New Health Equity Report Card Set to Address Structural and Interpersonal Bigotry in Cancer Care

The National Comprehensive Cancer Network (NCCN) has joined forces with the American Cancer Society Cancer Action Network (ACS CAN) and the National Minority Quality Forum (NMQF) to create a Health Equity Report Card (HERC) pilot program which will address the structural and interpersonal bigotry that is embedded in the cancer care system and which results in disparities in care and outcomes.¹

“The goal of this initiative is to develop a tool that is feasible to implement and useful to an organization striving to provide or improve equitable cancer care,” Crystal S. Denlinger, MD, NCCN senior vice president and chief scientific officer, said in an email to Oncology Nursing News®. “We hope that this sparks conversations about how best to deliver equitable care in their own communities, how best to engage with the surrounding community, and how best to support the patients who live in the local community surrounding them.”

Incidence and death rates for cancer have declined for both Black and White patients from 1975 to 2020. The ACS credits the steep drop in smoking among Black teens over that period for reducing the difference in risk, Black patients still have a 12% excess risk for cancer death.²

Furthermore, Black men have the highest incidence rates for cancer at 527.5 per 100,000 population. Black women are significantly less likely to develop breast cancer than their White counterparts (127.8 vs 133.7 per 100,000 population), but they are much more likely to die from the disease (27.6 vs 19.7 per 100,000 population).³

Poverty, lack of health insurance, sexual and gender orientation, and geography are also factors in care disparities. The Centers for Disease Control and Prevention found that rural patients had lower 5-year annual age-adjusted cancer incidence rates from 2009 to 2013 but higher average annual age-adjusted death rates from 2011 to 2015.⁴

To address these disparities, the NCCN, ACS CAN, and NMQF initiated the Elevating Cancer Equity initiative in 2020, featuring a working group chaired by Robert A. Winn, MD, director of the Virginia Commonwealth University Massey Cancer Center, and Shonta Chambers, MSW, executive vice president of Health Equity and Community Engagement at the Patient Advocate Foundation.

In early 2021, that group developed the HERC to establish guidelines that would help health care providers and organizations identify and address discriminatory behaviors and bias in care delivery, address social determinants of health, and overcome systemic barriers to optimal care. The group developed 17 “actionable practice changes and created an implementation plan with concrete metrics, sources of evidence, and a scoring methodology based on those practice changes. The HERC recommended practice changes to reduce racial disparities are as follows:⁵

Community Engagement

• Incorporates meaningful community involvement in practice leadership through a community/patient advisory committee or designated board position that is reflective of:
• the community the health care systems serves or
• that is reflective of the community where the health care system resides or
• is reflective of the demographics identified through the community needs assessment.
• Marketing and educational materials use messaging that is linguistically and culturally appropriate for the community served.
• Contracts with or has formal and equitable partnership with community providers, community-based organizations, and/or faith-based organizations (when mutually appropriate and not harmful) for community engagement and/or patient navigation.
• Demonstrates the results of the community health needs assessments are used as a tool for program development through documented action plan tied to results.
• Accessibility of Care and Social Determinants

Accessibility of Care and Social Determinants of Health

• Facilitates access to government, commercial, or community-based non-emergency transportation services or financial support for public transportation where available.
• Collects Social Determinants of Health data at intake and throughout the continuum of care. Population-level data collected (z-codes) helps to guide patient care and population-level health management as documented through the medical record or meeting notes.
• Offers flexible hours for screening and treatment appointments.
• Offers culturally and linguistically representative patient navigators or community health workers through internal hiring or contracting with community-based organizations.
• Establish a process to navigate patients with identified social needs to local and or national resources.
• Training is provided to staff on barriers to clinical trial participation and there are targeted efforts to reduce barriers to clinical trial participation through connection to appropriate services.

Addressing Bias in Care Delivery

• Diversity, inclusion, and equity is embedded into the practice, institution, or health system policies (Examples: recruitment, hiring, and promotion policies, resource allocation standards).
• Adopts measures related to the recruitment, retention, and promotion of minority researchers and practitioners.
• Implements Health Information Technology or other workflow processes to identify critical moments in shared decision making and care planning when disparate care can occur.
• Incorporates disparities and equity framework into quality improvement activities.
• Provides and requires annual implicit bias training for all employees.

Quality of Comprehensiveness of Care

• When appropriate, patients are offered or referred to appropriate preventive and supportive care services (e.g., smoking cessation and weight management programs, reducing exposure to environmental hazards).
• Clinical trial options are discussed with all patients as documented through medical records.
• Offers culturally and linguistically representative patient navigators or community health workers through internal hiring or contracting with community-based organizations.

Clinical Practice Guideline Recommendations

• Clinical practice guidelines should be reviewed for disparity issues within guidelines that could eliminate or reduce disparity. Additionally, clinical practice guidelines should incorporate language recognizing the existence of bias in care.
• Clinical practice guidelines should incorporate a framework to account for health disparities into the panel processes. Panels should also consider adding a health equity expert representative.
• Clinical Practice Guidelines should consider incorporating age adjustments on screening recommendations for specific populations that may have earlier manifestations.

In the first phase of a multi-phase pilot, 5 leading academic cancer centers are assessing the feasibility of implementing the HERC as a tool that can both meaningfully and feasibly measure and report on equitable care practices.

“We specifically designed the HERC so that organizations can be judged based on objective, concrete metrics. Each domain is scored based on the performance measures included and whether the organization meets the metrics,” Denlinger said. She added that an article scheduled for the February 2023 issue of the Journal of the National Comprehensive Cancer Network will explain how each of the 4 domains in the HERC is individually scored. “An overall score for each domain can then be generated based on whether the institution meets 100% of the metrics, more than 50%, or less than half.

“We envision the potential for serial scoring evaluations, in which an organization can track progress over time and demonstrate changes in response to areas in which lower performance may have been identified.”

References

1. Health equity report card pilot project to help close the care gap highlighted on World Cancer Day. News release. The National Comprehensive Cancer Network. February 4, 2023. Accessed February 7, 2023. https://bit.ly/3XbFPjd
2. Cancer statistics 2023 slide presentation. American Cancer Society. Accessed February 7, 2023. https://bit.ly/40BQBSQ
3. American Cancer Society. Cancer Facts and Figures 2023. Incidence and mortality rates for selected cancers by race and ethnicity, US, 2015-2020. Accessed February 7, 2023. https://bit.ly/3HGbaFa
4. Henley SJ, Anderson RN, Thomas CC, Massetti GM, Peaker B, Richardson LC. Invasive cancer incidence, 2004-2013, and deaths, 2006-2015, in nonmetropolitan and metropolitan counties - United States. MMWR Surveill Summ. 2017;66(14):1-13. doi:10.15585/mmwr.ss6614a1
5. The National Comprehensive Cancer Network. Elevating cancer equity: recommendations to reduce racial disparities in access to guideline adherent cancer care. February 4, 2023. Accessed February 7, 2023. https://bit.ly/3DRGnUK