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Singal AK, Vatsalya V, Agrawal R. Integrated Multidisciplinary Care Model to Manage the Dual Pathology of Alcohol Use Disorder and of Liver Disease. Clin Liver Dis 2024; 28:793-807. [PMID: 39362722 DOI: 10.1016/j.cld.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2024]
Abstract
Alcohol-associated liver disease (ALD) is the most common cause of liver disease and an indication for liver transplantation. Identification of ALD at an earlier stage and treatment of concomitant alcohol use disorder (AUD) could potentially prevent or delay the progression to advanced stages of ALD like alcohol-associated cirrhosis and alcohol-associated hepatitis. However, screening for alcohol use is often not performed and treatment of AUD is rarely administered in ALD patients, due to several barriers at the level of patients, clinicians, and administrative levels.
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Affiliation(s)
- Ashwani K Singal
- University of Louisville, 505 South Hancock Street, Louisville, KY 40202, USA.
| | - Vatsalya Vatsalya
- University of Louisville, 505 South Hancock Street, Louisville, KY 40202, USA
| | - Ruchita Agrawal
- Department of Psychiatry and Behavioral Sciences, Seven Counties Services, Inc, 530 South Jackson Street, Louisville, KY 40202, USA
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2
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Lee DU, Shaik MR, Bhowmick K, Fan GH, Schuster K, Yousaf A, Refaat M, Shaik NA, Lee KJ, Yang S, Bahadur A, Urrunaga NH. Racial and ethnic disparities in post-liver transplant outcomes for patients with acute-on-chronic liver failure: An analysis of the UNOS database. Aliment Pharmacol Ther 2024; 60:1087-1109. [PMID: 39185724 DOI: 10.1111/apt.18221] [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: 06/19/2024] [Revised: 07/08/2024] [Accepted: 08/07/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND The incidence of hospitalisations related to acute-on-chronic liver failure (ACLF) is increasing. Liver transplantation (LT) remains the definitive treatment for the condition. AIM To evaluate the influence of race and ethnicity on LT outcomes in ACLF. METHODS We conducted a retrospective analysis utilising LT data from the United Network for Organ Sharing (UNOS) database. White patients served as the control group and patients of other races were compared at each ACLF grade. The primary outcomes assessed were graft failure and all-cause mortality. RESULTS Blacks exhibited a higher all-cause mortality (Grade 1: aHR 1.36, 95% CI 1.18-1.57, p < 0.001; Grade 2: aHR 1.27, 95% CI 1.08-1.48, p = 0.003; Grade 3: aHR 1.19, 95% CI 1.04-1.37, p = 0.01) and graft failure (Grade 1: aHR 2.05, 95% CI 1.58-2.67, p < 0.001; Grade 2: aHR 1.91, 95% CI 1.43-2.54, p < 0.001; Grade 3: aHR 1.50, 95% CI 1.15-1.96, p = 0.002). Hispanics experienced a lower all-cause mortality at grades 1 and 3 (Grade 1: aHR 0.83, 95% CI 0.72-0.96, p = 0.01; Grade 3: aHR 0.80, 95% CI 0.70-0.91, p < 0.001) and Asians with severe ACLF demonstrated decreased all-cause mortality (Grade 3: aHR 0.55, 95% CI 0.42-0.73, p < 0.001). CONCLUSION Black patients experienced the poorest outcomes and Hispanic and Asian patients demonstrated more favourable outcomes compared to Whites.
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Affiliation(s)
- David Uihwan Lee
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mohammed Rifat Shaik
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kuntal Bhowmick
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Gregory Hongyuan Fan
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Kimberly Schuster
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Abdul Yousaf
- University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Mohamed Refaat
- University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Nishat Anjum Shaik
- Department of Medicine, Saint Louis University, Saint Louis, Missouri, USA
| | - Ki Jung Lee
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Sarah Yang
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aneesh Bahadur
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Nathalie H Urrunaga
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Solano QP, Chen X, Parikh ND, Tapper EB. Racial and Ethnic Disparities in Outcomes After the Development of Ascites: A National Cohort Study. Dig Dis Sci 2024; 69:3214-3219. [PMID: 39080087 DOI: 10.1007/s10620-024-08572-w] [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: 02/18/2024] [Accepted: 07/17/2024] [Indexed: 09/22/2024]
Abstract
INTRODUCTION Ascites, a severe complication of cirrhosis, significantly impacts patient morbidity and mortality especially in Black patients. Access to disease optimizing care has been proposed as a potential driver of this disparity. In this study, we evaluate TIPS utilization across racial and ethnic groups. METHODS We examined data from a 20% random sample of US Medicare enrollees with continuous Part D coverage. We required 180 days of continuous outpatient enrollment prior to cirrhosis diagnosis and all patients had ≥1 paracentesis within 180 days of their cirrhosis diagnosis. Time zero was the date of the first paracentesis. We assessed the likelihood of TIPS placement. Analyses were conducted to determine the independent associations between each outcome and race/ethnicity. RESULTS 5915 patients (average age 68.2, 64.4% male) were included in the analysis. 439 (7.4%) patients were identified as Black, 223 (3.8%) as Hispanic, and 4942 (83.6%) as white. When compared to white patients in a multivariable analysis, Black patients were less likely to receive a TIPS procedure (hazard ratio 0.4; 95% confidence interval (CI) 0.2-0.8) and had less days alive outside of the hospital (-100.5; 95% CI -189.4 - -11.6). There were no significant differences in transplant-free survival or number of paracenteses per year between ethnic and racial groups. CONCLUSION Black patients are less likely to receive a TIPS procedure when controlling for common patient- and disease-specific variables. Access to optimal specialized services may be a significant driver for disparities in outcomes of patients with cirrhosis between racial and ethnic groups.
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Affiliation(s)
- Quintin P Solano
- Division of Internal Medicine, University of Michigan, Ann Arbor, USA
| | - Xi Chen
- Division of Gastroenterology and Hepatology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
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Kodali S, Mobley CM, Brombosz EW, Lopez A, Graves R, Ontiveros J, Velazquez M, Saharia A, Cheah YL, Simon CJ, Valverde C, Brown A, Corkrean J, Moore LW, Graviss EA, Victor DW, Maresh K, Hobeika MJ, Egwim C, Ghobrial RM. Effect of a Hispanic outreach program on referral and liver transplantation volume at a single center. Transpl Immunol 2024; 84:102034. [PMID: 38499048 DOI: 10.1016/j.trim.2024.102034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Although Hispanic patients have high rates of end-stage liver disease and liver cancer, for which liver transplantation (LT) offers the best long-term outcomes, they are less likely to receive LT. Studies of end-stage renal disease patients and kidney transplant candidates have shown that targeted, culturally relevant interventions can increase the likelihood of Hispanic patients receiving kidney transplant. However, similar interventions remain largely unstudied in potential LT candidates. METHODS Referrals to a single center in Texas with a large Hispanic patient population were compared before (01/2018-12/2019) and after (7/2021-6/2023) the implementation of a targeted outreach program. Patient progress toward LT, reasons for ineligibility, and differences in insurance were examined between the two eras. RESULTS A greater proportion of Hispanic patients were referred for LT after the implementation of the outreach program (23.2% vs 26.2%, p = 0.004). Comparing the pre-outreach era to the post-outreach era, more Hispanic patients achieved waitlisting status (61 vs 78, respectively) and received a LT (971 vs 82, respectively). However, the proportion of Hispanic patients undergoing LT dropped from 30.2% to 20.3%. In the post-outreach era, half of the Hispanic patients were unable to get LT for financial reasons (112, 50.5%). CONCLUSIONS A targeted outreach program for Hispanic patients with end-stage liver disease effectively increased the total number of Hispanic LT referrals and recipients. However, many of the patients who were referred were ineligible for LT, most frequently for financial reasons. These results highlight the need for additional research into the most effective ways to ameliorate financial barriers to LT in this high-need community.
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Affiliation(s)
- Sudha Kodali
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA; JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Constance M Mobley
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | | | - Analisa Lopez
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Riki Graves
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - John Ontiveros
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Marcela Velazquez
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Ashish Saharia
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Yee Lee Cheah
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Caroline J Simon
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Christian Valverde
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Alphonse Brown
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Julie Corkrean
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Linda W Moore
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Edward A Graviss
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA; Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - David W Victor
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA; JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Kelly Maresh
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Mark J Hobeika
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | | | - R Mark Ghobrial
- JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Weill Cornell Medical College, New York, NY, USA.
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Li R, Sarin S. Disparity Among African Americans in Transjugular Intrahepatic Portosystemic Shunt Procedure: A National Inpatient Sample Analysis from 2015 to 2020. Dig Dis Sci 2024; 69:713-719. [PMID: 38319431 DOI: 10.1007/s10620-024-08273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 01/02/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate patients with chronic liver cirrhosis and portal hypertension. Racial disparities were present in TIPS where numerous studies suggested African American patients experience higher in-hospital mortality rates. However, the incidence of post-TIPS surgical complications, such as HE, has yet to be examined among African Americans. Therefore, this study aimed to provide a comprehensive examination of the disparities in TIPS procedures among African American patients. METHODS The study compared African American and Caucasian patients who underwent TIPS procedures in the National Inpatient Sample (NIS) database from the last quarter of 2015-2020 after ICD-10 change. Preoperative variables, including demographics, comorbidities, primary payer status, and hospital characteristics, were examined and multivariable analysis was used to assess outcomes correcting preoperative variables with p < 0.1. RESULTS Compared to Caucasians, African Americans had higher in-hospital mortality (16.18 vs 8.22%, aOR 1.781, p < 0.01), hepatic encephalopathy (33.09 vs 27.44%, aOR 1.300, p = 0.05), and acute kidney injury (45.59 vs 29.60%, aOR 2.019, p < 0.01). Using the generalized linear model, African Americans have longer length of stay (11.04 ± 0.77 days vs 8.54 ± 0.16 days, p < 0.01). CONCLUSION Despite a higher prevalence of cirrhosis, African Americans continue to have marked underrepresentation in TIPS procedures in recent years. Their underrepresentation, in conjunction with higher mortality, morbidity, and increased comorbidity conditions, could imply disparity in accessing care. This finding underscores the necessity for improved access to diagnostic and therapeutic services for African Americans with liver cirrhosis.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA.
| | - Shawn Sarin
- Department of Interventional Radiology, George Washington University Hospital, Washington, DC, USA
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Singal AK, Leggio L, DiMartini A. Alcohol use disorder in alcohol-associated liver disease: Two sides of the same coin. Liver Transpl 2024; 30:200-212. [PMID: 37934047 DOI: 10.1097/lvt.0000000000000296] [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: 05/16/2023] [Accepted: 10/16/2023] [Indexed: 11/08/2023]
Abstract
Alcohol-associated liver disease (ALD) has emerged as the leading indication for liver transplantation (LT) worldwide, with 40% of LTs in the United States performed for ALD in 2019. The ALD-related health care burden accelerated during the COVID-19 pandemic, especially in young individuals. Alcohol use disorder (AUD), which focuses on the negative effects of alcohol on psychosocial, physical, and mental health, is present in the majority of patients with ALD, with moderate to severe AUD in 75%-80%. During the last decade, early liver transplantation (eLT) has emerged as a lifesaving treatment for selected patients with alcohol-associated hepatitis; these patients may have a higher risk of using alcohol after LT. The risk of alcohol use recurrence may be reduced during the pretransplant or post-transplant period with AUD treatment using behavioral and/or pharmacological therapies and with regular monitoring for alcohol use (self-reported and complemented with biomarkers like phosphatidylethanol). However, AUD treatment in patients with ALD is challenging due to patient, clinician, and system barriers. An integrated model to provide AUD and ALD care by hepatologists and addiction experts in a colocated clinic starting from LT evaluation and selection to monitoring listed candidates and then to following up on recipients of LT should be promoted. However, the integration of addiction and hepatology teams in an LT program in the real world is often present only during evaluation and candidate selection for LT. Data are emerging to show that a multidisciplinary integrated AUD treatment within an LT program reduces recurrent alcohol use after LT. If we want to continue using early liver transplantation for patients with severe alcohol-associated hepatitis, LT programs should focus on building integrated multidisciplinary care teams for the integrated treatment of both AUD and ALD.
