MedicalResearch.com Interview with:
Samuel Cykert, MD
Professor of Medicine and Director of the Program on Health and Clinical Informatics
UNC School of Medicine, and
Associate Director for Medical Education, NC AHEC Program
Chapel Hill, NC
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: Reports going as far back as the early 1990’s through reports published very recently show that Black patients with early stage, curable lung cancer are not treated with aggressive, curative treatments as often as White patients. These type of results have been shown in other cancers also. It’s particularly important for lung cancer because over 90% of these patients are dead within 4 years if left untreated. In 2010, our group published a study in the Journal of the American Medical Association that showed that Black patients who had poor perceptions of communication (with their provider), who did not understand their prognosis with vs. without treatment, and who did not have a regular source of care ( a primary care doctor) were much less likely to get curative surgery. Also our results suggested that physicians who treated lung cancer seemed less willing to take the risk of aggressive treatments in treating Black patients (who they did not identify with as well) who had other significant illnesses.
Because of the persisting disparities and our 2010 findings, we worked with a community group, the Greensboro Health Disparities Collaborative to consider potential solutions. As these omissions were not overt or intentional because of race on the part of the patients or doctors, we came up with the idea that we needed transparency to shine light on treatment that wasn’t progressing and better communication to ensure that patients were deciding on good information and not acting on mistrust or false beliefs. We also felt the need for accountability – the care teams needed to know how things were going with patients and they needed to know this according to race. To meet these specifications, we designed a system that received data from electronic health records about patients’ scheduled appointments and procedures. If a patient missed an appointment this umbrella system triggered a warning. When a warning was triggered, a nurse navigator trained specially on communication issues, re-engaged the patient to bring him/her back into care. In the system, we also programmed the timing of expected milestones in care, and if these treatment milestones were not reached in the designated time frame, a physician leader would re-engage the clinical team to consider the care options.
Using this system that combined transparency through technology, essentially our real time warning registry, and humans who were accountable for the triggered warnings, care improved for both Black and White patients and the treatment disparity for Black patients was dramatically reduced. In terms of the numbers, at baseline, before the intervention, 79% of White patients completed treatment compared to 69% of Black patients. For the group who received the intervention, the rate of completed treatment for White patients was 95% and for Black patients 96.5%.
MedicalResearch.com: What should readers take away from your report?
Response: Specifically, there are historical reasons in our society that make trust, communication, and the responsiveness of systems more difficult for Black patients and other patients of color. By using technology to measure these discrepancies, then applying well thought out solutions, we can measure again and adjust the solutions until disparities and contributing barriers are resolved. Notably, the transparency and systematic approach in our study intervention improved care for White patients too.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: We need to apply this intervention to whole cancer center populations instead of just those enrolled in a study and prove that it can be scaled up. Generally, I think this type of intervention can also be applied to other disparities such as high blood pressure treatment and diabetes care and provide the chance of effective solutions in these areas.
Any disclosures? No conflicts of interest.
Samuel Cykert, Eugenia Eng, Paul Walker, Matthew A. Manning, Linda B. Robertson, Rohan Arya, Nora S. Jones, Dwight E. Heron. A system-based intervention to reduce Black-White disparities in the treatment of early stage lung cancer: A pragmatic trial at five cancer centers. Cancer Medicine, 2019; DOI: 10.1002/cam4.2005
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