AASLD 2013: Mortality due to Chronic Liver Disease among American Indians and Alaska Natives in the United States, 1999–2009

(Abstract #269) Mortality due to Chronic Liver Disease among American Indians and Alaska Natives in the United States, 1999–2009
Authors: B. J. McMahon*; A. Suryaprasad; K. K. Byrd; J. T. Redd; D. G. Perdue; M. Manos

Note: this is the original abstract from the AASLD website

Background and Aims:
Chronic liver disease (CLD) is a leading cause of death among American Indian and Alaska Natives Peoples (AI/ANs). The precision of mortality estimates, however, is limited by the underestimation of chronic liver disease cases with narrow definitions in mortality data and the misclassification of AI/ANs in death records.

We employed a previously-validated definition of chronic liver disease deaths, based on comprehensive diagnostic disease codes, and used techniques to improve American Indian and Alaska Natives Peoples race classification to describe disparities and compare trends in chronic liver disease mortality during 1999–2009 between American Indian and Alaska Natives Peoples in the United States.

Methods:
Chronic Liver Disease deaths and causes in American Indian and Alaska Natives Peoples were identified from death certificates using the comprehensive codes. Chronic liver disease deaths with a primary liver cancer code were classified as hepatocellular carcinoma (HCC), and all others classified as cirrhosis. To improve American Indian and Alaska Natives Peoples race classification, the National Death Index was linked to Indian Health Service (IHS) enrollment records and analyses were restricted to Contract Health Service Delivery Areas, which contain or are adjacent to federally-recognized tribal reservations. Death rates (per 100,000) were directly age-adjusted to the 2000 U.S. standard population and were calculated in six geographic regions. Trends were described using Joinpoint regression techniques.

Results:
From 1999–2009, chronic liver disease death rates increased by 24.1% in American Indian and Peoples and 14.2% in Alaska Native peoples, increasing annually in both (P-value <0.05). The overall chronic liver disease death rate in Alaska Natives was 66.1/100,000 (95% Confidence Interval [CI] 64.7–67.6).

The overall CLD death rate ratio (RR) of Alaska Natives to non-Hispanic whites was 3.7 (95% CI 3.7–3.8) and varied across regions.

The death rate ratio was greater in females (4.7, 95% CI 4.6–4.9), ages 25–44 years (7.4, 95% CI 7.1–7.8), Northern Plains residents (6.4, 95% CI 6.1–6.8), and persons dying with cirrhosis (4.0, 95% CI 3.9–4.1) versus hepatocellular carcinoma (2.5, 95% CI 2.3–2.7), particularly in ages 25–44 years (7.7, 95% CI 7.3–8.1).

Cirrhosis-related chronic liver disease death rates were significantly higher in American Indians and Alaska Natives than non-Hispanic whites for deaths with underlying alcoholic liver disease (RR 5.2, 95% CI 5.0–5.4), hepatitis C (RR 2.5, 95% CI 2.3–2.7), and hepatitis B (RR 2.4, 95% CI 1.9–3.1).

Conclusions:
Chronic liver disease mortality is nearly four times greater in Alaska Natives and American Indians than non-Hispanic whites.  Death rate disparities were greatest among cirrhosis deaths, compared to hepatocellular carcinoma (liver cancer) deaths and greater in females and Northern Plains residents. The disparity in premature chronic liver disease mortality between American Indians/Alaska Natives and non-Hispanic whites is especially concerning. These findings can guide resource allocation that is urgently needed for comprehensive prevention and care strategies, to stem the chronic liver disease epidemic in this population.

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