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Affiliation(s)
- Ashwani K Singal
- Department of Medicine, University of South Dakota, Vermillion, South Dakota, USA
- Department of Gastroenterology and Hepatology, Avera McKennan University Hospital, Sioux Falls, South Dakota, USA
- Department of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, South Dakota, USA
- Department of Medicine, VA Medical Center, Sioux Falls, South Dakota, USA
| | - Lorenzo Leggio
- Department of Neuropsychopharmacology Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, Division of Intramural Clinical and Biological Research, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island, USA
- Department of Medicine, Division of Addiction Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Neuroscience, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Andrea DiMartini
- Departments of Psychiatry and Transplant Surgery, and the Clinical and Translational Science Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Thomas K, Babajide O, Gichoya J, Newsome J. Disparities in Transplant Interventions. Tech Vasc Interv Radiol 2023; 26:100921. [PMID: 38123285 DOI: 10.1016/j.tvir.2023.100921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
- Kaesha Thomas
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Owosela Babajide
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Judy Gichoya
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA.
| | - Janice Newsome
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
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Kilani Y, Kamal SAF, Vikash F, Vikash S, Aldiabat M, Alsakarneh S, Aljabiri Y, Sohail H, Kumar V, Numan L, Al Khalloufi K. Racial Disparities in Liver Transplantation for Hepatocellular Carcinoma in the United States: An Update. Dig Dis Sci 2023; 68:4050-4059. [PMID: 37584869 DOI: 10.1007/s10620-023-08084-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/07/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Previous studies have demonstrated a disparity in liver transplantation (LT) for hepatocellular carcinoma (HCC) among races in the United States (U.S.). AIMS We aimed to update the literature on the odds, trends, and complications of LT in the treatment of hepatocellular carcinoma (HCC), among individuals of different racial backgrounds. METHODS This is a nationwide study of adult individuals admitted for LT with a primary diagnosis of HCC. Using weighted data from the National Inpatient Sample (NIS) database, we compared the odds of LT among different races from 2016 to 2020, using a multivariate regression analysis. We further assessed the trends and outcomes of LT among races. RESULTS A total of 112,110 adult were hospitalized with a primary diagnosis of HCC. 3020 underwent LT. When compared to Whites, the likelihood of undergoing LT for HCC was significantly reduced in Blacks (OR = 0.60, 95% CI = 0.46-0.78). Further, Blacks had increased mortality rates (7% in Blacks vs. 1% in Whites, p < 0.001), sepsis (11% in Blacks vs. 3% in Whites, p = 0.015), and acute kidney injury (AKI) (54% in Blacks vs. 31% in Whites, p < 0.001) following LT. CONCLUSIONS Individuals identifying as Blacks were less likely to undergo LT for HCC, and more likely to develop complications. Further initiatives are warranted to mitigate the existing disparities among racial groups.
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Affiliation(s)
- Yassine Kilani
- Department of Medicine, Lincoln Medical Center/Weill Cornell Medicine, New York, NY, USA.
| | | | - Fnu Vikash
- Department of Medicine, Jacobi Medical Center, New York, NY, USA
| | - Sindhu Vikash
- Department of Medicine, Jacobi Medical Center, New York, NY, USA
| | | | - Saqr Alsakarneh
- Department of Medicine, University of Missouri, Kansas City, MO, USA
| | - Yazan Aljabiri
- Department of Medicine, Lincoln Medical Center/Weill Cornell Medicine, New York, NY, USA
| | - Haris Sohail
- Department of Medicine, Lincoln Medical Center/Weill Cornell Medicine, New York, NY, USA
| | - Vikash Kumar
- Department of Medicine, Brooklyn Hospital Center, New York, NY, USA
| | - Laith Numan
- Department of Gastroenterology, Saint Louis University, Saint Louis, MO, USA
| | - Kawtar Al Khalloufi
- Department of Transplant Hepatology, University of South Florida, Tampa, FL, USA
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Marchak K, Singh D, Malavia M, Trivedi P. A Review of Healthcare Disparities Relevant to Interventional Radiology. Semin Intervent Radiol 2023; 40:427-436. [PMID: 37927511 PMCID: PMC10622245 DOI: 10.1055/s-0043-1775878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Racial, ethnic, and gender disparities have received focused attention recently, as they became more visible in the COVID era. We continue to learn more about how healthcare disparities manifest for our patients and, more broadly, the structural underpinnings that result in predictable outcomes gaps. This review summarizes what we know about disparities relevant to interventional radiologists. The prevalence and magnitude of disparities are quantified and discussed where relevant. Specific examples are provided to demonstrate how factors like gender, ethnicity, social status, geography, etc. interact to create inequities in the delivery of interventional radiology (IR) care. Understanding and addressing health disparities in IR is crucial for improving real-world patient outcomes and reducing the economic burden associated with ineffective and low-value care. Finally, the importance of intentional mentorship, outreach, education, and equitable distribution of high-quality healthcare to mitigate these disparities and promote health equity in interventional radiology is discussed.
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Affiliation(s)
- Katherine Marchak
- Division of Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Davinder Singh
- Division of Diagnostic Radiology/Department of Radiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Mira Malavia
- University of Missouri, Kansas City School of Medicine, Kansas City, Missouri
| | - Premal Trivedi
- Division of Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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Kardashian A, Serper M, Terrault N, Nephew LD. Health disparities in chronic liver disease. Hepatology 2023; 77:1382-1403. [PMID: 35993341 PMCID: PMC10026975 DOI: 10.1002/hep.32743] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 12/14/2022]
Abstract
The syndemic of hazardous alcohol consumption, opioid use, and obesity has led to important changes in liver disease epidemiology that have exacerbated health disparities. Health disparities occur when plausibly avoidable health differences are experienced by socially disadvantaged populations. Highlighting health disparities, their sources, and consequences in chronic liver disease is fundamental to improving liver health outcomes. There have been large increases in alcohol use disorder in women, racial and ethnic minorities, and those experiencing poverty in the context of poor access to alcohol treatment, leading to increasing rates of alcohol-associated liver diseases. Rising rates of NAFLD and associated fibrosis have been observed in Hispanic persons, women aged > 50, and individuals experiencing food insecurity. Access to viral hepatitis screening and linkage to treatment are suboptimal for racial and ethnic minorities and individuals who are uninsured or underinsured, resulting in greater liver-related mortality and later-stage diagnoses of HCC. Data from more diverse cohorts on autoimmune and cholestatic liver diseases are lacking, supporting the need to study the contemporary epidemiology of these disorders in greater detail. Herein, we review the existing literature on racial and ethnic, gender, and socioeconomic disparities in chronic liver diseases using a social determinants of health framework to better understand how social and structural factors cause health disparities and affect chronic liver disease outcomes. We also propose potential solutions to eliminate disparities, outlining health-policy, health-system, community, and individual solutions to promote equity and improve health outcomes.
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Affiliation(s)
- Ani Kardashian
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Norah Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Simon Comprehensive Cancer Center, Indianapolis, Indiana, USA
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Trivedi PS, Guerra B, Kumar V, Akinwande G, West D, Abi-Jaoudeh N, Salazar G, Rochon P. Healthcare Disparities in Interventional Radiology. J Vasc Interv Radiol 2022; 33:1459-1467.e1. [PMID: 36058539 DOI: 10.1016/j.jvir.2022.08.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 08/08/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022] Open
Abstract
Racial, ethnic, and sex-based healthcare disparities have been documented for the past several decades. Nonetheless, disparities remain firmly entrenched in our care delivery systems, with multiple contributing factors, including patient interactions with care providers, systemic barriers to access, and socioeconomic determinants of health. Interventional radiology is also subject to these drivers of health inequity. In this review, documented disparities for the most common conditions being addressed by interventional radiologists are summarized; their magnitude is quantified where relevant, and underlying drivers are identified. Specific examples are provided to illustrate how medical, cultural, and socioeconomic factors interact to produce unequal outcomes. By outlining known disparities and common contributors, this review aims to motivate future efforts to mitigate them.
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Affiliation(s)
- Premal S Trivedi
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Bernardo Guerra
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Vishal Kumar
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Goke Akinwande
- Midwest Institute for Non-Surgical Therapy, St. Louis, Missouri
| | - Derek West
- Department of Radiology, Emory School of Medicine, Atlanta, Georgia
| | - Nadine Abi-Jaoudeh
- Department of Radiology, University of California Irvine, Irvine, California
| | - Gloria Salazar
- Department of Radiology, University of North Carolina, Chapel Hill, North Carolina
| | - Paul Rochon
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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12
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Characteristics and Outcomes of Black and White Patients Hospitalized With Nonalcoholic Steatohepatitis: A Nationwide Analysis. J Clin Gastroenterol 2022; 57:508-514. [PMID: 35357331 DOI: 10.1097/mcg.0000000000001698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/02/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Nonalcoholic steatohepatitis (NASH) is an increasingly common etiology for liver-related hospitalizations in the United States. The aim of this study was to examine the differences of disease characteristics and outcomes between hospitalized Black and White patients with NASH. MATERIALS AND METHODS We used the National Inpatient Sample (NIS) to identify all adult hospitalizations with NASH (ICD-10 code: K75.81) from 2016 to 2018. We compared demographic and clinical characteristics between Black and White patients. Multivariable models were computed to compare all-cause mortality, length of stay (LOS), and total hospital costs between the groups. RESULTS There were 43,409 hospitalizations with NASH (41,143 White, 2266 Black). Black patients were less likely to have cirrhosis (33.6%) compared with Whites (56.4%), P<0.0001. Black patients were less likely to have esophageal variceal bleeding (1.2% vs. 3.5%), ascites (17.1% vs. 28.8%), and acute liver failure (16.2% vs. 28.9%) compared with Whites (all P<0.0001). These findings were consistent among patients with cirrhosis. Mortality was higher among Blacks compared with Whites (3.9% vs. 3.7%, adjusted odds ratio=1.34; 95% confidence interval: 1.05-1.71, P=0.018). Compared with Whites, Blacks had a longer LOS (6.3 vs. 5.6, P<0.001), and higher hospital costs ($18,602 vs. $17,467; P=0.03). CONCLUSION In this large population of inpatients with NASH, Black patients were less likely to have cirrhosis and liver disease-related complications, but had overall worse hospital mortality, longer LOS, and higher hospital costs. Further research is warranted to elaborate on factors that generate the health inequities in NASH outcomes between Black and White patients.
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13
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Kulkarni N, Priya A, Lagu T. Implicit bias or selection bias? The need for rigorous methods when attempting to identify disparities in care. J Hosp Med 2022; 17:144-145. [PMID: 35504591 DOI: 10.1002/jhm.12783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/24/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Nita Kulkarni
- Division of Hospital Medicine, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Aruna Priya
- Department of Healthcare Delivery and Population Science, UMass Chan Medical School - Baystate Health, Springfield, Massachusetts, USA
| | - Tara Lagu
- Division of Hospital Medicine, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Health Services and Outcomes Research, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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14
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DiMartini AF, Leggio L, Singal AK. Barriers to the management of alcohol use disorder and alcohol-associated liver disease: strategies to implement integrated care models. Lancet Gastroenterol Hepatol 2022; 7:186-195. [DOI: 10.1016/s2468-1253(21)00191-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
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15
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Helzberg JH, Parish A, Niedzwiecki D, Kim CY, Patel YA, Wilder JM, Muir AJ. Racial disparities in transjugular intrahepatic portosystemic shunt procedure outcomes. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000747. [PMID: 35086849 PMCID: PMC8796249 DOI: 10.1136/bmjgast-2021-000747] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 12/29/2021] [Indexed: 12/24/2022] Open
Abstract
Objective The transjugular intrahepatic portosystemic shunt (TIPS) procedure is an important intervention for management of complications of portal hypertension. The objective of this study was to identify predictors of mortality from the TIPS procedure with a focus on race and ethnicity. Design TIPS procedures from 2012 to 2014 in the National Inpatient Sample were identified. Weighting was applied to generate nationally representative results. In-hospital mortality was the primary outcome of interest. χ2 and Student’s t-tests were performed for categorical and continuous variables, respectively. Predictors of mortality following TIPS were assessed by survey-weighted logistic regression. Results 17 175 (95% CI 16 254 to 18 096) TIPS cases were identified. Approximately 71% were non-Hispanic (NH) white, 6% were NH black, 16% were Hispanic and 7% were other. NH black patients undergoing TIPS had an in-hospital mortality rate of 20.1%, nearly double the in-hospital mortality of any other racial or ethnic group. NH black patients also had significantly longer median postprocedure and total lengths of stay (p=0.03 and p<0.001, respectively). The interaction of race by clinical indication was a significant predictor of in-hospital mortality (p<0.001). NH black patients had increased mortality compared with other racial/ethnic groups when presenting with bleeding oesophageal varices (OR 3.85, 95% CI 2.14 to 6.95). Conclusion This cohort study presents important findings in end-stage liver disease care, with clear racial disparities in in-hospital outcomes following the TIPS procedure. Specifically, black patients had significantly higher in-hospital mortality and longer lengths of stay. Further research is needed to understand how we can better care for black patients with liver disease.
