Welcome to the Clinical Center Grand Rounds, a weekly series of educational lectures for physicians and health care professionals broadcast from the Clinical Center at the National Institutes of Health in Bethesda, MD. The NIH Clinical Center is the world's largest hospital totally dedicated to investigational research and leads the global effort in training today's investigators and discovering tomorrow's cures. Learn more by visiting us online at http://clinicalcenter.nih.gov >>WELCOME TO TODAY'S CLINICAL CENTER GRAND ROUNDS. THIS WEEK IS PATIENT SAFETY AWARENESS WEEK. PATIENT SAFETY AWARENESS WEEK WAS FOUNDED IN 2003, BY THE NATIONAL PATIENT SAFETY FOUNDATION, WHICH LATER MERGED WITH THE INSTITUTE FOR HEALTH CARE IMPROVEMENT. THIS WEEK WAS ESTABLISHED TO ESTABLISH EVERYONE TO LEARN MORE ABOUT HEALTH CARE SAFETY, TO ADVANCE IMPORTANT DISCUSSIONS LOCALLY AND GLOBALLY, AND TO INSPIRE ACTION TO IMPROVE THE SAFETY OF THE HEALTH CARE SYSTEM FOR PATIENTS AND FOR THE WORKFORCE. AT THE NIH CLINICAL CENTER, WE'RE GUIDED BY OUR INDIVIDUAL AND COLLECTIVE PASSION FOR HIGH RELIABILITY IN THE SAFE DELIVERY OF PATIENT-CENTRIC CARE IN A CLINICAL RESEARCH ENVIRONMENT. WE PROVIDE HOPE THROUGH PIONEERING CLINICAL RESEARCH TO IMPROVE HUMAN HEALTH. FOR US, WE KNOW SAFE AND HIGH-QUALITY PATIENT CARE ARE INTEGRAL TO THE WORLD CHANGING CLINICAL RESEARCH. OUR SPEAKER TODAY IS DR. BLAIR EIG, WITH THE NON-PATIENT SAFETY ORGANIZATION DESIGNATED BY MARYLAND AND BY OUR SIBLING FEDERAL AGENCY THE AGENCY FOR HEALTH CARE RESEARCH AND QUALITY. DR. EIG IS A NATIVE OF MARYLAND, AND RECEIVED A BACHELOR'S IN BIOLOGY AND BIOCHEMISTRY AND MASTER'S IN BIOCHEMISTRY IN BRANDEIS UNIVERSITY. HE EARNED A MEDICAL DEGREE FROM HARVARD MEDICAL SCHOOL, AND COMPLETED HIS PEDIATRIC RESIDENCY AND CHIEF RESIDENCY AT CHILDREN'S NATIONAL MEDICAL CENTER IN WASHINGTON, D.C. HE LATER COMPLETED A MASTER'S IN BUSINESS ADMINISTRATION FROM AMERICAN UNIVERSITY, ALSO IN WASHINGTON, D.C. DR. EIG IS AT THE GEORGE WASHINGTON SCHOOL OF MEDICINE, CHIEF MEDICAL OFFICER AT HOLY CROSS HEALTH SYSTEM, PART OF THE MARYLAND REGION OF TRINITY HEALTH FOR 19 YEARS. PRIOR TO THAT, HE PRACTICED PRIMARY CARE PEDIATRICS FOR 14 YEARS IN SILVER SPRING. HE HAS SERVED AS PRESIDENT OF THE MEDICAL STAFF AT CHILDREN'S NATIONAL, CHAIR OF THE LABORATORY ADVISORY COMMITTEE FOR STATE OF MARYLAND, BOARD CHAIR FOR MARYLAND HEALTH CARE EDUCATION INSTITUTE, A MEMBER OF THE EXECUTIVE COMMITTEE OF THE MARYLAND HOSPITAL ASSOCIATION. I RECEIVED A LEADERSHIP AWARD FROM MONTGOMERY COUNTY PEDIATRIC SOCIETY, AND PEDIATRICIAN OF THE YEAR FROM THE SAME SOCIETY, AS WELL AS MAYNARD CONE AWARD FOR PEDIATRICS FROM CHILDREN'S NATIONAL MEDICAL CENTER. PLEASE WELCOME OUR SPEAKER, DR. BLAIR EIG, FOR HIS PRESENTATION, HEALTH EQUITY AS A PATIENT SAFETY ISSUE. DR. EIG. >> THANK YOU VERY MUCH, DAVID. THANK YOU ALL FOR INVITING ME HERE TO SPEAK TODAY ON THE TIMELY AND IMPORTANT ISSUE FOR SAFE DELIVERY OF HEALTH CARE AND FOR THE SUCCESS OF CLINICAL RESEARCH. I'M A NATIVE OF THE COMMUNITY, HONORED TO PRESENT TO THE CLINICAL CENTER. I ATTENDED A LOCAL HIGH SCHOOL, HAVE A BIG NUMBER REUNION WITH A ZERO AT THE END LATER THIS YEAR. I ALSO CARED FOR MANY OF THE CLINICAL STAFF FAMILY MEMBERS WHEN I WAS IN PEDIATRIC PRACTICE IN SILVER SPRING EARLY IN MY CAREER AND OVERSAW CARE OF MANY MORES CHIEF MEDICAL OFFICER AT HOLY CROSS FOR ALMOST 20 YEARS. FINALLY, AS I THINK DAVID MENTIONED, WE REALLY APPRECIATE HAVING THE CLINICAL CENTER AS A MEMBER OF THE MARYLAND PATIENT SAFETY CENTER. WE HAVE MANY CONFERENCES AND EDUCATIONAL PROGRAMS THAT YOU CAN ATTEND, MOST FOR FREE, SOME FOR REDUCED FREE, AND MANY INCLUDE CONTINUING EDUCATION LIKE CME FOR FREE. SO WE OFFER THAT TO YOU AND PLEASE WOULD LIKE YOU TO AVAIL YOURSELF OF THAT. TODAY I'LL BE DISCUSSING HEALTH EQUITY. WHAT IT IS, MORE ACCURATELY THE LACK OF IT, HOW IT IMPACTS DISPARITIES IN CLINICAL CARE AND CLINICAL RESEARCH AND WHAT WE CAN DO TO PROMOTE A MORE EQUITABLE HEALTH CARE SYSTEM, BECAUSE A MORE EQUITABLE HEALTH CARE SYSTEM WILL RESULT IN BETTER AND SAFER HEALTH CARE OUTCOMES FOR ALL OF OUR PATIENTS. THROUGHOUT THE TALK I'LL WEAVE IN WHAT WE'RE DOING AT THE MARYLAND PATIENT SAFETY CENTER IN THIS REGARD, WORKING ON DISPARITIES IN HEALTH CARE, IMPROVING SAFETY OF CARE PROVIDED, AND TRYING TO HELP BOTH CLINICIANS AND RESEARCHERS DO BETTER IN TERMS OF PROVIDING EQUITABLE CARE. I'LL END WITH SOME IDEAS ON WHAT YOU AS CLINICAL RESEARCHERS AND CAREGIVERS CAN DO TO IMPROVE HEALTH EQUITY AND THE GREAT WORK YOU DO. ASSISTED IN PREPARING THIS TALK BY MY STAFF AT THE MARYLAND PATIENT SAFETY CENTER. I WANT TO CALL OUT SPECIFICALLY DR. ADRIAN BURGESS, AN R.N. Ph.D., EXPERT IN MATERNAL CARE AND LED PROGRAMS IN THAT AREA INCLUDING SOME I'LL TALK ABOUT TODAY INCLUDING BIRTH EQUITY. I HAVE NO CONFLICTS, ACTUAL OR POTENTIAL, CONFLICTS OF INTEREST TO REPORT. THESE ARE LEARNING OBJECTIVES. BOTH VERY GOOD, A LITTLE COMPLEX BUT UNDERSTANDING THE IMPACT OF PERSONAL BIASES, IMPLICIT AND EXPLICIT, OF DIVERSITY AND INCLUSION ON SAFETY PATIENT CARE, AND STRATEGIES TO MITIGAE BUYS AND IMPROVE REPRESENTATION, ESPECIALLY IN CLINICAL RESEARCH. WE'LL GET STARTED WITH A QUOTE FROM DR. KING. OF ALL THE FORMS OF INEQUALITY INJUSTICE IN HEALTH IS THE MOST SHOCKING AND MOST INHUMAN BECAUSE IT OFTEN RESULTS IN PHYSICAL DEATH. THE DIAGRAM YOU SEE ON THE SLIDE, SORRY IT'S NOT AS CLEAR AS IT MIGHT BE, IS FROM THE MID-1960s, WHERE THEY STILL HAD SEGREGATED UNITS AT THE HOSPITAL. THERE'S A WING FOR BLACK FEMALES, BLACK MALES, AND WHITE FEMALES. AND AS IT WAS IN EDUCATION, SEPARATE WAS NOT