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A Prescription for Reducing Bias in Medical Care

Illustration of people of color standing in the shadows of a wall of medical items

Illustration by Rose Wong

Illustration by Rose Wong

  • Shanoor Seervai
    Shanoor Seervai

    Researcher, Writer, and Lead Podcast Producer, The Commonwealth Fund

  • Shanoor Seervai
    Shanoor Seervai

    Researcher, Writer, and Lead Podcast Producer, The Commonwealth Fund

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  • Because of racial biases in health care, people of color are less likely to receive prescriptions for the most effective medical treatments. Listen to this episode of #TheDosePodcast to learn one approach to achieving equity.

  • To reduce disparities in medical prescriptions, @UREssien coined the term pharmacoequity — the goal of creating a health system where all people, regardless of race, socioeconomic status, or disability, have access to the highest-quality treatment.

Racial bias in medical care extends all the way to the prescription pad. Research shows that people of color are less likely to receive the most effective treatments for life-threatening conditions, including cancer and heart disease.

One way to address this is by aiming for “pharmacoequity” — where all patients, regardless of race, socioeconomic status, disability, or other characteristics, have access to the highest-quality evidence-based medical therapies that meet their health needs.

On the latest episode of The Dose podcast, the man who coined this term, Utibe Essien, M.D., an assistant professor of medicine at the University of Pittsburgh, explains what it will take to achieve pharmacoequity.

“The data are not lying about how we're prescribing medications,” Essien says. To eliminate such biases, he believes we must be honest about the data and develop strategies to ensure greater equity.

Transcript

SHANOOR SEERVAI: Systemic biases in health care are well documented, even down to the prescription pad. That’s right, the kind of medicine a patient gets tracks with demographic traits like race, class, and gender. I’m Shanoor Seervai, and on this episode of The Dose, we’re going to talk to Dr. Utibe Essien, who has coined the term “pharmacoequity” to address this problem. Dr. Essien is a physician and an assistant professor of medicine and health disparities researcher at the University of Pittsburgh. We’re going to talk about what it will take to uproot biases in prescribing and get to a point when all people have access to the same medical therapies.

Dr. Essien, thank you so much for joining me today.

UTIBE ESSIEN: Thanks so much for having me. It’s a real pleasure.

SHANOOR SEERVAI: Let’s start with a definition. What is pharmacoequity and why is it needed now?

UTIBE ESSIEN: Absolutely. So, we coined this term to be the goal of ensuring that every patient, regardless of their race, ethnicity, socioeconomic status, disability, whatever some of these traditionally vulnerable social determinants are, have access to the highest quality of medications they need to take care of their health needs. And this is so critical right now, not just because we are in the middle of a pandemic where millions of individuals have lost their lives, and we have exciting new therapies available to treat it. But because as we start to transition towards this “normal,” we have the same health disparities that we’ve had within our health care system that are going to start to play out. And those have really ensured that, unfortunately, these vulnerable groups that I referred to earlier have had poor access to the necessary treatments they need to take care of their health.

SHANOOR SEERVAI: And I feel like there’s been a conversation about health equity for at least a few years now. But why is pharmacoequity or this medical therapies piece not a bigger part of that?

UTIBE ESSIEN: Yeah, I think a lot of the conversation . . . I started med school a little over a decade ago, and we learned about disparities in health. We learned that Black patients were more likely to have kidney disease, cancer, hypertension, diabetes, pretty much you name it. We saw that people who looked like me and my family members were more likely to have these conditions. And a lot of that conversation talked about different genes that we had, or, for some reason, there was something different about our bodies compared to other individuals.

And then, the conversation shifted a little bit to the social determinants of health. And so, it’s because of the neighborhoods that certain communities have been redlined into, or because of differential access to resources, wealth, and goods. And I think when some ways we forgot about the conversation of what actually happens in the doctor’s office. And so, whether one of us shows up to the doctor with a new diagnosis of high blood pressure, a new diagnosis of diabetes. Are we likely, or as likely to get the right prescription when we walk out of that office as someone else who came in who does not look like us, who has more wealth, who has more education? And, unfortunately, I think we have left a little bit of that focus to focus on, really importantly, the social determinants of health. And I’m hopeful that pharmacoequity can bring us back to that conversation.

SHANOOR SEERVAI: And building on pharmacoequity, you’ve also been working on doing a full equity impact analysis. So can you explain what you’re building and the gaps that it aims to close in the delivery of medicine?

