Racial disparities in treatment of patients with cirrhosis and complications of portal hypertension

May 2 2007

African-American and Hispanic patients hospitalized for complications of portal hypertension were less likely to undergo a palliative shunt, prompt endoscopy, or liver transplantation compared to white patients, according to a new study in the May issue of Hepatology, a journal published by John Wiley & Sons on behalf of the American Association for the Study of Liver Diseases (AASLD).

Liver disease is very common in the United States and as it progresses, patients develop portal hypertension-related complications, such as variceal bleeding, ascites or hepatic encephalopathy. These patients should be considered for liver transplantation, without which they face a 2-year survival prognosis of less than 50 percent. While awaiting transplants, they may be candidates for palliative procedures including endoscopic band ligation or portosystemic shunts.

Previous studies have revealed widespread racial disparities in disease treatments and outcomes. To determine the influence of race and health insurance for patients with serious liver disease, including their likelihood of receiving palliative procedures or transplants, researchers, led by Paul J. Thuluvath. MD (and Geoffrey Nguyen, Fellow in Gastroenterology & Hepatology) of Johns Hopkins University School of Medicine examined a nationally representative, population-based sample of hospitalized patients with cirrhosis and complications of portal hypertension.

Using the Nationwide Inpatient Sample, the researchers included 63,696 patients with cirrhosis who were admitted to a hospital between 1998 and 2003 for a complication of portal hypertension. The researchers gathered demographic data, information on health insurance and treatment efforts, and then performed statistical analyses, adjusting for potential confounding factors. They found that during hospital stays, African-American and Hispanic patients were significantly less likely than white patients to receive a portosystemic shunt, a prompt endoscopic variceal hemostasis, or a liver transplant.

Compared to white patients, the odds ratio of undergoing portosystemic shunt for was .37 for African-Americans, and .69 for Hispanics. Similarly, the odds ratio of undergoing liver transplantation was .32 for African-Americans and .46 for Hispanics. For patients with variceal bleeding, rates of upper endoscopy and variceal treatment were similar, however, the odds ratio of delayed endoscopy (more than 24 hours after admission) was 1.6 for African-American patients, compared to white patients. African-American patients were more likely to die in the hospital compared to white patients, while Hispanic patients were less likely than white patients to die in the hospital.

Relative to those who had private insurance, patients receiving Medicare, Medicaid or who were uninsured were less likely to undergo a shunt procedure, more likely to have a delayed endoscopy, and much less likely to receive a liver transplant.

"We have shown that there are striking racial variations in surgical and endoscopic procedures used in the inpatient management of complications of portal hypertension in the USA," the authors report. "The reasons for these racial differences are unclear from this study."

While non-medical factors such as health care access may play a contributing role, the authors also found that racial differences were independent of type of health insurance. They suggest that disease severity, for which they were unable to control, might also play a role.

"Further primary studies are warranted to confirm and elucidate the mechanisms of racial disparities in order to enact interventions to rectify them," the authors conclude. "Concurrently, it is a measure of good practice and quality of care to develop more standardized protocols in the management of portal hypertension to ensure equitable care regardless of race, health insurance coverage, or socioeconomic status."