Eosinophilic esophagitis presentation, care vary by race, socioeconomics in children

August 31, 2023

3 min read

Source/Disclosures

Disclosures:
Mehta reports receiving a training grant from the Consortium of Eosinophilic Gastrointestinal Disease Researchers. The other authors report no relevant financial disclosures.

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Key takeaways:

• 78% of children with eosinophilic esophagitis and 53% of the pediatric hospital population were white.
• Children from more socioeconomically disadvantaged areas had less radiographic evaluation.

Children diagnosed with eosinophilic esophagitis were predominantly white, non-Hispanic and English speaking, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.

These children also were more likely to come from more urban and socioeconomically advantaged neighborhoods compared with the general population, Pooja Mehta, MD, MSCS, pediatric gastroenterologist of the gastrointestinal eosinophilic diseases program at the Digestive Health Institute of Children’s Hospital Colorado, and colleagues wrote.

Data were derived from Mehta, et al. J Allergy Clin Immunol Pract. 2023;doi:10.1016/j.jaip.2023.06.011.

“There is growing recognition that marginalized communities experience increased morbidity and mortality in numerous diseases,” Mehta told Healio.

“Despite this, there have been very few studies that have researched disparities in relatively rare diseases such as EoE,” she continued. “This is particularly relevant in EoE because EoE is an allergic disease and other allergic diseases aside from EoE disproportionately impact marginalized communities.”

Study design, results

The study compared 2,117 children (68.2% boys) with EoE seen at Children’s Hospital Colorado between Jan. 1, 2009, and Dec. 31, 2020, with the hospital’s global population.

Pooja Mehta

Race and ethnicity significantly differed between the EoE group and the hospital’s global population (P < .0001), with a larger proportion white individuals in the EoE group (78% vs. 53%) and a smaller proportion of Black (4.6% vs. 5%) and Hispanic (12.2% vs. 22%) individuals.

The EoE group was more likely to have caregivers who spoke English than the global hospital population (96.5% vs. 80%) and less likely to come from rural areas than the general population of Colorado based on 2020 Census data (7.2% vs. 13.9%; P < .0001 for both).

The researchers also assessed these populations via the Area Deprivation Index (ADI), which is a validated composite index of socioeconomic disadvantage based on U.S. Census and American Community Survey data taken at the block level.

Children who had higher state ADI scores, indicating greater neighborhood disadvantage, were less likely to have their disease evaluated with radiography (OR per unit increase in state ADI decile = 0.93; 95% CI, 0.89-0.97), were less likely to have had esophageal dilations at a younger age (Pearson correlation coefficient, –0.24; P = .007) and were seen in multidisciplinary clinics less frequently (OR per unit increase in state ADI decile = 0.9; 95% CI, 0.87-0.93).

Compared with white children, Black children were younger at diagnosis (8.3 years vs. 10 years; P = .002) at their first visits with feeding therapy (2 years vs. 4.3 years; P < .001),

when they first saw a dietician (5.1 years vs. 8.1 years; P = .01) and during their first dilation (8.9 years vs. 13 years; P = .03). However, race was not significantly associated with ages in seeing a feeding therapist or dietician or of first dilation in multivariate models.

Also, 3.9% of children who lived in rural areas had feeding therapy, compared with 9.9% of other children (P = .02), but they also were younger when they began their feeding therapy (2.3 years vs. 4.3 years; P < .001).

With univariate logistic regression analysis, the researchers found that odds for being seen in a multidisciplinary EoE clinic fell for children with higher ADI, Black or other non-white children and Hispanic children.

But with multivariate regression analysis, only ADI was significantly associated with less likelihood for being seen in a multidisciplinary clinic.

Conclusions, next steps

These findings point to a gap in understanding how sociodemographic factors impact EoE diagnosis and management, Mehta said, highlighting how whether there are true epidemiologic differences in prevalence or if EoE is underdiagnosed in marginalized communities is unknown.

Despite these overall differences in disease presentation and management based on race and social determinants of health, the researchers also said, the reasons behind these differences remain unknown but are likely multifactorial.

The researchers hypothesized that these differences are not genetic but, instead, are due to structural factors and health inequities that have intertwined with race, poverty and urbanization for decades.

“While the exact cause of these findings is unknown, we speculate that these findings may be secondary to the structural factors and health inequities that have historically linked race, poverty and urbanization,” Mehta said.

Mehta also said that physicians can implement changes at the organizational level to mitigate these disparities, such as improving access to care by screening and referring all patients with possible EoE symptoms to gastroenterologists.

“Moreover, they can provide financial support to make it easier for at-risk patients to attend appointments, identify language preferences at all visits (and using interpreters when appropriate), and enact policies that reduce explicit and implicit bias,” Mehta said.

Hospital systems should develop structures, processes and policies that support equity, the researchers said, improving access to specialists including pediatric gastroenterologists and allergists as well as dieticians and feeding therapists.

“Policy-level changes include expanding health insurance coverage, improving the capacity and number of providers in underserved communities, and increasing the representation of people from marginalized communities in both research and health care administration/delivery,” Mehta said.

Next, the researchers will conduct prospective studies in children who are at risk for EoE to better understand the prevalence of EoE in marginalized communities.

“These future studies can then guide interventions aimed at decreasing disparities and providing equitable care,” Mehta said.

For more information:

Pooja Mehta, MD, MSCS, can be reached at [email protected].

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