Chronic Liver Disease Linked to More Healthcare Barriers Than Other Chronic Diseases

Carrie Wong, MD, PhD

Credit: UCLA

Findings from a recent study suggest people with chronic liver disease (CLD) have an increased likelihood of experiencing healthcare barriers and a greater probability of recurrent acute care use compared to people with chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD).¹

Leveraging pooled self-reported National Health Interview Survey data representative of more than 43 million US adults, the study found more adults with CLD experienced unaffordability, organizational, and transportation-related barriers than those with COPD and CVD, likely related to the higher prevalence of socioeconomic vulnerabilities in this patient population. Additionally, results showed an increased prevalence of healthcare barriers was associated with a greater risk of recurrent acute care use.¹

“To our knowledge, the extent of barriers to care and the relationship between the prevalence of healthcare barriers and recurrent acute care use among US adults with CLD compared to other serious chronic diseases remains unknown,” Carrie Wong, MD, PhD, a transplant hepatologist at Ronald Reagan UCLA Medical Center and the Pfleger Liver Institute, and colleagues wrote.¹

According to the US Centers for Disease Control and Prevention, CLD is the tenth leading cause of death in the US.² The American Liver Foundation estimates more than 100 million people in the US have some form of liver disease, yet many have not been diagnosed.³

To determine the extent of healthcare barriers and their association with acute care use among adults with CLD relative to other chronic conditions, investigators conducted a population-based, cross-sectional study using pooled self-reported 2011–2017 National Health Interview Survey data among community-dwelling persons. They enrolled adult participants ≥ 18 years of age with affirmative responses to questions about CLD and COPD and/or CVD.¹

Investigators noted the CLD group included adults with COPD or CVD because concomitant COPD or CVD is common among persons with CLD. Additionally, those with COPD and CVD were grouped together because of considerable overlap between both disease groups.¹

The primary outcome was the number of healthcare barriers, captured via self-reported surveys. Specific healthcare barriers, representing the care-seeking continuum, included:

• Healthcare unaffordability (foregoing needed medical care, prescription medication, follow-up care, and/or specialty care due to cost)
• Organizational barriers at the point of entry to healthcare (lack of usual place for care, trouble finding a general provider, declined by clinic as a new patient, clinic declined one’s healthcare coverage)
• Organizational barriers within healthcare (could not get an appointment, inconvenient clinic hours, could not reach the clinic by telephone, long wait to see the doctor at the clinic)
• Delays in medical care related to lack of transportation in the past year

A secondary outcome was recurrent acute care use, defined as having ≥ 2 emergency department (ED) visits and/or overnight hospital admissions in the past year.¹

The final sample included 47,037 adults, which provided weighted estimates for 43,264,685 persons. The CLD group consisted of 5062 participants representative of 4,742,444 persons, and the COPD/CVD group included 41,975 participants representative of 38,522,241 persons. Investigators pointed out the CLD group included 1422 respondents with concomitant CVD (28.1%; 95% confidence interval [CI], 26.5%–29.9%) and 881 adults with COPD (17.4%; 95% CI, 16.1%–18.8%).¹

The CLD group was younger (median age 55 vs 62 years) and included more individuals who identified as Hispanic (17.5% vs 8.6%; P <.001) and persons with poverty (20.1% vs 15.3%; P <.001) than the COPD/CVD group. Additionally, more respondents with CLD vs COPD/CVD reported barriers (44.7% vs 34.4%; P <.001), including unaffordability (27.5% vs 18.8%; P <.001), transportation-related (6.1% vs 4.1%; P <.001), and organizational barriers at entry to (17.6% vs 13.0%; P <.001) and within healthcare (19.5% vs 14.2%; P <.001).¹

Investigators noted the adjusted likelihood of having any barriers to care was 12% greater for respondents with CLD compared to those with COPD/CVD (incident rate ratio [IRR], 1.12; 95% CI, 1.01–1.24; P = .03). However, while adults with CLD were more likely to experience at least 1 barrier, the adjusted number of barriers was not significantly different between the groups (IRR, 1.05; 95% CI, 1.00–2.71; P = .06).¹

Further analysis revealed recurrent hospitalizations and/or ED visits in the past year were more prevalent in the CLD group than in the COPD/CVD group (P <.001). Additionally, more respondents with recurrent acute care use had ≥ 1 healthcare barrier. Investigators observed a dose-dependent relationship between the probability of recurrent acute care use and the number of barriers with the highest adjusted probability of recurrent acute care use for those with at least 5 healthcare barriers and CLD (predicted probability, 0.37; 95% CI, 0.34–0.39).¹

Investigators outlined multiple limitations to these findings, including the inability to determine causality due to the pooled cross-sectional observational study design; the potential underestimation of both disease populations due to the use of survey questions to identify CLD, COPD, and CVD; the inability to delineate the etiology or severity of liver disease; and the lack of information about rural or urban classification, which can affect healthcare access.¹

“This study highlights the need to consider CLD as a priority condition in future public policies and disease-specific programs such that resources can be appropriately directed to reduce the burden of socioeconomic vulnerabilities, barriers to care, and potentially avoidable recurrent acute care use in this disease population,” investigators concluded.¹

References

1. ^{Wong CR, Crespi CM, Glenn B, et al. Prevalence of Healthcare Barriers Among US Adults With Chronic Liver Disease Compared to Other Chronic Diseases. Gastro Hep Advances. https://doi.org/10.1016/j.gastha.2024.05.004}
2. ^{Centers for Disease Control and Prevention. Leading Causes of Death. Life Stages and Populations. May 2, 2024. Accessed September 5, 2024. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm}
3. ^{American Liver Foundation. How Many People Have Liver Disease?. About Your Liver. September 11, 2023. Accessed September 5, 2024. https://liverfoundation.org/about-your-liver/facts-about-liver-disease/how-many-people-have-liver-disease/}