Working Toward Equitable, Accurate and Impactful Radiology Research
Intentional practice can elevate health equity in medical research
This is the second in a series of articles addressing equity health care issues in radiology. Read part one and part three.
While medical research continues to advance the understanding of health conditions and enhance the lives of patients challenged by disease, inequities in the racial and ethnic representation of studied populations persist. The result has been research that is not optimally generalizable to underrepresented populations and that subsequently results in worse health outcomes for these populations.
To help rectify these circumstances, experts recommend that health equity be considered in every step of clinical research—from who is developing the research questions, to study design, recruitment and enrollment. Equity should also be considered in how the data is analyzed, interpreted and described.
“I personally believe that considering equity in every part of the research study should be mandatory for researchers and a prerequisite of each study,” said Federica Vernuccio, MD, PhD, a radiologist at the University of Padua, Italy. “The main incentive to performing equitable research should be the awareness and satisfaction of mitigating disparities and improving health outcomes for all populations.”
Tools to Improve Equity in Research
Improving the equity of research requires multi-level frameworks and high-level benchmarks, according to Heike DaldrupLink, MD, professor of radiology at Stanford University, CA. Physicians have a responsibility for research that is equitable from population identification through the study parameters and to the final results.
Academic institutions and organizations such as the Research with Inclusion, Social justice and Equity (RISE) initiative, provide resources and tools to assist radiology researchers.
RISE was created by Jessica Tsai Wen, MD, PhD, Stanford radiology resident, and Marta Flory, MD, assistant professor in the department, with the goal to move toward research that advances equitable racial and ethnic representation in evidence-based health care. The RISE website offers an equity-minded medical research guide and asks medical researchers to pledge to report the demographic breakdown of research cohorts by race/ ethnicity in future research studies.
In addition, the website documents the lack of representation in existing medical research including:
• White Americans make up 83% of clinical trial participants but only 60% of the U.S. population.
• Only 5% of medical literature and less than half of U.S. clinical trials report race/ethnicity.
• By 2060, more than 55% of Americans will belong to populations historically excluded in medical research.
“Not all researchers are aware of how to construct research criteria and designs that are equitable or that there are new benchmarks available,” Dr. Daldrup-Link said. “Physicians aren’t full-time researchers and have limited time for outreach. Academic centers and other entities can be a resource and a bridge to the community.”
To improve the generalizability and relevance of its research, the University of Wisconsin Carbone Cancer Center created a community engagement toolkit to provide researchers with best practices and principles to help ensure research provides bi-directional benefits to the institution and community. Additionally, the University of Wisconsin Center for Health Disparities Research includes a freely available tool that maps neighborhoods based on social determinants of health.
“These tools have been valuable sources of information to strengthen and guide local, regional and national health equity efforts,” said Anand K. Narayan MD, PhD, associate professor and vice chair of equity in the Department of Radiology at the University of Wisconsin.
The Role of Unconscious Bias
Researchers’ unconscious bias may also play a role in the development and implementation of research studies. Many organizations require that researchers and reviewers undergo formal unconscious bias training before undergoing any research development.
“Canadian Institutes of Health Research (CIHR) offers tools to help integrate awareness about sex and gender biases into research,” said Charlotte Yong-Hing, MD, FRCPC, clinical associate professor and co-vice chair of Equity, Diversity and Inclusion (EDI) at University of British Columbia Radiology, Vancouver. “The first step for all radiologists and researchers is to understand the importance of bias and become aware of their personal biases so that they can work to mitigate them.”
Dr. Yong-Hing discusses the importance of equity in radiology research:
In radiology research, does the high number of imaging exams used in large research studies mitigate some of the unconscious bias in research?
Perhaps, according to Cesare Maino, MD, a radiologist at the Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Gerardo dei Tintori in Monza, Italy. The IRCCS designation is granted by the Italian Department of Health to biomedical institutions of relevant national interest to provide clinical assistance in research activities.
“From my point of view, I think that a solid blinded evaluation of images that will be included in the study process can help minimize the risk of bias,” he said. “Moreover, I think that an educational policy, such as one endorsed by each institution or directly from a Ministry of Health type organization, should be extensively implemented by every researcher and clinician to quickly recognize and better manage the risk of bias.”
Establishing Guidelines
Throughout the world, universities and institutions are looking to national health care entities to set the guidelines and standards that will ensure diverse and equitable research, such as through the IRCCS in Italy.
“There are local ethical committees that approve studies for local institutions and all institutions must be compliant with Italian and European law and the requirements of the Italian Ministry of Universities and Research,” Dr. Vernuccio said. “Each institution is responsible for its own best practices and policies around equitable research development.”
Similar requirements are in place for research proposals and funded research in Canada.
“The imposed incentive is that equity is now included in the review process of national and local granting agencies focusing on EDI and indigenous health,” Dr. Yong-Hing said. “For example, Natural Sciences and Engineering Research Council of Canada (NSERC) and CIHR include this in their evaluation criteria in some capacity. CIHR has a mandatory section in the application that requires consideration of First Nations, Inuit and Métis Peoples of Canada and Indigenous partnering community/organizational ethical guidelines. Applicants must also indicate how sex and gender characteristics will be integrated into their research proposal.”
Developing Research That Seeks Solutions
While health disparities research plays an important role—especially in areas where data is lacking, such as for colorectal and lung cancer—there’s a gap between descriptive literature and studies on interventions that address those disparities, according to Dr. Narayan.
“We’ve long known about the disparities in breast cancer mortality rates between Black and white women,” Dr. Narayan said. “We need to be asking what we can do on the ground to move forward and improve clinical outcomes. What interventions can be implemented to enhance high quality short term and intermediate outcomes?”
In a review of the last two decades of health equity literature in radiology, Andrew Ross, MD, MPH, found that the majority of studies documented race/ethnicity disparities. Of those, 72% identified reduced or inappropriate imaging use in minority groups. Only 8% of studies evaluated strategies to mitigate the inequitable use of imaging.
“Research documenting inequities is an important first step,” said Dr. Ross, associate professor of radiology at the University of Wisconsin School of Medicine and Public Health, Madison. “But to make progress toward an equitable health care system, we, as radiologists, need to find innovative ways to promote health equity, evaluate those tools, and distribute them broadly through published research.”
For More Information
Access the RISE website at www.pledgetorise.org
Explore RSNA's Health Equity Resources, including news, education, multimedia and research.
Read the RSNA News equity series and other previous stories on equity in radiology:
- Changes Needed to Make Health Care Screenings Equitable
- Radiology: Hear the Call to Action in Overcoming Health Care Disparities
- Radiology’s Role in Overcoming Health Care Disparities for Children
- Rural Areas Face Imaging Obstacles on the Road to Health Care Equity
- Navigating the Imaging Suite with Transgender Patients