Ethnoracial Disparity in Hospital Survival following Transjugular Intrahepatic Portosystemic Shunt Creation for Acute Variceal Bleeding in the United States

Clinical question
What are the racial/ethnic inequalities contributing to mortality after transjugular intrahepatic portosystemic shunts (TIPS) creation for acute variceal bleeds? Do hospital characteristics and processes contribute to inequalities?

Take away point
Following TIPS creation for acute variceal bleeding, Black patients have twice the in-hospital mortality than non-Black patients, which cannot be attributed to hospital care processes or characteristics.

Reference
Ethnoracial Disparity in Hospital Survival following Transjugular Intrahepatic Portosystemic Shunt Creation for Acute Variceal Bleeding in the United States. Trivedi, F.. et al. Journal of Vascular and Interventional Radiology, Volume 32, 941-949.

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Study design
Retrospective review from the National Inpatient Sample (NIS), which is a sample of all nonfederal hospitals in 44 participating states. This sample encompasses >95% of the U.S. population.

Funding Source
No funding

Setting
Multi-center.

Figure

Summary

Transjugular intrahepatic portosystemic shunt (TIPS) creation is currently performed in patients with variceal bleeding that cannot be controlled endoscopically or are at a high risk of recurrent bleeding. Prior research has established that being Black was a strong predictor of mortality following TIPS creation. Given these findings, this study attempts to address the racial/ethnic inequalities in mortality after TIPS creation. Additionally, they sought to decipher if there are any hospital care processes that may contribute to this increase in mortality via three main questions:

“1. Are there racial/ethnic differences in hospital characteristics for TIPS admissions?

2. Are black and/or minority patients less likely to receive first-line treatment with endoscopy and blood product repletion prior to TIPS, and if so, to what extent does that contribute to a mortality gap?

3. Is all-cause inpatient mortality after TIPS creation for variceal bleeding higher for Black and/or minority patients than for White patients. Adjusting for demographics, comorbid risk factors and disease severity?”

Data was collected from the National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP), which encompasses >95% of the US population. Patients aged 18 and older with a primary diagnosis of acute variceal bleeding treated with TIPS creation were included (n=10,331). The following demographics were obtained: age, sex, income, primary payer, Deyo-Charlson score (All Patients Refined Diagnosis Related Groups mortality risk), APR-DRG severity of illness, and comorbidities. The comorbidities included: ascites, portal vein thrombus, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome, hepatocellular carcinoma, sarcopenia, congestive heart failure, pulmonary circulation disease, chronic pulmonary disease, coagulopathy, alcohol abuse and drug abuse. Hospital characteristics included hospital bed size, location, teaching status and if the hospital was a transplant center. Hospital processes included first line treatments for variceal bleeding and timing of TIPS creation.

In patients undergoing TIPS creation for acute variceal bleeding, Black patients had twice the in-hospital mortality than White patients. Liver failure was the most common procedural complication among all races and was most frequently seen in Black patients. Interestingly, no other demographic factor was predictive of mortality. There were no significant associations involving hospital structures, admission to academic or non-academic hospitals or liver transplant centers.

The authors theorize that the higher in-hospital mortality in Black patients is due to a higher disease severity at the time of TIPS creation, which was shown by a higher rate of liver failure following TIPS creation. Notably, when patients with a Child-Pugh score of 13 or less were analyzed, there was no difference in mortality that could be attributed to race. Black patients were found to be disproportionately poor and living in urban areas, but they were more frequently admitted to teaching hospitals and liver transplant centers with adequate access to first line treatments such as blood transfusions and endoscopy. Black patients were more likely to have a longer time to TIPS creation than White patients (4.1 days versus 2.8 days). However, there was actually a lower mortality with a delayed TIPS for all races, which is likely attributed to acuity. The authors underscore that even though there was no difference in treatment and hospital processes, Black patients have more advanced liver disease prior to TIPS creation. Prior research has established poor management of chronic liver disease in Black patients and this research underscores those findings. Given the higher degree of pre-existing liver disease in Black patients, the authors discuss that in order to improve outcomes following TIPS creation, there needs to be a way to capture these patients earlier. For example, they proposed monitoring via the number of variceal bleeding episodes and/or improving screening endoscopies.

Commentary

This study seeks to address the racial inequalities of in-hospital mortality following TIPS creation for acute variceal bleeds. It shows that Black patients have a significantly higher mortality than White patients, which cannot be explained by demographics, hospital characteristics, socioeconomic determinants or care processes.

A major challenge to this study involves the inherent complexity of simplifying the concept of race into something measurable within a study. Racial inequalities include many factors that cannot necessarily be captured by numbers or discrete variables.

The most glaring result of this study is that regardless of in-hospital treatment, Black patients have more severe liver disease as a baseline prior to TIPS creation than white patients, which is likely due to inadequate treatment of their chronic liver disease prior to admission. The persistence and urge to ask these questions are what is important. Though imperfect, it helps slowly tease apart this complicated topic and expose inequalities. Further research should focus on exploring ways that chronic liver disease may be managed, so that by the time TIPS creation is necessary, there are improved outcomes for Black patients.

Post Author
Marissa Stumbras, MD
Interventional Radiology Resident, PGY3
Oregon Health & Science University
@MarissaStumbras

Edited and formatted by @NingchengLi