Is there an association between social determinants of health and UTI related morbidity?
Ted Lee, MD, MSc, Andrea Balthazar, MD, Tanya Logvinenko, PhD, Harry Lee, MD, Caleb P. Nelson, MD, MPH.
Boston Children's Hospital, Boston, MA, USA.
Background: Social determinants of health (SDOH) are conditions in the environments where people live that affect a wide range of health, functioning, and quality-of-life outcomes. Yet, the relationship between SDOH and urinary tract infection (UTI) related morbidity has not been previously investigated. The aim of this study was to evaluate whether SDOH, measured using Childhood Opportunity Index (COI), was associated with UTI related morbidity in patients with prior history of UTI. COI is a widely used index that quantifies relative opportunity in educational, health and environmental, and social and economic domains across census tracts. We hypothesized an association between lower levels of COI and UTI-related morbidity, including UTI recurrence and renal scarring.
Methods: We retrospectively identified children younger than 14 years old with known history of UTI and DMSA scan between 2006 and 2009 from a single institution. Demographic and clinical characteristics, including age, sex, VUR, duplicated renal anatomy, insurance status, and race were collected. Childhood opportunity index was categorized into tertiles: low (0-33), moderate (34-66), and high (67-100). Main outcomes included recurrent UTI (>1 episode) and renal scarring on DMSA, defined as focal cortical defect, multi-focal cortical defects, or global cortical thinning on DMSA scan. Univariate logistic regression analyses examined associations between the main outcomes and COI, as well as other demographic and clinical characteristics. Associations between COI and outcomes (recurrent UTI and renal scarring) were evaluated using a multivariable logistic regression model adjusting for the following covariates: age, sex, presence of VUR, and collecting system duplication. Multiple imputations were used to account for missing data. Race and insurance were not included as covariates due to collinearity with COI (e.g., lower COI associated with non-White race and public insurance).
Results: Among 600 subjects, recurrent UTI was present in 51% (306/600) and renal scarring was present in 47% (279/600). Multivariable logistic regression revealed that those in the lowest third of COI had a 90% higher odds of having a history of recurrent UTI when compared to subjects in the middle third of the COI (OR=1.90; 95% CI 0.98-3.70; p-value=0.058). There was no association between COI and renal scarring (OR=1.09; 95% CI 0.59-2.03; p-value= 0.786 for lower third of COI and OR=1.04; 95% CI 0.64-1.68; p-value= 0.886 for upper third of COI).
Conclusions: In a highly selected group of subjects with history of UTI evaluated with DMSA from a single institution, our results suggest a possible association between SDOH and UTI recurrence. Population-based studies are needed to further delineate the relationship between SDOH and UTI related morbidity.
Table 1. Baseline demographics and clinical characteristics, including missingness
| Overall | No rUTI | rUTI | No Scar | Scar | |
| n (%) | 600 | 294 (49.0%) | 306 (51.0%) | 321 (53.5%) | 279 (46.5%) |
| Female (%) | 504 (84.0) | 235 (79.9) | 269 (87.9) | 283 (88.2) | 221 (79.2) |
