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

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).

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.

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^58-60, language disparities⁶¹, advancing equity for LGBTQ+ peoples^62,63) or covered only sparingly (eg, tools⁶⁴/interventions⁶⁵ 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^73-78).

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,^79-88 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 review⁸⁹ 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.

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.

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

Correspondence: Warren B. Fingrut, University of Texas MD Anderson Cancer Center, 1515 Holcolmbe Blvd, Houston, TX 77030; email: wbfingrut@mdanderson.org; and Angela C. Weyand, University of Michigan Medical School, 1301 Catherine St, Ann Arbor, MI 48109; email: acweyand@med.umich.edu.