1
|
Hundt M, Chen A, Donovan J, Kim N, Yilma M, Tana M, Mehta N, Zhou K. Barriers to liver transplant referral in safety net settings: A national provider survey. Liver Transpl 2024; 30:896-906. [PMID: 38687168 DOI: 10.1097/lvt.0000000000000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 04/12/2024] [Indexed: 05/02/2024]
Abstract
Safety net systems care for patients with a high burden of liver disease yet experience many barriers to liver transplant (LT) referral. This study aimed to assess safety net providers' perspectives on barriers to LT referrals in the United States. We conducted a nationwide anonymous online survey of self-identified safety net gastroenterologists and hepatologists from March through November 2022. This 27-item survey was disseminated via e-mail, society platforms, and social media. Survey sections included practice characteristics, transplant referral practices, perceived multilevel barriers to referral, potential solutions, and respondent characteristics. Fifty complete surveys were included in analysis. A total of 60.0% of respondents self-identified as White and 54.0% male. A total of 90.0% practiced in an urban setting, 82.0% in tertiary medical centers, and 16.0% in community settings, with all 4 US regions represented. Perceived patient-level barriers ranked as most significant, followed by practice-level, then provider-level barriers. Patient-level barriers such as lack of insurance (72.0%), finances (66.0%), social support (66.0%), and stable housing/transportation (64.0%) were ranked as significant barriers to referral, while medical mistrust and lack of interest were not. Limited access to financial services (36.0%) and addiction/mental health resources (34.0%) were considered important practice-level barriers. Few reported existing access to patient navigators (12.0%), and patient navigation was ranked as most likely to improve referral practices, followed by an expedited/expanded pathway for insurance coverage for LT. In this national survey, safety net providers reported the highest barriers to LT referral at the patient level and practice level. These data can inform the development of multilevel interventions in safety net settings to enhance equity in LT access for vulnerable patients.
Collapse
Affiliation(s)
- Melanie Hundt
- Department of Medicine, Los Angeles General Hospital, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ariana Chen
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - John Donovan
- Department of Medicine, Los Angeles General Hospital, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Nicole Kim
- Department of Medicine, University of Washington, Seattle, Washington
| | - Mignote Yilma
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Michele Tana
- Department of Medicine, University of California San Francisco Medical Center, San Francisco, California, USA
- Zuckerberg San Francisco General Hospital & Trauma Center, San Francisco, California, USA
- University of California San Francisco Liver Center, San Francisco, California, USA
| | - Neil Mehta
- Department of Medicine, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Kali Zhou
- Department of Medicine, Los Angeles General Hospital, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| |
Collapse
|
2
|
Sharma P, Shenoy A, Shroff H, Kwong A, Lim N, Pillai A, Devuni D, Haque LY, Balliet W, Serper M. Management of alcohol-associated liver disease and alcohol use disorder in liver transplant candidates and recipients: Challenges and opportunities. Liver Transpl 2024; 30:848-861. [PMID: 38471008 DOI: 10.1097/lvt.0000000000000362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/01/2024] [Indexed: 03/14/2024]
Abstract
Alcohol-associated liver disease poses a significant global health burden, with rising alcohol consumption and prevalence of alcohol use disorder (AUD) contributing to increased morbidity and mortality. This review examines the challenges and opportunities in the care of candidates and recipients of liver transplant (LT) with AUD. Despite advancements in posttransplant patient survival, the risk of disease recurrence and alcohol relapse remains substantial. Several challenges have been identified, including (1) rising disease burden of alcohol-associated liver disease, variable transplant practices, and systemic barriers; (2) disparities in mental health therapy access and the impact on transplant; (3) variable definitions, underdiagnosis, and stigma affecting access to care; and (4) post-LT relapse, its risk factors, and consequential harm. The review focuses on the opportunities to improve AUD care for candidates and recipients of LT through effective biochemical monitoring, behavioral and pharmacologic approaches, creating Centers of Excellence for post-LT AUD care, advocating for policy reforms, and ensuring insurance coverage for necessary services as essential steps toward improving patient outcomes. The review also highlights unmet needs, such as the scarcity of addiction specialists, and calls for further research on personalized behavioral treatments, digital health, and value-based care models to optimize AUD care in the LT setting.
