By - October 03, 2022
The laboratory is the foundation of healthcare, and touches almost every part of a patient’s journey. According to one 2021 study,1 “Up to 70% of all medical decisions are based, in part, on laboratory findings.”
Laboratories, pathologists, and medical laboratory professionals are, therefore, in a prime position to be leaders in helping improve care for all patients, especially those patient populations that are marginalized or underrepresented. Improving the laboratory’s reach to underserved populations requires using data, setting target goals, and partnering with other areas of health systems to make necessary changes.
Even after the Affordable Care Act made strides in expanding health insurance access, and diversity, equity, and inclusion (DEI) efforts around the country are tackling the issue in numerous ways,2 the current healthcare system is still rife with disparities in reaching underserved and marginalized populations. Patients marginalized by such factors as race/ethnicity, socioeconomic status, gender, disabilities, geographic access to care, and health insurance status, to name a few,3 may be at higher risk for multiple health problems, have limited healthcare options, face greater barriers to accessing care, and experience different types of discrimination, among other issues, according to “Serving Vulnerable and Underserved Populations,” a publication by the Department of Health and Human Services.4
The first step in improving gaps in care is to identify them, and labs are uniquely positioned to do this. “On a broad basis, the laboratory has more objective data than any other part of healthcare. Their numbers are standardized, and so, with some exceptions, if you test in Los Angeles, it’s no different than if you test in St. Louis or Seattle,” says Lee Hilborne, MD, MPH, DLM(ASCP)CM, professor of Pathology and Laboratory Medicine at the David Geffen School of Medicine at UCLA, Senior Medical Director in Medical Affairs for Quest Diagnostics, and past president of ASCP.
With those data come a responsibility to use them in service of closing gaps. Underserved populations are not a monolith, and each lab may be dealing with different subsets. Sarah Wheeler, PhD, associate professor, Department of Pathology at the University of Pittsburgh, and associate medical director, Clinical Immunopathology at University of Pittsburgh Medical Center, says, “Laboratory professionals need to understand the local population they’re affecting to be able to make changes.”
The laboratory is often the first indication that people need care, says Dr. Hilborne. “That’s often the diagnostic entry point. If you are going to close gaps in care, you have to know what those gaps are. We can use our data to see if somebody routinely gets care at our organization.”
Ways to use data include looking for such factors as poor control of diabetes and cholesterol, or missing pap smears or other examinations for cervical cancer, for example, he says. “Or you can look by zip code to identify gaps in specific geographic areas.”
“When you have the data, you have to analyze them and make sure the conclusions are valid. Then you need to inform policy to drive access and make sure those people who need it most have that access to care,” Dr. Hilborne notes.
Identifying the gaps alone won’t solve problems, however, he adds. “The most important thing is to link gaps as identified in some of these tools to actual interventions. So, to make sure if somebody has a test, or a health screening, that they get follow up and then plugged into either a federally qualified health center or other [organizations] that are available.”
Dr. Wheeler adds that it’s helpful to focus on a specific goal when analyzing data. “I don’t necessarily think it makes a lot of sense to just blanket survey who is getting what testing,” she explains. “But if you can recognize that a disparity has been identified, you can see where you are. You have to have a goal of what you’re trying to improve.”
When caring for some populations, such as transgender patients, a common problem is a simple lack of education on the part of providers that can act as a barrier to care, says Gabrielle Winston-McPherson, PhD, DABCC, associate director, Chemistry Division, Henry Ford Health, in Michigan.
“Without that basic education, [a clinician or laboratory professional] may end up having inappropriate patient-provider interactions, for example, a care provider may misgender a patient or use the wrong name. Experiences such as these may lead to transgender patients avoiding clinical settings and not getting the care that they need. We want to ensure we’re not creating more barriers to care for these populations,” she says.
Other populations may not receive appropriate care because they aren’t considered marginalized in a traditional way, says Chris Farnsworth, PhD, medical director of Clinical Chemistry, BJH Core Laboratory and Assistant Professor of Pathology and Immunology at Washington University School of Medicine. Dr. Farnsworth has researched and presented on IV drug users, who, he notes, are very clearly marginalized but not necessarily based on race or gender.
For example, he says, Fentanyl-related overdoses and deaths are on the rise because not enough labs are testing for this serious opioid, and stigmas persist around those who use drugs. “As a result, we don’t know what the prevalence is in our population, who is actually on fentanyl, and how much there is within particular communities.”
And, of course, undocumented people face incredible barriers, as fear of being deported compounds their likelihood of seeking medical treatment when they need it, Dr. Hilborne explains.
Getting care to these vulnerable groups is an important part of public health, Dr. Hilborne says. As the pandemic has revealed, we are intimately connected when it comes to our health, whether we admit it or not.
Another common problem is access. Just because testing exists, doesn’t mean underserved populations can or will be able to access it. Many underserved patient populations, particularly those of low socioeconomic status, get their healthcare through emergency departments (ED), which is often little more than a stop gap. “Those folks are getting their main care [in the ED] and it’s really kind of a spiral, because oftentimes there’s no appropriate intervention, follow-up, or connection to continuing care for chronic conditions,” Dr. Wheeler says. “So, it just spirals to larger disparities and marginalization.”
Dr. Farnsworth suggests, “Like anything, [the problem of health disparities] is multifaceted, and collaboration goes much further than one particular group trying to go it alone.”
Indeed, health disparities are a systemic problem, says Dr. Wheeler, “So every part of the system must contribute to a solution. I don’t believe that lab medicine can fix all the problems, but there are many areas where we play a key role.” She points to infectious disease serology screening, type 2 diabetes screening and other similar tests. “These tests are key to making sure that people are getting the diagnosis they need to get needed treatment.”
As an intervention, laboratories can spearhead efforts to bring testing, such as diabetes or cholesterol screenings, to the communities where underserved populations live. EDs can build in algorithms to automatically test for such things as diabetes and cholesterol, sexually transmitted infections, and drugs when patients come in, as well. Though, this kind of testing must be done in an equitable way. Research has proven bias in certain kinds of testing; for example, Dr. Farnsworth points out, one study found that Black mothers are more likely to be tested for THC than white mothers.
A recent effort to take out the race coefficient when reporting the estimated glomerular filtration rate (eGFR) for chronic kidney disease may in some cases alter kidney transplant eligibility. This change helps make screening less biased against Black patients. Labs that are adopting the new screening calculation are already striving to make such tests more equitable.5 Efforts of this kind can make a significant difference in marginalized patients’ care.
Dr. Wheeler would also like to see some incentive for developing higher quality point-of-care tests that are affordable so marginalized populations can receive rapid test results where they seek care and get the needed interventions. “Whether it’s coming up with better serologic infectious disease screening tests or changing the way we do molecular testing at point of care, we are not appropriately incentivizing that development.”
While labs may not be able to solve all the problems of health disparities alone, Dr. Wheeler says, “We have to focus on the things we can impact. The information that’s available in our clinical laboratory and the people that we partner with is a really great place to start. Any little contribution that we can make helps solve the larger problem.”