A nationwide population-based cross-sectional time series study of hospitalized chronic liver disease burden in Thailand from 2017 to 2022

Abstract

Chronic liver disease (CLD) is a major global public health challenge due to its high morbidity and mortality. In Thailand, the burden of CLD remains underexplored despite its significant impact on healthcare systems. This study examines trends in hospitalizations, etiologies, and in-hospital mortality associated with CLD, including cirrhosis and hepatocellular carcinoma (HCC), from 2017 to 2022. We conducted a nationwide, population-based, cross-sectional time-series study using inpatient claims data from the National Health Security Office (NHSO) in Thailand. Data from fiscal years 2016 to 2022 were analyzed, focusing on CLD-related hospitalizations categorized by etiology using ICD-10 codes. Age- and sex-standardized incidence and mortality rates were assessed through descriptive and trend analyses, with LOESS smoothing applied to identify temporal patterns. Between 2017 and 2022, 119,464 hospitalizations for CLD were recorded, with 77% of patients being male and a median age of 45–66 years. Alcohol-associated liver disease was the leading cause (30.8%), followed by chronic hepatitis B (11.3%), hepatitis C (10.3%), and metabolic dysfunction-associated steatotic liver disease (MASLD, 9.6%). Etiology was unidentified in 37.5% of cases. Cirrhosis accounted for most hospitalizations, with a stable incidence of 1200–1600 cases per month. Alcohol-associated cirrhosis was the most prevalent, while MASLD-related cirrhosis had the highest mortality. Age-standardized mortality rates for hepatitis B- and C-related cirrhosis declined over the study period. HCC incidence remained stable, with hepatitis B, hepatitis C, and MASLD contributing 23, 16, and 8 cases per 10 million population per month, respectively. By 2022, MASLD-related HCC mortality had surpassed alcohol-related causes. CLD remains a major health burden in Thailand, with high mortality driven by viral hepatitis, alcohol consumption, and MASLD. Strengthening prevention strategies, early diagnosis, and equitable access to effective therapies is essential. Enhanced public health interventions and ongoing surveillance are critical to mitigating the growing CLD burden.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-025-16645-7.

Introduction

Chronic liver disease (CLD) is a major global health challenge, contributing significantly to morbidity, mortality, and economic burden^1–3. Each year, approximately 2 million deaths worldwide are attributed to liver disease, with nearly half resulting from complications of cirrhosis and the other half from viral hepatitis and hepatocellular carcinoma (HCC)⁴. Cirrhosis ranks as the 11th leading cause of death globally, while liver cancer remains the 16th most common cause of mortality, together accounting for 3.5% of global deaths⁵. Despite significant advancements in prevention and treatment, CLD continues to pose a substantial public health challenge, particularly in low- and middle-income countries where healthcare access remains uneven.

Beyond its impact on mortality, CLD imposes a significant economic burden. Patients with CLD experience high healthcare costs and reduced quality of life. Global and regional estimates of CLD-related disability-adjusted life years (DALYs) and years of life lost (YLL) consistently rank cirrhosis among the top 20 causes of disease burden. The highest burden is observed in Southeast Asia, with Thailand among the most affected countries⁶.

Like many nations in Southeast Asia, Thailand faces a significant burden of liver disease. Liver cancer is the second most common cancer overall and the leading cause of cancer-related deaths among men, resulting in 27,143 deaths in both sexes combined, including 18,562 deaths among men in 2022^7,8. Cirrhosis-related complications also contribute substantially to hospitalizations, with in-hospital mortality rates reaching 26% among patients with decompensated cirrhosis⁹. The primary causes of CLD in Thailand include alcohol-associated liver disease (ALD), hepatitis B virus (HBV), hepatitis C virus (HCV), and metabolic dysfunction-associated steatotic liver disease (MASLD)^10–12. In recent years, mortality due to viral hepatitis has declined, largely due to expanded antiviral treatments and vaccination programs. However, MASLD-related liver disease and HCC have emerged as growing concerns, underscoring the need for continued public health efforts to address the evolving landscape of CLD in Thailand¹².

