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Pan CW, Guifarro D, Poudel A, Abboud Y, Kotwal V. Racial Disparities in Alcoholic Hepatitis Hospitalizations in the United States: Trends, Outcomes, and Future Projections. Dig Dis Sci 2024:10.1007/s10620-024-08462-1. [PMID: 38811506 DOI: 10.1007/s10620-024-08462-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/20/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Alcoholic hepatitis (AH) is a serious complication of alcohol consumption with high morbidity and mortality, particularly in the United States where alcohol-related liver diseases rank as one of the leading causes of preventable death. Our study aims to analyze the morbidity and mortality of AH across racial groups and project hospitalization trends up to 2028, thereby informing public health initiatives. METHODS We conducted a cross-sectional study utilizing data from the Nationwide Inpatient Sample (NIS) spanning 2012 to 2021. The study population comprised hospitalizations identified using specific ICD-9-CM and ICD-10-CM codes for AH. We assessed hospitalizations, in-hospital mortality rates, length of stay (LOS), and morbidities related to alcoholic hepatitis adjusting for sociodemographic factors and hospital characteristics. Statistical analyses were performed using Stata and R software, employing logistic and linear regression analyses, and SARIMA models for forecasting. RESULTS Our results indicated a predominantly White cohort (68%), with a notable increase in AH hospitalizations among Hispanics (129.1% from 2012 to 2021). Racial disparities were observed in inpatient mortality, liver transplant accessibility, and the occurrence of in-hospital complications. The study forecasts a continued rise in hospitalizations across all racial groups, with Hispanics experiencing the sharpest increase. CONCLUSION Our study reveals a disproportionate rise in the AH burden among Hispanics with projections indicating a persistent upward trend through 2028. These findings highlight the need for targeted public health strategies and improved healthcare access to mitigate the increasing AH burden and address disparities in care and outcomes.
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Affiliation(s)
- Chun-Wei Pan
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA.
| | - Daniel Guifarro
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Ayusha Poudel
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Yazan Abboud
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Vikram Kotwal
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
- Division of Gastroenterology and Hepatology, Cook County Health and Hospitals System, Chicago, USA
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2
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Brahmania M, Kuo A, Tapper EB, Volk ML, Vittorio JM, Ghabril M, Morgan TR, Kanwal F, Parikh ND, Martin P, Mehta S, Winder GS, Im GY, Goldberg D, Lai JC, Duarte-Rojo A, Paredes AH, Patel AA, Sahota A, McElroy LM, Thomas C, Wall AE, Malinis M, Aslam S, Simonetto DA, Ufere NN, Ramakrishnan S, Flynn MM, Ibrahim Y, Asrani SK, Serper M. Quality measures in pre-liver transplant care by the Practice Metrics Committee of the American Association for the Study of Liver Diseases. Hepatology 2024:01515467-990000000-00816. [PMID: 38536021 DOI: 10.1097/hep.0000000000000870] [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: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 05/19/2024]
Abstract
The liver transplantation (LT) evaluation and waitlisting process is subject to variations in care that can impede quality. The American Association for the Study of Liver Diseases (AASLD) Practice Metrics Committee (PMC) developed quality measures and patient-reported experience measures along the continuum of pre-LT care to reduce care variation and guide patient-centered care. Following a systematic literature review, candidate pre-LT measures were grouped into 4 phases of care: referral, evaluation and waitlisting, waitlist management, and organ acceptance. A modified Delphi panel with content expertise in hepatology, transplant surgery, psychiatry, transplant infectious disease, palliative care, and social work selected the final set. Candidate patient-reported experience measures spanned domains of cognitive health, emotional health, social well-being, and understanding the LT process. Of the 71 candidate measures, 41 were selected: 9 for referral; 20 for evaluation and waitlisting; 7 for waitlist management; and 5 for organ acceptance. A total of 14 were related to structure, 17 were process measures, and 10 were outcome measures that focused on elements not typically measured in routine care. Among the patient-reported experience measures, candidates of LT rated items from understanding the LT process domain as the most important. The proposed pre-LT measures provide a framework for quality improvement and care standardization among candidates of LT. Select measures apply to various stakeholders such as referring practitioners in the community and LT centers. Clinically meaningful measures that are distinct from those used for regulatory transplant reporting may facilitate local quality improvement initiatives to improve access and quality of care.
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Affiliation(s)
- Mayur Brahmania
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexander Kuo
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael L Volk
- Department of Medicine, Baylor Scott and White Health, Temple, Texas, USA
| | - Jennifer M Vittorio
- Division of Pediatric Gastroenterology, Department of Medicine, New York University (NYU) Langone Health, New York, New York, USA
| | - Marwan Ghabril
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Timothy R Morgan
- Division of Gastroenterology, Department of Medicine, University of California, Irvine, California, USA
- Medical Service, VA Long Beach Healthcare System, Long Beach, California, USA
| | - Fasiha Kanwal
- Division of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul Martin
- Division of Gastroenterology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Shivang Mehta
- Department of Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Gene Y Im
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David Goldberg
- Division of Gastroenterology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Jennifer C Lai
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Angelo H Paredes
- Division of Gastroenterology, Department of Medicine, University of San Antonio, San Antonio, Texas, USA
| | - Arpan A Patel
- Division of Gastroenterology, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Amandeep Sahota
- Department of Transplant Hepatology, Southern California Permanente Medical Group, Los Angeles, California, USA
| | - Lisa M McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Charlie Thomas
- Banner University Medical Center Phoenix Transplant Program, Phoenix, Arizona, USA
| | - Anji E Wall
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Maricar Malinis
- Section of Infectious Diseases, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nneka N Ufere
- Department of Medicine, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Mary Margaret Flynn
- Division of Gastroenterology, Department of Medicine, University of Massachusetts, Boston, Massachusetts, USA
| | | | - Sumeet K Asrani
- Department of Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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3
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Park JE, Nguyen VH, Tsai PC, Toyoda H, Leong J, Guy JE, Yeh ML, Huang CF, Yasuda S, Abe H, Hsu YC, Tseng CH, Liu J, Chen YL, Lin PY, Jun DW, Yoshimaru Y, Ogawa E, Ishigami M, Enomoto M, Tamori A, Uojima H, Wang XZ, Xu Q, Takahashi H, Eguchi Y, Inoue K, Huang DQ, Zhao WJ, Chuang WL, Dai CY, Huang JF, Barnett S, Maeda M, Cheung R, Landis C, Tanaka Y, Roberts LR, Schwartz ME, Kumada T, Yu ML, Nguyen MH. Racial and ethnic disparities in untreated patients with hepatitis C virus-related hepatocellular carcinoma but not in those with sustained virologic response. Aliment Pharmacol Ther 2024; 59:742-751. [PMID: 38173278 DOI: 10.1111/apt.17863] [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: 09/18/2023] [Revised: 11/14/2023] [Accepted: 12/20/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Racial and ethnic disparities exist for hepatitis C virus (HCV) treatment and hepatocellular carcinoma (HCC) survival. AIM To evaluate the impact of HCV treatment on such disparities. METHODS In a retrospective cohort study, we analysed 6069 patients with HCV-related HCC (54.2% Asian, 30.1% White, 8.5% Black, and 7.3% Hispanic) from centres in the United States and Asia. RESULTS The mean age was 61, 60, 59 and 68, respectively, for White, Black, Hispanic and Asian patients. Black patients were most likely to have Barcelona Clinic Liver Cancer stage D, vascular invasion and distant metastasis (23% vs. 5%-15%, 20% vs. 10%-17% and 10% vs. 5%-7%, respectively; all p < 0.0001). Treatment rate with direct-acting antiviral agents (DAA) was 35.9% for Asian, 34.9% for White, 30.3% for Hispanic (30.3%), and 18.7% for Black patients (p < 0.0001). Among those untreated or without sustained virologic response (SVR), 10-year survival rates were 35.4, 27.5, 19.3 and 14.0, respectively, for Asian, Hispanic, White and Black patients (p < 0.0001). There were no statistically significant differences among those with SVR (p = 0.44). On multivariable analysis adjusted for relevant confounders, there was no statistically significant association between survival and being Hispanic (aHR: 0.68, p = 0.26) or Black (aHR: 1.18, p = 0.60) versus White. There was a significant association between being Asian American and survival (aHR: 0.24, p = 0.001; non-U.S. Asian: aHR: 0.66, p = 0.05), and for SVR (aHR: 0.30, p < 0.0001). CONCLUSION DAA treatment rates were suboptimal. Racial and ethnic disparities resolved with HCV cure. Early diagnosis and improved access to HCV treatment is needed for all patients with HCV infection.
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Affiliation(s)
- Jung Eun Park
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Vy H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Pei-Chien Tsai
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, College of Medicine and Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center of Excellence for Metabolic Associated Fatty Liver Disease, School of Medicine and Doctoral Program of Clinical and Experimental Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Hidenori Toyoda
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Jennifer Leong
- Henry D. Janowitz Division of Gastroenterology, Mount Sinai Health System, New York, New York, USA
| | - Jennifer E Guy
- Division of Gastroenterology and Hepatology, California Pacific Medical Center, San Francisco, California, USA
| | - Ming-Lun Yeh
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, College of Medicine and Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center of Excellence for Metabolic Associated Fatty Liver Disease, School of Medicine and Doctoral Program of Clinical and Experimental Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Chung-Feng Huang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, College of Medicine and Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center of Excellence for Metabolic Associated Fatty Liver Disease, School of Medicine and Doctoral Program of Clinical and Experimental Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Satoshi Yasuda
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Hiroshi Abe
- Division of Gastroenterology and Hepatology, Shinmatsudo Central General Hospital, Matsudo, Japan
| | - Yao-Chun Hsu
- Division of Gastroenterology and Hepatology, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Cheng-Hao Tseng
- Division of Gastroenterology and Hepatology, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Joanne Liu
- University of Washington, Seattle, Washington, USA
| | - Yao-Li Chen
- Department of Surgery, Liver Transplantation Center, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ping-Yi Lin
- Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Dae Won Jun
- Department of Internal Medicine, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, South Korea
| | - Yoko Yoshimaru
- Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Eiichi Ogawa
- Department of General Internal Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Masatoshi Ishigami
- Department of Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masaru Enomoto
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
- Department of Transfusion Medicine, Osaka Metropolitan University Hospital, Osaka, Japan
| | - Akihiro Tamori
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Haruki Uojima
- Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Xiao Zhong Wang
- Division of Gastroenterology and Hepatology, Xinjiang Medical University, Xinjiang, China
| | - Qiang Xu
- Division of Gastroenterology and Hepatology, Xinjiang Medical University, Xinjiang, China
| | - Hirokazu Takahashi
- Liver Center, Saga University Hospital, Saga, Japan
- Division of Metabolism and Endocrinology, Saga University Faculty of Medicine, Saga, Japan
| | - Yuichiro Eguchi
- Liver Center, Saga University Hospital, Saga, Japan
- Locomedical General Institute, Locomedical Eguchi Hospital, Saga, Japan
| | - Kaori Inoue
- Liver Center, Saga University Hospital, Saga, Japan
- Division of Metabolism and Endocrinology, Saga University Faculty of Medicine, Saga, Japan
| | - Daniel Q Huang
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wen Jing Zhao
- Department of Hepatology, Hepatobiliary Disease Hospital of Jilin Province, Jilin, China
| | - Wan-Long Chuang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, College of Medicine and Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Yen Dai
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, College of Medicine and Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center of Excellence for Metabolic Associated Fatty Liver Disease, School of Medicine and Doctoral Program of Clinical and Experimental Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Jee-Fu Huang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, College of Medicine and Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center of Excellence for Metabolic Associated Fatty Liver Disease, School of Medicine and Doctoral Program of Clinical and Experimental Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Scott Barnett
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Mayumi Maeda
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
- Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | | | - Yasuhito Tanaka
- Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
- Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Lewis R Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Myron E Schwartz
- Henry D. Janowitz Division of Gastroenterology, Mount Sinai Health System, New York, New York, USA
| | - Takashi Kumada
- Department of Nursing, Gifu Kyoritsu University, Ogaki, Japan
| | - Ming-Lung Yu
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, College of Medicine and Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center of Excellence for Metabolic Associated Fatty Liver Disease, School of Medicine and Doctoral Program of Clinical and Experimental Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
- Department of Epidemiology and Population Health, Stanford University Medical Center, Palo Alto, California, USA
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4
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Cotter TG, Mitchell MC, Patel MJ, Anouti A, Lieber SR, Rich NE, Arab JP, Díaz LA, Louissaint J, Kerr T, Mufti AR, Hanish SI, Vagefi PA, Patel MS, VanWagner LB, Lee WM, O'Leary JG, Singal AG. Racial and Ethnic Disparities in Liver Transplantation for Alcohol-associated Liver Diseases in the United States. Transplantation 2024; 108:225-234. [PMID: 37340542 DOI: 10.1097/tp.0000000000004701] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
BACKGROUND Emerging data suggest disparities exist in liver transplantation (LT) for alcohol-associated liver disease (ALD). As the incidence of ALD increases, we aimed to characterize recent trends in ALD LT frequency and outcomes, including racial and ethnic disparities. METHODS Using United Network for Organ Sharing/Organ Procurement and Transplantation Network data (2015 through 2021), we evaluated LT frequency, waitlist mortality, and graft survival among US adults with ALD (alcohol-associated hepatitis [AH] and alcohol-associated cirrhosis [AAC]) stratified by race and ethnicity. We used adjusted competing-risk regression analysis to evaluate waitlist outcomes, Kaplan-Meier analysis to illustrate graft survival, and Cox proportional hazards modeling to identify factors associated with graft survival. RESULTS There were 1211 AH and 26 526 AAC new LT waitlist additions, with 970 AH and 15 522 AAC LTs performed. Compared with non-Hispanic White patients (NHWs) with AAC, higher hazards of waitlist death were observed for Hispanic (subdistribution hazard ratio [SHR] = 1.23, 95% confidence interval [CI]: 1.16-1.32), Asian (SHR = 1.22, 95% CI:1. 01-1.47), and American Indian/Alaskan Native (SHR = 1.42, 95% CI: 1.15-1.76) candidates. Similarly, significantly higher graft failures were observed in non-Hispanic Black (HR = 1.32, 95% CI: 1.09-1.61) and American Indian/Alaskan Native (HR = 1.65, 95% CI: 1.15-2.38) patients with AAC than NHWs. We did not observe differences in waitlist or post-LT outcomes by race or ethnicity in AH, although analyses were limited by small subgroups. CONCLUSIONS Significant racial and ethnic disparities exist for ALD LT frequency and outcomes in the United States. Compared with NHWs, racial and ethnic minorities with AAC experience increased risk of waitlist mortality and graft failure. Efforts are needed to identify determinants for LT disparities in ALD that can inform intervention strategies.
