Hello, everyone. I'm very pleased to give the first ever patient debrief at the liver meeting. I've also added advocates as a targeted audience because I believe that issues that affect patients are also issues that advocates care about as well. And many of these advocates are clinicians that are part of ASLD or other attendees of the liver meeting. My name is Sue Wong and I am a general internist with a public health background and an interest in liver disease. I'm the medical director of the Center for Asian Health and Viral Hepatitis Programs at St. Barnabas Medical Center, which is part of RWJ Barnabas Health Rutgers Medical Group. I'm also living with Hepatitis B and I serve as current president of the World Hepatitis Alliance. We are a patient-led NGO and our mission is to harness the power of people living with viral hepatitis to achieve its elimination. I have the following disclosures, a research grant from Gilead. So I want to start off by answering the question, why a patient debrief? Well, this year at the liver meeting held its first ever patient and advocate track. This is part of ASLD strategy to increase patient engagement. We had curated programming with 15 interactive sessions and daily abstract tours. We also had a patient connection area and a community lounge and a special registration rate for patients and advocates, which really increased access of the meeting to a much wider community and was very much appreciated. So we think it's really important that the work of the double ASLD and the liver meeting be accessible to patients and the affected community. After all, this affects patients at the heart and this is a chance for to inform them of the latest research. Also, patients and their advocates are powerful partners to drive advocacy and policy, which benefits everybody. We also want to promote patient-centered research. Patient involvement can improve uptake, design, and delivery of research. And in fact, by tapping into lived experience, this is a way to ensure that outcomes have meaningful impact for patients. I want to go over the topics and scope of my talk. Of much interest during this time is COVID-19 and liver disease. People living with liver disease are very concerned about their risk to acquire COVID and if they will have worse disease. So make sure you check out a really excellent on-demand talk called COVID-19 and Chronic Liver Disease, Connecting Patients and Physicians, which answers those very questions. These patient-centered updates are presented by the COVID-19 Patient Engagement Subcommittee and they did a really nice job. So I will be talking about viral hepatitis, hepatitis B and C, NAFLD and NASH, or non-alcoholic fatty liver disease, and non-alcoholic steatohepatitis, and also cirrhosis, liver cancer, and liver transplant. So I want to say a really big thanks to all the authors, other debrief presenters, staff, and patient and advocates who assisted with this first-ever patient debrief. So just as a caveat, this is not meant to be a comprehensive review of everything, but a sample of some of the highlights at TLMDx. Because of the breadth of the topics, only a few abstracts of each topic could be included and many important topics are not. So those that were selected highlight a new development, a patient-centered approach, a unique type of study, an important health disparity, or an area where advocacy is needed. So I will cover one study that was done on the predictors of outcomes of COVID-19 in patients with chronic liver disease, or as it was called, COLD. And this was conducted at 23 centers across the U.S. from March to May 30th this year. An EMR review was done identifying patients who had had a positive SARS-CoV-2 test that was positive, an RNA test, along with a ICD-10 code of chronic liver disease. They found 978 patients who fit this category, and of those, 868 had chronic liver disease, 110 had a liver transplant. The graph on the left shows some of the outcomes with the line indicating roughly what was the rate in the normal population. So you see in this group, 61% were hospitalized, 23% were in the ICU, 18% were ventilated, and the overall mortality was 14%, with 12% mortality from COVID-19. So those with alcohol like liver disease, decompensated cirrhosis, and HCC had higher COVID mortality. So for high-risk patients, physicians should continue to emphasize telemedicine to reduce the risk of exposure to COVID-19 in inpatient and outpatient settings. Prioritize this group for future COVID vaccines, and actively include these patients in prospective COVID-19 surveillance studies and drug trials. So this is another COVID-related study looking at patients' perspective on hepatology-based telehealth visits. As we know, COVID-19 has prompted wide telehealth usage, and this was a study looking at a single center from May 11 to June 15 of this year. It was a survey conducted of English-speaking patients age over 18 after their first telehealth visits, and these were all patients who had been established