The prevalence of pediatric eosinophilic esophagitis (EoE) may be lower among children living in impoverished areas compared with that of children living in areas of higher socioeconomic status, according to study data published in the Journal of Allergy and Clinical Immunology: In Practice. In a cohort of pediatric Medicaid beneficiaries, the prevalence of EoE was significantly reduced in rural areas and areas with increased neighborhood-level poverty. The reasons for this reduced prevalence remain unclear, but could comprise under-diagnosis of EoE, underutilization of healthcare, or potentially protective environmental exposures.
Investigators conducted a cross-sectional study of individuals aged 0-17 years of age who were enrolled in Medicaid in 2012. Patients who were not enrolled for a full 12-month period were excluded. EoE was defined as having at least 1 inpatient or outpatient visit with an International Classification of Diseases, Ninth Revision (ICD-9) code for EoE in 2012. Prevalence was computed by dividing the number of EoE cases by the total number of participants in the cohort. Prevalence estimates were stratified by age, race and ethnicity, gender, urban and rural status of residence, and poverty status. Multivariable logistic regression was performed to assess the effects of poverty and urban and rural status on EoE prevalence. Regression models were adjusted for age, gender, and race and ethnicity. Individuals from states with missing race and ethnicity data were excluded from the primary models.
The final analysis included 18,452,886 individuals, among whom 4836 had an EoE diagnostic code in 2012. The overall prevalence of EoE was 26.21 cases per 100,000 persons. Prevalence estimates were highest among males (35.68/100,000 cases), white patients (43.97/100,000 cases), patients of “unknown” race/ethnicity (62.85/100,000 cases), patients living in suburban areas (32.03/100,000 cases), and patients living in areas where 0-5% of the population lives below the poverty level (42.91/100,000 cases). The states with the highest EoE prevalence rates were New Hampshire, West Virginia, Tennessee, Utah, and Arizona. In adjusted regression models, rural residence appeared protective against EoE diagnosis (OR, 0.68; 95% CI, 0.59-0.79; P <.001) compared with large-central metro residence. This relationship appeared to be driven the high proportion of white residents in rural areas, for whom EoE prevalence is significantly elevated. Poverty had an inverse relationship with EoE prevalence. Residence in a low-poverty area appeared to confer significantly greater risk for EoE (OR, 3.09; 95% CI, 2.69-3.54; P <.001). These trends persisted in sensitivity analyses which included states with missing race and ethnicity data.
Compared with the nationwide prevalence rates, EoE prevalence was significantly reduced among Medicaid enrollees living in rural areas and areas with high poverty levels. According to the study authors, differential EoE rates by poverty status may be a result of healthcare underutilization, under-diagnosis of EoE among poor patients, and potential protective environmental exposures. Further study is necessary to examine the mechanisms which underlie EoE prevalence in these populations.
Disclosure: One study author declared affiliations with the pharmaceutical industry.
Please see the original reference for a full list of authors’ disclosures.
McGowan EC, Keller JP, Dellon ES, Peng R, Keet CA. Prevalence and geographic distribution of pediatric eosinophilic esophagitis in the 2012 U.S. Medicaid population [published online April 19, 2020]. J Allergy Clin Immunol Pract. doi: 10.1016/j.jaip.2020.04.009