EQUAL. AND THIS OBVIOUSLY IS LONG GONE BUT THERE STILL ARE SOME STRUCTURAL ISSUES IN THE HEALTH CARE WE PROVIDE THAT MAY LEAD TO UNEQUAL OUTCOMES DEPENDING UPON YOUR ETHNICITY, RACE, COUNTRY OF ORIGIN, LANGUAGE. WE'LL TALK MORE ABOUT THAT TODAY. SO WHAT IS HEALTH EQUITY? THIS IS THE DEFINITION FROM THE CDC, I REFER YOU TO THE CDC FOR MORE EXTENSIVE DISCUSSION ON THE WEBSITE. BUT HEALTH EQUITY IS THE STATE IN WHICH EVERYONE HAS A FAIR AND JUST OPPORTUNITY TO ATTAIN THEIR HIGHEST LEVEL OF HEALTH. NOT EVERYONE WILL BE ABLE OR WILL WANT TO SEEK THAT OUT, BUT EVERYBODY SHOULD HAVE THAT OPPORTUNITY. AND I'LL ALSO POINT OUT, SOMETHING WE'LL TALK ABOUT HERE, IS IN THE THIRD BULLET POINT THAT IS INVOLVES ACKNOWLEDGING AND ADDRESSING RACISM AS A THREAT TO PUBLIC HEALTH AND RESEARCH, AND THE HISTORY OF UNETHICAL PRACTICES IN PUBLIC HEALTH TO LED TO INEQUITABLE HEALTH OUTCOMES. THIS ALSO IMPACTS THE TRUST THAT VARIOUS COMMUNITIES HAVE IN THE HEALTH CARE SYSTEM, AND IN CLINICAL RESEARCH. AGAIN, WE'LL TALK ABOUT THAT, BUT IT'S IMPORTANT TO UNDERSTAND THAT THERE IS A LEVEL OF -- IN THE STRUCTURE OF OUR HEALTH CARE SYSTEM AND IN OUR CLINICAL RESEARCH THAT STILL LEADS TO UNEQUAL REACHING OUT AT OUTCOMES, AND A LACK OF TRUST THAT CERTAIN COMMUNITIES HAVE IN US. AND WE NEED TO OVERCOME THAT. SO, WHAT IS THE IMPORTANCE OF HEALTH EQUITY? AND THE FIRST IS MAYBE THE MOST IMPORTANT. IT'S WHAT AMERICA IS ABOUT. IT'S OUR DREAM. HERE'S THE QUOTE FROM DECLARATION OF INDEPENDENCE, ACKNOWLEDGE THAT WAS WRITTEN BY THOMAS JEFFERSON WHO OWNED SLAVES. HE ALSO WROTE, WHICH WAS THE -- IN THE SPIRIT OF THE TIME ALL MEN ARE CREATED EQUAL, I CHANGED THAT, ALL ARE CREATED EQUAL. THAT'S WHAT WE BELIEVE IN OUR SYSTEM, THAT EVERYBODY HAS AN EQUAL CHANCE. AND SHOULD HAVE AN EQUAL CHANCE TO LIFE, LIBERTY, PURSUIT OF HAPPINESS AND HEALTH CARE. THERE'S AN ETHICAL IMPERATIVE. IT'S THE RIGHT THING TO DO. WE ALL AGREE, I WOULD HOPE, THAT EVERYBODY SHOULD HAVE THAT EQUAL CHANCE TO THE BEST HEALTH CARE ATTAINABLE. THERE'S COMMUNITY STANDARDS. WE DON'T THINK THAT ONE GROUP OF OUR COMMUNITY HAS A LESS OF A RIGHT THAN ANOTHER. AND MANY OF OUR SOCIAL AND RELIGIOUS TRADITIONS SPEAK TO COMPASSION FOR THOSE WHO HAVE LESS THAN THE REST OF US, THAT WE SHOULD HAVE COMPASSION AND PROVIDE FOR THOSE IN NEED BECAUSE THEY DON'T HAVE THE RESOURCES, THEY DON'T HAVE THE KNOWLEDGE, THEY DON'T HAVE THE ABILITY TO GAIN THAT, AND WE SHOULD HELP PROVIDE THAT FOR THEM. FINALLY, I'LL COME BACK TO THIS AGAIN A FEW TIMES, THERE'S A FINANCIAL COST TO SOCIETY. MAYBE IT GOES WITHOUT SAYING, BUT I OFTEN WANT TO REPEAT FOR EVERYONE THAT IT IS MUCH MORE EXPENSIVE TO TREAT THE ILLNESS OR THE MEDICAL ERROR THAT OCCURS THAN TO PREVENT IT. SO DEVELOPING SAFE AND BROAD HEALTH CARE AND RESEARCH IS AN IMPERATIVE BECAUSE IT'S CHEAPER THAN HAVING TO BE REACTIONARY AND PAY FOR IT WHEN IT GOES WRONG. CAUSES OF HEALTH CARE DISPARITIES WE'LL CONTINUE TO LEARN OF THE SOCIAL DETERMINANTS OF HEALTH. THOSE INCLUDE NOT HAVING RESOURCES, POVERTY, ENVIRONMENTAL THREATS THAT SOME COMMUNITIES, AND WE'VE LEARNED OF THIS MOST RECENTLY IN OHIO, IT'S ALSO HAPPENED IN VARIOUS COMMUNITIES STRUGGLING WITH LEAD CONTAMINATING THE WATER, THAT THERE ARE ENVIRONMENTAL THREATS OUT THERE THAT PUT SOME PEOPLE AT MORE RISK AND THEY TEND TO BE IN AREAS THAT HAVE LESS ACCESS TO BOTH HEALTH CARE AND OTHER RESOURCES. THERE'S INDIVIDUAL AND BEHAVIORAL FACTORS THAT MAY NOT HAVE TO DO WITH SOCIAL DETERMINANTS OF HEALTH, BUT THE LACK OF TRUST IN THE SYSTEM OR NOT JUST UNDERSTANDING, EDUCATIONAL INEQUALITIES, AGAIN WITHOUT THE KNOWLEDGE OF WHAT IS NEEDED. AND RACISM, STILL BUILT IN SOME OF OUR SYSTEMS THAT WILL FAVOR SOME OVER OTHERS IN TERMS OF THE ABILITY TO GET THEIR OPTIMAL HEALTH, AND THERE IS WITHIN US ALL SOME IMPLICIT BIAS, WE'RE BORN WITH THAT. WE DEAL WITH IT, THAT MAY CAUSE US TO TREAT DIFFERENT GROUPS IN OUR CASE AS HEALTH CARE PROVIDERS, DIFFERENT GROUPS OF PATIENTS, RESEARCH SUBJECTS DIFFERENTLY BECAUSE OF THE CATEGORY THEY COME FROM, WHETHER THAT BE ETHNICITY, RACE, COUNTRY OF ORIGIN, LANGUAGE FOCUSED. WE HAVE TO ACKNOWLEDGE THAT EXISTS, AND OVERCOME IT, EVEN THOUGH WE CAN'T ALL -- WE HAVE TO -- THE KNOWLEDGE WE'RE NOT PERFECT. WE'LL GET INTO THIS A LITTLE BIT MORE AS WE GO ALONG. ON THE RIGHT SIDE, THE COLUMN SHOWS MANY OF THE DISEASES THAT ARE IMPACTED, THAT SHOW SIGNIFICANT DISPARITIES AMONG VARIOUS GROUPS, AGAIN ETHNICITY, RACE, LANGUAGE, COUNTRY OF ORIGIN. DIABETES, HEART DISEASE, CANCER, COMPLICATIONS OF PREGNANCY, AND OF COURSE WE KNOW COVID, WE'VE JUST BEEN LIVING THROUGH THAT, WHERE THERE ARE DIFFERENTIAL OUTCOMES DEPENDING UPON PERHAPS WHERE YOU LIVE OR WHO YOU ARE. I WILL BE PRESENTING DATA AS I DO IN THIS SLIDE ON MATERNAL MORBIDITY AND MORTALITY BECAUSE THAT'S WHAT WE'RE CONCENTRATING ON IN OUR HEALTH EQUITY WORK AT THE PATIENT SAFETY CENTER. AND WHAT YOU SEE HERE IS DATA FROM THE CDC ON COMPLICATIONS OF PREGNANCY, SEVERE MATERNAL MORBIDITY AND MORTALITY, I'M SORRY SEVERE MATERNAL MORBIDITY, WHERE BLACK AND NATIVE AMERICAN WOMEN HAVE TWICE THE RATE OF COMPLICATIONS OF PREGNANCY AS WHITE WOMEN IN AMERICA. THAT HOLDS TRUE FOR MOST OF THE STATES IN THE COUNTRY. WE'LL GET TO MARYLAND DATA IN A LITTLE BIT. THERE ARE REASONS FOR THAT, THAT WE COVERED ON THE LAST SLIDE, IN TERMS OF SOCIAL DETERMINANTS OF HEALTH, AND PERHAPS STRUCTURAL RACISM, AND SOME IMPLICIT BIAS IN THE CAREGIVERS. ALL OF WHICH VARY IN ALL OF THESE DISEASES. THEY ALSO AFFECT ACCESS TO HEALTH CARE, DEPENDING UPON WHERE YOU LIVE, INNER CITY OR PERHAPS RURAL AREAS, YOU MAY NOT HAVE THE SAME ACCESS. AND PREVENTIVE