for 14,820 hospitalizations and 1.2 billion dollars in total costs.

    “Candida infections (26,735 hospitalizations, total cost $1.4 billion) and Aspergillus infections (14,820 hospitalizations, total cost $1.2 billion) accounted for the most hospitalizations and the highest total costs of any disease.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.

  • May combine two claims.

    Findingown data

    Of the non-invasive candidiasis visits, 1,354,331 (37%) were for vaginal candidiasis, with a total cost of 368 million dollars.

    “Of those, 1,354,331 visits (37%) were for vaginal candidiasis (total cost $368 million), 782,522 visits (22%) were for oral candidiasis (total cost $335 million), and 792,057 visits (22%) were for candidiasis of an unspecified site.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.

  • May combine two claims.

    Findingown data

    Candida infections accounted for 26,735 hospitalizations and 1.4 billion dollars in total costs.

    “Candida infections (26,735 hospitalizations, total cost $1.4 billion) and Aspergillus infections (14,820 hospitalizations, total cost $1.2 billion) accounted for the most hospitalizations and the highest total costs of any disease.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.

  • May combine two claims.

    Findingown data

    Over half of all outpatient visits were for dermatophyte infections (4,981,444 visits), with a national cost of 821 million dollars.

    “Over half of all outpatient visits were for dermatophyte infections (4,981,444 visits), resulting in a national cost of $821 million.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.

  • May combine two claims.

    Findingown data

    There were 3,639,037 outpatient visits for non-invasive candidiasis, at a total cost of nearly 2.1 billion dollars.

    “3,639,037 outpatient visits occurred for non-invasive candidiasis at a total cost of nearly $2.1 billion.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.

  • May combine two claims.

    Findingown data

    In this analysis, cutaneous fungal diseases and vaginal candidiasis were associated with nearly 1 billion dollars and 5.3 million average yearly visits.

    “compared with nearly $1 billion and 5.3 million average yearly visits for these two groups of infections in this analysis.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.

  • May combine two claims.

    Findingown data

    Superficial fungal infections were associated with more than 8 million national outpatient visits and 2.4 billion dollars in costs.

    “These superficial fungal infections were associated with >8 million national outpatient visits and $2.4 billion in costs.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.

  • May combine two claims.

    Findingown data

    The number of visits and high associated costs for other and unspecified mycoses (ICD-9-CM code 117.9) were remarkable.

    “We also observed a remarkable number of visits and high associated costs for “other and unspecified mycoses” (ICD-9-CM code 117.9)”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.

  • May combine two claims.

    Interpretationcitation

    Fungal diseases have direct medical costs of more than 7 billion dollars annually, approximately 0.22% of total national health expenditures of 3.3 trillion dollars in 2016.

    “Our findings suggest that fungal diseases have direct medical costs of more than $7 billion annually, approximately 0.22% of the total national health expenditures of $3.3 trillion in 2016 (the most recent year of data available) [18].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] Centers for Medicare & Medicaid Services

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.

  • May combine two claims.

    Premisecitation

    ICD-9-CM codes for aspergillosis and candidemia have only modest sensitivity and sometimes poor positive predictive values.

    “Other studies have found that ICD-9-CM codes for aspergillosis and candidemia have only modest sensitivity and sometimes poor positive predictive values [26–28].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [26] Asti L , NewlandJ, ZerrD, et al Multi-center validation of ICD-9 codes for candidemia in a pediatric population. In: Program and abstracts of the 48th Annual Meeting of the Infectious Diseases Society of America, Vancouver, 2010; poster number: 561. Available at: https://idsa.confex.com/idsa/2010/webprogram/Paper2463.html

      Not checked in the free run.

    • cites [27] Chang, 2008, Comparison of the use of administrative data and an active system for surveillance of invasive aspergillosis, Infect Control Hosp Epidemiol source
    • cites [28] Schneeweiss, 2007, Veteran’s affairs hospital discharge databases coded serious bacterial infections accurately, J Clin Epidemiol source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The national cost of aspergillosis, candidiasis, cryptococcosis, and histoplasmosis in high-risk patients was previously estimated to be 2.6 billion dollars in 1998, equivalent to 5.1 billion dollars in 2017.

    “The national cost of aspergillosis, candidiasis, cryptococcosis, and histoplasmosis in high-risk patients was previously estimated to be $2.6 billion in 1998, equivalent to $5.1 billion in 2017 [4].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] Wilson, 2002, The direct cost and incidence of systemic fungal infections, Value Health source

  • May combine two claims.

