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Blood advances · 2024

The American Society of Hematology Health Equity Compendium: examining health equity across the Blood journals.

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Fingrut WB, Troyer J, Russell E, Aviles M, Della-Moretta S, Dobson D, Hasanali Z, Hu B, Lapite A, Pillai PM, Schramm JW, Villagomez LM, Vo P, Wang'ondu R, Yui J, Weyand AC

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This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

TO THE EDITOR:

Health equity is increasingly recognized as a critical priority throughout medicine. Through an initiative of the American Society of Hematology (ASH) Health Equity Task Force, we set out to develop a compendium connecting health equity manuscripts published across Blood journals. Our goals were to gather published manuscripts together to highlight the important work being done related to health equity in hematology, note areas that would benefit from more attention, connect stakeholders, and inspire others to spearhead projects to characterize and address disparities.

To build the compendium, we systematically reviewed all articles published in Blood/Blood Advances/Hematology , ASH Education Program between January 2018 and June 2023, for which the full-length manuscript contained ≥1 health equity keyword (see Table 1 ). Manuscripts were eligible for inclusion if principally focused on health equity in hematology, for patients, blood/stem cell donors, or the workforce. We excluded papers on care delivery challenges/outcome differences for patients who are frail or those with high comorbidity burdens or high-risk disease features; understudied diseases (eg, sickle cell disease and amyloidosis) unless otherwise related to health equity; or global health (ie, care differences in lower/middle income countries). Two coauthors screened each article, with disagreements resolved by a third. For included articles, 2 coauthors extracted the following data, with disagreements resolved by a third: journal, publication year, topic, design, population, health disparities examined, disease site, and partnership with patient/community advocates (see supplemental Table 1 for a complete list of data extracted).

Table 1.
Health equity keywords used to identify articles for screening
Manuscript keyword search was performed by Blood family journal staff members.

CategoryKeywords
OverallDisparities, disparity, “access to care,” “equality of outcomes,” equity, inequities, “social determinants of health,” underprivileged, underserved, “implicit bias,” “unconscious bias”
SexSexism
Race/ethnicityMinoritize, “underrepresented minorities,” racism
Socioeconomic statusPoverty, “socioeconomic status,” “financial barriers,” “zip code,” “transportation barriers,” “lack of insurance,” uninsured, “health literacy”
Sexual orientation/gender identityLGBT, LGBTQ, lesbian, gay, bisexual, transgender
Incarceration/legal historyIncarcerated

Overall, the keyword search returned 1178 manuscripts. Of these, 1121 were determined to be ineligible, with 57 included in the compendium ( https://ashpublications.org/collection/41840/Health-Equity-Compendium ). Table 2 lists included manuscripts by topic. Supplemental Table 2 reports all data extracted.

Table 2.
Articles included in the ASH Health Equity Compendium, by manuscript topic
ALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia; BMT, bone marrow transplant; CAR, chimeric antigen receptor; CLL, chronic lymphocytic leukemia; FDA, Food and Drug Administration; GVHD, graft-versus-host disease; heme/onc, hematology/oncology; n/a, not applicable; SES, socioeconomic status; SLL, small lymphocytic lymphoma; TTP, thrombotic thrombocytopenic purpura.

