A Multicenter Study of Associations between Area-Level Child Opportunity, Initial Disease Severity and Outcomes among Children with Lupus.

Abstract

Objective: Child opportunity encompasses neighborhood resources and conditions that influence healthy childhood development. We determined whether area-level opportunity associates with disease severity or disease control in a geographically and socioeconomically diverse, multi-center cohort of patients with childhood-onset systemic lupus erythematosus (cSLE).

Methods: We linked medical records of patients with cSLE at 3 tertiary centers (2016-2022) to the Child Opportunity Index (COI) 2.0 (29 indicators across education, health and environment, socioeconomics). Primary outcomes included severe initial disease presentation (composite of Systemic Lupus Erythematosus Disease Activity Index (SLEDAI-2K) ≥10, intensive care, or dialysis) and acute care (inpatient/emergency) visits. Associations between nationally ranked COI levels and outcomes were estimated using mixed effects models clustered by site, adjusted for age, sex, race and ethnicity, language and insurance status.

Results: Among 538 cSLE patients, living in areas with low vs. very high COI associated with 1.93 higher adjusted odds of severe disease presentation (95% CI [1.05-3.57]) and 2.03 higher adjusted incidence of acute care visits within the first year ([1.29-3.18]). At most recent follow-up, living in low vs. very high COI areas associated with higher disease activity (aβ 1.69 [0.54-2.84]) and lower odds of concurrent achievement of SLEDAI-2K≤4 and ≤7.5 mg/day of prednisone, adjusted for initial disease severity and disease duration (aOR 0.44 [0.22-0.88]).

Conclusion: Structural inequities in area-level child opportunity may contribute to disparities in both cSLE severity and disease control. Tailoring interventions for communities with low levels of child opportunity may improve access to pediatric subspecialty care and cSLE outcomes.