Cracking the Racial Disparity Nut

This year’s Digestive Disease Week (DDW) annual meeting included disparities in gastrointestinal care access and outcomes for Black and other racial/ethnic minority patients as one of its main themes.

Multiple lectures and panel discussions as well as at least two dozen research abstracts focused on the issue, with many speakers acknowledging that it had been neglected too long — and not just in their specialty, but across all of medicine.

Here’s a sample of presentation titles:

This last one exemplified the overall tenor of these reports. Omid Salehi, MD, of Tufts University in Boston, reported that having government insurance such as Medicaid predicted worse survival probability — but Black patients fared poorly irrespective of insurance status.

Data for this study came from a multi-institutional prospective cancer registry and covered 1,072 patients with colorectal, esophageal, gastric, liver, pancreatic, and hepatobiliary cancers. As the title indicates, adjustments were taken for age and gender. Black patients with private insurance showed nearly the same increased risk of early death as those with government insurance (HR 1.936 vs 2.077, relative to white patients with private insurance). White patients with government insurance showed poorer survival in the same range (HR 1.844).

Another study at DDW previously summarized on MedPage Today found that Black patients undergoing bariatric surgery were at 24% higher risk of complications within the first month, after adjusting for a host of factors including comorbidities.

These and similar results reported at DDW were disturbing but not surprising. Reports that Americans of Black, Hispanic, and Asian ancestry face poorer outcomes have become a staple of medical journals in the past decade. Even in the military, where everyone uses the same facilities and ostensibly enjoys the same access to care, the picture has been mixed, with some studies finding that disparities in outcomes by race and ethnicity were smaller than in civilian society but had not vanished entirely.

DDW held a media briefing on Monday after the meeting’s official end to explore some of these issues in more detail.

Jennifer Christie, MD, of Emory University in Atlanta, and Lukejohn Day, MD, of the University of California San Francisco, reviewed some of the studies presented at DDW and offered their thoughts on why the disparities persist and what clinicians can do about them.

“We see that in some healthcare settings, again, race and ethnicity played a role in terms of receiving chemotherapy, surgical resection, and overall having worse outcomes in pancreatic cancer,” said Day. Similarly, Christie cited a study showing that Black patients were less likely than whites to undergo Whipple procedures for pancreatic cancer, even when they were similar with respect to insurance status.

But Day also pointed to a study in the VA system — which, like the military, is unified and open to all comers — that found few disparities in pancreatic cancer treatment and outcomes. “This raised again the issue of access to care, insurance, and overall health equity” in civilian medicine, he said.

Christie noted that the disparities are not just in cancer treatment, but the whole gamut of GI illnesses.

“What we’re seeing here is the downstream effects of structural and systemic racism, impacting access to care, and that relates to socioeconomic status, location, and all those things,” she said.

A vital question for clinicians, however, is what they can and should do to address the problem. Even those who accept that systemic racism is real may think they are powerless to address social determinants of health, let alone broader issues of segregation in education, housing, and employment.

Asked about that, Christie listed a number of concrete steps providers can take that, while not necessarily attacking these overarching problems directly, can make a difference both for individual patients and for the groups to which they belong. Diversity in clinical trial enrollment is one thing that clinicians can control, she pointed out.

“Engaging the community in the types of studies they would like to see done, and messaging on how it’s done,” is another action that clinical medicine can take, she said.

But, Christie added, “it has to be addressed from a national perspective and in the clinic, meeting the patient where he or she is,” Christie added.

Day said a more diverse healthcare workforce would be an important step in the right direction. He said the gastroenterology societies have “made a strong commitment” to work toward that, spanning the whole team and not just the physician component, addressing gender as well as racial/ethnic diversity. “We still have a long way to go,” he acknowledged.

Day and Christie also agreed that clinicians need to check themselves for implicit biases. “We all have them,” Christie pointed out, and “it definitely impacts patient care and patient outcomes, whether it’s intentional or unintentional.”

Medicine needs to think harder about “how do we embed cultural competency teaching within our healthcare settings, getting our teams to talk about issues of race and ethnicity,” said Day. “I think once we have those frank discussions, it makes people more attuned to them” and can help them “change their patterns of behavior.”

Last Updated May 27, 2021