THANK YOU ALL FOR TAKING TIME
OUT OF WHAT I'M SURE IS A VERY
BUSY SCHEDULE TO JOIN MYSELF AND
MY FRIEND AND COLLEAGUE,
DR. BENSON, FOR THIS NATIONAL
SYMPOSIUM THAT WE FEEL IS GOING
TO ADDRESS A VERY PREVALENT AND
RELEVANT AND COMMON ISSUE, WHICH
IS INEQUITIES IN ACCESS AND
DELIVERY IN ACUTE STROKE CARE.
I AM PART OF THE BRAIN ATTACK
COALITION, WHICH IS AN
ORGANIZATION THAT MEETS UNDER
THE AUSPICES OF THE NINDS.
THE CONSTITUENCIES OF THE BRAIN
ATTACK COALITION INCLUDE A LOT
OF PUBLIC AND PROFESSIONAL
GROUPS THAT ARE INVOLVED IN ALL
ASPECTS OF STROKE CARE,
INCLUDING PRE-HOSPITAL CARE,
HOSPITAL CARE, AND THEN POST
HOSPITAL CARE EDUCATION,
NON-PROFIT GROUPS, AND THE LIKE.
SO AGAIN, THANK YOU SO MUCH FOR
TAKING TIME OUT OF YOUR BUSY
SCHEDULE TO JOIN US.
NOW I'LL INTRODUCE MY CO-CHAIR,
DR. RICHARD BENSON.
RICHARD?
>> THANK YOU, DR. ALBERTS.
IT'S TRULY A PLEASURE TO BE WITH
YOU THIS MORNING.
AND IT MY HONOR, IT'S BEEN MY
HONOR TO WORK WITH YOU AS WELL
AS MEMBERS OF BRAIN ATTACK
COALITION AND MEMBERS OF THE
WORKING GROUPS.
OVER THE LAST THREE YEARS, THE
SARS COVID-19 PANDEMIC HAS
HIGHLIGHTED HEALTH INEQUITIES
RELATED TO UNMANAGED MEDICAL
COMORBIDITIES AND THE IMPACT OF
SOCIODETERMINANTS OF HEALTH LIKE
HOUSING, JOB AND FOOD
INSECURITY, POVERTY, INACCESS TO
QUALITY MEDICAL CARE, PROVIDER
LEVEL BIAS AND MEDICAL MISTRUST.
COINCIDENT WITH THE COVID
PANDEMIC HAS BEEN A GLOBAL
RECOGNITION OF RACISM,
PARTICULARLY STRUCTURAL AND
INTERPERSONAL, WITH THE MURDER
OF GEORGE FLOYD AND OTHERS.
AND THE NEGATIVE HEALTH IMPACT
OF THIS.
THESE PARALLEL PANDEMICS SPARCED
SEVERAL TRANS-NIH INITIATIVES
LIKE UNITE, THE NIH FIRST
PROGRAM, AND INTRAI.C.
INITIATIVES TO SPECIFICALLY
ADDRESS THE IMPACT OF RACISM ON
THE NIH MISSION.
AT THE NINDS, WE ARE COMPLETING
A TWO-YEAR HEALTH EQUITY
STRATEGIC PLANNING EFFORT THAT
WILL HELP SHAPE OUR INITIATIVES
OVER THE NEXT FIVE TO 10 YEARS.
UNDER THE DIRECTION OF A
30-MEMBER DIVERSE PANEL OF
EXPERT, THE WORKSHOP FOCUSED ON
HEALTH DISPARITIES AND
INEQUITIES IN NEUROLOGICAL
DISEASES.
FEEDBACK FROM MULTIPLE COMMUNITY
STAKEHOLDERS WAS OBTAINED AND
RECOMMENDATIONS PROVIDED TO THE
NINDS AT THE END OF THE PROCESS.
THIS INFORMATION WILL BE OPEN
AND AVAILABLE FOR THE PUBLIC IN
COMING MONTHS.
THIS BRAIN ATTACK COALITION
SYMPOSIUM IS ANOTHER MEANS TO
ADDRESS A HIGHLY RELEVANT
NEUROLOGICAL CONDITION WITH
GREAT INEQUITIES: STROKE.
IT IS OUR HOPE THAT THE
INFORMATION PROVIDED BY OUR
WORKING GROUPS AND THE
DISCUSSION OVER THE NEXT TWO
DAYS WILL LEAD TO SUBSTANTIVE
CHANGE IN STROKE TREATMENT,
CARE, AND THE NEGATIVE OUTCOMES.
AND NOW IT IS MY DISTINCT
PLEASURE TO INTRODUCE OUR
KEYNOTE SPEAKER, DR. DAVID
SATCHER.
DR. SATCHER HAS ALWAYS BEEN A
ROLE MODEL TO ME.
IN FACT, HIS BROTHER, DR. ROBERT
SATCHER, SENIOR, WAS MY DEAN IN
UNDERGRADUATE SCHOOL AND
DR. DAVID SATCHER WAS MY
PRESIDENT WHEN I ATTENDED
MEDICAL COLLEGE.
BOTH OF THESE IN NASHVILLE,
TENNESSEE.
SO AS DR. SATCHER TOLD ME
RECENTLY, I HAD BEEN FULLY
SATCHERIZED.
HE HAS AN EXTENSIVE TRACK RECORD
OF LEADERSHIP, RESEARCH AND
COMMUNITY ENGAGEMENT.
HE IS A PHI BETA KAPPA GRADUATE
OF MOREHOUSE COLLEGE AND HOLDS
AN M.D. AND PH.D. DEGREES FROM
CASE WESTERN UNIVERSITY WHERE HE
WAS ALSO ELECTED TO THE HONOR
SOCIETY.
DR. SATCHER SERVED AS THE 16TH
SURGEON GENERAL OF THE UNITED
STATES FROM 1998 TO 2002, AND
THE TENTH ASSISTANT SECRETARY
FOR HEALTH IN THE DEPARTMENT OF
HEALTH AND HUMAN SERVICES FROM
1998 TO 2001.
HE ALSO SERVED AS DIRECTOR OF
THE CENTERS FOR DISEASE CONTROL
AND PREVENTION, AND
ADMINISTRATOR OF THE AGENT SILL
FOAGENCY FORTOXIC SUBSTANCES AND DISEASE
REGISTRY.
HE HE'S ALSO HELD TOP LEADERSHIP
POSITIONS AT THE DREW UNIVERSITY
OF MEDICINE AND SCIENCE AND THE
MORE HOUSE SCHOOL OF MEDICINE.
HE HAS RECEIVED OVER 50
HONORARY DEGREES AND HAS
RECEIVED NUMEROUS AWARDS FROM
DIVERSE ORGANIZATIONS AND
AGENCIES.
CURRENTLY DR. SATCHER IS THE
FOUNDING DIRECTOR OF A SENIOR --
AND SENIOR ADVISOR FOR THE
SATCHER HEALTH LEADERSHIP
INSTITUTE AT THE MOREHOUSE
SCHOOL OF MEDICINE IN ATLANTA,
GEORGIA.
NOW I'D LIKE TO PRESENT TO YOU
DR. DAVID SATCHER.
>> GOOD MORNING.
I'M DAVID SATCHER, FORMER U.S.
SURGEON GENERAL AND FORMER
DIRECTOR OF THE CDC.
I'M DELIGHTED TO BE ABLE TO JOIN
YOU TODAY AND I'M ALSO VERY
PLEASED THAT YOU HAVE DECIDED TO
TAKE ON THIS VERY IMPORTANT AND
SOMETIMES DIFFICULT TOPIC.
AND I JUST HOPE THAT WE CAN ADD
SOMETHING TO OUR DISCUSSION THAT
WILL BE WORTHWHILE FOR YOU
TODAY.
BUT WE CERTAINLY APPRECIATE YOUR
GIVING US THE OPPORTUNITY TO
PARTICIPATE.
SO I'M GOING TO GO THROUGH A
SERIES OF SLIDES WITH BRIEF
DISCUSSIONS, BECAUSE AS YOU
KNOW, WE ONLY HAVE ABOUT 30
MINUTES.
IT'S TRUE, THE SATCHER
LEADERSHIP INSTITUTE HAS A
SAYING, AND IT IS, TODAY THE
NEED FOR LEADERS IS TOO GREAT TO
LEAVE THEIR EMERGENCE TO CHANCE
ALONE.
THE SATCHER LEADERSHIP INSTITUTE
WAS ACTUALLY BUILT AROUND THIS
CONCEPT THAT WE NEED TO BE
PROACTIVE IN HELPING PEOPLE TO
DEVELOP THEIR LEADERSHIP SKILLS.
SO THE NEXT SLIDE BEGINS TO MOVE
FORWARD IN TERMS OF THIS
DISCUSSION OF BRAIN ATTACK
COALITIONS.
THE FIRST QUESTION THAT WE DEAL
WITH IS, WHAT IS HEALTH EQUITY?
BECAUSE I KNOW THAT THAT'S AT
THE CENTER OF YOUR CONCERN AND
YOUR DISCUSSION.
NOW HEALTH EQUITY HAS BEEN
DEFINED BY DIFFERENT GROUPS AT
DIFFERENT TIMES.
AND HEALTHY PEOPLE 2010, WHICH
AS YOU KNOW, EVERY 10 YEARS, WE
DEVELOP A PLAN FOR THE NEXT 10
YEARS.
SO IN HEALTHY PEOPLE 2010, WE
DEFINE HEALTH EQUITY AS THE
ATTAINMENT OF THE HIGHEST LEVEL
OF HEALTH FOR ALL PEOPLE.
THE WORLD HEALTH ORGANIZATION
HAS DEFINED HEALTH EQUITY AS THE
ABSENCE OF AFFORDABLE OR
REMEDIABLE DIFFERENCES AMONG
GROUPS OF PEOPLE, WHETHER THESE
GROUPS ARE DEFINED SOCIALLY,
ECONOMICALLY, DEMOGRAPHICALLY OR
GEOGRAPHICALLY.
THE CDC HAS ALSO DEFINED HEALTH
EQUITY.
THAT DEFINITION IS A LITTLE
DIFFERENT FROM WHO.
CDC SAYS WHEN EVERYONE HAS THE
OPPORTUNITY TO ATTAIN THEIR FULL
HEALTH POTENTIAL, AND NO ONE IS
DISADVANTAGED FROM ACHIEVING
THIS POTENTIAL BECAUSE OF THEIR
SOCIAL POSITION OR OTHER
SOCIALLY DETERMINED
CIRCUMSTANCES.
THAT IS HEALTH EQUITY.
SO AS YOU CAN SEE, THE WHOLE
ISSUE OF HEALTH HAS BROUGHT US
TO THE POINT OF TRYING TO FIGURE
OUT HOW WE CAN DO AWAY WITH SOME
OF THE DIFFERENCES THAT
INTERFERE WITH HEALTHCARE,
INCLUDING DIAGNOSIS AND
TREATMENT OF THE BRAIN.
THE NEXT SLIDE GOES A LITTLE
FURTHER IN TERMS OF TRYING TO
ILLUSTRATE THE DIFFERENCE
BETWEEN EQUALITY AND HEALTH
EQUITY.
SOME PEOPLE THINK THAT HEALTH
EQUITY IS JUST ANOTHER WORD FOR
EQUALITY, BUT IT'S NOT.
EVEN THOUGH THIS IS NOT A
PERFECT SLIDE, I HOPE IT HELPS
TO SEE WHAT IS A CLEAR
DIFFERENCE BETWEEN EQUALITY AND
EQUITY.
AS YOU CAN SEE, WHEN IT COMES TO
EQUALITY, THE MEN ON THIS SLIDE
HAVE DIFFERENT OPPORTUNITIES,
THEY HAVE DIFFERENT HEIGHTS, AND
HOWEVER, THEY'RE STANDING ON THE
SAME HEIGHT SUPPORT.
IN OTHER WORDS, THE BOXES ARE
EQUAL IN HEIGHT.
AND, THEREFORE, THERE IS
EQUALITY.
THERE'S NOT EQUITY, BECAUSE,
BECAUSE OF THEIR DIFFERENT
HEIGHTS, THEY NEED DIFFERENT
HEIGHTS OF BOXES TO STAND UPON.
AND THAT'S WHAT EQUITY DOES.
IT GIVES THEM WHAT THEY NEED
WHEN THEY NEED IT IN ORDER TO
GET THE JOB DONE.
THAT'S HEALTH EQUITY.
WHAT DO YOU NEED TO DO WHAT
NEEDS TO BE DONE.
IF YOU HAVE THAT, THEN WE'VE
DEFINED THAT AS EQUITY.
WHATEVER IT TAKES TO DO WHAT YOU
NEED TO GET DONE.
THAT'S EQUITY.
SO THAT'S OUR ATTEMPT TO DEFINE
EQUALITY VERSUS EQUITY.
AND I DON'T MEAN TO IMPLY THAT I
THINK THAT'S EASY.
NEXT SLIDE.
WHAT ARE HEALTH DISPARITIES?
AS SURGEON GENERAL, I HAD THE
OPPORTUNITY TO RELEASE THE FIRST
EVER SURGEON GENERAL'S REPORT ON
HEALTH DISPARITIES, AND IT WAS
REALLY A MAJOR GOAL OF HEALTHY
PEOPLE 2010, AND IT GOE THE GOAL WAS TO
ELIMINATE DISPARITIES IN HEALTH.
I REMEMBER AS IF IT WERE
YESTERDAY, WHEN WE RELEASED
HEALTHY PEOPLE 2010, AS USUAL, I
HAD GOTTEN UP TO WALK THAT
MORNING ON THE CAMPUS OF NIH,
AND THERE WAS SNOW ON THE
GROUND.
AN UNUSUAL AMOUNT OF SNOW FOR
WASHINGTON, D.C. AREA.
6 INCHES OF SNOW.
AND THERE WERE 2,000 PEOPLE IN
HOTELS IN WASHINGTON, WAITING
FOR THE SURGEON GENERAL'S
RELEASE OF HEALTHY PEOPLE 2010.
SO THAT'S THE BACKGROUND FOR
THIS.
HEALTHY PEOPLE 2010 CAME OUT IN
THE YEAR 2000, WHEN I WAS
SURGEON GENERAL.
HEALTHY PEOPLE 2020 CAME OUT IN
2010.
SO WHAT IS HEALTHY PEOPLE 2020?
SO A PARTICULAR TYPE OF HEALTH
DIFFERENCE THAT IS CLOSELY
LINKED WITH SOCIAL, ECONOMIC,
AND/OR ENVIRONMENTAL
DISADVANTAGES.
SO EVEN THOUGH IT WAS VERY
DIFFICULT, WE MANAGE TO COME
TOGETHER EVERY 10 YEARS AND
AGREE ON WHAT OUR GOALS SHOULD
BE FOR THE NEXT 10 YEARS WHEN IT
COMES TO THE HEALTH OF THE
PEOPLE OF THIS COUNTRY.
AND TO A CERTAIN EXTENT, PEOPLE
IN OTHER PARTS OF THE WORLD.
SO HEALTH DISPARITIES WAS
DEFINED IN HEALTHY PEOPLE 2010,
2020, AND NIH HAS DEFINED IT AS
DIFFERENCES IN THE INCIDENCE,
PREVALENCE, MORTALITY, AND
BURDEN OF DISEASE, AND OTHER
ADVERSE HEALTH CONDITIONS THAT
EXIST AMONG SPECIFIC POPULATION
GROUPS.
THAT'S NIH.
THE CDC DEFINES HEALTH
DISPARITIES AS PREVENTABLE
DIFFERENCES IN THE BURDEN OF
DISEASE, IN THE BURDEN OF INJURY
AND VIOLENCE OR OPPORTUNITIES TO
ACHIEVE OPTIMAL HEALTH THAT ARE
EXPERIENCED BY SOCIALLY
DISADVANTAGED POPULATIONS.
SO THAT'S PART OF WHERE HEALTH
DISPARITIES ORIGINATE.
THEY ORIGINATE IN THE FACT THAT
PEOPLE HAVE DIFFERENT HISTORIES,
DIFFERENT BACKGROUNDS, DIFFERENT
TALENTS, AND, THEREFORE, THEY
START OFF SOMETIMES WITH
DISADVANTAGES THAT HAVE TO BE
OVERCOME.
THE NEXT SLIDE GOES A LITTLE
FURTHER.
AND ASKS THE QUESTION, WHAT ARE
THE SOCIAL DETERMINANTS OF
HEALTH?
NOW I HAVE TO TELL YOU A LITTLE
BIT ABOUT MY OWN PERSONAL
BACKGROUND WITH THIS.
WHEN I BECAME SURGEON GENERAL, I
HAD REPRESENTED THE UNITED
STATES AS A DELEGATE TO THE
WORLD HEALTH ORGANIZATION FOR
ALMOST EIGHT YEARS.
SO IT WAS REALLY AN OPPORTUNITY
FOR ME TO CONTINUE TO PURSUE
THIS WORK.
AND SO THE WHOLE ISSUE OF SOCIAL
DETERMINANTS OF HEALTH CAME
ABOUT AT EXACTLY THE TIME THAT I
WAS MAKING THE TRANSITION IN
GOVERNMENT.
WE DEFINED SOCIAL DETERMINANTS
OF HEALTH AS THE CONDITIONS IN
WHICH PEOPLE ARE BORN, GROW,
LIVE, WORK, AND AGE.
CONDITIONS.
THAT DETERMINES OUR SOCIAL
SITUATION, BUT ALSO OUR SOCIAL
SITUATION IMPACTS OUR HEALTH.
AND SO THAT'S PART OF THE REAL
ISSUE HERE, IS THAT PEOPLE
STRUGGLE WITH THEIR HEALTH, THAT
STRUGGLE IS IMPACTED BY HOW MUCH
MONEY THEY HAVE, HOW MUCH
EDUCATION THEY HAVE, WHERE THEY
WERE BORN, WHO THEY KNOW, AND SO
SOCIAL DETERMINANTS OF HEALTH
ARE MAJOR FACTORS WHEN IT COMES
TO TRYING TO IMPROVE THE HEALTH
OF ALL PEOPLE AND TRYING TO
ACHIEVE EQUITY WHEN IT COMES TO
HEALTH AND HEALTHCARE.
THE CONDITIONS IN WHICH PEOPLE
ARE BORN, GROW, LIVE, WORK AND
AGE ARE THE SOCIAL DETERMINANTS
OF HEALTH.
THEY'RE SHAPED BY THE
DISTRIBUTION OF MONEY, POWER,
AND RESOURCES AT THE GLOBAL,
NATIONAL, AND AT THE LOCAL
LEVEL.
CHANGES IN THE SOCIAL
DETERMINANTS OF HEALTH OFTEN
REQUIRE THAT WE CHANGE POLICIES.
I MEAN, THAT'S -- YOU KNOW, A
LOT OF WHAT CONGRESS DOES
RELATIVE TO HEALTH IS
RE-EXAMINING POLICIES.
AND I'LL SPEAK A LITTLE BIT
LATER ABOUT OBAMACARE AND HOW
THAT REPRESENTED AN ATTEMPT TO
GET IN PLACE POLICIES THAT
REALLY SUPPORTED HEALTH EQUITY.
SOCIAL DETERMINANTS OF HEALTH
ARE SHAPED BY HOW WE DISTRIBUTE
MONEY, POWER, AND RESOURCES AT
THE GLOBAL, NATIONAL AND LOCAL
LEVELS.
AND CHANGES IN THE SOCIAL
DETERMINANTS OF HEALTH OFTEN
REQUIRE POLICY CHANGES.
SO A LOT OF WORK GOES ON IN
CONGRESS AS IT RELATES TO
HEALTH, REPRESENT ATTEMPTS TO
MAKE POLICY CONSISTENT WITH OUR
GOALS AS A NATION.
SOMETIMES THOSE POLICIES HAVE TO
BE DRAMATICALLY CHANGED WHEN WE
REALIZE THAT THEY'RE NOT
CONSISTENT WITH EQUITY IN
HEALTHCARE.
WE SAY WE ALL AGREE THAT WE
SHOULD HAVE EQUITY IN HEALTH AND
HEALTHCARE.
THEN IF WE FIND THAT WE HAVE
POLICIES THAT ARE NOT CONSISTENT
WITH THAT, THEN WE HAVE TO BE
WILLING TO RE-EXAMINE THEM AND,
IN FACT, IN MANY CASES, TO
CHANGE THEM.
AND AS WE SAID BEFORE, THE
SOCIAL DETERMINANTS OF HEALTH
ARE THE CONDITIONS IN WHICH
PEOPLE ARE BORN, GROW, LIVE,
WORK AND AGE.
SO THAT'S HOW MUCH MONEY DO YOU
HAVE, HOW MUCH MONEY DO YOU
BRING TO THE TABLE WHEN IT COMES
TO GETTING QUALITY HEALTHCARE.
HOW MUCH SHOULD YOU BE REQUIRED?
THAT'S AN ONGOING DEBATE IN THIS
COUNTRY.
WHEN WE ALLOW MONEY TO BE A
BARRIER TO GOOD HEALTH AND GOOD
HEALTHCARE.
BUT THAT'S THE FACT OF THE
MATTER THAT IT IS.
THE NEXT SLIDE BRINGS US CLOSER
TO YOUR TOPIC.
AND THAT IS, THE BRAIN.
THE BRAIN IS, WITHOUT QUESTION,
THE MOST IMPORTANT ORGAN IN THE
BODY IN MANY WAYS.
AND WE DEFINE WORK OF THE BRAIN
AS MENTAL HEALTH.
SO WHAT IS MENTAL HEALTH?
MENTAL HEALTH IS THE SUCCESSFUL
PERFORMANCE OF MENTAL FUNCTION,
RESULTING IN PRODUCTIVE
ACTIVITY.
S.
FULFILLING RELATIONSHIPS WITH
OTHERS, AND THE ABILITY TO ADAPT
TO CHANGE AND SUCCESSFULLY COPE
WITH ADVERSITY.
THAT'S MENTAL HEALTH.
MENTAL HEALTH IS A STRUGGLE.
THERE ARE OBVIOUSLY -- NOT
EVERYBODY IS MENTALLY HEALTHY.
OBVIOUSLY NOT ALL OF OUR
ENDEAVORS SUPPORT MENTAL HEALTH.
AND SO IT'S AN ONGOING STRUGGLE
TO ACHIEVE MENTAL HEALTH OF
INDIVIDUALS, FAMILIES AND
COMMUNITIES.
THE NEXT SLIDE TAKES THAT A
LITTLE FURTHER, AND THERE WERE
THREE MAJOR REPORTS THAT I
RELEASED AS SURGEON GENERAL
DEALING WITH MENTAL HEALTH.
AND THE FIRST REPORT WAS THE
REPORT ON MENTAL HEALTH: A
REPORT OF THE SURGEON GENERAL,
WHICH WAS RELEASED IN DECEMBER
OF 1999.
AND THAT WAS IMPORTANT BECAUSE
THEY HAD NEVETHERE ARE NEVER BEFORE BEEN A
SURGEON GENERAL'S REPORT ON
MENTAL HEALTH.
SO THIS WAS A FIRST.
IT CAME OUT IN DECEMBER OF 1999.
NOW THAT WASN'T THE END.
THAT WAS SORT OF THE BEGINNING.
THERE WAS SO MUCH INTEREST IN
THE REPORT ON MENTAL HEALTH
UNTIL WE HAD TO PRODUCE
SUPPLEMENTS, WE HAD TO DO ONE ON
CHILDREN'S MENTAL HEALTH.
CHILDREN HAVE SPECIAL NEEDS, I'M
SURE YOU KNOW THAT.
AND WE ALSO FOUND, OF COURSE,
THAT MENTAL HEALTH IS CLOSELY
RELATED TO YOUR CULTURAL
BACKGROUND, TO YOUR RACE,
ETHNICITY.
AND THERE IS SUCH A THING AS
MENTAL RETARDATION THAT WE HAVE
TO DEAL WITH IN DEALING WITH
CHILDREN ESPECIALLY.
SO THE SURGEON GENERAL'S MENTAL
HEALTH REPORT WAS SORT OF THE
BEGINNING OF A MUCH MORE CLOSELY
WATCHED FOCUS ON MENTAL HEALTH.
AND WE CONTINUED, NEXT SLIDE, WE
TRIED TO PULL TOGETHER THESE
MAJOR FACTORS IN A MATRIX.
AND IN THIS MATRIX, WE INCLUDED,
IN TRYING TO DEFINE MENTAL
HEALTH AS PRODUCTIVE ACTIVITIES.
IN OTHER WORDS, HOW DO YOU
FUNCTION IF YOU'RE MENTALLY
HEALTHY?
TO WHAT EXTENT ARE YOU ABLE TO
ADAPT TO CHANGE?
CAN YOU SUCCESSFULLY COPE WITH
ADVERSITY?
CAN YOU DEVELOP AND MAINTAIN
FULFILLING RELATIONSHIPS WITH
OTHER PEOPLE?
THAT'S WHEN MENTAL HEALTH IS
FUNCTIONING FOR YOU AND FOR
THOSE AROUND YOU.
AND AS YOU KNOW, IT'S NOT ALWAYS
FUNCTIONING WELL, FOR FAMILIES
SOMETIMES, FOR COUPLES, FOR
TEAMS.
MENTAL HEALTH IS CRITICAL, BUT
IT DOESN'T ALWAYS FUNCTION THE
WAY IT NEEDS TO FUNCTION.
SO MENTAL HEALTH FUNCTION IS AN
ONGOING CHALLENGE.
AND AS WE TRIED TO POINT OUT IN
THIS MATRIX, WE LOOK AT THE
ACTIVITIES THAT TAKE PLACE, WE
LOOK AT ONE'S ABILITY TO ADAPT
TO CHANGES IN THE ENVIRONMENT.
AND THERE ARE A LOT OF THINGS
THAT CAN IMPACT OUR ABILITY TO
ADAPT TO OUR ENVIRONMENT.
OUR ABILITY TO COPE WITH
ADVERSITY.
WE SURE HAVE OUR SHARE OF
ADVERSITY TO COPE WITH.
OUR ABILITY TO DEVELOP AND
MAINTAIN FULFILLING
RELATIONSHIPS WITH OTHER PEOPLE.
THOSE ARE ALL THINGS THAT AFFECT
OUR MENTAL HEALTH.
THE NEXT SLIDE GOES A LITTLE
FURTHER WITH THIS DISCUSSION,
EVEN THOUGH WE COULD GO MUCH
FURTHER.
WE ASKED THE QUESTION, WHAT IS
THE ROLE OF PRIMARY CARE AS IT
RELATES TO MENTAL ILLNESS?
AND LET ME JUST SAY AT THE
OUTSET, THIS IS A MAJOR CONCERN.
BECAUSE THIS IS ONE OF THE MOST
UNDERSERVED AREAS OF HEALTHCARE
THAT WE DEAL WITH EVERY DAY.
THE FACT THAT WHEN IT COMES TO
MENTAL HEALTH, AND THE ROLE OF
PRIMARY CARE, IT TENDS TO BE
OFTEN IGNORED.
AND IGNORED BECAUSE, NUMBER ONE,
PARENTS DON'T ALWAYS COOPERATE
WHEN IT COMES TO MENTAL HEALTH.
SOME PARENTS ARE EMBARRASSED IF
THEIR CHILDREN HAVE MENTAL
HEALTH NEEDS, AND, THEREFORE,
THEY DON'T GET THE SUPPORT THEY
NEED FROM THE HEALTHCARE SYSTEM.
AND THEN, THERE ARE SOME PEOPLE
IN THE HEALTHCARE SYSTEM WHO
DON'T DO THE JOB THAT WE SHOULD
BE DOING.
WE DON'T ASK THE RIGHT
QUESTIONS, AND WHEN WE DO ASK
THE RIGHT QUESTIONS, WE DON'T
FOLLOW THROUGH.
AND WE CREATE AN ENVIRONMENT IN
WHICH PEOPLE ARE NOT COMFORTABLE
DISCUSSING THEIR MENTAL HEALTH.
THESE ARE ALL THINGS THAT WE
HAVE TO CHANGE IF WE'RE GOING TO
DEAL WITH THE BRAIN AND ITS
NEEDS AND ITS PARTICULAR
FUNCTION.
THAT INVOLVES SCREENING, EARLY
DIAGNOSIS, IT INVOLVES TREATMENT
WHEN APPROPRIATE, REFERRAL WHEN
APPROPRIATE, AND CERTAINLY
FOLLOW-THROUGH.
SO MENTAL ILLNESS IS IMPORTANT
AND PRIMARY CARE HAS A MAJOR
ROLE, AND I'M SURE THAT YOUR
PEDIATRICIAN, INTERNIST,
NEUROLOGIST, WHAT HAVE YOU, WHAT
HAPPENS IN PRIMARY CARE IS
CRITICAL IN TERMS OF HOW WE DEAL
WITH MENTAL ILLNESS AS OF
SOCIETY, BUT ALSO AS FAMILIES
AND ORGANIZATIONS AND WHAT HAVE
YOU.
WE'RE HEARING MORE ABOUT THAT
LATELY.
WE'RE HEARING MORE ABOUT
ATHLETES WHO ARE NOT PERFORMING
WELL, EVEN THOUGH THEY'RE
MEMBERS OF THE TEAM, THEY'RE NOT
ABLE TO PERFORM WELL BECAUSE OF
MENTAL DISORDERS.
BUT IT'S ONLY BEEN VERY RECENT
THAT WE HAVE BEEN WILLING TO
OPENLY DISCUSS THE ROLE THAT
MENTAL HEALTH PLAYS IN TERMS OF
PRIMARY CARE, AND, THEREFORE, IN
TERMS OF HOW WE FUNCTION AS
FAMILIES, AS MEMBERS OF TEAMS,
ET CETERA.
THE NEXT SLIDE TAKES THIS A
LITTLE FURTHER.
IT SAYS THAT MENTAL HEALTH IS
FUNDAMENTAL TO OVERALL HEALTH
AND WELL-BEING.
MENTAL DISORDERS ARE REAL.
YOU CAN'T BE HEALTHY WITHOUT
YOUR MENTAL HEALTH.
LET ME JUST SAY THAT AGAIN.
YOU CAN'T BE HEALTHY WITHOUT
YOUR MENTAL HEALTH.
AND, THEREFORE, THE BRAIN AND
HOW WE DEAL WITH THE BRAIN,
INCLUDING WHEN THERE ARE MAJOR
ISSUES AND PROBLEMS OF THE KIND
YOU'RE GOING TO BE DISCUSSING,
THE ROLE OF THE BRAIN AND HOW WE
DEAL WITH IT IS CRITICAL.
WE CAN MAKE A GREAT
CONTRIBUTION, BUT WE HAVE TO
WORK TOGETHER.
PRIMARY CARE POSITIONS AND
OTHERS HAVE TO WORK TOGETHER
WITH NEUROLOGISTS AND
NEUROSURGEONS AND OTHERS, THAT
WE'RE GOING TO GIVE THE KIND OF
CARE THAT PEOPLE NEED.
THE NEXT SLIDE IS VERY
IMPORTANT.
I'VE SPENT MORE TIME DISCUSSING
THIS SLIDE PROBABLY THAN
ANYTHING ELSE IN THE AREA OF
MENTAL HEALTH.
AND YOU MAY RECOGNIZE THIS
BECAUSE IT CAME OUT OF THE OBAMA
ADMINISTRATION.
AND IT SAYS -- WHAT WE TRIED TO
DO WAS TO PIN DOWN, WHAT WERE
THE THREE WAYS THAT THE
AFFORDABLE CARE ACT, WHICH CAME
OUT OF THE OBAMA ADMINISTRATION,
HOW IS THE AFFORDABLE CARE ACT
INCREASING ACCESS TO MENTAL
HEALTH AND SUBSTANCE USE
DISORDER SERVICES.
AND WE BOILED IT DOWN TO THREE
WAYS.
ONE, THE AFFORDABLE CARE ACT
WILL EXPAND MENTAL HEALTH AND
SUBSTANCE USE DISORDER BENEFITS
AND PARITY.
NOW, A GOOD FRIEND OF MINE,
PATRICK KENNEDY, AND AS SOME OF
YOU KNOW, PATRICK AND HIS FAMILY
HAVE FUNDED THE SATCHER HEALTH
LEADERSHIP INSTITUTE'S PROGRAM,
IN THE AREA OF MENTAL HEALTH.
SO IT'S CALLED THE
KENNEDY-SATCHER MENTAL HEALTH
PROGRAM.
I'M A PERSON WHO FEELS VERY
INDEBTED TO THE KENNEDYS,
ESPECIALLY PATRICK.
BECAUSE IN SO MANY WAYS, I HAVE
SEEN THEM IN ACTION.
WHEN I WAS A STUDENT AT THE
MOREHOUSE COLLEGE, ON ONE
OCCASION BACK IN THAT TIME, WHEN
MANY OF US WERE GOING TO JAIL
BECAUSE WE DISAGREED WITH THE
DISCRIMINATION THAT WAS TAKING
PLACE, I BELIEVE AT ONE TIME,
THERE WERE ONLY ONE OR TWO
RESTAURANTS IN ATLANTA THAT
WOULD SERVE BLACKS.
BUT ANYWAY, WE WERE ARRESTED,
AND I REMEMBER THE ROLE THAT THE
KENNEDY FAMILY PLAYED, BECAUSE
JOHN KENNEDY WAS RUNNING FOR
PRESIDENT, AND DR. KING WAS
ARRESTED, MRS. KING WAS VERY
CONCERNED, AND SO SHE CALLED THE
KENNEDY CAMPAIGN AND ASKED THEM
FOR HELP, BECAUSE SHE WAS
WORRIED ABOUT WHAT WAS GOING TO
HAPPEN TO HER HUSBAND IN JAIL
AND IN PRISON.
AND THERE WERE SIX OF US,
MOREHOUSE AND OTHER PEOPLE WHO
WERE ALSO IN JAIL, BUT ANYWAY,
BECAUSE OF THE WORK OF THE
KENNEDY CAMPAIGN, WE WERE ALL
RELEASED.
AND THAT'S JUST ONE EXAMPLE OF
THE COURAGE THAT THE KENNEDY
FAMILY SHOWED IN HELPING TO MAKE
SURE THAT WE GOT JUSTICE.
WELL, MOST HEALTH PLANS BU PLAN SERVICES
MUST NOWP COVER SERVICES LIKE
DEPRESSION SCREENING FOR ADULTS
AND BEHAVIORAL ASSESSMENTS FOR
CHILDREN AT NO COST.
YOU MIGHT WANT TO THINK ABOUT
THAT, BECAUSE I KNOW YOU'RE
CONCERNED ABOUT BEING ABLE TO
RESPOND TO THE NEEDS OF THE
BRAIN IN CHILDREN AND IN ADULTS,
BUT THERE ARE PREVENTIVE
SERVICES LIKE DEPRESSION
SCREENING FOR ADULTS, BEHAVIORAL
ASSESSMENTS FOR CHILDREN, AT NO
COST.
THAT CAME OUT OF THE AFFORDABLE
CARE ACT.
THOSE THINGS WERE TO BE
GUARANTEED.
SCREENING, DIAGNOSING
DEPRESSION.
NOW DEPRESSION IS ONE OF THE
MAJOR PROBLEMS THAT WE SEE IN
MENTAL HEALTH.
PEOPLE, WHEN THEY ARE DEPRESSED,
ARE NOT ABLE TO FUNCTION
OPTIMALLY, AND, THEREFORE, IT'S
OF GREAT CONCERN.
