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Factors Associated with Eosinophilic Esophagitis in Nevada UNLV Theses, Dissertations, Professional Papers, and Capstones 8-1-2019 Factors Associated with Eosinophilic Esophagitis in Nevada Julia Lorraine Anderson Follow this and additional works at: https://digitalscholarship.unlv.edu/thesesdissertations Part of the Biostatistics Commons, and the Epidemiology Commons Repository Citation Anderson, Julia Lorraine, "Factors Associated with Eosinophilic Esophagitis in Nevada" (2019). UNLV Theses, Dissertations, Professional Papers, and Capstones. 3709. http://dx.doi.org/10.34917/16076249 This Dissertation is protected by copyright and/or related rights. It has been brought to you by Digital Scholarship@UNLV with permission from the rights-holder(s). You are free to use this Dissertation in any way that is permitted by the copyright and related rights legislation that applies to your use. For other uses you need to obtain permission from the rights-holder(s) directly, unless additional rights are indicated by a Creative Commons license in the record and/or on the work itself. This Dissertation has been accepted for inclusion in UNLV Theses, Dissertations, Professional Papers, and Capstones by an authorized administrator of Digital Scholarship@UNLV. For more information, please contact [email protected]. FACTORS ASSOCIATED WITH EOSINOPHILIC ESOPHAGITIS IN NEVADA By Julia Lorraine Anderson Bachelor of Science – Biomedical Microbiology Northern Arizona University 2009 Master of Public Health Grand Canyon University 2014 A dissertation submitted in partial fulfillment of the requirements for the Doctor of Philosophy – Public Health Department of Environmental and Occupational Health School of Public Health The Graduate College University of Nevada, Las Vegas August 2019 Copyright 2019 by Julia Lorraine Anderson All rights reserved Dissertation Approval The Graduate College The University of Nevada, Las Vegas June 11, 2019 This dissertation prepared by Julia Lorraine Anderson entitled Factors Associated with Eosinophilic Esophagitis in Nevada is approved in partial fulfillment of the requirements for the degree of Doctor of Philosophy – Public Health Department of Environmental and Occupational Health Sheniz Moonie, Ph.D. Kathryn Hausbeck Korgan, Ph.D. Examination Committee Chair Graduate College Dean Brain Labus, Ph.D. Examination Committee Member Mary Beth Hogan, Ph.D. Examination Committee Member Jessica Word, Ph.D. Graduate College Faculty Representative ii Abstract Eosinophilic esophagitis (EoE) is a rare immune-mediated illness with symptoms that range from difficulty swallowing to food impaction of the esophagus. Most published studies have been documented among patients residing in cool regions with significant annual rainfall. No published studies to our knowledge have been performed examining the healthcare utilization trends of EoE in Nevada. Utilizing two unique databases, the factors associated with EoE healthcare utilization patterns in Nevada were examined. All analyses were performed in R version 3.5.1. This study included a demographic and regional analysis identifying risk factors associated with having an EoE healthcare visit in Nevada. Several trends complemented those seen in other EoE studies including increased utilization among male and pediatric subgroups, as well as those of Caucasian descent. In the second part of the study, clinical EoE comorbidities among subgroups were identified. While this disease typically has a well-documented relationship with atopic illness, the comorbidities identified in Nevada were largely gastric in nature; indicating a trend of late-stage diagnoses of the disease. Treatment by region differed significantly, pointing to a lack of consistency of EoE knowledge among healthcare providers. Data from a small cohort of EoE positive pediatric patients from a local clinic (n=59) were also obtained. This clinical EoE subset was used to complement the hospital utilization database in order to identify common sensitization patterns among the pediatric population. Surprisingly, this population was largely sensitized to aeroallergens, as opposed to the common food allergens reported in the literature. This indicates that treatment approaches for this condition in Nevada may be unique to those found in other regions. The final part of this study examined the financial impact of EoE healthcare utilization in Nevada. The cost of EoE was significantly greater for the pediatric subgroup as well as those receiving treatment in the Southern Nevada region. Lastly, in order to gain a better understanding of cost relative to similar chronic inflammatory diseases, a comparison was performed between EoE, Crohn’s disease and Celiac disease. Significant differences in cost and utilization patterns existed by gender, age and healthcare setting. Findings from this study fill an important gap in EoE knowledge in this region. Improved physician and iii public health education for treatment is critical as the sensitization patterns in Nevada appear unique relative to other regions. Early identification of EoE diagnosis may improve knowledge and treatment among patients and providers in Nevada. iv Acknowledgements First, I want to thank my committee chair, Dr. Sheniz Moonie. Her constant support, patience, and advice throughout my program have been invaluable. I am so grateful for her positive energy and for helping me find a passion for biostatistics. I would also like to thank my committee members, I could not have done this without your help. Dr. Mary Beth Hogan for her clinical insight throughout this project. Dr. Brian Labus for exuding his passion for infectious diseases and epidemiology, especially in late night courses where it was needed the most. Finally, thank you to Dr. Jessica Word for inviting me to work with different types of data for the city of Las Vegas and for joining our Public Health crew. Additionally, I would like to thank Joseph Greenway and his team at Center for Health Information Analysis for Nevada (CHIA) for the data for this project. The data provided by CHIA is vital for future public health studies in Nevada. I would like to also thank my previous supervisors, Dr. Erin Price and Heidie Hornstra O’Neill. Two women who made more of an impact on my career than they will ever know. They helped me fall in love and stay in love with science. Thank you both from the bottom of my heart. Finally, and most importantly, I would like to thank my family. My parents, Alan and Michelle, for their constant support and pushing me to follow my dreams. I would not be where I am today without you. And to my husband, Bryan, who was my rock through the late nights, early mornings, and opposite schedules. I truly would not have made it through this program without you by my side. v Table of Contents Abstract ........................................................................................................................................................ iii Acknowledgements ....................................................................................................................................... v List of Tables .............................................................................................................................................. vii Chapter 1: Background Literature Review of Eosinophilic Esophagitis ...................................................... 1 1.1 Eosinophilic Esophagitis ..................................................................................................................... 1 1.2 Clinical Presentation of the Disease .................................................................................................... 1 1.3 Diagnosis and Pharmacotherapy ......................................................................................................... 2 1.4 Pathophysiology .................................................................................................................................. 2 1.5 Risk factors ......................................................................................................................................... 3 1.6 Genetic Components of the Disease ................................................................................................... 4 1.7 Comorbidities ...................................................................................................................................... 5 1.8 Rates Reported Internationally and Nationally ................................................................................... 5 1.9 Overall Impact of EoE ........................................................................................................................ 8 1.10 Eosinophilic Esophagitis in Nevada ................................................................................................. 9 1.11 Summary of Database and Ethical Considerations ......................................................................... 10 Chapter 2: Factors Associated with Eosinophilic Esophagitis in Nevada .................................................. 11 Chapter 3: Comorbidities, Sequela, and Atopic Disease Associated with EoE in Nevada ......................... 22 Chapter 4: Impact of Eosinophilic Esophagitis in Nevada ......................................................................... 36 Chapter 5: Summary, Implications, and Conclusions ................................................................................. 51 5.1 Summary ..........................................................................................................................................
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