at a liver clinic. So of the 104 eligible patients, 70 of them participated, and of those, 37 had had a phone visit, and 33 had had a video visit. So the patients reported 96% satisfaction, 90% of them felt comfortable with the interface, 75% felt it was equivalent to an in-person visit, and 65% reported being interested in a future visit this way. In terms of what are some of the reasons they would consider telehealth visits, 81% chose personal preference, 50% cited time constraints, and 49% liked the option with not having to worry about transportation to their doctor's office. So there were no significant differences found between patients who had accessed the visit via phone or video, or patients who had had compensated or decompensated cirrhosis, and also across different types of liver disease. So as in-patient visits do resume, we should individualize our visit types based on a patient's preference and comfort with telehealth. So next I'll be covering hepatitis C virus. We have the cures now, so our next step is to focus on implementation science and getting the treatments to the people who need it the most. We're going to look at treatment simplification due to COVID-19, psychosocial assessment of treatment uptake, and patients that are modeled for people who inject drugs. So this is looking at the impact of COVID-19 on an outpatient hep C testing and treatment program in New York City, a natural experiment in sudden HCV treatment simplification. The REACH program at Mount Sinai provides hep C treatment for people who use drugs through our harm reduction primary care model. In mid-March, the outpatient practice was closed and the medical providers were assigned to COVID-19 related tasks. Telehealth had not been done before, and actually the program had required that people with hep C be seen in person to have monthly monitoring visits until SVR 12. So instead, now RNs began monitoring all the patients, reaching out to them via phone or epic video visits to discuss and check in on them and medication adherence and any side effects. So notes from these encounters were then routed to the medical provider. So between March 20th and July 6th, they engaged 12 new hep C infected patients in the treatment work process. They were able to maintain engagement via telemedicine with 13 patients who are already in the treatment workup process. 16 patients started treatment during this 15 week period, and three of them were given the psychosocial readiness evaluation in preparation for hep C treatment by a social worker. And the workups were done entirely via telehealth. So of the 10 patients on treatment at the beginning of the period, there was a treatment completion rate of 80%. And in total, the program RN followed up with 34 separate hep C infected patients in 55 encounters. So rapid treatment simplification allowed REACH to provide uninterrupted care during the public health crisis through virtual care. However, it also created some barriers in implementing the program's team-based model of care and making strong connections with patients, which may have had an effect on the adherence rate and attendance rates. So REACH is now revising its existing hep C care models to systematically incorporate telemedicine, nurse-driven treatment monitoring, and streamlined patient visit schedules, thereby establishing a hybrid model of telehealth and in-person care. One of the issues that comes up frequently is why many hep C patients are still untreated. There are many other factors that come into play besides just access to care and treatment. And if you were or are someone living with hep C, you might recognize some of these. So this study called CARE-C utilized a psychosocial assessment and social worker and peer navigator intervention to improve hep C treatment uptake. These were hepatology outpatient clinics serving in Appalachian counties. The intervention was to add a social worker-patient navigator to the hep C care team. And then they conducted PrEP-C assessments along with providing behavioral interventions. So the study randomized patients one-to-one into a standard of care arm and then an intervention arm. And the endpoint was hep C treatment uptake one year after initial clinical visit. So the PrEP-C assessment, which was actually mentioned in the previous study, looks at a number of domains. One is motivation, so patient's reasons or concerns about the health and knowing how important today field treatment is. Number two is information, their knowledge on the treatment and their own disease status. Number three is medication adherence, and that would be with any current treatment that they might be on for any other conditions. Number four is self-efficacy, their own confidence about adherence. Number five is their social support and stability, which would look at their family or social networks, their housing, and financial support. And then usage of alcohol or other substances, their psychiatric stability, their energy level, and also cognitive