All is not equal where US IR procedure access is concerned

Nima Kokabi (Emory Healthcare, Atlanta, USA) addressed the “uncomfortable truth” of healthcare disparities in the USA specifically within interventional radiology (IR) in a presentation at the Society of Interventional Radiology 2023 annual scientific meeting (4–9 March, Phoenix, USA). He referenced a Journal of Interventional Radiology (JVIR) publication from 2022 to share with delegates the extent of the disparities at play within IR, before putting forward suggestions as to why IR care is as unequally received as it is in the USA, and what interventional radiologists can and should be doing to redress the imbalance.

‘UNEQUAL TREATMENT’ IS A

2003 US Institute of Medicine report on implicit bias and racial disparities in medicine in the USA, that Kokabi began by highlighting. The presenter lamented the fact that the reality of implicit bias and healthcare disparities has not changed as much as one might have hoped in the 20 years since the report was published. In Kokabi’s view, it contains “uncomfortable truths” that he believes all healthcare providers should have awareness of. A key point from the report, he went on, is that “although Black people are disproportionately [affected] by poverty […] that alone cannot explain why they are sicker and have shorter lives compared to their white counterparts”. What is more, “even if they have the same income, age, and severity of condition”, this is still the case. “The lower quality of healthcare is down to us as physicians,” Kokabi opined.

Beyond healthcare more widely, Kokabi then drew audience attention to a recent JVIR article that dissects the disparities that exist within IR in the USA. The article examines the unequal treatment that members of minority groups receive across different disease areas, but Kokabi chose to home in on those most relevant to his practice—these included uterine interventions and hepatocellular carcinoma (HCC). “If you are Black,

“As a society we have tried to introduce IR everywhere in Brazil,” Andrade asserted. “We have almost everything—yttrium [Y]90, reversible electroporation, hybrid suites—much like the USA”. Yet, awareness of IR is not as good as it could be, he admitted. With this in mind, SOBRICE has launched several campaigns to improve understanding of IR procedures. These include holding social media livestreams during which patients can ask interventional radiologists questions and an annual course for medical students. Andrade homed in on the importance of helping students understand that IR is more than “stopping bleeding or treating a tumour”. The speaker proceeded to clarify that “in Brazil, we do have industry—we produce wires, catheters, sheaths, coils, filters, stents, and prostheses.” There is also a SOBRICE-published, Portuguese-language collection of IR textbooks available to interventional radiologists and trainees, Andrade added, before leaving the audience with the fact that “finally, in the big centres, we are established as a clinical service, but beyond the big centres, we are not known yet and that is the biggest challenge”. you are two to three times more likely to undergo hysterectomy for fibroids [over embolization],” Kokabi relayed, adding that those in the Hispanic and rural-dwelling communities also experience a “significantly higher rate” of hysterectomy. This is further exacerbated if you are Black and live rurally, Kokabi shared. When it comes to postpartum haemorrhage, the same phenomenon occurs, according to the article—the aforementioned communities have a higher likelihood of hysterectomy as opposed to embolization, with “Asians suffering from the same trend,” Kokabi said. In terms of HCC treatment, the presenter then conveyed, “if you are Black or Hispanic, even adjusting for tumour stage, you are less likely to receive any treatment”. In addition, Black, Native American, and Hispanic patients are less likely to undergo certain IR procedures, such as transarterial chemoembolization (TACE) and thermal ablation. Black patients with HCC also have a lower survival rate, which, Kokabi explained, is due to “more fragmented care, lower screening rates, and less access to treatment”.

The disparities extend beyond race, the JVIR article details, to patients of a less favourable socioeconomic background. Those with non-private medical insurance are “less likely to receive IR treatments”.

Regarding finding solutions to the disparities present in IR care, the article recommends “identifying and understanding the underlying causes” first. “If you are a realist or pessimist like myself, you know that finding solutions is very difficult […] it is hard to intervene and be successful,” Kokabi lamented. “One thing that we could all do better with is implicit bias and we are lying to ourselves if we say we are not affected by it.” The presenter urged delegates to seek out implicit bias training, which, in his experience is “very eye-opening—you realise things that you may not have thought you do subconsciously”.

Equally, Kokabi advocated for “[trying] to learn about those who you have biases towards” and then “[engaging] in dialogue with them”. He sees it as “the least we can do [to] reduce the gap [in IR service access],” the reasons for which he sees as being multifactorial. Kokabi suggested that “a lack of uniform access” to IR services in the USA is at play, as well as a lack of understanding from healthcare leaders and insurance companies of the value of IR, which creates inequalities in access. “We are not working hard enough,” were Kokabi’s concluding words, encouraging interventional radiologists to “do a better job” of promoting what IR can offer patients of all demographics.