Local geographic variation in chronic liver disease and hepatocellular carcinoma: contributions of socioeconomic deprivation, alcohol retail outlets, and lifestyle

Ann Epidemiol. 2014 Feb;24(2):104-10. doi: 10.1016/j.annepidem.2013.11.006. Epub 2013 Nov 21.


Purpose: Hepatocellular carcinoma (HCC) incidence rates continue to increase in the United States. Geographic variation in rates suggests a potential contribution of area-based factors, such as neighborhood socioeconomic deprivation, retail alcohol availability, and access to health care.

Methods: Using the National Institutes of Health-American Association of Retired Persons Diet and Health Study, we prospectively examined area socioeconomic variations in HCC incidence (n = 434 cases) and chronic liver disease (CLD) mortality (n = 805 deaths) and assessed contribution of alcohol outlet density, health care infrastructure, diabetes, obesity, and health behaviors. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated from hierarchical Cox regression models.

Results: Area socioeconomic deprivation was associated with increased risk of HCC incidence and CLD mortality (HR, 1.48; 95% CI, 1.03-2.14 and HR, 2.36; 95% CI, 1.79-3.11, respectively) after accounting for age, sex, and race. After additionally accounting for educational attainment and health risk factors, associations for HCC incidence were no longer significant; associations for CLD mortality remained significant (HR, 1.78; 95% CI, 1.34-2.36). Socioeconomic status differences in alcohol outlet density and health behaviors explained the largest proportion of socioeconomic status-CLD mortality association, 10% and 29%, respectively. No associations with health care infrastructure were observed.

Conclusions: Our results suggest a greater effect of area-based factors for CLD than HCC. Personal risk factors accounted for the largest proportion of variance for HCC but not for CLD mortality.

Keywords: Census; Cohort; Health care; Kernel density estimation; Liver cancer; Liver disease; Multilevel; Neighborhood; Socioeconomic disparities.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Alcohol Drinking / adverse effects*
  • Alcohol Drinking / epidemiology
  • Carcinoma, Hepatocellular / epidemiology*
  • Carcinoma, Hepatocellular / etiology
  • Chronic Disease
  • Female
  • Geography
  • Health Services Accessibility
  • Humans
  • Incidence
  • Life Style
  • Liver Diseases / etiology
  • Liver Diseases / mortality*
  • Liver Neoplasms / complications
  • Liver Neoplasms / epidemiology*
  • Liver Neoplasms / etiology
  • Male
  • Middle Aged
  • Proportional Hazards Models
  • Prospective Studies
  • Residence Characteristics
  • Risk Assessment
  • Social Class
  • Socioeconomic Factors
  • Surveys and Questionnaires
  • United States / epidemiology