Eosinophilic esophagitis presentation, care vary by race, socioeconomics in children
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Key takeaways:
- 78% of children with eosinophilic esophagitis and 53% of the pediatric hospital population were white.
- Children from more socioeconomically disadvantaged areas had less radiographic evaluation.
Children diagnosed with eosinophilic esophagitis were predominantly white, non-Hispanic and English speaking, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
These children also were more likely to come from more urban and socioeconomically advantaged neighborhoods compared with the general population, Pooja Mehta, MD, MSCS, pediatric gastroenterologist of the gastrointestinal eosinophilic diseases program at the Digestive Health Institute of Children’s Hospital Colorado, and colleagues wrote.
“There is growing recognition that marginalized communities experience increased morbidity and mortality in numerous diseases,” Mehta told Healio.
“Despite this, there have been very few studies that have researched disparities in relatively rare diseases such as EoE,” she continued. “This is particularly relevant in EoE because EoE is an allergic disease and other allergic diseases aside from EoE disproportionately impact marginalized communities.”
Study design, results
The study compared 2,117 children (68.2% boys) with EoE seen at Children’s Hospital Colorado between Jan. 1, 2009, and Dec. 31, 2020, with the hospital’s global population.
Race and ethnicity significantly differed between the EoE group and the hospital’s global population (P < .0001), with a larger proportion white individuals in the EoE group (78% vs. 53%) and a smaller proportion of Black (4.6% vs. 5%) and Hispanic (12.2% vs. 22%) individuals.
The EoE group was more likely to have caregivers who spoke English than the global hospital population (96.5% vs. 80%) and less likely to come from rural areas than the general population of Colorado based on 2020 Census data (7.2% vs. 13.9%; P < .0001 for both).
The researchers also assessed these populations via the Area Deprivation Index (ADI), which is a validated composite index of socioeconomic disadvantage based on U.S. Census and American Community Survey data taken at the block level.
Children who had higher state ADI scores, indicating greater neighborhood disadvantage, were less likely to have their disease evaluated with radiography (OR per unit increase in state ADI decile = 0.93; 95% CI, 0.89-0.97), were less likely to have had esophageal dilations at a younger age (Pearson correlation coefficient, –0.24; P = .007) and were seen in multidisciplinary clinics less frequently (OR per unit increase in state ADI decile = 0.9; 95% CI, 0.87-0.93).
Compared with white children, Black children were younger at diagnosis (8.3 years vs. 10 years; P = .002) at their first visits with feeding therapy (2 years vs. 4.3 years; P < .001),
when they first saw a dietician (5.1 years vs. 8.1 years; P = .01) and during their first dilation (8.9 years vs. 13 years; P = .03). However, race was not significantly associated with ages in seeing a feeding therapist or dietician or of first dilation in multivariate models.
Also, 3.9% of children who lived in rural areas had feeding therapy, compared with 9.9% of other children (P = .02), but they also were younger when they began their feeding therapy (2.3 years vs. 4.3 years; P < .001).
With univariate logistic regression analysis, the researchers found that odds for being seen in a multidisciplinary EoE clinic fell for children with higher ADI, Black or other non-white children and Hispanic children.
But with multivariate regression analysis, only ADI was significantly associated with less likelihood for being seen in a multidisciplinary clinic.
Conclusions, next steps
These findings point to a gap in understanding how sociodemographic factors impact EoE diagnosis and management, Mehta said, highlighting how whether there are true epidemiologic differences in prevalence or if EoE is underdiagnosed in marginalized communities is unknown.
Despite these overall differences in disease presentation and management based on race and social determinants of health, the researchers also said, the reasons behind these differences remain unknown but are likely multifactorial.
The researchers hypothesized that these differences are not genetic but, instead, are due to structural factors and health inequities that have intertwined with race, poverty and urbanization for decades.
“While the exact cause of these findings is unknown, we speculate that these findings may be secondary to the structural factors and health inequities that have historically linked race, poverty and urbanization,” Mehta said.
Mehta also said that physicians can implement changes at the organizational level to mitigate these disparities, such as improving access to care by screening and referring all patients with possible EoE symptoms to gastroenterologists.
“Moreover, they can provide financial support to make it easier for at-risk patients to attend appointments, identify language preferences at all visits (and using interpreters when appropriate), and enact policies that reduce explicit and implicit bias,” Mehta said.
Hospital systems should develop structures, processes and policies that support equity, the researchers said, improving access to specialists including pediatric gastroenterologists and allergists as well as dieticians and feeding therapists.
“Policy-level changes include expanding health insurance coverage, improving the capacity and number of providers in underserved communities, and increasing the representation of people from marginalized communities in both research and health care administration/delivery,” Mehta said.
Next, the researchers will conduct prospective studies in children who are at risk for EoE to better understand the prevalence of EoE in marginalized communities.
“These future studies can then guide interventions aimed at decreasing disparities and providing equitable care,” Mehta said.
For more information:
Pooja Mehta, MD, MSCS, can be reached at pooja.mehta@childrenscolorado.org.
Perspective
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This is an important contribution to our understanding of how there may be disparities in the diagnosis and management of EoE. There has been an assumption that EoE is more prevalent among individuals identified as white race.
Although the authors report a higher proportion of white race among those diagnosed, the proportion of missing data for racial groups was high among the hospital population (22%) as compared with those diagnosed with EoE (3.3%). Therefore, any assertion that the distribution of EoE is more prevalent among white individuals is not fully supported by the data provided.
Still, the finding that children with higher ADI scores, in multivariable analysis, were less likely to have been provided care in the multispecialty EoE clinic suggests that there are differences in management according to factors related to social determinants of health (SDOH), suggesting the possibility that these differences contribute to differences in prevalence between groups.
A surprising finding was the observation that children identified as Black race were diagnosed at a younger age. If there is underdiagnosis among Black children, one possibility is that those with more severe disease are diagnosed more readily, with more severe disease, generally, manifesting at a younger age.
These findings also are consistent with other reports suggesting that EoE may be underdiagnosed among some groups, including children residing in rural areas where access to specialty care providers may be more limited. A challenge with comparing the prevalence of EoE among racial groups, as compared with the catchment population from where the cases arose, is the substantial missing data for racial designation.
In our own center, we see evidence of differences in the management of patients according to SDOH. It can be challenging to disentangle race from SDOH in the U.S., where certain racial groups are often marginalized and experience implicit bias and racism as part of the “lived experience.” It is this lived experience, and the barriers that this experience creates, that we must focus on as we strive to ensure health care access and equity in care for all.
To mitigate these disparities, doctors can be aware of implicit biases. The data presented here should not be interpreted as EoE occurring more commonly in individuals of white race. This perpetuates underdiagnosis of EoE among other groups.
Instead, these data support the assertion that there are differences observed in the diagnosis and management of EoE across groups, and we must be vigilant in ensuring we offer the same opportunity for diagnosis and treatment, irrespective of racial, ethnic, geographic or economic group.
At the policy level, health care systems can work toward mitigating barriers in access to care, including providing flexibility in clinic and endoscopy suite hours.
Also, work can be done to identify potential barriers in seeking care and develop policies for mitigating these barriers (eg, providing transportation to appointments, locating outpatient clinics in less resourced communities).
Consider how staffing composition and signage in clinics provides a welcoming or less welcoming space for patients.
For patients with a food bolus impaction and presenting to the ED for care, develop protocols for obtaining biopsies to support timely diagnosis of EoE.
Finally, ensure patients are provided adequate support for follow-up of their diagnosis following a food bolus impaction.
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