Social determinants of health influence the risk of cirrhosis: A diverse nationwide cohort study

BACKGROUND AND AIMS: Cirrhosis is a leading cause of mortality in the United States, with significant disparities influenced by social determinants of health (SDOH). This study evaluated the effects of SDOH on the risk of cirrhosis in a nationwide cohort of patients. APPROACH AND RESULTS: We conducted a retrospective cross-sectional cohort study from the All of Us Research Program (AOURP), enrolled from 2017 to 2022. The primary outcome was cirrhosis, defined using International Classification of Diseases codes. The primary predictors were SDOH factors measured by validated questionnaires and scaled to a 1-5 score or dichotomized. In all, 83,061 adults with SDOH assessments were included in the final cohort, of whom 1008 had cirrhosis. Neighborhood-level factors of social disorder (per-point OR: 1.36, 95% CI: 1.21-1.54, p <0.001) and crime (per-point OR: 1.17, 95% CI: 1.10-1.24, p <0.001) were linked to increased cirrhosis risk. Combined neighborhood and individual-level factors of food insecurity (OR: 2.00, 95% CI: 1.71-2.32, p <0.001) and everyday discrimination (per-point OR: 1.19, 95% CI: 1.09-1.30, p <0.001) were similarly associated with higher risk. Conversely, social cohesion (per-point OR: 0.83, 95% CI: 0.76-0.90, p <0.001), English proficiency (OR: 0.64, 95% CI: 0.49-0.84, p =0.001), and social support (per-point OR: 0.82, 95% CI: 0.78-0.87, p <0.001) were associated with decreased risk of cirrhosis. The population attributable fraction for most SDOH ranged from 0.10 to 0.15. CONCLUSIONS: SDOH factors were strongly associated with the risk of cirrhosis in a diverse nationwide population and explained a high proportion of variability in cirrhosis risk. SDOH should be considered key modifiable risk factors for advanced liver disease.