Reply to McGowan et al: Do rural health disparities affect prevalence data in pediatric Eosinophilic esophagitis?

To the editor:

We read with great interest the clinical communication by McGowan et al. exploring the prevalence and geographic distribution of eosinophilic esophagitis (EoE) among pediatric patients with Medicaid¹. The authors observed that when accounting for race, EoE was less prevalent in rural America. This finding is noteworthy, as previous adult studies have shown that EoE prevalence is higher in rural population². A major reason for these contradictory findings, as the authors point out, could be the focus on pediatric patients or less access to subspecialty care. Based on their findings, we hypothesized that rural health care disparities may exist in pediatric populations.

To receive a diagnosis of EoE, pediatric patients must 1) be referred to and be evaluated by a pediatric gastroenterologist and 2) undergo endoscopy with biopsies under anesthesia³. Thus, access to pediatric subspecialty care and a tertiary care center with anesthesia capabilities is a requisite for diagnosis. In an examination of the distribution of pediatric gastroenterologists in the United states obtained from the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) we found a dearth of pediatric GI care in rural areas of the county (Figure 1) and that most US pediatric GI practitioners were located in urban communities. We have further corroborated these data evaluating publicly available pediatric board association and population density evaluations (board certification: https://www.abp.org/content/us-map-pediatric-subspecialists-county, population density: https://eoimages.gsfc.nasa.gov/images/imagerecords/7000/7052/us_population_2005_lrg.jpg). Thus diminished prevalence may be a function of underdiagnosis due to decreased provider access.

Figure 1.

Heat map of pediatric gastroenterologists in the United States. Tableau Public software was used to create this heat map by translating zip codes of pediatric gastroenterologists with memberships to NASPGHAN in the United States into longitudinal and latitudinal geospatial coordinates. Small dots represents location and larger circles represent percent of total population in the country.

Although no studies to date have evaluated health care disparities or access to care issues in EoE, Benchimol et al studied this issue in patients with inflammatory bowel disease in rural vs. urban Canada⁴. They found that patients from rural Canada were less likely to seek care from a gastroenterologist and had increased rates of hospitalization and emergency department visits. Regarding asthma, limited access to care led to increased morbidity and mortality for rural asthmatic patients⁵. Moreover, over the last 10 years, a disproportionate number of rural hospitals have closed, diminishing access to subspecialty care⁶. Rather than travel to obtain medical care/testing, many patients have opted to forgo care. Compounding this problem are factors related to poverty within rural communities; families with incomes less than 200% of the federal poverty limit are reported in 47% of rural populations compared with 27% in urban populations⁵.

Although EoE has rapidly increased in incidence and prevalence over the past 2 decades, it is considered a rare disease. EoE publications are derived from urban tertiary pediatric centers, and thus our understanding of factors contributing to the development of EoE and analysis of its epidemiology are based on the assumption that there is equal care access. Because of the lack of access to pediatric subspecialists in rural communities, we should be cautious in our perceptions that EoE has decreased in prevalence in rural areas. Emphasis on increasing access to subspecialty care will benefit patients and permit better analysis of the epidemiology of pediatric EoE.