Impact of housing instability on hospital outcomes in alcohol-associated liver disease: A single-center retrospective cohort study

Among unhoused individuals, alcohol use significantly contributes to the burden of liver disease. This study examines the effects of being unhoused on hospital outcomes and associated psychiatric conditions with alcohol-associated liver disease (ALD). We conducted a retrospective cohort study of adults hospitalized with ALD from 2020 to 2024 at a tertiary care center. Patients were stratified into housed (reference) and unhoused (exposure) cohorts. Multivariable regression analyses were performed to evaluate the association between housing status and clinical outcomes, using logistic regression for categorical outcomes and negative binomial regression for count outcomes. A total of 3523 patients, 330 unhoused and 3193 housed, were included. Unhoused patients were younger, more often male, and had lower body mass index (all P < .001). Unhoused patients had significantly more hospital admissions (3.65 ± 0.23 vs 2.46 ± 0.06; adjusted incidence rate ratio [aIRR] 1.62, 95% confidence interval [CI] 1.46-1.79, P < .001), greater total days hospitalized (22.35 ± 1.62 vs 15.91 ± 0.51; aIRR 1.60, 95% CI 1.42-1.82, P < .001), and more emergency department visits (10.11 ± 0.70 vs 2.21 ± 0.07; aIRR 4.89, 95% CI 4.18-5.74, P < .001) and intensive care unit visits (0.23 ± 0.03 vs 0.13 ± 0.01; aIRR 1.62, 95% CI 1.22-2.12, P < .001). Mortality and average length of stay per encounter did not differ. Unhoused patients had higher odds of hepatic encephalopathy (adjusted odd ratio [aOR] 1.38, 95% CI 1.04-1.83, P = .02), malnutrition (aOR 1.79, 95% CI 1.38-2.31, P < .001), and sepsis (aOR 2.13, 95% CI 1.61-2.81, P < .001). Substance use and psychiatric comorbidities were more prevalent among unhoused patients. Being unhoused is associated with greater hospital utilization and complications among patients with ALD, underscoring the need for integrated medical, addiction, psychiatric, and social-support interventions.