Despite the substantial burden of chronic liver disease (CLD) in Thailand, comprehensive nationwide epidemiological data remain limited. Previous studies have primarily relied on small-scale hospital-based data^10,13,14, and the most recent nationwide data on hospitalized CLD were last updated in 2013^9,15,16. As a result, a critical knowledge gap remains regarding trends in CLD-related hospitalizations, mortality, and the evolving disease etiology within Thailand’s inpatient population. Understanding these patterns is essential for guiding healthcare policies, optimizing resource allocation, and implementing targeted interventions.

This nationwide population-based study aims to provide an updated epidemiological perspective on the burden of hospitalized CLD in Thailand from 2017 to 2022. Utilizing inpatient claims data from the National Health Security Office (NHSO), we analyze trends in hospitalizations, etiologies, and in-hospital mortality rates associated with chronic hepatitis, cirrhosis, and HCC. The findings from this study will serve as a critical foundation for public health strategies, early detection programs, and policy development aimed at mitigating the growing burden of CLD in Thailand.

Methods

Study design

We conducted a cross-sectional time series analysis using claims data from the National Health Security Office (NHSO) in Thailand. The dataset spans fiscal years 2016 to 2022, corresponding to the period from January 1, 2017, to December 31, 2022. This timeframe allowed for a retrospective examination of health trends and outcomes related to CLD across the Thai population.

Study participants

This study included hospitalized patients diagnosed with liver diseases based on International Classification of Diseases, 10th Revision (ICD-10) codes (Supplementary Table 1). The cohort comprised individuals with CLD, including chronic hepatitis (alcohol-related, viral, metabolic, and other causes), cirrhosis, and HCC. Patients with cirrhosis were further categorized by etiology, including ALD, viral hepatitis B or C, MASLD, and other or unidentified causes. Additionally, the study documented common cirrhosis-related complications, such as variceal bleeding, spontaneous bacterial peritonitis (SBP), ascites, hepatorenal syndrome (HRS), and hepatic encephalopathy (HE). HCC cases were classified based on underlying etiologies, including ALD, viral hepatitis, MASLD, and other or unidentified causes. The study also recorded HCC treatment modalities, such as surgical resection, radiofrequency ablation (RFA), and transarterial chemoembolization (TACE).

Data sources and procedures

We retrieved individual inpatient claims data from the Thai Health Information Portal (THIP), the data warehouse of the NHSO, Thailand. The dataset included a comprehensive set of variables, such as age, sex, ICD-10 diagnoses, admission and discharge dates, and discharge status. To ensure accurate patient tracking, all referral hospitalization records, from the initial admission at a primary hospital to the final referral hospital, were consolidated into a single record. This process captured the entire patient journey, ensuring that multiple referrals across different hospitals were counted as a single hospitalization event per patient. All individual data were linked using encrypted citizen numbers to maintain confidentiality.

Hospitalizations for chronic hepatitis, cirrhosis, and HCC were identified using ICD-10 primary diagnosis codes from the claims database. The etiology of CLD was further ascertained through an examination of codes listed as primary, secondary, and other diagnoses, as delineated in Table 1. Recognizing that the etiology of MASLD might be underestimated through the direct application of codes K74.0 and K76.0, we additionally employed an indirect method. This method involved the use of a combination of codes K74.6, K75.8, or C22.x alongside E11 or E66 to enhance the identification of etiology¹⁷. Individuals whose etiology could not be determined were classified under an unidentified etiology. Additionally, patients with HBV/HCV co-infection were excluded from the cirrhosis and HCC etiology classifications to avoid misclassification bias.

Table 1.

Population demographics and etiology of hospitalized patients with chronic liver disease, cirrhosis, and hepatocellular carcinoma (2017–2022).