function, which assess their difficulty in a health care setting, their problem-solving abilities, and their memory. So in the interim analysis of 431 patients that participated, 217 were randomized into the standard of care arm and 214 into the social worker peer navigator PrEP-C intervention arm. They were followed for a mean of 10.4 months, and by the end of the 12-month period, you see that 60% of those in the intervention arm had initiated treatment uptake, whereas only 47% in the standard of care arm, and that was a statistically significant difference. It just highlights that we may want to spend a little bit more time assessing a patient's reasoning for starting or not starting treatment uptake and gearing some of our interventions towards that in order to really reach difficult-to-reach populations. Next is one of the largest studies in the U.S. looking at a patient-centered model of hep C treatment for people who inject drugs, or the HERO study, which stands for Hepatitis C Real Options. Facilitating access to hep C treatment in people who inject drugs is an urgent public health priority as it continues to be a source of new infections in the U.S. and globally. We need better models of care in this population, which have not been studied in this group, and this was a late breaker this year. So this was a study in 25 sites in eight different U.S. states. Participants had recently injected drugs at least within 12 weeks of the study of entry and were given Safel or Abclusa for 12 weeks. Treatment was on-site either at community-based clinics or opioid treatment programs. The study examined the cascade of care ending at SVR-12 in people who initiated treatment using one of two methods, either modified DOT, which consisted either of in-person DOT, or this picture of somebody where it's face-to-face. This is the picture on the right. Or the other option would be using an app, a phone app, where one could take a video of one self-administering the pill, and that was the other option of MDOT. So then the other option was through a peer navigator program who assisted the client in completing hep C therapy. So these are the results tracking along the cascade of care. You can see that more than 80% of each of the groups initiated treatment, and of those who initiated, 82-83% of those completed treatment, and of those, 81-80% of those who completed achieved SVR, and none of these differences were significant between the MDOT and the peer navigator group. So looking at the intention of treat, among those who were in treatment in the opioid treatment programs, there was a difference noted in adherence in those who were in the modified DOT program versus the peer navigator program. So increased adherence, treatment duration, and treatment completion were significantly associated with SVR. So the next topic is hepatitis B virus, where I will touch on peer research, the evolving approach to therapy, including finite therapy, and then a reminder that finding the missing millions is actually our first step to eliminating both hepatitis B and hepatitis C viruses. So there are many new therapies under investigation, and many were featured during this meeting. I won't go into specific studies, but I just want to share this slide that describes the hep B life cycle and the targets of what some of these treatments are. It's important for hepatitis B patients to realize that the virus is complex, and the development of cure will likely not unfold like it did with hep C, where we had a flood of very effective oral medications with extremely high cure rates in just a couple of years. We are hopeful, though, and there are many promising therapies in the pipeline. The furthest along are in phase two clinical trials. If you want a snapshot, I recommend going to the Hep B Foundation's Drug Watch website. But here is a quick overview. There are, on the left, entry inhibitors that keep the virus from entering the hepatocyte, and Rikladex B is one of those. Then there are polymerase inhibitors, which is how the current therapies work by inhibiting DNA synthesis that the virus cannot replicate. They are also inhibitors of nucleocapsid assembly, and these are called CPAMs, or core protein allosteric modulators, and these disrupt capsid protein assembly so that the shells assemble incorrectly and interrupt the life cycle of the virus. In hep B infection, the most abundant viral antigen of the protein is the hep B surface antigen, which actually plays an important role in preventing immune control of the hep B virus. Most of this circulating antigen is actually noninfectious. This next set of therapies, what you see here called inhibitors of hep B S release, enter the hepatocyte and stop the production of surface antigen, or surface antigen depletors, with the goal of allowing the body to, by removing the immune inhibition, it allows the body to reestablish immune control. Next is this group called immune modulators, and in those include the TLR agonist, or toll-like receptor agonist, and