Nakul Ganju, Shubham Gupta, Sahak Hovsepian, Samay Shah, Shaunak Ganju, Farshad Aduli
Structural inequities in post-TIPS outcomes persisted and worsened during the COVID-19 era, with race, payer status, and income independently predicting mortality across both eras. These findings have direct implications for equitable access to liver transplantation and underscore the need for policy reforms targeting postprocedural care coordination, insurance parity, and hospital-level accountability.
BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) reduces mortality in esophageal variceal hemorrhage. Whether the COVID-19 pandemic worsened existing disparities in outcomes among patients undergoing TIPS remains unclear. We aimed to characterize racial, payer-based, and income-based disparities in post-TIPS outcomes before and after the COVID-19 pandemic.
METHODS: Using the 2016-2022 National Inpatient Sample, we conducted a retrospective cohort analysis of 31,860 weighted hospitalizations of adults with cirrhosis and esophageal variceal hemorrhage who underwent TIPS. Admissions were stratified as pre-COVID (2016-2019) and post-COVID (2020-2022). Primary outcomes were in-hospital mortality, length of stay, and total hospital charges. Multivariable regression models with COVID-19 era interaction terms were constructed; pre- and post-COVID stratified models were performed as sensitivity analyses.
RESULTS: In-hospital mortality increased from 7.8% to 9.4% post-COVID (P < .001). Black patients had significantly higher mortality (adjusted odds ratio [AOR]: 1.67; 95% confidence interval: 1.27-2.19) that worsened in stratified analyses (pre-COVID AOR: 1.53 vs post-COVID AOR: 1.93). Self-pay mortality risk escalated markedly post-COVID (AOR: 2.12 pre-COVID vs 3.26 post-COVID, a 54% worsening). Black patient length of stay disparity nearly doubled post-COVID (+1.71 days pre-COVID vs +3.90 days post-COVID). Native American patients emerged as disproportionately affected post-COVID (mortality AOR: 2.39; 95% confidence interval: 1.76-3.25), a group nonsignificant in the pre-COVID era.
CONCLUSION: Structural inequities in post-TIPS outcomes persisted and worsened during the COVID-19 era, with race, payer status, and income independently predicting mortality across both eras. These findings have direct implications for equitable access to liver transplantation and underscore the need for policy reforms targeting postprocedural care coordination, insurance parity, and hospital-level accountability.