UTIBE ESSIEN: So I believe that this equity impact analysis is just one of the levers that we can pull to actually achieve pharmacoequity. And so, again, with this explicit goal of ensuring every patient has access to the care that they need, one of the first steps that we can take is really collecting the data. Understanding how am I, when I’m in clinic next week, prescribing these novel therapies, whether it’s for cardiovascular diseases like atrial fibrillation that I study, or it’s for rheumatologic diseases — how am I prescribing those medications at the same rate for white patients, Black patients, non-English primary-language-speaking patients, et cetera?

And I think once we have those data, we then report it back to our clinicians, report it back to pharmacy leaders, and health system leaders, and really start to prioritize equity as a quality metric within our health care systems. And I think that equity impact analysis will help us not just ensuring that we’re equitably prescribing meds to our patients, but also takes a step back to when we’re discovering new medications that when we’re thinking about cost effectiveness, when we’re thinking about efficacy, we’re also thinking about how these drugs can be equitably applied across communities.

SHANOOR SEERVAI: And do you see other physicians also using this sort of analysis?

UTIBE ESSIEN: So it’s really novel, I think, in a way that we are just now starting to have these conversations. Along with my University of Pittsburgh position, I also work in the VA. And one of my colleagues does have a health equity dashboard that she’s creating what looks at hypertension treatment across VA hospitals in our region to see how they’re being done compared by race and ethnicity. And so, I think slowly, we’re starting to see these kinds of analyses get displayed around the country. And our hope is, again, that just as we’ve had quality as a goal within our health care systems, we’re also going to have equity right at the same side with them.

SHANOOR SEERVAI: Now, there’s another piece of this, which is patients need to understand what’s going on with their health, what a doctor may be prescribing, but sometimes even the language that physicians use creates a barrier. So, how does patient education around medication happen ideally?

UTIBE ESSIEN: Yeah, it’s such an important area because I agree that, like I said, I wanted to be the social justice warrior as a new medical student, and a new resident. And I thought I was going to prescribe my way out of the inequities in our health system. But I, in a way, forgot about what our patients were experiencing. And that just because I learned this new language and spent four years training to do so, of course doesn’t mean that our patients have that same health literacy level, that same education level, to be able to understand what is a direct oral anticoagulate medication to help prevent stroke if I have atrial fibrillation. “What do any of those words mean, doc? What’s my risk of stroke?” And kind of the list goes on.

And so, in the ideal world, I think we would have these partnerships between our patients and our pharmacy experts who really are, I think, the experts who can help bridge that health literacy gap when it comes to medications. That’s a relationship that we haven’t really strengthened as much as we can within our health care system. And I think that’s an important way to bridge that education and literacy gap.

And another way will be really to be partnering with our community members. So, during residency, we created a peer mentorship program for Hispanic patients with diabetes. We grouped patients who had really high levels of poorly controlled diabetes with patients who are doing better over time. And we found that those relationships, those peer support groups, were just as important as the conversations we were having with our patients in the clinical space. And so, finding patients who are on these new therapies, who can say, “I’ve been taking that medication for 5, 10 years. You don’t have to worry about the risks. You should trust your doctor when they tell you to on that.” We’ve seen some of that be successful with COVID and the vaccine. And I think it has a role to play here with pharmacoequity as well.

SHANOOR SEERVAI: I did want to ask a little bit about trust because, of course, in these places where these community relationships exist that’s great. But when it’s just the patient and their provider, or just the patient and the health system, are we placing the burden then, on the patient to know what questions to ask?

UTIBE ESSIEN: Absolutely. It’s such an important question. And I think the way that we’ve framed adherence to medications, compliance to medications, even just using those words, have really put the burden on our patients. And said, “Mr X is noncompliant. He never takes his warfarin medication. And that’s why he developed a stroke over time.” But we have to reframe and say, “What are some of the languages that we can be using? What are some of the interventions that we can be developing within our health care system so it just makes it easier for our patients to take these medications, use them safely and effectively?”

And I think the trust piece plays an important role here. How trustworthy is the health system for our communities? We know the legacy of experimentation, and racism, kind of focus on the racial differences, has played such a critical role in our health care system. And so, what are we doing to make up for that unfortunate legacy to bring our patients back to be able to trust in us as we provide them the care that they need?

SHANOOR SEERVAI: So, what are you doing to make them trust you?