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Affiliation(s)
- James H Helzberg
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Charles Y Kim
- Department of Radiology, Division of Interventional Radiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Yuval A Patel
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Julius M Wilder
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrew J Muir
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA .,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
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16
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Waitlist mortality and transplant free survival in Hispanic patients listed for liver transplant using the UNOS database. Ann Hepatol 2022; 23:100304. [PMID: 33444852 DOI: 10.1016/j.aohep.2021.100304] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES After the implementation of "Share 35", several concerns arose such as the potential to increase travel distance, costs, and decreased liver availability. These elements could have a negative impact on waitlist outcomes among ethnic minorities. We aimed to determine waitlist survival after the implementation of the Share 35 policy in non-Hispanic white and Hispanic patients. MATERIALS AND METHODS We identified non-Hispanic whites and Hispanics who were listed for liver transplantation from June 18th, 2013 to June 18, 2018. We excluded pediatric patients, patients with acute hepatic necrosis, re-transplants, multiorgan transplant, living donor, and exception cases. The primary outcome was death or removal from the waitlist due to clinical deterioration. We used competing risk analysis to compare waitlist survival between the two groups. RESULTS There were 23,340 non-Hispanic whites and 4938 Hispanics listed for transplant. On competing risk analysis, Hispanic patients had a higher risk of being removed from the waitlist for death or clinical deterioration compared to their counterpart (SHR 1.23, 95% CI 1.13-1.34; P < 0.001). CONCLUSION After the implementation of Share 35, disparities are still present and continue to negatively impact outcomes in minority populations especially Hispanic patients.
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17
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Shaheen M, Schrode KM, Pan D, Kermah D, Puri V, Zarrinpar A, Elisha D, Najjar SM, Friedman TC. Sex-Specific Differences in the Association Between Race/Ethnicity and NAFLD Among US Population. Front Med (Lausanne) 2021; 8:795421. [PMID: 34926533 PMCID: PMC8674562 DOI: 10.3389/fmed.2021.795421] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/08/2021] [Indexed: 12/12/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is spreading worldwide, with a racial/ethnic disparity. We examined the gender role in the racial/ethnic difference in NAFLD in the US population. We analyzed data for 3,292 individuals ≥18 years old from NHANES 2017-2018, a representative sample of the non-institutionalized adult population in the US. Exclusions were subjects with elevated transferrin level, chronic hepatitis B or C, excessive alcohol use, or prescription medications that might cause hepatic steatosis. NAFLD was diagnosed by FibroScan® using controlled attenuation parameter (CAP) values: S0 <238, S1 = 238-259, S2 = 260-290, S3 >290. Data were analyzed using Chi square and multinomial regression. The overall prevalence of NAFLD was 47.9% [S2 = 16.1%, and S3 = 31.8%]. The prevalence of S3 was highest among Mexican Americans (46%), lowest among Blacks (22.7%), 29.9% in other Hispanics and 32.1% in Whites (p < 0.05). It was higher among Mexican American males (54.1%) compared to Mexican American females (37.7%) (p < 0.05). In the adjusted model, Mexican Americans were two times more likely than Whites to have S2 and S3 (p < 0.05). Only male Mexican Americans had higher odds of S2 and S3 relative to male White (p < 0.05). Males had higher odds of S3 relative to non-menopausal females (p < 0.05). There was no difference in the odds of S2 or S3 NAFLD among the menopausal females with or without hormone therapy relative to non-menopausal females (p > 0.05). While Mexican Americans had the highest prevalence of severe NAFLD relative to the other racial/ethnic groups, only male Mexican Americans, but not females, had higher likelihood of both moderate and severe NAFLD relative to Whites. Interventions that specifically target Mexican American males are needed to increase awareness about NAFLD and its prevention.
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Affiliation(s)
- Magda Shaheen
- College of Medicine, Charles R Drew University, Los Angeles, CA, United States
| | - Katrina M Schrode
- College of Medicine, Charles R Drew University, Los Angeles, CA, United States
| | - Deyu Pan
- College of Medicine, Charles R Drew University, Los Angeles, CA, United States
| | - Dulcie Kermah
- College of Medicine, Charles R Drew University, Los Angeles, CA, United States
| | - Vishwajeet Puri
- Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, United States
| | - Ali Zarrinpar
- University of Florida College of Medicine, Gainesville, FL, United States
| | - David Elisha
- College of Medicine, Charles R Drew University, Los Angeles, CA, United States
| | - Sonia M Najjar
- Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, United States
| | - Theodore C Friedman
- College of Medicine, Charles R Drew University, Los Angeles, CA, United States
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18
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Rosenblatt R, Wahid N, Halazun KJ, Kaplan A, Jesudian A, Lucero C, Lee J, Dove L, Fox A, Verna E, Samstein B, Fortune BE, Brown RS. Black Patients Have Unequal Access to Listing for Liver Transplantation in the United States. Hepatology 2021; 74:1523-1532. [PMID: 33779992 DOI: 10.1002/hep.31837] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/27/2021] [Accepted: 03/17/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS The Model for End-Stage Liver Disease score may have eliminated racial disparities on the waitlist for liver transplantation (LT), but disparities prior to waitlist placement have not been adequately quantified. We aimed to analyze differences in patients who are listed for LT, undergo transplantation, and die from end-stage liver disease (ESLD), stratified by state and race/ethnicity. APPROACH AND RESULTS We analyzed two databases retrospectively, the Center for Disease Control Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) and the United Network for Organ Sharing (UNOS) databases, from 2014 to 2018. We included patients aged 25-64 years who had a primary cause of death of ESLD and were listed for transplant in the CDC WONDER or UNOS database. Our primary outcome was the ratio of listing for LT to death from ESLD-listing to death ratio (LDR). Our secondary outcome was the transplant to listing and transplant to death ratios. Chi-squared and multivariable linear regression evaluated for differences between races/ethnicities. There were 135,367 patients who died of ESLD, 54,734 patients who were listed for transplant, and 26,571 who underwent transplant. Patients were mostly male and White. The national LDR was 0.40, significantly lowest in Black patients (0.30), P < 0.001. The national transplant to listing ratio was 0.48, highest in Black patients (0.53), P < 0.01. The national transplant to death ratio was 0.20, lowest in Black patients (0.16), P < 0.001. States that had an above-mean LDR had a lower transplant to listing ratio but a higher transplant to death ratio. Multivariable analysis confirmed that Black race is significantly associated with a lower LDR and transplant to death ratio. CONCLUSIONS Black patients face a disparity in access to LT due to low listing rates for transplant relative to deaths from ESLD.
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Affiliation(s)
- Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
| | - Nabeel Wahid
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Karim J Halazun
- Center for Liver Disease and Transplantation, New York, NY.,Liver Transplant and HPB Surgery, Weill Cornell Medical College, New York, NY
| | - Alyson Kaplan
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Arun Jesudian
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
| | - Catherine Lucero
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
| | - Jihui Lee
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Lorna Dove
- Center for Liver Disease and Transplantation, New York, NY.,Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, NY
| | - Alyson Fox
- Center for Liver Disease and Transplantation, New York, NY.,Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, NY
| | - Elizabeth Verna
- Center for Liver Disease and Transplantation, New York, NY.,Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, NY
| | - Benjamin Samstein
- Center for Liver Disease and Transplantation, New York, NY.,Liver Transplant and HPB Surgery, Weill Cornell Medical College, New York, NY
| | - Brett E Fortune
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
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19
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Wong RJ, Hirode G. The Effect of Hospital Safety-Net Burden and Patient Ethnicity on In-Hospital Mortality Among Hospitalized Patients With Cirrhosis. J Clin Gastroenterol 2021; 55:624-630. [PMID: 33136780 DOI: 10.1097/mcg.0000000000001452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Over 2.1 million individuals in the United Stats have cirrhosis, including 513,000 with decompensated cirrhosis. Hospitals with high safety-net burden disproportionately serve ethnic minorities and have reported worse outcomes in surgical literature. No studies to date have evaluated whether hospital safety-net burden negatively affects hospitalization outcomes in cirrhosis. We aim to evaluate the impact of hospitals' safety-net burden and patients' ethnicity on in-hospital mortality among cirrhosis patients. METHODS Using National Inpatient Sample data from 2012 to 2016, the largest United States all-payer inpatient health care claims database of hospital discharges, cirrhosis-related hospitalizations were stratified into tertiles of safety-net burden: high (HBH), medium (MBH), and low (LBH) burden hospitals. Safety-net burden was calculated as percentage of hospitalizations per hospital with Medicaid or uninsured payer status. Multivariable logistic regression evaluated factors associated with in-hospital mortality. RESULTS Among 322,944 cirrhosis-related hospitalizations (63.7% white, 9.9% black, 15.6% Hispanic), higher odds of hospitalization in HBHs versus MBH/LBHs was observed in blacks (OR, 1.26; 95%CI, 1.17-1.35; P<0.001) and Hispanics (OR, 1.63; 95% CI, 1.50-1.78; P<0.001) versus whites. Cirrhosis-related hospitalizations in MBHs or HBHs were associated with greater odds of in-hospital mortality versus LBHs (HBH vs. LBH: OR, 1.05; 95% CI, 1.00-1.10; P=0.044). Greater odds of in-hospital mortality was observed in blacks (OR, 1.27; 95% CI, 1.21-1.34; P<0.001) versus whites. CONCLUSION Cirrhosis patients hospitalized in HBH experienced 5% higher mortality than those in LBH, resulting in significantly greater deaths in cirrhosis patients. Even after adjusting for safety-net burden, blacks with cirrhosis had 27% higher in-hospital mortality compared with whites.
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Affiliation(s)
- Robert J Wong
- Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA
| | - Grishma Hirode
- Toronto Centre for Liver Disease, University Health Network, Toronto General Hospital, University of Toronto, Canada
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20
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Mazumder NR, Simpson D, Atiemo K, Jackson K, Zhao L, Daud A, Kho A, Gabra LG, Caicedo JC, Levitsky J, Ladner DP. Black Patients With Cirrhosis Have Higher Mortality and Lower Transplant Rates: Results From a Metropolitan Cohort Study. Hepatology 2021; 74:926-936. [PMID: 34128254 DOI: 10.1002/hep.31742] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/30/2020] [Accepted: 01/19/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Estimates of racial disparity in cirrhosis have been limited by lack of large-scale, longitudinal data, which track patients from diagnosis to death and/or transplant. APPROACH AND RESULTS We analyzed a large, metropolitan, population-based electronic health record data set from seven large health systems linked to the state death registry and the national transplant database. Multivariate competing risk analyses, adjusted for sex, age, insurance status, Elixhauser score, etiology of cirrhosis, HCC, portal hypertensive complication, and Model for End-Stage Liver Disease-Sodium (MELD-Na), examined the relationship between race, transplant, and cause of death as defined by blinded death certificate review. During the study period, 11,277 patients met inclusion criteria, of whom 2,498 (22.2%) identified as Black. Compared to White patients, Black patients had similar age, sex, MELD-Na, and proportion of alcohol-associated liver disease, but higher comorbidity burden, lower rates of private insurance, and lower rates of portal hypertensive complications. Compared to White patients, Black patients had the highest rate all-cause mortality and non-liver-related death and were less likely to be listed or transplanted (P < 0.001 for all). In multivariate competing risk analysis, Black patients had a 26% increased hazard of liver-related death (subdistribution HR, 1.26; 95% CI, [1.15-1.38]; P < 0.001). CONCLUSIONS Black patients with cirrhosis have discordant outcomes. Further research is needed to determine how to address these real disparities in the field of hepatology.
