Reviewer ’s report  
 
Title: Racial Disparities of Black Americans Hospitalized for Decompensated Liver Cirrhosis  
 
Version: 0 Date: 14 Feb 2020  
 
Reviewer: Khalid Mumtaz  
 
Reviewer's report:  
 
Dear Editor,  
 
BMC Gastroenterology,  
 
Thanks for asking me to review and comment on manuscript entitled, "Health Disparities of Black 
Americans Hospitalized for Decompensated Liver Cirrhosis". In this paper, authors have 
conducted a retrospective study including 463 patients with cirrhosis over 5 years at a tertiary care 
academic medical center. They studied the effect of race, income, and health insurance on 
cirrhosis -related outcomes (receipt of quality cirrhosis care), hospital readmission, and mortal ity 
among patients hospitalized for decompensated cirrhosis.  
Multivariable proportional odds regression analysis showed that race was a statistically significant 
predictor of 30 and 90 -day readmission. Other predictors were related to severity of cirrhosi s and 
presence of comorbid conditions. They concluded that African Americans (AA) hospitalized for 
complications of cirrhosis experience significant disparities in healthcare outcomes compared to 
whites despite high quality cirrhosis care.  
 
Major comments:   
 
- Title of the study is about the "health disparities", but the results and rest of paper is 
addressing "racial disparities". The two entities are entirely different. Consider changing the title.  
- Out of the three outcomes (receipt of quality cirrhosis  care, hospital readmission, and 
mortality), authors found that number of early hospital readmission was higher in AA. Receipt of 
quality of cirrhosis care and mortality was not different. AA patients have higher MELD score and 
more comorbid conditions.  
- Background is lacking the existing knowledge on racial disparities in cirrhosis. I would 
suggest adding a para on existing literature on this topic and why there is need to further study it.    
Comments: Despite getting quality of cirrhosis care, AA race has increased readmission. 
Therefore, I wonder if increased readmission were related to race or severity of cirrhosis.  
 
- On multivariate analysis, predictors of 30 -day readmission were race (AA vs White), 
higher MELD, AKI, HCV, cardiac disease and DM. 90  day readmission predictors were also 
reported and found out to be HE, DM and ascites along with AA race.  
Comments:  
- I am unable to find if they adjusted the significant variables in their model to assess the 
independent impact of "race" on 30 -day and 90 -day readmission. If not adjusted then it's difficult 
to prove that readmission was related to race or severity of clin ical condition and multiple chronic 
conditions.  
 
In methods section, authors have mentioned about the use of specific ICD -10 codes for cirrhosis 
or its complications. The United States transitioned from ICD -9 to ICD 10 around 2016.  
Comments:  
This study w as conducted from 2013 to 2018. I wonder how they used ICD -10 codes in those 
enrolled prior to 2016.   
 
Authors claim to study the health disparity but no definition of health disparity is mentioned in 
method section.  
In statistical analysis, authors ment ioned about reporting "multivariable regression analysis" for 
readmissions and mortality.  
Comments: No multivariable model for mortality is found in the manuscript.  
 
In the results, they reported "multivariable proportional odds regression analysis" inst ead of 
multivariable regression. How the two are different?  
Results were written in a very disjointed manner and not maintaining the flow.    
There are sentences too lengthy and incomprehensible due to erroneous structuring. .  
 
I hope that my comments wil l be helpful for the authors and editors. I would like to thank you 
again for sending over this manuscript for review.  
 
Sincerely,  
 
Khalid Mumtaz, MD, MSc  
Associate Professor,  
Gastroenterology, Hepatology &amp;  Nutrition  
Ohio State University, Wexner Medi cal Center  
Columbus, Ohio 43210  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported  by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an additional 
statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Decl aration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that holds 
or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I  declare that I have no competing interests' below.  
If your reply is yes to any, please give details below.  
 
None  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manus cript is accepted f or publication, my nam ed report 
including any attachments I upload will be posted on the website along with the authors' responses. 
I agree for my report to be made available under an Open Access Creative Commons CC-BY 
license ( http://cr eativecommons.org/licenses/by/4.0/ ). I understand that any comments which I do 
not wish to be included in my named report can be in cluded as confidential comments to the 
editors, which will not be published.  
 
