Functional Vulnerability and All-Cause Mortality Among Community-Dwelling United States Adults with a History of Hepatitis or Chronic Liver Disease

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Background and aims Frailty predicts death in advanced cirrhosis and among transplant candidates, but whether a frailty-like functional index identifies mortality risk in the far larger population of community-dwelling adults with liver disease, who are rarely assessed for it, is unsettled. We examined whether a survey-based functional vulnerability index (FVI) was associated with all-cause mortality among US adults reporting a history of hepatitis or a chronic liver condition, independent of poverty and insurance status. Methods Retrospective cohort study using the National Health Interview Survey (2008–2018) linked to the National Death Index through December 31, 2019. Adults 18 years or older reporting a history of hepatitis or a chronic liver condition, eligible for mortality linkage, and without baseline liver cancer were included. The FVI was defined as the proportion of 9 self-reported deficits present (fair/poor self-rated health; ADL or IADL difficulty; work limitation; and difficulty walking, climbing, standing, carrying, or grasping), modeled per 0.10-unit higher score and by deficit count (0, 1, 2, or ≥ 3). Survey-weighted Cox models estimated hazard ratios (HRs) for all-cause mortality, and survey-weighted modified Poisson models estimated 5-year mortality risk ratios. Results Among 9291 adults (1151 deaths; 59,732 person-years; mean follow-up, 6.4 years), 64.6% had no functional deficit. In the fully adjusted model, each 0.10-unit higher FVI was associated with higher mortality (HR: 1.19, 95% confidence interval [CI]: 1.15–1.22), corresponding to an HR of 1.56 (95% CI: 1.44–1.68) per 1 − SD higher FVI. Versus no deficit, mortality rose with increasing burden: 1 deficit (HR: 1.37, 95% CI: 1.05–1.80); 2 deficits (HR: 2.49, 95% CI: 1.86–3.33); and ≥3 deficits (HR: 3.29, 95% CI: 2.65–4.08). Weighted 5-year mortality increased from 3.2% with no deficit to 23.0% with ≥3 deficits. The association was nonproportional and strongest during the first 2 years (HR: 1.28, 95% CI: 1.22–1.35), but persisted beyond 5 years (HR: 1.12, 95% CI: 1.07–1.18). Multiple imputation yielded similar results (HR: 1.20, 95% CI: 1.17–1.23). Poverty predicted mortality before but not after FVI adjustment; uninsurance did not. Conclusion Among community-dwelling US adults with hepatitis or chronic liver disease, a survey-based functional index was strongly and gradually associated with all-cause mortality, capturing risk not explained by poverty or insurance status. Brief functional assessment may identify high-risk patients well outside the transplant clinic.