A growing body of research is revealing a wide array of healthcare disparities affecting patients of various racial and ethnic backgrounds and those of lower socioeconomic status (SES) in the United States. In gastroenterology, for example, recent studies have shown Black patients are less likely to undergo eradication testing following treatment for Helicobacter pylori infection compared with White patients (odds ratio [OR], 0.62; 95% CI, 0.48-0.79), and non-White patients with gastric cancer are less likely to receive preoperative chemotherapy.1,2

Additionally, emerging findings have highlighted specific disparities among pediatric gastroenterology patients. In a retrospective study published in April 2021 in Health Equity, May et al conducted a review of 2556 charts to investigate the risk factors and role of SES on emergent vs nonemergent gastrointestinal (GI) procedures among different pediatric age groups.3

Results showed that the likelihood of seeking emergent care was lower among patients in the 6 to 11 year-old (OR, 0.47; 95% CI, 0.33-0.66) and 12 to 17 year-old (OR, 0.61; 95% CI, 0.45-0.84) age groups compared with the 0 to 5 year-old age group.3


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Odds of seeking emergent care were higher among patients with Medicaid (OR, 1.68; 95% CI, 1.27-2.26) and those who identified as African American (OR, 2.07; 95% CI, 1.48-2.90) or “other” race (OR, 2.43; 95% CI, 1.77-3.36), as well as among those who spoke a language other than English (OR, 2.1; 95% CI, 1.14-3.99).3

Analysis of geocoded health data linked to each patient’s SES demonstrated that each increase of 1 in SES was associated with a 2.9% reduction in the risk for emergent procedures (OR, 0.97; P =.045).3

Earlier research by the same group found a greater likelihood of emergent GI procedures in patients over the age of 18 years (OR, 2.16; P =.003), as well as Black patients (OR, 1.94; P <.0001) and those of other races (OR, 1.72; P =.039]; the odds of these procedures were lower among female patients (OR, 0.62; P =.001) and those with commercial insurance (OR, 0.49; P <.0001).4

“Disparities exist throughout healthcare, and pediatric [GI] endoscopy is no exception,” Harpreet Pall, MD, MBA, CPE, chair and professor in the department of pediatrics at Hackensack Meridian School of Medicine and K. Hovnanian Children’s Hospital in Neptune, New Jersey, told us in an interview. “This study highlights that SES and economic deprivation are key factors driving emergency department and specialty care utilization.” 

These findings suggest a potential lack of access to timely elective outpatient care that could obviate the need for emergent inpatient care. “Improving access to outpatient elective care in disadvantaged and vulnerable groups will be helpful in decreasing emergency care,” Dr Pall stated. “Additional work is needed to address the underlying causes of poverty and best navigate the social determinants of health in underserved populations.”

For further discussion regarding these disparities, we interviewed Robert Kramer, MD, co-medical director of the Digestive Health Institute at Children’s Hospital Colorado and professor of pediatrics at the University of Colorado School of Medicine Anschutz Medical Campus in Aurora.

What are your thoughts on why some of these reported disparities may exist?  

Dr Kramer: I think that there are obviously a multitude of variables that impact how and when different populations end up getting endoscopic intervention for common GI conditions. This work is important in highlighting how SES and native language influence the role of emergent endoscopy in the care of children.

I think the broader question is whether these same factors influence the decision to do endoscopy at all in these patients and, if so, under what circumstances. I can conceive of these factors making endoscopic evaluation in general both more and less likely to occur in non-native English speakers, Medicaid patients/low SES patients.

Language can be the most obvious factor, and in evaluating children with chronic abdominal pain, for example, these barriers can make it more challenging for providers to ferret out important details regarding the character of the child’s pain. This, in turn, may make providers more likely to “just scope them” for fear of missing a chronic inflammatory process, rather than pursuing lengthy trials of treatment for more common functional GI disorders before considering endoscopy.

Conversely, barriers that these same patients face in terms of scheduling follow-up appointments and getting to and from visits might also result in these patients being less likely to be referred for endoscopy. One would hope this is not the case, but the low reimbursement provided for performing endoscopy in Medicaid patients might disincentivize some providers and medical systems from performing endoscopy.

The various and likely conflicting influences on how care is given to these different patient populations needs serious study, and the manuscript in question is an important step in examining these disparities in children.   

What are the implications of these disparities on patient outcomes? 

Dr Kramer: We know that doing procedures emergently is more costly and leads to worse outcomes than doing them electively. It may also limit the utility of the procedure, not allowing for adjunctive diagnostic testing (such as additional biopsies) or therapeutic interventions (such as esophageal dilation) that could have been performed in an elective setting.

This is analogous to trying to provide primary care in an emergency room setting. It provides a band aid without addressing the underlying disease or promoting wellness.  

What is needed to reduce these disparities? 

Dr Kramer: First and foremost, we must do better in breaking down the language barriers for our non-English speaking patients at every phase of care — not just in the clinic setting but also for scheduling appointments, setting up procedures, and providing prep instructions. From the SES/Medicaid standpoint we must try to disengage from the 2-tier model that our current health system provides between commercially insured patients and Medicare/Medicaid patients. This effort needs to be driven by a shift toward a population health model that incentivizes outcomes over numbers of procedures performed.  

What are some remaining research needs in this area? 

Dr Kramer: The foundation of this seismic shift in medical care needed to address disparities are robust quality improvement programs that focus on tracking “equitability” of the care provided as a primary metric. Rates of all types of endoscopy — [esophagogastroduodenoscopy], colonoscopy, [endoscopic retrograde cholangiopancreatography] — need to be tracked and examined by all of these factors (language, payor, ethnicity, age) and then provided to the public as transparently as possible.

Additionally, we cannot just focus on the numbers of procedures performed but ultimately on the impact that these care decisions have on the outcome of the patient.  

References

  1. Reichstein J, Parish A, Garbarino S, et al. Variations and racial disparities in Helicobacter pylori guideline adherence for eradication testing. Am J Gastroenterol. 2020;115:S670-S671. doi:10.14309/01.ajg.0000707376.86601.3a
  2. Ikoma N, Cormier JN, Feig B, et al. Racial disparities in preoperative chemotherapy use in gastric cancer patients in the United States: analysis of the National Cancer Data Base, 2006-2014. Cancer. 2018;124(5):998-1007. doi:10.1002/cncr.31155
  3. May E, Brown KO, Gracely E, Podkameni G, Franklin L, Pall H. The role of health disparities and socioeconomic status in emergent gastrointestinal procedures. Health Equity. 2021;5(1):270-276. doi:10.1089/heq.2020.0141
  4. Andrews A, Franklin L, Rush N, Witts R, Blanco D, Pall H. Age, sex, health insurance, and race associated with increased rate of emergent pediatric gastrointestinal procedures. J Pediatr Gastroenterol Nutr. 2017;64(6):907-910. doi:10.1097/MPG.0000000000001377