AUA2023 TAKE HOME MESSAGES Health Care Disparities
By: Bernice Ofori, MPH, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Jamila Sweis, BS, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Adam B. Murphy, MD, MBA, MSCI, Northwestern University Feinberg School of Medicine, Chicago, Illinois | Posted on: 30 Aug 2023
For the first time in the history of the AUA, this year’s meeting included sessions on DEI (Diversity, Equity, and Inclusion). There were 5 moderated poster sessions: 3 on Outcomes, 1 on Increasing Representation in Urology, and 1 Knowledge Sharing session on women’s issues in Urology. There was also a best practices session on improving gender equity for trainees in Urology programs. This year’s abstracts each highlighted important topics that every urologist should know about not only to improve patient care, but also to deliver equitable care for all, including women and sexual, gender, and racial/ethnic minorities.
The AUA and National Comprehensive Cancer Network guidelines recommend PSA screenings at an increased rate at earlier ages in Black men. The low specificity of PSA requires the use of secondary tools such as multiparametric MRI of the prostate, 4Kscore, Prostate Health Index, or ExoDx. These are not calibrated in minority populations. Moreover, there are disparities in the utilization of these risk prediction tools in biopsy-naïve Black men. This likely leads to excessive biopsies in Black patients, as highlighted by Pandit et al (MP12-13).1
Several abstracts this year highlight social determinants of health as predictors of hormone and semen parameters (MP12-06),2 stage of presentation of penile cancer (MP12-14)3 and survival, and early onset prostate cancer (MP12-05).4 Medicaid patients suffer the most with reduced prostate cancer screenings and diagnoses. They are 4 times more likely to present with metastatic disease and twice as likely to die of their cancer compared to patients with private insurance.
In this era of anti-Black racism, nephrology and kidney societies have made efforts to remove Black race from kidney function equations in efforts to combat stereotypes of hypermuscularity in Black people. However, a recent article by Hsu et al in New England Journal of Medicine suggest that race-containing formulas were more accurate in staging chronic kidney disease.5 Two abstracts highlighted the clinical implications of that change (MP12-03, MP12-08).6,7 The change in the removal of Black race term from estimated glomerular filtration rate may inadvertently result in increased exclusion of Black patients from clinical trials. The best poster for this session (MP12-03)6 also showed that the removal of the race term decreases renal function by Black patients by 16%. This meant more pressure for surgeons to choose partial nephrectomies in more complicated tumors.
A key urological disparity was seen in women undergoing radical cystectomy and urinary diversion for bladder cancer. Relative to men, women received more ileal conduits and significantly fewer continent diversions but experienced similar health-related quality of life postoperatively. They did, however, report a lower body image postcystectomy (MP12-07).8 A bladder cancer focused urologist from the audience reported lower experience with neobladders in women among urologic oncologists as a likely contributor.
Assumptions, misperceptions, and lack of knowledge are harmful elements that may unintentionally exist in clinical practice. In order to correct these implicit biases, it is imperative sensitive topics are given proper attention and discussed openly to better improve patient health care experiences.
A literature review was conducted examining the physician-patient relationship among persons with disabilities (PWD) with regard to sexual medicine (MP21-16).9 From 63 articles, results indicate PWD have both urological physiological and psychological needs many providers do not feel comfortable addressing. Some of these concerns include bowel and bladder incontinence during sexual intercourse, pain, and low confidence. The providers’ discomfort may be a combination of lack of knowledge and lack of skill set in navigating sensitive concerns with this population. The lack of communication currently in place between providers and PWD has resulted in negative consequences such as patients experiencing poor sexual confidence, rise in sexually transmitted diseases, and unplanned pregnancies (MP21-16).9 According to this study, society and many urologists assume PWD are asexual, and therefore do not discuss these topics. Research is needed to improve providers’ knowledge about basic epidemiology of sexual dysfunction in PWD to help guide future therapies and establish patients’ priorities.
In terms of LGBTQ concerns at the AUA, a qualitative study conducted by Xu et al showed that while 74.5% of surveyed urologists agreed to be identified as an “LGBTQ-friendly provider,” 74.3% have reported additional training is necessary, and 65.8% stated they would want to participate in further training if offered. Additionally, the number of hours included in a medical school curriculum dedicated to LGBTQ education vary greatly, with North Central and South Central AUA sections reporting 0 hours (MP21-01).10 These data are an important call to action for further education.
A current study by Tamalunas et al set out to assess whether gender impacts a patient’s decision in choosing a urologist (MP21-04).11 According to the results, the vast majority of 1,012 patients who completed the questionnaire indicated a gender preference for various reasons. Reasons reported included patients’ own gender, preference for a male urologist for concerns considered “embarrassing, limiting daily activities, or when worrisome.” Preference for a female urologist occurred when their concern was perceived as painful and based on prior positive or negative experiences with prior providers. Given this feedback, it is important to continue to diversify the workforce and ensure male- and female-identified urologists are aware of patients’ preferences.
Since 2021, the AUA has made strong strides in highlighting issues of DEI for patient care and urological research. Given the growing diversity in this country, we applaud the presenters for addressing clinical knowledge gaps to improve the care for sexual, gender, and racial/ethnic minorities. The incorporation of shared decision-making and inclusion of patient-specific values into clinical practice will positively influence patient care.
- Pandit A, Sholklapper T, Drevik J, Ginzburg S. MP12-13 Disparities in prostate multi-parametric magnetic resonance imaging utilization in biopsy naive men. J Urol. 2023;209(Suppl 4):e138.
- Kassab J, Lipshultz L. MP12-06 Socioeconomic determinants as a predictor of hormone and semen parameters. J Urol. 2023;209(Suppl 4):e135.
- Zekan D, O’Connor L, Novak M, et al. MP12-14 Rural disparities in penile cancer: a multi-institutional. Statewide review in West Virginia. J Urol. 2023;209(Suppl 4):e139.
- Riveros C, Chalfant V, El-Shafie A, et al. MP12-05 The impact of socioeconomic status on the survival of men with early-onset prostate cancer. J Urol. 2023;209(Suppl 4):e134.
- Hsu CY, Yang W, Parikh RV, et al. Race, genetic ancestry, and estimating kidney function in CKD. N Engl J Med. 2021;385(19):1750-1760.
- Schmeusser BN, Palacios AR, Midenberg ER, et al. Race-free renal function estimation equations and potential impact on black patients: implications for cancer clinical trial enrollment. Cancer. 2023;129(6):920-924.
- Khan A, Wang S, Choudhary R, Phelan M, Onukwugha E, Siddiqui M. MP12-08 Evaluating the impact of excluding the race factor from the eGFR equation on bladder cancer treatment options. J Urol. 2023;209(Suppl 4):e136.
- Pekala KR, Sjoberg D, Clements MB, et al. MP12-07 Prospective health related quality of life in women undergoing radical cystectomy and urinary diversion. J Urol. 2023;209(Suppl 4):e135.
- Howland R, Tooke B, Streur C, Wittmann D. MP21-16 Providing culturally sensitive sexual medicine for persons with disabilities. J Urol. 2023;209(Suppl 4):e292.
- Xu A, Panken E, Gonzales-Alabastro C, Zhang H, Murphy A, Amarasekera C. MP21-01 Urologists and LGBTQ patients: a qualitative study of the practice patterns, attitudes, and knowledge base of urologists toward their LGBTQ patients. J Urol. 2023;209(Suppl 4):e284.
- Tamalunas A, Lenau P, Stadelmeier L, et al. MP21-04 Gender bias in urology: how do patients really choose their urologist?. J Urol. 2023;209(Suppl 4):e285.