Measuring chronic liver disease mortality using an expanded cause of death definition and medical records in Connecticut, 2004

Disparities in Social Vulnerability and Premature Mortality among Decedents with Hepatitis B, United States, 2010-2019

BACKGROUND

Current US hepatitis B mortality rates remain three times higher than the national target. Mortality reduction will depend on addressing hepatitis B disparities influenced by social determinants of health.

OBJECTIVES

This study aims to describe characteristics of hepatitis B-listed decedents, which included US birthplace status and county social vulnerability attributes and quantify premature mortality.

METHODS

We conducted a cross-sectional analysis of 17,483 hepatitis B-listed decedents using the 2010-2019 US Multiple-Cause-of-Death data merged with the county-level Social Vulnerability Index (SVI). Outcomes included the distribution of decedents according to US birthplace status and residence in higher versus lower death burden counties by sociodemographic characteristics, years of potential life lost (YPLL), and SVI quartiles.

RESULTS

Most hepatitis B-listed decedents were US-born, male, and born during 1945-1965. Median YPLL was 17.2; 90.0% died prematurely. US-born decedents were more frequently White, non-college graduates, unmarried, and had resided in a county with < 500,000 people; non-US-born decedents were more frequently Asian/Pacific Islander, college graduates, married, and had resided in a county with ≥ 1 million people. Higher death burden (≥ 20) counties were principally located in coastal states. US-born decedents more frequently resided in counties in the highest SVI quartile for "Household Characteristics" and "Uninsured," whereas non-US-born decedents more frequently resided in counties in the highest SVI quartile for "Racial/Ethnic Minority Status" and "Housing Type/Transportation."

CONCLUSION

This analysis found substantial premature hepatitis B mortality and residence in counties ranked high in social vulnerability. Successful interventions should be tailored to disproportionately affected populations and the social vulnerability features of their geographic areas.

Secular trends in cryoglobulinemia mortality in the USA in the era of direct-acting antivirals

Background

Hepatitis C virus (HCV) is the main etiology of cryoglobulinemia with mortality around 25%. Little is known on the changes in cryoglobulinemia mortality after the introduction of direct-acting antivirals (DAA) for treatment of HCV in 2014 in the USA.

Methods

We used the multiple-cause mortality files compiled by the National Center for Health Statistics to calculate cryoglobulinemia mortality from 1999 to 2018. The proportionate mortality ratio (PMR) of cryoglobulinemia cases with HCV and those with autoimmune diseases was computed to assess the impact of introduction of DAA.

Results

We identified 1299 people aged ≥ 20 years who died with cryoglobulinemia between 1999 and 2018. The cryoglobulinemia mortality (deaths per million) declined from 1999 (0.4) to 2010 (0.22) and mildly increased to 2014 (0.26), and then decreased abruptly from 2014 to 2018 (0.19) with annual percent change of − 14.3%. The proportion of cryoglobulinemia patients with HCV was 39% (118/302) in 2009–2013 and 26% (81/310) in 2014–2018, with a PMR of 0.67 (95% CI 0.50–0.89). By contrast, the proportion of cryoglobulinemia patients with systemic autoimmune diseases was 2.6% (8/302) in 2009–2013 and 4.2% (13/310) in 2014–2018, with a PMR of 1.58 (95% CI 0.66–3.82).

Conclusion

The changes in cryoglobulinemia mortality during the past two decades are mainly related to the aging and dying of the “baby boomer” cohort who had a high HCV prevalence and to the introduction of a DAA in 2014.

Common musculoskeletal disorders in chronic liver disease patients

Chronic liver disease (CLD) is the commonest ailment affecting the hepatobiliary system. Six significant pathologies related to CLD include hepatic osteodystrophy (HO), increased infection susceptibility, sarcopenia, osteonecrosis of the femoral head (OFH), increased risk of periprosthetic complications and fracture. Hepatic osteodystrophy, which comprises osteopenia, osteoporosis, and osteomalacia, refers to alterations in bone mineral metabolism found in patients with CLD. The HO prevalence ranges from 13 to 95%. Low complement levels, poor opsonization capacity, portosystemic shunting, decreased albumin levels, and impaired reticuloendothelial system make the cirrhotic patients more susceptible to developing infectious diseases. Septic arthritis, osteomyelitis, prosthetic joint infection, and cellulitis were common types of CLD-associated infectious conditions. The incidence of septic arthritis is 1.5 to 2-fold higher in patients with cirrhosis. Sarcopenia, also known as muscle wasting, is one of the frequently overlooked manifestations of CLD. Sarcopenia has been shown to be independent predictor of longer mechanical ventilation, hospital stay, and 12-month mortality of post-transplantation. Alcohol and steroid abuse commonly associated with CLD are the two most important contributory factors for non-traumatic osteonecrosis. However, many studies have identified cirrhosis alone to be an independent cause of atraumatic osteonecrosis. The risk of developing OFH in cirrhosis patients increases by 2.4 folds and the need for total hip arthroplasty increases by 10 folds. Liver disease has been associated with worse outcomes and higher costs after arthroplasty. Cirrhosis is a risk factor for arthroplasty complications and is associated with a prolonged hospital stay, higher costs, readmission rates, and increased mortality after arthroplasty. Greater physician awareness of risk factors associated with musculoskeletal complications of CLD patients would yield earlier interventions, lower healthcare costs, and better overall clinical outcomes for this group of patients.

