1 00:00:05,640 --> 00:00:08,080 >>I'M SHANNON ZENK, DIRECTOR OF 2 00:00:08,080 --> 00:00:09,640 THE NATIONAL INSTITUTE OF 3 00:00:09,640 --> 00:00:11,920 NURSING RESEARCH. 4 00:00:11,920 --> 00:00:12,200 WELCOME. 5 00:00:12,200 --> 00:00:15,520 THANK YOU FOR JOINING US THIS 6 00:00:15,520 --> 00:00:16,840 EVENING, AND I CERTAINLY HOPE 7 00:00:16,840 --> 00:00:17,920 EVERYONE WILL BE ABLE TO JOIN US 8 00:00:17,920 --> 00:00:21,800 TOMORROW MORNING AS WELL. 9 00:00:21,800 --> 00:00:25,440 SO IT TRULY IS A PLEASURE TO 10 00:00:25,440 --> 00:00:27,040 WELCOME YOU TO THE 2022 NATIONAL 11 00:00:27,040 --> 00:00:30,280 NURSING RESEARCH ROUNDTABLE 12 00:00:30,280 --> 00:00:31,040 PROGRAM. 13 00:00:31,040 --> 00:00:32,120 FROM CONTEXT TO CARE, 14 00:00:32,120 --> 00:00:34,520 UNDERSTANDING THE CONVERGENCE OF 15 00:00:34,520 --> 00:00:35,440 SOCIAL FACTORS AND EMERGENCY 16 00:00:35,440 --> 00:00:38,080 DEPARTMENT CARE. 17 00:00:38,080 --> 00:00:40,160 I WANT TO THANK THE EMERGENCY 18 00:00:40,160 --> 00:00:42,600 NURSES ASSOCIATION FOR 19 00:00:42,600 --> 00:00:43,560 CO-SPONSORING THIS YEAR'S 20 00:00:43,560 --> 00:00:45,920 ROUNDTABLE WITH US AT NINR, AND 21 00:00:45,920 --> 00:00:48,160 THANK YOU FOR YOUR WILLINGNESS 22 00:00:48,160 --> 00:00:50,600 TO BE PART OF THIS IMPORTANT 23 00:00:50,600 --> 00:00:52,320 CONVERSATION ABOUT SOCIAL 24 00:00:52,320 --> 00:00:53,840 FACTORS AND HEALTH, MANY OF 25 00:00:53,840 --> 00:00:56,040 WHICH, AS WE KNOW, CONVERGE IN 26 00:00:56,040 --> 00:00:58,360 OUR NATION'S EMERGENCY SERVICES. 27 00:00:58,360 --> 00:01:00,680 AND I WANT TO ACKNOWLEDGE 28 00:01:00,680 --> 00:01:02,840 EVERYONE ON THE PLANNING 29 00:01:02,840 --> 00:01:05,680 COMMITTEE, FROM ENA AS WELL AS 30 00:01:05,680 --> 00:01:07,520 NINR, TO THE MANY INDIVIDUALS 31 00:01:07,520 --> 00:01:08,880 WHO HAVE WORKED TIRELESSLY TO 32 00:01:08,880 --> 00:01:10,040 BRING THIS YEAR'S EXCITING 33 00:01:10,040 --> 00:01:13,360 PROGRAM TO FRUITION, PLEASE DO 34 00:01:13,360 --> 00:01:14,240 KNOW HOW MUCH WE APPRECIATE YOUR 35 00:01:14,240 --> 00:01:15,880 EFFORTS. 36 00:01:15,880 --> 00:01:17,720 WE DON'T HAVE TIME UNFORTUNATELY 37 00:01:17,720 --> 00:01:19,480 TO ACKNOWLEDGE EVERYONE ON THE 38 00:01:19,480 --> 00:01:22,160 PLANNING COMMITTEE BY NAME, BUT 39 00:01:22,160 --> 00:01:24,320 I DO WANT TO TAKE A MOMENT TO 40 00:01:24,320 --> 00:01:26,960 THANK DR. LISA WOLF, THE ENR 41 00:01:26,960 --> 00:01:29,240 DIRECTOR FOR ALL HER EFFORTS AND 42 00:01:29,240 --> 00:01:32,240 ALSO TO THANK DR. TANIA STROUT 43 00:01:32,240 --> 00:01:36,560 FOR HER WILLINGNESS TO STEP IN 44 00:01:36,560 --> 00:01:37,840 FOR DR. WOLF TODAY. 45 00:01:37,840 --> 00:01:39,360 AGAIN, THANK YOU SO MUCH FOR 46 00:01:39,360 --> 00:01:41,320 PUTTING TOGETHER SUCH AN 47 00:01:41,320 --> 00:01:42,200 INTERESTING PROGRAM FOR THIS 48 00:01:42,200 --> 00:01:44,280 YEAR'S MEETING. 49 00:01:44,280 --> 00:01:46,040 I AM PLEASED ALSO THAT THIS YEAR 50 00:01:46,040 --> 00:01:48,000 FOR THE FIRST TIME, THE 51 00:01:48,000 --> 00:01:50,440 ROUNDTABLE IS OPEN TO ALL 52 00:01:50,440 --> 00:01:52,280 NURSING ORGANIZATIONS, AND 53 00:01:52,280 --> 00:01:53,880 BUILDING ON LAST YEAR'S 54 00:01:53,880 --> 00:01:57,560 EVOLUTION, WE'RE ALSO 55 00:01:57,560 --> 00:01:58,760 VIDEOCASTING THIS PROGRAM FOR 56 00:01:58,760 --> 00:02:02,920 ANYONE TO VIEW LIVE NOW OR 57 00:02:02,920 --> 00:02:03,240 LATER. 58 00:02:03,240 --> 00:02:05,040 I WILL EXTEND A VERY WARM 59 00:02:05,040 --> 00:02:06,840 WELCOME TO THOSE OF WHO YOU ARE 60 00:02:06,840 --> 00:02:09,040 ATTENDING THE ROUNDTABLE FOR THE 61 00:02:09,040 --> 00:02:10,240 VERY FIRST TIME, AS WELL AS TO 62 00:02:10,240 --> 00:02:13,840 THOSE WHO ARE RETURNING. 63 00:02:13,840 --> 00:02:15,800 AS A COOPERATIVE OF NURSING 64 00:02:15,800 --> 00:02:16,880 ORGANIZATIONS, THE ROUNDTABLE 65 00:02:16,880 --> 00:02:18,080 BRINGS TOGETHER 66 00:02:18,080 --> 00:02:20,040 SCIENTISTS,ICALLY NUSHES, 67 00:02:20,040 --> 00:02:22,560 EDUCATORS, SCHOLARS AND POLICY 68 00:02:22,560 --> 00:02:24,560 LEADERS LIKE YOU TO DISCUSS 69 00:02:24,560 --> 00:02:26,280 PRIORITIES IN SCIENCE, PRACTICE, 70 00:02:26,280 --> 00:02:29,640 AND POLICY. 71 00:02:29,640 --> 00:02:30,640 MOREOVER, THE ROUNDTABLE WILL 72 00:02:30,640 --> 00:02:35,680 OFFER YOU AN OPPORTUNITY TO 73 00:02:35,680 --> 00:02:36,600 SHARE AND EXCHANGE INFORMATION 74 00:02:36,600 --> 00:02:37,840 AMONG LEADERS OF NATIONAL 75 00:02:37,840 --> 00:02:43,840 NURSING ORGANIZATIONS SO DURING 76 00:02:43,840 --> 00:02:46,560 THIS YEAR'S TWO-DAY EVENT, YOU, 77 00:02:46,560 --> 00:02:47,840 OUR PARTICIPANTS, WILL LEARN OW 78 00:02:47,840 --> 00:02:49,280 EMERGENCY DEPARTMENTS CAN 79 00:02:49,280 --> 00:02:50,680 APPROPRIATELY IDENTIFY AND 80 00:02:50,680 --> 00:02:53,280 ADDRESS SOCIAL NEEDS, UNDERSTAND 81 00:02:53,280 --> 00:02:54,840 THE ROLE OF SOCIAL INJUSTICES 82 00:02:54,840 --> 00:02:58,040 AND SOCIAL RISK AND DRIVING THE 83 00:02:58,040 --> 00:03:02,040 DEMAND FOR EMERGENCY HEALTHCARE 84 00:03:02,040 --> 00:03:03,560 SERVICES, AND, IDENTIFY FACTORS 85 00:03:03,560 --> 00:03:05,200 THAT INFLUENCE THE SUCCESS OF 86 00:03:05,200 --> 00:03:08,040 TRANSITION FROM EMERGENCY TO 87 00:03:08,040 --> 00:03:09,800 COMMUNITY-BASED CARE. 88 00:03:09,800 --> 00:03:11,440 THROUGHOUT MY CAREER, AND 89 00:03:11,440 --> 00:03:13,840 ESPECIALLY IN MY ROLE AS NINR 90 00:03:13,840 --> 00:03:15,120 DIRECTOR, I'VE MADE CLEAR MY 91 00:03:15,120 --> 00:03:17,760 BELIEF THAT NURSING SCIENCE CAN 92 00:03:17,760 --> 00:03:19,400 AND MUST MAKE A DIFFERENCE IN 93 00:03:19,400 --> 00:03:22,000 THE AREAS OF HEALTH INEQUITIES 94 00:03:22,000 --> 00:03:23,800 AND UNDERSTANDING THE SOCIAL 95 00:03:23,800 --> 00:03:24,520 DETERMINANTS OF HEALTH, AND 96 00:03:24,520 --> 00:03:27,160 THESE AREAS ARE PARTICULARLY 97 00:03:27,160 --> 00:03:28,480 RELEVANT TO THE TOPIC OF THIS 98 00:03:28,480 --> 00:03:29,040 YEAR'S PROGRAM. 99 00:03:29,040 --> 00:03:32,040 SO I'LL HAVE MORE TO SAY IN MY 100 00:03:32,040 --> 00:03:33,200 REMARKS TOMORROW MORNING, BUT 101 00:03:33,200 --> 00:03:35,040 THESE ARE AREAS IN WHICH NINR 102 00:03:35,040 --> 00:03:36,840 AND THE NURSING SCIENCE 103 00:03:36,840 --> 00:03:38,080 COMMUNITY MUST LEAD. 104 00:03:38,080 --> 00:03:40,680 SO IT'S NOW MY PLEASURE TO 105 00:03:40,680 --> 00:03:43,560 INTRODUCE DR. TANIA STROUT, WHO 106 00:03:43,560 --> 00:03:45,160 WILL PROVIDE HER WELCOMING 107 00:03:45,160 --> 00:03:48,440 REMARKS AND THEN GO -- PROCEED 108 00:03:48,440 --> 00:03:50,320 TO INTRODUCE OUR KEYNOTE 109 00:03:50,320 --> 00:03:52,040 SPEAKER. 110 00:03:52,040 --> 00:03:54,680 SO LET ME INTRODUCE DR. STROUT. 111 00:03:54,680 --> 00:03:56,360 DR. TANIA STROUT IS A PROFESSOR 112 00:03:56,360 --> 00:03:59,280 OF EMERGENCY MEDICINE AT THE 113 00:03:59,280 --> 00:04:01,000 TUFTS UNIVERSITY SCHOOL OF 114 00:04:01,000 --> 00:04:02,240 MEDICINE, A MEMBER OF THE 115 00:04:02,240 --> 00:04:04,240 EMERGENCY NURSES ASSOCIATION, 116 00:04:04,240 --> 00:04:07,480 AND A CHAIRPERSON OF THE ENA 117 00:04:07,480 --> 00:04:09,360 EMERGENCY NURSING RESEARCH 118 00:04:09,360 --> 00:04:11,640 ADVISORY COUNCIL. 119 00:04:11,640 --> 00:04:13,320 SHE'S ALSO A MEMBER OF THE 120 00:04:13,320 --> 00:04:16,240 SOCIETY FOR ACADEMIC EMERGENCY 121 00:04:16,240 --> 00:04:21,440 MEDICINE, THE THE ACADEMY FOR WOMEN 122 00:04:21,440 --> 00:04:23,400 IN ACADEMIC EMERGENCY MEDICINE, 123 00:04:23,400 --> 00:04:24,680 ACADEMY FOR DIVERSITY AND 124 00:04:24,680 --> 00:04:25,920 INCLUSION IN EMERGENCY MEDICINE, 125 00:04:25,920 --> 00:04:29,200 AND THE RESEARCH DIRECTORS 126 00:04:29,200 --> 00:04:30,280 INTEREST GROUP. 127 00:04:30,280 --> 00:04:32,120 HER PRIMARY RESEARCH INTERESTS 128 00:04:32,120 --> 00:04:33,120 INCLUDE HEALTH RELATED 129 00:04:33,120 --> 00:04:33,880 MEASUREMENT, PSYCHOMETRICS AND 130 00:04:33,880 --> 00:04:36,560 SCALE DEVELOPMENT, HER WORK HAS 131 00:04:36,560 --> 00:04:39,320 INCLUDED THE STUDY OF 132 00:04:39,320 --> 00:04:40,320 MEASUREMENT IN EMERGENCY 133 00:04:40,320 --> 00:04:43,280 DEPARTMENT TRIAGE SYSTEMS, ACUTE 134 00:04:43,280 --> 00:04:45,680 PAIN IN ADULTS AND CHILDREN, AND 135 00:04:45,680 --> 00:04:47,880 ACUTE AGITATION. 136 00:04:47,880 --> 00:04:49,200 OTHER RESEARCH AREAS INCLUDE 137 00:04:49,200 --> 00:04:52,880 ACCESS TO CARE, HOSPITAL FLOW, 138 00:04:52,880 --> 00:04:54,440 PALLIATIVE MEDICINE IN THE 139 00:04:54,440 --> 00:04:55,840 EMERGENCY DEPARTMENT SETTING, 140 00:04:55,840 --> 00:04:57,280 INTERPERSONAL VIOLENCE, HEALTH 141 00:04:57,280 --> 00:05:01,200 PROFESSIONS EDUCATION, CLINICIAN 142 00:05:01,200 --> 00:05:02,720 TOLERANCE OF UNCERTAINTY, 143 00:05:02,720 --> 00:05:04,040 INITIATION OF BUPRENORPHINE FOR 144 00:05:04,040 --> 00:05:07,040 THE TREATMENT OF OPIOID USE 145 00:05:07,040 --> 00:05:08,160 DISORDER IN THE EMERGENCY 146 00:05:08,160 --> 00:05:10,080 DEPARTMENT, AND THE ROLE OF 147 00:05:10,080 --> 00:05:11,200 NURSES IN CARING FOR PATIENTS 148 00:05:11,200 --> 00:05:13,800 WITH OPIOID USE DISORDER. 149 00:05:13,800 --> 00:05:16,760 SO PLEASE JOIN ME IN WELCOMING 150 00:05:16,760 --> 00:05:20,240 DR. STROUT. 151 00:05:20,240 --> 00:05:22,200 >> THANK YOU SO MUCH, DR. ZENK, 152 00:05:22,200 --> 00:05:23,200 FOR THAT KIND WELCOME. 153 00:05:23,200 --> 00:05:24,840 I AM VERY PLEASED TO BE JOINING 154 00:05:24,840 --> 00:05:26,480 YOU ALL FOR THE NEXT TWO DAYS 155 00:05:26,480 --> 00:05:27,840 AND REPRESENTING THE EMERGENCY 156 00:05:27,840 --> 00:05:31,200 NURSES ASSOCIATION. 157 00:05:31,200 --> 00:05:32,520 SO COLLEAGUES, ON BEHALF OF THE 158 00:05:32,520 --> 00:05:34,480 EMERGENCY NURSES ASSOCIATION, 159 00:05:34,480 --> 00:05:36,320 OUR ORGANIZATION'S PRESIDENT, 160 00:05:36,320 --> 00:05:37,920 JEN SCHMITZ, WHO SHOULD BE 161 00:05:37,920 --> 00:05:39,800 ATTENDING WITH US TODAY, AND THE 162 00:05:39,800 --> 00:05:41,320 EMERGENCY NURSES ASSOCIATION 163 00:05:41,320 --> 00:05:43,720 RESEARCH ADVISORY COUNCIL, I 164 00:05:43,720 --> 00:05:45,360 WOULD ALSO LIKE TO EXTEND A VERY 165 00:05:45,360 --> 00:05:47,760 WARM WELCOME TO EVERYONE TO THIS 166 00:05:47,760 --> 00:05:51,480 YEAR'S NATIONAL NURSING RESEARCH 167 00:05:51,480 --> 00:05:52,360 ROUNDTABLE. 168 00:05:52,360 --> 00:05:57,280 ENA IS THE PREMIER PROFESSIONAL 169 00:05:57,280 --> 00:06:02,240 NURSING SITUATION DEDICATED TO 170 00:06:02,240 --> 00:06:03,520 RESEARCH, INNOVATION AND 171 00:06:03,520 --> 00:06:04,840 LEADERSHIP, AND OUR ORGANIZATION 172 00:06:04,840 --> 00:06:06,120 REPRESENTS APPROXIMATELY 50,000 173 00:06:06,120 --> 00:06:07,680 MEMBERS AROUND THE WORLD. 174 00:06:07,680 --> 00:06:09,880 WE ARE PART OF A HIGHLY ENGAGED 175 00:06:09,880 --> 00:06:10,960 COMMUNITY COMMITTED TO PROVIDING 176 00:06:10,960 --> 00:06:13,240 THE HIGHEST LEVEL OF CARE TO OUR 177 00:06:13,240 --> 00:06:15,000 PATIENTS AND FAMILIES THAT WE 178 00:06:15,000 --> 00:06:16,640 SERVE, OUR MEMBERS SUPPORT THE 179 00:06:16,640 --> 00:06:18,160 DEVELOPMENT OF NEW KNOWLEDGE FOR 180 00:06:18,160 --> 00:06:20,640 EMERGENCY NURSING PRACTICE BY 181 00:06:20,640 --> 00:06:22,840 SHARING THEIR RESEARCH IN OUR 182 00:06:22,840 --> 00:06:24,040 OFFICIAL PUBLICATION, THE 183 00:06:24,040 --> 00:06:26,400 JOURNAL OF EMERGENCY NURSING, BY 184 00:06:26,400 --> 00:06:27,720 DISSEMINATING THEIR WORK AT OUR 185 00:06:27,720 --> 00:06:28,640 ANNUAL CONFERENCE, AND THROUGH 186 00:06:28,640 --> 00:06:31,400 SUPPORT FOR THE ENA FOUNDATION. 187 00:06:31,400 --> 00:06:33,040 THE FOUNDATION HAS A SIGNIFICANT 188 00:06:33,040 --> 00:06:34,360 IMPACT ON THE PROFESSION OVER 189 00:06:34,360 --> 00:06:38,400 THE LAST 31 YEARS, SUPPORTING 190 00:06:38,400 --> 00:06:39,600 EMERGENCY NURSES BY PROVIDING 191 00:06:39,600 --> 00:06:43,640 FUNDING TO MORE THAN 2400 NURSES 192 00:06:43,640 --> 00:06:44,720 TOTALING $5.3 MILLION IN 193 00:06:44,720 --> 00:06:45,840 EDUCATIONAL SCHOLARSHIPS, 194 00:06:45,840 --> 00:06:47,640 RESEARCH GRANTS, AND CONFERENCE 195 00:06:47,640 --> 00:06:48,320 SUPPORT. 196 00:06:48,320 --> 00:06:51,480 I'D LIKE TO RECOGNIZE OUR ENA 197 00:06:51,480 --> 00:06:52,600 PRESIDENT, JENNIFER SCHMITZ, 198 00:06:52,600 --> 00:06:59,240 WHO'S A 199 00:06:59,240 --> 00:07:00,400 ALSO SERVING AS THE CHIEF 200 00:07:00,400 --> 00:07:03,040 NURSING OFFICER AT SOUTHERN 201 00:07:03,040 --> 00:07:04,080 MAINE HEALTHCARE, A SISTER 202 00:07:04,080 --> 00:07:06,600 INSTITUTION TO MY OWN. 203 00:07:06,600 --> 00:07:08,400 JEN IS LEADING ENA MEMBERS THIS 204 00:07:08,400 --> 00:07:11,240 YEAR WITH A FOCUS ON CHARGING 205 00:07:11,240 --> 00:07:16,640 AND RECHARGING 206 00:07:16,640 --> 00:07:18,000 MEMBERS AFTER GIVING SO MUCH OF 207 00:07:18,000 --> 00:07:19,440 THEMSELVES THROUGHOUT THE 208 00:07:19,440 --> 00:07:20,280 COVID-19 PANDEMIC. 209 00:07:20,280 --> 00:07:23,160 THERE IS SOME SIN SYNERGY BETWEEN 210 00:07:23,160 --> 00:07:24,640 OUR THEME OF RECHARGING AND THE 211 00:07:24,640 --> 00:07:26,080 WORK WE'RE DOING HERE TODAY ON 212 00:07:26,080 --> 00:07:27,200 SOCIAL DETERMINANTS, AS EVEN 213 00:07:27,200 --> 00:07:28,840 PRIOR TO THE PANDEMIC, EMERGENCY 214 00:07:28,840 --> 00:07:30,120 NURSES HAVE BEEN ON THE FRONT 215 00:07:30,120 --> 00:07:31,840 LINES OF ADDRESSING SO MANY 216 00:07:31,840 --> 00:07:34,480 SOCIAL ISSUES SUCH AS THE OPIOID 217 00:07:34,480 --> 00:07:36,360 CRISIS, VIOLENCE, UNSTABLE 218 00:07:36,360 --> 00:07:38,160 HOUSING, FOOD INSECURITY, THE 219 00:07:38,160 --> 00:07:40,240 EFFECTS OF RACISM ON HEALTH, AND 220 00:07:40,240 --> 00:07:43,000 THE ESCALATING NEEDS OF OUR MANY 221 00:07:43,000 --> 00:07:45,960 PATIENTS STRUGGLING WITH UN AND 222 00:07:45,960 --> 00:07:46,520 UNDERTREATED MENTAL HEALTH 223 00:07:46,520 --> 00:07:46,840 CONDITIONS. 224 00:07:46,840 --> 00:07:48,440 SO WE ARE REALLY EXCITED TO BE 225 00:07:48,440 --> 00:07:50,240 HERE PARTICIPATING IN THESE VERY 226 00:07:50,240 --> 00:07:51,640 IMPORTANT CONVERSATIONS AROUND 227 00:07:51,640 --> 00:07:52,720 SOCIAL DETERMINANTS OF HEALTH, 228 00:07:52,720 --> 00:07:55,760 AND HOW WE IN PARTICULAR AS 229 00:07:55,760 --> 00:07:56,520 EMERGENCY NURSES CAN CONTRIBUTE 230 00:07:56,520 --> 00:07:58,640 TO THE DEVELOPMENT OF NEW 231 00:07:58,640 --> 00:07:59,720 KNOWLEDGE IN THIS AREA THROUGH 232 00:07:59,720 --> 00:08:01,240 OUR RESEARCH AND ALSO THROUGH 233 00:08:01,240 --> 00:08:03,240 THE IMPLEMENTATION OF RESEARCH 234 00:08:03,240 --> 00:08:04,640 FINDINGS INTO CLINICAL PRACTICE 235 00:08:04,640 --> 00:08:06,920 TO IMPROVE OUTCOMES FOR OUR 236 00:08:06,920 --> 00:08:07,840 PATIENTS IN THE COMMUNITIES WE 237 00:08:07,840 --> 00:08:09,080 SERVE. 238 00:08:09,080 --> 00:08:10,080 WE'RE LOOKING FORWARD TO 239 00:08:10,080 --> 00:08:12,040 LEARNING WITH YOU ALL, AS WELL 240 00:08:12,040 --> 00:08:13,400 AS TO BRINGING OUR LEARNINGS 241 00:08:13,400 --> 00:08:15,560 BACK TO OUR ORGANIZATIONS, OUR 242 00:08:15,560 --> 00:08:17,520 LOCAL COMMUNITIES, AND MOST 243 00:08:17,520 --> 00:08:19,200 IMPORTANTLY, TO THE SERVICE OF 244 00:08:19,200 --> 00:08:21,560 OUR PATIENTS. 245 00:08:21,560 --> 00:08:23,440 SO WITH THAT, I HAVE THE 246 00:08:23,440 --> 00:08:24,760 DISTINCT PRIVILEGE OF 247 00:08:24,760 --> 00:08:25,960 INTRODUCING THIS YEAR'S 248 00:08:25,960 --> 00:08:31,520 ROUNDTABLE KEYNOTE SPEAKER, 249 00:08:31,520 --> 00:08:33,320 DR. RENEE HSIA. 250 00:08:33,320 --> 00:08:37,440 DR. HSIA IS PROFESSOR IN THE 251 00:08:37,440 --> 00:08:39,600 DEPARTMENT OF EMERGENCY MEDICINE 252 00:08:39,600 --> 00:08:40,240 AT THE UNIVERSITY OF CALIFORNIA 253 00:08:40,240 --> 00:08:40,840 SAN FRANCISCO. 254 00:08:40,840 --> 00:08:42,320 SHE IS ALSO A CORE FACULTY 255 00:08:42,320 --> 00:08:44,960 MEMBER OF THE UCSF INSTITUTE FOR 256 00:08:44,960 --> 00:08:46,800 HEALTH POLICY STUDIES, AS WELL 257 00:08:46,800 --> 00:08:49,680 AS A MEMBER OF THE UCSF CENTER 258 00:08:49,680 --> 00:08:52,400 FOR HEALTHCARE VALUE AND THE 259 00:08:52,400 --> 00:08:53,680 UCSF GLOBAL HEALTH ECONOMICS 260 00:08:53,680 --> 00:08:54,240 CONSORTIUM. 261 00:08:54,240 --> 00:08:56,240 SHE IS CERTIFIED BY THE AMERICAN 262 00:08:56,240 --> 00:08:58,880 BOARD OF EMERGENCY MEDICINE, AND 263 00:08:58,880 --> 00:09:01,360 SHE SPEAKS MANDARIN, CANTONESE, 264 00:09:01,360 --> 00:09:03,120 SPANISH, AND FRENCH, IN ADDITION 265 00:09:03,120 --> 00:09:04,840 TO ENGLISH, AND PROVIDED 266 00:09:04,840 --> 00:09:06,600 EMERGENCY CARE TO PATIENTS WITH 267 00:09:06,600 --> 00:09:08,680 A VARIETY OF BACKGROUNDS AS AN 268 00:09:08,680 --> 00:09:10,440 ATTENDING PHYSICIAN IN THE 269 00:09:10,440 --> 00:09:13,040 EMERGENCY DEPARTMENT AT THE 270 00:09:13,040 --> 00:09:13,680 ZUCKERBERG SAN FRANCISCO GENERAL 271 00:09:13,680 --> 00:09:14,600 HOSPITAL AND TRAUMA CENTER, 272 00:09:14,600 --> 00:09:16,440 WHICH IS THE ONLY COUNTY 273 00:09:16,440 --> 00:09:18,520 HOSPITAL AND TRAUMA CENTER 274 00:09:18,520 --> 00:09:19,440 SERVING SAN FRANCISCO, 275 00:09:19,440 --> 00:09:22,040 CALIFORNIA. 276 00:09:22,040 --> 00:09:23,840 DR. HSIA'S BROAD RESEARCH 277 00:09:23,840 --> 00:09:25,200 INTERESTS ARE IN HEALTH SERVICES 278 00:09:25,200 --> 00:09:26,480 ISSUES RELATING TO INCREASING 279 00:09:26,480 --> 00:09:27,920 ACCESS TO EMERGENCY CARE AND THE 280 00:09:27,920 --> 00:09:29,360 REGIONALIZATION OF CARE. 281 00:09:29,360 --> 00:09:31,440 SHE HAS BEEN FUNDED BY SEVERAL 282 00:09:31,440 --> 00:09:33,000 PRIVATE FOUNDATION AND FEDERAL 283 00:09:33,000 --> 00:09:34,480 GRANTS TO STUDY POPULATION 284 00:09:34,480 --> 00:09:36,040 ACCESS TO EMERGENCY DEPARTMENTS 285 00:09:36,040 --> 00:09:38,760 AND TRAUMA CENTERS IN THE U.S., 286 00:09:38,760 --> 00:09:40,400 THE DISTRIBUTION OF EMERGENCY 287 00:09:40,400 --> 00:09:43,800 CARE ACROSS INCOME AREAS, 288 00:09:43,800 --> 00:09:45,000 FACTORS ASSOCIATED WITH THE 289 00:09:45,000 --> 00:09:46,760 CLOSURE OF EMERGENCY SERVICES, 290 00:09:46,760 --> 00:09:48,840 BOTH EMERGENCY DEPARTMENTS AND 291 00:09:48,840 --> 00:09:50,480 TRAUMA CENTERS, AND HOW THESE 292 00:09:50,480 --> 00:09:52,040 CLOSURES AFFECT PATIENT 293 00:09:52,040 --> 00:09:52,800 OUTCOMES, SPECIFICALLY FOCUSING 294 00:09:52,800 --> 00:09:55,600 ON PATIENTS WITH ACUTE 295 00:09:55,600 --> 00:09:56,600 MYOCARDIAL INFARCTION, STROKE, 296 00:09:56,600 --> 00:09:59,960 AS 297 00:09:59,960 --> 00:10:01,840 ASTHMA, COPD, SEPSIS AND TRAUMA. 298 00:10:01,840 --> 00:10:03,560 HER RESEARCH ALSO FOCUSES ON 299 00:10:03,560 --> 00:10:04,720 HEALTHCARE COSTS AND FINANCE 300 00:10:04,720 --> 00:10:06,200 ISSUES REGARDING EMERGENCY CARE. 301 00:10:06,200 --> 00:10:08,200 SHE'S THE SITE P.I. FOR SEVERAL 302 00:10:08,200 --> 00:10:10,360 MULTI-SITE STUDIES VALIDATING 303 00:10:10,360 --> 00:10:11,880 TRAUMA TRIAGE CRITERIA FOR 304 00:10:11,880 --> 00:10:13,440 DIFFERENT AGE GROUPS, AS WELL AS 305 00:10:13,440 --> 00:10:15,040 THEIR ABILITY TO PREDICT HIGH 306 00:10:15,040 --> 00:10:15,720 RISK PATIENTS. 307 00:10:15,720 --> 00:10:17,600 SHE'S PUBLISHED ON THESE ISSUES 308 00:10:17,600 --> 00:10:19,760 IN A BROAD RANGE OF JOURNALS, 309 00:10:19,760 --> 00:10:21,240 INCLUDING THE NEW ENGLAND 310 00:10:21,240 --> 00:10:21,880 JOURNAL OF MEDICINE, THE JOURNAL 311 00:10:21,880 --> 00:10:23,160 OF THE AMERICAN MEDICAL 312 00:10:23,160 --> 00:10:24,880 ASSOCIATION, AND HEALTH AFFAIRS. 