Material economic hardships are associated with second-year hospitalizations after pediatric liver transplantation: Results from the SOCIAL-Tx study

Material economic hardship, defined as difficulty meeting essential needs (e.g. food, housing, utilities), is linked to increased morbidity in the first year after pediatric liver transplant. Its longer-term impact is less understood. We examined whether hardship at transplant was associated with hospitalizations and clinical outcomes in the second post-transplant year, and how hardship changed in the first post-transplant year. This prospective cohort study included pediatric liver transplant recipients (<18 y) and caregivers from nine U.S. transplant centers. Caregivers completed social risk questionnaires shortly after transplant and one year later. Responses were linked with the Society of Pediatric Liver Transplantation registry. McNemar's tests assessed changes in hardship over time and log-binomial regression evaluated associations with second-year hospitalizations and ideal outcomes. Among 63 participants, 23 (37%) caregivers reported economic hardship at transplant and 18 (29%) one year later (X2=1.32, p=0.36). Hardship status changed for some families over time. Children whose caregivers reported hardship at transplant were more likely to be hospitalized in the second year (relative risk [RR] 1.99, 95% CI 1.03, 3.84, p=0.04), a finding that remained significant after adjusting for social isolation (RR 2.35, 95% CI 1.23, 4.49, p=0.01). Our findings highlight the lasting impact of material economic hardship at transplant on longer-term health outcomes. Although overall prevalence of hardship remained stable, a subset of families experienced changes in hardship status over time. These findings support routine screening for material economic hardship both before and after transplant to identify families in need and enhanced social care intervention strategies to reduce avoidable healthcare use.