Author information

¹Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA lnephew@iu.edu.

²Indiana University Simon Comprehensive Cancer Center, Indianapolis, Indiana, USA.

³Indiana University School of Nursing, Indianapolis, Indiana, USA.

⁴Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA.

⁵Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.

⁶Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.

⁷Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.

Abstract

Objective: To investigate how individual social determinants of health (SDOH) and cumulative social disadvantage (CSD) affect survival and receipt of liver transplant (LT) in patients with hepatocellular carcinoma (HCC).

Methods: We enrolled 139 adult patients from two Indianapolis hospital systems between June 2019 and April 2022. Structured questionnaires collected SDOH and social risk factor data. We compared SDOH and CSD by race, gender and disease aetiology, assigning one point per adverse SDOH. Multivariable competing risk survival analysis assessed associations between SDOH, CSD, survival and LT receipt.

Results: Black patients experienced higher CSD than white patients in the cohort (5.4±2.5 vs 3.2±2.1, p<0.001). Black patients were significantly more likely to have household incomes <US$15 000 per year (52.6% vs 18.3%, p=0.003), to be insured by Medicaid (57.9% vs 33.0%, p=0.04), and to live in high Social Deprivation Index areas (68.4% vs 17.5%, p<0.001) than white patients. Patients with hepatitis C virus and alcohol-related liver disease had more adverse SDOH than those with metabolic dysfunction-associated steatotic liver disease, while there were no significant differences by gender. On multivariable analysis, a higher health literacy score was a significant predictor of survival (HR 2.54, 95% CI 1.19 to 5.43 CI, p=0.02) and higher CSD was associated with a lower probability of receipt of LT (HR 0.80, 95% CI 0.68 to 0.95, p=0.01).

Conclusions: There are significant racial and aetiology-related differences in SDOH burden. Low health literacy and high CSD are linked to worse outcomes in HCC patients. Health literacy screening and targeted interventions for those with high CSD could improve LT access and survival rates.