{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T15:13:41Z","timestamp":1786115621323,"version":"build-2736575974"},"reference-count":68,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T00:00:00Z","timestamp":1785801600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Med. Sci.","Medical Sciences"],"abstract":"<jats:p>Importance: Chronic liver disease requires sustained engagement with the health system, which co-occurring social and functional risks may disrupt. Whether these risks form reproducible patterns with different mortality associations is uncertain. Objective: To identify social and functional risk patterns among US adults with chronic liver disease and evaluate their associations with all-cause mortality. Design, Setting, and Participants: Nationally representative cohort study of National Health Interview Survey sample adults interviewed from 2011 through 2018 and linked to the National Death Index through 31 December 2019. Participants were aged 18 years or older, eligible for mortality linkage, reported a chronic liver condition, and had no baseline liver cancer. Exposures: Latent class membership derived from 7 binary indicators: poverty, food insecurity, uninsurance, cost-related delayed care, no usual place of care, single-adult household status, and activity limitation. A complete 0- to 7-item count was a secondary exposure. Main Outcomes and Measures: All-cause mortality. Survey-weighted Cox models estimated hazard ratios (HRs) with sequential demographic, clinical, and liver-specific adjustment. Prespecified sensitivity analyses used 20 multiple imputed data sets, sampling-weighted pseudo-likelihood latent class models, complete-case re-estimation, a fixed 5-year horizon, and class-by-age interaction testing. Results: Among 3407 adults (weighted mean age, 54.0 years; 49.4% female), 529 deaths occurred over 17,297.6 person-years (median follow-up, 5.0 years [IQR, 3.0\u20137.0]). Four classes were retained: low social and access burden (weighted prevalence, 63.1%); functional limitation with financial strain (13.2%); poverty, single-adult household, and functional limitation (15.0%); and uninsurance with major access barriers (8.7%). Compared with the low-burden class, the functional-limitation\/financial-strain class had higher adjusted mortality (HR, 1.95; 95% CI, 1.34\u20132.82; p &lt; 0.001); the other 2 classes did not differ significantly. Sampling-weighted latent class analysis after multiple imputation reproduced 97.2% of modal assignments, and the association persisted with attenuation (HR, 1.55; 95% CI, 1.08\u20132.22; p = 0.02). Each additional risk was associated with higher mortality (exact count: HR, 1.24 [95% CI, 1.13\u20131.36]; imputed count: HR, 1.19 [95% CI, 1.10\u20131.29]). The class-by-age interaction was not significant (p = 0.41). Conclusions and Relevance: Among US adults with self-reported chronic liver disease, social and functional adversity was both cumulative and patterned. A profile combining functional limitation, food insecurity, and cost-related delayed care had the clearest independent mortality association despite largely retained insurance coverage. These profiles are not a validated clinical score, but the findings argue against reliance on any single indicator, particularly insurance status, as a marker of vulnerability.<\/jats:p>","DOI":"10.3390\/medsci14040455","type":"journal-article","created":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T15:08:09Z","timestamp":1785856089000},"page":"455","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Social and Functional Risk Patterns and All-Cause Mortality Among US Adults with Chronic Liver Disease"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9958-8478","authenticated-orcid":false,"given":"Chukwuemeka E.","family":"Ogbu","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, Cape Fear Valley Health, Fayetteville, NC 28304, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ndukwe J.","family":"Kalu","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Cape Fear Valley Health, Fayetteville, NC 28304, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-6931-1856","authenticated-orcid":false,"given":"Henry E.","family":"Orjiudeh","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Cape Fear Valley Health, Fayetteville, NC 28304, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nonso Desmond","family":"Okeke","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Cape Fear Valley Health, Fayetteville, NC 28304, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8582-687X","authenticated-orcid":false,"given":"Maureen","family":"Okafor","sequence":"additional","affiliation":[{"name":"New York City Health + Hospitals\/South Brooklyn Health, Brooklyn, NY 