>>I'M SHANNON ZENK, DIRECTOR OF
THE NATIONAL INSTITUTE OF
NURSING RESEARCH.
WELCOME.
THANK YOU FOR JOINING US THIS
EVENING, AND I CERTAINLY HOPE
EVERYONE WILL BE ABLE TO JOIN US
TOMORROW MORNING AS WELL.
SO IT TRULY IS A PLEASURE TO
WELCOME YOU TO THE 2022 NATIONAL
NURSING RESEARCH ROUNDTABLE
PROGRAM.
FROM CONTEXT TO CARE,
UNDERSTANDING THE CONVERGENCE OF
SOCIAL FACTORS AND EMERGENCY
DEPARTMENT CARE.
I WANT TO THANK THE EMERGENCY
NURSES ASSOCIATION FOR
CO-SPONSORING THIS YEAR'S
ROUNDTABLE WITH US AT NINR, AND
THANK YOU FOR YOUR WILLINGNESS
TO BE PART OF THIS IMPORTANT
CONVERSATION ABOUT SOCIAL
FACTORS AND HEALTH, MANY OF
WHICH, AS WE KNOW, CONVERGE IN
OUR NATION'S EMERGENCY SERVICES.
AND I WANT TO ACKNOWLEDGE
EVERYONE ON THE PLANNING
COMMITTEE, FROM ENA AS WELL AS
NINR, TO THE MANY INDIVIDUALS
WHO HAVE WORKED TIRELESSLY TO
BRING THIS YEAR'S EXCITING
PROGRAM TO FRUITION, PLEASE DO
KNOW HOW MUCH WE APPRECIATE YOUR
EFFORTS.
WE DON'T HAVE TIME UNFORTUNATELY
TO ACKNOWLEDGE EVERYONE ON THE
PLANNING COMMITTEE BY NAME, BUT
I DO WANT TO TAKE A MOMENT TO
THANK DR. LISA WOLF, THE ENR
DIRECTOR FOR ALL HER EFFORTS AND
ALSO TO THANK DR. TANIA STROUT
FOR HER WILLINGNESS TO STEP IN
FOR DR. WOLF TODAY.
AGAIN, THANK YOU SO MUCH FOR
PUTTING TOGETHER SUCH AN
INTERESTING PROGRAM FOR THIS
YEAR'S MEETING.
I AM PLEASED ALSO THAT THIS YEAR
FOR THE FIRST TIME, THE
ROUNDTABLE IS OPEN TO ALL
NURSING ORGANIZATIONS, AND
BUILDING ON LAST YEAR'S
EVOLUTION, WE'RE ALSO
VIDEOCASTING THIS PROGRAM FOR
ANYONE TO VIEW LIVE NOW OR
LATER.
I WILL EXTEND A VERY WARM
WELCOME TO THOSE OF WHO YOU ARE
ATTENDING THE ROUNDTABLE FOR THE
VERY FIRST TIME, AS WELL AS TO
THOSE WHO ARE RETURNING.
AS A COOPERATIVE OF NURSING
ORGANIZATIONS, THE ROUNDTABLE
BRINGS TOGETHER
SCIENTISTS,ICALLY NUSHES,
EDUCATORS, SCHOLARS AND POLICY
LEADERS LIKE YOU TO DISCUSS
PRIORITIES IN SCIENCE, PRACTICE,
AND POLICY.
MOREOVER, THE ROUNDTABLE WILL
OFFER YOU AN OPPORTUNITY TO
SHARE AND EXCHANGE INFORMATION
AMONG LEADERS OF NATIONAL
NURSING ORGANIZATIONS SO DURING
THIS YEAR'S TWO-DAY EVENT, YOU,
OUR PARTICIPANTS, WILL LEARN OW
EMERGENCY DEPARTMENTS CAN
APPROPRIATELY IDENTIFY AND
ADDRESS SOCIAL NEEDS, UNDERSTAND
THE ROLE OF SOCIAL INJUSTICES
AND SOCIAL RISK AND DRIVING THE
DEMAND FOR EMERGENCY HEALTHCARE
SERVICES, AND, IDENTIFY FACTORS
THAT INFLUENCE THE SUCCESS OF
TRANSITION FROM EMERGENCY TO
COMMUNITY-BASED CARE.
