MULTIPLE ENVIRONMENTAL AND SOCIAL DETERMINANTS OF HEALTH FACTORS WERE NOT ASSOCIATED WITH THE GASTROINTESTINAL SYMPTOMATIC BURDEN OF ULCERATIVE COLITIS WITH MUCOSAL HEALING
Authors: Tse Chung Sang , Yonan Aed , Nguyen Hang , Dulai Parambir , Singh Siddharth , Dervieux Thierry , Gaidos Jill , Valasek Mark , Neill Jennifer , Le Helen , Collins Angelina , Boland Brigid 
Published: January 2023

Abstract

INTRODUCTION
In a biopsychosocial interdisciplinary model, complex interactions between the hosts (individuals/patients), disease (e.g., ulcerative colitis [UC]), and environment (e.g., social determinants of health [SDOH]) may all contribute to the disease burden. Whether SDOH contributes to the symptomatic burden of UC in deep remission is unclear.

METHODS
We performed a secondary analysis on prospectively collected data from adults with UC enrolled in the biobank at a tertiary referral center in southern California from 2014-2021. Standardized clinical (unweighted two-item patient-reported outcome [PRO-2] for stool frequency [SF] and rectal bleeding [RB]; remission=SF0/RB0), endoscopic (Ulcerative Colitis Endoscopic Index of Severity [UCEIS]; remission UCEIS=0), and histologic (Geboes score; remission &lt;2B.0) disease activity assessments were performed within 30 days of a colonoscopy (case) with segmental colonic biopsies. SDOH were assessed using the California Healthy Places Index (SDOH Index), a publicly available zip code-based system that ranks SDOH domain and subdomain scores from the least to most healthy (0-100 percentile) using weighted z-scores. Patients without SDOH scores (e.g., reside outside of California; n=88 cases) were excluded.
We used χ2-square and Wilcoxon-Mann Whitney tests to investigate for associations between SDOH factors (non-parametric, independent variables dichotomized as below vs above the median) and cardinal GI symptoms (continuous unweighted PRO-2 symptomatic severity and dichotomized clinical remission/active disease), patient-, and disease-related factors. In adults with UC in endoscopic or endo-histologic remission, we used univariate logistic regression to assess the risk of health disadvantage (SDOH score below median) and the presence of GI symptoms.

RESULTS
Of the 166 UC cases, 46% (76/166), 38% (63/166), and 30% (49/166) were in clinical, endoscopic, and endo-histologic remission, respectively. Approximately one-fifth of cases (21%, 35/166) had SDOH scores below the state median. However, health disadvantage (below SDOH index median) was not associated with clinical, endoscopic, or endo-histologic disease activity; and neither were IBD duration; gender or race/ethnicity (all p&gt;0.05) (Tab 1).

Approximately one-third of cases had active GI symptoms despite endoscopic (32%, 20/63) and endo-histologic remission (29%, 14/49). However, none of the eight investigated SDOH domains were associated with increased risks for GI symptoms when UC had objective mucosal healing on colonoscopy (Tab 2)

CONCLUSION
Although one-third of adults with mucosal healing of UC report GI symptoms (diarrhea/rectal bleeding), there was no association with multiple social determinants of health factors (e.g., education, neighborhood, economic, social, and environmental) in this secondary analysis of a prospective cohort.