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Childhood Lupus Severity Linked to Social Determinants of Health

NEW ORLEANS — The sociodemographic characteristics of Black and Hispanic children with systemic lupus erythematosus (SLE) appear to play a strong role in influencing the severity of disease in these patients, according to two studies presented at the Pediatric Rheumatology Symposium (PRSYM) 2023. One study showed an association between multiple determinants of health and disease severity among children seen in a large Texas city, and a separate descriptive cross-sectional cohort study of predominantly Black children at two centers in Mississippi and Alabama reinforced the finding of greater severity of disease and social hardships among this racial group. The findings from both studies supplement existing evidence that the prevalence of childhood-onset SLE is greater among Black and Hispanic children. "Several demographic and social determinants of health parameters influenced disease severity at levels that reached statistical significance, including insurance status, race/ethnicity, referral source, PCP [primary care provider] availability, primary language, and transportation needs," Emily Beil, MD, a pediatric rheumatologist at Texas Children's Hospital in Houston, told attendees at the conference, which was sponsored by the American College of Rheumatology. Her team's goal, she said, was to "better understand our patient population and social disparities that contribute to disease severity." Beil and her colleagues conducted a retrospective review of 136 children who had been diagnosed with childhood-onset SLE between January 2018 and May 2022 at Texas Children's Hospital in Houston. Only children who were younger than 18 years at the time of diagnosis at Texas Children's were included. The analysis considered demographics, clinical characteristics, insurance status, social work consultation, access to a primary care provider, transportation needs, primary language, and other parameters related to social determinants of health. The average age of the patients was 13 years, and most were girls (82%). Just over half were Hispanic (53%), and just over a quarter were Black (26%). Half had Medicaid or participated in the Children's Health Insurance Program (CHIP), and 1 in 10 were uninsured (10%). Half the diagnoses were made during an inpatient admission; 36% were made on the floor, and 14% were made in the intensive care unit (ICU). The average Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score was 12.5, and 48.5% of patients had severe disease, indicated by a score of at least 12. Only 2 in 3 children were documented as having a primary care physician (66%), and 32% preferred a language other than English. Most of the children (80%) had a social work consult. Black and biracial children had higher SLEDAI scores at presentation. Non-Hispanic White children were less likely to have a social work consult, compared with other racial/ethnic groups (P = .01 for both). Central nervous system involvement was most prevalent among Black patients (P = .004). Cyclophosphamide was used most often for Black and biracial patients. Uninsured patients were most likely to be diagnosed on an inpatient floor. The highest proportion of ICU admissions was among patients insured by Medicaid (P = .034). Average SLEDAI scores were highest among uninsured patients, followed by Medicaid patients. More than half of the patients who did not have insurance lacked access to a regular primary care provider, compared with 12% of Medicaid patients and 7% of privately insured patients (P = .001). All the uninsured patients had transportation needs, which was a significantly higher rate than among those with Medicaid (13%) or private insurance (15%) (P = .001). The highest percentage of social work consults was among patients who were insured by Medicaid or were without insurance (P = .001).

Salient Demographics and Clinical Features In the second presentation, Anita Dhanrajani, MBBS, an assistant professor of pediatrics at the University of Mississippi Medical Center in Jackson, began by noting that Alabama and Mississippi are ranked in the top 10 states for the highest poverty rate: Mississippi is number one, followed by Alabama at number seven. Further, 40% of children in Mississippi and 29% of children in Alabama are of African American ancestry, she said. "So, we know that this population that we're dealing with has several high-risk factors that can lead them to have poor outcomes, and yet, we haven't really ever characterized their clinical features or their social demographic features," Dhanrajani told attendees. "My hope is that with this very miniscule first step, we're able to move towards solutions to decrease healthcare disparities in this population." She presented findings regarding the first of three aims in the study, which was to describe the baseline clinical, demographic, and socioeconomic profiles of childhood lupus patients at the two centers. The two other aims are to examine genetic factors potentially linked to poor outcomes in the cohort and to assess the mental health status of the population. The study relied on a retrospective chart review for the 17 patients at the University of Mississippi Medical Center and Childhood Arthritis and Rheumatology Research Alliance registry data for the 19 patients at the University of Alabama at Birmingham. Most of the patients (86%) were female, Black (78%), and insured by Medicaid (64%). The average age at diagnosis was 13 years. Most (83%) also lived in a ZIP code that met the criteria for a medium-high or high Social Vulnerability Index. The children had to travel an average 75 miles to see a rheumatologist, compared with the national average of 43 miles. At diagnosis, their average Systemic Lupus International Collaborating Clinics (SLICC) score was 8.8, their average American College of Rheumatology score was 5.2, and their average SLEDAI score was 12.1 ― the latter was substantially higher than the average 3.1 score in a multiethnic Canadian cohort (the 1000 Canadian Faces of Lupus Study) with 10% Black children (P < .00001). The SLEDAI score dropped to 6.8 at 6 months and to 4 at 1 year. Nearly half (47%) had a SLICC Damage Index (SDI) greater than 0, and one third had an SDI of 2 or greater, compared with 16% and 7%, respectively, reported in other recent studies (P < .0001 for both). "These disparities are very difficult to investigate in terms of causal relationships and [are] likely to be very modifiable," Coziana Ciurtin, MD, PhD, an associate professor in rheumatology at University College London in the United Kingdom, told Medscape Medical News. "I think the socioeconomic status, the level of education, poverty, [type of] medical insurance, and probably genetic variants are all underpinning the presentation, damage, or disease activity being very high, and also organ involvement," such as the greater CNS involvement seen in non-White patients. Being mindful of these risk profiles can help doctors in asking about patients' support at home and their families' education, beliefs, and cultural practices, Ciurtin added. "Helping them to engage and be involved in decision-making is probably the most important" aspect of learning this information about families, she said. Collecting this information should not be the sole responsibility of the physician, added Eve Smith, PhD, MBCHB, an academic clinical lecturer at the University of Liverpool in the United Kingdom who attended the presentations. Smith noted a discussion in a work group during the previous day of the conference concerning questionnaires for screening patients regarding the need for social services and for identifying areas in which patients and their families were having difficulties. "Obviously, if you're going to do that, you have to have access to someone who can actually help to deal with that. Some hospitals have patient navigators that can help, for example, with a food security issue to highlight resources within the community, so it's not all on the doctor," Smith told Medscape. "To really make a difference in this area, it can't just be down to the doctor. There needs to be social care, there needs to be community-based interventions and things to do about it. Doctors can help identify these patients, or maybe somebody in the [medical] team can help with that, but there needs to be an intervention. Otherwise, you're left with this problem without a solution that you can't do anything about." The researchers did not note any external funding for either study. Beil, Dhanrajani, Smith, and Ciurtin report no relevant financial relationships.

Reference Pediatric Rheumatology Symposium (PRSYM) 2023: Abstracts 011 and 014. Presented March 30, 2023. Tara Haelle is a health/science journalist based in Dallas. Follow her at @tarahaelle. For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube.

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