AuthorsJournalYearStudy summaryStudy designStudy siteDiseaseDisparities examinedSES measures
Basic science correlates of disparities
Hu et al 1Blood2018Genetic determinants of racial disparities in vitamin B12 levelsBasic sciencen/aHematopoiesisRace/ethnicityn/a
Qian et al 2Blood2019Genetic basis for racial disparities in ALLBasic sciencen/aHematologic malignancyRace/ethnicityn/a
Fillmore et al 3Blood Advances2021Genetic basis for racial disparities in multiple myelomaBasic sciencen/aHematologic malignancyRace/ethnicityn/a
Mittelman et al 4Blood2021Genetic basis for racial disparities in ALLBasic sciencen/aHematologic malignancyRace/ethnicityn/a
Health equity in laboratory medicine
Merz et al 5Blood2021Appeal to stop labeling common phenotypes in non-White populations as abnormalPerspective/editorialn/aLeukocytes, inflammation, immunologyRace/ethnicityn/a
Merz et al 6Blood Advances2023Duffy-null phenotype is common among Black people and is associated with lower absolute neutrophil countProspective observationalSingle centerLeukocytes, inflammation, immunologyRace/ethnicityn/a
Bagheri et al 7Blood Advances2023Duffy-null phenotype is common among Black people and is associated with lower absolute neutrophil countRetrospectiveSingle centerLeukocytes, inflammation, immunologyRace/ethnicityn/a
Disease phenotype and outcome differences by patient demographics
Østgård et al 8Blood2018Association between cohabitation status, treatment, and outcome in patients with AMLRetrospectiveDatabaseHematologic malignancySESCohabitation, marital status
Goldstein et al 9Blood2018Disparities in survival by insurance status in follicular lymphomaRetrospectiveDatabaseHematologic malignancySESInsurance status
Ailawadhi et al 10Blood Advances2019Racial disparities in treatment patterns and outcomes among patients with multiple myelomaRetrospectiveDatabaseHematologic malignancyRace/ethnicityn/a
Fillmore et al 11Blood2019Racial differences in survival among patients with multiple myelomaRetrospectiveDatabaseHematologic malignancyRace/ethnicity, SESIncome
Zhang et al 12Blood Advances2020Impact of single parenthood on cardiopulmonary function in pediatric patients with sickle cell anemiaProspective observationalMulticenterRed cell physiology and disordersSESSingle-parent household
Kim et al 13Blood2020Racial differences in ITP prevalence and phenotypeRetrospectiveMulticenterHemostasis, thrombosis, vascular wall biologyRace/ethnicityn/a
Conneely et al 14Blood Advances2021Racial/ethnic disparities in clinical phenotype, genetics, and survival in pediatric AMLRetrospectiveDatabaseHematologic malignancyRace/ethnicityn/a
Yao et al 15Blood Advances2021Disparities in skeletal toxicity among patients with childhood ALLRetrospectiveSingle centerHematologic malignancyRace/ethnicityn/a
Glimelius et al 16Blood Advances2021Marital status affects transplant access and survival for patients with mantel cell lymphomaRetrospectiveDatabaseHematologic malignancySESMarital status
Bona et al 17Blood2021Neighborhood poverty and pediatric allogeneic transplant outcomesRetrospectiveDatabaseBMT and cell therapiesRace/ethnicity, SESNeighborhood poverty, insurance status
Milrod et al 18Blood2021Skin hyperpigmentation in Black patients receiving treatment with immunomodulatory drugsRetrospectiveSingle centerBMT/cell therapiesRace/ethnicityn/a
Van der Meulen et al 19Hematology, ASH Education Program2022Review of the impact of von Willebrand disease on womenReviewn/aHemostasis, thrombosis, vascular wall biologyGendern/a
Peres et al 20Blood Advances2022Racial disparities in clonal hematopoiesis, tumor markers, and outcomes in patients with multiple myelomaRetrospectiveSingle centerHematologic malignancyRace/ethnicityn/a
Datta et al 21Blood Advances2022Racial disparities in cancer-associated thrombosisRetrospectiveDatabaseHemostasis, thrombosis, vascular wall biologyRace/ethnicityn/a
Faruqi et al 22Blood Advances2022Racial/ethnic disparities in CAR T-cell therapy outcomesRetrospectiveSingle centerBMT/cell therapiesRace/ethnicityn/a
Chaturvedi et al 23Blood2022Racial disparities in relapse risk and response to rituximab in patients with TTPRetrospectiveMulticenterHemostasis, thrombosis, vascular wall biologyRace/ethnicityn/a
Abraham et al 24Blood2022Structural racism is a mediator of disparities in AML outcomesRetrospectiveMulticenterHematologic malignancyRace/ethnicity, SESStructural racism, insurance status
Kittai et al 25Blood Advances2023Racial and socioeconomic disparities in CLL/SLLRetrospectiveDatabaseHematologic malignancyRace/ethnicity, SESNeighborhood poverty
Larkin et al 26Blood Advances2022Racial disparities in early death rates, treatment resistance, and survival in Black adolescents and young adults with AMLRetrospectiveMulticenterHematologic malignancyRace/ethnicityn/a
Gangat et al 27Blood Advances2023Racial disparities in myelofibrosis phenotype and survivalRetrospectiveMulticenterHematologic malignancyRace/ethnicityn/a
Newman et al 28Blood2023Impact of poverty on outcomes for children treated with CD19-directed CAR T-cell therapyRetrospectiveSingle centerBMT and cell therapiesRace/ethnicity, SESNeighborhood poverty, insurance status
Access to care for underserved populations
Bhatt et al 29Blood Advances2018Socioeconomic status disparities in treatment patterns among patients with newly diagnosed AMLRetrospectiveDatabaseHematologic malignancyRace/ethnicity, SESInsurance status, median household income
Husson et al 30Blood2018Review of unique barriers affecting care delivery and outcomes for adolescents and young adults with hematologic malignanciesReviewn/aHematologic malignancyAge, SESEducation, employment, and financial challenges, social relationship
Keegan et al 31Hematology, ASH Education Program2018Disparities in clinical trial enrollments for adolescent patientsReviewn/an/aAge, race/ethnicity, SESInsurance status
Franceschi et al 32Blood2019Access to emergency departments for acute events and identification of sickle cell disease in refugeesRetrospectiveMulticenterRed cell physiology and disordersImmigration statusn/a
Chino et al 33Blood Advances2019Disparities in place of death for patients with hematologic malignanciesRetrospectiveDatabaseHematologic malignancyRace/ethnicity, SESMarital status, education level
Barker et al 34Blood Advances2019Racial disparities in access to HLA-matched unrelated donor transplantsProspective observationalSingle centerBMT/cell therapiesRace/ethnicityn/a
Webb et al 35Hematology, ASH Education Program2020Review of the social aspects of chronic transfusion supportReviewn/an/aSESSocial determinants of health, health literacy
Buchbinder et al 36Hematology, ASH Education Program2021Review of psychosocial and financial issues after hematopoietic cell transplantationReviewn/aBMT/cell therapiesSESSocial/financial barriers
Hong et al 37Hematology, ASH Education program2021Review of access to allogeneic transplantation according to race, geography, and socioeconomicsReviewn/aBMT/cell therapiesRace/ethnicity, SESInsurance, education, poverty, employment
Teichman et al 38Blood Advances2021Socioeconomic disparities in iron deficiency screening in pregnancyRetrospectiveDatabaseRed cell physiology and disordersSESNeighborhood poverty
Fingrut et al 39Blood Advances2022Racial disparities in access to optimal alternative donor allograftsRetrospectiveSingle centerBMT/cell therapiesRace/ethnicityn/a
Hussaini et al 40Blood Advances2022Rural-urban disparities in place of death among patients with hematologic malignanciesRetrospectiveDatabaseHematologic malignancyGeographicn/a
Fingrut et al 41Blood Advances2023Racial disparities in time to allogeneic transplantationRetrospectiveSingle centerHematologic malignancyRace/ethnicityn/a
Wolfson et al 42Blood Advances2023Neighborhood poverty, health status, and health use after stem cell transplantationRetrospectiveMulticenterBMT/cell therapiesSESNeighborhood poverty, annual household income, education
Diversity, equity, and inclusion in clinical trials enrollment
Hantel et al 43Blood Advances2021Racial/ethnic disparities in enrollment and demographic reporting requirements in acute leukemia clinical trialsMeta-analysisDatabaseHematologic malignancyRace/ethnicityn/a
Kanapuru et al 44Blood Advances2022Racial/ethnic disparities in multiple myeloma US FDA approval trialsMeta-analysisDatabaseHematologic malignancyRace/ethnicityn/a
Muffly et al 45Blood Advances2022Disparities in trial enrollment and outcomes of Hispanic adolescent and young adult patients with ALLRetrospectiveMulticenterHematologic malignancyRace/ethnicity, SES, geographicHousehold income
Birhiray et al 46Blood Advances2023Practical strategies for creating diversity, equity, inclusion, and access in cancer clinical researchPerspective/editorialn/an/aRace/ethnicityn/a
Improving processes for the collection of data related to the social determinants of health
Fingrut et al 47Blood Advances2023Race/ethnicity and ancestry data collection process improvementRetrospectiveSingle centerBMT/cell therapiesRace/ethnicityn/a
Fingrut et al 48Blood Advances2023Socioeconomic status data collection process improvementRetrospectiveSingle centerBMT/cell therapiesRace/ethnicity, SESNeighborhood poverty, insurance status, receipt of financial support for medical or cost-of-living expenses
Interventions to address equity issues
Chou et al 49Blood2018Investigation of RH-genotype matching to improve use of African-American blood donor inventoryProspective observationalSingle centerTransfusion medicineRace/ethnicityn/a
Barker et al 50Blood Advances2020Optimizing cord blood transplantation to extend allograft accessRetrospectiveSingle centerBMT/cell therapiesRace/ethnicityn/a
Qayed et al 51Blood Advances2022Abatacept for GVHD prophylaxis can reduce racial disparities by abrogating the impact of mismatching in unrelated donor transplantationClinical trialMulticenterBMT/cell therapiesRace/ethnicityn/a
Bashey et al 52Blood Advances2023Close integration of leukemia and transplant services and use of haploidentical donors improves allograft access, but caregiver requirements continue to limit access for Black patientsRetrospectiveSingle centerBMT/cell therapiesRace/ethnicityLack of caregiver support
DeZern et al 53Blood2023Alternative donor BMT with posttransplant cyclophosphamide improves allograft access for patients with acquired severe aplastic anemiaClinical trialSingle centerBMT/cell therapiesRace/ethnicityn/a
Workforce disparities
King et al 54Blood Advances2020Gender and caregiving disparities in academic success in hematologyRetrospectiven/an/aGendern/a
Moazzam et al 55Blood Advances2020Gender disparities in question-asking at the 2019 ASH annual meetingRetrospectiven/an/aGendern/a
Syaj et al 56Blood Advances2022Gender disparities in heme/onc board review lecture series speakersRetrospectiven/an/aGendern/a
Jacobs et al 57Blood Advances2023Gender disparities in nontrainee hemostasis and thrombosis recognition award recipientsRetrospectiven/an/aGendern/a