STARTING IN 2014, IT WAS STATED,
BECAUSE OF THE WORK AGAIN OF
PATRICK KENNEDY PRIMARILY,
STARTING IN 2014, THE PLANS
WOULD NOT BE ABLE TO DENY
COVERAGE OR CHARGE MORE DUE TO
PRE-EXISTING HEALTH CONDITIONS,
INCLUDING MENTAL ILLNESS.
SO THIS AFFORDABLE CARE ACT WAS
VERY IMPORTANT AND IS SOMETHING
WE NEED TO CONTINUE TO KEEP OUR
EYES ON.
NEXT SLIDE.
WELL, I DON'T WANT YOU TO THINK
ALL OF THE NEWS IS BAD.
THERE'S GOOD NEWS BECAUSE MANY
OF THESE THINGS HAVE BEEN
IMPLEMENTED, WE FOLLOWED
THROUGH.
RESEARCH HAS IMPROVED OUR
ABILITY TO RECOGNIZE, DIAGNOSE
AND TREAT CONDITIONS
EFFECTIVELY.
80 TO 90% OF MENTAL DISORDERS
ARE TREATABLE, USING MEDICATION
AND OTHER THERAPIES.
SO WE'RE MAKING PROGRESS.
THE NEXT SLIDE, AND I'M COMING
TO THE END SLIDES, THE BAD NEWS,
OF COURSE, IS THAT OF THOSE WITH
A DIAGNOSABLE MENTAL DISORDER,
FEWER THAN HALF OF ADULTS
ACTUALLY GET THE HELP THEY NEED,
AND ONLY ONE-THIRD OF CHILDREN
GET THE HELP THEY NEED WHEN
DEALING WITH THE MENTAL
DISORDER.
SO KEEP THAT IN MIND AS YOU
TACKLE THE CHALLENGES OF THE
BRAIN.
THERE'S A TREMENDOUS NEED OUT
THERE, AND IT'S NOT BEING MET
FOR MANY REASONS.
IF YOU SAY ONLY ONE-THIRD OF
CHILDREN ARE GETTING THE HELP
THEY NEED, THEN THAT TELLS YOU A
LOT ABOUT THE FACT THAT THERE
ARE A LOT OF CHILDREN OUT THERE
WHO NEED HELP AND ARE NOT
GETTING IT.
INDIVIDUALS SUFFER WITH STIGMA.
PART OF THE REAL PROBLEM IN
MENTAL HEALTH IS THERE'S SO MUCH
STIGMA THAT A LOT OF PARENTS
DON'T EVEN WANT TO TAKE THEIR
CHILDREN TO THE DOCTOR AND ADMIT
THAT THEIR CHILDREN HAVE MENTAL
HEALTH PROBLEMS.
AND OF COURSE, AGAIN, IN
PROFESSIONAL SPORTS, WE'RE JUST
BEGINNING TO SEE PEOPLE COME OUT
AND ADMIT THEY NEED HELP IN THIS
AREA.
SO YOU CAN IMAGINE THE MILLIONS
OF DOLLARS THAT HAVE BEEN WASTED
BECAUSE WE HAVE NOT STOPPED TO
DEAL WITH MENTAL HEALTH
PROBLEMS.
INDIVIDUALS WITH MENTAL HEALTH
PROBLEMS AND EXPERIENCING
PROBLEMS PREVENTS THEM FROM
ACKNOWLEDGING THE PROBLEM, KEEPS
THEM FROM RECOMMENDING HELP OR
ACKNOWLEDGING PROBLEMS FOR
FAMILY AND FRIENDS, AND IN THE
POLICY ARENA, WE NEED MORE
PEOPLE ON THE FRONT LINE, LIKE
PATRICK KENNEDY WAS WHEN HE WAS
THERE, TO KEEP GOVERNMENT AND
PRIVATE SECTOR FROM ADDRESSING
PROBLEMS.
I APPRECIATE THE FACT THAT
YOU'RE TAKING THE TIME TO BEGIN
TO EXAMINE THIS PROBLEM MORE
DEEPLY, AND LOOK FORWARD TO
WORKING WITH YOU.
NEXT SLIDE, PLEASE.
CULTURE IS AN ISSUE HERE.
MAKE NO MISTAKE ABOUT IT.
WITH PATIENTS, CULTURE IMPACTS
HOW THEY MANIFEST AND DESCRIBE
ILLNESSES, HOW THEY COPE WITH
ILLNESSES, THE TYPES OF STRESSES
THEY EXPERIENCE, AND WHETHER
THEY'RE WILLING TO SEEK
TREATMENT.
THERE ARE A LOT OF PEOPLE
SUFFERING SILENTLY WITH MENTAL
DISORDERS.
SOMETIMES THEIR SILENCE PERSISTS
THROUGH VIOLENCE, IT PERSISTS
THROUGH ILLNESS AND MURDER,
WITHOUT EVER SAYING, I NEED
HELP.
AND SO WE TOGETHER GOING TO HAVE
TO TAKE ON THIS, AND I'M REALLY,
AGAIN, HAPPY THAT YOU ARE TAKING
THE LEADERSHIP YOU'RE TAKING.
WITH HEALTH PROFESSIONALS,
CULTURE IMPACTS THE WAY PATIENTS
ARE DIAGNOSED, THE KIND OF
TREATMENTS OFFERED TO PATIENTS,
AND HOW SERVICES ARE ORGANIZED
AND FINANCED.
MENTAL HEALTH, CULTURE, RACE AND
ETHNICITY.
NEXT SLIDE.
ASK THE QUESTION, WHAT IF WE HAD
ELIMINATED DISPARITIES IN THE
LAST CENTURY?
I DON'T KNOW IF YOU YOU HAVE
EVER ASKED YOURSELF THAT
QUESTION, BUT I WANT TO TAKE A
MINUTE AS WE COME TO A CLOSE.
AND SHOW YOU HOW WE RESPONDED.
GEORGE RUSS, WHO WAS HERE AT
MOREHOUSE AT THE TIME WHEN I
CAME BACK FROM WASHINGTON, AND
WE ASKED THE QUESTION, WHAT DID
WE ELIMINATE?
WHAT WE WERE ABLE TO SHOW IS,
THERE WOULD HAVE BEEN 83,500
FEWER BLACK DEATHS IN THE YEAR
2000 IF WE HAD ELIMINATED
DISPARITIES IN THE LAST CENTURY.
24,000 FEWER HEART DISEASE
CASES.
7,000 FROM HIV/AIDS, FEWER
DEATHS.
ALMOST 5,000 FEWER INFANT
DEATHS.
22,000 FROM DIABETES.
AND OVER 2,000 BLACK WOMEN WHO
DIED FROM BREAST CANCER WOULD
NOT HAVE DIED.
MORE HEALTH INSURANCE COVERAGE
WOULD HAVE BEEN AVAILABLE.
2.5 MILLION BLACKS, INCLUDING
620,000 CHILDREN WOULD HAVE BEEN
COVERED WHO WERE NOT COVERED.
AND PROBABLY ARE NOT COVERED.
NEXT SLIDE.
I WON'T TRY TO GET YOU TO
ANALYZE THIS SLIDE, BUT THIS IS
WHAT WE DID HERE, WAS TO TRY TO
PUT IN GRAPHIC FORM WHAT
HAPPENED FROM 1960 TO 2000, AND
WHAT YOU SEE IS THINGS CHANGE IN
TERMS OF MALE/FEMALE
INTERACTION, MORTALITY RATES FOR
FEMALES WERE GREATER IN 1960
THAN THEY WERE COMPARED TO MALES
THAN THEY WERE IN 1990.
AND SINCE 1980, REALLY, THERE'S
BEEN AN INCREASE, RELATIVELY
SPEAKING, IN MORTALITY AMONG
MALES, ESPECIALLY AFRICAN
AMERICAN MALES.
THERE ARE MANY REASONS WE CAN
POINT TO, TO EXPLAIN THIS
DISPARITY, AND WE'RE ALSO --
WE'VE SEEN SIMILAR DISPARITY IN
TERMS OF RACE CONTINUE.
SO KEEP THAT SLIDE IN MIND AS
YOU GO ABOUT YOUR WORK THAT IS
SO GREATLY NEEDED.
NEXT SLIDE.
WELL, I THINK THAT ENDS THIS
DISCUSSION, AND I DON'T KNOW
WHETHER WE WILL HAVE TIME NOW
FOR QUESTIONS, BUT WHENEVER WE
DO, I LOOK FORWARD TO
INTERACTING WITH YOU AND
DISCUSSING FURTHER THIS ISSUE OF
HOW DO WE OVERCOME THE BARRIERS
THAT PREVENT US FROM ATTACKING
BRAIN PROBLEMS AS OPPOSED TO
HAVING THEM ATTACK US.
THAT'S A VERY IMPORTANT
QUESTION.
I LOOK FORWARD TO BEING ABLE TO
DISCUSS IT WITH YOU.
THANK YOU.
>>
[SPEAKER ON MUTE]
>> RICHARD, YOU'RE MUTED.
>> OKAY, GREAT.
I HAD DIFFICULTY UNMUTING
MYSELF.
THANK YOU, THANK YOU,
DR. SATCHER, FOR THAT EXCELLENT
PRESENTATION.
AGAIN, IT WAS TRULY AN HONOR AND
A PRIVILEGE FOR YOU TO SPEAK TO
US TODAY.
I KNOW WHEN I SPOKE WITH YOU
SEVERAL WEEKS AGO, YOU SAID THAT
YOU -- YOU KNOW, YOU AREN'T
TAKING AS MANY SPEAKING
INVITATIONS, BUT WE'RE SO HAPPY
AND GRATEFUL THAT YOU DID CHOOSE
TO PRESENT TO US TODAY.
I'M GOING TO OPEN THE FLOOR FOR
QUESTIONS, BUT I WANT TO START
US OUT WITH A QUESTION, I HAVE
SEVERAL QUESTIONS BUT I'M GOING
TO START WITH ONE QUESTION AS
OTHERS TYPE IN THE CHAT.
I WAS REALLY STRUCK BY YOUR
HISTORICAL PERSPECTIVE OF WHEN
YOU WERE IN UNDERGRADUATE SCHOOL
AT MOREHOUSE IN ATLANTA AND YOU
TALKED ABOUT, AT THAT TIME,
BEING ARRESTED WITH OTHERS, AND
THE TIME WITH DR. KING.
COULD YOU TALK A LITTLE BIT
ABOUT THE IMPACT OF RACISM AND
HOW THAT IMPACTS HEALTH, AS WELL
AS YOU TALKED ABOUT THE SOCIAL
DETERMINANTS OF HEALTH.
I THINK -- I MENTIONED AT THE
START THE COVID PANDEMIC AND HOW
THAT HAS SHOWN THE DISPARITIES
THAT WE HAVE DUE TO CO-MORBID
CONDITIONS BUT ALSO THE IMPACT
OF RACISM WITH THE MURDER OF
GEORGE FLOYD, BREONNA TAYLOR AND
OTHERS.
SO SORT OF DUELING PANDEMICS AND
THE IMPACT OF HEALTH.
IF YOU DON'T MIND COMMENTING ON
THAT.
>> WELL, AS YOU KNOW, RICHARD,
IT WAS A LONG TIME AGO WHEN I
WAS A STUDENT.
AT MOREHOUSE COLLEGE.
BUT I REMEMBER THAT TIME PERIOD
VERY WELL BECAUSE IT SORT OF
HELPED TO SHAPE US INTO WHO WE
ARE.
IT WASN'T ALWAYS PLEASANT.
BUT THE STUDENTS DURING THAT
PERIOD OF TIME, YOU MIGHT SAY,
ROSE UP AND DECIDED THAT WE'RE
JUST NOT GOING TO TAKE IT
ANYMORE.
AND WE ORGANIZED -- THERE WERE
STUDENTS FROM MOREHOUSE, SPELL
SPELLMAN, BROWN, CLARKE, AND WE
ORGANIZED AND WE WOULD GO
DOWNTOWN AND WE WOULD GO IN
RESTAURANTS TO BE SERVED,
KNOWING THAT WE WOULD BE
ARRESTED AS OPPOSED TO BEING
SERVED.
THAT WENT ON FOR AT LEAST TWO
YEARS.
AND DR. KING, OF COURSE, AT THE
TIME WAS CO-PASTORING EBONEZER
WITH HIS FATHER.
HE BECAME INVOLVED WITH THE
STUDENTS.
HE WAS QUITE A MOTIVATIONAL
LEADER WITH US.
SO WAS A.D. KING, HIS BROTHER.
IN FACT, A.D. WAS ONE OF THE SIX
STUDENTS, SIX OF US WHO WERE
PLAYING LEADERSHIP ROLES HAD
SAID THAT WE'RE GOING TO ASK THE
STUDENTS TO FILL THE JAILS IN
ATLANTA, SO THAT THERE WOULD BE
NO MORE PLACE FOR STUDENTS TO BE
SENT TO JAIL.
WE SUCCEEDED.
THE STUDENTS REALLY TURNED OUT.
THEN THERE WERE SIX OF US
LEADERS WHO WERE LEFT, AND THEY
HAD NO MORE SPACE IN THE JAIL
FOR US, SO THEY SENT US TO
PRISON.
SO IT'S THE ONE TIME IN MY LIFE
THAT I'VE BEEN TO PRISON AND THE
ONLY TIME I WOULD WANT TO BE.
BUT IT WAS -- WE LEARNED A LOT
ABOUT WHAT GOES ON IN PRISON,
AND WE WERE IN PRISON WHEN
DR. KING, YOU KNOW -- MRS. KING
CALLED THE KENNEDY CAMPAIGN TO
ASK THEM TO HELP IN GETTING
DR. KING OUT OF JAIL, AND HER
CONCERN WAS, IF YOU REMEMBER,
THAT DR. KING AND OTHERS HAD
BEEN SO MISTREATED IN JAILS, AND
THEY WERE TALKING ABOUT TAKING
DR. KING OUT OF ATLANTA AND
SENDING HIM TO ATHENS OR
SAVANNAH.
THAT WAS OF GREAT CONCERN TO
MRS. KING.
AND IT WAS OUT OF THAT CALL THAT
WE ENDED UP INTERACTING WITH
PRESIDENT KENNEDY, AND OTHERS IN
THE KENNEDY FAMILY, E ESPECIALLY
BOBBY KENNEDY, WHO REALLY MADE
THE CALL TO THE MAYOR OF ATLANTA
SO ASTO ASK THAT DR. KING BE
RELEASED.
>> THANK YOU, DR. SATCHER.
THERE ARE SEVERAL QUESTIONS IN
THE CHAT THAT RELATE TO STROKE
DISPARITIES, ONE, IN NATIVE
POPULATIONS.
I THINK WE'LL TALK ABOUT THAT
MORE OVER THE COURSE OF THE DAY.
WE HAVE PANELS OF EXPERTS THAT
HAVE BEEN STUDYING THOSE TYPES
OF DISPARITIES.
BUT ONE OF THE QUESTIONS I WANT
TO ASK YOU ABOUT, IT'S RELATED
TO THE IMPACT OF MENTAL HEALTH.
THE QUESTION IS RELATED TO
MENTAL HEALTH DISORDERS AND ITS
IMPACT ON STROKE.
IN GENERAL, JUST THE IMPACT OF
MENTAL HEALTH AND DISEASE IN
GENERAL.
I KNOW THAT THAT IMPACTS
COMPLIANCE WITH MEDICAL REGIMES.
IT ALSO PROBABLY IMPACTS
SOCIOECONOMIC STATUS AND OTHER
THINGS, BUT JUST WANT TO -- AND
ITS IMPACT ON BEING ABLE TO SEE
GOOD MEDICAL PROVIDERS, SO ANY
COMMENTS ON THAT?
QUESTION?
>> REPEAT THE QUESTION.
>> THE IMPACT OF MENTAL HEALTH
DISORDERS ON SPECIFIC DISEASES.
THE QUESTION WAS ABOUT STROKE,
BUT I WANT TO EXPAND TO OTHER
DISEASES AS WELL SO YOU DON'T
HAVE TO FEEL THAT YOU NEED TO
RESPOND SPECIFICALLY TO STROKE,
BUT ANY COMMENTS YOU HAVE.
>> WELL, STROKE IS SUCH A MAJOR
PROBLEM, ESPECIALLY IN OUR
POPULATION.
BECAUSE OF HYPERTENSION
ESPECIALLY AMONG AFRICAN
AMERICANS, AND BECAUSE OF
DIABETES AMONG NATIV NATIVE AMERICANS
AND OTHERS, STROKE IS A VERY
SERIOUS PROBLEM, AND IT IS
RELATE THED TORERELATED TO, AS YOU SORTRER ELATED TO AS YOU PUT IT
EARLIER THOSE DISPARITIES IN
HEALTH LEAD TO DISPARITIES IN
OUTCOMES SUCH AS STROKE.
NOW TODAY, YOU COULD SAY, THOUGH
DISPARITIES IN HEALTH LEAD TO
DISPARITIES IN COVID-19, AND IN
NORMAL PEOPLE WHO GET IT, NORMAL
PEOPLE WHO ARE HOSPITALIZED AND
ALL THE THINGS THAT GO ALONG
WITH IT, SOME OF THEM, WE DON'T
KNOW YET BECAUSE WE HAVEN'T
STUDIED LONG ENOUGH, WE HAVEN'T
STUDIED COVID-19 TO KNOW WHAT
SOME OF THE LONG-TERM EFFECTS
ARE.
BUT THESE ARE ALL RELATED, AND I
THINK RIGHT NOW, CONCERN SHOULD
BE, ALMOST A MILLION PEOPLE IN
THIS COUNTRY HAVE DIED FROM
COVID-19.
SO HOW MANY OF PEOPLE WHO HAVE
NOT DIED ARE GOING TO CONTINUE
TO SUFFER OTHER DISPARITIES.
SO THAT'S WHAT WE'RE DEALING
WITH, AND WE SHOULD BE VERY
CLEAR ABOUT THAT.
THAT THE PANDEMIC WILL NOT END,
OR EVEN WHEN EVERYBODY IS
DECEASED OR DIED -- WHO ARE
DECEASED, INCAPACITATED FROM THE
DISEASE/INFECTION.
WE REALLY NEED TO GET SERIOUS
ABOUT VACCINATION, BECAUSE IT'S
THE BEST HOPE WE HAVE NOT JUST
FOR PREVENTING COVID-19, BUT
PREVENTING A LOT OF THE THINGS
THAT WE'RE GOING TO SEE LATER,
IN TERMS OF THE AFTERMATH OF
COVID-19.
>> THANK YOU FOR THAT ANSWER.
THE OTHER THING THAT WE KNOW IS
THAT IN ADDITION TO THE RACIAL
DISPARITIES WHEN WE LOOK
SPECIFICALLY AT STROKE, WE KNOW
THAT THERE ARE GEOGRAPHIC
DISPARITIES AS WELL.
WE HAVE THE STROKE BELT AND THE
STROKE BUCKLE.
I KNOW THAT YOU OFTEN TALK ABOUT
GROWING UP IN RURAL ALABAMA, AND
SORT OF THE IMPACT ON HEALTH.
SO DO YOU HAVE ANY COMMENTS IN
TERMS OF GEOGRAPHIC DISPARITIES?
AGAIN, YOU DON'T HAVE TO FEEL --
TO SPEAK SPECIFICALLY TO STROKE,
BUT IN GENERAL, HEALTHCARE GEE GEE
GRAPHICS AND HOW THAT IMPACTS
HEALTHCARE.
>> YOU COULD ARGUE THAT I GREW
UP IN THE STROKE BELT, THAT PART
OF THE COUNTRY, ALONG SEVERAL
STATES, NOT JUST ALABAMA, WHERE
PEOPLE ARE MORE LIKELY TO SUFFER
AND DIE OF STROKE.
AFRICAN AMERICANS ESPECIALLY SO.
WE REALLY NEED TO FOCUS ON THIS
ISSUE.
WHEN I WAS DIRECTOR OF THE CDC,
WE TRIED TO ILLUSTRATE WHAT
COULD HAPPEN WHEN YOU FOCUS.
WE DID IT LOOKING AT NATIVE
AMERICANS, AMERICAN INDIANS.
NEWT GINGRICH WAS A --
[SPEAKER FROZE]
-- TO GET $200 MILLION, I
BELIEVE, DIABETES, AMERICAN
INDIANS HAVE THE HIGHEST RATE OF
DIABETES IN THIS COUNTRY, AND WE
WERE ABLE TO IMPLEMENT PROGRAMS,
THESE WERE NOT JUST MEDICAL
PROGRAMS BUT THEY WERE LIFESTYLE
PROGRAMS AND WHAT WE SAW WAS A
DRAMATIC DECREASE IN RENAL
DISEASE AMONG NATIVE AMERICANS
AND SEVERAL OTHERS.
IT'S THE RESULTS OF THAT STUDY
UNFORTUNATELY DIDN'T COME OUT
UNTIL I HAD LEFT THE CDC AND I
WAS IN WASHINGTON AS SURGEON
GENERAL.
BUT I THINK WE ALL NEED TO STOP
AND LOOK BACK AT THAT STUDY AND
WHAT IT REALLY TOLD US ABOUT OUR
ABILITY, BECAUSE WE OFTEN THINK
WE CAN'T DO ANYTHING ABOUT IT,
OUR ABILITY TO IMPACT SOMETHING
LIKE DIABETES IN A POPULATION
LIKE AMERICAN INDIANS AND NATIVE
AMERICANS.
>> THANK YOU, DR. SATCHER.
I THINK THIS HAS BEEN A
WONDERFUL SESSION.
YOU'VE GIVEN US GREAT INSIGHT
FROM YOUR EXPERIENCE, YOUR VAST
EXPERIENCE FROM GOVERNMENT, AS
SURGEON GENERAL AS WELL AS YOUR
OTHER EXPERIENCE BEING AT THE
HIGHEST LEVELS OF ACADEMIC
INSTITUTIONS.
WE THANK YOU.
ANY LAST REMARKS IN TERMS OF
YOUR VISION FOR THE FUTURE IN
TERMS OF HEALTH EQUITY WORK?
>> WELL, YOU KNOW, I'M NOW
COMMITTED TO CONTINUING TO PLAY
A MAJOR ROLE IN LEADERSHIP
DEVELOPMENT, BECAUSE I JUST
BELIEVE THAT AMONG OUR PEOPLE
ESPECIALLY, WE NEED MORE
LEADERS, BECAUSE WE'RE BEING
CONTINUALLY CHALLENGED.
IN EVERY WAY, NOT JUST BY
RACISM.
BUT WE HAVE THIS SAYING AT THE
SATCHER LEADERSHIP INSTITUTE AND
THE MOREHOUSE SCHOOL OF
MEDICINE, IN ORDER TO ELIMINATE
DISPARITIES IN HEALTH, WE NEED
LEADERS.
WE NEED LEADERS WHO CARE ENOUGH,
WE NEED LEADERS WHO KNOW ENOUGH,
LEADERS WHO WILL DO ENOUGH, AND
LEADERS WHO WILL PERSEVERE UNTIL
THE JOB IS DONE.
THAT'S WHAT WE NEED.
AND WE'VE GOT TO KEEP WORKING
FOR THAT DAY.
>> THANK YOU.
THANK YOU, DR. SATCHER.
THAT'S A GREAT WAY TO END THIS
SESSION.
AGAIN, WE THANK YOU FOR YOUR
TIME.
I KNOW YOU'RE VERY BUSY.
WE THANK YOU FOR PRESENTING TO
US TODAY.
>> DELIGHTED, RICHARD.
>> THANK YOU, DR. SATCHER.
VERY MUCH APPRECIATE YOUR WORDS
OF WISDOM.
>> THANK YOU.
>> AND BACK OVER TO YOU,
DR. ALBERTS.
>> THANK YOU, RICHARD, FOR
MODERATING DR. SATCHER AND
SHARING HIS WORDS OF WISDOM.
SO TO FRAME THINGS AS WE GET
INTO OUR REPORTS, I WANTED TO
JUST TAKE A FEW MINUTES TO
EXPLAIN TO MANY OF THE
PARTICIPANTS HOW WE ENDED UP
HERE IN TERMS OF THE ADVISORY
COUNCIL TO THE BAC AND THE
RETREATS THAT WE HAD THAT REALLY
IDENTIFIED THIS ISSUE OF THE
INEQUITY AND DISPARITY IN STROKE
CARE.
IT'S SUCH A HUGE TOPIC, AND
STROKE IS SUCH A BIG MEDICAL
PROBLEM.
WHAT WE DECIDED AFTER EXTENSIVE
DISCUSSION AND DELIBERATION IS
THAT IT MADE MORE SENSE TO LOOK
AT IT AMONG DIFFERENT ACCESSES.
AND ONE ACCESS, AND DR. SATCHER
TOUCHED ON THIS IN HIS COMMENTS
OF A FEW MINUTES AGO, WAS TO
BREAK IT DOWN INTO SORT OF MAJOR
REALMS THAT WE COULD HAVE AN
INFLUENCE ON OR THAT WE NEEDED
TO ANALYZE AND DIGEST.
AND AGAIN, DR. SATCHER SAID IT
VERY ELOQUENTLY A FEW MINUTES
AGO, BUT THERE'S BASICALLY FOUR
OF THEM.
NUMBER ONE HAS TO DO WITH
DEMOGRAPHICS, PATIENT
DEMOGRAPHICS, RISK FACTORS,
THINGS LIKE THAT.
NUMBER TWO HAD TO DO WITH
RESOURCES AND ECONOMICS, WHICH
SORT OF PARTIALLY -- HE TOUCHED
ON A LOT IN TERMS OF FINANCIAL
RESOURCES, THINGS LIKE THAT.
A THIRD AREA WHICH HE TOUCHED ON
UNDER THE NAME OF POWER, BUT WE
REFRAMED THAT OR WE RENAMED IT
IN TERMS OF POLICY AND
LEGISLATION.
SINCE THAT -- IF YOU HAVE THE
RIGHT POLICIES AND THE
LEGISLATION WHERE THE LAWS
BEHIND IT CAN REALLY DICTATE
WHAT YOU CAN DO, WHEN YOU CAN DO
IT AND HOW YOU CAN DO IT, AND
THEN LAST BUT NOT LEAST, WHICH
AGAIN DR. SATCHER VERY
ELOQUENTLY TOUCHED UPON WAS
GEOGRAPHY.
WHERE IS THE PATIENT, WHERE DO
THEY LIVE, WHAT'S THE POLITICS
OF THAT AREA, WHAT ARE THE
LIMITATIONS OF LIVING IN THE
NORTH VERSUS THE SOUTH AND
THINGS LIKE THAT.
AND AGAIN, THIS I HAS REALLY
HELPED FRAME THE DIFFERENT
BUCKETS WE PUT THESE BREAKOUT
GRAWPBREAKOUTGROUPS INTO ON ONE AXIS.
THE OTHER AXIS WE'VE IMPOSED IS
THE DIFFERENT TIME -- OF STROKE.
THE REASON WHY THAT'S IMPORTANT
WHICH I'M SURE THE MEDICAL
PEOPLE ON THE CALL UNDERSTAND
BUT THE NON-MEDICINE PEOPLE MAY
NOT FULLY APPRECIATE IS THAT OUR
CARE PARADIGMS AND THE PEOPLE
WHO DELIVER THE CARE AND THEIR
FOCUS IS VASTLY DIFFERENT IN
THESE DIFFERENT TIME EPOCHS.
FOR EXAMPLE, THE EMS, WHAT
HAPPENS BEFORE THE PATIENT GETS
TO THE HOSPITAL OR IN THE
AMBULANCE ON THEIR WAY THERE?
THAT CARE IS DELIVERED REALLY BY
DIFFERENT PEOPLE IN DIFFERENT
WAYS THAN THE HYPERACUTE CARE,
WHICH IS WHAT WOULD HAPPEN IN
THE EMERGENCY DEPARTMENT ONCE
YOU GET TO THE HOSPITAL, AND
THEN THAT ALSO IS A LITTLE BIT
DIFFERENT ABOUT WHAT HAPPENS
ONCE A PATIENT IS ACTUALLY
ADMITTED TO THE HOSPITAL, THEY
GO UP TO THE FLOOR AND THEY HAVE
ONGOING CARE.
SO AGAIN, STROKE IS SO HUGE AND
SO MULTIDIMENSIONAL WITH
DIFFERENT FACTORS, DIFFERENT
PEOPLE, DIFFERENT CARE
PARADIGMS, THAT'S WHY WE DECIDED
TO BREAK IT UP IN SORT OF THIS
DUAL ACCESSES IN THE MAJOR
POLICY ISSUES AND THE CARE
PARADIGMS AS WELL AS THE TIME
EPOCHS.
HYPERACUTE BY EMS, IN THE E.D.,
AND THEN ONCE THE PATIENT WAS
ADMITTED INTO THE HOSPITAL.
BUT I THINK ALSO AN OVERLYING
THEME, WHEN WE TALK ABOUT
ADDRESSING DISPARITIES AND LACK
OF EQUITY, IS THAT THERE SHOULD
BE ONE STANDARD OF CARE.
ONE STANDARD OF CARE.
THE CHALLENGE IS HOW DO WE MEET
THESE DIFFERENT STANDARDS OF
CARE WITH THE LIMITATIONS OF
LACK OF EQUITY?
WITH THE LIMITATIONS OF LACK OF
RESOURCES?
WITH THE DIFFERENT GEOGRAPHIC
BURDENS, WITH THE DIFFERENT CARE
PARADIGMS?
HOW CAN WE IDENTIFY THE ISSUES
AND COME UP WITH SOLUTIONS,
TESTABLE HYPOTHESES TO OVERCOME
SOME OF THESE ISSUES THAT MAKE
IT VERY CHALLENGING FOR SOME
PATIENTS TO RECEIVE THE STANDARD
OF CARE IN VARIOUS PARTS OF THE
COUNTRY, VARIOUS CARE PARADIGMS,
DIFFERENT VENUES.
SO I THINK THOSE CONSTRUCTS HAVE
HELPED SHAPE SOME OF THE REPORT
THAT YOU WILL HEAR FROM THE
VARIOUS TASK FORCES, AND WE HOPE
THEY WILL HELP SHAPE THE ONGOING
DISCUSSIONS AS WE GO BEYOND
DESCRIPTIVE DATA, BUT AS WE TRY
TO DEVELOP ASSOCIATIONS AND
DEVELOP TESTABLE HYPOTHESES FOR
HOW WE CAN ADDRESS SOME OF THESE
ISSUES ABOVE AND BEYOND JUST THE
DESCRIPTIVE LEVEL THAT WE'RE AT
FOR I THINK MANY OF THESE
CHALLENGES.
SO I JUST WANTED TO HELP FRAME
THIS, ESPECIALLY IN THE SETTING
OF THE EXCELLENT KICKOFF THAT
DR. SATCHER HAS GIVEN US.
RICHARD, DO YOU HAVE ANYTHING TO
ADD TO THAT?
>> NO, THANK YOU, MARK.
I THINK THAT WAS AN EXCELLENT
OVERVIEW.
I'M EXCITED TO HEAR THE
PRESENTATIONS.
>> OKAY.
THANK YOU VERY MUCH.
I'M GOING TO TURN IT BACK OVER
TO YOU, GREG, AND WE'LL GET INTO
THE REPORTOUTS.
>> ALL RIGHT.
THANK YOU SO MUCH.
WE ARE NOW GOING TO START OUR
PRE-HOSPITAL REPORTOUT SECTION.
>> WELCOME TO THE BRAIN ATTACK
COALITION SYMPOSIUM ON
INEQUITIES IN ACCESS AND
DELIVERY OF ACUTE STROKE CARE.
I'M COMMANDER ERICA ODOM.
AS A CDC EMPLOYEE, I NEED TO
PROVIDE THE DISCLAIMER THAT THE
INFORMATION PROVIDED TODAY DOES
NOT REPRESENT CDC'S OFFICIAL
POSITION OR RECOMMENDATIONS.
DR. TODD CROCCO AND I REPRESENT
A TASK FORCE OF CENTRAL ENTED
AND DEDICATED RESEARCHERS AND
PHYSICIANS WHO HAVE COME
TOGETHER FOR AREAS THAT ALREADY
MAY, THROUGH SYSTEMATIC ACTION,
BEGIN TO DISMANTLE SOME
INEQUITIES AND PRE-HOSPITAL
STROKE CARE.
THE PRIORITY AREAS WERE
DEVELOPED THROUGH SUBJECT MATTER
EXPERTISE AND CRITICAL
ASSESSMENT OF THE LITERATURE.
POTENTIAL INEQUITIES AND
DISPARITIES WERE ASSESSED IN
FOUR DOMAINS: GEOGRAPHY,
POLICIES AND REGULATIONS,
ECONOMICS IN HEALTHCARE
RESOURCES AND DEMOGRAPHICS.
IN THIS RECORDING, WE WILL
HIGHLIGHT A LIST OF PRIORITIES
WITHIN EACH DOMAIN THAT FALL
INTO THREE BROAD CATEGORIES.
EDUCATION AND TRAINING, SYSTEM
STRUCTURES AND GOVERNMENT OR
REGULATIONS.
THIS CATEGORIZATION MAY BE
HELPFUL FOR FUTURE EFFORTS AIMED
AT IDENTIFYING SOLUTIONS TO
ADDRESS INEQUITIES IN
PRE-HOSPITAL STROKE CARE, BUT
THIS IS NOT A COMPREHENSIVE
LIST.
WE, THEREFORE, INVITE YOU TO
REFLECT AND CONSIDER SOME GAPS
THAT REMAIN TO BE ADDRESSED AND
BRING YOUR THOUGHTS FOR
DISCUSSION TO OUR SESSION.
IT IS WELL-KNOWN THAT STROKE IS
A LEADING CAUSE OF DEATH IN LONG
TERM DISABILITY IN THE UNITED
STATES, IMPACTING ABOUT 795,000
PERSONS ANNUALLY.
TIME IS A CRITICAL FACTOR
FOLLOWING A STROKE, WITH EACH
PASSING MINUTE RESULTING IN THE
LOSS OF MILLIONS OF NEURONS.
THUS, TIME-SENSITIVE HIGH
QUALITY CARE IS NEEDED TO
SUPPORT PATIENTS AT THE EARLIEST
SIGNS OF STROKE.
FOR MOST PATIENTS, STROKES OCCUR
IN THE COMMUNITY SETTING.
DURING A PERIOD WE WILL DEFINE
AS THE PRE-HOSPITAL SETTING.
THE PRE-HOSPITAL STROKE SETTING
IS DYNAMIC, DIVERSE, AND
INCLUDES A BROAD RANGE OF
PEOPLE, PLACES AND ENVIRONMENTS.
THESE MAY INCLUDE FAMILY, AND
COMMUNITY MEMBERS, EMERGENCY
MEDICAL SERVICES OR EMS
PROFESSIONALS, AS WELL AS THE
SYSTEMS, STRUCTURES AND POLICIES
THAT SHAPE THE STROKE CARE
ENVIRONMENT.
AND THE COMMUNITY, AFTER IT IS
RECOGNIZED THAT A PERSON MAY BE
HAVING A STROKE, 911 SHOULD BE
CALLED IMMEDIATELY.
EMS PLAYS A SIGNIFICANT ROLE IN
THE STROKE CHAIN OF SURVIVAL.
COMMONLY BEING THE FIRST MEDICAL
PERSONNEL ON SCENE, THEY'RE ABLE
TO STABILIZE THE PATIENT AND
QUICKLY TRY TO DETERMINE IF THE
PERSON IS HAVING A STROKE,
GATHER INFORMATION ABOUT THE
PATIENT, WHEN THEY WERE LAST
KNOWN TO BE WELL, TRANSPORT THE
PATIENT TO THE HOSPITAL WITH THE
BEST LEVEL OF CARE FOR STROKE
SEVERITY AND TIMING, AND
PRE-NOTIFY HOSPITAL TEAMS OF
STROKE ARRIVAL.
