Disparities in Cirrhosis Management of Black Patients: Do We Know What to Address?

Abstract

Mazumder NR, Simpson D, Atiemo K, et al. Black patients with cirrhosis have higher mortality and lower transplant rates: results from a metropolitan cohort study. Hepatology 2021;74:926–936.The background of this study is based on the fact that estimates of racial disparities in cirrhosis management have been confined by the lack of large-scale, longitudinal data that follow patients from diagnosis to transplant or death. Most of the studies examining racial disparities in liver disease of Black patients were conducted 15–20 years ago. The study methods used here were based on the analysis of a large, metropolitan, population-based health record (HealthLNK) in the Chicago area. This record included data from approximately 2.4 million patients spanning health care encounters from January 2006 to December 2012 from 6 large health care institutions. This was linked to the national transplant database (United Network for Organ Sharing), which comprises national registry data from all patients listed for transplantation. A further link was the state death registry (Social Security Death Master File for the state of Illinois). The authors conducted multivariate competing risk analyses, using sex, age, insurance status, Elixhauser comorbidity index, etiology of cirrhosis, hepatocellular carcinoma, portal hypertensive complications (ascites, hepatic encephalopathy, varices or variceal bleeding), and Model for End-stage Liver Disease (MELD)-Na as variables. They examined the relationship between race, transplant and cause of death as defined by blinded death certificate review. There were 11,277 patients who met the inclusion criteria; 2498 (22.2%) were Black. The results found that Black patients had similar age, sex, MELD-Na, and proportion of alcohol-associated liver disease compared with White patients. However, Black patients had a higher comorbidity burden, lower rates of private insurance, and lower rates of portal hypertensive complications. Black patients had the highest rate of all-cause mortality and non–liver-related deaths and were less likely to be listed for transplantation (P < .0001 for all) as compared with White patients. The conclusions were that in multivariate competing risk analysis the hazard of liver-related death was increased by 27% for Black patients (subdistribution hazard ratio [sHR], 1.27; 95% confidence interval [CI], [1.14–1.40]; P < .001).CommentAwareness of health disparities in minority populations will help to identify health care gaps and improve disease outcomes. Factors contributing to health disparities include (a) socioeconomic status, influenced by education, employment, and income, (b) lifestyle, including nutrition and physical activity, (c) physical and social environment, (d) access to health care for prevention and treatment, (e) systemic or structural racism against race, gender, gender identity, sexual orientation, and disability, and (f) implicit bias. Recognizing factors resulting in health disparities of specific populations can advance their resolution.The prevalence of cirrhosis in the United States is approximately 525:100,000 people (Lancet Gastroenterol Hepatol 2020;5:245–266). Deaths owing to cirrhosis constitute approximately 14:100,000, with an increase compared with 1990 and imposing a substantial health burden. The main causes of cirrhosis are still chronic hepatitis B and C virus infection, although effective preventative measures and treatment options are available respectively. Alcohol remains another contributor; however, nonalcoholic steatohepatitis is expected to become the major cause in the future. Thus, cost-effective interventions are required to achieve early diagnosis and prevention of cirrhosis.In this article, Mazumder et al studied the outcomes of liver cirrhosis, including morbidity, mortality, and transplant rates, in self-identified Black patients (22%). To date, this study is the largest to examine health disparities in cirrhosis management. Black patients had similar age (mean, 56 years), distribution of sex (43.8% female), proportion of public insurance (52%), and proportion of alcohol-associated liver disease (43%) compared with White patients. However, compared with other patient groups, they had the lowest rates of private insurance (20.1%), the highest comorbidity burden as measured by the Elixhauser score, and the highest rate of hepatitis C virus (HCV)-related cirrhosis (56.9%). It has been described that minority groups often do not preclude their racial background, to avoid systemic racism and inferior health care (Med Care 2019;57:e28–e33). Thus, comparing self-identified groups may not capture the whole picture.Although this study was recently published, it incorporated patient data collected between 2006 and 2012, and may not reflect the current situation. Owing to its retrospective character, it depended on procedure codes to define diagnoses. This method may be unprecise in case such codes were not documented accurately. Additionally, omitting dialysis information from MELD-Na scores may lead to underestimation. The study was further able to capture only the greater Chicago area, and it is unclear whether this is representing the situation in suburban areas and at the national level. Accessing and analyzing the aforementioned databases in suburban areas and in other states may generate a better overview