In medical school, I took additional courses in bioethics and one of the influential lecturers was Tristramm Engelhardt (Right to Health Care). “According to him, injuries, disabilities, and diseases arising from natural causes are considered unfortunate. On the other hand, those situations become unfair when brought about by the doing of others. Engelhardt also notes that the result of someone’s unfair action should not be attributed to the society as a whole.”
Two recent articles detail the link between socioeconomics and outcomes in liver transplantation. Are these problems unfair or just unfortunate?
Disparities remain in pediatric liver transplantation at all time points: from access to referral for transplantation, likelihood of living donor transplantation, use of exception narratives, waitlist mortality, and inequitable posttransplant outcomes
Black children are less likely to be petitioned for exception scores, have higher waitlist mortality, are less likely to be the recipient of a living donor transplant, and have worse posttransplant outcomes compared with White children.
Children living in the most socioeconomically deprived neighborhoods have worse posttransplant outcomes.
Children living farther from a transplant center have higher waitlist mortality
Based on retrospective analysis of 3454 patients (2011-2018), neighborhood poverty was independently associated with waitlisting (odds ratio 0.56, 95% confidence interval [CI] 0.38–0.82) and death during LT evaluation (hazard ratio 1.49, 95% CI 1.09–2.09)
Despite use of the objective prioritization with MELD scores in the allocation of organs, disparities in access for LT continues for vulnerable populations
My take: It is unfortunate but not surprising that poverty and socioeconomic factors adversely affect liver transplantation; the outcomes show stark differences. These issues, however, affect every aspect of health care (& beyond). Though they are not easily addressed, efforts to try to level the playing field are important especially with regard to transplantation to assure optimal use of this life-saving resource.
“It was Feb. 1, 1960, when four black students sat down at Woolworth’s lunch counter in Greensboro, N.C., and ordered coffee” (Time: Why the Woolworth’s Sit-In Worked)
This lunch counter sit-in was a big step in the civil rights movement. The article cited above shows that there is still a lot of work to make sure black patients have equal access to the liver counter too.
Using two databases (CDC WONDER, and UNOS) for 2014-2018, the authors identified 135,367 patients who died of ESLD, 54,734 patients who were listed for transplant, and 26,571 who underwent transplant.
The national LDR (listing-to-death ratio) was 0.40, significantly lowest in Black patients (0.30), P < 0.001. The highest LDRs clustered in the Northeast and the lowest in the Southeast and Northwest
The national transplant to listing ratio was 0.48, highest in Black patients (0.53), P < 0.01
The national transplant to death ratio was 0.20, lowest in Black patients (0.16), P < 0.001
“The most desirable outcome is a high transplant to death ratio—which was present in states like Maryland as well as Georgia, Nebraska, and Wisconsin.” (State values are provided in Tables 1, 3, and 4). Overall, these data show low listing rates for black patients relative to deaths from ESLD. Due to the adoption of MELD score which has objective criteria, the lower transplant rates indicate that Black patients face a disparity in access to liver transplantation.
The authors point out potential roadblocks:
ESLD first needs to be identified and patient referred to a liver transplant center
Black patients “were much less likely to understand the LT process”
Timing is critical, “especially in patients with HCC, which presents a more advanced in Black patients”
Insurance: “Black patients are more likely to be uninsured or to have public insurance, which is associated with poor access to listing and LT”
My take: This study shows that Black patients face disparities prior to transplant listing. In order to improve outcomes, patients first need to get a seat at the table.
Among 172 549 apparently healthy children from a retrospective database, the incidence of 30-day mortality, postoperative complications, and serious adverse events were 0.02%, 13.9%, and 5.7%, respectively. Compared with their white peers, AA children had 3.43 times the odds of dying within 30 days after surgery (odds ratio: 3.43; 95% CI: 1.73–6.79)
At age 6 to 7 years, compared with those with a healthy weight, children with overweight had higher metabolic syndrome risk scores by 0.23 SD units (95% confidence interval 0.05 to 0.41) and with obesity by 0.76 SD units (0.51–1.01), with associations almost doubling by age 10 to 11 years. Thus, overweight and obesity from early childhood onward were strongly associated with higher cardiometabolic risk at 11 to 12 years of age.
In addition, obesity but not overweight had slightly higher outcome carotid intima-media thickness (0.20–0.30 SD units) at all ages
In a recent commentary (EC Schneider, D Squires. NEJM 2017; 377: 901—4) explains why the U.S. Health Care System is last among high-income countries.
