Gut Check: Philip Okafor, MD, on Disparities in GI Health Care

Dr Brian Lacy hosts Dr Philip Okafor for a discussion about health disparities in gastroenterology, including defining health disparities, health equality, and health equity, the populations most affected by disparities, and some potential steps and solutions to alleviate the problem.

Brian Lacy, MD, is a professor of medicine at Mayo Clinic Florida in Jacksonville, Florida. Philip Okafor, MD, is an associate professor of medicine in the Division of Gastroenterology at Mayo Clinic Jacksonville.

Welcome to Gut Check, a podcast from the Gastroenterology Learning Network. My name is Brian Lacy. I'm a professor of medicine at the Mayo Clinic in Jacksonville, Florida. I am absolutely delighted to be speaking today with Dr Philip Okafor, Associate Professor of Medicine in the Division of Gastroenterology at Mayo Clinic Jacksonville. Our topic today is one that influences the practice of medicine in all specialties, disparity in healthcare. This topic has been recognized as critically important by the National Institutes of Health and the National Academy of Medicine. So Dr Okafor, welcome.

Let's start really simply. Ideally, all Americans would have equitable access to healthcare, a concept referred to as healthcare equity, but unfortunately that is not always the case.

How do you define healthcare disparity?

Dr Okafor:

Hello, Dr Lacy. Thanks for having me today. That's a very good question and I'm going to leverage on that question to talk about two other terms, including health equality and health equity. So going back to your initial question of health disparities, health disparities are essentially differences in outcomes or access to healthcare experienced by typically subpopulations of our demographic or the country where you live or community where you live. And importantly, these are typically driven by social, economic, environmental differences within those populations. And also important to measure that potentially disparities are preventable. So that's the easy way to understand just differences in health outcomes or access to health in general between demographics of our population.

And I talked about health equity and health inequality, because I think it's important to emphasize those terms too. And oftentimes people use those terms interchangeably, they're not. So health equality is giving everybody the same amount of resources to succeed, while health equity means tailoring those resources to what that particular demographic needs. An example I give is, for instance, you do gastroenterology, you see patients with severe constipation. If you look at your practice and you find that different patients with severe constipation have different outcomes of getting better, then you can tailor your resources to say, okay, for patients who, for instance, don't have English as a primary language, you want to have an interpreter in clinic, you want to have your instructions in the language they prefer so that they can better complete their tests, understand their medications so that the outcomes are the same for everybody. So those are the 3 major terms to talk about today.

Dr Lacy:

Dr Okafor, I really like the way you tease that out and I kind of just like this concept of giving everybody the tools and resources so that they can succeed with their healthcare needs. I really like that basic concept. So teasing this concept out a little bit more, you kind of covered this, but I want to go through it again because it's so important. Healthcare disparity is not just about accessing healthcare, but it can also involve how patients experience healthcare or receive healthcare. Is one component more important or prevalent than another?

Dr Okafor:

I think that's an excellent question. And I think about it when we try to answer research questions, how do you identify these different parts of disparities? One, like you said, accessing healthcare, then also differences in how people experience healthcare when they're in the healthcare system. So one, you don't even get in and two, you get in, but you experience it differently from other people. I think they're just as important.

Honestly, it's very difficult, the way our data is captured and just the way these disparities exist, because sometimes they're very qualitative. So I think that's a challenge how we measure those experiences, for instance. And that's why it's hard to do an apples to apples comparison, which is more prevalent, which is more important. I would say they're just as important. We need to ensure everyone has an equal chance to get into the healthcare system and also when they get into the healthcare system, they have an equal chance of attaining that highest level of health in a way that's tailored to them.

So I'll give you an example. A patient who has a particular disease who doesn't get to the hospital and has a poor outcome because they simply don't get to the hospital. And the second example is a patient who has, for instance, a gastrointestinal bleed who gets into the hospital, but for whatever reason has a delay in getting their colonoscopy or the endoscopy done on the first day when they come in for a GI bleed, either because of language or health literacy or whatever reason, those are the two examples of those two points you emphasize in your question.