PRE-NOTIFICATION TRIGGERS STROKE
TEAMS TO BE ACTIVATED IN THE
EMERGENCY DEPARTMENT AND
NEUROIMAGING MACHINES TO BE
CLEAR, AVOIDING TRIAGE DELAYS
AND DECREASING WAIT TIME.
WHILE MANY BEST PRACTICES ARE
WELL-KNOWN AND LIFE SAVING
INTERVENTIONS ARE AVAILABLE,
BARRIERS CONTINUE TO EXIST IN
EFFECTIVELY DELIVERING CARE.
WHILE MANY BEST PRACTICES ARE
WELL-KNOWN AND LIFE-SAVING
INTERVENTIONS ARE AVAILABLE,
BARRIERS CONTINUE TO EXIST IN
EFFECTIVELY DELIVERING CARE.
FOR EXAMPLE, MANY PATIENTS CAN
RAPIDLY ACCESS STROKE CENTERS,
YET ONLY 50 TO 60% OF STROKE
PATIENTS ARRIVE TO THE HOSPITAL
BY AMBULANCE.
IN ADDITION, ONLY 25 TO 30% OF
STROKE PATIENTS ARRIVE WITHIN
RECOMMENDED TREATMENT WINDOWS TO
RECEIVE ENDO VASCULAR TREATMENT
OR I.V.
>> HELLO, EVERYONE.
MY NAME IS TODD CROCCO,
PROFESSOR OF EMERGENCY MEDICINE
AT THE UNIVERSITY OF MARYLAND
SCHOOL OF MEDICINE AND VICE
PRESIDENT FOR TELEHEALTH AT THE
UNIVERSITY OF MARYLAND MEDICAL
SYSTEM.
THE PRE-HOSPITAL TASK FORCE
BROKE INTO SEVERAL DIFFERENT
SUBGROUPS AND IDENTIFIED
OPPORTUNITIES ACROSS THE
DIFFERENT CROSS-CUTTING THEMES.
I'M GOING TO START BY COVERING
THE THEME OF GEOGRAPHY.
NOW GEOGRAPHIC DISPARITIES EXIST
REGARDING VARIABILITY IN
QUALITY, ACCESS, EMS
INFRASTRUCTURE, PROVIDER
TRAINING AND EXPERIENCE, AND
OTHER AREAS.
THE DISPARITIES ARE HEIGHTENED
IN RURAL AREAS, BUT ALSO EXIST
IN URBAN AND SUBURBAN AREAS.
IN FACT, ENDOVASCULAR STROKE
THERAPY HAS HIGHLIGHTED SOME OF
THESE DISPARITIES DUE TO THE
LIMITED LOCATIONS WHERE
ENDOVASCULAR STROKE THERAPY CAN
BE PERFORMED.
ADDITIONALLY, GEOGRAPHIC
VARIATIONS INTRODUCE CULTURAL
DIFFERENCES IN EMS PROVIDER
GROUPS AND PATIENT POPULATIONS.
SO WITH THAT AS THE BACKDROP,
THE GEOGRAPHY SUBGROUP
IDENTIFIED THREE DIFFERENT
PRIORITY AREAS.
THE FIRST PRIORITY AREA
IDENTIFIED WAS TO TAKE A
MULTIFACETED PRE-HOSPITAL STROKE
SYSTEM OF CARE TO SUPPORT
GEOGRAPHIC NETWORKS,
DIFFERENTIATING BETWEEN RURAL,
URBAN, AND SUBURBAN SETTINGS.
GEOGRAPHIC STROKE SYSTEMS OF
CARE NEED TO CONSIDER QUANTITY
AND DISTANCE AND AVAILABILITY OF
AMBULANCE AGENCIES, AIR MEDICAL
TRAPT, FACILITY TRANSPORT, TO
HAVE A TRULY SYSTEM-BASED
APPROACH WILL REQUIRE
COLLABORATION BETWEEN STATE AND
LOCAL GOVERNMENT POLICY MAKERS
AND REGIONAL HEALTH SYSTEMS,
LOCAL HOSPITALS, AND AMBULANCE
AGENCIES.
IT ALSO REQUIRES COLLABORATION
WITHIN REGIONALIZED STROKENET
WORKS TO OVERCOME MARKET
COMPETITIVENESS.
AND INSTEAD, FOCUS ON THE
STANDARDIZATION OF PRE-HOSPITAL
STROKE SCREENING AND ROUTING
PROTOCOLS, EMS TRAINING AND
EDUCATION.
THE GOAL IS TO BUILD IN A
GEOGRAPHICALLY MINDFUL WAY A
SYSTEM OF CARE THAT FACILITATE
COLLABORATION RATHER THAN
COMPETITION PERTAINING TO STROKE
TRIAGE.
THE SECOND PRIORITY AREA THAT
THE SUBGROUP IDENTIFIED WAS TO
SUPPORT EDUCATION AND CULTURAL
AWARENESS OF PREHOSPITAL STROKE
RECOGNITION AND PREVENTION
THROUGH ENHANCED COMMUNITY
ENGAGEMENT.
THIS PRIORITY SUPPORTS ENHANCED
TRAINING FOR UNDERSERVED AREAS,
FOR ACCURATE IDENTIFICATION OF
STROKE BY FIRST RESPONDERS
ACROSS THE PRE-HOSPITAL
CONTINUUM.
AND THAT INCLUDES DISPATCH, EMS,
FIRE, RESCUE, AND POLICE.
UNDERSERVED AREAS INCLUDE
FACTORS LIKE SOCIOECONOMIC
STATUS, CULTURAL DIFFERENCES,
AND LOCAL GOVERNANCE AND
POLICIES, AND AFFECT THE MAKEUP
OF PRE-HOSPITAL PROVIDER
POPULATIONS AND STROKE AWARENESS
IN THE LOCAL COMMUNITY.
LEADERS MUST WORK WITH STATE AND
LOCAL REGULATORS TO IMPROVE
EDUCATION AND RESOURCES FOR
STROKE EDUCATION AND TRAINING
AMONG PREHOSPITAL PROVIDERS.
LASTLY, STATE-WIDE EFFORTS
SHOULD BE INCORPORATED TO
STANDARDIZE TRAINING AND
APPLICATION OF PREHOSPITAL
STROKE SKILLS.
THE THIRD AND FINAL PRIORITY
AREA IDENTIFIED BY THE SUBGROUP
WAS TO ADVOCATE FOR SUSTAINED
ACCESS AND SUSTAINABILITY OF
TELESTROKE SYSTEMS OF CARE THAT
SUPPORT HUB AND SPOKE MODELS OF
PREHOSPITAL AND INTERFACILITY
STROKE CARE, INCLUDING EXPANSION
INTO THE PREHOSPITAL SETTING.
WHILE TELESTROKE SYSTEMS ARE
DESIGNED TO ADDRESS GEOGRAPHIC
DISPARITIES IN HOSPITAL-BASED
ACUTE STROKE CARE, THEY'RE ALSO
RELEVANT TO PREHOSPITAL STROKE
CARE.
THIS MEANS WE NEED TO WORK WITH
POLICY MAKERS, PAYORS, INCLUDING
REIMBURSEMENT, AVAILABILITY OF
BROADBAND AND WIRELESS
INFRASTRUCTURE.
>> THE CHALLENGES AROUND TROLL
OF EMS IN THE U.S. ARE EXPLORED.
THIS AREA CAN BE COMPLEX AND
SOMETIMES CONFUSING, YET HAS THE
POTENTIAL TO RESULT IN LONG TERM
SUSTAINABLE INTERVENTIONS.
ALTHOUGH EMS PRACTITIONERS AND
AGENCY CERTIFICATIONS ARE
LARGELY REGULATED BY THE STATE,
MEDICAL PROTOCOLS ARE DETERMINED
AT THE LOCAL LEVEL.
FEDERAL ENTITIES SUCH AS THE
NATIONAL HIGHWAY AND
TRANSPORTATION SAFETY
ADMINISTRATION, THE FEDERAL
INTERAGENCY COMMITTEE ON EMS AND
THE NATIONAL EMS ADVISORY
COUNCIL ALSO PROVIDE GUIDANCE
AND COORDINATION AMONG REGIONAL
ENTITIES.
FEDERAL ENTITIES SUCH AS THE
NATIONAL HIGHWAY AND
TRANSPORTATION SAFETY
ADMINISTRATION, THE FEDERAL
INTERAGENCY COMMITTEE ON EMS,
AND THE NATIONAL EMS ADVISORY
COUNCIL ALSO PROVIDE GUIDANCE
AND COORDINATION AMONG REGIONAL
ENTITIES.
AS A RESULT OF THIS TIERED
SYSTEM OF REGULATION,
COORDINATION OF POLICY IS
VARIABLE AND FRAGMENTATION CAN
OCCUR EVEN WITHIN STATES.
WITHIN THE FIRST PRIORITY AREA,
MODIFICATION OF REIMBURSEMENT
MODELS, WE EXPLORE FEE SCHEDULES
FOR REIMBURSEMENT OF
PRE-HOSPITAL STROKE CARE AS A
FUNCTION OF PATIENT DECISION TO
ALLOW TRANSPORT, MILEAGE AND
COMPLEXITY OF CARE.
THE LITERATURE SUGGESTS THAT
CARE PROVIDED BY EMS FOR STROKE
MAY NOT REQUIRE NUMEROUS
CLINICAL PROCEDURES.
HOWEVER, EMS DECISION-MAKING FOR
STROKE PATIENTS CAN BE COMPLEX
AND MAY NOT BE FULLY ACCOUNTED
FOR IN CURRENT EMS REIMBURSEMENT
MODEL.
WITHIN THE SECOND PRIORITY AREA,
ALIGNMENT FOR REIMBURSEMENT AND
COMPLEXITY OF CARE, WE EX-PLR EXPLORE
THE EVIDENCE REGARDING
PATIENT-CENTERED CARE MODELS,
LIKE CMS'S EMERGENCY TRIAGE,
TREAT AND TRANSPORT PROGRAM, AND
THE NATIONAL EMS QUALITY
ALLIANCE -- [INAUDIBLE].
WE CONSIDER THESE AS PREHOSPITAL
STROKE CARE MODELS FOR
DETERMINING REIMBURSEMENT RATHER
THAN RELIANCE ON PROCEDURE BASIS
AND TRANSPORT [INAUDIBLE].
IN OUR THIRD PRIORITY AREA, WE
EXPLORE EVIDENCE ON THE
INTEGRATION OF PREHOSPITAL
STROKE CARE DATA TO THE HOSPITAL
AND DISCHARGE OUTCOME.
INITIATIVES BY FEDERAL ENTITIES
LIKE THE CDC'S NATIONAL STROKE
PROGRAM, PRIVATE ORGANIZATIONS
AND INDIVIDUAL INVESTIGATORS
HAVE MADE STRIDES TO IMPROVE
DATA LANGUAGE.
HOWEVER, UNIVERSAL DATA
INTEGRATION HAS NOT BEEN
ACHIEVED TO DATE.
FRAGMENTATION IN PREHOSPITAL
REGULATION, REIMBURSEMENT AND
LINKAGE OF DATA CAN RESULT IN
DIFFERENTIAL ACCESS TO HIGH
QUALITY EMS CARE FOR PATIENTS.
THUS, SYSTEMATIC IMPLEMENTATION
OF PREHOSPITAL STROKE CARE
POLICIES AND REGULATIONS COULD
HELP DRIVE MORE EQUITABLE STROKE
CARE.
>> I'M NOW GOING TO TALK ABOUT
THE NEXT CROSS-CUTTING THEME,
AND THAT IS, ECONOMICS AND
HEALTHCARE RESOURCES.
SO BY WAY OF BACKGROUND, THIS IS
A COMPLEX TOPIC.
EMS REGULATION TAKES PLACE AT
THE STATE, TERRITORY OR LOCAL
LEVEL, STANDARDS ARE CREATED
PRIMARILY BY PROFESSIONAL
ORGANIZATIONS, PAYMENTS ARE
DRIVEN BY THE STATE, FEDERAL,
AND PRIVATE SOURCES.
ADDITIONALLY, PREHOSPITAL SAIR
SYSTEMS ARE INTERDEPENDENT WITH
HOSPITAL-BASED STROKE CARE.
VERY IMPORTANTLY, VARIABILITY IN
REGIONAL RESOURCE AVAILABILITY
IS ASSOCIATED WITH DISPARITIES
IN HEALTH OUTCOMES.
THESE DISPARITIES IMPACT RACIAL
AND ETHNIC MINORITY GROUPS,
RURAL AREAS, AND THE MOST
ECONOMICALLY DISADVANTAGED.
THIS SUBGROUP ALSO IDENTIFIED
THREE PRIORITY AREAS.
THE FIRST PRIORITY AREA
IDENTIFIED WAS TO ALIGN
PREHOSPITAL AND HOSPITAL BASED
STROKE CARE WITH THE BROADER
OBJECTIVE OF ENHANCING EMERGENCY
CRITICAL CARE SYSTEMS.
SIMPLY STATED, PREHOSPITAL CARE
IS A CENTRAL TOUCH POINT BETWEEN
THE COMMUNITY AND THE HEALTHCARE
SYSTEM.
DEVELOPING A MODEL THAT ALLOWS
FOR SHARED ACCOUNTABILITY FOR
HEALTH OUTCOMES AT THE COMMUNITY
LEVEL WOULD ALIGN INCENTIVES
AMONG KEY STAKEHOLDERS TO WORK
TOGETHER TO IMPROVE ACCESS TO
CARE AND OPTIMIZE OUTCOMES.
ADDITIONALLY, NEW REGULATORY,
PAYMENT AND WORKFORCE SOLUTIONS
TARGETING HEALTHCARE
PROFESSIONALS THAT COMMIT TO
TREATING PATIENTS IN UNDERSERVED
AREAS WOULD BE BENEFICIAL.
THE SECOND PRIORITY THIS
SUBGROUP IDENTIFIED WAS TO
DEVELOP NATIONAL AND LOCAL
LEGISLATION ENSURING
POPULATION-BASED PLANNING
SOLUTIONS THAT ARE DESIGNED TO
MEET THE STROKE NEEDS OF
COMMUNITIES INDEPENDENT OF THE
ECONOMICS.
AS THE SUBGROUP NOTES, WHILE
MOST PREHOSPITAL CARE IS
ORGANIZED AT THE COMMUNITY
LEVEL, HEALTHCARE IS PRIMARILY
FOCUSED ON THE INDIVIDUAL
PATIENT CARE LEVEL.
THE TASK FORCE BELIEVES THAT
NATIONAL LEGISLATION COULD
CREATE A PATHWAY FROM
MEASUREMENT TO IMPLEMENTATION OF
BEST PRACTICES, AS WELL AS
MANDATE PUBLIC REPORTING OF THE
VARIABILITY IN REGIONAL
RESOURCES.
THIS COULD IMPROVE OUR
UNDERSTANDING OF HOW THE
UNDERLYING ECONOMIC DRIVERS OF
HEALTHCARE RESOURCE ALLOCATION
IMPACTS THE DISPARITIES IN
HEALTH OUTCOMES.
THE THIRD AND FINAL PRIORITY
AREA DEVELOPED BY THIS SUBGROUP
WAS TO DEVELOP A NATIONAL STROKE
REGISTRY IN ORDER TO BETTER
UNDERSTAND THE ROLE OF
COMMUNITY, ECONOMIC, AND HEALTH
SYSTEMS FACTORS DRIVING STROKE
OUTCOMES.
THE STROKE REGISTRY ENSURES THAT
ECONOMIC BIAS IS INTRODUCED INTO
STROKE CARE BECAUSE RESOURCE
CENTERS ARE MORE INCLINED TO
PARTICIPATE IN VOLUNTARY
REGISTRIES.
HEALTHCARE RESOURCES ARE
PARTICULARLY SHORT IN MINORITY
POPULATIONS.
THE LACK OF REPRESENTATIVE DATA
FROM UNDERRESOURCED AREAS LIMIT
THE ABILITY TO DEVELOP
MEANINGFUL METRICS TO INFORM
NATIONAL POLICIES.
AND STANDARDS AROUND VALUE BASED
REIMBURSEMENT.
AND EMS PROTOCOLS AND TELESTROKE
UTILIZATION AND OTHER AREAS.
THE ESTABLISHMENT OF A NATIONAL
STROKE REGISTRY WOULD PROVIDE
REALTIME DATA ON THE CARE
RENDERED TO STROKE PATIENTS.
>> IN THE FOURTH CROSS-CUTTING
THEME, DEMOGRAPHICS, WE IDENTIFY
COMMUNITY INCREASED HOSPITAL
RELATED FACTORS ASSOCIATED WITH
SEX AND GENDER, RACE AND
ETHNICITY, SOCIOECONOMIC STATUS
AND INSURANCE STATUS DISPARITIES
SEEN IN STROKE TREATMENT.
IN THE FIRST PRIORITY AREA, WE
EXPLORE THE LITERATURE ON
SYSTEMATIC, HIGH QUALITY DATA
COLLECTION.
DATA ARE ESSENTIAL TO EVALUATE
EMS PERFORMANCE, IDENTIFY AREAS
OF IMPROVEMENT, AND TO EXAMINE
THE EFFECTS OF CONTINUOUS
QUALITY IMPROVEMENT.
DATA MAY ALSO LEAD TO THE
IDENTIFICATION OF DEMOGRAPHIC
DISPARITIES AT THE LOCAL LEVEL,
PROVIDING OPPORTUNITIES FOR
INTERVENTIONS AIMED AT
STANDARDIZING STROKE CARE
OUTCOMES FOR ALL.
IN THE SECOND PRIORITY AREA,
PROGRAMS AND PRACTICES THAT
EDUCATE THE PUBLIC ABOUT STROKE
CARE ARE REVIEWED.
PUBLIC AWARENESS AND EDUCATIONAL
ACTIVITIES HAVE BEEN REGARDED AS
INTEGRAL FOR THE EARLY
IDENTIFICATION OF STROKE AND
EARLY ACTIVATION OF THE
PREHOSPITAL STROKE SYSTEM.
WHILE SUCH INTERVENTIONS MAY
INCREASE STROKE KNOWLEDGE,
LIMITATIONS MAY EXIST IN THE
LINKAGE TO BEHAVIOR CHANGE IN
MEDICALLY UNDERSERVED
POPULATIONS.
FURTHER, TAILORED INTERVENTIONS
MAY BE NECESSARY TO INCREASE
UNDERSERVED COMMUNITIES'
UNDERSTANDING AND TRUST OF
PREHOSPITAL STROKE SYSTEMS.
FURTHER, TAILORED INTERVENTIONS
MAY BE NECESSARY TO INCREASE
UNDERSERVED COMMUNITIES'
UNDERSTANDING AND TRUST OF
PREHOSPITAL STROKE SYSTEMS.
IN THE THIRD PRIORITY AREA FOR
THE DEMOGRAPHIC THEME, EMS
WORKFORCE DIVERSITY AND HEALTH
EQUITY TRAINING ARE REVIEWED.
HAVING A DIVERSE WORKFORCE CAN
BE ASSOCIATED WITH IMPROVED
ACCESS TO MEDICAL CARE FOR THOSE
IN RACIAL AND ETHNIC MINORITY
COMMUNITIES.
GREATER PATIENT CHOICE AND
SATISFACTION, IMPROVEMENT IN THE
REPORTED QUALITY OF CARE AND
INCREASED INTEREST IN THE SYSTEM
OF CARE.
PUBLIC EDUCATION CAMPAIGNS AND
INITIATIVES THAT SUPPORT
BEHAVIOR CHANGE IN COMMUNITIES
CAN BE INFORMED BY ACCESSING AND
INTERPRETING HIGH QUALITY DATA.
SYSTEMATIC COLLECTION OF
PREHOSPITAL DATA STARTS WITH A
DIVERSE, WELL TRAINED EMS
WORKFORCE THAT MAY SERVE AS THE
INITIAL ENTRY POINT INTO THE
HEALTHCARE SYSTEM, AND A
COMMUNITY RESOURCE PROVIDING
EQUITABLE ACCESS TO HIGH QUALITY
CARE.
>> HAVING GONE THROUGH THE
DIFFERENT CROSS-CUTTING THEMES
WITHIN THE PREHOSPITAL TASK
FORCE, I'D LIKE TO NOW PROVIDE
YOU WITH A SUMMARY OF THE KEY
FINDINGS.
THE PREHOSPITAL TASK FORCE
IDENTIFIED 10 SEPARATE KEY
FINDINGS.
FIRST, SPECIFIC STROKE SYSTEMS
OF CARE NEED TO BE OPTIMALLY
DESIGNED FOR SPECIFIC RURAL,
URBAN, AND SUBURBAN REGIONS.
SECOND, WE NEED TO ASSESS STROKE
EDUCATION AND TRAINING NEEDS
AMONG PREHOSPITAL CARE PROVIDERS
TO STANDARDIZE CARE IN A
SPECIFIC REGION.
THIRD, TELESTROKE SYSTEMS OF
CARE SHOULD EXPAND INTO THE
PREHOSPITAL SETTING.
FOURTH, EMS REIMBURSEMENT MODELS
NEED TO BE MODIFIED TO
APPROPRIATELY REFLECT AND ALIGN
WITH THE COMPLEX DECISION-MAKING
THAT OCCURS WITH POTENTIAL
STROKE PATIENTS IN THE
PREHOSPITAL SETTING.
FIFTH, PREHOSPITAL PATIENT CARE
REPORTS NEED TO BE LINKED AND
INTEGRATED WITH HOSPITAL PATIENT
CARE REPORTS AND OUTCOMES.
SIXTH, WE NEED TO ESTABLISH A
NATIONAL STROKE REGISTRY.
SEVENTH, ESTABLISH NATIONAL
STROKE STANDARDS FOR PREHOSPITAL
CARE.
EIGHTH, WE NEED TO ENHANCE
REGISTRY DATA AT THE STATE AND
LOCAL LEVELS.
NINTH, WE NEED TO EXPAND AND
ENHANCE CULTURALLY SENSITIVE,
SUSTAINABLE STROKE MESSAGING TO
THE PUBLIC.
AND LASTLY, WE NEED TO PROMOTE
EMS WORKFORCE DIVERSITY.
HAVING GONE THROUGH THE SUMMARY
ITEMS PUT FORTH BY THE
PREHOSPITAL TASK FORCE, WE'RE
LEFT WITH SOME ACTIONS,
OPPORTUNITIES AND
RECOMMENDATIONS.
THE PREHOSPITAL TASK FORCE BROKE
THESE RECOMMENDATIONS DOWN VERY
BROADLY INTO THREE CATEGORIES.
EDUCATION/TRAINING, SYSTEMS AND
STRUCTURE, AND GOVERNMENT AND
REG WILL TRI OPPORTUNITIES.
REGULATORY OPPORTUNITIES.
LET ME HIT A FEW OF THE
HIGHLIGHTS.
I'LL START WITH EDUCATION AND
TRAINING.
WE NEED TO ENLANCE TRAINING FOR
UNDERSERVED AREAS.
AS NATIONALLY VALIDATED
PREHOSPITAL STROKE SCALES
EVOLVE, THERE NEEDS TO BE
IMPLEMENTATION OF STATEWIDE
POLICIES PROMULGATING THE USE OF
SUCH SCALES.
WITHIN THE SYSTEMS AND STRUCTURE
CATEGORY, WE NEED TO ENCOURAGE
RESEARCH THAT FURTHER OPTIMIZES
REALTIME ADAPTIVE PREHOSPITAL
ROUTING ALGORITHMS.
WE NEED TO ENHANCE ACCESS TO
PRESTROKE HOSPITAL RESEARCH AND
PROMOTE GEOGRAPHIC SPECIFIC
HOSPITAL TRIAGE PROGRAMS.
WE NEED TO STANDARDIZE
PREHOSPITAL COMMUNICATIONS
WITHIN STROKE SYSTEMS OF CARE,
AND INCORPORATE COMMUNITY
PARAMEDICINE AND LOCAL
PARTNERSHIPS INTO THOSE STROKE
SYSTEMS OF CARE.
AND LASTLY, WE NEED TO ESTABLISH
LINKAGES BETWEEN PREHOSPITAL AND
HOSPITAL PATIENT CARE RECORDS.
THEN IN THE GOVERNMENT AND
REGULATORY CATEGORY, WE NEED
LEGISLATION TO PROMOTE
STANDARDIZED EMS PROTOCOLS AND
REGIONALIZATION OF PREHOSPITAL
STROKE CARE.
THE TASK FORCE ADVOCATES FOR
POLICIES, LEGISLATION, AND
RESOURCES TO SUPPORT THE
CREATION OF STATE OR COMMUNITY
LEVEL STROKE REGISTRIES, TO LINK
PREHOSPITAL DATA METRICS TO
HEALTH SYSTEM OUTCOMES, AND TO
SERVE AS A BASIS FOR POLICY
DEVELOPMENT AND CONTINUING
QUALITY IMPROVEMENT INITIATIVES.
WE NEED TO PROVIDE GUIDANCE TO
STATES REGARDING MINIMUM
ELEMENTS REQUIRED FOR
PREHOSPITAL STROKE SYSTEMS OF
CARE, AND FINALLY, WE NEED TO
SUPPORT EVOLUTION OF CMS
REIMBURSEMENT GUIDELINES THAT
PROMOTE REIMBURSEMENT FOR
PREHOSPITAL CARE COMMENSURATE
WITH THE LEVEL OF CARE PROVIDED.
THAT'S IT FROM THE PREHOSPITAL
TASK FORCE.
WE HOPE YOU FOUND THIS VALUABLE
AND WE GREATLY APPRECIATE YOUR
PARTICIPATION IN OUR SYMPOSIUM.
>> THANK YOU SO
MUCH FOR JOINING THIS
PREHOSPITAL SECTION.
I GUESS SO NOW WE'LL BEGIN THE Q
& A SESSION.
I HAVE A CO-HOST JOINING TODAY,
CHARLES, IF YOU'RE ON THE LINE,
YOU CAN ALSO JOIN.
AND WE CAN GO AHEAD AND GET
STARTED WITH SOME Q & As
BEFORE WE GO TO OUR BREAKOUT
SESSION.
>> DR. ODOM OR COLONEL ODOM, IS
IT?
>> IT'S COMMANDER.
THANK YOU SO MUCH.
>> IT'S MARK ALBERT.
THANK YOU AND TODD AND YOUR
COLLEAGUES FOR PUTTING TOGETHER
THIS REALLY SPECTACULAR
PRESENTATION.
I MEAN, I AGREE WITH SO MUCH OF
WHAT YOU SAID SAID HAVING TO
DEAL WITH THIS IN THE VARIOUS
STATES I'VE LIVED AND WORKED IN.
JUST A COUPLE QUESTIONS OR
COMMENTS.
I DIDN'T HEAR MUCH, AND AGAIN, I
MIGHT HAVE MISSED IT, AUDIO
FADES IN AND OUT, I DIDN'T HEAR
MUCH ABOUT MOBILE STROKE UNITS.
DID YOU TOUCH ON THAT?
DID I MISS IT?
DO YOU NOT SEE THAT AS IMPORTANT
IN THE CARE PARADIGMS?
WHAT'S YOUR PERCEPTION OF THE
PLACE OF THAT MOBILE STROKE
UNITS COULD OR WOULD OR
SHOULDN'T PLAY IN THIS WHOLE
CARE PARADIGM?
>> HI, MARK.
THAT'S A GREAT QUESTION.
ERIKA, UNLESS YOU WANT TO
RESPOND FIRST, I'M HAPPY TO
OFFER AN INITIAL RESPONSE.
I THINK, YOU KNOW, THERE IS
GREAT POTENTIAL AND IMPORTANCE
PERSONALLY FOR MOBILE STROKE
UNITS BEING INCORPORATED INTO
THESE SCHEMES.
AS WAS TALKED ABOUT AND AS
RECENT PUBLICATIONS HAVE
ADDRESSED, PATIENTS IN RURAL
AREAS HAVE THE LONGEST DISTANCES
TO TRAVEL TO RECEIVE ACCESS TO
STROKE CARE.
AND THE QUESTION IN THE CHAT
BOXY SAW THAT SOMEONE HAD A
QUESTION ABOUT NATIVE AMERICAN
POPULATIONS AS WELL.
AND SIMILARLY, IN THIS RECENT
STUDY, NATIVE AMERICANS LIKEWISE
HAD THE LONGEST TRAVEL TIME TO
RECEIVING STROKE CARE.
SO POTENTIALLY, MOBILE STROKE
UNITS CAN BE FURTHER --
UTILIZATION CAN BE FURTHER
ENHANCED TO BRIDGE THESE
DISTANCE AND TRAVEL GAPS THAT
MAY EXIST.
THERE ARE SOME POTENTIAL NOVEL
THINGS THAT MAY BE COMING DOWN
THE PIKE.
THERE'S BEEN A VEN TOOR CAPITAL
COMPANY THAT AS RECENTLY AS LAST
NOVEMBER, I THINK, WAS TRIALING
A TELE-911 SYSTEM BY WHICH --
THERE WAS, FOR BACKGROUND
OBVIOUSLY IN TODD AND ERIKA'S
PRESENTATION AND THE WORK GROUP
REPORT DISCUSSION ABOUT
TELEMEDICINE BEING UTILIZED ON
AMBULANCES.
WHAT THIS COMPANY IS
INVESTIGATING IS WHETHER OR NOT
TELEMEDICINE COULD BE UTILIZED
BY DISPATCHERS BEFORE AMBULANCES
EVEN ARRIVE ON SITE.
THE ORIGINAL INTENTIONS ARE TO
SEE IF PATIENTS CAN BE TRIAGED
TO AN URGENT CARE CENTER OR
MANAGED AT HOME, BUT THERE IS
POTENTIAL GREAT UTILITY IF THIS
DOES TRANSLATE TO BECOME USED ON
A MORE WIDESPREAD BASIS FOR
USING TELE-911 TO ASSESS STROKE
PATIENTS.
AND THAT POTENTIALLY COULD THEN
LEAD TO DOWNSTREAM EFFECTS OF
DISPATCH DECISIONS FOR WHAT
LEVEL OF AMBULANCE OR MOBILE
STROKE UNIT IS DISPATCHED TO THE
XENOAND WHETHER OR NOT AS WAS
DISCUSSED BY THE WORK GROUP AS
WELL, WHETHER OR NOT DOWNSTREAM
ROUTING DECISIONS ARE THEN
IMPLEMENTED AS WELL BASED UPON
THE PREDICTABILITY OF A LARGE
VESSEL OCCLUSION.
AND JUST FOR BACKGROUND FOR THE
NON-CLINICAL PEOPLE WHO MAY BE
JOINING OUR CONFERENCE TODAY,
LVO, AS YOU MAY BE AWARE OF THE
TERM STANDS FOR LARGE VESSEL
OCCLUSION, AND THESE TYPES OF
STROKES HAVE BLOCKAGES VISIBLE
ON CT ANGIOGRAMS WHICH ARE CAT
SCANS LOOKING AT THE CEREBRAL
VASCULATURE, THE BLOOD VESSELS
GOING TO THE BRAIN, AND THESE
TYPES OF STROKES ARE AMENABLE TO
THE TREATMENT OF MECHANICAL
THROM BECKETTHROMBECTOMY BY WHICH A CATHET ER
IS PLACED TO THEN EXTRACT THE
CLOTS.
FOR THESE TYPES OF LVO STROKES
AND NON-LVO STROKES, WE STILL
HAVE GREAT BENEFIT FROM THE CLOT
BUSTER MEDICATION ALTOPLASE
WHICH WAS ALSO REFERRED TO.
SO MARK, I DON'T KNOW IF THAT
FULLY ANSWERS YOUR QUESTION, BUT
SOME INITIAL THOUGHTS.
>> THANK YOU.
COMMANDER ODOM, DO YOU HAVE ANY
THOUGHTS ON THAT?
>> I WOULD AGREE WITH EVERYTHING
THAT CHARLES MENTIONED,
ESPECIALLY IN THINKING ABOUT
MORE RURAL AREAS AND AREAS WHERE
NATIVE PERSONS LIVE, IN TERMS OF
HAVING ACCESS TO THAT CARE
RATHER QUICKLY, MOBILE STROKE
UNITS WOULD BE ESSENTIAL IN
PROVIDING SOME OF THAT INITIAL
CARE AND EVEN THINKING ABOUT
THAT SORT OF DISPATCH SITUATION
THAT YOU MENTIONED AND I HADN'T
EVEN -- I WASN'T FULLY AWARE OF
THE RESEARCH IN THAT AREA, SO
THANK YOU FOR SHARING THAT.
BUT YEAH, ABSOLUTELY, I AGREE
THAT THOSE ARE -- IT IS AN AREA
THAT, YOU KNOW, SHOULD BE
ADDRESSED IN TERMS OF PROVIDING
EQUITABLE CARE ACROSS GEOGRAPHIC
REGIONS AND SHOULD BE SOMETHING
THAT WE INCLUDE IN OUR
DISCUSSIONS.
I DO SEE THAT WE HAD A COUPLE OF
OTHER QUESTIONS IN THE CHAT, AND
I WANTED TO MAKE SURE WE BRING
THOSE FORWARD.
SO ONE IS REGARDING ANY
ESTIMATES ON A NATIONAL LINKED
SYSTEM THAT MIGHT BE AVAILABLE.
AND THIS QUESTION WAS FROM
ANDREA.
ANDREA, IF YOU WANT TO JUMP ON
AND SAY MORE.
IN TERMS OF SYSTEMS -- DATA
SYSTEMS IF YOU'RE SPEAKING
SPECIFICALLY TO NATIONAL
DATABASES THAT EXIST FOR STROKE
CARE, I'M SURE YOU ALL ARE AWARE
OF THE NATIONAL ACUTE STROKE
PROGRAM.
THAT IS NOT NATIONAL, IT'S BASED
ON FUNDING THAT'S AVAILABLE FROM
CONGRESS FROM THE DIFFERENT
CYCLES THAT EXIST AND THE MOST
RECENT CYCLE COVERED ABOUT 13
STATES.
SO THAT'S NOT NATIONALLY
REPRESENTATIVE, BUT THE GOAL
WITHIN THIS LAST NOFO WAS TO
MAKE SURE THAT WE ADDRESSED AND
INCLUDED STATES WITHIN REGIONS
WHERE STROKE HAS A HIGH
INCIDENCE.
SO THAT'S SOMETHING THAT WE
ENSURED THAT THE PEOPLE WHO
APPLIED FOR THE GRANTS WROTE
ABOUT AND SO OUR GOAL WAS TO
ADDRESS SOME OF THESE INEQUITIES
THAT WE SEE WITHIN STROKE WITHIN
THE PROGRAM PUSHING THAT TOPIC
FORWARD.
DID YOU HAVE ANYTHING ELSE TO
ADD IN TERMS OF YOUR QUESTION,
ANDREA?
IF NOT, I DID SEE A COUPLE OF
OTHER QUESTIONS.
ONE WAS RELATED SPECIFICALLY TO
ADDRESSING COMMUNITY EDUCATION
WITHIN THE HOSPITAL SETTING TO
INCREASE STROKE READINESS AND
KNOWLEDGE.
SO CHARLES, I'LL KICK IT BACK TO
YOU IF YOU WANT TO EY ADDRESS THAT,
AND I CAN ADD ON.
>> SURE, HAPPY TO.
I DO THINK WE HAVE AT THE END OF
THE DAY AN ENTIRE TIME EPOCH
PERIOD OF IN-HOSPITAL CARE SO
THAT MAY ADDRESS THIS ISSUE, BUT
CERTAINLY AS MANY KNOW, STROKE
CAN STRIKE ANYWHERE, INCLUDING
AMONG INPATIENTS WHO ARE
ADMITTED WITHOUT STROKES.