Of 57 included manuscripts, 17 were published in Blood , 35 in Blood Advances , and 5 Hematology, ASH Education Program . These 57 articles reflect 0.67% of all articles published in these journals between January 2018 and November 2023. Compared with compendium articles published in Blood , those published in Blood Advances or Hematology, ASH Education Program made up nearly 3 times the proportion of all articles published in those journals during the search period (17/3160 [0.35%] vs 40/3565 [1.11%]; P < .001). Most manuscripts (n = 53) focused on patients, with 4 on the workforce and none about blood/stem cell donors. Eighteen included pediatric (n = 14) and/or adolescent/young adult (n = 7) patients, with 13 having a predominant pediatric focus. Most manuscripts (37/57, 65%) were retrospective, with only 6/57 (11%) being prospective observational studies (n = 4) or clinical trials (n = 2). Of 39 retrospective/prospective patient studies, 16 were single-center studies, 10 were multicenter studies, and 13 were database studies. Other manuscripts were basic science (n = 4), meta-analyses (n = 2), perspectives/editorials (n = 2), or reviews (n = 6). All but 5 manuscripts were conducted in, and/or focused on, the United States, with 1 each from Canada, Denmark, Italy, Sweden, and Britain. When analyzing by period, health equity–related outputs increased over time, with only one-third (19/57, 33%) of compendium articles published between January 2018 and December 2020 vs two-thirds (38/57, 67%) published between January 2021 and November 2023 ( P = .012 by 1-sample proportion test). Compendium articles also made up >2× the proportion of all published manuscripts in these journals in the recent (January 2021 to November 2023: 38/4163, 0.91%) vs earlier (January 2018 to December 2020: 19/4305, 0.44%) periods ( P = .008).

