Determinants of racial disparities in outcomes from liver transplantation Open Access
Ross Driscoll, Katherine (Fall 2020)
Published
Abstract
Black patients experience significant and persistent disparities in survival after liver transplant, the only treatment for end-stage liver disease. The association of race, survival, and shorter-term outcomes, such as hospital admission, remains unclear. The overall goal of this project was to identify determinants of racial disparities in hospital admission and survival among liver transplant recipients.
In Aim 1, we used national data from a population-based registry of transplant recipients to determine whether the association of race with post-transplant survival differed by characteristics of the transplant center. While Black patients had lower post-transplant survival than White patients overall, racial disparities varied substantially across transplant centers. We did not find significant effect modification by center volume, proportion of minority patients, quality rating, or geographic region.
In Aim 2, we estimated the association between patient race and risk of hospital readmission within six months of transplant (Aim 2A), and did not find a clinically meaningful difference in hospitalization between Black and White patients. In a mediation analysis, we found that readmission within six months of transplant did not impact the association between race and survival (Aim 2B).
In Aim 3, we used data from the Emory Transplant Center (ETC) to estimate the association between race and aspects of post-transplant hospitalization not collected in national data. We found that disparities in hospital admission rates arose in the late post-transplant period. Black patients were more likely to have rejection as a cause of admission, and were more likely to be admitted emergently than White patients.
In this dissertation, we identified substantial variation in racial disparities after liver transplantation across transplant centers that was not explained by selected characteristics. While race was not associated with readmission within six months of transplant in a national cohort, preliminary data from the ETC suggests that disparities in hospital admissions may arise beyond six months. Black patients appeared to have different causes of readmission than White patients, and differences in admission urgency may point to opportunities to prevent these admissions. Further research is needed to identify modifiable factors associated with racial disparities in hospital admissions and survival after liver transplant.
Table of Contents
Chapter 1: Background and Literature Review.. 12
Chronic Liver Disease, End-Stage Liver Disease and Hepatocellular Carcinoma. 12
Epidemiology of CLD and ESLD in Adults. 13
Hepatocellular Carcinoma. 15
Liver Transplantation. 15
Living Donor Liver Transplantation. 15
Deceased Donor Allocation. 16
Indications and Evaluation for Transplant 17
Care of the Liver Transplant Recipient 20
Outcomes of Liver Transplantation. 21
Graft and Overall Survival 21
Unplanned Hospitalization after Transplant 27
Disparities in Outcomes for Black Liver Transplant Recipients. 31
Disparities along the Health Care Trajectory. 32
Potential Determinants of Disparities. 35
Summary of Critical Literature Review.. 42
Chapter 2: Significance and Specific Aims. 43
Study Motivation. 43
Potential Application of the Results to Liver Transplantation. 44
Potential Application of the Results Outside Transplantation. 45
Specific Aims. 45
Chapter 3: Data Sources and Methods. 47
Data Sources. 47
Scientific Registry of Transplant Recipients. 47
Emory Transplant Center 47
Study Population. 47
Specific Aims 1 and 2. 47
Specific Aim 3. 48
Variables. 48
Exposure. 48
Outcomes. 49
Covariates. 50
Analytic Methods. 53
Aim 1. 53
Aim 2A.. 53
Aim 2B.. 54
Aim 3. 54
Chapter 4: Aim 1. 56
Abstract 56
Introduction. 57
Methods. 58
Results. 61
Discussion. 63
Tables and Figures. 68
Chapter 5: Aim 2. 81
Abstract 81
Introduction. 82
Methods. 83
Results. 86
Discussion. 89
Tables and Figures. 94
Chapter 6: Aim 3. 101
Abstract 101
Introduction. 103
Methods. 104
Results. 106
Discussion. 111
Tables and Figures. 115
Chapter 7: Public Health Implications and Future Directions. 127
Summary of Findings. 127
Strengths and Limitations. 129
Future Directions. 130
References. 133
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