313 00:10:24,880 --> 00:10:26,800 HER RESEARCH HAS ALSO BEEN 314 00:10:26,800 --> 00:10:29,920 WIDELY PUBLICIZE IN PRINT MEDIA 315 00:10:29,920 --> 00:10:31,240 AS WELL AS NATIONAL NETWORK NEWS 316 00:10:31,240 --> 00:10:34,840 AND RADIO. 317 00:10:34,840 --> 00:10:35,760 DR. HSIA HOPES THIS WORK WILL 318 00:10:35,760 --> 00:10:37,040 HELP TO INFORM THE PUBLIC AND 319 00:10:37,040 --> 00:10:38,640 POLICY MAKERS ON ISSUES RELATED 320 00:10:38,640 --> 00:10:40,400 TO THE EQUITABLE PROVISION OF 321 00:10:40,400 --> 00:10:41,920 CRITICAL SERVICES TO PATIENTS 322 00:10:41,920 --> 00:10:44,040 ACROSS THE COUNTRY AND GLOBALLY. 323 00:10:44,040 --> 00:10:45,640 SO I HOPE THAT YOU WILL ALL 324 00:10:45,640 --> 00:10:48,200 PLEASE JOIN ME IN WELCOMING 325 00:10:48,200 --> 00:10:48,720 DR. HSIA. 326 00:10:48,720 --> 00:10:50,240 DOCTOR, WE ARE SO FORTUNATE TO 327 00:10:50,240 --> 00:10:51,880 HAVE YOU WITH US TODAY, AND 328 00:10:51,880 --> 00:10:52,760 WE'RE VERY MUCH LOOKING FORWARD 329 00:10:52,760 --> 00:10:56,760 TO YOUR REMARKS THIS AFTERNOON. 330 00:10:56,760 --> 00:10:57,920 >> THANK YOU SO MUCH FOR HAVING 331 00:10:57,920 --> 00:10:58,360 ME. 332 00:10:58,360 --> 00:11:05,120 I'D LIKE TO THANK DR. ZENK, 333 00:11:05,120 --> 00:11:07,080 DR. STOUT, MISS WILLIAMS 334 00:11:07,080 --> 00:11:08,000 WASHINGTON AND EMERGENCY NURSES 335 00:11:08,000 --> 00:11:08,760 ASSOCIATION FOR PUTTING THIS 336 00:11:08,760 --> 00:11:11,360 TOGETHER AND FOR INVITING ME. 337 00:11:11,360 --> 00:11:12,240 I'M LOOKING FORWARD TO THIS 338 00:11:12,240 --> 00:11:13,560 BECAUSE I THINK IT'S AN EXCITING 339 00:11:13,560 --> 00:11:14,840 OPPORTUNITY TO GET US THINKING 340 00:11:14,840 --> 00:11:15,960 TOGETHER ABOUT NOT JUST THE 341 00:11:15,960 --> 00:11:17,160 RESEARCH AGENDA BUT HOW WE 342 00:11:17,160 --> 00:11:18,480 APPROACH THESE ISSUES FROM THE 343 00:11:18,480 --> 00:11:21,240 EMERGENCY DEPARTMENT TO KIND OF 344 00:11:21,240 --> 00:11:22,040 REALLY INTEGRATE ALL THE THINGS 345 00:11:22,040 --> 00:11:23,080 WE'RE DOING TOGETHER. 346 00:11:23,080 --> 00:11:24,840 SO JUST GIVE ME A MOMENT FOR ME 347 00:11:24,840 --> 00:11:33,400 TO SHARE MY SCREEN. 348 00:11:33,400 --> 00:11:34,560 DOES EVERYONE SEE THAT OKAY? 349 00:11:34,560 --> 00:11:34,880 >> YES. 350 00:11:34,880 --> 00:11:37,280 >> ALL RIGHT, GREAT. 351 00:11:37,280 --> 00:11:38,600 SO JUST SOME DISCLOA SAWYERS 352 00:11:38,600 --> 00:11:42,280 JUST DISCLOSURES JUST TO 353 00:11:42,280 --> 00:11:42,520 START. 354 00:11:42,520 --> 00:11:43,400 THESE ARE THE FUNDING 355 00:11:43,400 --> 00:11:44,160 ORGANIZATIONS THAT HAVE FUNDED 356 00:11:44,160 --> 00:11:45,440 SOME OF THE RESEARCH THAT I'VE 357 00:11:45,440 --> 00:11:46,040 DONE. 358 00:11:46,040 --> 00:11:49,600 AND NONE OF THEM WILL POSE ANY 359 00:11:49,600 --> 00:11:50,480 CONFLICT OF INTEREST IN WHAT I 360 00:11:50,480 --> 00:11:51,680 SHARE WITH YOU TODAY, BUT I DID 361 00:11:51,680 --> 00:11:56,280 WANT TO SHARE THAT. 362 00:11:56,280 --> 00:11:57,800 I AM EXCITED TO TALK WITH YOU 363 00:11:57,800 --> 00:11:59,360 TODAY BECAUSE I THINK MOST OF 364 00:11:59,360 --> 00:12:00,760 THE TIME, WHEN PEOPLE THINK 365 00:12:00,760 --> 00:12:01,400 ABOUT THE EMERGENCY DEPARTMENT, 366 00:12:01,400 --> 00:12:04,520 THEY HAVE IN MIND THAT THIS IS 367 00:12:04,520 --> 00:12:08,000 KIND OF AN AREA WHERE THERE IS 368 00:12:08,000 --> 00:12:08,720 EQUITABLE ACCESS BECAUSE 369 00:12:08,720 --> 00:12:10,160 EMERGENCY SERVICES, WE TEND TO 370 00:12:10,160 --> 00:12:16,800 THINK ABOUT 911, ANY1 CAN ANYONE CAN CALL 371 00:12:16,800 --> 00:12:17,240 911. 372 00:12:17,240 --> 00:12:18,560 AMBULANCE SERVICES DON'T ASK YOU 373 00:12:18,560 --> 00:12:21,200 FOR INSURANCE, THEY DON'T ASK 374 00:12:21,200 --> 00:12:22,440 YOU FOR ANY FORM OF PAYMENT, SO 375 00:12:22,440 --> 00:12:24,280 WE THINK OF JUST HOW IN GENERAL, 376 00:12:24,280 --> 00:12:26,040 THE EMERGENCY DEPARTMENT SHOULD 377 00:12:26,040 --> 00:12:27,240 THEORETICALLY BE A PLACE THAT IS 378 00:12:27,240 --> 00:12:28,760 AN AREA WHERE THERE ARE NO 379 00:12:28,760 --> 00:12:29,520 BARRIERS TO CARE. 380 00:12:29,520 --> 00:12:31,600 BUT IN FACT, THE EMERGENCY 381 00:12:31,600 --> 00:12:32,600 DEPARTMENT WE KNOW FOR ALL OF US 382 00:12:32,600 --> 00:12:34,120 WHO WORK THERE KNOW THAT THERE 383 00:12:34,120 --> 00:12:36,920 ARE PLENTY OF BARRIERS TO CARE 384 00:12:36,920 --> 00:12:38,440 IN EVEN ACCESSING EMERGENCY 385 00:12:38,440 --> 00:12:40,280 CARE, AND I WANTED TO SET THE 386 00:12:40,280 --> 00:12:42,840 STAGE FOR WHAT YOU'RE GOING TO 387 00:12:42,840 --> 00:12:46,640 BE LISTENING TO TOMORROW IN 388 00:12:46,640 --> 00:12:48,040 TERMS OF THE BROAD ARRAY OF 389 00:12:48,040 --> 00:12:50,400 SERVICES THAT WE'RE TRYING TO 390 00:12:50,400 --> 00:12:51,600 THINK ABOUT IN TERMS OF 391 00:12:51,600 --> 00:12:52,560 ACCESSING NOT JUST EMERGENCY 392 00:12:52,560 --> 00:12:54,320 CARE BUT HOW WE TIE THE NEEDS 393 00:12:54,320 --> 00:12:56,520 THAT PEOPLE PRESENT WITH TO 394 00:12:56,520 --> 00:12:58,600 OTHER SERVICES WITHIN NOT JUST 395 00:12:58,600 --> 00:13:00,640 HEALTHCARE BUT OTHER SOCIAL 396 00:13:00,640 --> 00:13:02,960 NEEDS THAT PEOPLE HAVE, SO I 397 00:13:02,960 --> 00:13:04,080 THINK IT'S IMPORTANT FOR US TO 398 00:13:04,080 --> 00:13:05,800 ALL BE ON THE SAME PAGE IN TERMS 399 00:13:05,800 --> 00:13:08,320 OF UNDERSTANDING WHEN PEOPLE 400 00:13:08,320 --> 00:13:10,400 COME TO THE EMERGENCY 401 00:13:10,400 --> 00:13:12,600 DEPARTMENT, WHEN PEOPLE SEEK 402 00:13:12,600 --> 00:13:14,240 EMERGENCY CARE, WHAT ARE THE 403 00:13:14,240 --> 00:13:15,440 FACTORS THAT ARE ALREADY FACING 404 00:13:15,440 --> 00:13:17,840 THEM IN TERMS OF COMING TO THE 405 00:13:17,840 --> 00:13:18,000 ED? 406 00:13:18,000 --> 00:13:19,400 AND SO I WANTED TO START WITH A 407 00:13:19,400 --> 00:13:22,120 LITTLE BIT OF THAT KIND OF 408 00:13:22,120 --> 00:13:23,520 INTRODUCTION TO KIND OF SET THE 409 00:13:23,520 --> 00:13:26,560 STAGE, AND SO THIS IS A MODEL 410 00:13:26,560 --> 00:13:27,680 THAT I CAME UP WITH A LONG TIME 411 00:13:27,680 --> 00:13:28,240 AGO. 412 00:13:28,240 --> 00:13:31,080 IT'S VERY SIMPLE, STRUCK TOOR, 413 00:13:31,080 --> 00:13:32,600 PROCESS AND OUTCOMES, BUT THIS 414 00:13:32,600 --> 00:13:35,120 IS THE WAY I THINK AT LEAST I 415 00:13:35,120 --> 00:13:39,560 GENERALLY HAVE THOUGHT OF HEALTH 416 00:13:39,560 --> 00:13:40,520 INEQUITIES AND SOCIAL NEEDS IN 417 00:13:40,520 --> 00:13:41,440 THE EMERGENCY DEPARTMENT. 418 00:13:41,440 --> 00:13:42,920 SO WHEN I FIRST STARTED 419 00:13:42,920 --> 00:13:44,360 EMERGENCY MEDICINE, I USED TO 420 00:13:44,360 --> 00:13:45,920 THINK OKAY, THERE'S PATIENT 421 00:13:45,920 --> 00:13:46,640 FACTORS LIKE THERE ARE PATIENTS 422 00:13:46,640 --> 00:13:48,040 WHO SMOKE, THERE ARE PATIENTS 423 00:13:48,040 --> 00:13:49,640 WHO ENGAGE IN DIFFERENT TYPES OF 424 00:13:49,640 --> 00:13:51,880 BEHAVIOR, THERE'S DIFFERENT 425 00:13:51,880 --> 00:13:52,800 ACUTITY OF PATIENTS WHO PRESENT 426 00:13:52,800 --> 00:13:55,040 TO THE E.D., SOME OF THEM COME 427 00:13:55,040 --> 00:13:57,040 WITH THE NEED FOR LACERATION 428 00:13:57,040 --> 00:13:58,120 REPAIR, SOME OF THEM COME WITH 429 00:13:58,120 --> 00:14:00,440 HEART ATTACKS OR ST ELEVATION 430 00:14:00,440 --> 00:14:03,360 MIs, AND THAT AFFECTS THE 431 00:14:03,360 --> 00:14:05,440 PROCESSES THAT GO ON IN THE 432 00:14:05,440 --> 00:14:05,920 EMERGENCY DEPARTMENT. 433 00:14:05,920 --> 00:14:08,720 SO WHETHER THEY SMOKE OR NOT, 434 00:14:08,720 --> 00:14:10,480 MAYBE THAT SOMEHOW AFFECTS 435 00:14:10,480 --> 00:14:12,920 PEOPLE'S BEHAVIOR BECAUSE MAYBE 436 00:14:12,920 --> 00:14:14,080 THERE ARE PROVIDERS WHO FEEL 437 00:14:14,080 --> 00:14:15,480 LIKE, OH, THIS IS SOMETHING THEY 438 00:14:15,480 --> 00:14:18,480 BROUGHT UPON THEMSELVES OR THEY 439 00:14:18,480 --> 00:14:21,640 HAVE DIABETES AND IT AFFECTS 440 00:14:21,640 --> 00:14:23,440 BEHAVIOR, IF THEY'RE LOW ACUTE, 441 00:14:23,440 --> 00:14:24,920 THAT AFFECTS THEIR E.D. WAIT 442 00:14:24,920 --> 00:14:26,800 TIMES BECAUSE THERE'S TRIAGE 443 00:14:26,800 --> 00:14:28,080 SYSTEMS, SO THAT AFFECT 444 00:14:28,080 --> 00:14:28,760 OUTCOMES. 445 00:14:28,760 --> 00:14:31,360 SO WE THINK ABOUT IF THERE ARE 446 00:14:31,360 --> 00:14:33,120 REALLY ACUTE AND THEY HAD TO 447 00:14:33,120 --> 00:14:35,280 WAIT A LONG TIME, THAT MIGHT 448 00:14:35,280 --> 00:14:37,400 MEAN THEY HAVE POORER OUTCOMES, 449 00:14:37,400 --> 00:14:38,600 THEY MAY HAVE COMPLICATIONS 450 00:14:38,600 --> 00:14:40,080 BECAUSE OF THEIR COMORBIDITIES, 451 00:14:40,080 --> 00:14:41,280 BECAUSE OF THE BEHAVIOR THEY 452 00:14:41,280 --> 00:14:42,480 ENGAGE WITH, AND SOMETIMES 453 00:14:42,480 --> 00:14:44,240 PATIENT FACTORS DIRECTLY AFFECT 454 00:14:44,240 --> 00:14:46,520 THE OUTCOME. 455 00:14:46,520 --> 00:14:47,200 SO WHETHER OR NOT THEY ARE 456 00:14:47,200 --> 00:14:49,240 TAKING THEIR MEDICINES MIGHT 457 00:14:49,240 --> 00:14:51,120 AFFECT THE OUTCOME OF THEIR 458 00:14:51,120 --> 00:14:55,400 HOSPITAL STAY, WHETHER THEY HAVE 459 00:14:55,400 --> 00:14:57,360 CERTAIN ACUITY, A VISIT WILL 460 00:14:57,360 --> 00:14:58,440 CERTAINLY AFFECT YOUR OUTCOME. 461 00:14:58,440 --> 00:15:00,000 SO I THINK THIS IS A VERY KIND 462 00:15:00,000 --> 00:15:02,360 OF LINEAR MODEL AND SOMETHING AS 463 00:15:02,360 --> 00:15:03,720 CLINICIANS, WE TEND TO THINK 464 00:15:03,720 --> 00:15:05,040 ABOUT, THERE'S PATIENT FACTORS 465 00:15:05,040 --> 00:15:06,320 THAT AFFECT PROCESSES THAT 466 00:15:06,320 --> 00:15:07,880 AFFECT YOUR OUTCOMES. 467 00:15:07,880 --> 00:15:09,240 BUT I THINK SOMETHING THAT WE'RE 468 00:15:09,240 --> 00:15:10,400 NOW UNDERSTANDING MORE OF IS 469 00:15:10,400 --> 00:15:12,120 THAT THERE ARE SYSTEM FACTORS 470 00:15:12,120 --> 00:15:14,120 THAT NOT ONLY AFFECT PATIENTS, 471 00:15:14,120 --> 00:15:17,040 SO FOR EXAMPLE, PATIENTS MAY NOT 472 00:15:17,040 --> 00:15:20,480 BE PRESENTING TO THE EMERGENCY 473 00:15:20,480 --> 00:15:21,640 DEPARTMENT BECAUSE THEY'RE 474 00:15:21,640 --> 00:15:22,320 FARTHER AWAY THAN OTHER PEOPLE 475 00:15:22,320 --> 00:15:23,640 WHO MIGHT HAVE THE SAME 476 00:15:23,640 --> 00:15:25,400 CONDITION AND THE EXACT SAME 477 00:15:25,400 --> 00:15:26,000 PRESENTATION BUT BECAUSE THEY 478 00:15:26,000 --> 00:15:28,200 ARE LOCATED MORE PROXIMATELY TO 479 00:15:28,200 --> 00:15:29,640 ANOTHER E.D., THAT AFFECTS THEIR 480 00:15:29,640 --> 00:15:32,360 WILLINGNESS TO GO. 481 00:15:32,360 --> 00:15:33,560 THERE'S SYSTEM FACTORS IN TERMS 482 00:15:33,560 --> 00:15:35,200 OF INSURANCE CERTAINLY, IF YOU 483 00:15:35,200 --> 00:15:37,240 ARE INSURED OR NOT INSURED, THAT 484 00:15:37,240 --> 00:15:38,520 AFFECTS YOUR CALCULUS ABOUT 485 00:15:38,520 --> 00:15:39,840 WHETHER OR NOT TO SEEK CARE, 486 00:15:39,840 --> 00:15:40,720 WHETHER OR NOT YOU ARE GOING TO 487 00:15:40,720 --> 00:15:44,800 HAVE A FINANCIAL CONSEQUENCE OF 488 00:15:44,800 --> 00:15:46,200 THAT VISIT, AND THEN THERE ARE 489 00:15:46,200 --> 00:15:47,320 SYSTEM FACTORS THAT AFFECT THE 490 00:15:47,320 --> 00:15:47,840 PROCESSES. 491 00:15:47,840 --> 00:15:51,040 SO FOR EXAMPLE, THE OWNERSHIP OF 492 00:15:51,040 --> 00:15:55,400 A HOSPITAL MAY BE HIGHLY RELATED 493 00:15:55,400 --> 00:15:56,200 TO WHETHER OR NOT THEY PROVIDE 494 00:15:56,200 --> 00:15:58,240 CERTAIN SERVICES. 495 00:15:58,240 --> 00:16:00,640 NOT JUST THINGS LIKE DERMATOLOGY 496 00:16:00,640 --> 00:16:02,600 OR THINGS THAT WE TEND TO THINK 497 00:16:02,600 --> 00:16:05,600 OF AS LUXURY KIND OF HEALTHCARE 498 00:16:05,600 --> 00:16:09,040 SERVICES, BUT THINGS THAT ARE 499 00:16:09,040 --> 00:16:10,240 EVEN VERY CRITICAL TO YOUR 500 00:16:10,240 --> 00:16:10,480 HEALTH. 501 00:16:10,480 --> 00:16:11,800 SO THERE ARE SYSTEM FACTORS THAT 502 00:16:11,800 --> 00:16:13,200 WE'LL TALK ABOUT TODAY AND WHAT 503 00:16:13,200 --> 00:16:14,400 I SHARE WITH YOU TO KIND OF 504 00:16:14,400 --> 00:16:15,840 THINK MORE BROADLY ABOUT HOW 505 00:16:15,840 --> 00:16:17,680 THOSE AFFECT PROCESSES BECAUSE 506 00:16:17,680 --> 00:16:21,000 YOU DON'T HAVE CERTAIN 507 00:16:21,000 --> 00:16:22,040 HEALTHCARE SERVICES AVAILABLE IN 508 00:16:22,040 --> 00:16:23,440 YOUR AREA, THAT AFFECTS YOUR 509 00:16:23,440 --> 00:16:25,640 ABILITY TO GET TREATED AND THAT 510 00:16:25,640 --> 00:16:30,000 AFFECTS YOUR OUTCOME. 511 00:16:30,000 --> 00:16:31,360 SO NOT ONLY DO THE SYSTEM 512 00:16:31,360 --> 00:16:32,240 FACTORS AFFECT THE PROCESSES 513 00:16:32,240 --> 00:16:34,040 THAT AFFECTS YOUR OUTCOME, THE 514 00:16:34,040 --> 00:16:35,280 SYSTEM FACTORS CAN DIRECTLY 515 00:16:35,280 --> 00:16:36,480 AFFECT YOUR OUTCOME, AND HOW CAN 516 00:16:36,480 --> 00:16:37,200 THAT BE? 517 00:16:37,200 --> 00:16:40,680 WELL, IF WE THINK ABOUT THINGS 518 00:16:40,680 --> 00:16:41,640 LIKE -- IF YOU THINK BROADLY, 519 00:16:41,640 --> 00:16:43,160 YOU THINK ABOUT CALIFORNIA IS 520 00:16:43,160 --> 00:16:45,040 ONE OF THE ONLY STATES WITH 521 00:16:45,040 --> 00:16:46,920 NURSING RATIOS THAT CAN AFFECT 522 00:16:46,920 --> 00:16:47,880 YOUR OUTCOME, THERE ARE 523 00:16:47,880 --> 00:16:50,760 OWNERSHIP FACTORS ABOUT WHETHER 524 00:16:50,760 --> 00:16:53,360 OR NOT THEY HAVE CERTAIN 525 00:16:53,360 --> 00:16:55,240 GUIDELINES OR PROTOCOLS IN THAT 526 00:16:55,240 --> 00:16:56,440 HOSPITAL SYSTEM AND THAT CAN 527 00:16:56,440 --> 00:16:58,320 AFFECT YOUR OUTCOME IF THEY'RE 528 00:16:58,320 --> 00:16:59,760 NOT PROTOCOLIZED IN THE SAME 529 00:16:59,760 --> 00:17:00,240 WAY. 530 00:17:00,240 --> 00:17:01,480 FINANCIAL FACTORS CERTAINLY OF 531 00:17:01,480 --> 00:17:02,680 THAT HOSPITAL SYSTEM CAN AFFECT 532 00:17:02,680 --> 00:17:04,680 YOUR OUTCOME BECAUSE OF THE WAY 533 00:17:04,680 --> 00:17:09,480 THEY DI DECIDE TO INCENTIVIZE CARE, 534 00:17:09,480 --> 00:17:11,080 WHETHER IT'S THE WAY THEY PAY 535 00:17:11,080 --> 00:17:12,200 THEIR PROVIDERS OR THE WAY 536 00:17:12,200 --> 00:17:13,280 THEY'RE CAPITATED OR NOT AND 537 00:17:13,280 --> 00:17:14,400 THEY TRY TO CONNECT WITH PRIMARY 538 00:17:14,400 --> 00:17:17,640 CARE OR NOT. 539 00:17:17,640 --> 00:17:18,840 SO THIS IS WHAT I WANT TO 540 00:17:18,840 --> 00:17:19,720 ENCOURAGE US TO THINK ABOUT 541 00:17:19,720 --> 00:17:21,360 TODAY, IS TAKING A LARGER VIEW 542 00:17:21,360 --> 00:17:22,680 OF THE STRUCTURAL FACTORS THAT 543 00:17:22,680 --> 00:17:26,840 ARE FACING OUR PATIENTS. 544 00:17:26,840 --> 00:17:28,080 SO WE TEND TO THINK OF SOCIAL 545 00:17:28,080 --> 00:17:30,440 NEEDS AND HEALTH INEQUITIES AS 546 00:17:30,440 --> 00:17:31,640 VERY INDIVIDUAL ORIENTED, THINGS 547 00:17:31,640 --> 00:17:33,200 LIKE INCREASED E.D. WAIT TIMES 548 00:17:33,200 --> 00:17:35,440 OR LESS FREQUENT PAIN MEDICATION 549 00:17:35,440 --> 00:17:37,800 ADMINISTRATION OR HE DECREASED 550 00:17:37,800 --> 00:17:39,240 RATES OF IMAGING. 551 00:17:39,240 --> 00:17:40,640 SO THERE'S PLENTY OF STUDIES, 552 00:17:40,640 --> 00:17:42,440 HUNDREDS IF NOT THOUSANDS, OF 553 00:17:42,440 --> 00:17:43,680 HOW THERE ARE DIFFERENT 554 00:17:43,680 --> 00:17:45,880 RELATIONSHIPS OF WHETHER YOU 555 00:17:45,880 --> 00:17:47,040 GET, FOR EXAMPLE, PAIN 556 00:17:47,040 --> 00:17:47,920 MEDICATION WITHIN -- IF YOU HAVE 557 00:17:47,920 --> 00:17:52,160 A LONG BONE FRACTURE, IF YOU ARE 558 00:17:52,160 --> 00:17:52,880 BLACK OR AFRICAN AMERICAN, YOU 559 00:17:52,880 --> 00:17:54,840 MAY HAVE TO WAIT LONGER FOR 560 00:17:54,840 --> 00:17:56,040 THE -- TO GET YOUR PAIN 561 00:17:56,040 --> 00:17:57,920 MEDICATION THAN A WHITE PATIENT 562 00:17:57,920 --> 00:17:59,640 WHO HAS THE SAME LONG BONE 563 00:17:59,640 --> 00:18:00,000 FRACTURE. 564 00:18:00,000 --> 00:18:01,760 SO THOSE ARE EXAMPLES OF THINGS 565 00:18:01,760 --> 00:18:03,840 WE TEND TO THINK OF, I THINK AT 566 00:18:03,840 --> 00:18:05,120 LEAST I DO IN THE TBINNING, WE 567 00:18:05,120 --> 00:18:07,320 TEND TO THINK OF THEM AS 568 00:18:07,320 --> 00:18:07,800 INDIVIDUAL INEQUITIES. 569 00:18:07,800 --> 00:18:09,960 THIS IS ONE PROVIDER WHO HAS 570 00:18:09,960 --> 00:18:12,040 DECIDED TO TREAT A PATIENT 571 00:18:12,040 --> 00:18:13,240 DIFFERENTLY BASED ON THE COLOR 572 00:18:13,240 --> 00:18:16,320 OF THEIR SKIN OR THEIR INSURANCE 573 00:18:16,320 --> 00:18:18,720 STATUS, OR WHETHER OR NOT -- 574 00:18:18,720 --> 00:18:20,640 THEY HAVE THEIR OWN BIASES, 575 00:18:20,640 --> 00:18:21,680 WHETHER THEY'RE HOUSED OR 576 00:18:21,680 --> 00:18:22,880 STRUGGLING WITH OTHER BEHAVIORS. 577 00:18:22,880 --> 00:18:26,800 SO I THINK THIS IS A TRADITIONAL 578 00:18:26,800 --> 00:18:28,640 MODEL OF THINKING ABOUT 579 00:18:28,640 --> 00:18:29,800 INEQUITIES AND SOCIAL FACTORS, 580 00:18:29,800 --> 00:18:30,480 VERY MUCH BASED ON THE 581 00:18:30,480 --> 00:18:32,560 INDIVIDUAL, WHETHER IT'S THE 582 00:18:32,560 --> 00:18:33,600 PROVIDER OR THE PATIENT. 583 00:18:33,600 --> 00:18:37,920 I JUST WANT TO SHOW THIS SLIDE 584 00:18:37,920 --> 00:18:38,880 BECAUSE WHEN I -- I REMEMBER 585 00:18:38,880 --> 00:18:40,280 SEEING THIS A LONG TIME AGO IN 586 00:18:40,280 --> 00:18:41,600 RESIDENCY AND I PICKED IT OFF 587 00:18:41,600 --> 00:18:42,840 THE ACTUAL REPORT, SO HERE 588 00:18:42,840 --> 00:18:44,800 YOU'LL SEE, THIS IS TAKEN FROM 589 00:18:44,800 --> 00:18:49,640 THE CDC, NCHS, AND WE'RE GOING 590 00:18:49,640 --> 00:18:57,600 TO TOMORROW DELVE IN TO THE DATA 591 00:18:57,600 --> 00:19:01,880 RESOURCES ALREADY COLLECTED, WE 592 00:19:01,880 --> 00:19:03,080 HAVE EXCITING WAYS TO THINK 593 00:19:03,080 --> 00:19:03,640 ABOUT DATA. 594 00:19:03,640 --> 00:19:05,120 BUT THIS IS SOMETHING THEY 595 00:19:05,120 --> 00:19:06,120 PUBLISHED ABOUT 10 YEARS AGO, 596 00:19:06,120 --> 00:19:06,440 I'D SAY. 597 00:19:06,440 --> 00:19:08,520 SO THIS IS JUST SAYING WHAT IS 598 00:19:08,520 --> 00:19:10,840 THE MEAN WAIT TIME TO SEE A 599 00:19:10,840 --> 00:19:11,360 PHYSICIAN IN THE EMERGENCY 600 00:19:11,360 --> 00:19:12,160 DEPARTMENT. 601 00:19:12,160 --> 00:19:13,640 AND THIS ISN'T ADJUSTED, IT'S 602 00:19:13,640 --> 00:19:17,040 JUST KIND OF A RAW OUTPUT. 603 00:19:17,040 --> 00:19:18,920 SO LOOKING AT AGE, SEX, RACE AND 604 00:19:18,920 --> 00:19:19,360 HISPANIC ORIGIN. 605 00:19:19,360 --> 00:19:26,240 SO YOU'LL SEE HERE THAT WHITES, 606 00:19:26,240 --> 00:19:28,560 NOT HISPANICS, HAD A MEAN WAIT 607 00:19:28,560 --> 00:19:30,040 TIME OF 15 MINUTES AND BLACK 608 00:19:30,040 --> 00:19:32,600 NON-HISPANIC HAD A MEAN WAIT 609 00:19:32,600 --> 00:19:34,320 TIME OF 68 AND HISPANIC PATIENTS 610 00:19:34,320 --> 00:19:35,680 HAD A MEAN WAIT TIME OF 60. 611 00:19:35,680 --> 00:19:38,720 SO I THINK WHEN PEOPLE LOOK AT 612 00:19:38,720 --> 00:19:40,800 THIS, THEY MAY SAY, WELL, THIS 613 00:19:40,800 --> 00:19:46,160 IS CLEARLY INDIVIDUAL BIAS, THIS 614 00:19:46,160 --> 00:19:47,160 IS ONE PHYSICIAN WHO HAS 615 00:19:47,160 --> 00:19:48,240 DECIDED, WHEN THEY'RE LOOKING AT 616 00:19:48,240 --> 00:19:49,120 WHO TO TREAT, WHETHER IT'S IN 617 00:19:49,120 --> 00:19:51,000 THE WAITING ROOM OR WHETHER 618 00:19:51,000 --> 00:19:52,280 THEY'VE BEEN ALREADY IN THE 619 00:19:52,280 --> 00:19:53,920 E.D., AND I'M NOT SAYING 620 00:19:53,920 --> 00:19:54,760 CLINICIANS WOULD NECESSARILY 621 00:19:54,760 --> 00:19:56,560 THINK OF THIS, I WOULD SAY LAY 622 00:19:56,560 --> 00:19:57,760 PEOPLE MIGHT LOOK AT THIS AND 623 00:19:57,760 --> 00:19:59,680 SAY THIS IS AN EXAMPLE OF STRONG 624 00:19:59,680 --> 00:20:02,240 INDIVIDUAL PIE BIAS. 625 00:20:02,240 --> 00:20:03,360 I WANT TO ENCOURAGE US TO THINK 626 00:20:03,360 --> 00:20:04,520 ABOUT WHAT THE STRUCTURAL 627 00:20:04,520 --> 00:20:05,840 FACTORS MIGHT BE THAT HAVE 628 00:20:05,840 --> 00:20:06,960 CREATED THESE INEQUITIES AND 629 00:20:06,960 --> 00:20:11,280 THESE TYPES OF SOCIAL NEEDS. 