MEASURES VARY DEPENDING ON WHERE YOU LIVE AND WHO YOU ARE. FINALLY, AS I SAID BEFORE, THE OVERALL COST TO THE SYSTEM OF ALLOWING DISPARITIES AND ALLOWING ERRORS TO OCCUR FOR POORER HEALTH TO RESULT COSTS US MORE. PREVENTION OF BOTH ERRORS AND DISEASE IS LESS EXPENSIVE. AS I SAID, I'LL TALK A LITTLE BIT MORE ABOUT COMPLICATIONS OF PREGNANCY. THESE ARE DISPARITIES IN MATERNAL MORTALITY IN THE U.S. THE REASON I BRING UP THIS SLIDE IS TO SHOW THAT THERE'S THREE TIMES THE RATE OF MATERNAL MORTALITY IN BLACK WOMEN COMPARED TO WHITE WOMEN IN THE COUNTRY. AND AS YOU CAN SEE FROM 2018 TO 2020, IT'S GETTING WORSE. SO THIS IS A CALL FOR ACTION. WE NEED TO ADDRESS THIS. AND HAPPY TO SAYS MANY AREAS ARE ADDRESSING IT, EVEN IN OP EDS IN THE "WASHINGTON POST," NOT A BAD THING, IT'S CALLING OUR ATTENTION TO IT. THIS IS LOOKING AT IT FROM THE VIEW OF EDUCATION. I THINK THIS POINTS OUT THAT IT'S NOT ALL EVERY SOCIAL DETERMINANT OF HEALTH THAT IS INVOLVED IN THE DISPARITY. SPECIFICALLY HERE, YOU SEE THAT WHITE WOMEN ARE THE THIRD GROUP OF BARS OVER FROM THE LEFT, BLACK WOMEN ARE THE LAST GROUP OF BARS, CLOSEST TO THE RIGHT. AND THAT DESPITE HIGHER EDUCATION, GREEN AND YELLOW ARE COLLEGE EDUCATED, THERE'S STILL TWO TO THREE TIMES THE MORTALITY RATE IN BLACK WOMEN COMPARED TO WHITE. SO IT ISN'T EDUCATION THAT'S PREVENTING THAT DISPARITY. IT'S STILL THERE. OTHER CONFOUNDING FACTORS, PHYSICIAN-PATIENT RACIAL CONCORDANCE, DOES IT MATTER, DOES HAVING A DOCTOR OF THE SAME ETHNICITY OR RACE MAKE A DIFFERENCE? IN SOME STUDIES IT DOES. IN SOME IT DOES NOT. SPECIFICALLY, THIS WAS A STUDY DONE IN STATE OF FLORIDA, YOU CAN SEE 1.8 MILLION HOSPITAL BIRTHS REVIEWED. AND IT'S FOUND THAT RACIAL CONCORDANCE, THAT IS A BLACK PHYSICIAN WITH A BLACK INFANT, RESULTED IN A SIGNIFICANT IMPROVEMENT IN MORTALITY FOR THOSE BLACK INFANTS. THAT WAS NOT THE SAME FOR THE MOTHERS. MATERNAL MORTALITY WAS NOT AFFECTED IN THIS STUDY. BUT IT DOES BRING UP THE QUESTION OF WHY WOULD THIS HAPPEN, SO MORE INVESTIGATION IS NEEDED, AND DOES IT MAKE A DIFFERENCE IN THE OUTCOME FOR PATIENTS, AND MAKE IT SAFER FOR CARE? THIS IS WHERE I THROW IN MY APPEAL, I THINK AS MANY HAVE, FOR MORE DIVERSITY IN THE HEALTH CARE WORKFORCE. WE BELIEVE THAT IT CAN IMPROVE QUALITY OF CARE, OUTCOMES IN DISPARITIES. OBVIOUSLY THERE ARE BARRIERS TO DIVERSITY IN EDUCATION, UNDERREPRESENTATION OF FACULTY, MEDICINE AND NURSING, BUT WE'RE ON A JOURNEY TO GET THERE. AGAIN, WE BELIEVE THAT THIS WILL HELP IMPROVE OR REDUCE THE DISPARITIES WE'RE SEEING IN THE CARE THAT IS GIVEN. SO, THIS IS FROM AN ARTICLE BY MARSHAL CHIN IN 2021, BRITISH MEDICAL JOURNAL. IT HAS SOME GOOD IDEAS ABOUT HOW TO IMPROVE PATIENT SAFETY THROUGH HEALTH EQUITY. I THINK ONE OF THE MAIN CONFLICTS HERE IS TO INCLUDE HEALTH EQUITY EXPERTS ON INTERDISCIPLINARY TEAMS SO YOU CAN LOOK AT SYSTEMS FOR BIAS, SEE WHETHER THE SOCIAL DETERMINANTS OF HEALTH ARE AFFECTING THE CARE THAT IS PROVIDED TO DIFFERENT GROUPS OF PEOPLE, OR IN THE CASE OF THE CLINICAL CENTER ON THE CLINICAL RESEARCH THAT IS CONDUCTED ON DIFFERENT GROUPS OF PEOPLE. WE NEED TO DEVELOP VALIDATED PERFORMANCE MEASURES, ONES THAT EVALUATE NOT JUST OVERALL OUTCOMES OF CARE THAT IS PROVIDED OR CLINICAL RESEARCH STUDY THAT IS PERFORMED, BUT AMONGST VARIOUS GROUPS, BECAUSE UNTIL YOU LOOK, YOU MAY NOT KNOW THAT IT IS BETTER FOR SOME GROUPS THAN OTHERS. AND THEN IMPLEMENTING IT, IMPLEMENTING THOSE HEALTH EQUITY CONSCIOUS INTERVENTIONS THAT YOU MAY DEVELOP, AND NURTURING MORAL INCENTIVES TO IMPROVE EQUITY AND SAFETY PATIENT CARE. SO NOW WE'LL MOVE ON TO HEALTH EQUITY IN CLINICAL RESEARCH. SOMETHING I THINK THAT WILL BE OF INTEREST, HOPEFULLY, TO MOST OF YOU LISTENING IN TODAY. THIS IS FROM A STUDY, SORRY, IT'S A WORKING PAPER THAT WAS PUBLISHED IN CHILD HEALTH IN 2019, AN EXCELLENT READ FOR THOSE OF YOU INVOLVED IN CLINICAL RESEARCH. I'LL READ THE QUOTE ON HERE. RACIAL AND ETHNIC EQUITY IN RESEARCH MEANS APPLYING TOOLS AND PRACTICES NEEDED TO RECOGNIZE PEOPLE OF COLOR'S EXPERIENCES WITH UNEQUAL POWER DIFFERENTIALS AND ACCESS TO RESOURCES AND OPPORTUNITY, WHILE CONSIDERING HISTORICAL AND CURRENT LIVED REALITIES, INCLUDING STRUCTURAL RACISM." UNTIL I THINK WE UNDERSTAND THIS, WE WON'T BE ABLE TO DEAL WITH EFFECTIVELY DIFFERENTIAL OUTCOMES THAT WE MAY SEE IN RESEARCH AND ALSO DIFFERENTIAL ENROLLMENT, BECAUSE AS THE NEXT SLIDE WILL SHOW, THAT ALTHOUGH PEOPLE OF COLOR MAKE UP ABOUT 39% OF THE USE POPULATION, PERCENTAGE GROWING, ONLY 2 TO 16% IN TRIALS REPRESENT THAT COMMUNITY OF PEOPLE OF COLOR. WE NEED CLINICAL TRIALS THAT LOOK LIKE ALL OF US TO BE EFFECTIVE, AS SAID ON THE SLIDE. IT'S AN UNDERSTANDING AS WE MOVE FORWARD. AGAIN, I'LL COME BACK TO THIS LATER, THAT TO BE EFFECTIVE IN OUR CLINICAL TRIALS, WE NEED TO BE ABLE TO BROADEN THEM. AND I KNOW THERE'S WORK ON THAT HAPPENING AT THE CLINICAL CENTE. SO A LITTLE BIT OF HISTORY NOW, TO UNDERSTAND WHY THERE MAY BE ISSUES IN TERMS OF ENROLLING COMMUNITIES OF COLOR IN CLINICAL RESEARCH. THERE'S A LACK OF TRUST. BASED UPON A LOT OF HISTORY, SOME OF THIS IS WELL KNOWN, SOME YOU MAY NOT BUT WE'LL GO OVER IT AGAIN. WE'LL START WITH DR. MARION SIMMS, LAUDED AS FOUNDER OF MODERN SURGICAL GYNECOLOGY. HE DEVELOPED A TREATMENT FOR VESCOVAGINAL FISTULAS IN THE 1800S, OPERATING ON ENCLAVED AFRICAN WOMEN, NO CONSENT, NO ANESTHESIA, OPERATING WITHOUT PERMISSION ON AFRICAN AMERICAN ENSLAVED WOMEN. IT'S TAKEN A WHILE TO COME TO GRIPS WITH EXACTLY WHAT HAPPENED, AND YOU CAN SEE IN THE BACKGROUND OF THE SLIDE A STATUE OF DR. SIMMS IN CENTRAL PARK IN NEW YORK THAT WAS TAKEN DOWN ALONG WITH MANY OTHER STATUES OF