Multiple Social Disadvantages Linked to Progressively Worse JIA and Pediatric Lupus

Childhood Lupus and Reduced Childhood Opportunity

In a similar study looking at children with childhood-onset lupus, researchers similarly identified the way that compounding social determinants of health were linked to greater disease activity.

“We know that structural racism segregates children from historically marginalized groups into different neighborhoods with lower childhood opportunity,” Joyce C. Chang, MD, of Boston Children’s Hospital, told attendees. “When we talk about child opportunity, we’re really describing all of the resources and conditions that helped to promote healthy childhood development,” including factors related to education, physical health, the built environment, and social and economic security, she said.

Dr. Chang and her colleagues therefore assessed the relationship between a 29-indicator Child Opportunity Index for patients with childhood-onset lupus and the severity of their disease presentation and activity over time. They determined the Child Opportunity Index for different neighborhoods and assessed the amount of racial residential segregation around the three institutions involved in the study. Severity of lupus presentation was based on the need for intensive care unit admission or dialysis or a Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score of 10 or higher. Disease activity over time was based on the SLEDAI-2K score.

The patient population included 553 patients with childhood-onset lupus from three institutions: Boston Children’s Hospital, Lurie Children’s Hospital of Chicago, and Children’s of Alabama in Birmingham, Alabama. Across the full population, 30% of the patients were Black and 30% were Hispanic, but the distribution of race and ethnicity varied by institution. Most of the Black patients, for example, were at Children’s of Alabama (59%), while 43% of the Hispanic patients were at Lurie. Across all the sites, 14% of the patients’ families preferred a non-English language as their first language, and just over half the patients (52%) had public insurance.

Dr. Chang did not have data yet from the Lurie and Alabama cohorts, so she presented preliminary data from the Boston Children’s cohort of 148 patients. In those results, children living in neighborhoods of low childhood opportunity had four times higher odds of presenting with severe disease than children living in neighborhoods of very high opportunity. Then the researchers factored in the location quotient that represented the magnitude of racial segregation in a residential area. In areas with high levels of Black vs White segregation, children were 2.5 times more likely to have a more severe initial disease presentation. However, there was not a significant difference in areas highly segregated between Hispanic and non-Hispanic residents.

After initial presentation, the data revealed a dose-dependent relationship between childhood opportunity and severity of disease activity based on SLEDAI-2K. After adjustment for insurance status, race, preferred language, age at disease onset, sex, major organ involvement, initial SLEDAI-2K score at presentation, and follow-up time, disease activity incrementally increased as childhood opportunity decreased (P < .001 for the trend).

The findings suggested that even in regions like Boston, where overall childhood opportunity is higher than the national average, “poor relative neighborhood opportunity is still associated with more severe lupus presentation, as well as higher lupus disease activity during follow-up,” Dr. Chang said. “Area-level conditions may drive inequitable outcomes at numerous points,” including initial access to subspecialty care and after establishing that care, she said.

Dr. Soulsby, Dr. Chang, and Dr. Ardoin reported having no disclosures. Dr. Soulsby’s research was funded by CARRA and the Arthritis Foundation, and Dr. Chang’s research was funded by CARRA.
 

A version of this article appeared on Medscape.com.