Annual Health Care Utilization and Costs for Treatment of Cutaneous and Anogenital Warts Among a Commercially Insured Population in the US, 2017-2019

Abstract

This cohort study evaluates annual health care utilization and costs associated with common cutaneous and anogenital wart treatments, such as cryotherapy, intralesional immunotherapy, and prescription topical treatments.

Cutaneous warts are common growths responsible for several million office visits per year.¹ While multiple treatments are available, including topical treatments, intralesional immunotherapy, and cryotherapy,^2,3 little is known about health care utilization and costs associated with different treatments.

Methods

To evaluate annual health care utilization and costs associated with common cutaneous and anogenital wart treatments, such as cryotherapy, intralesional immunotherapy, and prescription topical treatments, a retrospective cohort study was conducted using the deidentified Optum Clinformatics Database. This study was deemed exempt from review by the institutional review board of the University of Pennsylvania owing to the use of deidentified data. We identified encounters with diagnoses of cutaneous warts (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] B07.x) and anogenital warts (ICD-10 A63.0) from January 1, 2017, through December 31, 2019. Wart management costs (standardized to 2020 USD) were stratified by costs for encounters (Current Procedural Terminology [CPT] codes 99201-99205, 99211-99215), benign destruction procedures (CPT codes 17110, 17111, plus codes for anogenital warts in the Supplement), intralesional injections (CPT code 11900, plus J codes for Candida antigen and bleomycin), and prescription topical treatments (podofilox, podophyllin, imiquimod, sinecatechins). Number of prescriptions/procedures/encounters, in addition to number of individuals per treatment modality, were reported. Wart subtypes were analyzed independently.

Population-level costs were estimated by scaling Optum costs to the 2017, 2018, and 2019 US commercially insured populations, assuming an Optum population size of 20 million unique members.^4,5 Sensitivity analyses were conducted excluding evaluation and management (E&M) codes, including prescriptions that may be used for warts but also have alternate indications (adapalene, bexarotene, tazarotene, tretinoin), and excluding encounters with concurrent diagnoses of seborrheic keratoses (ICD-10 L82.x) or actinic keratoses (ICD-10 L57.0). Upper and lower bounds for annual wart costs were computed by combining the highest/lowest values for each of the subcosts (medications, benign destruction, injection, E&M) across sensitivity analyses. Analyses were conducted in Stata 16.1.

Results

On average, 263 070 individuals with cutaneous warts and 28 516 individuals with anogenital warts were captured for each year from 2017 through 2019. For patients with cutaneous warts, mean age was 44 years, 52% were female, and 81% were White. For patients with anogenital warts, mean age was 43 years, 40.7% were female, and 70% were White. For cutaneous warts, on average, 64.2% of individuals were treated with lesional destruction, 1.8% with intralesional injection, and 2.2% with prescription topical medications. For anogenital warts, on average, 35.3% of individuals were treated with lesional destruction, 0.6% with intralesional injection, and 16.5% with prescription topical medications. Stratified costs by treatment type are presented in Table 1. For 2019, we estimated annual costs of $846 million for cutaneous warts (lower bound, $431 million; upper bound, $850 million), and $127 million for anogenital warts (lower bound, $90 million; upper bound, $127 million) (Table 2).

Table 1. Stratified and Cumulative Costs for Cutaneous and Anogenital Warts, 2017-2019.

	Cutaneous warts			Anogenital warts
	2017	2018	2019	2017	2018	2019
Total individuals	259 104	264 354	265 753	31 954	26 923	26 670
Medications
No. of individuals	5880	5999	6252	4814	4837	4780
No. of prescriptions	7592	7761	7974	5781	5819	5751
Total cost, $	938 733.20	921 423.05	961 890.21	773 190.42	720 411.80	756 430.69
Benign destruction procedures
No. of individuals	165 377	169 996	171 121	10 022	10 131	9854
No. of prescriptions	274 908	282 478	285 056	18 302	18 684	18 118
Total cost, $	43 626 142	44 691 947	44 974 527	7 092 972.20	7 705 402.80	7 344 929.00
Injections
No. of individuals	4434	4814	4822	154	169	159
No. of procedures	7317	8246	8005	211	240	201
Cost, $
Procedural codes	463 112.59	538 768.04	514 505.22	13 381.79	12 556.02	12 922.16
Medications	445 391.18	454 455.27	477 793.89	32 308.62	44 291.73	58 300.76
Total	908 503.77	993 223.31	992 299.11	45 690.41	56 847.75	71 222.92
E&M
No. of individuals	210 015	213 881	215 569	22 584	19 861	19 878
No. of visits	302 732	308 137	310 690	34 604	31 409	31 547
Total cost, $	28 430 323	29 038 623	29 682 243	3 592 665.10	3 273 645.30	3 334 653.50
Optum cost, $
Total	73 903 701.97	75 645 216.36	76 610 959.32	11 504 518.13	11 756 307.65	11 507 236.11
Per patient	285.23	286.15	288.28	360.03	436.66	431.47

Abbreviation: E&M, evaluation and management.