the anti-PD-1 monoclonal antibodies and vaccine, and these help boost the immune system to clear the virus. Next up is these RNA interference agents, and this is by, this works by harnessing the pathway, which promises that you could actually degrade quite a bit of viral transcripts by disrupting the RNA pathway. So this is promising as it could drastically reduce the production of viral proteins. There's some thought this may possibly even disable CCCDNA during chronic infection. So, and then finally, at the very top, you see here the inhibitors of CCCDNA. Eliminating these would really be the holy grail, the hep B cure, what we could get, what we could call sterilizing cure, not just functional cure. So just as background, the hep B persists in hepatocytes, even in people who have naturally resolved and are surface antigen negative, but remain core antibody positive and potentially could have surface antibody as well. And the virus persists in the reservoir of CCCDNA, which remains in the hepatocyte. And this CCCDNA can act as a template for hep B replication when certain circumstances exist, such as immunosuppression in a patient, which can then lead to reactivation of hep B or flares. And thus screening in cancer patients and other people getting immunosuppression is really critical in order to help prevent by administering antivirals during such therapy. And ASCO, the Cancer Society, did recently update their guidelines. So this one category is looking at ways of silencing CCCDNA through some possible mechanisms, such as the CRISPR-Cas system or dye-substituted sulfonamides. All right, so that's an overview. Next, we're going to talk a little bit about the different phases of hep B, just so people understand this is what we see as physicians and clinicians and what the patient sees in terms of what are the diagnostics that are actually measurable at this time. So we have hep B viral load, the hep B DNA at ALT level, and more recently, the quantitative hep B surface antigen as well. So our current approach to treatment is not to treat those who are on the very left, the immune-tolerant, where the hep B viral load is high, but the ALT is low, because there is no immune activity or evidence of inflammation. We also don't treat those who are in the inactive phase. We can see the row at the bottom, where the viral load is low or undetectable, and ALT does not show evidence of liver inflammation. The people we are treating at this point are those who have active disease, where we can see the liver enzymes elevated and the viral load maybe fluctuating or elevated. So we hope for these therapies is that we are able to suppress the virus, and eventually we would like to see functional cure, which is where there's a durable suppression of viral load and also normalization of ALT here. And ultimately, a loss of surface antigen. The hep B treatment paradigm is changing. On the left, we have the current approach being suppressive, meaning that on treatment, hep B.DNA suppression is our current goal. But it does mean for now that patients are on medications for long-term or indefinite. What we're hoping in the future is a functional cure, where off-treatment surface antigen loss is the goal. And even off-treatment hep B.DNA suppression would be important to see. That way, we could actually have finite courses of therapy. So as someone who treats people living, many people living with hep B, this is a big concern for people being on lifelong therapy. And having this functional or functional cure and finite courses of therapy would mean a lot to patients. So speaking of things important to patients, this is an interesting study looking at how hep B patients perceive the value of their hep B medication and also what challenges they have in managing their hepatitis B infection. So this was actually done as an anonymous international online survey by the Hep B Foundation from February to June 2020 this year in preparation for FDA patient-focused drug development meeting for new hep B drugs. So there were 1,700 adults who completed the survey, with 17% of them from the US, and the majority at 83% who were international. The top countries were in Africa, Nigeria, and Ghana. But then there were also other countries such as India and the Philippines represented. When asked about what were positive results of taking their hep B medications for those who were the US patients strongly cited the following things, not worrying about transmitting the virus and being less worried that I may live a shorter life and less afraid that I may develop liver cancer. For international respondents, they reported higher responses about not having to avoid others and feeling less shame or stigma and feeling tired. On the right, medical access challenges were found to be higher in international patients, with more than half having difficulty going for checkups, more than 60% reporting the cost of their doctor being an issue, along with blood work and ultrasound costs. And more than half responded