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Affiliation(s)
- Nikhilesh R Mazumder
- Department of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIL.,Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL
| | - Dinee Simpson
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Division of TransplantDepartment of SurgeryNorthwestern MedicineChicagoIL
| | - Kofi Atiemo
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Tulane Abdominal Transplant InstituteDepartment of SurgeryTulane University School of MedicineNew OrleansLA
| | - Kathryn Jackson
- Institute for Public Health and Medicine-Center for Health Information PartnershipsNorthwestern University, Feinberg School of MedicineChicagoIL
| | - Lihui Zhao
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Department of Preventative MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Amna Daud
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL
| | - Abel Kho
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Institute for Public Health and Medicine-Center for Health Information PartnershipsNorthwestern University, Feinberg School of MedicineChicagoIL
| | - Lauren G Gabra
- Feinberg School of MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Juan C Caicedo
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Division of TransplantDepartment of SurgeryNorthwestern MedicineChicagoIL
| | - Josh Levitsky
- Department of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIL.,Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL
| | - Daniela P Ladner
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Division of TransplantDepartment of SurgeryNorthwestern MedicineChicagoIL
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21
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Nephew LD, Serper M. Racial, Gender, and Socioeconomic Disparities in Liver Transplantation. Liver Transpl 2021; 27:900-912. [PMID: 33492795 DOI: 10.1002/lt.25996] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/30/2020] [Accepted: 01/13/2021] [Indexed: 12/11/2022]
Abstract
Liver transplantation (LT) is a life-saving therapy; therefore, equitable distribution of this scarce resource is of paramount importance. We searched contemporary literature on racial, gender, and socioeconomic disparities across the LT care cascade in referral, waitlist practices, allocation, and post-LT care. We subsequently identified gaps in the literature and future research priorities. Studies found that racial and ethnic minorities (Black and Hispanic patients) have lower rates of LT referral, more advanced liver disease and hepatocellular carcinoma at diagnosis, and are less likely to undergo living donor LT (LDLT). Gender-based disparities were observed in waitlist mortality and LT allocation. Women have lower LT rates after waitlisting, with size mismatch accounting for much of the disparity. Medicaid insurance has been associated with higher rates of chronic liver disease and poor waitlist outcomes. After LT, some studies found lower overall survival among Black compared with White recipients. Studies have also shown lower literacy and limited educational attainment were associated with increased posttransplant complications and lower use of digital technology. However, there are notable gaps in the literature on disparities in LT. Detailed population-based estimates of the advanced liver disease burden and LT referral and evaluation practices, including for LDLT, are lacking. Similarly, little is known about LT disparities worldwide. Evidence-based strategies to improve access to care and reduce disparities have not been comprehensively identified. Prospective registries and alternative "real-world" databases can provide more detailed information on disease burden and clinical practices. Modeling and simulation studies can identify ways to reduce gender disparities attributed to size or inaccurate estimation of renal function. Mixed-methods studies and clinical trials should be conducted to reduce care disparities across the transplant continuum.
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Affiliation(s)
- Lauren D Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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22
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Molleston JP, Bennett WE. Mortality, Risk Factors and Disparities Associated with Esophageal Variceal Bleeding in Children's Hospitals in the US. J Pediatr 2021; 232:176-182. [PMID: 33450222 DOI: 10.1016/j.jpeds.2020.12.082] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/30/2020] [Accepted: 12/31/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To use a large administrative database to determine the mortality, risk factors, and comorbidities of esophageal variceal bleeding in children. STUDY DESIGN Retrospective cohort study using Pediatric Health Information System data from 50 tertiary children's hospitals in the US. International Classification of Diseases (ICD) codes (FY 2020 ICD-10 update and revision 10 of ICD-9) from 2004 through 2019 identified children 18 years and younger with variceal bleeding and complications. Univariate analyses used the Student t -test for continuous variables (age) and the χ2 test for categorical variables (all others). A mixed-effects linear regression was performed for multiple variables. RESULTS There were 1902 patients who had 3399 encounters for esophageal variceal bleeding. The mortality rate for variceal bleeding was 7.3%, increasing to 8.8% by 6 weeks; any mortality during the study was 20.1%. Transfusion was required in 54.7% of encounters, and 42.6% were admitted to the intensive care unit. Variceal bleeding encounters were complicated by peptic ulcer disease (6.9%), bacteremia (11.4%), acute renal failure (5.1%), mechanical ventilation (18%), ascites (21.3%), and peritonitis (3.3%). Multivariable mixed-effects logistic regression showed that Black race (OR, 2.59; P < .001) or Hispanic ethnicity (OR, 2.31; P = .001), but not sex, household income, or insurance type, were associated with increased mortality. Bacteremia, peritonitis, mechanical ventilation, acute renal failure, and transfusion were associated with higher mortality (ORs of 2.29, 2.18, 1.93, 6.33, and 1.81, respectively; P < .001, .005, .011, <.001, and .005, respectively). CONCLUSIONS The 6-week mortality rate for variceal bleeding in children is 8.8%. Black or Hispanic children are at higher risk of dying. Serious morbidities associated with variceal hemorrhage impact mortality. These data can inform consideration of prophylactic or therapeutic interventions for children at risk.
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Affiliation(s)
- Jean P Molleston
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, IN.
| | - William E Bennett
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, IN; Department of Pediatrics, Division of Pediatric and Adolescent Comparative Effectiveness Research, Indiana University School of Medicine, Indianapolis, IN
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23
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Bajaj JS, O'Leary JG, Tandon P, Wong F, Kamath PS, Biggins SW, Garcia-Tsao G, Lai J, Fallon MB, Thuluvath PJ, Vargas HE, Maliakkal B, Subramanian RM, Thacker LR, Reddy KR. Insurance Status But Not Race and Ethnicity Are Associated With Outcomes in a Large Hospitalized Cohort of Patients With Cirrhosis. Clin Gastroenterol Hepatol 2021; 19:565-572.e5. [PMID: 32389884 DOI: 10.1016/j.cgh.2020.04.081] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/09/2020] [Accepted: 04/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Insurance, race, and ethnicity can affect outcomes of patients with cirrhosis, but findings from prospective studies are unclear. We investigated the role of insurance status and race and ethnicity (race/ethnicity) on inpatient and 90-day postdischarge outcomes in a large inpatient cohort of patients with cirrhosis. METHODS We used data from the North American Consortium for the Study of End-Stage Liver Disease (NACSELD) database, from 13 tertiary care centers. Insurance status (uninsured, Medicare, Medicaid, private, and Canadian), race, and ethnicity, were analyzed independent of clinical covariates for their association with transfer to the intensive care unit, acute on chronic liver failure (ACLF), length of hospital stay, inpatient and 90-day death or liver transplantation, and readmission to the hospital within 90 days. Multi-variable analyses and interaction terms were created for insurance, race/ethnicity, and for each outcome, with or without Canadian patients. RESULTS We analyzed data from 2640 patients in the NACSELD database (971 with private insurance, 770 with Medicare, 456 Canadians, 265 with Medicaid, 178 uninsured, 540 non-Caucasian and 220 Hispanic); 23% required admittance to the intensive care unit, 12% developed NACSELD-defined ACLF, 7% died, 5% underwent liver transplantation. Of the 2288 patients discharged from hospital, 13% underwent liver transplantation, 19% died, and 42% were readmitted within 90 days. In the univariate model, uninsured patients accounted for the highest percentage of alcohol- or bleeding-related admissions and the lowest proportion of outpatient cirrhosis-related medication users. Canadians had the lowest rifaximin use and but higher proportions had hepatic encephalopathy, compared with other groups. Lack of insurance was higher among non-Caucasians, regardless of Hispanic ethnicity. In multi-variable analysis, lack of insurance was associated with ACLF (P = .02) and inversely associated with inpatient liver transplant (P = .05) and 90-day liver transplant (P = .02), regardless of whether Canadians were included or specific insurance type. Race or ethnicity were not significantly associated with outcomes. CONCLUSIONS In analyzing the NACSELD database, we found that insurance status, but not race or ethnicity, were independently associated with ACLF and inpatient or 90-day liver transplantation, regardless of inclusion of Canadian patients.
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Affiliation(s)
- Jasmohan S Bajaj
- Department of Bio-statistics, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia.
| | | | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, Canada
| | | | - Scott W Biggins
- Department of Medicine, University of Washington, Seattle, Washington
| | | | - Jennifer Lai
- Department of Medicine, University of California, San Francisco, California
| | | | - Paul J Thuluvath
- Department of Medicine, Mercy Medical Center, Baltimore, Maryland
| | - Hugo E Vargas
- Department of Medicine, Mayo Clinic, Phoenix, Arizona
| | | | | | - Leroy R Thacker
- Department of Bio-statistics, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Kardashian A, Wilder J, Terrault NA, Price JC. Addressing Social Determinants of Liver Disease During the COVID-19 Pandemic and Beyond: A Call to Action. Hepatology 2021; 73:811-820. [PMID: 33150599 DOI: 10.1002/hep.31605] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/28/2020] [Accepted: 10/06/2020] [Indexed: 12/16/2022]
Abstract
The COVID-19 pandemic has exposed healthcare inequities in the USA and highlighted the importance of social conditions in shaping the health of persons. In the field of hepatology, social determinants of health (SDOH) are closely linked to disparities in liver disease prevalence, outcomes, and access to treatment. The economic disruption and physical distancing policies brought on by the COVID-19 pandemic have further exacerbated these disparities, and may have long-lasting health consequences for marginalized patients with chronic liver disease. There are several ways that hepatology providers can bridge the gap in health equity through addressing SDOH, extending from the individual to the community and societal levels. Interventions at the individual level include implementation of systematic screening for social barriers in our hepatology practices to identify gaps in the care cascade. At the community and societal levels, interventions include creating collaborative partnerships with public health workers to expand healthcare access to the community, increasing funding for research investigating the association of SDOH, health disparities, and liver disease, engaging in advocacy to support policy reform that tackles the upstream social determinants, and addressing racism and implicit bias. As hepatology practices adapt to the "new normal," now is the time for us to address our patients' social needs within the context of healthcare delivery and reimagine ways in which to provide care to best serve our most vulnerable patients with liver disease in the COVID-19 era and beyond.
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Affiliation(s)
- Ani Kardashian
- Division of Gastrointestinal and Liver DiseasesUniversity of Southern CaliforniaLos AngelesCA
| | - Julius Wilder
- Division of GastroenterologyDepartment of MedicineDuke University School of MedicineDurhamNC.,Duke Clinical Research InstituteDurhamNC
| | - Norah A Terrault
- Division of Gastrointestinal and Liver DiseasesUniversity of Southern CaliforniaLos AngelesCA
| | - Jennifer C Price
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of California San FranciscoSan FranciscoCA
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Thuluvath PJ, Amjad W, Zhang T. Liver transplant waitlist removal, transplantation rates and post-transplant survival in Hispanics. PLoS One 2020; 15:e0244744. [PMID: 33382811 PMCID: PMC7774861 DOI: 10.1371/journal.pone.0244744] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/15/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hispanics are the fastest growing population in the USA, and our objective was to determine their waitlist mortality rates, liver transplantation (LT) rates and post-LT outcomes. METHODS All adults listed for LT with the UNOS from 2002 to 2018 were included. Competing risk analysis was performed to assess the association between ethnic group with waitlist removal due to death/deterioration and transplantation. For sensitivity analysis, Hispanics were matched 1:1 to Non-Hispanics using propensity scores, and outcomes of interest were compared in matched cohort. RESULTS During this period, total of 154,818 patients who listed for liver transplant were involved in this study, of them 23,223 (15%) were Hispanics, 109,653 (71%) were Whites, 13,020 (8%) were Blacks, 6,980 (5%) were Asians and 1,942 (1%) were others. After adjusting for differences in clinical characteristics, compared to Whites, Hispanics had higher waitlist removal due to death or deterioration (adjusted cause-specific Hazard Ratio: 1.034, p = 0.01) and lower transplantation rates (adjusted cause-specific Hazard Ratio: 0.90, p<0.001). If Hispanics received liver transplant, they had better patient and graft survival than Non-Hispanics (p<0.001). Compared to Whites, adjusted hazard ratio for Hispanics were 0.88 (95% CI 0.84, 0.92, p<0.001) for patient survival and 0.90 (95% CI 0.86, 0.94, p<0.001) for graft survival. Our analysis in matched cohort showed the consistent results. CONCLUSIONS This study showed that Hispanics had higher probability to be removed from the waitlist due to death, and lower probability to be transplanted, however they had better post-LT outcomes when compared to whites.