Changes in liver-related mortality by etiology and sequelae: underlying versus multiple causes of death

Background

The expanded definition of liver-related deaths includes a wide range of etiologies and sequelae. We compared the changes in liver-related mortality by etiology and sequelae for different age groups between 2008 and 2018 in the USA using both underlying and multiple cause of death (UCOD and MCOD) data.

Methods

We extracted mortality data from the CDC WONDER. Both the absolute (rate difference) and relative (rate ratio and 95% confidence intervals) changes were calculated to quantify the magnitude of change using the expanded definition of liver-related mortality.

Result

Using the expanded definition including secondary liver cancer and according to UCOD data, we identified 68,037 liver-related deaths among people aged 20 years and above in 2008 (29 per 100,000) and this increased to 90,635 in 2018 (33 per 100,000), a 13% increase from 2008 to 2018. However, according to MCOD data, the number of deaths was 113,219 (48 per 100,000) in 2008 and increased to 161,312 (58 per 100,000) in 2018, indicating a 20% increase. The increase according to MCOD was mainly due to increase in alcoholic liver disease and secondary liver cancer (liver metastasis) for each age group and hepatitis C virus (HCV) and primary liver cancer among decedents aged 65–74 years.

Conclusion

The direction of mortality change (increasing or decreasing) was similar in UCOD and MCOD data in most etiologies and sequelae, except secondary liver cancer. However, the extent of change differed between UCOD and MCOD data.

Hepatitis C virus infection mortality trends according to three definitions with special concern for the baby boomer birth cohort

We examined mortality trends of hepatitis C virus (HCV) infection in the United States in 1999-2018 according to the following definitions: HCV as the underlying cause of death (UCOD), HCV mentioned anywhere on the death certificate (mentioned), and HCV recorded in Part 1 of the death certificate. By using entity axis information in mortality multiple-cause files, we ascertained the position of HCV on the death certificate. Joinpoint regression analysis was used to evaluate changes in HCV mortality rates according to the definitions. The age-standardized HCV mortality rates (deaths per 100,000 people) in terms of UCOD, mentioned, and Part 1 were, respectively, 1.36, 2.87 and 1.94, in 1999; increased to 1.90, 5.09 and 2.96 in 2013; and declined to 0.98, 3.77 and 2.29 in 2018. The mentioned/UCOD mortality ratio was 2.11 in 1999 and increased to 3.86 in 2018. The mentioned/Part 1 ratio was almost identical (ie 1.48 in 1999 and 1.65 in 2018). The extent of decline from 2014 to 2018 differed according to the definitions; the annual per cent changes for UCOD, mentioned, and Part 1 were -14.6%, -7.1% and -9.8%, respectively. For the same age group, the baby boomer subcohort 1950-1954 had the highest mortality rates among the subcohorts (1945-1949, 1955-1959 and 1960-1964). HCV mortality according to HCV in Part 1 of the death certificate-the explicit opinion of a certifying physician that HCV played a substantial role and directly caused death-differed from that according to HCV as UCOD and HCV mentioned.

Deaths Associated With Hepatitis C Virus Infection Among Residents in 50 States and the District of Columbia, 2016-2017

BACKGROUND

Mortality associated with hepatitis C virus (HCV) has been well-documented nationally, but an examination across regions and jurisdictions may inform health-care planning.

METHODS

To document HCV-associated deaths sub-nationally, we calculated age-adjusted, HCV-associated death rates and compared death rate ratios (DRRs) for 10 US regions, 50 states, and Washington, D.C., using the national rate and described rate changes between 2016 and 2017 to determine variability. We examined the mean age at HCV-associated death, and rates and proportions by sex, race/ethnicity, and birth year.

