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Association between social determinants of health and rates of liver transplantation in individuals with cirrhosis

Flemming JA, Muaddi H, Djerboua M, Neves P, Sapisochin G, Selzner N. Hepatology. 2022; Mar 21 [Epub ahead of print]. DOI:

Background and Aims — This study evaluated the association between neighbourhood-level social determinants of health (SDOH) and LT among patients with cirrhosis who have universal access to healthcare.

Methods — Retrospective population-based cohort study from 2000-2019 using administrative healthcare data from Ontario, Canada. Adults aged 18-70 years with newly decompensated cirrhosis and/or hepatocellular carcinoma were identified using validated coding. The association between five neighbourhood level SDOH quintiles and LT were assessed with multivariate Fine-Grey competing risks regression to generate subdistribution hazard ratios (sHR) where death competes with LT.

Results — Overall, n=38,719 individuals formed the cohort, median age 57 years, 67% male and n=2,788 (7%) received LT after a median of 23 months (IQR 3-68). Due to an interaction, results were stratified by sex. After multivariable regression and comparing those in the lowest versus highest quintiles, individuals living in the most materially resource deprived areas (female sHR: 0.61, 95% CI 0.49-0.76; male subhazard ratio [sHR]: 0.55, 95% CI 0.48-0.64), most residentially unstable neighbourhoods (female sHR: 0.61 95% CI 0.49-0.75; male sHR: 0.56, 95% CI 0.49-0.65) and lowest income neighbourhoods (female sHR: 0.57, 95% CI 0.46-0.7; male sHR: 0.58, 95% CI 0.50-0.67) had a ~40% reduced subhazard for LT (P <.01 for all). No associations were found between neighbourhoods with the most diverse immigrant or racial minority populations or age and labor force quintiles and LT.

Conclusions and Relevance — This information highlights an urgent need to evaluate how SDOH influence rates of LT with the overarching goal to develop strategies to overcome inequalities.