AND SIMILARLY HAVING RAPID
IDENTIFICATION AND RAPID ACCESS
TO DIAGNOSTICS FOR THESE
PATIENTS ARE OF THE UTMOST
IMPORTANCE.
PER THE LITERATURE, THERE ARE
TIME LAGS AS MOBILIZATION OF THE
SYSTEM IN THE IN-HOUSE SETTING
IS SOMETIMES FRAUGHT WITH
CHALLENGES COMPARED TO THE
EMERGENCY DEPARTMENT SETTING.
SO THERE ARE FURTHER
OPPORTUNITIES FOR ENHANCEMENT
HERE AND CERTAINLY THERE'S A LOT
OF PEOPLE WHO ARE SHINING A
MAGNIFYING GLASS ON THIS AREA TO
TRY TO MAKE FURTHER
IMPROVEMENTS.
ANOTHER QUESTION I SEE, ERIKA,
IS FROM DR. BENSON.
ANY DISCUSSION OF PREHOSPITAL
SYSTEMS TAKING ON THE ROLE ROLE
OR ASSISTING WITH COMMUNITY
EDUCATION AND ENGAGEMENT TO
INCREASE STROKE READINESS
KNOWLEDGE?
I'M NOT AN EXPERT BUT I THINK
THIS IS A VERY IMPORTANT
QUESTION, IMPORTANT AREA TO
FOCUS ON.
HERE AT YALE, I HAVE A LITTLE
BIT OF EXPERIENCE BECAUSE ONE OF
MY COLLEAGUES HAD A DIFFERENT
PREHOSPITAL PROJECT THAT WAS
LOOKING AT COMMUNITY EDUCATION
THAT WAS CALLED THE PRAD STUDY,
IT WAS LOOKING AT A DIFFERENT
POPULATION OF ELDERLY PATIENTS
WITH FALLS, AND UTILIZE
PARAMEDIC FOLLOW-UP VISITS TO GO
OVER RISK FACTORS, FALL
ASSESSMENTS, REVIEW OF
MEDICATIONS, AND THEN REFERRING
PATIENTS TO APPROPRIATE
PROVIDERS IF NEEDED AND
NECESSARY.
AND I THINK -- I'M NOT AWARE
OFFHAND OF ANY LARGE SCALE
SIMILAR INTERVENTIONS BEING DONE
LIKE THIS IN THE PREHOSPITAL
SETTING FOR STROKE PRIMARY AND
SECONDARY PREVENTION OR
EDUCATION REGARDING THE
IDENTIFICATION OF STROKE.
BUT I THINK IT DOES REALLY LEND
ITSELF TO A GREAT OPPORTUNITY
OVER THE COURSE OF THE NEXT
DECADE, BUILDING UPON WHAT THE
PRAD GROUP AND WHAT OTHER GROUPS
HAVE IDENTIFIED FOR OTHER
PATIENT POPULATIONS.
DR. BENSON, I DON'T KNOW IF YOU
HAVE ANY FURTHER THOUGHTS ON
THERE, OR DR. ALBERT OR ERIKA AS
WELL.
>> THANK YOU.
THANK YOU, DR. WIRA, THAT WAS
SPOT-ON.
WE KNOW, AND IT WAS MENTIONED AT
THE OUTSET OF THE PRESENTATION
THAT IN GENERAL, PEOPLE PRESENT
TO THE HOSPITAL LATE, AND WHEN
WE THINK ABOUT DISPARITIES, WE
KNOW THAT THERE'S A LOT OF
MEDICAL MISTRUST.
WE'VE TALKED ABOUT THE NEED FOR
BETTER COMMUNITY ENGAGEMENT FOR
CLINICAL CARE, BUT ALSO FOR
ENROLLING IN CLINICAL TRIALS,
WHICH I THINK, YOU KNOW,
CLINICAL RESEARCH AND CLINICAL
CARE GO HAND IN HAND.
AND SO I SEE THIS AS AN
OPPORTUNITY, AND I REALLY LOVE
THE IDEA OF THIS PREHOSPITAL
STROKE SYSTEMS WORKING WITH THE
HOSPITALS AS WELL, AS A WAY TO
SORT OF ENGAGE THE COMMUNITY AND
CREATE THESE COMMUNITY NETWORKS.
AND SO I THINK IT'S DEFINITELY
AN OPPORTUNITY GAP AND SO THAT
WAS SORT OF WHERE I WAS
THINKING.
>> SO ONE OF THE UNIQUE THINGS
ABOUT THE COVERDALE PROGRAM IS
THAT INITIALLY WE WORK WITH THE
STATE HEALTH DEPARTMENT, AND WE
BUILD INTO THE PROGRAMS THAT
THERE IS GOING TO BE A
COMMUNICATION EFFORT WITH THE
COMMUNITY AROUND THESE ISSUES OF
HOW TO RECOGNIZE THE SIGNS AND
SYMPTOMS OF STROKE.
SO A NUMBER OF OUR PROGRAMS
WITHIN THE COVERDALE PROGRAM PUT
TOGETHER COMMUNICATION EFFORTS,
WHETHER IT BE BY RADIO OR
ADVERTISEMENTS ON SIDE OF BUSES,
OR EVEN WITH THIS IDEA AROUND
COMMUNITY PARAMEDICINE AND
GETTING THE EMS PROVIDERS WHEN
THEY GO IN FOR FALLS AND
DIFFERENT THINGS LIKE THAT, THEY
WOULD HAVE MAGNETS REGARDING THE
SIGNS AND SYMPTOMS OF STROKE
THAT THEY JUST SLAP ON THE
REFRIGERATOR OR SOMETHING, YOU
KNOW, MAGNETIC.
AND TALK TO FAMILY MEMBERS AND
DIFFERENT THINGS ABOUT THE SIGNS
AND SYMPTOMS OF STROKE IF YOU
HAVE ELDERLY FOLKS AT RISK FOR A
STROKE.
THERE ARE ALSO PROGRAMS THAT
HOSPITALS HAVE BUILT AROUND
EDUCATING NOT ONLY EMS PROVIDERS
ABOUT EDUCATING IN THE
COMMUNITY, BUT ALSO PROVIDING
EDUCATION PROGRAMS WITHIN SCHOOL
SYSTEMS BECAUSE YOU'RE ABLE TO
CONNECT THESE YOUNG CHILDREN
WITH THEIR OLDER FAMILY MEMBERS
AND RECOGNIZING THOSE SIGNS AND
SYMPTOMS OF STROKE.
SO THERE'S THINGS LIKE HIP-HOP
STROKE AND, AN EDUCATIONAL PROGRAM
TARGETING SCHOOL AGED FOLKS SO
THEY CAN RECOGNIZE THE SIGNS AND
SYMPTOMS OF STROKE SO THEY'RE
ABLE TO RECOGNIZE THAT WITHIN
THEIR FAMILY MEMBERS.
SO I THINK THERE ARE MANY SORT
OF AVENUES TO GET THOSE MESSAGES
OUT TO THE COMMUNITY, BUT
THINKING SPECIFICALLY ABOUT HOW
PREHOSPITAL AND EMS PROVIDERS
CAN PLAY A ROLE IN THAT IS ONE
THAT CONTINUES TO BE AN AREA
THAT CONTINUES TO BE BUILT OUT.
>> JUST TO BUILD ON THE
EXCELLENT COMMENTS THAT
COMMANDER ODOM JUST SAID, WE
KNOW FROM DECADES OF RESEARCH
RELATED TO TPA AND HYPERACUTE
THERAPIES THAT THE MESSAGE NEEDS
TO BE REPETITIVE.
YOU CAN'T JUST THINK YOU CAN DO
IT ONE AND DONE.
BECAUSE REALLY WHAT WE'RE TRYING
TO DO WITH STROKE EDUCATION,
WE'RE TRYING TO TRAIN PEOPLE TO
REACT TO AN EVENT, TO A
CIRCUMSTANCE, TO A SET OF
SYMPTOMS, THAT THEY MAY ONLY
EXPERIENCE ONCE IN THEIR
LIFETIME.
SO IT'S NOT LIKE WHERE THE
PUBLIC EDUCATION CAMPAIGNS HAVE
BEEN SUCCESSFUL, LIKE USING YOUR
SEAT BELTS, WHICH PEOPLE DO
MULTIPLE TIMES A DAY, THAT'S
VERY SUCCESSFUL BECAUSE, AGAIN,
IT'S A FREQUENT BEHAVIOR.
WHEREAS CALLING 911 BECAUSE
SOMEONE HAS WEAKNESS OR NUMBNESS
IS A VERY INFREQUENT BEHAVIOR,
AND TO THE EXTENT AS DR. BENSON
SAID A FEW MINUTES AGO, THAT
THERE'S DISTRUST IN LACK OF
UNDERSTANDING BETWEEN
DISAFFECTED GROUPS AND THE
MEDICAL SYSTEM THAT MAKES THE
BARRIER, THE HURDLE OF THIS EVEN
MORE CHALLENGING.
>> AND I THINK JUST IN GENERAL,
WE HAVE TO THINK ABOUT
COMMUNITIES, DIFFERENT
COMMUNITIES AND THEIR
WILLINGNESS TO CALL A SYSTEM
LIKE 911 AND EXPECTING
RESPONSIVENESS, SO THINKING
ABOUT THOSE ISSUES TOO, IN TERMS
OF THAT TRUST OR MISTRUST ON THE
MEDICAL COMMUNITY.
>> TOTALLLY AGREE.
THE OTHER ASPECT -- WELL,
THERE'S MANY ASPECTS THAT ARE
IMPORTANT, BUT SEVERAL OF THE
FOLKS WERE TALKING ABOUT
BREAKING DOWN BARRIERS, AND YOU
KNOW, I THINK REMOVING
ARTIFICIAL BARRIERS IS A HUGE
OPPORTUNITY, BECAUSE THERE
SHOULDN'T BE A BARRIER, I MEAN,
THERE'S NO BRICK WALL, THERE'S
NO IRON CURTAIN BETWEEN
ADJOINING STATES.
AND TO THE BEST OF MY KNOWLEDGE,
IF YOU'RE HAVING A MEDICAL
EMERGENCY SUCH AS AN ACUTE
STROKE OR ACUTE CORONARY
SYNDROME, THERE ARE NO INSURANCE
BARRIERS THAT SHOULD BLOCK
PATIENT TRANSFER OR
REIMBURSEMENT AS OPPOSED TO
GOING TO THE NEAREST FACILITY,
WHICH WE ALL KNOW TIME IS BRAIN.
SO I THINK THAT'S AN OPPORTUNITY
TO REMOVE ARTIFICIAL BARRIERS OF
SAYING THIS AMBULANCE COULD NOT
CROSS STATE LINES, OR COULD NOT
GO INTO A DIFFERENT COUNTY.
TO THE BEST OF MY KNOWLEDGE, IF
IT'S A MEDICAL EMERGENCY, MAJOR
TRAUMA, MVA, WHATEVER, YOU ARE
ALLOWED TO DO THAT TO PROVIDE
EMERGENCY CARE.
>> AGREE.
IF I CAN ALSO ADD IN TOO, I
THINK WHEN YOU THINK ABOUT
ENGAGING COMMUNITIES THAT ARE
MORE DIFFICULT TO ENGAGE, IT'S
IMPORTANT -- WE TALK ABOUT THIS
IN RESEARCH BUT MAYBE ALSO WE
SHOULD CONSIDER THIS IN THE SORT
OF PREHOSPITAL ENGAGEMENT
SETTINGS, MAKING SURE THAT THERE
ARE PEOPLE WHO REPRESENT THE
COMMUNITY IN TERMS OF CULTURE
AND HOW THEY LOOK, EMPLOYED TO
WORK WITH THEM TO HELP GIVE
MESSAGES THAT ARE UNDERSTANDABLE
AND DEAL WITH SOME OF THE GAPS
THAT ARE THERE.
AND I LIKE THE TERM THAT MARK
MENTIONED IN TERMS OF THESE
BARRIERS, ARTIFICIAL BARRIERS, A
LOT OF THEM, I THINK THROUGH
HAVING THEM MESSAGED CORRECTLY,
SOME OF THEM COULD BE ADDRESSED.
AND AGAIN, TYING THAT TO
ENGAGEMENT ENROLLMENT AND
CLINICAL TRIALS AS WELL AS
UNDERSTANDING MEDICAL BEHAVIORS
IN ALL OF THAT.
BUT -- AND ALSO DEALING WITH THE
MEDICAL MISTRUST, I THINK
COMMUNITIES ARE PRETTY SAVVY, SO
THIS BIDIRECTIONAL COMMUNICATION
IS IMPORTANT.
THERE ARE PEOPLE THAT ARE EXPERT
AND TRAINED IN COMMUNITY
ENGAGEMENT, SO MAYBE HAVING
PEOPLE AT THE HOSPITAL OR THE
PREHOSPITAL SETTING WHO HAS
TRAINING IN ENGAGING TIE VERSE DIVERSE
COMMUNITIES, WORKING WITH THE
TEAM AS WELL IS IMPORTANT IS A
BARRIER THAT CAN BE BROUGHT DOWN
AS WELL.
CHERYL WROTE IN OUR EFFORTS TO
EDUCATE, WHY DO WE NOT DO A GOOD
JOB EXPLAINING WHY IT'S CRITICAL
TO CALL 911?
THIS KIND OF DOVETAILS WHY WE
ARE TALKING.
WHY SHOULD WE UNDERSTAND TO
EXPECT SOMEONE TO -- WHEN WE
SPEND UP TO AN HOUR EXPLAINING
THE PENUMBRA TO STUDENTS AND
RESIDENTS?
WE NEED A STRATEGIC CONSISTENT
MESSAGE TO THIS EFFECT.
THAT'S PART OF THE CHALLENGE, NO
TWO STROKES ARE THE SAME IN
TERMS OF THEIR PRESENTATION.
ONE PERSON MAY PRESENT WITH SORT
OF THE CLASSIC PARALYSIS ON ONE
SIDE OF THEIR BODY, ANOTHER
PERSON MAY JUST HAVE DIZZINESS
AND VOMITING, SO THERE CAN
SOMETIMES BE CHALLENGES.
IT'S HARD JUST FOR OUR RESIDENTS
JUST TO CONVEY THE MESSAGE ACUTE
SYMPTOM IS VASCULAR OR STROKE
UNTIL PROVEN OTHERWISE.
THAT'S HARD ENOUGH TO EDUCATE
OUR STAFF IN THE HOSPITAL LET
ALONE AT THE COMMUNITY LEVEL,
LET ALONE ALL OF THE OTHER
BARRIERS THAT EXIST IN TERMS OF
TRANSLATING THE EDUCATION TO
DIFFERENT GEOGRAPHICAL AREAS AND
DIFFERENT POPULATIONS, AND IT
CERTAINLY IS AN ONGOING CHAL
CHALLENGE BUT ALSO OPPORTUNITY
TO WORK ON FURTHER.
>> I AGREE.
AS YOU KNOW, FOR THE NON-MEDICAL
PEOPLE ON THE CALL, EVEN
PATIENTS IN THE HOSPITAL OR IN
THE EMERGENCY DEPARTMENT WHO WE
THINK ARE HAVING A STROKE AND
WHO WE CALL A STROKE CODE ON,
WE'RE WRONG 50 -- THAT'S 5-0,
WE'RE WRONG 50% OF THE TIME.
AND THAT'S TRAINED MEDICAL
PEOPLE.
IN THE COMMUNITY, THEY'RE GOING
TO BE WRONG AS OFTEN IF NOT MORE
OFTEN THAN WE ARE, AND THAT'S
PART OF THE CHALLENGES AND THEN
YOU HAVE THE ISSUES OF LACK OF
COMMUNICATION WITH THE MEDICAL
SYSTEM, MISTRUST, I SAW ONE OF
THE COMMENTS, OR RELUCTANCE TO
CALL 911 THAT IT'S INTIMIDATING.
TOTALLY GET THAT.
THE FLIP SIDE IS THAT PATIENTS
STAY HOME FOR HOURS AND THEN
THEY'RE OUT OF THE TIME WINDOW
WHERE THEY CAN BENEFIT FROM A
THERAPY.
SO IT IS A VERY VEXING PROBLEM.
THE OTHER THING I WAS THINKING
ABOUT AND I KNOW WE'RE ALMOST
OUT OF TIME HERE IS THAT IN
TERMS OF SETTING ONE STANDARD OF
CARE, WE'RE TALKING ABOUT FANCY
TELEHEALTH SYSTEMS AND MOBILE
STROKE UNITS WHICH ARE GREAT.
BUT WHEN PUSH COMES TO SHOVE, WE
ALL HAVE ONE OF THESE.
[HOLDING UP PHONE]
THREE OR FOUR MINUTES WITH AN
IPHONE VIDEO CHAT WHICH MY KIDS
DO CONTINUALLY, WITH THE TRAINED
OBSERVER ON THE OTHER END.
I THINK WE COULD DO A GOOD JOB
AT LEAST PICKING OUT THE MAJOR
LVOs OR THE MAJOR MEDICAL
THINGS, SO DON'T LET THE PERFECT
BE THE ENEMY OF THE GOOD,
SOMETIMES THIS IS ALL THAT WE
HAVE AVAILABLE FOR TRIAGE IN A
REMOTE LOCATION, AND IF IT'S
GOING TO SPUR OR ACCELERATE
MEDICAL CARE, I THINK THIS IS A
VIABLE OPTION IN SOME CASES.
>> SOMEONE ELSE WROTE IN THE
CHAT, ACCORDING TO YOU, MANY
RURAL RESIDENTS HAVE HAD A BAD
EXPERIENCE OF DELAYED
911 RESPONSE DUE TO COVID.
SUCH AS THE STAFFING CRISIS
AVAILABILITY.
THEY'D JUST RATHER DRIVE
THEMSELVES TO THE E.D. AND THIS
IS CERTAINLY -- AGAIN, AS
DR. BENSON KIND OF HIGHLIGHTED,
OVER THE COURSE OF THE PAST
THREE YEARS WITH COVID BUT THEN
ALSO WITH THE NATIONAL SENTINEL
EVENT OF THE GEORGE FLOYD,
BREONNA TAYLOR AND AHMAUD AUBREY
MURDERS, THE SPOTLIGHT HAS
REALLY BEEN SHINED ON THE
INEQUITIES, AND THEN WE ALSO
HAVE SOME OF THESE OTHER THINGS
LIKE THE STAFFING CRISIS THAT'S
BEEN ALLUDED THAT ALSO HAS AN
IMPACT ON SOME OF OUR PATIENTS'
DESIRE TO ACCESS THE SYSTEM AND
TO RECEIVE HELP.
SO IT'S A GOOD POINT THAT
THERE'S MULTIFACTORIAL REASONS
OF WHY 911 MAY NOT BE UTILIZED
BUT HOPEFULLY AS WE MOVE
FORWARD, TAKE THAT SPOTLIGHT
THAT I ALLUDE TO, AND SHINE IT
TODAY ON THE DIFFERENT FOUR
CATEGORY AREAS OF STROKE CARE,
WE CAN HOPEFULLY WORK TO
IDENTIFY NEW OPPORTUNITIES, THE
CURRENT GAPS TO FILL THE VOID OF
AND ALSO RESEARCH PRIORITIES FOR
FUTURE UTILIZATION BY THE NIH.
>> SO THANK YOU ALL FOR THIS
GREAT DISCUSSION AND
CONTRIBUTIONS.
ON THE EAST COAST HERE, IT
NOONTIME.
SO I THINK WE'RE DUE TO GO TO
OUR BREAKOUT SESSIONS.
I'M GOING TO GO AHEAD AND
INTRODUCE THE NEXT SESSION AND
WE WILL PLAY YOUR PRE-RECORDED
SUMMARY, SO WE ARE ABOUT TO HEAR
THE REPORT-OUT SUMMARY FROM OUR
TASK FORCE, LED BY AMIR AND LEE,
FOCUSING ON HEALTH INEQUITIES IN
THE HYPER/ACUTE CARE TIME EPOCH
OF STROKE CARE.
WE WILL HAVE AS BEFORE A VIDEO
THAT WILL PLAY, WITH ALL OF
THEIR FINDINGS.
THEN WE WILL MOVE INTO A
DISCUSSION SESSION, AND I THINK
THAT THEY HAVE A COUPLE
DISCUSSANTS WHO ARE GOING TO
PARTICIPATE.
THAT WOULD BE A GREAT
OPPORTUNITY FOR YOU ALL TO BEGIN
PUTTING QUESTIONS IN THE CHAT AS
THE VIDEO IS PLAYING.
WHEN THEY MOVE INTO LIVE
DISCUSSION.
AND THIN AFTER -- THEN WE'LL GO
BACK INTO BREAKOUTS BY
CROSS-CUTTING AREAS, HAVE
CAMERAS ON, HAVE AN ORGANIC
DISCUSSION ABOUT CROSS-CUTTING
TOPICS IN THE BREAKOUT SESSIONS.
I THINK OUR CONTRACTORS ARE
GOING TO PLAY THE VIDEO, WITHOUT
FURTHER ADO.
>> HELLO, I'M AMEER HASSAN,
TODAY I WILL BE CO-CHAIRING THE
HYPERACUTE CARE SECTION OF THE
INEQUITIES AND DELIVERY OF ACUTE
STROKE CARE WITH MARY LEE
JENSON.
A QUICK OVERVIEW, HYPER AND
ACUTE CARE TASK FORCE IS
FOCUSING ON IDENTIFYING DRIVERS
OF DISPARITY IN ACUTE STROKE
CARE THAT AFFECT EQUITABLE
ACCESS IN THE U.S. AND
TERRITORIES.
PRIMARY FOCUS WILL BE DELIVERY
OF CARE IN TRADITIONAL EMERGENCY
DEPARTMENTS.
OTHER IMPORTANT AREAS OF FOCUS
ARE THE SPOKES IN THE HUB AND
SPOKE MODEL, ESPECIALLY IN RURAL
AREAS.
ME BEING IN TEXAS, IT'S NOT
REALLY RURAL BUT IT'S A
POPULATION OF ABOUT 70,000, I
KNOW WHAT IT'S LIKE TO FEEL
DISCONNECTED, TRYING TO BUILD A
PROGRAM OUTSIDE OF A MAJOR CITY.
EMERGENCY CARE ENTRY POINTS
WHERE CARE IS DELIVERED IN
NON-TRADITIONAL EMERGENCY
DEPARTMENTS AND CLINICS
UTILIZATION OF TELEMEDICINE TO
MEET NEEDS OF UNDERSERVED
POPULATIONS AND/OR LOCATIONS,
ACCESS TO BROADBAND AND OTHER
TELL MEDICINE EQUIPMENT AND
STAFFING, EDUCATION, ALIGNMENT
OF REGULATION, POLICY, LOCAL,
STATE, NATIONAL LEVELS.
SO, I'M GOING TO DISCUSS TODAY
DEMOGRAPHICS AND ECONOMIC
SUBGROUPS.
AND THEN LEE WILL BE PRESENTING
GEOGRAPHY AND POLICY.
FOR DEMOGRAPHIC SUBGROUP
PRIORITY NUMBER ONE IS DIVERSITY
IN THE WORK FORCE, SHOWN TO
IMPROVE THE LEARNING EXPERIENCE
OF DIVERSE STUDENTS AND MEDICAL
TRAINEES, IMPROVE PATIENT CARE
AND HEALTH OUTCOMES, IMPROVE
QUALITY OF HEALTH CARE RESEARCH.
SO, FOR PRIORITY 1,
UNFORTUNATELY THE CURRENT RACIAL
AND ETHNIC DIVERSITY AMONG
STROKE, EVEN OVERALL NEUROLOGY
AND NEUROSURGERY WORKFORCE DOES
NOT REFLECT DIVERSITY OF THE
UNITED STATES POPULATION.
ANOTHER IS LACK OF GENDER
DIVERSE IN ACADEMIC STROKE
MEDICINE, ESPECIALLY IN
LEADERSHIP POSITIONS.
AND VERY PROUD OF WORKING WITH
LUIS MCCULLOUGH, WE'VE
COLLABORATED ON A NUMBER OF
THINGS.
LACK OF DIVERSITY EXISTS IN
FACULTY WORKFORCE AND LACK OF
RACIAL AND ETHNIC WORKFORCE IN
TRAINEES.
INCLUDING VASCULAR NEUROLOGY.
IN ADDITION HAVING A LOW
PROPORTION OF FACULTY AND
TRAINEES FOR MINORITY GROUPS
INDIVIDUALS ARE A PART OF THE
WORKFORCE AND FACE CHALLENGES IN
ADVANCING WITHIN ACADEMIC
MEDICINE.
THESE INCLUDE AS YOU CAN SEE
LISTED THE MINORITY TAX, LOYALTY
TAX, DISTANCE TRAVELED, POWER
DISTANCE, INCREASE THE IMPOSTOR
SYNDROME.
PRIORITY 2 IS NEED FOR STROKE
OUTREACH TO UNDERSERVED
POPULATION AND AT-RISK
POPULATIONS.
FOR ME THIS HITS HOME.
85% OF MY POPULATION IS MEXICAN
AMERICAN, 15 MINUTES FROM THE
BORDER, SO I SEE THIS A LOT.
ANOTHER PRIORITY IS CRITICAL --
THAT IS CRITICAL TO REDUCTION OF
DISPARITIES IS NEED FOR IMPROVED
OUTREACH TO UNDERSERVED
COMMUNITIES AND INDIVIDUALS AT
RISK IN OUTCOMES.
SOCIAL DETERMINANTS OF HEALTH
IMPACT ACCESS TO ACUTE STROKE
CARE.
ESPECIALLY THROMBOLYSIS AND
MECHANICAL THROMBECTOMY.
WE DID RESEARCH SEVERAL YEARS
AGO SHOWING SIGNIFICANTLY
DECREASED IVTP UTILIZE ATION
LEADING TO INCREASED MORTALITY.
BLACKS, HISPANICS, SPANISH
SPEAKING, LOWER INCOME, LOW
EDUCATION, THOSE LIVING IN RURAL
AREAS.
AND THEN OF COURSE ADD INTO THIS
THAT THE EDUCATIONAL PNEUMONICS
LIKE FAST AND B FAST FOR STROKE
SIGNS AND SYMPTOMS ARE PRIMARILY
IN ENGLISH, NEW TOOLS OF SPANISH
LANGUAGE TOOLS ARE BEING
DEVELOPED, AND WE'RE WORKING
WITH TO GET WITH GUIDELINES
PARTNERS ON THIS.
LEE SHWAM IS HEADING THIS.
PRIORITY 3, THERE HAVE BEEN
DISPARITIES IN HOSPITAL
RESOURCES ACROSS THE BOARD
ESPECIALLY IN MINORITY GROUPS,
IN HOSPITALS IN U.S. TERRITORIES
ARE NO EXCEPTION.
ONE OF THE CHALLENGES THE
TERRITORIES FACE IS DISTANCE
FROM CONTINENTAL U.S. AND
POTENTIAL TRANSFER CENTERS.
DISTANCE CREATES URGENCY TO
IMPROVE SYSTEMS OF CARE AND
HOUSEHOLD RESOURCES SPECIFICALLY
AT THOSE TERRITORIES.
INCREASED UTILIZATION OF
TELEMEDICINE COULD HELP.
RAFI WILL BE PART OF THE
DISCUSSION.
SDIM, MT 2220 AND SILK ARE TWO
SUBCOMMITTEES WORKING ON
CREATING TRAINING PATHWAYS FOR
LOW-INCOME COUNTRIES ACROSS THE
WORLD, ESPECIALLY U.S.
TERRITORIES THAT WOULD BE A
PRIORITY.
INCREASED UTILIZATION OF
TELEMEDICINE AND MEDICAL
PROFESSIONALS IN THE TERRITORIES
COULD HELP AND MENTORING AND
EDUCATION ARE ESSENTIAL TO
IMPROVE THE CARE OF STROKE
PATIENTS LIVING IN U.S.
TERRITORIES.
POTENTIAL SOLUTIONS TO LACK OF
DIVERSITY IN STROKE WORK FORCE
TRACK AND MEASURE USING
DIVERSITY INDEX, DEVELOP ROLE OF
DIVERSITY OFFICERS, D.E.I. OR
DIE COMMITTEES IN ACADEMIC
NEUROLOGY DEPARTMENTS,
PARTICULARLY WITH REGARD TO
RESIDENCY, FELLOWSHIP, AND
FACULTY RECRUITMENT.
FORMALIZED TRAINING THROUGH USE
OF CERTIFICATION PROGRAMS, MAKE
USE OF SOCIAL MEDIA TO INCREASE
NETWORKING AND MEMBERSHIP
OPPORTUNITIES FOR DIVERSITY AND
TRAINEES AND JUNIOR FACULTY.
OF COURSE, CREATE MULTI-PRONGED
AND CONTINUOUS PIPELINE, THIS
HELPS RECRUIT AND RETAIN
TRAINEES IN OUR FIELD,
ESPECIALLY VASCULAR NEUROLOGY.
LOOK TO OTHER SPECIALTIES FOR
EXAMPLES OF SIMILAR PROGRAMS
SUCH AS EMERGENCY MEDICINE,
RADIOLOGY, GENERAL
MULTI-SPECIALTY AND G.I.
INCREASE DIVERSITY AND TRAINING
THROUGH TARGETED FUNDING
OPPORTUNITIES.
NOW WE'LL SWITCH GEARS TO
ECONOMIC AND HEALTH CARE
RESOURCE SUBGROUP, CROSS-CUTTING
THEME IS TELEMEDICINE.
WHAT IS KNOWN?
TELEMEDICINE AS YOU KNOW IS USE
OF REALTIME AV
TELECOMMUNICATIONS TO PROVIDE
STROKE EXPERTISE AND DECISION IN
ACUTE STROKE SETTING.
WE KNOW TELESTROKE,
TELERADIOLOGY EVALUATIONS OF
STROKE PATIENTS CAN BE EFFECTIVE
FOR CORRECT THROMBOLYSIS
ELIGIBILITY DECISION MAKING AND
TELESTROKE SERVICES IS MORE
ACCURATE IN DETERMINING FOR
PATIENTS PRESENTING WITH
SYMPTOMS IN THEE R.
WHEN IMPLEMENTED WITHIN A
TELESTROKE NETWORK,
TELERADIOLOGY SYSTEMS ARE
EFFECTIVE IN SUPPORTING RAPID
IMAGE INTERPRETATION, END TIME
FOR THROMBO LYTIC ADMINISTRATION
DISTINCTION MAKING.
NETWORKS MAY BE REASONABLE FOR
TRIAGING PATIENTS WITH ACUTE
STROKE CARE WHO MAY BE ELIGIBLE
FOR INTERFACILITY TRANSFER FOR
MECHANICAL THROMBECTOMY AND USE
OF SERVICES AND RESOURCES AND
SYSTEMS SHOULD BE SUPPORTED BY
HEALTH CARE INSTITUTIONS,
GOVERNMENTS, PAYERS AND VENDORS
AS A METHOD TO ENSURE ADEQUATE
24/7 COVERAGE IN A VARIETY OF
SETTINGS.
SO WHAT ARE THE GAPS IN
OPPORTUNITIES?
SMALL RURAL HOSPITALS LESS
LIKELY TO HAVE TELESTROKE
SYSTEMS COMPARED TO URBAN
HOSPITALS AND FACILITIES,
STUDIED IN THE UNITED STATES, WE
HAVE DATA ON THIS.
NEUROLOGIST DENSITY HAS
INCREASED IN RURAL SETTINGS.
IN 2020 THEY LOOKED AT 2017
CAPACITY, AND LOOKING AT THE
HIGHEST QUARTILE YOU HAD 33% OF
LARGER HOSPITALS HAVING
TELESTROKE SERVICES, ONLY 14.8
IN LOWEST QUARTILE, SMALLER
HOSPITALS ARE NOT GETTING THIS.
YOU SEE IT MOSTLY BASED ON SIZE
BUT ALSO SEE IT BASED ON
LOCATION.
30% OF URBAN HOSPITALS HAD
TELESTROKE SERVICES, ONLY 23% IN
RURAL.
FOR SHORT-TERM ACUTE CARE
HOSPITALS 31%, CRITICAL ACCESS
17%.
2018 DATA LOOKED AT UNITS IN 51,
37, 18% BREAKING UP LARGE
METROPOLITAN, MEDIUM, SMALL,
METRO COUNTIES, FOUR OUT OF FIVE
RURAL COUNTIES DO NOT HAVE A
TELESTROKE UNIT.
BARRIERS IS COST.
CAPACITY.
CAPACITY, LIMITATIONS, AVAILABLE
OF RURAL BROADBAND AND
TELESTROKE PROVIDERS.
LACK OF PERSPECTIVE COMPARATIVE
RESEARCH TO CONFIRM
EFFECTIVENESS OF TELESTROKE AND
TELESTROKE SYSTEMS IN THE ACUTE
STROKE TREATMENT AND TRIAGE.
HOW DO WE MAKE IMPROVEMENTS TO
DISSOLVE DISPARITIES?
EXPAND LICENSURE, EXPAND
LICENSURE TO PERFORM TELESTROKE
SERVICES ACROSS STRAIGHT LINES.
ALLOW UNIVERSAL PARITY BETWEEN
STROKE CARE PERFORMED VIA
TELEMEDICINE AND IN-PERSON
SERVICES.
MAINTAIN ELIMINATION OF
ORIGINATING SITE RESTRICTIONS
FOR TELESTROKE SERVICES.
2019 FAST ACT LEGISLATION
REQUIRES CMS TO REIMBURSE FOR
TELESTROKE SERVICES REGARDLESS
OF WHERE A PATIENT RECEIVES
TREATMENT.
IN SITUATION WHERE IS
VIDEO-BASED CONSULTATION IS NOT
AVAILABLE ALLOW EMERGENCY
TELEPHONE CONSULTATION TO BE
REIMBURSABLE AS A LIMITED
TELEPHONE-ONLY ENCOUNTER.
CONTINUE POLICIES ENACTED THE
WITH THE COVID-19 ENERGY
AUTHORIZATION ACT THAT
INCENTIVIZE ADOPTION OF
TELESTROKE SERVICES ACROSS ALL
GEOGRAPHIES.
WORK WITH LEGISLATURE,
POLICYMAKERS, REGULATORY
AGENCIES AND COMMERCIAL
PROVIDERS TO ENSURE ACCESS TO
HIGH QUALITY BROADBAND FOR RURAL
SETTINGS.
TO CONTINUE ON THIS, EMPOWER
STATE DEPARTMENTS OF HEALTH,
GHOSTAL AGENCIES AND REGIONAL
HEALTH SYSTEMS TO PARTNER IN
PROVISION OF TELESTROKE SERVICES
FOR CRITICAL ACCESS HOSPITALS
WITHIN STROKE SYSTEMS OF CARE.
CREATE MORE FEDERAL GRANT
FUNDING OPPORTUNITIES FOR
ADOPTION OF TELEASTROS PROGRAMS
AND NETWORKS FOR RURAL AND
CRITICAL ACCESS HOSPITALS.
FOR EXAMPLE, HRSA.
AND NIH, OF COURSE.
DEVELOP LOAN REPAYMENT PROGRAMS
FOR TELESTROKE PROVIDERS WHO
PROVIDE CARE FOR RURAL-BASED
HOSPITALS WITH GOAL OF GROWING
AND INCENTIVIZING THE TELESTROKE
WORKFORCE.
