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Brahmania M, Rogal S, Serper M, Patel A, Goldberg D, Mathur A, Wilder J, Vittorio J, Yeoman A, Rich NE, Lazo M, Kardashian A, Asrani S, Spann A, Ufere N, Verma M, Verna E, Simpson D, Schold JD, Rosenblatt R, McElroy L, Wadwhani SI, Lee TH, Strauss AT, Chung RT, Aiza I, Carr R, Yang JM, Brady C, Fortune BE. Pragmatic strategies to address health disparities along the continuum of care in chronic liver disease. Hepatol Commun 2024; 8:e0413. [PMID: 38696374 PMCID: PMC11068141 DOI: 10.1097/hc9.0000000000000413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 01/05/2024] [Indexed: 05/04/2024] Open
Abstract
Racial, ethnic, and socioeconomic disparities exist in the prevalence and natural history of chronic liver disease, access to care, and clinical outcomes. Solutions to improve health equity range widely, from digital health tools to policy changes. The current review outlines the disparities along the chronic liver disease health care continuum from screening and diagnosis to the management of cirrhosis and considerations of pre-liver and post-liver transplantation. Using a health equity research and implementation science framework, we offer pragmatic strategies to address barriers to implementing high-quality equitable care for patients with chronic liver disease.
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Affiliation(s)
- Mayur Brahmania
- Department of Medicine, Division of Gastroenterology and Transplant Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shari Rogal
- Department of Medicine, Division of Gastroenterology, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Marina Serper
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arpan Patel
- Department of Medicine, Division of Gastroenterology, University of California Los Angeles, Los Angeles, California, USA
| | - David Goldberg
- Department of Medicine, Division of Gastroenterology, University of Miami, Miami, Florida, USA
| | - Amit Mathur
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Julius Wilder
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer Vittorio
- Department of Pediatrics, Division of Pediatric Gastroenterology, NYU Langone Health, New York, New York, USA
| | - Andrew Yeoman
- Department of Medicine, Gwent Liver Unit, Aneurin Bevan University Health Board, Newport, Wales, UK
| | - Nicole E. Rich
- Department of Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Mariana Lazo
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ani Kardashian
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Sumeet Asrani
- Department of Medicine, Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas, USA
| | - Ashley Spann
- Department of Medicine, Division of Gastroenterology, Vanderbilt University, Nashville, Tennessee, USA
| | - Nneka Ufere
- Department of Medicine, Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Elizabeth Verna
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Dinee Simpson
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - Jesse D. Schold
- Department of Surgery and Epidemiology, University of Colorado, Aurora, Colorado, USA
| | - Russell Rosenblatt
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Lisa McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sharad I. Wadwhani
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Tzu-Hao Lee
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Alexandra T. Strauss
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Raymond T. Chung
- Department of Medicine, Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ignacio Aiza
- Department of Medicine, Liver Unit, Hospital Ángeles Lomas, Mexico City, Mexico
| | - Rotonya Carr
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Jin Mo Yang
- Department of Medicine, Division of Gastroenterology, Catholic University of Korea, Seoul, Korea
| | - Carla Brady
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brett E. Fortune
- Department of Medicine, Division of Hepatology, Montefiore Einstein Medical Center, Bronx, New York, USA
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Bonner SN, Thumma JR, Valbuena VSM, Stewart JW, Combs M, Lyu D, Chang A, Lin J, Wakeam E. The intersection of race and ethnicity, gender, and primary diagnosis on lung transplantation outcomes. J Heart Lung Transplant 2023; 42:985-992. [PMID: 36967318 PMCID: PMC11258797 DOI: 10.1016/j.healun.2023.02.1496] [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: 05/11/2022] [Revised: 01/10/2023] [Accepted: 02/18/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Reducing racial disparities in lung transplant outcomes is a current priority of providers, policymakers, and lung transplant centers. It is unknown how the combined effect of race and ethnicity, gender, and diagnosis group is associated with differences in 1-year mortality and 5-year survival. METHODS This is a longitudinal cohort study using Standard Transplant Analysis Research files from the United Network for organ sharing. A total of 25,444 patients undergoing first time lung transplantation between 2006 and 2019 in the United States. The primary exposures were lung transplant recipient race and ethnicity, gender, and primary diagnosis group at listing. Multivariable regression models and cox-proportional hazards models were used to determine adjusted 1-year mortality and 5-year survival. RESULTS Overall, 25,444 lung transplant patients were included in the cohort including 15,160 (59.6%) men, 21,345 (83.9%) White, 2,318 (9.1%), Black and Hispanic/Latino (7.0%). Overall, men had a significant higher 1-year mortality than women (11.87%; 95% CI 11.07-12.67 vs 12.82%; 95% CI 12.20%-13.44%). Black women had the highest mortality of all race and gender combinations (14.51%; 95% CI 12.15%-16.87%). Black patients with pulmonary vascular disease had the highest 1-year mortality (19.77%; 95% CI 12.46%-27.08%) while Hispanic/Latino patients with obstructive lung disease had the lowest (7.42%; 95% CI 2.8%-12.05%). 5-year adjusted survival was highest among Hispanic/Latino patients (62.32%) compared to Black (57.59%) and White patients (57.82%). CONCLUSIONS There are significant differences in 1-year and 5-year mortality between and within racial and ethnic groups depending on gender and primary diagnosis. This demonstrates the impact of social and clinical factors on lung transplant outcomes.
