Low Childhood Opportunity Index score may drive inequitable outcomes in pediatric lupus
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WASHINGTON — Children with lupus from areas of lower socioeconomic opportunity experience more severe disease complications and poorer outcomes than those from higher opportunity areas, according to data presented at ACR Convergence 2024.
“Co-author Joyce Chang, MD, MSCE, led a prior study using data collected through the Pediatric Health Information System to examine outcomes for children hospitalized for SLE,” Emily Smitherman, MD, MS, assistant professor of pediatric rheumatology at the University of Alabama at Birmingham, told Healio. “We observed inequities in disease outcomes by race and ethnicity. What was very interesting was the inequities were associated with the racial and ethnic compositions of the children’s hospital where they were admitted.”
To further examine these finding at a “more granular level,” Smitherman and colleagues identified children with SLE at three tertiary centers, including 148 patients from Boston Children’s Hospital, 265 patients from Lurie Children’s Hospital of Chicago, and 138 patients from the Children’s Hospital of Alabama, between 2016 and 2022.
“These centers had diverse geographic and socioeconomic characteristics,” Smitherman said. “Across the three sites, we were able to link outpatient electronic health record data and neighborhood-level data with the hospital-level data from Pediatric Health Information System for pediatric patients with SLE.”
Initial disease presentation — defined as a Systemic Lupus Erythematosus Disease Activity Index (SLEDAI-2K) score of 10 or greater, intensive care admission or dialysis and acute care use — served as the primary endpoint. Secondary endpoints included concurrent achievement of a SLEDAI-2K score of 4 or greater, and a prednisone-equivalent dose of 7.5 mg/day or less at the most recent follow-up visit.
The researchers additionally used the Child Opportunity Index — which assesses census tract-level data and includes 29 factors involving education, socioeconomic status and physical environment — as the exposure of interest.
Of the 538 patients with available data, half had public insurance, 29% reported Black race, 30% reported Hispanic ethnicity, and 14% had a preferred language other than English. The highest proportion of Black patients was observed at the Children’s Hospital of Alabama, at 59%, while Lurie Children’s Hospital had 43% Hispanic patients. The average Child Opportunity Index was higher at Boston Children’s Hospital than at the other two sites. Meanwhile, half the of cohort met criteria for severe presentation. The median number of inpatient or ED visits during the 1-year period was one (range 1 to 13).
According to the researchers, patients who lived in low Childhood Opportunity Index area were at an increased risk for severe presentation compared with their counterparts in higher index areas (HR = 1.93; 95% CI, 1.05-3.57). Children within these areas demonstrated similarly increased risks for greater use of acute care during the first year of follow-up (HR = 2.03; 95% CI, 1.29-3.18), and lower odds of achieving a SLEDAI-2K score of 4 or lower and a prednisone dose of 7.5 mg/day or lower (HR = 0.47; 95% CI, 0.23-0.94), vs. those in higher opportunity areas.
“Overall, we observed a consistent association between a neighborhood-level index that represents child opportunity and several measures of disease — severity at SLE presentation, acute care utilization within the year after diagnosis, and low disease activity at most recent follow-up,” Smitherman said. “This suggests the educational, socioeconomic and physical environment conditions of neighborhoods where children with SLE live may drive inequitable outcomes at multiple points along their disease course, from initial access to subspecialty care, through ongoing follow-up.”
Smitherman suggested that further study is necessary to understand the trajectory of disease once a child has established care with a tertiary subspecialty center, and how to mitigate disparities.
“For example, would designing an intervention to systemically identify patients who live in neighborhoods with lower child opportunity, and providing targeted resources through social work, be effective to reduce inequities?” she said. “The more effectively we are able to leverage existing real-world data, as we did for this study, the more rapidly we will be able to start identifying real-world solutions.”
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Smitherman E. Abstract #2556. Presented at: ACR Convergence 2024; Nov. 14-19, 2024; Washington, D.C.
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