Sandra Quezada, MD, on Social Disparities in IBD Treatment

Sandra Quezada, MD, MS, identified various disparities in the determinants of health that interfere in the treatment of inflammatory bowel disease (IBD) among patients who belong to minority groups or have financial and social stress during her presentation at the Advances in Inflammatory Bowel Disease annual meeting in Orlando, Florida, on December 5.

Dr Quezada is the associate dean for admissions, the associate dean for faculty diversity and inclusion, and an associate professor of medicine in the gastroenterology and hepatology department at the University of Maryland School of Medicine in Baltimore, Maryland.

Risk factors of disease progression and complications in Crohn disease (CD) include onset of disease at the age of 40 years or younger, perianal or stenotic diseases, involvement of the upper gastrointestinal tract, use of corticosteroids, and lack of mucosal healing after induction of clinical remission.

Major reasons for disparity in access to effective IBD treatment are racial, ethnic and income inequality. Racial inequality results in “increased hospitalizations, shorter time to readmission, increased perianal complications, increased financial-related stress about medication and health care costs, decreased IBD specialty referrals, and decreased utilization of immunomodulators,” Dr Quezada pointed out.

Although many studies have identified biological predictors of long-term outcomes in IBD such as genes, antibodies, or phenotype characteristics, research has shown socioeconomic status (SES) to be a better and stronger determinant for diagnosis trends. “Low SES is associated with worse outcomes in IBD,” she said.

A retrospective cohort study of 944 patients found that compared to higher income groups, patients with lower incomes faced 4 times the risk of hospitalization. Lower income groups were also at higher risk of ICU admissions, higher corticosteroid usage, and mortality.

“This begs the question if SES is the greater predictor of worse outcomes rather than a biological difference related to race,” Dr Quezada stressed. “The role of race in CD cannot be fully understood without appreciating the contributions of socioeconomic status.” Using Dr Martin Luther King Jr.’s words, she said “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Income and race are not the only social determinants of health. Conditions in the environments in which people are born, live, learn, work, play, worship, and age affect a wide range of health, functioning, and quality-of-life outcomes and risks and are all social determinants of health, according to US Department of Health and Human Services.

Economic stress may manifest in the form of debt, employment status, expenses, income disparity, medical bills, and financial support. Neighborhood and environment stressors may include zip code, geographical access to health care, access to digital services, housing, transportation, parks and playgrounds, and access to nutritious food. Educational stressors range from early childhood education and general literacy levels to language and vocational training, and, of course, higher education. Social and community context could refer to community engagement, exposure to violence and trauma, policing, and justice policy. Finally and most importantly, Dr Quezada said, health care access and quality includes access to health insurance plans, health coverage, availability of providers and pharmacy services, and access to culturally and linguistically appropriate and respectful care.

Dr Quezada laid out steps to implement social determinants of health into IBD research and practice to encourage transparency and recognize limitations. Purpose-driven research that goes beyond describing racial and ethnic IBD disparities can help in investigating underlying mechanisms that contribute to this disparity.

A new way to document social determinants of health—the wheel—can guide physicians in processing this information easily. Patients are surveyed about 10 domains that influence health: financial resource strain, transportation needs, alcohol use, depression, intimate partner violence, social connections, physical activity, tobacco use, stress, and food insecurity. Their answers are entered into a computer algorithm that sorts the responses so that the panels of the wheel turn green to indicate low risk, yellow for moderate risk and red for high risk.

Addressing the social determinants of health during clinical encounters can help doctors and patients reach the ultimate goal of improving overall health outcomes, Dr Quezada said.

—Priyam Vora

Reference:

Quezada S. Social determinants of health in IBD outcomes. Presented at: Advances in Inflammatory Bowel Disease Annual Meeting; December 5, 2022. Orlando, Florida.