Socioeconomic and marital status among liver cirrhosis patients and associations with mortality: a population-based cohort study in Sweden

Abstract

Background The importance of socioeconomic status for survival in cirrhosis patients is more or less pronounced within different populations, most likely due to cultural and regional differences combined with dissimilarities in healthcare system organisation and accessibility. Our aim was to study the survival of patients with cirrhosis in a population-based Swedish cohort, using available data on marital status, employment status, and occupational skill level. Methods We conducted a retrospective cohort study of 582 patients diagnosed with cirrhosis in the Region of Halland (total population 310,000) between 2011 and 2018. Medical and histopathologic data, obtained from registries, were reviewed. Cox regression models were used to estimate associations between survival and marital status (married, never married, previously married), employment status (employed, pensioner, disability retired, unemployed), and occupational skill level (low-skilled: level I; medium-skilled: level II; medium-high skilled: level III; professionals: level IV); adjusting for sex, age, aetiology, Model for End-stage Liver Disease (MELD) score, Child-Pugh class, and comorbidities. Results Alcohol was the most common aetiology (51%). Most patients were male (63%) and the median age was 66 years. Occupational skill level was associated with the severity of cirrhosis at diagnosis and the prevalence of Child-Pugh C gradually increased from professionals through low-skilled. The mean survival for professionals (6.39 years, 95% CI 5.54–7.23) was higher than for low-skilled (3.00 years, 95% CI 2.33–3.67) and medium-skilled (4.04 years, 95% CI 3.64–4.45). The calculated hazard ratios in the multivariate analysis were higher for low-skilled (3.43, 95% CI 1.89–6.23) and medium-skilled (2.48, 95% CI 1.48–4.12), compared to professionals. When aggregated, low- and medium-skilled groups also had poorer mean survival (3.79 years, 95% CI 3.44–4.14; vs 5.64 years, 95% CI 5.00–6.28) and higher hazard ratios (1.85, 95% CI 1.32–2.61) compared to the aggregated medium-high skilled and professional groups. Marital and employment status were not statistically significant predictors of mortality in the multivariate analysis. Conclusions Occupational skill level was strongly associated with mean survival and mortality risk. Poorer prognosis among patients with low and medium occupational skill level could not be explained by differences in sex, age, marital status, employment status, MELD score, Child-Pugh class, or comorbidity.

Targeting population groups with heavier burden of hepatocellular carcinoma incidence: A nationwide descriptive epidemiological study in Sweden

“…21,22 As educational level, occupational complexity, and income level are intrinsically related to each other in Sweden, our results support prior observations. 32 Neighbourhood deprivation level was directly associated with HCC incidence, which was in line with studies from England, France and Germany. [16][17][18] The inclusion of IMD in regression models considerably reduced the effect of individual-level SES indicators and vice versa.…”

“…[41][42][43] In cirrhosis, low individual-SES has been associated with a 3.4 times (95% CI 1.9-6.2) higher risk for mortality, compared to high individual-SES. 32 High prevalence of HCC at cirrhosis diagnosis (12.5%) have been described, and HCC is the second leading cause of death in patients with cirrhosis in Sweden. 32,40 Cirrhosis diagnosis delay might be common, and roughly 50% of the patients are already decompensated at the time of cirrhosis diagnosis.…”

“…32,40 Cirrhosis diagnosis delay might be common, and roughly 50% of the patients are already decompensated at the time of cirrhosis diagnosis. 32,40 Decompensated cirrhosis patients with HCC seldom receive curative treatment. 39 In a quarter of cirrhosis patients, cirrhosis might also be unrecognised prior HCC diagnosis.…”

Association of tumor necrosis factor‐α inhibitors and liver cirrhosis in patients with rheumatoid arthritis: A nationwide population‐based nested case‐control study

“…Our findings corroborated a number of prior studies demonstrating increased mortality from liver cirrhosis in patients with low socioeconomic status. [31][32][33] Low socioeconomic status apparently not only increased the risk for liver cirrhosis, but also worsened its prognosis. This issue needs more attention as it might affect resource allocation, and planned interventions for socially deprived RA patients in preventing and managing liver cirrhosis.…”

Socioeconomic Factors Associated with Poor Prognosis in Patients with Alcoholic Liver Cirrhosis

“…Divorced had 1.22 times higher mortality than married [6]. In a study of cirrhosis from Sweden, in which 51% of cirrhosis was alcoholic, low-and middle-skilled workers, compared to professionals, had 1.85 times higher mortality [7].…”