Table 2. Annual US Cost Estimates for Cutaneous and Anogenital Warts, With Sensitivity Analyses^a.

	$
	Cutaneous warts			Anogenital warts
	2017	2018	2019	2017	2018	2019
Total costs, primary analysis
Medications	10 231 910	10 045 907	10 628 887	8 427 544	7 854 362	8 358 559
Procedures	475 511 860	487 258 421	496 968 523	77 311 269	84 008 925	81 161 465
Injections	9 902 419	10 828 716	10 964 905	498 012	619 788	787 013
E&M	309 881 992	316 596 491	327 988 785	39 158 972	35 691 245	36 847 921
Total costs	805 528 180	824 729 536	846 551 100	125 395 796	128 174 320	127 154 959
Total costs, excluding E&M codes
Total costs	495 646 189	508 133 045	518 562 315	86 236 824	92 483 075	90 307 038
Total costs, including prescriptions with alternate indications
Medications	13 726 126	13 344 799	13 683 551	8 694 645	7 950 932	8 452 804
Procedures	475 511 860	487 258 421	496 968 523	77 311 269	84 008 925	81 161 465
Injections	9 902 419	10 828 716	10 964 905	498 012	619 788	787 013
E&M	309 881 992	316 596 491	327 988 785	39 158 972	35 691 245	36 847 921
Total costs	809 022 396	828 028 428	849 605 765	125 662 897	128 270 890	127 249 204
Total costs, excluding encounters with SK or AK
Medications	9 409 154	9 187 143	9 619 804	8 002 175	7 451 182	7 940 154
Procedures	404 164 778	409 769 239	412 027 538	73 876 669	79 559 258	76 838 913
Injections	9 235 932	10 154 281	10 299 712	490 805	598 709	754 203
E&M	250 972 721	252 638 852	256 742 010	37 301 647	33 549 875	34 500 470
Total costs	673 782 586	681 749 515	688 689 063	119 671 296	121 159 024	120 033 741
Total costs
Lower boundb	422 809 865	429 110 663	431 947 053	85 811 456	92 079 894	89 888 633
Upper boundc	809 022 396	828 028 428	849 605 765	125 662 897	128 270 890	127 249 204

Abbreviations: AK, actinic keratosis; E&M, evaluation and management; SK, seborrheic keratosis.

^a Cost estimates scaled from Optum estimates assuming 20 million unique Optum members and a US population of 322, 324, and 325 million for 2017, 2018, and 2019, respectively, and a commercially insured percentage of 67.7%, 67.3%, and 68.0%, respectively.⁵

^b Lower bound estimates determined by excluding E&M codes, including only topical medications without common alternate indications, and excluding concurrent AK/SK diagnostic codes.

^c Upper bound estimates determined by including E&M codes, all prescriptions, and concurrent AK/SK diagnostic codes.

Discussion

In this claims-based study, we estimate a 2019 US annual cost of more than $800 million for wart treatment within the commercially insured population, with most cost driven by lesional destruction and management costs, rather than intralesional injections or prescription topical medications. Per-patient costs were $288.28 for cutaneous warts and $431.47 for anogenital warts. These findings are similar to a study of cryotherapy-associated treatment in the UK³ and a 2004 evaluation of US health care costs associated with anogenital wart treatment.⁶ Although procedural treatments such as cryotherapy remain the most common treatment approaches, these are associated with high costs. Given the limited effectiveness and adverse effects of these treatments, more effective topical treatments may be valuable for streamlining care and reducing population-level costs. This study is limited by its restriction to a commercially insured population and an inability to assess relative effectiveness of wart treatments. Given the nature of claims data, it is not possible to evaluate over-the-counter costs or in-office procedures and medications that are not billed; thus, costs from the patient perspective may be higher. Understanding health care utilization for warts provides useful information for anticipatory guidance (eg, expected number of treatments) and insight into the burden of disease.

Supplement.

eMethods. CPT codes for procedures on genital warts