Jennifer Guy|Hal F. Yee
Health disparities in liver disease: Time to take notice and take action
University of California, San Francisco|University of California, San Francisco
hepatologyvolume 50 issue 1 p 309313 aasld public policyfree access health disparities liver disease time take notice take action jennifer guy jennifer guy gi health outcomes policy economics research center university california san francisco ca liver center university california san francisco ca ucsfsfgh center specialty access quality university california san francisco ca department medicine university california san francisco casearch papers authorhal f yee jr corresponding author hal f yee jr hyeemedsfghucsfedu gi health outcomes policy economics research center university california san francisco ca liver center university california san francisco ca ucsfsfgh center specialty access quality university california san francisco ca department medicine university california san francisco ca fax 4156410745san francisco general hospital 1001 potrero avenue building 40 room 4102 san francisco ca 94110search papers author jennifer guy jennifer guy gi health outcomes policy economics research center university california san francisco ca liver center university california san francisco ca ucsfsfgh center specialty access quality university california san francisco ca department medicine university california san francisco casearch papers authorhal f yee jr corresponding author hal f yee jr hyeemedsfghucsfedu gi health outcomes policy economics research center university california san francisco ca liver center university california san francisco ca ucsfsfgh center specialty access quality university california san francisco ca department medicine university california san francisco ca fax 4156410745san francisco general hospital 1001 potrero avenue building 40 room 4102 san francisco ca 94110search papers author first published 24 june 2009 httpsdoiorg101002hep22942citations 24 potential conflict interest nothing report aboutsectionspdf toolsrequest permissionexport citationadd favoritestrack citation shareshare give accessshare full text accessshare fulltext accessplease review terms conditions use check box share fulltext version articlei read accept wiley online library terms conditions useshareable linkuse link share fulltext version article friends colleagues learn morecopy url share linkshare onfacebooktwitterlinkedinredditwechat health disparities various groups united states received increasing attention past decade solving problem become major public health priority federally sponsored program healthy people 2010 nations health promotion disease prevention initiative calls us eliminate health disparities including differences occur gender race ethnicity education income disability geographic location sexual orientation1 health disparity populations constitute large proportion patients liver disease2 3 evidence suggests populations disproportionately affected several common hepatic disorders include viral hepatitis47 nonalcoholic fatty liver disease8 9 hepatocellular carcinoma1013 health disparities therefore special relevance field hepatology policy statement aims inform hepatology community importance health disparities field provide framework approaching health disparities research clinical practice recommend ways american association study liver diseases aasld membership work toward reduction elimination health disparities patients liver disease importance health disparities liver health acknowledged healthy people 2010 health disparities become one nations pressing public health concerns institute medicines groundbreaking report unequal treatment confronting racial ethnic disparities health care14 describes significant disparities health various groups united states call action medical community commitment improving health disparities shared many organizations including centers disease control prevention15 department health human services16 many academic community medical centers professional political philanthropic patient organizations furthermore numerous health care systems payers including centers medicare medicaid services private insurers placing increasing emphasis quality care initiatives including promotion health equity december 2008 national institutes health nih shapes nations research agenda scientific funding priorities convened health summit science eliminating health disparities address best ways integrate science policy practice solve growing problem17 taken together examples underscore mounting professional political payer public support programs reduce health disparities multiple definitions health disparities exist literature practice18 19 broadly defined health disparities clinically statistically significant differences health outcomes health care use socially distinct vulnerable less vulnerable populations20 specific definition provided minority health health disparities research education act 200021 population health disparity population significant disparity overall rate disease incidence prevalence morbidity mortality survival rate population compared health status general population order optimize understanding health disparities must mindful many determinants health beyond access provision health care studies suggest provision health care accounts small proportion individuals overall health state22 23 genetics external social environment socioeconomic status education literacy cultural norms personal behavior contribute powerfully individuals health22 thus health disparities occur differences groups aforementioned determinants world health organization commission social determinants health recently issued