Neighborhood Disadvantage and Access to Liver Transplant Referral for Severe Alcohol-Associated Hepatitis

Severe alcohol-associated hepatitis (sAH) is a leading indication for liver transplant (LT). However, access to LT begins with referral, a step that may not have been previously characterized using prospective multicenter data with detailed measures of social determinants of health.

To examine the association of clinical severity and neighborhood disadvantage with referral, wait-listing, transplant, and short-term mortality in patients hospitalized with sAH.

This prospective multicenter cohort study was a secondary analysis of the Alcohol-Associated Hepatitis Network observational cohort. It included patients hospitalized with sAH (Model for End-Stage Liver Disease [MELD] >20) across 5 US transplant centers from May 6, 2019, to November 8, 2023. Clinical, demographic, and social determinants of health data, including the Area Deprivation Index (ADI), were collected prospectively.

Clinical severity (MELD score) and neighborhood-level disadvantage (ADI).

The primary outcomes were referral for LT evaluation, wait-listing, and receipt of LT, and the secondary outcome was 180-day mortality. Logistic regression and generalized additive models were used to evaluate independent and interactive associations of MELD and ADI with outcomes.

The cohort included 325 patients (mean [SD] age, 44.8 [10.2] years; 197 males [60.6%]). The mean (SD) MELD score was 29.2 (7.6), and the mean (SD) ADI was 56.2 (24.4). Only 120 patients (36.9%) were referred for LT. In multivariable analysis, higher MELD scores were associated with lower referral odds (odds ratio, 1.13 [95% CI, 1.07-1.18]; P < .001). ADI was not associated with referral odds (odds ratio, 0.99 [95% CI, 0.97-1.00]; P = .06). Generalized additive model analyses demonstrated significant MELD × ADI interactions for referral (P for interaction = .01), wait-listing (P for interaction = .004), and mortality (P for interaction = .01). At a MELD score 20 to 30, referral probability was 40% to 60% among patients with an ADI less than 30 vs 20% among those with an ADI 30 or more. Among patients with a MELD score 20 to 30, mortality exceeded 20% in those with an ADI 60 or more compared with 10% to 20% in those with an ADI less than 20.

In this multicenter cohort study of severe alcohol-associated hepatitis, neighborhood disadvantage was associated with referral at intermediate MELD scores. These findings suggest that referral is a critical leverage point for interventions and that outreach and navigation strategies informed by social context may improve access to LT.