Neighbourhood Deprivation Is Associated With Greater Mortality in Patients With Alcohol-Associated Liver Disease

Abstract

Background and Aim

Significant health disparities persist in alcohol-associated liver disease (ALD), largely driven by social determinants of health (SDOH). However, the influence of neighbourhood-level SDOH on ALD outcomes remains underexplored. In this study, we aimed to evaluate how neighbourhood-level SDOH are associated with disease burden, comorbid conditions, and mortality in individuals with ALD.

Methods

We conducted a retrospective cohort study of patients with ALD in the Banner Health System, representing hospitals across Arizona, California, Nevada, Wyoming and Colorado, from January 2012 to October 2024 using ICD codes. Neighbourhood-level SDOH were quantified using the Social Deprivation Index (SDI). Patients were stratified into quartiles based on SDI score, with Quartile 4 representing the most socioeconomically disadvantaged neighbourhoods. Primary outcomes included incidence of mortality, cirrhosis, major adverse liver outcome (MALO), Type 2 diabetes mellitus, any cancer, and major adverse cardiovascular events (MACE). A multivariable competing risk analysis was performed adjusting for age, sex, race/ethnicity, insurance type, primary language, smoking status, Type 2 diabetes mellitus, hypertension, hyperlipidemia, aspirin use, statin use, alcohol use disorder and a composite mental-health/substance-use disorder variable encompassing depression, anxiety disorders, post-traumatic stress disorder, bipolar disorder, schizophrenia, and non-alcohol substance use disorders.

Results

Among 11,394 patients with ALD and available SDI data, 6747 had ≥ 365 days of follow-up. The average age was 51 years and 65.6% were female; 68.8% were non-Hispanic White, 19.7% Hispanic, 5.9% Native American/Alaskan Native (NA), 3.2% Black, and 0.4% Asian/Pacific Islanders. Patients residing in the most disadvantaged neighbourhoods (Quartile 4) were significantly younger, more likely to be female, had a higher median BMI, and more frequently reported a non-English primary language compared with those in the least disadvantaged areas (Quartile 1). Patients in the most deprived neighbourhoods were more likely to be Hispanic, Black, or Native American/Alaska Native and to be uninsured or on Medicaid, whereas those in the least disadvantaged neighbourhoods predominantly had private insurance. Individuals in Quartile 4 had increased mortality (adjusted hazard ratio [aHR]: 1.48, 95% Confidence Interval [CI]: 1.09–2.01) compared with individuals in Quartile 1.

Conclusions

In this large and demographically diverse ALD cohort, residing in socioeconomically disadvantaged neighbourhoods was associated with increased risk of mortality. These findings support the need for contextually tailored clinical interventions and broader treatment strategies that target upstream sociocultural and environmental factors that are associated with health outcomes. Addressing neighbourhood-level SDOH through community engagement, policy reform, and cross-sector partnerships to improve collaborative care efforts is needed to reduce health disparities in ALD.