THROUGHOUT MY CAREER, AND
ESPECIALLY IN MY ROLE AS NINR
DIRECTOR, I'VE MADE CLEAR MY
BELIEF THAT NURSING SCIENCE CAN
AND MUST MAKE A DIFFERENCE IN
THE AREAS OF HEALTH INEQUITIES
AND UNDERSTANDING THE SOCIAL
DETERMINANTS OF HEALTH, AND
THESE AREAS ARE PARTICULARLY
RELEVANT TO THE TOPIC OF THIS
YEAR'S PROGRAM.
SO I'LL HAVE MORE TO SAY IN MY
REMARKS TOMORROW MORNING, BUT
THESE ARE AREAS IN WHICH NINR
AND THE NURSING SCIENCE
COMMUNITY MUST LEAD.
SO IT'S NOW MY PLEASURE TO
INTRODUCE DR. TANIA STROUT, WHO
WILL PROVIDE HER WELCOMING
REMARKS AND THEN GO -- PROCEED
TO INTRODUCE OUR KEYNOTE
SPEAKER.
SO LET ME INTRODUCE DR. STROUT.
DR. TANIA STROUT IS A PROFESSOR
OF EMERGENCY MEDICINE AT THE
TUFTS UNIVERSITY SCHOOL OF
MEDICINE, A MEMBER OF THE
EMERGENCY NURSES ASSOCIATION,
AND A CHAIRPERSON OF THE ENA
EMERGENCY NURSING RESEARCH
ADVISORY COUNCIL.
SHE'S ALSO A MEMBER OF THE
SOCIETY FOR ACADEMIC EMERGENCY
MEDICINE, THE THE ACADEMY FOR WOMEN
IN ACADEMIC EMERGENCY MEDICINE,
ACADEMY FOR DIVERSITY AND
INCLUSION IN EMERGENCY MEDICINE,
AND THE RESEARCH DIRECTORS
INTEREST GROUP.
HER PRIMARY RESEARCH INTERESTS
INCLUDE HEALTH RELATED
MEASUREMENT, PSYCHOMETRICS AND
SCALE DEVELOPMENT, HER WORK HAS
INCLUDED THE STUDY OF
MEASUREMENT IN EMERGENCY
DEPARTMENT TRIAGE SYSTEMS, ACUTE
PAIN IN ADULTS AND CHILDREN, AND
ACUTE AGITATION.
OTHER RESEARCH AREAS INCLUDE
ACCESS TO CARE, HOSPITAL FLOW,
PALLIATIVE MEDICINE IN THE
EMERGENCY DEPARTMENT SETTING,
INTERPERSONAL VIOLENCE, HEALTH
PROFESSIONS EDUCATION, CLINICIAN
TOLERANCE OF UNCERTAINTY,
INITIATION OF BUPRENORPHINE FOR
THE TREATMENT OF OPIOID USE
DISORDER IN THE EMERGENCY
DEPARTMENT, AND THE ROLE OF
NURSES IN CARING FOR PATIENTS
WITH OPIOID USE DISORDER.
SO PLEASE JOIN ME IN WELCOMING
DR. STROUT.
>> THANK YOU SO MUCH, DR. ZENK,
FOR THAT KIND WELCOME.
I AM VERY PLEASED TO BE JOINING
YOU ALL FOR THE NEXT TWO DAYS
AND REPRESENTING THE EMERGENCY
NURSES ASSOCIATION.
SO COLLEAGUES, ON BEHALF OF THE
EMERGENCY NURSES ASSOCIATION,
OUR ORGANIZATION'S PRESIDENT,
JEN SCHMITZ, WHO SHOULD BE
ATTENDING WITH US TODAY, AND THE
EMERGENCY NURSES ASSOCIATION
RESEARCH ADVISORY COUNCIL, I
WOULD ALSO LIKE TO EXTEND A VERY
WARM WELCOME TO EVERYONE TO THIS
YEAR'S NATIONAL NURSING RESEARCH
ROUNDTABLE.
ENA IS THE PREMIER PROFESSIONAL
NURSING SITUATION DEDICATED TO
RESEARCH, INNOVATION AND
LEADERSHIP, AND OUR ORGANIZATION
REPRESENTS APPROXIMATELY 50,000
MEMBERS AROUND THE WORLD.