UTIBE ESSIEN: Yes, we’re being real, I think. We’re being explicit, and we’re calling out the injustices that our health system has had. The amount of people that I’ve encouraged to read the book Medical Apartheid by Harriet Washington it just continues to expand because it’s so critical for us to say, “Hey, this is what racism in our health care system, this is what mistrust in our health care system has looked like. And this is why several patients are feeling weary of being able to start a new therapy, start a new drug. Not just because of the study that took place in Macon County, Alabama, of the U.S. Public Health Service Syphilis Study, but because of all of this other history that’s out there.”

And so, unpacking and being real about that history, I think, is one huge step. And the next step is really training the next generation of physicians so that they — physicians, nurses, pharmacists, et cetera — so that we are all providing the most equitable care that we can provide.

SHANOOR SEERVAI: Can you talk a little about the conversation that clinicians have amongst themselves, and how that differs from how they talk to their patients, particularly patients of color, in terms of what medicines get prescribed, and what people have access to?

UTIBE ESSIEN: Yeah so, a lot of the way that we learn about these medications is in medical journals, is at conferences, is at grand rounds where they tell us about this brand-new therapy that’s now guideline-recommended, and this is what you need to prescribe for your patients. So, we do have a lot of conversations about the data, this P value for those of us who are nerdy researchers like myself of 0.05 shows that 5 percent of patients had more efficacious responses to this new medication. And that’s it. And all of a sudden, that’s now in our guidelines for how we treat patients with heart failure. And you can’t leave the hospital without getting this new medication because this new research paper showed that it’s effective.

But we don’t have a conversation about what it actually means for our patients to take that new medication. That’s now $1,200 a month. That’s now being added to the four or five other medications that they’re taking. That you have to fill out a prior authorization form that’s going to take you 20 minutes in between patients. And I think that’s another huge area that we need to bridge: from the critical, important scientific data around effective drugs to how we can effectively, safely, and equitably get patients these medications they need. And, I think, we’re talking across each other sometimes when we get to that space. And so, that’s why I really love that question, because that’s a really important gap for us to close.

SHANOOR SEERVAI: And since you said $1,200, I want to ask a question about cost and what happens when the cost gets steeper. We know that providers get paid less for Medicaid patients. If you have a patient on Medicaid, who’s more likely to be Black or brown, female or gender nonbinary, then is it just a foregone conclusion that the clinician would not even think to provide a cutting-edge treatment?

UTIBE ESSIEN: So, that is the question that I’m hoping my research is going to answer. I think that subconscious implicit explicit bias that we might have based on the patient in front of us, based on the fact that it may not just be the color of our skin, though our data consistently showing that. Black patients get worse care regardless of their insurance, education, et cetera. But when we see the patient who is enrolled in Medicaid who, because of that insurance program, has differential access to some of the newer guideline-based therapies, like you said, do we just say, “You know what? I’m not even going to offer them this medication because, unfortunately, this insurance is not going to pay for it. Maybe they’ll give them a rebate, or a coupon for the first 30 days. But over the next three months, they’re not going to be able to take it.”

And that’s an important question when we’re seeing our patients in our office. But that’s an important question even before they get to us in the office when they’re in a hospital. When our cardiology colleagues are deciding, “Should I actually even take this patient to get a cardiac catheterization to see if they have a blockage in their heart? Because I know after I put the stent that helps them to be able to have a normal heart function, no longer have chest pain, they need to be on two medications to help keep that stent open. A blood thinner, as well as an aspirin. And if they can’t afford the blood thinner, how are they going to be able to do well on this stent?”

So, again, you go back to the chest pain patient coming into the hospital. They’re not even getting offered the procedures that they need to be able to find out why they’re showing up with pain because we’re thinking two steps away and wondering how they’re going to be able to afford the medications to manage that. And, to me, that is just scary. That is not what we want our health system to look like, that we have to make decisions about the care we provide for our patients based on what they’re going to be able to afford.

SHANOOR SEERVAI: And since you brought up social determinants of health earlier, I also wonder if the conversation around that also has an impact in the hospital. So then, you might have a provider who says, “Oh, should I put a stent in because I know that when this patient goes out, even if they can get their blood thinner, they won’t have access to good food and oh, they’re homeless, so what’s the point?”