11235, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lekhya","family":"Kollu","sequence":"additional","affiliation":[{"name":"Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chinazor","family":"Umerah","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Cape Fear Valley Health, Fayetteville, NC 28304, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philip N.","family":"Okafor","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL 32224, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,4]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1016\/j.jhep.2018.09.014","article-title":"Burden of liver diseases in the world","volume":"70","author":"Asrani","year":"2019","journal-title":"J. Hepatol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1589","DOI":"10.1001\/jama.2023.5997","article-title":"Diagnosis and management of cirrhosis and its complications: A review","volume":"329","author":"Tapper","year":"2023","journal-title":"JAMA"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1797","DOI":"10.1097\/HEP.0000000000000323","article-title":"AASLD practice guidance on the clinical assessment and management of nonalcoholic fatty liver disease","volume":"77","author":"Rinella","year":"2023","journal-title":"Hepatology"},{"key":"ref_4","first-page":"1515","article-title":"AASLD-IDSA HCV Guidance Panel. Hepatitis C guidance 2023 update: AASLD-IDSA recommendations for testing, managing, and treating hepatitis C virus infection","volume":"77","author":"Bhattacharya","year":"2023","journal-title":"Clin. Infect. Dis."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"k2817","DOI":"10.1136\/bmj.k2817","article-title":"Mortality due to cirrhosis and liver cancer in the United States, 1999\u20132016: Observational study","volume":"362","author":"Tapper","year":"2018","journal-title":"BMJ"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2664","DOI":"10.1016\/j.cgh.2021.07.009","article-title":"Mortality trends in chronic liver disease and cirrhosis in the United States, before and during COVID-19 pandemic","volume":"19","author":"Kim","year":"2021","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"798","DOI":"10.1016\/j.cgh.2023.11.013","article-title":"Chronic liver disease and cirrhosis mortality rates are disproportionately increasing in younger women in the United States between 2000 and 2020","volume":"22","author":"Abboud","year":"2024","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1966","DOI":"10.1097\/HEP.0000000000000520","article-title":"NAFLD Nomenclature Consensus Group. A multisociety Delphi consensus statement on new fatty liver disease nomenclature","volume":"78","author":"Rinella","year":"2023","journal-title":"Hepatology"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1382","DOI":"10.1002\/hep.32743","article-title":"Health disparities in chronic liver disease","volume":"77","author":"Kardashian","year":"2023","journal-title":"Hepatology"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1548","DOI":"10.14309\/ajg.0000000000003171","article-title":"Social disadvantage and disparities in chronic liver disease: A systematic review","volume":"120","author":"Hasjim","year":"2025","journal-title":"Am. J. Gastroenterol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1093\/jn\/nxz212","article-title":"Food insecurity may be an independent risk factor associated with nonalcoholic fatty liver disease among low-income adults in the United States","volume":"150","author":"Golovaty","year":"2020","journal-title":"J. Nutr."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"2790","DOI":"10.1016\/j.cgh.2021.11.029","article-title":"Food insecurity is associated with mortality among US adults with nonalcoholic fatty liver disease and advanced fibrosis","volume":"20","author":"Kardashian","year":"2022","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1016\/j.jhep.2023.03.020","article-title":"Healthcare affordability and effects on mortality among adults with liver disease from 2004 to 2018 in the United States","volume":"79","author":"Dodge","year":"2023","journal-title":"J. Hepatol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"796","DOI":"10.1016\/j.gastha.2024.05.004","article-title":"Prevalence of healthcare barriers among US adults with chronic liver disease compared with other chronic diseases","volume":"3","author":"Wong","year":"2024","journal-title":"Gastro Hep Adv."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e0358","DOI":"10.1097\/HC9.0000000000000358","article-title":"Health care-related transportation insecurity is associated with adverse health outcomes among adults with chronic liver disease","volume":"8","author":"Ufere","year":"2024","journal-title":"Hepatol. Commun."