Collapse
Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Akhil Shenoy
- Department of Psychiatry, Columbia University Medical Center, New York, New York, USA
| | - Hersh Shroff
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Allison Kwong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Stanford University, Stanford, California, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anjana Pillai
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago, Chicago, Illinois, USA
| | - Deepika Devuni
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Lamia Y Haque
- Department of Internal Medicine, Section of Digestive Diseases and Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Wendy Balliet
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
3
|
Brahmania M, Rogal S, Serper M, Patel A, Goldberg D, Mathur A, Wilder J, Vittorio J, Yeoman A, Rich NE, Lazo M, Kardashian A, Asrani S, Spann A, Ufere N, Verma M, Verna E, Simpson D, Schold JD, Rosenblatt R, McElroy L, Wadwhani SI, Lee TH, Strauss AT, Chung RT, Aiza I, Carr R, Yang JM, Brady C, Fortune BE. Pragmatic strategies to address health disparities along the continuum of care in chronic liver disease. Hepatol Commun 2024; 8:e0413. [PMID: 38696374 PMCID: PMC11068141 DOI: 10.1097/hc9.0000000000000413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 01/05/2024] [Indexed: 05/04/2024] Open
Abstract
Racial, ethnic, and socioeconomic disparities exist in the prevalence and natural history of chronic liver disease, access to care, and clinical outcomes. Solutions to improve health equity range widely, from digital health tools to policy changes. The current review outlines the disparities along the chronic liver disease health care continuum from screening and diagnosis to the management of cirrhosis and considerations of pre-liver and post-liver transplantation. Using a health equity research and implementation science framework, we offer pragmatic strategies to address barriers to implementing high-quality equitable care for patients with chronic liver disease.
Collapse
Affiliation(s)
- Mayur Brahmania
- Department of Medicine, Division of Gastroenterology and Transplant Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shari Rogal
- Department of Medicine, Division of Gastroenterology, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Marina Serper
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arpan Patel
- Department of Medicine, Division of Gastroenterology, University of California Los Angeles, Los Angeles, California, USA
| | - David Goldberg
- Department of Medicine, Division of Gastroenterology, University of Miami, Miami, Florida, USA
| | - Amit Mathur
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Julius Wilder
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer Vittorio
- Department of Pediatrics, Division of Pediatric Gastroenterology, NYU Langone Health, New York, New York, USA
| | - Andrew Yeoman
- Department of Medicine, Gwent Liver Unit, Aneurin Bevan University Health Board, Newport, Wales, UK
| | - Nicole E. Rich
- Department of Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Mariana Lazo
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ani Kardashian
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Sumeet Asrani
- Department of Medicine, Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas, USA
| | - Ashley Spann
- Department of Medicine, Division of Gastroenterology, Vanderbilt University, Nashville, Tennessee, USA
| | - Nneka Ufere
- Department of Medicine, Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Elizabeth Verna
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Dinee Simpson
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - Jesse D. Schold
- Department of Surgery and Epidemiology, University of Colorado, Aurora, Colorado, USA
| | - Russell Rosenblatt
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Lisa McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sharad I. Wadwhani
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Tzu-Hao Lee
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Alexandra T. Strauss
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Raymond T. Chung
- Department of Medicine, Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ignacio Aiza
- Department of Medicine, Liver Unit, Hospital Ángeles Lomas, Mexico City, Mexico
| | - Rotonya Carr
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Jin Mo Yang
- Department of Medicine, Division of Gastroenterology, Catholic University of Korea, Seoul, Korea
