Insurance Status But Not Race and Ethnicity Are Associated With Outcomes in a Large Hospitalized Cohort of Patients With Cirrhosis.

BACKGROUND & AIMS: Insurance, race, and ethnicity can affect outcomes of patients with cirrhosis, but findings from prospective studies are unclear. We investigated the role of insurance status and race and ethnicity (race/ethnicity) on inpatient and 90-day postdischarge outcomes in a large inpatient cohort of patients with cirrhosis. METHODS: We used data from the North American Consortium for the Study of End-Stage Liver Disease (NACSELD) database, from 13 tertiary care centers. Insurance status (uninsured, Medicare, Medicaid, private, and Canadian), race, and ethnicity, were analyzed independent of clinical covariates for their association with transfer to the intensive care unit, acute on chronic liver failure (ACLF), length of hospital stay, inpatient and 90-day death or liver transplantation, and readmission to the hospital within 90 days. Multi-variable analyses and interaction terms were created for insurance, race/ethnicity, and for each outcome, with or without Canadian patients. RESULTS: We analyzed data from 2640 patients in the NACSELD database (971 with private insurance, 770 with Medicare, 456 Canadians, 265 with Medicaid, 178 uninsured, 540 non-Caucasian and 220 Hispanic); 23% required admittance to the intensive care unit, 12% developed NACSELD-defined ACLF, 7% died, 5% underwent liver transplantation. Of the 2288 patients discharged from hospital, 13% underwent liver transplantation, 19% died, and 42% were readmitted within 90 days. In the univariate model, uninsured patients accounted for the highest percentage of alcohol- or bleeding-related admissions and the lowest proportion of outpatient cirrhosis-related medication users. Canadians had the lowest rifaximin use and but higher proportions had hepatic encephalopathy, compared with other groups. Lack of insurance was higher among non-Caucasians, regardless of Hispanic ethnicity. In multi-variable analysis, lack of insurance was associated with ACLF (P = .02) and inversely associated with inpatient liver transplant (P = .05) and 90-day liver transplant (P = .02), regardless of whether Canadians were included or specific insurance type. Race or ethnicity were not significantly associated with outcomes. CONCLUSIONS: In analyzing the NACSELD database, we found that insurance status, but not race or ethnicity, were independently associated with ACLF and inpatient or 90-day liver transplantation, regardless of inclusion of Canadian patients.

Hepatitis C as a prognostic indicator among noncirrhotic patients hospitalized with alcoholic hepatitis.

OBJECTIVE: A nationwide analysis of alcoholic hepatitis (AH) admissions was conducted to determine the impact of hepatitis C virus (HCV) infection on short-term survival and hospital resource utilization. METHODS: Using the Nationwide Inpatient Sample, noncirrhotic patients admitted with AH throughout the United States between 1998 and 2006 were identified with diagnostic codes from the International Classification of Diseases, Ninth Revision. The in-hospital mortality rate (primary end point) of AH patients with and without co-existent HCV infection was determined. Hospital resource utilization was assessed as a secondary end point through linear regression analysis. RESULTS: From 1998 to 2006, there were 112,351 admissions for AH. In-hospital mortality was higher among patients with coexistent HCV infection (41.1% versus 3.2%; P=0.07). The adjusted odds of in-hospital mortality in the presence of HCV was 1.48 (95% CI 1.10 to 1.98). Noncirrhotic patients with AH and HCV also had longer length of stay (5.8 days versus 5.3 days; P<0.007) as well as greater hospital charges (US$25,990 versus US$21,030; P=0.0002). CONCLUSIONS: Among noncirrhotic patients admitted with AH, HCV infection was associated with higher in-hospital mortality and resource utilization.

Prolonged waiting times for liver transplantation in obese patients.