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Affiliation(s)
- Thomas G Cotter
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Mack C Mitchell
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Mausam J Patel
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Ahmad Anouti
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Sarah R Lieber
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Nicole E Rich
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Juan Pablo Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, ON, Canada
| | - Luis Antonio Díaz
- Departmento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jeremy Louissaint
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Thomas Kerr
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Arjmand R Mufti
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Steven I Hanish
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Parsia A Vagefi
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Madhukar S Patel
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - William M Lee
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Jacqueline G O'Leary
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
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5
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Lim WH, Yong JN, Ong CEY, Ng CH, Tan DJH, Zeng RW, Chung CH, Kaewdech A, Chee D, Tseng M, Wijarnpreecha K, Syn N, Bonney GK, Kow A, Huang DQ, Noureddin M, Muthiah M, Tan E, Siddiqui MS. Ethnic disparities in waitlist outcomes of patients with nonalcoholic steatohepatitis listed for liver transplantation in the US. Liver Transpl 2023; 29:1181-1191. [PMID: 37039547 DOI: 10.1097/lvt.0000000000000148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/06/2023] [Indexed: 04/12/2023]
Abstract
NASH is the fastest-growing cause of liver cirrhosis and is the leading indication for liver transplantation (LT). However, significant racial and ethnic disparities in waitlist outcomes and LT allocation may unfairly disadvantage minorities. Our aim was to characterize racial and ethnic disparities in waitlist mortality and transplantation probability among patients with NASH. This is a retrospective analysis of the United Network for Organ Sharing registry data of LT candidates from January 1, 2000 to December 31, 2021. Outcomes analysis was performed using competing risk analysis with the Fine and Gray model. The multivariable adjustment was conducted, and mixed-effect regression was used to compare the model for end-stage liver disease scores at listing and removal. Of 18,562 patients with NASH cirrhosis, there were 14,834 non-Hispanic Whites, 349 African Americans, 2798 Hispanics, 312 Asians, and 269 of other races/ethnicities; African American (effect size: 2.307, 95% CI: 1.561-3.053, and p < 0.001) and Hispanic (effect size: 0.332, 95% CI: 0.028-0.637, p = 0.032) patients were found to have a significantly higher model for end-stage liver disease scores at the time of listing than non-Hispanic Whites. African Americans had a higher probability of receiving LT relative to non-Hispanic Whites (subdistribution HR: 1.211, 95% CI: 1.051-1.396, and p = 0.008). However, Hispanic race/ethnicity was associated with a lower transplantation probability (subdistribution HR: 0.793, 95% CI: 0.747-0.842, and p < 0.001) and increased waitlist mortality (subdistribution HR: 1.173, CI: 1.052-1.308, and p = 0.004) compared with non-Hispanic Whites. There are significant racial and ethnic disparities in waitlist outcomes of patients with NASH in the US. Hispanic patients are less likely to receive LT and more likely to die while on the waitlist compared with non-Hispanic Whites despite being listed with a lower model for end-stage liver disease scores.
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Affiliation(s)
- Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Christen En Ya Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Cheng Han Ng
- Department of Medicine, Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Charlotte Hui Chung
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Apichat Kaewdech
- Department of Medicine, Division of Internal Medicine, Gastroenterology and Hepatology Unit, Prince of Songkla University, Hat Yai, Thailand
| | - Douglas Chee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Medicine, Division of Gastroenterology and Hepatology, National University Hospital, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Michael Tseng
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Karn Wijarnpreecha
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Arizona College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Glenn K Bonney
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, National University Hospital Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Alfred Kow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, National University Hospital Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Medicine, Division of Gastroenterology and Hepatology, National University Hospital, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | | | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Medicine, Division of Gastroenterology and Hepatology, National University Hospital, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Eunice Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Medicine, Division of Gastroenterology and Hepatology, National University Hospital, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Mohammad Shadab Siddiqui
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
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6
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Ross-Driscoll K, Gunasti J, Ayuk-Arrey AT, Adler JT, Axelrod D, McElroy L, Patzer RE, Lynch R. Identifying and understanding variation in population-based access to liver transplantation in the United States. Am J Transplant 2023; 23:1401-1410. [PMID: 37302576 PMCID: PMC10529375 DOI: 10.1016/j.ajt.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/04/2023] [Accepted: 06/02/2023] [Indexed: 06/13/2023]
Abstract
We aimed to identify variations in liver transplant access across transplant referral regions (TRRs), accounting for differences in population characteristics and practice environments. Adult end-stage liver disease (ESLD) deaths and liver waitlist additions from 2015 to 2019 were included. The primary outcome was listing-to-death ratio (LDR). We modeled the LDR as a continuous variable and obtained adjusted LDR estimates for each TRR, accounting for clinical and demographic characteristics of ESLD decedents, socioeconomic and health care environment within the TRR, and characteristics of the transplant environment. The overall mean LDR was 0.24 (range: 0.10-0.53). In the final model, proportion of patients living in poverty and concentrated poverty was negatively associated with LDR; organ donation rate was positively associated with LDR. The R2 was 0.60, indicating that 60% of the variability in LDR was explained by the model. Approximately 40% of this variation remained unexplained and may be due to transplant center behaviors amenable to intervention to improve access to care for patients with ESLD.
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Affiliation(s)
- Katie Ross-Driscoll
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Jonathan Gunasti
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arrey-Takor Ayuk-Arrey
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joel T Adler
- Division of Abdominal Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
| | - David Axelrod
- Solid Organ Transplant Center, Department of Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Lisa McElroy
- Division of Abdominal Transplantation, Department of Surgery and Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Raymond Lynch
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
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Khalil A, Quaglia A, Gélat P, Saffari N, Rashidi H, Davidson B. New Developments and Challenges in Liver Transplantation. J Clin Med 2023; 12:5586. [PMID: 37685652 PMCID: PMC10488676 DOI: 10.3390/jcm12175586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/15/2023] [Accepted: 08/26/2023] [Indexed: 09/10/2023] Open
Abstract
Liver disease is increasing in incidence and is the third most common cause of premature death in the United Kingdom and fourth in the United States. Liver disease accounts for 2 million deaths globally each year. Three-quarters of patients with liver disease are diagnosed at a late stage, with liver transplantation as the only definitive treatment. Thomas E. Starzl performed the first human liver transplant 60 years ago. It has since become an established treatment for end-stage liver disease, both acute and chronic, including metabolic diseases and primary and, at present piloting, secondary liver cancer. Advances in surgical and anaesthetic techniques, refined indications and contra-indications to transplantation, improved donor selection, immunosuppression and prognostic scoring have allowed the outcomes of liver transplantation to improve year on year. However, there are many limitations to liver transplantation. This review describes the milestones that have occurred in the development of liver transplantation, the current limitations and the ongoing research aimed at overcoming these challenges.
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Affiliation(s)
- Amjad Khalil
- Liver Unit, Wellington Hospital, London NW8 9TA, UK
- Centre for Surgical Innovation, Organ Regeneration and Transplantation, University College London, London NW3 2PS, UK
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London NW3 2QG, UK
| | - Alberto Quaglia
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Pierre Gélat
- Division of Surgery and Interventional Science, University College London, London NW3 2PS, UK
| | - Nader Saffari
- Department of Mechanical Engineering, University College London, London WC1E 7JE, UK
| | - Hassan Rashidi
- Institute of Child Health, University College London, London WC1N 1EH, UK;
| | - Brian Davidson
- Liver Unit, Wellington Hospital, London NW8 9TA, UK
- Centre for Surgical Innovation, Organ Regeneration and Transplantation, University College London, London NW3 2PS, UK
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London NW3 2QG, UK
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8
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Yilma M, Cogan R, Shui AM, Neuhaus JM, Light C, Braun H, Mehta N, Hirose R. Community-level social vulnerability and individual socioeconomic status on liver transplant referral outcome. Hepatol Commun 2023; 7:e00196. [PMID: 37378636 DOI: 10.1097/hc9.0000000000000196] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/06/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Recent endeavors emphasize the importance of understanding early barriers to liver transplantation (LT) by consistently collecting data on patient demographics, socioeconomic factors, and geographic social deprivation indices. METHODS In this retrospective single-center cohort study of 1657 adults referred for LT evaluation, we assessed the association between community-level vulnerability and individual socioeconomic status measures on the rate of waitlisting and transplantation. Patients' addresses were linked to Social Vulnerability Index (SVI) at the census tract-level to characterize community-level vulnerability. Descriptive statistics were used to describe patient characteristics. Multivariable cause-specific HRs were used to assess the association between community-level vulnerability, individual measures of the socioeconomic status, and LT evaluation outcomes (waitlist and transplantation). RESULTS Among the 1657 patients referred for LT during the study period, 54% were waitlisted and 26% underwent LT. A 0.1 increase in overall SVI correlated with an 8% lower rate of waitlisting (HR 0.92, 95% CI 0.87-0.96, p < 0.001), with socioeconomic status, household characteristics, housing type and transportation, and racial and ethnic minority status domains contributing significantly to this association. Patients residing in more vulnerable communities experienced a 6% lower rate of transplantation (HR 0.94, 95% CI 0.91- 0.98, p = 0.007), with socioeconomic status and household characteristic domain of SVI significantly contributing to this association. At the individual level, both government insurance and employment status were associated with lower rates of waitlisting and transplantation. There was no association with mortality prior to waitlisting or mortality while on the waitlist. CONCLUSION Our findings indicate that both individual and community measures of the socioeconomic status (overall SVI) are associated with LT evaluation outcomes. Furthermore, we identified individual measures of neighborhood deprivation associated with both waitlisting and transplantation.