630 00:20:11,280 --> 00:20:14,640 SO I WANT TO KIND OF URGE US TO 631 00:20:14,640 --> 00:20:16,240 THINK ABOUT THIS LEFT SIDE OF 632 00:20:16,240 --> 00:20:18,480 THE SYSTEM FACTORS OF WHAT THESE 633 00:20:18,480 --> 00:20:19,000 RELATIONSHIPS ARE. 634 00:20:19,000 --> 00:20:20,520 SO HOW CAN WE GO BEYOND THE 635 00:20:20,520 --> 00:20:22,200 INDIVIDUAL LEVEL OR EVEN THE 636 00:20:22,200 --> 00:20:23,240 FACILITY LEVEL. 637 00:20:23,240 --> 00:20:24,880 WHEN I SAY FACILITY LEVEL, I'M 638 00:20:24,880 --> 00:20:25,880 TALKING ABOUT THINGS THAT ARE 639 00:20:25,880 --> 00:20:27,320 LIKE HOSPITAL PRACTICES. 640 00:20:27,320 --> 00:20:29,720 SO THERE MAY BE SURGEON 641 00:20:29,720 --> 00:20:31,040 HOSPITALS THAT HAVE DIFFERENT 642 00:20:31,040 --> 00:20:32,120 HOSPITALS THAT MIGHT HAVE 643 00:20:32,120 --> 00:20:33,560 CERTAIN INEQUITIES BAKED IN 644 00:20:33,560 --> 00:20:35,640 ABOUT HOW THEY TRIAGE PATIENT OR 645 00:20:35,640 --> 00:20:38,480 HOW THEY REGISTER PATIENTS AND 646 00:20:38,480 --> 00:20:40,240 THAT HAS DOWNSTREAM EFFECTS OF 647 00:20:40,240 --> 00:20:41,240 WHETHER OR NOT THOSE PATIENTS DO 648 00:20:41,240 --> 00:20:45,080 END UP HAVING AND EXPERIENCING 649 00:20:45,080 --> 00:20:45,360 INEQUITY. 650 00:20:45,360 --> 00:20:48,000 BUT I WANT TO THINK ABOUT 651 00:20:48,000 --> 00:20:48,440 STRUCTURAL ISSUES. 652 00:20:48,440 --> 00:20:49,440 I THINK OVER THE PAST FIVE 653 00:20:49,440 --> 00:20:50,880 YEARS, WE MIGHT HAVE HEARD MORE 654 00:20:50,880 --> 00:20:52,280 OF THIS BUT IT'S STILL NOT USED 655 00:20:52,280 --> 00:20:53,840 THAT COMMONLY WHEN WE TALK ABOUT 656 00:20:53,840 --> 00:20:54,280 INEQUITIES. 657 00:20:54,280 --> 00:20:57,040 I THINK THE INEQUITY COMMUNITY 658 00:20:57,040 --> 00:20:58,560 TALKS MORE ABOUT THIS AND THERE 659 00:20:58,560 --> 00:21:00,760 IS A REALLY GREAT SERIES OF 660 00:21:00,760 --> 00:21:03,920 STUDIES OR OF JUST EXPOSITIONS 661 00:21:03,920 --> 00:21:06,560 BY THE NATIONAL INSTITUTE FOR 662 00:21:06,560 --> 00:21:08,040 MINORITY HEALTH AND HEALTH 663 00:21:08,040 --> 00:21:10,240 DISPARITIES, NIMHD AND THE 664 00:21:10,240 --> 00:21:11,160 AMERICAN JOURNAL OF PUBLIC 665 00:21:11,160 --> 00:21:12,760 HEALTH, I THINK THAT WAS IN 2019 666 00:21:12,760 --> 00:21:14,080 OR 2020, BUT IT WAS A SPECIAL 667 00:21:14,080 --> 00:21:16,160 ISSUE DEDICATED TO THINKING 668 00:21:16,160 --> 00:21:16,560 ABOUT THIS. 669 00:21:16,560 --> 00:21:18,240 WHEN WE TALK ABOUT STRUCTURAL 670 00:21:18,240 --> 00:21:19,560 DISCRIMINATION, IT'S NOT SAYING 671 00:21:19,560 --> 00:21:22,280 THERE'S ONE PERSON WHO IS 672 00:21:22,280 --> 00:21:24,680 CHOOSING TO OVERLAY THEIR OWN 673 00:21:24,680 --> 00:21:26,560 BIASES ON ANOTHER PERSON, BUT 674 00:21:26,560 --> 00:21:28,640 IT'S -- AND IT'S MORE THAN JUST 675 00:21:28,640 --> 00:21:29,440 A FACILITY. 676 00:21:29,440 --> 00:21:30,680 IT'S TALKING ABOUT HOW THE 677 00:21:30,680 --> 00:21:36,040 SYSTEM IN AND OF ITSELF CONTAINS 678 00:21:36,040 --> 00:21:37,600 ELEMENTS THAT AFFECT PEOPLE'S 679 00:21:37,600 --> 00:21:39,520 OUTCOMES AND MAY NOT -- IT MAY 680 00:21:39,520 --> 00:21:44,200 NOT AT ALL BE RELATED TO AN 681 00:21:44,200 --> 00:21:45,440 INTENTIONAL DESIRE TO DO SO, BUT 682 00:21:45,440 --> 00:21:47,640 THAT WE MAY BE WORKING IN 683 00:21:47,640 --> 00:21:52,280 SYSTEMS THAT ALREADY HAVE A 684 00:21:52,280 --> 00:21:55,440 STRUCTURAL FOUNDATION WHERE 685 00:21:55,440 --> 00:21:57,200 INEQUITY IS THE OUTCOME OF THE 686 00:21:57,200 --> 00:21:57,640 SYSTEM. 687 00:21:57,640 --> 00:21:59,040 AND AGAIN, I WANT TO EMPHASIZE 688 00:21:59,040 --> 00:22:00,360 THAT THIS IS NOT SAYING THAT 689 00:22:00,360 --> 00:22:01,600 IT'S FINGER-POINTING AND SAYING 690 00:22:01,600 --> 00:22:02,640 THAT THIS IS ONLY INDIVIDUALS 691 00:22:02,640 --> 00:22:04,200 WHO ARE INVOLVED IN THIS, BUT 692 00:22:04,200 --> 00:22:05,840 THAT IT'S BAKED INTO THE SYSTEM, 693 00:22:05,840 --> 00:22:07,160 AND THAT'S WHAT I'LL TALK ABOUT 694 00:22:07,160 --> 00:22:09,000 TODAY, SO THAT WHEN WE WORK IN 695 00:22:09,000 --> 00:22:11,000 THE SYSTEM, IF WE AREN'T AWARE 696 00:22:11,000 --> 00:22:13,600 OF THAT, THAT THE OUTCOME OF OUR 697 00:22:13,600 --> 00:22:15,800 WORK CAN LEAD TO INEQUITIES. 698 00:22:15,800 --> 00:22:19,280 SO I'M GOING TO JUST SHOW THIS 699 00:22:19,280 --> 00:22:20,440 SLIDE HERE, WHICH IS A STUDY 700 00:22:20,440 --> 00:22:24,080 THAT I DID A WHILE BACK WITH A 701 00:22:24,080 --> 00:22:25,440 COLLABORATOR, SO THIS IS JUST 702 00:22:25,440 --> 00:22:27,960 LOOKING AT AMBULANCE DIVER 703 00:22:27,960 --> 00:22:28,280 VERSION. 704 00:22:28,280 --> 00:22:33,200 I'M SURE A LOT OF YOU KNOW WHAT 705 00:22:33,200 --> 00:22:34,040 AMBULANCE DIVERSION IS, BUT IT'S 706 00:22:34,040 --> 00:22:37,800 WHAT HAPPENS WHEN YOUR HOSPITAL 707 00:22:37,800 --> 00:22:38,600 DECIDES IT IS TOO FULL. 708 00:22:38,600 --> 00:22:40,000 THERE CAN BE MANY REASONS FOR 709 00:22:40,000 --> 00:22:41,440 THAT OR IT CAN DECIDE IT DOESN'T 710 00:22:41,440 --> 00:22:43,320 HAVE CAPACITY, SO FOR EXAMPLE, 711 00:22:43,320 --> 00:22:44,880 OTHER REASONS MIGHT BE IF THE CT 712 00:22:44,880 --> 00:22:47,280 SCANNER IS DOWN, BUT IN GENERAL, 713 00:22:47,280 --> 00:22:48,080 AMBULANCE DIVERSION HAPPENS WHEN 714 00:22:48,080 --> 00:22:50,040 THERE IS A BOTTLENECK IN THE 715 00:22:50,040 --> 00:22:51,840 E.D., AND USUALLY THAT 716 00:22:51,840 --> 00:22:55,440 BOTTLENECK, AS MOST OF US KNOW, 717 00:22:55,440 --> 00:22:57,400 ARE ON THE INPATIENT SIDE. 718 00:22:57,400 --> 00:23:01,200 THEY HAVE PATIENTS WAITING BUT 719 00:23:01,200 --> 00:23:02,200 THERE'S NO EMPTY BEDS SO THE 720 00:23:02,200 --> 00:23:03,720 HOSPITAL BACKS UP. 721 00:23:03,720 --> 00:23:07,760 SO WHEN THE HOSPITAL DECIDES 722 00:23:07,760 --> 00:23:09,280 IT'S UNSAFE TO TAKE MORE 723 00:23:09,280 --> 00:23:11,360 AMBULANCE TRAFFIC, THEY GO ON 724 00:23:11,360 --> 00:23:12,560 AMBULANCE DIVERGENCE, SO THEY 725 00:23:12,560 --> 00:23:15,520 CAN NO LONGER DROP OFF PATIENTS 726 00:23:15,520 --> 00:23:18,520 THAT -- THAT HOSPITAL -- USUALLY 727 00:23:18,520 --> 00:23:20,000 THE EMS SERVICE TAKES PATIENTS 728 00:23:20,000 --> 00:23:22,240 TO THE NEAREST HOSPITAL BUT IF 729 00:23:22,240 --> 00:23:23,520 YOU'RE ON AMBULANCE DIVERT, THE 730 00:23:23,520 --> 00:23:24,840 HOSPITAL SAYS YOU CAN'T COME 731 00:23:24,840 --> 00:23:26,240 HERE AND NOW THE AMBULANCE NEEDS 732 00:23:26,240 --> 00:23:27,560 TO GO TO THE NEXT NEAREST 733 00:23:27,560 --> 00:23:29,680 HOSPITAL, WHICH HAS 734 00:23:29,680 --> 00:23:30,000 CONSEQUENCES. 735 00:23:30,000 --> 00:23:31,240 NAT ONLY FOR THE PATIENT, NOW 736 00:23:31,240 --> 00:23:32,560 THE PATIENT HAS TO WAIT LONGER 737 00:23:32,560 --> 00:23:35,440 FOR CARE, AND WE KNOW THAT FOR 738 00:23:35,440 --> 00:23:37,600 CONDITIONS THAT REQUIRE -- THAT 739 00:23:37,600 --> 00:23:39,000 ARE TIME-SENSITIVE, YOU NEED TO 740 00:23:39,000 --> 00:23:43,240 GET TO CARE AS SOON AS POSSIBLE. 741 00:23:43,240 --> 00:23:44,680 BUT EVEN EVEN OUTSIDE OF THE 742 00:23:44,680 --> 00:23:45,840 PATIENT, IT PUTS THAT AMBULANCE 743 00:23:45,840 --> 00:23:46,560 OUT OF SERVICE. 744 00:23:46,560 --> 00:23:48,640 SO OTHER PATIENTS WHO DEPEND ON 745 00:23:48,640 --> 00:23:49,640 AMBULANCE SERVICES NOW, THEY 746 00:23:49,640 --> 00:23:50,360 HAVE TO WAIT TOO. 747 00:23:50,360 --> 00:23:51,680 SO YOU CAN DEFINITELY JUST SEE 748 00:23:51,680 --> 00:23:55,280 THIS DOMINO EFFECT. 749 00:23:55,280 --> 00:23:57,600 BUT AMBULANCE DIVERSION AT LEAST 750 00:23:57,600 --> 00:23:59,320 IN HEALTH RESEARCH, WE USE IT AS 751 00:23:59,320 --> 00:24:00,640 A PROXY FOR CROWDING. 752 00:24:00,640 --> 00:24:02,320 AND SO WHEN WE THINK ABOUT E.D. 753 00:24:02,320 --> 00:24:05,600 WAIT TIMES, THEN WE ALSO CAN USE 754 00:24:05,600 --> 00:24:06,880 AMBULANCE DIVERSION AS KIND OF A 755 00:24:06,880 --> 00:24:10,920 VERY ROUGH PROXY FOR CROWDING. 756 00:24:10,920 --> 00:24:12,360 SO NOW WHAT WE SEE HERE IS WHEN 757 00:24:12,360 --> 00:24:15,400 WE LOOK AT HOSPITALS BASED ON 758 00:24:15,400 --> 00:24:18,640 THEIR PATIENTS THAT THEY SERVE, 759 00:24:18,640 --> 00:24:20,880 SO NON-MINORITY SERVING 760 00:24:20,880 --> 00:24:24,240 HOSPITALS -- EXCUSE HE -- 761 00:24:24,240 --> 00:24:27,720 MINORITY SERVING HOSPITALS, 762 00:24:27,720 --> 00:24:29,320 THEY'RE THE ONES IN THE DOTTED 763 00:24:29,320 --> 00:24:29,720 RED LINE. 764 00:24:29,720 --> 00:24:31,800 SO WHEN WE LOOKED AT 10 YEARS OF 765 00:24:31,800 --> 00:24:33,320 DATA, EVERY YEAR AND EVERY MONTH 766 00:24:33,320 --> 00:24:35,320 OF DATA, WE SAW THERE'S A VERY 767 00:24:35,320 --> 00:24:36,640 CONSISTENT PATTERN WHERE 768 00:24:36,640 --> 00:24:37,560 NON-MINORITY SERVING HOSPITALS 769 00:24:37,560 --> 00:24:39,640 HAD A MUCH HIGHER NUMBER OF 770 00:24:39,640 --> 00:24:41,400 AMBULANCE DIVERSION THAN -- 771 00:24:41,400 --> 00:24:42,600 SORRY, MINORITY SERVING 772 00:24:42,600 --> 00:24:45,000 HOSPITALS HAD A MUCH HIGHER MEAN 773 00:24:45,000 --> 00:24:46,960 DAILY HOURS OF DIVERSION THAN 774 00:24:46,960 --> 00:24:48,040 NON-MINORITY SERVING HOSPITALS. 775 00:24:48,040 --> 00:24:49,280 SO YOU'LL SEE THAT EVEN THOUGH 776 00:24:49,280 --> 00:24:50,880 OVER TIME THAT NUMBER HAS 777 00:24:50,880 --> 00:24:52,840 DECREASED, AND THAT'S DUE TO A 778 00:24:52,840 --> 00:24:53,880 LOT OF DIFFERENT INTERVENTIONS 779 00:24:53,880 --> 00:24:56,600 WE'VE HAD, WE GET E.D. CASE 780 00:24:56,600 --> 00:24:58,120 MANAGERS AND SOME PLACES, THIS 781 00:24:58,120 --> 00:25:00,040 WAS LOOKING AT CALIFORNIA DATA, 782 00:25:00,040 --> 00:25:02,840 I BELIEVE, SOME PLACES HAVE 783 00:25:02,840 --> 00:25:04,600 BANNED DIVERSION, SO THAT'S WHY 784 00:25:04,600 --> 00:25:05,840 IN GENERAL, THE NUMBERS ARE 785 00:25:05,840 --> 00:25:07,280 LOWER, BUT YOU'LL SEE IT'S A 786 00:25:07,280 --> 00:25:07,960 SIGNIFICANT PERCENTAGE EVERY 787 00:25:07,960 --> 00:25:12,200 YEAR, THAT IS CONSISTENTLY 788 00:25:12,200 --> 00:25:13,440 HIGHER FOR HOSPITALS THAT SERVE 789 00:25:13,440 --> 00:25:14,280 MINORITY PATIENTS. 790 00:25:14,280 --> 00:25:15,880 THIS IS THE SAME THING WHEN WE 791 00:25:15,880 --> 00:25:19,640 LOOKED AT BLACK-SERVING 792 00:25:19,640 --> 00:25:21,240 HOSPITALS, WE ALSO FOUND 793 00:25:21,240 --> 00:25:22,920 BLACK-SERVING HOSPITALS HAD A 794 00:25:22,920 --> 00:25:25,360 HIGHER NUMBER OF PATIENTS WHO 795 00:25:25,360 --> 00:25:25,920 EXPERIENCE DIVERGENCE. 796 00:25:25,920 --> 00:25:27,440 SO NOT ONLY IS IT THE NUMBER OF 797 00:25:27,440 --> 00:25:28,520 HOURS, THE REASON WHY WE WANTED 798 00:25:28,520 --> 00:25:29,720 TO LACK AT THIS, IF YOU LOOK 799 00:25:29,720 --> 00:25:30,680 BACK AT THE SLIDE, THIS IS THE 800 00:25:30,680 --> 00:25:31,880 NUMBER OF HOURS PER HOSPITAL. 801 00:25:31,880 --> 00:25:33,560 BUT YOU COULD SAY, WELL, LET'S 802 00:25:33,560 --> 00:25:35,640 SAY, FOR EXAMPLE, THAT THE 803 00:25:35,640 --> 00:25:38,200 HOSPITAL IS NOT AS BUSY, SO 804 00:25:38,200 --> 00:25:40,080 MAYBE MINORITY-SERVING HOSPITALS 805 00:25:40,080 --> 00:25:41,480 ARE LESS BUSY SO IT DOESN'T 806 00:25:41,480 --> 00:25:42,640 AFFECT AS MANY PATIENTS. 807 00:25:42,640 --> 00:25:44,080 BUT IF WE LOOK AT THE NUMBER OF 808 00:25:44,080 --> 00:25:45,520 PATIENTS WHO EXPERIENCE 809 00:25:45,520 --> 00:25:46,640 DIVERSION, IT'S THE SAME THING, 810 00:25:46,640 --> 00:25:49,880 AND WE ALSO WANTED TO LOOK AT 811 00:25:49,880 --> 00:25:50,880 NOT JUST MINORITY STATUS BUT 812 00:25:50,880 --> 00:25:52,760 BLACK SERVING HOSPITALS AS WELL, 813 00:25:52,760 --> 00:25:53,840 YOU'LL SEE THE TOP LINE ARE THE 814 00:25:53,840 --> 00:25:55,240 HOSPITALS THAT HAVE A HIGH 815 00:25:55,240 --> 00:25:57,440 PROPORTION OF PATIENTS WHO ARE 816 00:25:57,440 --> 00:25:58,560 BLACK, AND THERE'S A HIGHER 817 00:25:58,560 --> 00:26:00,000 NUMBER OF PATIENTS ALSO WHO 818 00:26:00,000 --> 00:26:00,760 EXPERIENCE DIVERSION. 819 00:26:00,760 --> 00:26:02,160 SO IT'S NOT ONLY BY THE NUMBER 820 00:26:02,160 --> 00:26:04,120 OF HOURS, BUT IT BY THE NUMBER 821 00:26:04,120 --> 00:26:05,560 OF PATIENTS, THE PERCENTAGE OF 822 00:26:05,560 --> 00:26:11,640 PATIENTS WHO ARE EXPERIENCING 823 00:26:11,640 --> 00:26:12,000 DIVERSION. 824 00:26:12,000 --> 00:26:13,400 NOW WHY IS IT WHEN WE LOOK AT 825 00:26:13,400 --> 00:26:14,640 HOSPITALS THAT SERVE DIFFERENT 826 00:26:14,640 --> 00:26:15,840 RATES OF MINORITY PATIENTS, WHY 827 00:26:15,840 --> 00:26:23,000 DOES THAT MATTER? 828 00:26:23,000 --> 00:26:25,800 SO I'M QUOTING THIS STUDY, BUT 829 00:26:25,800 --> 00:26:27,240 YOU'LL SEE HERE, I'LL SHOW YOU 830 00:26:27,240 --> 00:26:28,640 TWO SLIDES, SO THIS IS JUST 831 00:26:28,640 --> 00:26:29,040 WHITE PATIENTS. 832 00:26:29,040 --> 00:26:30,160 SOME PEOPLE SAY, WELL, MAYBE 833 00:26:30,160 --> 00:26:32,160 WHEN WE LOOK AT THE GENERAL 834 00:26:32,160 --> 00:26:37,680 LITERATURE, YOU'LL LOOK AT MAYBE 835 00:26:37,680 --> 00:26:39,400 NEWSPAPER REPORTS THAT SAY BLACK 836 00:26:39,400 --> 00:26:40,640 OR HISPANIC PATIENTS HAVE HIGHER 837 00:26:40,640 --> 00:26:41,720 MORTALITY THAN WHITE PATIENTS. 838 00:26:41,720 --> 00:26:42,920 THEN WE START TO WONDER IS THAT 839 00:26:42,920 --> 00:26:44,000 BECAUSE OF INDIVIDUAL 840 00:26:44,000 --> 00:26:45,560 DISCRIMINATION OR ARE THERE 841 00:26:45,560 --> 00:26:46,440 ISSUES RELATED TO THE HOSPITALS 842 00:26:46,440 --> 00:26:48,040 THAT THEY GO TO? 843 00:26:48,040 --> 00:26:50,040 AND SO WHEN WE LOOK HERE, THIS 844 00:26:50,040 --> 00:26:51,240 STUDY LOOKS AT DIFFERENT 845 00:26:51,240 --> 00:26:54,640 CONDITIONS OF AMI, ACUTE 846 00:26:54,640 --> 00:26:58,880 MYOCARDIAL INFARCTION, CHF, 847 00:26:58,880 --> 00:27:01,040 CONGESTIVE HEART FAILURE, 848 00:27:01,040 --> 00:27:02,480 PNEUMONIA, AND ALSO IT LOOKS AT 849 00:27:02,480 --> 00:27:04,360 MORTALITY RATES, WHAT HAPPENS TO 850 00:27:04,360 --> 00:27:06,920 YOUR 30, 90 DAY MORTALITY RATES, 851 00:27:06,920 --> 00:27:08,880 BASED ON WHETHER YOU WENT TO A 852 00:27:08,880 --> 00:27:12,360 BLACK-SERVING HOSPITAL OR A 853 00:27:12,360 --> 00:27:12,920 NON-BLACK-SERVING HOSPITAL? 854 00:27:12,920 --> 00:27:15,000 YOU'LL SEE THE FIRST NUMBER IS 855 00:27:15,000 --> 00:27:16,120 14.9%. 856 00:27:16,120 --> 00:27:20,160 IT'S YOUR MORTALITY RACE. 857 00:27:20,160 --> 00:27:21,360 IF YOU'RE WHITE AND GO TO A 858 00:27:21,360 --> 00:27:26,720 BLACK SERVING HOSPITAL, YOUR 859 00:27:26,720 --> 00:27:31,200 FATALITY RATE -- SO YOU'LL SEE 860 00:27:31,200 --> 00:27:34,880 THAT ACROSS CONDITIONS, FOR EACH 861 00:27:34,880 --> 00:27:36,080 CONDITION AND FOR EACH MORTALITY 862 00:27:36,080 --> 00:27:37,840 RATE, THE MORTALITY RATE IS 863 00:27:37,840 --> 00:27:40,960 HIGHER FOR WHITE PATIENTS THAT 864 00:27:40,960 --> 00:27:42,400 GO TO BLACK-SERVING HOSPITALS, 865 00:27:42,400 --> 00:27:44,160 AND WHEN YOU LOOK AT THE ODDS 866 00:27:44,160 --> 00:27:45,440 RATIO, YOU'LL SEE THAT 867 00:27:45,440 --> 00:27:46,200 CONSISTENTLY, THERE'S ONLY ONE 868 00:27:46,200 --> 00:27:48,320 THAT'S NOT STATISTICALLY 869 00:27:48,320 --> 00:27:49,920 SIGNIFICANT FOR CHF, BUT THAT 870 00:27:49,920 --> 00:27:51,640 ALL OF THEM HAVE HIGHER -- IF 871 00:27:51,640 --> 00:27:52,680 YOU -- BASICALLY THE WAY TO 872 00:27:52,680 --> 00:27:54,200 INTERPRET THIS IS IF YOU ARE A 873 00:27:54,200 --> 00:27:55,840 WHITE PATIENT THAT GOES TO A 874 00:27:55,840 --> 00:27:56,960 BLACK-SERVING HOSPITAL, YOU HAVE 875 00:27:56,960 --> 00:28:00,000 A HIGHER ODDS OF DYING, WHETHER 876 00:28:00,000 --> 00:28:01,640 AT 30 DAYS OR AT 90 DAYS, EVEN 877 00:28:01,640 --> 00:28:04,680 WITH THE SAME CONDITION, 878 00:28:04,680 --> 00:28:05,880 CONTROLLING FOR YOUR CONDITION, 879 00:28:05,880 --> 00:28:09,720 YOUR AGE, AND HERE WE'RE LOOKING 880 00:28:09,720 --> 00:28:11,240 AT WHITE PATIENTS AS A 881 00:28:11,240 --> 00:28:12,880 STRATIFIED ANALYSIS, AND ALL 882 00:28:12,880 --> 00:28:13,840 YOUR COMORBIDITIES, THAT YOU 883 00:28:13,840 --> 00:28:15,640 HAVE A HIGHER RISK OF DYING IF 884 00:28:15,640 --> 00:28:17,720 YOU GO TO A BLACK-SERVING 885 00:28:17,720 --> 00:28:19,920 HOSPITAL THAN A 886 00:28:19,920 --> 00:28:21,240 NON-BLACK-SERVING HOSPITAL. 887 00:28:21,240 --> 00:28:23,640 THIS IS THE SLIDE LOOKING AT 888 00:28:23,640 --> 00:28:24,520 BLACK PATIENTS -- IF YOU'RE 889 00:28:24,520 --> 00:28:26,240 BLACK AND GO TO A BLACK SERVING 890 00:28:26,240 --> 00:28:27,640 HOSPITAL, THE ONLY ONE THAT 891 00:28:27,640 --> 00:28:30,840 ISN'T SIGNIFICANT HERE IS FOR 892 00:28:30,840 --> 00:28:31,840 AMI, BUT FOR THE OTHER 893 00:28:31,840 --> 00:28:34,240 CONDITIONS HERE, YOU'LL SEE THAT 894 00:28:34,240 --> 00:28:39,240 FOR -- AND SORRY, HERE IT'S CHS 895 00:28:39,240 --> 00:28:41,440 AND PNEUMONIA FOR 90 DAYS, THAT 896 00:28:41,440 --> 00:28:42,600 NOT ALL OF THEM ARE SIGNIFICANT 897 00:28:42,600 --> 00:28:43,960 HERE, BUT FOR BLACK PATIENTS, 898 00:28:43,960 --> 00:28:47,040 THAT YOU HAVE A HIGHER RISK OF 899 00:28:47,040 --> 00:28:53,840 DYING FOR CHF AT 30 DAYS AND CHF 900 00:28:53,840 --> 00:28:55,040 AND PNEUMONIA AT 90 DAYS. 901 00:28:55,040 --> 00:28:56,280 SO WHAT DOES THIS TELL US? 902 00:28:56,280 --> 00:29:00,440 THIS TELLS US THAT IT'S NOT JUST 903 00:29:00,440 --> 00:29:02,080 THAT BLACK PATIENTS AND WHITE 904 00:29:02,080 --> 00:29:03,240 PATIENTS GO TO DIFFERENT 905 00:29:03,240 --> 00:29:03,760 HOSPITALS. 906 00:29:03,760 --> 00:29:05,880 WHILE THAT IS ALSO TRUE AND 907 00:29:05,880 --> 00:29:07,440 IMPORTANT, BUT IT ALSO TELLS US 908 00:29:07,440 --> 00:29:09,640 THAT THERE ARE DIFFERENT -- 909 00:29:09,640 --> 00:29:11,240 THERE'S DIFFERENT QUALITY AT 910 00:29:11,240 --> 00:29:12,960 THESE HOSPITALS, SO IT'S NOT 911 00:29:12,960 --> 00:29:14,320 NECESSARILY AN INDIVIDUAL ISSUE 912 00:29:14,320 --> 00:29:16,280 OF DISCRIMINATION, BUT WHITE 913 00:29:16,280 --> 00:29:17,600 PATIENTS WHO GO TO DIFFERENT 914 00:29:17,600 --> 00:29:18,640 HOSPITALS GET DIFFERENT 915 00:29:18,640 --> 00:29:20,040 TREATMENT AND WHITE PATIENT WHO 916 00:29:20,040 --> 00:29:21,160 GO TO BLACK SERRING HOSPITALS 917 00:29:21,160 --> 00:29:24,840 WILL HAVE SERVING HOSPITAL 918 00:29:24,840 --> 00:29:26,440 WILL HAVE HIGHER MORTALITY THAN 919 00:29:26,440 --> 00:29:29,440 IF THEY GO TO A NON-BLACK 920 00:29:29,440 --> 00:29:30,320 SERVING HOSPITAL AND SAME FOR 921 00:29:30,320 --> 00:29:30,760 BLACKS. 922 00:29:30,760 --> 00:29:32,040 SO WHY IS THIS POSSIBLE, WHAT IS 923 00:29:32,040 --> 00:29:33,400 THE MECHANISM BEHIND WHAT'S 924 00:29:33,400 --> 00:29:34,360 HAPPENING HERE? 925 00:29:34,360 --> 00:29:36,520 THIS IS A STUDY I DID AGAIN WITH 926 00:29:36,520 --> 00:29:39,480 MY COLLABORATOR SHOWING THAT LOW 927 00:29:39,480 --> 00:29:40,880 INCOME COMMUNITIES ARE MORE 928 00:29:40,880 --> 00:29:42,240 LIKELY TO EXPERIENCE LARGE 929 00:29:42,240 --> 00:29:43,840 INCREASES IN DRIVING TIME TO THE 930 00:29:43,840 --> 00:29:46,600 NEAREST E.D. DUE TO E.D. 931 00:29:46,600 --> 00:29:47,160 CLOSURES. 