OBJECTIVE: To quantify the independent association between obesity and access to liver transplantation. BACKGROUND: Obesity is associated with higher complication rates, longer hospitalization, and worse survival after liver transplantation. Nevertheless, transplantation provides survival benefit to patients with end-stage liver disease, regardless of body mass index (BMI). We hypothesized that, despite survival benefit, providers were reluctant to transplant obese patients because of the inherent difficulty of these cases and their inferior outcomes. Our goal was to quantify the independent association between BMI and waiting time for orthotopic liver transplantation as a surrogate marker for this reluctance. METHODS: We studied 29,136 wait-list candidates in the model for end-stage liver disease (MELD) era, categorized as severely obese (BMI 35-40), morbidly obese (BMI 40-60), and reference (BMI 18.5-35). All models were adjusted for factors relevant to the allocation system, factors possibly influencing access to healthcare, and factors biologically related to disease progression and outcomes. RESULTS: The odds of receiving a MELD exception were 30% lower in severely obese and 38% lower in morbidly obese patients. Similarly, the likelihoods of being turned down for an organ were 10% and 16% higher, and the rates of being transplanted were 11% and 29% lower in severely obese and morbidly obese patients, respectively. CONCLUSIONS: Current practice seems to indicate a reluctance to transplant obese patients. If indeed as a community we feel that liver allografts should not be distributed to patients with excessive postoperative risk, we should consider expressing this as a formal change to our allocation policy rather than through informal practice patterns.

Racial disparity in liver disease: Biological, cultural, or socioeconomic factors.

Chronic liver diseases are a major public health issue in the United States, and there are substantial racial disparities in liver cirrhosis-related mortality. Hepatitis C virus (HCV) is the most significant contributing factor in the development of chronic liver disease, complications such as hepatocellular carcinoma, and the need for liver transplantation. In the United States, African Americans have twice the prevalence of HCV seropositivity and develop hepatocellular carcinoma at more than twice the rate as whites. African Americans are, however, less likely to respond to interferon therapy for HCV than are whites and have considerably lower likelihood of receiving liver transplantation, the only definitive therapy for end-stage liver disease. Even among those who undergo transplantation, African Americans have lower 2-year and 5-year graft and patient survival compared to whites. We will review these racial disparities in chronic liver diseases and discuss potential biological, socioeconomic, and cultural contributions. An understanding of their underlying mechanisms is an essential step in implementing measures to mollify racially based inequities in the burden and management of liver disease in an increasingly racially and ethnically diverse population.

Outcomes of patients with cirrhosis undergoing non-hepatic surgery: risk assessment and management.

The reported mortality rates in patients with cirrhosis undergoing various non-transplant surgical procedures range from 8.3% to 25%. This wide range of mortality rates is related to severity of liver disease, type of surgery, demographics of patient population, expertise of the surgical, anesthesia and intensive care unit team and finally, reporting bias. In this article, we will review the pathophysiology, morbidity and mortality associated with non-hepatic surgery in patients with cirrhosis, and then recommend an algorithm for risk assessment and evidence based management strategy to optimize post-surgical outcomes.

Racial disparities in the management of hospitalized patients with cirrhosis and complications of portal hypertension: a national study.

UNLABELLED: Having complications of portal hypertension is a harbinger of decompensated cirrhosis and warrants consideration for liver transplantation (LT). Racial disparities in LT have been reported. We sought to characterize disparities in the performing of surgical and endoscopic procedures among hospitalized patients with complications of portal hypertension. We queried the Nationwide Inpatient Sample from 1998 to 2003 to identify patients with cirrhosis and complications of portal hypertension. Logistic regression controlling for confounders was used to evaluate race as a predictor of undergoing a portosystemic shunt and LT and of dying in the hospital. Compared to whites, the adjusted odds ratios of receiving a portosystemic shunt were 0.37 (95% CI: 0.27-0.51) and 0.69 (95% CI: 0.54-0.88) for African Americans (AAs) and Hispanics, respectively. AAs with variceal bleeding were more likely to have endoscopic variceal hemostasis delayed more than 24 hours after admission than were whites (OR 1.6; 95% CI: 1.2-2.1). The adjusted odds ratios of undergoing LT were 0.32 (95% CI:0.20-0.52) and 0.46 (95% CI: 0.25-0.83) for AAs and Hispanics, respectively. Compared to whites, AAs experienced higher in-hospital mortality (OR 1.12; 95% CI: 1.01-1.24), whereas Hispanics had a lower risk of death (OR 0.83; 95% CI: 0.75-0.92). Among variceal bleeders, the odds ratio of death for AAs was 1.7 (95% CI: 1.2-2.4) compared to whites. CONCLUSION: AAs and Hispanics hospitalized for complications of portal hypertension were less likely to undergo a palliative shunt or LT than whites, which may contribute to the higher in-hospital mortality of AAs. Further studies are warranted to elucidate the mechanisms of these exploratory findings.

Noninvasive markers of fibrosis for longitudinal assessment of fibrosis in chronic liver disease: are they ready for prime time?