Demographics	Alcohol	HBV	HCV	MASLD	Others	UE	Total
Non-cirrhosis
Total, N	3917	790	1285	573	521	–	7086
Sex, n (%)
Female	639 (16.3)	261 (33)	412 (32.1)	333 (58.1)	373 (71.6)	–	2018 (28.5)
Male	3278 (83.7)	529 (67)	873 (67.9)	240 (41.9)	148 (28.4)	–	5068 (71.5)
Age (years), median (IQR)	45 (37, 52)	54 (44, 63)	57 (49, 63)	56 (48, 64)	45 (20, 58)	–	49 (40,58)
Length of hospital stay (days)
median (IQR)	3 (2, 5)	3 (2, 5)	2 (1, 4)	1 (1, 3)	4 (2.5, 7)	–	3 (2,5)
Average cost per hospitalization claim (USD)
median (IQR)	156 (136, 257)	217 (168, 325)	216 (168, 302)	168 (156, 217)	216 (168, 325)	–	167.5 (155.5,276.4)
Cirrhosisa
Total, N	30,184	4018	4731	7245	224	26,574	72,976
Sex, n (%)
Female	7498 (24.8)	1103 (27.5)	1290 (27.3)	3597 (49.6)	113 (50.4)	8612 (32.4)	22,213 (30.4)
Male	22,686 (75.2)	2915 (72.5)	3441 (72.7)	3648 (50.4)	111 (49.6)	17,962 (67.6)	50,763 (69.6)
Age (years), median (IQR)	52 (45,59)	56 (48,64)	56 (49,63)	62 (54,69)	13 (3,52)	55 (47,64)	54 (46,62)
Length of hospital stay (days)
median (IQR)	4 (2, 6.5)	4.5 (3, 7)	4 (3, 6.5)	4 (2, 6)	3 (2, 6)	3.5 (2,6)	4 (2,6)
Average cost per hospitalization claim (USD)
median (IQR)	331 (227, 785)	785 (276, 843)	785 (277, 843)	276 (192, 730)	276 (145, 438)	276 (156, 730)	276.4 (191.9,785.2)
Complication, n (%) (not mutually exclusive)
Variceal bleeding	10,300 (34.1)	1296 (32.3)	1531 (32.4)	2053 (28.3)	110 (49.1)	8204 (30.9)	23,494 (32.2)
SBP	5392 (24.3)	785 (27.1)	1020 (29.2)	1477 (25.8)	43 (23.6)	5190 (26.2)	13,907 (19.1)
Ascites	7824 (25.9)	1214 (30.2)	1452 (30.7)	2644 (36.5)	44 (19.6)	7822 (29.4)	21,000 (28.8)
Hepatorenal syndrome	847 (2.8)	140 (3.5)	171 (3.6)	264 (3.6)	4 (1.8)	783 (2.9)	2209 (3)
Hepatic encephalopathy	7059 (23.4)	844 (21)	1022 (21.6)	2031 (28)	37 (16.5)	5755 (21.7)	16,748 (23)
Hepatic hydrothorax	700 (2.3)	103 (2.6)	138 (2.9)	227 (3.1)	4 (1.8)	635 (2.4)	1807 (2.5)
Portal hypertension	3834 (12.7)	586 (14.6)	661 (14)	881 (12.2)	86 (38.4)	3194 (12)	9242 (12.7)
Hepatocellular carcinomab
Total, N	2557	8652	6313	3673	40	18,167	39,402
Sex, n (%)
Female	229 (9)	1812 (20.9)	1388 (22)	1416 (38.6)	10 (25)	4658 (25.6)	9513 (24.1)
Male	2328 (91)	6840 (79.1)	4925 (78)	2257 (61.4)	30 (75)	13,509 (74.4)	29,889 (75.9)
Age (years), median (IQR)	60 (54, 66)	60 (53, 66)	60 (55, 65)	66 (59, 73)	65 (59, 69)	61 (54, 68)	61 (54,68)
Length of hospital stay (days)
median (IQR)	3 (2.5, 5)	3 (2.7, 4.5)	3 (2.5, 4)	3 (2.5, 6)	3.5 (3, 7)	3 (2, 5)	3 (2.3,5)
Average cost per hospitalization claim (USD)
median (IQR)	1019 (782, 1381)	1168 (1019, 1764)	1192 (1019, 1381)	783 (566, 1191)	782 (782, 1019)	644 (526, 1102)	1019.4 (626,1353.7)
Treatment claim, n (%) (not mutually exclusive)
Surgery/resection	44 (1.7)	210 (2.4)	97 (1.5)	58 (1.6)	0 (0)	258 (1.4)	667 (1.7)
RFA/local ablation	367 (14.4)	1411 (16.3)	992 (15.7)	431 (11.7)	10 (25)	1467 (8.1)	4678 (11.9)
TACE	1281 (50.1)	4548 (52.6)	3286 (52.1)	1362 (37.1)	29 (72.5)	6564 (36.1)	17,070 (43.3)