of health disparities in liver cirrhosis. Because center-derived characteristics account for disparate racial outcomes, and Black patients are more often hospitalized in suburban hospitals with higher mortality rates (J Racial Ethn Health Disparities 2017;4:243–251), this factor may affect the results of such studies.When applying univariate competing risk analysis the authors demonstrate that Black patients have an increased hazard of all-cause mortality and non–liver-related death compared with White patients, as well as lower rates of transplantation. After adjusting these analyses and controlling for insurance status, the increased hazard of non–liver-related death stayed statistically significant (sHR, 1.69; 95% CI, [1.41–2.03]; P < .001). However, HCV infection was identified as one of the major causes of liver disease in the Black population. The diagnosis of chronic HCV infection, has been linked with lower socioeconomic status (Clin Epidemiol 2013;5:163–172), when defined as a combination of education, employment, and income. It has further been demonstrated that Black patients are 30% less likely to receive HCV treatment despite equal cure rates (Public Health Rep 2018;133:452–460). Thus, social disparities seem to be a contributing factor to differences in cirrhosis management, because low income has been linked to inadequate access to health insurance, inadequate health care, and unaffordability of drugs needed for treatment. Thus, adjusting these analyses not only for insurance status, but also for education, income, residency and employment is important to better reflect socioeconomic status. In contrast, a recent article demonstrated that mortality owing to COVID-19 is not different in the Black community after adjustment for insurance status and low-income residency (N Engl J Med 2020;382:2534–2543). Collectively, it is extremely difficult to compare results from different studies if parameters are not standardized. Thus, in disparities research sociodemographic data should be standardized to include education, income, employment, insurance, and residency to capture the whole data and extract meaningful results, rather than using vague definitions of socioeconomic status.When adding hypothesized mediators of death to patients with cirrhosis, the authors declare that Black patients had an even more pronounced association with all-cause mortality and low likelihood of transplantation, as well as an increased hazard of liver-related death (sHR, 1.29; 95% CI, [1.15–1.45]; P < .001). Furthermore, Black patients had the highest rates of hypertension, diabetes and renal failure in their Elixhauser scores, which is consistent with what has been published elsewhere (Circulation 2021;143:2367–2369; JAMA 2017;318:2457–2465). It has been reported recently that creatinine values, which are used to estimate renal function by glomerular filtration rate (GFR), if used irrespective of race introduce systemic misclassification owing to GFR underestimation (N Engl J Med 2021;385(19):1750-1760). The use of creatinine may have been accountable for declaring Black patients as having the highest rates of renal failure. However, adults who identify as Black have higher serum creatinine levels on average. It was thus proposed to estimate renal function and GFR by cystatin C, eliminating negative consequences of current race-based approaches. Because creatinine may introduce misclassifications also in the MELD-Na scores, using cystatin C may be a promising alternative. However, this approach would need to be validated in clinical studies.Overall, the results of this study imply that health disparities exist in liver cirrhosis management of Black patients. However, more studies with standardized comparison criteria need to be conducted to extract conclusive results. Offering Black and other minority populations equal opportunities to education, employment, and health care may eliminate some of the major contributors to social discrepancies and subsequent health disparities in the United States. Because viral hepatitis is the leading cause of cirrhosis, and it is often identified in minority populations, health programs for specific patient groups are important. Educating physicians about implicit bias, avoiding structural racism, and offering lifestyle consultations need to be implemented widely. Different patient groups may face different barriers, which need to be identified and addressed at multiple levels to treat liver cirrhosis effectively. Mazumder NR, Simpson D, Atiemo K, et al. Black patients with cirrhosis have higher mortality and lower transplant rates: results from a metropolitan cohort study. Hepatology 2021;74:926–936. The background of this study is based on the fact that estimates of racial disparities in cirrhosis management have been confined by the lack of large-scale, longitudinal data that follow patients from diagnosis to transplant or death. Most of the studies examining racial disparities in liver disease of Black patients were conducted 15–20 years ago. The study methods used here were based on the analysis of a large, metropolitan, population-based health record (HealthLNK) in the Chicago area. This record included data from approximately 2.4 million patients spanning health care encounters from January 2006 to December 2012 from 6 large health care institutions. This was linked to the national transplant database (United Network for Organ Sharing), which comprises