Racial, ethnic disparities impact subcutaneous immunotherapy for allergic rhinitis

Key takeaways:

• 160 of 153,141 Black patients received subcutaneous immunotherapy (SCIT) compared with 403 of 153,141 white patients.
• 141 of 69,656 Hispanic patients received SCIT compared with 181 of 69,656 white patients.

Black and Hispanic patients with allergic rhinitis get fewer prescriptions for subcutaneous immunotherapy compared with white patients, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.

Barriers to this treatment among these patients should be investigated and addressed, Sunjay Modi, MD, fellow in the department of medicine, section of allergy, asthma and immunology, Penn State College of Medicine, and colleagues wrote.

“Researchers and physicians have seen many racial and ethnic differences in allergic disease processes such as in asthma, eczema and allergic rhinitis. They have also seen disparities related to the treatment of these atopic diseases,” Modi told Healio.

Sunjay Modi

“Because of these previous findings, we hypothesized that there may be disparities in allergy shot prescription practices in patients who have severe allergic rhinitis who are refractory to allergy medications,” Modi said.

The researchers examined data from 1,038,000 adult patients with allergic rhinitis (mean age at index, 49.7 years; standard deviation, 16.1 years; 64.6% women) in the TriNetX US Collaborative Network.

These patients included 906,596 (87.3%) with ethnicity information, with 92.3% of this group identified as non-Hispanic. Next, 632,603 (75.6%) identified as white, 153,318 (18.3%) identified as Black and 23,174 (2.8%) identified as Asian.

Among the 69,660 patients who identified as Hispanic, 42,728 (61.3%) identified as white, 2,164 (3.1%) identified as Black and 257 (0.4%) identified as Asian, with approximately 34% not reporting any co-racial identification.

The researchers matched the Black patients with a reference, non-Hispanic white cohort with 153,141 in each, balancing them for baseline demographics and atopic comorbidities. During 3 years of observation, 160 patients in the Black cohort and 403 in the white cohort began subcutaneous immunotherapy (SCIT; RR = 0.4; 95% CI, 0.33-0.48).

Also, 1:1 propensity score matching found that fewer Asian patients (44 of 23,173) began SCIT compared with non-Hispanic white patients (64 of 23,173; RR = 0.69; 95% CI, 0.47-1.009), which the researchers called statistically nonsignificant.

Based on survival analysis, Black (HR = 0.4; 95% CI, 0.33-0.48) and Asian (HR = 0.69; 95% CI, 0.47-1.009) patients had a lower 3-year probability for SCIT initiation compared with white patients.

Fewer Hispanic patients were prescribed SCIT (144 of 69,656) compared with non-Hispanic white patients (181 of 69,656) during the 3-year observation period as well (RR = 0.8; 95% CI, 0.64-0.99).

SCIT prescriptions additionally lagged among Hispanic white patients (79 of 42,727) compared with non-Hispanic white patients (108 of 42,727; RR = 0.73; 95% CI, 0.55-0.98) after 1:1 propensity score matching.

Compared with non-Hispanic white patients, the researchers continued, there was no significant difference in the proportion of Hispanic non-white patients who started on SCIT (RR = 0.82; 95% CI, 0.59-1.14).

Further survival analysis indicated similar results with lower 3-year estimated probabilities for beginning SCIT among overall Hispanic (HR = 0.8; 95% CI, 0.64-0.99) and Hispanic white (HR = 0.73; 95% CI, 0.55-0.98) compared with non-Hispanic white patients.

“Surprisingly, Black patients were 60% less likely to be prescribed allergy shots compared to white patients with allergic rhinitis. Hispanic patients were 20% less likely to be prescribed allergy shots when compared to white patients,” Modi said.

“This was a surprising result, as we know that underrepresented populations tend to have more severe allergies,” he continued.

Barriers to treatment may include the treatment’s frequent in-office administration at specialists’ offices over 3 to 5 years, requiring time away from family, work or school while also presenting potential transportation challenges, the researchers explained.

A lack of available allergists in underserved areas and inequitable referral practices also are major barriers, the researchers continued. Sublingual immunotherapy could be a solution, they added, but insurance approval may be an obstacle here too.

Providers and other stakeholders can play a role in improving care, Modi advised.

“Prompt referral to allergy subspecialist should be advocated, as we know that underrepresented populations tend to have more severe environmental allergies,” Modi said. “Policy makers should work to develop policies that make it easier for underrepresented populations to access care, especially subspecialists.”

The researchers called for additional studies that would identify and eliminate barriers to SCIT while ensuring equitable care for patients in historically disadvantaged ethnic and racial groups with allergic rhinitis.

Editor's note: Modi would like to acknowledge his coauthors, Matthew R. Norris, MD; Victoria Nguyen, DO; Robert Bower; Timothy J. Craig, DO; and Taha Al-Shaikhly, MBChB.

For more information:

Sunjay Modi, MD, can be reached at smodi@pennstatehealth.psu.edu.