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Affiliation(s)
- Paul J. Thuluvath
- Institute for Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Waseem Amjad
- Institute for Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, United States of America
| | - Talan Zhang
- Institute for Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, United States of America
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Nephew LD, Mosesso K, Desai A, Ghabril M, Orman ES, Patidar KR, Kubal C, Noureddin M, Chalasani N. Association of State Medicaid Expansion With Racial/Ethnic Disparities in Liver Transplant Wait-listing in the United States. JAMA Netw Open 2020; 3:e2019869. [PMID: 33030554 PMCID: PMC7545310 DOI: 10.1001/jamanetworkopen.2020.19869] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/29/2020] [Indexed: 12/27/2022] Open
Abstract
Importance Millions of Americans gained insurance through the state expansion of Medicaid, but several states with large populations of racial/ethnic minorities did not expand their programs. Objective To investigate the implications of Medicaid expansion for liver transplant (LT) wait-listing trends for racial/ethnic minorities. Design, Setting, and Participants A cohort study was performed of adults wait-listed for LT using the United Network of Organ Sharing database between January 1, 2010, and December 31, 2017. Poisson regression and a controlled, interrupted time series analysis were used to model trends in wait-listing rates by race/ethnicity. The setting was LT centers in the United States. Main Outcomes and Measures (1) Wait-listing rates by race/ethnicity in states that expanded Medicaid (expansion states) compared with those that did not (nonexpansion states) and (2) actual vs predicted rates of LT wait-listing by race/ethnicity after Medicaid expansion. Results There were 75 748 patients (median age, 57.0 [interquartile range, 50.0-62.0] years; 48 566 [64.1%] male) wait-listed for LT during the study period. The cohort was 8.9% Black and 16.4% Hispanic. Black patients and Hispanic patients were statistically significantly more likely to be wait-listed in expansion states than in nonexpansion states (incidence rate ratio [IRR], 1.54 [95% CI, 1.44-1.64] for Black patients and 1.21 [95% CI, 1.15-1.28] for Hispanic patients). After Medicaid expansion, there was a decrease in the wait-listing rate of Black patients in expansion states (annual percentage change [APC], -4.4%; 95% CI, -8.2% to -0.6%) but not in nonexpansion states (APC, 0.5%; 95% CI, -4.0% to 5.2%). This decrease was not seen when Black patients with hepatitis C virus (HCV) were excluded from the analysis (APC, 3.1%; 95% CI, -2.4% to 8.9%), suggesting that they may be responsible for this expansion state trend. Hispanic Medicaid patients without HCV were statistically significantly more likely to be wait-listed in the post-Medicaid expansion era than would have been predicted without Medicaid expansion (APC, 13.2%; 95% CI, 4.0%-23.2%). Conclusions and Relevance This cohort study found that LT wait-listing rates have decreased for Black patients with HCV in states that expanded Medicaid. Conversely, wait-listing rates have increased for Hispanic patients without HCV. Black patients and Hispanic patients may have benefited differently from Medicaid expansion.
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Affiliation(s)
- Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Kelly Mosesso
- Department of Biostatistics, Indiana University Fairbanks School of Public Health and School of Medicine, Indianapolis
| | - Archita Desai
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Kavish R. Patidar
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Chandrashekhar Kubal
- Division of Organ Transplantation, Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Mazen Noureddin
- Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
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Spiewak T, Taefi A, Patel S, Li CS, Chak E. Racial disparities of Black Americans hospitalized for decompensated liver cirrhosis. BMC Gastroenterol 2020; 20:245. [PMID: 32727386 PMCID: PMC7391571 DOI: 10.1186/s12876-020-01392-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 07/21/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Racial disparities have been reported in liver transplantation and chronic hepatitis C treatment outcomes. Determining causes of these disparities is important given the racially diverse American population and the economic burden associated with chronic liver disease. METHODS A retrospective study was performed among 463 patients diagnosed with cirrhosis admitted from (January 1, 2013 to January 1, 2018) to a tertiary care academic medical center. Patients were identified based on the International Classification of Diseases (ICD-10) for cirrhosis or its complications. Demographic information, laboratory data, medical comorbidities, insurance and adherence to cirrhosis quality care indicators were recorded to determine their relationship to readmission rates and other healthcare outcomes. RESULTS A total of 463 individual patients with cirrhosis were identified including Whites (n = 241), Hispanics (n = 106), Blacks (n = 50), Asian and Pacific Islander Americans (API, n = 27) and Other (n = 39). A significantly higher proportion of Blacks had Medicaid insurance compared to Whites (40% versus 20%, p = 0.0002) and Blacks had lower median income than Whites ($45,710 versus $54,844, p = 0.01). All groups received high quality cirrhosis care. Regarding healthcare outcomes, Black patients had the highest mean total hospital admissions (6.1 ± 6.3, p = 0.01) and the highest mean number of 30-day re-admissions (2.1 ± 3.7, p = 0.05) compared to all other racial groups. Multivariable proportional odds regression analysis showed that race was a statistically significant predictor of 90-day readmission (p = 0.03). CONCLUSIONS Black Americans hospitalized for complications of cirrhosis may experience significant disparities in healthcare outcomes compared to Whites despite high quality cirrhosis care. Socioeconomic factors may contribute to these disparities.
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Affiliation(s)
- Ted Spiewak
- Department of Internal Medicine, UC Davis Medical Center, Sacramento, California, USA
| | - Amir Taefi
- Department of Gastroenterology and Hepatology, UC Davis Medical Center, 4150 V Street, PSSB 3500, Sacramento, CA, 95817, USA
| | - Shruti Patel
- Department of Internal Medicine, UC Davis Medical Center, Sacramento, California, USA
| | - Chin-Shang Li
- School of Nursing, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Eric Chak
- Department of Gastroenterology and Hepatology, UC Davis Medical Center, 4150 V Street, PSSB 3500, Sacramento, CA, 95817, USA.
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Abstract
BACKGROUND Despite the increasing prevalence of end-stage liver disease in older adults, there is no consensus to determine suitability for liver transplantation (LT) in the elderly. Disparities in LT access exist, with a disproportionately lower percentage of African Americans (AAs) receiving LT. Understanding waitlist outcomes in older adults, specifically AAs, will identify opportunities to improve LT access for this vulnerable population. METHODS All adult, liver-only white and AA LT waitlist candidates (January 1, 2003 to October 1, 2015) were identified in the Scientific Registry of Transplant Recipients. Age and race categories were defined: younger white (age <60 years), younger AA, older white (age, ≥60 years), and older AA. Outcomes were delisting, transplantation, and mortality and were modeled using Fine and Gray competing risks. RESULTS Among 101 805 candidates, 58.4% underwent transplantation, 14.7% died while listed, and 21.4% were delisted. Among those delisted, 36.1% died, whereas 7.4% were subsequently relisted. Both older AAs and older whites were more likely than younger whites to be delisted and to die after delisting. Older whites had higher incidence of waitlist mortality than younger whites (subdistribution hazard ratio, 1.07; 95% confidence interval, 1.01-1.13). All AAs and older whites had decreased incidence of LT, compared with younger whites. CONCLUSIONS Both older age and AA race were associated with decreased cumulative incidence of transplantation. Independent of race, older candidates had increased incidences of delisting and mortality after delisting than younger whites. Our findings support the need for interventions to ensure medical suitability for LT among older adults and to address disparities in LT access for AAs.
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Walker RW, Belbin GM, Sorokin EP, Van Vleck T, Wojcik GL, Moscati A, Gignoux CR, Cho J, Abul-Husn NS, Nadkarni G, Kenny EE, Loos RJ. A common variant in PNPLA3 is associated with age at diagnosis of NAFLD in patients from a multi-ethnic biobank. J Hepatol 2020; 72:1070-1081. [PMID: 32145261 PMCID: PMC7840172 DOI: 10.1016/j.jhep.2020.01.029] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 12/17/2019] [Accepted: 01/10/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS The Ile138Met variant (rs738409) in the PNPLA3 gene has the largest effect on non-alcoholic fatty liver disease (NAFLD), increasing the risk of progression to severe forms of liver disease. It remains unknown if the variant plays a role in age of NAFLD onset. We aimed to determine if rs738409 impacts on the age of NAFLD diagnosis. METHODS We applied a novel natural language processing (NLP) algorithm to a longitudinal electronic health records (EHR) dataset of >27,000 individuals with genetic data from a multi-ethnic biobank, defining NAFLD cases (n = 1,703) and confirming controls (n = 8,119). We conducted i) a survival analysis to determine if age at diagnosis differed by rs738409 genotype, ii) a receiver operating characteristics analysis to assess the utility of the rs738409 genotype in discriminating NAFLD cases from controls, and iii) a phenome-wide association study (PheWAS) between rs738409 and 10,095 EHR-derived disease diagnoses. RESULTS The PNPLA3 G risk allele was associated with: i) earlier age of NAFLD diagnosis, with the strongest effect in Hispanics (hazard ratio 1.33; 95% CI 1.15-1.53; p <0.0001) among whom a NAFLD diagnosis was 15% more likely in risk allele carriers vs. non-carriers; ii) increased NAFLD risk (odds ratio 1.61; 95% CI 1.349-1.73; p <0.0001), with the strongest effect among Hispanics (odds ratio 1.43; 95% CI 1.28-1.59; p <0.0001); iii) additional liver diseases in a PheWAS (p <4.95 × 10-6) where the risk variant also associated with earlier age of diagnosis. CONCLUSION Given the role of the rs738409 in NAFLD diagnosis age, our results suggest that stratifying risk within populations known to have an enhanced risk of liver disease, such as Hispanic carriers of the rs738409 variant, would be effective in earlier identification of those who would benefit most from early NAFLD prevention and treatment strategies. LAY SUMMARY Despite clear associations between the PNPLA3 rs738409 variant and elevated risk of progression from non-alcoholic fatty liver disease (NAFLD) to more severe forms of liver disease, it remains unknown if PNPLA3 rs738409 plays a role in the age of NAFLD onset. Herein, we found that this risk variant is associated with an earlier age of NAFLD and other liver disease diagnoses; an observation most pronounced in Hispanic Americans. We conclude that PNPLA3 rs738409 could be used to better understand liver disease risk within vulnerable populations and identify patients that may benefit from early prevention strategies.
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Affiliation(s)
- Ryan W. Walker
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Corresponding author. Address: Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029. (R.W. Walker)
| | - Gillian M. Belbin
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Center for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Elena P. Sorokin
- Department of Genetics, Stanford School of Medicine, Stanford University, Stanford, CA
| | - Tielman Van Vleck
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Genevieve L. Wojcik
- Department of Genetics, Stanford School of Medicine, Stanford University, Stanford, CA
| | - Arden Moscati
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Center for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Christopher R. Gignoux
- Center for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA,Department of Biostatistics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Judy Cho
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Noura S. Abul-Husn
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Center for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Girish Nadkarni
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Eimear E. Kenny
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Center for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Ruth J.F. Loos
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029,Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029,The Mindich Child Health Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Nephew L, Zia Z, Ghabril M, Orman E, Lammert C, Chalasani N. Black Adult Patients With Acute Liver Failure Are Sicker and More Likely to Undergo Liver Transplantation Than White Patients. Liver Transpl 2019; 25:1634-1641. [PMID: 31271697 DOI: 10.1002/lt.25594] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 06/10/2019] [Indexed: 02/07/2023]
Abstract
Racial and ethnic differences in the presentation and outcomes of patients wait-listed with acute liver failure (ALF) have not been explored. Adult patients with ALF wait-listed for liver transplantation (LT) from 2002 to 2016 were investigated using the United Network for Organ Sharing database. Clinical characteristics and causative etiologies were compared between white, black, Hispanic, and Asian patients with ALF who were wait-listed as status 1. A competing risk analysis was used to explore differences in LT and wait-list removal rates. Kaplan-Meier survival curves were used to explore differences in 1-year posttransplant survival. There were 8208 patients wait-listed with a primary diagnosis of ALF; 4501 were wait-listed as status 1 (55.3% of whites, 64.4% of blacks, 51.6% of Hispanics, 40.7% of Asians; P < 0.001). Black patients had higher bilirubin and Model for End-Stage Liver Disease at wait-listing than other groups. White patients were the most likely to have acetaminophen toxicity as a causative etiology, whereas black patients were the most likely to have autoimmune liver disease. Black patients were significantly more likely to undergo LT than white patients (hazard ratio, 1.20; 95% confidence interval, 1.08-1.30). There was no difference in wait-list removal because of death or clinical deterioration among racial/ethnic groups. The 1-year posttransplant survival was lowest in black patients (79.6%) versus white (82.8%), Hispanic (83.9%), and Asian (89.3%) patients (P = 0.02). In conclusion, etiologies of ALF vary by race and ethnicity. Black patients with ALF were more likely to be wait-listed as status 1 and undergo LT than white patients, but they were sicker at presentation. The 1-year posttransplant survival rate was lowest among black patients.
