Diagnosing Disparities in IMIDs

In her presentation at the Interdisciplinary Autoimmune Summit 2021, Junko Takeshita, MD, PhD, MSCE, outlined examples of health care disparities and offered insights on how to address them in clinical practice and training.

She first clarified that health disparities are a difference in health that is avoidable, unjust, or unfair. A number of factors can contribute to health, including health care (eg, access to doctor), genetics, individual behavior (eg, smoking, drinking, exercise), and social and environmental factors (eg, housing quality, neighborhood safety, access to fresh foods).

Further, health care disparities, per the Institute of Medicine, are differences in healthcare access and clinical interventions experienced by certain groups that are not due to … clinical appropriateness or patient preferences. In short, health care disparities result in differential health outcomes.

It is important to note, said Dr Takeshita, the US population is moving toward a “minority majority”, with non-White individuals making up the majority of the country’s demographics. Identifying areas in which racial-ethnic minority groups experience health care disparities, then, are critical as the demographics move toward a more diverse majority.

For example, in psoriasis, patients with moderate to severe disease are more likely to be undertreated. However, Dr Takeshita highlighted a number of research outcomes that point to health care disparities between minority and White patients, including:

• Black individuals are more likely to have severe disease, though the current data suggest that psoriasis is more prevalent in White patients
• Black, Asian, and Hispanic patients report greater impact on QoL due to psoriasis, independent of objective disease severity
• Racial minority patients with psoriasis are less likely than White patients to see dermatologists
• Black patients and those who pay more for drugs are less likely to receive a biologic therapy for psoriasis. These findings are independent of financial status and insurance
• Black patients are less familiar with biologic options, and pharmaceutical advertisements for these products overwhelmingly feature White characters

Similar disparities exist for rheumatoid arthritis (RA) as well. Older patients, Black patients, and patients with low income are less likely to receive disease-modifying antirheumatic drugs (DMARD) to treat their RA. An evaluation of different treatment preferences between Black and White patients with RA, a study found that Black patients are more concerned than White patients with risks and toxicity vs benefits and remission with DMARD.

Inflammatory bowel disease (IBD) has less data regarding disparities in care than psoriasis and RA, but the current literature notes a trend in disparities based on racial-ethnic and socioeconomic factors. Race/ethnicity and socioeconomic status negatively correlate with bowel resection rates in hospitalized patients with Crohn disease, and Black patients and patients who pay out of pocket are less likely to receive a colectomy for their ulcerative colitis.

In the post-presentation Q&A, moderator Adam Cheifetz, MD, asked Dr Takeshita if physicians are less likely to prescribe biologics for Black patients or if prescribing disparities are due to an ability to pay for biologics or other factors. Dr Takeshita indicated that this is a great but challenging question. The treatment decision-making process, she explained, can be largely dependent on socioeconomic and insurance factors. She noted while her presentation did not feature as much data from electronic health records (EHRs), which would more accurately describe what is being prescribed by the physician rather than claims databases (which show whether a patient picks up a prescription), analysis of EHRs show a difference in prescribing patterns. However, many providers have been faced with those socioeconomic or insurance factors affecting therapy access, so the answer is likely a combination of things, though more research is needed

Dr Cheifetz followed up to ask about patients on Medicare who cannot afford self-administered biologics because they cannot get the copay assistance. In response, Dr Takeshita said that even she struggles with this in everyday practice, especially for patients who do not meet the definition of poverty but still cannot afford out-of-pocket costs. She pointed to resources such as pharmaceutical direct patient assistance ad well as payment plans. Dr Cheifetz added that he tends to steer these patients from self-injectables toward fusible drugs because the later will fall under the other benefit vs the pharmacy benefit.

Is there any information on Native and indigenous people? “Short answer, no,” said Dr Takeshita, “This is a challenge with studying disparities because we are often dealing with small numbers of individuals in the ‘vulnerable’ population, which can make it difficult to obtain reliable and consistent information on whether a disparity exists and, if so, its extent.”

Finally, Drs Takeshita and Chefeitz discussed how to better incorporate health care disparities and racism in medicine into teaching medical students, residents, and fellows, as well as in clinical practice. It is a matter of adding in lectures as early as possible in medical school, said Dr Takeshita, but also continual conversations during training in clinics. Further, in practice, as rheumatologists, dermatologists, or gastroenterologists, the first step is recognizing these disparities. “We need more research in this area, but we certainly need to start by identifying these problems in order to begin to address them” Think, also, about our own comforts and discomforts. Practice culturally mindful care, and really ask patients what is important to them and take that into account in a shared-decision making process,” concluded Dr Takeshita.

Reference
Takeshita J. Healthcare disparities in IMIDs. Presented at: Interdisciplinary Autoimmune Summit; April 15-18, 2021; virtual.