WE ARE PART OF A HIGHLY ENGAGED
COMMUNITY COMMITTED TO PROVIDING
THE HIGHEST LEVEL OF CARE TO OUR
PATIENTS AND FAMILIES THAT WE
SERVE, OUR MEMBERS SUPPORT THE
DEVELOPMENT OF NEW KNOWLEDGE FOR
EMERGENCY NURSING PRACTICE BY
SHARING THEIR RESEARCH IN OUR
OFFICIAL PUBLICATION, THE
JOURNAL OF EMERGENCY NURSING, BY
DISSEMINATING THEIR WORK AT OUR
ANNUAL CONFERENCE, AND THROUGH
SUPPORT FOR THE ENA FOUNDATION.
THE FOUNDATION HAS A SIGNIFICANT
IMPACT ON THE PROFESSION OVER
THE LAST 31 YEARS, SUPPORTING
EMERGENCY NURSES BY PROVIDING
FUNDING TO MORE THAN 2400 NURSES
TOTALING $5.3 MILLION IN
EDUCATIONAL SCHOLARSHIPS,
RESEARCH GRANTS, AND CONFERENCE
SUPPORT.
I'D LIKE TO RECOGNIZE OUR ENA
PRESIDENT, JENNIFER SCHMITZ,
WHO'S A
ALSO SERVING AS THE CHIEF
NURSING OFFICER AT SOUTHERN
MAINE HEALTHCARE, A SISTER
INSTITUTION TO MY OWN.
JEN IS LEADING ENA MEMBERS THIS
YEAR WITH A FOCUS ON CHARGING
AND RECHARGING
MEMBERS AFTER GIVING SO MUCH OF
THEMSELVES THROUGHOUT THE
COVID-19 PANDEMIC.
THERE IS SOME SIN SYNERGY BETWEEN
OUR THEME OF RECHARGING AND THE
WORK WE'RE DOING HERE TODAY ON
SOCIAL DETERMINANTS, AS EVEN
PRIOR TO THE PANDEMIC, EMERGENCY
NURSES HAVE BEEN ON THE FRONT
LINES OF ADDRESSING SO MANY
SOCIAL ISSUES SUCH AS THE OPIOID
CRISIS, VIOLENCE, UNSTABLE
HOUSING, FOOD INSECURITY, THE
EFFECTS OF RACISM ON HEALTH, AND
THE ESCALATING NEEDS OF OUR MANY
PATIENTS STRUGGLING WITH UN AND
UNDERTREATED MENTAL HEALTH
CONDITIONS.
SO WE ARE REALLY EXCITED TO BE
HERE PARTICIPATING IN THESE VERY
IMPORTANT CONVERSATIONS AROUND
SOCIAL DETERMINANTS OF HEALTH,
AND HOW WE IN PARTICULAR AS
EMERGENCY NURSES CAN CONTRIBUTE
TO THE DEVELOPMENT OF NEW
KNOWLEDGE IN THIS AREA THROUGH
OUR RESEARCH AND ALSO THROUGH
THE IMPLEMENTATION OF RESEARCH
FINDINGS INTO CLINICAL PRACTICE
TO IMPROVE OUTCOMES FOR OUR
PATIENTS IN THE COMMUNITIES WE
SERVE.
WE'RE LOOKING FORWARD TO
LEARNING WITH YOU ALL, AS WELL
AS TO BRINGING OUR LEARNINGS
BACK TO OUR ORGANIZATIONS, OUR
LOCAL COMMUNITIES, AND MOST
IMPORTANTLY, TO THE SERVICE OF
OUR PATIENTS.
SO WITH THAT, I HAVE THE
DISTINCT PRIVILEGE OF
INTRODUCING THIS YEAR'S
ROUNDTABLE KEYNOTE SPEAKER,
DR. RENEE HSIA.
DR. HSIA IS PROFESSOR IN THE
DEPARTMENT OF EMERGENCY MEDICINE
AT THE UNIVERSITY OF CALIFORNIA
SAN FRANCISCO.