932 00:29:47,160 --> 00:29:50,560 SO WE KNOW THAT HOSPITALS 933 00:29:50,560 --> 00:29:51,520 ACTUALLY IN THE UNITED STATES, 934 00:29:51,520 --> 00:29:52,720 THERE'S NO MANDATE FOR THEM TO 935 00:29:52,720 --> 00:29:53,840 HAVE AN EMERGENCY DEPARTMENT. 936 00:29:53,840 --> 00:29:55,560 I MEAN, THERE ARE FEDERAL 937 00:29:55,560 --> 00:29:56,760 FACILITIES LIKE V.A. FACILITIES 938 00:29:56,760 --> 00:29:58,040 THAT MIGHT HAVE CERTAIN 939 00:29:58,040 --> 00:30:00,440 MANDATES, BUT IN GENERAL, ALL 940 00:30:00,440 --> 00:30:05,640 OTHER HOSPITAL THE, SO HOSPITALS, WHETHER YOU'RE 941 00:30:05,640 --> 00:30:09,800 FOR PROFIT, NON-PROFIT, THERE'S 942 00:30:09,800 --> 00:30:10,880 NO MANDATE THAT SAYS YOU HAVE TO 943 00:30:10,880 --> 00:30:14,280 HAVE AN E.D. 944 00:30:14,280 --> 00:30:16,240 AND SO HOSPITALS CAN CHOOSE TO 945 00:30:16,240 --> 00:30:17,160 CLOSE THEIR E.D.s. 946 00:30:17,160 --> 00:30:18,560 THERE MIGHT BE GOOD REASONS TO 947 00:30:18,560 --> 00:30:21,280 CLOSE, YOU MIGHT HAVE REDUNDANT 948 00:30:21,280 --> 00:30:23,480 SERVICES, THERE MIGHT BE SO MANY 949 00:30:23,480 --> 00:30:25,000 HOSPITALS IN THE AREA, YOU DON'T 950 00:30:25,000 --> 00:30:28,240 NEED EMERGENCY DEPARTMENTS, BUT 951 00:30:28,240 --> 00:30:31,120 THIS IS TO SHOW WHO'S BEING 952 00:30:31,120 --> 00:30:32,640 AFFECTED AND WHAT ARE THE RISK 953 00:30:32,640 --> 00:30:33,960 FACTORS FOR CLOSURE. 954 00:30:33,960 --> 00:30:35,600 SO YOU'LL SEE THE GREEN DOTS 955 00:30:35,600 --> 00:30:37,080 HERE, THOSE ARE DECREASES IN 956 00:30:37,080 --> 00:30:37,440 DRIVING TIME. 957 00:30:37,440 --> 00:30:38,920 SO THOSE ARE PLACES THAT HAVE 958 00:30:38,920 --> 00:30:41,000 ACTUALLY EXPERIENCED E.D. 959 00:30:41,000 --> 00:30:41,640 OPENINGS. 960 00:30:41,640 --> 00:30:43,080 SO NOW BEFORE, WHERE THEY MIGHT 961 00:30:43,080 --> 00:30:44,840 HAVE HAD TO DRIVE 30 MINUTES TO 962 00:30:44,840 --> 00:30:46,480 THE NEXT EMERGENCY DEPARTMENT, 963 00:30:46,480 --> 00:30:48,240 NOW THEY HAVE TO DRIVE 15. 964 00:30:48,240 --> 00:30:50,080 SOME MIGHT SEE THAT AS A GOOD 965 00:30:50,080 --> 00:30:50,440 THING. 966 00:30:50,440 --> 00:30:52,160 I WILL TALK ABOUT THAT A LITTLE 967 00:30:52,160 --> 00:30:53,800 LATER WHETHER MORE IS BETTER AND 968 00:30:53,800 --> 00:30:54,920 THAT'S NOT ALWAYS THE CASE. 969 00:30:54,920 --> 00:30:57,840 BUT YOU'LL SEE THE RED IS WHERE 970 00:30:57,840 --> 00:30:59,080 THERE'S MORE -- THESE CLOSURES 971 00:30:59,080 --> 00:31:00,240 HAVE AFFECTED THEM SUCH THAT 972 00:31:00,240 --> 00:31:02,000 PATIENT WHO USED TO BE ABLE TO 973 00:31:02,000 --> 00:31:06,840 DRIVE X AMOUNT OF TIME NOW 974 00:31:06,840 --> 00:31:08,040 ACTUALLY NEED TO DRIVE X PLUS 30 975 00:31:08,040 --> 00:31:09,880 MINUTES TO GET TO THEIR NEAREST 976 00:31:09,880 --> 00:31:10,240 E.D. 977 00:31:10,240 --> 00:31:11,760 WHEN YOU LOOK AT THIS, I'LL SHOW 978 00:31:11,760 --> 00:31:13,480 YOU THE ADJUSTED ANALYSIS IN A 979 00:31:13,480 --> 00:31:16,600 LITTLE BIT, BUT THERE HAVE BEEN 980 00:31:16,600 --> 00:31:18,000 MORE RURAL AREAS AND THESE TEND 981 00:31:18,000 --> 00:31:19,920 TO BE MORE LOW INCOME AREAS TOO, 982 00:31:19,920 --> 00:31:21,440 AND THEY'RE NOT NECESSARILY 983 00:31:21,440 --> 00:31:24,000 HAPPENING IN BIG METROPOLITAN 984 00:31:24,000 --> 00:31:25,840 AREAS, AND A LOT OF THESE PLACES 985 00:31:25,840 --> 00:31:28,840 ALREADY DO NOT HAVE ADEQUATE 986 00:31:28,840 --> 00:31:29,120 SERVICES. 987 00:31:29,120 --> 00:31:30,440 SO THIS IS WHEN WE STARTED TO 988 00:31:30,440 --> 00:31:34,040 LOOK MORE CAREFULLY, WHAT WE DID 989 00:31:34,040 --> 00:31:35,840 IS WE DID A SURVIVE ANALYSIS. 990 00:31:35,840 --> 00:31:40,280 WE TEND TO THINK OF SURVIVAL 991 00:31:40,280 --> 00:31:41,440 ANALYSES, WE WERE THINKING ABOUT 992 00:31:41,440 --> 00:31:42,640 BREAST CANCER PATIENTS, SOME OF 993 00:31:42,640 --> 00:31:44,840 THEM HAD A HIGHER SURVIVAL AND 994 00:31:44,840 --> 00:31:47,280 SOME OF THEM HAD LOWER SURVIVAL, 995 00:31:47,280 --> 00:31:49,640 WHETHER IT DUE TO SMOKING, 996 00:31:49,640 --> 00:31:50,640 ESTROGEN USE, THESE ARE THE 997 00:31:50,640 --> 00:31:51,840 COMMON EXAMPLES THAT ARE USED. 998 00:31:51,840 --> 00:31:54,680 NOW WHAT WE DID IS WE LOOKED AT 999 00:31:54,680 --> 00:31:57,440 DATA FROM 2001 TO 2013, AND WE 1000 00:31:57,440 --> 00:32:00,280 LOOKED AT EVERY E.D. IN THE 1001 00:32:00,280 --> 00:32:04,520 UNITED STATES THAT REPORTED TO 1002 00:32:04,520 --> 00:32:07,640 THE AMERICAN HOSPITAL 1003 00:32:07,640 --> 00:32:08,800 ASSOCIATION, AND WE LOOKED AT 1004 00:32:08,800 --> 00:32:11,000 EACH YEAR THEY HAD AN E.D., WE 1005 00:32:11,000 --> 00:32:12,680 LOOKED THE THEIR ZIP CODES, WHEN 1006 00:32:12,680 --> 00:32:14,280 THEY WERE OPENING AND CLOSING. 1007 00:32:14,280 --> 00:32:16,440 THE RED LINE SHOWS YOU OPERATING 1008 00:32:16,440 --> 00:32:16,800 E.D.s. 1009 00:32:16,800 --> 00:32:18,000 OF COURSE WHILE YOU HAVE 1010 00:32:18,000 --> 00:32:19,200 CLOSURES, THERE ARE ALWAYS 1011 00:32:19,200 --> 00:32:20,200 OPENINGS AS WELL. 1012 00:32:20,200 --> 00:32:22,840 WE FOUND ABOUT -- ON AVERAGE 1013 00:32:22,840 --> 00:32:24,920 ABOUT 80 CLOSURES PER YEAR, BUT 1014 00:32:24,920 --> 00:32:26,520 IT'S NOT 80 TIMES 13 YEARS OF 1015 00:32:26,520 --> 00:32:27,280 DATA. 1016 00:32:27,280 --> 00:32:30,240 THERE ARE SOME OPENINGS AS WELL. 1017 00:32:30,240 --> 00:32:32,440 BUT WHEN YOU ASK IS IT POSSIBLE 1018 00:32:32,440 --> 00:32:34,960 THAT THESE E.D.s ARE CLOSING 1019 00:32:34,960 --> 00:32:36,360 IN REDUNDANT AREAS, YOU'LL SEE 1020 00:32:36,360 --> 00:32:37,640 THAT IT'S NOT -- IF THEY WERE 1021 00:32:37,640 --> 00:32:40,720 CLOSING IN REDUNDANT AREAS, YOU 1022 00:32:40,720 --> 00:32:42,680 WOULD HAVE A SMALL NUMBER OF THE 1023 00:32:42,680 --> 00:32:43,640 PERCENT POPULATION AFFECTED BY 1024 00:32:43,640 --> 00:32:45,640 THE E.D. CLOSURE, IT WOULD 1025 00:32:45,640 --> 00:32:48,480 PACEICALLY IT WOULD 1026 00:32:48,480 --> 00:32:49,440 BASICALLY NOT BUDGE. 1027 00:32:49,440 --> 00:32:53,840 IF YOU HAD 10 E.D.S -- IT 1028 00:32:53,840 --> 00:32:55,440 WOULDN'T REALLY AFFECT THE 1029 00:32:55,440 --> 00:32:56,080 PERCENT POPULATION BECAUSE THEY 1030 00:32:56,080 --> 00:32:57,000 STILL HAVE ACCESS. 1031 00:32:57,000 --> 00:32:58,840 BUT WHAT WE SEE HERE IS THAT 1032 00:32:58,840 --> 00:33:03,240 OVER TIME, IT'S AFFECTED UP TO 1033 00:33:03,240 --> 00:33:04,680 14% -- 14.5% OF THE POPULATION 1034 00:33:04,680 --> 00:33:06,720 IN THIS PERIOD OF THE STUDY. 1035 00:33:06,720 --> 00:33:08,360 SO WHAT WE DID IS, WE LOOKED AND 1036 00:33:08,360 --> 00:33:10,640 WE ASKED THE QUESTION, WHAT ARE 1037 00:33:10,640 --> 00:33:11,960 THE RISK FACTORS THAT ARE 1038 00:33:11,960 --> 00:33:15,680 ASSOCIATED WITH E.D. CLOSURE? 1039 00:33:15,680 --> 00:33:17,640 SO WE WANTED TO LOOK AT HOSPITAL 1040 00:33:17,640 --> 00:33:18,760 FACTORS, SO WHAT HE WITH FOUND, 1041 00:33:18,760 --> 00:33:21,200 THIS ISN'T ROCKET SCIENCE, BUT 1042 00:33:21,200 --> 00:33:23,560 IF YOU HAVE LOW PROFIT MARGINS, 1043 00:33:23,560 --> 00:33:24,160 THE STEPLADDER DOWN IS MUCH 1044 00:33:24,160 --> 00:33:25,200 LOWER THAN THE GREEN AND THE RED 1045 00:33:25,200 --> 00:33:25,520 LINE. 1046 00:33:25,520 --> 00:33:27,160 SO THEY HAD A HIGHER TETHER 1047 00:33:27,160 --> 00:33:27,880 RATE. 1048 00:33:27,880 --> 00:33:28,920 HOSPITALS WITH LOW PROFIT 1049 00:33:28,920 --> 00:33:30,560 MARGINS HAD A MUCH HIGHER DEATH 1050 00:33:30,560 --> 00:33:31,440 RATE. 1051 00:33:31,440 --> 00:33:35,000 THEY WERE MUCH LESS LIKELY TO 1052 00:33:35,000 --> 00:33:35,440 SURVIVE. 1053 00:33:35,440 --> 00:33:37,640 30 TO 40% LESS LIKELY TO SURVIVE 1054 00:33:37,640 --> 00:33:39,880 THAN HOSPITALS WHO HAD HIGH 1055 00:33:39,880 --> 00:33:41,480 PROFIT MARGINS OR EVEN WERE IN 1056 00:33:41,480 --> 00:33:41,920 THE MIDDLE. 1057 00:33:41,920 --> 00:33:43,360 WE ALSO FOUND THAT IF YOUR 1058 00:33:43,360 --> 00:33:45,760 HOSPITAL WAS TAKING CARE OF A 1059 00:33:45,760 --> 00:33:47,040 HIGH PERCENTAGE OF PATIENTS WHO 1060 00:33:47,040 --> 00:33:49,560 ARE IN POVERTY, THEN YOU HAD A 1061 00:33:49,560 --> 00:33:50,640 HIGHER DEATH RATE AS WELL. 1062 00:33:50,640 --> 00:33:51,840 SO HERE THE GREEN AT THE VERY 1063 00:33:51,840 --> 00:33:53,440 BOTTOM ARE HOSPITALS THAT TOOK 1064 00:33:53,440 --> 00:33:56,240 CARE OF A HIGH SHARE OF PATIENTS 1065 00:33:56,240 --> 00:33:57,080 IN POVERTY. 1066 00:33:57,080 --> 00:33:58,840 SO THOSE HOSPITALS WERE ALSO AT 1067 00:33:58,840 --> 00:34:01,480 A HIGHER LIKELIHOOD OF DYING OR 1068 00:34:01,480 --> 00:34:04,000 CLOSING. 1069 00:34:04,000 --> 00:34:05,520 WHEN WE LOOKED AT SAFETY NET 1070 00:34:05,520 --> 00:34:07,040 HOSPITALS TOO, SO SAFETY NET IS 1071 00:34:07,040 --> 00:34:08,000 A DEFINITION WE USE FOR 1072 00:34:08,000 --> 00:34:09,560 HOSPITALS THAT TAKE CARE OF A 1073 00:34:09,560 --> 00:34:11,320 CERTAIN NUMBER OF UNINSURED OR 1074 00:34:11,320 --> 00:34:12,280 MEDICAID PATIENTS, THOSE 1075 00:34:12,280 --> 00:34:14,160 HOSPITALS THAT ARE DEPICTED HERE 1076 00:34:14,160 --> 00:34:16,240 IN RED ALSO HAD A HIGHER DEATH 1077 00:34:16,240 --> 00:34:16,440 RATE. 1078 00:34:16,440 --> 00:34:18,520 AND THEN FINALLY, THIS IS AN 1079 00:34:18,520 --> 00:34:21,240 INTERESTING FINDING, THAT 1080 00:34:21,240 --> 00:34:26,040 HOSPITALS WHO ARE FOR PROFIT, SO 1081 00:34:26,040 --> 00:34:27,440 THEY -- WITH THEIR MONEY, THEY 1082 00:34:27,440 --> 00:34:31,280 ACTUALLY PAY IT OUT TO 1083 00:34:31,280 --> 00:34:32,840 SHAREHOLDERS, SO THESE ARE 1084 00:34:32,840 --> 00:34:33,840 FOR-PROFIT HOSPITALS, ACTUALLY 1085 00:34:33,840 --> 00:34:35,360 HAVE A HIGHER DEATH RATE. 1086 00:34:35,360 --> 00:34:37,400 SOME PEOPLE THINK WHY IS THAT 1087 00:34:37,400 --> 00:34:41,440 THE CASE? 1088 00:34:41,440 --> 00:34:42,640 YOU'LL FIND HOSPITALS CAN MAKE 1089 00:34:42,640 --> 00:34:44,360 DECISIONS ABOUT CLOSING THEIR 1090 00:34:44,360 --> 00:34:45,240 E.D.s TO PROTECT THEMSELVES 1091 00:34:45,240 --> 00:34:47,560 FROM HAVING TO ADMIT OR CARE FOR 1092 00:34:47,560 --> 00:34:49,960 PATIENTS THAT MAY NOT BE 1093 00:34:49,960 --> 00:34:51,440 FINANCIALLY PROFITABLE. 1094 00:34:51,440 --> 00:34:53,520 A LOT OF US HAVE HEARD OF THE 1095 00:34:53,520 --> 00:34:55,120 EMERGENCY MEDICAL TREATMENT AND 1096 00:34:55,120 --> 00:34:58,920 LABOR ACT, THAT WAS INACTED IN 1097 00:34:58,920 --> 00:35:01,320 1986 TO PREVENT PATIENT DUMPING. 1098 00:35:01,320 --> 00:35:04,000 BEFORE IF YOU SHOWED UP AND WERE 1099 00:35:04,000 --> 00:35:07,840 UNINSURED, THEY THEY'D SAY GO DOWN 1100 00:35:07,840 --> 00:35:09,760 THE STREET. 1101 00:35:09,760 --> 00:35:11,080 AND IT SAYS YOU HAVE TO TREAT 1102 00:35:11,080 --> 00:35:12,040 PATIENT REGARDLESS OF THEIR 1103 00:35:12,040 --> 00:35:13,040 ABILITY TO PAY. 1104 00:35:13,040 --> 00:35:14,240 SO WHAT HAPPENED IS THAT 1105 00:35:14,240 --> 00:35:15,440 HOSPITALS SAY, WELL, IF YOU'RE 1106 00:35:15,440 --> 00:35:16,640 GOING TO DO THAT, THEN I'M 1107 00:35:16,640 --> 00:35:18,040 PROBABLY GOING TO CLOSE MY E.D. 1108 00:35:18,040 --> 00:35:19,840 BECAUSE I DON'T WANT TO OPEN MY 1109 00:35:19,840 --> 00:35:21,440 DOORS UP TO PATIENTS THAT DON'T 1110 00:35:21,440 --> 00:35:25,200 PAY, AND SO I'M GOING TO NOW BE 1111 00:35:25,200 --> 00:35:26,680 JUST A SPECIALTY-SPECIFIC 1112 00:35:26,680 --> 00:35:27,880 HOSPITAL, I AM GOING TO BE ONLY 1113 00:35:27,880 --> 00:35:30,080 A CANCER HOSPITAL OR ONLY AL 1114 00:35:30,080 --> 00:35:31,520 CARDIAC HOSPITAL OR ONLY A 1115 00:35:31,520 --> 00:35:33,040 HOSPITAL FOR SPECIAL SURGERY OR 1116 00:35:33,040 --> 00:35:35,000 ONLY AN ORTHOPEDIC HOSPITAL. 1117 00:35:35,000 --> 00:35:37,360 SOL THAT'S WHAT'S HAPPENING 1118 00:35:37,360 --> 00:35:39,000 HERE, THAT'S WHAT'S BEHIND THIS 1119 00:35:39,000 --> 00:35:40,320 SIGNAL HERE. 1120 00:35:40,320 --> 00:35:42,840 AND WHAT HAPPENS IS, AS WE HAVE 1121 00:35:42,840 --> 00:35:44,160 THESE DIFFERENTIAL CLOSURES, YOU 1122 00:35:44,160 --> 00:35:46,640 HAVE MORE CLOSURES IN POOR 1123 00:35:46,640 --> 00:35:48,040 AREAS, AND YOU ACTUALLY HAVE 1124 00:35:48,040 --> 00:35:50,040 OPENINGS IN RICH AREAS THAT THIS 1125 00:35:50,040 --> 00:35:52,360 IS ANOTHER STUDY THAT I DID, TO 1126 00:35:52,360 --> 00:35:53,880 ACTUALLY LOOK AT DOES THIS 1127 00:35:53,880 --> 00:35:55,720 AFFECT YOUR ABILITY TO GET TO 1128 00:35:55,720 --> 00:35:56,840 THE HOSPITAL IF YOU ARE LOW 1129 00:35:56,840 --> 00:35:58,000 INCOME AND HIGH INCOME? 1130 00:35:58,000 --> 00:36:00,760 SO WE LOOKED AT ACTUALLY 1131 00:36:00,760 --> 00:36:02,000 AMBULANCE DATA TO LOOK AT 1132 00:36:02,000 --> 00:36:04,240 RESPONSE TIME, AND WE LOOKED -- 1133 00:36:04,240 --> 00:36:06,120 FOR THIS STUDY, WE LOOK AT 1134 00:36:06,120 --> 00:36:07,640 PATIENTS WHO WERE IN LOW INCOME 1135 00:36:07,640 --> 00:36:08,960 VERSUS HIGH INCOME, BUT WE ALSO 1136 00:36:08,960 --> 00:36:10,280 HAVE DONE THIS FOR CARDIAC 1137 00:36:10,280 --> 00:36:11,160 ARREST PATIENTS ALSO. 1138 00:36:11,160 --> 00:36:13,000 SO NOT JUST LOOKING AT 1139 00:36:13,000 --> 00:36:14,800 ALL-COMERS BUT EVEN FOR CARDIAC 1140 00:36:14,800 --> 00:36:16,440 ARREST, IT TRUE THAT IF YOU ARE 1141 00:36:16,440 --> 00:36:19,960 IN A LOW INCOME AREA, THAT YOUR 1142 00:36:19,960 --> 00:36:21,800 RESPONSE TIME IS LONGER BECAUSE 1143 00:36:21,800 --> 00:36:23,760 YOUR RESPONSE TIME, ON-XENOTIME, 1144 00:36:23,760 --> 00:36:25,840 YOUR TOTAL TIME IS MUCH LONGER, 1145 00:36:25,840 --> 00:36:29,760 IT 10% LONGER, THIS IS NOT 1146 00:36:29,760 --> 00:36:32,400 JUST -- YOU JUST NEEDED TO GET 1147 00:36:32,400 --> 00:36:36,440 YOUR EARS CHECKED OR -- YOU'VE 1148 00:36:36,440 --> 00:36:39,920 HAD CARDIAC ARREST, YOU MAY OR 1149 00:36:39,920 --> 00:36:41,760 MAY NOT HAVE HAD CPR AND YOU 1150 00:36:41,760 --> 00:36:43,040 NEED TO GET TO THE NEAREST 1151 00:36:43,040 --> 00:36:45,240 HOSPITAL RIGHT AWAY, AND NOW WE 1152 00:36:45,240 --> 00:36:49,080 FIND IT IS INDEED TRUE THAT IT 1153 00:36:49,080 --> 00:36:50,280 TAKES YOU LONGER TO GET TO THE 1154 00:36:50,280 --> 00:36:51,840 HOSPITAL WHEN YOU CALL AN 1155 00:36:51,840 --> 00:36:52,160 AMBULANCE. 1156 00:36:52,160 --> 00:36:54,240 SO HERE'S WHAT WE FIND. 1157 00:36:54,240 --> 00:36:57,600 "THE NEW YORK TIMES" WHEN I -- 1158 00:36:57,600 --> 00:37:00,800 COVERAGE ABOUT HOW THERE'S FEWER 1159 00:37:00,800 --> 00:37:03,200 EMERGENCY DEPARTMENTS, REUTERS 1160 00:37:03,200 --> 00:37:05,160 LOOKED AT THAT TOO, "U.S.A. 1161 00:37:05,160 --> 00:37:06,600 TODAY," SAYING THERE'S A LOT OF 1162 00:37:06,600 --> 00:37:06,880 CLOSURES. 1163 00:37:06,880 --> 00:37:07,840 ONE OF THE THINGS THAT I THINK 1164 00:37:07,840 --> 00:37:13,680 PEOPLE ARE CONFUSED ABOUT IS 1165 00:37:13,680 --> 00:37:15,440 THAT THERE'S THIS CRY FOR HELP 1166 00:37:15,440 --> 00:37:18,160 FOR EMERGENCY SERVICES. 1167 00:37:18,160 --> 00:37:19,480 YOU ALSO SEE SOMETHING ELSE 1168 00:37:19,480 --> 00:37:22,400 THAT'S A LITTLE OF A TALE OF TWO 1169 00:37:22,400 --> 00:37:22,640 CITIES. 1170 00:37:22,640 --> 00:37:24,840 YOU ALSO LOOK AT THIS, WHETHER 1171 00:37:24,840 --> 00:37:27,640 IT'S MAGAZINES OR -- ON THE 1172 00:37:27,640 --> 00:37:28,920 HIGHWAY, YOU'LL SEE PEOPLE 1173 00:37:28,920 --> 00:37:31,920 TRYING TO ADVERTISE YOUR 1174 00:37:31,920 --> 00:37:32,800 EMERGENCY SERVICES, WE CAN 1175 00:37:32,800 --> 00:37:34,120 GUARANTEE YOU'LL SEE THE ER 1176 00:37:34,120 --> 00:37:36,120 DOCTOR IN 60 MINUTES OR LESS, O 1177 00:37:36,120 --> 00:37:37,920 YOU'LL SEE THESE BILLBOARDS, AND 1178 00:37:37,920 --> 00:37:40,880 NOW IT'S JUST 9 MINUTES. 1179 00:37:40,880 --> 00:37:44,000 AND THIS IS UCSF, SO I WORK 1180 00:37:44,000 --> 00:37:45,760 ACTUALLY AT THE PUBLIC HOSPITAL, 1181 00:37:45,760 --> 00:37:47,640 THE SAN FRANCISCO GENERAL 1182 00:37:47,640 --> 00:37:49,040 HOSPITAL BUT THIS IS WHAT I SAW 1183 00:37:49,040 --> 00:37:50,360 ACTUALLY WHEN I WAS WALKING DOWN 1184 00:37:50,360 --> 00:37:53,320 THE HALL FOR A MEETING A PFAU 1185 00:37:53,320 --> 00:37:55,720 YEARS AGO. 1186 00:37:55,720 --> 00:37:56,040 A FEW 1187 00:37:56,040 --> 00:37:56,800 YEARS AGO. 1188 00:37:56,800 --> 00:37:58,880 THIS IS A PLACE WHERE YOU CAN 1189 00:37:58,880 --> 00:38:01,840 HOLD YOUR PLACE ONLINE, THEY'D 1190 00:38:01,840 --> 00:38:03,400 GIVE YOU A TEXT AND MAKE YOUR 1191 00:38:03,400 --> 00:38:04,840 WAY IN SO YOU CAN WAIT IN THE 1192 00:38:04,840 --> 00:38:06,240 COMFORT OF YOUR OWN HOME AND 1193 00:38:06,240 --> 00:38:07,960 SAID THERE'S NO PLACE LIKE HOME, 1194 00:38:07,960 --> 00:38:09,960 NO NEED TO WAIT IN THE RATING 1195 00:38:09,960 --> 00:38:12,440 ROOM, COME IN AND REGISTER 1196 00:38:12,440 --> 00:38:13,440 ONLINE AND WE'LL SEE YOU THERE. 1197 00:38:13,440 --> 00:38:15,200 SO THIS IS -- WHAT WE FIND IS 1198 00:38:15,200 --> 00:38:19,920 THAT GEOGRAPHY REALLY IS DESTINY 1199 00:38:19,920 --> 00:38:20,880 IN EMERGENCY SERVICES AND OTHER 1200 00:38:20,880 --> 00:38:22,200 SERVICES AS WELL, SO I'LL TALK 1201 00:38:22,200 --> 00:38:24,840 ABOUT THAT TOO, BUT IF YOU ARE 1202 00:38:24,840 --> 00:38:29,000 AN E.R. THAT IS IN A AFFLUENT 1203 00:38:29,000 --> 00:38:30,920 AREA, THEN YOU ARE A REVENUE 1204 00:38:30,920 --> 00:38:31,160 CENTER. 1205 00:38:31,160 --> 00:38:32,440 I TRAINED AT STANFORD HOSPITAL, 1206 00:38:32,440 --> 00:38:34,000 WHERE MOST OF THE PATIENTS IN 1207 00:38:34,000 --> 00:38:36,120 THAT AREA IN PALO ALTO ARE 1208 00:38:36,120 --> 00:38:37,920 INSURED, SO STANFORD NEEDS THAT 1209 00:38:37,920 --> 00:38:39,320 E.D., BECAUSE MOST ADMISSIONS 1210 00:38:39,320 --> 00:38:44,000 COME FROM THE E.D. 1211 00:38:44,000 --> 00:38:46,120 SO YOU NEED YOUR ED IN THOSE 1212 00:38:46,120 --> 00:38:48,960 CASES BECAUSE YOU NEED A WAY FOR 1213 00:38:48,960 --> 00:38:52,520 PEOPLE TO GET IN THE DOOR TO BE 1214 00:38:52,520 --> 00:38:53,920 ADMITTED BUT IN OTHER PLACES, 1215 00:38:53,920 --> 00:38:55,760 YOUR E.D. MAY BE A COST CENTER 1216 00:38:55,760 --> 00:38:57,400 IF YOU LIVE IN AN AREA WHERE 1217 00:38:57,400 --> 00:38:58,480 THAT HOSPITAL IS LOCATED IN AN 1218 00:38:58,480 --> 00:38:59,840 AREA THAT HAS A LOT OF PATIENTS 1219 00:38:59,840 --> 00:39:01,320 WHO ARE UNINSURED. 1220 00:39:01,320 --> 00:39:02,440 AND SO I THINK IT'S IMPORTANT 1221 00:39:02,440 --> 00:39:04,040 FOR US TO RECOGNIZE THAT WHEN 1222 00:39:04,040 --> 00:39:07,640 PEOPLE COME TO THE E.D. WITH 1223 00:39:07,640 --> 00:39:08,960 SOCIAL NEEDS, THAT THERE ARE 1224 00:39:08,960 --> 00:39:09,960 FACTORS THAT HAVE AFFECTED THEIR 1225 00:39:09,960 --> 00:39:12,000 ABILITY TO EVEN OBTAIN EMERGENCY 1226 00:39:12,000 --> 00:39:13,240 SERVICES OR OTHER SERVICES THAT 1227 00:39:13,240 --> 00:39:17,160 ARE VERY TIME-SENSITIVE. 1228 00:39:17,160 --> 00:39:18,440 SO THEY ALREADY COME WITH THE 1229 00:39:18,440 --> 00:39:19,600 BURDEN OF NOT BEING ABLE TO 1230 00:39:19,600 --> 00:39:21,000 ACCESS CARE IN THE SAME WAY THAT 1231 00:39:21,000 --> 00:39:21,560 OTHERS DO. 1232 00:39:21,560 --> 00:39:23,960 AND I THINK IT'S IMPORTANT 1233 00:39:23,960 --> 00:39:26,360 BECAUSE THERE'S A COMMON THEME 1234 00:39:26,360 --> 00:39:29,120 WHEN POLICY MAKERS MAKE POLICY 1235 00:39:29,120 --> 00:39:30,400 OR -- AND I'M NOT SAYING ALL, 1236 00:39:30,400 --> 00:39:32,000 BUT YOU TEND TO SEE THIS KIND OF 1237 00:39:32,000 --> 00:39:33,560 VICTIM BLAMING OF WHERE WE SHIFT 1238 00:39:33,560 --> 00:39:35,400 THE BLAME ON THE PATIENT, 1239 00:39:35,400 --> 00:39:36,440 WHETHER OR NOT THEY'RE COMING IN 1240 00:39:36,440 --> 00:39:40,800 FOR AN INAPPROPRIATE VISIT, OR 1241 00:39:40,800 --> 00:39:41,240 AVOIDABLE VISIT. 