Individual- and Community-level Socioeconomic Status and Liver Transplant Outcomes: A Retrospective Cohort Study

This study evaluated the relationship between socioeconomic status (SES) at both the individual- and community-level and clinical outcomes among liver transplant recipients. A retrospective cohort study was conducted with 1567 deceased donor liver transplantation cases performed at Mayo Clinic Arizona from 2004 to 2022. Predictors included insurance status, self-reported education, the HOUsing-based index of Socioeconomic Status (HOUSES) index, and the Area Deprivation Index (ADI). The primary outcome was time to graft failure, analyzed using Cox proportional hazard models. The secondary outcome was mortality, also analyzed using Cox proportional hazard models. Exploratory outcomes included 30-day readmission and follow-up appointments using Poisson regression models. The sample was 66% male and 73% non-Hispanic White. There were 127 graft failures (8.1%), with 1-year, 5-year, and 10-year graft survival rates of 95.8%, 83.0%, and 67.7%, respectively. None of the individual- or community-level SES predictors were significantly associated with graft failure in the Cox proportional hazard models. There were 298 deaths, with 1-year, 5-year, and 10-year patient survival rates of 96.7%, 91.3%, and 86.5%, respectively. Patients with Medicaid and Medicare had a higher hazard of mortality compared to those with private insurance (HR = 2.20, 95% CI: 1.38-3.52 and HR = 1.54, 95% CI: 1.19-2.00, respectively). The other SES predictors were not significantly associated with mortality. Exploratory analyses showed inconsistent associations, though patients with Medicare had a longer hospital length of stay (Beta = 0.22, 95% CI: 0.07-0.37). Individual- and community-level SES were inconsistently associated with clinical outcomes following liver transplantation, but insurance status emerged as the most important clinical outcome predictor; future studies should develop interventions to mitigate this relationship.