HBV, hepatitis B virus; HCV, hepatitis C virus; MASLD: Metabolic dysfunction-associated steatotic liver disease; UE, Unidentified etiology; IQR, Interquartile range.

^a134 patients with hepatitis C virus/ hepatitis B virus coinfection were excluded.

^b280 patients with hepatitis C virus/ hepatitis B virus coinfection were excluded.

The data were subsequently linked to the vital registry to determine individuals’ vital status and date of death, facilitating comprehensive survival follow-up.

Statistical analyses

Demographic data were analyzed using descriptive statistics. Age- and sex-standardized hospitalization incidence rates per 10 million population for chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC) were calculated using the WHO World Standard Population¹⁸. For each condition, trends over the five-year period (2017–2022) were evaluated using locally weighted scatterplot smoothing (LOESS) to generate smoothed curves of the monthly rates. A stacked bar plot was used to depict monthly hospitalization figures, while Kaplan–Meier curves illustrated 5-year patient survival. To ensure complete follow-up, only the 2017–2019 cohort was included in the survival analysis, as complete 5-year data were not available for later cohorts. All plots were stratified by etiology, providing a comprehensive view of the temporal and etiological patterns in hospitalization rates.

The analyses were performed using the tidyverse (version 2.0.0)¹⁹epiDisplay (version 3.5.0.2)²⁰and survminer (version 0.5.0)²¹ packages in R language and environment version 4.1.1 (R Core Team (2021). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria.

Results

Incidence and etiology of hospitalized chronic liver disease in Thailand (2017–2022)

Our data estimated the incidence of hospitalized patients with CLD in Thailand to be 119,464 hospitalizations between 2017 and 2022. The overall etiology of CLD was identified as ALD in 36,658 cases (30.6%), chronic hepatitis B in 13,460 cases (11.3%), chronic hepatitis C in 12,329 cases (10.3%), MASLD in 11,491 cases (9.6%), and other rare causes such as primary sclerosing cholangitis, primary biliary cirrhosis, and Wilson’s disease in 785 cases (0.6%). Additionally, 44,741 cases (37.5%) had an unidentified etiology. Most patients with CLD were male, aged 45–66 years.

Trends and mortality of non-cirrhotic chronic liver disease in Thailand (2017–2022)

From 2017 to 2022, a significant number of patients under Thailand’s Universal Coverage Scheme (UCS) were hospitalized with a primary diagnosis of non-cirrhotic CLD, including alcohol-associated hepatitis, chronic hepatitis B or C, MASLD, and other CLD. Alcohol-associated hepatitis was the leading cause of non-cirrhotic CLD, accounting for 55.3% of cases, followed by hepatitis C (18.1%), hepatitis B (11.1%), MASLD (8.1%), and other causes, as shown in Table 1. The age- and sex-standardized incidence rates of chronic hepatitis B and C, MASLD, and other causes remained stable between 2017 and 2022 (Fig. 1A). In contrast, the number of adult inpatients diagnosed with alcohol-associated hepatitis steadily increased over time, peaking in late 2020 before showing a declining trend (Fig. 1B). Most patients were male (71.5%), aged 49 (40–58) years. Length of hospital stay and average hospitalization costs were not significantly different across the groups. The overall mortality rate of non-cirrhotic CLD in Thailand is shown in Fig. 1C, with the five-year survival rate of all groups gradually declining over time.