1242 00:39:41,240 --> 00:39:43,840 THESE ARE ALL TERMS TO TEND TO 1243 00:39:43,840 --> 00:39:45,200 MAKE YOU THINK THE PATIENT HAD A 1244 00:39:45,200 --> 00:39:47,480 CHOICE AND THEY JUST HAD OTHER 1245 00:39:47,480 --> 00:39:48,640 OPTIONS BUT THEY DECIDED TO COME 1246 00:39:48,640 --> 00:39:49,320 TO THE E.D. 1247 00:39:49,320 --> 00:39:50,720 SO I JUST THINK IT'S IMPORTANT 1248 00:39:50,720 --> 00:39:53,040 FOR US TO UNDERSTAND THE CONCEPT 1249 00:39:53,040 --> 00:39:54,120 THAT PATIENTS COME TO THE E.D. 1250 00:39:54,120 --> 00:39:55,760 AND E.D.s ARE NOT ALL THE SAME 1251 00:39:55,760 --> 00:39:56,840 AND PATIENT DON'T HAVE ALL THE 1252 00:39:56,840 --> 00:40:00,360 SAME ACCESS TO E.D.s, SO WHEN 1253 00:40:00,360 --> 00:40:02,760 THEY PRESENT AND WE SEE THEM, 1254 00:40:02,760 --> 00:40:04,040 THIS IS THE CONTEXT THAT THEY 1255 00:40:04,040 --> 00:40:06,680 COME FROM. 1256 00:40:06,680 --> 00:40:08,080 THIS IS A PICTURE OF -- I GREW 1257 00:40:08,080 --> 00:40:10,280 UP IN TEXAS AND MY PARENTS STILL 1258 00:40:10,280 --> 00:40:11,440 LIVE THERE SO WHEN I VISIT THEM, 1259 00:40:11,440 --> 00:40:15,360 I WILL NOTICE WHAT'S GOING ON IN 1260 00:40:15,360 --> 00:40:16,120 HEALTHCARE. 1261 00:40:16,120 --> 00:40:17,240 TEXAS IS NOT UNIQUE, THERE ARE 1262 00:40:17,240 --> 00:40:18,640 OTHER STATES THAT DO THIS, BUT 1263 00:40:18,640 --> 00:40:19,920 THEY ALLOW FOR SOMETHING CALLED 1264 00:40:19,920 --> 00:40:21,240 FREE-STANDING E.D.s. 1265 00:40:21,240 --> 00:40:24,120 WHAT A FREE-STANDING E.D. IS, 1266 00:40:24,120 --> 00:40:26,600 USUALLY WE'RE USED TO HAVING AN 1267 00:40:26,600 --> 00:40:27,520 E.D. ASSOCIATED WITH A HOSPITAL, 1268 00:40:27,520 --> 00:40:28,880 IT'S THE BOTTOM FLOOR, THERE'S 1269 00:40:28,880 --> 00:40:30,120 AN AMBULANCE SIGN AND THAT'S 1270 00:40:30,120 --> 00:40:31,200 WHERE PATIENTS COME IN. 1271 00:40:31,200 --> 00:40:32,840 BUT WHAT A FREE-STANDING E.D. 1272 00:40:32,840 --> 00:40:34,360 IS, IT'S NOT TIED TO A HOSPITAL, 1273 00:40:34,360 --> 00:40:35,600 THERE'S NO HOSPITAL THAT'S 1274 00:40:35,600 --> 00:40:36,560 ATTACHED TO IT. 1275 00:40:36,560 --> 00:40:38,600 IT'S FREE-STANDING, IT CAN BE 1276 00:40:38,600 --> 00:40:39,800 ANYWHERE, AND THEN IF THEY 1277 00:40:39,800 --> 00:40:41,240 DECIDE THEY NEED TO ADMIT 1278 00:40:41,240 --> 00:40:42,520 PATIENTS, THEN THEY PUT THEM IN 1279 00:40:42,520 --> 00:40:43,960 AN AMBULANCE AND GO TO THAT 1280 00:40:43,960 --> 00:40:45,040 OTHER HOSPITAL. 1281 00:40:45,040 --> 00:40:48,320 NOW FREE-STANDING EDs ARE 1282 00:40:48,320 --> 00:40:49,960 LUCRATIVE, BECAUSE OF THE WAY WE 1283 00:40:49,960 --> 00:40:51,160 IN AMERICA HAVE DECIDED TO 1284 00:40:51,160 --> 00:40:53,120 FINANCE AND PAY FOR CARE. 1285 00:40:53,120 --> 00:40:55,080 I WON'T SPEND TOO MUCH TIME ON 1286 00:40:55,080 --> 00:40:56,560 IT, BUT ANOTHER THREAD OF MY 1287 00:40:56,560 --> 00:40:57,840 RESEARCH IS LOOKING AT THE 1288 00:40:57,840 --> 00:40:59,160 INCENTIVES OF HEALTHCARE, AND 1289 00:40:59,160 --> 00:41:00,240 PLJ DEPARTMENTS ARE ALLOWED TO 1290 00:41:00,240 --> 00:41:01,560 CHARGE A FACILITY FEE. 1291 00:41:01,560 --> 00:41:02,840 THAT MEANS ONCE YOU STEP IN THE 1292 00:41:02,840 --> 00:41:03,720 DOOR, EVEN IF YOU COME OUT WITH 1293 00:41:03,720 --> 00:41:06,800 A BAND-AID, I'M SURE YOU'VE SEEN 1294 00:41:06,800 --> 00:41:09,120 STUDIES OF THIS AND REPORTS OF 1295 00:41:09,120 --> 00:41:10,240 THIS IN THE "NEW YORK TIMES" AND 1296 00:41:10,240 --> 00:41:12,200 EVERYWHERE ELSE, WHERE PATIENTS 1297 00:41:12,200 --> 00:41:14,040 GO IN WITH A SPRAINED ANKLE AND 1298 00:41:14,040 --> 00:41:15,400 THEY COME OUT WITH A $10,000 1299 00:41:15,400 --> 00:41:15,600 BILL. 1300 00:41:15,600 --> 00:41:17,080 I MEAN, IT ALL SOUNDS VERY 1301 00:41:17,080 --> 00:41:19,200 CRAZY, BUT MOST OF THOSE ARE 1302 00:41:19,200 --> 00:41:20,440 BECAUSE OF FACILITY FEES WHICH 1303 00:41:20,440 --> 00:41:22,400 ARE LAWFUL TO CHARGE, AND ONLY 1304 00:41:22,400 --> 00:41:23,240 EMERGENCY DEPARTMENTS CAN CHARGE 1305 00:41:23,240 --> 00:41:24,080 THEM. 1306 00:41:24,080 --> 00:41:25,880 SO URGENT CARES CANNED CHARGE 1307 00:41:25,880 --> 00:41:27,600 THEM. 1308 00:41:27,600 --> 00:41:29,640 SO THERE USED TO BE A BIG FLOOD 1309 00:41:29,640 --> 00:41:33,600 OF URGENT CARES, BUT NOW 1310 00:41:33,600 --> 00:41:34,800 PEOPLE -- IT DOESN'T MATTER WHAT 1311 00:41:34,800 --> 00:41:36,360 HAPPENED IN THE HOSPITAL, COME 1312 00:41:36,360 --> 00:41:38,600 IN, I'VE GOT HIM, THAT'S ALREADY 1313 00:41:38,600 --> 00:41:40,240 LIKE $2,000 OFF THE TOP. 1314 00:41:40,240 --> 00:41:45,160 SO IN TEXAS, YOU'LL SEE THE D. 1315 00:41:45,160 --> 00:41:46,800 JUST TWO-DOOR DOWN IS AN 1316 00:41:46,800 --> 00:41:47,680 AMBULANCE BAY. 1317 00:41:47,680 --> 00:41:50,440 THIS AMBULANCE BAY IS TIED TO -- 1318 00:41:50,440 --> 00:41:51,640 I THINK I MIGHT HAVE BEEN 1319 00:41:51,640 --> 00:41:53,680 DRIVING IN THE PASSENGER'S SIDE 1320 00:41:53,680 --> 00:41:55,240 OR SOMETHING SO I DIDN'T GET A 1321 00:41:55,240 --> 00:41:56,760 GREAT PICTURE, BUT THIS IS FIRST 1322 00:41:56,760 --> 00:41:57,640 CHOICE EMERGENCY ROOM. 1323 00:41:57,640 --> 00:41:58,840 IT'S AN EMERGENCY ROOM, IT'S NOT 1324 00:41:58,840 --> 00:41:59,160 A DEPARTMENT. 1325 00:41:59,160 --> 00:42:00,800 YOU CAN DROP THE PATIENT OFF 1326 00:42:00,800 --> 00:42:02,320 THERE, BUT IF YOU ACTUALLY NEED 1327 00:42:02,320 --> 00:42:04,160 TO GET ANOTHER PLANS TO GO. 1328 00:42:04,160 --> 00:42:06,240 AND SO WHAT WE SEE HERE IS 1329 00:42:06,240 --> 00:42:07,800 ANOTHER EXAMPLE OF INEQUITY. 1330 00:42:07,800 --> 00:42:09,120 SO THERE ARE OTHER STATES THAT 1331 00:42:09,120 --> 00:42:13,600 DO THIS AGAIN, BUT OTHER PEOPLE 1332 00:42:13,600 --> 00:42:16,440 HAVE LOOKED AT WHAT -- IT MAKES 1333 00:42:16,440 --> 00:42:18,920 YOU MORE LIKELY TO HAVE A 1334 00:42:18,920 --> 00:42:19,720 FREE-STANDING E.D. 1335 00:42:19,720 --> 00:42:21,880 BECAUSE A LOT OF THE TIME, WHEN 1336 00:42:21,880 --> 00:42:26,440 FREE-STANDING E.D.S APPLY FOR 1337 00:42:26,440 --> 00:42:27,360 LICENSURE IN THE STATE, THEY 1338 00:42:27,360 --> 00:42:29,120 WILL SAY WE ARE PROVIDING CARE 1339 00:42:29,120 --> 00:42:30,200 TO PEOPLE WHO NEED IT. 1340 00:42:30,200 --> 00:42:33,680 WE ARE PROVIDING MILLIMETER 1341 00:42:33,680 --> 00:42:35,000 CARE, IF YOU SAY THAT, SURE, YOU 1342 00:42:35,000 --> 00:42:39,800 GET THE STAMP OF APPROVAL, BUT 1343 00:42:39,800 --> 00:42:41,520 WHERE ACTUALLY ARE THESE PLACES 1344 00:42:41,520 --> 00:42:41,760 LOCATED? 1345 00:42:41,760 --> 00:42:43,040 THEY'RE IN DALLAS-FORT WORTH, 1346 00:42:43,040 --> 00:42:43,840 AUSTIN AND HOUSTON. 1347 00:42:43,840 --> 00:42:45,120 THEY'RE NOT ACTUALLY IN PLACES 1348 00:42:45,120 --> 00:42:46,880 THAT NECESSARILY NEED THEM. 1349 00:42:46,880 --> 00:42:48,520 YOU CAN SEE THESE DOTS ARE JUST 1350 00:42:48,520 --> 00:42:51,160 PILING UPON EACH OTHER. 1351 00:42:51,160 --> 00:42:52,800 SO WHAT THEY'VE FOUND IS WHEN 1352 00:42:52,800 --> 00:42:54,560 THEY DID AN ADJUSTED ANALYSIS 1353 00:42:54,560 --> 00:42:55,640 AND REGRESSION, THEY FOUND 1354 00:42:55,640 --> 00:42:57,160 THERE'S MORE FREE-STANDING 1355 00:42:57,160 --> 00:42:58,680 E.D.s IN AREAS WITH HIGHER 1356 00:42:58,680 --> 00:43:00,680 INCOME, LOWER RATES OF MEDICAID 1357 00:43:00,680 --> 00:43:04,160 SERVICES AND ALREADY AT 1358 00:43:04,160 --> 00:43:05,240 BASELINE, HAD MORE HEALTHCARE 1359 00:43:05,240 --> 00:43:05,600 SERVICES. 1360 00:43:05,600 --> 00:43:08,440 SO AGAIN, WHEN WE THINK ABOUT ED 1361 00:43:08,440 --> 00:43:09,560 SERVICES, AND I DON'T WANT 1362 00:43:09,560 --> 00:43:11,080 PEOPLE TO THINK -- I'M NOT 1363 00:43:11,080 --> 00:43:12,280 SAYING THAT THEY DON'T PROVIDE 1364 00:43:12,280 --> 00:43:13,480 GOOD SERVICES. 1365 00:43:13,480 --> 00:43:15,000 I'M JUST SAYING OVERALL THE 1366 00:43:15,000 --> 00:43:15,800 CONTEXT IS IMPORTANT TO 1367 00:43:15,800 --> 00:43:16,680 UNDERSTAND THAT THERE ARE AREAS 1368 00:43:16,680 --> 00:43:18,520 THAT HAVE A LOT OF EMERGENCY 1369 00:43:18,520 --> 00:43:20,480 SERVICES AND THERE'S SOME THAT 1370 00:43:20,480 --> 00:43:21,840 DO NOT, AND I THINK THAT'S VERY 1371 00:43:21,840 --> 00:43:23,000 SIMILAR WHEN WE THINK ABOUT HOW 1372 00:43:23,000 --> 00:43:25,640 WE CONNECT PEOPLE TO SOCIAL 1373 00:43:25,640 --> 00:43:27,400 SERVICES, WE ARE ALREADY WORKING 1374 00:43:27,400 --> 00:43:28,440 IN ENVIRONMENTS THAT DON'T HAVE 1375 00:43:28,440 --> 00:43:31,960 A LOT OF RESOURCES AVAILABLE. 1376 00:43:31,960 --> 00:43:33,320 SO THIS IS AN INTERESTING -- 1377 00:43:33,320 --> 00:43:34,720 JUST A LITTLE GRAPH. 1378 00:43:34,720 --> 00:43:37,840 THE BLUE ARE NON-FREE-STANDING 1379 00:43:37,840 --> 00:43:38,040 EDs. 1380 00:43:38,040 --> 00:43:39,600 THESE ARE BASICALLY 1381 00:43:39,600 --> 00:43:42,640 HOSPITAL-BASED EDs. 1382 00:43:42,640 --> 00:43:44,400 THEN THE RED ONES ARE 1383 00:43:44,400 --> 00:43:45,400 FREE-STANDING EDs. 1384 00:43:45,400 --> 00:43:49,560 YOU'LL SEE AT THE TOP HERE, THE 1385 00:43:49,560 --> 00:43:51,160 TOP IS PRIVATE INSURANCE, RIGHT? 1386 00:43:51,160 --> 00:43:53,680 IF YOU'VE GOT AN AREA WITH A ZIP 1387 00:43:53,680 --> 00:43:55,120 CODE THAT HAS A LOT OF PRIVATE 1388 00:43:55,120 --> 00:43:56,560 INSURANCE, YOU HAVE A MUCH 1389 00:43:56,560 --> 00:43:59,680 HIGHER CHANCE OF GETTING A 1390 00:43:59,680 --> 00:44:01,040 FREE-STANDING ED THAN DOWN HERE, 1391 00:44:01,040 --> 00:44:03,080 BECAUSE NOBODY WANTS TO OPEN IN 1392 00:44:03,080 --> 00:44:03,640 YOUR NEIGHBORHOOD BECAUSE 1393 00:44:03,640 --> 00:44:06,920 THEY'RE NOT GOING TO GET PAID. 1394 00:44:06,920 --> 00:44:08,600 AND SO HERE IS ANOTHER EXAMPLE 1395 00:44:08,600 --> 00:44:09,960 OF HOW HEALTHCARE IN THE UNITED 1396 00:44:09,960 --> 00:44:11,640 STATE, LIKE MANY THINGS, IS PUT 1397 00:44:11,640 --> 00:44:14,720 IN THE MARKET AND THERE ARE 1398 00:44:14,720 --> 00:44:16,440 THESE VERY REAL CONSEQUENCES OF 1399 00:44:16,440 --> 00:44:18,720 WHO GETS CARE AND WHO DOESN'T. 1400 00:44:18,720 --> 00:44:20,480 AND THIS IS JUST A BRIEF STUDY 1401 00:44:20,480 --> 00:44:23,960 JUST SHOWING THAT FREE-STANDING 1402 00:44:23,960 --> 00:44:27,240 EDS ARE RAPIDLY EXPANDING, THEY 1403 00:44:27,240 --> 00:44:29,320 ACTUALLY CHARGE HIGHER PRICES TO 1404 00:44:29,320 --> 00:44:32,440 THE UR VANT CAR EVEN THOUGH A 1405 00:44:32,440 --> 00:44:39,080 LOT OF ACUTES ARE ACUTITIES ARE URGENT 1406 00:44:39,080 --> 00:44:39,280 CARES. 1407 00:44:39,280 --> 00:44:40,960 SO I THINK IT'S IMPORTANT TO 1408 00:44:40,960 --> 00:44:42,640 UNDERSTAND THAT THE Es ARE NOT 1409 00:44:42,640 --> 00:44:47,240 ALL THE SAME AND THAT 1410 00:44:47,240 --> 00:44:48,000 FREE-STANDING -- REGARDLESS OF 1411 00:44:48,000 --> 00:44:50,640 WHAT WE WORK IN, MOST OF THE 1412 00:44:50,640 --> 00:44:53,560 SOCIAL VCHS 1413 00:44:53,560 --> 00:44:57,280 SOCIAL SERVICES -- IF YOU GO 1414 00:44:57,280 --> 00:44:58,720 THERE, I'VE BEEN -- IT'S KIND OF 1415 00:44:58,720 --> 00:45:01,240 MY HOBBY WHEN I VISIT MY PARENTS 1416 00:45:01,240 --> 00:45:02,440 WHEN I DO THESE FIELD 1417 00:45:02,440 --> 00:45:03,520 INVESTIGATIONS KIND OF ON THE 1418 00:45:03,520 --> 00:45:05,360 SIDE, BUT THEY ARE REALLY, 1419 00:45:05,360 --> 00:45:13,600 REALLY NICELY EQUIPPED, THERE'S 1420 00:45:13,600 --> 00:45:14,560 NO ONE IN THE WAITING ROOM OR 1421 00:45:14,560 --> 00:45:16,120 THE E.D. BECAUSE US HAVE ONE 1422 00:45:16,120 --> 00:45:18,160 PHYSICIAN AND FIRSTS WAITING FOR 1423 00:45:18,160 --> 00:45:19,440 PATIENTS, BUT IT'S BECAUSE IT'S 1424 00:45:19,440 --> 00:45:24,400 A HIGHLY PROFITABLE SERVICE, SO 1425 00:45:24,400 --> 00:45:25,840 SIMILAR STORY WITH TRAUMA 1426 00:45:25,840 --> 00:45:26,200 CENTERS. 1427 00:45:26,200 --> 00:45:28,120 I'LL GO THROUGH THIS A LITTLE 1428 00:45:28,120 --> 00:45:29,520 MORE QUICKLY PAUSE I WANT TO 1429 00:45:29,520 --> 00:45:30,760 SPEND TIME ON ANOTHER PART WHEN 1430 00:45:30,760 --> 00:45:34,880 WE TALK ABOUT DISPARITIES IN 1431 00:45:34,880 --> 00:45:35,440 SOCIAL MEANS. 1432 00:45:35,440 --> 00:45:36,640 BUT I WANTED TO SHOW THAT IT'S 1433 00:45:36,640 --> 00:45:39,440 NOT JUST LIMITED TO EDs BUT 1434 00:45:39,440 --> 00:45:42,040 IT'S THE SAME SORE STORY WITH 1435 00:45:42,040 --> 00:45:45,120 TRAUMA CENTERS, THEY'RE VERY 1436 00:45:45,120 --> 00:45:49,840 PROFITABLE IN SOME AREAS AND NOT 1437 00:45:49,840 --> 00:45:51,480 PROFITABLE IN OTHERS. 1438 00:45:51,480 --> 00:45:58,680 THAT SIMILAR THING, SO HAVE A 1439 00:45:58,680 --> 00:46:00,880 LOWER -- IF YOU TREAT A HIGHER 1440 00:46:00,880 --> 00:46:02,720 PROPORTION OF MINORITIES YOU'RE 1441 00:46:02,720 --> 00:46:04,160 MORE LIKELY TO CLOSE. 1442 00:46:04,160 --> 00:46:06,120 WHEN WE LOOK AT ACCESS TO LEVEL 1443 00:46:06,120 --> 00:46:10,680 ONE OR TWO TRAUMA CENTERS IF 1444 00:46:10,680 --> 00:46:12,280 YOU'RE UNINSURED, YOU HAVE A 1445 00:46:12,280 --> 00:46:16,840 VERY, VERY, VERY LOW ODDS OF 1446 00:46:16,840 --> 00:46:18,680 HAVING ACCESS TO A TRAUMA CENTER 1447 00:46:18,680 --> 00:46:19,240 WITHIN 60 MINUTES. 1448 00:46:19,240 --> 00:46:20,880 SAME THING WITH YOUR MEDICARE. 1449 00:46:20,880 --> 00:46:23,760 IT'S HIGHER BUT STILL, .69 ODDS 1450 00:46:23,760 --> 00:46:26,160 RATIO OF HAVING ACCESS TO A 1451 00:46:26,160 --> 00:46:28,880 TRAUMA CENTER WITHIN 16 MINUTES. 1452 00:46:28,880 --> 00:46:31,160 AND YOU HAVE ACTUALLY A POSITIVE 1453 00:46:31,160 --> 00:46:32,920 SIGNAL HERE, WHERE BLACKS AND 1454 00:46:32,920 --> 00:46:35,120 NON-WHITES HAVE A HIGHER 1455 00:46:35,120 --> 00:46:36,800 LIKELIHOOD OF ACCESS TO TRAUMA 1456 00:46:36,800 --> 00:46:38,360 CENTER, BUT I'LL GO INTO THAT IN 1457 00:46:38,360 --> 00:46:40,880 JUST A LITTLE BIT BECAUSE PEOPLE 1458 00:46:40,880 --> 00:46:43,040 SAY YOU'VE BEEN TALKING ABOUT 1459 00:46:43,040 --> 00:46:44,360 THERE'S DISCRIMINATION BUT 1460 00:46:44,360 --> 00:46:46,640 YOU'RE SAYING BLACKS AND 1461 00:46:46,640 --> 00:46:47,520 MINORITY -- I WILL TALK ABOUT IT 1462 00:46:47,520 --> 00:46:48,840 IN JUST TWO SLIDES BUT I WANT TO 1463 00:46:48,840 --> 00:46:51,920 KIND OF POINT OUT THE UNINSURED 1464 00:46:51,920 --> 00:46:56,720 AND A LOT OF -- IS WITH INCOME. 1465 00:46:56,720 --> 00:46:57,960 YOU'LL FIND THAT TRAUMA CENTERS 1466 00:46:57,960 --> 00:46:59,360 HAVE BEEN GROWING, THERE'S ALSO 1467 00:46:59,360 --> 00:47:03,040 BEEN A GROWING NUMBER OF TRAUMA 1468 00:47:03,040 --> 00:47:04,040 CENTERS THAT HAVE BEEN OPENING 1469 00:47:04,040 --> 00:47:06,000 ACROSS THE NATION, SO THE NET 1470 00:47:06,000 --> 00:47:08,360 NUMBER OF TRAUMA CENTERS HAS 1471 00:47:08,360 --> 00:47:11,360 BEEN INCREASING AS SO WHAT'S 1472 00:47:11,360 --> 00:47:13,320 HAPPENING HERE IS THAT TRAUMA 1473 00:47:13,320 --> 00:47:16,640 CENTER SAME THING AS EDS, THEY 1474 00:47:16,640 --> 00:47:17,600 HAVE ACTIVATION FEES SO THEY ARE 1475 00:47:17,600 --> 00:47:27,120 ABLE TO CHARGE THESE SOMETIMES 1476 00:47:27,120 --> 00:47:34,640 $10,000, SOME OF THEM ARE EVEN 1477 00:47:34,640 --> 00:47:36,120 HIGHER EVERYONE -- MEDICARE 1478 00:47:36,120 --> 00:47:37,920 TENDS TO -- IT DOESN'T HAVE A 1479 00:47:37,920 --> 00:47:40,960 HIGHER RATE OF PAYMENT BUT THEY 1480 00:47:40,960 --> 00:47:42,000 KNOW THAT IT'S WELL INSURED 1481 00:47:42,000 --> 00:47:43,880 BECAUSE YOU HAVE A LOT OF 1482 00:47:43,880 --> 00:47:45,240 RETIREES THERE, BUT YOU'LL SEE 1483 00:47:45,240 --> 00:47:46,520 LEFT, RIGHT, WHEN YOU'RE ON THE 1484 00:47:46,520 --> 00:47:47,920 HIGHWAY, YOU'LL SEE A TRAUMA 1485 00:47:47,920 --> 00:47:48,920 CENTER, ON THE OTHER SIDE YOU'LL 1486 00:47:48,920 --> 00:47:50,360 SEE A TRAUMA CENTER TOO, AND 1487 00:47:50,360 --> 00:47:51,360 YOU'RE WONDERING IF THAT'S A 1488 00:47:51,360 --> 00:47:54,600 GOOD USE OF RESOURCES. 1489 00:47:54,600 --> 00:47:56,480 IF YOU NEED A CARDIAC CATH 1490 00:47:56,480 --> 00:47:57,880 BECAUSE YOU HAVE A HEART ATTACK, 1491 00:47:57,880 --> 00:48:02,480 YOU'LL FIND THAT YOU HAVE LESS 1492 00:48:02,480 --> 00:48:05,120 ACCESS, THIS IS KIND OF THE 1493 00:48:05,120 --> 00:48:06,560 BACKWARDS WAY BUT UNTIMELY 1494 00:48:06,560 --> 00:48:08,200 ACCESS, MEANING POOR ACCESS TO 1495 00:48:08,200 --> 00:48:09,400 PCI, YOU'RE MUCH LESS LIKELY TO 1496 00:48:09,400 --> 00:48:10,600 HAVE POOR ACCESS IF YOU LIVE IN 1497 00:48:10,600 --> 00:48:12,240 A POOR AREA OR IF YOU HAVE LOW 1498 00:48:12,240 --> 00:48:13,320 INCOME OR IF YOU HAVE A HIGH 1499 00:48:13,320 --> 00:48:15,440 SHARE OF HISPANICS, BUT THEN 1500 00:48:15,440 --> 00:48:16,400 INTERESTINGLY HERE, AGAIN, THIS 1501 00:48:16,400 --> 00:48:20,440 IS -- WE FIND A LITTLE BIT OF A 1502 00:48:20,440 --> 00:48:23,160 STRANGE SIGNAL THAT IT LOOKS 1503 00:48:23,160 --> 00:48:24,120 LIKE BLACK PATIENTS, IF YOU HAVE 1504 00:48:24,120 --> 00:48:25,480 A HIGH SHARE OF BLACK PATIENTS 1505 00:48:25,480 --> 00:48:28,320 THAT YOU HAVE A LOWER ODDS OF 1506 00:48:28,320 --> 00:48:30,040 HAVING ACCESS TO PCI, SO WHAT 1507 00:48:30,040 --> 00:48:31,400 WE'RE FINDING THERE IS ACTUALLY 1508 00:48:31,400 --> 00:48:34,080 JUST -- IT'S AN ISSUE WITH URBAN 1509 00:48:34,080 --> 00:48:35,440 CITIES, SO IF YOU LIFE LIVE IN 1510 00:48:35,440 --> 00:48:39,200 KIND OF A CITY CENTER, YOU DO 1511 00:48:39,200 --> 00:48:42,840 HAVE A P KRI. CI CENTER. 1512 00:48:42,840 --> 00:48:44,360 IT'S NOT JUST ABOUT ACCESS BUT 1513 00:48:44,360 --> 00:48:45,440 IT'S TALKING ABOUT THE 1514 00:48:45,440 --> 00:48:46,240 CROWDEDNESS OF THAT HOSPITAL 1515 00:48:46,240 --> 00:48:47,240 BECAUSE WE KNOW FROM OTHER 1516 00:48:47,240 --> 00:48:48,400 STUDIES THAT BLACK SERVING 1517 00:48:48,400 --> 00:48:49,480 HOSPITALS TEND TO BE MORE 1518 00:48:49,480 --> 00:48:49,720 CROWDED. 1519 00:48:49,720 --> 00:48:51,040 SO IF YOU'RE IN AN AREA THAT, 1520 00:48:51,040 --> 00:48:52,800 YES, YOU HAVE ACCESS TO PCI BUT 1521 00:48:52,800 --> 00:48:54,000 IT'S A REALLY CROWDED HOSPITAL, 1522 00:48:54,000 --> 00:48:55,840 YOU STILL MAY HAVE POOR OUTCOMES 1523 00:48:55,840 --> 00:48:56,840 BECAUSE THERE'S NOT ENOUGH 1524 00:48:56,840 --> 00:49:00,440 RESOURCES FOR YOU. 1525 00:49:00,440 --> 00:49:01,880 SO I WON'T SPEND TOO MUCH TIME 1526 00:49:01,880 --> 00:49:02,840 HERE BUT THIS IS BASICALLY 1527 00:49:02,840 --> 00:49:06,160 SHOWING THAT PCI CENTERS TEND TO 1528 00:49:06,160 --> 00:49:07,240 PROLIFERATE IN AREAS WITH HIGHER 1529 00:49:07,240 --> 00:49:08,200 RATES OF PRIVATE INSURANCE, 1530 00:49:08,200 --> 00:49:12,240 WHERE THERE ARE ALREADY PCI 1531 00:49:12,240 --> 00:49:13,120 SERVICES. 1532 00:49:13,120 --> 00:49:14,320 BUT IT'S NOT JUST ABOUT 1533 00:49:14,320 --> 00:49:14,600 GEOGRAPHY. 1534 00:49:14,600 --> 00:49:17,840 I WANT TO GO INTO A LITTLE 1535 00:49:17,840 --> 00:49:19,120 ABOUT -- WHILE WE HAVE ABOUT 1536 00:49:19,120 --> 00:49:21,320 SEVEN MINUTES LEFT, EVEN IF YOU 1537 00:49:21,320 --> 00:49:23,000 LIVE CLOSE TO A HOSPITAL, THERE 1538 00:49:23,000 --> 00:49:27,360 ARE STUDYS THAT HAVE SHOWN THAT 1539 00:49:27,360 --> 00:49:28,440 IT'S NOT JUST SHOWN THAT YOU 1540 00:49:28,440 --> 00:49:30,200 LIVE CLOSE AND YOU GO THERE, 1541 00:49:30,200 --> 00:49:32,480 THERE ARE STUDIES SHOWING EVEN 1542 00:49:32,480 --> 00:49:33,840 IF YOU'RE CLOSE TO HOSPITALS, 1543 00:49:33,840 --> 00:49:35,800 YOU TEND TO GO TO LOW QUALITY 1544 00:49:35,800 --> 00:49:36,240 HOSPITALS. 