UTIBE ESSIEN: Yeah. Again, these are the conversations that we need to have more of. And I think we need to be open about them because they’re happening every day on rounds. I work a round with our two residents, three residents rather, two medical students, sometimes a pharmacist. And we’re having these conversations on rounds. And then, we put in our notes, “Needs an aspirin, needs a blood thinner.” And we don’t discuss kind of these nuanced discussions that we have because sometimes we feel like they’re not supposed to be part of the medical conversation. That we just need to provide evidence-based, guideline-based care. But the reality is we’re not doing it and we’re not actually talking about the reasons why.

And so, yes, we are having those conversations slowly but surely. I think our next generation of doctors are going to be way more nuanced than even we were just five, 10 years ago about this. But how do we actually move a conversation forward?

People are writing about this. There’s a study two years ago in JAMA Internal Medicine that showed that homeless patients who, unfortunately 40 percent of homeless Americans are African American, are less likely to get cardiac catheterization to look for heart disease, less likely to get the surgery needed to treat it depending on the type of heart disease that they have. And so, as we are thinking about these social determinants on kind of the broad scale, the research data are also showing us just how powerful those findings are.

SHANOOR SEERVAI: And people are writing and talking about this. And that’s partly in the last two years because, from the start, the pandemic has disproportionately impacted communities of color. And now, we’ve seen ample instances of the absence of pharmacoequity, there’s disparate access to tests, vaccines, treatments. So could you talk a little bit more about this and how it’s impacted your work?

UTIBE ESSIEN: Absolutely. So again, across the pandemic, we’ve seen these disparities lay out that didn’t start back in March of 2020 but, of course, have been amplified by the pandemic. I think critical areas that, like I mentioned earlier, we saw such incredible innovation. We see this repurposing of antiviral therapies to treat COVID. Obviously, we saw these novel vaccinations become available. And then, these newer monoclonal antibodies to treat COVID. And I think the area that we really see pharmacoequity play out is, as you mentioned, in testing.

And so, what does it mean when you have a new medication, for example, Paxlovid, where you need to get a treatment within five days of your first symptoms. And so, let’s say a patient all of a sudden gets a little bit of a sore throat on Monday. They already went through the two tests that the government provided us all with a couple of weeks ago. And so, we have to figure out how to get a new test. Drive to their local pharmacy, which for some people is a 20-minute, a 30-minute drive, two different subway trips. And then, they finally get there, perhaps the pharmacy ran out because we’re all in the same boat trying to get tests. But maybe they did have access to the test. Maybe we’re getting into day two or day three.

The antigen test is negative. And so they are still worried. They have more symptoms. They go get the PCR test. They realize insurance is no longer covering it. And all of a sudden we’re in day four or five. And they no longer meet the criteria, meet the guidelines to be able to get that treatment. And those all get amplified by our patients’ social determinants. They don’t have the stockpile of tests that some of us were able to stockpile at home over the last several months.

And so, I think, that testing point is critical because, as we’re telling our patients to ask your doctor, or community members to ask your doctor about your symptoms, we forgot about the 30 million individuals who are uninsured, who don’t have a doctor to be able to ask about their symptoms. And so, I think that’s not just a COVID issue, of course. We’re going to see more and more of this play out over the next year as we start to “open back up,” and realize how many diagnoses we’ve missed over this pandemic time as well.

SHANOOR SEERVAI: And what could it have looked like, the pandemic, if we were further along in the direction of pharmacoequity.

UTIBE ESSIEN: Yeah, I think that what it could have been was that we would’ve been ready. We would’ve been armed with the resources we needed within the communities that we knew were going to be hardest hit. When the data were coming out of Italy and China suggesting who was at highest risk of severe disease. So patients with hypertension, with diabetes, with obesity. And older patients, a lot of us focus on the older aged patients. And forgot about who was going to be affected with those high rates of risk factors which, unfortunately, have been communities of color, underserved populations. And so, we knew that those are going to be individuals who are hardest hit, and yet that was not where our attention was focused. And that’s why we saw the high rates of infection, high rates of hospitalization, high rates of death.

I think if we had a pharmacoequity focus, first of all, we would not see these differential risk factor rates within our communities of color and poorer socioeconomic communities. We would’ve been able to see incredible earlier access to testing and, ultimately, treatment, and not been worrying about how we were going to allocate scarce resources. Should we include race in the models for prioritizing certain communities or not? And again, on this side of the pandemic, we would’ve been able to not see some of these other chronic diseases, the cancers that have been missed, the heart failure diagnoses, and heart attacks that, unfortunately, have been missed due to people just being fearful of showing up to the hospital.

