Considerations for Achieving Health Equity in Gastroenterology Clinical Guidelines

doctor with older Black patient wearing mask
Doctor giving emotional support to a senior patient using face mask
Experts review the current use of race and ethnicity in gastroenterology guidelines and offer recommendations for incorporating health equity into future guidelines.

Due to increased awareness of race being a social construct with limited biological basis, the use of race and ethnicity in clinical decision making has been critically examined. Racial and ethnic differences observed in many large studies reflect the differences in exposure and availability of health care resources rather than the biological basis of race and ethnicity itself.

In gastroenterology, there is an unmet need to further examine, critique, and reconsider the use of race and ethnicity in clinical decision making. In a recent review, Siddique and May highlighted the extent to which race and ethnicity are used in current gastroenterology guideline recommendations and further proposed recommendations to incorporate health equity for guideline developers.1

Current race- and ethnicity-based recommendations in clinical guidelines

The researchers conducted a comprehensive search of United States-based clinical guidelines or recommendations from several professional societies, including the American Gastroenterological Association (AGA), American College of Gastroenterology (ACG), American Association for the Study of Liver Diseases (AASLD), and American Society for Gastrointestinal Endoscopy (ASGE), published between January 1, 2010, and December 1, 2021.

A total of 7 guidelines that included 8 race- and ethnicity-based recommendations were identified. 28

Early screening for hepatocellular carcinoma

Due to the increased incidence of hepatocellular carcinoma (HCC) in Black and Asian individuals, the 2018 AASLD guidance recommends early screening for patients with HCC and chronic hepatitis B virus (HBV) infection.2 For Asian or Black men over 40 years of age and Asian or Black women over 50 years of age, ultrasound screening was recommended every 6 months. However, the recommendation did not consider the chronic stage of the disease, including factors such as suspected/confirmed vertical transmission, active viremia, or the prevalence of HBV in the country of origin.

The authors stated that compared with race and ethnicity, variables such as chronicity of disease that define suspected vertical transmission, viremia, and presence of fibrosis, identify risk more accurately and appropriately.

Potential impacts on health disparities include the cost of ultrasound and blood testing.

Helicobacter pylori

A 2015 ASGE guideline recommends screening and treating Helicobacter pylori (H pylori) based on race and ethnic factors in all non-White racial and ethnic groups.3 The guideline specifically emphasizes consideration of race and ethnicity to help reduce health inequities associated with health care access, while acknowledging differences within racial and ethnic groups.

Studies have reported an association between the seroprevalence of H pylori and socioeconomic variables, such as education, employment, and property values; however, it may not apply to individuals of African ancestry, and several other factors may influence the differences in prevalence. Hence, the authors mention that factors such as country of origin and living environment may more appropriately identify patients who might benefit from H pylori screening. The prohibitive cost of H pylori testing may contribute to health disparities.

Gastric intestinal metaplasia

Currently, 3 guidelines use race and/or ethnicity in their recommendations for gastric intestinal metaplasia (GIM)­.35 Two ASGE 2015 guidelines recommend surveillance for individuals from racial and ethnic backgrounds at increased risk for gastric cancer. The 2019 AGA guideline conditionally recommends against routine use of endoscopic surveillance for all individuals, with few exceptions where it may be reasonable to screen some populations based on specific rationale, including racial or ethnic background.5 All 3 guidelines did not specify a particular race and used nonspecific definitions of non-White racial and/or ethnic groups. The authors consider this to be problematic, as it encourages clinicians to treat all non-White individuals in the same manner without a clear assessment of environmental factors, such as country of origin or recent immigration status, which might predict risk.

The high cost of routine endoscopy with biopsy may lead to potential health disparities.

Barrett Esophagus

Three current guidelines — AGA, 2011; ASGE, 2015; and ACG, 2016 — specifically identify White individuals to be at a higher risk of developing Barrett esophagus based on higher prevalence of esophageal adenocarcinoma among the White population compared with other racial and ethnic groups.68 Screening using upper endoscopy is recommended in all 3 guidelines. Compared with other racial and ethnic groups, White individuals have greater access to screening and early detection for Barrett esophagus.

Moreover, the authors mention that the association between White race and Barrett esophagus is still unclear. Some studies postulate a genetic basis for comparing American individuals of European and African descent.

The newer 2019 ASGE guideline on Barrett esophagus does not specify White individuals in their recommendation.9 However, the authors highlight the need to provide clarification on whether the removal of race was purposeful or not, along with a discussion about the potential impact on health equity, which would aid in transparency during this shift in guideline recommendations.