PROMINENT MEMBERS OF THE CONFEDERATE STATES BACK A FEW YEARS AGO. IT'S A MIXED BAG OF HIS LEGACY IN TERMS OF WHAT HE ACCOMPLISHED, AND HOW HE DID IT. YOU'LL SEE ON THESE SLIDES REFERENCES TO VERY GOOD BOOKS COVERING THE SUBJECT. SOMETHING MORE WELL KNOWN IS THE TUSKEGEE STUDY, 399 PARTICIPANTS, BLACK MALES WITH SYPHILIS, 201 WITHOUT, NO CONSENT AT THAT TIME. WHAT'S MOST REMARKABLE WHEN PENICILLIN WAS COVERED AND CAME INTO GENERAL USE IN MID-1940s, KNOWN TO BE A TREATMENT, NONE OF THE MEN IN THE STUDY WERE TREATED, DID NOT COME TO LIGHT UNTIL 1972 WHEN AN ARTICLE WAS PUBLISHED, CREATING A GREAT SENSATION AT THE TIME, QUICKLY THE STUDY WAS CLOSED. BUT THIS STUDY LIVES ON, NOT ONLY IN PRINT, THERE'S AN EXCELLENT EXCELLENT BOOK ON IT, "BAD BLOOD." YOU CAN UNDERSTAND THE LINGERING LACK OF TRUST IN THE HEALTH CARE SYSTEM, IN THE GOVERNMENT, AND CLINICAL RESEARCH BASED ON WHAT HAPPENED TO THESE MEN IN THE TUSKEGEE SYPHILIS STUDY. WE'VE ALL HEARD OF HENRIETTA LACKS, WENT TO JOHNS HOPKINS, DIED SEVEN MONTHS LATER, A BIOPSY SIMPLE DEVELOPED THE HEEL A -- HeLa CELL LINE, WHICH I REMEMBER USING IN COLLEGE IN MEDICAL CENTER. THERE WAS NO CONSENT, NO FAMILY KNOWLEDGE, UNTIL 1975. THIS HAS BEEN WELL DOCUMENTED IN BOOKS AND NOW MOVIES. BUT AGAIN, CREATED A MISTRUST WITHIN COMMUNITIES OF THE SYSTEM, HEALTH CARE SYSTEM, OF THE RESEARCH COMMUNITY, BECAUSE OF WHAT HAPPENED MANY YEARS AGO BUT IT STILL LINGERS. AND IN FACT LINGERED THROUGH COVID, AS WE KNOW HESITANCY IN CLINICAL STUDIES OF VACCINE DEVELOPMENT AND VACCINE HESITANCY, HESITANCY TO RECEIVE THE VACCINE WAS A SIGNIFICANT ISSUE IN COMMUNITIES OF COLOR DURING THE PANDEMIC. AND AS WE ALSO KNOW, THOSE COMMUNITIES SUFFERED GREATER. THERE AGAIN WAS DISPARITY IN TERMS OF OUTCOMES, IN COMMUNITIES OF COLOR, WITH COVI. HISTORIC RACISM, INSTITUTIONAL RACISM DRIVES DISTRUST, THE HISTORY I JUST DETAILED ABOUT VARIOUS CLINICAL STUDIES LED TO CONTINUED DISTRUSTFUL COMMUNITIES. THE GOOD NEWS IS WE'VE SEEN SIGNIFICANT IMPROVEMENT IN PARTICIPATION IN RESEARCH STUDIES, RELATED TO COVID VACCINATION AND TREATMENT, AND IN RECEIVING THE VACCINE, ALTHOUGH VACCINATION RATES STILL ARE LOWER THAN IN THE WHITE COMMUNITY. I'LL PIVOT WHO WE IN THE MARYLAND PATIENT SAFETY CENTER ARE DOING RELATED TO HEALTH EQUITY. AS I THINK DR. LANG TALKED ABOUT BEFORE, WE ARE ARE AN INDEPENDENT NON-PROFIT IN THE STATE OF MARYLAND, CREATED BY AN ACT OF THE MARYLAND LEGISLATURE, AND DESIGNATED BY MARYLAND HEALTH CARE COMMISSION. OUR MISSION IS SIMPLE. KEEPING MARYLAND HEALTH CARE SAFE. WE HAVE MANY ACTIVITIES. WE HAVE COLLABORATIVES ACROSS THE STATE, BOTH AT HOSPITALS AND IN THE OUTPATIENT COMMUNITY, ON INFECTION CONTROL, ON HAND WASHING, ON C-SECTION RATES, ANYTHING THAT WE CAN GET EVERYONE TO AGREE TO AND WORK ON, WE WILL WORK ON TO IMPROVE THE CARE ACROSS ALL MARYLANDERS. WE DO A LOT OF EDUCATION, BOTH IN PERSON AND ONLINE AND e-LEARNING WITH TWO MAJOR CONFERENCES A YEAR, ONE I'LL TALK ABOUT IN A MOMENT, BUT ALSO A SAFETY CONFERENCE IN THE FALL. FINALLY CARING FOR THE CAREGIVER PROGRAM WHICH I THINK THE CLINICAL CENTER IS IMPLEMENTING AT THIS TIME. THAT'S THE RISE PROGRAM FROM JOHNS HOPKINS, WHICH IS PEER SUPPORT, STAFF PEER SUPPORT, IN TIMES OF STRESS. RECENTLY CREATED BY ARMSTRONG INSTITUTE AT JOHNS HOPKINS FOR WHEN MEDICAL ERRORS OCCUR IN CLINICAL UNITS, BUT IT'S BEEN EXTENDED FOR ANY STRESS THAT STAFF CAN SUPPORT OTHER STAFF WITH, INCLUDING ALL OF THE STRESS OF THE PANDEMIC, AND WORKFORCE SHORTAGES THAT MANY HOSPITALS ARE GOING THROUGH RIGHT NOW, AND IN WORKPLACE VIOLENCE, AS I THINK WE'RE ALL AWARE IN HEALTH CARE, WE'VE SEEN AN INCREASE, SIGNIFICANT INVIOLENCE IN THE HEALTH CARE WORKPLACE. WE'RE A FEDERALLY DESIGNATED PATIENT SAFETY ORGANIZATION SO WE RUN THE MID-ATLANTIC PATIENT SAFETY ORGANIZATION WITH REPORTING MEDICAL ERRORS, BUT MOST IMPORTANTLY WITH CONVENING PATIENT SAFETY OFFICERS ACROSS THE STATE REGULAR MEETINGS TO DISCUSS PATIENT SAFETY ISSUES INCLUDING SAFE TABLES WHERE WE CAN DISCUSS UNTOWARD EVENTS AND SOLUTIONS FOR IMPROVING THE CARE OF PATIENTS ACROSS THE STATE. OUR WORK IN HEALTH EQUITY IS DETAILED ON THE RIGHT SIDE, BUT THE FIRST IS OUR HEALTH EQUITY CONFERENCE COMING UP. THIS IS OUR ANNUAL PATIENT SAFETY CONFERENCE HELD IN PERSON AT THE HILTON IN BALTIMORE, BUT ALSO HELD ONLINE, AS MEMBERS OF THE MARYLAND PATIENT SAFETY CENTER, YEAR ALL WELCOME TO JOIN US FOR FREE, AND AS I SAID BEFORE, THERE ARE CONTINUING EDUCATION CREDITS INCLUDING CME CREDITS THAT ARE AVAILABLE TO YOU FOR ATTENDING THIS CONFERENCE, WHETHER IN PERSON AT THE HILTON WHERE YOU GET A NICE LUNCH OR ONLINE AT YOUR COMPUTE. IT'S ON MARCH 31st, COMING UP IN JUST A BIT OVER TWO WEEKS, AND WE'LL BE TALKING A LOT ABOUT HEALTH EQUITY ACROSS ALL ASPECTS OF HEALTH EQUITY, AND HOW WE CAN IMPROVE HEALTH EQUITY, IMPROVING OUTCOMES FOR PATIENTS. WE'VE ALSO DONE WORK IN COVID VACCINE HESITANCY, AND THE BIRTH EQUITY PROGRAM, AND I'LL JUST START WITH SAYING THAT MARYLAND IS ONE OF THE MOST DIVERSE STATES IN THE COUNTRY. I THINK IT'S 7th ON THIS LIST. HAS APPEARED HIGHER ON OTHER LISTS DEPENDING HOW YOU DEFINE DIVERSITY. BUT THAT JUST, TO US, IT SUGGESTS WE DO HAVE WORK TO DO ON VARIOUS ISSUES ASSOCIATED WITH DISPARITIES IN MARYLAND. SO WE STARTED OFF WITH REDUCING COVID VACCINE HESITANCY IN COMMUNITIES OF COLOR. WE DID THIS IN CONJUNCTION WITH MARYLAND HOSPITAL ASSOCIATION AND THE STATE, REALIZING THAT BLACK AND LATINX COMMUNITIES WERE SIGNIFICANTLY LESS LIKELY TO GET THE COVID VACCINE ESPECIALLY EARLY WHEN THE VACCINE BECAME AVAILABLE. DR. NICOLE ROCHESTER LED WEBINARS DISCUSSING SYSTEMIC RACISM AND BIAS