    Interpretationreasoning

    Patients at risk for severe fungal diseases often have underlying conditions that can require additional healthcare expenditures, which are captured in this analysis if billed in the same visit or hospitalization with a fungal disease, and would inflate these estimates.

    “Patients at risk for these severe fungal diseases often have underlying conditions that can require additional healthcare expenditures, which are captured in our analysis if billed in the same outpatient visit or hospitalization with a fungal disease, and would inflate these estimates.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.

  • May combine two claims.

    Premisecitation

    Fungal diseases in the United States are likely substantially underdiagnosed, and no national public health surveillance exists for most fungal diseases.

    “The overall burden of fungal diseases in the United States is unknown and is difficult to quantify because they are likely substantially underdiagnosed, and no national public health surveillance exists for most fungal diseases [1].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [1] Vallabhaneni, 2016, The global burden of fungal diseases, Infect Dis Clin North Am source

  • May combine two claims.

    Study design and conductreasoning

    Because HCUP and NAMCS/NHAMCS cannot identify unique patients, this analysis captures prevalent rather than incident disease and represents a snapshot of yearly costs rather than average costs during an entire illness episode.

    “Because HCUP and NAMCS/NHAMCS cannot identify unique patients, our analysis captures prevalent rather than incident disease and therefore represents a snapshot of yearly costs rather than average costs incurred during a patient’s entire illness episode.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Invasive candidiasis and aspergillosis affect a much smaller number of people (about 15,000 hospitalizations in this analysis) but result in similarly large national costs because of their severity.

    “Lesser-known diseases like invasive candidiasis and aspergillosis affect a much smaller number of people (~15,000 hospitalizations in this analysis) but result in similarly large national costs because of their severity.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.

  • May combine two claims.

    Premisecitation

    Indirect costs have not been well-established for most fungal diseases, but several studies document negative impacts on quality of life.

    “In general, these indirect costs have not been well-established for most fungal diseases, but several studies document the negative impacts of certain diseases on patients’ quality of life [29, 30].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [29] Tsang, 2010, Enhanced surveillance of coccidioidomycosis, Arizona, USA, 2007–2008, Emerg Infect Dis source
    • cites [30] Drake, 1998, Effect of onychomycosis on quality of life, J Am Acad Dermatol source
17 of 17

  • The paper relies on this without support.

    Average costs per hospitalization and outpatient visit derived from the MarketScan databases are representative of national average costs for the corresponding payer groups.

    “We used the Truven Health MarketScan® 2014 Research Databases to obtain the average cost per hospitalization and outpatient visit among patients with private insurance, Medicare supplemental insurance, and Medicaid.”
    “To estimate total national costs by disease from a healthcare payer perspective, we multiplied the average cost per hospitalization and outpatient visit from MarketScan by the corresponding proportion of payers and the total number of hospitalizations and outpatient visits in the HCUP NIS and NAMCS/NHAMCS, respectively.”
1 of 1

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • This $6.6 billion was more than 1.5 times the costs reported 4 years prior.

    “more than 1.5 times that of the costs reported 4 years prior [26].”

    From Prevalence and Healthcare Burden of Fungal Infections in the United States, 2018 (2022) · cites this paper as [26]

    The Abstract Results report fungal-disease costs of more than $7.2 billion, not an amount less than $6.6 billion. Thus $6.6 billion cannot be more than 1.5 times the cost reported by this paper. The Discussion likewise describes annual costs as more than $7 billion (page unavailable in our copy). (LLM, conf=0.90)

    Checked by a reasoning model — may be wrong.

    Experimental — accuracy not yet measured

  • In a study from 2019, invasive candidiasis accounted for 12,770 US hospitalizations, with an average of 28 workdays lost per hospitalization.

    “In a study from 2019, IC accounted for 12,770 US hospitalizations, with an average of 28 workdays lost per hospitalization.49”

    From Epidemiology of Invasive Candidiasis (2024) · cites this paper as [49]

    The Results report 26,735 Candida-infection hospitalizations, 48% of which were due to invasive candidiasis—approximately 12,800, though the passage does not give the exact figure 12,770. The Discussion says the study did not include productivity losses such as time away from work; it does not support an average of 28 workdays lost per hospitalization. No page numbers are provided in our copy. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • It has previously been reported that there were nearly 75,000 hospitalizations and 8.9 million outpatient visits attributable to fungal infections in 2014, resulting in at least $7.2 billion in healthcare costs.

    “It has previously been reported that there were nearly 75 000 hospitalizations and a further 8.9 million outpatient visits attributable to fungal infections in 2014, resulting in at least $7.2 billion in healthcare costs [26].”