RESULTS

In 2017, there were 17 253 HCV-associated deaths, representing 4.13 (95% confidence interval [CI], 4.07-4.20) deaths/100 000 standard population, in a significant, 6.56% rate decline from 4.42 in 2016. Age-adjusted death rates significantly surpassed the US rate for the following jurisdictions: Oklahoma; Washington, D.C.; Oregon; New Mexico; Louisiana; Texas; Colorado; California; Kentucky; Tennessee; Arizona; and Washington (DRRs, 2.87, 2.77, 2.24, 1.62, 1.57, 1.46, 1.36, 1.35, 1.35, 1.35, 1.32, and 1.32, respectively; P < .05). Death rates ranged from a low of 1.60 (95% CI, 1.07-2.29) in Maine to a high of 11.84 (95% CI, 10.82-12.85) in Oklahoma. Death rates were highest among non-Hispanic (non-H) American Indians/Alaska Natives and non-H Blacks, both nationally and regionally. The mean age at death was 61.4 years (range, 56.6 years in West Virginia to 64.1 years in Washington, D.C.), and 78.6% of those who died were born during 1945-1965.

CONCLUSIONS

In 2016-2017, the national HCV-associated mortality declined but rates remained high in the Western and Southern regions and Washington, D.C., and among non-H American Indians/Alaska Natives, non-H Blacks, and Baby Boomers. These data can inform local prevention and control programs to reduce the HCV mortality burden.

Cirrhosis-related musculoskeletal disease: radiological review

Musculoskeletal problems in patients with liver disease are common; however, they are not so well described in the literature. Therefore, there is a need to collate information on these disorders, as their incidence is on a constant rise and some of these pathologies can severely debilitate the patient's quality of life. These disorders are parietal wall varices with or without bleeding, spontaneous intramuscular haematoma (e.g. rectus sheath), abdominal wall hernia, anasarca, hepatic osteodystrophy, septic arthritis, osteomyelitis, necrotizing fasciitis, osseous metastases from hepatocellular carcinoma etc. While portal hypertension plays a key role in disorders, in others, dysregulation of the coagulation system or a compromised immune system are responsible. Imaging plays an essential role in the assessment of these complications and awareness of these musculoskeletal manifestations is vital for establishing a timely diagnosis and planning of appropriate therapy, as these disorders can significantly impact the morbidity and mortality and also influence candidacy for liver transplantation. We herein comprehensively appraise various musculoskeletal complications associated with chronic liver disease/liver cirrhosis especially from an imaging perspective which, to the best of our knowledge, have not been collectively described in English literature.

Racial diversity in mortality and morbidity in urban patients with hepatitis C

Defining mortality for Caucasians and African American patients with chronic hepatitis C with respect to racial diversity is critical for counselling patients on therapy options. The objective of this study was to define racial diversity influence on mortality and morbidity of 3724 consecutive hepatitis C virus (HCV)-infected patients seen in an urban clinic between 1995 and 2008. Mortality, as of 2011, was defined using the SSA National Death Index and correlated with early visit medical information. The HCV chronically infected patient population consisted of 2879 African Americans (AA), 758 Caucasians and 87 other, and the majority were not treated for their infection prior to 2011. The average time to death from first visit was 5 years, the average age at death was 55 years, and despite racial diversity, AA were just as likely to be reported dead as Caucasians (23% AA vs 22% Caucasians). Cirrhosis and fibrosis (liver biopsy, AST Platelet Ratio Index or Fibrosis-4) at first visit as well as low albumin, diabetes, renal impairment and cardiac symptoms were associated with increased mortality. Treated patients who cleared the virus (sustained viral response (SVR); AA = 59; Caucasians = 40) had lower mortality than patients who were not treated (AA: 5% vs 27%; Caucasians 5% vs 26%). Hence, we find that race is not a factor in the early mortality of patients with chronic HCV infection and achieving a SVR reduced mortality. Unexpectedly, nonresponding AA also benefited by a lower mortality. African American patients with kidney disease and low albumin were at highest risk and should be treated as soon as identified.

Estimating the Number of Patients Infected With Chronic HCV in the United States Who Meet Highest or High-Priority Treatment Criteria

We estimated the number of people infected with HCV in the United States who would qualify for immediate treatment according to the 2014 guidance. We based fibrosis stage on biopsy results, when available, or on FIB-4 scores. We used laboratory tests and International Classification of Diseases, Ninth Revision, Clinical Modification codes to determine if patients had any qualifying comorbidities. Of the 2.7 million people with HCV infection, we assumed that 1.35 million (50%) had been diagnosed. We estimated 457, 000 met the highest and 356, 000 the high-priority criteria for treatment, indicating that as many as 813,000 people could be treated immediately with new therapies. These estimates can inform planning efforts to address clinical capacity constraints and treatment costs.