Lupus racial disparities worse in children’s hospitals that serve more Black patients
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Key takeaways:
- Outcome disparities between Black and white patients were worse in children’s hospitals that served more Black children.
- Hospitals can clarify the picture by collecting data on social determinants of health, researchers said.
Disparities in lupus ICU admission and renal outcomes between Black and white children are greater in children’s hospitals serving more Black patients, according to data published in Arthritis Care & Research.
“Clinicians will recognize that the relationship between health care disparities and the characteristics of the communities they serve is really complicated — it’s not all about individual patient characteristics,” Joyce C. Chang, MD, MSCE, of Boston Children’s Hospital and Harvard Medical School, told Healio. “We have to think beyond patient-provider interactions to consider broader societal forces and their interactions with health systems.”
To examine whether juvenile systemic lupus erythematosus outcomes in hospitals are impacted by the racial or ethnic demographics served, Chang and colleagues conducted a retrospective cohort study of data from 47 freestanding U.S. children’s hospitals in the Pediatric Health Information System. The researchers examined data from 2006 through 2021 for patients who were discharged with a primary or secondary diagnosis of SLE, then used generalized mixed effect models with hospital-level random effects to compare their outcomes with hospital-reported patient demographics.
The analysis included 8,125 patients with SLE. The median age at admission was 15 years. Among the included patients, 32.9% were Black, 21.88% were non-Hispanic white, 15.74% were Hispanic white, 12.46% were Hispanic “other race,” 7.66% were American Indian or other non-Hispanic race, 7.45% were Asian or Pacific Islander, and 1.92% were of unknown race or ethnicity.
Overall, 28% of patients with SLE — a total of 2,293 individuals — required ICU admission. According to the researchers, Black children with SLE had a greater risk for ICU admission vs. non-Hispanic white patients only at the 23 hospitals serving a larger proportion of Black children (OR = 1.29; 95% CI, 1.04-1.59). Meanwhile, ICU admission disparities among Hispanic vs. non-Hispanic white patients demonstrated no link to Hispanic ethnic composition.
Adverse renal outcomes impacted 9% of patients with SLE — or 698 individuals. Black children demonstrated 1.8-fold increased odds for adverse renal outcomes vs. non-Hispanic white children, regardless of any adjustments for Black or Hispanic patient composition. Meanwhile, at hospitals serving higher proportions of Black patients, the estimated magnitude of disparity between Black and white children was larger, with ORs of 2 (95% CI, 1.4-2.8) vs. 1.7 (95% CI, 1.1-2.4).
The researchers reported the opposite effect for Hispanic patients, where renal outcome disparities were only observed in hospitals serving a smaller proportion of Hispanic patients.
“One thing that jumped out was how different our findings in this pediatric health network were from other studies performed in adult health systems, where racial segregation across hospital systems is strongly associated with overall inequities in health outcomes,” Chang said. “I think it just further highlights the fact that systems and context matter, so we can’t just extrapolate. It was also interesting to see how different our findings were for relative disparities between Black vs. white children compared to Hispanic vs. non-Hispanic children in relation to the racial and ethnic make-up of patients at each hospital.
“Although we cannot jump to any conclusions based on these preliminary findings, I think it should push us to think about historical context and how to incorporate that into our research,” she added. “If we can mobilize children’s hospitals to start routinely collecting and reporting data on social determinants of health among the populations that they serve, and reporting other hospital characteristics related to resources used to address those social determinants, then we can really start digging into why we see the patterns that we see and figuring out what to do about it.”
Perspective
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Daniel J. Wallace, MD, FACP, MACR
A government funded study under the supervision of Harvard University studied whether health disparities may be driven by hospital-level factors. A total of 8,125 patients with lupus admitted to 47 children’s hospitals were studied over a 15-year period with a primary outcome evaluating the influence of race and ethnicity upon intensive care unit (ICU) admissions and adverse renal outcomes. Since one-third of lupus patients in the United States are African American, this group was also one-third African American.
According to the study, adverse renal outcomes were greater among facilities with a higher Black racial composition, but this was not necessarily the case among those with higher Hispanic composition. Black patients also had more ICU admissions.
Although this information is interesting, it raises more questions than answers. There are hypotheses that systemic lupus erythematosus is more severe in the African American population independent of socioeconomic factors, but these are not raised or cited. How many of the hospitals had pediatric rheumatologists on the staff and did this play a role with outcomes? Was there any difference between Medicaid patients and those with no insurance? Were there any geographical variations or differences?
It is not clear what the take-home message is or how this very useful information should be acted upon to improve the quality of care of these children. It is clear that children with SLE often have multiple admissions, and this could have been at several different hospitals. How was this accounted for?
In summary, race and ethnicity play a role in the evolution of renal impairment and ICU admissions, but we need more clarification and guidance.
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