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Dr. Bloom: 
Hi, my name is Patty Bloom. I'm an Assistant Professor and Transplant Hepatologist at University of Michigan. And today we're going to be talking about racial disparities in hepatic encephalopathy treatment.

So, there are several recent studies that have shown us that especially black patients are receiving inequitable liver disease care. The first study I'm going to show you analyzed a large metropolitan electronic health record dataset from seven large health systems. And what they did is they performed a competing risk analysis that accounted for age, sex, insurance status, MELD score, the etiology of cirrhosis, whether or not the patients had portal hypertensive complications, really just controlled for a whole host of factors, and then examined the relationship between race, transplant, and mortality.

And what they found, in the figure on the left, is that unfortunately, black patients are far more likely to die than patients of other races. There's really quite a large gap in mortality that starts fairly early, within the first year of being followed, and extends out for several years. The figure on the right is showing that there's also a disparity in access to liver transplant. So, black patients are far less likely to be listed or transplanted. And we know that black patients have a 26% increased hazard of liver-related death.

And another study that was published last year showed a similar phenomenon, that again, black patients are less likely to have a transplant and more likely to die. On the figure on the left there, you can see that over time, there's been this persistent gap in liver transplantation between black and non-black patients. And then in the figure on the right, you can see that death in hospitalized patients with decompensated cirrhosis is much more frequent in black patients than non-black patients. And while in some cases the disparity is being narrowed slightly, there, just still even at the most recent date, appears to be a really large disparity here.

And then getting specifically a bit more into hepatic encephalopathy, we see that non-white patients are at greater risk of hepatic encephalopathy after a TIPS procedure. So, that's the shunt that we sometimes place to treat ascites or variceal hemorrhage. And you can see that non-white patients have a 31% chance of HE versus 17% chance in white patients. And it's sort of unclear what has created this particular discrepancy, if that is access to care, if there are some inherent bias from providers, if perhaps certain patients are getting pre-emptive medications for HE. We don't know all of the reasons behind some of these gaps, but it's clear that these gaps exist.

One of the reasons why there is a gap in hepatic encephalopathy in particular is definitely from unequal prescribing. So, we know rifaximin is a key medication for the treatment of hepatic encephalopathy. And when used in combination with lactulose, reduces hospitalizations for encephalopathy. And this study here that I'm showing the figure from, looked at 30,000 patients with cirrhosis who had hepatic encephalopathy and they were on lactulose. And it looked at the time of the first encephalopathy diagnosis to when they finally got prescribed rifaximin. And you can see that there is this, you know, big gap between black and white patients in terms of the percentage that were ultimately prescribed to rifaximin. And the gap again is sort of narrowing over time but still remains.

And they also found that out-of-pocket spending on rifaximin was higher in black patients than white patients. And because it was so much more expensive for black patients, that led to less odds of actually filling the rifaximin prescription.

And this is another study that also looks at just the odds of filling a rifaximin prescription. It decreases over time to the point where at 540 days, only a little over 15% of patients are actually filling this script. And black patients are less likely to fill the prescription for rifaximin probably, to some extent, because of cost.

And the last example of unequal prescribing I'll give is that it appears to be affecting black patients more is opiate prescribing. So, 1 in 5 visits with patients with cirrhosis yields opiate prescriptions. And among the factors that increases the likelihood of an opiate prescription is black race. And we know that opiates increased HE.

So, overall, I’ll just say that there is a big disparity between black and non-black patients in hepatic encephalopathy, and a major driver of that does appear to be prescribing practices.

Thanks for listening.

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