1545 00:49:36,240 --> 00:49:37,640 HERE, THIS STUDY LOOKS AT BLACK 1546 00:49:37,640 --> 00:49:39,720 AND WHITE MEDICARE PATIENTS' 1547 00:49:39,720 --> 00:49:41,480 PROXIMITY AND ADMISSION TO LOW 1548 00:49:41,480 --> 00:49:42,040 QUALITY HOSPITALS. 1549 00:49:42,040 --> 00:49:43,560 SO ON THE LEFT, YOU'LL SEE 1550 00:49:43,560 --> 00:49:45,880 PROXIMITY TO AN AVERAGE OR HIGH 1551 00:49:45,880 --> 00:49:46,400 QUALITY HOSPITAL. 1552 00:49:46,400 --> 00:49:48,560 IF YOU ARE LESS THAN FIVE MILES, 1553 00:49:48,560 --> 00:49:50,320 THERE'S ACTUALLY MORE BLACK 1554 00:49:50,320 --> 00:49:51,440 PATIENTS, 15% OF PATIENTS WHO 1555 00:49:51,440 --> 00:49:56,800 ARE LESS THAN FIVE MALES TO A 1556 00:49:56,800 --> 00:49:57,640 CENTER THAN WHITE PATIENTS. 1557 00:49:57,640 --> 00:50:00,920 BUT FOR SOME STRANGE REASON, 1558 00:50:00,920 --> 00:50:02,800 EVEN THOUGH YOU'RE CLOSER TO 1559 00:50:02,800 --> 00:50:05,200 THAT HIGH QUALITY CBG CENTER, 1560 00:50:05,200 --> 00:50:07,280 YOU HAVE A HIGHER ODDS OF GOING 1561 00:50:07,280 --> 00:50:08,680 TO A LOW QUALITY CENTER IF 1562 00:50:08,680 --> 00:50:10,320 YOU'RE BLACK VERSUS WHITE. 1563 00:50:10,320 --> 00:50:12,080 SO THAT'S WHAT THIS SHOWING, 1564 00:50:12,080 --> 00:50:13,840 EACH AREA, WHETHER YOU'RE LESS 1565 00:50:13,840 --> 00:50:16,080 THAN LESS THAN FIVE MILES, FIVE 1566 00:50:16,080 --> 00:50:17,880 TO 20 MILES, GREATER THAN 1567 00:50:17,880 --> 00:50:21,720 20 MILES, YOU STILL HAVE A 1568 00:50:21,720 --> 00:50:23,240 HIGHER PROBABILITY OF GOING TO A 1569 00:50:23,240 --> 00:50:24,120 LOW QUALITY HOSPITAL. 1570 00:50:24,120 --> 00:50:25,560 SAME THING, WE FIND A HIGHER 1571 00:50:25,560 --> 00:50:27,720 RISK OF GOING TO A LOW QUALITY 1572 00:50:27,720 --> 00:50:29,200 HOSPITAL FOR EVEN THINGS LIKE 1573 00:50:29,200 --> 00:50:30,440 ELECTIVE SURGERIES, LIKE LUNG 1574 00:50:30,440 --> 00:50:31,000 CANCER. 1575 00:50:31,000 --> 00:50:32,320 SO FOR CERTAIN THINGS, THERE 1576 00:50:32,320 --> 00:50:34,040 MIGHT BE AN ELEMENT OF 1577 00:50:34,040 --> 00:50:34,640 INDIVIDUAL DISCRIMINATION. 1578 00:50:34,640 --> 00:50:37,040 IT MIGHT BE, FOR EXAMPLE, FOR 1579 00:50:37,040 --> 00:50:38,920 CBG, IF YOU'RE HAVING A BIG 1580 00:50:38,920 --> 00:50:41,560 HEART ATTACK AND IT'S MANY 1581 00:50:41,560 --> 00:50:43,520 VESSELS, MAYBE YOU NEED A CBG. 1582 00:50:43,520 --> 00:50:45,040 I HEAR IT IN THE HOSPITAL WHERE 1583 00:50:45,040 --> 00:50:46,800 THE MEDICS OR THE AMBULANCE 1584 00:50:46,800 --> 00:50:48,240 PROVIDERS WILL COME IN AND SAY, 1585 00:50:48,240 --> 00:50:50,440 WELL, YOU LOOK LIKE A GENERAL 1586 00:50:50,440 --> 00:50:51,920 PATIENT SO I BROUGHT HIM HERE 1587 00:50:51,920 --> 00:50:55,440 EVEN THOUGH HE WAS FARTHER AWAY 1588 00:50:55,440 --> 00:50:56,640 AND YOU WONDER WHAT DOES A 1589 00:50:56,640 --> 00:50:57,720 GENERAL PATIENT LOOK LIKE, AND 1590 00:50:57,720 --> 00:50:59,040 YOU KNOW THEY ALREADY HAVE IN 1591 00:50:59,040 --> 00:51:01,680 THEIR MINDS AN IDEA OF WHAT A 1592 00:51:01,680 --> 00:51:03,080 GENERAL PATIENT LOOKS LIKE, SF 1593 00:51:03,080 --> 00:51:04,320 GENERAL IS WHAT WE CALL OUR 1594 00:51:04,320 --> 00:51:04,600 HOSPITAL. 1595 00:51:04,600 --> 00:51:06,040 BUT THERE ARE OTHER THINGS 1596 00:51:06,040 --> 00:51:07,360 OUTSIDE OF THE SYSTEM TOO, SO IF 1597 00:51:07,360 --> 00:51:08,880 YOU LOOK AT LUNG CANCER 1598 00:51:08,880 --> 00:51:10,160 RESECTION, THIS IS PROBABLY NOT 1599 00:51:10,160 --> 00:51:11,800 SOME PATIENT WHO'S BEING BROUGHT 1600 00:51:11,800 --> 00:51:13,480 BY EMS FOR LUNG CANCER RESEC 1601 00:51:13,480 --> 00:51:16,320 SHUFNLT THIS 1602 00:51:16,320 --> 00:51:18,200 RESECTION. 1603 00:51:18,200 --> 00:51:19,400 IT'S LIKELY RELATED TO THEIR 1604 00:51:19,400 --> 00:51:21,800 ABILITY TO GET REFERRALS OR 1605 00:51:21,800 --> 00:51:23,080 THEIR PRIMARY CARE PHYSICIANS 1606 00:51:23,080 --> 00:51:24,240 ARE ASSOCIATED WITH HIGH QUALITY 1607 00:51:24,240 --> 00:51:24,560 HOSPITALS. 1608 00:51:24,560 --> 00:51:27,240 SO THIS IS AGAIN A ANOTHER 1609 00:51:27,240 --> 00:51:29,600 EXAMPLE OF HOW WE HAVE BAKED IN 1610 00:51:29,600 --> 00:51:31,440 STRUCTURAL INEQUITIES AND THAT 1611 00:51:31,440 --> 00:51:34,480 PATIENTS' SOCIAL NEEDS ARE 1612 00:51:34,480 --> 00:51:37,200 AFFECTED BY OUR ABILITY TO 1613 00:51:37,200 --> 00:51:37,760 MAINTAIN QUALITY CARE. 1614 00:51:37,760 --> 00:51:39,480 THIS IS MY LAST KIND OF SECTION 1615 00:51:39,480 --> 00:51:44,640 JUST ABOUT WHEN WE THINK ABOUT 1616 00:51:44,640 --> 00:51:45,440 STRUCTURAL DISCRIMINATION AND 1617 00:51:45,440 --> 00:51:46,400 SOCIAL NEEDS, THAT WHILE WE DO 1618 00:51:46,400 --> 00:51:48,040 WANT TO THINK ABOUT PROXIMITY 1619 00:51:48,040 --> 00:51:50,240 AND GEOGRAPHY, AND WE THINK, 1620 00:51:50,240 --> 00:51:51,840 WELL, LET'S JUST DISSEMINATE 1621 00:51:51,840 --> 00:51:54,600 TECHNOLOGY TO THESE PLACES SO 1622 00:51:54,600 --> 00:51:56,640 THAT THEY HAVE MORE PCI IN THESE 1623 00:51:56,640 --> 00:51:57,840 AREAS OR THAT WE HAVE BETTER -- 1624 00:51:57,840 --> 00:51:59,760 YOU KNOW, THERE'S A LOT OF 1625 00:51:59,760 --> 00:52:04,240 STUDIES THAT SHOW THAT THERE ARE 1626 00:52:04,240 --> 00:52:05,440 ACTUALLY INEQUITIES IN THE WAY 1627 00:52:05,440 --> 00:52:07,720 WE DI DISSEMINATE TECHNOLOGY. 1628 00:52:07,720 --> 00:52:09,680 SO WE SEE THIS IN EMERGENCY 1629 00:52:09,680 --> 00:52:10,120 MEDICINE AS WELL. 1630 00:52:10,120 --> 00:52:13,280 THE QUESTION IS, DOES THE RISING 1631 00:52:13,280 --> 00:52:14,480 TIDE LIFT ALL BOATS? 1632 00:52:14,480 --> 00:52:18,560 SOME PEOPLE THINK IF THERE'S SEC 1633 00:52:18,560 --> 00:52:19,520 TECHNOLOGY, IT WILL HELP 1634 00:52:19,520 --> 00:52:19,960 EVERYBODY. 1635 00:52:19,960 --> 00:52:22,240 WE DON'T HAVE TO THINK ABOUT 1636 00:52:22,240 --> 00:52:24,320 DISSEMINATING IN A WAY THAT IT 1637 00:52:24,320 --> 00:52:27,640 HAS MORE FOCUS ON UNDERSERVED 1638 00:52:27,640 --> 00:52:28,680 AREAS BECAUSE EVERYONE WILL 1639 00:52:28,680 --> 00:52:29,040 BENEFIT. 1640 00:52:29,040 --> 00:52:31,560 THIS WAS A STUDY I DID THAT 1641 00:52:31,560 --> 00:52:35,160 LOOKS AT CARDIAC CARE 1642 00:52:35,160 --> 00:52:36,440 REGIONALIZATION, IF YOU HAVE A 1643 00:52:36,440 --> 00:52:37,840 HEART ATTACK YOU'RE USUALLY 1644 00:52:37,840 --> 00:52:40,240 BROUGHT TO THE NEAREST E.D. 1645 00:52:40,240 --> 00:52:41,680 NOW WE KNOW BECAUSE NOT ALL 1646 00:52:41,680 --> 00:52:45,320 E.D.s HAVE PCI OR PERCUTANEOUS 1647 00:52:45,320 --> 00:52:45,960 CORONARY INTERVENTION, THAT YOU 1648 00:52:45,960 --> 00:52:47,600 NEED TO GO TO THE NEAREST 1649 00:52:47,600 --> 00:52:49,440 HOSPITAL WHERE THEY HAVE PCI, 1650 00:52:49,440 --> 00:52:50,880 WHERE THEY CAN PUT A LINE IN 1651 00:52:50,880 --> 00:52:52,840 YOUR GROIN, GO UP TO YOUR HEART 1652 00:52:52,840 --> 00:52:56,000 AND OPEN UP THAT OBSTRUCTION. 1653 00:52:56,000 --> 00:52:57,360 SO THIS SAYS IN A CERTAIN EA WE 1654 00:52:57,360 --> 00:53:00,400 WILL MAKE AGREEMENTS THAT THE 1655 00:53:00,400 --> 00:53:01,680 ANNUAL SERVICE TAKES YOU TO THE 1656 00:53:01,680 --> 00:53:03,240 NEAREST PCI HOSPITAL, AND THAT 1657 00:53:03,240 --> 00:53:05,440 YOU WILL HAVE BETTER OUTCOMES. 1658 00:53:05,440 --> 00:53:07,480 SO WE'VE ACTUALLY LOOKED AT, 1659 00:53:07,480 --> 00:53:09,360 WELL, IS THAT TRUE, DID 1660 00:53:09,360 --> 00:53:09,960 REGIONALIZATION HELP ALL 1661 00:53:09,960 --> 00:53:10,800 COMMUNITIES THE SAME? 1662 00:53:10,800 --> 00:53:12,560 OR IS IT POSSIBLE THAT 1663 00:53:12,560 --> 00:53:14,760 REGIONALIZATION HELPED SOME 1664 00:53:14,760 --> 00:53:15,240 COMMUNITIES DIFFERENTLY? 1665 00:53:15,240 --> 00:53:16,600 I KNOW THE SLIDE IS HARD TO READ 1666 00:53:16,600 --> 00:53:18,000 SO I'LL JUST ZOOM IN ON ONE. 1667 00:53:18,000 --> 00:53:20,000 SO THIS PARTICULAR OUTCOME PANEL 1668 00:53:20,000 --> 00:53:22,840 B IS LOOKING AT THE RECEIPT OF 1669 00:53:22,840 --> 00:53:24,240 SAME-DAY PCI. 1670 00:53:24,240 --> 00:53:27,440 SO WHAT IS THE LIKELIHOOD OF 1671 00:53:27,440 --> 00:53:30,960 RECEIVING PERCUTANEOUS CORE CORONARY 1672 00:53:30,960 --> 00:53:32,560 INTERVENTION IF YOU HAD A HEART 1673 00:53:32,560 --> 00:53:33,440 ATTACK AND IS THAT DIFFERENT IF 1674 00:53:33,440 --> 00:53:34,360 YOU LIVED IN DIFFERENT 1675 00:53:34,360 --> 00:53:35,720 COMMUNITIES AND IF YOU WERE 1676 00:53:35,720 --> 00:53:36,640 DIFFERENTLY WHITE OR BLACK? 1677 00:53:36,640 --> 00:53:39,400 SO HERE'S WHAT WE FIND, WHICH I 1678 00:53:39,400 --> 00:53:40,640 FIND VERY SOBERING. 1679 00:53:40,640 --> 00:53:43,680 SO YOU HAD A MUCH HIGHER 1680 00:53:43,680 --> 00:53:45,080 LIKELIHOOD THAT TO RECEIVE 1681 00:53:45,080 --> 00:53:48,520 SAME-DAY PCI BASED ON 1682 00:53:48,520 --> 00:53:49,480 REGIONALIZATION'S EFFECT, IF 1683 00:53:49,480 --> 00:53:51,880 YOU'RE A WHITE RESIDENT IN A 1684 00:53:51,880 --> 00:53:53,040 NON-MINORITY COMMUNITY THAN IF 1685 00:53:53,040 --> 00:53:55,160 YOU WERE AT THE -- NO EFFECT AT 1686 00:53:55,160 --> 00:53:56,800 ALL IF YOU WERE A BLACK OR 1687 00:53:56,800 --> 00:53:59,760 HISPANIC RESIDENT IN A MINORITY 1688 00:53:59,760 --> 00:54:00,080 COMMUNITY. 1689 00:54:00,080 --> 00:54:01,720 SO WHAT THIS IS SHOWING TO US IS 1690 00:54:01,720 --> 00:54:03,120 THAT REGIONALIZATION, EVEN WHEN 1691 00:54:03,120 --> 00:54:05,640 WE HAVE TECHNOLOGY, IT'S NOT 1692 00:54:05,640 --> 00:54:06,400 DISSEMINATED IN THE SAME WAY, 1693 00:54:06,400 --> 00:54:07,400 AND PEOPLE DON'T HAVE THE 1694 00:54:07,400 --> 00:54:09,240 SAME -- WELL, WHAT I SHOULD SAY 1695 00:54:09,240 --> 00:54:10,680 IS, NOT THAT IT'S NOT 1696 00:54:10,680 --> 00:54:11,640 DISSEMINATED IN THE SAME WAY, 1697 00:54:11,640 --> 00:54:13,600 BUT BECAUSE WE HAVE THESE 1698 00:54:13,600 --> 00:54:14,960 UNDERLYING STRUCTURES OF HOW THE 1699 00:54:14,960 --> 00:54:16,120 PROVISION OF THE EMERGENCY 1700 00:54:16,120 --> 00:54:18,120 SERVICES IS ALREADY INEQUITABLE, 1701 00:54:18,120 --> 00:54:19,520 THAT MEANS WHEN YOU DISTRIBUTE 1702 00:54:19,520 --> 00:54:22,240 TECHNOLOGY, IT CONTINUES TO BE 1703 00:54:22,240 --> 00:54:23,640 INEQUITABLE BECAUSE THE BASELINE 1704 00:54:23,640 --> 00:54:24,600 STRUCTURE IS ALREADY DESIGNED 1705 00:54:24,600 --> 00:54:25,520 THAT WAY. 1706 00:54:25,520 --> 00:54:27,920 SO THAT'S WHY WE SEE THAT 1707 00:54:27,920 --> 00:54:29,680 ACTUALLY BLACK RESIDENTS IN 1708 00:54:29,680 --> 00:54:31,000 MINORITY COMMUNITIES, BLACK OR 1709 00:54:31,000 --> 00:54:32,800 HISPANIC RESIDENTS IN MINORITY 1710 00:54:32,800 --> 00:54:33,720 COMMUNITIES RECEIVE NO BENEFIT 1711 00:54:33,720 --> 00:54:35,040 FROM REGIONALIZATION, AND THAT'S 1712 00:54:35,040 --> 00:54:35,760 LIKELY BECAUSE THEY DIDN'T HAVE 1713 00:54:35,760 --> 00:54:37,040 A LOT OF THOSE SERVICES IN THE 1714 00:54:37,040 --> 00:54:38,400 BEGINNING AND I THINK THIS IS 1715 00:54:38,400 --> 00:54:39,080 VERY SOBERING. 1716 00:54:39,080 --> 00:54:41,120 WHEN WE LOOKED AT OUTCOMES TOO, 1717 00:54:41,120 --> 00:54:42,360 I'LL JUST SHOW YOU THIS SLIDE, 1718 00:54:42,360 --> 00:54:44,080 SAME THING WITH MORTALITY. 1719 00:54:44,080 --> 00:54:45,520 WHO BENEFITED FROM 1720 00:54:45,520 --> 00:54:45,880 REGIONALIZATION? 1721 00:54:45,880 --> 00:54:48,040 IT WAS WHITE RESIDENTS IN 1722 00:54:48,040 --> 00:54:50,240 NON-MINORITY COMMUNITIES, BUT 1723 00:54:50,240 --> 00:54:51,800 ALL OTHER RESIDENTS, WHETHER 1724 00:54:51,800 --> 00:54:53,400 THEY WERE BLACK OR HISPANIC, 1725 00:54:53,400 --> 00:54:57,760 WHETHER THEY WERE IN 1726 00:54:57,760 --> 00:54:59,280 NON-MINORITY COMMUNITIES OR 1727 00:54:59,280 --> 00:55:03,240 MINORITY COMMUNITIES, ONLY WHITE 1728 00:55:03,240 --> 00:55:05,080 RESIDENTS IN NON-MINORITY 1729 00:55:05,080 --> 00:55:08,240 COMMUNITIES HAD IMPROVED 1730 00:55:08,240 --> 00:55:08,840 MORTALITY. 1731 00:55:08,840 --> 00:55:10,040 STRATIFYING OUR ANALYSES TO LOOK 1732 00:55:10,040 --> 00:55:12,200 TO SEE WHO HAS BENEFITED IS 1733 00:55:12,200 --> 00:55:14,840 REALLY IMPORTANT, BECAUSE IF YOU 1734 00:55:14,840 --> 00:55:16,240 AVERAGE THEM ALL TOGETHER, THEN 1735 00:55:16,240 --> 00:55:17,480 YOU'LL THINK MAYBE THERE'S A 1736 00:55:17,480 --> 00:55:18,440 BENEFIT FOR EVERYBODY, BUT 1737 00:55:18,440 --> 00:55:19,640 ACTUALLY WHEN YOU SEPARATE THEM 1738 00:55:19,640 --> 00:55:20,640 OUT, THERE ARE DIFFERENT 1739 00:55:20,640 --> 00:55:21,680 POPULATIONS THAT ARE RECEIVING 1740 00:55:21,680 --> 00:55:24,000 BENEFIT AND THAT'S A 1741 00:55:24,000 --> 00:55:24,760 DIFFERENTIAL BENEFIT THAN 1742 00:55:24,760 --> 00:55:26,480 OTHERS. 1743 00:55:26,480 --> 00:55:28,240 SOME MAY RECEIVE A LOT, SOME MAY 1744 00:55:28,240 --> 00:55:29,680 RECEIVE NONE, WHEN WE AVERAGE 1745 00:55:29,680 --> 00:55:31,760 THEM OUT IT'S OKAY BUT IT'S 1746 00:55:31,760 --> 00:55:32,680 ACTUALLY A REALLY DIFFERENT 1747 00:55:32,680 --> 00:55:33,520 EXPERIENCE FOR PATIENTS ON 1748 00:55:33,520 --> 00:55:33,760 GROUND. 1749 00:55:33,760 --> 00:55:36,680 SO I THINK THIS IS JUST A WAY TO 1750 00:55:36,680 --> 00:55:39,640 CAPTURE, PEOPLE TEND TO THINK A 1751 00:55:39,640 --> 00:55:40,920 RISING TIDE LIFTS ALL BOATS. 1752 00:55:40,920 --> 00:55:42,240 IT'S GREAT NEWS IF YOU OWN A 1753 00:55:42,240 --> 00:55:43,640 BOAT, BUT IT'S NOT TRUE, WHAT WE 1754 00:55:43,640 --> 00:55:45,200 FOUND IN RESEARCH IS A RISING 1755 00:55:45,200 --> 00:55:47,200 TIDE DOES NOT LIFT ALL BOATS. 1756 00:55:47,200 --> 00:55:48,600 SO THIS IS JUST AN ENCOURAGEMENT 1757 00:55:48,600 --> 00:55:51,640 FOR US TO THINK ABOUT HOW EVEN A 1758 00:55:51,640 --> 00:55:53,600 WELL-INTENTIONED IMPLEMENTATION 1759 00:55:53,600 --> 00:55:56,160 OF REFORM ON A SICK SYSTEM CAN 1760 00:55:56,160 --> 00:55:58,000 LEAD TO GREATER GAPS IN HEALTH 1761 00:55:58,000 --> 00:55:59,200 OUTCOMES BETWEEN ADVANTAGED AND 1762 00:55:59,200 --> 00:55:59,760 DISADVANTAGED COMMUNITIES. 1763 00:55:59,760 --> 00:56:01,680 WHEN WE THINK ABOUT KIND OF 1764 00:56:01,680 --> 00:56:04,120 PEOPLE'S SOCIAL NEEDS, WHEN WE 1765 00:56:04,120 --> 00:56:06,760 THINK ABOUT PEOPLE'S PEOPLE'S SOCIAL 1766 00:56:06,760 --> 00:56:09,120 NEEDS THAT IT'S ALREADY WITHIN A 1767 00:56:09,120 --> 00:56:10,440 SICK SYSTEM, WE HAVE TO EXTEND 1768 00:56:10,440 --> 00:56:11,800 OUR -- WHETHER IT'S OUR 1769 00:56:11,800 --> 00:56:13,200 PROTOCOLS OR THE WAY WE THINK 1770 00:56:13,200 --> 00:56:14,400 ABOUT INTEGRATING THEM IN 1771 00:56:14,400 --> 00:56:15,840 TRANSITIONINGS OF CARE OR 1772 00:56:15,840 --> 00:56:17,680 HOUSING, THAT THEY ALREADY HAVE 1773 00:56:17,680 --> 00:56:18,560 THESE BARRIERS. 1774 00:56:18,560 --> 00:56:19,800 I WANT TO ENCOURAGE THE 1775 00:56:19,800 --> 00:56:21,040 RESEARCHERS OUT THERE, THIS IS A 1776 00:56:21,040 --> 00:56:22,600 STUDY THAT I FOUND THAT SAID, 1777 00:56:22,600 --> 00:56:24,160 IT'S A STUDY OF STUDIES, SO IT'S 1778 00:56:24,160 --> 00:56:27,440 A STUDY THAT SAYS THEY LOOKED AT 1779 00:56:27,440 --> 00:56:29,000 THE 50 HIGHEST IMPACT JOURNALS 1780 00:56:29,000 --> 00:56:30,200 IN SIX CATEGORIES REPRESENTING 1781 00:56:30,200 --> 00:56:31,400 THE PUBLIC HEALTH FIELD IN THE 1782 00:56:31,400 --> 00:56:32,240 U.S. 1783 00:56:32,240 --> 00:56:34,280 THE ENTIRE 14-YEAR PERIOD OF 1784 00:56:34,280 --> 00:56:36,080 2002 TO 2015 INCLUSIVE, THERE 1785 00:56:36,080 --> 00:56:38,840 WERE ONLY 25 ARTICLES THAT NAMED 1786 00:56:38,840 --> 00:56:39,760 INSTITUTIONAL RACISM IN THE 1787 00:56:39,760 --> 00:56:42,680 TITLE OR THE ABSTRACT. 1788 00:56:42,680 --> 00:56:43,600 SO I THINK IT'S IMPORTANT FOR US 1789 00:56:43,600 --> 00:56:44,600 TO THINK ABOUT THAT BECAUSE WE 1790 00:56:44,600 --> 00:56:47,960 NEED TO START INCORPORATING THIS 1791 00:56:47,960 --> 00:56:50,920 IN THE WAY THAT WE STUDY 1792 00:56:50,920 --> 00:56:52,000 INTERVENTIONS OR IN THE WAY WE 1793 00:56:52,000 --> 00:56:54,640 STUDY ACCESS TO CARE. 1794 00:56:54,640 --> 00:56:55,800 THIS IS JUST A SCREEN SHOT OF 1795 00:56:55,800 --> 00:56:56,920 KIND OF WHAT THEY FOUND, BUT 1796 00:56:56,920 --> 00:56:59,240 THIS IS VERY, VERY FEW, AND 1797 00:56:59,240 --> 00:57:00,280 YOU'LL FIND THAT SOME OF THEM 1798 00:57:00,280 --> 00:57:01,480 WERE JUST COMMENTARIES, THERE 1799 00:57:01,480 --> 00:57:05,640 WERE A FEW ORIGINAL RESEARCH 1800 00:57:05,640 --> 00:57:06,880 PIECES, A COUPLE LITERATURE VIEW 1801 00:57:06,880 --> 00:57:07,520 BUT NOT VERY MUCH. 1802 00:57:07,520 --> 00:57:09,240 SO WHEN WE THINK ABOUT NEXT 1803 00:57:09,240 --> 00:57:11,760 STEPS, I'M EXCITED TO KIND OF 1804 00:57:11,760 --> 00:57:14,960 THINK ABOUT ALL THE WAYS THAT I 1805 00:57:14,960 --> 00:57:16,080 HOPE THAT PEOPLE PARTICIPATING 1806 00:57:16,080 --> 00:57:17,120 IN THIS CONFERENCE, IN THIS 1807 00:57:17,120 --> 00:57:18,440 ROUNDTABLE L BENEFIT FROM 1808 00:57:18,440 --> 00:57:19,320 HEARING FROM THE SPEAKERS WHO 1809 00:57:19,320 --> 00:57:22,840 ARE TALKING ABOUT THINGS RANGING 1810 00:57:22,840 --> 00:57:27,480 FROM HOUSING AND THINKING ABOUT 1811 00:57:27,480 --> 00:57:29,040 SOCIAL SERVICES, THINKING ABOUT 1812 00:57:29,040 --> 00:57:30,600 DATA AND HOW WE KIND OF ATTACK 1813 00:57:30,600 --> 00:57:31,720 THIS PROBLEM OF SOCIAL NEEDS IN 1814 00:57:31,720 --> 00:57:32,320 THE EMERGENCY DEPARTMENT. 1815 00:57:32,320 --> 00:57:35,240 SO I'LL JUST STOP THERE SINCE MY 1816 00:57:35,240 --> 00:57:36,880 45 MINUTE RINGER WENT OFF, AND 1817 00:57:36,880 --> 00:57:38,840 I'M HAPPY TO TAKE QUESTIONS OR 1818 00:57:38,840 --> 00:57:40,080 WE CAN HAVE OTHER CONVERSATIONS. 1819 00:57:40,080 --> 00:57:42,680 THANK YOU VERY MUCH. 1820 00:57:42,680 --> 00:57:44,600 >> THANK YOU SO MUCH, DR. HSIA, 1821 00:57:44,600 --> 00:57:46,280 FOR YOUR VERY THOUGHTFUL 1822 00:57:46,280 --> 00:57:46,840 PRESENTATION. 1823 00:57:46,840 --> 00:57:49,840 NOW WE HAVE ABOUT 30 MINUTES FOR 1824 00:57:49,840 --> 00:57:50,120 DISCUSSION. 1825 00:57:50,120 --> 00:57:52,240 SO I WOULD REALLY LIKE TO 1826 00:57:52,240 --> 00:57:54,320 WELCOME EVERYONE WHO'S ATTENDING 1827 00:57:54,320 --> 00:57:56,800 TO USE THE RAISE HAND FUNCTION. 1828 00:57:56,800 --> 00:57:58,880 THAT'S LOCATED ON THE BOTTOM OF 1829 00:57:58,880 --> 00:58:00,200 YOUR SCREEN IN THE SECTION 1830 00:58:00,200 --> 00:58:01,840 CALLED REACTIONS NEAR THE LITTLE 1831 00:58:01,840 --> 00:58:03,560 SMILING FACE IMAGE IF YOU WOULD 1832 00:58:03,560 --> 00:58:05,640 LIKE TO ASK A QUESTION OR OFFER 1833 00:58:05,640 --> 00:58:07,640 A COMMENT, WE WILL CALL ON YOU 1834 00:58:07,640 --> 00:58:12,520 AND OUR TECHNOLOGY GEU GURUS GURUS ARE 1835 00:58:12,520 --> 00:58:13,720 GOING TO ENSURE PEOPLE ARE 1836 00:58:13,720 --> 00:58:15,040 UNMUTED AND ABLE TO PARTICIPATE 1837 00:58:15,040 --> 00:58:15,440 IN THE DISCUSSION. 1838 00:58:15,440 --> 00:58:17,040 SO WE'RE NOT GOING TO PUT 1839 00:58:17,040 --> 00:58:19,840 QUESTIONS IN THE CHAT AT THIS 1840 00:58:19,840 --> 00:58:20,840 POINT, SO PLEASE, I WOULD 1841 00:58:20,840 --> 00:58:21,920 ENCOURAGE YOU TO RAISE YOUR HAND 1842 00:58:21,920 --> 00:58:23,280 IF YOU HAVE A QUESTION. 1843 00:58:23,280 --> 00:58:25,080 I SEE MARY BETH, WOULD YOU LIKE 1844 00:58:25,080 --> 00:58:35,000 TO UNMUTE AND GO AHEAD? 1845 00:58:35,000 --> 00:58:36,040 >> THANK YOU. 1846 00:58:36,040 --> 00:58:36,680 FASCINATING PRESENTATION, THANK 1847 00:58:36,680 --> 00:58:37,120 YOU VERY MUCH. 1848 00:58:37,120 --> 00:58:38,120 ONE OF THE QUESTIONS I GUESS I 1849 00:58:38,120 --> 00:58:39,840 WAS THINKING ABOUT IN TERMS OF 1850 00:58:39,840 --> 00:58:42,840 STRUCTURAL DEFICITS DOES HAVE TO 1851 00:58:42,840 --> 00:58:45,640 DO WITH, YOU KNOW, HOW PCP 1852 00:58:45,640 --> 00:58:48,080 APPOINTMENTS ARE 9:00 TO 5:00. 