Racial disparities persist in renal outcomes among children with lupus
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Black children with lupus are significantly more likely than white children to have an adverse renal outcome at any hospital encounter, despite an overall decrease in said outcomes since 2006, according to data presented at ACR Convergence 2021.
“Previous literature has shown that children with lupus belonging to racial and ethnic minority groups experience greater renal morbidity,” Joyce C. Chang, MD, MSCE, of Boston Children’s Hospital, told attendees at the virtual meeting. “Over the last 15 years, there have been several advances in pediatric lupus care, including an expansion of therapeutic options, standardization of their use, as well as a focus on quality indicators, which only have contributed to improved renal outcomes over time.”
“Advances in care do that the potential to narrow racial disparities if, for example, they reduce unnecessary treatment variation,” she added. “However, they can also widen disparities if advances do not reach all groups equally.”
To examine whether advances in renal outcomes among hospitalized children with systemic lupus erythematosus over time have varied by race and ethnicity, and whether trends differed based on hospital demographics, Change and colleagues studied records from the Pediatric Health Information System inpatient database from 2006 to 2019. The researchers identified at total of 7,434 unique patients with SLE aged 21 years or younger, with 20,893 admissions across 50 hospitals.
Among these patients, 2,370 were Black, 1,667 were non-Hispanic white, 1,217 were Hispanic white, 891 were classified as Hispanic other, and 563 were Asian, including 132 who were Pacific Islander. The remaining 1,617 patients were classified as non-Hispanic other, including 93 who were American Indian.
The researchers defined an adverse renal outcome as the presence of a diagnosis or procedure code for end-stage renal disease (ESRD), dialysis, or renal transplant, all analyzed separately and as a composite outcome. They used logistic regression models with fixed effects for time and hospital-level random effects, as well as demographic and disease characteristics, to estimate the odds of either an adverse renal outcome at any single hospital encounter, or the event of hospitalization for an adverse renal outcome, after which subsequent encounters were censored.
In addition, Chang and colleagues assessed interactions between race, ethnicity and time to determine whether changes over time differed based on race and ethnicity. They also grouped hospitals by whether at least 50% of their SLE population was Black or Hispanic, to test multiplicative interactions between facility demographics, race and time.
According to the researchers, the proportion of SLE admissions with any adverse renal outcome, ESRD, or dialysis decreased from 2006 to 2019 (P < .01). However, Black children were significantly more likely to demonstrate an adverse renal outcome at any hospital encounter (adjusted OR = 2.5; 95% CI, 1.8-3.5) over time, compared with non-Hispanic whites. In addition, Black (OR = 1.4; 95% CI, 1.1-1.8) and Asian (OR = 1.5; 95% CI, 1-2.4) children with SLE were more likely to be hospitalized for an adverse renal outcome.
Although there were no significant changes in the magnitude of racial disparity over the years, the researchers noted significant differences in both the magnitudes of disparities and changes in disparity levels over time between hospitals where Black or Hispanic patients made up at least 50% of the SLE population, compared with facilities where they were the minority (P < .01).
At hospitals with where at least 50% of patients with SLE were Hispanic, renal outcomes failed to improve at the same rate among Black and Hispanic white patients, compared with non-Hispanic whites. At hospitals where at least 50% patients with SLE were Black, rates of renal outcomes improved less over time among Black versus non-Hispanic white children, and worsened among Hispanic white children.
“This focus on improving care quality to reduce treatment variation alone is likely not going to be sufficient to close the gap in racial disparities,” Chang said. “We actually need to understand the root causes of racial inequities in order to identify processes that would preferentially target improved outcomes among highest risk groups. The population-based estimates can only provide so much information, especially with the type of health system data we have to date.”
“But more critical are the next steps, which include systematic collection of local data, using coordinated efforts, on individual and area-level social determinants of health, and how these interact health and hospital-level peer processes,” she added. “And the goal is to understand why there may be differential risks within minority groups, and at what local context this occurs, so that we can design our hospital peer processes around these issues.”
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Chang JC. Abstract 0956. Presented at: ACR Convergence 2021; November 5-9, 2021 (virtual meeting).
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