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Affiliation(s)
- Sidra N Bonner
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan.
| | - Jyothi R Thumma
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Valeria S M Valbuena
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan
| | - James W Stewart
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Yale University, New Haven, Connecticut
| | - Michael Combs
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Dennis Lyu
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Andrew Chang
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jules Lin
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Elliot Wakeam
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
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Singh N, Watt KD, Bhanji RA. The fundamentals of sex-based disparity in liver transplantation: Understanding can lead to change. Liver Transpl 2022; 28:1367-1375. [PMID: 35289056 DOI: 10.1002/lt.26456] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 02/21/2022] [Accepted: 03/09/2022] [Indexed: 01/13/2023]
Abstract
Liver transplantation (LT) is the definitive treatment for end-stage liver disease. Unfortunately, women are disadvantaged at every stage of the LT process. We conducted a literature review to increase the understanding of this disparity. Hormonal differences, psychological factors, and Model for End-Stage Liver Disease (MELD) score inequalities are some pretransplantation factors that contribute to this disparity. In the posttransplantation setting, women have differing risk than men in most major outcomes (perioperative complications, rejection, long-term renal dysfunction, and malignancy) and assessing the two groups together is disadvantageous. Herein, we propose interventions including standardized criteria for LT referral, using an alternate MELD, education for support of women, and motivating women to seek living donors. Understanding sex-based differences will allow us to improve access, tailor management, and improve overall outcomes for all patients, particularly women.
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Affiliation(s)
- Noreen Singh
- Division of Gastroenterology (Liver Unit), University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rahima A Bhanji
- Division of Gastroenterology (Liver Unit), University of Alberta Hospital, Edmonton, Alberta, Canada
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Walters SM, Richter EW, Lutzker T, Patel S, Vincent AN, Kleiman AM. Perioperative Considerations Regarding Sex in Solid Organ Transplantation. Anesthesiol Clin 2020; 38:297-310. [PMID: 32336385 DOI: 10.1016/j.anclin.2020.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sex plays a role in all stages of the organ transplant process, including listing, sex/size matching of organs, complications, graft survival, and mortality. Sex-related differences in organ transplantation are likely multifactorial related to biological and social characteristics. More information is needed to determine how sex-related differences can lead to improved outcomes for future donors and recipients of solid organs. This article provides an overview on the impact of sex on various types of solid organ transplant, including kidney, pancreas, liver, lung, and heart transplants.
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Affiliation(s)
- Susan M Walters
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908, USA
| | - Ellen W Richter
- Department of Anesthesiology, Emory University School of Medicine, 1364 Clifton Road Northeast, Atlanta, GA 30322, USA
| | - Tatiana Lutzker
- Department of Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, 900 23rd Street, Northwest, Washington, DC 20037, USA
| | - Suraj Patel
- Department of Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, 900 23rd Street, Northwest, Washington, DC 20037, USA
| | - Anita N Vincent
- Department of Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, 900 23rd Street, Northwest, Washington, DC 20037, USA
| | - Amanda M Kleiman
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908, USA.
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More Severe Deficits in Performance Status at Time of Liver Transplant is Associated With Significantly Higher Risk of Death Following Liver Transplantation. J Clin Gastroenterol 2019; 53:e392-e399. [PMID: 30762610 DOI: 10.1097/mcg.0000000000001187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
GOAL To evaluate the impact of Karnofsky Performance Status score (KPSS) at the time of liver transplantation (LT) on post-LT survival. BACKGROUND While the Model for End-Stage Liver Disease (MELD) score is used to prioritize individuals for LT, it does not specifically incorporate functional status into patient assessment for LT. METHODS Using 2005 to 2016 United Network for Organ Sharing data, all adults (age 18 y and above) undergoing LT were identified. The association of KPSS at the time of LT (KPSS 1: functional status 80% to 100%, KPSS 2: 60% to 70%, KPSS 3: 40% to 50%, KPSS 4: 10% to 30%) with post-LT survival was evaluated using Kaplan-Meier methods and adjusted multivariate logistic regression models. RESULTS Among 66,397 LT recipients (68% male, 72% non-Hispanic white, 22% hepatocellular carcinoma, median age: 55 to 57), women were more likely to be KPSS 4 at the time of LT compared with men (27.95% vs. 22.79%; P<0.001) and African Americans (25.43% vs. 23.03%; P<0.001) and Hispanics (31.69% vs. 23.03%; P<0.001) were more likely to be KPSS 4 than non-Hispanic whites. Worse KPSS at LT correlated with higher post-LT mortality [compared with KPSS 1: Hazard Ratio (HR) for KPSS 2: 1.16, 95% confidence interval (CI): 1.10-1.22; HR for KPSS 3: 1.40; 95% CI: 1.32-1.49; HR for KPSS 4: 1.67; 95% CI: 1.55-1.79]. This increased mortality seen with worse KPSS was observed among all liver disease etiologies and in patients with and without hepatocellular carcinoma. CONCLUSIONS Worse functional status at the time of LT is strongly associated with higher risk of mortality following LT, emphasizing the importance of optimizing performance status in the preoperative period.
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