| | - Carla Brady
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brett E. Fortune
- Department of Medicine, Division of Hepatology, Montefiore Einstein Medical Center, Bronx, New York, USA
| |
Collapse
|
4
|
Dowlatshahi S, Koh J, Vyas A, Mack WJ, Turner BJ. Disparities in Care for Low-Income Patients with Cirrhosis: Implementing an Innovative Outpatient Clinic for Refractory Ascites in a Safety Net Hospital. J Gen Intern Med 2024; 39:1245-1251. [PMID: 38378980 PMCID: PMC11116333 DOI: 10.1007/s11606-024-08675-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/02/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Disparities in life-saving interventions for low-income patients with cirrhosis necessitate innovative models of care. AIM To implement a novel generalist-led FLuid ASPiration (FLASP) clinic to reduce emergency department (ED) care for refractory ascites. SETTING A large safety net hospital in Los Angeles. PARTICIPANTS MediCal patients with paracentesis in the ED from 6/1/2020 to 1/31/2021 or in FLASP clinic or the ED from 3/1/2021 to 4/30/2022. PROGRAM DESCRIPTION According to RE-AIM, adoption obtained administrative endorsement and oriented ED staff. Reach engaged ED staff and eligible patients with timely access to FLASP. Implementation trained FLASP clinicians in safer, guideline-based paracentesis, facilitated timely access, and offered patient education and support. PROGRAM EVALUATION After FLASP clinic opened, significantly fewer ED visits were made by patients discharged after paracentesis [rate ratio (RR) of 0.33 (95% CI 0.28, 0.40, p < 0.0001)] but not if subsequently hospitalized (RR = 0.88, 95% CI 0.70, 1.11). Among 2685 paracenteses in 225 FLASP patients, complications were infrequent: 39 (1.5%) spontaneous bacterial peritonitis, 265 (9.9%) acute kidney injury, and 2 (< 0.001%) hypotension. FLASP patients rated satisfaction highly on a Likert-type question. DISCUSSION Patients with refractory ascites in large safety net hospitals may benefit from an outpatient procedure clinic instead of ED care.
Collapse
Affiliation(s)
- Shadi Dowlatshahi
- Department of Hospital Medicine, Los Angeles General Medical Center, Los Angeles, CA, USA
- Department of Medicine, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Jennifer Koh
- Department of Medicine, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Annasha Vyas
- Department of Medicine, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Wendy J Mack
- Department of Population and Public Health Sciences, Keck School of Medicine, USC, Los Angeles, CA, USA
| | - Barbara J Turner
- Department of Medicine, Keck Medical Center of University of Southern California, Los Angeles, CA, USA.
- Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine of USC, Clinical Sciences Center, Los Angeles, CA, USA.
| |
Collapse
|
5
|
Bragança S, Ramos M, Lopes S, Alexandrino G, Mendes M, Perdigoto R, Coimbra J, Marques HP, Cardoso FS. Referral for liver transplant following acute variceal bleeding: a multicenter cohort study. Eur J Gastroenterol Hepatol 2024; 36:657-664. [PMID: 38477864 DOI: 10.1097/meg.0000000000002749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
OBJECTIVES Referral for liver transplant (LT) following acute variceal bleeding (AVB) varies widely. We aimed to characterize and assess its impact on clinical outcomes. METHODS Observational retrospective cohort including cirrhosis patients with AVB from 3 hospitals in Lisbon, Portugal, from 2018 to 2019. Primary exposure was referral for LT and primary endpoint was all-cause mortality within 2 years of index hospital admission. RESULTS Among 143 patients, median (IQR) age was 59 (52-72) years and 90 (62.9%) were males. Median (IQR) MELDNa scores on hospital admission and discharge were 15 (11-21) and 13 (10-16), respectively. Overall, 30 (21.0%) patients were assessed for LT, 13 (9.1%) prior to and 17 (11.9%) within 2 years of hospital admission. Overall, 58 (40.6%) patients had at least one potential contra-indication for transplant. LT was performed in 3 (2.1%) patients (among 5 listed). Overall, 34 (23.8%) and 62 (43.4%) patients died at 6 weeks and 2 years post hospital admission, respectively. Following adjustment for confounders, referral for LT was associated with lower 2-year mortality (aHR (95% CI) = 0.20 (0.05-0.85)). CONCLUSION In a multicenter cohort of cirrhosis patients with AVB, less than a quarter underwent formal LT evaluation. Improved referral for LT following AVB may benefit cirrhosis patients' longer-term mortality.