report describing important role social environmental factors shaping health inequity worldwide24 moreover indepth assessment nonmedical contributors health status united states currently undertaken commission build healthier america sponsored robert wood johnson foundation25 hence public policy relates nonmedical determinants health strongly influence propagation elimination health disparities health disparity populations traditionally derive groups disadvantaged underserved often referred vulnerable populations26 healthy people 2010 agenda inclusive many patient groups including differ gender race ethnicity sexual preference geography socioeconomic status patients uninsured underinsured thus lack adequate access health care27 represent growing vulnerable patient population aaslds mission statement recognizes importance socioeconomic influences health outcomes ensuring provision liver health care americans regardless ability pay28 however discussed previously health disparities persist even equalization access health care highlights multiple causes health disparities medical care including genetic behavioral cultural environmental social determinants health disparities described diverse liver diseases2 3 including viral hepatitis47 nonalcoholic liver disease8 9 hepatocellular carcinoma1013 together account greatest burden liver disease facing hepatologists today29 indeed recent review article journal nguyen thuluvath2 provides comprehensive overview racial ethnic disparities liver disease disparities due socioeconomic statusregardless race ethnicityhave also demonstrated important hepatic risk factors injection drug use30 obesity diabetes31 goal article provide extensive overview health disparities liver disease rather hope emphasize substantial impact health disparities field hepatology highlight special importance organization abbreviations aasld american association study liver diseases nih national institutes health t0 pretranslation t1 phase 1 translation t2 phase 2 translation t3 phase 3 translation t4 phase 4 translation promotion integrated multidisciplinary approach addressing health disparities partnership researchers clinicians public health workers payers policymakers philanthropic organizations patients imperative achieve thorough understanding disparities exist develop implement programs reduce health disparities nih roadmap espoused elias zerhouni former nih director focuses three research funding initiatives improve nations health 1 new pathways discovery 2 research teams future 3 reengineering clinical research enterprise32 nih roadmap emphasizes pretranslation fundamental scientific research term t0 research upon diagnoses treatments prevention based phase 1 translation t1 research transfers fundamental scientific knowledge health applications phase 2 translation t2 research determines value health applications establish evidencebased guidelines approach improving health concentrating t0 t1 t2 research echoed action plan liver disease research national institute diabetes digestive kidney diseases33 however address health disparities t0 t1 t2 research pathways necessary sufficient improvements health therefore reductions health disparities require extension nih roadmap include phase 3 translation t3 phase 4 translation t4 pathways table 1 t3 research studies delivery dissemination diffusion evidencebased guidelines health practice34 t4 research assesses health outcomes t1 t2 health applications actual practice35 benchtobedside research ie t0 t1 t2 allows understanding underlying biological genetic differences groups development targeted therapeutics novel diagnostics parallel bedsidetocommunity research ie t3 necessary move proven health interventions clinical practice finally address problem health disparities also necessary determine effectiveness diagnostics treatments realworld clinical settings evaluate interactions patient provider health care system affect health outcomes ie t4 table 1 benchtobedside research pathways pretranslation t0 research elucidates pathogenesis pathophysiology disease phase 1 translation t1 research seeks move basic discovery candidate health application phase 2 translation t2 research assesses value t1 applications health practice leading development evidencebased guidelines phase 3 translation t3 research attempts move evidencebased guidelines health practice delivery dissemination diffusion research phase 4 translation t4 research seeks evaluate realworld health outcomes t1 t2 applications practice table adapted zerhouni32 westfall et al34 khoury et al35 importance continuum translation research mirrored several proposed models approaching health disparities research clinical practice16 20 26 health disparities result complex interplay medical nonmedical factors models recognize integrated interdisciplinary approach required useful framework adapted kilbourne colleagues20 presented table 2 key steps approach include 1 measuring identifying health disparities 2 investigating understanding causes disparities 3 developing implementing evaluating interventions aimed reducing disparities past health disparities research largely focused documenting disparities exist however emphasis must placed future understanding causes disparities implementing programs aimed reduction table 2 systematic approach health disparities research steps goals research pathways measurement disparity document differences incidence prevalence natural history outcomes epidemiological patientcentered research identification causes disparity determine social environmental biological cultural behavioral contributors basic science clinical health services qualitative research implementation programs reduce