that finding a doctor knowledgeable about hepatitis B was an issue. Even in the US, these challenges were reported at 30 to 40% of the respondents, so we were not that far behind. So a takeaway message being that hep B drug development should take into account barriers to ongoing care, and also patient reported outcomes. Next is a study called the RETRACT-B study, or response after end of treatment with antivirals in chronic hepatitis B. It was a retrospective cohort of patients who discontinued their nucleoside or nucleotide therapy from 2000 to 2020. This was done in 12 centers in North America, Europe, and Asia. In total, they looked at more than 1,500 patients who discontinued therapy. Their off-treatment follow-up included five visits and a medium follow-up of 17 months. Overall, 41% did need to be retreated, but there were 8% who had surface antigen loss. What they found is that those who needed retreatment were more likely to be Asians, those who had been on Entecavir, and those who are of older age. Those who had higher rates of surface antigen loss were males and Caucasians. So these are things to consider when considering discontinuing therapy. Finally, it's important to remember that we still need to scale up screening if we are to achieve hepatitis elimination. Globally, only 9% of those with hep B have been identified, and close to 20% with hep C. This was an emergency department and hospital-based automated hepatitis screening project. The ED is becoming a more common site of screening across the U.S. As a disclosure, this was my abstract that I submitted with my team. What we did here was an EHR automated ordering of hep B and hep C tests based on eligibility criteria. It started originally as just the emergency department and then expanded to the inpatient in 2020. There was linkage to care provided by a patient navigator, which linked patients to a primary care-based hep B and hep C care program that included an ambulatory pharmacist who assisted with hep C therapy. So on the left, you see the protocol, which was automated on a computer and looked at country of birth for hep B treatment. For hep C, it was for anybody 18 or over, at least recently. It started off with a birth cohort, but is now universal. And on the right, there's also additional considerations. So those who had urine toxicology or serum toxicology ordered or peer recovery also had hep B and hep C testing done. The graph just kind of shows the trend that happened with COVID during COVID peak. There was a drop in volume where you saw the hepatitis testing drop as well, but then stabilize following. So 53,000 screenings were conducted between 2018 to 2020. For hep B, the infection rate was 1.1%. The country of birth was used to identify those who are at risk from endemic areas. And this also had the secondary benefit of serving as a community needs assessment for a hospital. And it provided more disaggregated data than race could have alone. So the top countries of hep B screening were people from Haiti, Jamaica, Guyana, Portugal, and India. For hep C, our infection rate was 0.7%. We saw the prevalence come down after we added the universal screening, just because of the much larger denominator. In the ED, we had higher infection rates for hep C in the inpatient setting. And our primary care clinic was able to initiate hep C therapy in 37 patients with 31 successfully cured so far. The patient navigator through phone calls and physician telehealth visits were an important asset during COVID-19 and will continue to be. So on the right, you see the impact of what the hep C screenings had in terms of the age of those who are found to be infected. And you see that the middle groups, age 55 to 74, are those who fall in the baby boomer birth cohort. But you see in the green, which are the active cases, that there were cases in every age group from as young as the 25 to 34 age group to as old as the 95 to 104. Next, we're going to talk about NAFLD and NASH, that weight and diet make a difference. First of all, fat is important, not just liver fat. Lean NAFLD may be different. There are many treatment trials happening, and statins may reduce cancer risk. So this was an oral presentation out of a study looking at the global burden of disease data, looking at dietary risk for liver-related mortality amongst those with NAFLD. Overall, liver deaths due to NAFLD are 8.6%, although rates in areas of highest burden vary and are seen in the map below, and with the highest burden in certain parts of Latin America, Africa, and Asia. So when they looked at deaths from metabolic causes due to NAFLD, the rates were also higher, but not shown here. And they did further analysis looking at metabolic risk and dietary risk, and those that are outlined in red and green are shown to be significant. The study showed was that besides the known contributors of metabolic risk, so including high BMI, high blood pressure, high glucose, even impaired kidney function, that dietary risk can independently drive