I agree to the open peer review policy of the jo urnal  
Reviewer ’s report  
 
Title: Racial Disparities of Black Americans Hospitalized for Decompensated Liver Cirrhosis  
 
Version: 0 Date: 14 Feb 2020  
 
Reviewer: Khalid Mumtaz  
 
Reviewer's report:  
 
Dear Editor,  
 
BMC Gastroenterology,  
 
Thanks for asking me to review and comment on manuscript entitled, "Health Disparities of Black 
Americans Hospitalized for Decompensated Liver Cirrhosis". In this paper, authors have 
conducted a retrospective study including 463 patients with cirrhosis over 5 years at a tertiary care 
academic medical center. They studied the effect of race, income, and health insurance on 
cirrhosis -related outcomes (receipt of quality cirrhosis care), hospital readmission, and mortal ity 
among patients hospitalized for decompensated cirrhosis.  
Multivariable proportional odds regression analysis showed that race was a statistically significant 
predictor of 30 and 90 -day readmission. Other predictors were related to severity of cirrhosi s and 
presence of comorbid conditions. They concluded that African Americans (AA) hospitalized for 
complications of cirrhosis experience significant disparities in healthcare outcomes compared to 
whites despite high quality cirrhosis care.  
 
Major comments:   
 
- Title of the study is about the "health disparities", but the results and rest of paper is 
addressing "racial disparities". The two entities are entirely different. Consider changing the title.  
- Out of the three outcomes (receipt of quality cirrhosis  care, hospital readmission, and 
mortality), authors found that number of early hospital readmission was higher in AA. Receipt of 
quality of cirrhosis care and mortality was not different. AA patients have higher MELD score and 
more comorbid conditions.  
- Background is lacking the existing knowledge on racial disparities in cirrhosis. I would 
suggest adding a para on existing literature on this topic and why there is need to further study it.    
Comments: Despite getting quality of cirrhosis care, AA race has increased readmission. 
Therefore, I wonder if increased readmission were related to race or severity of cirrhosis.  
 
- On multivariate analysis, predictors of 30 -day readmission were race (AA vs White), 
higher MELD, AKI, HCV, cardiac disease and DM. 90  day readmission predictors were also 
reported and found out to be HE, DM and ascites along with AA race.  
Comments:  
- I am unable to find if they adjusted the significant variables in their model to assess the 
independent impact of "race" on 30 -day and 90 -day readmission. If not adjusted then it's difficult 
to prove that readmission was related to race or severity of clin ical condition and multiple chronic 
conditions.  
 
In methods section, authors have mentioned about the use of specific ICD -10 codes for cirrhosis 
or its complications. The United States transitioned from ICD -9 to ICD 10 around 2016.  
Comments:  
This study w as conducted from 2013 to 2018. I wonder how they used ICD -10 codes in those 
enrolled prior to 2016.   
 
Authors claim to study the health disparity but no definition of health disparity is mentioned in 
method section.  
In statistical analysis, authors ment ioned about reporting "multivariable regression analysis" for 
readmissions and mortality.  
Comments: No multivariable model for mortality is found in the manuscript.  
 
In the results, they reported "multivariable proportional odds regression analysis" inst ead of 
multivariable regression. How the two are different?  
Results were written in a very disjointed manner and not maintaining the flow.    
There are sentences too lengthy and incomprehensible due to erroneous structuring. .  
 
I hope that my comments wil l be helpful for the authors and editors. I would like to thank you 
again for sending over this manuscript for review.  
 
Sincerely,  
 
Khalid Mumtaz, MD, MSc  
Associate Professor,  
Gastroenterology, Hepatology &amp;  Nutrition  
Ohio State University, Wexner Medi cal Center  
Columbus, Ohio 43210  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported  by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an additional 
statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Decl aration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that holds 
or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I  declare that I have no competing interests' below.  
If your reply is yes to any, please give details below.  
 
None  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manus cript is accepted f or publication, my nam ed report 
including any attachments I upload will be posted on the website along with the authors' responses. 
I agree for my report to be made available under an Open Access Creative Commons CC-BY 
license ( http://cr eativecommons.org/licenses/by/4.0/ ). I understand that any comments which I do 
not wish to be included in my named report can be in cluded as confidential comments to the 
editors, which will not be published.  
 