Fig. 1.

Age-sex standardized incidence rate of newly hospitalized cases primarily diagnosed with non-cirrhotic chronic liver disease per month in the population (A), total number of hospitalized cases primarily diagnosed with non-cirrhosis (B), and mortality rate of hospitalized cases primarily diagnosed with non-cirrhosis (C).

Hospitalized cirrhosis cases and complications in Thailand (2017–2022)

The age- and sex-standardized incidence rate of alcohol-associated cirrhosis increased from 25 per 10 million population per month in early 2017 to 62 per 10 million population per month in late 2020, followed by a gradual decline (Fig. 2A). The number of hospitalized cirrhosis cases between 2017 and 2022 remained relatively stable, averaging 1200–1600 cases per month (Fig. 2B). As shown in Table 1, the leading cause of cirrhosis was ALD, accounting for 41.5% of cases, followed by MASLD (9.9%), HCV (6.5%), HBV (5.5%), and other rare causes (0.3%). Most patients were male (69.6%), aged 54 (46–62) years. The most common complication among hospitalized cirrhotic patients was variceal bleeding, accounting for 32.2% of cases, followed by ascites (28.8%), HE 23%), and SBP (19.1%, Table 1). Other less common complications included portal hypertension (12.8%) and HRS (3%). Notably, more than 36% of cirrhotic patients had cirrhosis with unidentified etiology, as shown in Table 1. The five-year survival rate of hospitalized patients primarily diagnosed with cirrhosis is illustrated in Fig. 2C. Although alcohol-associated cirrhosis was consistently the most common cause of cirrhosis, data from the study suggest that MASLD had a greater impact on mortality risk compared to alcohol-related cirrhosis.

Fig. 2.

Age-sex standardized incidence rate of newly hospitalized cases primarily diagnosed with cirrhosis per month in the population (A), total number of hospitalized cases primarily diagnosed with cirrhosis (B), and mortality rate of hospitalized cases primarily diagnosed with cirrhosis (C).

Hospitalized HCC cases and treatment in Thailand (2017–2022)

This study found that nearly half of hospitalized HCC patients (46%) had an unidentified etiology. As shown in Table 1, the leading causes of inpatient HCC were HBV (22%), HCV (16%), MASLD (9.3%), alcohol-related HCC (6.5%), and other rare causes (0.1%). The age- and sex-standardized incidence rates of HCC in admitted patients in Thailand remained relatively stable across groups, with an estimated 23 per 10 million population per month for HBV-related HCC, 16 per 10 million population per month for HCV-related HCC, 8 per 10 million population per month for MASLD-related HCC, and 7 per 10 million population per month for alcohol-related HCC (Fig. 3A). While HBV and HCV remain the leading causes of HCC in Thailand, the study confirmed that nearly half of hospitalized HCC cases had an unidentified etiology (Fig. 3B). Most patients were elderly males (75.9%), aged 61 (54–68) years. The data also revealed that the average cost per hospitalization for HCC was higher than for cirrhosis and chronic hepatitis, although the length of hospital stay did not significantly differ between these groups. The five-year survival rate of hospitalized HCC patients, shown in Fig. 3C, indicated that MASLD-related HCC had a lower survival rate compared to alcohol-related, HBV-related, and HCV-related HCC. Furthermore, TACE was the most common treatment modality for HCC in Thailand, accounting for 43.3% of cases (Supplementary Fig. 1), followed by RFA or local ablation (11.9%) and surgical resection (1.4%). Notably, approximately 45% of hospitalized HCC patients did not receive any specific HCC-directed intervention during their admission (Supplementary Fig. 2).

