Rurality and Neighborhood Socioeconomic Status are Associated With Overall and Cause-Specific Mortality and Hepatic Decompensation in Type 2 Diabetes - 14/02/25

Doi : 10.1016/j.amjmed.2025.01.007

Vincent L. Chen, MD ^a,^⁎ , Nicholas R. Tedesco, MS ^a, Jingyi Hu, BS ^a, Venkata S.J. Jasty, MD ^b, Ponni V. Perumalswami, MD ^a,^c,^d
^a Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor
^b Department of Internal Medicine, University of Michigan, Ann Arbor
^c Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Mich
^d Gastroenterology Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Mich

^⁎Requests for reprints should be addressed to Vincent Chen, MD, MS, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109.Division of Gastroenterology and Hepatology, Department of Internal MedicineUniversity of Michigan1500 East Medical Center DriveAnn ArborMI48109

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Friday 14 February 2025

Highlights

•	We assessed effects of rurality and neighborhood-level poverty in >28,000 patients with type 2 diabetes.
•	Neighborhood poverty and rurality associated with overall and cause-specific mortality
•	These same factors were associated with incidence of severe liver disease (hepatic decompensation).
•	Effects of rurality and neighborhood poverty were stronger for liver-related death and hepatic decompensation than death from other causes.

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ABSTRACT

Introduction

Social determinants of health are key factors driving disease progression. In type 2 diabetes there is limited literature on how distal or intermediate factors (eg, those at the neighborhood level) influence cause-specific mortality or liver disease outcomes.

Methods

This was a single-center retrospective study of patients with type 2 diabetes seen at an integrated healthcare system in the United States. The primary outcomes were overall mortality; death due to cardiovascular disease, cancer, or liver disease; or hepatic decompensation. The primary predictors were neighborhood-level (intermediate) factors measuring neighborhood poverty (Area Deprivation Index [ADI], affluence score, disadvantage score) and rurality (Rural-Urban Commuting Area scores). Associations were modeled using Cox proportional hazards or Fine-Grey competing risk models.

Results

28,424 participants were included. Higher neighborhood poverty associated with increased overall mortality, with hazard ratio (HR) 1.11 (95% confidence interval 1.10-1.12, P < .001) per 10 points of ADI and HR 1.32 (95% CI 1.26-1.37, P < .001) for 10 points of disadvantage. Conversely, higher neighborhood affluence associated with lower overall mortality with HR 0.87 (95% CI 0.86-0.89, P < .001) per 10 points of affluence. Living in a rural region associated with increased overall mortality: HR 1.08 (95% CI 1.01-1.15, P = .031). Associations were consistent across cause-specific mortality, though effect sizes were larger for liver-related mortality than for other causes. Living in a more rural neighborhood was associated with increased risk of hepatic decompensation.

Conclusions

Intermediate neighborhood-level socioeconomic status was associated with overall and cause-specific mortality in type 2 diabetes, with larger effects on liver-related mortality than other causes.

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Keywords : Disparities, Liver related events, Survival analysis

Plan

Sensitivity Analyses: Excluding Chronic Liver Diseases

Individual-Level Social Determinants of Health: Secondary Predictors

DISCUSSION

	Funding: The project was supported by P30DK092926 (Michigan Center for Diabetes Translational Research) from the National Institute of Diabetes and Digestive and Kidney Diseases. VLC was supported in part by K08DK132312 from the National Institute of Diabetes and Digestive and Kidney Diseases.
	Conflicts of interest: VLC received grants from AstraZeneca, KOWA, and Ipsen, paid to University of Michigan. The remaining authors have no relevant disclosures.
	Authorship: The guarantor of the article is Vincent Chen. All authors approved the final version of the manuscript. All authors had access to the data and a role in writing the manuscript. VLC: Writing - original draft, Formal analysis, Conceptualization; NRT: Formal analysis; JH: Writing – review & editing, Formal analysis, VSJJ: Writing - review & editing, Formal analysis; PVP: Writing - review & editing, Formal analysis, Conceptualization.