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Hundt M, Chen A, Donovan J, Kim N, Yilma M, Tana M, Mehta N, Zhou K. Barriers to liver transplant referral in safety net settings: A national provider survey. Liver Transpl 2024; 30:896-906. [PMID: 38687168 DOI: 10.1097/lvt.0000000000000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 04/12/2024] [Indexed: 05/02/2024]
Abstract
Safety net systems care for patients with a high burden of liver disease yet experience many barriers to liver transplant (LT) referral. This study aimed to assess safety net providers' perspectives on barriers to LT referrals in the United States. We conducted a nationwide anonymous online survey of self-identified safety net gastroenterologists and hepatologists from March through November 2022. This 27-item survey was disseminated via e-mail, society platforms, and social media. Survey sections included practice characteristics, transplant referral practices, perceived multilevel barriers to referral, potential solutions, and respondent characteristics. Fifty complete surveys were included in analysis. A total of 60.0% of respondents self-identified as White and 54.0% male. A total of 90.0% practiced in an urban setting, 82.0% in tertiary medical centers, and 16.0% in community settings, with all 4 US regions represented. Perceived patient-level barriers ranked as most significant, followed by practice-level, then provider-level barriers. Patient-level barriers such as lack of insurance (72.0%), finances (66.0%), social support (66.0%), and stable housing/transportation (64.0%) were ranked as significant barriers to referral, while medical mistrust and lack of interest were not. Limited access to financial services (36.0%) and addiction/mental health resources (34.0%) were considered important practice-level barriers. Few reported existing access to patient navigators (12.0%), and patient navigation was ranked as most likely to improve referral practices, followed by an expedited/expanded pathway for insurance coverage for LT. In this national survey, safety net providers reported the highest barriers to LT referral at the patient level and practice level. These data can inform the development of multilevel interventions in safety net settings to enhance equity in LT access for vulnerable patients.
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Affiliation(s)
- Melanie Hundt
- Department of Medicine, Los Angeles General Hospital, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ariana Chen
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - John Donovan
- Department of Medicine, Los Angeles General Hospital, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Nicole Kim
- Department of Medicine, University of Washington, Seattle, Washington
| | - Mignote Yilma
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Michele Tana
- Department of Medicine, University of California San Francisco Medical Center, San Francisco, California, USA
- Zuckerberg San Francisco General Hospital & Trauma Center, San Francisco, California, USA
- University of California San Francisco Liver Center, San Francisco, California, USA
| | - Neil Mehta
- Department of Medicine, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Kali Zhou
- Department of Medicine, Los Angeles General Hospital, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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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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Dowlatshahi S, Koh J, Vyas A, Mack WJ, Turner BJ. Disparities in Care for Low-Income Patients with Cirrhosis: Implementing an Innovative Outpatient Clinic for Refractory Ascites in a Safety Net Hospital. J Gen Intern Med 2024; 39:1245-1251. [PMID: 38378980 PMCID: PMC11116333 DOI: 10.1007/s11606-024-08675-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/02/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Disparities in life-saving interventions for low-income patients with cirrhosis necessitate innovative models of care. AIM To implement a novel generalist-led FLuid ASPiration (FLASP) clinic to reduce emergency department (ED) care for refractory ascites. SETTING A large safety net hospital in Los Angeles. PARTICIPANTS MediCal patients with paracentesis in the ED from 6/1/2020 to 1/31/2021 or in FLASP clinic or the ED from 3/1/2021 to 4/30/2022. PROGRAM DESCRIPTION According to RE-AIM, adoption obtained administrative endorsement and oriented ED staff. Reach engaged ED staff and eligible patients with timely access to FLASP. Implementation trained FLASP clinicians in safer, guideline-based paracentesis, facilitated timely access, and offered patient education and support. PROGRAM EVALUATION After FLASP clinic opened, significantly fewer ED visits were made by patients discharged after paracentesis [rate ratio (RR) of 0.33 (95% CI 0.28, 0.40, p < 0.0001)] but not if subsequently hospitalized (RR = 0.88, 95% CI 0.70, 1.11). Among 2685 paracenteses in 225 FLASP patients, complications were infrequent: 39 (1.5%) spontaneous bacterial peritonitis, 265 (9.9%) acute kidney injury, and 2 (< 0.001%) hypotension. FLASP patients rated satisfaction highly on a Likert-type question. DISCUSSION Patients with refractory ascites in large safety net hospitals may benefit from an outpatient procedure clinic instead of ED care.
