Racial disparities in the management of hospitalized patients with cirrhosis and portal hypertension
Authors: Robert P. Myers
Journal: Hepatology (2007)

I read with interest the report by Nguyen et al. that described alarming racial disparities in the performance of surgical and endoscopic procedures in U.S. patients with cirrhosis.1 Compared with whites, African Americans (AAs) and Hispanics were much less likely to receive a portosystemic shunt (odds ratios [ORs] 0.37 [95% confidence interval {CI} 0.27-0.51] and 0.69 [0.54-0.88], respectively) or liver transplant (ORs 0.32 [95% CI 0.20-0.52] and 0.46 [0.25-0.83], respectively) for complications of portal hypertension. In addition, AAs with variceal bleeding had a higher rate of delayed endoscopic hemostasis. The authors speculated that these disparities may have contributed to the higher in-hospital mortality observed among AA patients.1 An important limitation of this study is the apparent failure to control for the transplantation status of the admitting hospital as a predictor of a patient's likelihood of undergoing transplantation. This is vital because the database used for this study (the Nationwide Inpatient Sample [NIS]) does not permit longitudinal patient follow-up.2 Therefore, if a patient was admitted to a nontransplant center for acute management of their portal hypertensive complication and then referred to a transplant center for elective liver transplantation, this would not have been captured in the NIS database (nor in this study because patients admitted electively for transplantation were excluded).1 Because significant differences in admitting hospital characteristics were evident between racial groups,1 I re-examined the NIS database adjusting for whether the admitting hospital was actually a transplant center. Specifically, any hospital that performed at least one liver transplant in a given year was considered a transplant center during that year. To control for the clustered nature of this data (that is, the nesting of patients within hospitals), I employed hierarchical linear models (HLMs) to determine the impact of race on receipt of a liver transplant (GLIMMIX procedure; SAS version 9.1; SAS Institute Inc., Cary, NC).3 I also assessed the influence of race on the likelihood of undergoing a paracentesis (ICD-9-CM code 54.91) for ascites to determine if the racial disparities observed by Nguyen and colleagues were consistent for other portal hypertension–related procedures. A multiple logistic regression model (SURVEYLOGISTIC procedure; SAS version 9.1) with adjustment for the sample discharge weights in the NIS data was used in this analysis due to a failure of convergence in the HLM analysis.3 Between 1998 and 2004, 68,004 patients with cirrhosis were admitted to 1937 U.S. hospitals for complications of portal hypertension. Only 62 of these hospitals (3.2%) performed liver transplants and are included in this analysis. These hospitals admitted 9412 eligible patients with cirrhosis and performed 493 transplants in these patients. After excluding 171 patients admitted electively for transplantation on the same day (as described by Nguyen et al.),1 9241 patients were included in the final analysis (racial composition: white 67%; AA 11%; Hispanic 16%; Asian 2%; other, 3%). Whereas 4.1% of whites underwent transplantation, AAs (1.1% underwent transplantation; OR 0.32; 95% CI 0.17-0.59) and Asians (2.3% underwent transplantation; OR 0.40; 95% CI 0.16-0.98), but not Hispanics (2.7% underwent transplantation; OR 0.75; 95% CI 0.52-1.08), were less likely to undergo liver transplantation. In a multivariate analysis controlling for admitting hospital, age, gender, primary health insurer, Charlson comorbidity score, geographic region, and clinical presentation, only AAs (OR 0.35; 95% CI 0.19-0.66), but not Hispanics (OR 0.81; 95% CI 0.56-1.18), were significantly less likely than whites to undergo liver transplantation for portal hypertension–related complications. In addition, compared to patients with private health insurance, those with Medicare, Medicaid, and no insurance were less likely to undergo transplantation (Fig. 1A). Predictors of undergoing (A) liver transplantation for complications of portal hypertension and (B) paracentesis for ascites in the NIS between 1998 and 2004. Solid circles indicate the reference categories for polychotomous variables. Note: x-axes are on a logarithmic scale. In supplemental analyses of 37,099 patients admitted with ascites, AAs were more likely than whites to have a paracentesis (OR 1.25; 95% CI 1.15-1.37), but less likely to receive a portosystemic shunt (OR 0.57; 95% CI 0.43-0.76). The likelihood of paracentesis was similar between other racial groups and whites, but was higher in patients with Medicaid or no health insurance than patients with private insurance (Fig. 1B). Paracentesis rates were also higher in patients with hepatorenal syndrome, but lower in those with variceal bleeding and hepatic encephalopathy. In summary, this revised analysis supports Nguyen and colleagues' findings of a lower rate of liver transplantation for portal hypertension–related complications in AAs than whites and patients without private health insurance.1 For the majority of the important covariates, the effect of the adjusted analysis was to slightly attenuate the estimated effects, but the impact of Hispanic race on the likelihood of liver transplantation was no longer statistically significant. Supplemental analyses revealed that AAs with ascites are more likely than whites to undergo paracentesis and less likely to receive a portosystemic shunt. In addition, compared with patients with private health insurance, those with Medicaid or no insurance have a higher likelihood of paracentesis. Among other factors, these findings may reflect racial differences in ascites severity and/or race-specific preferences of patients for paracentesis versus portosystemic shunts. Moreover, the large difference in cost between these procedures may explain their differential use according to the race and insurance coverage of patients with ascites. Future studies should explore reasons for these disparities and promote the equitable distribution of healthcare regardless of race and health insurance coverage. This work was supported by a Clinical Investigator Award from the Alberta Heritage Foundation for Medical Research. Robert P. Myers M.D.*, * Division of Gastroenterology, Department of Medicine, Liver Unit, University of Calgary, Calgary, Alberta, Canada.