SHE IS ALSO A CORE FACULTY
MEMBER OF THE UCSF INSTITUTE FOR
HEALTH POLICY STUDIES, AS WELL
AS A MEMBER OF THE UCSF CENTER
FOR HEALTHCARE VALUE AND THE
UCSF GLOBAL HEALTH ECONOMICS
CONSORTIUM.
SHE IS CERTIFIED BY THE AMERICAN
BOARD OF EMERGENCY MEDICINE, AND
SHE SPEAKS MANDARIN, CANTONESE,
SPANISH, AND FRENCH, IN ADDITION
TO ENGLISH, AND PROVIDED
EMERGENCY CARE TO PATIENTS WITH
A VARIETY OF BACKGROUNDS AS AN
ATTENDING PHYSICIAN IN THE
EMERGENCY DEPARTMENT AT THE
ZUCKERBERG SAN FRANCISCO GENERAL
HOSPITAL AND TRAUMA CENTER,
WHICH IS THE ONLY COUNTY
HOSPITAL AND TRAUMA CENTER
SERVING SAN FRANCISCO,
CALIFORNIA.
DR. HSIA'S BROAD RESEARCH
INTERESTS ARE IN HEALTH SERVICES
ISSUES RELATING TO INCREASING
ACCESS TO EMERGENCY CARE AND THE
REGIONALIZATION OF CARE.
SHE HAS BEEN FUNDED BY SEVERAL
PRIVATE FOUNDATION AND FEDERAL
GRANTS TO STUDY POPULATION
ACCESS TO EMERGENCY DEPARTMENTS
AND TRAUMA CENTERS IN THE U.S.,
THE DISTRIBUTION OF EMERGENCY
CARE ACROSS INCOME AREAS,
FACTORS ASSOCIATED WITH THE
CLOSURE OF EMERGENCY SERVICES,
BOTH EMERGENCY DEPARTMENTS AND
TRAUMA CENTERS, AND HOW THESE
CLOSURES AFFECT PATIENT
OUTCOMES, SPECIFICALLY FOCUSING
ON PATIENTS WITH ACUTE
MYOCARDIAL INFARCTION, STROKE,
AS
ASTHMA, COPD, SEPSIS AND TRAUMA.
HER RESEARCH ALSO FOCUSES ON
HEALTHCARE COSTS AND FINANCE
ISSUES REGARDING EMERGENCY CARE.
SHE'S THE SITE P.I. FOR SEVERAL
MULTI-SITE STUDIES VALIDATING
TRAUMA TRIAGE CRITERIA FOR
DIFFERENT AGE GROUPS, AS WELL AS
THEIR ABILITY TO PREDICT HIGH
RISK PATIENTS.
SHE'S PUBLISHED ON THESE ISSUES
IN A BROAD RANGE OF JOURNALS,
INCLUDING THE NEW ENGLAND
JOURNAL OF MEDICINE, THE JOURNAL
OF THE AMERICAN MEDICAL
ASSOCIATION, AND HEALTH AFFAIRS.
HER RESEARCH HAS ALSO BEEN
WIDELY PUBLICIZE IN PRINT MEDIA
AS WELL AS NATIONAL NETWORK NEWS
AND RADIO.
DR. HSIA HOPES THIS WORK WILL
HELP TO INFORM THE PUBLIC AND
POLICY MAKERS ON ISSUES RELATED
TO THE EQUITABLE PROVISION OF
CRITICAL SERVICES TO PATIENTS
ACROSS THE COUNTRY AND GLOBALLY.
SO I HOPE THAT YOU WILL ALL
PLEASE JOIN ME IN WELCOMING
DR. HSIA.
DOCTOR, WE ARE SO FORTUNATE TO
HAVE YOU WITH US TODAY, AND
WE'RE VERY MUCH LOOKING FORWARD
TO YOUR REMARKS THIS AFTERNOON.
>> THANK YOU SO MUCH FOR HAVING
ME.
I'D LIKE TO THANK DR. ZENK,
DR. STOUT, MISS WILLIAMS
WASHINGTON AND EMERGENCY NURSES
ASSOCIATION FOR PUTTING THIS
TOGETHER AND FOR INVITING ME.
