Health Equity in Preventive Services: Giving Name to Structural Barriers

I met Ms. F when she came in to establish care with a new primary care physician (PCP). She was an older Black woman who had been chronically homeless over the years and had recently been placed in community-funded housing. The sidebar on Epic (Epic Systems Corporation) that lists care gaps was exploding with “deficiencies” that we needed to address as soon as possible—mammography, colonoscopy, dual-energy x-ray absorptiometry (DXA) scan, diabetes screening, and lipid check.

As noted in a review article in Annals about health equity in preventive care (1), Ms. F is far from an outlier. Despite efforts to improve adherence to preventive screening, millions of Americans still are missed each year. As the Annals review points out, these missed opportunities disproportionately affect disadvantaged ethnic and racial groups. One intervention that has been shown to be effective is engagement by physicians and clinic workers in person or over the telephone. After several visits addressing Ms. F’s acute concerns (untreated diabetes and pervasive fungal infection), we were able to implement such measures by deliberately scheduling a 40-minute follow-up visit to address her health maintenance.

However, this type of direct engagement requires continuity. In Seattle, the connection between vulnerable patients, physicians, and clinics has been eroded by waves of gentrification and resultant housing instability. As patients are pushed past the edges of the city limits, they lose contact with previous physicians and easy access to familiar clinics. I’ve had patients who’ve had to travel an hour or more to reach my clinic near the city center. I’ve sat in visits where they’ve lamented about how long they have to travel to see their PCPs and wondered for how much longer they can keep this up. A trip into the city center to visit our affiliated mammogram clinic or to get a DXA scan done sounds laughably infeasible.

Obviously, the most extreme manifestation of this issue is homelessness. In Ms. F’s case, she previously had a PCP at Harborview Hospital, the safety-net hospital in Seattle. At our first visit, she had a handwritten list in cursive of the screenings that the PCP had recommended, with the date showing that this had happened nearly 8 years ago. After she lost her housing, this had all stalled.

To implement the direct patient engagement strategies discussed in the Annals article, we need to acknowledge the forces that erode patient–clinician relationships and make these interventions impossible. Part of doing so involves moving beyond vague notions of “structural barriers.” They have names, such as gentrification, urban displacement, and homelessness. Ultimately, the ideas in the Annals article are meaningful only if these root causes of inequitable care are addressed.

This is a role that we can play as clinicians, engaging actively in the public conversation around gentrification and affordable housing. We should advocate for policies that help our patients keep their homes and communities intact as much as we attempt to achieve clinical engagement. As long as our patients struggle to stay where they are, we will struggle to reach them.

References

1. Nelson HD, Cantor A, Wagner J , et al. Achieving health equity in preventive services: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2020;172:258-271. [PMID: 31931527] doi:10.7326/M19-3199