disparity develop interventions academic community hospitals health centers physicians offices communities public health public policy venues clinical trials health services research evaluation debrief intervention effectiveness health services qualitative research table adapted kilbourne et al20 case study health disparities research hepatitis b virus control alaska natives hepatitis b virus major public health concern worldwide disease concentrated several highrisk groups united states including foreignborn immigrants alaska natives46 36 remarkable success past 4 decades hepatitis b virus control program alaska serves superlative example effectiveness multidisciplinary approach addressing health disparities although symptoms signs complications hepatitis b virus well recognized hundreds years fundamental scientific advances t0 research including blood protein analysis immunology virology efforts manage hepatitis b virus could begin37 t0 research discoveries permitted development key clinical applications identification characterization australia antigen38 known hepatitis b surface antigen permitted creation first diagnostic test hepatitis b virus3941 improved understanding immunological responses pathobiology hepatitis b virus t1 research advances made including creation application successful vaccine42 elucidation hepatitis b virology allowed development effective treatments include interferon several nucleotide nucleoside analogs43 clinical trials medications development clinical guidelines treat hepatitis b virus excellent examples t2 applications field44 45 illustrated advances realized diagnosis prevention treatment hepatitis b virus t0 t1 t2 research play important role improving health care provide essential foundation t3 t4 research pathways scientific discoveries allowed epidemiologists clinicians begin measure burden hepatitis b virus diverse populations united states included alaska natives although population fact racially diverse functional standpoint represents distinct health disparity population based socioeconomic environmental geographic factors46 epidemiological surveys performed newly available hepatitis b surface antigen radio immunoassay demonstrated disparity existed alaska natives incidence prevalence hepatitis b virus complications comparison caucasians united states nonalaska native american populations47 48 researchers also documented increased incidence hepatocellular carcinoma higher mortality rate among alaska natives comparison overall population49 50 measurement differences incidence prevalence outcomes brought efforts identify causes disparities develop programs aimed reduction identification causes underlying increased disease burden alaska natives included elucidation differences viral transmission comparison populations studies alaska natives showed childchild transmission major form infectivity alaska comparison parts world vertical transmission dominated36 51 knowledge unique infection patterns geographic distribution hepatitis b different alaskan communities helped officials design implement comprehensive vaccination program early 1980s control transmission hepatitis b virus51 extensive efforts partnerships health workers researchers community required make program success studies shown prevalence hepatitis b virus alaska natives born program implementation dropped nearly zero52 53 another aspect comprehensive program included populationbased surveillance hepatocellular carcinoma chronically infected individuals using serial alpha fetal protein measurements54 program resulted increased survival hepatocellular carcinoma 16year followup period comparison historical cohort55 promising results shown reducing disparities t3 t4based studies interventions underscore importance identifying factors contributing observed differences implementing programs address populationspecific trends needs recommendations action health disparities growing public health imperative important problem within field liver disease illustrated case hepatitis b virus disparities alaska natives integrated multidisciplinary partnership basic scientists clinical health services researchers practitioners public health workers policy makers payers patients effective approach complex challenge identifying understanding reducing health disparities liver disease aasld membership opportunity take action reduce health disparities improve health vulnerable patient populations liver disease goals mind public policy committee 1 work toward organizing multidisciplinary program liver meeting eg focused study group minisymposium workshop establish priority areas liver health disparities targeted future study intervention 2 support aaslds development funding basic science clinical health services research specifically addresses health disparities liver disease 3 advocate vulnerable patient populations receive adequate private local federal support access liver health care enrollment clinical trials 4 encourage education hepatology trainees practitioners health disparities provide culturally sensitive languageappropriate health care recommendations mirror goals mission aasld56 hence propose recommendations considered adoption aasld implementation member committees including basic research clinical research nih liaison practice guidelines public policy scientific program training clinical policy committees efforts understand eliminate health disparities patients liver disease essential achieve aaslds vision prevent cure liver disease references 1 us department health human services healthy people 2010 understanding improving health objectives improving health vol 1 2 2nd ed 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