Disparities in Outcomes of Alcohol-Associated Cirrhosis: Increased Mortality and Procedural Burden in a Nationwide Study

Background: Alcohol-associated cirrhosis is a leading cause of liver-related hospitalizations and mortality globally. Despite its prevalence, the determinants of clinical outcomes, procedural utilization, and disparities by race and gender remain incompletely characterized. This study aimed to compare in-hospital outcomes and resource utilization between patients with alcohol-associated cirrhosis and those with cirrhosis from other etiologies. Methods: We conducted a retrospective cohort study using the National Inpatient Sample (NIS) from 2016 to 2019. Adult hospitalizations with cirrhosis were stratified by etiology (alcohol-associated vs. other). Primary outcomes included in-hospital mortality, length of stay, and hospitalization costs. Secondary outcomes included utilization of upper gastrointestinal endoscopy (EGD), variceal interventions, transjugular intrahepatic portosystemic shunt (TIPS), hemodialysis, liver transplantation, and blood product transfusions. Multivariable logistic and Poisson regression models were used to assess associations, adjusting for demographics, comorbidities, and hospital characteristics. Results: Among 1,428,425 cirrhosis-related hospitalizations, 733,495 (51.4%) were alcohol-associated. Patients with alcohol-associated cirrhosis were younger (mean age 55.8 vs. 64.0 years), more likely to be male, and had higher Medicaid coverage. In-hospital mortality was higher in alcohol-associated cirrhosis (9.0% vs. 8.4%; adjusted OR 1.13, 95% CI 1.10–1.16, p < 0.001). These patients underwent more EGD (16% vs. 11%; OR 1.50), variceal interventions (11% vs. 8.2%; OR 1.30), TIPS (1.4% vs. 1.1%; OR 1.19), and blood transfusions (17% vs. 13%; OR 1.27), but had lower odds of liver transplantation (1.1% vs. 1.5%; OR 0.57). Female sex and minority race were independently associated with disparities in mortality and procedural utilization, with pronounced effects among alcohol-associated cirrhosis patients. Conclusion: Alcohol-associated cirrhosis is the most common cause of cirrhosis-related hospitalizations and in-hospital mortality and is associated with a higher procedural burden. Notable racial and gender disparities exist in both outcomes and access to advanced procedures. These findings highlight the need for targeted strategies to improve equity and optimize care in patients with alcohol-related cirrhosis. Trial Registration: Not applicable. This study is a retrospective analysis of a publicly available, de-identified administrative database and does not involve a prospective healthcare intervention.