I agree to the open peer review policy of the jo urnal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Racial Disparities of Black Americans Hospitalized for Decompensated Liver Cirrhosis  
 
Version: 0 Date: 14 Feb 2020  
 
Reviewer: Khalid Mumtaz  
 
Reviewer's report:  
 
Dear Editor,  
 
BMC Gastroenterology,  
 
Thanks for asking me to review and comment on manuscript entitled, "Health Disparities of Black 
Americans Hospitalized for Decompensated Liver Cirrhosis". In this paper, authors have 
conducted a retrospective study including 463 patients with cirrhosis over 5 years at a tertiary care 
academic medical center. They studied the effect of race, income, and health insurance on 
cirrhosis -related outcomes (receipt of quality cirrhosis care), hospital readmission, and mortal ity 
among patients hospitalized for decompensated cirrhosis.  
Multivariable proportional odds regression analysis showed that race was a statistically significant 
predictor of 30 and 90 -day readmission. Other predictors were related to severity of cirrhosi s and 
presence of comorbid conditions. They concluded that African Americans (AA) hospitalized for 
complications of cirrhosis experience significant disparities in healthcare outcomes compared to 
whites despite high quality cirrhosis care.  
 
Major comments:   
 
- Title of the study is about the "health disparities", but the results and rest of paper is 
addressing "racial disparities". The two entities are entirely different. Consider changing the title.  
- Out of the three outcomes (receipt of quality cirrhosis  care, hospital readmission, and 
mortality), authors found that number of early hospital readmission was higher in AA. Receipt of 
quality of cirrhosis care and mortality was not different. AA patients have higher MELD score and 
more comorbid conditions.  
- Background is lacking the existing knowledge on racial disparities in cirrhosis. I would 
suggest adding a para on existing literature on this topic and why there is need to further study it.    
Comments: Despite getting quality of cirrhosis care, AA race has increased readmission. 
Therefore, I wonder if increased readmission were related to race or severity of cirrhosis.  
 
- On multivariate analysis, predictors of 30 -day readmission were race (AA vs White), 
higher MELD, AKI, HCV, cardiac disease and DM. 90  day readmission predictors were also 
reported and found out to be HE, DM and ascites along with AA race.  
Comments:  
- I am unable to find if they adjusted the significant variables in their model to assess the 
independent impact of "race" on 30 -day and 90 -day readmission. If not adjusted then it's difficult 
to prove that readmission was related to race or severity of clin ical condition and multiple chronic 
conditions.  
 
In methods section, authors have mentioned about the use of specific ICD -10 codes for cirrhosis 
or its complications. The United States transitioned from ICD -9 to ICD 10 around 2016.  
Comments:  
This study w as conducted from 2013 to 2018. I wonder how they used ICD -10 codes in those 
enrolled prior to 2016.   
 
Authors claim to study the health disparity but no definition of health disparity is mentioned in 
method section.  
In statistical analysis, authors ment ioned about reporting "multivariable regression analysis" for 
readmissions and mortality.  
Comments: No multivariable model for mortality is found in the manuscript.  
 
In the results, they reported "multivariable proportional odds regression analysis" inst ead of 
multivariable regression. How the two are different?  
Results were written in a very disjointed manner and not maintaining the flow.    
There are sentences too lengthy and incomprehensible due to erroneous structuring. .  
 
I hope that my comments wil l be helpful for the authors and editors. I would like to thank you 
again for sending over this manuscript for review.  
 
Sincerely,  
 
Khalid Mumtaz, MD, MSc  
Associate Professor,  
Gastroenterology, Hepatology &amp;  Nutrition  
Ohio State University, Wexner Medi cal Center  
Columbus, Ohio 43210  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported  by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an additional 
statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Decl aration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that holds 
or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I  declare that I have no competing interests' below.  
If your reply is yes to any, please give details below.  
 
None  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manus cript is accepted f or publication, my nam ed report 
including any attachments I upload will be posted on the website along with the authors' responses. 
I agree for my report to be made available under an Open Access Creative Commons CC-BY 
license ( http://cr eativecommons.org/licenses/by/4.0/ ). I understand that any comments which I do 
not wish to be included in my named report can be in cluded as confidential comments to the 
editors, which will not be published.  
 
I agree to the open peer review policy of the jo urnal  
assistant