Racial, Ethnic Disparities Persist in the Treatment, Hospitalization of Patients With IPF

Two posters presented at the CHEST 2024 annual meeting last week in Boston, Massachusetts, demonstrated racial and ethnic differences in the hospitalization and treatment of patients with idiopathic pulmonary fibrosis (IPF).

Two posters revealed significant racial and ethnic disparities in the hospitalization and treatment of patients with idiopathic pulmonary fibrosis (IPF). | Image Credit: Sviatlana - stock.adobe.com

Racial, Ethnic Disparities in Hospitalized Patients With IPF

Previous research discovered racial and ethnic disparities among patients with PF, especially in PF-related outcomes. More specifically, a recent study found that Black patients with PF were diagnosed, hospitalized, underwent lung transplants, and died at a younger age than Hispanic and White patients.¹

The first poster at CHEST described racial differences in outcomes among hospitalized patients with IPF as a primary diagnosis.² The researchers identified IPF hospitalizations in the National Inpatient Sample database (2016-2019) using the International Classification of Diseases, 10th Revision (ICD-10) code J84.112.

They identified 14,815 hospitalizations with a primary diagnosis of IPF. Of these hospitalizations, 1355 (9.15%) and 13,460 (90.85%) were of Black and White patients, respectively (P < .001). The researchers determined that hospitalized Black patients were admitted at a younger mean (standard deviation [SD]) age than non-Hispanic White patients (mean [SD] age, 63.67 [13.22] vs 72.02 [10.48]; P < .001).

Conversely, inpatient mortality during hospitalization was higher in non-Hispanic White patients than in Black patients (11.6% vs 7.4%; P < .001). Despite this, the length of stay was similar for both patient populations (9.34 vs 9.46 days; P = .793).

Overall, the findings indicate that Black patients were significantly less likely to be hospitalized with a primary diagnosis of IPF. However, the researchers noted that this could potentially be due to Black patients not being coded for an IPF diagnosis. Lastly, Black patients had significantly better inpatient survival, indicating the potential role that timely hospitalization could play in helping improve the overall outcomes of Black patients with IPF.

"...I think it's still important to raise awareness so that we can move on to the next step with prospective studies, with steps to push our boundaries and push where health care is now and to provide better care and be aware that maybe Black patients can be diagnosed with IPF at a younger age," lead investigator Cesar Davila-Chapa, MD, pulmonary and critical care cochief fellow at the University of Nebraska Medical Center, told The American Journal of Managed Care^® (AJMC^®) at the conference. "That is something to raise awareness in terms of putting in our differential as pulmonary physicians."

Racial Disparities in Antifibrotic Prescriptions Among Patients With IPF

Building on the previous one's findings, the second poster analyzed if racial disparities exist in the prescription rates of antifibrotic medication among patients with IPF³; these medications, namely pirfenidone and nintedanib, slow the progression of lung fibrosis, or scarring, in the lungs.⁴ The poster also evaluated the impact of antifibrotic therapy on all-cause hospitalization outcomes.³

The researchers used 5-year retrospective data (1/1/19-1/1/24) of patients with IPF using Slicer-Dicer, a self-service cohort exploration tool embedded in an electronic health record at a Midwest integrated health system of 7 hospitals and outpatient sectors. Patients were categorized into 2 groups based on the prescribed antifibrotic therapy.

Then, the researchers evaluated the differences in prescription rates based on race, sex, and age. They also compared the incidence of hospitalization and overall length of stay in patients on antifibrotics with those not on antifibrotics.

The researchers identified 10,667 patients with IPF, 1.8% of which were prescribed antifibrotics; of these patients, 22.3% were on pirfenidone and 77.7% were on nintedanib. Of all patients with IPF, 89.6% were White. Similarly, the cohort of patients on antifibrotics consisted mostly of White patients vs Black patients (96.3% vs 3.7%; P = .0022).

Additionally, hospitalization rates for all patients with IPD were 26% vs 31.9% among those on antifibrotics. Of those with IPF, 91.1% were hospitalized for more than 3 days. Similarly, 85.1% of those receiving antifibrotics were hospitalized for more than 3 days.

“Better and early access to diagnostics for all patients, especially for minorities, would improve overall outcomes in patients with IPF,” the authors concluded.

The 2 posters collectively highlight racial disparities in IPF management, showing that Black patients are diagnosed and hospitalized at younger ages but have better inpatient survival than White patients. Conversely, White patients are significantly more likely to receive antifibrotic medications, with higher associated hospitalization rates. Overall, these posters emphasize the need for equity in IPF treatment.

