Addressing Racial Disparities to Advance Quality Care for Adults with Acute Leukemia: A Health Equity-Focused Quality Improvement Program

Background

Racial disparities in acute leukemias, including acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL), have persisted for decades due to multi-level etiologies. To ensure that equitable care is delivered, healthcare professionals (HCPs) must be aware of potential, systemic disparities gaps in personalized treatment planning, shared decision-making (SDM), clinical trial enrollment, and treatment delivery among patient populations with acute leukemia and identify potential opportunities to overcome ongoing disparities gaps. In this quality improvement (QI) initiative, we assessed acute leukemia practice patterns and patient- and health system-level barriers to evidence-based, equitable, patient-centered care in 2 community oncology practices.

Methods

Between 7/2021-9/2021, 30 hematology/oncology HCPs and 102 patients with acute leukemia (52 Black, 32 Hispanic, and 10 White patients) completed surveys designed to evaluate self-reported practice patterns, challenges, and barriers to equitable care (Table 1). HCP cohorts within each oncology clinic participated in 1-hour live small-group audit-feedback (AF) sessions in which the teams reviewed the survey data, reflected on their own practice patterns and developed action plans to close identified acute leukemia care gaps. Additional surveys conducted before and after the AF sessions evaluated changes in participants’ knowledge and confidence in delivering equitable, patient-centered care.

Results

Patient and Provider Tethered Surveys: HCPs and patients both identified feeling confident in their treatment plan and identifying goals of treatment as the biggest challenges patients face in acute leukemia care. Although 57% of HCPs rated difficulty getting the best care because of race or ethnic background as not a problem at all, only 6% of Black patients agreed (57% vs. 6%, p<0.001), with approximately half (48%) of Black patients identified this as a minor or major problem. HCPs reported not enough time (43%) and patient resistance (10%) as their biggest barrier to engaging patients in SDM, whereas Black patients (58%) reported a lack of understanding about what the care team is saying as the main barrier, and Hispanic (65%) and White (78%) patients reported the biggest barrier as trusting their care team to make the best decisions. When asked about clinical trial enrollment, 86% of HCPs stated they often or always discuss the possibility of clinical trial enrollment with eligible patients and 94% refer patients for clinical trial enrollment. However, 38% of all patients recalled no experience with clinical trials. Black patients (64%) identified insurance/financial counseling as the aspect of care that could be most improved, Hispanic patients (55%) identified provision of a translator/translated educational materials, and White patients (63%) identified education about treatment options, expectations and prognosis.

Small-Group AF Sessions: HCPs plan to address the following challenges: engaging patients in SDM (29%), providing adequate patient education about treatment options and potential side effects (24%), and ensuring equitable access to novel therapies for all patients (19%) (Figure 1). To achieve these goals, HCPs committed to expand access to clinical trials, provide translated materials or interpreters, assist patients in finding ways to cover the costs of therapies, and increase documentation of quality of life. HCPs reported 100% confidence post-AF session for aligning treatment decisions with evidence-based guidelines and incorporating SDM techniques into treatment planning.

Conclusions

Barriers to providing equitable, patient-centered care in acute leukemia identified in this QI initiative include access to care, effective SDM, and clinical trial enrollment. Racial disparities were uncovered in access to transportation for Black patients and access to a translator/translated material for Hispanic patients. After participating in this QI initiative, HCPs developed action plans to address the gaps identified and reported increased confidence in delivering equitable care. Practice gaps uncovered in this initiative can inform future QI programs.

Study Sponsor Statement

The study reported in this abstract was funded by an independent educational grant from Bristol Myers Squibb. The grantors had no role in the study design, execution, analysis, or reporting.

Ascensao:Incyte: Other: Advisory Board.