national registry data from all patients listed for transplantation. A further link was the state death registry (Social Security Death Master File for the state of Illinois). The authors conducted multivariate competing risk analyses, using sex, age, insurance status, Elixhauser comorbidity index, etiology of cirrhosis, hepatocellular carcinoma, portal hypertensive complications (ascites, hepatic encephalopathy, varices or variceal bleeding), and Model for End-stage Liver Disease (MELD)-Na as variables. They examined the relationship between race, transplant and cause of death as defined by blinded death certificate review. There were 11,277 patients who met the inclusion criteria; 2498 (22.2%) were Black. The results found that Black patients had similar age, sex, MELD-Na, and proportion of alcohol-associated liver disease compared with White patients. However, Black patients had a higher comorbidity burden, lower rates of private insurance, and lower rates of portal hypertensive complications. Black patients had the highest rate of all-cause mortality and non–liver-related deaths and were less likely to be listed for transplantation (P < .0001 for all) as compared with White patients. The conclusions were that in multivariate competing risk analysis the hazard of liver-related death was increased by 27% for Black patients (subdistribution hazard ratio [sHR], 1.27; 95% confidence interval [CI], [1.14–1.40]; P < .001). CommentAwareness of health disparities in minority populations will help to identify health care gaps and improve disease outcomes. Factors contributing to health disparities include (a) socioeconomic status, influenced by education, employment, and income, (b) lifestyle, including nutrition and physical activity, (c) physical and social environment, (d) access to health care for prevention and treatment, (e) systemic or structural racism against race, gender, gender identity, sexual orientation, and disability, and (f) implicit bias. Recognizing factors resulting in health disparities of specific populations can advance their resolution.The prevalence of cirrhosis in the United States is approximately 525:100,000 people (Lancet Gastroenterol Hepatol 2020;5:245–266). Deaths owing to cirrhosis constitute approximately 14:100,000, with an increase compared with 1990 and imposing a substantial health burden. The main causes of cirrhosis are still chronic hepatitis B and C virus infection, although effective preventative measures and treatment options are available respectively. Alcohol remains another contributor; however, nonalcoholic steatohepatitis is expected to become the major cause in the future. Thus, cost-effective interventions are required to achieve early diagnosis and prevention of cirrhosis.In this article, Mazumder et al studied the outcomes of liver cirrhosis, including morbidity, mortality, and transplant rates, in self-identified Black patients (22%). To date, this study is the largest to examine health disparities in cirrhosis management. Black patients had similar age (mean, 56 years), distribution of sex (43.8% female), proportion of public insurance (52%), and proportion of alcohol-associated liver disease (43%) compared with White patients. However, compared with other patient groups, they had the lowest rates of private insurance (20.1%), the highest comorbidity burden as measured by the Elixhauser score, and the highest rate of hepatitis C virus (HCV)-related cirrhosis (56.9%). It has been described that minority groups often do not preclude their racial background, to avoid systemic racism and inferior health care (Med Care 2019;57:e28–e33). Thus, comparing self-identified groups may not capture the whole picture.Although this study was recently published, it incorporated patient data collected between 2006 and 2012, and may not reflect the current situation. Owing to its retrospective character, it depended on procedure codes to define diagnoses. This method may be unprecise in case such codes were not documented accurately. Additionally, omitting dialysis information from MELD-Na scores may lead to underestimation. The study was further able to capture only the greater Chicago area, and it is unclear whether this is representing the situation in suburban areas and at the national level. Accessing and analyzing the aforementioned databases in suburban areas and in other states may generate a better overview of health disparities in liver cirrhosis. Because center-derived characteristics account for disparate racial outcomes, and Black patients are more often hospitalized in suburban hospitals with higher mortality rates (J Racial Ethn Health Disparities 2017;4:243–251), this factor may affect the results of such studies.When applying univariate competing risk analysis the authors demonstrate that Black patients have an increased hazard of all-cause mortality and non–liver-related death compared with White patients, as well as lower rates of transplantation. After adjusting these analyses and controlling for insurance status, the increased hazard of non–liver-related death stayed statistically significant (sHR, 1.69; 95% CI, [1.41–2.03]; P < .001). However, HCV infection was identified as one of the major causes of liver disease in the Black population. The diagnosis of chronic HCV infection, has been linked with lower socioeconomic status (Clin Epidemiol 2013;5:163–172), when defined as a combination of education, employment, and income. It