IN HEALTH CARE, WHICH HAS LED TO THE VACCINE AWARENESS. AND STRATEGIES TO INCREASE ACCEPTANCE IN COMMUNITIES OF COLOR, AND STRATEGIES TO INCREASE VACCINE ACCEPTANCE IN HEALTH CARE STAFF, ALSO A SIGNIFICANT ISSUE. WE HAD 700 LEADERS FROM ACROSS THE REGION INVOLVED IN THAT. WE HOPE WE WERE PART OF IMPROVING THE ACCEPTANCE OF VACCINE THAT WE'VE SEEN OVER THE LAST COUPLE OF YEARS. OUR MAJOR PROGRAM HAS BEEN DEALING WITH SEVERE MATERNAL MORBIDITY IN MARYLAND. AS I DESCRIBED BEFORE, THE DATA IN MARYLAND IS NO DIFFERENT THAN MANY OF THE STATES ACROSS THE COUNTRY. BLACK MATERNAL MORBIDITY IS TWICE THE RATE OF WHITE MATERNAL MORBIDITY IN MARYLAND. IN GRAPH YELLOW IS BLACK MATERNAL MORBIDITY, RED AT THE BOTTOM IS WHITE MATERNAL MORBIDITY. MARYLAND MADE A PLEDGE TO REDUCE THIS, THE OVERALL MATERNAL MORBIDITY BY 20% OVER THE NEXT THREE YEARS, FOUR YEARS I GUESS NOW, AND WE RECOGNIZE THAT WE CAN'T MAKE HEADWAY WITH THIS, YOU CAN SEE THE DOTTED LINES ARE THE WAY MARYLAND WANTS TO REDUCE THESE PROJECTING HOW THE TO REDUCE MATERNAL MORBIDITY, CAN'T MAKE HEADWAY IF WE DON'T ACTUALLY ADDRESS THE DISPARITY THAT IS THERE. SO WE'VE DEVELOPED THE BIRTH EQUITY MARYLAND PROGRAM, TO PROMOTE HEALTH EQUITY, AND ANTI-RACISM IN MATERNAL HEALTH ACROSS THE STATE. WE'RE EDUCATING NON-OBSTETRIC PROVIDERS, THERE'S ALREADY A PROGRAM TO EDUCATE BOTH IMPLICIT BIAS AND ANTI-RACISM AND IMPROVE MATERNAL CARE WITH THE PROGRAM THROUGH JOHNS HOPKINS ACROSS THE STATE, ALL BIRTHING HOSPITALS IN MARYLAND ARE PARTICIPATING. THAT'S INVOLVING OBSTETRICIANS, MIDWIVES, MATERNITY NURSES. WE RECOGNIZE, AND WE ACTUALLY PARTICIPATE AS PART OF THE MD MOM PROGRAM, BUT WE RECOGNIZE THAT BOTH PREGNANT AND POSTPARTUM WOMEN ARE FREQUENTLY SEEN BY NON-OBSTETRIC PROVIDERS, EMERGENCY ROOM, CLINICS AND QUALIFIED HEALTH CENTERS AND COMMUNITY HEALTH WORKERS AND WANT TO EXTEND THAT EDUCATION TO NON-OBSTETRIC PROVIDERS AND WE'VE ALREADY STARTED. WE'VE BEEN THROUGH OUR FIRST PILOT PHASE AND ARE ABOUT TO ROLL IT OUT ACROSS THE STATE. IN FACT, MARYLAND HOSPITAL ASSOCIATION'S EXECUTIVE COMMITTEE HAS PLEDGED ALL MARYLAND HOSPITALS WILL PARTICIPATE. AND THE EDUCATION INCLUDES EDUCATION ABOUT DISPARITIES, IDENTIFICATION OF COMPLICATIONS, AND WHAT TO DO ABOUT IT. SIMPLY SAID, IF WE CAN GET MORE OF OUR NON-OBSTETRIC PROVIDERS WHO SEE WOMEN TO RECOGNIZE SOMETHING BRONC MAY -- WRONG MAY BE GOING ON RELATED TO MATERNAL MORBIDITY THEY WILL CONTACT OBSTETRICIAN COLLEAGUE TO SEE THE PATIENT SO WE DON'T MISS SOMETHING BECAUSE IT'S MISSED OPPORTUNITIES, THE THINGS WE COULD HAVE HAVE FIXED, THAT WE'RE TRYING TO ADDRESS. THIS IS THE STEPS WE'RE TAKING. WE HAVE INITIAL BASELINE ASSESSMENT, WE GET ON TO EDUCATION, WEBINARS ON RACISM AND BIAS IN MATERNAL HEALTH CARE AND EDUCATION ON THE DRIVERS OF MATERNAL MORBIDITY AND MORTALITY ESPECIALLY IN THE BLACK COMMUNITY. FINALLY A TEAM STEPS-BASED TRAINING. IF YOU HAVEN'T PARTICIPATED, IT INVOLVES THE ENTIRE HEALTH CARE TEAM, GETS EVERYONE ON THE HEALTH CARE TEAM ENABLED TO SPEAK UP WHEN THEY SEE SOMETHING THEY THINK MAY BE GOING WRONG. WE DON'T WANT TO MISS ANYBODY'S OBSERVATIONS THAT SOMETHING MAY BE HAPPENING AND JUST RELY ON THE PROVIDER, THE DOCTOR, THE NURSE. WE WANT EVERYBODY TO PARTICIPATE. IN CLINICS ACROSS THE STATE, THIS IS IMPORTANT, MOST OF THEM ARE DEFINITELY COMMITTING TO IT, TO SEE IF THEY CAN IMPROVE, ESPECIALLY IN DISPARITIES WE'RE SEEING IN MATERNAL CARE, REDUCE OVERALL RATE OF MATERNAL MORBIDITY IN MARYLAND. SO IN MY CLOSING SECTION HERE, I'LL TALK ABOUT HOW IN RESEARCH, CLINICAL RESEARCH, WE CAN DO BETTER. THE QUESTION HOW DO WE ADDRESS INEQUITIES IN OUTCOME, THE GRAPHIC IS FROM THE CDC LOOKING AT THE WAYS TO ADDRESS HEALTH EQUITY, BOTH IN THE INFRASTRUCTURE THAT WE BUILD, IN PROGRAMS, IN MEASUREMENT, IN POLICY. WE'LL TALK A LITTLE BIT ABOUT THAT HERE. WHAT ARE THE PITFALLS IN CLINICAL RESEARCH? WELL, ONE OF THE BIG ONES IS LACK OF DIVERSITY IN STUDY PARTICIPANTS WE ALREADY DISCUSSED, BUT ALSO ON STUDY TEAMS, ON THE COMMITTEES INVOLVED IN RESEARCH, AND ON THE IRB. WE DON'T HAVE EQUITABLE REPRESENTATION THROUGHOUT THE PROCESS. IT'S HARD TO UNDERSTAND, REALIZE, BE AWARE, SEE, THE INEQUITIES, THE INEQUALITIES, DISPARITIES THAT MIGHT RESULT WITHIN A STUDY, BECAUSE WE JUST DIDN'T KNOW. SO, IMPLICIT AND EXPLICIT BIAS EXISTS. SPECIFICALLY TO IMPLICIT BIAS, I HIGHLY RECOMMEND EVERYONE, AND THIS IS IN -- I THINK THE LINK IS IN THE RESOURCES SLIDE AT THE END OF THIS TALK, BUT THE HARVARD IMPLICIT ASSOCIATION TEST, WHICH IS ANONYMOUS, ONLY YOU GET THE RESULTS, THEY DO COLLECT DE-IDENTIFIED DATA BUT OVERALL BUT DON'T KNOW YOU, YOU DON'T KNOW THEM. AND TO TEST WHAT BIASES YOU MAY HAVE, WE ALL HAVE THEM. I KNOW I HAVE THEM. THAT ARE BUILT INTO US, FOR WHATEVER REASONS, THAT MAY INFECT -- THAT MAY AFFECT YOUR PERFORMANCE OF YOUR CLINICAL DUTIES, THE WAY YOU TREAT VARIOUS GROUPS OF PATIENTS, OR THE WAY YOU TREAT VARIOUS GROUPS OF CLINICAL RESEARCH SUBJECTS. OTHER PITFALLS, LACK OF COMMUNICATION, NOT CONNECTING TO COMMUNITIES, I DISCUSSED LACK OF TRUST FROM COMMUNITIES OF COLOR AND HISTORY THAT'S THERE, THAT LACK OF TRUST STILL EXISTING, THE ABILITY TO MEASURE HEALTH EQUITY. IF WE JUST LOOK AT OVERALL OUTCOMES OF OUR CLINICAL RESEARCH STUDIES, AND NOT STRATIFY THE DATA AS TO ETHNICITY, RACE, COUNTRY OF ORIGIN, LANGUAGE, WE ARE MISSING DISPARITIES IN OUTCOMES THAT ARE IMPORTANT AS WE MOVE THAT TREATMENT FORWARD. AND NEED TO UNDERSTAND THAT BECAUSE IF WE DON'T ASK FOR THAT DATA, WE WON'T GET IT AND WON'T KNOW. OBVIOUSLY THE SOCIAL DETERMINANTS OF HEALTH ARE A MAJOR FACTOR, BUT THOSE ARE GOING TO TAKE A LONG TIME