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Affiliation(s)
- Mignote Yilma
- General Surgery, University of California, San Francisco, California, USA
- National Clinician Scholars Program at the University of California, San Francisco, California, USA
| | - Raymond Cogan
- University of California, San Francisco Transplant Program, California, USA
| | - Amy M Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - John M Neuhaus
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Carolyn Light
- University of California, San Francisco Transplant Program, California, USA
| | - Hillary Braun
- General Surgery, University of California, San Francisco, California, USA
| | - Neil Mehta
- Division of Gastroenterology, University of California, San Francisco, California, USA
| | - Ryutaro Hirose
- Division of Transplant Surgery, University of California, San Francisco, California, USA
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Cooper KM, Colletta A, Hathaway NJ, Liu D, Gonzalez D, Talat A, Barry C, Krishnarao A, Mehta S, Movahedi B, Martins PN, Devuni D. Delayed referral for liver transplant evaluation worsens outcomes in chronic liver disease patients requiring inpatient transplant evaluation. World J Transplant 2023; 13:169-182. [PMID: 37388395 PMCID: PMC10303412 DOI: 10.5500/wjt.v13.i4.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/21/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Indications to refer patients with cirrhosis for liver transplant evaluation (LTE) include hepatic decompensation or a model for end stage liver disease (MELD-Na) score ≥ 15. Few studies have evaluated how delaying referral beyond these criteria affects patient outcomes.
AIM To evaluate clinical characteristics of patients undergoing inpatient LTE and to assess the effects of delayed LTE on patient outcomes (death, transplantation).
METHODS This is a single center retrospective cohort study assessing all patients undergoing inpatient LTE (n = 159) at a large quaternary care and liver transplant center between 10/23/2017-7/31/2021. Delayed referral was defined as having prior indication (decompensation, MELD-Na ≥ 15) for LTE without referral. Early referral was defined as referrals made within 3 mo of having an indication based on practice guidelines. Logistic regression and Cox Hazard Regression were used to evaluate the relationship between delayed referral and patient outcomes.
RESULTS Many patients who require expedited inpatient LTE had delayed referrals. Misconceptions regarding transplant candidacy were a leading cause of delayed referral. Ultimately, delayed referrals negatively affected overall patient outcome and an independent predictor of both death and not receiving a transplant. Delayed referral was associated with a 2.5 hazard risk of death.
CONCLUSION Beyond initial access to an liver transplant (LT) center, delaying LTE increases risk of death and reduces risk of LT in patients with chronic liver disease. There is substantial opportunity to increase the percentage of patients undergoing LTE when first clinically indicated. It is crucial for providers to remain informed about the latest guidelines on liver transplant candidacy and the transplant referral process.
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Affiliation(s)
- Katherine M Cooper
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01605, United States
| | - Alessandro Colletta
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01605, United States
| | - Nicholas J Hathaway
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01605, United States
| | - Diana Liu
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01605, United States
| | - Daniella Gonzalez
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01605, United States
| | - Arslan Talat
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01605, United States
| | - Curtis Barry
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01605, United States
| | - Anita Krishnarao
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01605, United States
| | - Savant Mehta
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01605, United States
| | - Babak Movahedi
- Department of Surgery, Transplant Division, UMass Chan Medical School, Worcester, MA 01605, United States
| | - Paulo N Martins
- Department of Surgery, Transplant Division, UMass Chan Medical School, Worcester, MA 01605, United States
| | - Deepika Devuni
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01605, United States
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Yilma M, Kim NJ, Shui AM, Tana M, Landis C, Chen A, Bangaru S, Mehta N, Zhou K. Factors Associated With Liver Transplant Referral Among Patients With Cirrhosis at Multiple Safety-Net Hospitals. JAMA Netw Open 2023; 6:e2317549. [PMID: 37289453 PMCID: PMC10251211 DOI: 10.1001/jamanetworkopen.2023.17549] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 04/25/2023] [Indexed: 06/09/2023] Open
Abstract
Importance A high proportion of underserved patients with cirrhosis receive care at safety-net hospitals (SNHs). While liver transplant (LT) can be a life-saving treatment for cirrhosis, data on referral patterns from SNHs to LT centers are lacking. Objective To identify factors associated with LT referral within the SNH context. Design, Setting, and Participants This retrospective cohort study included 521 adult patients with cirrhosis and model for end-stage liver disease-sodium (MELD-Na) scores of 15 or greater. Participants received outpatient hepatology care at 3 SNHs between January 1, 2016, and December 31, 2017, with end of follow-up on May 1, 2022. Exposures Patient demographic characteristics, socioeconomic status, and liver disease factors. Main Outcomes and Measures Primary outcome was referral for LT. Descriptive statistics were used to describe patient characteristics. Multivariable logistic regression was performed to evaluate factors associated with LT referral. Multiple chained imputation was used to address missing values. Results Of 521 patients, 365 (70.1%) were men, the median age was 60 (IQR, 52-66) years, most (311 [59.7%]) were Hispanic or Latinx, 338 (64.9%) had Medicaid insurance, and 427 (82.0%) had a history of alcohol use (127 [24.4%] current vs 300 [57.6%] prior). The most common liver disease etiology was alcohol associated liver disease (280 [53.7%]), followed by hepatitis C virus infection (141 [27.1%]). Median MELD-Na score was 19 (IQR, 16-22). One hundred forty-five patients (27.8%) were referred for LT. Of these, 51 (35.2%) were wait-listed, and 28 (19.3%) underwent LT. In a multivariable model, male sex (adjusted odds ratio [AOR], 0.50 [95% CI, 0.31-0.81]), Black race vs Hispanic or Latinx ethnicity (AOR, 0.19 [95% CI, 0.04-0.89]), uninsured status (AOR, 0.40 [95% CI, 0.18-0.89]), and hospital site (AOR, 0.40 [95% CI, 0.18-0.87]) were associated with lower odds of being referred. Reasons for not being referred (n = 376) included active alcohol use and/or limited sobriety (123 [32.7%]), insurance issues (80 [21.3%]), lack of social support (15 [4.0%]), undocumented status (7 [1.9%]), and unstable housing (6 [1.6%]). Conclusions In this cohort study of SNHs, less than one-third of patients with cirrhosis and MELD-Na scores of 15 or greater were referred for LT. The identified sociodemographic factors negatively associated with LT referral highlight potential intervention targets and opportunities to standardize LT referral practices to increase access to life-saving transplant among underserved patients.
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Affiliation(s)
- Mignote Yilma
- Department of General Surgery, University of California, San Francisco
- National Clinician Scholars Program, University of California, San Francisco
| | - Nicole J. Kim
- Division of Gastroenterology, University of Washington, Seattle
| | - Amy M. Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Michele Tana
- Department of Gastroenterology and Hepatology, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Charles Landis
- Division of Gastroenterology, University of Washington, Seattle
| | - Ariana Chen
- Department of Medicine, University of Michigan, Ann Arbor
| | - Saroja Bangaru
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles
| | - Neil Mehta
- Department of Gastroenterology, University of California, San Francisco
| | - Kali Zhou
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles
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11
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Recipient Age Predicts 20-Year Survival in Pediatric Liver Transplant. Can J Gastroenterol Hepatol 2022; 2022:1466602. [PMID: 36164664 PMCID: PMC9509270 DOI: 10.1155/2022/1466602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/12/2022] [Accepted: 08/25/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Pediatric liver transplant recipients have demonstrated excellent long-term survival. The purpose of this analysis is to investigate factors associated with 20-year survival to identify areas for improvement in patient care. METHODS Kaplan-Meier with log-rank test as well as univariate and multivariate logistic regression methods were used to retrospectively analyze 4,312 liver transplant recipients under the age of 18 between September 30, 1987 and March 9, 1998. Our primary endpoint was 20-year survival among one-year survival. RESULTS Logistic regression analysis identified recipient age as a significant risk factor, with recipients below 5 years old having a higher 20-year survival rate (p < 0.001). A preoperative primary diagnosis of a metabolic dysfunction was found to be protective compared to other diagnoses (OR 1.64, CI 1.20-2.25). African-American ethnicity (OR 0.71, CI 0.58-0.87) was also found to be a risk factor for mortality. Technical variant allografts (neither living donor nor cadaveric) were not associated with increased or decreased rates of 20-year survival. CONCLUSIONS Our analysis suggests that long-term survival is inversely correlated with recipient age following pediatric liver transplant. If validated with further studies, this conclusion may have profound implications on the timing of pediatric liver transplantation.
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12
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Chapin SE, Goldberg DS, Kaplan DE, Mahmud N. External Validation of the FIPS Score for Post-TIPS Mortality in a National Veterans Affairs Cohort. Dig Dis Sci 2022; 67:4581-4589. [PMID: 34797445 PMCID: PMC9117561 DOI: 10.1007/s10620-021-07307-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/25/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Freiburg index of post-TIPS survival (FIPS) score was recently demonstrated to improve prediction of post-TIPS mortality relative to existing standards. As this score was derived from a German cohort over an extended time period, it is unclear if performance will translate well to other settings. This study aimed to externally validate the FIPS score in a large Veterans Affairs (VA) cohort over two separate eras of TIPS-related care. METHODS This was a retrospective cohort study of patients with cirrhosis who underwent TIPS placement in the VA from 2008 to 2020. Cox regression models for post-TIPS survival were constructed using FIPS, MELD, MELD-Na, or CTP scores as predictors. Discrimination (Harrell's C) and calibration (joint tests of calibration curve slope and intercept) were evaluated for each score. A stratified analysis was performed for time periods between 2008-2013 and 2014-2020. RESULTS The cohort of 1,274 patients was 97.3% male with mean age 60.9 years and mean MELD-Na 14. The FIPS score demonstrated the highest overall discrimination versus MELD, MELD-Na, and CTP (0.634 vs. 0.585, 0.626, 0.612, respectively). However, in the modern treatment era (2014-2020), the FIPS score performed similarly to MELD-Na. Additionally, the FIPS score demonstrated poor calibration at one-month and six-month post-TIPS timepoints (joint p = 0.04 and 0.004, respectively). MELD, MELD-Na, and CTP were well-calibrated at each timepoint (each joint p > 0.05). CONCLUSION The FIPS score performed similarly to MELD-Na in the modern TIPS treatment era and demonstrated regions of poor calibration. Future models derived with contemporary data may improve prediction of post-TIPS mortality.
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Affiliation(s)
- Sara E Chapin
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA.