Collapse
Affiliation(s)
- Sofia Bragança
- Gastroenterology Division, Fernando Fonseca Hospital, Amadora
| | - Marta Ramos
- Gastroenterology Division, Central Lisbon University Hospital Center, Lisbon
| | - Sara Lopes
- Gastroenterology Division, São Bernardo Hospital, Setúbal
| | | | - Milena Mendes
- Gastroenterology Division, Central Lisbon University Hospital Center, Lisbon
| | - Rui Perdigoto
- Transplant Unit, Curry Cabral Hospital, Nova Medical School, Lisbon, Portugal
| | - João Coimbra
- Gastroenterology Division, Central Lisbon University Hospital Center, Lisbon
| | - Hugo P Marques
- Transplant Unit, Curry Cabral Hospital, Nova Medical School, Lisbon, Portugal
| | - Filipe S Cardoso
- Gastroenterology Division, Central Lisbon University Hospital Center, Lisbon
- Transplant Unit, Curry Cabral Hospital, Nova Medical School, Lisbon, Portugal
| |
Collapse
|
6
|
Rengers TA, Warner SG. Importance of Diversity, Equity, and Inclusion in the Hepatopancreatobiliary Workforce. Cancers (Basel) 2024; 16:326. [PMID: 38254815 PMCID: PMC10814790 DOI: 10.3390/cancers16020326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
Diversity is a catalyst for progress that prevents institutional stagnation and, by extension, averts descent to mediocrity. This review focuses on the available data concerning hepatopancreatobiliary (HPB) surgical workforce demographics and identifies evidence-based strategies that may enhance justice, equity, diversity, and inclusion for HPB surgeons and their patients. We report that the current United States HPB surgical workforce does not reflect the population it serves. We review data describing disparity-perpetuating hurdles confronting physicians from minority groups underrepresented in medicine at each stage of training. We further examine evidence showing widespread racial and socioeconomic disparities in HPB surgical care and review the effects of workforce diversity and physician-patient demographic concordance on healthcare outcomes. Evidence-based mitigators of structural racism and segregation are reviewed, including tailored interventions that can address social determinants of health toward the achievement of true excellence in HPB surgical care. Lastly, select evidence-based data driving surgical workforce solutions are reviewed, including intentional compensation plans, mentorship, and sponsorship.
Collapse
Affiliation(s)
| | - Susanne G. Warner
- Mayo Clinic Division of Hepatobiliary and Pancreas Surgery, Rochester, MN 55905, USA
| |
Collapse
|
7
|
Im GY. Second thoughts about second opinions for liver transplantation. Liver Transpl 2023; 29:1253-1254. [PMID: 37747274 DOI: 10.1097/lvt.0000000000000262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 08/31/2023] [Indexed: 09/26/2023]
Affiliation(s)
- Gene Y Im
- Icahn School of Medicine at Mount Sinai, Division of Liver Diseases, Recanati/Miller Transplantation Institute, New York, New York, USA
| |
Collapse
|
8
|
Wang MC, Bangaru S, Zhou K. Care for Vulnerable Populations with Chronic Liver Disease: A Safety-Net Perspective. Healthcare (Basel) 2023; 11:2725. [PMID: 37893800 PMCID: PMC10606794 DOI: 10.3390/healthcare11202725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Safety-net hospitals (SNHs) and facilities are the cornerstone of healthcare services for the medically underserved. The burden of chronic liver disease-including end-stage manifestations of cirrhosis and liver cancer-is high and rising among populations living in poverty who primarily seek and receive care in safety-net settings. For many reasons related to social determinants of health, these individuals often present with delayed diagnoses and disease presentations, resulting in higher liver-related mortality. With recent state-based policy changes such as Medicaid expansion that impact access to insurance and critical health services, an overview of the body of literature on SNH care for chronic liver disease is timely and informative for the liver disease community. In this narrative review, we discuss controversies in the definition of a SNH and summarize the known disparities in the cascade of the care and management of common liver-related conditions: (1) steatotic liver disease, (2) liver cancer, (3) chronic viral hepatitis, and (4) cirrhosis and liver transplantation. In addition, we review the specific impact of Medicaid expansion on safety-net systems and liver disease outcomes and highlight effective provider- and system-level interventions. Lastly, we address remaining gaps and challenges to optimizing care for vulnerable populations with chronic liver disease in safety-net settings.
Collapse
Affiliation(s)
- Mark C Wang
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Saroja Bangaru
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Los Angeles General Medical Center, Los Angeles, CA 90033, USA
| | - Kali Zhou
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Los Angeles General Medical Center, Los Angeles, CA 90033, USA
- Research Center for Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| |
Collapse
|