1853 00:58:48,080 --> 00:58:51,240 SO I'M WONDERING ABOUT THE 1854 00:58:51,240 --> 00:58:53,440 ADVERSE IMPACT OF THAT STRUCTURE 1855 00:58:53,440 --> 00:58:56,840 WE HAVE FOR PRIMARY CARE BEING 1856 00:58:56,840 --> 00:59:00,000 9:00 TO 5:00 THAT ACTUALLY FEEDS 1857 00:59:00,000 --> 00:59:03,280 INTO THEN THE STRUCTURAL 1858 00:59:03,280 --> 00:59:04,520 INEQUITIES FOR PEOPLE HAVING TO 1859 00:59:04,520 --> 00:59:07,120 GO TO E.D.s, IF YOU'VE STUDIED 1860 00:59:07,120 --> 00:59:07,680 THAT OR THOUGHTS. 1861 00:59:07,680 --> 00:59:09,200 >> CAN YOU REPEAT THE QUESTION 1862 00:59:09,200 --> 00:59:10,520 AGAIN, THE PRECISE QUESTION? 1863 00:59:10,520 --> 00:59:11,840 >> SO THE QUESTION REALLY HAS TO 1864 00:59:11,840 --> 00:59:14,960 DO, HAS THERE BEEN MUCH RESEARCH 1865 00:59:14,960 --> 00:59:17,360 DONE LOOKING AT THE STRUCTURAL 1866 00:59:17,360 --> 00:59:18,920 INEQUITIES ASSOCIATED WITH HOW 1867 00:59:18,920 --> 00:59:19,760 PRIMARY CARE IS PROVIDED? 1868 00:59:19,760 --> 00:59:21,960 IT'S A 9:00 TO 5:00 MODEL, AND 1869 00:59:21,960 --> 00:59:25,160 HOW DOES THAT IMPACT OUR E.D. 1870 00:59:25,160 --> 00:59:26,960 USAGE AND/OR INEQUITIES? 1871 00:59:26,960 --> 00:59:27,840 >> YES. 1872 00:59:27,840 --> 00:59:29,160 SORRY, TOOK ME A LITTLE WHILE TO 1873 00:59:29,160 --> 00:59:30,600 KIND OF GET IN GEAR ABOUT THAT, 1874 00:59:30,600 --> 00:59:32,640 BUT I THINK THAT'S A GREAT 1875 00:59:32,640 --> 00:59:33,040 QUESTION. 1876 00:59:33,040 --> 00:59:34,640 I THINK THERE ARE A FEW STUDIES 1877 00:59:34,640 --> 00:59:35,640 I CAN CALL THAT LOOK AT 1878 00:59:35,640 --> 00:59:36,600 AVAILABILITY OF PRIMARY CARE, 1879 00:59:36,600 --> 00:59:38,600 AND ALSO NOT ALL PRIMARY CARE IS 1880 00:59:38,600 --> 00:59:39,080 THE SAME. 1881 00:59:39,080 --> 00:59:40,080 SO THERE ARE PRIMARY CARE 1882 00:59:40,080 --> 00:59:41,320 SERVICES THAT THEY CALL YOU 1883 00:59:41,320 --> 00:59:44,280 BACK, THEY'VE GOT AFTER HOUR 1884 00:59:44,280 --> 00:59:45,480 SERVICES, AND I THINK -- I DON'T 1885 00:59:45,480 --> 00:59:46,680 KNOW IF THERE'S A PARTICULAR 1886 00:59:46,680 --> 00:59:49,520 STUDY, BUT I WOULD BET THAT 1887 00:59:49,520 --> 00:59:56,120 THERE ARE MORE KIND OF ADVICE 1888 00:59:56,120 --> 00:59:58,080 NURSES IF YOU LOOK BASED ON 1889 00:59:58,080 --> 00:59:58,840 INCOME, BECAUSE THOSE ARE 1890 00:59:58,840 --> 01:00:00,400 PATIENTS WHO HAVE RESOURCES AND 1891 01:00:00,400 --> 01:00:04,360 HAVE GOOD CHOICE ARE GOING TO DO 1892 01:00:04,360 --> 01:00:07,080 THAT AND THAT'S GOING TO DO 1893 01:00:07,080 --> 01:00:08,840 MARKET PRESSURE FOR PRIMARY CARE 1894 01:00:08,840 --> 01:00:11,560 PROVIDER RS TO DO THAT. 1895 01:00:11,560 --> 01:00:12,880 THAT'S A LARGE REASON PEOPLE 1896 01:00:12,880 --> 01:00:13,080 COME. 1897 01:00:13,080 --> 01:00:16,640 >> THANK YOU. 1898 01:00:16,640 --> 01:00:23,000 >> OTHER FOLKS WITH QUESTIONS? 1899 01:00:23,000 --> 01:00:23,520 DON'T BE SHY. 1900 01:00:23,520 --> 01:00:24,680 IT'S A SMALL ZOOM. 1901 01:00:24,680 --> 01:00:29,200 OH, CARLY, GO AHEAD. 1902 01:00:29,200 --> 01:00:30,200 >> HELLO, YES. 1903 01:00:30,200 --> 01:00:31,840 SO MY QUESTION, I'M REPRESENTING 1904 01:00:31,840 --> 01:00:33,160 THE HISPANIC NURSES ASSOCIATION, 1905 01:00:33,160 --> 01:00:37,840 IS THE HAT I HAVE ON TODAY, AND 1906 01:00:37,840 --> 01:00:39,160 HAVE YOU NOTICED ANY -- 1907 01:00:39,160 --> 01:00:40,560 ESPECIALLY WITH YOUR POPULATION 1908 01:00:40,560 --> 01:00:41,960 IN TEXAS, LOOKING AT DIFFERENT 1909 01:00:41,960 --> 01:00:43,040 AREA, TALKING ABOUT ACCESS TO 1910 01:00:43,040 --> 01:00:44,600 CARE FOR UNDOCUMENTED 1911 01:00:44,600 --> 01:00:45,640 INDIVIDUALS OR MY GRANT 1912 01:00:45,640 --> 01:00:48,320 POPULATIONS FOR PRIMARY CARE USE 1913 01:00:48,320 --> 01:00:52,360 OF THE E.R., SINCE THE LAW KIND 1914 01:00:52,360 --> 01:00:53,560 OF PROTECTS THAT, CAN YOU SPEAK 1915 01:00:53,560 --> 01:00:55,280 TO THAT A LITTLE BIT AND MAYBE 1916 01:00:55,280 --> 01:00:57,160 SOME INEQUITIES WE'RE FACING IN 1917 01:00:57,160 --> 01:01:01,160 TERMS OF THAT POPULATION? 1918 01:01:01,160 --> 01:01:03,640 >> MY COLLEAGUE DOES A LOT OF 1919 01:01:03,640 --> 01:01:09,960 WORK ON UNDOCUMENTED MIGRANTS 1920 01:01:09,960 --> 01:01:11,800 AND THEIR UNWILLINGNESS TO COME 1921 01:01:11,800 --> 01:01:13,440 TO THE E.D. 1922 01:01:13,440 --> 01:01:14,640 THREA MUCH MORE YEN RUSS 1923 01:01:14,640 --> 01:01:16,640 COVERAGE IN CALIFORNIA, BUT 1924 01:01:16,640 --> 01:01:18,240 THERE'S STILL THE SAME FEARS 1925 01:01:18,240 --> 01:01:19,360 THAT COMMUNITIES HAVE S BUT 1926 01:01:19,360 --> 01:01:20,800 MAYBE LESS ALSO EVEN WITHIN 1927 01:01:20,800 --> 01:01:23,480 DIFFERENT CITIES AND IN 1928 01:01:23,480 --> 01:01:24,280 CALIFORNIA, SAN FRANCISCO IS 1929 01:01:24,280 --> 01:01:26,040 REALLY DIFFERENT FROM OTHER 1930 01:01:26,040 --> 01:01:29,240 PLACES, SO I THINK THEY 1931 01:01:29,240 --> 01:01:30,800 DEFINITELY MAY NOT BE AS WILLING 1932 01:01:30,800 --> 01:01:31,960 TO -- I THINK THAT'S PART OF 1933 01:01:31,960 --> 01:01:33,040 WHAT'S DIFFICULT IN THINKING 1934 01:01:33,040 --> 01:01:35,240 ABOUT SOCIAL NEEDS, THERE'S 1935 01:01:35,240 --> 01:01:37,160 GOING TO BE A TALK TOMORROW 1936 01:01:37,160 --> 01:01:38,600 ABOUT DO PATIENTS WANT THEIR 1937 01:01:38,600 --> 01:01:39,560 NEEDS CARED FOR? 1938 01:01:39,560 --> 01:01:40,880 I THINK ANOTHER QUESTION IS 1939 01:01:40,880 --> 01:01:42,280 WHETHER THEY FEEL COMFORTABLE 1940 01:01:42,280 --> 01:01:43,640 ENOUGH TO EVEN SHARE THOSE OR 1941 01:01:43,640 --> 01:01:47,440 DISCLOSE THOSE, BECAUSE THEY MAY 1942 01:01:47,440 --> 01:01:48,840 NOT KNOW THAT THERE'S NO 1943 01:01:48,840 --> 01:01:50,640 RELATIONSHIP WITH THEIR 1944 01:01:50,640 --> 01:01:51,840 REGISTRATION HERE AND 1945 01:01:51,840 --> 01:01:52,600 REGISTRATION WITH THE 1946 01:01:52,600 --> 01:01:53,680 GOVERNMENT, ESPECIALLY IF IT'S A 1947 01:01:53,680 --> 01:01:55,000 GOVERNMENT HOSPITAL, RIGHT? 1948 01:01:55,000 --> 01:01:55,960 THESE PUBLIC HOSPITALS THAT TEND 1949 01:01:55,960 --> 01:01:57,240 TO SERVE A HIGH PROPORTION OF 1950 01:01:57,240 --> 01:01:58,720 THESE IMMIGRANTS, THEY'RE 1951 01:01:58,720 --> 01:01:59,040 PUBLIC. 1952 01:01:59,040 --> 01:02:04,840 SO THERE'S A LOT OF, I THINK, 1953 01:02:04,840 --> 01:02:07,800 FEAR AND WHILE WE MAY SAY THAT'S 1954 01:02:07,800 --> 01:02:08,680 UNJUSTIFIED FEAR BECAUSE WE 1955 01:02:08,680 --> 01:02:10,840 NEVER REPORT IT, BUT WHO KNOWS? 1956 01:02:10,840 --> 01:02:12,160 I THINK THAT'S A REALLY GOOD 1957 01:02:12,160 --> 01:02:13,920 POINT. 1958 01:02:13,920 --> 01:02:15,120 >> THANK YOU. 1959 01:02:15,120 --> 01:02:18,640 HOW ABOUT NATALIE? 1960 01:02:18,640 --> 01:02:22,400 >> THANK YOU SO MUCH FOR YOUR 1961 01:02:22,400 --> 01:02:22,920 EYE-OPENING PRESENTATION. 1962 01:02:22,920 --> 01:02:26,400 IT WAS ABSOLUTELY OUTSTANDING. 1963 01:02:26,400 --> 01:02:27,960 I WANTED TO HEAR FROM YOU A 1964 01:02:27,960 --> 01:02:30,680 LITTLE BIT ABOUT THE RESEARCH 1965 01:02:30,680 --> 01:02:32,640 CHALLENGES THAT YOU'VE 1966 01:02:32,640 --> 01:02:34,720 ENCOUNTERED, AND TO HEAR ALSO 1967 01:02:34,720 --> 01:02:36,360 ABOUT WHAT'S NEXT FOR YOU IN 1968 01:02:36,360 --> 01:02:38,440 TERMS OF YOUR RESEARCH 1969 01:02:38,440 --> 01:02:39,240 TRAJECTORY, IF YOU WOULDN'T MIND 1970 01:02:39,240 --> 01:02:39,600 SHARING THAT. 1971 01:02:39,600 --> 01:02:40,440 THANK YOU. 1972 01:02:40,440 --> 01:02:41,560 >> I THINK ONE OF THE THINGS 1973 01:02:41,560 --> 01:02:43,560 THAT I'VE BEEN INTERESTED IN 1974 01:02:43,560 --> 01:02:44,840 DOING IS WHEN THAT STUDY CAME 1975 01:02:44,840 --> 01:02:46,600 OUT IN 2011 ACTUALLY, IT WAS 1976 01:02:46,600 --> 01:02:49,840 SHOWING THAT HOSPITALS -- THAT 1977 01:02:49,840 --> 01:02:51,040 E.D.s TENDED TO CLOSE MORE 1978 01:02:51,040 --> 01:02:52,840 OFTEN IN POOR AREAS, AND THE 1979 01:02:52,840 --> 01:02:55,840 REPORTER SAID, OH, YOU KNOW, DR. HSIA, THA T'S UNFORTUNATE 1980 01:02:55,840 --> 01:02:59,240 THAT PATIENTS IN POOR AREAS ARE 1981 01:02:59,240 --> 01:03:02,040 MORE LIKELY TO LOSE THEIR 1982 01:03:02,040 --> 01:03:05,600 SERVICES, BUT HOW DOES THIS 1983 01:03:05,600 --> 01:03:06,240 AFFECT -- SERVICES? 1984 01:03:06,240 --> 01:03:07,320 I DON'T FAULT THAT QUESTION AT 1985 01:03:07,320 --> 01:03:08,840 ALL BUT I THINK SHE WANTS TO 1986 01:03:08,840 --> 01:03:10,160 WRITE A REPORT HER READERS WILL 1987 01:03:10,160 --> 01:03:10,560 CARE ABOUT. 1988 01:03:10,560 --> 01:03:12,040 SO I THINK THAT'S A COMMON 1989 01:03:12,040 --> 01:03:13,160 RESPONSE PEOPLE HAVE, IS THIS 1990 01:03:13,160 --> 01:03:14,240 IDEA THAT, WELL, THE POOR WILL 1991 01:03:14,240 --> 01:03:15,520 ALWAYS BE WITH YOU, THAT'S JUST 1992 01:03:15,520 --> 01:03:16,720 TOO BAD, THAT'S THE UNITED 1993 01:03:16,720 --> 01:03:17,400 STATES. 1994 01:03:17,400 --> 01:03:18,920 BUT WHAT I WANT TO LOOK AT MORE 1995 01:03:18,920 --> 01:03:21,240 AND WHAT I WOULD ENCOURAGE 1996 01:03:21,240 --> 01:03:22,000 PEOPLE WHO ARE INTERESTED IN 1997 01:03:22,000 --> 01:03:25,240 THESE AREAS IS TO SHOW HOW WE 1998 01:03:25,240 --> 01:03:27,360 ARE ALL DEPENDENT ON HEALTHCARE 1999 01:03:27,360 --> 01:03:28,640 SERVICES AND THAT IF YOU ARE IN 2000 01:03:28,640 --> 01:03:30,840 AN AREA WITH TOO MUCH, IT IS 2001 01:03:30,840 --> 01:03:32,280 VERY, VERY POSSIBLE THAT YOUR 2002 01:03:32,280 --> 01:03:33,600 OUTCOMES COULD BE WORSE BECAUSE 2003 01:03:33,600 --> 01:03:37,040 I'LL JUST GIVE YOU ONE EXAM, SO 2004 01:03:37,040 --> 01:03:39,880 PC I, IF YOU ARE AN 2005 01:03:39,880 --> 01:03:40,520 INTERVENTIONAL CARDIOLOGIST, YOU 2006 01:03:40,520 --> 01:03:41,640 ARE SUPPOSED TO HAVE A CERTAIN 2007 01:03:41,640 --> 01:03:43,000 NUMBER OF MINIMUM PROCEDURES PER 2008 01:03:43,000 --> 01:03:44,560 YEAR TO STAY CERTIFIED. 2009 01:03:44,560 --> 01:03:46,520 BUT WHEN YOU'VE GOT ALL THESE 2010 01:03:46,520 --> 01:03:48,440 HOSPITALS POPPING UP PCI CENTERS 2011 01:03:48,440 --> 01:03:50,360 AROUND YOU, YOU SHOULD HAVE A 2012 01:03:50,360 --> 01:03:52,560 FIXED VOLUME OF PCI IN A CERTAIN 2013 01:03:52,560 --> 01:03:56,200 EA YOU AREN'T CREATING OR 2014 01:03:56,200 --> 01:03:57,280 INDUCING HEART ATTACKS BY 2015 01:03:57,280 --> 01:03:58,040 PUTTING A HOSPITAL THERE. 2016 01:03:58,040 --> 01:03:59,480 BUT WHAT WE FIND IS BECAUSE YOU 2017 01:03:59,480 --> 01:04:01,080 HAVE MORE CARDIOLOGISTS AND MORE 2018 01:04:01,080 --> 01:04:05,240 HOSPITALS OFFERING THIS, YOUR 2019 01:04:05,240 --> 01:04:06,040 PER-INDIVIDUAL CARDIOLOGIST 2020 01:04:06,040 --> 01:04:06,600 NUMBER WILL DROP. 2021 01:04:06,600 --> 01:04:09,320 SO WHAT ACTUALLY ENDS UP 2022 01:04:09,320 --> 01:04:11,280 HAPPENING IS THEY START DOING 2023 01:04:11,280 --> 01:04:12,920 DISCRETIONARY PROCEDURES, 2024 01:04:12,920 --> 01:04:15,440 PROCEDURES THAT MAY NOT BE AS 2025 01:04:15,440 --> 01:04:16,640 BENEFICIAL BECAUSE THEY NEED TO 2026 01:04:16,640 --> 01:04:18,840 KEEP THEIR NUMBERS UP. 2027 01:04:18,840 --> 01:04:20,560 THESE ARE REAL MOTIVATIONS AND 2028 01:04:20,560 --> 01:04:21,560 REAL INCENTIVES THAT ARE OUT 2029 01:04:21,560 --> 01:04:23,200 THERE AND REAL PRESSURES. 2030 01:04:23,200 --> 01:04:24,400 SO THERE'S ACTUALLY A STUDY THAT 2031 01:04:24,400 --> 01:04:25,480 I'M IN THE MIDDLE OF WRITING UP 2032 01:04:25,480 --> 01:04:27,040 THAT SHOWS ACTUALLY THERE ARE 2033 01:04:27,040 --> 01:04:29,520 THE HIGHER NUMBER AS YOU HAVE 2034 01:04:29,520 --> 01:04:31,360 THE INTRODUCTION OF PCI SERVICES 2035 01:04:31,360 --> 01:04:33,160 IN THESE ALREADY SATURATED AREAS 2036 01:04:33,160 --> 01:04:35,680 THAT ARE PROPORTION OF PCI THAT 2037 01:04:35,680 --> 01:04:37,920 IS DONE FOR STABLE CORONARY 2038 01:04:37,920 --> 01:04:40,080 ARTERY DISEASE INCREASES. 2039 01:04:40,080 --> 01:04:42,760 AND YOU SHOULD REALLY NEVER HAVE 2040 01:04:42,760 --> 01:04:44,840 A PCI DONE FOR STABLE CORONARY 2041 01:04:44,840 --> 01:04:45,160 ARTERIES. 2042 01:04:45,160 --> 01:04:46,880 SO THAT'S JUST ONE EXAMPLE OF 2043 01:04:46,880 --> 01:04:48,280 KIND OF THE DIRECTION THAT I'M 2044 01:04:48,280 --> 01:04:49,760 WORKING IN, KIND OF JUST SHOWING 2045 01:04:49,760 --> 01:04:50,960 HOW CAN WE GET PEOPLE TO CARE 2046 01:04:50,960 --> 01:04:51,480 ABOUT THIS? 2047 01:04:51,480 --> 01:04:54,080 BECAUSE I THINK IT'S A LOT ABOUT 2048 01:04:54,080 --> 01:04:55,720 PEOPLE'S POLITICAL WILL, LIKE IF 2049 01:04:55,720 --> 01:04:57,320 THERE'S NOT POLITICAL WILL TO 2050 01:04:57,320 --> 01:04:58,160 MAKE THESE CHANGES, IT WILL 2051 01:04:58,160 --> 01:04:59,800 NEVER HAPPEN, SO HOW DO WE 2052 01:04:59,800 --> 01:05:00,360 PROVIDE EVIDENCE THAT GETS 2053 01:05:00,360 --> 01:05:04,080 PEOPLE TO SEE WHAT'S HAPPENING? 2054 01:05:04,080 --> 01:05:09,080 >> THAT'S VERY IMPORTANT. 2055 01:05:09,080 --> 01:05:09,320 REBEKAH. 2056 01:05:09,320 --> 01:05:10,400 >> I WANTED TO ASK YOU ABOUT 2057 01:05:10,400 --> 01:05:11,960 SOMETHING A LITTLE BIT OUTSIDE 2058 01:05:11,960 --> 01:05:14,760 OF THE NARROW CONFINES OF YOUR 2059 01:05:14,760 --> 01:05:16,080 RESEARCH, OR THE BROAD CONFINES 2060 01:05:16,080 --> 01:05:17,400 OF YOUR RESEARCH. 2061 01:05:17,400 --> 01:05:19,440 WHICH IS, HOW DO YOU THINK ABOUT 2062 01:05:19,440 --> 01:05:21,640 A LOT OF THE CLINICAL RESEARCH 2063 01:05:21,640 --> 01:05:23,200 THAT YOUR COLLEAGUES DO? 2064 01:05:23,200 --> 01:05:28,040 AND IN TERMS OF WHETHER WHAT 2065 01:05:28,040 --> 01:05:31,720 YOU'RE POINTING TO IN TERMS OF 2066 01:05:31,720 --> 01:05:34,320 TECHNOLOGY ACCESS, RESOURCE 2067 01:05:34,320 --> 01:05:35,720 ACCESS, IS THAT THE RESOURCE 2068 01:05:35,720 --> 01:05:37,240 ENTERPRISE ITSELF IS FOCUSING ON 2069 01:05:37,240 --> 01:05:40,840 A NARROW SECTOR OF THE 2070 01:05:40,840 --> 01:05:44,240 POPULATION TO DEVELOP IMPROVED 2071 01:05:44,240 --> 01:05:45,320 TREATMENTS THAT ARE AIMED AT 2072 01:05:45,320 --> 01:05:48,960 THAT NARROW SECTOR, AND IF 2073 01:05:48,960 --> 01:05:51,400 THERE'S A CERTAIN PAROCHIALISM 2074 01:05:51,400 --> 01:05:51,600 TO IT. 2075 01:05:51,600 --> 01:05:56,720 >> YEAH, I THINK -- I MEAN, I 2076 01:05:56,720 --> 01:05:57,640 THINK THERE'S IMPORTANT RESEARCH 2077 01:05:57,640 --> 01:05:59,440 BEING DONE IN MANY SPHERES, SO 2078 01:05:59,440 --> 01:06:00,600 IT'S HARD FOR ME TO COMMENT 2079 01:06:00,600 --> 01:06:01,520 SPECIFICALLY BECAUSE I DON'T -- 2080 01:06:01,520 --> 01:06:03,440 I'M NOT AN EXPERT IN THEM AND 2081 01:06:03,440 --> 01:06:05,240 I'M NOT DESIGNING THOSE STUDIES. 2082 01:06:05,240 --> 01:06:08,320 I THINK I DO ENCOURAGE PEOPLE TO 2083 01:06:08,320 --> 01:06:09,560 THINK ABOUT -- I MEAN, I THINK 2084 01:06:09,560 --> 01:06:11,000 THAT'S WHY I CARE ABOUT WHAT I 2085 01:06:11,000 --> 01:06:12,800 DO, IS BECAUSE I THINK IT'S 2086 01:06:12,800 --> 01:06:13,560 IMPORTANT, NOT THAT IT'S NOT 2087 01:06:13,560 --> 01:06:14,680 IMPORTANT FOR OTHER PEOPLE, 2088 01:06:14,680 --> 01:06:16,200 THAT'S NOT MY PASSION, BUT I DO 2089 01:06:16,200 --> 01:06:17,200 WANT TO ENCOURAGE PEOPLE EVEN 2090 01:06:17,200 --> 01:06:18,160 LOOKING AT CLINICAL 2091 01:06:18,160 --> 01:06:21,240 INTERVENTIONS TO THINK ABOUT THE 2092 01:06:21,240 --> 01:06:22,960 BIGGER PICTURE OF WHEN WE 2093 01:06:22,960 --> 01:06:25,040 DISSEMINATE THESE, HOW CAN WE 2094 01:06:25,040 --> 01:06:26,400 DESEMI NATE THEM IN A WAY THAT 2095 01:06:26,400 --> 01:06:27,560 REALLY DOES DECREASE GAPS? 2096 01:06:27,560 --> 01:06:32,600 AS I SAID EARLIER, ACTUALLY, 2097 01:06:32,600 --> 01:06:33,600 IN -- IT IS POSSIBLE THAT IF YOU 2098 01:06:33,600 --> 01:06:34,760 JUST LOOKED AT THE GAP, WE 2099 01:06:34,760 --> 01:06:36,000 ACTUALLY KNOW THE GAP IS 2100 01:06:36,000 --> 01:06:37,240 INCREASING OVER TIME FOR MANY 2101 01:06:37,240 --> 01:06:38,880 CONDITIONS, BUT IN SOME AREAS, 2102 01:06:38,880 --> 01:06:41,240 FOR EXAMPLE, IF YOU LOOK AT PCI 2103 01:06:41,240 --> 01:06:43,640 AND YOU HAVE REDUNDANT SERVICES 2104 01:06:43,640 --> 01:06:46,080 IN REALLY RICH AREA, YOUR 2105 01:06:46,080 --> 01:06:47,120 OUTCOMES COULD BE WORSE IN THE 2106 01:06:47,120 --> 01:06:48,600 RICH AREAS BECAUSE YOU'RE GET 2107 01:06:48,600 --> 01:06:49,600 INAPPROPRIATE PROCEDURES SO IN 2108 01:06:49,600 --> 01:06:51,040 THAT SENSE, YOUR GAP IS 2109 01:06:51,040 --> 01:06:52,080 DECREASING NOT BECAUSE 2110 01:06:52,080 --> 01:06:52,840 UNDERSERVED PATIENTS ARE GETTING 2111 01:06:52,840 --> 01:06:54,240 BETTER TREATMENT BUT IT'S 2112 01:06:54,240 --> 01:06:56,040 BECAUSE OVERSERVED PATIENTS ARE 2113 01:06:56,040 --> 01:06:56,800 GETTING WORSE TREATMENT. 2114 01:06:56,800 --> 01:06:57,720 SO I THINK IT'S JUST IMPORTANT 2115 01:06:57,720 --> 01:06:59,080 TO HAVE THE MINDSET OF LET'S 2116 01:06:59,080 --> 01:07:01,720 LOOK AT THESE POPULATIONS AND 2117 01:07:01,720 --> 01:07:02,840 SEPARATE THEM OUT SO WE DON'T 2118 01:07:02,840 --> 01:07:04,040 AVERAGE OUT WHAT IS ACTUALLY 2119 01:07:04,040 --> 01:07:04,760 HAPPENING. 2120 01:07:04,760 --> 01:07:09,640 AND WE MISS THAT. 2121 01:07:09,640 --> 01:07:10,800 >> THANK YOU. 2122 01:07:10,800 --> 01:07:12,440 >> FANTASTIC. 2123 01:07:12,440 --> 01:07:14,400 IT'S REALLY IMPORTANT AND I HAVE 2124 01:07:14,400 --> 01:07:15,840 REALLY IMPORTANT STRATEGY FOR US 2125 01:07:15,840 --> 01:07:17,120 AS RESEARCHERS TO THINK ABOUT 2126 01:07:17,120 --> 01:07:18,120 INCORPORATING INTO OUR OWN WORK 2127 01:07:18,120 --> 01:07:20,640 FOR SURE. 2128 01:07:20,640 --> 01:07:22,040 OTHER THOUGHTS OR COMMENTS FROM 2129 01:07:22,040 --> 01:07:25,840 THE GROUP? 2130 01:07:25,840 --> 01:07:26,240 PEOPLE ARE QUIET. 2131 01:07:26,240 --> 01:07:26,640 ALL RIGHT. 2132 01:07:26,640 --> 01:07:31,120 I HAVE A COUPLE OF JUST 2133 01:07:31,120 --> 01:07:32,040 THOUGHTS/COMMENTS TO OFFER, BUT 2134 01:07:32,040 --> 01:07:34,280 THEN A QUESTION FOR YOU AS WELL. 2135 01:07:34,280 --> 01:07:36,520 ONE THING I WANTED TO SHARE WITH 2136 01:07:36,520 --> 01:07:39,480 THE GROUP IS THAT DR. HSIA HAD 2137 01:07:39,480 --> 01:07:42,440 MENTIONED SORT OF THIS DEARTH OF 2138 01:07:42,440 --> 01:07:43,520 ARTICLES PUBLISHED IN JOURNALS 2139 01:07:43,520 --> 01:07:44,880 THAT DIRECTLY CALL OUT 2140 01:07:44,880 --> 01:07:46,480 STRUCTURAL OR INSTITUTIONAL 2141 01:07:46,480 --> 01:07:48,040 RACISM IN THE TITLE OR THE 2142 01:07:48,040 --> 01:07:48,440 ABSTRACT. 2143 01:07:48,440 --> 01:07:51,320 SO IN A MUCH LESS RIGOROUS WAY, 2144 01:07:51,320 --> 01:07:53,040 THE PAPER THAT WAS PUBLISHED, I 2145 01:07:53,040 --> 01:07:54,480 TOOK A QUICK LOOK AT THE 2146 01:07:54,480 --> 01:07:55,240 LITERATURE THAT'S SPECIFIC TO 2147 01:07:55,240 --> 01:07:58,760 EMERGENCY NURSING, A COHORT OF 2148 01:07:58,760 --> 01:07:59,840 EMERGENCY NURSING FOCUSED 2149 01:07:59,840 --> 01:08:01,080 JOURNAL AND VERY UNFORTUNATELY, 2150 01:08:01,080 --> 01:08:02,440 THE SAME THING SEEMS TO HOLD 2151 01:08:02,440 --> 01:08:04,240 TREUL IN OUR OWN JOURNAL, SO I 2152 01:08:04,240 --> 01:08:07,000 QUICKLY SEARCHED THIS AFTERNOON 2153 01:08:07,000 --> 01:08:11,320 THE JOURNAL OF NJ EMERGENCY 2154 01:08:11,320 --> 01:08:12,720 NURSING, ACCIDENT AND EMERGENCY 2155 01:08:12,720 --> 01:08:16,040 NURSING, AND THE INTERNATIONAL 2156 01:08:16,040 --> 01:08:17,240 JOURNAL OF TRAUMA NURSING AND I 2157 01:08:17,240 --> 01:08:19,960 ONLY IDENTIFIED IN MY QUICK 2158 01:08:19,960 --> 01:08:21,160 PERUSE ONE PAPER THAT 2159 01:08:21,160 --> 01:08:22,720 SPECIFICALLY MENTIONED 2160 01:08:22,720 --> 01:08:25,080 STRUCTURAL OR INSTITUTIONAL 2161 01:08:25,080 --> 01:08:25,320 RACISM. 