Neighborhood socioeconomic deprivation is associated with worse patient and graft survival following pediatric liver transplantation

Abstract

Long-term outcomes remain suboptimal following pediatric liver transplantation; only one third of children have normal biochemical liver function without immunosuppressant comorbidities 10 years posttransplant. We examined the association between an index of neighborhood socioeconomic deprivation with graft and patient survival using the Scientific Registry of Transplant Recipients. We included children <19 years who underwent liver transplantation between January 1, 2008 to December 31, 2013 (n = 2868). Primary exposure was a neighborhood socioeconomic deprivation index-linked via patient home ZIP code-with a range of 0-1 (values nearing 1 indicate neighborhoods with greater socioeconomic deprivation). Primary outcome measures were graft failure and death, censored at 10 years posttransplant. We modeled survival using Cox proportional hazards. In univariable analysis, each 0.1 increase in the deprivation index was associated with a 14.3% (95% confidence interval [CI]): 3.8%-25.8%) increased hazard of graft failure and a 12.5% (95% CI: 2.5%-23.6%) increased hazard of death. In multivariable analysis adjusted for race, each 0.1 increase in the deprivation index was associated with a 11.5% (95% CI: 1.6%-23.9%) increased hazard of graft failure and a 9.6% (95% CI: -0.04% to 20.7%) increased hazard of death. Children from high deprivation neighborhoods have diminished graft and patient survival following liver transplantation. Greater attention to neighborhood context may result in improved outcomes for children following liver transplantation.

Keywords: Scientific Registry for Transplant Recipients (SRTR); clinical research/practice; ethnicity/race; graft survival; health services and outcomes research; insurance; liver transplantation/hepatology; patient survival; pediatrics; social sciences.

Figure 1.. Direct acyclic graph of hypothesized causal pathway

The solid boxes indicate measurable variables while the dotted boxes indicate unmeasurable variables within the Scientific Registry for Transplant Recipient data system. This diagram is the theoretical model of the hypothesized causal pathway for the impact of neighborhood deprivation on outcomes for children following liver transplantation.

Figure 2.. 10-year graft and patient survival curves by high and low neighborhood deprivation.

These figures depict graft survival (2a) and patient survival (2b) for patients from high and low deprivation neighborhoods. High and low deprivation were classified as above and below the median deprivation index of the cohort, respectively.

Figure 3.. Subgroup analyses for patients with public and private insurance by high and low neighborhood deprivation.

Figure 3a and 3b display graft survival for patients with public insurance and private insurance, respectively. Figure 3c and 3d display patient survival for patients with public insurance and private insurance, respectively. High and low deprivation were classified as above and below the median deprivation index of the cohort, respectively.