Submitted by Jeremy Louissaint, MD and Ashley Spann, MD from The Association of Black Gastroenterologists and Hepatologists

African Americans experience disparities at each phase along the spectrum of chronic liver disease. These health inequities are deeply rooted within the healthcare system and manifest as disparities in the diagnosis, management, and treatment of chronic liver disease. Therefore, it is not surprising that African Americans experience worse liver-related outcomes compared to other racial groups. Herein, we outline a few of the existing health disparities in liver disease and suggest methods to promote a more equitable delivery of liver-related care.

As with other chronic illnesses, the mainstay of management in chronic liver disease is to diagnose and treat the underlying etiology of disease. African Americans experience inequities in both measures. For example, interval screening for hepatocellular carcinoma is recommended by all major liver societies; early detection being key to successful treatment. Yet, African Americans are screened for this life-threatening complication at disproportionally lower rates. The consequences of this are subsequent delays in the diagnosis of liver cancer, and it ultimately culminates in limited therapeutic options and worsened survival. Similar disparities in delayed access to treatment are also seen in the management of chronic hepatitis C virus. Despite the availability of highly efficacious direct antiviral agents, African Americans are less likely to receive these curative medications that reduce the risk of progression of their liver disease.

Longstanding liver disease can lead to significant scarring in the liver, called cirrhosis, and patients with cirrhosis are at risk for serious life-threatening medical complications that can, and often do, result in death. The only cure for cirrhosis is liver transplant, which is an extensive surgical procedure that requires removing the diseased liver and replacing it with a liver from someone who has died or from someone who has agreed to donate a portion of their own liver. For this to even be an option, patients need to be referred to and evaluated at a dedicated liver transplantation center. African Americans experience the lowest rates of referral to transplant centers despite a high burden of cirrhosis that warrants consideration for transplant. This disproportionally low referral rate unfortunately equates to more African Americans with severe liver disease never being considered for this life-saving surgery. Moreover, this leads to higher rates of liver-related deaths in the African American community.

These roots of inequity grow deep in all areas of medicine but are particularly harmful when it can be a matter of life or death. But, there are ways forward to promote health equity in liver disease. First, we must continue to routinely monitor for existing and emerging health inequities through research and institutional accountability. Second, we should employ novel methods, such as telehealth and remote patient monitoring, to reach disadvantaged communities and provide them with high-quality care. Third, implicit and explicit biases contribute to these disparities and need to be removed from the healthcare system. Lastly, we must recognize and value the societal health equity benefits of a diverse healthcare workforce.

This article brought to you with the generous support of Mallinckrodt Pharmaceuticals