Racial Disparities in Treatment of Patients with Cirrhosis and Complications of Portal Hypertension

African-American and Hispanic patients hospitalized for complications of portal hypertension were less likely than white patients to receive palliative and life-saving treatment, including liver transplants, according to a new study in the May 2007 issue of Hepatology.

Portal hypertension refers to high blood pressure in the portal vein (which carries blood from the digestive tract to the liver) and its branches. It is often defined as a portal pressure gradient (the difference in pressure between the portal vein and the hepatic veins) of 12 mm Hg or greater. Many conditions can result in portal hypertension; in North America and Europe, it usually is the result of cirrhosis of the liver, which may be due to chronic hepatitis B or C virus infection, heavy alcohol consumption, or other factors.

As liver disease progresses, patients may develop complications related to portal hypertension, such as variceal bleeding, ascites (abdominal fluid accumulation), or hepatic encephalopathy. Such patients should be considered for liver transplantation; without it, they face a 2-year survival prognosis of less than 50%. While awaiting transplantation, patients may be candidates for palliative procedures including endoscopic band ligation or portosystemic shunts.

Previous studies have revealed widespread racial disparities in disease treatment and outcomes. To determine the influence of race and health insurance on the likelihood of receiving palliative procedures or transplants, researchers at 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 investigators included 63,696 patients with cirrhosis who were admitted to a hospital between 1998 and 2003 due to complications of portal hypertension. They gathered demographic data and information on health insurance and treatment efforts, then performed statistical analyses adjusting for potential confounding factors.

The authors found that during hospital stays, African-American and Hispanic patients were significantly less likely than white patients to receive a portosystemic shunt, prompt endoscopic variceal hemostasis, or a liver transplant.

Compared with white patients, the odds ratio of receiving a portosystemic shunt 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 across racial/ethnic groups. However, the odds ratio of delayed endoscopy (more than 24 hours after admission) was 1.6 for African-American patients compared with white patients.

African-American patients were more likely to die in the hospital compared with white patients, while Hispanic patients were less likely than white patients to die in the hospital.

Relative to those who had private insurance, patients on Medicare or Medicaid, and those who were uninsured, were less likely to undergo a shunt procedure, more likely to receive 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 reported. "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 suggested 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 concluded.

In addition, they noted, "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."

05/15/07

Reference
G C Nguyen, D L Dorrey Segev and P J Thuluvath. Racial Disparities in the Management of Hospitalized Patients with Cirrhosis and Complications of Portal Hypertension: A National Study. Hepatology 45(5): 1282-1289. May 2007.