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13
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Mansour MM, Fard D, Basida SD, Obeidat AE, Darweesh M, Mahfouz R, Ahmad A. Disparities in Social Determinants of Health Among Patients Receiving Liver Transplant: Analysis of the National Inpatient Sample From 2016 to 2019. Cureus 2022; 14:e26567. [PMID: 35936191 PMCID: PMC9350951 DOI: 10.7759/cureus.26567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 11/05/2022] Open
Abstract
Background Liver transplantation is the life-saving standard of care for those with end-stage liver disease. Unfortunately, many patients on the liver transplant list die waiting. Several studies have demonstrated significant differences based on disparities in race, gender, and multiple socioeconomic factors. We sought to evaluate recent disparities among patients receiving liver transplants using the latest available data from the National Inpatient Sample (NIS), the largest publicly available inpatient care database in the United States. Methods We performed an analysis of discharge data from the NIS between 2016 and 2019. We identified adult patients with chronic liver disease who underwent a liver transplant using the International Classification of Diseases, 10th revision (ICD-10) codes. Multivariate logistic regression was used to adjust for differences in race, gender, socioeconomic status, and comorbidities among those who received a liver transplant. Results A total of 24,595 liver transplants were performed over the study period. Female gender was independently associated with decreased transplant rates (adjusted odds ratio (AOR) 0.83, 95% confidence interval (CI), 0.78-0.89, P < 0.001). Compared to White patients, Black patients had decreased transplant rates (AOR 0.86, 95% CI, 0.75-0.99, P = 0.034), as did Native Americans (AOR 0.64; 95% CI, 0.42-0.97, P = 0.035). Hispanics and Asian Americans had increased rates of liver transplantation (AOR 1.16, 95% CI 1.02-1.32, P = 0.022, and 1.36, 95% CI 1.11-1.67, P = 0.003; respectively). The increase in income quartile was associated with an incremental increase in transplant rates. Additionally, patients with private insurance had much higher transplant rates compared to those with Medicare (AOR 2.50, 95% CI 2.31-2.70, P < 0.001) while patients without insurance had the lowest rates of transplantation (AOR 0.18, 95% CI 0.12-0.28, P < 0.001). Conclusions Our analysis demonstrates that race, gender, and other social determinants of health have significant impacts on the likelihood of receiving a liver transplant. Our study, on a national level, confirms previously described disparities in receiving liver transplantation. Patient-level studies are needed to better understand how these variables translate into differing liver transplantation rates.
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Ferri F, Milana M, Abbatecola A, Pintore A, Lenci I, Parisse S, Vitale A, Di Croce G, Mennini G, Lai Q, Rossi M, Angelico R, Tisone G, Anselmo A, Angelico M, Corradini SG. Electronic Outpatient Referral System for Liver Transplant Improves Appropriateness and Allows First Visit Triage. Clin Gastroenterol Hepatol 2022; 20:e1388-e1415. [PMID: 34648952 DOI: 10.1016/j.cgh.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 09/07/2021] [Accepted: 10/05/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Missed or inappropriate referrals of potential candidates for liver transplantation (LT) are common and traditional referral methods (tRs) do not allow for efficient triage. We investigated the effects of a website developed for electronic outpatient referral to LT (eRW-LT) on these issues. METHODS We prospectively collected data on all consecutive outpatient referrals to 2 Italian LT centers from January 2015 to December 2019. In the second half of the study, starting from July 2017, referring physicians had the option of using eRW-LT, quickly obtaining the judgment on the appropriateness and urgency of the visit from a transplant hepatologist. RESULTS In the second half of the study, there were 99 eRW-LTs and 96 traditional referrals (new tRs), representing a 17.4% increase over the 161 traditional referrals (old tRs) of the first half. With eRW-LT, 11.1% of referrals were judged inappropriate online without booking a visit. Appropriateness, judged at the time of the first visit, was 59.6%, 56.2%, and 94.3% with old tRs, new tRs, and eRW-LT, respectively. Considering the appropriate visits, the median waiting time in days between referral date and first visit appointment was significantly shorter for urgent visits referred with eRW-LT (5.0; 95% CI, 4.8-9.3) compared with nonurgent visits sent with the same system (17.0; 95% CI, 11.5-25.0; P < .0001), those referred with old tRs (14.0; 95% CI, 8.0-23.0; P < .001) and with new tRs (16.0; 95% CI, 10.0-23.0; P < .001). CONCLUSIONS eRW-LT allows an increase in the number of referrals for LT, ensuring effective triage and better appropriateness of visits.
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Affiliation(s)
- Flaminia Ferri
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
| | - Martina Milana
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Aurelio Abbatecola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandro Pintore
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Ilaria Lenci
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Simona Parisse
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | | | | | - Gianluca Mennini
- General Surgery and Organ Transplantation Unit, Department of Specialistic and Transplant Surgery "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Department of Specialistic and Transplant Surgery "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Massimo Rossi
- General Surgery and Organ Transplantation Unit, Department of Specialistic and Transplant Surgery "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Roberta Angelico
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Giuseppe Tisone
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Alessandro Anselmo
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Mario Angelico
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
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Keeling SS, McDonald MF, Anand A, Handing GE, Prather LL, Christmann CR, Jalal PK, Kanwal F, Cholankeril G, Goss JA, Rana A. Significant improvements, but consistent disparities in survival for African Americans after liver transplantation. Clin Transplant 2022; 36:e14646. [PMID: 35304775 PMCID: PMC9310351 DOI: 10.1111/ctr.14646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 02/20/2022] [Accepted: 03/06/2022] [Indexed: 11/28/2022]
Abstract
Despite improvements in survival across races in the past 20 years, African Americans have worse liver transplant outcomes after orthotopic liver transplantation (OLT). This study aims at quantifying the change in disparities between African Americans and other races in survival after OLT. We retrospectively analyzed the United Network for Organ Sharing (UNOS) database for patient data for candidates who received a liver transplant between January 1, 2007 and December 31, 2017. Multivariate Cox proportional hazards regression indicated similar decreases in mortality over time for each race with a decrease in mortality for African Americans: 2010-2012 (HR = .930), 2012-2015 (HR = .882), and 2015-2017 (HR = .883) when compared to 2007-2010. Risk of mortality for African Americans compared to Caucasians varied across the 4 eras: 2007-2010 (HR = 1.083), 2010-2012 (HR = 1.090), 2012-2015 (HR = 1.070), and 2015-2017 (HR = 1.125). While African Americans have seen increases in survival in the past decade, a similar increase in survival for other races leaves a significant survival disparity in African Americans.
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Affiliation(s)
| | - Malcolm F. McDonald
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Adrish Anand
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Greta E. Handing
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Lyndsey L. Prather
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | | | - Prasun K. Jalal
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Fasiha Kanwal
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - George Cholankeril
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - John A. Goss
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Abbas Rana
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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16
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A scoping review of inequities in access to organ transplant in the United States. Int J Equity Health 2022; 21:22. [PMID: 35151327 PMCID: PMC8841123 DOI: 10.1186/s12939-021-01616-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/24/2021] [Indexed: 02/06/2023] Open
Abstract
Background Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research. Methods We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes. Results Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant. Conclusions This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01616-x.
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17
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Hughes DL, Parikh ND. The Road to Liver Transplantation: Avoiding Early Delays. Transplantation 2022; 106:14-15. [PMID: 33587430 DOI: 10.1097/tp.0000000000003616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Dempsey L Hughes
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
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18
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Lee BP, Dodge JL, Terrault NA. Changes and mediators of survival disparity among Black liver transplant recipients in the United States. Am J Transplant 2021; 21:3883-3893. [PMID: 34374495 DOI: 10.1111/ajt.16767] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/02/2021] [Accepted: 07/13/2021] [Indexed: 01/25/2023]
Abstract
A landmark 2002 study identified Black liver transplant (LT) recipients as having lower post-LT survival compared to other races. While persistent disparities exist, changes over time and mediating factors are understudied. Capturing LT recipients between 2002 and 2018 in UNOS, we used logistic regression and Cox proportional-hazard models to calculate differences in post-LT mortality among races. We examined interactions between transplant year and race. A mediation analysis assessed biologic and environmental factors potentially associated with race differences in post-LT survival. The cohort included 46,997 LT recipients (3898 Black;36,560 White;6539 Hispanic). In most years, Black (vs. White) LT recipients had a higher probability of age-adjusted mortality, not observed among Hispanics. In multivariable analysis, Blacks (vs. Whites) had higher (aHR = 1.15, 95% CI 1.07-1.24), whereas Hispanics had lower (aHR = 0.78, 95% CI 0.72-0.83) risk of mortality. Differences in post-LT mortality among Blacks (vs. Whites) narrowed between 2002 and 2009, were similar between 2010 and 2013, and may have worsened between 2014 and 2018. Race differences were larger for mortality beyond 1-year post-LT (vs. within 1-year), and among non-HCV (vs. HCV). Alcohol-associated liver disease (ALD) was the strongest mediator (13.9%, 95% CI 8.7-32.7%) of the Black-White disparity in 2010-2018. Our analyses suggest disparities may worsen with longer follow-up, as HCV recedes with elimination efforts, and with further increases in ALD.
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Affiliation(s)
- Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, CA
| | - Jennifer L Dodge
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, CA.,Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA
| | - Norah A Terrault
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, CA
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19
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Malespin M, May EJ, Nephew LD, Paul S, McCary A, Kilaru S, Mukhtar NA, Hassan MA, Brady CW. AASLD Deepens Commitment to Diversity, Equity, and Inclusion. Hepatology 2021; 74:2216-2225. [PMID: 34028073 DOI: 10.1002/hep.31918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/07/2021] [Accepted: 04/23/2021] [Indexed: 01/24/2023]
Affiliation(s)
| | | | - Lauren D Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Sonali Paul
- Section of Gastroenterology Center for Liver Diseases, University of Chicago Medicine, Chicago, IL
| | - Alexis McCary
- Department of Gastroenterology, Mid-Atlantic Permanente Medical Group, Upper Marlboro, MD
| | - Saikiran Kilaru
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Nizar A Mukhtar
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Mohamed A Hassan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN
| | - Carla W Brady
- Department of Medicine, Division of Gastroenterology, Duke University, Durham, NC
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20
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Yuan Q, Haque O, Yeh H, Markmann JF, Dageforde LA. The impact of race and comorbid conditions on adult liver transplant outcomes in obese recipients. Transpl Int 2021; 34:2834-2845. [PMID: 34580936 DOI: 10.1111/tri.14125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/09/2021] [Accepted: 09/10/2021] [Indexed: 11/28/2022]
Abstract
Many prior studies comparing liver transplant outcomes between obese and nonobese recipients found no significant differences in survival. However, obesity is intrinsically associated with demographic factors such as race and comorbidities. Thus, this work aimed to analyze the effects of obesity, in conjunction with these factors, on liver transplant outcomes. OPTN data was analyzed to identify adult-only, first-time liver transplants between 1995 and 2019. Obesity was defined by the CDC obesity classification. Race, insurance status, age, and comorbidities were analyzed together with patient survival and graft survival using a multivariable Cox Proportional-Hazards model and long-term survival with Kaplan-Meier curves. The multivariable models found that being black, older than 50 years, having diabetes, or having nonprivate insurance were all risk factors for both patient survival and graft survival after liver transplant. Adjusting for obesity class, black recipients had a 20% lower patient survival and 23% lower graft survival compared with nonblack recipients. Survival curves verified that obese black liver transplant recipients had poorer long-term patient survival and graft survival compared with both obese nonblack and nonobese recipients. In conclusion, obesity compounds known factors associated with poor outcomes after liver transplantation. Further work is critical to understand why these discrepancies persist.