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"560","DOI":"10.1016\/j.cgh.2025.07.018","article-title":"Social isolation from living alone and mortality among US adults with chronic liver disease","volume":"24","author":"Walker","year":"2026","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1177\/1745691614568352","article-title":"Loneliness and social isolation as risk factors for mortality: A meta-analytic review","volume":"10","author":"Smith","year":"2015","journal-title":"Perspect. Psychol. Sci."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1661","DOI":"10.1016\/S0140-6736(08)61690-6","article-title":"Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health","volume":"372","author":"Marmot","year":"2008","journal-title":"Lancet"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"742","DOI":"10.1089\/pop.2022.0184","article-title":"Cumulative social disadvantage and all-cause mortality in the United States","volume":"25","author":"Javed","year":"2022","journal-title":"Popul. Health Manag."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1553","DOI":"10.1001\/jama.2020.2436","article-title":"Addressing social determinants of health: Time for a polysocial risk score","volume":"323","author":"Figueroa","year":"2020","journal-title":"JAMA"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2060","DOI":"10.1007\/s11606-024-08788-6","article-title":"Patterns of social needs predict quality-of-life and healthcare utilization outcomes in patients from a large hospital system","volume":"39","author":"Zeng","year":"2024","journal-title":"J. Gen. Intern. Med."},{"key":"ref_22","unstructured":"National Academies of Sciences, Engineering, and Medicine (2019). Integrating Social Care Into the Delivery of Health Care: Moving Upstream to Improve the Nation\u2019s Health, National Academies Press."},{"key":"ref_23","first-page":"1","article-title":"United States: Health system review","volume":"22","author":"Rice","year":"2020","journal-title":"Health Syst. Transit."},{"key":"ref_24","first-page":"1","article-title":"France: Health system review","volume":"25","author":"Or","year":"2023","journal-title":"Health Syst. Transit."},{"key":"ref_25","first-page":"1","article-title":"Spain: Health system review","volume":"26","year":"2024","journal-title":"Health Syst. Transit."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1016\/S0140-6736(21)01701-3","article-title":"The EASL-Lancet Liver Commission: Protecting the next generation of Europeans against liver disease complications and premature mortality","volume":"399","author":"Karlsen","year":"2022","journal-title":"Lancet"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1922","DOI":"10.1097\/HEP.0000000000000466","article-title":"AASLD practice guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma","volume":"78","author":"Singal","year":"2023","journal-title":"Hepatology"},{"key":"ref_28","unstructured":"National Center for Health Statistics (2026, July 24). National Health Interview Survey: Survey Methods, Available online: https:\/\/www.cdc.gov\/nchs\/nhis\/about\/nhis-methods.html."},{"key":"ref_29","unstructured":"National Center for Health Statistics (2026, July 24). Public-Use Linked Mortality File Description, Available online: https:\/\/www.cdc.gov\/nchs\/data\/datalinkage\/public-use-linked-mortality-file-description.pdf."},{"key":"ref_30","unstructured":"IPUMS NHIS (2026, July 24). User Note on Sampling Weights. Available online: https:\/\/nhis.ipums.org\/nhis\/userNotes_weights.shtml."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"573","DOI":"10.7326\/0003-4819-147-8-200710160-00010","article-title":"STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies","volume":"147","author":"Altman","year":"2007","journal-title":"Ann. Intern. Med."},{"key":"ref_32","unstructured":"IPUMS NHIS (2026, July 24). LIVERCHRON: Ever Had Any Chronic Liver Condition. Available online: https:\/\/nhis.ipums.org\/nhis-action\/variables\/LIVERCHRON."},{"key":"ref_33","unstructured":"IPUMS NHIS (2026, July 24). LANY: Has Any Activity Limitation. Available online: https:\/\/nhis.ipums.org\/nhis-action\/variables\/LANY."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1","DOI":"10.18637\/jss.v042.i10","article-title":"poLCA: An R package for polytomous variable latent class analysis","volume":"42","author":"Linzer","year":"2011","journal-title":"J. Stat. Softw."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"440","DOI":"10.1037\/tps0000176","article-title":"Ten frequently asked questions about latent class analysis","volume":"4","author":"Choi","year":"2018","journal-title":"Transl. Issues Psychol. Sci."