Background: National mortality databases serve as a useful resource to assess the burden of systemic autoimmune diseases [1]. We previously reported disproportionately high predicted annual mortality rates in lupus-related deaths relative to all-cause deaths in the general population, which significantly differed by race and ethnicity.[2,3] Determinants of differential mortality by race and ethnicity remain largely unclear. Here, we asked if education level as a surrogate measure of socioeconomic status is associated with the risk of early death with lupus, and whether the association of education with early SLE death accounts for racial and ethnic differences in lupus mortality.

Objectives: To determine whether educational attainment is associated with the odds of early death (<65 years) overall and within racial and ethnic groups.

Methods: We used United States national mortality database to retrieve lupus death counts for years 2018-2023 by 8 education levels (8th grade or less, 9th through 12th grade with no diploma, High school graduate or GED completed, Some college credit, but not a degree, Associate degree (AA,AS), Bachelor’s degree (BA, AB, BS), Master’s degree (MA, MS, MEng, MEd, MSW, MBA), and Doctorate (PhD, EdD) or Professional Degree (MD, DDS, DVM, LLB, JD). We included deaths where lupus was recorded as the underlying or a contributing cause of death, but excluded deaths where COVID-19 was recorded as the underlying cause of death. For analyses of lupus deaths by race and ethnicity, we pooled deaths in three educational strata (high school or less, some college/associate degree, bachelor’s degree or higher) in 7 racial and ethnic groups (Hispanic, and non-Hispanic American Indian or Alaska Native, Asian, Black, Native Hawaiian or Other Pacific Islander, White, and More than one race). We only included decedents 25-years and older, since most people complete their formal education by age 25. Chi-square tests were performed to assess associations between education level and age-at-death (25–64 versus 65 years and older) within racial and ethnic groups.

Results: Data on education level were available in 12,154 of 22,593 decedents with lupus from 2018 through 2023. Relative to lupus decedents with doctorate or professional degree, the odds of early death (<65-years age) were higher or not significantly different in decedents at all other education levels. The odds of early death were significantly higher in lupus decedents with high school or less education (odds ratio [OR], 1.236, 95% CI, 1.124 to 1.361, p<0.0001) and those with some college or associate degree (OR, 1.327, 95% CI, 1.212 to 1.454, p<0.0001) compared to decedents with bachelor or higher education. However, when stratified by race and ethnicity, the association between lower educational attainment and higher odds of early lupus death was observed primarily in non-Hispanic White decedents (p <0.01 and <0.0001). non-Hispanic Asian and non-Hispanic Black decedents with lupus also had higher odds of death in those with some college/associate degree compared to bachelor or higher educated decedents (p 0.02, and p 0.04, respectively). No statistically significant association was observed between education level and the odds of early lupus death in Hispanic, non-Hispanic American Indian or Alaska Native, non-Hispanic Native Hawaiian or Other Pacific Islander, and non-Hispanic populations with more than one race. Of note, there were no significant racial and ethnic differences in the proportions of lupus decedents that had education data available versus those whose education level was unknown or not available in both age groups. Finally, when stratified by education level, the odds of early lupus death were higher in all racial and ethnic groups compared to non-Hispanic White decedents at all three education levels. Notably, at the bachelor and higher education level, non-Hispanic Black decedents had the highest odds of early lupus death (OR, 4.496, 95% CI, 3.637 to 5.565, p <0.0001).

Conclusions: Educational attainment is associated with age-at-death patterns among individuals with lupus, but its apparent protective effect varies across racial and ethnic groups. This suggests that education or socioeconomic status alone does not fully account for observed racial and ethnic disparities in lupus mortality. Persistent disparities at higher education levels highlight the need to examine structural and systemic factors beyond education that contribute to unequal mortality outcomes in lupus.

REFERENCES: [1] Singh RR. National Mortality Databases to Assess Disease Burden in Systemic Autoimmune Diseases: A Valuable Resource But With Limitations. Arthritis Rheumatol 2025.

[2] Yen EY, Shaheen M, Woo JMP, et al. 46-Year Trends in Systemic Lupus Erythematosus Mortality in the United States, 1968 to 2013: A Nationwide Population-Based Study. Ann Intern Med 2017; 167 (11): 777-85.

[3] Singh RR, Yen EY. SLE mortality remains disproportionately high, despite improvements over the last decade. Lupus 2018; 27 (10): 1577-81.

Acknowledgments: NIL.

Disclosure of Interests: None declared.