Apparent discrimination in the provision of biologic therapy to patients with Crohn's disease according to ethnicity

Abstract

ObjectivesThe objective of the study was to investigate whether patients from a South Asian ethnic background who had Crohn's disease received equivalent access to therapy with biologics compared to patients with an English background. Study designThe study was retrospective and covered the period 2008 to 2012. It was based on a register of all patients with Crohn's disease in Leicestershire who are treated with biologics. The prevalence of Crohn's disease in Leicestershire amongst South Asian and English patients was known from earlier studies and from these data it was possible to make corrections to allow for the difference in frequency of the condition between the two communities. MethodsAll adult patients who received biologics for treatment of Crohn's disease in Leicestershire between 2008 and 2012 were reviewed and their gender and ethnicity noted as well as whether they had received infliximab or adalumimab. The expected numbers of patients who should have received these therapies were calculated in two ways:i.The proportion of the total population of cases based on prevalence data (the preferred method);ii.The proportion who should have received the treatment based on the population distribution within Leicester and Leicestershire. ResultsOne hundred and twenty six patients with Crohn's disease who received treatment with biologics were European and 13 South Asian. The patients' gender was also noted and 67 European patients (53%) were female as were six Asians (46%). Based on prevalence data, the expected distribution of the treatment would have been for 97 of the patients to have been European and 42 to have been South Asian. If 126 European patients warranted treatment, on this basis the expected number of South Asian patients in need of biologic therapy would have been 55. Based on the smaller predicted number of South Asian patients (42) the difference is significant at P < 0.0001 [Proportion difference=0.69 (95% confidence interval=0.539278–0.809576]. For the difference to be extinguished the number of English patients who should have received biologic therapy would have been as low as between 30 and 39 cases (based on the calculated proportion of 97 and the actual figure of 126 European patients respectively). Based on a population composition, rather than prevalence data, in which 24% of the Leicester community should have been of South Asian origin, 33 patients would have received biologics compared with 92 patients of English origin (66%). This is significantly different to the 13 patients who did receive treatment (z=−3.2, P < 0.001). ConclusionsSuggested reasons for these differences have included concerns about the animal origins of infliximab as well as difficulties associated with accessing the service, such as the provision of information in an appropriate language through appropriate media. For those who come from groups with significant social deprivation there is often a readiness to accept more limited clinical services. However, such differences themselves, are examples of discrimination in clinical practice.