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Affiliation(s)
- Qing Yuan
- Department of Urology, Chinese PLA General Hospital, Beijing, China.,Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Omar Haque
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Surgery, Beth Issrael Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Shriners Hospitals for Children, Boston, MA, USA
| | - Heidi Yeh
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - James F Markmann
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Leigh Anne Dageforde
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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21
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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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22
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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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23
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Choi DT, Davila JA, Sansgiry S, David E, Singh H, El-Serag HB, Sada YHF. Factors Associated With Delay of Diagnosis of Hepatocellular Carcinoma in Patients With Cirrhosis. Clin Gastroenterol Hepatol 2021; 19:1679-1687. [PMID: 32693047 PMCID: PMC7855025 DOI: 10.1016/j.cgh.2020.07.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 07/02/2020] [Accepted: 07/15/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS We examined the frequency of and factors associated with delays in diagnosis of hepatocellular carcinoma (HCC) in a cohort of patients with cirrhosis in the Veterans Health Administration. METHODS In a retrospective study, we collected and analyzed data from the Veterans Health Administration's electronic health records. We used a multivariate logistic regression model to identify factors associated with a delay in diagnosis of HCC of more than 60 days following a red flag (defined as the earliest date at which a diagnosis of HCC could have been made, based on American Association for the Study of Liver Disease 2005 guidelines). We used multivariate Cox proportional hazards model to evaluate the effects of delayed diagnosis on survival, adjusting for patient and provider characteristics. RESULTS Among 655 patients with cirrhosis and a diagnosis of HCC from 2006 through 2011, 46.9% had a delay in diagnosis of more than 60 days following a red flag for HCC. Delays in diagnosis for more than 60 days were significantly associated with lack of provider adherence to the guidelines (adjusted odds ratio [OR], 4.82; 95% CI, 3.12-7.45), a diagnostic imaging evaluation instead of only measurement of alfa fetoprotein (adjusted OR, 2.63; 95% CI, 1.09-6.24), and diagnosis as an incidental finding during examination for an unrelated medical problem (compared with an HCC-related assessment) (adjusted OR, 2.26; 95% CI, 1.09-4.67). Diagnostic delays of 60 days or more were associated with lower mortality compared to patients without a delay in diagnosis (unadjusted hazard ratio, 0.57; 95% CI, 0.47-0.68 and adjusted hazard ratio, 0.63; 95% CI, 0.50-0.78). CONCLUSIONS Nearly half of veterans with cirrhosis have delays in diagnosis of HCC of 60 days or more after a red flag, defined by guidelines. Interventions are needed to improve timely follow-up of red flags for HCC and adherence to guidelines, to increase early detection of HCC.
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Affiliation(s)
- Debra T. Choi
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Jessica A. Davila
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Shubhada Sansgiry
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX,Veterans Affairs South Central Mental Illness Research Education and Clinical Center (MIRECC), Houston, TX,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Eric David
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Hashem B. El-Serag
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX,Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Yvonne Hsiao-Fan Sada
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX,Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX,Section of Hematology and Oncology, Department of Medicine, Baylor College of Medicine, Houston, TX
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24
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Ivanics T, Shwaartz C, Claasen MPAW, Patel MS, Yoon P, Raschzok N, Wallace D, Muaddi H, Murillo Perez CF, Hansen BE, Selzner N, Sapisochin G. Trends in indications and outcomes of liver transplantation in Canada: A multicenter retrospective study. Transpl Int 2021; 34:1444-1454. [PMID: 33977568 DOI: 10.1111/tri.13903] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/12/2021] [Accepted: 05/05/2021] [Indexed: 12/30/2022]
Abstract
The liver transplantation (LT) landscape is continuously evolving. We sought to evaluate trends in indications for LT in Canada and the impact of primary liver disease on post-LT outcomes using a national transplant registry. Adult patients who underwent a primary LT between 2000 and 2018 were retrospectively identified in the Canadian Organ Replacement Registry. Outcomes included post-LT patient and graft survival. A total of 5,722 LTs were identified. The number of LT per year increased from 251 in 2000 to 349 in 2018. The proportion of patients transplanted for HCV decreased from 31.5% in 2000 to 3.4% in 2018. In contrast, the percentage of transplants for HCC increased from 2.3% in 2000 to 32.4% in 2018, and those performed for NASH increased from 0.4% in 2005 to 12.6% in 2018. Year of transplant (per 1 year) was protective for both patient (HR:0.96,95%CI:0.94-0.97; P < 0.001) and graft survival (HR:0.97, 95%CI: 0.96-0.99; P = 0.001). Post-LT outcomes have improved over time in this nationwide analysis spanning 18 years. Moreover, trends in the indications for LT have changed, with HCC becoming the leading etiology. The decrease in the proportion of HCV patients and increase in those with NASH has implications on the evolving management of LT patients.
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Affiliation(s)
- Tommy Ivanics
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Chaya Shwaartz
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Marco P A W Claasen
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Madhukar S Patel
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Peter Yoon
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Nathanael Raschzok
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - David Wallace
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Hala Muaddi
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Carla Fiorella Murillo Perez
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, ON, Canada
| | - Bettina E Hansen
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, ON, Canada
| | - Nazia Selzner
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
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25
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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: 55] [Impact Index Per Article: 18.3] [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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Ross-Driscoll K, Kramer M, Lynch R, Plantinga L, Wedd J, Patzer R. Variation in Racial Disparities in Liver Transplant Outcomes Across Transplant Centers in the United States. Liver Transpl 2021; 27:558-567. [PMID: 37160041 PMCID: PMC8201428 DOI: 10.1002/lt.25918] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
Little is known about the role that transplant centers may play in perpetuating racial disparities after liver transplantation, which are unexplained by patient-level factors. We examined variation in between-center and within-center disparities among 34,114 Black and White liver transplant recipients in the United States from 2010 to 2017 using Scientific Registry of Transplant Recipient (SRTR) data. We used Cox proportional hazards models to calculate transplant center-specific Black-White hazard ratios and hierarchical survival analysis to examine potential effect modification of the race-survival association by transplant center characteristics, including transplant volume, proportion of Black patients, SRTR quality rating, and region. Models were sequentially adjusted for clinical, socioeconomic, and center characteristics. After adjustment, Black patients experienced 1.11 excess deaths after liver transplant per 100 person-years compared with White patients (95% confidence interval [CI], 0.65-1.56), corresponding to a 21% increased mortality risk (95% CI, 1.12-1.31). Although there was substantial variation in this disparity across transplant centers, there was no evidence of effect modification by transplant center volume, proportion of minority patients seen, quality rating, or region. We found significant racial disparities in survival after transplant, with substantial variation in this disparity across transplant centers that was not explained by selected center characteristics. This is the first study to directly evaluate the role transplant centers play in racial disparities in transplant outcomes. Further assessment of the qualitative factors that may drive disparities, such as selection processes and follow-up care, is needed to create effective center-level interventions to address health inequity.
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Affiliation(s)
- Katherine Ross-Driscoll
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Center for Health Services Research, Emory University School of Medicine, Atlanta, GA
| | - Michael Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Raymond Lynch
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Laura Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Joel Wedd
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Rachel Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Center for Health Services Research, Emory University School of Medicine, Atlanta, GA,Department of Surgery, Emory University School of Medicine, Atlanta, GA,Department of Medicine, Emory University School of Medicine, Atlanta, GA
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Watanabe ALC, Feijó MS, Menezes VPLD, Galdino-Vasconcelos MR, Caballero JLS, Ferreira G, Jorge F, Trevizoli N, Diaz LG, Campos PBD, Cajá G, Ullmann R, Figueira AV, Morato T, Moraes A, Pereira JRB, Perosa M. 500 Consecutive Liver Transplants: The Outcomes of a New Transplantation Program in the Middle West of Brazil. Transplant Proc 2021; 53:73-82. [PMID: 32981691 DOI: 10.1016/j.transproceed.2020.06.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/04/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Liver transplantation is the standard treatment for end-stage liver disease. Brazil holds the third highest number of liver transplants performed per year, but center maldistribution results in high discrepancies in accessing this treatment. In 2012, an interstate partnership successfully implemented a new liver transplantation program in the middle west of Brazil. Here, we report the results of the first 500 liver transplants performed in this new program and discuss the impacts of a new transplant center in regional transplantation dynamics. METHODS We reviewed data from the first 500 consecutive deceased donor liver transplants performed in the new program during an 8-year period. We analyzed data on patients' clinical and demographic profiles, postoperative outcomes, and graft and recipient survival rates. Univariate survival analysis was conducted using log-rank tests to compare the groups. RESULTS Almost half (48%) of the procured organs and 40% of the recipients transplanted in our center were from outside our state. Recipient 30-day mortality was 9%. Overall recipient survival at 1 year and 5 years was 85% and 80%, respectively. Mortality was significantly associated with higher Model for End-Stage Liver Disease (P < .001) but not with the presence of hepatocellular carcinoma (P = .795). DISCUSSION The new transplantation program treated patients from different regions of Brazil and became the reference center in liver transplantation for the middle west region. Despite the recent implementation, our outcomes are comparable to experienced centers around the world. This model can inspire the creation of new transplantation programs aiming to democratize access to liver transplantation nationwide.
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Affiliation(s)
- André Luís Conde Watanabe
- Faculty of Medicine, University of Brasilia, Campus Universitário Darcy Ribeiro, Brasilia, Federal District, Brazil; Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal (ICDF), Setor HFA Hospital das Forças Armadas, Brasilia, Federal District, Brazil; Department of Liver Transplantation, Hospital Brasilia, Setor de Habitações Individuais Sul, Brasilia, Federal District, Brazil
| | - Mateus Silva Feijó
- Faculty of Medicine, University of Brasilia, Campus Universitário Darcy Ribeiro, Brasilia, Federal District, Brazil.
| | | | | | - Jorge Luis Salinas Caballero
- Faculty of Medicine, University of Brasilia, Campus Universitário Darcy Ribeiro, Brasilia, Federal District, Brazil
| | - Gustavo Ferreira
- Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal (ICDF), Setor HFA Hospital das Forças Armadas, Brasilia, Federal District, Brazil
| | - Fernando Jorge
- Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal (ICDF), Setor HFA Hospital das Forças Armadas, Brasilia, Federal District, Brazil; Department of Liver Transplantation, Hospital Brasilia, Setor de Habitações Individuais Sul, Brasilia, Federal District, Brazil
| | - Natália Trevizoli
- Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal (ICDF), Setor HFA Hospital das Forças Armadas, Brasilia, Federal District, Brazil; Department of Liver Transplantation, Hospital Brasilia, Setor de Habitações Individuais Sul, Brasilia, Federal District, Brazil
| | - Luiz Gustavo Diaz
- Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal (ICDF), Setor HFA Hospital das Forças Armadas, Brasilia, Federal District, Brazil; Department of Liver Transplantation, Hospital Brasilia, Setor de Habitações Individuais Sul, Brasilia, Federal District, Brazil
| | - Priscila Brizolla de Campos
- Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal (ICDF), Setor HFA Hospital das Forças Armadas, Brasilia, Federal District, Brazil; Department of Liver Transplantation, Hospital Brasilia, Setor de Habitações Individuais Sul, Brasilia, Federal District, Brazil
| | - Gabriel Cajá
- Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal (ICDF), Setor HFA Hospital das Forças Armadas, Brasilia, Federal District, Brazil; Department of Liver Transplantation, Hospital Brasilia, Setor de Habitações Individuais Sul, Brasilia, Federal District, Brazil
| | - Raquel Ullmann
- Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal (ICDF), Setor HFA Hospital das Forças Armadas, Brasilia, Federal District, Brazil; Department of Liver Transplantation, Hospital Brasilia, Setor de Habitações Individuais Sul, Brasilia, Federal District, Brazil
| | - Ana Virgínia Figueira
- Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal (ICDF), Setor HFA Hospital das Forças Armadas, Brasilia, Federal District, Brazil; Department of Liver Transplantation, Hospital Brasilia, Setor de Habitações Individuais Sul, Brasilia, Federal District, Brazil
| | - Tiago Morato
- Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal (ICDF), Setor HFA Hospital das Forças Armadas, Brasilia, Federal District, Brazil; Department of Liver Transplantation, Hospital Brasilia, Setor de Habitações Individuais Sul, Brasilia, Federal District, Brazil
| | - Adriano Moraes
- Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal (ICDF), Setor HFA Hospital das Forças Armadas, Brasilia, Federal District, Brazil
| | - Juan Rafael Branez Pereira
- Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal (ICDF), Setor HFA Hospital das Forças Armadas, Brasilia, Federal District, Brazil
| | - Marcelo Perosa
- Department of Liver Transplantation, Instituto de Cardiologia do Distrito Federal (ICDF), Setor HFA Hospital das Forças Armadas, Brasilia, Federal District, Brazil
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Watanabe ALC, Feijó MS, Menezes VPLD, Galdino-Vasconcelos MR, Caballero JLS, Ferreira G, Jorge F, Trevizoli N, Diaz LG, Campos PBD, Cajá G, Ullmann R, Figueira AV, Morato T, Moraes A, Pereira JRB, Perosa M. 500 Consecutive Liver Transplants: The Outcomes of a New Transplantation Program in the Middle West of Brazil. Transplant Proc 2021; 53:73-82. [DOI: https:/doi.org/10.1016/j.transproceed.2020.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
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Lee BP, Vittinghoff E, Pletcher MJ, Dodge JL, Terrault NA. Medicaid Policy and Liver Transplant for Alcohol-Associated Liver Disease. Hepatology 2020; 72:130-139. [PMID: 31705545 PMCID: PMC7318101 DOI: 10.1002/hep.31027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/22/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS In some states, liver transplantation (LT) for alcohol-associated liver disease (ALD) is covered by Medicaid only with documentation of abstinence and/or alcohol rehabilitation. Different Medicaid policies may affect the distribution of LT for ALD, particularly post-2011, as centers have adopted early (i.e., specific abstinence period not required) LT practices. APPROACH AND RESULTS We surveyed Medicaid policies in all states actively performing LT and linked state policies to prospectively collected national registry data on LT recipients from 2002 to 2017 with ALD as the primary listing diagnosis. We categorized Medicaid policies for states as "restrictive" (requiring documentation of a specific abstinence period and/or rehabilitation) versus "unrestrictive" (deferring to center eligibility policies). Difference-of-differences analysis, comparing 2002-2011 versus 2012-2017, evaluated whether restrictive policies were associated with decreased proportion of LTs paid by Medicaid among patients with ALD post-2011. We performed sensitivity analyses to account for any differences by diagnosis of hepatocellular carcinoma, hepatitis C virus, nonalcoholic steatohepatitis, or Medicare insurance. We also performed a sensitivity analysis to account for any difference by prevalence of ALD among restrictive versus unrestrictive states. Of 10,836 LT recipients in 2002-2017, 7,091 were from 24 states in the restrictive group and 3,745 from 14 states in the unrestrictive group. The adjusted proportion (95% confidence interval) of LTs paid by Medicaid among restrictive versus unrestrictive states between 2002 and 2011 was 17.6% (15.4%-19.8%) versus 18.9% (15.4%-22.3%) (P = 0.54) and between 2012 and 2017, 17.2% (14.7%-19.7%) versus 23.2% (19.8%-26.6%) (P = 0.005). In difference-of-differences analysis, restrictive (versus unrestrictive) policies were associated with a 4.7% (0.8%-8.6%) (P = 0.02) absolute lower adjusted proportion of LTs for ALD paid by Medicaid post-2011. CONCLUSIONS Restrictive Medicaid policies are present in most states with active LT centers and are associated with lower proportions of LTs for ALD paid by Medicaid post-2011 compared to states with unrestrictive Medicaid policies. Reevaluation of Medicaid alcohol use policies may be warranted, to align more closely with contemporary center-level practices.