Dr Lacy:

And what are some of the groups most commonly affected? For example, we know that many indigenous Americans, Native Americans, have not had access to good healthcare for years and people in rural areas often have reduced access to healthcare, right?

Dr Okafor:

Yeah, that's a good point. And there are a lot of studies that have tried to address that question you just raised. And so speaking in general, not specific to my specialty, just in general in medicine, consistently there's certain patterns or themes that have been identified. So obviously there's a racial and ethnicity risk factor. So underrepresented minorities, including Black Americans, American Indians, Alaskan Natives, Hispanic or Latino patients—this is not exhaustive—having commonly reported to experience worse outcomes and experience health disparities is also the socioeconomic spin to it. So if you're coming from a low income family, you live in a zip code that's disadvantaged. So say the median or the average income in that zip code is lower compared to other zip codes, you tend to have more health disparities than the rural-urban disparity, folks who live in rural areas may have longer time to travel to access healthcare. They may not have specialty and subspecialty services close to them and so can have worse outcomes. Then there are other populations that have been described. So language proficiency, which is something I'm very interested in. So folks who don't speak English as a primary language, elderly. Then in present day, folks who are sexual and gender minorities, there are a lot of disparities that have been reported in these groups too.

Dr Lacy:

Wow, you've really covered this so very nicely. So just to highlight what you said, and then maybe you can fill in the gaps, but some of these key issues involve race, gender, ethnicity, education, language, socioeconomic status, geography. There are so many factors at play, aren't there?

Dr Okafor:

Yes, they are. Yes, they are. And what's interesting is that they're hard to separate. They're all interconnected. And when I explain to folks who ask this question, if you go back to math and those Venn diagrams and you can have multiple Venn diagrams of health disparities or construct of health disparities that are all interlinked. So if you fix on a problem and you don't fix the other, you may not necessarily eliminate those disparities. So that's an important point to make. They're very, very interconnected.

Dr Lacy:

Yeah, I like that point a lot. So Philip, the next question really seems very basic, but it lies at the heart of the matter. Why does healthcare disparity matter?

Dr Okafor:

Yeah, that's a fundamental question. So I think for me and what drives me to do this kind of research is just the human ethical part of wanting everybody to get the best opportunity for their health, to attain the highest level of health just the way that WHO defined it back in the day. So that's the part I think it's just that human part, the ethical part, providing folks with the resources they need specific and tailored to them so they can understand what they need to do, either it's diet, nutrition, exercise, whatever domain of healthcare you practice in to get that highest level of health.

Then the second big bucket is probably the cost to it. And that's something that we don't report a lot and it's because cost here in the US is very hard to attain, the hospitals report charges and how you assign costs to disparities. It's often not accurate, but it's definitely more expensive to have health disparities.

I'll give you an example. So if you live in a city and you have an emergency room in your part of town that's affluent and there's another part of town where that's less affluent. If folks there don't have primary care in the other part of town, they're going to end up coming to your part of town for emergency room care and eventually you're going to get affected and that can lead to more cost, delays in care. So there's an ethical part to it where we need to just make things right and there's a big, big cost component to it that's often not emphasized.

Dr Lacy:

I like that last point a lot because this doesn't exist in silos or in isolation. So you may think you have great healthcare in one part, but the neighborhood next door, that's going to trickle over and it's going to affect everybody and we need to fix that. So you've mentioned a few examples, but let's drill down a little bit more into this issue with some more specific examples for our audience today. And in the broad field of medicine, can you highlight a few key areas of healthcare disparity? Is it vaccine distribution or mammograms or stroke prevention? What do you think are some of the hot topics we need to be aware of?

Dr Okafor:

Yeah, so I think that's a very important question. And the folks who are listening to our podcast today will have the part of medicine where they practice or they're involved in and it's good to reflect and look at what disparities exist in your own domain so you're aware of them because that's the first part, just being aware.

