ABSTRACT
Objective
To investigate trends in coded eosinophilic esophagitis (EoE) diagnosis within the TriNetX healthcare population and the association between food impaction (FI) and subsequent EoE diagnosis across demographic groups.
Methods
A retrospective review (2016–2024) was conducted in the TriNetX US Network. Platform‐derived annual incidence of coded EoE diagnosis (ICD‐10 K20.0) in patients < 21 years was assessed and stratified by sex, race, and ethnicity. Patients presenting with FI (ICD‐10 T18.12) were identified, and demographic characteristics of those with and without a subsequent coded EoE diagnosis were compared. The FI analysis did not evaluate endoscopy, biopsy, histology, referral, or other elements of the diagnostic process.
Results
A total of 42,519 incident coded EoE diagnoses were identified, with TriNetX‐derived diagnosis incidence increasing from 27.8 to 65.8 per 100,000 persons between 2016 and 2024 (136.6% rise). In 2024, males had nearly double the diagnosis rate of females (88.1 vs. 44.2 per 100,000). White patients had the highest diagnosis rate (84.7), compared with Black (31.5), Asian (37.7), and American Indian (62.2) patients. Non‐Hispanic patients had higher rates than Hispanic patients (73.3 vs. 30.0). Among 6215 patients presenting with FI (mean age 11.9 ± 6.3 years), 1849 (29.8%) had a subsequent coded EoE diagnosis (mean age 14.7 ± 4.3). Females had lower unadjusted odds than males (OR = 0.5, 95% CI: 0.4–0.5, p < 0.001). Black (OR = 0.3, 95% CI: 0.2–0.4) and Asian (OR = 0.4, 95% CI: 0.2–0.6) patients had lower unadjusted odds than White patients (p < 0.001).
Conclusion
Within the TriNetX healthcare population, coded pediatric EoE diagnoses increased over time and differed by sex, race, and ethnicity. Following FI, the frequency of subsequent coded EoE diagnosis also differed across demographic groups; these descriptive findings do not establish differences in underlying disease prevalence or diagnostic care.
Keywords: airway management, demographic differences, eosinophilic esophagitis
1. Introduction
Eosinophilic esophagitis (EoE) is a chronic, immune‐mediated disease characterized by eosinophilic infiltration of the esophagus [1]. EoE has many differential diagnoses, including gastroesophageal reflux disease (GERD), inflammatory bowel disease (IBD), and allergic vasculitis [1]. According to the updated International Consensus diagnostic criteria established by the AGREE Conference in 2018, the diagnosis of EoE requires the presence of symptoms related to esophageal dysfunction, histological evidence of eosinophilic infiltration (> 15 eosinophils per high‐power field), and the exclusion of other potential causes of esophageal eosinophilia such as GERD [2, 3]. Food impaction (FI) is often a common presentation among many patients with EoE [2, 3]. These findings highlight the importance of obtaining esophageal mucosal biopsies when FI is present.
Recent studies suggest that racial differences can affect the diagnosis and management of EoE. Barlowe et al. [3] described the clinical value of obtaining esophageal biopsies during FI episodes, which can expedite the diagnosis of EoE. This retrospective cohort study found that among patients who underwent esophagogastroduodenoscopy (EGD) for FI, no Black patients had a concurrent biopsy and older White patients were significantly less likely to undergo concurrent biopsy [3]. These findings demonstrate variability in biopsy practice within that cohort and raise concern that inconsistent biopsy performance may contribute to delayed diagnosis in some patients.
Early detection of EoE is important. Without timely diagnosis, the disease may progress to tissue fibrosis, luminal narrowing, rigidity, and esophageal remodeling [1]. All of these factors subsequently increase the emotional and physical burden on patients whose diagnosis is delayed [1]. Multiple studies have suggested that obtaining a biopsy during FI treatment allows for early identification of EoE [4, 5]. In a cross‐sectional survey‐based study by Hiremath et al., only 34% of gastroenterologists reported routinely obtaining esophageal biopsies during EGDs performed for FI [5]. Based on their analysis, an estimated 10,494 patients presenting to the emergency department across the United States with FI annually may be at risk of missing the opportunity to make an early diagnosis of EoE [5].
In our study, we investigated trends in coded EoE diagnosis within the TriNetX healthcare population and the association between FI and subsequent EoE diagnosis across demographic groups. Specifically, we aimed to answer the research question: What demographic differences are observed in EoE diagnosis, and how is presentation with FI associated with subsequent coded EoE diagnosis? We hypothesized that Black, Asian, Hispanic, and female pediatric patients would have lower rates of subsequent coded EoE diagnosis.
