Multicenter Study of Associations Between Area-Level Child Opportunity, Initial Disease Severity, and Outcomes Among Children with Lupus.

Abstract

Child opportunity encompasses neighborhood resources and conditions that influence healthy childhood development. We determined whether area-level opportunity is associated with disease severity or disease control in a geographically and socioeconomically diverse multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE). We linked medical records of patients with cSLE at three 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 and adjusted for age, sex, race and ethnicity, language, and insurance status. Among 538 patients with cSLE, living in areas with low versus very high COI was associated with 1.93 times higher adjusted odds of severe disease presentation (95% confidence interval [CI] 1.05-3.57) and 2.03 higher adjusted incidence of acute care visits within the first year (95% CI 1.29-3.18). At the most recent follow-up, living in low versus very high COI areas was associated with higher disease activity (adjusted β 1.69 [95% CI 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 (adjusted odds ratio 0.44 [95% CI 0.22-0.88]). 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.