A recently published literature review shows decreased or inappropriate use of diagnostic imaging for close to 75 percent of minority patients across a wide variety of clinical settings (J Am Coll Radiol 2022; https://doi.org/10.1016/j.jacr.2022.01.008). The study sought to summarize the existing literature evaluating differences in imaging use based on patient race and ethnicity, the authors wrote.
To that end, a team led by researchers from the University of Wisconsin School of Medicine and Public Health performed a structured search of four databases for the dates January 1, 2000, to April 13, 2021, using keywords and derivatives focused on imaging and patient race.
The authors reviewed retrieved citations by abstract and then full text to identify articles evaluating the likelihood of imaging use by patient race or ethnicity controlling for sociodemographic factors. Data regarding publication characteristics, study population, clinical setting, and results were extracted and summarized, according to the researchers.
"A lot of previous research has been done on health disparities for minority patients, including within radiology, and the pace of publication has been increasing in the last 5 years," said study co-author Andrew Ross, MD, MPH, Assistant Professor of Radiology; Director of the Musculoskeletal Fellowship Program; and Fellowship Director of Musculoskeletal Imaging and Intervention at the University of Wisconsin School of Medicine and Public Health.
"For a health equity researcher, it can be hard to get an accurate sense of what has already been done and what research gaps exist," Ross added. "We wanted to summarize the existing literature to make it readily accessible and highlight areas that should be prioritized for future research. We hypothesized that minorities would face obstacles to accessing diagnostic imaging across a wide range of clinical scenarios and, indeed, that is what we found."
Study Details
The structured search that Ross and colleagues conducted identified nearly 3,000 articles, of which 206 met inclusion criteria. Overall, 72 percent of the included studies-179 of which were conducted in the United States-found "decreased or inappropriate imaging use in minority groups," the researchers wrote.
Breast cancer screening was the most common clinical setting, representing 50 percent of included studies, followed by cancer care (10%) and general imaging use (9%). Government-administrated surveys served as the most common data source, and just 8 percent of studies evaluated strategies to mitigate the unusual use of imaging based on patient race and ethnicity.
The research team also reported a number of negative outcomes related to inadequate or inappropriate imaging, such as higher rates of breast cancer deaths among Australian Aboriginal women as the result of decreased cancer screening, and higher mortality rates in racial and ethnic minority patients with lung cancer who had lower rates of PET/CT utilization.
Overall, "we can't estimate the precise percentage of patients not getting the right imaging," Ross said. "Diagnostic imaging plays a key role in modern health care. It's how we screen for cancers, diagnose disease, and monitor treatment."
While noting that most studies didn't directly measure how imaging disparities affected health outcomes, "the ones that did were worrisome," said Ross, noting examples such as the aforementioned higher rates of breast cancer mortality and the increased likelihood of rupture in appendicitis. Answers as to why these disparities exist are elusive.
"Health care disparities arise from a complex mix of patient, provider, and systemic factors. Unconscious provider bias may play a role, but that's just one of many. People of color may be more likely to live in areas served by safety net hospitals with fewer resources," he stated.
Minority patients may have a harder time accessing primary care in some cases, Ross noted. Or "they may have distrust in a health care system that in the past has been explicitly racist. They may feel uncomfortable coming to the hospital and finding that few health care providers look like them. They may be more likely to be uninsured or have high deductible health plans. The list is long."
Of course, there are steps that care providers, including radiologists and the rest of the radiology team, can take to help ensure that more minority patients get the needed imaging procedures.
"The most important thing is to first ask the question," Ross suggested. "It's up to all of us to play a role in promoting an equitable health care system. Once you've asked the question, start looking around, and I think most people will find opportunities they can implement locally."
He noted the questions that providers should be asking should include: Do you have flexible scheduling so that imaging exams can be done outside of work hours? Do you have resources for people needing help with transportation or childcare for imaging appointments? Are your appointment reminder messages in a language that your patient speaks?
Beyond these types of questions, radiologists should also play a role in advocating for systemic changes that promote equitable care.
"One way that is already being done is through the promotion of evidence-based imaging guidelines. If you're a health care provider and you have a patient coming in with a specific problem-acute hip pain after a fall, let's say-it's helpful to have a resource to guide what kind of imaging should be done. Indeed, in several of the articles we reviewed, we found that racial disparities were decreased when evidence-based imaging guidelines were implemented for all patients," Ross concluded.
Mark McGraw is a contributing writer.