2. Materials and Methods
2.1. Data Source
A retrospective study was conducted within the TriNetX United States Collaborative Network, a federated system providing real‐time access to de‐identified and aggregated electronic medical records data, encompassing demographics, diagnoses, procedures, medications, and laboratory values. This data is sourced from approximately 116 million US patients across 71 participating healthcare organizations, including academic medical centers, specialty physician practices, and community hospitals. Data for this study were obtained on January 18, 2025. The University at Buffalo Institutional Review Board exempted this study from approval as it was deemed non‐human research.
2.2. FI and EoE Outcomes
Patients aged ≤ 21 years who presented with FI between January 1, 2016, and December 31, 2024, were identified with ICD‐10 code T18.12, and demographic information was recorded. Among these patients, those who subsequently received a coded diagnosis of EoE, defined by the presence of ICD‐10 code K20.0 on or after the date of FI, were compared with those without a subsequent EoE code. This analysis evaluated coded diagnoses only and did not ascertain whether patients underwent EGD, esophageal biopsy, histologic evaluation, gastroenterology referral, or follow‐up encounters. Propensity score matching was not performed because the primary objective was descriptive comparison of demographic characteristics (Figure 1).
FIGURE 1.
Flowchart of patient selection.
2.3. Incidence Measures
The built‐in analytic function “Incidence and Prevalence” within the TriNetX platform was used to analyze trends in coded EoE diagnosis. Platform‐derived annual incidence of EoE diagnosis (ICD‐10 K20.0) in patients ≤ 21 years was extracted for 2016 through 2024 and stratified by sex, race, and ethnicity to describe demographic differences. Rates were calculated using the total population of patients ≤ 21 years of age with any recorded ICD code as the denominator. Accordingly, these estimates represent the incidence of coded EoE diagnosis within the TriNetX healthcare population rather than population‐based incidence in the general pediatric population.
2.4. Statistical Analyses
Statistical analyses were conducted using TriNetX's built‐in analytics features and R 4.4.2. Categorical data were summarized as frequency counts and percentages, and continuous data as means and standard deviations (SD). Chi‐square tests were employed to evaluate associations between categorical variables. Odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated to quantify unadjusted associations. Statistical significance was defined as p < 0.05. Multivariable regression was not performed because the analysis was designed as a descriptive comparison; therefore, the reported ORs should not be interpreted as independent demographic effects after adjustment for potential confounders.
3. Results
3.1. Demographic Comparisons of Subsequent EoE Diagnosis Following FI
A total of 6215 patients were identified who presented with FI between 2016 and 2024. Mean age at the time of FI was 11.9 years (SD = 6.3). Of these patients, 1849 (29.8%) had a subsequent coded EoE diagnosis at a mean age of 14.7 years (SD = 4.3), and 4366 (70.2%) did not. Females had lower unadjusted odds of subsequent coded EoE diagnosis than males (OR = 0.5, 95% CI: 0.4–0.5, p < 0.001). Hispanic or Latino patients also had lower unadjusted odds than non‐Hispanic patients (OR = 0.4, 95% CI: 0.3–0.5, p < 0.001). Racial differences were observed: Black or African American patients (OR = 0.3, 95% CI: 0.2–0.4, p < 0.001) and Asian patients (OR = 0.4, 95% CI: 0.2–0.6, p < 0.001) had lower unadjusted odds of subsequent coded EoE diagnosis than White or Caucasian patients (Table 1).
TABLE 1.
Demographic comparison between patients with a history of food impaction (FI) with and without a subsequent coded diagnosis of eosinophilic esophagitis (EoE).
| Demographic | All FI, N (%) | FI and EoE, N (%) | FI and No EoE, N (%) | OR (95% CI) | p a |
|---|---|---|---|---|---|
| Age at diagnosis (years), mean ± SD | 11.9 ± 6.3 | 14.7 ± 4.3 | — | — | |
| Sex | |||||
| Male | 3954 (63.6) | 1338 (72.4) | 2616 (59.9) | Reference | — |
| Female | 1850 (29.8) | 359 (19.4) | 1491 (34.2) | 0.5 (0.4–0.5) | < 0.001 |
| Unknown | 411 (6.6) | 152 (8.2) | 259 (5.9) | 1.1 (0.9–1.4) | 0.221 |
| Ethnicity | |||||
| Not Hispanic or Latino | 3844 (61.9) | 1275 (69.0) | 2569 (58.8) | Reference | — |
| Unknown Ethnicity | 1934 (31.1) | 498 (26.9) | 1436 (32.9) | 0.7 (0.6–0.8) | < 0.001 |
| Hispanic or Latino | 437 (7.0) | 76 (4.1) | 361 (8.3) | 0.4 (0.3–0.5) | < 0.001 |
| Race | |||||
| White | 4123 (66.3) | 1396 (75.5) | 2727 (62.5) | Reference | — |
| American Indian or Alaska Native | 16 (0.3) | 10 (0.5) | 6 (0.1) | 3.2 (1.2–9.7) | 0.032 |
| Asian | 158 (2.5) | 25 (1.4) | 133 (3.1) | 0.4 (0.2–0.6) | < 0.001 |
| Black or African American | 608 (9.8) | 83 (4.5) | 525 (12.0) | 0.3 (0.2–0.4) | < 0.001 |
| Native Hawaiian or Other Pacific Islander | 24 (0.4) | 10 (0.5) | 14 (0.3) | 1.4 (0.6–3.2) | 0.556 |
| Other race | 268 (4.3) | 59 (3.2) | 209 (4.8) | 0.6 (0.4–0.7) | < 0.001 |
| Unknown race | 1018 (16.4) | 279 (15.1) | 739 (16.9) | 0.7 (0.6–0.9) | < 0.001 |
Note: Percentages represent the proportion of patients within each FI group. Unadjusted odds ratios (OR) and 95% confidence intervals (CI) compare the odds of subsequent coded EoE diagnosis within each demographic group relative to the reference category.
