title: Local geographic variation in chronic liver disease and hepatocellular carcinoma: contributions of socioeconomic deprivation, alcohol retail outlets, and lifestyle.
abstract: OBJECTIVE
  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.
authors: Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD; Office of Surveillance and Epidemiology, US Food and Drug Administration, Silver Spring, MD. Electronic address: jacqueline.major@fda.hhs.gov.
authors: Jacqueline M
authors: JM
authors: Major
authors: Cancer Control Research Program, Norris Cotton Cancer Center, Dartmouth College, Lebanon, NH.
authors: James D
authors: JD
authors: Sargent
authors: Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD.
authors: Barry I
authors: BI
authors: Graubard
authors: Cancer Control Research Program, Norris Cotton Cancer Center, Dartmouth College, Lebanon, NH.
authors: Heather A
authors: HA
authors: Carlos
authors: AARP, Washington, DC.
authors: Albert R
authors: AR
authors: Hollenbeck
authors: Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD.
authors: Sean F
authors: SF
authors: Altekruse
authors: Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD.
authors: Neal D
authors: ND
authors: Freedman
authors: Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD.
authors: Katherine A
authors: KA
authors: McGlynn
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000428:Alcohol Drinking / Q000009:adverse effects* / Q000453:epidemiology; D006528:Carcinoma, Hepatocellular / Q000453:epidemiology* / Q000209:etiology; D002908:Chronic Disease; D005260:Female; D005843:Geography; D006297:Health Services Accessibility; D006801:Humans; D015994:Incidence; D008019:Life Style; D008107:Liver Diseases / Q000209:etiology / Q000401:mortality*; D008113:Liver Neoplasms / Q000150:complications / Q000453:epidemiology* / Q000209:etiology; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012111:Residence Characteristics; D018570:Risk Assessment; D012923:Social Class; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D014481:United States / Q000453:epidemiology
keywords: Census; Cohort; Health care; Kernel density estimation; Liver cancer; Liver disease; Multilevel; Neighborhood; Socioeconomic disparities