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Affiliation(s)
- Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Zahra Zia
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Eric Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Craig Lammert
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
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Mukthinuthalapati VVPK, Akinyeye S, Fricker ZP, Syed M, Orman ES, Nephew L, Vilar-Gomez E, Slaven J, Chalasani N, Balakrishnan M, Long MT, Attar BM, Ghabril M. Early predictors of outcomes of hospitalization for cirrhosis and assessment of the impact of race and ethnicity at safety-net hospitals. PLoS One 2019; 14:e0211811. [PMID: 30840670 PMCID: PMC6402644 DOI: 10.1371/journal.pone.0211811] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 01/21/2019] [Indexed: 12/30/2022] Open
Abstract
Background Safety-net hospitals provide care for racially/ethnically diverse and disadvantaged urban populations. Their hospitalized patients with cirrhosis are relatively understudied and may be vulnerable to poor outcomes and racial/ethnic disparities. Aims To examine the outcomes of patients with cirrhosis hospitalized at regionally diverse safety-net hospitals and the impact of race/ethnicity. Methods A study of patients with cirrhosis hospitalized at 4 safety-net hospitals in 2012 was conducted. Demographic, clinical factors, and outcomes were compared between centers and racial/ethnic groups. Study endpoints included mortality and 30-day readmission. Results In 2012, 733 of 1,212 patients with cirrhosis were hospitalized for liver-related indications (median age 55 years, 65% male). The cohort was racially diverse (43% White, 25% black, 22% Hispanic, 3% Asian) with cirrhosis related to alcohol and viral hepatitis in 635 (87%) patients. Patients were hospitalized mainly for ascites (35%), hepatic encephalopathy (20%) and gastrointestinal bleeding (GIB) (17%). Fifty-four (7%) patients died during hospitalization and 145 (21%) survivors were readmitted within 30 days. Mortality rates ranged from 4 to 15% by center (p = .007) and from 3 to 10% by race/ethnicity (p = .03), but 30-day readmission rates were similar. Mortality was associated with Model for End-stage Liver Disease (MELD), acute-on-chronic liver failure, hepatocellular carcinoma, sodium and white blood cell count. Thirty-day readmission was associated with MELD and Charlson Comorbidity Index >4, with lower risk for GIB. We did not observe geographic or racial/ethnic differences in hospital outcomes in the risk-adjusted analysis. Conclusions Hospital mortality and 30-day readmission in patients with cirrhosis at safety-net hospitals are associated with disease severity and comorbidities, with lower readmissions in patients admitted for GIB. Despite geographic and racial/ethnic differences in hospital mortality, these factors were not independently associated with mortality.
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Affiliation(s)
- V. V. Pavan Kedar Mukthinuthalapati
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indianapolis, United States of America
- Department of Medicine, Cook County Health and Hospitals System, Chicago, Illinois, United States of America
| | - Samuel Akinyeye
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Zachary P. Fricker
- Evans Department of Medicine, Section of Gastroenterology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Moinuddin Syed
- Department of Medicine, Cook County Health and Hospitals System, Chicago, Illinois, United States of America
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indianapolis, United States of America
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indianapolis, United States of America
| | - Eduardo Vilar-Gomez
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indianapolis, United States of America
| | - James Slaven
- Department of Biostatistics, Indiana University, Indianapolis, Indianapolis, United States of America
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indianapolis, United States of America
| | - Maya Balakrishnan
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Michelle T. Long
- Evans Department of Medicine, Section of Gastroenterology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Bashar M. Attar
- Department of Gastroenterology and Hepatology, Cook County Health and Hospitals System, Chicago, Illinois, United States of America
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indianapolis, United States of America
- * E-mail:
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Long-term clinical outcomes in patients with viral hepatitis related liver cirrhosis after transjugular intrahepatic portosystemic shunt treatment. Virol J 2018; 15:151. [PMID: 30285813 PMCID: PMC6167830 DOI: 10.1186/s12985-018-1067-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/25/2018] [Indexed: 12/14/2022] Open
Abstract
Background Transjugular intrahepatic portosystemic shunt (TIPS) procedure has played a vital role in management of portal hypertension. Thus, we aimed to investigate the natural history, long-term clinical outcome, predictors of survival in viral hepatitis related cirrhotic patients post-TIPS. Method A total of 704 patients with complete followed-up data were enrolled, and clinical characteristics of patients were collected and analyzed. Kaplan-Meier method was used to calculate survival, and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results TIPS implatantion significantly decreased portal vein pressure with 9.77 cmH2O reduction, without influencing long-term liver functions. The total incidence rate of major complication post-TIPS, including HE and re-bleeding/bleeding, was 37.9% and 15.5%, respectively. Patients in Child-Pugh C stage revealed higher overt hepatic encephalopathy (HE) occurrence (65.6%), while patients receiving covered, 6 mm in diameter stents indicated notably lower incidence of HE in comparison with other groups (6.4%). The median survival was > 60 months, 27.0 months, and 11.5 months in cirrhotic patients with variceal bleeding, refractory ascites, and both complications, respectively. The cumulative 5-year survival was significantly higher in patients with variceal bleeding (75.6%) in comparison with either that in patients with refractory ascites (12.5%) or that in patients with both complications (1.96%) (P < 0.0001). Covered stents usage, baseline model for end-stage liver disease (MELD) score, and baseline Child-Pugh classification were predictive of survival (P < 0.001). Other variables including age, male gender, and pre-TIPS PVP were not emerged as significant predictors (P > 0.05). Conclusion TIPS was an effective and safe therapeutic method for decompression of portal hypertension and for treatment of its complications. Careful selection of patients with minimal liver dysfunction for TIPS implantation was essential for better long-term outcomes.
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Wen JW, Kohn MA, Wong R, Somsouk M, Khalili M, Maher J, Tana MM. Hospitalizations for Autoimmune Hepatitis Disproportionately Affect Black and Latino Americans. Am J Gastroenterol 2018; 113:243-253. [PMID: 29380822 PMCID: PMC6522224 DOI: 10.1038/ajg.2017.456] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 10/30/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The healthcare burden of autoimmune hepatitis (AIH) in the United States has not been characterized. We previously showed that AIH disproportionately affects people of color in a single hospital system. The current study aimed to determine whether the same disparity occurs nationwide. METHODS We analyzed hospitalizations with a primary discharge diagnosis corresponding to the ICD-9 code for AIH in the National Inpatient Sample between 2008 and 2012. For each racial/ethnic group, we calculated the AIH hospitalization rate per 100,000 population and per 100,000 all-cause hospitalizations, then calculated a risk ratio compared to the reference rate among whites. We used multivariable logistic regression models to assess for racial disparities and to identify predictors of in-hospital mortality during AIH hospitalizations. RESULTS The national rate of AIH hospitalization was 0.73 hospitalizations per 100,000 population. Blacks and Latinos were hospitalized for AIH at a rate 69% (P<0.001) and 20% higher (P<0.001) than whites, respectively. After controlling for age, gender, payer, residence, zip code income, region, and cirrhosis, black race was a statistically significant predictor for mortality during AIH hospitalizations (odds ratio (OR) 2.81, 95% confidence interval (CI) 1.43, 5.47). CONCLUSIONS Hospitalizations for AIH disproportionately affect black and Latino Americans. Black race is independently associated with higher odds of death during hospitalizations for AIH. This racial disparity may be related to biological, genetic, environmental, socioeconomic, and healthcare access and quality factors.
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Affiliation(s)
- Jason W. Wen
- Augusta University,Emory University School of Medicine, San Francisco, California, USA
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Ross K, Patzer RE, Goldberg DS, Lynch RJ. Sociodemographic Determinants of Waitlist and Posttransplant Survival Among End-Stage Liver Disease Patients. Am J Transplant 2017; 17:2879-2889. [PMID: 28695615 DOI: 10.1111/ajt.14421] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 06/02/2017] [Accepted: 07/01/2017] [Indexed: 01/25/2023]
Abstract
While regional organ availability dominates discussions of distribution policy, community-level disparities remain poorly understood. We studied micro-geographic determinants of survival risk and their distribution across Donor Service Areas (DSAs). Scientific Registry of Transplant Recipients records for all adults waitlisted for liver transplantation 2002-2014 were reviewed. The primary exposure variables were county-level sociodemographic risk, as measured by the Community Health Score (CHS), a previously-validated composite index local health conditions, and distance to listing transplant center. Among 114 347 patients, the median CHS was 19.4 (range: 0-40). Compared the lowest risk counties (CHS 1-10), highest-risk counties (CHS 31-40) had more black (14.6% vs. 5.4%), publicly insured (44.9% vs. 33.0), and remote candidates (34.0% vs. 15.1% living >100 miles away). Higher-CHS candidates had greater waitlist mortality in Cox multivariable (HR 1.16 for CHS 31-40, 95% CI 1.11-1.21) and competing risks analysis (sHR 1.07, 95% CI 0.99-1.14). Post-transplant survival was similar across CHS quartiles. Living >25 miles from the transplant center conferred excess mortality risk (sHR 1.08, 95% CI 1.03-1.12). Proposed distribution changes would disproportionately impact DSAs with more high-CHS or distant candidates. Low-income, rural and minority patients experience excess mortality while awaiting transplant, and risk disproportionately worse outcomes with reduced organ availability under current proposals.
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Affiliation(s)
- K Ross
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - R E Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - D S Goldberg
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - R J Lynch
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Robinson A, Tavakoli H, Liu B, Bhuket T, Cheung R, Wong RJ. African-Americans with Cirrhosis Are Less Likely to Receive Endoscopic Variceal Screening Within One Year of Cirrhosis Diagnosis. J Racial Ethn Health Disparities 2017; 5:860-866. [PMID: 29052175 DOI: 10.1007/s40615-017-0432-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/06/2017] [Accepted: 09/08/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Esophageal variceal hemorrhage is a complication of cirrhosis that carries high mortality, and can be reduced with timely endoscopic variceal screening and treatment. AIM We aim to evaluate overall rates of and disparities in receipt of endoscopic variceal screening among an ethnically diverse urban safety-net hospital. METHODS All consecutive adults with cirrhosis (7/1/2014 to 12/31/2015) were retrospectively evaluated to determine the rates of receiving esophageal variceal screening within 6 months and within 1 year after cirrhosis diagnosis. Race-/ethnicity-specific differences in rates of variceal screening were compared using chi-square testing and multivariate regression methods. RESULTS Among 157 patients (65% male, 33.8% Hispanic, 22.3% African-American, 44.6% alcoholic liver disease, 29.9% chronic HCV), 56.8% received variceal screening within 6 months and 65.8% received screening within 1 year. Compared to non-Hispanic whites with cirrhosis, African-Americans (52.2 vs. 76.2%, p < 0.05), Asians (57.1 vs. 76.2%, p < 0.05), and Hispanics (43.9 vs. 76.2%, p < 0.05) were all significantly less likely to receive endoscopic variceal screening within 6 months after cirrhosis diagnosis. On multivariate analysis, African-Americans with cirrhosis were 66% less likely to receive variceal screening compared to non-Hispanic whites (HR 0.34, 95% CI 0.15-0.77, p < 0.01). CONCLUSION Among adults with cirrhosis at a community-based safety-net hospital system, overall first-time variceal screening remains suboptimal. African-Americans were the least likely to receive timely variceal screening. These findings are particularly concerning given the significant barriers that ethnic minorities and safety-net populations already face in timely access to medical care.