Fig. 3.

Age-sex standardized incidence rate of newly hospitalized cases primarily diagnosed with hepatocellular carcinoma (HCC) per month in the population (A), total number of hospitalized cases primarily diagnosed with HCC (B), and mortality rate of hospitalized cases primarily diagnosed with HCC (C).

Discussion

This nationwide study provides an updated overview of the burden of CLD in Thailand. The most common causes of cirrhosis worldwide include alcohol consumption, viral hepatitis, and MASLD, which aligns with findings in Thailand⁴. Based on inpatient data from the THIP, ALD was the leading cause of CLD (30.6%), followed by chronic hepatitis B (11.3%), chronic hepatitis C (10.3%), and MASLD (9.6%). However, 37.5% of cases had an unidentified etiology, highlighting the need for improved diagnostic coding and reporting. Males, particularly in the 45–66 age group, were at a higher risk of developing CLD.

Between 2017 and 2022, most patients under Thailand’s UCS were hospitalized with CLD, primarily due to alcohol-associated hepatitis. The highest-risk group consisted of men aged 45–56 years. The number of alcohol-associated hepatitis hospitalizations increased from early 2017, peaking in late 2020, coinciding with the COVID-19 pandemic. This trend may have resulted from limited hospital resources, lockdown measures, and changes in healthcare access, leading to delayed hospital visits or deaths at home²². Kaplan-Meier survival analysis indicated that alcohol-associated cirrhosis had a better five-year survival rate compared to MASLD and viral hepatitis-related cirrhosis.

Cirrhosis remains a significant cause of morbidity and mortality among patients with CLD globally. In 2019, cirrhosis accounted for 2.4% of global deaths². In Thailand, hospitalizations for cirrhosis remained stable, with an incidence of 1200–1600 cases per month between 2017 and 2022. A previous study from a tertiary-care hospital reported chronic hepatitis B as the most common cause of CLD¹⁰. However, in contrast, our nationwide inpatient data identified ALD as the leading cause of cirrhosis hospitalizations. Although alcohol is a major contributor to cirrhosis, patients with HBV/HCV-related cirrhosis had lower survival rates than those with alcohol-related cirrhosis, consistent with previous studies indicating that HBV is a leading cause of liver disease-related mortality in many countries¹⁰. Notably, MASLD-related cirrhosis had the lowest five-year survival rate, highlighting the emerging burden of metabolic liver diseases. While the absolute number of MASLD cases was lower, its economic and healthcare impact remains substantial²³.

Our findings contrast with prior data from the National Health and Nutrition Examination Survey (NHANES), which demonstrated lower overall survival in patients with ALD compared to those with MASLD²⁴. One possible explanation for this discrepancy lies in differences between study populations and outcome ascertainment. NHANES is a population-based cohort that primarily identifies patients at earlier stages of liver disease, whereas our study focused on hospitalized patients with more advanced disease. In our cohort, MASLD patients were typically older (median age 62 vs. 52 in ALD), which likely contributed to higher non-liver-related mortality, particularly from cardiovascular events due to coexisting cardiovascular risk factors in elderly patients. In addition, a recent study from the national Veterans Health Administration cohort similarly found that patients with MASLD cirrhosis had higher mortality from cardiovascular causes compared to those with ALD cirrhosis²⁵. This competing risk may have contributed to the attenuated long-term survival observed in MASLD patients in our study, despite their liver disease being comparable or even less advanced than that in patients with ALD.