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Affiliation(s)
- Brian P. Lee
- Department of Gastroenterology, University of California, San Francisco, San Francisco, CA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Mark J. Pletcher
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Jennifer L. Dodge
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Norah A. Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, CA
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Racial/Ethnic Disparities in Access and Outcomes of Simultaneous Liver-Kidney Transplant Among Liver Transplant Candidates With Renal Dysfunction in the United States. Transplantation 2020; 103:1663-1674. [PMID: 30720678 DOI: 10.1097/tp.0000000000002574] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Since the Model for End-stage Liver Disease (MELD) allocation system was implemented, the proportion of simultaneous liver-kidney transplantation (SLKT) has increased significantly. However, whether racial/ethnic disparities exist in access to SLKT and post-SLKT survival remains understudied. METHODS A retrospective cohort of patients aged ≥18 years with renal dysfunction on the liver transplant (LT) waiting list was obtained from Organ Procurement and Transplantation Network. Renal dysfunction was defined as estimated glomerular filtration rate <60 mL/min/1.73 m at listing for LT. Multilevel time-to-competing-events regression adjusting for center effect was used to examine the likelihood of receiving SLKT. Inverse probability of treatment weighted survival analyses were used to analyze posttransplant mortality outcomes. RESULTS For patients with renal dysfunction at listing for LT, not listed for simultaneous kidney transplant, non-Hispanic black (NHB) and Hispanic patients were more likely to receive SLKT than non-Hispanic white (NHW) patients (NHB: multivariable-adjusted hazard ratio [aHR] 2.57; 95% confidence interval [CI], 1.42-4.65; Hispanic: aHR, 2.03; 95% CI, 1.14-3.60). For post-SLKT outcomes, compared to NHW patients, NHB patients had a lower mortality risk before 24 months (aHR, 0.80; 95% CI, 0.65-0.97) but had a higher mortality risk (aHR, 2.00; 95% CI, 1.59-2.55) afterward; in contrast, Hispanic patients had a lower overall mortality risk than NHW patients (aHR, 0.61; 95% CI, 0.51-0.74). CONCLUSIONS In the MELD era, racial/ethnic differences exist in access and survival of SLKT for patients with renal dysfunction at listing for LT. Future studies are warranted to examine whether these differences remain in the post-SLK allocation policy era.
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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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Patel A, Asch S, Antonio AL, Kanwal F, Lorenz K, Riopelle D, Dickey A, Larkin J, Lee M, Walling A. Measuring the Quality of Palliative Care for Patients with End-Stage Liver Disease. Dig Dis Sci 2020; 65:2562-2570. [PMID: 31927765 PMCID: PMC7223418 DOI: 10.1007/s10620-019-05983-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/27/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND/AIMS We examined the quality of palliative care received by patients with decompensated cirrhosis using an explicit set of palliative care quality indicators (QIs) for patients with end-stage liver disease (PC-ESLD). METHODS We identified patients newly diagnosed with decompensated cirrhosis at a single veterans health center and followed up them for 2 years or until death. We piloted measurement of PC-ESLD QIs in all patients confirmed to have ESLD using a chart abstraction tool. RESULTS Out of 167 patients identified using at least one sampling strategy, 62 were confirmed to meet ESLD criteria with chart abstraction. Ninety-eight percent of veterans in the cohort were male, mean age at diagnosis was 61 years, and 74% were White. The overall QI pass rate was 68% (64% for information care planning QIs and 76% for supportive care QIs). Patients receiving specialty palliative care consultation were more likely to receive information care planning QIs (67% vs. 37%, p = 0.02). The best performing sampling strategy had a sensitivity of 62% and specificity of 60%. CONCLUSION Measuring the quality of palliative care for patients with ESLD is feasible in the veteran population. Our single-center data suggest that the quality of palliative care is inadequate in the veteran population with ESLD, though patients offered specialty palliative care consultation and those affected by homelessness, drug, and alcohol abuse may receive better care. Our combination of ICD-9 codes can be used to identify a cohort of patients with ESLD, though better sensitivity and specificity may be needed.
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Affiliation(s)
- Arpan Patel
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Steven Asch
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | | | - Fasiha Kanwal
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Karl Lorenz
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Deborah Riopelle
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Anna Dickey
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Jennifer Larkin
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Martin Lee
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Anne Walling
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
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Uygun E, Özer Ü. Alkolik karaciğer hastalığı nedeniyle karaciğer nakli yapılan hastalarda psikiyatrik eştanı ve yeniden alkol kullanımı: Bir ön çalışma. EGE TIP DERGISI 2020. [DOI: 10.19161/etd.452206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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34
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Koola JD, Ho S, Chen G, Perkins AM, Cao A, Davis SE, Matheny ME. Development of a national Department of Veterans Affairs mortality risk prediction model among patients with cirrhosis. BMJ Open Gastroenterol 2019; 6:e000342. [PMID: 31875140 PMCID: PMC6904155 DOI: 10.1136/bmjgast-2019-000342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/16/2019] [Accepted: 10/30/2019] [Indexed: 12/20/2022] Open
Abstract
Objective Cirrhotic patients are at high hospitalisation risk with subsequent high mortality. Current risk prediction models have varied performances with methodological room for improvement. We used current analytical techniques using automatically extractable variables from the electronic health record (EHR) to develop and validate a posthospitalisation mortality risk score for cirrhotic patients and compared performance with the model for end-stage liver disease (MELD), model for end-stage liver disease with sodium (MELD-Na), and the CLIF Consortium Acute Decompensation (CLIF-C AD) models. Design We analysed a retrospective cohort of 73 976 patients comprising 247 650 hospitalisations between 2006 and 2013 at any of 123 Department of Veterans Affairs hospitals. Using 45 predictor variables, we built a time-dependent Cox proportional hazards model with all-cause mortality as the outcome. We compared performance to the three extant models and reported discrimination and calibration using bootstrapping. Furthermore, we analysed differential utility using the net reclassification index (NRI). Results The C-statistic for the final model was 0.863, representing a significant improvement over the MELD, MELD-Na, and the CLIF-C AD, which had C-statistics of 0.655, 0.675, and 0.679, respectively. Multiple risk factors were significant in our model, including variables reflecting disease severity and haemodynamic compromise. The NRI showed a 24% improvement in predicting survival of low-risk patients and a 30% improvement in predicting death of high-risk patients. Conclusion We developed a more accurate mortality risk prediction score using variables automatically extractable from an EHR that may be used to risk stratify patients with cirrhosis for targeted postdischarge management.
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Affiliation(s)
- Jejo David Koola
- Veteran's Health Administration, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA.,Department of Medicine, University of California San Diego, La Jolla, California, USA.,UC San Diego Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California, United States
| | - Samuel Ho
- Department of Medicine, University of California San Diego, La Jolla, California, USA.,Department of Medicine, VA San Diego Healthcare System, San Diego, California, USA.,Department of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Guanhua Chen
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Amy M Perkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aize Cao
- Veteran's Health Administration, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sharon E Davis
- Veteran's Health Administration, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael E Matheny
- Veteran's Health Administration, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Jesse MT, Abouljoud M, Goldstein ED, Rebhan N, Ho CX, Macaulay T, Bebanic M, Shkokani L, Moonka D, Yoshida A. Racial disparities in patient selection for liver transplantation: An ongoing challenge. Clin Transplant 2019; 33:e13714. [PMID: 31532023 DOI: 10.1111/ctr.13714] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 09/03/2019] [Accepted: 09/07/2019] [Indexed: 01/14/2023]
Abstract
Ample evidence suggests continued racial disparities once listed for liver transplantation, though few studies examine disparities in the selection process for listing. The objective of this study, via retrospective chart review, was to determine whether listing for liver transplantation was influenced by socioeconomic status and race/ethnicity. We identified 1968 patients with end-stage liver disease who underwent evaluation at a large, Midwestern center from January 1, 2004 through December 31, 2012 (72.9% white, 19.6% black, and 7.5% other). Over half (54.6%) of evaluated patients were listed; the three most common reasons for not listing were medical contraindications (11.9%), patient expired during evaluation (7.0%), and psychosocial contraindications (5.9%). In multivariable logistic regressions (listed vs not listed), across the three racial categories, the odds of being listed were lower for alcohol-induced hepatitis (±hepatitis C), unmarried, more than one insurance, inadequate insurance, and lower annual household income quartile. Similar factors predicted time to transplant listing, including being identified as black race. Black race, even when adjusting for the above mentioned medical and socioeconomic factors, was associated with 26% lower odds of being listed and a longer time to listing decision compared to all other patients.
