From screening to action: Social determinants and early outcomes in pediatric liver transplant recipients

Pediatric liver transplantation is a life-saving intervention, but long-term posttransplant outcomes are increasingly recognized as being influenced by social determinants of health (SDOH).1,2 Despite their importance, gaps remain in how SDOH are addressed in this population. Many SDOH, such as socioeconomic status or educational attainment, are difficult to modify and often fall outside the immediate scope of conventional interventions. Focusing on SDOH targets that can be effectively and standardly assessed is critical to translating our understanding of SDOH into meaningful improvements in transplant outcomes. In this month’s issue of Liver Transplantation, Wadhwani et al3 report prospective data on 77 pediatric transplant recipients across 8 US liver transplant centers from the Social & Contextual impact after Liver Transplantation (SOCIAL-Tx) cohort. Using the well-validated Accountable Healthcare Communities (AHC) screening tool at the time point of index hospitalization for transplant or first posttransplant clinic visit, the authors assessed 4 SDOH measures collectively described as “material economic hardship”: food insecurity, housing instability, transportation challenges, and utility concerns. The individual and joint associations between these household material economic hardships, defined as reporting “yes” to any of the relevant screening questions, and posttransplant length of stay, hospitalizations, and T cell–mediated rejection (TCMR) at 90 days and 1 year were examined. Overall, one-third of recipients reported at least 1 household material economic hardship, underscoring the prevalence of social risks in this population. After adjustment for health literacy, insurance, and transplant center, children from households with material economic hardship compared with those without had 1.37 times more total inpatient-bed days within 90 days after transplant (95% CI: 1.02, 1.84; p=0.04) and 2.17 times more within 1 year (95% CI: 0.68, 6.89; p=0.20), demonstrating a persistently positive association despite the latter not reaching statistical significance. TCMR risk was 2.1 times higher with hardships within 1 year after transplant, though not statistically significant in propensity score–matched analysis (RR: 1.44, 95% CI: 0.89, 2.34; p=0.14). Among the 4 individual hardships, transportation challenge was strongly associated with increased 90-day total inpatient-bed days and TCMR in univariable analyses. The study also found an additive effect of material economic hardships with worse outcomes across several posttransplant measures, emphasizing the cumulative impact of social risks. These results provide compelling evidence of a link between social risks identified through a screening tool and their association with adverse pediatric posttransplant outcomes. While these findings provide important insights into the social determinants of posttransplant outcomes, certain limitations should be considered. One is the relatively short follow-up period, thus the relationship between social risks and longer-term outcomes is yet to be seen. Additionally, the sample size is constrained, which may particularly affect outcomes with fewer events, such as TCMR. While this study was focused on the posttransplant setting, there is likely merit to performing such assessments much earlier than at the time of transplant. Despite these limitations, the study’s prospective and multicenter design is a clear strength and adds to an early but robust evidence base for the integration of structured social risk screening in the provision of transplant care. At present, most transplant programs lack a systematic approach to incorporating social risk screening outside of the pretransplant psychosocial evaluation into routine pretransplant and posttransplant care,4 an often extended period of time during which social risks may evolve as the cumulative strain of high healthcare needs compounds financial burden for patients and their caregivers. Indeed, both adult and pediatric literature have highlighted social adversities in the pretransplant and posttransplant period, including financial toxicity, caregiver burden, and more.5,6 Identifying these needs is a critical first step, but how best to do so remains an open question. Numerous social risk screening tools exist; many were originally developed in primary care settings and are potentially adaptable to the posttransplant setting.7 Social Interventions Research and Evaluation Network (SIREN) at the University of California, San Francisco, has compiled a comprehensive database of these tools, with selected examples summarized in Table 1.8 Some screening tools are lengthy and may not be practical in fast-paced transplant clinics, while others may require adaptation to better capture social risks relevant to the transplant setting. Despite these challenges, Wadhwani et al demonstrate the potential added value of screening for social risks given downstream negative consequences after transplant. We would argue that the best screening tool is the one that will actually be implemented, easily integrated into clinic flow, and accessible to all stakeholders; the AHC tool used in this study may be a practical choice given its endorsement by the Centers for Medicare and Medicaid Services.9 We further advocate for standardization of screening with respect to both instrument utilized and timing of assessments across centers, a practice that would need to be championed at the level of the Organ Procurement and Transplantation Network. TABLE 1 - Comparison of selected pediatric social needs screening tools, adapted from Social Interventions Research and Evaluation Network (SIREN) Screening tools AHC tool iHELP SEEK SWYC WE CARE Social needs questions 19 14 9 9 6–15 Non-social needs questions 8 0 11 24–35 0 Target population Non-specific Peds Peds Peds Peds Reading level 8th grade 7th grade 4th–5th grade 10th grade 9th grade Completion time Not reported Not reported Not reported 10 min <5 min Languages English English English, Spanish, Chinese, Swedish, Vietnamese English, Spanish, Burmese, Nepali, Portuguese, Arabic English Social and community contexta Food insecurity x x x x x Interpersonal violence x x x x Social support x x Stress x x Immigration concerns x Neighborhood and build environment Housing instability x x x Childcare access x Disability needs x Transportation challenges x Economic stability Financial strain x x Utility concerns x x Employment concerns x x Healthcare access and quality Healthcare access x Education access and quality Educational needs x x x aThe question categories are grouped by major domains of social determinants of health as defined by Healthy People 2030. Adapted with permission from UCSF SIREN (Social Interventions Research and Evaluation Network) (https://sirenetwork.ucsf.edu/social-needs-screening-tools-comparison-table-pediatric-settings).8Abbreviations: AHC, Accountable Health Communities; SEEK, Safe Environment for Every Kid; SWYC, Survey of Well-being of Young Children; WE CARE, Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education. However, screening is only the first step—effectively connecting patients and families to existing resources or developing targeted interventions based on identified needs is the next frontier. This study highlights transportation as one actionable and important material hardship. At our center, we have piloted a rideshare transportation assistance program for at-need adult liver transplant candidates during the evaluation process, with preliminary data demonstrating feasibility and high acceptability among the intervention group (unpublished data). While addressing SDOH in liver transplantation may, on the surface, seem daunting, streamlined and validated screening tools are available to simplify the process of identifying modifiable SDOH, such as material hardships, which in turn allows us to take collective action and divert resources to those in greatest need. Moving in this direction is a meaningful and necessary step toward improving long-term liver transplant outcomes.