Mitigating Health Disparities: The Role of the Clinical Laboratory Marissa White, MDJohns Hopkins University School of MedicineDepartment of Pathology October 29, 2020

Clinical laboratory Improvement Advisory Committee Meeting: Clinical Laboratory Medicine in the Age of COVID-19

Disclosures

• I have no relevant financial disclosures.

Objectives• List the 5 domains of the social determinants of health (SODH), as defined by the

U.S. Department of Health and Human Services.

• Identify an example of how SODH exacerbated health disparities during the COVID-19 pandemic.

• List some resources to further expand your understanding of health disparities.

• As a laboratory professional, design and implement an initiative to mitigate a health disparity.

Social determinants of health (SODH)“Conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes.”

Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved [date graphic was accessed], from https://health.gov/healthypeople/objectives-and-data/social-determinants-health

Federal initiatives to identify, measure, and address US health disparities• 1985 - Report of the Secretary’s Task Force on Black and Minority Health • 1986 - Office of Minority Health • 1990 - Americans with Disabilities Act • 2000 - National Center on Minority Health and Health Disparities • 2000 - Healthy People 2010 • 2000 - Minority Health and Health Disparities Research and Education Act• 2000 - National Standards for Culturally and Linguistically Appropriate Services (CLAS) in

Health Care• 2007 - National Partnership for Action to End Health Disparities • 2009 - Race, Ethnicity, and Language Data: Standardization for Health Care Quality

Improvement• 2011 - HHS Action Plan to Reduce Racial and Ethnic Health Disparities • 2011 - National Stakeholder Strategy for Achieving Health Equity • 2013 - National Healthcare Quality and Disparities Report• 2018 National Healthcare Quality and Disparities Report

The impact of SODH during the COVID-19 pandemic

Racism, Social Class, Social Stratification ----- Socio-Political ContextThakur et al Am J Respir Crit Care Med. 2020 Oct 1; 202(7): 943–949

Native American Communities• Increased prevalence of chronic diseases• Higher rates of poverty• Vulnerable elderly population • Larger households• Linguistically and culturally appropriate public health

communications• Remote and isolated communities

– Limited healthcare infrastructure and access – Limited access to potable water and safe wastewater disposal– Some subsistence lifestyles– Limited internet and mobile phone service

Van Dorn A, Cooney R. Sabin M. The Lancet. April 18, 2020;395:1243-1244https://www.ndoh.navajo-nsn.gov/#

Influenza Preparedness and Response for Vulnerable PopulationsPandemic Influenza Preparedness and Vulnerable Populations in Tribal Communities

AM J Public 2009 October

How can lab professionals identify opportunities to mitigate health disparities?

Thakur et al Am J Respir Crit Care Med. 2020 Oct 1; 202(7): 943–949

National Standards for Culturally and Linguistically Appropriate (CLAS) in Health and Health Care

“Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.”

https://thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedCLASStandardsBlueprint.pdf

Healthy People 2030“To promote, strengthen, and evaluate the nation’s efforts to improve

the health and well-being of all people.”

• National goals and measurable objectives to guide evidence-based policies, programs, and other actions to improve health and well-being.

• Plan of Action– Identify needs and priority populations– Set your own targets– Find inspiration and practical tools– Monitor national progress and use HP2030 data as a benchmark

https://health.gov/healthypeople/objectives-and-data

How can I use healthy people in 2030 in my work

Healthy People 2030 objectives in research and development relevant to pathology• Increase the proportion of state public health laboratories that provide

comprehensive laboratory services to support emerging public health issues

• Increase the proportion of state public health laboratories that have implemented emerging technology to provide enhanced laboratory services

• Enhance the use and capabilities of informatics, including data-sharing, data exchange, and application to practice and use in decision-making

Healthy People 2030 core objectives relevant to pathology• Increased serum creatinine, lipids, and urine albumin

tests for Medicare beneficiaries• Increase the proportion of adults with diagnosed diabetes

who receive an annual urinary albumin test• Reduce the female breast cancer death rate• Increase the proportion of persons who know their

sexually transmitted infection status• Reduce the rate of new cases of end-stage kidney

disease (ESKD) https://www.cdc.gov/dengue/testing/index.html

Reducing the rate of ESKD: Hemoglobin A1cpoint-of-care (POC) testing in under-resourced settings

• Glycemic control drives diabetes outcomes

• Well-established racial, ethnic, socioeconomic, and geographic disparities in pre-diabetes and diabetes prevalence and outcomes

• HbA1c POC has the potential reduce diabetes disparities by allowing for immediate clinical decision-making

• Significant limitations with HbA1c POC instrument performances…

John et al. Clin Diabetes. 2019 Jul; 37(3): 242–249Lenters-Westra et al. Clin Chem. 2014 Aug;60(8)1062-72.Hirst et al. Clin Chem Lab Med. 2017;55(2):167-180.

What happens when we laboratory professionals don’t do our part?

Inadvertent exacerbation of health disparities

• Culturally inappropriate and non-patient-centered care

• Diagnostic, therapeutic, and risk-stratification algorithms

• Laboratory reference ranges

• Electronic medical record systems

• Analysis of a partial list of race-adjusted algorithms

• Inadvertently encourages “race-based” medicine

• Diversion of resources and/or medical attention away from racial and ethnic minorities

• Opportunities for pathologists to collaborate with clinical colleagues to reconsider and rigorously validate algorithms

Transgender and nonbinary patient health • Numerous barriers to healthcare access

• Overt bias• Issues securing insurance coverage• Provider unfamiliarity of unique healthcare needs • Access to routine cancer screening • Failure to use preferred names, pronouns, and gender identity in the clinical

setting and/or electronic medical record (EMR)• Laboratory reference intervals for individuals on hormone therapy

• Recommended inclusion of preferred name, pronoun preference, assigned sex at birth, and gender identity in the EMR per the World Professional Association for Transgender Health

Imborek KL et al. J Pathol Inform. 2017;8:42. Published 2017 Oct 3.Ahmad T et al. Transgend Health. 2019;4(1):335-338. Published 2019 Nov 21Gupta S et al. Lab Med. 2016;47(3):180-188

The last piece of the puzzle: Workforce diversity

Increased Medical Work-Force Diversity

Distribution of pathology faculty by race and ethnicity between 1970 and 2018

(AI = American Indian; AN = Alaska Native; NH = Native Hawaiian; PI = Pacific Islander) White MJ et a; Am J Clin Pathol. 2020 Sep 8;154(4):450-458

Summary• Social determinants of health directly impact health equity.

• As “gatekeepers” of diagnostic tests and data, laboratory professionals are uniquely positioned to mitigate health disparities.

• Failure to emphasize diversity, inclusion, and equity in pathology may inadvertently exacerbate health disparities.

• Numerous federal initiatives and resources can assist with the development and implementation of pathology-specific health equity initiatives.

• Work-force diversity directly contributes towards improved health outcomes and reduction of health disparities by enhancing patient-provider concordance, delivery of culturally appropriate and patient-centered care, innovation, awareness and emphasis of health disparities, clinical trial diversity, and quality of care.