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Affiliation(s)
- Michelle T Jesse
- Transplant Institute, Henry Ford Health System, Detroit, MI.,Consultation-Liaison Psychiatry, Behavioral Health, Henry Ford Health System, Detroit, MI.,Center for Health Policy & Health Services Research, Henry Ford Health System, Detroit, MI
| | - Marwan Abouljoud
- Transplant Institute, Henry Ford Health System, Detroit, MI.,Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI
| | | | | | - Chuan-Xing Ho
- Transplant Institute, Henry Ford Health System, Detroit, MI
| | | | - Mubera Bebanic
- Transplant Institute, Henry Ford Health System, Detroit, MI
| | - Lina Shkokani
- Transplant Institute, Henry Ford Health System, Detroit, MI
| | - Dilip Moonka
- Transplant Institute, Henry Ford Health System, Detroit, MI.,Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, MI
| | - Atsushi Yoshida
- Transplant Institute, Henry Ford Health System, Detroit, MI.,Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI
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Bababekov YJ, Hung YC, Rickert CG, Njoku FC, Cao B, Adler JT, Brega AG, Pomposelli JJ, Chang DC, Yeh H. Health Literacy Burden Is Associated With Access to Liver Transplantation. Transplantation 2019; 103:522-528. [PMID: 30431496 DOI: 10.1097/tp.0000000000002536] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Getting listed for liver transplantation is a complex process. Institutional health literacy may influence the ability of patients with limited educational attainment (EA) to list. As an easily accessible indicator of institutional health literacy, we measured the understandability of liver transplant center education websites and assessed whether there was any association with the percentage of low EA patients on their waitlists. METHODS Patients on the waitlist for liver transplantation 2007-2016 were identified in Scientific Registry of Transplant Recipients. Understandability of patient education websites was assessed using the Clear Communication Index (CCI). The Centers for Disease Control and Prevention has set itself a goal CCI of 90 as being easy to understand. Low EA was defined as less than a high school education. We adjusted for center case-mix, Donor Service Area characteristics, and EA of the general population. RESULTS Patients (84 774) were listed across 112 liver transplant centers. The median percent of waitlisted patients at each center with low EA was 11.0% (IQR, 6.6-16.8). CCI ranged from 53 to 88 and correlated with the proportion of low EA patients on the waitlist. However, CCI was not associated with the percentage of low EA in the general population. For every 1-point improvement in CCI, low EA patients increase by 0.2% (P < 0.05), translating to a 3.6% increase, or additional 3000 patients, if all centers improved their websites to CCI of 90. CONCLUSIONS Educational websites that are easier to understand are associated with increased access to liver transplantation for patients with low EA. Lowering the health literacy burden by transplant centers may improve access to the liver transplant waitlist.
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Affiliation(s)
- Yanik J Bababekov
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ya-Ching Hung
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Charles G Rickert
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Faith C Njoku
- University of California, Irvine Medical School, Irvine, CA
| | - Bonnie Cao
- University of Rochester Medical School, Rochester, NY
| | - Joel T Adler
- Department of Surgery, University of Wisconsin Hospital and Clinics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Angela G Brega
- Department of Community and Behavioral Health, University of Colorado Hospital, Aurora, CO
| | | | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Heidi Yeh
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Mahmud N, Kaplan DE, Taddei TH, Goldberg DS. Incidence and Mortality of Acute-on-Chronic Liver Failure Using Two Definitions in Patients with Compensated Cirrhosis. Hepatology 2019; 69:2150-2163. [PMID: 30615211 PMCID: PMC6461492 DOI: 10.1002/hep.30494] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/20/2018] [Indexed: 12/12/2022]
Abstract
The term acute-on-chronic liver failure (ACLF) is intended to identify patients with chronic liver disease who develop rapid deterioration of liver function and high short-term mortality after an acute insult. The two prominent definitions (European Association for the Study of the Liver [EASL] and Asian Pacific Association for the Study of the Liver [APASL]) differ, and existing literature applies to narrow patient groups. We sought to compare ACLF incidence and mortality among a diverse cohort of patients with compensated cirrhosis, using both definitions. This was a retrospective cohort study of patients with incident compensated cirrhosis in the Veterans Health Administration from 2008 to 2016. First ACLF events were identified for each definition. Incidence rates were computed as events per 1,000 person-years, and mortality was calculated at 28 and 90 days. Among 80,383 patients with cirrhosis with 3.35 years median follow-up, 783 developed EASL and APASL ACLF, 4,296 developed EASL ACLF alone, and 574 developed APASL ACLF alone. The incidence rate of APASL ACLF was 5.7 per 1,000 person-years (95% confidence interval [CI]: 5.4-6.0), and the incidence rate of EASL ACLF was 20.1 (95% CI: 19.5-20.6). The 28-day and 90-day mortalities for APASL ACLF were 41.9% and 56.1%, respectively, and were 37.6% and 50.4% for EASL ACLF. The median bilirubin level at diagnosis of EASL-alone ACLF was 2.0 mg/dL (interquartile range: 1.1-4.0). Patients with hepatitis C or nonalcoholic fatty liver disease had among the lowest ACLF incidence rates but had the highest short-term mortality. Conclusion: There is significant discordance in ACLF events by EASL and APASL criteria. The majority of patients with EASL-alone ACLF have preserved liver function, suggesting the need for more liver-specific ACLF criteria.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David E. Kaplan
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - David S. Goldberg
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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38
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Lee BP, Terrault NA. Liver-related mortality in the United States: hepatitis C declines, non-alcoholic fatty liver and alcohol rise. Transl Gastroenterol Hepatol 2019; 4:19. [PMID: 30976722 DOI: 10.21037/tgh.2019.03.04] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/28/2018] [Indexed: 12/21/2022] Open
Affiliation(s)
- Brian P Lee
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Norah A Terrault
- Department of Medicine, University of Southern California, Los Angeles, CA, USA
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Bodek D, Patel P, Ahlawat S, Orosz E, Nasereddin T, Pyrsopoulos N. Superior Performance of Teaching and Transplant Hospitals in the Management of Hepatic Encephalopathy from 2007 to 2014. J Clin Transl Hepatol 2018; 6:362-371. [PMID: 30637212 PMCID: PMC6328739 DOI: 10.14218/jcth.2017.00078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 09/05/2018] [Accepted: 10/03/2018] [Indexed: 12/04/2022] Open
Abstract
Background and Aims: Hepatic encephalopathy is a liver disease complication with significant mortality and costs. The aim of this study was to evaluate the relative performance of facilities based on their teaching status and transplant capability by correlating their connections to mortality, cost, and length of stay from 2007 to 2014. Methods: The Nationwide Inpatient Sample database was utilized to collect information on (USA) American patients admitted with a primary diagnosis of hepatic encephalopathy from 2007-2014. Hospitals were placed into one of four categories using their teaching and transplant status. Using regression analysis, mortality, length of stay and cost adjusted rate ratios were calculated. Results: The study revealed that teaching transplant centers had a mortality risk ratio of 0.783 (95% confidence interval (CI): 0.750-0.819, p < 0.001). Blacks had the highest mortality risk ratio, of 1.273 (95%CI: 1.217-1.331, p < 0.001). Furthermore, teaching transplant hospitals had a cost rate ratio of 1.226 (95%CI: 1.214-1.238, p < 0.001) and a length of stay rate ratio of 1.104 (95%CI: 1.093-1.115, p < 0.001). Conclusions: It appears that admission to transplant facilities for hepatic encephalopathy is associated with reduced mortality but increased costs and longer stay independent of transplantation. Moreover, factors impacting black mortality should also be examined more closely.
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Affiliation(s)
- Daniel Bodek
- Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
| | - Pavan Patel
- Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
| | - Sushil Ahlawat
- Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
| | - Evan Orosz
- Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
| | - Thayer Nasereddin
- Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
| | - Nikolaos Pyrsopoulos
- Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
- *Correspondence to: Nikolaos Pyrsopoulos, Rutgers New Jersey Medical School, University Hospital, MSB H538, 185 South Orange Avenue, Newark, NJ 07103, USA. Tel: +1-973-972-5252, Fax: +1-973-972-3144, E-mail:
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40
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Burra P, Giannini EG, Caraceni P, Ginanni Corradini S, Rendina M, Volpes R, Toniutto P. Specific issues concerning the management of patients on the waiting list and after liver transplantation. Liver Int 2018; 38:1338-1362. [PMID: 29637743 DOI: 10.1111/liv.13755] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/27/2018] [Indexed: 02/06/2023]
Abstract
The present document is a second contribution collecting the recommendations of an expert panel of transplant hepatologists appointed by the Italian Association for the Study of the Liver (AISF) concerning the management of certain aspects of liver transplantation, including: the issue of prompt referral; the management of difficult candidates; malnutrition; living related liver transplants; hepatocellular carcinoma; and the role of direct acting antiviral agents before and after transplantation. The statements on each topic were approved by participants at the AISF Transplant Hepatology Expert Meeting organized by the Permanent Liver Transplant Commission in Mondello on 12-13 May 2017. They are graded according to the GRADE grading system.
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Affiliation(s)
- Patrizia Burra
- Multivisceral Transplant Unit, University Hospital, Padova, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | | | - Riccardo Volpes
- Hepatology and Gastroenterology Unit, ISMETT-IRCCS, Palermo, Italy
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41
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Lindenmeyer CC, Welch N, Carey WD. Patient 2 with decompensated cirrhosis due to alcohol with short duration of sobriety. Clin Liver Dis (Hoboken) 2018; 11:152-155. [PMID: 30992807 PMCID: PMC6385959 DOI: 10.1002/cld.706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/07/2018] [Accepted: 02/18/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
| | - Nicole Welch
- Department of Gastroenterology and HepatologyCleveland ClinicClevelandOH
| | - William D. Carey
- Department of Gastroenterology and HepatologyCleveland ClinicClevelandOH
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42
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Burra P, Zanetto A, Germani G. Liver Transplantation for Alcoholic Liver Disease and Hepatocellular Carcinoma. Cancers (Basel) 2018; 10:E46. [PMID: 29425151 PMCID: PMC5836078 DOI: 10.3390/cancers10020046] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 12/11/2022] Open
Abstract
Hepatocellular carcinoma is one of the main important causes of cancer-related death and its mortality is increasingly worldwide. In Europe, alcohol abuse accounts for approximately half of all liver cancer cases and it will become the leading cause of hepatocellular carcinoma in the next future with the sharp decline of chronic viral hepatitis. The pathophysiology of alcohol-induced carcinogenesis involves acetaldehyde catabolism, oxidative stress and chronic liver inflammation. Genetic background plays also a significant role and specific patterns of gene mutations in alcohol-related hepatocellular carcinoma have been characterized. Survival is higher in patients who undergo specific surveillance programmes than in patients who do not. However, patients with alcohol cirrhosis present a significantly greater risk of liver decompensation than those with cirrhosis due to other aetiologies. Furthermore, the adherence to screening program can be suboptimal. Liver transplant for patients with Milan-in hepatocellular carcinoma represents the best possible treatment in case of tumour recurrence/progression despite loco-regional or surgical treatments. Long-term result after liver transplantation for alcohol related liver disease is good. However, cardiovascular disease and de novo malignancies can significantly hamper patients' survival and should be carefully considered by transplant team. In this review, we have focused on the evolution of alcohol-related hepatocellular carcinoma epidemiology and risk factors as well as on liver transplantation in alcoholic patients with and without hepatocellular carcinoma.
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Affiliation(s)
- Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128 Padua, Italy.
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128 Padua, Italy.
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128 Padua, Italy.
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43
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Singal AK, Bataller R, Ahn J, Kamath PS, Shah VH. ACG Clinical Guideline: Alcoholic Liver Disease. Am J Gastroenterol 2018; 113:175-194. [PMID: 29336434 PMCID: PMC6524956 DOI: 10.1038/ajg.2017.469] [Citation(s) in RCA: 463] [Impact Index Per Article: 77.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 11/08/2017] [Indexed: 02/07/2023]
Abstract
Alcoholic liver disease (ALD) comprises a clinical-histologic spectrum including fatty liver, alcoholic hepatitis (AH), and cirrhosis with its complications. Most patients are diagnosed at advanced stages and data on the prevalence and profile of patients with early disease are limited. Diagnosis of ALD requires documentation of chronic heavy alcohol use and exclusion of other causes of liver disease. Prolonged abstinence is the most effective strategy to prevent disease progression. AH presents with rapid onset or worsening of jaundice, and in severe cases may transition to acute on chronic liver failure when the risk for mortality, depending on the number of extra-hepatic organ failures, may be as high as 20-50% at 1 month. Corticosteroids provide short-term survival benefit in about half of treated patients with severe AH and long-term mortality is related to severity of underlying liver disease and is dependent on abstinence from alcohol. General measures in patients hospitalized with ALD include inpatient management of liver disease complications, management of alcohol withdrawal syndrome, surveillance for infections and early effective antibiotic therapy, nutritional supplementation, and treatment of the underlying alcohol-use disorder. Liver transplantation, a definitive treatment option in patients with advanced alcoholic cirrhosis, may also be considered in selected patients with AH cases, who do not respond to medical therapy. There is a clinical unmet need to develop more effective and safer therapies for patients with ALD.