So to answer your question, so I'll go as broadly as I can. And again, this is not exhaustive. There's so many more health disparities that have been described on a consistent basis in different populations. But for one, you can look at maternal mortality rate when it comes to obstetrics and childcare, it's definitely been shown that Black Americans, American Indians, and Alaskan Natives have much higher maternal mortality rates when they have babies. If you look at in the cardiology space, it has been shown that women are more likely to have delays in care when they come in with an acute coronary syndrome. And that's because they're more likely to have atypical presentation, not classic chest pain that is reported in the literature or when you do your test questions. So there may be a delay in recognizing when female patients come into the emergency room with an acute coronary syndrome.

So another example I'll think about is maybe in this diabetes space, if you look at Black Americans and Hispanics, they're more likely to have foot amputations and just poor diabetes outcomes that reflect that gap of delays in getting a diagnosis of diabetes, delays in getting adequate treatment, delays in getting the A1C down. Then one study we published a few years ago where we looked at zip code level exposure to environmental data. So if you look at toxins where you live, water pollution, we found that living in certain zip codes, you have higher rates of disease. Lung cancer has been reported, different kind of cancers have been reported.

So those are a few examples that the list goes on and on specific examples of healthcare disparities.

Dr Lacy:

Yes. Unfortunately, it's kind of a long list showing that we've got a lot of work to do. And Philip, since we're both gastroenterologists, you've already mentioned a few issues in gastroenterology, but what are some of the two, three, four hot topics or key areas of healthcare disparity in gastroenterology?

Dr Okafor:

Yeah, that's a great question. Something dear to my heart. So colorectal cancer, obviously. March just went by, colorectal cancer awareness month, and we still see those disparities in, for instance, in Black Americans being about 15 to 20 times more likely to develop colorectal cancer than White Americans. If you look at after getting colorectal cancer, how patients are treated, there's disparities in Black Americans, Alaskan Natives, and American Indians in when they get treated. So there's delays and there's data using the Medicare database that these demographics received care later and this impacts outcomes. So the mortality rate for certain publications is as high as 40%. So that's staring us in the face. And that's just talking about developing colorectal cancer. If you're going to screening, that's a whole different circle again in that Venn diagram of disparities where underrepresented minorities have lower rates of screening for colorectal cancer. Patients who have limited English proficiency have lower rates of colorectal cancer screen. So those are two big ones. S

Something that's coming up more recently now, Dr Lacy, is we have these new wonderful medications that we used to treat inflammatory bowel disease that have totally transformed the landscape and there are reports of disparities in underrepresented minorities gaining access to these medications. So they have worse inflammatory bowel disease outcomes. They're more likely to be hospitalized acutely for complications or flares of these conditions. And even when they get into the hospital, they're less likely to get the highly specialized J pouch procedures and more likely to just get resections. So there's a lot of work to be done and there are multiple reasons for why these disparities occur and I'm happy there's some focus on it now.

Dr Lacy:

Wonderful. We're lucky to have you leading the field in this area, hoping that we can make things better. So I want to talk a little bit about public policy efforts and in two different ways. And could you tell us a few things that are going on on a national level first and then we'll talk about maybe local community efforts to help address some of these issues you brought up today?

Dr Okafor:

No, I think that's very important. I don't want to sound all doom and gloom. There's a lot of work and a lot of improvement. These are definitely better than they were 20, 15 years ago. If we go into the colorectal cancer space, the noninvasive stool tests, states offering more support there, offering navigation to underserved and minorities so that they can get access to this noninvasive stool test has totally changed the way colorectal cancer screening is being approached. So there's been historically that fear in getting colonoscopies, but now people are getting more receptive to getting these noninvasive stool tests. So that definitely made a big change nationally. Well aware of the Affordable Care Act that addresses discrimination, has provided more resources, particularly for folks who, for instance, who have limited English proficiency. So there's definitely a national policy that's definitely helped improving access, like you talked about that first question, that photocare act to get into the healthcare system, at least to see a healthcare provider.

So those are some examples of the big ones in our space that have made an impact.

Then at the community level or individual level, I think that's where I think we can all make a difference. I think we practice in different situations, different parts of the country. So I always encourage people to look at your own institution and look at what your institution or your division and your department has that is creating a disadvantage towards certain demographic. I'm very passionate about English proficiency. And so are your instructions in other languages that are not English, especially if you see a particular demographic that doesn't speak English more so than others? Then you may want to cater to those people. You have patient navigators. I always encourage people to look at their own data. So if you don't measure, you don't know. So for those who are leaders in this space trying to get dashboards that collect data on what's important. So is it race, is it ethnicity, is it language?