Chi‐square test.
3.2. Incidence of Coded EoE Diagnosis Within the TriNetX Healthcare Population
A total of 42,519 incident coded EoE diagnoses were identified, with annual diagnosis incidence within the TriNetX healthcare population rising from 27.8 to 65.8 per 100,000 between 2016 and 2024, a 136.6% increase (Figure 2). Throughout the study period, males consistently demonstrated higher rates of coded diagnosis than females, with nearly double the diagnosis rate observed in 2024 (88.1 vs. 44.2 per 100,000 persons; Figure 3). Non‐Hispanic patients similarly exhibited higher diagnosis rates than Hispanic patients in all years, with rates of 73.3 and 30.0 per 100,000, respectively, in 2024 (Figure 4). White patients had consistently higher coded diagnosis rates than any other racial group, with a 2024 rate of 84.7 per 100,000 persons, compared with 31.5 in Black or African American patients, 37.7 in Asian patients, and 62.2 in American Indian patients (Figure 5).
FIGURE 2.
Overall incidence of coded eosinophilic esophagitis diagnosis within the TriNetX healthcare population between 2016 and 2024.
FIGURE 3.
Sex‐stratified incidence of coded eosinophilic esophagitis diagnosis within the TriNetX healthcare population between 2016 and 2024.
FIGURE 4.
Ethnicity‐stratified incidence of coded eosinophilic esophagitis diagnosis within the TriNetX healthcare population between 2016 and 2024.
FIGURE 5.
Race‐stratified incidence of coded eosinophilic esophagitis diagnosis within the TriNetX healthcare population between 2016 and 2024.
4. Discussion
Without treatment, EoE can lead to persistent symptoms and irreversible esophageal remodeling [6, 7, 8, 9]. A multicenter analysis by Murray et al. of 1100 patients reported a mean diagnostic delay of 4 years from symptom onset, with one‐third of patients waiting over 10 years [10]. Although the 2018 and 2025 guidelines have introduced important updates to standardize and streamline EoE diagnosis, diagnostic delays remain a significant challenge in clinical practice [10]. This persistent gap in timely diagnosis highlights the need for broader provider education and more standardized approaches to identifying EoE across diverse patient populations [11].
EoE is strongly associated with atopic conditions, including allergic rhinitis, asthma, atopic dermatitis, and food allergies [1, 7]. Several studies have also demonstrated a male predominance [12, 13, 14]. Lynch et al. found that FI was more common in males, suggesting a true sex‐related difference in presentation rather than solely a difference in diagnosis [12]. Proposed explanations include genetic predisposition, sex‐related differences in gene expression profiles, anatomical and functional esophageal differences, and differences in environmental exposures [12, 14]. These observations indicate that demographic differences in EoE diagnosis may reflect differences in underlying disease prevalence or clinical presentation. In our analysis, 63.6% of identified FIs occurred in males, 29.8% in females, and 6.6% in patients with unknown sex. Because the present study did not measure underlying EoE prevalence, endoscopic evaluation, or clinician decision‐making, the lower frequency of subsequent EoE diagnosis in females cannot be attributed to diagnostic bias or under‐recognition.
Racial differences in coded diagnosis were also evident. White patients accounted for 75.5% of EoE diagnoses, while Asian, Native American/Alaska Native, Hawaiian/Pacific Islander, and Black patients collectively represented 6.9%. In contrast, a cross‐sectional study of 755 patients with EoE noted similar histologic findings, duration of symptoms, history of FIs, and history of esophageal dilations between African American, White, Asian, and Hispanic patients [13]. Higher diagnosis rates have also been reported in non‐Hispanic patients compared with Hispanic patients [15]. Nearly one‐third of patients presenting with FI in our cohort had a subsequent coded EoE diagnosis. These findings describe demographic patterns in diagnosis but do not establish differences in underlying disease prevalence or diagnostic evaluation.