| Age, mo (median [IQR]) | 46.0 [22.0, 79.0] | 29.0 [16.3, 56.5] | 63.5 [37.0, 94.0] | 43.00 [20.00, 79.00] | 47.00 [24.50, 77.50] |
| Race, n (%) | |||||
| White | 417 (69.5) | 205 (69.7) | 212 (69.3) | 225 (70.1) | 192 (68.8) |
| Asian | 9 (1.5) | 4 (1.4) | 5 (1.6) | 3 (0.9) | 6 (2.2) |
| Black | 10 (1.7) | 3 (1.0) | 7 (2.3) | 4 (1.2) | 6 (2.2) |
| Hispanic | 23 (3.8) | 14 (4.8) | 9 (2.9) | 15 (4.7) | 8 (2.9) |
| Other | 58 (9.7) | 30 (10.2) | 28 (9.2) | 24 (7.5) | 34 (12.2) |
| Missing | 83 (13.8) | 38 (12.9) | 45 (14.7) | 50 (15.6) | 33 (11.8) |
| Insurance, n (%) | |||||
| Public | 138 (23.0) | 50 (17.0) | 88 (28.8) | 61 (19.0) | 77 (27.6) |
| Private | 453 (75.5) | 243 (82.7) | 210 (68.6) | 257 (80.1) | 196 (70.3) |
| Other | 7 (1.2) | 1 (0.3) | 6 (2.0) | 2 (0.6) | 5 (1.8) |
| Missing | 2 (0.3) | 0 (0.0) | 2 (0.7) | 1 (0.3) | 1 (0.4) |
| VUR, n (%) | |||||
| No | 147 (24.5) | 46 (15.6) | 101 (33.0) | 93 (29.0) | 54 (19.4) |
| Yes | 430 (71.7) | 239 (81.3) | 191 (62.4) | 211 (65.7) | 219 (78.5) |
| Missing | 23 (3.8) | 9 (3.1) | 14 (4.6) | 17 (5.3) | 6 (2.2) |
| COI, n (%) | |||||
| < 34 | 71 (11.8) | 25 (8.5) | 46 (15.0) | 38 (11.8) | 33 (11.8) |
| (34 - 66) | 88 (14.7) | 50 (17.0) | 38 (12.4) | 48 (15.0) | 40 (14.3) |
| > 67 | 320 (53.3) | 163 (55.4) | 157 (51.3) | 169 (52.6) | 151 (54.1) |
| Missing | 121 (20.2) | 56 (19.0) | 65 (21.2) | 66 (20.6) | 55 (19.7) |
| Duplication, n (%) | |||||
| No | 506 (84.3) | 252 (85.7) | 254 (83.0) | 271 (84.4) | 235 (84.2) |
| Yes | 60 (10.0) | 25 (8.5) | 35 (11.4) | 26 (8.1) | 34 (12.2) |
| Missing | 34 (5.7) | 17 (5.8) | 17 (5.6) | 24 (7.5) | 10 (3.6) |
Table 2. Univariate and Multivariate analyses for outcomes of recurrent UTI and renal scarring
| Recurrent UTI | Renal Scarring | |||||||||
| Characteristic | Univariate | Multivariate | Univariate | Multivariate | ||||||
| OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | |||
| Female | 1.83 (1.17, 2.85) | 0.008 | 2.25 (1.34, 3.77) | 0.002 | 0.51 (0.33, 0.8) | 0.003 | 0.52 (0.33, 0.82) | 0.005 | ||
| Age, months | 1.02 (1.02, 1.03) | <0.001 | 1.02 (1.01, 1.02) | <0.001 | 1 (1, 1.01) | 0.315 | 1 (1, 1.01) | 0.074 | ||
| Race | ||||||||||
| White | Ref | Ref | ||||||||
| Asian | 1.21 (0.32, 4.56) | 0.78 | n/a | n/a | 2.34 (0.58, 9.5) | 0.233 | n/a | n/a | ||
| Black | 2.26 (0.58, 8.84) | 0.243 | n/a | n/a | 1.76 (0.49, 6.32) | 0.388 | n/a | n/a | ||
| Hispanic | 0.62 (0.26, 1.47) | 0.278 | n/a | n/a | 0.63 (0.26, 1.51) | 0.295 | n/a | n/a | ||
| Other | 0.9 (0.52, 1.56) | 0.715 | n/a | n/a | 1.66 (0.95, 2.9) | 0.074 | n/a | n/a | ||
| Insurance | ||||||||||
| Public | Ref | Ref | ||||||||
| Private | 0.49 (0.33, 0.73) | <0.001 | n/a | n/a | 0.6 (0.41, 0.89) | 0.010 | n/a | n/a | ||
| Other | 3.41 (0.4, 29.13) | 0.262 | n/a | n/a | 1.98 (0.37, 10.56) | 0.424 | n/a | n/a | ||
| VUR | 0.36 (0.24, 0.54) | <0.001 | 0.49 (0.32, 0.75) | 0.001 | 1.79 (1.22, 2.63) | 0.003 | 2.01 (1.34, 3.01) | <0.001 | ||
| COI | ||||||||||
| < 34 | 2.42 (1.27, 4.61) | 0.007 | 1.9 (0.98, 3.7) | 0.058 | 1.04 (0.56, 1.95) | 0.897 | 1.09 (0.59, 2.03) | 0.786 | ||
| (34 - 66) | Ref | Ref | Ref | |||||||
| > 67 | 1.27 (0.79, 2.04) | 0.329 | 0.97 (0.57, 1.64) | 0.911 | 1.07 (0.67, 1.72) | 0.773 | 1.04 (0.64, 1.68) | 0.886 | ||
| Duplication | 1.39 (0.81, 2.39) | 0.235 | 1.67 (0.91, 3.06) | 0.097 | 1.51 (0.88, 2.59) | 0.136 | 1.37 (0.79, 2.4) | 0.266 | ||
COI (Childhood Opportunity Index); VUR (Vesico-ureteral Reflux); rUTI (recurrent UTI)
Back to 2021 Abstracts