WORK WITH ACGME AND SPECIALTY
BOARDS TO INSTILL EDUCATIONAL
AND TRAINING REQUIREMENTS IN
TELEMEDICINE COMPETENCY, STEM
PROMOTE SKILLS TRAINING AND
CERTIFICATION FOR EMERGENCY
PROVIDERS, NURSES AND SUPPORT
STAFF, IN TELESTROKE COMPETENCY.
EXPAND RESEARCH BY INTEGRATING
WITH CLINICAL TRIALS,
EPIDEMIOLOGICAL STUDIES,
DEVELOPING MULTI-CENTER
TELESTROKE RESEARCH NETWORKS.
>> GOOD AFTERNOON.
THANK YOU FOR PARTICIPATING IN
THIS EXCITING SYMPOSIUM.
DR. HASSAN DISCUSSED
DEMOGRAPHICS AND ADDRESSED OUR
MOST IMPORTANT TELEMEDICINE
CONCERNS.
I WILL BE TOUCHING ON SOME MAJOR
GEOGRAPHIC AND POLICY ISSUES
INVOLVING STROKE CARE AT THE
ACUTE LEVEL.
KEY CONTRIBUTING FACTORS FOR
GEOGRAPHIC INTHE QUESTIONS AND
ACCESS AND DELIVERY OF ACUTE
STROKE CARE INCLUDE MAL
DISTRIBUTION OF HIGHER LEVEL
STROKE HOSPITALS, SUCH AS
PSCs, TSCs, CSCs, STROKE
EXPERTISE, LACK OF CONTINUING
EDUCATION AND RESEARCH
PARTICIPATION FOR PROVIDERS AND
PATIENTS, AND NON-UNIFORM ACCESS
TO TELEMEDICINE.
OUR FIRST PRIORITY IS IMPROVING
ACCESS TO STROKE LEVEL
HOSPITALS.
SEVERAL MANUSCRIPTS HAVE BEEN
PUBLISHED OVER YEARS MAPPING
DISTRIBUTION OF PSCS AND CSCs.
TECHNOLOGY IS AVAILABLE TO
FACILITATE DETERMINATION OF
DISTANCE AND TIME BETWEEN WHERE
POPULATIONS LIVE AND CLOSEST
APPROPRIATE HOSPITAL.
THE CHALLENGE WITH MAINTAINING
SUCH A MAP OF STROKE RESOURCES
IS A CONTINUOUS EVOLUTION OF
HOSPITAL CERTIFICATION,
THEREFORE THIS ISSUE NEEDS TO BE
REVISITED WITH FREQUENCY AND
CHANGES IN HOSPITAL STATUS
IDENTIFIED.
THE LARGER CHALLENGE IS IN
DETERMINING THE MOST EFFECTIVE
WAY TO FILL THE GAPS IN ACCESS
TO QUALITY PSCs, TSCs,
CSCs FOR DEFINITIVE CARE AND
REDUCE GEOGRAPHICAL DISPARITY.
IT IS IMPORTANT TO GET PATIENTS
WITH SUSPECTED STROKE TO THE
RIGHT PLACE AT THE RIGHT TIME
FOR THE RIGHT CARE.
ROUTING PROTOCOLS SUCH AS
AUTOMATICALLY BYPASSING
APPROPRIATE HOSPITALS TO A
DEFAULT HOSPITAL, IF THE CENTER
DOESN'T GET THE PATIENTS THE
CENTER CANNOT DEMONSTRATE
MASTERY.
THE SIGNIFICANT FINANCIAL
RESOURCES NECESSARY TO ADVANCE
FROM ONE LEVEL OF CERTIFICATION
TO ANOTHER MAY NOT BE
FORTHCOMING.
OUR SECOND PRIORITY INVOLVES
IMPROVING ACCESS TO EXPERTISE.
98% OF AMERICANS LIVE WITHIN 60
MINUTES OF EMERGENCY DEPARTMENT,
ACCESS TO CERTIFIED STROKE
CENTERS IS A MOVING TARGET
PARTICULARLY IN RURAL AREAS.
THIS IS PARTIALLY DUE TO
EVOLUTION OF HOSPITALS THROUGH
ESCALATING CERTIFICATION
PROGRAMS.
HOSPITALS WITHOUT CERTIFICATION
HAVE LESS ACCESS TO ACUTE STROKE
PATIENTS AND HAVE LESS
OPPORTUNITY TO ESTABLISH
PROFICIENCY.
BED SIZE, RURAL OR UNDERSERVED
DESIGNATION, LOW POPULATION
DENSITY ARE SIGNIFICANTLY
ASSOCIATED WITH LOW tPA
TREATMENT RATES.
EMERGENCY MEDICINE RESIDENCY
PROGRAMS LACK STANDARDIZATION
FOR STROKE MANAGEMENT TRAINING.
THERE ARE NO STROKE-SPECIFIC
ONGOING REQUIREMENTS FOR
EMERGENCY MEDICINE PHYSICIANS.
ACCESS TO EXPERTS IS LIMITED.
THERE ARE ALSO GAPS IN ACCESS TO
ADVANCED NEUROIMAGING RESULTING
IN REROUTING PATIENTS TO OUT OF
AREA TSC OR CSC RATHER THAN
CLOSER PSC WHEN APPROPRIATE.
IF WE'RE TO RESOLVE THE
GEOGRAPHIC DISPARITIES, THE
NUMBER OF VASCULAR NEUROLOGISTS
AND INTERVENTIONALLISTS NEEDS TO
BE INCENTIVIZED TO WORK IN AREAS
OF SHORTAGE.
TRAINING AND POST GRADUATE
EDUCATION CAN IMPROVE
PROFICIENCY WITH IDENTIFYING AND
TREATING CANDIDATES FOR
THERAPIES.
ACCESS TO NEURAL RADIOLOGISTS
AND ADVANCED IMAGING CAN IMPROVE
INTERPRETATION TIMES FOR
IDENTIFICATION OF LARGE VESSEL
OCCLUSIONS RESULTING IN
EFFICIENT TRANSFER OF
THROMBECTOMY CANDIDATES.
KNOWLEDGE OF STROKE SIGNS AND
SYMPTOMS IS LOWER IN RURAL
AREAS, PREFERENCE OF
HYPERTENSION DIABETES AND
TOBACCO USE IS HIGHER.
LOWER EDUCATION, POVERTY,
MACROLEVEL INEQUITIES LIKELY
CONTRIBUTE TO PARTICIPATION,
COMPREHENSION FOR PATIENTS.
U.S. CLINICAL TRIAL SITES ARE
CLUSTERED AROUND URBAN AREAS, A
PERCEPTION SMALLER HOSPITALS ARE
LESS LIKELY TO BE INVOLVED IN
RESEARCH AND LESS LIKELY TO
PARTICIPATE IN RESEARCH STUDIES.
INVESTMENT IN RURAL COMMUNITIES
POTENTIALLY REDUCED INTEREST IN
TRIAL PARTICIPATION IS A
BARRIER.
RURAL HOSPITALS MAY BE LESS
LIKELY TO FUND OR SUPPORT TIME
FOR CLINICIANS TO ATTEND
CONFERENCES WHERE PRACTICE
CHANGING TRIALS ARE PRESENTED.
POTENTIAL STRATEGIES TO ADDRESS
THESE ISSUES INCLUDE PATIENT
ROUTING BY STATE-FUNDED
COMMUNICATION CENTERS TO
IDENTIFY CLOSEST APPROPRIATE
HOSPITAL BASED ON PATIENT
LOCATION, CLINICAL SYMPTOMS,
INITIAL DESTINATION PROTOCOL
SHOULD BE IN PLACE, REALTIME
RECOMMENDATIONS FOR CLOSEST
APPROPRIATE HOSPITAL, MECHANISM
FOR CROSSING STATE LINES IN
ORDER TO ACCESS CLOSER EMERGENCY
CARE IN TIME SENSITIVE TREATMENT
SHOULD BE PROVIDED.
IMPROVED TRAINING IN STROKE CARE
FOR EMERGENCY MEDICINE RESIDENTS
AND PHYSICIANS WILL IMPROVE
COMFORT LEVEL WITH PATIENTS
DEMONSTRATING STROKE SYMPTOMS.
OTHER IDEAS INCLUDE
INVESTIGATING IDEA OF A MOBILE
INTERVENTIONAL STROKE TEAM MODEL
THAT COULD IMPROVE REGIONAL
ACCESS TO THROMBECTOMY AND
REDUCE EXTENDED TRANSFER.
MIST TEAMS COULD CONCERT MANY
PSCs WITH FUNCTIONAL CATH LABS
INTO THROMBECTOMY CAPABLE
HOSPITALS.
ANOTHER IDEA IS STUDENT LOAN
REPAYMENT PROGRAM TO STROKE
NEUROLOGISTS TO CLOSE THE GAP ON
ACCESS TO STROKE EXPERTISE AND
POTENTIAL HOSPITAL
CERTIFICATION.
STATES AND TERRITORIES SHOULD
WORK TO IDENTIFY CENTERS CAN
GREATEST POTENTIAL IMPACT ON
REDUCING DISTANCE NECESSARY TO
ACCESS THROMBECTOMY.
IN GENERAL, PROVIDERS WOULD BE
RECRUITED TO PRACTICE IN
DESIGNATED HEALTH PROFESSIONAL
SHORTAGE AREAS AS DETERMINED BY
MAPS OF ACCESS TO STROKE CENTERS
OFFERING THROMBECTOMY.
PRIOR STUDIES DEMONSTRATED
PHYSICIAN RETENTION AND
SATISFACTION WITH SOME OF THESE
PROGRAMS.
RESEARCH OPPORTUNITIES ABOUND.
SOME EXAMPLES INCLUDE SURVEYING
VASCULAR NEUROLOGY FELLOWS AND
INTERVENTIONAL FELLOWS TO GAUGE
INTEREST IN LOAN FORGIVENESS
PROGRAMS IN EXCHANGE FOR THREE
YEARS OF SERVICE IN A HIGH NEED
AREA.
DEVELOPMENT OF A MAP OF
HOSPITALS WITH CATH LABS, AND
VALIDATION OF THE SAFETY
EFFICACY AND EFFICIENCY OF A
MIST MODEL COMPARED TO THE
TRADITIONAL MOTHER SHIP
APPROACH.
POLICY AND REGULATION SUBGROUP
IDENTIFIED ISSUES WITH RESPECT
TO HUB AND SPOKE MODEL OF CARE,
TRANSPORT AND TRANSFER, AND
INTERSTATE VARIABILITY IN
POLICIES AND REGULATIONS.
FIRST PRIORITY ISSUES, HUB AND
SPOKE, MAY DEVELOP FORMAL
TRANSFER PROTOCOLS TO OFFLOAD
PATIENTS BY TRANSFERRING THEM TO
A MORE ESTABLISHED STROKE
CENTER.
THIS HUB AND SPOKE MODEL HAS
BROKEN AS TELEMEDICINE CAN NOW
PROVIDE REALTIME SUPPORT.
RADIUS BETWEEN HUBS AND SPOKES
HAS GROWN CREATING OVERLAPPING
SYSTEMS IN STATES, LEADING TO
PATIENTS GOING DIRECTLY TO THE
MOTHER SHIP AND BYPASSING CLOSER
FACILITIES THAT COULD PROVIDE
NEEDED CARE, LEADING TO DELAY.
IN ADDITION PHYSICAL SEPARATION
IMPEDES FAMILY AND CAREGIVERS
FROM BEING PRESENT DURING
HOSPITALIZATION AND REHAB
LEADING TO BURDEN AND STRESS FOR
FAMILY MEMBERS AND PATIENT.
SECOND PRIORITY DEALS WITH
INTERFACILITY TRANSPORT AND
TRANSFER.
THE HUB HOSPITAL RESPONDS WHEN
NOTIFIED OF CLINICAL CHANGE.
DURING TRANSFER WHO OWNS THE
RESPONSIBILITY FOR MANAGING THE
PATIENT IS MORE AMBIGUOUS.
JOINT COMMISSION CONSIDERS IT TO
OF RESPONSIBILITY OF THE
CERTIFIED CENTER TO ESTABLISH
EXPECTATIONS FOR MONITORING
PATIENT BEFORE AND DURING
TRANSFER, YET LEGAL
RESPONSIBILITY MAY FALL TO THE
SENDING PHYSICIAN OR TO MED
CONTROL UNDER UMBRELLA OF EMS
AGENCY, THIS SITUATION IS
DANGEROUS FOR PATIENT AND MAY
PLACE HEALTH CARE PROVIDERS AND
SYSTEMS AT RISK LEGALLY.
THIRD PRIORITY IS ADDRESSING
INTERSTATE VARIABILITY IN STROKE
CARE POLICY AND REGULATION.
SURVEY OF STATES STROKE CARE
POLICIES AND REGULATIONS HAS
DEMONSTRATED WIDE VARIABILITY IN
RIGOR.
REGISTRIES ARE NEEDED TO TRACK
COMES BUT LINKING HAS LOGISTICAL
CHALLENGES.
SMALLER HOSPITALS WITH LIMITED
RESOURCES MAY FIND THIS A BURDEN
YET INCLUDE OF DATA IS NECESSARY
TO AVOID BIAS.
SOME STATES CERTIFY STROKE
PROGRAMS, SOME RECOGNIZE AN
ENTITY.
TASK FORCE HAS IDENTIFIED THE
FOLLOWING HIGH PRIORITY ACTION
ITEMS.
NUMBER ONE, POLICY AND
LEGISLATION IS NEEDED TO SUPPORT
SMALLER HOSPITALS TO GAIN ACCESS
TO CLOSEST APPROPRIATE HOSPITAL
POTENTIALLY UTILIZING NEUROLOGY
EXPERT FROM A DIFFERENT HOSPITAL
SYSTEM.
CENTRALIZED STROKE COMMAND
CENTER COULD BE USED AT THE
LOCAL LEVEL TO HELP TRIAGE
PATIENTS TO THE CLOSEST
APPROPRIATE FACILITY AND
DETERMINE MODE OF SECONDARY
TRANSFER.
NUMBER 2, UNIFORMITY OF
LICENSING RULES, STANDARDIZED
EDUCATIONAL REQUIREMENTS FOR
TELEMEDICINE ACROSS STATES IS
NEEDED TO ALLOW FOR APPROPRIATE
CARE REGARDLESS OF TREATING
NEUROLOGIST PHYSICAL LOCATION.
NUMBER 3, POLICIES ARE NEEDED TO
ACCOMMODATE INTERHOSPITAL TO
FACILITY TRANSFER TO ENSURE ALL
PATIENTS CONTINUE TO RECEIVE
QUALITY STROKE CARE DURING
TRANSPORTATION.
NOBLE 4, EDUCATION AND MATERIALS
FOR MANAGEMENT AND DOCUMENTATION
DURING SECONDARY TRANSFER COULD
BE STANDARDIZED TO PROMOTE
PATIENT SAFETY DURING PERIODS
FOR THE STROKE SPECIALIST
DISCONNECTED FROM THE PATIENT.
QUALITY IMPROVEMENT EFFORTS
SHOULD BE IN PLACE TO
TROUBLESHOOT AVOIDABLE ADVERSE
OUTCOMES.
AND NUMBER 5, LOCAL GUIDELINES
SHOULD BE CONSISTENT, NATIONAL
GUIDELINES, FOR PARTNERSHIP
BETWEEN REFERRING AND ACCEPTING
TEAMS AND LOCAL AMBULANCE
SERVICES INCLUDING TRANSFER FROM
SPOKE TO HUB PHYSICIAN.
IN SHORT I'D LIKE TO THANK THE
MEMBERS OF OUR TASK FORCE, MY
CO-CHAIR FOR ALL OF THEIR HARD
WORK, I LOOK FORWARD TO THE
OUTSTANDING DISCUSSIONS TO COME.
THANK YOU AGAIN.
>> GREAT TALKS, YOU TOUCHED ON
GREAT POINTS.
THANK YOU ALL.
IF YOU'RE TALKING, I'M NOT
HEARING YOU, LEE.
I THINK YOU'RE MUTED.
>> YEAH, YOU'RE MUTED.
>> OKAY.
DO WE HAVE ANY QUESTIONS?
I'M LOOKING AT THE -- SHERYL
MARTIN, WOULD YOU LIKE TO JOIN
US TOO?
THANKS FOR JOINING US.
WE'RE GOING TO OPEN THE FLOOR
FOR QUESTIONS.
DOES ANYBODY HAVE QUESTIONS?
>> I HAVE A QUESTION.
THIS IS RICHARD BENSON.
WE KNOW THAT EXCELLENT
PRESENTATION AND GREAT WORK,
LOOK FORWARD TO BREAKOUT
SESSIONS AND DISCUSSION.
ANY DISCUSSION AMONG THE GROUP
IN TERMS OF WHY WE HAVE
DISPARITIES IN tPA AND
EMBOLECTOMY?
WE KNOW IT'S DIFFICULT TO GET TO
FACILITIES IN ENOUGH TIME BUT
FOR THOSE WHO DO WE STILL KNOW
THERE ARE DISPARITIES IN
UTILIZATION OF THOSE
INTERVENTIONS.
ANY COMMENTS ABOUT THAT IN TERMS
OF ANYTHING WE CAN DO TO
INTERVENE ON THOSE AS WELL?
>> IT IS A PROBLEM EVEN IN URBAN
AREAS, PREVIOUSLY EXAMINED NEW
ORLEANS AREA, COMPREHENSIVE
CENTERS, AND PATIENTS, MINORITY
BACKGROUND, WERE LESS LIKELY TO
ARRIVE TO THE HOSPITAL WITHIN
THE WINDOW OF OPPORTUNITY.
LESS LIKELY TO UTILIZE EMS.
AND THOSE ARE PRETTY SIGNIFICANT
BARRIERS TO BEING ELIGIBLE FOR
TIME-SENSITIVE TREATMENT.
WHAT WE DON'T KNOW IS WHY THEY
ARE LESS LIKELY, ONE GROUP IS
LESS LIKELY TO UTILIZE EMS THAN
ANOTHER.
THAT REMAINS TO BE DETERMINED.
>> SO, WE HAD A PUBLICATION ON
THIS YEARS AGO AND LOOKED IN
HARLINGEN TEXAS, 20 MINUTES FROM
THE BORDER OF MEXICO.
THE RIO GRANDE VALLEY, SOUTH
TEXAS, AS LOW UTILIZATION OF
911, EMS, AND OUR MECHANICAL
THROMBECTOMY DOUBLED, IT'S A
SIGNIFICANT ISSUE OF THEM COMING
IN ON TIME AND THEM USING
RESOURCES THAT ARE AVAILABLE,
YET THEY DON'T WANT TO.
IT'S AN EDUCATION THING.
WE SPENT TIME WORKING ON FAST
FOR EXAMPLE IN SPANISH AND NOW
AHORA, GETTING THEM TO
UNDERSTAND THAT NOBODY'S GOING
TO CALL ANYBODY, IT'S HEALTH
CARE.
IT'S NOT POLITICS.
IT'S NOT IMMIGRATION SERVICES.
IT'S HEALTH CARE.
WE'RE GOING TO PICK YOU UP AND
TAKE YOU TO THE RIGHT FACILITY
AND TREAT YOU IN THE APPROPRIATE
TIME.
I THINK THAT EDUCATION PIECE IS
MISSING, ESPECIALLY IN THE
POPULATION HERE IN SOUTH TEXAS
WHICH IS 85% MEXICAN AMERICAN.
>> I SEE THAT DR. HERRERA PUT
IN -- SORRY, SOMEONE PUT IN THE
CHAT ABOUT TRUST.
I THINK IT COMES BACK TO THE
PREVIOUS CONVERSATION AS WELL.
I THINK THIS IS AN OVERARCHING
THEME IN TERMS OF MEDICAL
FACILITIES DOING OUTREACH TO THE
COMMUNITY, HOWEVER THAT LOOKS
THROUGH COMMUNITY CHAMPIONS OR
FEDERALLY QUALIFIED HEALTH
CENTERS, BUT NOT SORT OF STAYING
THERE, SORT OF THAT INSTITUTION
AND NOT DOING OUTREACH TO THE
COMMUNITY BECAUSE THAT DOESN'T
PROMOTE TRUST WE NEED.
GREAT POINT.
>> THIS ALSO CAME UP IN THE
MORNING SESSION ON EMS, AND
CALLING 911, AND DR. BENSON
BROUGHT UP THE EXCELLENT POINT
ABOUT CERTAIN GROUPS NOT WANTING
TO CALL 911 BECAUSE OF RECENT
WELL-PUBLICIZED VERY
CATASTROPHIC INTERACTIONS WITH
POLICE AND OTHER EMS PEOPLE THAT
COULD LEAD TO AN OVERFLOW
REACTION, I DON'T WANT TO SAY
OVERREACTION BECAUSE THE
REACTION -- THE ACTION MAY BE
ENTIRELY APPROPRIATE, NOT
WANTING TO GET INTO THAT EMS 911
REALM AND HAVING THE POLICE COME
KNOCKING ON YOUR DOOR.
RICHARD, I DON'T KNOW IF YOU
WANT TO ELABORATE ON THAT BUT I
THOUGHT THAT WAS AN EXCELLENT
POINT YOU BROUGHT UP IN THE
MORNING SESSION.
>> YEAH, NO, IT'S A GREAT POINT.
YEAH, IT'S BEEN -- YEAH, SEVERAL
PUBLICATIONS ABOUT THAT IN TERMS
OF CERTAIN COMMUNITIES NOT
WANTING TO CALL 911 BECAUSE OF
THAT FEAR, BUT ALSO NOT WANTING
TO LET THE NEIGHBORS KNOW WHAT'S
GOING ON, QUOTE/UNQUOTE, THEIR
BUSINESS, IN THE INDIVIDUAL
HOME, FEARS ABOUT -- IF IT'S
FEARS WITH PEOPLE WHO ARE
CITIZENS OR CITIZENSHIP, AS WELL
AS FEARS WITH AN EXTRA BILL TO
PAY.
THERE ARE A LOT OF REASONS
PEOPLE CHOOSE NOT TO CALL 911.
AGAIN, I LIKE HOW MARK MENTIONED
THIS EARLIER IN TERMS OF
BARRIERS, I THINK IT'S IMPORTANT
TO SEE FIRST OF ALL WE HAVE TO
DO THE RESEARCH TO KNOW WHAT ALL
OF THE CONCERNS ARE THAT PEOPLE
HAVE.
BUT THEN FINDING WAYS TO ADDRESS
THOSE CONCERNS THAT PEOPLE HAVE.
BUT THERE IS A MAJOR CONCERN,
MAJOR CONCERNS, I MENTIONED SOME
IN TERMS OF CALLING 911.
>> I THINK SOME OF THE OTHER
ISSUES THAT WE DISCUSSED, WE
NEED TO HIGHLIGHT ALSO, WHICH IS
NOT SO MUCH NOT CALLING EMS BUT
CALLING EMS AND GETTING TO THE
HOSPITAL, AND THEN AT THE
HOSPITAL THE STROKE NOT BEING
RECOGNIZED BY EMERGENCY MEDICINE
PERSONNEL.
YOU KNOW, IF EVERYBODY CAME IN
THE SAME IT WOULD BE
STRAIGHTFORWARD, BUT THAT'S NOT
THE WAY IT IS.
WE NOTED IN OUR INVESTIGATION,
THERE'S NO STANDARD AMOUNT OF
NEUROLOGICAL OR TRAINING
EMERGENCY MEDICINE PHYSICIANS
NEED.
MY ONLY PERSONAL EXPERIENCE SOME
PEOPLE ARE EXTREMELY COMFORTABLE
WITH EVALUATING A PATIENT
NEUROLOGICALLY, OTHERS LESS SO.
SOMETIMES THAT RELUCTANCE TO
ACTUALLY STATE THE PATIENT
HAVING A STROKE THEN LEADS TO
THEM NOT GETTING THE APPROPRIATE
IMAGING OR CONSULTATION.
SO I THINK THAT WE NEED TO ALSO
FOCUS ON THE TRAINING OF OUR
IN-HOSPITAL OR E.D. FIRST
RESPONDERS IDENTIFYING STROKES
AND GETTING THEM INTO THE
PATHWAY FASTER.
>> EXCELLENT QUESTIONS IN THE
CHAT AS WELL.
ONE QUESTION IS, IS DOES ANYONE
KNOW ABOUT DIFFERENCES IN
CONSENT TO ALTEPLASE OR
THROMBECTOMY ACROSS GROUPS?
>> I BELIEVE THERE WERE SEVERAL
STUDIES LOOKING AT AT LEAST USE
OF ALTEPLASE.
I DON'T KNOW IF IT WAS RELATED
TO CONSENT.
WE HAVE TO BE CAREFUL ABOUT
ASSOCIATION VERSUS CAUSATION.
BUT IN A GROUP OF PATIENTS, IN
GROUPS OF PATIENTS WHO MET ALL
QUALIFICATIONS FOR ALTEPLASE
WITHIN I THINK THREE HOURS BACK
THEN, IT WAS STILL A DISPARITY
IN USE OF ALTEPLASE BETWEEN
MINORITY GROUPS AND CAUCASIANS.
SOMEBODY ELSE ON THE CALL MAY
HAVE MORE SPECIFIC INFORMATION
BUT I RECALL THAT THAT WAS THE
CASE.
AGAIN, CONTROLLING FOR ALL OF
THOSE MEDICAL FACTORS AND BEING
WITHIN THE TIME WINDOW, THINGS
LIKE THAT.
>> S
>> THAT'S WHAT I REMEMBER AS
WELL.
I'M SORRY, ANDY.
>> I WAS GOING TO SUPPORT WHAT
YOU, RICHARD AND MARK HAD
ALREADY SAID.
THERE WAS A LARGE STUDY
PUBLISHED IN NEURALGIA COUPLE
YEARS AGO, LOOKING AT tPA
UTILIZATION RATES THAT VERIFIED
SIGNIFICANT DISPARITY AND
RECEIVING IVTPA AND ENDOVASCULAR
THERAPY COMPARED TO NON-HISPANIC
WHITE, ET CETERA.
KNOWS LARGE EPIDEMIOLOGY STUDIES
IT'S HARD TO GET AT UNDERLYING
REASONS OF COURSE BUT I THINK
THERE'S GUIDELINES DATA.
I THINK CHRIS PUT IT IN THE
CHAT, THAT LOOKS AT DECLINATION
RATES AS WELL.
THAT LEVEL, IS THERE STRUCTURAL
RACISM, UNCONSCIOUS BIAS ON
PROVIDERS OR TEAM, IS IT ISSUES
RELATED TO SOCIOECONOMIC
DISPARITIES, ARRIVAL TIME?
AND INSURANCE AND ASPECTS,
HOSPITALIZATION THAT MAY CREATE
BARRIERS?
AND THEN THERE'S SOMEONE ALREADY
SAID RIGHTLY I THINK THERE'S A
TRUST EDUCATION ISSUE WE FACE,
LACK OF DIVERSIFICATION IN
STROKE WORKFORCE.
YOU KNOW, OF THE PERSON THAT'S
DOING THE DISCUSSION, CONSENTING
ON THE RISKS AND BENEFITS.
I THINK WE HAVE MULTIPLE LEVELS
AT WHICH A GROUP LIKE THIS CAN
ADDRESS AND TAKE IT HEAD ON.
CHAZ HAS A HAND RAISED.
>> YEAH, THANKS, ANDY.
REVISITING THE POINT BROUGHT UP
BY DR. JENSON FOR RESIDENCY
EDUCATION, THE COALITION WITH
ALL THE COLLABORATIVE EXPERTISE
THAT IT HAS I THINK HAS THE
OPPORTUNITY TO POTENTIALLY MAKE
SOME STATEMENTS THAT COULD
CHANGE OTHER ORGANIZATIONS,
INCLUDING THOSE WITH OVERSIGHT
FOR RESIDENCY TRAINING.
AND THAT COULD POTENTIALLY
COMPLEMENT OTHER EFFORTS FROM
OTHER ORGANIZATIONS AS WELL.
AS WAS ALLUDED TO IN EMERGENCY
MEDICINE WE DID A PAST SURVEY
AND ONLY 50% OF E.M. RESIDENCY
PROGRAM ARE STROKE OR NEUROLOGY
ROTATIONS FOR RESIDENTS.
SO, QUESTION NUMBER 1, SHOULD
THE STATEMENT THAT WE KIND OF ON
BEHALF OF BRAIN ATTACK
COALITION, SHOULD IT MIMIC WHAT
TRAUMA CENTERS DO?
QUESTION NUMBER 2 THAT CAME OUT
OF THE SMALL GROUP IN TERMS OF
-- THE MORNING SESSION,
BRAINSTORMING WITH DR. BENSON,
SHOULD MEDICAL SCHOOLS OR
RESIDENCIES OF DIFFERENT
DISCIPLINES ALSO HAVE COMMUNITY
ENGAGEMENT REQUIREMENTS LIKE A
TWO-WEEK TIME PERIOD WHERE
RESIDENTS GO INTO THE COMMUNITY
PERFORMING EDUCATION, E.M.,
NEUROLOGY, INTERNAL MEDICINE,
THERE'S MANY PLUSES THAT COULD
COME FROM THAT IN TERMS OF
BREAKING DOWN BARRIERS AND
BUILDING UP OTHER ASPECTS THAT
STRENGTHEN THE SYSTEM.
AND I DO THINK FOR MYSELF BEING
E.M. AND I.M. TRAINED, A MONTH
IN THE FIELD IN DETROIT AS PART
OF HOSPICE ROTATION, GREAT VALUE
SEEING ENVIRONMENTS OUR PATIENTS
LIVED IN.
CURIOUS FOR WHAT THE GROUP
THINKS ABOUT ADVOCATING AT THE
MEDICAL STUDENT LEVEL, WE COULD
EXTEND TO THE P.A. EDUCATION,
NURSE PRACTITIONER EDUCATION,
ALSO RESIDENCY LEVEL TOO.
>> WE HAD DISCUSSED THAT IN OUR
MORNING SESSION ALSO, TAPPING
INDIVIDUALS SUCH AS PHARMACISTS
AND NURSES, NOT NECESSARILY JUST
NURSE PRACTITIONERS, JUST OTHER
GROUPS THAT HAVE HEALTH CARE
EDUCATION THAT COULD REACH OUT
TO THE COMMUNITY, AND THAT WOULD
BUILD TRUST.
>> WE ALSO DISCUSSED ABOUT THAT.
IT'S VERY IMPORTANT TO INCLUDE
ESPECIALLY EMERGENCY PHYSICIANS,
TO HELP EXPOSURE IN VASCULAR
NEUROLOGY.
>> I ALSO WANTED TO MENTION --
>> WHAT I HEARD FROM PROGRAM
DIRECTOR HERE MORE MEDICAL
SCHOOLS ARE MANDATING ROTATIONS
IN NEUROLOGY FOR INTERNAL
MEDICINE RESIDENTS AND FAMILY
MEDICINE RESIDENTS WHICH CAN
ONLY BE BENEFICIAL IN TERMS OF
TRAINING UP THESE PEOPLE.
ANOTHER THING I WANTED TO BRING
UP, I HOPE THE NINDS PEOPLE ARE
ON OR LISTENING, ONE OF THE
PURPOSES OF THIS SYMPOSIUM IS TO
GENERATE SOME HYPOTHESES, TO DO
HIGH LEVEL RESEARCH, BECAUSE
AGAIN EVENTUALLY WE WANT TO MOVE
BEYOND ASSOCIATION AND GIVE IN
TO CAUSATION AND
HYPOTHESIS-DRIVEN TYPES OF
RESEARCH, I WAS INTRIGUED BY THE
DISCUSSION ABOUT ALTEPLASE, I.V.
ALTEPLASE UTILIZATION OR LACK
THEREOF AMONG CERTAIN
UNDERSERVED POPULATIONS.
AND PERHAPS OUR PRECONCEIVED
NOTION IS THAT IT IS LACK OF
EDUCATION, OR BACKGROUND, RACIAL
OR ETHNICITY BACKGROUND, OR LACK
OF TRUST, BUT WE DON'T KNOW THAT
THAT'S THE CASE.
STRIKES ME THAT'S A TESTABLE
HYPOTHESIS.
MAYBE, FOR EXAMPLE, THE REASON
WHY CERTAIN GROUPS MAY REFUSE TO
GET IT IS THAT MAYBE THEY ARE
UNDER THE MISTAKEN BELIEF THEY
ARE GOING TO HAVE TO PAY FOR IT.
AND THEY THINK IT'S A NEW AND
BRAND NEW AND EXPENSIVE
MEDICATION.
OR THEY THINK BECAUSE THEY HAVE
NEVER HEARD OF IT BEFORE, THAT
IT'S IN SOME WAYS AN
EXPERIMENTAL MEDICATION.
SO, I THINK GRANTED ALSO A NICHE
THING BUT IT'S VERY IMPACTFUL
FROM PUBLIC HEALTH POINT OF VIEW
STILL THE EASIEST ACUTE
MEDICATION FOR STROKE AND
REQUIRES VERY LITTLE
INFRASTRUCTURE AND MODEST AMOUNT
OF MEDICAL EXPERTISE.
I THINK THAT'S AN INTRIGUING
POINT THAT COULD BE VERY
FUNDABLE HYPOTHESIS-DRIVEN TYPE
OF RESEARCH AND COULD BE VERY
IMPACTFUL FOR UNDERSERVED AND
OTHER COMMUNITIES.
>> YOU COULD TEST BEFORE AND
AFTER INITIATING A STANDARDIZED
SCRIPT THAT IS CONCISE,
EVIDENCE-BASED, UNDERSTANDABLE
AND AT EVEN 6th GRADE LEVEL OF
EDUCATION.
IF YOU IMPLEMENT THAT ACROSS A
REGION OR STATE, YOU MIGHT FIND
THAT THERE ARE DIFFERENT --
THERE'S A CHANGE IN THE TREND
WITH PROPORTION OF PATIENTS NOT
GETTING TREATED WHO ARE WITHIN
THE WINDOW, CITING THAT THE
PATIENT REFUSED.
>> I LOVE THAT.
I THINK THAT'S A GREAT IDEA.
IT COULD BE STANDARDIZED,
OBJECTIVE, YOU COULD MEASURE IT,
MEASURE HAVE A MULTI-LINGUAL
SCRIPT, THINGS LIKE THAT.
>> I CAN SHARE MINE.
>> OKAY.
ALL RIGHT.
PUT THAT ON THE LIST OF THINGS
WE COULD ASK FOR FUNDING ABOUT.
>> I THINK ONE OF THE THINGS
THAT WAS MENTIONED ALSO IN THE
HOSPITAL GROUP IS THAT ALTHOUGH,
YOU KNOW, WE CAN MAKE TESTABLE
HYPOTHESES IN TERMS OF EDUCATION
AT THE COMMUNITY LEVEL, IT HAS
TO BE A MESSAGE THAT IS SEND OUT
OVER AND OVER AGAIN BECAUSE
STROKES ARE SO RARE AND PEOPLE
DON'T SEE IT OFTEN IN THEIR DAY
TO DAY.
SO EXAMPLE WAS GIVEN OF, YOU
KNOW, EARLY MESSAGING AROUND
WEARING A SEAT BELT.
IT JUST BECAME AN EVERYDAY
THING, THAT YOU WEAR YOUR SEAT
BELT, AND IT'S REQUIRED BY LAW.
BUT IT'S A MORE DIFFICULT, YOU
KNOW, SORT OF MESSAGE THAT YOU
WOULD HAVE TO REITERATE IN TERMS
OF COMMUNITY MEMBERS RECOGNIZING
THE SIGNS AND SYMPTOMS OF
STROKE, ALSO KNOWING THAT
GETTING EMS AND TAKING EMS,
CALLING 911 IS VERY CRITICAL,
AND WHY IT'S IMPORTANT.