AND INVOLVE ALL OF US IN COMMUNITIES, AND IN GOVERNMENT, TO BE WORKING ON IN TERMS OF IMPROVEMENT OF THE SOCIAL DETERMINANTS OF HEALTH SO THAT WE CAN DECREASE DISPARITIES BASED ON THOSE. THE SURVEYS THAT YOU MIGHT BE USING, GETS BACK TO THE DATA, ARE THEY BIASED, THAT WILL BE GETTING BACK TO THE LACK OF DIVERSITY ON STUDY TEAMS, COMMITTEES, IRBs. AND FINALLY, A QUOTE FROM, AGAIN, ANOTHER ARTICLE WE HAVE IN THE RESOURCES SECTION, IMPLEMENTATION RESEARCH METHODOLOGIES FOR ACHIEVING SCIENTIFIC EQUITY IN HEALTH EQUITY FROM ETHNICITY AND DISEASE IN 2019. IMPLEMENTATION SCIENCE CAN EXACERBATE HEALTH DISPARITIES IF IT'S USED AS BIAS TOWARD EMPATHIES THAT ALREADY HAVE HIGHEST CAPACITIES FOR DELIVERING EVIDENCE-BASED INTERVENTIONS, SO WE COME UP WITH EVIDENCE-BASED INTERVENTIONS AND THEN WE DISTRIBUTE TO PLACES THAT ALREADY DO WELL, TAKE IT TO PLACES THAT DON'T DO IT WELL THEY WON'T GET THE BENEFIT. WE NEED TO UNDERSTAND THAT. SO, TALK ABOUT THE PITFALLS, ALSO TALK ABOUT WHAT YOU CAN DO. AND HOW YOU CAN DO BETTER. REACHING OUT TO THE COMMUNITY, EITHER AS INDIVIDUAL, AS A TEAM, AND AS AN ORGANIZATION. IT'S NOT JUST YOUR LOCAL COMMUNITY. BETHESDA, FOR EXAMPLE, WHERE THE CLINICAL CENTER IS LOCATED, BUT COMMUNITIES WHERE YOU LIVE, OUT AND AROUND THIS AREA, AND ESPECIALLY MONTGOMERY COUNTY, FOR EXAMPLE, IS THE LARGEST COUNTY IN THE STATE OF MARYLAND, ALSO ONE OF THE MOST DIVERSE COUNTIES, IF NOT THE MOST DIVERSE, IN THE COUNTRY. IT'S REALLY AN OPPORTUNITY TO REACH OUT TO VARIOUS ETHNIC GROUPS, RACIAL GROUPS, COUNTRY OF ORIGIN GROUPS, LANGUAGE GROUPS, TO GET REPRESENTATION ON YOUR CLINICAL RESEARCH COMMITTEES, IRB, TO BE ABLE TO ENGAGE THE COMMUNITY IN THAT RESEARCH. PARTNER WITH TRUSTED RESEARCHERS AND COMMUNITIES, WE LEARNED A GREAT DEAL DURING COVID, BOTH IN THE CLINICAL RESEARCH THAT WAS DONE, AND IN THE ROLLOUT OF THE VACCINE, THAT THERE ARE TRUSTED RESOURCES IN COMMUNITIES, I THINK WE ALL KNOW THAT THE HAIR SALONS AND BARBERSHOPS ARE A GREAT RESOURCE FOR EDUCATION AND COMMUNICATION, AND UNDERSTANDING HOW THE COMMUNITY STANDS ON VARIOUS ISSUES. SO THAT COULD BE A GREAT SITE FOR RECRUITMENT. THERE ARE OTHER PLACES WITHIN COMMUNITIES THAT ARE SIMILAR. THERE IS COMMUNITY-BASED PARTICIPATORY RESEARCH, WHICH INCREASES THE VALUE OF STUDY FOR COMMUNITY AND RESEARCHERS, INVOLVE THE COMMUNITY, AND BOTH CAN BENEFIT, AND UNDERSTAND THE COMMUNITY DATA, THE POLICY, THE HISTORIES ASSOCIATED WITH THE COMMUNITIES YOU'RE WORKING WITH. ENGAGE PATIENTS AND FAMILIES. I THINK PRETTY MUCH ALL HOSPITALS ACROSS THE COUNTRY HAVE SOME FORM OF PATIENT FAMILY ADVISORY COUNCIL. I THINK IT'S NOW REQUIRED, ALTHOUGH NOT ALL USE THEM FOR THE SAME PURPOSES. BUT ENGAGING PATIENTS AND FAMILIES THAT ARE INVOLVED IN THE RESEARCH, ENGAGING THEM IN THE DESIGN AND THE ONGOING RESULTS OF THE STUDY I THINK IS A VERY GOOD THING TO FIND OUT HOW YOU'RE DOING AND HOW IT'S RELATING TO BOTH THE PATIENT'S FAMILIES AND THE COMMUNITY. RECOGNIZE THAT THERE ARE DIFFERENCES THAT EXIST BETWEEN CULTURES. YOU'RE NOT GOING TO -- WE'RE NOT HOMOGENOUS. THAT'S A GOOD THING. BUT YOU NEED TO UNDERSTAND THAT. RESEARCH TEAM, I SAID THIS BEFORE, NEEDS TO REFLECT THE POPULATION YOU'RE STUDYING. AND UNDERSTAND THAT CULTURAL DIFFERENCES CAN HAVE A SIGNIFICANT IMPACT ON THE OUTCOME OF YOUR STUDY, AND COULD AFFECT -- COULD POSITIVELY OR NEGATIVELY AFFECT YOUR STUDY DESIGN. TRAIN THE TEAM ON IMPLICIT BIAS AND CULTURAL COMPETENCY. THERE ARE VARIOUS IMPLICIT BIAS PAINTINGS OUT THERE, SOME BETTER THAN OTHERS, STILL UNKNOWN WHETHER THE STRAIGHT IMPLICIT BIAS TRAINING IS EFFECTIVE BUT IT'S A START. AND UNDERSTANDING WHAT YOU'RE DEALING WITH ESPECIALLY WITH COMMUNITIES YOU'RE REACHING OUT TO IS HELPFUL. ENGAGE THE COMMUNITY THERE. RESEARCH SHOULD BE PATIENT CENTERED. MAKE SURE THERE'S TRANSLATED INFORMED CONSENTS AND RECRUITMENT DOCUMENTS SO CAN YOU GET PATIENTS FROM A VARIETY OF BACKGROUNDS, AND HOLD FOCUS GROUPS, AGAIN BACK TO THE COMMUNITY, TO UNDERSTAND AND WHERE YOU'RE HOLDING THEM, GO TO THE COMMUNITY, DON'T EXPECT THEM ALWAYS TO COME TO YOU. AND FINALLY, I THINK MAYBE PRETTY OBVIOUS, WHAT IS REPRESENTATIVE? WHAT GROUPS, IS IT EVERYBODY? IS IT SPECIFIC POPULATIONS OF SPECIFIC ETHNIC CULTURAL GROUPS THAT ARE APPROPRIATE REPRESENTATIVES FOR THE DISEASE THAT YOU ARE INVESTIGATING AND TRYING TO COME UP WITH SOLUTIONS FOR. ONE FINAL NOTE IS THAT ANALYZING PRESENTING RESEARCH IS A SIGNIFICANT ISSUE, AND YOU NEED TO BE THOUGHTFUL ABOUT THIS BECAUSE THE WAY THAT RACE AND ETHNICITY, EVEN COUNTRY OF ORIGIN REPORTED ACROSS CLINICAL STUDIES VARIES SIGNIFICANTLY. THIS WAS AN OPINION PIECE IN JAMA, THAT IN 2021, THAT SUGGESTED WAYS TO STANDARDIZE THE REPORTING OF RACE AND ETHNICITY ACROSS CLINICAL STUDIES SO WE'RE ALL TALKING IN THE SAME LANGUAGE, AND THAT'S VERY IMPORTANT SO I HIGHLY RECOMMEND READING THIS. AGAIN, IT'S IN OUR RESOURCES SECTION HERE. WORDS DO MATTER. AND YOU NEED TO ASK QUESTIONS AND STRATIFY YOUR DATA CONSIDERING THE VARIOUS RACE/ETHNICITY AS SUGGESTED BEFORE, SO YOU KNOW IF THERE'S DIFFERENTIAL IMPACT OF YOUR INVESTIGATION AND THE OUTCOME ON VARIOUS GROUPS. THAT IS MY LAST SLIDE. THIS IS RESOURCES SECTION, AND HOPEFULLY THESE SLIDES WILL BE AVAILABLE TO YOU ON REQUEST. SO THAT YOU CAN LOOK AT ANY OF THE SLIDES, OR SPECIFICALLY, OR ESPECIALLY RESOURCES THAT ARE AVAILABLE, BECAUSE THEY ARE ALL GOOD. THERE'S A LOT THERE. BUT THEY WILL HELP, I THINK, IN DEVELOPING MORE CULTURALLY APPROPRIATE AND HEALTH EQUITY AWARE CLINICAL RESEARCH IN THE FUTURE THAT I THINK WILL HELP US ALL, BECAUSE IT WILL IMPROVE THE OUTCOMES FOR EVERYONE, WHICH IS OUR GOAL, AND