Disparities in Pediatric Eosinophilic Esophagitis

Background: studying disparities in patients with eosinophilic esophagitis (EoE)

Race, ethnicity and socioeconomic status are known to affect rates of hospital admission, readmission and mortality. There is also disparity in disease prevalence and health outcomes based on race, socioeconomic status and urbanization for several atopic diseases, including asthma.

Eosinophilic esophagitis (EoE) is a rare atopic disease driven by food allergies that is increasing in incidence and prevalence.

• Thought to primarily impact White, non-Hispanic patients
• A recent study found children in high poverty or rural areas are less likely to be diagnosed with EoE

This study was led by researchers from the Gastrointestinal Eosinophilic Diseases Program within the Digestive Health Institute at Children’s Hospital Colorado. Researchers included Pooja Mehta, MD, Zhaoxing Pan, PhD, Calies Menard-Katcher, MD, and Glenn Furuta, MD.

There were two key objectives:

• Identify patient and neighborhood characteristics of children with EoE diagnosis in a large tertiary care center with broad catchment area.
• Determine if there are any associations between a patient’s demographics or neighborhood advantage/disadvantage and depth of evaluation or treatment choices.

Methods: a retrospective cohort study of children with EoE

Data from electronic health records for children up to 18 years old seen at Children’s Colorado were included in this retrospective cohort study if they met the following criteria:

• Resided in Colorado
• Diagnosed with EoE (based on ICD-9 or ICD-10 codes)
• Seen in hospital’s general gastroenterology clinic or multidisciplinary eosinophilic esophagitis clinic between Jan. 1, 2009, and Dec. 31, 2020

Study population demographics were compared to demographics of patients seen at Children’s Colorado during the same period.

• Rural-Urban Commuting Area (RUCA) taxonomy codes used to classify patients as living in rural or urban areas
• Area Deprivation Index (ADI) scores calculated using home addresses (1 to 100 percentiles (nationally) and 1 to 10 deciles (state); higher scores indicate more neighborhood disadvantage)

There were 2,117 children included in the study.

Results: factors impacting presentation, management of EoE

Sample characteristics of the study population compared patients seen at Children’s Hospital Colorado during the same time:

Of note:

• Fewer children from rural areas in study population than in Colorado general population (2020 census data)
• Majority of children from more advantaged neighborhoods
  • 19^th percentile median national ADI score
  • 4^th decile state score
• ADI scores indicate higher social economic status of study population than general population of U.S. and Colorado

Impact of neighborhood advantage/disadvantage

Patients with higher state ADI/greater neighborhood disadvantage:

• Slight correlation with body mass index z-score at diagnosis
• Less likely to have radiographic evaluation of their disease
• More likely to have esophageal dilation at younger age
• Less frequently seen at multidisciplinary clinic

ADI was not associated with:

• Age of diagnosis
• Seeing a feeding therapist or dietitian
• Age of seeing feeding therapist or dietitian
• Needing esophageal dilation or esophageal foreign body removal

Impact of race, ethnicity, and urbanization

Compared to White children, Black children were younger at:

• EoE diagnosis
• First feeding therapy visit
• First dietitian visit
• First dilation

After multivariate analysis, race was not significantly associated with age of seeing feeding therapist, dietitian or first dilation.

Compared to White children, Hispanic children had:

• Slightly higher body mass index z-score at diagnosis
• No other differences

Language was not significantly associated with any finding.

Compared to children from urban areas, children from rural areas were:

• Less likely to be seen by feeding therapy
• When seen, were younger

Univariate regression analysis found factors that lowered the likelihood of being seen in a multidisciplinary EoE clinic (per unit increase in state ADI decile):

• Higher ADI
• Black or non-white children
• Hispanic children

After multivariate analysis, ADI was the only significant factor associated with decreased likelihood of being seen in a multidisciplinary EoE clinic.

Discussion and conclusion: health disparities include race, social determinants of health

Findings from this study showed differences in disease presentation and management of EoE varied by race and social determinants of health, though it is unknown why.

Study authors observed children who were Black, from rural areas and disadvantaged areas appeared to experience greater disease severity based on age of dilation and age of seeing dietitians/feeding therapists. They noted a growing body of evidence supporting race is not a reliable substitute for genetic difference.

Study authors hypothesized:

• Differences documented in the study are not genetic but may be result of structural factors and health inequities
• Patients with EoE often subtly adapt to their disease instead of seeking medical care
  • Possible only most severe patients referred to specialty care
  • Structural factors of more severe atopic diseases in marginalized communities may exist for EoE

They also identified potentially important areas of intervention to address disparities in the EoE population:

• Hospital systems need to develop structures and process to support equity and improve access to specialists, including pediatric gastroenterologists, allergists, dietitians, feeding therapists

Policy changes need to be made to improve access to care and equitable opportunities - feeding therapists, dietitians knowledgeable in EoE limited in rural areas and are not often covered by insurance.