Disparities in palliative care utilization among patients with acute-on-chronic liver failure in the United States: a retrospective analysis.

BACKGROUND: Acute-on-chronic liver failure (ACLF) is associated with high short-term mortality, yet palliative care (PC) remains underutilized. Critically, the extent of this underutilization has not been rigorously quantified among patients who ultimately die during hospitalization. Characterizing PC utilization and its predictors in this terminal cohort is essential to identify disparities and improve end-of-life care quality. This study aimed to quantify PC utilization among terminal ACLF hospitalizations in the United States and identify demographic, clinical, and hospital-level factors associated with its use. METHODS: The National Inpatient Sample Database (2016-2022) was used to identify adult terminal ACLF hospitalizations. Patients were divided into two groups, stratified by PC utilization. Data were obtained on patient demographics, underlying liver disease, liver-related decompensations, comorbidities, and clinical outcomes. Multivariate logistic and linear regression analyses were used to identify predictors of PC utilization in patients with ACLF and to assess the impact of PC on resource utilization. RESULTS: Of the total 163,060 terminal ACLF hospitalizations ending in in-hospital mortality, only 75,365 (46.2%) received PC. Among those who received PC, the majority were male (60.9%), White (67.3%), and had Medicare insurance (42.7%). Compared to Whites, Black/African Americans and Hispanics had 29% and 34% lower odds of receiving PC, respectively. There was an incremental increase in PC use across income quartiles, with patients in the highest quartiles having 32% higher odds of receiving PC than those in the lowest quartile. Patients who had a history of liver transplantation were less likely to receive PC (adjusted odds ratio, 0.51; P=0.001). There were no significant differences in the length of stay; however, the use of PC was associated with lower total hospitalization charges (adjusted coefficient, -$7,942.93; 95% CI: -$14,065.26 to -$1,820.59; P=0.01). CONCLUSIONS: Our study highlights significant racial, regional, socioeconomic, and clinical disparities in PC utilization with respect to in-hospital mortalities with terminal ACLF hospitalizations. These findings suggest that PC resources are not being equitably provided, underscoring the need for targeted interventions to address these gaps.