New Study Finds Risk Groups, Outpatient Care Barriers in Chronic Liver Disease

Barriers to outpatient care among patients with chronic liver disease can significantly increase their likelihood of requiring hospitalization.

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Barriers to outpatient care among patients with chronic liver disease (CLD) can significantly increase their likelihood of requiring hospitalization, new findings published today in PLoS One revealed.¹ Compared with those facing minimal barriers, patients unable to establish care were 85% more likely to require recurrent hospitalizations. This group included a disproportionate number of women and individuals with physical limitations affecting their health.

“We need to address community-based health care barriers, particularly for persons who struggle to establish care, as a potential approach to reduce recurrent hospital use among adults with chronic liver disease in the US,” study author Carrie Wong, MD, PhD, assistant professor of medicine at the David Geffen School of Medicine at UCLA, said in a statement.²

According to data from the CDC, 1.8% of adults, or about 4.5 million Americans, are diagnosed with CLD,³ and they typically require more hospital-based care than those with other chronic diseases.¹

Using data from the National Health Interview Survey (2011–2017), the new research analyzed responses from over 5000 individuals representing 4.7 million US adults with CLD.¹ Respondents answered 13 questions about their experiences with barriers such as the inability to afford specialist care, difficulty obtaining prescriptions, or delays due to transportation issues.

The median age was 55 years, and over half of respondents were female (51.5%) and non-Hispanic White (65.8%). The CLD population faced significant health challenges, with 41.4% reporting fair or poor health and 68.2% experiencing functional limitations due to their condition. Despite most participants having at least a high school education (92.8%), economic vulnerabilities were evident, with 20.1% living in poverty and 57.8% unemployed. While half of the sample had private insurance, 11.2% were uninsured, highlighting disparities in coverage.

Four Risk Groups Identified

The study identified 4 distinct risk groups based on the types of barriers faced:

1. Minimal barriers (78.1%): This largest group was older, had fewer social and economic limitations, and reported better overall health.
2. Health care unaffordability (10.7%): Members of this group were most likely to be uninsured.
3. Care delays (6.5%): Predominantly insured individuals who experienced delays in care due to logistical challenges.
4. Inability to establish care (4.8%): The smallest group but the most vulnerable, including younger adults, women, unemployed individuals, and those living in poverty.

Compared with those facing minimal barriers, individuals in the “inability to establish care” group were 85% more likely to require recurrent hospitalizations. This group also consisted of a disproportionate number of women and individuals with physical limitations affecting their health.

Those in the minimal barriers group were older, had the best health, and faced the least economic hardship. Conversely, the unaffordability group was the youngest and most uninsured, while the care delays group, which was predominantly insured, had higher rates of fair or poor health and included more non-White respondents. The inability to establish care group, predominantly female, experienced the highest rates of unemployment (70.6%), poverty (35.3%), and health-related functional limitations (84.6%).

Barriers to care varied across groups. In the unaffordability group, 78.5% reported being unable to afford specialty care, while 90.1% of the care delays group faced difficulty securing timely appointments. Alarmingly, 95% of the inability to establish care group were declined as new patients, making this group the most likely to require recurrent acute care, including hospital and emergency department visits. This association was most pronounced among individuals with public insurance and was especially significant for women, suggesting unique gender-based challenges in accessing care.

The researchers noted that community-based health care interventions targeting organizational barriers could play a crucial role in reducing hospital-based care among the most at-risk groups.

Limitations and Future Directions

The study’s cross-sectional design did not allow for causal conclusions, and some key details—such as the severity of CLD and specific health insurance plans—were not captured. Despite these limitations, the researchers stated that the findings provide a foundation for future investigation and policy making.

“Our results can guide efforts to prioritize interventions for the most vulnerable persons with chronic liver disease,” the researchers wrote, “especially those facing significant organizational barriers to accessing care.”

References
1. Wong CR, Crespi CM, Glenn B, Han SHB, Macinko JA, Bastani R. Distinct risk groups with different healthcare barriers and acute care use exist in the U.S. population with chronic liver disease. PLoS One. 2024;19(11):e0311077. doi:10.1371/journal.pone.0311077

2. Over 4 million US adults with chronic liver disease can be grouped into unique risk groups based on barriers to care. University of California, Los Angeles Health Sciences. November 18, 2024. Accessed November 20, 2024. https://www.newswise.com/articles/over-4-million-us-adults-with-chronic-liver-disease-can-be-grouped-into-unique-risk-groups-based-on-barriers-to-care

3. Chronic liver disease and cirrhosis. CDC. Updated November 6, 2023. Accessed November 20, 2024. https://www.cdc.gov/nchs/fastats/liver-disease.htm#:~:text=Chronic%20Liver%20Disease%20and%20Cirrhosis%20*%20Number,and%20older%20with%20diagnosed%20liver%20disease:%201.8%