Race, Socioeconomic Status Play Major Role in Disparities Seen in Pediatric NMOSD Outcomes

Kelsey E. Poisson, MD

(Credit: Nationwide Children’s)

A newly published study showed that pediatric patients from Black and low-income backgrounds with neuromyelitis optica spectrum disorder (NMOSD) experience significantly worse health outcomes compared with their nonHispanic White and more affluent peers. Published in Pediatric Neurology, these findings highlight the interplay of race, socioeconomic factors, and healthcare disparities in managing this rare autoimmune condition of the optic nerve and spinal cord.¹

Among 38 cases of aquaporin-4-positive (AQP4+) NMOSD diagnosed in pediatric patients, researchers observed that Black or African American (AA) patients had an average Expanded Disability Status Scale (EDSS) score of 2.46 compared with 0.33 in nonHispanic White patients (P = 0.003). Notably, this minority pediatric patient population also had 2.37 more hospital admissions (P = 0.002) and spent 28.40 additional inpatient days (P = 0.002) within 2 years of their diagnosis in comparison with their nonHispanic White counterparts.

“Higher attack severity and mortality have been reported in Black/African American adults with NMOSD, and our study corroborates that similar disparities likely exist in children. Historically, these disparate clinical outcomes were attributed to presumed genetic factors, which disregards the fact that race and ethnicity are social constructs," lead author Kelsey E. Poisson, MD, codirector of the Neuroimmunology Program at Nationwide Children’s told NeurologyLive^®. "Black/African American children in our study had a higher degree of socioeconomic disadvantage, which may contribute to poorer outcomes. Given the trend in our study toward more delayed diagnosis in Black/African American children, a more severe burden of disease may develop, requiring longer inpatient hospitalization and ultimately resulting in higher disability."

In this study, researchers analyzed the cases of pediatric patients diagnosed with AQP4+ NMOSD based on 2015 international consensus criteria from 3 tertiary pediatric care centers in the United States between 2009 and 2021.² Using socioeconomic data linked to the patients' addresses, the investigators assessed the influence of race, ethnicity, and socioeconomic status on disease progression and healthcare utilization over a 2-year period post-diagnosis. Authors noted that the data collection included clinical measures, hospitalization records, and neighborhood-level indicators from data in the U.S. Census.

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Additional findings showed that pediatric patients with AQP4+ NMOSD who had public insurance experienced a higher relapse rate than those on private insurance (P = 0.046). Results also revealed that a significantly higher EDSS correlated with pediatric patients who lived in census tracts with a lower median income, higher deprivation index, and higher proportion of population on assisted income, in poverty, and with vacant housing (all, P < 0.05) at 2 years and at the most recent follow-up. Thus, these results emphasize the role of social determinants in exacerbating health disparities beyond initial diagnosis.

"These neighborhood characteristics illustrate the daily living conditions of our patients and are also influenced by the inequitable distribution of resources through structural racism," Poisson, who also serves as an assistant professor of Clinical Pediatrics and Neurology at The Ohio State University College of Medicine, said. "Living in more disadvantaged neighborhoods can affect health outcomes through environmental exposures, poor access to transportation and healthy food, lack of adequate health insurance and medication adherence, and lower health literacy."

The current study faced several limitations including the exclusion of patients without 2-year follow-up data, which might have made the results biased toward those with better access to care. Furthermore, incomplete documentation may have prevented accurate assessment of delays in initiating disease-modifying therapy. Health care utilization data was also limited for patients seeking care outside study centers, and the sample was less representative of White patients because of regional recruitment biases. Additionally, the assessed neighborhood-level socioeconomic data might not fully capture individual or household-level disparities.

“Ultimately we need larger studies that enable us to pursue sub-analyses on identified disparities in minoritized populations to determine the influence of social determinants of health within these sub-populations," Poisson said. "Given that this will be very difficult due to the rarity of AQP4+ NMOSD in children, we simultaneously need to be screening to identify those that are at-risk and offering interventions such as care navigation services, transportation assistance, legal advocacy for unsafe housing, and further caregiver education to promote health literacy about NMOSD."

REFERENCES
1. Poisson KE, Nguyen L, Horn PS, et al. Racial, Ethnic, and Socioeconomic Disparities in Pediatric Aquaporin-4-Positive Neuromyelitis Optica Spectrum Disorder. Pediatr Neurol. Published online October 11, 2024. doi:10.1016/j.pediatrneurol.2024.09.028
2. Wingerchuk DM, Banwell B, Bennett JL, et al. International consensus diagnostic criteria for neuromyelitis optica spectrum disorders. Neurology. 2015;85(2):177-189. doi:10.1212/WNL.0000000000001729