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Affiliation(s)
- Shadi Dowlatshahi
- Department of Hospital Medicine, Los Angeles General Medical Center, Los Angeles, CA, USA
- Department of Medicine, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Jennifer Koh
- Department of Medicine, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Annasha Vyas
- Department of Medicine, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Wendy J Mack
- Department of Population and Public Health Sciences, Keck School of Medicine, USC, Los Angeles, CA, USA
| | - Barbara J Turner
- Department of Medicine, Keck Medical Center of University of Southern California, Los Angeles, CA, USA.
- Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine of USC, Clinical Sciences Center, Los Angeles, CA, USA.
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Wang MC, Bangaru S, Zhou K. Care for Vulnerable Populations with Chronic Liver Disease: A Safety-Net Perspective. Healthcare (Basel) 2023; 11:2725. [PMID: 37893800 PMCID: PMC10606794 DOI: 10.3390/healthcare11202725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Safety-net hospitals (SNHs) and facilities are the cornerstone of healthcare services for the medically underserved. The burden of chronic liver disease-including end-stage manifestations of cirrhosis and liver cancer-is high and rising among populations living in poverty who primarily seek and receive care in safety-net settings. For many reasons related to social determinants of health, these individuals often present with delayed diagnoses and disease presentations, resulting in higher liver-related mortality. With recent state-based policy changes such as Medicaid expansion that impact access to insurance and critical health services, an overview of the body of literature on SNH care for chronic liver disease is timely and informative for the liver disease community. In this narrative review, we discuss controversies in the definition of a SNH and summarize the known disparities in the cascade of the care and management of common liver-related conditions: (1) steatotic liver disease, (2) liver cancer, (3) chronic viral hepatitis, and (4) cirrhosis and liver transplantation. In addition, we review the specific impact of Medicaid expansion on safety-net systems and liver disease outcomes and highlight effective provider- and system-level interventions. Lastly, we address remaining gaps and challenges to optimizing care for vulnerable populations with chronic liver disease in safety-net settings.
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Affiliation(s)
- Mark C Wang
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Saroja Bangaru
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Los Angeles General Medical Center, Los Angeles, CA 90033, USA
| | - Kali Zhou
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Los Angeles General Medical Center, Los Angeles, CA 90033, USA
- Research Center for Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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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: 7] [Impact Index Per Article: 7.0] [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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Ohikere K, Chitnis AS, Hahambis TA, Singal A, Wong RJ. Ethnic Minorities and Low Socioeconomic Status Patients With Chronic Liver Disease Are at Greatest Risk of Being Uninsured. Gastroenterology Res 2022; 14:313-323. [PMID: 35059065 PMCID: PMC8734498 DOI: 10.14740/gr1439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/15/2021] [Indexed: 12/16/2022] Open
Abstract
Background Chronic liver disease (CLD) predominantly affects ethnic minorities and socially vulnerable populations, who have high prevalence of risk factors (e.g., suboptimal insurance coverage) predisposing to healthcare disparities. We evaluate prevalence and predictors of uninsured status among CLD adults, and secondarily, how this affects documented immunity or vaccination for hepatitis A virus (HAV) and hepatitis B virus (HBV). Methods Using 2011 - 2018 National Health and Nutrition Examination Survey data, self-reported insurance status was determined among adults with CLD. Prevalence of uninsured status was stratified by patient characteristics and evaluated using multivariable logistic regression models. Prevalence of self-reported completion of vaccination as well as laboratory value-based documented immunity to HAV and HBV was stratified by insurance status. Results Overall, 19.0% of adults with CLD reported having no insurance, which was highest among individuals of Hispanic ethnicity (33.5%), less than high school education (33.7%), and below poverty status (35.3%). On multivariable analyses, significantly lower odds of having any insurance coverage was observed in men, Hispanics, and individuals with lower education and lower household income. Prevalence of documented immunity or vaccination for HAV was low across all insurance categories, ranging from 46.5% to 54.0%. Prevalence of documented immunity or vaccination for HBV was similarly low across all insurance categories, ranging from 24.3% to 40.8%. Conclusion Prevalence of uninsured status among CLD was more than twice the US adult population, and lack of insurance particularly impacted Hispanics and individuals with low education and low household income. Low prevalence of documented immunity or vaccination for HAV and HBV across all insurance categories is concerning.
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Affiliation(s)
- Kabiru Ohikere
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | - Amit S Chitnis
- Tuberculosis Section, Division of Communicable Disease Control and Prevention, Alameda County Public Health Department, San Leandro, CA, USA
| | | | - Ashwani Singal
- Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA.,Division of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, SD, USA
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA.,Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA
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