For background on how the ACR is taking the lead in advancing health equity by providing a roadmap of strategies and resources for radiologists, their partners and the patients, see Meeting the Challenges of Providing Equitable Healthcare.

In this month's BOC Chair column, A Different Strategy, guest columnist Peter Abraham, MD, ACR Representative on the Radiology Health Equity Coalition, shares research that shows how radiologists can facilitate more open discussion around diversity, equity and inclusion in healthcare.

Efforts to eradicate disparities in delivering critical imaging services continue to gain momentum as systemic problems within the healthcare system loom large over the house of medicine. Current healthcare inequities in radiology can result in lower quality of care, poor patient outcomes and higher costs to patients and providers. 

Marginalized populations often face barriers to treatment — including education and outreach, access to healthcare services and a host of social determinants that plague underserved communities. Initiatives that establish health equity coalitions and build from innovative institutional efforts to ensure health equity on a national united front are helping to put equitable healthcare services within reach.

The ACR supports the cause through its work with the Radiology Health Equity Coalition (RHEC), a group of 11 organizations that joined forces in 2021 to positively impact health equity for women, people of color and rural populations. Many radiology groups lack a dedicated health equity program, but committed radiologists and like-minded specialists are working to chip away at inequities that too often slip through the cracks of a beleaguered delivery landscape. 

“The ACR is committed to improving patient care and supporting its members in ensuring delivery of high-quality care for all patients,” says Carla Brathwaite, MS, who serves as the ACR’s diversity, equity and inclusion program manager and represents the ACR on the RHEC along with ACR BOC Chair Jacqueline Bello, MD, FACR. “As a founding member of the RHEC, the ACR works with other radiology and medical specialty organizations to improve and advance the radiological care of medically underserved patients.”

To paint a picture of how radiologists and physicians from other specialties are helping move the needle in the health equity discussion, the Bulletin is interviewing changemakers who are advancing equitable care for marginalized populations. This article is the first in a five-part series. 

Advocating Access to Uterine Fibroid Treatments

In the health equity movement, there is an ongoing battle among healthcare organizations that serve women. It targets the underuse of uterine fibroid embolization (UFE) as a treatment option for patients whose primary care providers and OB/GYNs commonly recommend more invasive procedures. 

“I have been frustrated with the lack of unified efforts around providing equitable patient education and care for vulnerable populations,” says Pratik A. Shukla, MD, a vascular and interventional radiologist at Rutgers University. Shukla is a passionate proponent of UFE as an effective and lower-risk alternative to hysterectomy and myomectomy.

When you go out into the community, visiting churches, or attending public events, referrals tend to go up. But that doesn't last.

Uterine fibroids disproportionately affect Black and Hispanic women, Shukla says, and symptomatic fibroids are more common among them. The severity of symptoms that require treatment also tends to be higher in these populations, he says.

UFE is performed by an IR and is a non-surgical, minimally invasive treatment option for uterine fibroids. A patient’s uterus remains preserved, and there is a lower complication rate — with reductions in pain, fibroid size and blood loss. Most patients can return home the same day and resume normal activities within one week, according to Johns Hopkins Medicine, and approximately nine of 10 patients who undergo UFE will experience significant improvement, or their symptoms will go away completely. 

In contrast, myomectomy involves the removal of fibroids by cutting or shaving them from affected parts of the uterus while preserving healthy parts of the organ. Myomectomy surgery has similar outcomes to UFE because new fibroids can resurface later in healthy uterine tissue.

Hysterectomy is an even more invasive and complicated procedure. It is major surgery that requires significant recovery time following the removal of the uterus to remove the fibroids, according to The Fibroid Treatment Collective. While hysterectomy surgery is the only permanent treatment option for uterine fibroids, it is a solution of last resort for women who want to preserve fertility.

Disparities in Referrals

“After my residency in New York City, I returned to Rutgers as an attending, where I expected to find a lot of fibroid embolization procedures happening,” Shukla says. “What I found were lots of women still undergoing hysterectomy and myomectomy. I couldn’t understand why we were only performing UFE about twice a week while the hospital was doing five hysterectomies a day. We just weren’t getting the referrals.”

Shukla was determined to advance awareness of fibroid embolization as a treatment option. He gave grand rounds on the procedure, reached out to OB/GYNs and hospital leadership, helped organize health fairs and sought out and joined fibroid support groups. “I found that many women in the support groups believed a heavy, painful period was something they just had to endure, without knowing their options,” he says.