Our study highlights recent trends in coded pediatric EoE diagnosis following FI and demonstrates demographic differences within the TriNetX healthcare population. Between 2016 and 2024, we identified more than 42,000 coded EoE diagnoses, with platform‐derived diagnosis incidence more than doubling during this period. Hahn et al. conducted a meta‐analysis using data from 40 studies that revealed a steady rise in both incidence and prevalence of EoE from 1976 to 2022 [6]. They reported an increase in prevalence from 40 cases per 100,000 inhabitant‐years in 2017 to 110 cases per 100,000 inhabitant‐years in 2022 [6]. While greater disease awareness may partially explain this trend, prior work suggests that both diagnostic practices and true disease burden may contribute to increasing EoE rates [11, 14]. Determining whether the demographic patterns observed in our study reflect underlying pathophysiologic differences, differences in presentation or healthcare utilization, or inequities in clinical recognition will require studies that directly assess the diagnostic process.
Within the TriNetX healthcare population, coded EoE diagnosis incidence was higher in White patients than in Black, Asian, and American Indian patients. These differences should not be interpreted as evidence of underdiagnosis or inequitable care because the present analysis did not measure underlying disease prevalence, clinical phenotype, healthcare utilization, access to care, endoscopy, biopsy, or clinician decision‐making. Multiple biologic and healthcare‐related factors may contribute to observed diagnosis patterns. Future studies comparing patients with similar clinical presentations and directly measuring diagnostic evaluation are needed to distinguish among these possibilities.
Prior studies have documented variability in obtaining esophageal biopsies during FI evaluation [8]. Standardized, guideline‐concordant evaluation may help reduce diagnostic delay [8]. However, the present analysis did not measure whether EGD, esophageal biopsy, histology, gastroenterology referral, or follow‐up occurred and therefore cannot determine whether FI evaluation differed across demographic groups.
The rising rate of coded EoE diagnosis within the TriNetX healthcare population remains clinically important, particularly in children. While part of this trend may be attributed to increased awareness and changing diagnostic frameworks, prior studies have proposed broader immunologic and environmental contributors, including early‐life antibiotic exposure, cesarean delivery, and a general rise in immune‐mediated diseases [14]. Population‐based studies and patient‐level investigations of diagnostic pathways are needed to clarify the relative contributions of disease biology, healthcare utilization, and clinical recognition.
4.1. Limitations
There are several limitations to this study. The retrospective design introduces the possibility of misclassification bias because identification of EoE and FI relies on ICD‐10‐CM codes, which may not capture all true cases. Variability in data entry, coding practices, healthcare utilization, and the composition of participating healthcare organizations may influence observed rates and limit generalizability. Only aggregate TriNetX output was available for this analysis, and the FI query did not include EGD, esophageal biopsy, histology, gastroenterology referral, follow‐up encounters, or other direct measures of the diagnostic process. Therefore, the study cannot determine whether demographic differences in subsequent EoE coding reflect differences in underlying disease prevalence, phenotype, presentation, healthcare utilization, diagnostic evaluation, or clinical recognition. Follow‐up time also varied across the 2016–2024 study period; patients presenting with FI later in the study had less opportunity to receive a subsequent EoE diagnosis, which may have led to incomplete outcome classification. In addition, the demographic ORs are unadjusted and do not account for potential confounders such as age, sex, race, ethnicity, calendar year, atopic disease, healthcare utilization, institution, or geographic region; they should therefore be interpreted as descriptive associations rather than independent effects. Finally, the TriNetX incidence denominator includes patients ≤ 21 years with any recorded ICD code, so the reported estimates reflect coded EoE diagnosis incidence within the TriNetX healthcare population rather than true population incidence. These limitations preclude causal inference or conclusions regarding inequity in diagnostic care.
5. Conclusion
Within the TriNetX healthcare population, the incidence of coded pediatric EoE diagnosis more than doubled from 2016 to 2024. Demographic differences were observed in annual coded diagnosis rates and in the frequency of subsequent coded EoE diagnosis after FI. Because this study did not assess underlying disease prevalence, EGD or biopsy, referral, follow‐up, or other features of the diagnostic process, these findings should not be interpreted as evidence of underdiagnosis or inequitable care. Instead, they identify demographic patterns that warrant patient‐level studies evaluating whether children with comparable presentations receive comparable diagnostic assessment.
Funding
The authors have nothing to report.
Disclosure
No AI were used in the preparation of this manuscript.
Conflicts of Interest
Osama Almadhoun reports serving on the speakers bureau for Dupixent (dupilumab). All other authors declare no conflicts of interest.
Acknowledgments
The authors would like to gratefully acknowledge Abraham Kassem for assistance in editing the manuscript.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.