Adapting the Patient-centered Specialty Practice Model for Populations With Cirrhosis

Actionable Solutions to Achieve Health Equity in Chronic Liver Disease

There are well-described racial and ethnic disparities in the burden of chronic liver diseases. Hispanic persons are at highest risk for developing nonalcoholic fatty liver disease, the fastest growing cause of liver disease. Hepatitis B disproportionately affects persons of Asian or African descent. The highest rates of hepatitis C occur in American Indian and Alaskan Native populations. In addition to disparities in disease burden, there are also marked racial and ethnic disparities in access to treatments, including liver transplantation. Disparities also exist by gender and geography, especially in alcohol-related liver disease. To achieve health equity, we must address the root causes that drive these inequities. Understanding the role that social determinants of health play in the disparate health outcomes that are currently observed is critically important. We must forge and/or strengthen collaborations between patients, community members, other key stakeholders, health care providers, health care institutions, professional societies, and legislative bodies. Herein, we provide a high-level review of current disparities in chronic liver disease and describe actionable strategies that have potential to bridge gaps, improve quality, and promote equity in liver care.

Breakthrough SARS-CoV-2 infection outcomes in vaccinated patients with chronic liver disease and cirrhosis: A National COVID Cohort Collaborative study

BACKGROUND AND AIMS

Outcomes of breakthrough SARS-CoV-2 infections have not been well characterized in non-veteran vaccinated patients with chronic liver diseases (CLD). We used the National COVID Cohort Collaborative (N3C) to describe these outcomes.

APPROACH AND RESULTS

We identified all CLD patients with or without cirrhosis who had SARS-CoV-2 testing in the N3C Data Enclave as of January 15, 2022. We used Poisson regression to estimate incidence rates of breakthrough infections and Cox survival analyses to associate vaccination status with all-cause mortality at 30 days among infected CLD patients. We isolated 278,457 total CLD patients: 43,079 (15%) vaccinated and 235,378 (85%) unvaccinated. Of 43,079 vaccinated patients, 32,838 (76%) were without cirrhosis and 10,441 (24%) with cirrhosis. Breakthrough infection incidences were 5.4 and 4.9 per 1000 person-months for fully vaccinated CLD patients without cirrhosis and with cirrhosis, respectively. Of the 68,048 unvaccinated and 10,441 vaccinated CLD patients with cirrhosis, 15% and 3.7%, respectively, developed SARS-CoV-2 infection. The 30-day outcome of mechanical ventilation or death after SARS-CoV-2 infection for unvaccinated and vaccinated CLD patients with cirrhosis were 15.2% and 7.7%, respectively. Compared to unvaccinated patients with cirrhosis, full vaccination was associated with a 0.34-times adjusted hazard of death at 30 days.

CONCLUSIONS

In this N3C study, breakthrough infection rates were similar among CLD patients with and without cirrhosis. Full vaccination was associated with a 66% reduction in risk of all-cause mortality for breakthrough infection among CLD patients with cirrhosis. These results provide an additional impetus for increasing vaccination uptake in CLD populations.

Risk Trajectories for Readmission and Death After Cirrhosis-Related Hospitalization

INTRODUCTION

Patients hospitalized for cirrhosis are at high risk for readmission and death for the first 30 days following discharge. However, there is no information on how these risks dynamically change over a full year after discharge. Our aim was to determine the absolute risks of first readmission and death and characterize these changes in the first year following hospital discharge.

METHODS

We conducted a retrospective cohort study of patients who were hospitalized with cirrhosis at all Veterans Affairs hospitals and discharged home between 01/01/2010 and 12/31/2013. We used separate survival models to determine risk of first readmission and death after hospital discharge. We also examined the absolute daily risks for first readmission and death by day and identified the time required for risks of readmission and death to decline 50% and 75% from maximum values.

RESULTS

Of the 38,955 patients who survived index hospitalization for cirrhosis, 23,318 patients (59.9%) had at least one readmission and 11,567 patients (29.7%) died within the first year. Daily risk of readmission was the highest on day 1 (1.23%) and declined 50% by day 71 and 75% by day 260. After 1 year, daily risk of readmission did not plateau. Daily risk of death was the highest on day 1 (0.78%) and declined 50% by day 31 and 75% by day 64.

CONCLUSION

The risk of readmission and death after cirrhosis-related hospitalization remains elevated for prolonged periods. Patients and providers should remain vigilant for clinical health deterioration beyond the first 30 days following hospitalization.