“We haven’t been able to do the type of direct patient marketing in this space that we have had success with for other procedures — mainly because of the makeup of the population who need fibroid treatment,” Shukla says. “It is a condition that largely affects an underserved population who may not have access to social media or a smartphone, for example. When you go out into the community, visiting churches or attending public events, referrals tend to go up. But that doesn’t last.”

Even if a woman chooses hysterectomy, she must be presented with all alternatives beforehand as part of an informed consent procedure, Shukla says. “We don’t get referrals from OB/GYNs in part because doing a hysterectomy is covered by insurance and more profitable for the healthcare system than UFE, which falls under Medicaid or charity care,” he says. “Also, patients go with what they know — moms, aunts and other friends and family members have all had hysterectomies. That’s what they know, and that’s what they opt for.”

Of invasive procedures for symptomatic uterine fibroids, a study published in the JACR found that hysterectomy was used more frequently than endometrial ablation, myomectomy and UFE combined. These types of findings about the underuse of uterine fibroid treatment options got Shukla very interested in equal access to healthcare. 

Awareness and Collaboration

Shukla decided to reach out to other organizations — including the ACR through the RHEC and the leadership of the Society of Interventional Radiology (SIR). “The idea is to raise awareness in our communities around the options women have,” Shukla says. “After a few conversations with the RHEC and SIR about drawing more attention to UFE, we are now trying to set up a few projects to that end.”

Through RHEC resources, Shukla also hopes to learn more about how insurance coverage impacts referrals for UFE. “We want to see more research on the economics of the problem,” he says. Through coalition participants, he hopes to attain, compile and publish findings based on large-scale data for Medicare, Medicaid and commercial insurance. 

“We need studies on a grander scale to garner more national attention,” Shukla says. “We designed a smaller, focused study at Rutgers — which took a few years to put in place — to identify and interview any woman who’d had a hysterectomy. We did it in the radiology department when women came in for imaging. Through our institution-approved independent review board, we were able to look at their charts to see if they had undergone a hysterectomy for fibroids. If so, they were contacted and asked to enroll in a survey.” 

Results showed that a significant percentage of these women had no idea what fibroid embolization was. “It was pretty striking to find they had never been told about this option,” he says.

During his fellowship at Mount Sinai, Shukla tried to convince newer OB/GYNs to form a joint clinic to consider more fibroid embolization treatment. He has also reached out to a similar group at Rutgers, but it has been a real challenge, he says. 

“I think that even relatively new OB/GYNs have been trained to believe that surgical options are the best options and that UFE isn’t as effective,” Shukla says. “If that’s what you are taught, that’s likely what you will believe.” Shukla is now working with hospital leadership to secure an in-house grant to recruit medical students to go out into local communities to bolster UFE awareness. 

“We have an inherent uphill battle when it comes to equitable care, but I am committed to public outreach and practice building to raise awareness of UFE and other procedures that marginalized populations may not be getting,” Shukla says. “Limited access to a treatment that has proven effective time and time again is a problem we can solve.”

About the RHEC

The Coalition was convened by the ACR and includes the American Board of Radiology, American Medical Association Section Council on Radiology, Association of University Radiologists, National Medical Association Section on Radiology and Radiation Oncology, Radiological Society of North America, Society of Chairs of Academic Radiology Departments, Society of Interventional Radiologists, Society of Nuclear Medicine and Molecular Imaging and American Association of Physicists in Medicine — with other specialty and state radiology organizations in line to join the initiative.

This network of patient-focused radiology societies will collect, assess and disseminate resources and best practices, advocate for and connect with patients and community members, and collaborate on programs and services to improve access and use of preventive and diagnostic imaging. Visit the RHEC website to find out more.  

Raising Awareness for Uterine Fibroids

Several resources became available in July to mark Fibroid Awareness Month, including:

• An ACR Voice of Radiology blog by Pratik A. Shukla, MD.
• An ACR Bulletin podcast with Shukla as the guest.  
• A patient-friendly video created by the ACR Commission on Patient- and Family-Centered Care. 
• An RHEC Community of Practice on-demand webinar on Disparities in Uterine Fibroid Treatment.

For more news, see a full list of the latest ACR Bulletin articles.