SHANOOR SEERVAI: And do you think these ideas are getting traction? You’ve published in JAMA now. Do you think it’s moving forward?

UTIBE ESSIEN: Yeah, I’m excited to see some of the conversations that are happening. I saw another group of colleagues who published on obesity medications and how pharmacoequity needs to play a role in these newer therapies that are becoming available for a condition that’s really going to be one of the most common conditions that we manage in primary care.

And so, I do see the traction going on in the physician workforce. I see it coming up in the research workforce. But what I’m personally most excited about is the conversations that pharmacists are having around pharmacoequity. And I’ve had a chance to speak to a couple of different pharmacy groups about this topic because I really do feel like they are going to be the ones who can drive this conversation. They are working in the community. They tend to live within the communities that our patients are in, speak the languages that our community members speak. And are way more objective than we are as clinicians in making those decisions about what our patients can take.

SHANOOR SEERVAI: And the pharmacy, of course, is the endpoint. But if we think about the way that medicines are developed, there’s a need to ensure that clinical trials are more inclusive and racially representative. So, what is the impact of diversity and trials on the data?

UTIBE ESSIEN: Yeah so, I love that question because it brings us back to the therapeutic continuum, as I’ve been calling it. So, from that first drug being developed in the lab, all the way to a patient picking it up at their local pharmacy. We absolutely need to have diversity of clinical trial participants. We need that, not just for patients to be able to see themselves in the data and in the research, but even for some providers who might say, “That study only had 2 percent Black patients. I’m not sure if this drug works as effectively in this population,” which again, I hope one parting message to share with the community is that race is a social and not a biological construct. And our bodies absolutely should respond to medications in the same way.

But we also want to see that clinical trials can be disseminated within our communities so that they can have the full benefit of these drugs. And so, if we say that drug A was tested in this trial that did not have enough patients who had some of these challenging social determinants experience in their lives, we may wonder if when you have to take a medication at 2:00 AM instead of 9:00 PM, before you go to bed because of your work schedule, if you have to miss a couple of doses because of the challenges that you had with your finances, are you still able to get the full effect of this medication?

SHANOOR SEERVAI: Right, that’s really important.

UTIBE ESSIEN: I think the more we have some of these real-world pragmatic type trials that really bake in our patients’ lives under social factors, we’ll be able to even see just how efficacious some of these medications are.

SHANOOR SEERVAI: And, again, are we seeing movement here? Are researchers really recruiting more people of color to clinical trials?

UTIBE ESSIEN: Yeah so, in the New England Journal of Medicine, there is this huge new trial, about 1,200 patients who were Black and Hispanic who had asthma. And so, it was 1,200 patients in the Boston area that they tested to see how inhaled corticosteroid medications did within this community. And, again, they focused on really using community members to recruit minority patients. This is being published in one of the higher-impact journals in our field. And so, I think that’s just a sign that we’re going to more and more see some of this energy around recruiting diverse participants.

And just a requirement that the journals are starting to give us that we must actually say how many patients were white, were Black or Hispanic. Again, not because those different groups respond differently to medications, but to show that we’re actually making the effort to recruit a diverse participant, I think, is going to be how our field moves in the next five to 10 years. And while we all want to be good — we all think individually, “we are not biased against our patients” — the data are not lying about how we’re prescribing medications. And so, what we must do to be able to eliminate those biases include just being honest about the data that are in front of us and developing strategies that we can make the right choice.

SHANOOR SEERVAI: Dr. Utibe Essien, thank you so much for joining me today.

UTIBE ESSIEN: Absolutely. It was a real pleasure. Thanks for having me.

SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Mickey Capper, Matthew Simonson, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thank you for listening.

Show Notes

Utibe R. Essien, M.D., M.P.H.

Publication Details

Date

Contact

Shanoor Seervai, Researcher, Writer, and Lead Podcast Producer, The Commonwealth Fund

[email protected]

Citation

Shanoor Seervai, “A Prescription for Reducing Bias in Medical Care,” May 20, 2022, in The Dose, produced by Jody Becker, Mickey Capper, Matthew Simonson, Naomi Leibowitz, and Joshua Tallman, podcast, MP3 audio, 25:55. https://doi.org/10.26099/bbnf-e624