Intra-State Differences in Liver Disease-Related Mortality in the United States

diseased liver
Investigators sought to identify factors at the US county level that contribute to liver-related mortality.

Significant intra-state differences in liver disease-related mortality exist in the United States, with much of this variability occurring as a result of patient demographics, clinical risk factors for liver disease, and access to specialty liver care, according to the results of a study published in Gastroenterology.

Although the number of deaths from cirrhosis and hepatocellular carcinoma occurring annually has been increasing in the United States, data have only demonstrated county-wide and state-wide variability in mortality rates from liver disease. Data are lacking at the local level to identify factors associated with variability in liver disease-related mortality and hotspots of liver disease mortality. Therefore, researchers used CDC Wonder data from 2009 to 2018 to calculate county-level age-adjusted liver disease-related death rates.

The investigators found that in multivariable models, 61% of the variability in among-county mortality was explained by county-level race/ethnicity; poverty; uninsured rates; distance to the closest transplant center; and local rates of obesity, diabetes, and alcohol use. Despite adjustment, there was significant within-state variability in county-level mortality rates. In addition, of counties with the highest mortality, 60% were located in 3 states: Oklahoma, Texas, and New Mexico. Adjusted mortality rates were highly spatially correlated and represented 5 clusters: South Florida; Appalachia and the eastern part of the Midwest; Texas and Oklahoma; New Mexico, Arizona, California, and southern Oregon; and parts of Washington and Montana.

“[O]ur data clearly demonstrates significant intra-state differences in liver disease-related mortality, and several socio-demographic and access-to-care variables that help to explain this variability,” stated the authors. “These data help to identify hotspots of liver disease while identifying potentially modifiable factors (e.g., proximity to a liver transplant center) that could help to remediate observed disparities, including improving access to specialized liver care.”


Goldberg D, Ross-Driscoll K, Lynch R. County differences in liver mortality in the US: impact of sociodemographics, disease risk factors, and access to care. Gastroenterology. Published online November 17, 2020. doi:10.1053/j.gastro.2020.11.016