Racial Inequalities Persist in Advanced Cirrhosis Care

Megan Brooks

July 21, 2023

A contemporary trends analysis shows persistent racial and ethnic disparities in receipt of complex lifesaving procedures for decompensated cirrhosis, including transjugular portosystemic shunt (TIPS) and liver transplant (LT).

The analysis is the first to assess disparities in receipt of procedures for patients with cirrhosis since a 2007 study of patients with the condition and complications of portal hypertension. That research also found significant racial and ethnic disparities in TIPS, as well as time to esophagogastroduodenoscopy for variceal hemorrhage (VH).

"Given the increasing diversity of our country, the growing concern over healthcare disparities, and increasing efforts to achieve health equity, it is imperative that we have current data on epidemiologic trends. Our study provides these crucial data," the colead authors of the new analysis told Medscape Medical News.

"Most importantly, we show that disparities in receipt of care for life-saving procedures persist in our healthcare system. Our data highlight the need for intentional public health efforts to address disparities and guide where these efforts are needed the most," said Lauren Nephew, MD, and Archita Desai, MD, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis.

The study was published online July 20 in JAMA Network Open.

Disparities Across Several Measures

Using data from the National Inpatient Sample, the researchers did a cross-sectional analysis of hospital admissions of adults for decompensated cirrhosis from 2009 to 2018.

Among 3,544,636 admissions, 345,644 patients (9.8%) were Black, 623,991 (17.6%) were Hispanic, 2,340,031 (47.4%) were White, and 234,970 patients (6.6%) identified as other race or ethnicity. The median patient age was 58 years.

By 2018, there were no significant disparities in the odds of receiving upper endoscopy for VH across racial and ethnic groups, the researchers report.

However, by 2018, Black patients remained less likely than White patients to undergo TIPS for VH (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.49 to 0.65). A disparity also remained in receiving TIPS for ascites, with Black patients (OR, 0.41; 95% CI, 0.37 to 0.45) and Hispanic patients (OR, 0.86; 95% CI, 0.81 to 0.92) less likely to undergo the procedure.

"These differences persisted even after adjusting for comorbidity and history of hepatic encephalopathy and excluding patients with heart failure," the researchers write.

During the study period, the disparity in receipt of LT improved for Black patients but declined for Hispanic patients. However, by 2018, both groups were less likely to undergo LT than their White peers, with an OR of 0.66 (95% CI, 0.61 to 0.70) for Black patients and 0.74 (95% CI, 0.70 to 0.78) for Hispanic patients.

"Reasons for disparities in the receipt of LT may include the social and structural determinants of health and the resultant sequalae of poor social support, high burden of disease, and substance use," the researchers write.

The odds of death decreased for Black and Hispanic patients over the study period but remained higher among Black patients compared with White patients (OR, 1.08; 95% CI, 1.05 to 1.11).

Call for Multilevel Action

"The evidence is clear that multilevel interventions have been the most successful at improving health care disparities, so solutions will need to consider intervening on both upstream and downstream factors to be effective," the researchers point out.

It's important to "acknowledge that disparities will not resolve without intentional action," they add.

The researchers propose several "next steps" using a socioecological model as a framework to target action "from upstream to downstream" — including comprehensive antiracism and unconscious bias training for healthcare professionals, expansion of Medicaid coverage, inclusion of safety-net and community hospitals in prospective trials, patient-involved qualitative and mixed-method studies, and multilevel interventions to improve healthcare disparities.

JAMA Netw Open. Published online July 20, 2023. Full text

Funding for the study was provided by the National Institute on Minority Health and Health Disparities and the National Institute of Diabetes and Digestive and Kidney Diseases. Nephew and Desai have disclosed no relevant financial relationships.

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