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Affiliation(s)
- Ann Robinson
- Department of Internal Medicine, Alameda Health System-Highland Hospital, Oakland, CA, USA
| | - Hesam Tavakoli
- Department of Internal Medicine, Alameda Health System-Highland Hospital, Oakland, CA, USA
| | - Benny Liu
- Division of Gastroenterology and Hepatology, Alameda Health System-Highland Hospital Campus, 1411 East 31st Street, Highland Hospital-Highland Care Pavilion 5th Floor, Endoscopy Unit, Oakland, CA, 94602, USA
| | - Taft Bhuket
- Division of Gastroenterology and Hepatology, Alameda Health System-Highland Hospital Campus, 1411 East 31st Street, Highland Hospital-Highland Care Pavilion 5th Floor, Endoscopy Unit, Oakland, CA, 94602, USA
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System-Highland Hospital Campus, 1411 East 31st Street, Highland Hospital-Highland Care Pavilion 5th Floor, Endoscopy Unit, Oakland, CA, 94602, USA.
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Xu Y, Li N, Lu M, Dixon E, Myers RP, Jolley RJ, Quan H. Comparison of risk adjustment methods in patients with liver disease using electronic medical record data. BMC Gastroenterol 2017; 17:5. [PMID: 28061757 PMCID: PMC5219741 DOI: 10.1186/s12876-016-0559-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 12/08/2016] [Indexed: 12/28/2022] Open
Abstract
Background Risk adjustment is essential for valid comparison of patients’ health outcomes or performances of health care providers. Several risk adjustment methods for liver diseases are commonly used but the optimal approach is unknown. This study aimed to compare the common risk adjustment methods for predicting in-hospital mortality in cirrhosis patients using electronic medical record (EMR) data. Methods The sample was derived from Beijing YouAn hospital between 2010 and 2014. Previously validated EMR extraction methods were applied to define liver disease conditions, Charlson comorbidity index (CCI), Elixhauser comorbidity index (ECI), Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), MELD sodium (MELDNa), and five-variable MELD (5vMELD). The performance of the common risk adjustment models as well as models combining disease severity and comorbidity indexes for predicting in-hospital mortality was compared using c-statistic. Results Of 11,121 cirrhotic patients, 69.9% were males and 15.8% age 65 or older. The c-statistics across compared models ranged from 0.785 to 0.887. All models significantly outperformed the baseline model with age, sex, and admission status (c-statistic: 0.628). The c-statistics for the CCI, ECI, MELDNa, and CTP were 0.808, 0.825, 0.849, and 0.851, respectively. The c-statistic was 0.887 for combination of CTP and ECI, and 0.882 for combination of MELDNa score and ECI. Conclusions The liver disease severity indexes (i.e., CTP and MELDNa score) outperformed the CCI and ECI for predicting in-hospital mortality among cirrhosis patients using Chinese EMRs. Combining liver disease severity and comorbidities indexes could improve the discrimination power of predicting in-hospital mortality.
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Affiliation(s)
- Yuan Xu
- Beijing YouAn Hospital, Capital Medical University, Beijing, China.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Ning Li
- Beijing YouAn Hospital, Capital Medical University, Beijing, China.
| | - Mingshan Lu
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Economics, University of Calgary, Calgary, AB, Canada
| | - Elijah Dixon
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Division of General Surgery, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Robert P Myers
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Rachel J Jolley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Beck KR, Kim N, Khalili M. Sofosbuvir-Containing Regimens for Chronic Hepatitis C Are Successful in the Safety-Net Population: A Real-World Experience. Dig Dis Sci 2016; 61:3602-3608. [PMID: 27743164 PMCID: PMC5106301 DOI: 10.1007/s10620-016-4340-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 10/03/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Vulnerable populations are disproportionately affected by hepatitis C virus (HCV) infection and experience high rates of health disparity. There are no data on real-world experience with highly efficacious direct-acting anti-HCV treatment in this population. AIMS We aimed to evaluate the real-world experience with sofosbuvir-based regimens among a vulnerable HCV-infected population. METHODS HCV treatment response was assessed among 204 patients who completed 12-24 weeks of sofosbuvir-based regimens (in combination with pegylated interferon and ribavirin, simeprevir, ledipasvir, or daclatasvir) at the San Francisco safety-net healthcare system liver specialty clinic between January 2014 and December 2015. Virologic response during therapy was assessed at weeks 4 and 8, end of therapy, and 12-week treatment discontinuation (SVR 12). RESULTS Patient characteristics were median age 58 years, 60 % male, 42 % Caucasian (21 % black, 19 % Hispanic), 72 % had genotype 1 (23 % genotype 2 or 3), and the median baseline log10 HCV viral load was 6.1 IU/ml and alanine transaminase 63 U/l. Cirrhosis was present in 36 % (of whom 40 % were decompensated), and 18 % were HCV treatment-experienced. Overall, SVR 12 was achieved in 97 % (99 % genotype 1, 100 % genotype 2, 84 % genotype 3). Five of six (83 %) patients who relapsed had decompensated cirrhosis, and 67 % were also non-adherent to therapy. On-treatment virologic response did not impact SVR. CONCLUSIONS High rates of sustained virologic response can be achieved in safety-net HCV-infected patients. Access to DAA-based regimens is critical to addressing HCV-related health disparity in this at-risk population.
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Affiliation(s)
- Kendall R Beck
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, NH 3-D, San Francisco, CA, 94110, USA
| | - Nicole Kim
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, NH 3-D, San Francisco, CA, 94110, USA
| | - Mandana Khalili
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, NH 3-D, San Francisco, CA, 94110, USA.
- Liver Center, University of California San Francisco, San Francisco, CA, USA.
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Moon AM, Dominitz JA, Ioannou GN, Lowy E, Beste LA. Use of Antibiotics Among Patients With Cirrhosis and Upper Gastrointestinal Bleeding Is Associated With Reduced Mortality. Clin Gastroenterol Hepatol 2016; 14:1629-1637.e1. [PMID: 27311621 DOI: 10.1016/j.cgh.2016.05.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/12/2016] [Accepted: 05/19/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Prophylactic antibiotics are recommended for all patients with cirrhosis hospitalized for upper gastrointestinal bleeding (UGIB). We evaluated the association between use of antibiotics, outcomes of re-admissions, and mortality in these patients. METHODS We performed a retrospective study of 6451 patients with cirrhosis (mean age, 60.6 y) in the Veterans Affairs health care system hospitalized for UGIB from January 1, 2005, through December 31, 2013 (8655 hospitalizations). We collected information on patients' baseline features, hospitalizations, etiology of UGIB, antibiotics given, hospital re-admission within 30 days of discharge, and mortality. We defined timely administration of antibiotics as receipt from 8 hours before admission through 48 hours afterward. RESULTS Timely administration of antibiotics occurred during 48.6% of admissions (n = 4210), increasing from 30.6% in 2005 to 58.1% in 2013. Independent predictors of antibiotic receipt included ascites, high model for end-stage liver disease score, esophageal variceal hemorrhage, and administration of octreotide or intravenous proton pump inhibitors. Variables associated with decreased odds of antibiotic provision included black race and nonalcoholic fatty liver disease. In multivariate analysis, timely administration of antibiotics was associated with a reduced 30-day mortality rate (adjusted odds ratio, 0.70; 95% confidence interval, 0.52-0.93; P = .012). CONCLUSIONS In a study of patients with cirrhosis and UGIB in the VA health care system, timely administration of antibiotics was associated with a 30% reduction in 30-day mortality. The proportion of patients with cirrhosis and UGIB receiving timely antibiotics nearly doubled from 2005 to 2013, but many patients-particularly those with less-advanced cirrhosis-did not receive this intervention. Targeted efforts are needed to promote the appropriate use of antibiotics among patients with cirrhosis and UGIB.
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Affiliation(s)
- Andrew M Moon
- Department of Medicine, University of Washington, Seattle, Washington
| | - Jason A Dominitz
- Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington
| | - George N Ioannou
- Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington
| | - Elliott Lowy
- VA Puget Sound Health Care System, Seattle, Washington; School of Public Health, University of Washington, Seattle, Washington
| | - Lauren A Beste
- Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington.
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Wilder JM, Oloruntoba OO, Muir AJ, Moylan CA. Role of patient factors, preferences, and distrust in health care and access to liver transplantation and organ donation. Liver Transpl 2016; 22:895-905. [PMID: 27027394 PMCID: PMC5567682 DOI: 10.1002/lt.24452] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 03/05/2016] [Accepted: 03/10/2016] [Indexed: 01/01/2023]
Abstract
Despite major improvements in access to liver transplantation (LT), disparities remain. Little is known about how distrust in medical care, patient preferences, and the origins shaping those preferences contribute to differences surrounding access. We performed a single-center, cross-sectional survey of adults with end-stage liver disease and compared responses between LT listed and nonlisted patients as well as by race. Questionnaires were administered to 109 patients (72 nonlisted; 37 listed) to assess demographics, health care system distrust (HCSD), religiosity, and factors influencing LT and organ donation (OD). We found that neither HCSD nor religiosity explained differences in access to LT in our population. Listed patients attained higher education levels and were more likely to be insured privately. This was also the case for white versus black patients. All patients reported wanting LT if recommended. However, nonlisted patients were significantly less likely to have discussed LT with their physician or to be referred to a transplant center. They were also much less likely to understand the process of LT. Fewer blacks were referred (44.4% versus 69.7%; P = 0.03) or went to the transplant center if referred (44.4% versus 71.1%; P = 0.02). Fewer black patients felt that minorities had as equal access to LT as whites (29.6% versus 57.3%; P < 0.001). For OD, there were more significant differences in preferences by race than listing status. More whites indicated OD status on their driver's license, and more blacks were likely to become an organ donor if approached by someone of the same cultural or ethnic background (P < 0.01). In conclusion, our analysis demonstrates persistent barriers to LT and OD. With improved patient and provider education and communication, many of these disparities could be successfully overcome. Liver Transplantation 22 895-905 2016 AASLD.
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Affiliation(s)
- Julius M. Wilder
- Division of Gastroenterology, Duke University Medical Center, Durham, NC,Duke Clinical Research Institute, Durham, NC
| | | | - Andrew J. Muir
- Division of Gastroenterology, Duke University Medical Center, Durham, NC,Duke Clinical Research Institute, Durham, NC
| | - Cynthia A. Moylan
- Division of Gastroenterology, Duke University Medical Center, Durham, NC,Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC
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African Americans Have Better Outcomes for Five Common Gastrointestinal Diagnoses in Hospitals With More Racially Diverse Patients. Am J Gastroenterol 2016; 111:649-57. [PMID: 27002802 DOI: 10.1038/ajg.2016.64] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/01/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We sought to characterize the relationship between hospital inpatient racial diversity and outcomes for African-American patients including rates of major complications or mortality during hospitalization for five common gastrointestinal diagnoses. METHODS Using the 2012 National Inpatient Sample database, hospital inpatient racial diversity was defined as the percentage of African-American patients discharged from each hospital. Logistic regression was used to predict major complication rates or death, long length of stay, and high total charges. Control variables included age, gender, payer type, patient location, area-associated income quartile, hospital characteristics including size, urban vs. rural, teaching vs. nonteaching, region, and the interaction of the percentage of African Americans with patient race. RESULTS There were 848,395 discharges across 3,392 hospitals. The patient population was on average 27% minority (s.d.±21%) with African Americans accounting for 14% of all patients. Overall, African-American patients had higher rates of major complications or death relative to white patients (adjusted odds ratio (aOR) 1.19; 95% confidence interval (CI) 1.16-1.23). However, when treated in hospitals with higher patient racial diversity, African-American patients experienced significantly lower rates of major complications or mortality (aOR 0.80; 95% CI 0.74-0.86). CONCLUSIONS African Americans have better outcomes for five common gastrointestinal diagnoses when treated in hospitals with higher inpatient racial diversity. This has major ramifications on total hospital charges.