The authors also suggest shifting away from race- and ethnicity-based recommendations in certain circumstances. For example, to address inequities, previous AGA guidance suggested screening Black individuals for colorectal cancer at an earlier age than White individuals due to higher incidence and mortality among Black individuals.10 However, there was no substantial evidence to support early screening to reduce disparities. Thus, current guidelines recommend initiating screening at age 45 for all average-risk patients across all racial and ethnic groups.11 The 2021 AGA colorectal cancer screening guideline also emphasizes the need for evidence-based efforts to reduce disparities among Black individuals.11

Similarly, the AASLD and the Infectious Diseases Society of America on hepatitis C virus (HCV) treatment previously recommended a longer course of antiviral therapy for Black individuals, which was later updated in 2019 to include all individuals with HCV to receive a longer course of treatment, irrespective of race or ethnicity.12-13

The authors noted, “These changes are examples of race-conscious medicine, which acknowledges that race is a social risk factor rather than a biological risk factor and promotes mindful use of race and ethnicity in health care.”1

Considerations for the guideline development process

The authors proposed the following suggestions while acknowledging race and ethnicity, as well as the implications of recommendations on existing health inequities:

  • Consideration of the racial and ethnic diversity of relevant existing research and examining any existing inequities.
  • The use of precise variables instead of race and ethnicity in clinical recommendations, if feasible.
  • Transparency on why race or ethnicity is (or is not) considered in a guideline, and the implications for care and health equity in including racial or ethnic factors in contemporary guidelines and/or removing from a previous recommendation.
  • Call for future research to consider the role of social determinants of health on disease incidence, outcomes, and response to treatment.

The authors concluded, “[I]t is prudent for gastroenterology societies to re-examine existing guidelines and current guideline development processes to avoid race- and ethnicity-based recommendations when possible, use more precise variables in place of race and ethnicity, and rationalize transparently the use of race and ethnicity and its potential impact on health equity.”

References

1.     Siddique SM, May FP. Race-based clinical recommendations in gastroenterology. Gastroenterol. 2022;162(2):408-414.e2. doi:10.1053/j.gastro.2021.12.234

2.     Terrault NA, Lok ASF, McMahon BJ, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatol. 2018;67(4):1560-1599. doi:10.1002/hep.29800

3.     Wang A, Shaukat A, et al. Race and ethnicity considerations in GI endoscopy. Gastrointest Endosc. 2015;82(4):593-599. doi:10.1016/j.gie.2015.06.002

4.     ASGE Standards of Practice Committee; Evans JA, Chandrasekhara V, et al. The role of endoscopy in the management of premalignant and malignant conditions of the stomach. Gastrointest Endosc. 2015;82(1):1-8. doi:10.1016/j.gie.2015.03.1967

5.     Gupta S, Li D, El Serag HB, et al. AGA clinical practice guidelines on management of gastric intestinal metaplasia. Gastroenterol. 2020;158(3):693-702. doi:10.1053/j.gastro.2019.12.003

6.     American Gastroenterological Association; Spechler SJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ. American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterol. 2011;140(3):1084-1091. doi:10.1053/j.gastro.2011.01.030

7.     ASGE Standards of Practice Committee; Muthusamy VR, Lightdale JR, et al. The role of endoscopy in the management of GERD. Gastrointest Endosc. 2015;81(6):1305-1310. doi:10.1016/j.gie.2015.02.021

8.     Shaheen NJ, Falk GW, Iyer PG, Gerson LB; American College of Gastroenterology. ACG clinical guideline: diagnosis and management of Barrett’s esophagus [published correction appears in Am J Gastroenterol. 2016;111(7):1077]. Am J Gastroenterol. 2016;111(1):30-51. doi:10.1038/ajg.2015.322

9.     ASGE Standards of Practice Committee; Qumseya B, Sultan S, et al. ASGE guideline on screening and surveillance of Barrett’s esophagus. Gastrointest Endosc. 2019;90(3):335-359.e2. doi:10.1016/j.gie.2019.05.012

10.  Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol. 2009;104(3):739-750. doi:10.1038/ajg.2009.104

11.  Shaukat A, Kahi CJ, Burke CA, Rabeneck L, Sauer BG, Rex DK. ACG clinical guidelines: colorectal cancer screening 2021. Am J Gastroenterol. 2021;116(3):458-479. doi:10.14309/ajg.0000000000001122

12.  AASLD-IDSA HCV Guidance Panel. Hepatitis C guidance 2018 update: AASLD-IDSA recommendations for testing, managing, and treating hepatitis C virus infection. Clin Infect Dis. 2018;67(10):1477-1492. doi:10.1093/cid/ciy585

13.  Ghany MG, Morgan TR; AASLD-IDSA Hepatitis C Guidance Panel. Hepatitis C guidance 2019 update: American Association for the Study of Liver Diseases-Infectious Diseases Society of America recommendations for testing, managing, and treating hepatitis C virus infection. Hepatol. 2020;71(2):686-721. doi:10.1002/hep.31060