Epidemiology

Racial disparities evident in management of portal hypertension complications

Last Updated: 2007-05-09 10:30:25 -0400 (Reuters Health)

By Will Boggs, MD

NEW YORK (Reuters Health) - Significant racial disparities exist in the treatment of patients hospitalized with cirrhosis and complications of portal hypertension, according to a report in the May issue of Hepatology.

"Physicians should be aware that the disparities in outcomes exist among minorities, whether it is a major university set-up or a community hospital," Dr. Paul J. Thuluvath told Reuters Health. "They should take these observations seriously and should work with the hospital administrators to set up multi-disciplinary committees to periodically audit and monitor outcomes among minority patients."

Dr. Thuluvath and colleagues from Johns Hopkins University School of Medicine, Baltimore, Maryland evaluated the influence of race and health insurance on the likelihood of receiving a portosystemic shunt and a liver transplant among nearly 64,000 patients with cirrhosis who were admitted for a complication of portal hypertension.

All data were obtained from the Nationwide Inpatient Sample, the largest database of hospital discharges, derived from a 20% stratified sample of acute care hospitals in the U.S.

The rate of portosystemic shunt procedures was significantly less for African Americans (12.2 per 1000 hospitalizations) and Hispanics (17.1 per 1000 hospitalizations) than for whites (28.7 per 1000 hospitalizations), the investigators report. These differences persisted after adjustment for demographic, clinical, and insurance variables.

Despite similar rates of variceal bleeding, African American patients were 60% more likely than white patients to have endoscopy delayed more than 24 hours after admission, the results indicate.

Similarly, the researchers found, while the rate of liver transplantation was 61.3 per 1000 hospitalizations among whites, it was only 23.1 and 29.9 per 1000 hospitalizations among African Americans and Hispanics, respectively.

In-hospital mortality rates ranged from 7.2% for Hispanics to 9.4% for African Americans, with intermediate rates for whites (8.4%).

Having Medicare or Medicaid instead of private insurance also contributed to lower shunt procedure rates, delayed endoscopy, and lower liver transplantation rates, the report indicates. Uninsured patients had higher mortality rates than those with private insurance.

"Racial disparity in health care outcomes is an area that has been marginalized either because of the sensitivity or 'discomfort' to discuss it openly," Dr. Thuluvath said. "Nevertheless, until we have a scientific discussion, we are not going to make any progress, despite the good intentions of the Institute of Medicine that has set an ambitious goal to remove all disparities by 2020."

Perhaps, Dr. Thuluvath suggested, "hospitals should be federally mandated to report their outcomes among minorities, and institutional committees should be set up to identify and reduce these disparities."

Hepatology 2007;45:1282-1289.