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

## TL;DR

Neighborhood disadvantage affects liver transplant referrals for severe alcohol-related liver disease, especially at moderate disease severity.

## Contribution

This study is the first to use prospective multicenter data to show how social factors influence liver transplant access for severe alcohol-associated hepatitis.

## Key findings

- Neighborhood disadvantage was linked to lower referral rates at intermediate MELD scores.
- Referral probability dropped from 40-60% to 20% for patients with higher neighborhood disadvantage at MELD 20-30.
- Mortality was higher in disadvantaged neighborhoods at the same MELD scores.

## Abstract

Is neighborhood disadvantage associated with referral for liver transplant in patients with severe alcohol-associated hepatitis?

In this cohort study of 325 patients, neighborhood disadvantage was associated with referral at intermediate Model for End-Stage Liver Disease scores.

The findings of this study suggest that outreach strategies informed by social context may improve access to liver transplant and may be applicable across organ systems, as referral is a critical equity leverage point.

This cohort study examines the association of clinical severity and neighborhood disadvantage with liver transplant referral, wait-listing, receipt, and short-term mortality in patients hospitalized with 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.