Classifying by topic, 4 manuscripts studied basic science correlates of disparities (all examining health impacts of population genetic differences). Three discussed laboratory hematology, all on structural racism in neutrophil reference ranges. Twenty-one reviewed disease phenotype/presentation, treatment patterns, and/or outcome differences by patient demographics. Fourteen characterized care delivery issues affecting underserved populations, including barriers to disease screening/diagnosis, therapies/transplantation, and emergency, follow-up, or palliative/hospice care. Four related to trial participation, including enrollment disparities, issues with reporting requirements, and barriers/facilitators for specific populations. Only 7 of 57 (12%) manuscripts outlined efforts to address disparities: 2 evaluated social determinant of health data collection process improvement (1 for patient race/ethnicity and ancestry, and 1 for socioeconomic status) and 5 reported interventions to advance equity (4 describing novel allograft platforms, and 1 outlining a transfusion medicine approach to address disparities). Four highlighted hematology workforce gender disparities in conference question-asking, academic awards, invited lectureships, and career success. None outlined educational initiatives.

By disease site, of 50 disease-related articles, most (38/50, 76%) examined hematologic malignancies (n = 23) or bone marrow transplant/cellular therapy (n = 15), with only 4 on hemostasis/thrombosis (1 cancer-associated thrombosis, 1 immune thrombocytopenic purpura, 1 thrombotic thrombocytopenic purpura, 1 von Willebrand disease), 3 leukocytes (all on Duffy-null–associated neutrophil count), 3 red cell physiology/disorders (2 sickle cell and 1 iron deficiency), 1 transfusion medicine, and 1 hematopoiesis.

