Implicit Bias, Healthcare Inequities Impact Cancer Care for Patients with Disabilities

Preexisting or coexisting disabilities among patients who are undergoing cancer care and the issues of implicit bias and healthcare inequities can impact patients’ cancer care were discussed in a presentation on the 2023 Oncology Nursing Society (ONS) Bridge live virtual conference.

The CDC has determined that as of last year up to 26% of US adults have some form of disability, noted Grace Cullen, DNP, FNP-BC, AOCNP, pmgt-BC, FPCN, a nurse practitioner at the Detroit VA Medical Center. But oftentimes, disabilities are missed, impacting patients’ quality of care and quality of life.

Eleven percent of patients have mobility disabilities; 11% have cognitive disabilities, such as memory or processing problems; 6% have hearing issues; 5% have vision problems; and more than 6% face challenges in independent living or self-care — problems that can be compounded by a cancer diagnosis and cancer treatment.

In her presentation, Cullen differentiated between impairment, disability, and handicaps. Impairment implies organ or musculoskeletal dysfunction, whereas disability refers to an inability to interact in home, social, or work settings due to an impairment. Handicaps are consequences of disability, she explained.

People with physical disabilities are also markedly more likely to have comorbid conditions such as obesity, heart disease, diabetes, or tobacco dependence that can impact cancer prognosis and treatment efficacy. Elderly patients are more likely to have disabilities and comorbidities, she said.

Formal assessment instruments such as the Oswestry Disability Index for spinal disorders and back pain, for example, can help identify patients affected by disabilities. However, Cullen cautioned that cognitive assessment tools can be challenging to interpret because cognitive impairment might be caused by a disability, cancer, cancer treatment, depression, or bipolar disorder.

The mini-mental state examination (MMSE) is used to identify patients’ cognitive disabilities by assessing the patient’s orientation to time, ability to recall details, their orientation to where they are (place), attention, language use, ability to repeat, and ability to follow complex instructions or commands.

Health care inequities are common among people with disabilities in the US: One-quarter have no healthcare provider prior to a cancer diagnosis, 20% have unmet healthcare needs because of costs, and one-quarter have not had a routine checkup in the past year, Cullen said. Physical disability is associated with less education; more economic, food, housing, and job insecurity; and less access to the Internet. Those disparities are disproportionately high among racial and ethnic minorities, she pointed out.

Cancer care centers and other medical facilities can exacerbate inequities thanks to limited equipment availability or physical access barriers, untrained or inadequately trained healthcare providers, and treatment guidelines that do not reflect consideration or understanding of what people with disabilities need.

“Unfortunately, all of these result in poorer outcomes for patients,” Cullen emphasized.

Healthcare workers frequently hold implicit biases or inaccurate assumptions about people with disabilities, or over-rely on family members or caregivers for conversations or to address patients’ disability-related needs.

“There has been unconscious bias noted amongst providers,” Cullen explained. “Some of us might rely on caregivers to get a history instead of actually engaging the patient because we make false assumptions that they are not capable of participating in that conversation. So be careful when you’re performing your assessments,” she added.

Research shows that provider attitudes about disability vary with providers’ age, political beliefs, gender, and with whether or not the provider has a disability or has family or friends with disabilities, Cullen noted.

“Younger providers who identify as strongly liberal, [are] female, have disabilities themselves or know people who do tend to have less of a bias about people with disabilities,” Cullen said.

Too frequently, it falls to the patients themselves to educate their clinical care team members about their needs — and not all patients are able to do so.

Patients might sometimes be unwilling to engage or use adaptive equipment, she acknowledged. “How often do we see patients who come in reporting recurring falls and who were issued a cane or walker, but who see you in clinic without those devices and tell you, ‘I don’t want to look sick’ or ‘I forgot it at the house’?” she asked. “We need to educate patients about sticking with a plan to keep them safe and mobile.”

Telemedicine can help but is frequently neglected.

Provider barriers include lack of specific training and confidence, familiarity, or understanding, about screening patients for disabilities. In addition to providers’ attitudes and stereotypical thinking, barriers to care for people with disabilities include patient transportation and institutional or programmatic issues such as staffing levels and a lack of time to carefully and effectively communicate with patients who have disabilities.

Addressing the needs of patients with disabilities is not just a nicety or fairness issue; failing to do so can violate federal law. The Americans with Disabilities Act (ADA) requires healthcare providers and facilities to accommodate people’s physical and mental impairments, Cullen noted. The Affordable Care Act mandates use of screening and accommodation equipment to meet patients’ needs.

Addressing the needs of these patients is interdisciplinary and requires a team, including a counselor.

Improving care for patients with disabilities hinges on identifying modifiable barriers, providing adaptive equipment, and communication aids, Cullen said.

But frequently, accommodations can be very simple: Use a large 48-point font size in written instructions for patients. Speak more loudly to patients with hearing impairments and use careful, slower enunciation to allow patients to lip read. Use short sentences and simple language for patients with cognitive impairments. These measures can make a big difference in patients’ comprehension of, and participation in, their care.

Use encouraging language that highlights a patient’s capabilities instead of spotlighting their disabilities is also helpful, she advised. “We need to be more mindful about how we interact with individuals,” she said.

Disclosures: Cullen reported no financial disclosures. She is a federal employee and the views and opinions expressed in the talk were not those of the US government or the Veterans Health Administration.

Reference

Cullen G. Caring for oncology patients with physical disabilities. Presented at: ONS Bridge 2023; September 12-14, 2023.