From the Journals

Fewer GI docs, more alcohol-associated liver disease deaths



People are more likely to die of alcohol-associated liver disease (ALD) when there are fewer gastroenterologists in their state, researchers say.

The finding raises questions about steps that policymakers could take to increase the number of gastroenterologists and spread them more evenly around the United States.

“We found that there’s a fivefold difference in density of gastroenterologists through different states,” said Brian P. Lee, MD, MAS, an assistant professor of clinical medicine at the University of Southern California, Los Angeles.

Dr. Lee and colleagues published their findings in Clinical Gastroenterology and Hepatology.

ALD is becoming more common, and it is killing more people. Research among veterans has linked visits to gastroenterologists to a lower risk for death from liver disease.

To see whether that correlation applies more broadly, Dr. Lee and colleagues compared multiple datasets. One from the U.S. Health Resources & Service Administration provided the number of gastroenterologists per 100,000 population. The other from the U.S. Centers for Disease Control and Prevention provided ALD-related deaths per 1,000,000 adults for each state and the District of Columbia.

The researchers adjusted for many variables that could affect the relationship between the availability of gastroenterologists and deaths related to ALD, including the age distribution of the population in each state, the gender balance, race and ethnicity, binge drinking, household income, obesity, and the proportion of rural residents.

They found that for every additional gastroenterologist, there is almost one fewer ALD-related death each year per 100,000 population (9.0 [95% confidence interval, 1.3-16.7] fewer ALD-related deaths per 1,000,000 population for each additional gastroenterologist per 100,000 population).

The strength of the association appeared to plateau when there were at least 7.5 gastroenterologists per 100,000 people.

From these findings, the researchers calculated that as many as 40% of deaths from ALD nationwide could be prevented by providing more gastroenterologists in the places where they are lacking.

The mean number of gastroenterologists per 100,000 people in the United States was 4.6, and the annual ALD-related death rate was 85.6 per 1,000,000 people.

The Atlantic states had the greatest concentration of gastroenterologists and the lowest ALD-related mortality, whereas the Mountain states had the lowest concentration of gastroenterologists and the highest ALD-related mortality.

The lowest mortality related to ALD was in New Jersey, Maryland, and Hawaii, with 52 per 1,000,000 people, and the highest was in Wyoming, with 289.

Study shines spotlight on general GI care

Access to liver transplants did not make a statistically significant difference in mortality from ALD.

“It makes you realize that transplant will only be accessible for really just a small fraction of the population who needs it,” Dr. Lee told this news organization.

General gastroenterologic care appears to make a bigger difference in saving patients’ lives. “Are they getting endoscopy for bleeding from varices?” Dr. Lee asked. “Are they getting appropriate antibiotics prescribed to prevent bacterial infection of ascites?”

The concentration of primary care physicians did not reduce mortality from ALD, and neither did the concentration of substance use, behavioral disorder, and mental health counselors.

Previous research has shown that substance abuse therapy is effective. But many people do not want to undertake it, or they face barriers of transportation, language, or insurance, said Dr. Lee.

“I have many patients whose insurance will provide them access to medical visits to me but will not to substance-use rehab, for example,” he said.

To see whether the effect was more generally due to the concentration of medical specialists, the researchers examined the state-level density of ophthalmologists and dermatologists. They found no significant difference in ALD-related mortality.

The finding builds on reports by the American Gastroenterological Association and the American Association for the Study of Liver Diseases that the number of gastroenterologists has not kept up with the U.S. population nor the burden of digestive diseases, and that predicts a critical shortage in the future.


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