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DENVER — The greater the social disadvantage is for children with juvenile idiopathic arthritis (JIA), the higher their odds are of having active disease, according to a cohort study presented at the CARRA 2025: Childhood Arthritis and Rheumatology Research Alliance Annual Scientific Meeting.

While it’s well understood that social determinants of health are associated with levels of disease activity in patients with rheumatologic conditions, it’s less clear how much individual-level factors vs community-level or broader social factors contribute to those associations.

“We thought that community-level social determinants may interact at these levels to contribute to and perpetuate health disparities, and improving our understanding of these relationships should help with system interventions,” Daniel Soulsby, MD, a pediatric rheumatologist at the University of California San Francisco told attendees.

“This kind of research is important because our patients’ wellbeing is more than just their physical health,” Giya Harry, MD, MPH, MSc, an associate professor of pediatric rheumatology at Wake Forest University School of Medicine, Winston-Salem, North Carolina, and chair of the CARRA Diversity, Equity, and Inclusion Committee, told Medscape Medical News. “How well our kids do is dependent on myriad factors that extend beyond the individual to the family, community, and healthcare systems,” said Harry, who was not involved in the research.

“The more we know about what matters to our patients and families and recognize the stressors that are present, we can better tailor the therapeutic plan to fit their lives,” she said. That could mean, for example, alternating in-person and virtual visits for those with transportation challenges, providing at-home medications instead of infusions, and connecting families with social or community-based services.

Details of Study With Nearly 8000 Patients

The researchers analyzed data from the CARRA registry from July 2015 to January 2022, including all patients diagnosed with JIA before age 16 years who had at least one visit with a complete clinical Juvenile Arthritis Disease Activity Score (cJADAS) and had a disease onset within the previous 6 months or more than 6 months after starting or restarting a prescription medication.

The two exposures were the Area Deprivation Index (ADI), which maps out the relative socioeconomic conditions of neighborhoods, and a cumulative social disadvantage score on a score of 0-3, with one point each given for an income below $50,000 per year, having public or no insurance, and having a guardian with a high school level of education or less. They defined active disease as a cJADAS-10 ≥ 1.1 for oligoarticular JIA and a score > 2.5 for all other JIA subtypes.

Among the 7963 patients, 21.8% in the lowest ADI quartile (least amount of deprivation) had the greatest proportion (81.2%) of patients with a 0 score for social disadvantage, with only 1.1% scoring a 3. Meanwhile, among the 20.3% in the highest ADI quartile (greatest socioeconomic deprivation), 35.1% scored a 0, 27.9% scored a 1, 24.6% scored a 2, and 12.4% scored a 3 on social disadvantage.

Overall, 7.5% of the population had a household income < $25,000, and 11.6% had a household income of $25,000-$49,999. About two thirds (67%) of caregivers, however, had greater than a high school education.

After adjusting for age at enrollment, time to diagnosis, race/ethnicity, sex, JIA category, presence of another rheumatologic disease, and medication, patients in the highest ADI quartile had 11% greater odds for active disease compared with those in the lowest ADI quartile, but the difference was not significant. Slightly increased odds for active disease in the second and third highest quartiles were also nonsignificant.

Cumulative social disadvantage had a much greater association with active disease. Compared with patients with a score of 0, those with a score of 3 had more than double the odds (adjusted odds ratio, 2.1; 95% CI, 1.73-2.53) for active disease. Patients with a score of 1 had 30% greater odds for active disease and those with a score of 2 had 79% greater odds, both statistically significant.

From here, Soulsby conducted a causal mediation analysis, which evaluates whether a mediating relationship exists between an exposure and outcome. This analysis looked at whether individual- and family-level social determinants of health (cumulative social disadvantage) mediated the relationship identified between community-level social determinants of health (ADI) and active disease.

The analysis revealed that the ADI’s effect on disease activity was mediated by individual- and family-level social determinants of health (cumulative social disadvantage score), on average, 68% of the time (P = .02). But analyzing each component of the cumulative social disadvantage score showed that low family income (80% mediating; P = .04) and having public or no insurance (75% mediating; P = .01) had a much greater mediating effect on ADI’s impact on active disease than the guardian having a low level of education (27%; P = .69), which did not significantly mediate ADI’s effects.

Need for Both Community- and Individual-Level Interventions

“What this really shows is that even though we need to generate population-level interventions for children who experience JIA health disparities, we are really going to have to couple it with individual-level interventions” to mitigate those disparities, Soulsby said. Such interventions could include social work support services and patient or peer navigators, for example.

The analysis was limited by assumptions in the directionality of the relationships between the variables and the limited information available on social determinants of health. It’s also unclear how generalizable the findings are, and it’s an open question whether these effects and relationships are limited to patients with JIA or would be similar for patients with other conditions, Soulsby said.

“Although not surprising to most pediatric rheumatologists, one striking takeaway from their work is that high school educational level does not mediate the causal relationship between ADI and JIA disease activity,” Harry told Medscape Medical News. “It does make one wonder whether the strong association between cumulative social disadvantage score and the outcome, or its significant indirect effect on ADI and disease activity, may not be driven by the educational level of the caregiver.”

The clinical implications of these findings are complex, Harry added, because it’s possible that a low income or having public or no insurance are proxies for other factors not yet identified.

“All these factors could influence a caregiver’s ability to keep appointments, help with medication adherence at home, deal with the financial stress of the JIA,” and other challenges, “all of which could influence disease activity as well,” Harry said. “For pediatric rheumatologists, it is important to continue to learn about the lives of our patients and their families to better understand whether these factors are present, with the goal of choosing therapeutic plans, if possible, that mitigate the role they may play.”

Soulsby disclosed receiving grant funding from CARRA, the Arthritis Foundation, and the UCSF Hellman Society of Fellows grant. Harry had no disclosures.

Tara Haelle is a science/health journalist based in Dallas.