>> I THINK THESE ARE REALLY
GREAT SUGGESTIONS.
I THINK THAT THOSE TIMES OF
INTERVENTIONS, I LIKE HOW DR.
MARTIN PUT IT IN THE CONTEXT OF
THAT TYPE OF STUDY, THAT WOULD
BE A GREAT IDEA, MAY FIT INTO
SOME OF OUR CURRENT MECHANISMS.
THE OTHER POINT THAT I WANTED TO
MENTION, DR. JENSON MADE A
REALLY GREAT POINT ABOUT NOT
HAVING ENOUGH MEDICAL PERSONNEL
IN CERTAIN RURAL AREAS.
AND INCENTIVIZING PEOPLE.
CREATING AS A SUGGESTION, WE
HAVE PAYBACK PROGRAMS OF LOAN,
TUITION PAYBACK PROGRAMS FOR
PROVIDERS TO WORK IN CERTAIN
AREAS, SOMETHING AVAILABLE THAT
WE CAN LOOK AT AS A
RECOMMENDATION.
I LIKE THE THOUGHT AS WELL IN
TERMS OF INCENTIVIZING PEOPLE IN
OTHER WAYS TO WORK IN THOSE
AREAS.
I THINK CLINT IS ON.
>> YEAH, HI, EVERYBODY.
GREAT TALKS.
JUST IN TERMS OF DR. ALBERT'S
CALL FOR RESEARCH, I WANTED TO
MENTION THAT WE'VE MOVED TOWARDS
THE DISSEMINATION IMPLEMENTATION
SCIENCE FUNDING OPPORTUNITIES,
THERE'S A BUNCH IN DIFFERENT
AREAS.
THOSE ARE THE ONES THAT YOU
WOULD RESPOND TO WHEN TRYING TO
DO THIS TYPE OF RESEARCH AND
WE'RE TRYING TO BE BETTER AT
SUPPORTING THAT TYPE OF
RESEARCH.
YOU KNOW, IN THE PAST IT HASN'T
ALWAYS DONE VERY WELL IN REVIEW.
AND ONE OF THE THINGS AT NINDS
WE'VE BEEN TRYING TO EMPHASIZE
IS NOW THAT WE'VE ACCUMULATED
ALL OF THIS WONDERFUL
OBSERVATIONAL DATA, OVER SEVERAL
DECADES, IT'S TIME TO DO MORE OF
THE IMPLEMENTATION WORK TO
REALLY UNDERSTAND HOW WE ADDRESS
SOME OF THESE BARRIERS AND
ISSUES THAT YOU ALL HAVE BEEN
TALKING ABOUT TODAY.
SO I JUST WANTED TO MENTION THAT
BECAUSE THERE ARE THOSE
OPPORTUNITIES OUT THERE OUTSIDE
OF TARGETED STUFF THAT MIGHT
HAPPEN.
OVER.
>> THANKS SO MUCH, CLINT.
THAT'S VERY VALUABLE.
THANK YOU.
WELCOME BACK.
SO, ACTUALLY WITHOUT FURTHER ADO
WE'RE GOING TO SEGUE RIGHT INTO
OUR LAST SESSION FOR OUR LAST
TIME POINT, SO I WANT TO MAKE
SURE THAT WE HAVE OUR CO-LEADS
FOR THE INPATIENT TASK FORCE AT
HAND, AND I'M JUST SCROLLING
THROUGH ... LOOKING FOR KAREN
FURY AND LAWRENCE FLESHLER.
>> THIS IS KAREN, I'M HERE.
>> I'M HERE AS WELL.
>> AS BEFORE, WE'RE ABOUT TO
HEAR A SUMMARY OF THE REPORT-OUT
FROM THE TASK FORCE, SUMMARY
PRE-RECORDED, THEN WE WILL SHIFT
INTO A LIVE DISCUSSION, QUESTION
AND ANSWER PERIOD.
I WANT TO ENCOURAGE EVERYONE TO
POST QUESTIONS IN THE CHAT AS
YOU LISTEN TO SUMMARY AND
DISCUSSION, FOLLOWING THAT
QUESTION AND ANSWER PERIOD WE'LL
SHIFT BACK INTO THE BREAKOUT
ROOMS BY CROSS-CUTTING THEME
AND, AGAIN, I ENCOURAGE EVERYONE
IN THE BREAKOUT TO TURN ON YOUR
VIDEO AND HAVE MUCH MORE OF AN
ORGANIC DISCUSSION, IF YOU'RE
ABLE.
WITHOUT FURTHER ADO, I'M GOING
TO ASK OUR CONTRACTORS TO START
PLAYING THE VIDEO.
>> I APPRECIATE THE OPPORTUNITY
TO PRESENT ON BEHALF OF THE
INPATIENT CARE GROUP EXPLORING
INTHE INEQUITIES.
THE TASK FORCE IDENTIFIED THE
FOLLOWING SUBCATEGORIES,
DIAGNOSTICS, PROCEDURES,
SECONDARY STROKE MEDICATIONS,
ACCESS TO POST STROKE CARE, AND
READMISSIONS.
OUR WRITING GROUP PERFORMED
LITERATURE SEARCHES IN EACH OF
THE CATEGORIES, FOR EACH
SUBCATEGORY WE IDENTIFIED ISSUES
RELATED TO DEMOGRAPHICS,
GEOGRAPHY, POLICY AND
REGULATIONS, ECONOMICS, AND
HEALTH CARE RESOURCES.
WE'LL START WITH WEEING --
GEOGRAPHY, LINKED TO STRENGTH OF
ECONOMY AND RESOURCES, WE KNOW
THIS INVOLVING LITERATURE WITH
LOW AND MIDDLE INCOME NATIONS
GLOBALLY.
IN IT'S UNITED STATES THERE ARE
INEQUITIES IN RURAL AREAS, LESS
EXPERTISE FOR COMPLICATED
CONDITIONS, LESS ACCESS TO
SPECIALIZED SUPPORT SERVICES,
LESS COORDINATION OF CARE THAT
RESULTS IN MORE HANDOFFS,
INCREASED RISK OF SECONDARY
COMPLICATIONS IN STROKE, AND
INCREASED RISKS OF READMISSION.
WE IDENTIFIED NUMEROUS GAPS WITH
REGARD TO GEOGRAPHY.
THERE WERE VERY FEW STUDIES
COMPARING INPATIENT CARE
DELIVERY IN RURAL AND URBAN CARE
FACILITIES.
GEOGRAPHIC DIFFERENCES DO NOT
EXIST IN ISOLATION.
WE NEED TO BETTER UNDERSTAND
STRUCTURAL AND SOCIOECONOMIC
CHARACTERISTICS OF REGIONS AND
NEIGHBORHOODS, TO UNDERSTAND
THEIR IMPACT ON ACUTE STROKE
CARE.
MORE INFORMATION IS NEEDED ON
IMPACT OF TELE AND HOME SERVICES
WITH COORDINATION OF BROADBAND
ACCESS AND DEVICE SKILLS.
NEXT WE CONSIDERED POLICIES AND
REGULATIONS.
SEVERAL KEY ISSUES EMERGED.
TECHNOLOGY CAN HELP WITH
STANDARDIZING BEST PRACTICES,
AND IMPLEMENTING GUIDELINES.
PROTOCOLS AND PATHWAYS SHOULD BE
DEVELOPED LOCALLY TO MATCH THE
RESOURCES WITH NEEDS.
AGAIN, WITH REGARD TO POLICY, WE
IDENTIFIED SEVERAL GAPS.
THERE'S LACK OF DATA ON IMPACT,
ON DIAGNOSTICS, PROCEDURES,
THERAPEUTICS, POST-ACUTE CARE.
THERE ARE SOME SUGGESTIONS THAT
COST AFFECTS POST-ACUTE CARE AND
MEDICATION USE.
BUT THESE ISSUES ARE VERY POORLY
UNDERSTOOD.
LITTLE IS KNOWN ABOUT HOSPITAL
POLICIES REGARDING INEQUITIES IN
DELIVERY OF CARE.
OVERALL WE FOUND MANY AREAS THAT
REQUIRE ADDITIONAL RESEARCH.
AND NOW I'LL PASS THIS OFF TO MY
PARTNER, DR. LARRY WECHSLER.
>> THANK YOU, KAREN.
THE THIRD CROSS-CUTTING THEME IS
ECONOMICS AND HEALTH CARE
RESOURCES.
AND THE INPATIENT WORK GROUP
IDENTIFIED SEVERAL KEY ISSUES IN
THIS AREA.
FIRST WAS THAT IN NEIGHBORHOODS
WITH LOWER SOCIOECONOMIC STATUS,
THIS WAS ASSOCIATED WITH POOR
OUTCOMES WITH LITERATURE TO
SUPPORT THAT.
SECONDARY STROKE PREVENTION
MEASURES WERE LESS UTILIZED IN
LOW INCOME SETTINGS.
THAT INCLUDES ANTI-COAGULATION,
AND REDUCED USE OF STATINS AND
ANTIPLATELET AGENTS,
PARTICULARLY IN LOW INCOME
PATIENTS.
THE GROUP FOUND THAT INCOME ALSO
AFFECTS THE USE OF
POST-DISCHARGE FACILITIES,
WHETHER THAT BE INPATIENT REHAB
FACILITIES, THE USE OF HOME
HEALTH SERVICES, AND SKILLED
NURSING FACILITIES, ALL OF THOSE
THINGS VARIED ACCORDING TO
INCOME.
WE ALSO FOUND THAT THE COST OF
TECHNOLOGY WAS A LIMITATION, AND
CONTRIBUTED TO INEQUITIES.
PARTICULARLY WITH THE USE OF
ADVANCED DIAGNOSTIC PROCEDURES,
AND TELEHEALTH SERVICES IN THE
POST-DISCHARGE PHASE.
THE WORK GROUP IDENTIFIED GAPS
IN THIS AREA THAT WE WANTED TO
POINT OUT.
FIRST IS THE FACT THAT THERE IS
NON-STANDARDIZATION OF
DEFINITIONS ACROSS ARTICLES IN
LITERATURE, A RECURRING THEME
THAT WE FEEL IS VERY IMPORTANT
TO ADDRESS BECAUSE IT MAKES IT
DIFFICULT TO COMPARE ACROSS
STUDIES AND ACROSS ARTICLES IN
THE LITERATURE.
ANOTHER GAP IS THAT VERY FEW OF
THESE ISSUES STAND ALONE.
AND THE EFFECT OF UNUTILIZATION
OF RESOURCES, PROTOCOLS,
ECONOMICS, PATIENT FACTORS, HOW
THEY ALL INTERACT IS NOT VERY
WELL UNDERSTOOD AND REPRESENTS A
SIGNIFICANT GAP.
FINALLY, THERE'S NOT A GREAT
DEAL OF DATA IN THE LITERATURE
ON EQUITY IN THINGS LIKE DOSING
OF MEDICATIONS, AND COMPLIANCE
AS WELL AS THE APPLICATION OF
INPATIENT DIAGNOSTIC PROCEDURES,
AND THERAPEUTIC PROCEDURES, SUCH
AS ENDARTERECTOMY, USE OF
IMPLANTABLE CARDIAC MONITORS.
WITH REGARD TO DEMOGRAPHICS, THE
NEXT CROSS-CUTTING TEAM, KEY
ISSUES THE INPATIENT WORK GROUP
IDENTIFIED WERE THE FOLLOWING.
POST-ACUTE SERVICES SEEM TO VARY
ACCORDING TO SEX, RACE, AGE,
INCLUDING APPLICATION OF
INPATIENT REHAB, HOME HEALTH
SERVICES, AND SKILLED NURSING
FACILITIES.
IT WAS ALSO FOUND THAT OLDER
PATIENTS, THAT IS THOSE OLDER
THAN 65, WERE LESS LIKELY TO
RECEIVE SECONDARY STROKE
PREVENTION THERAPIES, BOTH EARLY
ON WITHIN THE FIRST COUPLE OF
DAYS, AND AT DISCHARGE.
THIS INCLUDES ANTI-PLATE LIT
AGENTS, ANTICOAGULANTS AND
STATINS.
BLACKS AND HISPANICS WERE FOUND
TO BE LESS LIKELY TO RECEIVE
THESE SAME OPTIMAL MEDICAL
THERAPIES, AND WERE LESS LIKELY
TO RECEIVE VARIOUS POST-ACUTE
CARE MEASURES SUCH AS HOME
HEALTH SERVICES, FOR EXAMPLE.
FINALLY, WOMEN WERE ALSO LESS
LIKELY TO RECEIVE APPROPRIATE
ANTI-THROMBOTIC THERAPY.
FOR EXAMPLE, THE USE OF
ANTIPLATELET AGENTS FOLLOWING
CAROTID ENDARTERETCOMY, WOMEN
REST LIKELY TO RECEIVE
TREATMENTS.
FOR THE INPATIENT WORK GROUP,
SIMILAR TO PREVIOUS ONES
MENTIONED.
FIRST OF ALL THERE'S VERY LITTLE
STANDARDIZATION OF REPORTING
ACROSS STUDIES WITHIN THE
LITERATURE.
SECOND, DISENTANGLING THE
FEATURES OF DEMOGRAPHICS FROM
OTHER FACTORS SUCH AS
SOCIOECONOMIC STATUS AND
GEOGRAPHY A DIFFICULT AND COULD
USE FURTHER WORK.
WHAT ARE OPPORTUNITIES FOR
ACTION?
THE INPATIENT WORK GROUP
IDENTIFIED SEVERAL OF THESE,
FIVE OF THESE, LISTED HERE.
NUMBER ONE IS STANDARDIZATION OF
TERMS AND CATEGORIES, AND I'VE
ALREADY MENTIONED THIS.
BUT THE GROUP WAS THOUGHT THIS
WAS A VERY IMPORTANT FACTOR, NOT
ONLY IN TRYING TO UNDERSTAND THE
EXISTING LITERATURE BUT
HOPEFULLY TO BETTER UNDERSTAND
NEW LITERATURE GOING FORWARD.
THERE WAS LITTLE KNOWN ABOUT
INEQUITIES IN DIAGNOSTIC STUDIES
AND PROCEDURES SUCH AS CAROTID
VASCULARIZE ACE, PFO CLOSURE
DURING THE HOSPITAL STAY, SINCE
THESE COULD EASILY RESULT IN
DIFFERENCES IN OUTCOME DOWN THE
LINE.
THIRDLY, A NUMBER OF FACTORS,
PATIENT AND PROVIDER AND
SOCIETAL FACTORS NEED TO BE
BETTER DEFINED.
PATIENT FACTORS SUCH AS
NON-ADHERENCE, PROVIDER FACT
ORS, AND THERAPEUTIC INHERITTA
AND SOCIETAL FACTORS, DRUG COST,
REFERRAL PATTERNS, THOSE THINGS
NEED TO BE BETTER DEFINED TO
UNDERSTAND INEQUITIES.
WE NEED MORE RESEARCH ON THE
FACILITATION OF TRANSITIONING
INDIVIDUALS BACK TO THEIR
COMMUNITIES, PARTICULARLY IN LOW
RESOURCED RURAL COMMUNITIES.
AND FINALLY, ADDITIONAL RESEARCH
WAS FELT TO BE NEEDED TO BETTER
CHARACTERIZE THE FEATURES OF
RURALITY MOST IMPORTANT FOR THE
INPATIENT AND POST-STROKE CARE
EXPERIENCE.
I'D LIKE TO TAKE THIS
OPPORTUNITY TO GREATLY THANK THE
MANY TASK FORCE MEMBERS THAT
WORKED VERY HARD ON THIS TOPIC.
EVERYONE CONTRIBUTED A GREAT
DEAL.
AND SEVERAL OF THEM WILL BE PART
OF OUR PANEL THAT FOLLOWS THIS
PRESENTATION.
I'D LIKE TO PARTICULARLY THANK
KAREN FURIE, MY CO-LEAD FOR THIS
TASK FORCE, FOR ALL THE GREAT
CONTRIBUTIONS THAT SHE MADE TO
THIS EFFORT.
THANK YOU.
HERE ARE SOME KEY REFERENCES
IDENTIFIED BY THE TASK FORCE.
>> THANK YOU, LARRY.
THANK YOU, KAREN, FOR THAT
REPORT-OUT.
VERY COMPREHENSIVE.
CERTAINLY LAID OUT SOME GREAT
OPPORTUNITIES FOR FURTHER
RESEARCH AND STUDY.
WE'RE GOING TO MOVE NOW TO THE
QUESTION AND ANSWER PERIOD.
EITHER OF YOU, YOU PRESENTED A
LOT OF VERY INTRIGUING DATA AND
OPPORTUNITIES.
IN TERMS OF RESEARCH, THIS CAME
UP IN A DIFFERENT BREAKOUT
SESSION ON A DIFFERENT TOPIC,
BUT I THINK IT'S STILL RELEVANT.
IN TERMS OF DOING HIGH LEVEL
RESEARCH, ONE OF THE HOPES WILL
BE A RESULT OF THIS, WILL BE TO
GO BEYOND DESCRIPTIVE STUDIES
AND ASSOCIATION STUDIES INTO
HYPOTHESIS-DRIVEN RESEARCH,
CAUSATIVE MECHANISMS, AND THINGS
LIKE THAT.
FOR EXAMPLE, IT MAY OR MAY NOT
BE TRUE THAT PEOPLE FROM
DIFFERENT SOCIOECONOMIC GROUPS
DO OR DO NOT HAVE ACCESS TO
REHAB OR MAY OR MAY NOT BE
TAKING MEDICATIONS BECAUSE OF
FINANCIAL ISSUES OR RACIAL
ISSUES OR ETHNIC ISSUES.
I THINK WE'RE LOOKING FOR
OPPORTUNITIES TO TAKE IT TO THE
NEXT STEP BEYOND THIS GROUP
DOESN'T GET THIS TYPE OF
MEDICATION, WHICH IS ASSOCIATION
INTO CAUSATIVE FACTORS.
SO I WONDER IF YOU HAD ANY
THOUGHTS ON THAT, FROM YOUR
REVIEW OF THE LITERATURE IF
THERE WAS ANYTHING PUBLISHED ON
THAT IN THE LITERATURE?
>> THAT'S A GREAT QUESTION,
MARK.
AND, YOU KNOW, WHAT EXISTS IS
PRETTY SUPERFICIAL.
IT MAINLY IS OBSERVATIONAL.
AND IT'S NOT CLEAR THAT PEOPLE
EITHER RECEIVE OR DO NOT RECEIVE
TESTS, INTERVENTIONS, OR
MEDICATIONS BASED ON
ELIGIBILITY.
IN OTHER WORDS, IF THERE ARE
DISPARITIES, IS IT BECAUSE THEY
ARE NOT BEING OFFERED, WHATEVER
IT IS?
THE INTERVENTION?
OR IS IT THAT THEY DON'T MEET
THE CRITERIA TO ACTUALLY BE
ELIGIBLE FOR THAT TEST OR
PROCEDURE?
AND THERE'S REALLY NOTHING THAT
HELPS TEASE THAT OUT.
AND OUR GROUP, YOU KNOW, WAS
REALLY INTERESTED IN THIS.
AND ACTUALLY ONE OF OUR GROUP
MEMBERS WENT AND DIPPED INTO ONE
OF THE INSURANCE DATABASES, TO
TRY AND GET AT THIS INFORMATION.
BUT IT REALLY DOESN'T -- AGAIN,
YOU CAN LOOK AT THE DEMOGRAPHICS
OR THE GEOGRAPHY, AND IDENTIFY
THAT THERE MAY BE REGIONAL
DIFFERENCES, BUT IT'S REALLY
HARD FROM WHAT EXISTS CURRENTLY
TO SAY, YEP, THE FOLKS WHO ARE
BEING -- NOT BEING TREATED OR
NOT BEING STUDIED REALLY OUGHT
TO BE.
AND THAT'S WHERE STANDARDIZING
PROTOCOLS WITHIN THE HOSPITAL
MAY HELP ELIMINATE THIS, THAT
WHETHER, YOU KNOW, REGARDLESS OF
DEMOGRAPHICS, WHERE ARE YOU IN
THE UNITED STATES, YOUR CARE IS
GOING TO FOLLOW THAT PRESCRIBED
ALGORITHM.
AND YOU WILL NOT BE DENIED
EVIDENCE-BASED CARE.
>> SO, I WOULD JUST COMMENT
ADDITIONALLY, FIRST OF ALL, I
AGREE COMPLETELY, KAREN.
I AGREE WITH YOU, MARK, THAT'S
REALLY WHAT WE NEED TO GET TO,
IN ADDITION TO THE FACT THAT
THERE ARE DISPARITIES, WHAT THE
CAUSE OF THE DISPARITIES IS.
I WAS SURPRISED THAT WE DIDN'T
FIND MORE INFORMATION ABOUT
IN-HOSPITAL DISPARITIES, BECAUSE
OF ALL THE THREE AREAS WE'RE
TALKING ABOUT THAT'S THE AREA
WHERE THE MOST INFORMATION
SHOULD BE AVAILABLE.
YOU KNOW, EMRs ARE EVERYWHERE.
AND THEY HAVE VERY RICH
INFORMATION BASE IN THEM THAT
SHOULD ALLOW US TO KIND OF DIG
INTO THIS.
NOW, EXACTLY HOW TO PUT THAT
TOGETHER IS A DIFFICULT RESEARCH
QUESTION I THINK, BUT THERE
SHOULD BE QUITE A BIT OF BASIC
INFORMATION THAT WOULD ALLOW US
TO STUDY THIS.
NOW, OF COURSE THERE ARE
BARRIERS BECAUSE EVERYONE'S GOT
DIFFERENT EMRs, EMRs DON'T
TALK TO EACH OTHER, HIPAA
ISSUES, THAT SORT OF THING, BUT
I BET THERE'S INFORMATION
AVAILABLE OUT THERE GIVEN THE
PREVALENCE OF EMRs THAT WOULD
ALLOW US TO ADDRESS THIS IF WE
COULD FIGURE OUT A WAY TO MINE
IT.
>> WELL, I THINK THE GUIDELINES
DATABASE HAS EVERYBODY KNOW HAS
BAZILLIONS OF DATA POINTS, THAT
CAPTURES AT LEAST A PICTURE OF
IN-HOSPITAL CARE.
>> I DON'T ABOUT SOCIOECONOMIC
STATUS, ZIP CODES, WHERE PEOPLE
LIVE AND THE KIND OF STUFF THAT
YOU MIGHT NEED TO GET TO THIS.
I THINK THAT, GETTING WITH THE
GUIDELINES MIGHT BE A GOOD START
BUT THE EMR WOULD HAVE SUCH A
RICH DEPTH OF INFORMATION TO
HELP US IF WE COULD GET TO THAT
INFORMATION SOMEHOW.
>> I WANT TO SHARE THAT THE
REFERRALS WE DO, FOR EXAMPLE,
THE REHAB, THERE IS CLEAR
DISPARITIES THERE WHERE, YOU
KNOW, FEMALE, OLDER, AFRICAN
AMERICAN, UNINSURED PEOPLE ARE
LESS LIKELY TO GO TO ACUTE
REHAB.
THEY ARE MOST LIKELY UTILIZE
SKILLED FACILITIES, AND ALSO
PEOPLE WHO ARE LIVING NEXT --
CLOSE TO THE REHAB FACILITIES,
ACUTE REHAB, MALES AND
CAUCASIANS, THEY ARE MORE LIKELY
TO GET TO THE ACUTE REHAB AFTER
THE STROKE.
I WANT TO SHARE THAT PIECE OF
INFORMATION THAT IS THERE.
>> THANK YOU.
>> GO AHEAD, RICHARD.
>> THAT'S A GREAT POINT.
SORT OF ONE OF THE QUESTIONS I
HAD.
KAREN MAY HAVE ANSWERED IT AS
WELL IN TERMS OF THE REFERRALS
TO THE SKILLED NURSING
FACILITIES VERSUS REHAB, WAS IT
RELATED TO INSURANCE STATUS.
ONE POINT TO WHAT YOU WERE
SAYING, LARRY, IN TERMS OF THE
EHR, I WORKED ON WITH THE
REGISTRIES COMMITTEE THROUGH THE
AMERICAN ACADEMY OF NEUROLOGY,
THEY HAVE THE AXON REGISTRY, WE
WERE LOOKING THROUGH THAT
DATABASE TO SEE IF WE COULD FIND
DISPARITIES IN CARE.
YOU KNOW, THAT'S PURELY
OUTPATIENT SO DOESN'T INCLUDE
STROKE.
WHAT THEY FOUND WAS THAT THE
RACE AND ETHNIC DATA, A LOT OF
EHRs WAS INCORRECT, WASN'T
OBTAINED CORRECTLY.
SO THIS IS AN ISSUE, THIS IS
SOMETHING THAT WE'RE GOING TO
SORT OF TALK ABOUT AT THE
UPCOMING AAN MEETING BUT A LOT
OF INFORMATION IS NOT COLLECTED
CORRECTLY.
EHR SHOULD BE A RICH SOURCE BUT
WE HAVE TO DO TRAINING WHY IT'S
IMPORTANT TO COLLECT THIS
INFORMATION.
THERE IS A MISTRUST WE KNOW WITH
CERTAIN GROUPS CONCERNED ABOUT
CITIZENSHIP STATUS AND HOW THAT
INFORMATION IS GOING TO BE USED
IN TERMS OF GIVING RACE AND
ETHNIC DATA.
THERE ARE CHALLENGES IN
COLLECTING THAT BUT THAT CREATES
UNFORTUNATELY A BARRIER TO USING
THAT TYPE OF RESOURCE RIGHT NOW
TO GET SOME OF THAT INFORMATION.
THE OTHER THING I WANTED TO
MENTION, THIS THEME OF
TRANSITION OF CARE, PRE-HOSPITAL
STROKE SYSTEM, IT WOULD BE GREAT
IF, YOU KNOW,
POST-HOSPITALIZATION, POST-ACUTE
HOSPITALIZATION, IF THERE WAS
ANOTHER WAY FOR THAT TRANSITION
PIECE.
WE KNOW TRANSITIONS OF CARE ARE
ALSO DIFFICULT, BUT SORT OF
FOLLOWING UP ON PEOPLE.
THIS COULD BE DONE THROUGH THE
MEDICAL CENTER, FOLLOWING THEM
UP IN TERMS OF GOING TO AN ACUTE
CARE, SUBACUTE OR SKILLED
NURSING FACILITY, OR HOME.
SORT OF CLOSING THAT LOOP AND
TYING THAT BACK INTO THIS SORT
OF PRE-HOSPITAL STROKE SYSTEM WE
TALKED ABOUT BUT I THINK, AGAIN,
IT'S THE CONCEPT OF TYING THE
HOSPITAL TO THE COMMUNITY IN
SOME KIND OF WAY, THAT MAY BE
HELPFUL FOR THAT TRANSITION OF
CARE, PRE-HOSPITAL, EVEN
POST-HOSPITAL.
>> THOSE POINTS, RICHARD, I KNOW
THERE'S A PCORI PCRI PATIENT
CENTERED OUTSOME RESEARCH, THERE
ARE NUMBER OF GRANTS WHERE
PARTICIPATING CENTERS GET
RANDOMIZED WITH NURSES AND
PEOPLE VISITING THE HOME, JUST
TO SEE IF PATIENTS' RISK FACTORS
ARE ADDRESSED, THE CONTROL GROUP
IS -- THEY DO WHATEVER THEY
WOULD NORMALLY DO, THAT'S BEING
FOLLOWED, ONE-YEAR FOLLOW-UP,
MAY BE EXTENDED, BUT THAT'S A
GREAT IDEA.
THE OTHER THING IS MORE AND MORE
MEDICAL CENTERS ARE USING
PROVIDERS THAT WE CALL NURSE
NAVIGATORS TO NAVIGATE BETWEEN
INPATIENT, GOING TO OUTPATIENT
ARENA TO MAKE SURE MEDS GET
FOLLOWED UP, OUTPATIENT
FOLLOW-UP OR IMAGING STUDIES,
WHATEVER NEED GETS DONE, AS PART
OF ROUTINE CARE, NOT PART OF A
STUDY.
WE TAKE ALL COMERS, ELIGIBLE TO
MAKE USE OF NURSE NAVIGATOR, GET
CONTACTED AND GET FOLLOW-UP
PHONE CALLS, ALL GREAT IDEAS TO
EXTEND IN-HOSPITAL CARE INTO THE
OUTPATIENT ARENA.
>> I THINK TO SOME AGREE YOU
MAKE GOOD POINTS, RICHARD.
THEY ARE VERY IMPORTANT POINTS
IN TERMS OF PATIENT CARE.
AND TO SOME DEGREE IT'S AN
ARTIFACT OF THE WAY OUR MEDICAL
ECONOMICS IN COUNTRY IS SET UP.
THE HOSPITALS, FINANCES FOR THE
MOST PART ARE NOT DEPENDENT ON
WHAT HAPPENS TO THE PATIENT
AFTER THEY LEAVE THE HOSPITAL
EXCEPT THAT NOW CMS IS TRYING TO
CHANGE THAT BY LOOKING AT THINGS
LIKE 30-DAY READMISSIONS, AS
THEY DO THAT MORE HOSPITALS ARE
GETTING INTO THE BUSINESS OF
DOING APPROPRIATE POST-DISCHARGE
FOLLOW-UP TO MAKE SURE THAT
PEOPLE UNDERSTAND WHAT
MEDICATIONS THEY ARE SUPPOSED TO
BE ON AND WHAT TESTS THEY ARE
SUPPOSED TO GET, AND THE FACT
THAT THEY ARE SUPPOSED TO GET
FOLLOW-UP APPOINTMENTS AND SEE
THEIR DOCTOR.
I HATE TO BE CYNICAL BUT IT HAS
TO DO WITH THE FACT THEY GET
PENALIZED FOR 30-DAY
READMISSIONS SO THEY ARE TRYING
TO KEEP PEOPLE FROM COMING BACK
TO THE HOSPITAL.
UNFORTUNATELY, THAT FORCES
PEOPLE TO DO THE RIGHT THING.
BUT I THINK WE COULD DO A WHOLE
LOT MORE IN THAT REGARD, I THINK
WHEN PATIENTS ARE DISCHARGED
FROM THE HOSPITAL IT'S A
CONFUSING SITUATION.
MOST JUST WANT TO GET OUT AND
DON'T LISTEN WHEN PEOPLE REVIEW
MEDICATIONS AND APPOINTMENTS AND
THAT SORT OF THING.
AND SO ALL OF THESE, TO TRY TO
PULL THE SYSTEM TOGETHER IN THE
WAYS YOU'RE TALKING ABOUT, PRE
AND POST HOSPITAL, ACUTE
HOSPITAL EVENT, THAT IS THE WAY
TO GO IN TERMS OF POPULATION
HEALTH AND I THINK INSURANCE
COMPANIES ARE INTERESTED IN
THAT, HOPEFULLY HOSPITALS WILL
BECOME MORE INTERESTED AS WELL.
>> YEAH, IT'S NOT EVEN CLEAR
WHAT HOSPITALIZATION LOOKS LIKE
FOR DIFFERENT GROUPS.
ARE THESE 36-HOUR ADMISSIONS
WITH A LOT OF THE FOLLOW-UP
INTENDED TO BE DONE ON AN
OUTPATIENT BASIS AND MAY OR MAY
NOT GET DONE, OR ARE THERE
INDIVIDUALS OR AREAS WHERE
PATIENTS STAY IN THE HOSPITAL
FOR THREE OR FOUR DAYS BUT HAVE
MORE OF THE DIAGNOSTICS AND
POTENTIALLY EVEN INTERVENTION
PERFORMED DURING THAT INDEX
HOSPITALIZATION.
AND WE DIDN'T FIND ANYTHING IN
THE LITERATURE THAT HELPED
CATEGORIZE HOW THAT MIGHT VARY
BY THE DIFFERENT CROSS-CUTTING
PARAMETERS OR HOW IT WOULD
IMPACT OUTCOME.
>> SOMETIMES -- THESE ARE GREAT
POINTS.
SOMETIMES UNDER THE RUBRIC OF
UNINTENDED CONSEQUENCES, MANY OF
YOU KNOW THIS, IN CASE SOME
DON'T, WHILE WE THINK ADMITTING
THE PATIENT TO THE OBSERVATION
UNIT BECAUSE IT'S GOING TO BE A
47-HOUR STAY, THIS IS A GOOD
THING AND GOOD FOR THE HOSPITAL.
IT MAY BE GOOD FOR THE HOSPITAL.
BUT IN MANY CASES IT MAY BE BAD
FOR THE PATIENT BECAUSE THEY ARE
NEVER ADMITTED, THEY ARE NOT
UNDER THAT HOSPITAL DRG AND GET
STUCK WITH A HUGE BILL FOR ALL
OF THESE OUTPATIENT IMAGING AND
ECHOES AND BLOOD WORK.
SO THAT SOMETIMES WORKS AT
CROSS-PURPOSES, WHAT'S GOOD FOR
THE HOSPITAL, THE PATIENTS GET
SOCKED WITH A HUGE BILL, THAT
MAY DISINCENTIVIZE THEM TO GET
FURTHER CARE.
IF CERTAIN GROUPS ARE IMPACTED
MORE, FINANCIALLY DISADVANTAGED,
MAY FURTHER REINFORCE THE NOTION
I'M NOT DOING THIS AGAIN BECAUSE
I GOT SOCKED WITH A $30,000 BILL
FOR A SCAN AND BLOOD TESTS.
THAT'S ANOTHER IMPORTANT
CROSS-CUTTING THING IN TERMS OF
ECONOMICS AND RESOURCES.
>> THERE ARE A COUPLE OF
COMMENTS IN THE CHAT.
STEPHANIE ASKS A QUESTION, DR.
DENNY RESPONDS, ARE HOSPITAL
CONDUCTING SOCIAL NEEDS
ASSESSMENTS AND IF NOT HOW COULD
WE INCENTIVIZE.
DR. DENNY, IF YOU WANT TO
RESPOND.
IT'S MENTIONED IN THE CHAT AT
MEDSTAR THEY DO HAVE THE SOCIAL
WORKERS THAT DO THE NEEDS
ASSESSMENT PRIOR TO PATIENT
DISCHARGE, BUT I THINK IT'S A
VERY IMPORTANT POINT.
AND THIS GOES BACK IN TERMS OF
TYING THE HOSPITAL TO THE
COMMUNITY, AND COMPLIANCE.
WE KNOW SOCIAL DETERMINANTS OF
HEALTH ARE SO IMPORTANT AND SO
PEOPLE HAVE ALL KIND OF
COMPETING NEEDS, AND IF YOU'RE
DEALING WITH HOUSING AND FOOD
INSECURITY, THEN TAKING YOUR
ANTIPLATELET AGENT AND STATIN
AGENT IS PROBLEM -- PROBABLY AT
THE BOTTOM OF YOUR PRIORITY
LIST.
IT MAY BE IMPORTANT TO ASSESS
NEEDS PEOPLE HAVE BEFORE THEY
LEAVE THE HOSPITAL AND
INCORPORATING THIS INTO THE CARE
PLAN.
>> KAREN AND LARRY, A COMMON
THEME I HEARD, WE'VE HEARD IT
BEFORE, THAT ACCESS TO INPATIENT
REHAB AFTER STROKE IS VERY
PROBLEMATIC BECAUSE IT'S VERY
EXPENSIVE AND RESOURCE INTENSE
AND SOME PLACES DON'T OFFER IT.
AS WE KNOW THIS CAN BE UP TO
THREE WEEKS AND CAN COST TENS OF
THOUSANDS OF DOLLARS, AND YOU
HAVE TO HAVE PRETTY GOOD
INSURANCE FOR THIS.
