The Impact of Social Inequities on Presentation of Juvenile-Onset Systemic Lupus Erythematosus at a Large Tertiary Center

Abstract

Objective: The prevalence of juvenile-onset systemic lupus erythematosus (JSLE) differs by race/ethnicity with environmental, genetic, and social factors implicated in disease severity and outcomes. Yet, the role of social determinants of health (SDoH) in disease presentation is not well understood. We hypothesized that in an urban center with a large, diverse catchment area, SDoH influence the severity of JSLE at diagnosis.

Methods: We completed an institutional review board-approved medical record review of children newly diagnosed with JSLE between January 1, 2018, and May 31, 2022, at Texas Children's Hospital in Houston, TX. We collected demographic data, clinical severity measures, and SDoH variables such as Area Deprivation Index (ADI), insurance status, pollution burden, and food accessibility. Statistical analysis to compare SDoH with JSLE severity included Kruskal-Wallis test, Fisher exact test, and univariable and multivariable regression.

Results: Mean diagnosis age for 136 patients was 13.4 years, with 82.4% female, 52.9% Hispanic, and 25.7% non-Hispanic (NH) Black. One-third of patients did not have a documented primary care provider, and one-third preferred non-English language. We found NH Black patients had worse clinical severity measures, with highest Systemic Lupus Erythematosus Disease Activity Index and more central nervous system involvement and cyclophosphamide therapy. Uninsured and publicly insured patients were more likely to use inpatient resources at diagnosis and live in neighborhoods with higher pollution levels and higher ADI. Hispanic patients reside in communities with higher ADI scores and limited access to supermarkets.

Conclusion: In children with JSLE from a large urban catchment area, we observed significant association of nonmodifiable (race/ethnicity) and modifiable (insurance status, access to care, food accessibility) factors on disease severity at presentation.

Keywords: environmental influences; geospatial analysis; juvenile-onset systemic lupus erythematosus; pediatric rheumatology; social determinants of health.