Finally, with respect to health disparities examined, the majority of manuscripts (41/57, 72%) characterized racial/ethnic disparities, with 26 focusing on Black (n = 21) and/or Hispanic (n = 9) patients. Twenty articles related to socioeconomic status: 7 of 21 examined area-based measures (ie, neighborhood poverty), 13 of 21 examined individual financial barriers (insurance status and cost-of-living or medical expense financial support), and 10 of 21 examined individual social barriers (marital/cohabitation status, health literacy, caregivers, and educational attainment). Furthermore, 2 publications examined age (both regarding care delivery challenges affecting adolescent patients), 5 gender/parity (4 workforce and 1 bleeding disorders), 2 geographic, and 1 immigration status disparities. Only 12 of 57 (21%) publications considered intersectionality across multiple disparities. None focused on sexual and gender minorities, religion, disability, or incarceration/legal history, or described partnership with patient/community advocates to address disparities.

This compendium is, to our knowledge, the first of its kind in the literature. It highlights recent progress characterizing inequities and clarifies areas in which further study is especially warranted. Most manuscripts characterized racial/ethnic disparities for patients with hematologic malignancies or bone marrow transplant/cell therapy. Relatively few studied other underserved/underresourced populations or other disease sites, or piloted/evaluated interventions to mitigate disparities. Most did not consider intersectional impacts of multiple disparities, and none included explicit methodology outlining partnership with community/patient advocates. Our report highlights the need for works characterizing disparities across population demographics (incorporating consideration of the intersectional impacts of multiple disparities) and developing/testing interventions to address disparities in collaboration with patient/community advocates from the populations impacted.

Our analysis also highlights that, recently, nearly 1% of published works across the Blood journals relate to health equity. This finding can serve as benchmark for future comparisons of the proportion of health equity manuscripts published, within and across journals.

We acknowledge the important limitation that this compendium does not capture many important works in health equity in hematology published elsewhere, including on topics not yet covered in the Blood journals (eg, structural sexism in hematology 58 , 59 , 60 , language disparities 61 , advancing equity for LGBTQ+ peoples 62 , 63 ) or covered only sparingly (eg, tools 64 /interventions 65 to address disparities), or works conducted in partnership with patient/community advocates. 66 , 67 Additionally, this compendium does not consider works in development (eg, conference abstracts calling attention to ongoing racial discrimination, 68 evaluating disparities in understudied disease sites, 69 granularly characterizing patient socioeconomic status, 70 , 71 outlining health equity educational initiatives, 72 or developing/testing interventions to address disparities 73 , 74 , 75 , 76 , 77 , 78 ).

These limitations notwithstanding, the compendium (together with this analysis) will serve as an important tool to advance equity in hematology, by increasing dissemination/uptake of the latest advances in our understanding of disparities in hematology and how they can be addressed, and motivating researchers to study underexamined topics/diseases/populations. We commit to annual updates to include the lastest Blood journal health equity publications, 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 revising/expanding the keyword search as needed, with future iterations also including works published in Blood Neoplasia , Blood VTH , and all other forthcoming Blood journals. Finally, expanding on the work developing this compendium, we are currently conducting a scoping review 89 to examine and classify health equity publications across the major hematology journals and meetings. This review will permit us to describe the body of health equity work in hematology (including works in development), comparing across journals/meetings, and strengthen our ability to identify understudied areas warranting greater attention.

Conflict-of-interest disclosure: The authors declare no competing financial interests.

Acknowledgments

Acknowledgments: The authors thank the Blood / Blood Advances Editorial and Information Technology teams as well as the ASH Health Equity Task Force for their support.

Contribution: W.B.F. and A.C.W. cocurated the ASH Health Equity Compendium and designed the search strategy; W.B.F., M.A., S.D.-M., D.D., Z.H., B.H., A.L., P.M.P., J.W.S., L.M.V., P.V., R.W., J.Y., and A.C.W. developed the list of health equity keywords and screened articles for the compendium; W.B.F. and J.T. developed the data collection form and extracted data from included studies; W.B.F., J.T., and A.C.W. developed the search protocol for the ongoing scoping review; W.B.F. wrote the manuscript; and all authors reviewed and approved the final version of the manuscript.

Footnotes

Data related to the study are available on request from the corresponding authors, Warren B. Fingrut ( wbfingrut@mdanderson.org ) and Angela C. Weyand ( acweyand@med.umich.edu ).

The full-text version of this article contains a data supplement.

Contributor Information

Warren B. Fingrut, Email: wbfingrut@mdanderson.org.

Angela C. Weyand, Email: acweyand@med.umich.edu.

Supplementary Material

Supplemental Tables

References

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ИП Урсолов Владлен Сергеевич

ИНН 500118482352 · ОГРНИП 314500117700049

Реквизиты и контакты