BACKGROUND: Liver transplantation (LT) is a life-saving therapy for patients with end-stage liver disease, yet persistent disparities in post-transplant outcomes suggest that social and structural factors play an important role. This dissertation examines how individual and community-level social determinants of health (SDOH), including race, ethnicity, insurance type, education, and social vulnerability, affect post-transplant outcomes. Social vulnerability was measured using the Centers for Disease Control and Prevention’s Social Vulnerability Index (SVI). The study examined the relationships between these factors and readmission, mortality, and graft survival to inform public health practice and quality improvement in transplant care. METHODS: A retrospective cohort design included 2,138 adults aged ≥18 years who underwent LT between 2002 and 2023 at a major Southeastern U.S. transplant center. Two complementary analyses were conducted to ensure comparability across census-tract and county-level SVI. Multivariable modeling included Cox proportional hazards regression, Kaplan–Meier survival analysis, logistic regression, and domain-specific SVI assessments.
RESULTS: After adjustment for confounders, overall SVI, at both census-tract and county levels, was not independently associated with survival up to ten years or 90-day readmissions. At the census-tract level, no SVI domain significantly predicted readmission, though a borderline association emerged within the household composition domain. County-level analyses revealed that socioeconomic vulnerability, particularly unemployment and income, were key predictors of readmission. Survival analyses demonstrated limited domain-specific associations, but logistic regression identified higher odds of mortality or graft failure among Black recipients (OR 2.23, 95% CI 1.39–3.71; p = 0.003), White recipients (OR 2.01, 95% CI 1.29–3.26; p = 0.029), and those with a high school education (OR 1.31, 95% CI 1.05–1.65; p = 0.012).
CONCLUSIONS: Area-level SVI measures did not strongly predict readmission or long-term survival, though domain-specific indicators revealed nuanced socioeconomic and demographic effects. Neighborhood vulnerability influenced early readmission through socioeconomic pathways, while individual factors such as age, sex, and illness acuity more strongly shaped long-term outcomes. These findings highlight the need to integrate both individual and community vulnerability metrics into transplant risk stratification and equity-focused quality improvement.
