Achieving Health Equity with Diagnostic Tools
By Mary Reich Cooper, MD, JD, Associate Professor and Program Director, Healthcare Quality, Safety and Operational Excellence, Thomas Jefferson University
Health equity has been described by many, and generally refers to the concept that everyone receives the care they need, regardless of race, ethnicity, religion, sex, gender, or age. In the United States, the ability to pay is also a factor in the equation; in many other countries, care is available to all. However, even after accounting for those variables, access to diagnostics is not always equitable. Access to diagnostics may be predetermined by the number of miles patients have to travel using a reasonable amount of time and money. Sometimes, the very definitions used for tests and the clinical algorithms that drive results are structured so that care is not delivered equitably. And, sometimes, the diagnostic equipment itself may show outcomes that vary, depending on the person’s background.
Rural healthcare, for example, has always relied on proximity. With many health systems closing hospitals and consolidating office practices and diagnostic centers, healthcare has become less accessible for some people in rural environments. The explosion of telehealth over the past four years has remained strong for rural locations and stands to become an even bigger factor as broadband becomes more pervasive and practitioners grow more comfortable with telehealth as an alternative. Patients are already showing increased satisfaction with less driving and shorter waits. The development of at-home lab tests and wearables such as remote monitoring devices has mitigated some of the risks/challenges faced in brick-and-mortar structures. Even when diagnostics require in-person visits, the patient portals and open access mean lab and imaging results are available sooner.
Fostering health equity may take many perspectives into account. Three years ago, the recommendation from a task force associated with nephrologists (who treat the kidney), practitioners from laboratory medicine, and patients themselves, among others, advised that race should no longer be a factor when calculating estimated glomerular filtration rates (eGFR), a measure of kidney function. Acknowledging that race-based measurements can delay the diagnosis of chronic kidney disease (CKD), in 2022 the College of American Pathologists endorsed the recommendation and offered recommendations to ensure the adoption of newer approaches to measuring eGFR. By 2023, all persons awaiting transplants were required to have their eGFR recalculated with the new measurement to ensure they were not disadvantaged by an overestimation of kidney function. CKD is much more prevalent in Black and African-American patients, and their care was delayed by the prior calculations. The diagnostic community was listening.
Health Equity is not just about access to care, but also about the definitions, the algorithms, and how we practice.
Diagnostic images and equipment have also come under scrutiny to ensure equitable care. In lung disease, it was first noted more than 15 years ago that pulse oximeters may not accurately measure hypoxemia in persons with darker skin, regardless of race. That finding was reinforced in studies performed during the early months of the COVID-19 pandemic, and many more people became aware that in some situations, an arterial blood gas was needed to corroborate accuracy. Medical students have pointed out that reference pictures in their textbooks may not reflect the variety of people that they will eventually see in practice. The diagnosis of skin lesions is an area that needs attention to health equity, to ensure that students are trained in a variety of manifestations. Machine learning (ML) may obviate some of the biases and has already been used to calculate patient risk and diagnoses in imaging. Developers of the underlying software structures must be attuned to that risk.
Some religions discourage or even forbid care from a person of the opposite sex. Other religions do not allow certain treatments. Without practices and processes to account for those concerns, such as having women providers and chaperones available, or protocols for persons who do not want blood transfusions, healthcare organizations, and their diagnostic labs and imaging centers, may make themselves unwelcome to whole populations. Asking about personal preferences is patient-centered care. Health equity relies on patient-centered care.
Bias can occur if all testing of a new diagnostic tool occurs in one population, even though the tool can be used for all populations. Patients over 65 and those under 18 were often excluded from the research when a new diagnostic tool or algorithm was considered. The original rationale was protective, but since many clinicians use diagnostics without regard to age, no validation of the accuracy may have occurred in those two populations. In fact, if tests are only used in the populations in which they were tested, the sensitivity and specificity could be altered compared to use in general populations. In some cases, that alteration may require a second diagnostic test in a patient for validation of a clinical hypothesis. The use of a d-dimer in older results, and the potential necessity of adding a CT scan to validate a high result, is an example of age-related bias. Health equity is impacted if specific populations are not considered when enrolling participants for new tests and devices.
Chronic traumatic encephalopathy (CTE) is a pathological diagnosis, made only at autopsy. Risk factors are not completely understood, but repeated head trauma appears to be the defining factor in the development of CTE. Athletes who suffered repeated head trauma and military veterans who had concussive injuries are the most visible individuals who have been diagnosed with CTE. Symptoms such as aggressive and erratic behavior, memory impairment and cloudy judgment, and depression are characteristic of CTE. Health equity plays a role in the diagnosis of CTE; non-white people are less likely to get a CT scan for concussions, and early researchers alleged that a higher prevalence of diabetes and hypertension in Black athletes contributed to a higher incidence of CTE.
Health equity is the outcome of our structures and practices, decisions and designs. Working to overcome biases in diagnostic testing and instruments can go a long way to achieving health equity.