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Abstract Details
Insurance Status but Not Race/Ethnicity Are Associated With Outcomes in a Large Hospitalized Cohort of Patients With Cirrhosis
Clin Gastroenterol Hepatol. 2020 May 7;S1542-3565(20)30630-3.doi: 10.1016/j.cgh.2020.04.081. Online ahead of print.
Jasmohan S Bajaj1, Jacqueline G O'Leary2, Puneeta Tandon3, Florence Wong4, Patrick S Kamath5, Scott W Biggins6, Guadalupe Garcia-Tsao7, Jennifer Lai8, Michael B Fallon9, Paul J Thuluvath10, Hugo E Vargas11, Benedict Maliakkal12, Ram M Subramanian13, Leroy R Thacker14, K Rajender Reddy15
Author information
1Virginia Commonwealth University and McGuire VA Medical Center, Richmond, USA. Electronic address: jasmohan.bajaj@vcuhealth.org.
2Dallas VA Medical Center, Dallas, Dallas, USA.
3University of Alberta, Edmonton, Canada.
4University of Toronto, Toronto, Canada.
5Mayo Clinic, Rochester, USA.
6University of Washington, Seattle, USA.
7Yale University, New Haven, USA.
8University of California, San Francisco, USA.
9University of Arizona, Phoenix, USA.
10Mercy Medical Center, Baltimore, USA.
11Mayo Clinic, Phoenix, USA.
12University of Tennessee, Memphis, USA.
13Emory University, Atlanta, USA.
14Virginia Commonwealth University and McGuire VA Medical Center, Richmond, USA.
15University of Pennsylvania, USA.
Abstract
Background & aims: Insurance, race, and ethnicity can affect outcomes of patients with cirrhosis, but findings from prospective studies are unclear. We investigated the role of insurance status and race and ethnicity (race/ethnicity) on inpatient and 90-day post-discharge outcomes in a large inpatient cohort of patients with cirrhosis.
Methods: We used data from the North American Consortium for the Study of End-Stage Liver Disease (NACSELD) database, from 13 tertiary-care centers. Insurance status (uninsured, Medicare, Medicaid, private, and Canadian), race, and ethnicity, were analyzed independent of clinical co-variates for their association with transfer to the intensive care unit, acute on chronic liver failure (ACLF), length of hospital stay, inpatient and 90-day death or liver transplantation, and readmission to the hospital within 90 days. Multi-variable analyses and interaction terms were created for insurance, race/ethnicity, and for each outcome, with or without Canadian patients.
Results: We analyzed data from 2640 patients in the NACSELD database (971 with private insurance, 770 with Medicare, 456 Canadians, 265 with Medicaid, 178 uninsured, 540 non-Caucasian and 220 Hispanic); 23% required admittance to the intensive care unit, 12% developed NACSELD-defined ACLF, 7% died, 5% underwent liver transplantation. Of the 2288 patients discharged from hospital, 13% underwent liver transplantation, 19% died, and 42% were readmitted within 90 days. In the univariate model, uninsured patients accounted for the highest percentage of alcohol- or bleeding-related admissions and the lowest proportion of outpatient cirrhosis-related medication users. Canadians had the lowest rifaximin use and but higher proportions had hepatic encephalopathy, compared with other groups. Lack of insurance was higher among non-Caucasians, regardless of Hispanic ethnicity. In multi-variable analysis, lack of insurance was associated with ACLF (P=.02) and inversely associated with inpatient liver transplant (P=.05) and 90-day liver transplant (P=.02), regardless of whether Canadians were included or specific insurance type. Race or ethnicity were not significantly associated with outcomes.
Conclusions: In analyzing the NACSELD database, we found that insurance status, but not race or ethnicity, were independently associated with ACLF and inpatient or 90-day liver transplantation, regardless of inclusion of Canadian patients.