    From Prevalence and Healthcare Burden of Fungal Infections in the United States, 2018 (2022) · cites this paper as [26]

    The Abstract Results report 75,055 hospitalizations, 8,993,230 outpatient visits, and more than $7.2 billion in costs. However, the Abstract Methods specify that costs were adjusted to 2017 dollars, and the Methods (Data sources) say outpatient visits were estimated using survey data from multiple years through 2014—not solely visits in 2014. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • In the 4-year span from 2014 to 2018, the total direct costs (all primary and invasive infections; adjusted for inflation) of fungal infections in inpatient visits nearly doubled from 3.9 million to 6.7 million USD.

    “In the 4-year span from the 2014 HCUP dataset analyzed by Benedict et al [26] to the 2018 data analyzed here, the total direct costs (all primary and invasive infections; adjusted for inflation) of fungal infections in inpatient visits nearly doubled from 3.9 million to 6.7 million USD (Figure 2, Supplementary Table 1).”

    From Prevalence and Healthcare Burden of Fungal Infections in the United States, 2018 (2022) · cites this paper as [26]

  • In the 4-year span since 2014, the overall number of fungal infections deemed directly responsible for hospitalization moderately increased.

    “In the 4-year span since 2014 [26], the overall number of fungal infections deemed directly responsible for hospitalization, either listed as cause for admission or as having an invasive presentation of disease, moderately increased.”

    From Prevalence and Healthcare Burden of Fungal Infections in the United States, 2018 (2022) · cites this paper as [26]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Non-invasive candidiasis outpatient cost differs substantially

    Major

    For the same 3,639,037 visits, the abstract reports $1.6 billion, whereas the Results section reports nearly $2.1 billion.

  • Outpatient cost differs between abstract and results

    Major

    The abstract gives outpatient costs as $2.6 billion, but the Results section gives $2.7 billion.

  • Discussion cost for superficial infections conflicts with results

    Major

    The discussion gives $2.4 billion for dermatophyte infections and non-invasive candidiasis together. The results give $821 million and nearly $2.1 billion, respectively, or approximately $2.9 billion combined.

  • Dermatophyte outpatient cost has two values

    Major

    For the same 4,981,444 visits, the abstract reports $802 million and the results report $821 million.

  • Dermatophyte outpatient cost differs between sections

    Minor

    The same 4,981,444 dermatophyte visits are assigned $802 million in the abstract and $821 million in the Results section.

  • Hospitalization cost differs between abstract and results

    Minor

    The abstract reports $4.5 billion in hospitalization costs, while the Results section reports $4.6 billion for the same category.

  • Combined invasive-disease hospitalization count is understated

    Minor

    The discussion suggests approximately 15,000 hospitalizations for invasive candidiasis and aspergillosis together. The results instead imply about 12,833 invasive candidiasis hospitalizations (48% of 26,735), plus 14,820 Aspergillus hospitalizations-about 27,653 in total.

7 of 7

Cites

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1 of the 41 references couldn’t be matched to a known paper.

Cited by

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Related

Authors
Benedict, K., Jackson, B. R., Chiller, T., & Beer, K. D.
Affiliations
Centers for Disease Control and Prevention (US)
Corresponding author
Benedict, Kaitlin
ORCID
Venue
Clinical Infectious Diseases
Publisher
Oxford University Press (OUP)
Published
2018-09-10
Volume
68
Issue
11
Pages
1791-1797
ISSN
  • 1058-4838 (ISSN-L)
  • 1537-6591
DOI
10.1093/cid/ciy776
PMC
PMC6409199
OpenAlex
W2891999566
Cited by
438
References
41
Citations by year
2026: 33 · 2025: 55 · 2024: 73 · 2023: 72 · 2022: 72 · 2021: 63 · 2020: 44 · 2019: 21 · 2018: 3 · 2017: 2
FWCI
24.75
Type
journal article
Language
en
Open access
Licence
public-domain
Locations
  • Clinical Infectious Diseases (publishedVersion, public-domain)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health (CC999999)
  • Centers for Disease Control and Prevention
Topics
  • Health Sciences › Medicine › Infectious Diseases › Antifungal resistance and susceptibility
  • Health Sciences › Medicine › Epidemiology › Fungal Infections and Studies
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
Keywords
fungal diseases, direct healthcare costs, economic burden, hospital costs, outpatient visits, candidiasis, aspergillosis, dermatophytosis, underdiagnosis, Healthcare Cost and Utilization Project, National Ambulatory Medical Care Survey
MeSH terms
Hospitalization, Humans, Inpatients, Insurance Claim Review, Mycoses, Outpatients, United States, Health Care Costs, Cost of Illness, Health Care Surveys

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