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"721","DOI":"10.1198\/016214502388618465","article-title":"Latent class analysis of complex sample survey data: Application to dietary data","volume":"97","author":"Patterson","year":"2002","journal-title":"J. Am. Stat. Assoc."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"411","DOI":"10.1207\/s15328007sem1203_4","article-title":"Sampling weights in latent variable modeling","volume":"12","author":"Asparouhov","year":"2005","journal-title":"Struct. Equ. Model."},{"key":"ref_38","first-page":"1","article-title":"mice: Multivariate imputation by chained equations in R","volume":"45","year":"2011","journal-title":"J. Stat. Softw."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1982","DOI":"10.1002\/sim.3618","article-title":"Imputing missing covariate values for the Cox model","volume":"28","author":"White","year":"2009","journal-title":"Stat. Med."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1","DOI":"10.18637\/jss.v081.i13","article-title":"randomLCA: An R package for latent class with random effects analysis","volume":"81","author":"Beath","year":"2017","journal-title":"J. Stat. Softw."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Rubin, D.B. (1987). Multiple Imputation for Nonresponse in Surveys, John Wiley & Sons.","DOI":"10.1002\/9780470316696"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1","DOI":"10.18637\/jss.v009.i08","article-title":"Analysis of complex survey samples","volume":"9","author":"Lumley","year":"2004","journal-title":"J. Stat. Softw."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"713","DOI":"10.1002\/hep.31309","article-title":"Use of hepatocellular carcinoma surveillance in patients with cirrhosis: A systematic review and meta-analysis","volume":"73","author":"Wolf","year":"2021","journal-title":"Hepatology"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"2163","DOI":"10.1080\/03007995.2022.2124070","article-title":"Gaps in hepatocellular carcinoma surveillance in a United States cohort of insured patients with cirrhosis","volume":"38","author":"Nguyen","year":"2022","journal-title":"Curr. Med. Res. Opin."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"2340","DOI":"10.1016\/j.cgh.2019.12.035","article-title":"Coordination of care is associated with survival and health care utilization in a population-based study of patients with cirrhosis","volume":"18","author":"Waljee","year":"2020","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"e0157","DOI":"10.1097\/HC9.0000000000000157","article-title":"Multidisciplinary teams, efficient communication, procedure services, and telehealth improve cirrhosis care: A qualitative study","volume":"7","author":"Serper","year":"2023","journal-title":"Hepatol. Commun."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1002\/lt.24684","article-title":"Disability in patients with end-stage liver disease: Results from the Functional Assessment in Liver Transplantation study","volume":"23","author":"Samoylova","year":"2017","journal-title":"Liver Transpl."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"564","DOI":"10.1002\/hep.29219","article-title":"Development of a novel frailty index to predict mortality in patients with end-stage liver disease","volume":"66","author":"Lai","year":"2017","journal-title":"Hepatology"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"923","DOI":"10.1002\/hep4.1688","article-title":"Assessment of the frail patient with end-stage liver disease: A practical overview of sarcopenia, physical function, and disability","volume":"5","author":"Williams","year":"2021","journal-title":"Hepatol. Commun."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"e2209414120","DOI":"10.1073\/pnas.2209414120","article-title":"Social Frailty Index: Development and validation of an index of social attributes predictive of mortality in older adults","volume":"120","author":"Shah","year":"2023","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1056\/NEJM198007173030304","article-title":"Aging, natural death, and the compression of morbidity","volume":"303","author":"Fries","year":"1980","journal-title":"N. Engl. J. Med."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"822","DOI":"10.1001\/jama.2011.163","article-title":"Index event bias as an explanation for the paradoxes of recurrence risk research","volume":"305","author":"Dahabreh","year":"2011","journal-title":"JAMA"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"490","DOI":"10.12788\/jhm.2967","article-title":"Hospital readmissions in patients with cirrhosis: A systematic review","volume":"13","author":"Orman","year":"2018","journal-title":"J. Hosp. Med."