Racial Disparities Within Other Disease States

IPF is not the only area of chest medicine affected by racial disparities. Health equity was one of the main topics at CHEST 2024, with various sessions and posters discussing how it affects different chest medicine areas. For example, the session “Addressing Disparities in Lung Cancer Care” highlighted significant racial and ethnic disparities in lung cancer.⁵

Neelima Navuluri, MD, assistant professor of medicine at the Duke University School of Medicine, began the session by reporting that, in 2018, lung cancer screening rates were significantly lower in Black patients than in non-Black patients despite the lung cancer risk among Black or Hispanic patients being equivalent to or greater than that of White patients with histories of tobacco use.

Francesca Duncan, MD, MS, assistant professor of medicine at the Indiana University School of Medicine, added that these screening rate differences directly correlate to disparities in rates of lung cancer incidence, morbidity, and survival among patients of color. Black males have the highest lung cancer incidence rate, while American Indian and Alaskan Native females have the highest mortality rate. Also, Black patients are less likely to be diagnosed with early-stage disease and have worse survival rates than White patients.

Therefore, a larger percentage of Black patients were diagnosed with an advanced disease stage than White patients.⁶ Factors associated with advanced-stage diagnosis include being male, uninsured, and of Black race. Consequently, worse overall survival rates exist among Black patients, male patients, uninsured patients, and single patients compared to their counterparts.

Stella Ogake, MD, FCCP, assistant professor of medicine at The Ohio State University College of Medicine, shared similar trends among lung cancer treatment disparities. The standard of care for patients with early-stage non–small cell lung cancer (NSCLC) is anatomic lung resection with a multistation lymph node dissection. She noted that post-resection survival can be over 85% at 5 years among those with early-stage NSCLC. However, patients of color are significantly less likely to undergo surgery and sometimes receive no treatment at all.

When patients of color received treatment, Ogake noted that non-Hispanic Black patients were less likely to receive guideline-concordant care. She explained that these treatment disparities are driven by social determinants of health (SDOH) factors, like education level, care access, and insurance status. Other factors include implicit bias and being treated at an academic institution vs a community institution.

Ways to Mitigate These Disparities

Direct efforts have been made to mitigate racial disparities among patients with lung cancer. Samuel Cykert, MD, professor of medicine at the University of North Carolina (UNC) Chapel Hill School of Medicine, concluded the session by sharing the racial equity analysis and solution used by the Greensboro Health Disparities Collaborative (GHDC) through UNC’s Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) project.⁵

He explained that a warning system was created using electronic medical records (EMRs) to alert providers when patients missed appointments or care milestones, especially patients of color. Additionally, regular audits identified care disparities, and ACCURE navigators helped patients overcome barriers, like finances, transportation, and mistrust in the health care system.

Cykert noted that this method helped to mitigate disparities for Black patients with early-stage lung cancer and improved care for all patients, not just one group. Therefore, he encouraged other cancer centers to adopt similar interventions.

Conversely, providers can begin mitigating disparities among patients with IPF by using more general solutions.⁷ These include raising awareness of the issue and increasing health literacy in affected communities. Other solutions include advancing health equity through legislation and strengthening health care resources to better serve people in at-risk areas.

References

1. Adegunsoye A, Freiheit E, White EN, et al. Evaluation of pulmonary fibrosis outcomes by race and ethnicity in US adults. JAMA Netw Open. 2023;6(3):e232427. doi:10.1001/jamanetworkopen.2023.2427
2. Davila-Chapa C, Thotamgari SR, Chaaban S; Racial differences in hospitalizations for idiopathic pulmonary fibrosis in the United States. Poster presented at: CHEST Annual Meeting 2024; October 6-9, 2024; Boston, MA. doi:10.1016/j.chest.2024.06.2291
3. Ghimire P, Gupta S, Thameem D. Racial and gender disparities, and impact of antifibrotic therapy on hospital outcomes in patients with idiopathic pulmonary fibrosis. Poster presented at: CHEST Annual Meeting 2024; October 6-9, 2024; Boston, MA. doi:10.1016/j.chest.2024.06.1913
4. Nintedanib and Pirfenidone – antifibrotics for pulmonary fibrosis. Action for Pulmonary Fibrosis. Accessed October 14, 2024. https://www.actionpf.org/information-support/anti-fibrotic-treatments-for-ipf
5. McCormick B. Lung cancer experts encourage use of system-based interventions to address racial disparities. AJMC^®. October 7, 2024. Accessed October 14, 2024. https://www.ajmc.com/view/lung-cancer-experts-encourage-use-of-system-based-interventions-to-address-racial-disparities
6. Duncan FC, Al Nasrallah N, Nephew L, et al. Racial disparities in staging, treatment, and mortality in non-small cell lung cancer. Transl Lung Cancer Res. 2024;13(1):76-94. doi:10.21037/tlcr-23-407
7. 6 examples of health disparities and potential solutions. USC Price. November 17, 2023. Accessed October 14, 2024. https://healthadministrationdegree.usc.edu/blog/examples-of-health-disparities