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The Effect of Hospital Characteristics on Racial/Ethnic Variation in Cirrhosis Mortality. J Racial Ethn Health Disparities 2016; 4:243-251. [PMID: 27068660 DOI: 10.1007/s40615-016-0223-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 03/14/2016] [Accepted: 03/16/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Racial/ethnic disparities in liver disease and cirrhosis are well established. Cirrhosis mortality is improving overall despite vast differences between hospitals. We sought to understand the hospital characteristics where minorities seek care, whether disparities in cirrhosis mortality persist, and determine how hospital differences contribute to these differences. METHODS We used data from the Nationwide Inpatient Sample and the American Hospital Association to identify inpatient episodes of care for cirrhosis and structural characteristics at the parent hospital. We used multi-level hierarchical regression models to understand the effect of hospital structural characteristics on racial/ethnic variation in cirrhosis mortality. RESULTS From 2007 to 2011, 51,260 patients were admitted to the hospital with cirrhosis (White 66.5 %, Black 7.6 %, Hispanic 19.7 %, Asian 2.0 %, other 4.2 %). The overall adjusted mortality rate was 7.8 %, which significantly differed by race/ethnicity. Hospitals varied significantly in resource intensity. Higher mortality hospitals had a lower proportion of White patients and a higher proportion of Black and Hispanic patients compared to average and low mortality hospitals (p < 0.0001). Compared to White patients, there was significant racial/ethnic variation in unadjusted odds of mortality (Black OR 1.17; Hispanic OR 0.90; Asian 0.77; other 0.96; all p < 0.01). After accounting for hospital and patient differences, there were no racial/ethnic differences in mortality. CONCLUSIONS The increased risk of cirrhosis mortality in Black patients appears to be mediated by facility differences and clinical co-morbidities, suggesting that access to higher quality health services at several points in both the early and late management of liver disease may improve disparate population outcomes.
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Pant C, Desai M, Deshpande A, Taylor R, Olyaee M, Gilroy R. Esophageal variceal bleeding in hospitalized patients with cirrhosis. J Hosp Med 2015; 10:453-6. [PMID: 25976490 DOI: 10.1002/jhm.2360] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 03/04/2015] [Accepted: 03/09/2015] [Indexed: 01/01/2023]
Abstract
Esophageal variceal bleeding (EVB) is a frequent complication in cirrhotic patients resulting in considerable mortality and morbidity. The aim of this study was to investigate the occurrence, impact, and trends of EVB in hospitalized cirrhotic patients on a nationwide level in the United States. We interrogated data from the Nationwide Inpatient Sample from 2002 to 2012. Utilizing International Classification of Diseases, Ninth Revision, Clinical Modification codes, we analyzed hospital discharges for cirrhosis and related EVB in adult patients. EVB in cirrhotic patients was independently associated with overall worse outcomes with respect to in-hospital mortality (10% vs 5%; P < 0.01) and hospital charges (median $41,000 vs $26,000; P < 0.01). In the period from 2002 to 2012, the number of cirrhosis-related hospitalizations increased from 337,956 to 570,220 (P < 0.01). Concurrently, the incidence of EVB in hospitalized cirrhotic patients declined from 8.60% to 5.78%, with an overall decreased trend (P < 0.01). The decline in the rate of EVB in hospitalized cirrhotic patients from 2002 to 2012 likely reflects the effectiveness of primary and secondary prophylaxis.
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Affiliation(s)
- Chaitanya Pant
- Division of Gastroenterology, Hepatology and Motility, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Madhav Desai
- Division of Gastroenterology, Hepatology and Motility, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Abhishek Deshpande
- Medicine Institute Center for Value Based Care Research, Cleveland Clinic, Cleveland, Ohio
- Department of Infectious Diseases, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ryan Taylor
- Division of Gastroenterology, Hepatology and Motility, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Mojtaba Olyaee
- Division of Gastroenterology, Hepatology and Motility, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Richard Gilroy
- Division of Gastroenterology, Hepatology and Motility, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
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Independent effect of black recipient race on short-term outcomes after liver transplantation. Surgery 2015; 157:774-84. [DOI: 10.1016/j.surg.2014.10.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/17/2014] [Accepted: 10/31/2014] [Indexed: 12/26/2022]
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Kanwal F, Volk M, Singal A, Angeli P, Talwalkar J. Improving quality of health care for patients with cirrhosis. Gastroenterology 2014; 147:1204-7. [PMID: 25449026 DOI: 10.1053/j.gastro.2014.10.029] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Michael Volk
- University of Michigan Health System, Ann Arbor, Michigan
| | - Amit Singal
- University of Texas Southwestern Medical Center, Dallas, Texas
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Abstract
BACKGROUND We sought to compare liver transplant waiting list access by demographics and geography relative to the pool of potential liver transplant candidates across the United States using a novel metric of access to care, termed a liver wait-listing ratio (LWR). METHODS We calculated LWRs from national liver transplant registration data and liver mortality data from the Scientific Registry of Transplant Recipients and the National Center for Healthcare Statistics from 1999 to 2006 to identify variation by diagnosis, demographics, geography, and era. RESULTS Among patients with ALF and CLF, African Americans had significantly lower access to the waiting list compared with whites (acute: 0.201 versus 0.280; pre-MELD 0.201 versus 0.290; MELD era: 0.201 versus 0.274; all, P<0.0001) (chronic: 0.084 versus 0.163; pre-MELD 0.085 versus 0.179; MELD 0.084 versus 0.154; all, P<0.0001). Hispanics and whites had similar LWR in both eras (both P>0.05). In the MELD era, female subjects had greater access to the waiting list compared with male subjects (acute: 0.428 versus 0.154; chronic: 0.158 versus 0.140; all, P<0.0001). LWRs varied by three-fold by state (pre-MELD acute: 0.122-0.418, chronic: 0.092-0.247; MELD acute: 0.121-0.428, chronic: 0.092-0.243). CONCLUSIONS The marked inequity in early access to liver transplantation underscores the need for local and national policy initiatives to affect this disparity.
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Motzkus-Feagans C, Pakyz AL, Ratliff SM, Bajaj JS, Lapane KL. Statin use and infections in Veterans with cirrhosis. Aliment Pharmacol Ther 2013; 38:611-8. [PMID: 23889738 DOI: 10.1111/apt.12430] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 12/04/2012] [Accepted: 07/05/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Evidence about the beneficial effects of statins on reducing infections is accumulating. Identifying ways to reduce infection risk in patients with cirrhosis is important because of increased mortality risk and costs associated with infections. AIM To estimate the extent to which statin use prolongs time to infection among patients with cirrhosis. METHODS We identified Veterans with cirrhosis, but without decompensation (n = 19 379) using US Veterans Health Administration data from 2001 to 2009. New users of statins were identified and propensity matched to non-users and users of other cholesterol-lowering medications (1:1 matching). The cohort was followed up for hospitalisations with infections. Cox regression models with time-varying exposures provided estimates of adjusted hazard ratios (HR) and 95% confidence intervals (CI). RESULTS New statin use was present among 13% of VA patients with cirrhosis without decompensation. Overall, 12.4% of patients developed a serious infection, and 0.1% of patients died. In the propensity-matched sample, statin users experienced hospitalisations with infections at a rate 0.67 less than non-users (95% Confidence Interval: 0.47-0.95). CONCLUSIONS Infections are a major concern among cirrhotic patients and have the potential to seriously impact both life expectancy and quality of life. Statin use may potentially reduce the risk of infections among patients with cirrhosis.
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Affiliation(s)
- C Motzkus-Feagans
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Bajaj JS, Ratliff SM, Heuman DM, Lapane KL. Non-selective beta-blockers are not associated with serious infections in veterans with cirrhosis. Aliment Pharmacol Ther 2013; 38:407-14. [PMID: 23786291 PMCID: PMC3725127 DOI: 10.1111/apt.12382] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 05/20/2013] [Accepted: 06/03/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Studies evaluating outcomes associated with non-selective beta-blockers (NSBB) in cirrhosis have yielded mixed results. A major cause of death in decompensated cirrhosis is infection. AIM To determine the effect of NSBB use on serious infections (requiring hospitalisation) in compensated and decompensated cirrhosis. METHODS Using data from the US Veterans Health Administration from 2001-2009, we identified two cohorts: compensated cirrhotics (n = 12,656) and decompensated cirrhotics (n = 4834). From each cohort, we identified new NSBB users and propensity-matched them 1:1 to non-users (n = 1836 each in compensated users/non-users and n = 1462 each in decompensated users/non-users). They were followed up for serious infections (median time: 3.1 years), death and transplant. We estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) from Cox regression models. RESULTS Death or transplantation occurred in 0.7% compensated and 2.7% of decompensated patients. Among decompensated cirrhotics, death (P = 0.0061) and transplantation (P = 0.0086) occurred earlier in NSBB users compared with non-users. Serious infections were observed in 4.8% of compensated cirrhotics and in 13.7% of decompensated cirrhotics. There was no difference in the rate of serious infection development in new NSBB users compared with non-users in the compensated (adjusted HR: 0.90, CI: 0.59-1.36) or in the decompensated group (adjusted HR: 1.10, CI: 0.96-1.25). CONCLUSION The use of non-selective beta-blockers in U.S. veterans is not associated with an increased rate of serious infections in compensated or decompensated cirrhosis.
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Affiliation(s)
- J S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, VA 23249, USA.
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Czaja AJ. Autoimmune hepatitis in diverse ethnic populations and geographical regions. Expert Rev Gastroenterol Hepatol 2013; 7:365-85. [PMID: 23639095 DOI: 10.1586/egh.13.21] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Autoimmune hepatitis has diverse clinical phenotypes and outcomes in ethnic groups within a country and between countries, and these differences may reflect genetic predispositions, indigenous etiological agents, pharmacogenomic mechanisms and socioeconomic reasons. In the USA, African-American patients have cirrhosis more commonly, treatment failure more frequently and higher mortality than white American patients. Survival is poorest in Asian-American patients. Autoimmune hepatitis in other countries is frequently associated with genetic predispositions that may favor susceptibility to indigenous etiological agents. Cholestatic features influence treatment response; acute-on-chronic liver disease increases mortality and socioeconomic and cultural factors affect prognosis. Ethnic-based deviations from classical phenotypes and the frequency of late-stage disease can complicate the diagnosis and management of autoimmune hepatitis in non-white populations.
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Affiliation(s)
- Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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McNabb-Baltar J, Trinh QD, Barkun AN. Disparities in outcomes following admission for cholangitis. PLoS One 2013; 8:e59487. [PMID: 23555680 PMCID: PMC3612050 DOI: 10.1371/journal.pone.0059487] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 02/14/2013] [Indexed: 11/22/2022] Open
Abstract
Introduction Few have examined determinants of adverse outcomes in patients presenting with ascending cholangitis. The objective of this study was to examine factors associated with in-hospital mortality, prolonged length of stay (LOS) and increased hospital charges (HC) in patients presenting with acute cholangitis. Methods Within the Health Care Utilization Project Nationwide Inpatient Sample (NIS), we focused on patients, 18 years and older, admitted to the emergency department with cholangitis as primary diagnosis (1998–2009). Models were fitted to predict likelihood of in-hospital mortality, prolonged LOS and increased HC. Covariates included race, day of admission, insurance status, socio-economical status and other patient and hospital characteristics. Results Overall, weighted estimates of 248,942 patients were admitted with acute cholangitis between 1998 and 2009, of which 13,534 (5.4%) died during the admission. Multivariable analyses revealed that relative to Caucasian patients, African American, Hispanic and Asian and Pacific Islander patients were more likely to die (OR = 1.61, p<0.001, OR = 1.20, p = 0.01 and OR = 1.26, p = 0.008), to experience a prolonged LOS (OR = 1.77, p<0.001, OR = 1.30, p<0.001, 1.34, p<0.001), and to incur high HC (OR = 1.83, p<0.001, OR = 1.51, p<0.001, OR = 1.56, p<0.001). Moreover, Medicaid and Medicare patients were more likely to die (OR = 1.64, p<0.001, OR = 1.24, p<0.001), to experience a prolonged LOS (1.74, p<0.001, OR = 1.25, p<0.001) and to incur high HC (OR = 1.23, p = 0.002, OR = 1.12, p = 0.002) compared to privately insured patients. In subgroup analysis, there were no differences for Medicare patients age 65 years and over. However, those under 65, most of whom have disability or end stage renal disease, were more likely to experience the negative outcomes. Conclusion Race and insurance status represent independent predictors of in-hospital mortality and adverse outcomes in patients presenting with cholangitis. Whether these disparities are due to biological predisposition or unequal quality of care requires further investigation. Regardless, efforts should be made to reduce these outcome disparities.
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