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.

“Presenting symptoms were evaluated based on race and ethnicity, and there were no distinct differences identified in our study. Yet there were several differences in subsequent clinical characteristics and health care utilization outcomes based on race and ethnicity and a number of patient- and neighborhood-level variables capturing social, economic, and environmental dimensions,” lead author Kelsey E. Poisson, MD, codirector of the Neuroimmunology Program at Nationwide Children’s and colleagues wrote.¹ “This suggests that the effects of the [social determinants of health], and structural racism, likely extend to morbidity resulting from this rare diagnosis.”

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.

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.

“Given strong correlations of neighborhood-based socioeconomic risk factors with worse EDSS and the higher prevalence of minority populations living in such at-risk neighborhoods, our study does emphasize the necessity of considering [social determinants of health] as a driver of outcomes when reporting findings based on race and ethnicity,” Poisson, who also serves as an assistant professor of Clinical Pediatrics and Neurology at The Ohio State University College of Medicine, et al noted.¹ “Prospective work is needed across the age spectrum of NMOSD to further understand the relationship between genetics, [social determinants of health], and race so that ultimately systems-based interventions can be developed to address health disparities in this population.”

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