the global burden of NAFLD. And the risk factors most correlated with NAFLD liver deaths were those low-end components of the Mediterranean diet, such as low nuts and seeds, legumes, and whole grains. And the highest correlation was actually with high intake of sugar-sweetened beverages. You see the p-value for that was really low. And the high intake of trans fatty acid was associated with a 3% increase in NAFLD liver death, even after adjusting for metabolic risks. This is a natural history of lean NAFLD, interesting because it was a longitudinal U.S. population study in Minnesota, which is important as they were followed for 20 years. They categorized NAFLD into three weight categories, lean, overweight, and obese. And what you saw is that those with lean NAFLD may have had lower risk for cirrhosis. However, there was no difference in cardiovascular risk or cancer. For some reason, the mortality was higher than those who were obese. Unclear the reason for that. Maybe in Minnesota, you could survive the winters longer if you have more body fat. Who knows, but it was an interesting find. So next is a study looking at people with low liver fat, but high visceral fat. 12,000 people underwent analysis of fat through an MRI proton density fat fraction, and they looked at cardiovascular incidents. The study found that if you had fat in your abdomen, but lower liver fat, you're actually associated with higher risk for coronary heart disease. And authors conclude that lowering liver fat without a resolution of visceral obesity may actually put people at greater risk of heart disease. So this should be considered when developing treatments for NAFLD. So this was a prospective cohort study of 11,000 patients with NAFLD where 23% were on a statin. This is using NHANES data and included people who had been through it for eight consecutive rounds of the survey from 1999 to 2014. So after analysis using multivariate Cox regression and adjusting for many variables, including smoking, previous cancer, and many other things, they found that there was a 44% reduction in cancer mortality for those who were taking a statin, and it didn't matter if it was a lipophilic statin or a hydrophilic statin. So any statin reduced cancer. So this is just a snapshot of all the treatment trials ongoing for NAFLD and NASH. On the left are studies with histological endpoints like evidence of fibrosis, and on the right are those that are currently in proof of concept or up to phase IIa trials. I'm not going into them, but Dr. Talassani has done an excellent NAFLD debrief where you can learn more. Next for cirrhosis, we're going to talk about early screening and a tool called the SNAC tool. So this was a really elegant study. This was called Opportunities for Early Diagnosis of Unrecognized Cirrhosis in the VA. In 2018, in the VA system, there were 6.6 million veterans, and using their EMR, they were able to identify that 3 million of them, or 45% of them, had one or more liver disease risk factors, which included chronic hep B, hep C viremia at any time, alcohol use, obesity, diabetes, and they did include anybody who had a previous cirrhosis diagnosis. So they then looked at the preceding 24 months to see how many had had a lab for FIB4 or any kind of liver imaging or transient elastography. So of those who had had those tests done, 5% had abnormal tests with FIB4 over 3.25 or liver stiffness over 12.5 kPa, both of which are indicators of F3 to F4 fibrosis. So of those who did get a diagnosis of cirrhosis, which is just 9.7% of them, so 9.7% of those who had had abnormal testing actually received an ICD-9 or 10 code for cirrhosis. And of those, 33% of them decompensated within one year, indicating that the diagnosis occurred fairly late in the course. So this just shows cirrhosis diagnosis often occurs late, and we really need to use population level screening, which could uncover a large pool of patients with unrecognized cirrhosis and potentially enable interventions to occur earlier in the course of disease. So patient-reported outcomes are important in any condition, actually, and this study is called a multitude of unmet supportive care needs in Australians with cirrhosis, the patient's perspective. So there's a paucity of data on patient-reported outcomes or PRO for patients with cirrhosis, and these outcomes are best assessed by people with limited experience, which may actually differ from what the provider's clinical assessment of the patient is. So assessing these needs is important because it can allow us to improve patient care. So these were face-to-face interviews done with 458 patients with cirrhosis across five different hospitals in Australia. It utilized a health needs assessment tool called the supportive needs assessment tool for cirrhosis, or SNAC, and the range of cirrhosis etiology varied from alcohol, chronic viral hep C, and alpha-D being the most common ones. And on the right is a copy of the SNAP tool, which is accessible online. So the median SNAC score is varied