A significant proportion of cirrhosis cases in this study had an unknown etiology (37.5%), likely due to underreporting of alcohol consumption, progression of MASLD to cirrhosis, and limitations in hospital discharge documentation. Patients often underreport alcohol intake due to stigma or lack of awareness, leading to misclassification of alcohol-related cirrhosis as cryptogenic^26,27. Similarly, MASLD can “burn out” in late-stage cirrhosis, where metabolic risk factors such as obesity and diabetes diminish over time, making retrospective diagnosis difficult^28,29. Additionally, hospital discharge summaries and ICD coding often prioritize cirrhosis severity over etiology, leading to incomplete classification³⁰.

Our findings also confirmed that the most common cirrhosis-related complications among hospitalized patients included variceal bleeding, ascites, SBP, HE, portal hypertension, HRS, and hepatic hydrothorax, all of which significantly increased mortality risk⁵. A nationwide study in Thailand reported that cirrhosis complications increased the in-hospital mortality rate by nearly threefold compared to patients without complications, with HRS carrying the highest mortality risk (42.6%)¹⁵. Additionally, a population-based study on cirrhosis readmissions highlighted that 47% of early hospital readmissions were due to complications of portal hypertension, emphasizing the significant healthcare burden of recurrent hospitalizations⁹. These findings underscore the critical need for effective management strategies aimed at preventing and mitigating complications to reduce mortality and healthcare costs.

Although a large proportion of admitted HCC patients had an unidentified etiology, our study identified HBV, HCV, MASLD, and alcohol consumption as the primary risk factors for HCC in Thailand from 2017 to 2022. Similarly, other studies from tertiary centers in Thailand have found that chronic HBV infection is the most common cause of HCC^11,31. Additionally, data from the Global Burden of Disease (GBD) 2019 reported that chronic hepatitis B was the leading cause of HCC, followed by ALD and chronic HCV infection in Southeast Asia¹². Meanwhile, in the Western Pacific region, hepatitis B remained the most common cause of HCC, followed by hepatitis C and ALD, respectively¹².

The treatment of HCC varies based on disease stage, patient condition, and healthcare accessibility^32,33. Our study found that TACE was the most commonly used treatment, accounting for 43.3% of cases. Other treatments included RFA (11.9%) and surgical resection (1.7%). Of note, around 45% of hospitalized patients with HCC did not receive any specific HCC-directed treatment during their admission. In contrast, a previous study using NHSO data from 2009 to 2013 found that 90.24% of admitted HCC patients did not receive treatment, with only approximately 5% undergoing TACE and 2.6% receiving RFA or surgical resection¹⁶. This finding highlights the temporal changes in treatment uptake, indicating improved access to HCC interventions over time. Similarly, a previous study reported poor survival rates among admitted HCC patients, with a 1-year survival rate of 15% and a 5-year survival of only 1%¹⁶. Conversely, our updated data from 2017 to 2022 demonstrated significantly improved survival rates, with five-year survival increasing to 20–50%. The higher survival rates may be attributed to early detection through screening programs, increased access to curative therapies (e.g., hepatic resection and RFA), and expanded use of TACE for non-resectable cases.

This study represents the first nationwide epidemiological update on the burden of hospitalized CLD, cirrhosis, and HCC in Thailand. A key strength of our study is the use of a comprehensive database THIP from NHSO, which captures anonymized data on hospitalized Thai patients under the UCS. The UCS covers approximately 74% of the Thai population, providing healthcare through primary, secondary, and tertiary care settings³⁴. As a result, our findings provide a robust estimate of the incidence and burden of hospitalized CLD in Thailand.

However, this study has some limitations inherent to administrative database analysis. First, the study relied on ICD-10 WHO codes for CLD diagnosis, which may lead to misclassification bias due to miscoding. Second, a significant proportion of cirrhosis and HCC cases had an unknown etiology, potentially distorting trends in CLD etiology and influencing policy decisions. Third, this study focused on hospitalized patients, excluding outpatient cases and individuals covered by other insurance schemes. Fourth, although the data were linked to the national vital registry to capture all-cause mortality, cause-specific mortality, such as cardiovascular death, was not available in the dataset. Therefore, we could not account for the competing risk of cardiovascular mortality, particularly relevant in MASLD patients, which may have influenced survival estimates. Lastly, although our database included nationwide data, we did not analyze potential regional differences in admissions and mortality across Thailand, which may have provided additional insight into geographic disparities in disease burden and healthcare access. Future research should incorporate outpatient data, other healthcare systems, detailed cause-of-death information, and regional analyses to provide a more comprehensive assessment of CLD in Thailand.

