Unequal Systemic Access to Radiological Services

Systemic health inequity and socioeconomic disparities continue to be foundational issues the U.S. medical system must tackle. As future physicians, it is imperative to understand these effects and the limitations some populations may have in accessing radiological services. When I volunteered in an uninsured clinic, a patient came in with chronic pain in their left flank two years status-post percutaneous nephrolithotomy. Unfortunately, this uninsured patient could not afford imaging. Unable to elucidate an etiology, we were forced to proceed with conservative management until the patient could pay for radiological services.

Radiological disparities are a complex issue rooted in disparities at the level of the patient, the provider and the healthcare system. At the patient level, those with lower income, or racial and ethnic minorities do not have equal access to advanced radiological imaging, such as 3-T MRI and PET/MRI.^1–3 Furthermore, there have been studies analyzing how the rate of diagnostic imaging ordered in the ER is affected by patient race and ethnicity. Other studies have discussed different ways clinicians order imaging studies based on if they practice in low- versus high-income regions.^4–5 In addition to the decreased ability to receive advanced radiological services, patients are also affected by disparities in radiological screening. These screening disparities include reduced oncologic screening for prostate, breast and lung cancer. Patient adherence barriers, such as embarrassment, language barrier or lack of insurance, and other disparities, have been exacerbated by the COVID-19 pandemic.^{1, 6–9} Given pandemic-associated amplification of disparities, there have been bioethical-centered discussions on the reasonable implementation of equity-weighted rationing schemes as a measure to allocate radiological service access for the underserved population.¹⁰

Ultimately, a solution to unequal access for radiological services will rely on interventions in both upstream and downstream factors. Starting from the patient side, addressing missed appointments through transportation-based solutions and increasing cultural competency may help patients be more involved in obtaining radiological services.¹¹ Reducing healthcare costs by initiating efforts to eliminate inappropriate imaging  may help reduce disparities more than individual bias training according to Waite, et al.^{1, 12} Lastly, upstream factors may be addressed via governmental interventions in social services and increasing access to affordable healthcare through insurance company negotiations. Of note, the incorporation of race-neutral imaging evaluation algorithms to decrease subjectivity in care may be a potential solution in addressing disparities in radiological services.^{1, 13}

As future healthcare and radiological practitioners, it is imperative that we all recognize the unequal access to radiological services we face in society and its bioethical implications. Many of these issues will take numerous interventions and approaches from both upstream and downstream factors. However, recognition of one’s own biases and allocating efficient imaging resources can assist in reducing these disparities.

Resources

Radiology Health Equity Coalition

References

1. Waite, S., Scott, J., Colombo, D.. Narrowing the Gap: Imaging Disparities in Radiology. Radiology. 2021;299(1):27–35. doi:10.1148/radiol.2021203742
2. Tanenbaum, L.N. Clinical 3T MR imaging: mastering the challenges. Magn Reson Imaging Clin N Am 2006;14(1):1–15.
3. Mayerhoefer, M.E.,  Prosch , H.,  Beer,  L.,  et  al.  PET/MRI versus PET/CT in  oncology: a prospective single-center study of 330 examinations focusing on implications for patient management and cost considerations. Eur J Nucl Med Mol Imaging 2020;47(1):51–60.
4. Ross, A.B., Kalia, V., Chan, B.Y., Li, G. The influence of patient race on the use of diagnostic imaging in United States emergency departments: data from the National Hospital Ambulatory Medical Care survey. BMC Health Serv Res 2020;20(1):840.
5. Sirovich, B.E., Gottlieb, D.J., Welch, H.G., Fisher, E.S. Variation in the tendency of primary care physicians to intervene. Arch Intern Med 2005;165(19):2252–2256.
6. El Khoury, C.J., Ros, P.R. A Systematic Review for Health Disparities and Inequities in Multiparametric Magnetic Resonance Imaging for Prostate Cancer Diagnosis. Acad Radiol. 2021;28(7):953–962. doi:10.1016/j.acra.2021.03.012
7. Lee, C.I., Bogart, A., Germino, J.C., et al. Availability of Advanced Breast Imaging at Screening Facilities Serving Vulnerable Populations. J Med Screen. 2016;23(1):24–30. doi:10.1177/0969141315591616
8. Nguyen, D.L., Ambinder, E.B., Myers, K.S., Oluyemi, E. Addressing Disparities Related to Access of Multimodality Breast Imaging Services Before and During the COVID-19 Pandemic [published online ahead of print, 2022 Mar 25]. Acad Radiol. 2022;S1076–6332(22)00194-5. doi:10.1016/j.acra.2022.03.017
9. Wang, K.Y., Malayil Lincoln, C.M.,  Chen,  M.M.. Radiology Support, Communication, and  Alignment  Network  and  Its  Role  to  Promote  Health  Equity in the Delivery of Radiology Care. J Am Coll Radiol 2019;16(4 Pt B):638–643.
10. Brown, S.D., Hardy, S.M., Bruno, M.A. Rationing and Disparities in Health Care: Implications for Radiology Clinical Practice Guidelines. J Am Coll Radiol. 2022;19(1 Pt A):84–89. doi:10.1016/j.jacr.2021.09.023
11. Glover, M. 4th, Daye, D., Khalilzadeh, O., et al. Socioeconomic and Demographic Predictors of Missed Opportunities to Provide Advanced Imaging Services. J Am Coll Radiol 2017;14(11):1403–1411
12. Litkowski, P.E., Smetan,a G.W., Zeidel, M.L., Blanchard, M.S. Curbing the Urge to Image. Am J Med 2016;129(10):1131–1135.
13. Payne, N.R., Puumala, S.E. Racial disparities in ordering laboratory and radiology tests for pediatric patients in the emergency department. Pediatr Emerg Care 2013;29(5):598–606