The incidence of inflammatory bowel disease (IBD) is on the rise among racial and ethnic minority groups in the United States, and social determinants of health (SDOH) contribute to disparities in IBD care and outcome, say the authors of a new paper on the topic.
It’s an “overdue priority to acknowledge the weight and influence of the SDOH on health disparities in IBD care,” write Adjoa Anyane-Yeboa, MD, PhD, with Massachusetts General Hospital, Boston, and co-authors.
“Only after this acknowledgement can we begin to develop alternative systems that work to rectify the deleterious effects of our current policies in a more longitudinal and effective manner,” they say.
Their paper was published online in Clinical Gastroenterology and Hepatology.
Upstream factors propagate downstream outcomes
The authors found multiple examples in the literature of how upstream SDOH (for example, racism, poverty, neighborhood violence, and under-insurance) lead to midstream SDOH (for example, lack of social support, lack of access to specialized IBD care, poor housing conditions, and food insecurity) that result in poor downstream outcomes in IBD (for example, delayed diagnosis, increased disease activity, IBD flares, and suboptimal medical management).
The IBD literature shows that Black/African American adults with IBD often have worse outcomes across the IBD care continuum than White peers, with higher hospitalization rates, longer stays, increased hospitalization costs, higher readmission rates, and more complications after IBD surgery.
Unequal access to specialized IBD care is a factor, with Black/African American patients less likely to undergo annual visits to a gastroenterologist or IBD specialist, twice as likely than White patients to visit the emergency department over a 12-month period, and less likely to receive treatment with infliximab.
As has been shown for other chronic digestive diseases and cancers, disparities in outcomes related to IBD exist across race, ethnicity, differential insurance status and coverage, and socioeconomic status, the authors note.
Yet, they point out that, interestingly, a 2021 study of patients with Medicaid insurance from four states revealed no disparities in the use of IBD-specific medications between Black/African American and White patients, suggesting that when access to care is equal, disparities diminish.
Target multiple stakeholders to achieve IBD health equity
Achieving health equity in IBD will require strategies targeting medical trainees, providers, practices, and health systems, as well as community and industry leaders and policymakers, Dr. Anyane-Yeboa and colleagues say.
At the medical trainee level, racism and bias should be addressed early in medical student, resident, and fellow training and education. Curricula should move away from race-based training, where race is considered an independent risk factor for disease and often used to guide differential diagnoses and treatment, they suggest.
At the provider level, they say self-reflection around one’s own beliefs, biases, perceptions, and interactions with diverse and vulnerable patient groups is “paramount.” Individual self-reflection should be coupled with mandatory and effective implicit bias and anti-racism training.
At the practice or hospital system level, screening for SDOH at the point of care, addressing barriers to needed treatment, and connecting patients to appropriate resources are all important, they write.
The researchers also call for policy-level changes to increase funding for health equity research, which is historically undervalued and underfunded.
“Focusing on SDOH as the root cause of health inequity in IBD is essential to improve outcomes for marginalized patients,” they write.
Given that research describing specific interventions to address SDOH in IBD is currently nonexistent, “our paper serves as a call to action for more work to be done in this area,” they say.
“As medical providers and health care organizations, we all have a responsibility to address the SDOH when caring for our patients in order to provide each patient with IBD the opportunity to achieve the best health possible,” they conclude.
This research had no specific funding. The authors have disclosed no relevant financial relationships.
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