Disparities in Diagnosis, Access to Specialist Care and Treatment for Inborn Errors of Immunity

Diagnostic disparities in inborn errors of immunity: From clinical suspicion to diagnosis

Background

Emerging evidence suggests that inborn errors of immunity (IEI) are underdiagnosed among underserved populations. However, there remains a lack of national studies evaluating diagnostic disparities in IEI.

Objective

We examined disparities in the timely IEI diagnosis and related health outcomes.

Methods

A retrospective analysis was performed of a US national claims database (years 2007 to 2021). Participants included patients diagnosed with an "unspecified immune deficiency" (uID) and presented with IEI-related symptoms, who later received an IEI diagnosis (n = 1429). We quantified the diagnostic interval from clinical suspicion (uID) to IEI diagnosis and examined its association with sociodemographic factors and related health outcomes.

Results

The median (interquartile range) diagnostic interval was 369 (126-808) days. Diagnostic interval was 14% longer among patients residing in predominantly non-White neighborhoods, compared with those in predominantly White neighborhoods (P = .04), despite having more severe IEI-related symptoms at uID diagnosis and significantly more health care encounters for pneumonia (incidence rate ratio, 2.24; 95% confidence interval, 1.40-3.70) and sepsis (incidence rate ratio, 2.15; 95% confidence interval, 1.21-3.99) in the year after uID diagnosis. Residence in neighborhoods with greater deprivation was also associated with more severe IEI-related symptoms and greater health care utilization in the year after uID diagnosis. Older age was associated with longer diagnostic interval (P < .001). Longer diagnostic interval was associated with a longer interval to receiving IgR therapy (hazard ratio, 0.64; 95% confidence interval, 0.49-0.83).

Conclusion

We observed significant racial and socioeconomic disparities in the timeliness of IEI diagnosis and IEI-related outcomes. Further studies are needed to address the underlying factors contributing to diagnostic inequity.

Disparities in Genetic Testing for Inborn Errors of Immunity

BACKGROUND

Inequities in genetic testing have been documented in a range of diseases, and no-charge genetic testing programs have been proposed as a means to enhance access. However, no studies have examined disparities in genetic testing for inborn errors of immunity (IEI) and the impact of no-charge programs on testing equity.

OBJECTIVE

To examine socioeconomic, geographic, and racial disparities in the uptake of genetic testing for IEI in the United States and the impact of a no-charge sponsored program on testing equity.

METHODS

This was a retrospective cohort analysis of (1) a national claims database capturing individuals with IEI (n = 18,603), and (2) data from a clinical genetic testing laboratory capturing patients with IEI participating in a no-charge sponsored program (n = 6,681) and a non-sponsored program (n = 29,579) for IEI genetic testing.

RESULTS

Among patients with IEI captured in the claims database, those residing in areas of greater deprivation (odds ratio [OR] = 0.95; 95% CI, 0.92-0.98), rural areas (OR = 0.82; 95% CI, 0.71-0.96), and non-White neighborhoods (OR = 0.89, 95% CI 0.81-0.98) were less likely to undergo genetic testing. Participants in the sponsored IEI genetic testing program lived in areas of greater deprivation compared with the non-sponsored program (median, 46 vs 42; P < .001). However, historically excluded racial groups were underrepresented in both the sponsored and non-sponsored programs relative to disease burden.

CONCLUSIONS

We found significant disparities in genetic testing for IEI. Although eliminating the financial barriers to testing reduced socioeconomic disparities in genetic testing for IEI, racial disparities persisted. Further research is needed to address barriers to testing among underserved populations.

Bridging the gap: neurodevelopmental disorder risks in inborn errors of immunity

PURPOSE OF REVIEW

The aim of this review is to examine published reports of neurodevelopmental phenotypes in patients with inborn errors of immunity (IEI). We briefly discuss potential interactions between the immune and the central nervous system and the implications of this crosstalk for current clinical management guidelines.

RECENT FINDINGS

An increasing number of reports have described neurodevelopmental disorders (NDDs) comorbid with immune-mediated signs. However, the prevalence of this association in IEIs remains unknown.

SUMMARY

IEIs comprise a group of clinically heterogeneous disorders associated with a number of nonimmune comorbidities. Although certain neurological conditions such as microcephaly are recognized as associated features of some IEIs, NDDs are less well described. We reviewed published clinical descriptions of IEIs and found a number of comorbid NDDs in these patients, including autism spectrum disorder (ASD), behavioral deficits, and intellectual disability. Given the lack of uniform assessments for NDDs, we suspect they may be underdiagnosed in IEIs. As NDDs manifest early and can result in life-long cognitive and emotional deficits, which diminish quality of life and increase healthcare utilization, we hope to elucidate relevant pathomechanisms and raise clinician awareness of these comorbidities so appropriate and timely interventions are sought.

Artificial Intelligence and Machine Learning for Inborn Errors of Immunity: Current State and Future Promise

Artificial intelligence (AI) and machine learning (ML) research within medicine has exponentially increased over the last decade, with studies showcasing the potential of AI/ML algorithms to improve clinical practice and outcomes. Ongoing research and efforts to develop AI-based models have expanded to aid in the identification of inborn errors of immunity (IEI). The use of larger electronic health record data sets, coupled with advances in phenotyping precision and enhancements in ML techniques, has the potential to significantly improve the early recognition of IEI, thereby increasing access to equitable care. In this review, we provide a comprehensive examination of AI/ML for IEI, covering the spectrum from data preprocessing for AI/ML analysis to current applications within immunology, and address the challenges associated with implementing clinical decision support systems to refine the diagnosis and management of IEI.

Health-related quality of life in patients with inborn errors of immunity: A systematic review and meta-analysis

BACKGROUND

Inborn Errors of Immunity (IEI) significantly affect patients' health-related quality of life (HRQOL), presenting greater challenges than those faced by the healthy population and other chronic disease sufferers. Current research lacks comprehensive integration of this critical issue.

OBJECTIVE

This study explores HRQOL in IEI patients, identifies impacting factors, and advocates for increased research focus on their quality of life.

METHODS

Following systematic review and meta-analysis guidelines, a search of Scopus and PubMed until November 15, 2023, yielded 1633 publications. We evaluated the literature, assessed study quality, and compared the HRQOL of IEI patients to that of healthy individuals and other chronic disease patients.

RESULTS

Of 90 articles and 10,971 IEI patients analyzed, study quality varied (nine good, 63 moderate, and 18 poor). The Short Form-36 (SF-36) and Pediatric Quality of Life Inventory generic core scales (PedsQL) were the primary generic instruments used among adults and children, respectively, with 12 studies each using the disease-specific instruments. Meta-analysis showed IEI patients have significantly lower scores in general health, physical and mental health, and social and emotional roles compared to healthy populations. We noted significant differences between self and proxy reports, indicating caregiver anxiety and perception disparities.

CONCLUSION

Despite limitations like small sample sizes and reliance on generic instruments, this research underscores the substantially lower HRQOL among IEI patients, emphasizing the need for a patient-centered, multidisciplinary approach to improve their life quality and calling for more focused attention on IEI patients and their caregivers' HRQOL.