significantly by disease severity, with child pew B and C patients having higher median scores of the child pew A patients. And you can see the different colors represent different domains of the score, including practical and physical needs, psychosocial issues, overall SNAC score, lifestyle changes, information issues. Almost all patients with child pew C had at least one moderate to high unmet supportive care needs. On the right, this looks at the three most common liver disease that were studied, alcohol, hep C, and alpha-D and NASH. So except for lifestyle changes, the scores did not vary significantly across the groups. But for the alpha-D and NASH group, it was slightly higher for lifestyle changes compared to alcohol and hep C after adjusting for their child pew class. So finally, actually next to finally, we're going to talk about liver cancer and detection of hotspots of late-stage liver cancer. So this was a really interesting study looking at geographic hotspot detection of late-stage hepatocellular carcinoma, which could be a really novel approach to cancer control. This was done in LA County, looking at SEER data. There were 7,250 HCC cases, with 52% of them being late-stage. They determined hotspots where there were areas of high density of late-stage disease and found that 23 of these, they found 23 of these discrete hotspots. And they found the rates, the proportion of late-stage cases in these hotspots was 10% higher than outside the hotspots. When they looked into different factors, they found the hotspot cases were more likely to be in racial ethnic minority groups, foreign born, people who were under or uninsured and low income. And socioeconomic status was the strongest independent predictor of hotspot residents. So there was a disproportionate burden of late-stage cancer in those who were lowest and lower middle socioeconomic status. So this is just looking at the age-adjusted incidence rate of the late-stage HCC in LA County, looking at the hotspots versus the rest of the LA County. And the tributal risk was about 0.51, with the population attributable risk being 0.43. And they concluded that modifying the risk of late-stage cancer in hotspot areas may actually reduce late-stage HCC burden in LA County by 43%. So the takeaway is that this geographic hotspot approach is a really innovative tool with the potential to mitigate disparities in HCC. We can take this kind of approach to other areas. It can really help focus interventions on hotspot areas for liver screenings and other liver cancer preventions, and it would be important information for those working in the cancer field. So finally, we're going to talk about liver transplants and the impact of Medicaid expansion on wait time and disparities. So the ACA, Affordable Care Act, allowed states to expand Medicaid. And this study looked at states with transplant centers that expanded Medicaid compared to a control group of states that did not. So this chart shows annual percentage change, or APC, in liver related to death. And what you see on the right is just looking at different race categories and the annual percent change within the age categories. And so for those groups that had the expansion, the expansion states, you do see there was a reduction in racial disparities. I'll note that not a complete elimination compared to the non-expansion states, which are in orange. So they also calculated what they called LDR, listening to death ratio. And this is based on different databases. So they use the UNOS database to calculate listings and the CDC Wonder database to calculate death. So these two charts look at the comparison of the annual related liver deaths in the APC, which is the annual percent change. And on the left, you see the non-expansion states. On the right, you see the expansion states. And at 2014 is when the Medicaid expansion happens. So you can see what we're looking at is the time period after that. And in the expansion states, you can see that there is a clear decline in the annual percentage change of liver related deaths, which is pretty remarkable. And you don't see that in the non-expansion states. So Medicaid expansion did lead to decreased liver related mortality and listening to death ratio. And as we saw in the previous slide, it did improve racial disparities for liver related deaths. So it is advocacy in these areas like insurance coverage and Medicaid expansion that can really have profound impact on access and often affects groups that are hardest hit, including racial minorities. So I applaud the researchers for examining these factors. This is really much appreciated by the patient community so that by highlighting the disparities, we can actually do something about it to try to promote health equity. And so I want to close my talk that way and thank everybody for listening. And thank you to the organizers for having me do this presentation. Thank you.

Sue Wong

Liver Meeting

Patient Engagement

Viral Hepatitis

COVID-19

NAFLD

Liver Transplant