REALLY MAKE US MORE AWARE OF WHERE WE NEED TO GO IN THE FUTURE. SO, THAT'S IT. I THANK YOU VERY MUCH AGAIN FOR THIS OPPORTUNITY TO TALK ABOUT SOMETHING THAT WE HERE AT THE MARYLAND PATIENT SAFETY CENTER ARE VERY PASSIONATE ABOUT AND I'LL BE HAPPY TO ENTERTAIN ANY QUESTIONS. >> WELL, THANK YOU VERY MUCH, DR. EIG. THAT WAS FABULOUS. VERY, VERY IMPORTANT TOPICS, AND A LOT THERE. BUT DEFINITELY AS YOU SAID, YOU KNOW, ALL OF US ARE HERE OR IN HEALTH CARE TO PROVIDE HIGH-QUALITY AND SAFETY PATIENT CARE, AND ANY DISPARITIES AND EQUITY ISSUES ARE AFFECTING OUR ABILITY TO DO THAT. THAT GOES THE SAME WITH HIGH-QUALITY RESEARCH. SO THANK YOU FOR BRINGING THOSE. I'D LIKE TO REMIND EVERYBODY TO ASK A QUESTION IF YOU'RE WATCHING ON VIDEOCAST RIGHT BELOW YOU MIGHT SCROLL DOWN, THERE'S A BUTTON THAT SAYS LIVE FEEDBACK, SEND YOUR QUESTIONS, AND WE DO HAVE A QUESTION HERE. DR. EIG, CONCERNING THE MATERNAL MORBIDITY AND BLACK-WHITE DIFFERENCE AGAINST COLLEGE EDUCATED UNIVERSITY WOMEN, THERE MAY BE CULTURAL DIFFERENCES IN DIET AND PRACTICES NOT GENERALLY RECOGNIZED TO MATTER. IS THERE COMPARATIVE DATA FOR PHYSICIAN MATERNAL MORBIDITY AND ARE DIFFERENCES THE SAME? IN OTHER WORDS, PHYSICIANS AND OTHER HEALTH CARE MORE AWARE OF CHANGES NEEDED IN PREGNANCY. THE QUESTION IS PHYSICIANS WHO ARE BLACK, DO THEY HAVE DIFFERENT OUTCOMES VERSUS WHITES? >> SO FAR, THERE'S NO DATA TO THAT EFFECT THOUGH IT'S BEING LOOKED AT. I THINK WHEN I DISCUSSED THE STUDY DONE IN FLORIDA, WHICH WAS A VERY EXTENSIVE STUDY, TOOK A WHILE TO COLLECT THAT DATA, THEY DEFINITELY SAW CONCORDANCE WITH BLACK PHYSICIANS AND BLACK INFANT MORTALITY. THEY DID NOT SEE CONCORDANCE WITH BLACK PHYSICIANS AND BLACK MATERNAL MORTALITY. THAT DOESN'T MEAN IT DOESN'T EXIST. IT DIDN'T EXIST IN THAT STUDY. SO MORE RESEARCH IS BEING DONE. AND THIS IS NOT TO SUGGEST THAT BLACK PATIENTS SHOULD ONLY SEE BLACK DOCTORS. THIS IS THAT THERE'S AN ISSUE IN SOME CASES WITH PROBABLY TRUST, PROBABLY SOME CULTURAL DIFFERENCES, CULTURAL COMPETENCY, THAT MAY AFFECT OUTCOMES ESPECIALLY SEEN PROBABLY IN RECOMMENDATIONS, ADVICE GIVEN, HEALTH PREVENTION. THAT HAS BEEN SEEN IN STUDIES, WHERE A BLACK PHYSICIAN WAS MORE SUCCESSFUL IN GETTING BLACK PATIENTS TO CHANGE PRACTICES, IN TERMS OF PREVENTIVE CARE, ESPECIALLY IN CARDIAC DISEASE. SO THAT DOES EXIST, BUT AGAIN IT'S NOT THE SUGGESTION THAT WE SHOULD HAVE A DIFFERENT SYSTEM OF WHO CARES FOR WHO. IT'S THAT EVERYONE SHOULD RECOGNIZE THAT AND TRY TO FIGURE OUT HOW EVERYBODY, NO MATTER WHAT RACE OF PHYSICIAN OR RACE OF PATIENT IS, CAN GIVE THE BEST CARE POSSIBLE. IT'S GOING TO TO TAKE SOME TIMD WE NEED TO INVESTIGATE FULLY TO DO THAT. GOING BACK TO I THINK FIRST PART OF THE QUESTION, HAVING TO DO WITH EDUCATION, THE INTERESTING THING IN BLACK MATERNAL MORBIDITY IS CERTAINLY EDUCATION DOESN'T SEEM TO BE THE EFFECT HERE. AND IT IS AND ALSO WEALTH, IT'S NOT REGARDING WEALTH. IN FACT, THERE'S A HIGHER RATE IN THE WEALTHIER AND OLDER BLACK WOMEN. SO, THAT -- AND THAT'S BEING LOOKED AT RIGHT NOW. WHY IS THAT? IT'S TO SAY SOCIAL DETERMINANTS OF HEALTH GIVE US A DIRECTION I THINK INTO THESE DISPARITIES, BUT EACH SOCIAL DETERMINANT OF HEALTH IS NOT ACTIVE IN EACH DISPARITY. WE NEED TO UNDERSTAND THAT. IT'S MUCH MORE COMPLEX THAN WE'D LIKE IT TO BE BUT AS WE LOOK AT EACH DISPARITY WE CAN SEE WHAT IS ACTIVE, WHAT IS NOT, AND WORK ON THINGS THAT ARE ACTIVE. >> GREAT. THANKS VERY MUCH. THANKS FOR THE QUESTION. WHILE WE WAIT TO SEE IF THERE'S MORE QUESTIONS AS THEY COME IN, YOU DID TOUCH ON THIS, WHAT CAN WE DO? I JOTTED DOWN, AS A HEALTH CARE WORKER, MYSELF AS A PHYSICIAN BUT ANY HEALTH CARE WORKER NOT RUNNING A HOSPITAL OR RESEARCH, BUT WHAT COULD I AS AN INDIVIDUAL DO, I WAS THINKING ABOUT LIST OF SOCIAL DETERMINANTS OF HEALTH, IF SOMEBODY SAID, GOSH, THIS IS OVERWHELMING, WHAT ONE THING COULD I DO, ADD TO MY DAY OR WEEK, EVEN FOR A SMALL AMOUNT OF TIME THAT YOU THINK WOULD HAVE THE MOST IMPACT? >> I THINK IT'S REACHING OUT TO THE COMMUNITY, THOSE IN NEED IN YOUR COMMUNITY. THAT CAN BE DONE VARIOUS WAYS. THERE ARE COMMUNITY GROUPS THAT YOU CAN JOIN, THERE ARE COMMUNITY PROJECTS, WHETHER IT'S WORKING AT A FOOD KITCHEN, OR WORKING ON CONSTRUCTION PROJECTS, LIKE HABITAT FOR HUMANITY, WHATEVER THE LOCAL ORGANIZATION IS. YOU GET TO GO TO THE COMMUNITY. GET TO TALK TO PEOPLE FROM THE COMMUNITY. YOU START UNDERSTANDING THE ISSUES THAT THEY ARE DEALING WITH. UNDERSTANDING NOT ONLY THE SOCIAL DETERMINANTS OF HEALTH THAT MIGHT BE AFFECTING THAT COMMUNITY, BUT ALSO WHAT TRUST OR MISTRUST IS IN THAT COMMUNITY OF THE HEALTH CARE SYSTEM. BY BEING THERE YOU CAN REPRESENTATIVE THE HEALTH CARE COMMITTEE, SHOWING CARE AND CONCERN, START REDUCING THAT DISTRUST. I THINK THAT COMMUNICATION, WE TEND TO GET SILOED IN WHAT WE DO BECAUSE OUR LIVES ARE BUSY AND WE STAY WITHIN THE COMMUNITIES THAT WE'RE USED TO. SO WE DON'T REACH OUT, NOT BECAUSE WE'RE BAD PEOPLE, IT'S BECAUSE WE DON'T HAVE TIME. SO IT IS TAKING THE TIME TO FIND A COMMUNITY GROUP, COMMUNITY ACTIVITY, A COMMUNITY COMMITTEE, THAT YOU CAN PARTICIPATE ON SO THAT YOU CAN REACH OUT AND THEN THEY CAN START UNDERSTANDING YOU, AND THROUGH YOU, THE CLINICAL CENTER, FOR EXAMPLE, AND GAINING COMMUNITY'S TRUST IN WHAT YOU DO. >> GREAT. THANKS FOR THAT ANSWER. WE HAVE ANOTHER QUESTION. THANK YOU FOR A FANTASTIC TALK. YOU MENTIONED NURTURING MORAL INCENTIVES. ASKED IF YOU COULD ELABORATE ON THAT PHRASE OR GIVE SOME EXAMPLES. >> I THINK SIMPLY, MAYBE A TOO PACKED PHRASE, BUT THE IDEA IS WE ALL HAVE CERTAIN ETHICAL AND MORAL IDEALS WITHIN WHATEVER COMMUNITY AND WHATEVER COUNTRY WE LIVE IN, THAT WE