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Race/Ethnicity and Insurance-Specific Disparities in In-Hospital Mortality Among Adults with Primary Biliary Cholangitis: Analysis of 2007–2014 National Inpatient Sample

  • Artin Galoosian
  • Courtney Hanlon
  • Michele Tana
  • Ramsey Cheung
  • Robert J. WongEmail author
Original Article
  • 23 Downloads

Abstract

Background

Primary biliary cholangitis (PBC) is a progressive autoimmune liver disease that can result in cirrhosis and end-stage liver disease.

Aims

We aim to evaluate hospitalization burden and in-hospital mortality among PBC patients in the USA.

Methods

Using data from the Nationwide Inpatient Sample from 2007 to 2014, hospitalizations among US adults with PBC were stratified by sex, age, and race/ethnicity. Overall in-hospital mortality was stratified by these variables and adjusted multivariate regression models evaluated for predictors of in-hospital mortality.

Results

From 2007 to 2014, there were 18,279 hospitalizations among adults with PBC (15.0% male, mean age 63.8 years, 41.3% cirrhosis). Among non-Hispanic whites, the proportion of total PBC hospitalizations increased from 57.8% in 2007 to 71.2% in 2014, compared to 4.1–6.3% for African-Americans, 8.6–10.9% for Hispanics, and 1.7–2.8% for Asians (p < 0.001 for all). While overall in-hospital mortality was low (4.2%), increasing age was associated with higher odds of in-hospital mortality (OR: 1.02, 95% CI 1.01–1.03, p < 0.001). Compared to non-Hispanic white PBC patients, higher in-hospital mortality was observed in African-American PBC patients (OR: 1.40, 95% CI 1.16–2.03, p < 0.05). Compared to patients with private/commercial insurance, significantly higher odds of in-hospital mortality were observed in patients with Medicaid insurance (OR 1.42, 95% CI 1.00–1.99, p < 0.05).

Conclusion

In summary, among adults with PBC hospitalized in the USA from 2007 to 2014, the overall number of hospitalizations is increasing. Significant disparities in in-hospital mortality were observed; African-Americans with PBC and Medicaid patients with PBC have disproportionately higher odds of in-hospital mortality.

Keywords

Primary biliary cholangitis Cirrhosis Mortality Hospitalizations Nationwide Inpatient Sample Race/ethnic disparities 

Abbreviations

AHRQ

Agency for healthcare research and quality

ALD

Alcoholic liver disease

APR-DRG

All patient-refined diagnosis-related group

HCC

Hepatocellular carcinoma

HCV

Hepatitis C virus

HRS

Hepatorenal syndrome

NAFLD

Nonalcoholic fatty liver disease

NIS

Nationwide Inpatient Sample

PBC

Primary biliary cholangitis

UDCA

Ursodeoxycholic acid

MELD

Model for end-stage liver disease

Notes

Author’s contribution

AG contributed to the study concept and design, analysis and interpretation of data, writing of the manuscript, critical revision of the manuscript, study supervision. CH contributed to the analysis and interpretation of data, writing of the manuscript, critical revision of the manuscript. MT contributed to the analysis and interpretation of data, critical revision of the manuscript. RC contributed to the analysis and interpretation of data, critical revision of the manuscript. RW contributed to the study concept and design, analysis and interpretation of data, critical revision of the manuscript, study supervision.

Funding

No funding support was provided for this study. Robert Wong is supported by an AASLD Foundation Clinical and Translational Research Award in Liver Diseases.

Compliance with Ethical Standards

Conflict of interest

Artin Galoosian, Courtney Hanlon, Michele Tana, Benny Liu, Taft Bhuket: None. Ramsey Cheung: research grants: Gilead Sciences. Robert Wong: Advisory board, consultant, speaker’s bureau, and research grants: Gilead Sciences; research grant: Abbvie; speaker’s bureau: Salix.

Research involving human participants

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

For this retrospective observational cohort study, informed consent was not required.