},{"key":"ref_54","doi-asserted-by":"crossref","unstructured":"Vaz, J., Str\u00f6mberg, U., Eriksson, B., Buchebner, D., and Midl\u00f6v, P. (2020). Socioeconomic and marital status among liver cirrhosis patients and associations with mortality: A population-based cohort study in Sweden. BMC Public Health, 20.","DOI":"10.1186\/s12889-020-09783-2"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"100172","DOI":"10.1016\/j.lanepe.2021.100172","article-title":"Socioeconomic inequalities in the incidence of alcohol-related liver disease: A nationwide Danish study","volume":"8","author":"Askgaard","year":"2021","journal-title":"Lancet Reg. Health Eur."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"100600","DOI":"10.1016\/j.jhepr.2022.100600","article-title":"Social support and risk of mortality in cirrhosis: A cohort study","volume":"5","author":"Askgaard","year":"2023","journal-title":"JHEP Rep."},{"key":"ref_57","doi-asserted-by":"crossref","unstructured":"Borrell, C., Pal\u00e8ncia, L., Bosakova, L., Gotsens, M., Morrison, J., Costa, C., Dzurova, D., Deboosere, P., Lustigova, M., and Mar\u00ed-Dell\u2019olmo, M. (2021). Socioeconomic inequalities in chronic liver diseases and cirrhosis mortality in European urban areas before and after the onset of the 2008 economic recession. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18168801"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"517","DOI":"10.1016\/j.dld.2026.01.225","article-title":"Health inequalities in patients with cirrhosis: Investigating the impact of material deprivation on patients\u2019 outcomes","volume":"58","author":"Pasta","year":"2026","journal-title":"Dig. Liver Dis."},{"key":"ref_59","doi-asserted-by":"crossref","unstructured":"Billioux, A., Verlander, K., Anthony, S., and Alley, D. (2017). Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool, National Academy of Medicine. NAM Perspectives.","DOI":"10.31478\/201705b"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"719","DOI":"10.1016\/j.amepre.2017.05.011","article-title":"A systematic review of interventions on patients\u2019 social and economic needs","volume":"53","author":"Gottlieb","year":"2017","journal-title":"Am. J. Prev. Med."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"786","DOI":"10.1001\/jamainternmed.2019.0198","article-title":"Association between receipt of a medically tailored meal program and health care use","volume":"179","author":"Berkowitz","year":"2019","journal-title":"JAMA Intern. Med."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"1096","DOI":"10.1016\/j.jclinepi.2004.04.005","article-title":"Agreement between self-report questionnaires and medical record data was substantial for diabetes, hypertension, myocardial infarction and stroke but not for heart failure","volume":"57","author":"Okura","year":"2004","journal-title":"J. Clin. Epidemiol."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"474","DOI":"10.1002\/hep.31726","article-title":"Administrative coding in electronic health care record-based research of NAFLD: An expert panel consensus statement","volume":"74","author":"Adams","year":"2021","journal-title":"Hepatology"},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"1887","DOI":"10.1053\/j.gastro.2021.08.050","article-title":"MELD 3.0: The Model for End-Stage Liver Disease updated for the modern era","volume":"161","author":"Kim","year":"2021","journal-title":"Gastroenterology"},{"key":"ref_65","unstructured":"IPUMS NHIS (2026, July 24). HEPATEV: Ever Had Hepatitis. Available online: https:\/\/nhis.ipums.org\/nhis-action\/variables\/HEPATEV."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"1453","DOI":"10.1016\/S0140-6736(18)32111-1","article-title":"Clinical outcomes in patients with chronic hepatitis C after direct-acting antiviral treatment: A prospective cohort study","volume":"393","author":"Carrat","year":"2019","journal-title":"Lancet"},{"key":"ref_67","first-page":"18","article-title":"Methodological issues in measuring alcohol use","volume":"27","author":"Dawson","year":"2003","journal-title":"Alcohol. Res. Health"},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"450","DOI":"10.1093\/pan\/mpq025","article-title":"Latent class modeling with covariates: Two improved three-step approaches","volume":"18","author":"Vermunt","year":"2010","journal-title":"Political Anal."}],"container-title":["Medical Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/4\/455\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,6]],"date-time":"2026-08-06T04:17:38Z","timestamp":1785989858000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/4\/455"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,4]]},"references-count":68,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["medsci14040455"],"URL":"https:\/\/doi.org\/10.3390\/medsci14040455","relation":{},"ISSN":["2076-3271"],"issn-type":[{"value":"2076-3271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,4]]}}}