Over the past decade, there has been a renewed enthusiasm to develop noninvasive serum markers or tests to assess the presence and severity of fibrosis in chronic liver disease. Although a single marker or test has lacked the necessary accuracy to predict fibrosis, different combinations of these markers or tests have shown encouraging results. However, inter-laboratory variability and inconsistent results with liver diseases of varying etiologies have made it difficult to assess the reliability of these markers in clinical practice. In this issue of the journal, Poynard et al. describe the "histological" response to lamivudine in patients with chronic Hepatitis B Virus (HBV) over a 24-month period using surrogate serum biomarkers (Fibrotest-Actitest, FT-AT) without corroborating histological data. Investigators found improvement in fibrosis and inflammation in 85% and 91%, respectively, despite the emergence of YMDD mutation in 41.5% of patients. The higher improvement rates reported in this study should be interpreted with caution for a number of reasons including the absence of data on virological response rates, corroboratory histological data, and data on the validity of FT to evaluate fibrosis in a longitudinal manner. Although FT has been studied extensively by the authors of the current study, to date there are only few independent studies. In addition to significant inter-laboratory variations, these studies have shown that significant fibrosis could be missed, or conversely significant fibrosis diagnosed in the absence of minimal or no fibrosis in about 15% to 20% of patients. We may be approaching a time when serum biomarkers may become an integral part of the assessment of patients with chronic liver disease, but published evidence suggests that these markers are not yet ready for prime time.

Noninvasive markers of fibrosis for longitudinal assessment of fibrosis in chronic liver disease: are they ready for prime time?

Over the past decade, there has been a renewed enthusiasm to develop noninvasive serum markers or tests to assess the presence and severity of fibrosis in chronic liver disease. Although a single marker or test has lacked the necessary accuracy to predict fibrosis, different combinations of these markers or tests have shown encouraging results. However, interlaboratory variability and inconsistent results with liver diseases of varying etiologies have made it difficult to assess the reliability of these markers in clinical practice. In this issue of the Journal, Poynard and colleagues describe the "histological" response to lamivudine in patients with chronic HBV over a 24-month period using surrogate serum biomarkers (FibroTest-ActiTest) without corroborating histological data. Investigators found improvement in fibrosis and inflammation in 85% and 91%, respectively, despite the emergence of YMDD mutation in 41.5% of patients. The higher improvement rates reported in this study should be interpreted with caution for a number of reasons including the absence of data on virological response rates, corroboratory histological data, and data on the validity of FibroTest to evaluate fibrosis in a longitudinal manner. Although FibroTest has been studied extensively by the authors of the current study, to date there are only few independent studies. In addition to significant interlaboratory variations, these studies have shown that significant fibrosis could be missed, or conversely significant fibrosis diagnosed in the absence of minimal or no fibrosis in about 15-20% of patients. We may be approaching a time when serum biomarkers may become an integral part of the assessment of patients with chronic liver disease, but published evidence suggests that these markers are not yet ready for prime time.

Short-term postliver transplant survival after the introduction of MELD scores for organ allocation in the United States.

BACKGROUND: It has been suggested that the introduction of model for end-stage liver disease (MELD) for organ allocation may reduce overall graft and patient survival since elevated serum creatinine is an important predictor of poor outcome after liver transplantation. OBJECTIVE: In this study, we determined the outcomes of liver transplantation before (PreMELD group, 1998-February, 2002) and after (MELD group, March-December, 2002, n = 4642) the introduction of MELD score, and examined the impact of MELD scores on the outcome in the United States (US). PATIENTS & METHODS: After excluding patients for a variety of reasons (children, live-donor, fulminant liver failure, patients with hepatoma and others who received extra MELD points, multiple organ transplantation, re-transplantation, incomplete data), there were 3227 patients in the MELD group. These patients were compared with 14,593 patients in the preMELD group after applying similar exclusion criteria. The survival was compared using Kaplan-Meier survival analysis and Cox regression survival analysis. RESULTS: There was no difference in short-term (up to 10 months) graft and patient survival between MELD and preMELD groups. However, graft and patient survival was lower in patients with MELD score > or = 30 when compared with those with MELD score <30 after adjusting for the confounding variables. CONCLUSION: Introduction of MELD score for organ prioritization has not reduced the short-term survival of patients, but patients with MELD score of 30 or higher had a relatively poor outcome.

Outcome of liver transplantation in adult recipients: influence of neighborhood income, education, and insurance.

