While technological advances may help provide crucial warnings to young men, especially those who are black, about their heightened risk of early-onset colorectal cancer, the rise of other high-tech diagnostic aids may only worsen built-in, harmful racial biases in an array of medical practices.
Researchers at the University of Chicago, to their credit, have sought the assistance of health providers across the country to inventory and assess increasingly common medical software and the algorithms on which they rely to ensure whiz-bang decision-making tools don’t discriminate against patients of color.
The early results are distressing, showing how well-intentioned experts inject prejudices into programs that can lead to racially unfair choices about patient care. Ziad Obermeyer, an emergency medicine physician and co-author of the Chicago research, told Stat, the science and medical news site, this about algorithms used in many diagnostic tools:
“There is a clear market failure. These algorithms are in very widespread use and affecting decisions for millions and millions of people, and nobody is catching” their inherent biases.
As Stat reported:
“The report flags bias in algorithms to determine the severity of knee osteoarthritis; measure mobility; predict the onset of illnesses such as diabetes, kidney disease and heart failure; and identify which patients will fail to show up for appointments or may benefit from additional outreach to manage their conditions.
“The researchers found that the Emergency Severity Index, which groups patients based on the urgency of their medical needs, performs poorly in assessing black patients, a conclusion that mirrors findings in prior research. Obermeyer said the index suffers from a flaw found in many of the algorithms: It relies on certain proxies that are by degrees different from the thing clinicians are trying to measure, introducing imperceptible gaps where biases often hide. The tool uses a variety of factors to make triage decisions, such as vital signs and the resources patients may require when receiving care. But Obermeyer and his colleagues found its use fails black patients in multiple ways, underestimating the severity of their problems in some instances and in others suggesting they are sicker than they are. ’It’s very natural to make shortcuts … like, ‘This person’s blood pressure is fine, so they don’t have sepsis,’” Obermeyer said, referring to a life-threatening complication of infection. ‘But it’s very easy for those shortcuts to go wrong.’”
Algorithms — numerical or statistical calculations or decision-making processes — are used in software throughout health care, including by insurers, Stat reported, noting giant corporations can make wrong business choices based on them.
“The research to identify bias [in Chicago] …was established after an initial study uncovered racial bias in a widely used algorithm developed by the health services giant Optum to identify patients most in need of extra help with their health problems. They found that the algorithm, which used cost predictions to measure health need, was routinely giving preference to white patients over people of color who had more severe problems. Of the patients it targeted for stepped-up care, only 18% were black, compared to 82% who were white. When revised to predict the risk of illnesses instead of cost, the percent of black patients flagged by the algorithm more than doubled …
“Harvard Pilgrim Health Care, a nonprofit health plan in Massachusetts … wanted to assess the potential for bias in its efforts to identify members who might benefit from additional outreach and care. A preliminary review suggested that one algorithm, a model developed by a third party to predict cost, places people with chronic conditions such as diabetes at a lower priority level than patients with higher-cost conditions such as cancer. Since diabetes is experienced at a high rate among black patients, that could lead to a biased output.”
Databases and disease mapping
On the other hand, a different kind of technology-based research may prove valuable to patients and health providers in dealing with a rising, treatable, and all-too-common form of cancer — the colorectal cancers that increasingly afflict young men and especially young black men.
This disease got important public attention with the tragic, recent death of Academy Award-winning actor Chadwick Boseman.
Growing awareness of the risks this cancer poses has led researchers to fire up their computers and to tie a variety of databases to construct a “hot spot” map, showing where colorectal cancers pose the greatest challenges to young women and especially young men. As Stat reported, separately, of this data-driven study whose results have been published in a medical journal:
“To construct their hot spot map, [researchers] analyzed about 20 years of mortality data from the Centers for Disease Control and Prevention at the county level. They then linked the hot spots they made from that data with a National Cancer Institute database of nearly 32,500 men between 15 and 49 who had been diagnosed with colorectal cancer between 1999-2016. (Residents from Hawaii and Alaska were excluded.) The researchers identified 232 counties that were hot spots — the top about 7.5% of counties ranked by the rate of men dying of early-onset colorectal cancer. Men diagnosed with early-onset colorectal cancer in these locations had up to a 24% higher risk of dying from the disease than those living elsewhere. When the data were adjusted for differences in smoking rates, the risk to those living in the hot spots was 12% higher. Compared with white men living in the hot spots, black men had a 31% higher risk of dying from colorectal cancer. The hot spot counties were concentrated in the South — 92% — and 8% were in the Midwest. Many of the hot spots were clustered along the lower Mississippi Delta, in Appalachia, South Carolina, and along the Virginia-North Carolina border.
“Men living in the hot spots were more likely to be black than those living in counties that were not hot spots, about 31% compared with 13%. They were also more likely to be diagnosed at stage 4 and on average survived about a year less. White men living in the hot spots had much worse survival rates compared with white men living elsewhere.”
The researchers noted that this work does not explain why this cancer is so prevalent in specified areas, nor does it address what health resources might be available to deal with the disease in hot spots, where Stat noted:
“Those living in the hot spots … had less access to healthy food and higher rates of obesity and physical inactivity, and were more likely to be uninsured, low-income, and not college-educated than those outside of the hot spots. The hot spots were also more rural and had fewer primary care physicians.”
The Stat news article quotes experts not connected with the hot-spot study as saying the research points to places where health officials should devote extra attention to deal with colorectal cancer. The story also details well the challenges that patients, doctors, and specialists must deal with, so that those with the cancer get it detected and treated early when successful outcomes commonly can occur.
Young men, alas, too often consider themselves invulnerable and they may avoid routine medical check-ups and other health care, experts say. These patients also may hold macho attitudes and fear ridicule, so they ignore warning signs, such as bleeding, cramping, abdominal pain, and changes in bowl habits — until the disease progresses to the point where patients may need extensive surgical or other interventions. Or succumb to the disease, all too early.
In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them by misdiagnoses, and medical error. In the times before the coronavirus pandemic, researchers reported that medical errors claimed the lives of roughly 685 Americans per day — more people than died of respiratory disease, accidents, stroke and Alzheimer’s. This meant that medical errors ranked as the third leading cause of death in the U.S., behind only heart disease and cancer.
Patients also struggle to access and afford safe, excellent, and efficient medical care. This has become an ordeal due to the soaring cost, complexity, and uncertainty of treatments and prescription drugs, too many of which prove dangerous.
It makes sense for modern medicine to become as fast, accurate, and efficient as possible in diagnosing and treating patients. But women for too long have suffered mistreatment in health care, and for patients of color, especially those who are black, relentless health inequities demand urgent redress.
We can’t build into new technologies age-old racism, sexism, or any other kinds of unfair discrimination, especially when it lies deep in decision-making tools that have big effects on patients lives and care. We can and should use high-tech advances to help us see where racial differences increase patients’ risk for diseases or may improve their care. We have much work to do to ensure the 21st century medicine is better and fairer.