Disparities in Electronic Screening for Cancer-Related Psychosocial Distress May Promote Systemic Barriers to Quality Oncologic Care

Abstract

Background: Screening for cancer-related psychosocial distress is an integral yet laborious component of quality oncologic care. Automated preappointment screening through online patient portals (Portal, MyChart) is efficient compared with paper-based screening, but unstudied. We hypothesized that patient access to and engagement with EHR-based screening would positively correlate with factors associated with digital literacy (eg, age, socioeconomic status). Methods: Screening-eligible oncology patients seen at our Comprehensive Cancer Center from 2014 through 2019 were identified. Patients with active Portals were offered distress screening. Portal and screening participation were analyzed via multivariable logistic regression. Household income in US dollars and educational attainment were estimated utilizing zip code and census data. Results: Of 17,982 patients, 10,279 (57%) had active Portals and were offered distress screening. On multivariable analysis, older age (odds ratio [OR], 0.97/year; P<.001); male gender (OR, 0.89; P<.001); Black (OR, 0.47; P<.001), Hawaiian/Pacific Islander (OR, 1.54; P=.007), and Native American/Alaskan Native race (OR, 0.67; P=.04); Hispanic ethnicity (OR, 0.76; P<.001); and Medicare (OR, 0.59; P<.001), Veteran’s Affairs/military (OR, 0.09; P<.01), Medicaid (OR, 0.34; P<.001), or no insurance coverage (OR, 0.57; P<.001) were independently associated with lower odds of being offered distress screening; increasing income (OR, 1.05/$10,000; P<.001) and educational attainment (OR, 1.03/percent likelihood of bachelor’s degree or higher; P<.001) were independently associated with higher odds. In patients offered electronic screening, participation rate was 36.6% (n=3,758). Higher educational attainment (OR, 1.01; P=.03) was independently associated with participation, whereas Black race (OR, 0.58; P=.004), Hispanic ethnicity (OR, 0.68; P=.01), non-English primary language (OR, 0.67; P=.03), and Medicaid insurance (OR, 0.78; P<.001) were independently associated with nonparticipation. Conclusions: Electronic portal–based screening for cancer-related psychosocial distress leads to underscreening of vulnerable populations. At institutions using electronic distress screening workflows, supplemental screening for patients unable or unwilling to engage with electronic screening is recommended to ensure efficient yet equal-opportunity distress screening.

Psychosocial Care after Cancer Diagnosis: Recent Advances and Challenges

“…Further, the complexity of incorporating patient-centred care into the design has been identified as one of the barriers to implement telemedicine and may lead to new disparities [ 17 ]. Indeed, electronic screening for cancer-related psychosocial distress was found to lead to the underscreening of vulnerable populations who are older in age, non-White and of lower socioeconomic status [ 18 ]. Not everyone has easy and direct access to IT media and care should be taken not to exclude patient groups who are less privileged and are often known to be at a higher risk of having psychosocial needs.…”

Advancing Health Equity in Cancer-Related Distress: Lessons Learned From the COVID-19 Pandemic on Leveraging Digital Tools and Future Directions

“…As illustrated by the findings of Sutton et al, 2 who investigated disparities in distress screening using online patient portals, these disparities relating to distress and cancer outcomes permeate digital distress screening uptake. They found that older age, certain races or ethnicities (eg, Black, Hispanic, Hawaiian/Pacific Islander), and types of insurance (eg, Medicare, Veterans' Affairs/military) or no insurance coverage were independently associated with lower odds of being offered distress screening.…”

“…A study elsewhere in this issue investigated screening for cancerrelated distress through online patient portals and the factors contributing to its use and efficiency. 2…”