MEDICAL PROFESSIONALS ARE BECOMING INCREASINGLY AWARE of the catastrophic effects of racism in the American health care system. In 2021, the U.S. Centers for Disease Control and Prevention declared racism “a serious public health threat that directly affects the well-being of millions of Americans.”

Black Americans experience double the infant mortality rate compared with their white counterparts, CDC figures show. Hispanics, Native Hawaiians and African Americans all have less health insurance coverage than white people, which has led to reduced trust in America’s health care system and a consequent delay in seeking professional help for serious medical conditions, studies show.

Numerous medical research institutions, including the National Library of Medicine, have compiled an overwhelming body of evidence blaming structural racism, implicit bias and other institutional shortcomings for worse health care outcomes for Indigenous groups and people of color than for white Americans. The phenomenon is commonly referred to as racial health inequity.

But what is causing the disparities? And what can be done to fix the unequal health outcomes? Dru Riddle is on the case, starting by evaluating the research being done to assess the inequities.

“We know already that disparities and inequalities in health outcomes exist between different racial groups,” said Riddle, professor of professional practice in nurse anesthesia at TCU’s Harris College of Nursing & Health Sciences. “How do we address those gaps?”

A STUDY OF STUDIES

Riddle received a $1 million grant from the Robert Wood Johnson Foundation, whose guiding principle is to “seek bold and lasting change [in health care] rooted in the best available evidence, analysis and science.”

Riddle, also director of the Center for Translational Research at the Health Innovation Institute at TCU, was part of a team of medical professionals from six organizations in the U.S., Canada and the United Kingdom. As the project lead, Riddle was responsible for coordinating among the research groups and reviewing the results.

One of the main purposes of the team’s project was to evaluate whether current medical research is effective in identifying and addressing the root causes of racial health inequity.

“Probably more impactful than anything else … is building a research team that is inclusive of the entirety of the population it is trying to serve.”
Dru Riddle

To begin, Riddle’s team conducted an analysis of recent systematic reviews that addressed the topic.

Systematic reviews are critical to establishing medical standards for patient treatment. To conduct them, reviewers compile large swaths of individual medical studies to gain insights. The data from those findings — a research-based consensus, if you will — is used to set the standard for conducting research and making practice recommendations.

Riddle’s research included studies from the Medline, Cochrane and Campbell medical databases. His team found 157 systematic reviews published from 2020 to 2023 that focused on interventions to reduce health care inequities. Each study was then evaluated on how it addressed the topic of race in health care.

“What we realized,” Riddle said, “is that race is almost completely absent from those systematic reviews.”

As an example: Comprehensive peer-reviewed studies from the CDC show that Black, Hispanic and Asian adults all have significantly elevated rates of high blood pressure compared with white adults. This finding indicates that race is a determinant that needs to be considered when treating a patient for high blood pressure.

Yet Riddle’s team found the systematic reviews used to develop patient treatment guidelines for high blood pressure did not account for race in any meaningful way.

“If you’re a 65-year-old Black man or a 65-year-old white woman, [the doctor’s medical] recommendations should be different based on race,” Riddle said. “A lot of the time, unfortunately, the systematic reviews are not considering that.”

GETTING TO THE ROOT

Dru Riddle is part of a $1 million grant to conduct a systematic review of studies about reducing inequality in health care. Photo by Rodger Mallison

The end goal of the reviews is to build in practices, or structural interventions, to address racial health inequity. A structural intervention might be a change to an institutional policy or procedure or a recommendation for how a patient accesses a product or service.

Riddle’s team concluded that the structural interventions proposed in current systematic reviews are ineffective in addressing racial health inequity. Of the 157 studies that the team reviewed, only 22, or 14 percent, acknowledged the role of race in the health care inequities. The studies’ effectiveness was further reduced by recommendations that sought to remedy the symptoms of racial health inequity instead of solving its root cause.

“Most of these reviews focused on tailoring how care is delivered, such as cultural adaptations … rather than assessing how or which interventions could reduce structural and systemic barriers to health,” said Meera Viswanathan, director of RTI International-University of North Carolina Evidence-based Practice Center and a member of Riddle’s research team.

The team interviewed patients, community members, clinicians, medical guideline developers and researchers about the current state of systematic reviews that examine racial health inequity and asked about what could be done to improve the work.

“Our qualitative interviews of 29 experts found that they wanted changes to the funding, staffing, conduct, dissemination and implementation of systematic reviews to focus on racial health equity,” Viswanathan said.

Based on those interviews, the team developed several solutions it hopes will help researchers address the root causes of racial health inequity.

VITAL TEAM MEMBERS

One solution that Riddle’s team advises is to ensure greater racial representation in the teams conducting systematic reviews.

“Probably more impactful than anything else,” Riddle said, “is building a research team that is inclusive of the entirety of the population it is trying to serve.”

Another suggestion is to change foundational guidelines to make race a regular element in the systematic review process. This could include adjusting research training methods to focus more on race or to provide greater incentives, such as grant funding, for more comprehensive systematic reviews on racial health inequity.

With the research complete, Riddle’s team has been hard at work publicizing the findings. Team members have been hosting podcasts and webinars to raise awareness about racial health inequity in the medical science field.

The team is also seeking additional funding from the Robert Wood Johnson Foundation to test its conclusions.

“We now have some idea of what can be done to improve health care equity,” Riddle said. “But we need to test it and figure out if it actually makes a difference.”