THINK ARE RIGHT. THIS IS THE WAY IT OUGHT TO BE. I THINK GETTING BACK TO AMERICA, YOU KNOW, AND LEAVING THOMAS JEFFERSON AND PERSONAL ISSUES ASIDE THERE, THE CONCEPT THAT WE ALL HAVE THE RIGHT TO LIFE, LIBERTY, PURSUIT OF HAPPINESS, AND PURSUIT OF GOOD HEALTH CARE. SO, WHAT WE NEED TO DO IS NURTURE THAT IDEAL THAT WE LIVE IN, AGAIN, IT'S NOT TRUE FOR EVERYBODY BUT WE LIVE IN WHAT WE FEEL TO BE A FREE SOCIETY, AND THAT EVERYBODY SHOULD HAVE THE RIGHT TO ACCESS GOOD QUALITY HEALTH CARE. AND IF WE CAN NURTURE THAT, THAT SIMPLE MORAL AND ETHICAL CONSTRUCT, I THINK WE CAN ALL DO BETTER. YOU KNOW, I KNOW THIS BRINGS TO MIND TO EVERYBODY WITH ALL OF THE POLITICAL DISCOURSE WE'RE HAVING RIGHT NOW, IT MAKES IT MORE DIFFICULT. I TEND TO BE AN OPTIMIST, AND I TEND TO WANT PEOPLE TO DO BETTER. I THINK, AGAIN, THE IDEA WE HAVE THROUGH OUR SOCIETY, AND SOME PEOPLE THROUGH THEIR RELIGION OR CULTURAL GROUP, MORALS AND ETHICS WE THINK NEEDED TO BE THE RIGHT THING TO DO, WHAT BEE NEED TO DO IS NURTURE THAT, MOVE IT FORWARD, MAKE THIS PLACE BETTER WHICH WE BELIEVE AT THE SAFETY CENTER WILL IMPROVE, YOU KNOW, HEALTH EQUITY FOR ALL, AND THERE BY IMPROVE HEALTH OUTCOMES FOR ALL, WHICH IS OUR GOAL. >> GREAT. THANKS. HERE'S A QUESTION, DO YOU HAVE ANY SUGGESTIONS ON HOW WE CAN ENCOURAGE UNDERREPRESENTED INDIVIDUALS TO ENGAGE IN RESEARCH? I UNDERSTAND THAT WE NEED MORE INDIVIDUALS IN DIVERSE COMMUNITIES TO PARTICIPATE IN RESEARCH. THINKING ABOUT HOW TO OVERCOME THE UNDERSTANDABLE RELUCTANCE. >> RIGHT. AGAIN, FIRST IS UNDERSTANDING. I MEAN, FIRST IS KNOWLEDGE. AND I TRIED TO DO A LITTLE BIT OF THAT TODAY BUT READ SOME MORE ABOUT IT, READ ABOUT THE VARIOUS HISTORICAL -- I'VE GOT THE BOOKS THERE IN THE POWERPOINT. BUT READ ABOUT HISTORICAL EPISODES IN CLINICAL RESEARCH THAT ARE NOT GOOD, BUT WE CAN AT LEAST UNDERSTAND THEM, SPEAK TO IT. AND THEN IT IS, AGAIN, REACHING OUT TO THE COMMUNITIES, NOT ALL OF THEM ARE RIGHT THERE IN BETHESDA, BUT FINDING COMMUNITIES AND THE GOOD NEWS IS EVEN IN WHAT WE CONSIDER TO BE A WEALTHY MONTGOMERY COUNTY, DIFFERENT COMMUNITIES YOU DON'T KNOW ABOUT. AND REACHING OUT TO THOSE COMMUNITIES, START TALKING WITH THEM. ONCE YOU ENGAGED THEM AND ENGAGE WHETHER IT'S COMMITTEES, YOU KNOW, AGAIN COMMUNITY BOARDS, COMMITTEES, OR PERHAPS RELIGIOUS INSTITUTIONS IN THOSE COMMUNITIES OF VARIOUS KINDS, CULTURAL AND SOCIAL, COUNTRY OF ORIGIN GROUPS WHICH MAY HAVE A DIFFERENT LANGUAGE SO YOU MIGHT NEED A TRANSLATOR, AND AS WE FOUND WITH COVID, HAIR SALONS AND BARBERSHOPS, WHERE THE COMMUNITY GATHERS REGULARLY TO REACH OUT THERE AND SAY, HEY, I'M DOING WORK AT THE CLINICAL CENTER AT NIH, WE'RE TRYING TO IMPROVE HEALTH CARE FOR EVERYBODY, BUT WE CAN'T RECRUIT PEOPLE FROM YOUR COMMUNITY, WHAT'S WRONG, WHAT CAN WE DO? JUST STARTING THAT CONVERSATION. DOESN'T HAPPEN OVERNIGHT. NOTHING DOES. DON'T GET DISCOURAGED. KEEP TRYING. IT IS THE RIGHT THING TO DO. I THINK IT IS HAPPENING MORE NOW. I THINK COVID ACTUALLY OPENED OUR EYES ON THAT. BUT WE WILL NEED TO DO MORE. AND HONESTLY, TO TAKE BACK TO THE NIH LEADERSHIP, CLINICAL CENTER LEADERSHIP, THEY CAN DO MORE BY SPONSORING INDIVIDUAL STAFF IN THEIR ORGANIZATION OR HELPING THEM CONNECT WITH THOSE GROUPS IN THE COMMUNITY. >> THAT'S GREAT, YEAH. THANKS. MATERNAL MORTALITY, A QUESTION, WHAT IS THE MOST COMMON CAUSE OF DEATH IN THE MATERNAL MORTALITIES WHICH YOU HAD STUDIED? >> IT VARIES AS TO THE DATA THAT YOU'RE LOOKING AT. SOME MATERNAL MORTALITY DATA, ESPECIALLY FROM THE CDC, INVOLVES ONLY -- YOU KNOW, IN THE PERIOD OF TIME ESSENTIALLY THAT -- I'M TRYING TO REMEMBER IF IT'S CDC OR MARYLAND STATE DATA, SOME IS AT THE HOSPITAL, I'LL JUST TELL YOU SOME IS AT THE HOSPITAL, SOME IS WITHIN 365 DAYS, A YEAR OF DELIVERY. WHEN WE REVIEW WE SUPPORT THE STATE'S MATERNAL MORTALITY REVIEW THEME, THERE'S ABOUT 40 TO 50 DEATHS, MATERNAL DEATHS, IN MARYLAND A YEAR, BUT MANY OF THOSE ARE WITHIN A YEAR AFTER DELIVERY. AND SO IN THOSE, IN THE ONES THAT TAKE UP TO 365 DAYS AFTER DELIVERY, AS YOU MIGHT EXPECT OVER THE LAST SEVERAL YEARS DEATHS DUE TO OPIOID OVERDOSE WERE THE GREATEST NUMBER. BUT THAT WAS NOT DIRECTLY AND DID NOT APPEAR TO BE DIRECTLY RELATED TO THE PREGNANCY OR POSTPARTUM PERIOD. WHEN WE LOOK AT PREGNANCY AND POSTPARTUM PERIOD IT TENDS TO VARY YEAR TO YEAR, USUALLY HYPERTENSIVE-ASSOCIATED DISEASE, SO ECLAMPSIA, PREECLAMPSIA, ALSO HEMORRHAGIC DISEASE, BLEEDING, WHICH HOSPITALS HAVE GOTTEN MUCH BETTER AT IN TERMS OF HANDLING OBSTETRIC BLEEDING LIKE A TRAUMA, THAT'S IMPROVED SIGNIFICANTLY I THINK OVER THE LAST 10 YEARS. STILL NEEDS MORE IMPROVEMENT BUT IT'S BETTER. AND CARDIAC DISEASE, DISCOVERED OR UNDISCOVERED AT THE TIME OF DEATH. ALL OF THOSE ARE INVOLVED, CERTAINLY THERE ARE LESS COMMON DISORDERS, PULMONARY EMBOLUS, INFECTION, ALL OF THEM, MANY ARE PREVENTIBLE. WE HAVE TO RECOGNIZE THEM, WHICH IS ONE OF THE REASONS WE'RE DOING BOTH M.D. MOM PROGRAM AND BIRTH EQUITY PROGRAM. >> OKAY. THANKS VERY MUCH. WE'RE JUST IN THE LAST FEW SECONDS, SO THERE'S A FINAL COMMENT THAT SPEAKS FOR MANY. THANK YOU FOR THIS LOVELY AND PRACTICAL TALK. SO THANK YOU VERY MUCH, DR. EIG, I'LL TAKE THE OPPORTUNITY TO REMIND PEOPLE THAT NEXT TUESDAY THERE'S A SPECIAL TOWN HALL, FACILITATED DISCUSSION ON POLICE BRUTALITY THAT INCLUDES OUR CLINICAL CENTER CEO AND DIRECTOR OF NIH OFFICE OF EQUITY, DIVERSITY AND INCLUSION, ACTUALLY LIVE IN LIPSETT AUDITORIUM OR WEBCAST TUESDAY AT ELEVEN, LOOK FOR ANNOUNCEMENTS FROM THE CLINICAL CENTER DEIA PROGRAM ON THAT. AGAIN, THANK YOU VERY MUCH, DR. EIG. AND THANK YOU VERY MUCH TO ALL WHO VIEWED THIS. WE'LL SEE YOU NEXT WEEK. >> THANK YOU.