P1.083: Disparities in the Surgical Management and Outcomes of Biliary Atresia

Background: Biliary atresia (BA), progressive inflammation and fibrosis of the bile ducts leading to hepatic failure, is the most common indication for pediatric liver transplants. Timely surgical intervention to restore bile flow with Kasai portoenterostomy (KPE) remains the standard of care to reduce the risk of liver failure and transplantation. However, infants with significant hepatic fibrosis and dysfunction may require primary liver transplantation (PLT). This study aimed to evaluate disparities in initial surgical management of BA. We hypothesized that non-White infants and those with government insurance would have higher rates of PLT, representing delayed surgery, longer LOS, and worse in-hospital mortality.

Methods: We performed a retrospective cohort weighted analysis of infant ( < 1year) hospitalizations with primary diagnosis of BA from 2009-2019 using the Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database (KID). The primary outcome of interest was management with KPE or primary liver transplantation (PLT). Secondary outcomes of interest were hospital length of stay (LOS) and in-hospital mortality. Demographics and outcomes groups were compared. Weighted multivariate logistic regression analyses were used to identify factors independently associated with primary surgical management and secondary outcomes.

Results: A total of 1,862 weighted hospitalizations associated with a primary diagnosis of BA were identified. Of these hospitalizations 617 (33%) had no procedure, 364 (20%) had a diagnostic procedure only, 671 (36%) with KPE, 160 (8.6%) with PLT, and 49 (2.6%) with KPE and liver transplant. Most patients (n=730, 45%) were White, female (n=1048, 56%), and had Medicaid (n=910, 49%). Of the infants who underwent KPE, 10% were neonates at the time of admission (p=0001) compared with none of the infants who underwent PLT or KPE + LT.. A higher proportion of Medicaid patients had KPE(Table 1). A higher proportion of Black (n=25, 21%) and Hispanic (n=32, 20.3%) patients had PLT compared to White (n=53,15.8%) infants. More infants from households in the highest income quartile (n=163, 82.7%) had KPE, compared to those in the lowest income quartile (n=182, 72.5%) . In-hospital mortality was significantly higher among those with PLT (4.6%) and KPE +PLT (2.9%), compared to those with KPE only (n=0, p< 0.0001). On multivariate regression analysis (Table 2), there were no demographic factors that were associated with the type of surgical management strategy or hospital LOS among patients who had KPE or PLT.

Conclusion: In a nationally representative sample of infant hospitalizations due to BA, KPE was the most common management of BA, more commonly occurring among infants who were neonates at the time of admission and were covered by Medicaid. Yet, higher proportion of infants who were Black, Hispanic, and from low SES backgrounds had PLT, suggesting racial and socioeconomic disparities in the timely evaluation and management of BA.