2162 01:08:25,320 --> 01:08:26,640 SO FOLKS ON THE CALL, AS A 2163 01:08:26,640 --> 01:08:28,480 COLLECTIVE, WE HAVE WORK TO DO 2164 01:08:28,480 --> 01:08:30,120 IN THIS VERY IMPORTANT SPACE AND 2165 01:08:30,120 --> 01:08:32,760 WE HAVE UNIQUE PERSPECTIVE. 2166 01:08:32,760 --> 01:08:34,080 I THINK THIS IS VERY MUCH SORT 2167 01:08:34,080 --> 01:08:36,600 OF IN OUR WHEELHOUSE AND ISSUES 2168 01:08:36,600 --> 01:08:38,200 THAT WE SHOULD CARE ABOUT, SO 2169 01:08:38,200 --> 01:08:40,800 I'D ENCOURAGE PEOPLE TO REALLY 2170 01:08:40,800 --> 01:08:42,560 THINK ABOUT WAYS THAT YOU CAN 2171 01:08:42,560 --> 01:08:43,840 INCORPORATE THESE KINDS OF 2172 01:08:43,840 --> 01:08:45,200 QUESTIONS INTO YOUR OWN 2173 01:08:45,200 --> 01:08:47,120 PORTFOLIO OF RESEARCH. 2174 01:08:47,120 --> 01:08:48,240 THE SECOND THING I WOULD LIKE TO 2175 01:08:48,240 --> 01:08:53,240 OFFER TO THE GROUP IS THAT SO IN 2176 01:08:53,240 --> 01:08:56,440 2008, DR. STANLEY WILLIS, PAM 2177 01:08:56,440 --> 01:08:57,840 GREYSON -- PUBLISHED A PAPER ON 2178 01:08:57,840 --> 01:08:59,280 THE CENTRAL UNIFYING FOCUS FOR 2179 01:08:59,280 --> 01:09:01,960 THE DISCIPLINE OF NURSING. 2180 01:09:01,960 --> 01:09:03,040 SO THEY PROPOSED THAT THE 2181 01:09:03,040 --> 01:09:05,880 CENTRAL UNIFYING FOCUS, THE CORE 2182 01:09:05,880 --> 01:09:07,120 OF THE DISCIPLINE OF NURSING FOR 2183 01:09:07,120 --> 01:09:10,640 ALL NURSES, IS FACILITATING 2184 01:09:10,640 --> 01:09:11,520 HUMANIZATION, MEANING, CHOICE, 2185 01:09:11,520 --> 01:09:13,800 QUALITY OF LIFE, AND HEALING AND 2186 01:09:13,800 --> 01:09:14,600 LIVING AND DYING. 2187 01:09:14,600 --> 01:09:16,520 SO I WOULD OFFER TO EACH OF YOU 2188 01:09:16,520 --> 01:09:18,960 HERE TODAY THAT WORKING TOWARDS 2189 01:09:18,960 --> 01:09:21,640 HEALTH EQUITY IS ABSOLUTELY 2190 01:09:21,640 --> 01:09:22,280 FOUNDATION 2191 01:09:22,280 --> 01:09:23,640 FOUNDATIONAL FOR US AS A 2192 01:09:23,640 --> 01:09:24,400 DISCIPLINE, IN TERMS OF BEING 2193 01:09:24,400 --> 01:09:26,240 ABLE TO ACHIEVE THAT CENTRAL 2194 01:09:26,240 --> 01:09:26,640 UNIFYING FOCUS. 2195 01:09:26,640 --> 01:09:28,120 THIS IS ONE OF MY FAVORITE 2196 01:09:28,120 --> 01:09:29,680 PAPERS EVER PUBLISHED, SO I LOVE 2197 01:09:29,680 --> 01:09:30,960 TO TALK ABOUT IT AND GET OTHER 2198 01:09:30,960 --> 01:09:34,360 PEOPLE TO READ IT. 2199 01:09:34,360 --> 01:09:37,840 WE CANNOT HELP OUR PATIENTS AND 2200 01:09:37,840 --> 01:09:40,240 COMMUNITIES TRULY FLOURISH AND 2201 01:09:40,240 --> 01:09:42,800 ACHIEVE THESE GOALS WITHOUT 2202 01:09:42,800 --> 01:09:44,720 HEALTH EQUITY, AND THAT MEANS 2203 01:09:44,720 --> 01:09:46,800 DISMANTLING STRUCTURAL AND 2204 01:09:46,800 --> 01:09:47,440 INSTITUTIONALIZED RACISM, RIGHT? 2205 01:09:47,440 --> 01:09:48,440 IT'S BAKED INTO THE SYSTEM THAT 2206 01:09:48,440 --> 01:09:53,440 WE HAVE, AS YOU SAID, SO THIS IS 2207 01:09:53,440 --> 01:09:54,880 VERY MUCH IN OUR LANE AS NURSES 2208 01:09:54,880 --> 01:09:56,000 AND EMERGENCY NURSES, AND WE 2209 01:09:56,000 --> 01:09:57,520 SHOULD REALLY, AGAIN, BE 2210 01:09:57,520 --> 01:09:58,920 THINKING ABOUT WAYS THAT WE CAN 2211 01:09:58,920 --> 01:09:59,920 INCORPORATE THIS INTO ALL THAT 2212 01:09:59,920 --> 01:10:03,080 WE'RE DOING. 2213 01:10:03,080 --> 01:10:04,280 SO FINALLY MY QUESTION FOR YOU. 2214 01:10:04,280 --> 01:10:06,040 SO I WOULD LIKE TO ASK YOU ABOUT 2215 01:10:06,040 --> 01:10:09,200 SOME OF THE WAYS THAT WE MIGHT 2216 01:10:09,200 --> 01:10:10,840 THINK ABOUT ACHIEVING A MORE 2217 01:10:10,840 --> 01:10:11,640 EQUITABLE HEALTH SYSTEM. 2218 01:10:11,640 --> 01:10:12,880 SO IN YOUR WORK, YOU AND YOUR 2219 01:10:12,880 --> 01:10:15,240 COLLEAGUES HAVE DONE SO MUCH TO 2220 01:10:15,240 --> 01:10:19,440 HELP US PINPOINT WHERE THESE IP 2221 01:10:19,440 --> 01:10:21,320 EQUITIES LIE AND THE STRUCTURAL 2222 01:10:21,320 --> 01:10:22,200 REASONS BENEATH THEM. 2223 01:10:22,200 --> 01:10:26,360 IN HIS BOOK HOW TO BE AN 2224 01:10:26,360 --> 01:10:29,440 ANTI-RACIST, DR. IBRIM KENNEDY 2225 01:10:29,440 --> 01:10:31,520 SHARES THAT RACE ILL POLICIES 2226 01:10:31,520 --> 01:10:33,440 AND RACIST IDEAS REALLY COMBINE 2227 01:10:33,440 --> 01:10:35,200 TO PRODUCE AND NORMALIZE THESE 2228 01:10:35,200 --> 01:10:35,880 RACIAL INEQUITIES. 2229 01:10:35,880 --> 01:10:39,640 HE GOES ON TO SAY THAT ALL 2230 01:10:39,640 --> 01:10:41,040 POLICIES ARE EITHER RACIST OR 2231 01:10:41,040 --> 01:10:42,400 ANTIRAY CYST, THAT THERE'S NO 2232 01:10:42,400 --> 01:10:43,800 SUCH THING AS A NEUTRAL POLICY. 2233 01:10:43,800 --> 01:10:45,440 THESE ARE HIS FABULOUS IDEAS. 2234 01:10:45,440 --> 01:10:49,360 SO RACIST POLICIES PRODUCE OR 2235 01:10:49,360 --> 01:10:51,240 SUSTAIN THESE INEQUITIES BETWEEN 2236 01:10:51,240 --> 01:10:53,760 RACIAL GROUPS AND ANTI-RACIST 2237 01:10:53,760 --> 01:10:55,000 POLICIES ARE ACTIVELY WORKING TO 2238 01:10:55,000 --> 01:10:58,440 PRODUCE AND SUSTAIN RACIAL 2239 01:10:58,440 --> 01:10:58,680 EQUITY. 2240 01:10:58,680 --> 01:11:00,440 SO I'M WONDERING IF YOU HAVE 2241 01:11:00,440 --> 01:11:02,320 IDEAS ABOUT THAT, AND HOW WE CAN 2242 01:11:02,320 --> 01:11:05,440 BEGIN TO MOVE BEYOND THE 2243 01:11:05,440 --> 01:11:07,520 INEQUITIES THAT YOU DESCRIBED 2244 01:11:07,520 --> 01:11:09,080 AND SO ELOQUENTLY UNCOVERED FOR 2245 01:11:09,080 --> 01:11:11,240 US TO A MORE EQUITABLE STATE 2246 01:11:11,240 --> 01:11:12,960 THROUGH STRATEGIC ANTI-RACIST 2247 01:11:12,960 --> 01:11:14,560 POLICY MAKING, PARTICULARLY AS 2248 01:11:14,560 --> 01:11:18,440 IT APPLIES TO EMERGENCY CARE. 2249 01:11:18,440 --> 01:11:19,320 >> THANKS FOR THAT QUESTION. 2250 01:11:19,320 --> 01:11:20,520 I THINK IT'S REALLY IMPORTANT TO 2251 01:11:20,520 --> 01:11:25,040 THINK ABOUT HOW -- ONE OF THE 2252 01:11:25,040 --> 01:11:26,840 THINGS I REALLY THINK WE CAN 2253 01:11:26,840 --> 01:11:28,440 FOCUS ON IS JUST HOW IF WE HAVE 2254 01:11:28,440 --> 01:11:30,400 THIS UNDERLYING INEQUITABLE 2255 01:11:30,400 --> 01:11:31,560 SYSTEM, ANYTHING THAT GOES 2256 01:11:31,560 --> 01:11:34,520 THROUGH THAT WILL END UP HAVING 2257 01:11:34,520 --> 01:11:35,280 INEQUITABLE OUTCOMES. 2258 01:11:35,280 --> 01:11:38,080 I THINK THAT'S WHAT DR. KENDY IS 2259 01:11:38,080 --> 01:11:39,640 SAYING IN HIS BOOK, AND I MEAN, 2260 01:11:39,640 --> 01:11:40,960 THERE'S OTHER LAYERS TO TALK 2261 01:11:40,960 --> 01:11:42,400 ABOUT THAT, BUT HE'LL BRING UP 2262 01:11:42,400 --> 01:11:44,480 THE EXAMPLE OF LIKE FOR EXAMPLE 2263 01:11:44,480 --> 01:11:46,640 IF THERE'S TAX ADVANTAGES FOR 2264 01:11:46,640 --> 01:11:48,520 MARRIED VERSUS UNMARRIED 2265 01:11:48,520 --> 01:11:49,640 FACILITIES, THESE ARE RACIST 2266 01:11:49,640 --> 01:11:49,880 POLICIES. 2267 01:11:49,880 --> 01:11:51,240 I MEAN, I DON'T KNOW IF I WOULD 2268 01:11:51,240 --> 01:11:52,160 ACTUALLY GO THAT FAR. 2269 01:11:52,160 --> 01:11:53,880 I THINK THEY END UP HAVING 2270 01:11:53,880 --> 01:11:56,480 RACIST OUTCOMES BUT I DON'T KNOW 2271 01:11:56,480 --> 01:11:57,840 WHETHER A TAX BASIS IS 2272 01:11:57,840 --> 01:11:59,040 NECESSARILY A RACIST POLICY, BUT 2273 01:11:59,040 --> 01:12:00,760 IT MIGHT JUST BE BECAUSE OF THE 2274 01:12:00,760 --> 01:12:01,640 UNDERLYING STRUCTURE. 2275 01:12:01,640 --> 01:12:03,120 REGARDLESS OF THOSE KIND OF 2276 01:12:03,120 --> 01:12:03,920 SEMANTICS, I THINK ONE OF THE 2277 01:12:03,920 --> 01:12:09,280 THINGS WE CAN THINK ABOUT OF AS 2278 01:12:09,280 --> 01:12:10,680 A SPECIALTY, IS THAT WE DON'T 2279 01:12:10,680 --> 01:12:12,680 GIVE UP HOPE ON HAVING THAT MORE 2280 01:12:12,680 --> 01:12:13,120 FUNDAMENTAL REFORM. 2281 01:12:13,120 --> 01:12:14,440 I THINK A LOT OF TIMES WE ARE 2282 01:12:14,440 --> 01:12:16,440 USED TO, IN THE E.D., EVERYONE 2283 01:12:16,440 --> 01:12:20,760 KIND OF JUST -- EVERYONE EXPECTS 2284 01:12:20,760 --> 01:12:22,200 THE E.D. TO PICK UP THE PIECES. 2285 01:12:22,200 --> 01:12:23,400 NOW WE PROVIDE HOUSING FOR 2286 01:12:23,400 --> 01:12:23,840 PEOPLE. 2287 01:12:23,840 --> 01:12:25,160 WE PROVIDE HOUSING, FOOD, 2288 01:12:25,160 --> 01:12:26,240 SHELTER, AND WE'VE GOT TO DIRECT 2289 01:12:26,240 --> 01:12:27,080 THEM TO THESE THINGS. 2290 01:12:27,080 --> 01:12:28,720 WE'RE USED TO THAT AND WE'RE 2291 01:12:28,720 --> 01:12:29,840 GOOD AT THAT, BUT I DON'T THINK 2292 01:12:29,840 --> 01:12:33,840 THAT WE SHOULD GIVE UP HOPE, AND 2293 01:12:33,840 --> 01:12:35,000 ALSO STOP WORKING IN THE AREAS 2294 01:12:35,000 --> 01:12:37,200 OF GETTING PEOPLE TO UNDERSTAND 2295 01:12:37,200 --> 01:12:39,840 THAT THE FUNDAMENTAL ISSUES OF 2296 01:12:39,840 --> 01:12:41,400 THE WAY WE PAY FOR AND DESIGN 2297 01:12:41,400 --> 01:12:43,360 FOR CARE, THE WAY WE FINANCE 2298 01:12:43,360 --> 01:12:45,080 CARE AND DELIVER CARE IS 2299 01:12:45,080 --> 01:12:47,840 STRUCTURED IN SUCH A WAY THAT 2300 01:12:47,840 --> 01:12:48,440 EMPLOYER-BASED HEALTHCARE IS A 2301 01:12:48,440 --> 01:12:51,120 GOOD EXAMPLE OF HOW THAT IS -- 2302 01:12:51,120 --> 01:12:52,760 WHAT DR. KENNEDY WOULD PROBABLY 2303 01:12:52,760 --> 01:12:54,160 SAY IS A RACIST POLICY, WHICH I 2304 01:12:54,160 --> 01:12:55,200 WOULD AGREE WITH, BECAUSE 2305 01:12:55,200 --> 01:12:58,880 EMPLOYMENT WAS VERY RACIST AND 2306 01:12:58,880 --> 01:13:01,840 SO EMPLOYER-BASED INSURANCE IS 2307 01:13:01,840 --> 01:13:03,520 RACIST, RIGHT? 2308 01:13:03,520 --> 01:13:07,320 SO THAT'S AN EXAMPLE OF 2309 01:13:07,320 --> 01:13:08,400 SOMETHING THAT STRUCTURALLY 2310 01:13:08,400 --> 01:13:09,720 NEEDS TO BE REFORMED AND IS 2311 01:13:09,720 --> 01:13:10,800 REALLY DIFFICULT TO REFORM. 2312 01:13:10,800 --> 01:13:13,760 I THINK IN THE UNITED STATES, 2313 01:13:13,760 --> 01:13:17,800 MAYBE SINGLE PAIR IS POLITICALLY 2314 01:13:17,800 --> 01:13:19,840 FEASIBLE BUT THERE ARE OTHER 2315 01:13:19,840 --> 01:13:22,720 THINGS THAT MAY BE. 2316 01:13:22,720 --> 01:13:23,840 A PUBLIC OPTION VERY BRIEFLY IS 2317 01:13:23,840 --> 01:13:25,240 JUST SAYING WELL, WE CAN'T GET 2318 01:13:25,240 --> 01:13:26,240 EVERYONE ON THE SAME PLAN, BUT 2319 01:13:26,240 --> 01:13:27,720 PEOPLE CAN START OPTING -- 2320 01:13:27,720 --> 01:13:28,840 ANYONE WHO IS IN CALIFORNIA CAN 2321 01:13:28,840 --> 01:13:30,720 OPT TO BE PART OF THIS PLAN AND 2322 01:13:30,720 --> 01:13:32,360 THAT THIS PLAN WILL START HAVING 2323 01:13:32,360 --> 01:13:33,880 POWER TO NEGOTIATE, BECAUSE IF 2324 01:13:33,880 --> 01:13:35,240 YOU'RE INTO THESE THOUSANDS OF 2325 01:13:35,240 --> 01:13:36,280 SMALL HEALTH PLANS THAT DON'T 2326 01:13:36,280 --> 01:13:37,680 HAVE POWER, THEN YOU'RE NOT 2327 01:13:37,680 --> 01:13:40,200 GOING TO BE ABLE TO GET MUCH 2328 01:13:40,200 --> 01:13:40,640 NEGOTIATING LEVERAGE. 2329 01:13:40,640 --> 01:13:41,760 SO I THINK THERE ARE WAYS THAT 2330 01:13:41,760 --> 01:13:44,840 WE SHOULD ENCOURAGE OURSELVES TO 2331 01:13:44,840 --> 01:13:47,800 NOT GIVE UP HOPE, BECAUSE WE 2332 01:13:47,800 --> 01:13:48,800 REALLY -- ALL THE INTERVENTIONS 2333 01:13:48,800 --> 01:13:51,400 THAT WE CAN DO WILL NOT REALLY 2334 01:13:51,400 --> 01:13:53,880 HAVE MUCH EFFECT IF THE 2335 01:13:53,880 --> 01:13:55,000 FUNDAMENTAL STRUCTURE OF OUR 2336 01:13:55,000 --> 01:13:55,960 HEALTHCARE SYSTEM STAYS AS IT 2337 01:13:55,960 --> 01:13:57,960 IS. 2338 01:13:57,960 --> 01:14:00,240 >> GREAT. 2339 01:14:00,240 --> 01:14:01,640 ARE THERE OTHER AREAS THAT YOU 2340 01:14:01,640 --> 01:14:03,320 CAN SEE AS CLEAR GAPS WHERE WE 2341 01:14:03,320 --> 01:14:07,680 SHOULD BE WORKING? 2342 01:14:07,680 --> 01:14:10,640 >> I THINK THERE ARE 2343 01:14:10,640 --> 01:14:11,960 INTERVENTIONS NOW THAT WHEN WE 2344 01:14:11,960 --> 01:14:13,240 THINK ABOUT EVEN JUST THE TYPES 2345 01:14:13,240 --> 01:14:16,280 OF WORK THAT WE DO THAT TEND TO 2346 01:14:16,280 --> 01:14:17,920 BE FOCUSED ON POPULATIONS AS 2347 01:14:17,920 --> 01:14:19,720 OPPOSED TO CONSIDERING THE WHOLE 2348 01:14:19,720 --> 01:14:21,600 CONTEXT OF WHERE THEY LIVE IN 2349 01:14:21,600 --> 01:14:23,240 TERMS OF THEIR ACCESS TO 2350 01:14:23,240 --> 01:14:24,200 RESOURCES, WHETHER IT'S THINGS 2351 01:14:24,200 --> 01:14:26,440 LIKE FOOD DESERTS, WHEN WE SAY 2352 01:14:26,440 --> 01:14:28,560 FOOD DESERTS, WE MEAN ACCESS TO 2353 01:14:28,560 --> 01:14:30,400 HEALTHY FOOD AND SCARCITY OF 2354 01:14:30,400 --> 01:14:31,240 FRESH VEGETABLES. 2355 01:14:31,240 --> 01:14:32,680 WE DON'T TEND TO NECESSARILY 2356 01:14:32,680 --> 01:14:34,120 CONNECT THEM WITH EMERGENCY 2357 01:14:34,120 --> 01:14:35,040 DEPARTMENTS BECAUSE WE TEND TO 2358 01:14:35,040 --> 01:14:36,560 THINK OF THOSE AS LIKE 2359 01:14:36,560 --> 01:14:37,680 PREVENTABLE HEALTHCARE, 2360 01:14:37,680 --> 01:14:38,800 HYPERTENSION, YOU KNOW, PRIMARY 2361 01:14:38,800 --> 01:14:39,680 CARE AND THAT'S KIND OF ON THE 2362 01:14:39,680 --> 01:14:40,320 OTHER END. 2363 01:14:40,320 --> 01:14:41,520 BUT THESE THINGS ARE ALL 2364 01:14:41,520 --> 01:14:44,880 CONNECTED SO HOW CAN WE START 2365 01:14:44,880 --> 01:14:45,600 THINKING ABOUT -- YOU KNOW, 2366 01:14:45,600 --> 01:14:47,120 THERE ARE OTHER METRICS THAT ARE 2367 01:14:47,120 --> 01:14:48,120 AVAILABLE THAT HAVE BEEN IN THE 2368 01:14:48,120 --> 01:14:49,240 LITERATURE FOR 20 YEARS, THINGS 2369 01:14:49,240 --> 01:14:51,080 LIKE THE AREA DEPRIVATION INDEX, 2370 01:14:51,080 --> 01:14:53,480 OTHER INDICES OF SEGREGATION. 2371 01:14:53,480 --> 01:14:54,880 HOW DO WE PUT THIS TOGETHER IN A 2372 01:14:54,880 --> 01:14:59,040 WAY THAT IS UNDERSTANDABLE AND 2373 01:14:59,040 --> 01:15:00,480 PALATABLE AND DIGESTIBLE FOR 2374 01:15:00,480 --> 01:15:01,840 POLICY MAKERS TO TAKE ACTION. 2375 01:15:01,840 --> 01:15:04,320 I THINK ONE OF THE THINGS IS AS 2376 01:15:04,320 --> 01:15:07,240 RESEARCHERS, A LOT OF TIMES WE 2377 01:15:07,240 --> 01:15:08,240 PUBLISH THINGS IN A JOURNAL THAT 2378 01:15:08,240 --> 01:15:09,680 NOBODY READS, SO HOW DO WE 2379 01:15:09,680 --> 01:15:10,640 ENGAGE MORE WITH THE MEDIA SO 2380 01:15:10,640 --> 01:15:11,960 THE PUBLIC AND POLICY MAKERS CAN 2381 01:15:11,960 --> 01:15:14,600 LEARN ABOUT IT AND MAKE CHANGE. 2382 01:15:14,600 --> 01:15:15,920 >> YEAH, THAT'S A REALLY GREAT 2383 01:15:15,920 --> 01:15:16,120 POINT. 2384 01:15:16,120 --> 01:15:21,040 THAT ES SO THERE'S SO MUCH GREAT WORK 2385 01:15:21,040 --> 01:15:22,640 AND IT DOES FEEL LIKE IT'S 2386 01:15:22,640 --> 01:15:24,400 FALLING ON DEAF EARS. 2387 01:15:24,400 --> 01:15:25,440 IT'S NOT GETTING OUT THERE IN A 2388 01:15:25,440 --> 01:15:31,400 WAY THAT THE SOCIAL MEDIA DOES. 2389 01:15:31,400 --> 01:15:31,720 VERY GOOD. 2390 01:15:31,720 --> 01:15:32,360 THANK YOU SO MUCH. 2391 01:15:32,360 --> 01:15:33,680 SO IF THERE ARE NO OTHER 2392 01:15:33,680 --> 01:15:34,680 QUESTIONS, DOES ANYBODY HAVE ANY 2393 01:15:34,680 --> 01:15:38,360 LAST QUESTIONS FOR DR. HSIA? 2394 01:15:38,360 --> 01:15:38,880 ALL RIGHT. 2395 01:15:38,880 --> 01:15:40,440 PEOPLE ARE QUIET AND IT'S 2396 01:15:40,440 --> 01:15:41,960 GETTING LATE. 2397 01:15:41,960 --> 01:15:43,480 SO THANK YOU VERY MUCH FOR 2398 01:15:43,480 --> 01:15:45,800 SHARING YOUR IMPORTANT WORK AND 2399 01:15:45,800 --> 01:15:47,240 YOUR ILLUMINATING REMARKS WITH 2400 01:15:47,240 --> 01:15:47,880 OUR GROUP. 2401 01:15:47,880 --> 01:15:49,000 WE VERY MUCH APPRECIATE YOUR 2402 01:15:49,000 --> 01:15:50,840 WILLINGNESS TO JOIN US HERE 2403 01:15:50,840 --> 01:15:52,280 TODAY, AND WE'RE VERY THANKFUL 2404 01:15:52,280 --> 01:15:54,120 ALSO TO OUR ATTENDEES TO SHARING 2405 01:15:54,120 --> 01:15:55,960 THEIR QUESTIONS AND ENGAGING IN 2406 01:15:55,960 --> 01:15:57,400 THIS IMPORTANT DISCUSSION. 2407 01:15:57,400 --> 01:15:59,040 I AM REALLY LOOKING FORWARD TO 2408 01:15:59,040 --> 01:16:00,200 CONTINUING THIS DIALOGUE WITH 2409 01:16:00,200 --> 01:16:01,880 YOU ALL TOMORROW, AND I WOULD 2410 01:16:01,880 --> 01:16:03,720 LIKE TO INVITE DR. ZENK TO OFFER 2411 01:16:03,720 --> 01:16:05,920 A FEW REMARKS BEFORE WE CLOSE 2412 01:16:05,920 --> 01:16:11,520 OUT FOR THE EVENING. 2413 01:16:11,520 --> 01:16:12,680 >> ABSOLUTELY. 2414 01:16:12,680 --> 01:16:15,520 THANK YOU, DR. STROUT, AND THANK 2415 01:16:15,520 --> 01:16:18,720 YOU SO MUCH, DR. HSIA. 2416 01:16:18,720 --> 01:16:20,120 REALLY ENJOYED YOUR KEYNOTE, 2417 01:16:20,120 --> 01:16:23,400 REALLY SET THE STAGE FOR OUR 2418 01:16:23,400 --> 01:16:27,440 CONVERSATIONS TOMORROW, SO THANK 2419 01:16:27,440 --> 01:16:27,680 YOU. 2420 01:16:27,680 --> 01:16:29,320 AND DR. STROUT, OF COURSE THANK 2421 01:16:29,320 --> 01:16:31,280 YOU FOR MODERATING OUR Q & A AND 2422 01:16:31,280 --> 01:16:32,240 FOR YOUR COMMENTS. 2423 01:16:32,240 --> 01:16:33,360 REALLY INSIGHTFUL. 2424 01:16:33,360 --> 01:16:35,440 SO I AGREE, I SEE SOMEONE IN THE 2425 01:16:35,440 --> 01:16:36,680 CHAT, WONDERFUL PRESENTATION, I 2426 01:16:36,680 --> 01:16:38,640 COULDN'T AGREE MORE. 2427 01:16:38,640 --> 01:16:41,760 SO WE'RE GOING TO WRAP UP FOR 2428 01:16:41,760 --> 01:16:42,960 THE EVENING. 2429 01:16:42,960 --> 01:16:44,200 BEFORE I DO THAT, I'M JUST GOING 2430 01:16:44,200 --> 01:16:45,600 TO GIVE A COUPLE COMMENTS ABOUT 2431 01:16:45,600 --> 01:16:49,400 WHAT WE'LL BE DOING TOMORROW. 2432 01:16:49,400 --> 01:16:50,800 SO TOMORROW, WE OPEN EVERYONE 2433 01:16:50,800 --> 01:16:52,800 WILL BE ABLE TO JOIN US. 2434 01:16:52,800 --> 01:16:55,080 WE'LL START AT 11:00 A.M. 2435 01:16:55,080 --> 01:16:56,840 EASTERN TIME WITH OPENING 2436 01:16:56,840 --> 01:16:59,480 REMARKS FROM DR. STROUT. 2437 01:16:59,480 --> 01:17:01,560 I'LL THEN SHARE AN UPDATE FROM 2438 01:17:01,560 --> 01:17:03,280 NINR AND OUR ACTIVITIES, AND 2439 01:17:03,280 --> 01:17:04,160 THEN WE'LL HEAR FROM OUR 2440 01:17:04,160 --> 01:17:06,040 COLLEAGUES ACROSS THE RESEARCH 2441 01:17:06,040 --> 01:17:07,840 SPECTRUM, INCLUDING THOSE 2442 01:17:07,840 --> 01:17:08,800 SPECIALIZING IN FAMILY AND 2443 01:17:08,800 --> 01:17:10,320 COMMUNITY MEDICINE, PUBLIC 2444 01:17:10,320 --> 01:17:11,760 HEALTH, HEALTH POLICY, AND 2445 01:17:11,760 --> 01:17:13,040 EMERGENCY MEDICINE. 2446 01:17:13,040 --> 01:17:15,160 OUR PRESENTERS WILL SHARE THEIR 2447 01:17:15,160 --> 01:17:17,440 OWN PROGRAMS OF RESEARCH AS WELL 2448 01:17:17,440 --> 01:17:20,000 AS PARTICIPATE IN A PANEL 2449 01:17:20,000 --> 01:17:21,400 DISCUSSION TO SYNTHESIZE FINDING 2450 01:17:21,400 --> 01:17:23,040 ACROSS THESE MANY FIELDS. 2451 01:17:23,040 --> 01:17:25,240 SO I AM REALLY CONFIDENT THAT 2452 01:17:25,240 --> 01:17:28,640 THE ROUNDTABLE AS WE DRAW TO A 2453 01:17:28,640 --> 01:17:30,040 CLOSE TOMORROW, THAT WE'LL HAVE 2454 01:17:30,040 --> 01:17:33,000 MANY NEW CONVERSATIONS AND 2455 01:17:33,000 --> 01:17:35,200 HOPEFULLY EVEN SOME FORMING NEW 2456 01:17:35,200 --> 01:17:36,280 COLLABORATIONS AND PARTNERSHIPS 2457 01:17:36,280 --> 01:17:38,320 IN THESE AREAS. 2458 01:17:38,320 --> 01:17:40,400 SO AGAIN, SO APPRECIATE EVERYONE 2459 01:17:40,400 --> 01:17:41,480 JOINING TONIGHT, AND I LOOK 2460 01:17:41,480 --> 01:17:43,440 FORWARD TO SEEING EVERYONE 2461 01:17:43,440 --> 01:17:44,320 TOMORROW MORNING. 2462 01:17:44,320 --> 01:17:45,000 THANKS AGAIN, DR. HSAI 2463 01:17:45,000 --> 00:00:00,000 GOODNIGHT, EVERYONE.