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. Author manuscript; available in PMC: 2023 Jul 10.
Published in final edited form as: Lancet Gastroenterol Hepatol. 2022 Aug;7(8):695–697. doi: 10.1016/S2468-1253(22)00196-0

The light we cannot see: how safety-net health systems can advance equity in gastroenterology and hepatology

Nicole J Kim 1, Rachel B Issaka 2
PMCID: PMC10332170  NIHMSID: NIHMS1912865  PMID: 35809599

Universal health coverage refers to an individual’s ability to access the health services they need without facing financial hardship.1 Achieving universal health coverage is a global priority, but 3.5 billion people worldwide lack adequate access to healthcare.1 In the United States (U.S.), safety-net health systems are critical to attaining universal health coverage. Safety-net health systems provide care to the most vulnerable patient populations, including the uninsured, underinsured, and those receiving public insurance (e.g. Medicaid, Medicare).2 Patients who receive care in safety-net health settings are also more likely to experience health disparities due to the intersections of race,3,4 poverty,2 and multiple comorbidities.2,5

Despite serving a significant proportion of the U.S. population, safety-net health systems are often excluded from gastroenterology and hepatology research. The importance of addressing this research gap cannot be understated. For example, 34% of the U.S. population are uninsured or receive Medicaid3 and 25% of all U.S. hospitals are safety-net hospitals.6 However, less than five percent of research studies funded by the National Institutes of Health (NIH) (and less than one percent of gastroenterology and hepatology studies) include “safety-net” in the project terms.7 As research often leads to innovation in clinical care and improved health outcomes, increasing the representation of safety-net health systems in research is critical to improving the quality of gastroenterology and hepatology care provided to all patients.

Several studies have already highlighted how safety-net health systems can be integrated in gastroenterology and hepatology research. Data from one health system identified gaps in the hepatitis C care continuum; 23% of patients with a positive hepatitis C antibody test never received confirmatory viral load testing and 79% of eligible patients did not receive antiviral therapy.4 In other studies, interventions to improve colon and liver cancer screening have shown promise; a standardized workflow can improve colonoscopy follow-up after abnormal fecal immunochemical testing,8 while mailed outreach and patient navigators can significantly increase liver cancer screening rates among patients with cirrhosis in safety-net settings.9 Yet, such studies from safety-net health systems are sparse.

The urgent need to include safety-net health settings in research has become even more apparent since the COVID-19 pandemic. Since February 2020, Medicaid enrollment has increased 25%.10 This influx of patients, along with the integration of telehealth services and delays in routine care (e.g., colon and liver cancer screening) may create additional challenges in healthcare delivery within safety-net hospitals. Research opportunities to better study and understand the pandemic’s impact on safety-net health settings is therefore critical to identify and develop strategies that might mitigate some of the pandemic’s detrimental impacts on gastroenterology and hepatology care.

As Dr. Jim Yong Kim, physician, anthropologist, and former president of the World Bank, once said, “we can bend the arc of history to ensure that everyone in the world has access to affordable, quality health services in a generation”.1 We therefore advocate for increased representation of safety-net health systems in gastroenterology and hepatology research to advance health equity in the following ways. First, public and private funding agencies, including the NIH, should allocate specific funding to promote research in safety-net health settings within gastroenterology and hepatology. Additional funding could be used to support interpreters and cultural navigators who are essential to helping patients overcome socio-cultural barriers that might limit research participation in safety-net health settings. Second, funding agencies should stress the importance of strengthening and expanding academic-community collaborations. While some safety-net health systems are closely linked with academic centers, the majority are not. Therefore, resources to compensate trusted community members who could serve as intermediaries and to develop research infrastructure, such as electronic health record systems, patient registries, and biobanks, may help advance gastroenterology and hepatology research in safety-net health settings. Finally, funding agencies and investigators should disseminate research findings that emerge from safety-net health settings using multiple modes of communication. While publications in academic journals are valuable, patients within safety-net settings are unlikely to read these journals and thus might not find value in ongoing research participation. However, disseminating findings to safety-net patients and providers through social media outlets, newspapers, radio, and other news portals, can bring research back to safety-net health settings and increase the impact of key findings.

Safety-net health systems have and will continue to be a vital resource in achieving universal health coverage. In these settings, dedicated research funding, equal partnerships with academic institutions, and creative dissemination of research findings has the potential to improve the overall quality of gastroenterology and hepatology research. Prioritizing safety-net health systems and other settings where individuals can access healthcare without facing financial hardship is a pivotal step towards advancing health equity in gastroenterology and hepatology.

Funding

Writing was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) T32 DK007742 to NJK and National Cancer Institute (NCI) K08 CA241296 to RBI. The contents do not represent the views of the U.S. Government or funding agencies.

Contributor Information

Nicole J. Kim, University of Washington, Seattle, WA, USA.

Rachel B. Issaka, Fred Hutchinson Cancer Center and the University of Washington, Seattle, WA, USA.

References

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