Effects of social determinants of health on mortality and incident liver‐related events and cardiovascular disease in steatotic liver disease

Summary Background Social determinants of health (SDOH) are becoming increasingly recognised as mediators of human health. In the setting of metabolic dysfunction‐associated steatotic liver disease (MASLD), most of the literature on SDOH relates to individual‐level risk factors. However, there are very limited data on neighbourhood‐level SDOH in MASLD. Aim To assess whether SDOH impact fibrosis progression in patients who already have MASLD. Methods This was a retrospective cohort study of patients with MASLD seen at Michigan Medicine. The primary predictors were two neighbourhood‐level SDOH, ‘disadvantage’ and ‘affluence’. The primary outcomes were mortality, incident liver‐related events (LREs) and incident cardiovascular disease (CVD). We modelled these outcomes using Kaplan–Meier statistics for mortality and competing risk analyses for LREs and CVD, using a 1‐year landmark. Results We included 15,904 patients with MASLD with median follow‐up of 63 months. Higher affluence was associated with lower risk of overall mortality (hazard ratio 0.49 [0.37–0.66], p < 0.0001 for higher vs. lower quartile), LREs (subhazard ratio 0.60 [0.39–0.91], p = 0.02) and CVD (subhazard ratio 0.71 [0.57–0.88], p = 0.0018). Disadvantage was associated with higher mortality (hazard ratio 2.08 [95% confidence interval 1.54–2.81], p < 0.0001 for the highest vs. lowest quartile) and incident CVD (subhazard ratio 1.36 [95% confidence interval 1.10–1.68], p < 0.0001). These findings were robust across several sensitivity analyses. Discussion Neighbourhood‐level SDOH are associated with mortality, incidence of LREs and incident CVD in patients with steatotic liver disease. Interventions aimed at disadvantaged neighbourhoods may improve clinical outcomes.