Excess mortality from cirrhosis by neighbourhood deprivation, aetiology, and clinical presentation: a Swedish register-based cohort study

TL;DR

The study finds that cirrhosis-related deaths are higher in deprived neighborhoods in Sweden, despite universal healthcare.

Contribution

This study quantifies socioeconomic disparities in cirrhosis mortality in a high-income country with universal healthcare.

Findings

Excess mortality rate ratios were 1.19 in the most deprived neighborhoods compared to the least deprived.

There were 23 excess deaths per 100,000 inhabitants in the most deprived areas versus 12 in the least deprived.

Neighbourhood deprivation strongly correlates with cirrhosis-related mortality despite universal healthcare.

Abstract

Socioeconomic inequalities are a persistent determinant of health inequity, but their influence on excess mortality from cirrhosis in high-income countries with universal healthcare is not well characterised. We aimed to estimate cirrhosis-related excess mortality across neighbourhood deprivation levels in Sweden.

We conducted a nationwide, register-based cohort study, including all individuals aged 40 years or older residing in Sweden between 2012 and 2022. The open, underlying cohort was stratified by calendar year, sex, 5-year age groups, and residential neighbourhood. Neighbourhood strata were collapsed into deprivation quintiles, as per the national distribution of inhabitants with a low disposable household income, with Q1 being the least and Q5 the most deprived. Incident cirrhosis cases within the age span 40–74 years were identified using validated diagnostic algorithms, and followed for up to 5 years. Excess mortality rate ratios (EMRRs) were estimated using Poisson regression within a relative survival framework.

Among 21,583 individuals with incident cirrhosis, 8814 deaths occurred during 65,170 person-years of follow-up. The EMRR for 5-year excess mortality in Q5 versus Q1 was 1.19 (95% CI 1.10–1.29). At the population level, the age-standardised number of excess deaths within 5 years of diagnosis was substantially higher in deprived areas; with 2018 as the year of diagnosis, there were 23 excess deaths per 100,000 inhabitants in Q5 versus 12 in Q1, representing a 95% higher excess mortality burden.

Even within a universal healthcare system, cirrhosis-related excess mortality substantially increases with level of neighbourhood deprivation. Prevention and more optimal post-diagnostic management targeted towards deprived neighbourhoods are urgently needed to reduce avoidable deaths.

The Swedish Cancer Society (Cancerfonden), The Swedish Research Council for Health, Working life and Welfare (Forte), The Swedish Gastroenterology Fund (Mag-Tarmfonden), The Swedish Research Council (Vetenskapsrådet), The Swedish Society of Medicine, The Swedish Foundation for Transplant and Cancer Research, and Region Stockholm (via a CIMED and clinical researcher award).

Figures