And just create dashboards. Something that's simple as what are your bowel prep completion rates and how do they differ across different rates? So those are things you can do locally to measure and see how your own patients do. Then you can start to formulate strategies to address those because if you don't measure, you don't know. So that's probably the first step. Then I think community-wise, we need to engage more with our community. We need to engage with the people who live around us. Many academic centers are right in the middle of underrepresented minority populations and we're not doing enough to get into the community to involve them in our own practice and see how we can help them. So those are things we can do from a community level.

Dr Lacy:

I like that last point a lot too, that sometimes we expect people to come to us, but we need to do a better job reaching out to our community. And so as we wind down here, what do you think are some of the challenges that may slow the progress or prevent healthcare equity in the United States?

Dr Okafor:

That's a very big question and it's a very good one too, Dr Lacy. I think the climate we live in is one of them, just the political climate. So some emphasize disparities and support research funding in some areas it's not emphasized. So that's a big one. We definitely need more funding to come from the federal government and that's improved a lot. So now there's a lot of grants at a national level where you can actually build a career doing health disparities research, which wasn't always the case. So kudos to the national societies too for creating more funding opportunities. So that's been a big issue, just being able to fund those research, to get those databases to do practical studies where you're looking at impact, not just assessing and measuring disparities, but taking that to the next level, you can actually have intervention. So funding is a big one.

I talked about just systemic and institutional racism and that those terms sound like big words. I always try to caution people that it's not as aggressive as it sounds. It just means identifying what disparities or disadvantages your own institution or your division or department has or disadvantages certain populations who come to see you experience when they come to your division and trying to address those. And insurance is a big deal. A lot of patients are underinsured and even those who are insured, it's all very relative to where you go, which leads to economic inequality. You can go into another big domain in that Venn diagram I started with of health literacy and how you take care of that. Our country's so diverse. So the language and cultural barriers that we as providers are not very attuned to when we see these patients. So we address things the way we understand and we need to be more empathetic and look in the patient's eyes and be more patient with our patients.

So a lot of challenges, but there's definitely hope. I think things are definitely getting better. And the more we measure and the more we show people that these parties do exist and these challenges to exist, then the more opportunities we have to actually mitigate those issues.

Dr Lacy:

Yeah, I like that point too. We live in a wonderfully diverse country. However, that diversity presents with challenges, doesn't it? So Philip, this has been a great discussion. Any last comments for our listeners?

Dr Okafor:

Yes, it's been a wonderful discussion. I always encourage people that it's take your first step in your own place, start with your local practice. Do you measure your outcomes? If not, then start an initiative to measure outcomes in your own practice, however small that may be. You can start with bowel prep rates, you can start with anorectal manometry completion rates. So we're ordering them, but we're not checking if everyone is getting them done. And if you find issues, advocate; if you're a leader, provide those resources to cater to those demographics or solve those problems. Everyone can make a difference, no effort’s too small. We need to engage more with our communities like we talked about earlier. And importantly, we as providers need to recognize our own biases. And there's this implicit bias, implicit assessment test, IAT, I think it is, that I encourage what to always do to see where you stand in terms of what biases you have that you may not even know because they're unconscious.

So those are things that we can start and being just open-minded to listen to other people with different and divergent opinions.

Dr Lacy:

Wonderfully encouraging message there. Dr Okafor, again, thank you for lending your expertise on this important topic To our listeners on Apple, Spotify, and other streaming networks. I'm Brian Lacy, a professor of medicine at the Mayo Clinic in Jacksonville, Florida. You have been listening to Gut Check, a podcast from the Gastroenterology Learning Network. Our guest today was Dr Phillip Okafor, associate professor of medicine at Mayo Clinic, Jacksonville. I hope you found this just as enjoyable as I did and I look forward to having you join us in the future for another Gut Check podcast. Stay well.