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Affiliation(s)
- Ashwani K. Singal
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham School of Medicine , Birmingham , Alabama , USA
| | - Ramon Bataller
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Liver Research Center , Pittsburgh , Pennsylvania , USA
| | - Joseph Ahn
- Division of Gastroenterology and Hepatology, Oregon Health and Science University , Portland , Oregon , USA
| | - Patrick S. Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic , Rochester , Minnesota ,USA
| | - Vijay H. Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic , Rochester , Minnesota ,USA
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44
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Kling CE, Perkins JD, Carithers RL, Donovan DM, Sibulesky L. Recent trends in liver transplantation for alcoholic liver disease in the United States. World J Hepatol 2017; 9:1315-1321. [PMID: 29359014 PMCID: PMC5756720 DOI: 10.4254/wjh.v9.i36.1315] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/07/2017] [Accepted: 12/05/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To examine temporal changes in the indications for liver transplantation (LT) and characteristics of patients transplanted for alcoholic liver disease (ALD).
METHODS We performed a retrospective cohort analysis of trends in the indication for LT using the United Network for Organ Sharing (UNOS) database between 2002 and 2015. Patients were grouped by etiology of the liver disease and characteristics were compared using χ2 and t-tests. Time series analysis was used identifying any year with a significant change in the number of transplants per year for ALD, and before and after eras were modeled using a general linear model. Subgroup analysis of recipients with ALD was performed by age group, gender, UNOS region and etiology (alcoholic cirrhosis, alcoholic hepatitis and hepatitis C - alcoholic cirrhosis dual listing).
RESULTS Of 74216 liver transplant recipients, ALD (n = 9400, 12.7%) was the third leading indication for transplant after hepatitis C and hepatocellular carcinoma. Transplants for ALD, increased from 12.8% (553) in 2002 to 16.5% (1020) in 2015. Time series analysis indicated a significant increase in the number of transplants per year for ALD in 2013 (P = 0.03). There were a stable number of transplants per year between 2002 and 2012 (linear coefficient 3, 95%CI: -4.6, 11.2) an increase of 177 per year between 2013 and 2015 (95%CI: 119, 234). This increase was significant for all age groups except those 71-83 years old, was observed for both genders, and was incompletely explained by a decrease in transplants for hepatitis C and ALD dual listing. All UNOS regions except region 9 saw an increase in the mean number of transplants per year when comparing eras, and this increase was significant in regions 2, 3, 4, 5, 6, 8, 10 and 11.
CONCLUSION There has been a dramatic increase in the number of transplants for ALD starting in 2013.
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Affiliation(s)
- Catherine E Kling
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, United States
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, United States
| | - Robert L Carithers
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Dennis M Donovan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, United States
| | - Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, United States
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45
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Goldberg D, French B, Newcomb C, Liu Q, Sahota G, Wallace AE, Forde KA, Lewis JD, Halpern SD. Patients With Hepatocellular Carcinoma Have Highest Rates of Wait-listing for Liver Transplantation Among Patients With End-Stage Liver Disease. Clin Gastroenterol Hepatol 2016; 14:1638-1646.e2. [PMID: 27374003 PMCID: PMC5069141 DOI: 10.1016/j.cgh.2016.06.019] [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: 05/25/2016] [Accepted: 06/07/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Despite recent attention to differences in access to livers for transplantation, research has focused on patients already on the wait list. We analyzed data from a large administrative database that represents the entire US population, and state Medicaid data, to identify factors associated with differences in access to wait lists for liver transplantation. METHODS We performed a retrospective cohort study of transplant-eligible patients with end-stage liver disease using the HealthCore Integrated Research Database (2006-2014; n = 16,824) and Medicaid data from 5 states (2002-2009; California, Florida, New York, Ohio, and Pennsylvania; n = 67,706). Transplant-eligible patients had decompensated cirrhosis, hepatocellular carcinoma (HCC), and/or liver synthetic dysfunction, based on validated International Classification of Diseases, Ninth Revision-based algorithms and data from laboratory studies. Placement on the wait list was determined through linkage with the Organ Procurement and Transplantation Network database. RESULTS In an unadjusted analysis of the HealthCore database, we found that 29% of patients with HCC were placed on the 2-year wait list (95% confidence interval [CI], 25.4%-33.0%) compared with 11.9% of patients with stage 4 cirrhosis (ascites) (95% CI, 11.0%-12.9%) and 12.6% of patients with stage 5 cirrhosis (ascites and variceal bleeding) (95% CI, 9.4%-15.2%). Among patients with each stage of cirrhosis, those with HCC were significantly more likely to be placed on the wait list; adjusted subhazard ratios ranged from 1.7 (for patients with stage 5 cirrhosis and HCC vs those without HCC) to 5.8 (for patients with stage 1 cirrhosis with HCC vs those without HCC). Medicaid beneficiaries with HCC were also more likely to be placed on the transplant wait list, compared with patients with decompensated cirrhosis, with a subhazard ratio of 2.34 (95% CI, 2.20-2.49). Local organ supply and wait list level demand were not associated with placement on the wait list. CONCLUSIONS In an analysis of US healthcare databases, we found patients with HCC to be more likely to be placed on liver transplant wait lists than patients with decompensated cirrhosis. Previously reported reductions in access to transplant care for wait-listed patients with decompensated cirrhosis underestimate the magnitude of this difference.
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Affiliation(s)
- David Goldberg
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Benjamin French
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania,Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Craig Newcomb
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania
| | - Qing Liu
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania
| | | | | | - Kimberly A. Forde
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania,Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania
| | - James D. Lewis
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania,Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania,Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Scott D. Halpern
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania,Leonard Davis Institute of Health Economics, University of Pennsylvania,Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania
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46
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Sclair SN, Carrasquillo O, Czul F, Trivella JP, Li H, Jeffers L, Martin P. Quality of Care Provided by Hepatologists to Patients with Cirrhosis at Three Parallel Health Systems. Dig Dis Sci 2016; 61:2857-2867. [PMID: 27289585 DOI: 10.1007/s10620-016-4221-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/29/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Evidence-based guidelines and quality indicators for cirrhosis care have been established. Whether there are variations in adherence to these cirrhosis standards at different specialty settings has not been investigated. AIMS To evaluate the quality of cirrhosis care delivered at diverse hepatology care sites. METHODS We conducted a retrospective study comparing the quality of care at three hepatology specialty clinics: a Faculty Practice, safety-net hospital, and Veterans Affairs (VA) Medical Center. Consecutive patients with cirrhosis (85 Faculty Practice, 81 safety-net, and 76 VA) between 2010 and 2011 were included. Median follow-up was 2.3 years. Outcome measures were the adherence to six cirrhosis-specific quality-of-care indicators. RESULTS Adherence to hepatitis A and B vaccinations was highest at the safety-net hospital, 81 and 74 %, compared to 46 and 30 % at the Faculty Practice (P < .001). Adherence to yearly hepatocellular carcinoma surveillance was highest at the safety-net site (79 %) versus the VA (50 %) and Faculty Practice (42 %), P = .001. In contrast, screening rates for esophageal varices were 75 % at the Faculty Practice and only 58 and 43 % at the VA and safety-net sites, respectively (P < .001). Liver transplant discussions were documented most consistently at the Faculty Practice (82 %) compared to the safety-net site (53 %) and VA (54 %), P < .001. CONCLUSIONS Disparities in cirrhosis quality measures existed by site. Strategies to overcome these disparities need to be developed to improve the delivery of quality cirrhosis care as we face a rise in cirrhosis-related complications over the next two decades.
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Affiliation(s)
- Seth N Sclair
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Olveen Carrasquillo
- Division of General Internal Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Miami Clinical and Translational Sciences Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Frank Czul
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan P Trivella
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hua Li
- Miami Clinical and Translational Sciences Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Biostatistics Collaboration and Consulting Core, Department of Epidemiology and Public Health, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Lennox Jeffers
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Hepatology Section, Medicine Service, Miami VA Medical Center, Miami, FL, USA
| | - Paul Martin
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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47
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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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48
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Siddiqui MS, Charlton M. Liver Transplantation for Alcoholic and Nonalcoholic Fatty Liver Disease: Pretransplant Selection and Posttransplant Management. Gastroenterology 2016; 150:1849-62. [PMID: 26971826 DOI: 10.1053/j.gastro.2016.02.077] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 02/12/2016] [Accepted: 02/16/2016] [Indexed: 02/07/2023]
Abstract
Alcoholic fatty liver disease (ALD) and nonalcoholic fatty liver disease (NAFLD) are common causes of chronic liver disease throughout the world. Although they have similar histologic features, a diagnosis of NAFLD requires the absence of significant alcohol use. ALD is seen commonly in patients with a long-standing history of excessive alcohol use, whereas NAFLD is encountered commonly in patients who have developed complications of obesity, such as insulin resistance, hypertension, and dyslipidemia. Lifestyle contributes to the development and progression of both diseases. Although alcohol abstinence can cause regression of ALD, and weight loss can cause regression of NAFLD, many patients with these diseases develop cirrhosis. ALD and NAFLD account for nearly 30% of liver transplants performed in the United States. Patients receiving liver transplants for ALD or NAFLD have similar survival times as patients receiving transplants for other liver disorders. Although ALD and NAFLD recur frequently after liver transplantation, graft loss from disease recurrence after transplantation is uncommon. Cardiovascular disease and de novo malignancy are leading causes of long-term mortality in liver transplant recipients with ALD or NAFLD.
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Affiliation(s)
- M Shadab Siddiqui
- Division of Gastroenterology & Hepatology, Virginia Commonwealth University, Richmond, Virginia
| | - Michael Charlton
- Division of Transplant Hepatology, Intermountain Medical Center, Murry, Utah
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49
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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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Abstract
Alcoholic liver disease is the second most common indication for orthotopic liver transplantation in western countries. The majority of patients with alcoholic liver disease, however, are not referred for transplant evaluation. If evaluated, a 6 month period of sobriety is required before waitlisting for transplant. The consequences of relapse to alcohol use in patients on the waitlist are usually removal from the list. Therefore, identification and treatment of alcohol use disorder in patients with end-stage liver disease greatly impacts quality of life, treatment options and survival in patients’ course with this grave illness. Psychosocial and behavioral interventions prior to transplant appear to reduce drinking in the period before the surgery as well as reduce relapse rates post-transplant. Only one of the three medications approved by the Food and Drug Administration, acamprosate, seems feasible for use in patients with end-stage liver disease, while several other medications currently under investigation for the treatment of alcohol use disorder can be considered for use in this population. While only baclofen has been formally studied in alcoholic patients with end-stage liver disease with positive results for safety and efficacy, other medications also hold promise to treat alcohol use disorder in this population. Transplant programs with addictions specialists who function as an integral part of the treatment team may offer better outcomes to patients in terms of success of maintaining sobriety both pre- and post-transplant.
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Affiliation(s)
- Mary R. Lee
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, National Institute on Alcohol Abuse and Alcoholism and National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD
| | - Lorenzo Leggio
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, National Institute on Alcohol Abuse and Alcoholism and National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD,Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University, Providence, RI,Contact information: Lorenzo Leggio, M.D., Ph.D., M.Sc., Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, NIAAA & NIDA, NIH, 10 Center Drive (10CRC/15330) MSC 1108; Room 1-5429, Bethesda, MD 20892-1108, Phone: +1 301 435 9398; Fax: + 1 301 402 0445,
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