References

  1. 1.
    Carey EJ, Ali AH, Lindor KD. Primary biliary cirrhosis. Lancet. 2015;386:1565–1575.CrossRefGoogle Scholar
  2. 2.
    Boonstra K, Beuers U, Ponsioen CY. Epidemiology of primary sclerosing cholangitis and primary biliary cirrhosis: a systematic review. J Hepatol. 2012;56:1181–1188.CrossRefGoogle Scholar
  3. 3.
    Chuang NG, Rebekah G, Odin JA. Update on the epidemiology of primary biliary cirrhosis. Expert Rev Gastroenterol Hepatol. 2011;5:583–590.CrossRefGoogle Scholar
  4. 4.
    Lleo A, Jepsen P, Morenghi E, et al. Evolving trends in female to male incidence and male mortality of primary biliary cholangitis. Sci Rep. 2016;6:25906.CrossRefGoogle Scholar
  5. 5.
    Cheung KS, Seto WK, Fung J, Lai CL, Yuen MF. Epidemiology and natural history of primary biliary cholangitis in the Chinese: a territory-based study in Hong Kong between 2000 and 2015. Clin Transl Gastroenterol. 2017;8:e116.CrossRefGoogle Scholar
  6. 6.
    Rautiainen H, Salomaa V, Niemela S, et al. Prevalence and incidence of primary biliary cirrhosis are increasing in Finland. Scand J Gastroenterol. 2007;42:1347–1353.CrossRefGoogle Scholar
  7. 7.
    Tanaka A, Mori M, Matsumoto K, Ohira H, Tazuma S, Takikawa H. Increase trend in the prevalence and male-to-female ratio of primary biliary cholangitis, autoimmune hepatitis, and primary sclerosing cholangitis in Japan. Hepatol Res. 2019;49:881–889.CrossRefGoogle Scholar
  8. 8.
    Kim KA, Ki M, Choi HY, Kim BH, Jang ES, Jeong SH. Population-based epidemiology of primary biliary cirrhosis in South Korea. Aliment Pharmacol Ther. 2016;43:154–162.CrossRefGoogle Scholar
  9. 9.
    Hamlyn AM, Macklon AF, James O. Primary biliary cirrhosis: geographical clustering and symptomatic onset seasonality. Gut. 1983;24:940–945.CrossRefGoogle Scholar
  10. 10.
    Metcalf JV, Bhopal RS, Gray J, Howel D, James O. Incidence and prevalence of primary biliary cirrhosis in the city of Newcastle upon Tyne, England. Int J Epidemiol. 1997;26:830–836.CrossRefGoogle Scholar
  11. 11.
    Boonstra KK, Anton E, Stadhouders PH, et al. Rising incidence and prevalence of primary biliary cirrhosis: a large population-based study. Liver Int. 2014;34:e31–e38.CrossRefGoogle Scholar
  12. 12.
    McNally RJJ, James PW, Ducker S, Norman PD, James OFW. No rise in incidence but geographical heterogeneity in the occurence of primary biliary cirrhosis in North East England. Am J Epidemiol. 2014;179:492–498.CrossRefGoogle Scholar
  13. 13.
    Sumner AD, Sardi GL, Reed JF 3rd. Components of the metabolic syndrome differ between young and old adults in the US population. J Clin Hypertens (Greenwich). 2012;14:502–506.CrossRefGoogle Scholar
  14. 14.
    Podda M, Selmi C, Lleo A, Moroni L, Invernizzi P. The limitations and hidden gems of the epidemiology of primary biliary cirrhosis. J Autoimmun. 2013;46:81–87.CrossRefGoogle Scholar
  15. 15.
    Fan X, Wang T, Shen Y, Xi X, Yang L. Underestimated male prevalence of primary biliary cholangitis in China: results of a 16-yr cohort study involving 769 patients. Sci Rep. 2017;7:1–8.CrossRefGoogle Scholar
  16. 16.
    Gatselis NK, Zachou K, Lygoura V, et al. Geoepidemiology, clinical manifestations and outcome of primary biliary cholangitis in Greece. Eur J Intern Med. 2017;42:81–88.CrossRefGoogle Scholar
  17. 17.
    Terziroli Berett-Piccoli B, Stirnimann G, Cerny A, et al. Geoepidemiology of primary biliary cholangitis: lessons from Switzerland. Clin Rev Allergy Immunol. 2018;54:295–306.CrossRefGoogle Scholar
  18. 18.
    Cheung AC, Lammers WJ, Murillo Perez CF, et al. Effects of age and sex of on response to ursodeoxycholic acid and transplant-free survival in patients with primary biliary cholangitis. Clin Gastroenterol Hepatol. 2019;17:12.CrossRefGoogle Scholar
  19. 19.
    Peery AFD, Evan S, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology. 2012;143:1179–1187.CrossRefGoogle Scholar
  20. 20.
    Peery AF, Crockett SD, Murphy CC, et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018. Gastroenterology. 2019;156:e211.CrossRefGoogle Scholar
  21. 21.
    Trivedi PJ, Bruns T, Cheung A, et al. Optimising risk stratification in primary biliary cirrhosis: AST/platelet ratio index predicts outcome independent of urseodeoxycholic acid response. J Hepatol. 2014;60:1249–1258.CrossRefGoogle Scholar
