In the simplest terms, health equity means that everyone has a fair opportunity to be as healthy as possible.1 Equity in health determinants and access to healthcare and resources must exist across socioeconomic, demographic, and geographic differences in a population. Unfortunately, we know that heath disparities exist globally, including within the U.S. Access to appropriate imaging is critical to ensuring health equity. Screening programs are foundational to population health, providing early detection of aggressive cancers at treatable stages. Without accurate and specific diagnoses from imaging, patients will not have the opportunity for appropriate treatment.
A landmark study published in the March issue of Lancet Oncology found that 2.46 million cancer deaths could be avoided worldwide over a decade by expanding imaging availability. The Lancet Oncology Commission developed a microsimulation model of 11 cancers worldwide and evaluated the impact of scaling up access to imaging in 200 countries to match the mean of high-income countries. The study found drastic disparities in access to imaging, with radiologists per 1 million population averaging 97.9 in high-income countries, compared to 1.9 in low-income countries — or more than 50 times as many radiologists per capita. The access to imaging technology is striking as well, with numerous African nations having no MRI scanners in the entire country.2 Of course, from a public health and policy perspective, the next logical question when considering a global initiative on this scale is the cost of increasing imaging access relative to economic benefits. Globally, the return on investment for each dollar invested in expanding imaging was as high as $179. Interestingly, the ROI for imaging alone was far greater than the ROI for corresponding improvements to treatment and quality of care. ACR President Geraldine B. McGinty, MD, MBA, FACR, was a member of the Lancet Oncology Commission and an author of the study. When asked about her hope for the impact of the commission’s work, she said, “The report should be a call to action. The sizeable impact of imaging access on health and economic outcomes clearly supports the need for greater investment in imaging to improve population health on a global scale.”
The U.S. was, not surprisingly, among the tier of countries with the highest access across all assessed imaging equipment and the radiology workforce. Yet, incredibly, we still have a long way to go to ensure equity in access to diagnostic imaging.2 A recent Harvey L. Neiman Health Policy Institute® (HPI) study evaluated disparities in use of advanced imaging in the ED setting among Medicare beneficiaries and found striking differences among socioeconomic and geographic factors. Tarek N. Hanna, MD, in collaboration with Richard Duszak Jr., MD, FACR, director of the HPI Imaging Policy Analytics for Clinical Transformation (IMPACT) Center at Emory, and Danny R. Hughes, PhD, director of the HPI HEAL Center at Georgia Tech, evaluated nearly 87,000 ED encounters, including rural and critical access hospitals. Strikingly, Black patients were 31.6% less likely to undergo advanced imaging than White patients. Compared to urban hospitals, ED patients at rural hospitals were 6.9% less likely to have advanced imaging. Meanwhile, patients at critical access hospitals were 18% less likely to have advanced imaging than urban hospitals. There was also an interaction between race and urbanicity — Black patients in rural areas were 19.2% less likely to have advanced imaging than patients in urban areas, whereas White rural patients were only 6% less likely to have advanced imaging.3
ACR’s champions in rural health, Robert S. Pyatt Jr., MD, FACR, and Eric B. Friedberg, MD, FACR, deserve mention as contributing authors to this study. The results of this HPI study shine a magnifying glass on the remaining healthcare access issues in the U.S., where dramatic disparities in healthcare access and health outcomes exist depending on one’s zip code. All patients in the study had healthcare coverage through Medicare, yet they did not receive the same level of care. The rural-urban divide was clear and worse for Black patients, which could stem from the socioeconomic levels of the specific rural communities and access to imaging at their nearest hospital.
Racial disparities such as those shown in the HPI study can result in outcome disparities. In fact, cancer mortality rates for Black patients are as much as 42% higher than White patients. This outcome disparity has been attributed in part to coverage policies by the U.S Preventive Services Task Force (USPSTF) and CMS.4 Accordingly, a prior HPI study found that mammography screening rates that had previously been growing decreased significantly after the 2009 USPSTF guideline change.5 On a brighter note, an HPI study published this year by the IMPACT Center found that USPSTF recommendations supporting use of CT colonography (CTC) for colorectal cancer screening resulted in an immediate 50% increase in CTC rates in the U.S.6 More research is needed to determine whether the increase in CTC for cancer screening is also helping reduce disparities for underserved groups.
Clearly, we have a long way to go to ensure equitable healthcare and the opportunity for each person to achieve their full health potential, domestically and globally. Radiology is in a critical position to help narrow disparities by advocating for equal access to imaging and increased coverage by payers. The specialty must continue to contribute to innovative solutions to expand access for rural and underserved communities. To achieve this goal, the radiology community needs to continue to initiate and collaborate on population health and health equity research to drive evidence-based changes in policy and practice.