has further been demonstrated that Black patients are 30% less likely to receive HCV treatment despite equal cure rates (Public Health Rep 2018;133:452–460). Thus, social disparities seem to be a contributing factor to differences in cirrhosis management, because low income has been linked to inadequate access to health insurance, inadequate health care, and unaffordability of drugs needed for treatment. Thus, adjusting these analyses not only for insurance status, but also for education, income, residency and employment is important to better reflect socioeconomic status. In contrast, a recent article demonstrated that mortality owing to COVID-19 is not different in the Black community after adjustment for insurance status and low-income residency (N Engl J Med 2020;382:2534–2543). Collectively, it is extremely difficult to compare results from different studies if parameters are not standardized. Thus, in disparities research sociodemographic data should be standardized to include education, income, employment, insurance, and residency to capture the whole data and extract meaningful results, rather than using vague definitions of socioeconomic status.When adding hypothesized mediators of death to patients with cirrhosis, the authors declare that Black patients had an even more pronounced association with all-cause mortality and low likelihood of transplantation, as well as an increased hazard of liver-related death (sHR, 1.29; 95% CI, [1.15–1.45]; P < .001). Furthermore, Black patients had the highest rates of hypertension, diabetes and renal failure in their Elixhauser scores, which is consistent with what has been published elsewhere (Circulation 2021;143:2367–2369; JAMA 2017;318:2457–2465). It has been reported recently that creatinine values, which are used to estimate renal function by glomerular filtration rate (GFR), if used irrespective of race introduce systemic misclassification owing to GFR underestimation (N Engl J Med 2021;385(19):1750-1760). The use of creatinine may have been accountable for declaring Black patients as having the highest rates of renal failure. However, adults who identify as Black have higher serum creatinine levels on average. It was thus proposed to estimate renal function and GFR by cystatin C, eliminating negative consequences of current race-based approaches. Because creatinine may introduce misclassifications also in the MELD-Na scores, using cystatin C may be a promising alternative. However, this approach would need to be validated in clinical studies.Overall, the results of this study imply that health disparities exist in liver cirrhosis management of Black patients. However, more studies with standardized comparison criteria need to be conducted to extract conclusive results. Offering Black and other minority populations equal opportunities to education, employment, and health care may eliminate some of the major contributors to social discrepancies and subsequent health disparities in the United States. Because viral hepatitis is the leading cause of cirrhosis, and it is often identified in minority populations, health programs for specific patient groups are important. Educating physicians about implicit bias, avoiding structural racism, and offering lifestyle consultations need to be implemented widely. Different patient groups may face different barriers, which need to be identified and addressed at multiple levels to treat liver cirrhosis effectively. Awareness of health disparities in minority populations will help to identify health care gaps and improve disease outcomes. Factors contributing to health disparities include (a) socioeconomic status, influenced by education, employment, and income, (b) lifestyle, including nutrition and physical activity, (c) physical and social environment, (d) access to health care for prevention and treatment, (e) systemic or structural racism against race, gender, gender identity, sexual orientation, and disability, and (f) implicit bias. Recognizing factors resulting in health disparities of specific populations can advance their resolution. The prevalence of cirrhosis in the United States is approximately 525:100,000 people (Lancet Gastroenterol Hepatol 2020;5:245–266). Deaths owing to cirrhosis constitute approximately 14:100,000, with an increase compared with 1990 and imposing a substantial health burden. The main causes of cirrhosis are still chronic hepatitis B and C virus infection, although effective preventative measures and treatment options are available respectively. Alcohol remains another contributor; however, nonalcoholic steatohepatitis is expected to become the major cause in the future. Thus, cost-effective interventions are required to achieve early diagnosis and prevention of cirrhosis. In this article, Mazumder et al studied the outcomes of liver cirrhosis, including morbidity, mortality, and transplant rates, in self-identified Black patients (22%). To date, this study is the largest to examine health disparities in cirrhosis management. Black patients had similar age (mean, 56 years), distribution of sex (43.8% female), proportion of public insurance (52%), and proportion of alcohol-associated liver disease (43%) compared with White patients. However, compared with other patient groups, they had the lowest rates of private insurance (20.1%), the highest comorbidity burden as measured by the Elixhauser score, and the highest rate of hepatitis C virus (HCV)-related cirrhosis (56.9%). It has been described that minority groups often do not preclude their racial background, to avoid systemic racism and inferior health care (Med Care 2019;57:e28–e33). Thus, comparing self-identified groups may not capture the whole picture. Although this study was recently published, it incorporated patient data collected between 2006 and 2012, and may not reflect the current situation. Owing to its retrospective character, it depended on procedure codes to define diagnoses. This method may be unprecise in case such codes were not documented accurately. Additionally, omitting dialysis information from MELD-Na scores may lead to underestimation. The study was further able to capture only the greater Chicago area, and it is unclear whether this is representing the situation in suburban areas and at the national level. Accessing and analyzing the aforementioned databases in suburban areas and in other states may generate a better overview of health disparities in liver cirrhosis. Because center-derived characteristics account for disparate racial outcomes, and Black patients are more often hospitalized in suburban hospitals with higher mortality rates (J Racial Ethn Health Disparities 2017;4:243–251), this factor may affect the results of such studies. When applying univariate competing risk analysis the authors demonstrate that Black patients have an increased hazard of all-cause mortality and non–liver-related death compared with White patients, as well as lower rates of transplantation. After adjusting these analyses and controlling for insurance status, the increased hazard of non–liver-related death stayed statistically significant (sHR, 1.69; 95% CI, [1.41–2.03]; P < .001). However, HCV infection was identified as one of the major causes of liver disease in the Black population. The diagnosis of chronic HCV infection, has been linked with lower socioeconomic status (Clin Epidemiol 2013;5:163–172), when defined as a combination of education, employment, and income. It has further been demonstrated that Black patients are 30% less likely to receive HCV treatment despite equal cure rates (Public Health Rep 2018;133:452–460). Thus, social disparities seem to be a contributing factor to differences in cirrhosis management, because low income has been linked to inadequate access to health insurance, inadequate health care, and unaffordability of drugs needed for treatment. Thus, adjusting these analyses not only for insurance status, but also for education, income, residency and employment is important to better reflect socioeconomic status. In contrast, a recent article demonstrated that mortality owing to COVID-19 is not different in the Black community after adjustment for insurance status and low-income residency (N Engl J Med 2020;382:2534–2543). Collectively, it is extremely difficult to compare results from different studies if parameters are not standardized. Thus, in disparities research sociodemographic data should be standardized to include education, income, employment, insurance, and residency to capture the whole data and extract meaningful results, rather than using vague definitions of socioeconomic status. When adding hypothesized mediators of death to patients with cirrhosis, the authors declare that Black patients had an even more pronounced association with all-cause mortality and low likelihood of transplantation, as well as an increased hazard of liver-related death (sHR, 1.29; 95% CI, [1.15–1.45]; P < .001). Furthermore, Black patients had the highest rates of hypertension, diabetes and renal failure in their Elixhauser scores, which is consistent with what has been published elsewhere (Circulation 2021;143:2367–2369; JAMA 2017;318:2457–2465). It has been reported recently that creatinine values, which are used to estimate renal function by glomerular filtration rate (GFR), if used irrespective of race introduce systemic misclassification owing to GFR underestimation (N Engl J Med 2021;385(19):1750-1760). The use of creatinine may have been accountable for declaring Black patients as having the highest rates of renal failure. However, adults who identify as Black have higher serum creatinine levels on average. It was thus proposed to estimate renal function and GFR by cystatin C, eliminating negative consequences of current race-based approaches. Because creatinine may introduce misclassifications also in the MELD-Na scores, using cystatin C may be a promising alternative. However, this approach would need to be validated in clinical studies. Overall, the results of this study imply that health disparities exist in liver cirrhosis management of Black patients. However, more studies with standardized comparison criteria need to be conducted to extract conclusive results. Offering Black and other minority populations equal opportunities to education, employment, and health care may eliminate some of the major contributors to social discrepancies and subsequent health disparities in the United States. Because viral hepatitis is the leading cause of cirrhosis, and it is often identified in minority populations, health programs for specific patient groups are important. Educating physicians about implicit bias, avoiding structural racism, and offering lifestyle consultations need to be implemented widely. Different patient groups may face different barriers, which need to be identified and addressed at multiple levels to treat liver cirrhosis effectively.