IN TERMS OF TESTABLE HYPOTHESIS,
WOULD IT BE CLOSE TO EQUALLY AS
BENEFICIAL UNDER THE RUBRIC OF
LET'S NOT LET THE PERFECT BE THE
ENEMY OF THE GOOD, MAYBE THE
RESOURCES ARE NOT THERE TO OFFER
EVERYBODY THREE WEEKS OF
INTENSIVE INPATIENT REHAB, BUT
MAYBE FIVE DAYS OF INPATIENT
REHAB WOULD GENERATE ENOUGH
INCREMENTAL BENEFIT AT A
REASONABLE POINT THAT PEOPLE WHO
ARE FINANCIALLY DISADVANTAGED,
IT WOULDN'T EXCLUDE THEM FROM
THAT OR ANOTHER PAYER COULD PICK
UP THAT COST BECAUSE THE
DOWNSTREAM BENEFIT IN TERMS OF
GETTING THE PATIENTS BACK TO
WORK SOONER OR PREVENTING THEM
FROM GOING INTO A SNIFF, MAYBE
WAS JUST FIVE DAYS INSTEAD OF
THREE WEEKS, COULD PROVE EQUALLY
BENEFICIAL.
I JUST PUT THAT OUT THERE FOR
THE GROUP TO CONSIDER AND
DISCUSS AND SEE IF THIS COULD BE
THE GENESIS OF A TESTABLE
HYPOTHESIS.
>> OR ONE COULD PROPOSE A TRIAL
OF COMMUNITY-BASED AUGMENTED
REHAB EXPERIENCE AT HOME.
IF YOU COULDN'T PAY FOR THE
FACILITY, IS THERE A WAY TO USE
EITHER TELEHEALTH BUT PERHAPS
COMMUNITY HEALTH WORKERS AS WELL
TO HAVE THE PATIENT PARTICIPATE
IN A REHABILITATION THERAPY
WHILE SIMULTANEOUSLY GETTING
REINFORCEMENT OF THE SECONDARY
STROKE PREVENTION MEASURES.
SO THERE MAY BE DIFFERENT WAYS
TO ACCOMPLISH THE GOAL OF
OPTIMIZING OUTCOME, ENSURING
COMPLIANCE, REDUCING
READMISSION.
>> GREAT POINTS, KAREN.
THANK YOU FOR SHARING WITH THE
GROUP.
YEAH, GREAT IDEAS.
>> I THINK, MARK, THAT, YOU
KNOW, THAT -- I DON'T KNOW
WHETHER FIVE DAYS, I THINK IT'S
A GOOD IDEA, MAYBE THAT WOULD
WORK.
I THINK WE WOULD HAVE TO LOOK AT
THE -- STILL, THE FINANCIAL
ISSUES SURROUNDING THAT.
BUT I KIND OF AGREE WITH KAREN
THAT MAYBE THE WAY TO GO IS TRY
TO ENHANCE THE HOME THERAPY
ROUTE RATHER THAN PUTTING
PEOPLE, MORE PATIENTS, MORE
PEOPLE IN INPATIENT CARE IF WE
COULD ESTABLISH THAT WAS JUST AS
GOOD AND WOULD IMPROVE RECOVERY
TO THE SAME EXTENT.
I THINK FIRST OF ALL PATIENTS
WOULD LIKE IT BETTER.
AND IT MIGHT BE MORE COST
EFFECTIVE.
>> GOOD POINTS, LARRY.
AGAIN, JUST TRYING TO GENERATE
SOME TESTABLE HYPOTHESES, FOR US
TO GO FORWARD TO FIND SOLUTIONS
TO THESE, YOU KNOW, DISPARITIES
IN CARE AND ACCESS TO RESOURCES.
>> VERY IMPORTANT COMMENTS IN
THE CHAT.
DR. JENSEN MENTIONED NOACs,
PEOPLE END UP ON COUMADIN WHICH
IMPACTS COMPLIANCE.
AND THEN COMMENTS ABOUT
TELEHEALTH, IF YOU WANT TO
EXPAND, DR. JENSEN.
>> YES, MY NURSE PRACTITIONERS,
WE WROTE A PAPER, EDUCATION FOR
RURAL ELDERLY VIRGINIANS, LOOKED
AT PATIENTS WHO HAD BEEN
HOSPITALIZED AT UVA FROM A VERY
RURAL AREA OF VIRGINIA AND SHE
WORKED IN THE CLINIC FOR A
PERIOD OF TIME DOING FOLLOW-UP
WITH THE STROKE PATIENTS AND
THEN SHE ALSO DID FOLLOW-UP WITH
TELEHEALTH AND FOUND THAT THEY
WERE EQUALLY AS EFFECTIVE IN
PROVIDING FOLLOW-UP STROKE CARE.
SO ABSOLUTELY THERE'S A PLACE
FOR TELEHEALTH.
IN STROKE FOLLOW-UP.
>> I ALSO WANT TO ADD THAT IN
OUR SYSTEM DURING COVID WE HAD A
HUNDRED PERSON STROKE FOLLOW-UP
PATIENTS TO TELEHEALTH AND IT'S
WORKING VERY WELL.
>> OTHER QUESTIONS OR COMMENTS?
I'M CHECKING THE CHAT HERE TO
SEE IF THERE'S ANY OTHER THINGS.
>> MOST OF THE QUESTIONS IN THE
CHAT WE HIT.
ANY OTHER COMMENTS?
>> YEAH, CAN YOU HEAR ME?
>> YES.
>> I'LL JUST ADD I DON'T THINK
ANYONE'S ADVOCATING FOR
ABANDONING IN-PERSON VISITS BUT
THERE'S A COHORT OF PATIENTS FOR
WHOM TELEHEALTH DOESN'T WORK, IN
MY SPECIAL PRACTICE, THEY ARE
SCHEDULED AND GET CANCELED
BECAUSE THEY CAN'T FIGURE OUT
HOW TO LOG ON AND OPERATE THE
SOFTWARE AND ALL THAT.
I DO THINK TELEHEALTH HAS OPENED
UP FOR A LOT OF PATIENTS BUT
OBVIOUSLY WE CAN'T ABANDON
TRADITIONAL IN-PERSON VISITS.
>> TOTALLY AGREE.
DURING COVID IT WAS EYE-OPENING
TO ME THE SIGNIFICANT NUMBER OF
OUR PATIENTS, AT LEAST MY
PATIENTS, WHO DON'T HAVE A
SMARTPHONE.
DON'T HAVE ACCESS TO EVEN THE
BASICS.
AND I THINK IN TERMS OF LOOKING
AT DISPARITY AND INEQUALITY, I'M
SURE, NOT SURE, I SUSPECT THAT
THEME CARRIES INTO MANY
DIFFERENT GROUPS AND SUBGROUPS
OF OUR PERHAPS MOST VULNERABLE
PATIENTS.
>> RIGHT, EXACTLY.
>> YEAH.
WE JUST CAN'T ASSUME EVERYBODY
HAS A HIGH END IPHONE.
>> RIGHT.
>> I WOULD JUST ADD EVEN WHEN
YOU DO HAVE THE CONNECTIVITY AND
THE EQUIPMENT, TELEHEALTH IS NOT
NECESSARILY THE BEST THING FOR
EVERYBODY IN EVERY SITUATION.
PARTICULARLY AS NEUROLOGISTS,
THERE ARE SITUATIONS WHERE IT
WOULD BE NICE TO TAP ON THE
REFLEXES AND DO A SENSORY
EXAMINATION, SO ON.
SO DURING THE PANDEMIC WE DIDN'T
HAVE ANY CHOICE.
THAT WAS THE ONLY WAY WE COULD
SEE PATIENTS.
BUT NOT NECESSARILY THE RIGHT
THING FOR EVERY SITUATION,
EVERYONE.
JUST IT'S GOOD FOR A LOT OF
THINGS BUT NOT EVERYTHING.
>> AND AT TIMES FOR THAT, IT
GENERATES A SECOND VISIT BECAUSE
YOU DISCOVER SOMETHING ON
TELEHEALTH THAT I REALLY HAVE TO
SEE YOU, NOW THEY HAVE TO COME
FOR A SECOND VISIT, ARE GOING TO
GET BUILD FOR A SECOND VISIT.
FIGURING OUT WHO BENEFITS UNDER
WHAT SCENARIO IS IMPORTANT.
>> I WANTED TO MAKE ONE POINT
REGARDING ACCESS TO TECHNOLOGY
AND BROADBAND, THAT CERTAINLY IS
AN ISSUE IN SOME RURAL AREAS,
AND FOR THE UNDERSERVED.
ONE APPROACH FOR PEOPLE WITH
CHRONIC CONDITIONS AND THIS
COULD PERTAIN LET'S SAY
POST-STROKE, FOR FOLKS THAT HAVE
MOBILITY ISSUES OR RURAL AREAS,
WE, MEANING THE V.A., HAS LOANED
OR PROVIDED SOME SORT OF TABLET,
USUALLY AN IPAD, SOMETIMES WITH
A CELLULAR DATA PLAN, TO
VETERANS SO THEY CAN PARTICIPATE
IN TELEHEALTH TO THE HOME FOR
FOLLOW-UP.
AND WHILE THAT MAY SEEM VERY
EXPENSIVE, IT'S NOT IF YOU LOOK
AT THE COST OF NOT GETTING CARE.
WE HAVE ATLAS CENTERS IN V.A.,
BASICALLY TELEHEALTH PODS, NOT
AT A V.A. CLINIC OR RESOURCE,
THEY MIGHT BE AT A WALMART OR
VET CENTER OR COMMUNITY CENTER,
BUT THESE ARE LIKE PODS.
I'LL DESCRIBE THEM, WITH SOME
MINIMAL TECH TO HELP PEOPLE
CHECK IN AND WORK ON PATIENT
FLOW, WHERE THE PATIENT CAN GET
EQUIVALENT OF OUTPATIENT
TELEHEALTH VISIT CLOSE TO HOME.
THESE ARE NOT AS CONVENIENT OR
NOT AS CHEAP AS JUST SENDING
SOMEONE AN IPAD BUT YOU CAN DO
IT AS A ONE-OFF.
THOSE ARE SOME OF THE APPROACHES
THAT V.A. IS TAKING TO BRING
TELEHEALTH TO RURAL AND
UNDERSERVED AREAS.
>> THANK YOU.
I APPRECIATE YOUR SPEAKING UP
AND IT BRINGS ME BACK TO LARRY'S
EARLIER COMMENT ABOUT EMRs.
I WAS SURPRISED WE DIDN'T FIND
ANYTHING FROM THE V.A. SYSTEM
WHERE THEY MIGHT BE BETTER ABLE
TO TRACK APPROPRIATE UTILIZATION
OF DIAGNOSTIC STUDIES AND
PROCEDURES THAN EVEN EPIC WHERE
THOSE THINGS MIGHT OCCUR IN
DIFFERENT CARE SETTINGS, PERHAPS
AT DIFFERENT HOSPITALS.
>> THERE HAVE BEEN SOME DATA
REALLY LOOKING AT DISPARITIES IN
STROKE CARE, VARIOUS SORTS.
AS I RECALL LARRY GOLDSTEIN WHEN
HE WORKED IN THE V.A. SYSTEM WAS
THE CO-AUTHOR OF AT LEAST ONE.
FORTUNATELY IT DID NOT FIND OF
EVIDENCE OF ANY DISPARITY, AT
LEAST IN LOOKING AT RACE AND
GEOGRAPHY.
SO, THAT WAS A POSITIVE.
BUT I'M RELUCTANT TO GENERALIZE
BROADLY FROM LIMITED DATA BUT
SOME DATA DO EXIST THAT DR.
FURIE, IN ANSWER TO YOUR
QUESTION.
>> THANK YOU.
>> WE'RE ALMOST OUT OF TIME HERE
BUT I DID WANT TO BRING UP
SOMETHING THAT EITHER KAREN OR
LARRY OR BOTH OF YOU MENTIONED
IN YOUR REPORT-OUT THAT I
THOUGHT WAS INTRIGUING AND
WONDER IF YOU COULD SHARE MORE
INFORMATION.
IT WAS SAID THAT IN TERMS OF
SECONDARY PREVENTION TREATMENTS,
THAT THE UTILIZATION WENT DOWN
WITH AGE.
AND YOU KNOW THE LITERATURE AS
WELL AS I DO.
THE RISK OF STROKE OR RECURRENT
STROKE, EVERYBODY BAD FOR THE
MOST PART GOES UP WITH AGE, NOT
DOWN.
SO I WAS WONDERING IF LARRY OR
KAREN OR SOMEBODY ELSE ON THE
CALL, YOU KNOW, HAD SOME
EXPLANATION FOR THAT OR
OBSERVATION ABOUT WHAT MAY BE
DRIVING THAT?
BECAUSE, YOU KNOW, WE DON'T WANT
AGE TO BE A DISCRIMINATOR BUT IT
OBVIOUSLY COULD, DOES DEFINE
ANOTHER ASPECT OF UNDERSERVED
POPULATION.
SO ANY THOUGHTS ON THAT?
>> JUST HYPOTHESES.
IT MAY BE COMORBIDITIES OR
INTERACTIONS WITH OTHER
MEDICATIONS MAKES IT DIFFICULT
TO PRESCRIBE WHATEVER THE
OPTIMAL MEDICAL THERAPY IS.
AGAIN, THIS IS AN AREA WHERE
SOCIOECONOMICS MAY OVERLAP WITH
DEMOGRAPHICS, MAYBE THE OLDER
PATIENT DOESN'T HAVE THE
RESOURCES, SOMEONE PUT IN THE
CHAT ABOUT THE DOACs, IT'S A
GREAT EXAMPLE, THEY ARE
EXPENSIVE AND NOT EVERYONE CAN
AFFORD THEM.
THIS IS AN THAT I THINK IS
AMENABLE TO RESEARCH, WHY AREN'T
THOSE PATIENTS ON THE OPTIMUM
MEDICAL THERAPY?
RIGHT NOW IT'S ALL SPECULATIVE
BUT THERE MAY BE SOME REALLY
IMPORTANT ANSWERS THAT HELP US
BETTER MANAGE THE VERY ELDERLY.
>> I THINK THESE ISSUES ARE HARD
TO GET TO.
YOU CAN IMAGINE THAT AS WE ALL
KNOW, BECAUSE WE DO THIS ALL THE
TIME, THAT THESE DECISIONS ABOUT
THERAPY, SECONDARY STROKE
PREVENTION, INTERVENTIONS ARE
MULTI-FACTORIAL AND COMPLEX AND
INDIVIDUALIZED FOR EACH PATIENT,
SO, YEAH, THERE'S LOTS OF
FACTORS THAT WE'LL HAVE TO
ANALYZE IN ORDER TO GET TO THE
BOTTOM OF, YOU KNOW, WHY
SOMETHING LIKE THAT OCCURS, AND
OTHER THAN WHAT KAREN HAS
ALREADY MENTIONED I THINK THOSE
ARE ALL GOOD POTENTIAL
HYPOTHESES TO TEST.
>> JUST TO MAKE LIFE MORE
COMPLICATED, WE MAY HAVE SOME
DATA ABOUT WHAT PATIENTS RUN
WHEN THEY LEAVE THE HOSPITAL
THAN AFTER 30 OR 60 DAYS MAY
ABANDON THAT THERAPY FOR VARIOUS
REASONS.
COULD BE COST, COULD BE
SOCIOECONOMIC, COULD BE SIDE
EFFECTS, COULD BE ACCESS, AND I
KNOW THERE ARE SOME GROUPS THAT
ARE LOOKING AT THIS ISSUE OF
MEDICATION ABANDONMENT AFTER A
PERIOD OF TIME VERSUS
PERSISTENCE.
>> USEFUL IF WE LEARNED FOR
INSTANCE WHY PATIENT WITH ATRIAL
FIBRILLATION ARE NOT PRESCRIBED
ANTICOAGULANTS BECAUSE PROVIDERS
PERCEIVE A FALL RISK OR FRAILTY,
BY KNOWING THAT'S THE REASON
THAT'S THE BARRIER YOU CAN
ADDRESS IT HEAD ON SO BE -- SO
THERE MAY BE LOTS OF EXAMPLES
LIKE THAT.
>> TOTALLY AGREE.
>> IS TELEREHAB CURRENTLY
REIMBURSABLE, SOMEONE ELSE SAYS
TELEHEALTH AND STROKE WOULD BE
GREAT OPPORTUNITY TO EDUCATE THE
COMMUNITY.
ANY COMMENTS ABOUT REIMBURSEMENT
FOR TELEREHAB?
>> SO, IT IS NOT, AS FAR AS I
KNOW, EVEN DURING THE PANDEMIC,
ALTHOUGH I GUESS UNLESS YOU BILL
AS (INDISCERNIBLE) VISIT.
THE OTHER COMMENT IS
INTERESTING, BRINGS UP THE ISSUE
THERE ARE THINGS WE CAN DO WITH
TELEMEDICINE BEYOND JUST SEEING
THE PATIENT.
THAT WE REALLY OUGHT TO, YOU
KNOW, BE LOOKING AT NOT JUST HOW
TELEMEDICINE CAN REPLACE AN
IN-PERSON VISIT BUT WHAT CAN
MAKE OUR CARE BETTER THAN IN
PERSON IN THOSE SITUATIONS WHERE
IT'S APPROPRIATE, AND I THINK
TALKING DIRECTLY WITH FAMILY
MEMBERS WHO MAY BE SCATTERED
ACROSS THE COUNTRY, THEY MAY NOT
BE ALL IN THE HOUSE BUT THERE
COULD BE A DAUGHTER IN ARIZONA,
A SON IN MAINE, AND THEY CAN GET
ONLINE AND TALK AT THE SAME TIME
THROUGH TELEHEALTH, THEY CAN'T
COME INTO YOUR OFFICE AT THE
SAME TIME.
SO I THINK THOSE ARE GOOD
THOUGHTS.
I THINK THAT'S HOW WE OUGHT TO
BE THINKING ABOUT TELEHEALTH AS
ENHANCING OUR ABILITY TO DO
THINGS RATHER THAN JUST
REPLACING IN-PERSON VISITS.
>> AND I DID WANT TO MENTION
THAT THERE'S SOME USE, PROBABLY
COULD BE MORE, OF
TELEREHABILITATION AND IT DOES
BRING REHAB TO THE AREA OF THE
PATIENT.
IT CERTAINLY EXTENDS
GEOGRAPHICALLY AND ALSO HOURS
PER WEEK THE NUMBER OF HOURS
SOMEONE CAN DO A MIX OF
MONITORED UNSUPERVISED AND
SUPERVISED THERAPY.
I AM STRUCK AND I'LL MAKE
SOMETHING THAT I'M GOING GO OF
TO GO WAY OUT ON A LIMB.
I'M STRUCK AS I AM WHEN I DEAL
WITH THE PRIVATE VECTOR, 95% OF
MEDICAL CARE, HOW OFTEN
REIMBURSEMENT OR LACK THEREOF
ENTERS INTO THE DISCUSSION AS A
DRIVER OR ENHANCER OF
DISPARITIES.
AND I HAVE TO SAY THAT WORKING
IN THE SYSTEM WHERE THERE'S MUCH
BAD ABOUT IT WE GET A DIRECT
APPROPRIATION FROM CONGRESS AND
HAVE CONTROL IN OUR BUDGETS
WITHIN STATUTORY RULES, DICTATES
OF CONGRESSIONAL COMMITTEES TO
LIKE TO FIND FAULT WITH WHAT WE
DO TO DECIDE WHAT WE VALUE, WHAT
WE WILL SUPPORT AND WHAT WE WILL
NOT.
AND I HAVE TO SAY THAT FROM A
SOCIETAL STANDPOINT, EQUITY
STANDPOINT, THERE ARE SOME GOOD
THINGS ABOUT THAT.
NOW, THAT'S AN EXTREMELY
CONTROVERSIAL STATEMENT BUT I
THINK TO SOME DEGREE WE'RE
DANCING AROUND THE ELEPHANT IN
THE ROOM.
SO I'M GOING TO LEAVE THAT
COMMENT AS SOMETHING THAT MAY
SPUR FURTHER DISCUSSION.
THANK YOU.
>> I WOULD ADD, GLENN, THERE ARE
INTERMEDIATE WAYS TO GO TOO.
>> OH, FOR SURE.
>> IT DOESN'T HAVE TO BE ALL ONE
WAY OR THE ANOTHER.
>> NOT AT ALL.
I'M NOT AN ADVOCATE PARTICULARLY
OF SINGLE PAYER SYSTEM.
I COULD SPEND AN HOUR TELLING
YOU GOOD THINGS ABOUT THE V.A.
AND SPEND THE NEXT HOUR TELLING
YOU THE BAD THINGS.
LIKE ALMOST ANY OTHER HUMAN
INSTITUTION.
SO I'M TRYING TO BE NUANCED.
BUT I DO THINK -- I'LL COME BACK
ON VIDEO FOR THIS ONE.
AS WE HAVE LAYERED MORE AND MORE
ON TOP OF AN ARCHAIC
REIMBURSEMENT AND SUPPORT MODEL
FOR HEALTH CARE IN THE UNITED
STATES, WE -- YOU KNOW, IT'S
HARDER AND HARDER TO MANAGE.
THE OLD CLICHÉ, WE SPEND MORE
THAN ANY OTHER COUNTRY, HAVE FAR
MORE PEOPLE THAT ARE NOT
TREATED, HEALTH OUTCOMES WITH
LONGEVITY AND INFANT MORTALITY
ARE MEDIOCRE COMPARED TO
DEVELOPED WORLD.
TO IGNORE THAT WE'RE DELUDING
OURSELVES IS WHAT I'M SAYING.
I'M HAPPY TO LISTEN TO THOSE WHO
I'M SURE MANY OF YOU WHO
VIOLENTLY DISAGREE WITH WHAT I
SAID BUT IT IS WORTHK.
I WANT TO WELCOME YOU BACK FROM
OUR 30-MINUTE BREAK.
SO, THIS NEXT BRIEF SESSION IS
GOING TO BE JUST AN INITIAL HIGH
LEVEL REPORTOUT OF ALL OF THE
BREAKOUT DISCUSSIONS THAT WE HAD
OVER THE COURSE OF TODAY, REALLY
MAJOR HIGHLIGHTS THAT I'M GOING
TO ASK OUR TASK FORCE LEADS TO
SHARE FROM ALL OF THE DIFFERENT
NOTES THAT THEY HAVE RECEIVED
FROM ALL OF OUR CONVERSATIONS.
AGAIN, TOMORROW THE FULL MEETING
RESUMES AT 11 A.M., AND THAT
WILL BE WHEN THEY DO PROVIDE A
MORE DETAILED REPORT-OUT AND
SUMMARY OF ANTICIPATED
DIRECTIONS THAT THEIR RESPECTIVE
REPORTS ARE GOING TO GO.
SO WITH THAT, I AM WATCHING MARK
GET RESET.
HE'S GOING TO PASS THE TORCH TO
FACILITATE THE NEXT 30 TO 40
MINUTES.
HE'S TRYING TO UNMUTE, I THINK.
>> TESTING 123, CAN YOU HEAR ME?
>> THERE YOU GO.
>> ALL RIGHT.
THANK YOU ALL.
I THINK WE HAD A GREAT SESSION
IN THE MORNING AND IN THE
AFTERNOON.
I HEARD A LOT OF UNIQUE
OPINIONS, UNIQUE PERSPECTIVES,
UNIQUE OPTIONS.
SO, THANK YOU ALL FOR YOUR HARD
WORK AND DILIGENCE AS WE ALL GET
BACK TOGETHER.
SO, WHAT WE WANTED TO DO IS JUST
HAVE A DISCUSSION FOR A LITTLE
WHILE ABOUT SOME OF THE TAKEHOME
POINTS THAT YOU ALL HAVE BROUGHT
OUT DURING THE BREAKOUT SESSIONS
THAT HAVE BEEN GOING ON ALL DAY.
SO, I'M GOING TO SEQUENCE IN THE
SAME ORDER THAT THE DAY EVOLVED
IN AND SAM AND HER COLLEAGUES
AND TRANSCRIBERS AND WRITERS AND
MYSELF ARE GOING TO TRY TO JOT
DOWN SOME OF THE KEY TAKEHOME
POINTS AND TAKEHOME MESSAGES,
AND SEE IF WE CAN SYNTHESIZE
SOME THINGS TOGETHER TO GET THE
MEETING KICKED OFF TOMORROW
WHICH, AS SAM SAID, WILL BE AT
11:00.
WE'LL HAVE FINAL DISCUSSION AND
WRAP-UP AND THE PURPOSE, WHAT
WE'RE TRYING TO ACCOMPLISH, IS
TO FIND SOME COMMON THEMES, SOME
TAKEHOME POINTS, SOME PATHWAYS
FORWARD THAT WE CAN THEN USE TO
SYNTHESIZE THE FINAL WRITTEN
REPORT THAT WILL BE WRITTEN OVER
THE NEXT WEEKS AND A FEW MONTHS.
I HOPE THAT MAKES SENSE.
I'M GOING TO TURN MY CAMERA
AROUND AND SEE IF I CAN -- I
CAN'T REORIENT MYSELF, BUT IT'S
OKAY.
SO, HOPEFULLY CAN YOU HEAR ME.
IF NOT, SEE ME.
WE HAVE 41 PARTICIPANTS.
AGAIN, WE'LL START WITH THE
BREAKOUT LEADS FOR EACH OF THE
SESSIONS, AND THEN ANYBODY CAN
PARTICIPATE.
WE'RE GOING TO THE PRE-HOSPITAL
REPORT-OUT, THE FIRST BREAKOUT
LEAD WAS ACTUALLY GEOGRAPHIC.
SO, UNLESS ERIKA AND CHARLES
WANT TO GIVE A GENERAL OVERVIEW
OF THAT SESSION WE CAN GO TO THE
BREAKOUTS.
BUT I'LL OPEN UP FOR ERIKA,
SORRY, COMMANDER ODOM, AND
CHARLES TO SEE IF THEY WANT TO
PROVIDE SOME SUMMARY FROM THAT
SESSION AND THEN WE'LL ASK THE
BREAKOUT LEADS, SOME OF WHOM ARE
THE SAME PEOPLE.
SO COMMANDER ODOM, DO YOU WANT
TO BEGIN?
YOU MIGHT BE MUTED.
I CAN'T HEAR YOU.
I DON'T KNOW IF THAT'S MY FAULT
OR YOURS.
I AM NOT HEARING YOU.
>> MARK, I CAN HEAR YOU BUT I
CAN'T HEAR COMMANDER ODOM.
ARE YOU ABLE TO HEAR ME?
>> I CAN HEAR YOU, CHAZ.
>> YOU CAN?
OKAY.
>> SHE'S MAYBE HAVING A
MICROPHONE PROBLEM.
IF YOU WANT, I'M HAPPY TO --
JUST KIND OF LOOKING AT THE
NOTES FROM THE BREAKOUT SESSION
FOR GEOGRAPHY ONE THING THAT WAS
TALKED ABOUT, JUST A GENERAL
COMMENT, ALL OF THESE BREAKOUT
SESSIONS, YOU KNOW, ALL THE ONES
I WAS PARTAKING IN HAD GREAT
CONVERSATION, THE CLOCK RAN OUT
ON EACH OF THEM.
BUT FOR SOME OF THE HIGHLIGHTS
THAT I SAW IN A SCRIPT TEMPLATES
SENT TO ME DISCUSSING
EDUCATIONAL BARRIERS FOR
PROVIDERS AND PATIENTS AND
UNDERSERVED AREAS.
EDUCATION BARRIERS FOR
PROVIDERS, I IMAGINE
INCORPORATION ESPECIALLY FOR
RURAL SETTINGS JUST THE LOWER
FREQUENCY BY WHICH PRE-HOSPITAL
PROVIDERS MAY HAVE ACTUAL STROKE
ALERTS AND, YOU KNOW, CONTRASTED
TO AN URBAN SETTING.
FOR INSTANCE SOME RURAL
COMMUNITY SETTINGS WITH
VOLUNTEER EMS MAY SEE NO MORE
THAN FIVE STROKE ALERTS IN A
SIX-MONTH TIME PERIOD, IN A CITY
SETTING THERE MAY BE 3,000
STROKE ALERTS PER YEAR.
EDUCATION AS WELL ON THE PART OF
PATIENTS IN THESE UNDERSERVED
AREAS CAN HAVE DIFFERENT AND
UNIQUE LOGISTICAL BARRIERS AND
CHALLENGES.
ANOTHER THING TO HIGHLIGHT FROM
THE GROUP WAS INCENTIVES FOR EMS
TO SPECIALIZE IN STROKE IF
POSSIBLE AND CERTAINLY, YOU
KNOW, TO GARNER THE
APPROPRIATE CERTIFICATIONS AND
PERFORMANCE MODULES FOR
PRE-HOSPITAL SCALES THAT EXIST
FOR PRE-HOSPITAL PROVIDERS.
ANOTHER CHALLENGE AS WELL KIND
OF UNIQUE TO THE RURAL SETTING
IS WITH REGARDS TO
AMBULANCE-BASED TELL MEDICINE.
THERE CAN BE IMPAIRED ACCESS TO
CELLULAR COVERAGE.
SO THAT'S ANOTHER BARRIER IN THE
RURAL SETTING THAT'S NOT PRESENT
IN URBAN SETTINGS REGARDING
CONNECTIVITY AND USING OTHER
THINGS TO ENABLE THE UTILIZATION
OF PRE-HOSPITAL TELEMEDICINE.
ANY OTHER PEOPLE WHO WERE IN
THAT BREAKOUT SESSION?
I DON'T KNOW IF THERE'S OTHER
POINTS TO ADD OR IF THERE WERE
THINGS I MISREPRESENTED, BUT
HAPPY TO HEAR ANYBODY ELSE'S
THOUGHTS.
>> CHAZ, IN THE GEOGRAPHY THING,
I HEARD A FEW COMMENTS ABOUT
REGIONALIZATION, LOOKING AT THE
EMS AND HEALTH CARE SYSTEM IN A
REGIONAL WAY, NOT NECESSARILY A
CITY OR A PARTICULAR STATE OR
SOMETHING LIKE THAT.
AND I THINK THAT HAS SOME
TRACTION BECAUSE I THINK WE NEED
TO LOOK AT OPPORTUNITIES TO
REMOVE ARTIFICIAL BARRIERS, AND
-- YOU KNOW, I USE STATE LINES
AS ARTIFICIAL BARRIERS.
I MEAN, THE STROKE DOESN'T CARE
WHETHER IT'S ON THIS OR THAT
SIDE OF THE STATE LINE.
WE NEED TO GET THE PATIENT TO
THE MOST APPROPRIATE CARE
FACILITY, WHETHER IT'S ON THIS
SIDE OR THAT SIDE OF THE STATE
LINE I THINK WE NEED TO DO A
BETTER JOB REGIONALIZING THESE
RESPONSE SYSTEMS, YOU KNOW, ALSO
SO THAT WE NEED TO, YOU KNOW,
OVERCOME ANY OF THESE
DISPARITIES BECAUSE LET'S BE
HONEST, SOMETIMES HAVE MORE
RESOURCES THAN OTHERS, AND I
VIEW THAT AS A DISPARITY.
BUT THAT SHOULDN'T BE A BARRIER
TO STATE-OF-THE-ART STROKE CARE.
ANY OTHER COMMENTS ABOUT
GEOGRAPHIC BARRIERS FOR EMS OR
OUT-OF-HOSPITAL CARE?
IF NOT, THE NEXT TOPIC I SEE IS,
AGAIN, THIS IS IN THE
PRE-HOSPITAL ARENA, SHERYL, IF
YOU WANT TO MAKE A FEW COMMENTS.
>> HELLO.
WE DIDN'T RECEIVE ANY
CORRECTIONS IN TERMS OF A GAP
TO CONSIDER.
WE DISCUSSED MOBILE STROKE UNITS
IN TERMS OF WHAT THE FUNDING
SOURCE SHOULD BE, WHO WOULD HAVE
CONTROL, WHO PARTICIPATES, HOW
TO PREVENT IT FROM BEING USED TO
INCREASE MARKET SHARE, AND HOW
MANAGEMENT COULD BE
COLLABORATIVE, THE GROUP WAS IN
AGREEMENT THAT MSUs SHOULD NOT
BE USED AS A STRATEGY TO
INCREASE MARKET SHARE TAKING
PATIENTS AWAY FROM CLOSER
APPROPRIATE FACILITIES TO THE
MOTHER SHIP.
USING SUCH A THING AS LIKE A
COMMUNICATION CENTER, AND
EMPLOYING A PROTOCOL, AND ALL
STATES SHOULD HAVE PROTOCOLS FOR
INITIAL DESTINATION, WHICH CAN
BE REGIONALIZED WHEN IT'S
APPROPRIATE, DIRECTING PATIENTS
TO THE CLOSEST APPROPRIATE
FACILITY BASED ON THEIR SYMPTOM,
TIME OF SYMPTOM DETECTION AND
SCREENING, CAN WE AGREE TO
STANDARDIZE EDUCATION FOR
PRE-HOSPITAL PROVIDERS AT
NATIONAL LEVEL.
IN ABSENCE OF THIS USING
TELESTROKE TO BRING A NEURALLIST
TO -- NEUROLOGIST TO THE BACK
OF THE AMBULANCE CAN IMPROVE
ACCURACY OF SCREENING TOOLS, AT
LEAST A TARGET FOR A RESEARCH
PROJECT TO PROVE THAT USING
TELESTROKE CAN INCREASE ACCURACY
OF SCREENING TOOLS TO
DISTINGUISH THOSE WHO DON'T HAVE
A LARGE VASCULAR OCCLUSION FROM
THOSE WHO MAY.
WE DISCUSSED PRE-HOSPITAL
REIMBURSEMENT AND HOW TO TIE IT
TO THE COMPLEXITY OF THE CARE
PROVIDED.
BY ADDING ADDITIONAL METRIC, WAS
GLUCOSE CHECKED, DID THE
PROTOCOL GET FOLLOWED, DID
PATIENT GO TO THE CLOSEST
APPROPRIATE FACILITY BASED ON
PROTOCOL, DID THEY REQUIRE A
SECONDARY TRANSFER, IF SO IS IT
POSSIBLE THAT SECONDARY TRANSFER
COULD HAVE BEEN AVOIDED?
WE DISCUSSED LINKAGE OF
PRE-HOSPITAL TO HOSPITAL DATA,
IT'S COMPLEX BECAUSE IF WE'RE
RELYING ON HOSPITALS TO SUBMIT
THAT DATA, THE HOSPITALS USUALLY
GO THROUGH A BAA TO GAIN ACCESS
TO THOSE PRE-HOSPITAL CARE
REPORTS FROM A SPECIFIC EMS
ENTITY AND MANY HOSPITALS
RECEIVE PATIENTS FROM MULTIPLE
EMS ENTITIES AND HOW MIGHT WE
MAKE IT SUCH THAT A LIMITED DATA
IS THE -- DATASET WOULD BE ABLE
TO BE SHARED WITH ANOTHER ENTITY
WITH THE AGGREGATED DATA FOR
THAT REGION OR STATE.
WE DISCUSSED PRE-HOSPITAL
EDUCATION, IDEALLY A NATIONAL
GROUP OF PEERS TO CREATE A
SYMPOSIUM POSTED ON A WEBSITE
SUCH THAT ANYONE AT ANY TIME IN
THE STATE WOULD BE ABLE TO GAIN
ACCESS TO THAT BUT THAT EACH
STATE OR REGION WOULD HAVE TO
HAVE LOCAL EDUCATORS FOR THE EMS
PRACTITIONERS SO THERE CAN BE
SOME INDIVIDUALIZATION IN THOSE
REGIONS.