Poor socioeconomic status (SES) may be associated with lower survival after liver transplantation. In a previous study, we showed that African-American race was an independent predictor of poor survival, and one of the major criticisms of our study was that we had not adjusted the survival for SES as a confounding variable. The objective of the present study was to determine the posttransplant outcome of adult liver transplant recipients based on neighborhood income, education, and insurance using the United Network for Organ Sharing (UNOS) database from 1987 to 2001. Patients (n = 29,481) were divided into 5 groups based on median income as determined by zip code: <30,000 dollars, 30,001-40,000 dollars, 40,001-50,000 dollars, 50,001-60,000 dollars, and >60,000 dollars). Patients (n = 14,814) were divided into 4 groups based on level of education: higher than bachelor's degree; college attendance or technical school; high school education (grades 9-12); less than high school education. Insurance payer status (n = 23,440) was divided into Medicaid, Medicare, government agency, HMO/PPO, and private. Cox regression analysis was used to adjust the survival for other known independent predictors such as age, race, UNOS status, diagnosis, and creatinine. Results showed that neighborhood income had no effect on graft or patient survival either in the entire cohort or within different racial groups. Education had only marginal influence on the outcome; survival was lower in those with a high school education than in those with graduate education. Patients with Medicaid and Medicare had lower survival when compared to those with private insurance. African-Americans had a lower 5-year survival when compared to white Americans after adjusting for SES and other confounding variables. In conclusion, neighborhood income does not influence the outcome of liver transplantation. Education had minimal influence, but patients with Medicare and Medicaid had lower survival compared to those with private insurance.

Hospital experience and outcomes for esophageal variceal bleeding.

OBJECTIVE: Although higher hospital volume has been associated with better outcomes for many surgical procedures, this relationship does not appear to hold for most common medical diagnoses. We evaluated whether there is a volume-outcome relationship for a rarer and higher-mortality medical diagnosis, esophageal variceal bleeding. DESIGN: Cross-sectional retrospective study of hospital discharge data. SETTING: All Maryland hospitals from 1992 through 1996. STUDY PARTICIPANTS: All patients with diagnosis codes for both esophageal variceal bleeding and cirrhosis in relevant diagnosis-related groups. MAIN OUTCOME MEASURE: Mortality for esophageal variceal bleeding. We classified hospitals by tertiles of admissions as high (> 17 cases of variceal bleeding per year), medium (12-17 cases per year) or low (< 12 cases per year) volume. RESULTS: There were seven high-volume, 13 medium-volume, and 29 low-volume hospitals. Overall in-hospital mortality was 15%. After multiple regression was used to adjust for differences in age, sex, ethnicity, emergency room admission, use of procedures, complexity, Medicaid status, transfer status, and clinical variables associated with mortality from variceal bleeding, there were no significant differences between the high-, medium-, and low-volume hospital groups in in-hospital mortality (16%, 15%, and 13%, respectively). There were also no significant differences in hospital charges (dollar 17 000, dollar 15 000, and dollar 14 000, respectively) or length of stay (8.5, 8.7, and 7.8 days, respectively) between hospital volume groups. CONCLUSIONS: The volume-outcome relationship may not pertain to some medical diseases such as esophageal variceal bleeding. Alternatively, the biases inherent in research using administrative data may make this relationship appear weaker for some medical than for surgical diagnoses in this type of study.

Socioeconomic status does not affect the outcome of liver transplantation.

The outcome of liver transplantation is dependent on many factors. It was suggested that racial disparities in outcome may be related to differences in socioeconomic status (SES). In this retrospective study, we analyzed the effect of SES on graft and patient survival. Two hundred seventy-six adult patients who underwent liver transplantation at our institution from July 1988 to June 2001 were included in the analysis. Educational and occupation statuses were coded using established criteria (Hollingshead Index of Social Status [HI]). SES then was calculated using the HI formula: SES = education level x 3 + occupation x 5, and categorized into four groups: group 1, score less than 29 (n = 71); group 2, score of 29 to 42 (n = 82); group 3, score of 42 to 53 (n = 69); and group 4, score greater than 53 (n = 54). Kaplan-Meier analysis was used for graft and patient survival, and Cox regression analysis was used to determine the effect of confounding factors. Demographics of all four groups were similar. One-, 2-, and 5-year graft and patient survival did not differ significantly across groups by Kaplan-Meier and Cox regression survival analysis. In conclusion, SES did not predict graft and patient survival after liver transplantation.