A Call to Action

On October 27, 2021, the Massachusetts Radiological Society held a fall symposium on health equity in radiology. During the symposium, MRS members shared best practices on how to address equity in radiology practices across the Commonwealth. Below you will find several helpful resources. We hope that these resources will provide all practices with better ways to embrace health equity more fully and most importantly to permit improved access to quality care for patients.

General Themes

1. Health equity is a critical issue that must be addressed and radiologists are well-positioned to lead in these efforts.
2. In order to do meaningful work in health equity, it is important to understand how the interactions of healthcare, race and other factors contribute to health inequity. State, local, and non-governmental organizations are at different stages of understanding and action.
3. Radiologists who are committed to advancing health equity should start with gathering data pertinent to their daily work. This data will provide the lens by which each of us can better understand where we can make a difference in our practices.

Resources:

1. Brady A, Brink J, Slavotinek J. Radiology and value-based care. JAMA. 2020;324:1286-1287. PDF link: jama_brady_2020_vp_200167_1601660317.98622.pdf
2. Waite S, Scott J, Colombo D. Narrowing the gap: imaging disparities in radiology. Radiology. 2021;299: 27-35. PDF link: https://pubs.rsna.org/doi/pdf/10.1148/radiol.2021203742
3. JACR 2019 Health Equity collection at: https://www.jacr.org/issue/S1546-1440(18)X0018-0?_ga=2.237718784.1441041798.1635971028-238130958.1633470047 American College of Radiology resources at: https://www.acr.org/Practice-Management-Quality-Informatics/Health-Equity

Improving access to Cancer Screening

1. It is well known that certain populations are at higher risk for advanced stage at diagnosis and increased mortality from many of the more common malignancies (e.g. lung, colorectal, breast, hepatocellular).
2. Radiology practices can adopt proactive approaches to educating patients, identifying at-risk patients, and assisting with ensuring that patients have access to indicated screening.
3. Establish a comprehensive cancer screening program for lung cancer, breast cancer, colorectal cancer and hepatocellular cancer.
4. Integrate risk assessment at time of patient check-in for any scheduled diagnostic imaging exam. This can be accomplished either using an online established risk assessment tool or simply a paper questionnaire addressing smoking history and other risk factors. (see attached example used in a lung cancer screening program at Boston Medical Center). In either format, the questions should be provided to patients in multiple languages.
5. If a patient is found to be eligible for screening, the patient’s primary provider can be messaged via the online medical record to inform them about the patient’s eligibility for specific types of cancer screening. Consider directly notifying patient of their eligibility and encourage the patient to discuss the options further with their provider. Alternatively, practices could have patient schedule or employ a nurse navigator to assist patient with scheduling of the appropriate exam(s) – e.g. CT lung screening for lung cancer, abdominal US for hepatocellular cancer, CT colonography or colonoscopy for colorectal cancer, or mammography and breast MRI for breast cancer.
6. Other General Suggestions:
   1. Develop and make available all educational materials at the sixth-grade level and in multiple languages. This information could be distributed in waiting rooms, handed directly to patients during appointments, and be accessible on the practice’s website. Consider airing pre-recorded videos in waiting rooms.
   2. Hire patient and nurse navigators to facilitate patient scheduling and address patient barriers to access, such as transportation, health literacy, food/housing insecurity, or childcare needs.
      Increase availability of interpreters and number of different languages that are supported in your practice.
   3. Consider redesigning imaging workflow to meet patient needs. For example, hold clinics that are for patients with specific interpretation needs, offer extended weekday or even weekend hours, or provide free childcare during specific hours of the day to accommodate patients with small children.
   4. Offer same-day interpretations, and if indicated, same-day image-guided biopsy.
   5. Outreach to and partner with the community through presentations, designated screening days, etc…

Resource:

Wang GX, Narayan AK, Park ER et al., Screening mammography visits as opportunities to engage smokers with tobacco cessation services and lung cancer screening. J Am Coll Radiol. 2020;17:606-612.

Improving Community and Belonging

1. Collect data on what are contributing factors to existing inequities so as to better inform effective interventions to mitigate disparities.
2. Have all staff undergo training in unconscious bias and cultural competency.
   Build relationships among team members and across practice sites (e.g. main campus and community).

Improving Diversity in the Radiology Workforce

1. Be intentional about recruiting diverse people to the radiology team. Using standardized interview questions can help mitigate bias.
2. Amplify voices of those who are not always heard or seen by speaking up and drawing attention to innovative ideas from less visible team members.
3. Train all staff on existing disparities and general concepts relevant to diversity, equity and inclusion.

Resources:

1. APDR Healthcare Disparities Curriculum, found at: https://www.apdr.org/en/program-directors/APDR-healthcare-disparities
2. APDR Diversity, equity and inclusion curriculum, found at: https://www.apdr.org/program-directors/DEI-Curriculum
3. ACR Diversity resources, found at: https://www.acr.org/Member-Resources/Diversity-at-ACR

Effective Use of Advocacy

1. Effective advocacy requires understanding the issue, strong communication, active engagement of stakeholders, and ongoing investigation to inform subsequent actions.
2. Advocacy should occur locally, state-wide and nationally on issues important to patient care. For example, patients should be able to get care at their local hospitals rather than being referred to facilities hours from their home as they don’t have the “right” insurance.
3. Effective advocacy requires working collaboratively with grassroots activists (e.g. Boston Breast Cancer Equity Coalition), hospitals (e.g. Massachusetts Hospital Association), and other healthcare providers (e.g. Massachusetts Medical Society and other specialty societies, Massachusetts Interspecialty Society).
4. Effective advocacy requires engaging all members of the Massachusetts Radiological Society by encouraging them to write to legislators on topics of critical importance to radiology practice and our patients.

The English version of the patient smoking questionnaire that is presently being used in the Department of Radiology at Boston Medical Center is provided below.  For radiologists that would like to learn more about how to integrate this approach into your practice (or to obtain versions in other languages), please reach out to Dr. Christina LeBedis at christina.lebedis@bmc.org.