  22. 22.
    Levy C, Naik J, Giodano C, et al. Hispanics with primary biliary cirrhosis are more likely to have features of autoimmune hepatitis and reduced response to ursodeoxycholic acid than non-Hispanics. Clin Gastroenterol Hepatol. 2014;12:1398–1405.CrossRefGoogle Scholar
  23. 23.
    Wen JW, Kohn MA, Wong R, et al. Hospitalizations for autoimmune hepatitis disproportionately affect black and latino Americans. Am J Gastroenterol. 2018;113:243–253.CrossRefGoogle Scholar
  24. 24.
    Cholankeril GG, Gonzalez HC, Satapathy SK, et al. Increased waitlist mortality and lower rate for liver transplantation in Hispanic patients with primary biliary cholangitis. Clin Gastroenterol Hepatol. 2018;16:965–973.CrossRefGoogle Scholar
  25. 25.
    Sayiner MG, Golabi P, Stepanova M, et al. Primary biliary cholangitis in Medicare population: the impact on mortality and resource use. Hepatology. 2019;69:237–244.CrossRefGoogle Scholar
  26. 26.
    Shahab OSM, Paik J, Felix S, Golabi P, Younossi ZM. Burden of primary biliary cholangitis among inpatient population in the United States. Hepatol Commun. 2019;3:356–364.CrossRefGoogle Scholar
  27. 27.
    Yoshida EM, Mason A, Peltekian KM, et al. Epidemiology and liver transplantation burden of primary biliary cholangitis: a retrospective cohort study. Can Med Assoc J. 2018;6:e664–e670.Google Scholar
  28. 28.
    Tanaka AL, Patrick SC, Gershwin ME. The genetics of primary biliary cholangitis. Curr Opin Gastroenterol. 2019;35:93–98.CrossRefGoogle Scholar
  29. 29.
    Levy C, Bowlus CL, Carey E, et al. A real-world observational cohort of patients with primary biliary cholangitis: TARGET—primary biliary cholangitis study design and rationale. Hepatol Commun. 2018;2:484–491.CrossRefGoogle Scholar
  30. 30.
    Peters MG, Di Bisceglie AM, Kowdley KV, et al. Differences between Caucasian, African American, and Hispanic patients with primary biliary cirrhosis in the United States. Hepatology. 2007;46:769–775.CrossRefGoogle Scholar
  31. 31.
    Corpechot C, Chazouillères O, Poupon R. Early primary biliary cirrhosis: biochemical response to treatment and prediction of long-term outcome. J Hepatol. 2011;55:1361–1367.CrossRefGoogle Scholar
  32. 32.
    Carey E. Progress in primary biliary cholangitis. N Engl J Med. 2018;378:2234–2235.CrossRefGoogle Scholar
  33. 33.
    Floreani ACM. Primary biliary cholangitis: old and novel therapy. Eur J Intern Med. 2018;47:1–5.CrossRefGoogle Scholar
  34. 34.
    Boehmer U, Kressin NR, Berlowitz DR, Christiansen CL, Kazis LE, Jones JA. Self-reported vs administrative race/ethnicity data and study results. Am J Public Health. 2002;92:1471–1472.CrossRefGoogle Scholar
  35. 35.
    Kressin NR, Chang BH, Hendricks A, Kazis LE. Agreement between administrative data and patients’ self-reports of race/ethnicity. Am J Public Health. 2003;93:1734–1739.CrossRefGoogle Scholar
  36. 36.
    Zhan C, Miller MR. Administrative data based patient safety research: a critical review. Qual Saf Health Care. 2003;12:ii58–ii63.CrossRefGoogle Scholar
  37. 37.
    Ala A, Stanca CM, Bu-Ghanim M, et al. Increased prevalence of primary biliary cirrhosis near superfund toxic waste sites. Hepatology. 2006;43:525–531.CrossRefGoogle Scholar
  38. 38.
    Myers RP, Shaheen AA, Fong A, et al. Validation of coding algorithms for the identification of patients with primary biliary cirrhosis using administrative data. Can J Gastroenterol. 2010;24:175–182.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of MedicineCalifornia Pacific Medical CenterSan FranciscoUSA
  2. 2.Department of MedicineGeisel School of Medicine at DartmouthHanoverUSA
  3. 3.Department of MedicineKeck School of Medicine of USCLos AngelesUSA
  4. 4.Division of Gastroenterology and HepatologyUniversity of CaliforniaSan FranciscoUSA
  5. 5.Division of Gastroenterology and HepatologyUCSF—Zuckerberg San Francisco General Hospital, San Francisco General HospitalSan FranciscoUSA
  6. 6.Division of Gastroenterology and HepatologyStanford University School of MedicinePalo AltoUSA
  7. 7.Division of Gastroenterology and HepatologyAlameda Health SystemOaklandUSA

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