In conclusion, CLD remains a significant public health issue in Thailand, with ALD, viral hepatitis (HBV, HCV), and MASLD as the leading causes of cirrhosis and HCC. To reduce the morbidity, mortality, and healthcare costs associated with CLD, targeted prevention strategies, early diagnosis, and improved access to treatment are essential. This study utilized a nationwide database to assess the burden of CLD among hospitalized patients under Thailand’s UCS. Our findings provide valuable insights for healthcare providers and policymakers to develop effective strategies to address the impact of CLD in Thailand. However, a substantial proportion of CLD cases remain undiagnosed or are managed in outpatient settings, leading to an underestimated disease burden. Further research that incorporates data from other health insurance schemes and outpatient settings is needed for a more comprehensive understanding of CLD in Thailand.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

ALD

Alcohol-associated liver disease

FLD

Fatty liver disease

MASLD

Metabolic dysfunction-associated steatotic liver disease

NAFLD

Non-alcoholic fatty liver disease

HBV

Hepatitis B virus

HCV

Hepatitis C virus

HCC

Hepatocellular carcinoma

THIP

Thai Health Information Portal

ICD-10

International Classification of Diseases 10th Revision

Author contributions

Conceptualization: A.K. Data curation: R.S., P.K. Formal analysis: P.K. Funding acquisition: A.K. Investigation: R.S., P.K., A.K. Methodology: R.S., P.K., A.K.: Project administration: A.K. Supervision: A.K. Validation: R.S., A.K., P.S., N.C., S.L., P.K. Visualization: R.S., P.K. Writing, original draft: R.S., P.K., A.K. Writing, review, and editing: R.S., A.K., P.S., N.C., S.L., T.P., P.K.

Funding

Faculty of Medicine, Prince of Songkhla University, Songkhla, Thailand.

Data availability

Data from the Thailand Health Information Platform (THIP) can be accessed through the query tool available at https://thip.nbt.or.th/login, which requires user authentication via a registered institutional email and password. Access is available to qualified researchers upon reasonable request. This platform is a collaborative initiative among the National Health Security Office (NHSO), the National Science and Technology Development Agency (NSTDA), and Prince of Songkla University (PSU). The Institute of Research and Development for Health of Southern Thailand (RDH), Department of Epidemiology, Faculty of Medicine, PSU, serves as the gatekeeper for data access. NSTDA provides system design and development services as well as server support to host the database and are available from the corresponding author on reasonable request.

Declarations

Competing interests

Apichat Kaewdech received research grants or support from Roche, Roche Diagnostics, and Abbott Laboratories, and honoraria from Roche, Roche Diagnostics, Abbott Laboratories, and Esai. Dr. Liangpunsakul discloses consulting roles with Durect Corporation, Surrozen, and Korro Bio. However, these roles do not present any conflict of interest concerning the content of this work. Teerha Piratvisuth received research grants from Gilead Sciences, Roche Diagnostics, Janssen, Fibrogen, and VIR and honoraria from Bristol-Myers Squibb, Gilead Sciences, Bayer, Abbott, Esai, Mylan, Ferring, and MSD. The other authors have no relevant conflict of interest to declare.

Institutional review board approval

This study was exempt from the Ethics committee in accordance with the ethical guidelines of the 1975 Declaration of Helsinki and approved by the Human Research Ethics Unit (HREU) of the Faculty of Medicine, Prince of Songkla University (REC number: REC.66-514-14-1). Due to the retrospective nature of the study, HREU waived the need of obtaining informed consent.