Overall, the U.S. “begins with a challenge: its population is sicker and has higher mortality than those of other high-income countries.” The U.S. has a rate of death from “conditions that can be managed and treated effectively (referred to as ‘mortality amenable to health care’) is far higher than in other high-income countries.
Four areas that have to be addressed to help U.S. move from last to first:
U.S. must confront lack of access to health care. The top-ranked countries offer universal insurance coverage with minimal out-of-pocket costs for preventive and primary care.
Underinvestment in primary care. In other countries, a higher percentage of “the professional workforce is dedicated to primary care than to specialty care.”
Administrative inefficiency. “Both patients and professionals In the United States are baffled by the complexity of obtaining care and paying for it.”
Disparities in the delivery of care. This may be mediated in part by a less robust social safety net than other high-income countries. “Social spending [for] stable housing, educational opportunities, nutrition, and transportation may reduce the demand for” many health care services.
My take: It makes me mad that our health care system performs so poorly compared to other countries.
Recent articles highlight a huge gap in the availability of living donor liver transplants (LDLTs) when examined based on racial/ethnic background.
YR Nobel et al. Liver Transpl 2015; 21: 904-13.
A Doyle et al. Liver Transpl 2015; 21: 897-903.
What is the reason for this inequality?
The first study examined UNOS data from 2002-2014 among adult liver transplant recipients. Of 35,401 recipients, 2171 (6.1%) received a LDLT.
Cholestatic liver disease: When compared with white patients, the odds ratios of receiving LDLT were 0.35 for African American, 0.58 for Hispanic, and 0.11 for Asian.
Noncholestatic liver disease: When compared with white patients, the odds ratios of receiving LDLT were 0.53 for African American, 0.78 for Hispanic, and 0.45 for Asian.
LDLT recipients were more likely to have private insurance
The second study did not look at racial/ethnic background but instead focused on other recipient factors. Using a retrospective cohort of 491 consecutive patients, they determined that all of the following resulted in a lower likelihood of LDLT:
Single — OR 0.34
Divorced –OR 0.53
Immigrant — OR 0.38
Low income quintile — OR 0.44
Together these studies allow speculation on why there is such a disparity.
Financial costs, including lost wages, could preclude those with lower socioeconomic status from being available as donors
Distrust of donation system and/or fear of surgery
Bottomline: Racial/ethnic differences and financial resources are associated with significant access inequality to living donor liver transplantation.
“Of all the forms of inequality, injustice in health care is the most shocking and inhuman.”
-Martin Luther King, Jr
This quote is part of an editorial (Flores G, “Dead Wrong: The Growing List of Racial/Ethnic Disparities in Childhood Mortality” J Pediatr 2015; 166: 790-3). The author discusses the disparities among African-American (AA) and Latino children in comparison to white children.
AA children and young adults had ~6 times the death rate for drowning in swimming pools, 4 times more likely of dying after liver transplant, and about twice the likelihood of dying due to acute lymphoblastic leukemia.
Latino children have higher cancer death rates with about twice the likelihood of dying due to acute lymphoblastic leukemia and increased drowning death rate as well.
One new study (pages 812-8) shows that black children have increased in-hospital mortality (OR 1.66) after complications following congenital heart surgery and that hispanic children have an increased complication rate following surgery (OR 1.13). This was a retrospective study using the Kids’ Inpatient Database with approximately 3 million discharge abstracts for three separate years.
A second study (pages 819-26) with a data set of 98,833 children shows that birth defects resulted in higher 8-year adjusted hazards of death for black, latino, and Asian/Pacific Islander children.
Recognizing these disparities inevitable leads to the question of why. Dr. Flores postulates several factors.
Genetic differences. For example, some ethnicities have more difficult to treat cancers, either due to genetic mutations or due to metabolism of medications.
Delays in diagnosis and treatment. Patients who present at a later stage of diagnosis often have lower cure/response rates. The author notes that black children receive a diagnosis of autism a mean of 1.4 years later than white children.
Barriers to specialty care. Specialty care can result in improved outcomes.
Bias in healthcare delivery, both conscious and unintentional.
Bottomline: The problems of racial inequality is not just a matter of relationships between the police and the community. It is clear that more needs to be done to improve outcomes in healthcare as well.