WE COULD HAVE A COHESIVE
NATIONAL PLATFORM AND THEN HAVE
AN OPPORTUNITY AT THE END FOR
SOME INDIVIDUALIZATION TO BE
ADDED FOR THAT REGION OR STATE.
THAT'S THE GIST OF WHAT WE
DISCUSSED.
AND THEN WE RAN OUT OF TIME.
THE SESSION COULD HAVE GONE ON A
LOT LONGER BUT WE WERE OUT OF
TIME.
>> THANK YOU, SHERYL.
I ALSO RECALL YOU MAY HAVE
TOUCHED ON THIS BUT I THINK THIS
FITS UNDER PROBABLY POLICY,
MAYBE A LITTLE BIT ECONOMICS, IS
THAT THE NUMBER OF EMS PROVIDERS
HAS DECREASED SUBSTANTIALLY.
SO MAYBE THERE NEED TO BE SOME
POLICY CHANGES TO INCENTIVIZE
PEOPLE, MORE PEOPLE TO GO INTO
EMS, GET EMS TRAINING, NOT LEAVE
THE FIELD, I THINK THAT'S AN
OVERRIDING POLICY THING THAT I
HEARD IN SOME OF THE
DISCUSSIONS.
WOULD YOU AGREE WITH THAT?
>> I WOULD.
AND I'D SAY DURING THIS
EMERGENCY DECLARATION, AT LEAST
IN OUR STATE, BARRIERS WERE
MOVED AND ACTUALLY THE INSULT,
CALLING SOMEBODY AN AMBULANCE
DRIVER ALLOWED PEOPLE TO
BECOME AMBULANCE DRIVERS WITHOUT
BEING PARAMEDIC OR EMT, LOOKING
AT QUALITY OF CARE WHEN DELIVERY
DRIVER IS NOT AS HIGHLY
QUALIFIED AS MEDIC OR EMT.
>> YEAH, DON'T LET THE PERFECT
BE THE MEN OF -- ENEMY OF THE
GOOD.
THANK YOU FOR THAT REPORT.
COMMANDER ODOM, ECONOMIC ISSUES?
>> YES, SURE.
SOME OF THE OUTSTANDING
QUESTIONS OR GAPS, AS YOU
MENTIONED, RELATED TO EMS
PROVIDERS AND MANY OF THEM BEING
VOLUNTEER STAFF AROUND THE
COUNTRY, PARTICULARLY IN THOSE
RURAL AREAS, UNDERSTANDING HOW
STANDARDIZATION OF REIMBURSEMENT
FOR PROCEDURES THEY DO WITHIN
AMBULANCE, HOW THEY COULD BE
STANDARDIZED, THERE'S CURRENTLY
LITTLE TO NO REIMBURSEMENT
AROUND ISSUES OF STROKE BECAUSE
WE'RE PROCEDURE BASED.
THE NEED FOR A NATIONAL STROKE
REGISTRY TO IDENTIFY CONSISTENT
DATA ON DISPARITIES
S YSTEMATICICALLY, UNDERSTANDING
METRICS, IN TERMS OF COLLECTION
OF DATA.
AND THEN UNDERSTANDING
UNDERSTANDING UTILITY OF
TELESTROKE AND TELEMEDICINE, AT
DISPATCH AS WELL AS DISCHARGE,
PROVIDING EDUCATION TO PATIENTS
AT THEIR HOME.
THOSE WERE SOME GAPS TO
CONSIDER.
AND THEN SOME NEW BEST PRACTICES
AND SOLUTIONS TO CONSIDER
INCLUDED CONSIDER SUPPORTING
COMMUNITY EDUCATION VIA OTHER
TRUSTED MEMBERS OUTSIDE OF
PHYSICIANS, SO OTHER TRUSTED
MEMBERS OF SOCIETY INCLUDING
NURSES, PHARMACISTS, COMMUNITY
HEALTH WORKERS.
TESTING IMPLEMENTATION OF
VARIOUS EDUCATIONAL TOOLS,
COMMUNITY EDUCATIONAL TOOLS
THROUGH VARIOUS METHODOLOGIES,
AND DISSEMINATING THAT THROUGH
RESEARCH.
IDENTIFYING BARRIERS TO USE OF
911 INCLUDING MISTRUST OF LOCAL
AUTHORITIES, IMPACT OF RACE AND
RACIAL TENSIONS IN SOCIETY.
AND THAT IN CALLING EMS BEING A
PRIVATE ISSUE VERSUS WHAT YOUR
NEIGHBORS MAY KNOW.
AND THEN, AGAIN, THE ISSUE OF
INCENTIVIZING EVEN HIGH
SCHOOLERS TO GO INTO THE EMS
PROFESSION, HOW CAN WE ADD THAT
AS A SOLUTION TO INCREASED
DIVERSITY AMONG EMS.
PROFESSION.
>> THANK YOU, COMMANDER ODOM.
I JOTTED DOWN SOMETHING THAT
HADN'T OCCURRED TO ME BUT HAS
OCCURRED TO OTHER PEOPLE, THE
FACT WHEN PATIENTS CALL EMS THEY
GET A BILL FOR PROBABLY
THOUSANDS OF DOLLARS.
AND THAT MAY BE A BARRIER OR A
DISINCENTIVE, ESPECIALLY IF
THESE ARE DISADVANTAGED FOLKS OR
POPULATIONS WHO FRANKLY CAN'T
AFFORD IT.
SO I THINK THAT'S SOMETHING THAT
WE ALSO NEED TO INCLUDE IN THE
FINAL DOCUMENT TO REMOVE THE
FINANCIAL BARRIERS TO CALLING
EMS.
EVEN THOUGH IT MAY COST A FEW
THOUSAND DOLLARS UP FRONT, IF
THEY CAN GET TREATED AND THE
TREATMENT IS EFFECTIVE AND GETS
THEM BACK TO THEIR NORMAL STATE,
LONG TERM, YOU GET A LOT OF BANG
FOR THE BUCK.
SHORT TERM PEOPLE SEE THAT AS
UNWANTED EXPENSE, ESPECIALLY IN
CHALLENGED POPULATIONS WITH
LIMITED FINANCES.
OKAY.
THANK YOU.
NEXT IN TERMS OF DEMOGRAPHICS,
CHARLES, DO YOU WANT TO DO THAT?
>> SURE.
HAPPY TO.
AND THAT POINT THAT YOU RAISED
ABOUT JUST THE COST OF EMS,
YOU'RE ABSOLUTELY RIGHT.
I MEAN, IT'S FOUR DIGITS.
AND CERTAINLY SOMETHING TO
INCORPORATE.
FOR THE DEMOGRAPHIC JUST GOING
THROUGH THE HIGHLIGHTS OF THINGS
THAT WE DISCUSSED IN OUR
CONVERSATION, WE TALKED ABOUT
UTILIZING MULTIPLE COMPONENTS OF
THE STROKE SYSTEM TO PERFORM
COMMUNITY ENGAGEMENT AND
EDUCATION, HOSPITAL STAFF,
EMERGENCY PHYSICIANS, STROKE
TEAMS, EMS, RECOGNIZING THERE
ARE DIFFERENT BARRIERS AND
STRAINS ON DISCIPLINES,
DIFFERENT SETTINGS.
SECOND CONSIDERING
IDENTIFICATION ANT UTILIZATION
OF COMMUNITY CHAMPIONS TO WORK
WITH STROKE CENTERS, TO
COMPLEMENT AND ENHANCE STROKE
EDUCATION IN TERMS OF
IDENTIFICATION, PREVENTION, NINE
ONE ONE UTILIZATION, A BRIDGE
FOR THE BIDIRECTIONAL
COMMUNICATION THAT'S NECESSARY
TO ENGAGE COMMUNITIES.
NEXT WAS THE TRANSLATION OF KEY
STROKE EDUCATIONAL RESOURCES
INTO MOST PREVALENT LANGUAGES,
SPOKEN BY A PARTICULAR
COMMUNITY.
JUST AUGMENTATION OF STROKE
SYSTEM INTERACTION WITH
NON-ENGLISH SPEAKING
POPULATIONS, CORY GAVE THE
EXAMPLE OF CREATING
MULTI-LINGUAL STROKE RESOURCES
FOR DIFFERENT POPULATIONS.
NEXT WAS THE FURTHER
INCORPORATION OF CULTURAL AND
DEMOGRAPHIC COMPETENCY TRAINING,
AND ANNUAL ONGOING EMS EDUCATION
AND EMS PRE-CERTIFICATION
PROGRAMS FOR SEX, GENDER, RACE,
ECONOMIC DISPARITY SO THEY MAY
BE EMPOWERED WITH KNOWLEDGE AND
THUS BE ABLE TO BETTER SERVE
WHATEVER COMMUNITY THEY END UP
WORKING IN.
AND THEN THERE WAS A LITTLE TALK
AS WELL ABOUT BUILDING FURTHER
UPON CURRENT NIH INITIATIVES
WITH SPECIFIC FOCUS ON STROKE,
PERFORMING RESEARCH INTO
DISPARITIES FOR EDUCATION,
ACCESS TO SYSTEM FOR LGBTQ
POPULATION WITH AIMS OF
UNDERSTANDS UNIQUE BARRIERS THAT
THEY EXPERIENCE AND CHALLENGES
FOR ACCESS AND TREATMENT.
IF ANYBODY ELSE IN OUR BREAKOUT
GROUP OF HAS ANY OTHER THINGS TO
ADD, CERTAINLY WELCOME AT THIS
TIME.
>> JUST LOOKING IN THE CHAT BOX
TO SEE IF THERE'S ANY COMMENTS.
OKAY.
I THINK WE'RE GOOD WITH THAT.
SO WE'RE GOING TO THANK YOU,
EVERYBODY, FOR THOSE REPORTS.
WE'RE GOING TO MOVE NOW TO THE
HYPER ACUTE AND ACUTE CARE,
WE'RE GOING TO GET COMMENTS,
FEEDBACK FROM THE TASK FORCE
LEADS.
I THINK THAT WOULD BE MORE
EFFICIENT THAN GOING FOR ALL THE
BREAKOUTS BUT, AGAIN, EVERYBODY
IN THE BREAKOUTS IS WELCOME TO
PROVIDE COMMENTS AND STUFF.
SO IN TERMS OF THE HYPER ACUTE
REPORTS, AMEER OR MARY.
>> I'LL START.
IN TERMS OF GEOGRAPHY ONE OF THE
THINGS WE DISCUSSED WAS THE IDEA
OF A MOBLING INTERVENTION --
MOBILE INTERVENTION TEAM TO
SUPPORT REGIONAL ACTRESS TO
THROMBECTOMY AND REDUCE
TRANSFERS.
OBVIOUSLY THIS IS GOING TO
REQUIRE TRAINING AND IS GOING TO
REQUIRE MAKING SURE THAT THE
HOSPITALS THAT HAVE CARDIAC CATH
SUITES HAVE THE ABILITY ALSO TO
STAFF THEM IN CASE YOU NEED
TO -- IN CASE YOU HAVE AN
OPERATOR GOING TO THE TEAM, YOU
NEED TO HAVE TECHNOLOGY STAFF
AND NURSING STAFF AVAILABLE,
WILLING TO DO IT.
WE ALSO TOUCHED ON THE
POSSIBILITY OF ULTIMATELY GOING
TO ROBOTIC INSTRUMENTATION LIKE
THEY ARE DOING IN SOME CORONARY
CASES WHERE THE OPERATOR DOESN'T
EVEN NEED TO BE AT THE HOSPITAL,
CAN ACTUALLY COME IN, USING
TELEMEDICINE AND PERFORM THE
PROCEDURE ROBOTICALLY.
THAT'S IN THE FUTURE.
BUT THERE ARE SOME CASES, BRAIN
CASES, THAT HAVE BEEN DONE,
ANEURYSM CASES, FROM A CARDIAC
STANDPOINT.
WE ALSO TOUCHED ON THE STUDENT
LOAN REPAYMENT PLAN, IN ORDER TO
EXTEND -- TRY AND GET MORE
STROKE NEUROLOGISTS TO GO INTO
AREAS THAT ARE HEALTH CARE, YOU
KNOW, DESERTS.
THAT WAS A GOOD IDEA AND
CERTAINLY WORTH PURSUING
FURTHER.
THE OTHER IDEA THAT CAME OUT OF
THAT TOO SINCE WE TOUCHED UPON
THE FACT THAT THERE'S ISSUES
WITH THE EMERGENCY MEDICINE
PHYSICIANS, PERHAPS NOT BEING
COMFORTABLE WITH STROKE WAS TO
ACTUALLY DEVELOP A GROUP OF
HEALTH CARE PROFESSIONALS SUCH
AS P.A.s OR NPS TRAINED IN
STROKE TO HELP SUPPORT THAT
MISSION IN THE E.D., TO IDENTIFY
AND TAKE CARE OF THOSE PATIENTS.
WE ALSO TALKED ABOUT THE FACT
THAT WE REALLY NEED RESEARCH IN
THIS AREA.
AND IT WAS INTERESTING YOUR
REMARK, MARK, THAT THE PROPOSALS
THAT ARE MADE TO STROKE NET
OFTEN GET VERY LOW SCORES SO
THEY DON'T GET FUNDED.
SO WE FEEL LIKE THERE NEEDS TO
BE A WAY TO GET THOSE SORT OF
STUDIES FUNDED SO WE CAN GET THE
RESEARCH THAT WE NEED AND MAYBE
THERE NEEDS TO BE A SEPARATE
GROUP OF FUNDING FOR THOSE SORT
OF PROPOSALS OUTSIDE OF SORT OF
THE OVERALL STROKENET FUNDING
THAT'S THERE.
I WAS IN THE GEOGRAPHY BREAKOUT
SESSION, WE TALKED ABOUT THOSE
THREE THINGS IN OUR HALF HOUR.
ONE THING WE TALKED ABOUT TOO
WAS ISSUES WITH THE STROKE --
HUB AND SPOKE MODEL, THE FACT
THAT PLACES WILL BE BYPASSED,
THE MOTHERSHIP PATHWAY, WE
NEEDED TO WORK ON BEING ABLE TO
SEND THE PATIENT TO THE
APPROPRIATE AND CLOSEST SITE
REGARDLESS OF WHETHER OR NOT
THEY ARE IN THE SAME HEALTH CARE
SYSTEM.
AND HOW DO YOU DO THAT WITH
REQUIRING THE COMMAND CENTER
THAT CAN ACTUALLY SEND THE
PATIENT TO THE APPROPRIATE
LOCATION.
SO THOSE WERE THE MAJOR THINGS
THAT I GOT OUT OF MY POLICY
REGULATION AND GEOGRAPHY GROUP.
PERSONA, WHAT DID YOU TALK IN
YOUR GROUP WITH ECONOMICS AND
DEMOGRAPHICS?
>> YEAH, WE DISCUSSED ABOUT
THREE THINGS, MAINLY TELESTROKE
AND ADAPTATION.
THE TELESTROKE AND THE RURAL
COMMUNITIES, LIKE FINANCIAL AND
SO MANY HURDLES, WE WERE
DISCUSSING CHANGING THE POLICY,
REIMBURSEMENT, HOW WE CAN
REIMBURSE, THOSE ARE SOME OF THE
THINGS THAT WE DISCUSSED IN THE
TELESTROKE ADAPTATION.
AND THE SECOND THING WE
DISCUSSED, HOW WE CAN INCREASE
AVAILABILITY OF THE VASCULAR
NEUROLOGIST AND INTERVENTIONAL
NEUROLOGIST.
I THINK RAFAEL WAS THERE.
HE WAS DISCUSSING.
THERE ARE, YOU KNOW, TWO STROKE
NEUROLOGISTS FOR THE ENTIRE
TERRITORY.
SO SOME OF THE THINGS WE
MENTIONED IN OUR INVESTIGATION
IN THE REPORT THAT LOAN
REPAYMENT PROGRAM AND, YOU KNOW,
GREEN CARD, THAT WAY WE CAN
ATTRACT PEOPLE WHO ARE WILLING
TO COME TO THE UNDERSERVED AREAS
AND ARE WILLING TO SERVE THERE.
AND OTHER THING, THE THIRD
CROSS-CUTTING THEME WE DISCUSSED
PROVIDING EDUCATIONAL
OPPORTUNITIES, SO EVEN THOUGH WE
HAVE TELEMEDICINE, PEOPLE SHOULD
COME TO THE HOSPITAL.
SO HOW DO WE EDUCATE THEM?
AND ALSO EVEN IN SOME HOSPITALS,
WHERE THERE ARE NO NEUROLOGISTS
OR STROKE NEUROLOGISTS, HOW TO
EDUCATE THE E.R. PHYSICIANS AND
WHAT IS THE VARIOUS TEAMS TO
EDUCATE AND FUND.
WE DISCUSSED ABOUT THAT.
SO THOSE ARE THE THREE THINGS WE
DISCUSSED.
THANK YOU.
AND SHERYL, DID YOU HAVE
SOMETHING YOU WANTED TO ADD TOO?
>> I JUST MENTIONED WE WERE
TALKING ABOUT TRYING TO BRING
RESEARCH TO COMMUNITIES, IF
THERE WAS A PROOF OF CONCEPT
FUNDING FOR RURAL COORDINATORS
THAT COULD GO INTO A DESIGNATED
AREA THAT PERHAPS HAS A COUPLE
PSCs, BUT MORE RURAL WITH
BENCHMARKS FOR WHAT WOULD BE
CONSIDERED SUCCESS IN TERMS OF
ENROLLMENT AND CLINICAL TRIALS.
>> EXCELLENT.
THANK YOU ALL VERY MUCH.
WE'RE GOING MOVE ALONG NOW JUST
FOR THE SAKE OF TIME AND GET A
HARD STOP AT 4:53 FOR WALTER.
IN TERMS OF THE INPATIENT
REPORT-OUT I'M GOING TO ASK
KAREN AND LARRY TO GIVE A
SUMMARY AS THE LEADS AND WE'RE
NOT GOING TO DO THE INDIVIDUAL
BREAKOUTS BECAUSE I THINK WE
HAVE IDENTIFIED A FEW COMMON
THEMES.
BUT KAREN AND LARRY, YOU JUST
WANT TO GIVE A TOP LEVEL
REPORTOUT FROM YOUR IN-HOSPITAL
GROUP?
>> SURE.
>> YOU'RE MUTED.
>> I DON'T KNOW IF KAREN IS ON.
>> THANK YOU.
SORRY ABOUT THAT.
SO, THERE WERE A COUPLE AREAS
THAT OVERLAPPED ACROSS THE
VARIOUS BREAKOUTS.
ONE WAS TELEMEDICINE,
TELENEUROLOGY.
AND PARTICULARLY AROUND
TELEREHABILITATION AND THE
POST-ACUTE PHASE OF STROKE
RECOVERY.
THE OTHER AREA OF OVERLAP THAT I
SAW ACROSS ALL OF THE BREAKOUTS
HAD TO DO WITH COST AND HOW
INEQUITIES IN INSURANCE COVERAGE
DICTATED THE POST-ACUTE PHASE OF
RECOVERY.
AND SO THERE WAS WORK TO BE DONE
THERE.
WITH REGARD TO INTERACTION WITH
OTHER AREAS, THE DEFINITIONS OF
SOCIAL DETERMINANTS OF HEALTH
NEED TO BE STANDARDIZED.
AND IN ORDER TO MOVE FORWARD WE
NEED TO UNDERSTAND IN A
SYSTEMATIC WAY HOW PATIENTS
IDENTIFY THEMSELVES BY RACE, AND
SEX, AND ETHNICITY, SO WE CAN
MAKE ANY SENSE OF THE DATA
COMING FORWARD.
LARRY?
>> I'LL JUST ADD A COUPLE POINTS
THAT WERE PARTICULAR TO THE
POLICY AND REGULATIONS SUBGROUP.
I THINK THEY HAVE IMPLICATIONS
ACROSS ALL THESE BREAKOUTS.
SO, A COUPLE THINGS WE TALKED
ABOUT ARE THIS.
THAT FIRST OF ALL, WHAT WOULD BE
HELPFUL WOULD BE TO CREATE A
STANDARD OF CARE THAT COULD
CROSS HOSPITALS PARTICULARLY
WITH A SPOKE SYSTEM TO HUB
HOSPITALS TO SMALL RURAL AND
COMMUNITY HOSPITALS, TO -- AND
WE TALKED ABOUT WAYS THAT WE
COULD DO THAT.
FOR EXAMPLE, SHARING ORDER SETS
AND STROKE PATHWAYS FROM THE,
YOU KNOW, STROKE CENTERS TO THE
COMMUNITY HOSPITALS, THE RURAL
HOSPITALS, WHERE THEY DON'T HAVE
THE STROKE EXPERTISE, JUST
HAVING THOSE KINDS OF PATHWAYS
AND ORDER SETS TO PLACE THEIR
PATIENTS ON ONCE THEY GET INTO
THE HOSPITAL MIGHT HELP REDUCE
DISPARITIES.
OF COURSE AGAIN THERE'S A LOT OF
STUFFEDY STUFFED -- STUDY TO
FIND WHAT THE DISPARITIES ARE,
AS WE POINTED OUT EARLIER, BUT
WE THOUGHT THAT WOULD BE ONE WAY
TO ADDRESS THIS.
AND THAT COULD BE SUPPLEMENTED
BY TELEHEALTH WHICH SEEMS TO
KEEP COMING UP, BUT TO HAVE THE
PEOPLE WITH STROKE EXPERTISE NOT
ONLY IN THE EMERGENCY ROOM
MAKING DECISIONS ABOUT
REPERFUSION THERAPY BUT ALSO
SEEING THE PATIENTS WHEN THEY
ARE IN THE HOSPITAL TO DECIDE ON
WORKUP AND LOOK AT THE RESULTS
OF THAT WORKUP AND DECIDE ON --
MAKE DECISIONS ABOUT SECONDARY
STROKE PREVENTION WOULD HELP
CREATE A STANDARD OF CARE THAT
WENT BEYOND THE ACUTE CARE
HOSPITAL OR THE HUB HOSPITAL,
AND PERHAPS WOULD PREVENT
PATIENTS FROM HAVING TO BE
TRANSFERRED IN TO A HUB
HOSPITAL.
THEY COULD STAY IN THEIR
COMMUNITY WHICH THEY MUCH PREFER
AND STILL GET THE SAME LEVEL OF
CARE FROM THE STROKE EXPERTS.
SO THAT WAS ONE SUGGESTION.
THE OTHER WAS I THOUGHT A VERY
GOOD ONE WHERE WE TALK ABOUT
REGULATIONS FROM THE STATE AND
FROM THE FEDERAL GOVERNMENT IN
TERMS OF CREATING -- REDUCING
DISPARITIES, CREATING STANDARD
OF CARE
WHAT ABOUT JACO?
ALL THE HOSPITALS ARE DEPENDENT
UPON JACO FOR OVERALL
CERTIFICATION AND STROKE
CERTIFICATION AND TO WHAT EXTENT
DO THEY LOOK AT DISPARITIES AND
WHAT INFORMATION DOES JACO
REQUIRE HOSPITALS TO COLLECT
THAT COULD HELP US DECIDE ON
WHETHER DISPARITIES EXIST AND IF
SO HOW TO REDUCE THEM.
SO I THINK THAT WAS -- I THINK
THAT WAS QUITE A GOOD SUGGESTION
OF SOMETHING I HADN'T CONSIDERED
BEFORE.
AND THEN FINALLY LIKE KAREN
SUGGESTED, WE TALKED ABOUT COST
AND REIMBURSEMENT AND HOW THAT
AFFECTS IN-HOSPITAL CARE, AND
CERTAINLY THAT HAS A SIGNIFICANT
IMPLICATION FOR IN-HOSPITAL CARE
AS IT DOES ACROSS THE BOARD.
>> VERY GOOD.
THANK YOU, LARRY.
ANY OTHER COMMENTS FROM ANYBODY
ELSE ON THE CALL, PARTICIPANTS,
BREAKOUT LEADERS, ANY MAJOR
POINTS YOU FEEL WERE NOT
ADEQUATELY TOUCHED UPON?
AGAIN WE'RE GOING TO SYNTHESIZE
INTO A SUMMARY DOCUMENT AND
WRITTEN DOCUMENT OVER THE NEXT
FEW DAYS AND WEEKS.
>> I JUST WANT TO SHARE ANOTHER
SUBGROUP WE DISCUSSED ABOUT, YOU
KNOW, ONCE THE PATIENT IS IN THE
HYPER ACUTE PHASE AND COMES TO
THE HOSPITAL, AND FROM HOSPITAL,
ONCE THEY GET DISCHARGED, AND
SHERYL AND WE WERE ALL
DISCUSSING, YOU KNOW, IT'S A
BLACK BOX.
NOBODY, LIKE THE DATA AND
INFORMATION IS LIMITED, MAYBE
NEXT YEAR WE CAN INCLUDE
POST-HOSPITAL GROUP, THAT'S ONE
THING WE DISCUSSED.
>> YEAH, THAT'S AN EXCELLENT
POINT.
TRADITIONALLY THE BRAIN ATTACK
COALITION HAS BEEN FRONT LOADED
LOOKING AT THE HYPER ACUTE CARE
PARADIGMS, LESS SO FOR POST
DISCHARGE CARE, A VERY IMPORTANT
PART OF THE CARE EPOCH.
WE DIDN'T HAVE THE BAND WIDTH TO
TAKE THIS ON FOR THIS INITIAL
MEETING BUT I AGREE.
WE CAN HOPEFULLY DO THIS AGAIN
NEXT YEAR AND INCLUDE THE
POST-ACUTE CARE LIKE REHAB, MORE
ABOUT COMMUNITY CARE, SECONDARY
PREVENTION.
THANK YOU ALL VERY MUCH.
ANY OTHER COMMENTS BEFORE WE GO
TO WALTER?
IF NOT, GREG, DO YOU WANT TO
SWITCH TO WALTER'S COMMENTS AT
THIS POINT?
CAN YOU DO THAT?
>> HELLO, I'M WALTER KOROSHETZ,
DIRECTOR OF THE NATIONAL
INSTITUTE OF NEUROLOGICAL
DISORDERS AND STROKE.
ON BEHALF OF THE INSTITUTES AND
THE 16 MEMBERS OF THE BRAIN
ATTACK COALITION I WANT TO
WELCOME EVERYONE AND THANK YOU
FOR YOUR WORK ON THIS REALLY
IMPORTANT SYMPOSIUM ON ACCESS TO
ACUTE STROKE CARE AND THIS IS
SOMETHING THAT A NUMBER OF US
HAVE BEEN WORKING ON FOR THE
PAST 30+ YEARS.
I REMEMBER IN THE BEGINNING A
GROUP GOT TOGETHER TO TRY TO
IMPROVE ACCESS TO EMERGENCY
NEUROSURGERY FOR PEOPLE WITH
INTERCEREBRAL HEMORRHAGE AND
SUBARACHNOID HEMORRHAGE, BUT
THINGS HAVE CHANGED DRAMATICALLY
OVER THE LAST 30 YEARS.
INITIALLY THERE WAS THE
DISCOVERY THAT ACUTE TREATMENT
WITHIN THREE HOURS WITH
INTRAVENOUS THROMBOLYSIS DRUGS
CAN IMPROVE YOUR CHANCE OF
RECOVERY AFTER A STROKE.
THAT LAID ON TOP OF THE
IMPORTANCE OF HAVING ANEURYSMS
TREATED, SHOULD THEY HAVE HAVE
ONE, AND PATIENTS SURVIVE.
THE NEXT AMAZING RESULT OCCURRED
MORE RECENTLY AFTER NUMEROUS
INDUSTRY-SPONSORED TRIALS SHOWED
THAT REMOVING LOT WITH DEVICES
FROM LARGE ARTERIES IN THE
BRAIN, IF DONE BEFORE THE BRAIN
TISSUE HAD A CHANCE TO DIE,
COULD ALSO LEAD TO A DRAMATIC
EFFECT SIZE IN A PERSON'S CHANCE
OF RECOVERING FUNCTION AFTER
WHAT WOULD OTHERWISE BE A
DEVASTATING STROKE.
THROUGHOUT THE PROCESS THE STORY
IS THE SAME, WE IDENTIFY WAYS OF
TREATMENT AND THEN WE TRY TO
MAKE THOSE TREATMENTS ACCESSIBLE
THROUGHOUT THE COUNTRY.
AND THAT'S THE SITUATION THAT
WE'D LIKE TO DISCUSS TODAY,
BECAUSE DESPITE THE ADVANCES,
THERE ARE STILL TREMENDOUS
INEQUITIES, AND IT JUST SEEMS
UNFAIR THAT THE FATE OF YOUR
BRAIN WHEN YOU'RE HAVING A
STROKE DEPENDS UPON WHERE YOU
LIVE.
AND SO HOW TO MAKE THESE
TREATMENTS, WHICH ARE REALLY
DRAMATICALLY BRAIN SAVING IF NOT
LIFE SAVING, CERTAINLY SAVING
QUALITY OF LIFE, HOW TO MAKE
THEM ACCESSIBLE TO EVERYONE,
DESPITE WHERE THEY LIVE.
OF COURSE, NEEDLESS TO SAY, THE
ISSUE THAT'S RIGHT ON FRONT IS
THAT FOR THESE TREATMENTS TO
WORK THEY HAVE TO BE DELIVERED
VERY, VERY QUICKLY.
FOR SUBARACHNOID HEMORRHAGE
TREAT THE ANEURYSM BEFORE
THERE'S A REBLEED.
THROMBOLYSIS WE KNOW THE
TREATMENT EFFECT DISSIPATES
WITHIN MINUTES.
AND THEN STARTS TO DISSIPATE
WITHIN MINUTES, SEEMINGLY GONE
FOUR OR FIVE HOURS AFTERWARDS.
WITH INTRAARTERIALA THROMBOLYSIS
WE HAVE BETTER ABILITY USING
IMAGE TO IDENTIFY WHICH PATIENTS
CAN PROFIT BY THE TREATMENT OVER
MULTIPLE HOURS BUT STILL THE
MESSAGE IS ALWAYS THAT TO REDUCE
THE AMOUNT OF BRAIN DAMAGE, THE
EARLIER THE TREATMENT IS GIVEN,
THE BETTER THE RESULT IS GOING
TO BE.
SO THE REAL EMPHASIS IS ON
ACUTELY IDENTIFYING THESE
CONDITIONS, GETTING THE
EMERGENCY RESPONSE SYSTEMS
ALERTED AND GETTING TO THE
PATIENT AS FAST AS POSSIBLE.
THERE WILL BE DISCUSSION ABOUT
THE PRE-HOSPITAL SYSTEMS AND HOW
THEY CAN BE IMPROVED TO MAKE
ACCESS MORE EQUITABLE.
AND IN SOME RURAL COUNTRIES THIS
REQUIRES HELICOPTERS, MOST
OTHERS IT REQUIRES AMBULANCE
SERVICES.
SOMETIMES IN A FOG OFF MARTHA'S
VINEYARD IT REQUIRES A FIXED
WING PLANE TO GET PATIENTS IN.
BUT THE IMPORTANCE OF SAVING
SOMEONE'S BRAIN FROM THESE
MASSIVE STROKES REALLY SHOULD
MOTIVATE EVERYONE TO DO WHATEVER
IT TAKES TO ENABLE ACCESS TO
THESE TREATMENTS.
AND IT'S CLEARLY NOT EASY
DEPENDING UPON THE ENVIRONMENT
IN WHICH YOU LIVE BUT THAT'S THE
GOAL, IS TO TRY TO GET THOSE
EMERGENCY RESPONSE FOLKS OUT, TO
GET THE PATIENTS TO THE
TREATMENT AS FAST AS POSSIBLE,
AND THEN TO GET THEM TO PLACES
WHERE THE TREATMENT IS
AVAILABLE, THE SKILLED
NEUROSURGEONS OR
NEUROINTERVENTIONALLISTS THAT
CAN TREAT THE PATIENT, AND THEN
FOLLOWING THAT WE'VE MADE
TREMENDOUS STRIDES IN CARE OF
THE STROKE PATIENT IN THE
HOSPITAL, THIS WAS DRIVEN
HEAVILY BY THE BENEFIT OF THE
ACUTE TREATMENTS BUT THAT HELPS
WHO HAS A STROKE WHETHER THEY
GET ACUTE TREATMENT OR NOT ARE
GUIDELINES FOR HOSPITAL CARE YOU
NO, THOSE ARE THE THREE MAIN
AIMS OF THE DISCUSSION TODAY.
I KNOW THERE ARE ALL WAYS WE CAN
DO BETTER.
WE NEED TO KEEP OUR EYE ON THE
GOAL AND NEVER BE SATISFIED
UNTIL WE REACH THAT GOAL, WHERE
WHAT HAPPENS TO YOU REALLY DOES
NOT DEPEND ON WHERE YOU LIVE
ANYMORE.
THANKS VERY MUCH.
LOOK FORWARD TO HEARING ABOUT
THE SYMPOSIUM.
>> THANK YOU, DR. KOROSHETZ, FOR
YOUR GUIDANCE AND WISDOM AND
SUPPORT.
I'M SURE WE'LL BE TALKING AGAIN
IN THE FUTURE, WHEN PRODUCE THE
PROCEEDINGS AND HOPEFULLY CAN
GENERATE SOME STRONG
HYPOTHESIS-DRIVEN RESEARCH
PROJECTS THAT YOU AND NINDS AND
NIH ALMOST SUPPORT AND FIND IN
THE FUTURE TO HELP FURTHER
ADVANCE STROKE CARE.
WITH THAT, LOOKS LIKE WE'RE
RIGHT ON TIME.
AND JUST WANT TO TAKE THIS
OPPORTUNITY TO THANK DR. BENSON,
MY CO-CHAIR, SAM AND ANDREA FROM
NINDS, GREG FROM THE LOGISTICS
SERVICES, ESPECIALLY ALL OF YOU
FOR SHARING YOUR TIME, YOUR
WISDOM, YOUR EXPERTISE, AS WE
PUT TOGETHER THIS SYMPOSIUM AND
SYNTHESIZE IDEAS AND WE SHARE
YOUR CONTRIBUTIONS FOR THIS
PROJECT, FOR REDUCING LACK OF
EQUITY AND EQUALITY AND
ADDRESSING DISPARITIES AND
ACCESS TO ACUTE STROKE CARE AND
STROKE TREATMENTS.
YOUR INSIGHTS AND WISDOM AND
EXPERIENCE, EXPERIENCES, WE'RE
GRATEFUL FOR YOU SHARING THAT.
TOMORROW WE'LL BEGIN AT 11 A.M.
AND WE'RE GOING TO HAVE MORE
DISCUSSIONS ABOUT SOME COMMON
THEMES.
WE'LL WORK HARD TO ADDRESS THIS
AND HAVE THE ROBUST DISCUSSION
TOMORROW.
AND WE'LL USE THAT AS THE
LAUNCHING POINT FOR DOING EDITS
FOR THE FINAL SUMMARY DOCUMENT.
THIS IS OUR AGENDA FOR DAY 2.
AS YOU CAN SEE THERE, SYNTHESIS
OF THE DIALOGUE, CONFIRMATION,
CORRECTION, GENERATING NEW
IDEAS.
THEN FOLLOWED BY DISCUSSION AND
SYMPOSIUM WRAP-UP.
I PROMISE WE'LL ADJOURN AT 1
P.M. EASTERN TIME.
GREG OR SAM, OR DR. BENSON, DO
YOU WANT TO SAY ANYTHING ELSE IN
SUMMARY OR IN CONCLUSION?
>> NO.
HAVE A GOOD EVENING, EVERYONE.