I'M LOOKING FORWARD TO THIS
BECAUSE I THINK IT'S AN EXCITING
OPPORTUNITY TO GET US THINKING
TOGETHER ABOUT NOT JUST THE
RESEARCH AGENDA BUT HOW WE
APPROACH THESE ISSUES FROM THE
EMERGENCY DEPARTMENT TO KIND OF
REALLY INTEGRATE ALL THE THINGS
WE'RE DOING TOGETHER.
SO JUST GIVE ME A MOMENT FOR ME
TO SHARE MY SCREEN.
DOES EVERYONE SEE THAT OKAY?
>> YES.
>> ALL RIGHT, GREAT.
SO JUST SOME DISCLOA SAWYERS
JUST DISCLOSURES JUST TO
START.
THESE ARE THE FUNDING
ORGANIZATIONS THAT HAVE FUNDED
SOME OF THE RESEARCH THAT I'VE
DONE.
AND NONE OF THEM WILL POSE ANY
CONFLICT OF INTEREST IN WHAT I
SHARE WITH YOU TODAY, BUT I DID
WANT TO SHARE THAT.
I AM EXCITED TO TALK WITH YOU
TODAY BECAUSE I THINK MOST OF
THE TIME, WHEN PEOPLE THINK
ABOUT THE EMERGENCY DEPARTMENT,
THEY HAVE IN MIND THAT THIS IS
KIND OF AN AREA WHERE THERE IS
EQUITABLE ACCESS BECAUSE
EMERGENCY SERVICES, WE TEND TO
THINK ABOUT 911, ANY1 CAN ANYONE CAN CALL
911.
AMBULANCE SERVICES DON'T ASK YOU
FOR INSURANCE, THEY DON'T ASK
YOU FOR ANY FORM OF PAYMENT, SO
WE THINK OF JUST HOW IN GENERAL,
THE EMERGENCY DEPARTMENT SHOULD
THEORETICALLY BE A PLACE THAT IS
AN AREA WHERE THERE ARE NO
BARRIERS TO CARE.
BUT IN FACT, THE EMERGENCY
DEPARTMENT WE KNOW FOR ALL OF US
WHO WORK THERE KNOW THAT THERE
ARE PLENTY OF BARRIERS TO CARE
IN EVEN ACCESSING EMERGENCY
CARE, AND I WANTED TO SET THE
STAGE FOR WHAT YOU'RE GOING TO
BE LISTENING TO TOMORROW IN
TERMS OF THE BROAD ARRAY OF
SERVICES THAT WE'RE TRYING TO
THINK ABOUT IN TERMS OF
ACCESSING NOT JUST EMERGENCY
CARE BUT HOW WE TIE THE NEEDS
THAT PEOPLE PRESENT WITH TO
OTHER SERVICES WITHIN NOT JUST
HEALTHCARE BUT OTHER SOCIAL
NEEDS THAT PEOPLE HAVE, SO I
THINK IT'S IMPORTANT FOR US TO
ALL BE ON THE SAME PAGE IN TERMS
OF UNDERSTANDING WHEN PEOPLE
COME TO THE EMERGENCY
DEPARTMENT, WHEN PEOPLE SEEK
EMERGENCY CARE, WHAT ARE THE
FACTORS THAT ARE ALREADY FACING
THEM IN TERMS OF COMING TO THE
ED?
AND SO I WANTED TO START WITH A
LITTLE BIT OF THAT KIND OF
INTRODUCTION TO KIND OF SET THE
STAGE, AND SO THIS IS A MODEL
THAT I CAME UP WITH A LONG TIME
AGO.
IT'S VERY SIMPLE, STRUCK TOOR,
PROCESS AND OUTCOMES, BUT THIS
IS THE WAY I THINK AT LEAST I
GENERALLY HAVE THOUGHT OF HEALTH
INEQUITIES AND SOCIAL NEEDS IN
THE EMERGENCY DEPARTMENT.
SO WHEN I FIRST STARTED
EMERGENCY MEDICINE, I USED TO
THINK OKAY, THERE'S PATIENT
FACTORS LIKE THERE ARE PATIENTS
WHO SMOKE, THERE ARE PATIENTS
WHO ENGAGE IN DIFFERENT TYPES OF
BEHAVIOR, THERE'S DIFFERENT
ACUTITY OF PATIENTS WHO PRESENT
TO THE E.D., SOME OF THEM COME
WITH THE NEED FOR LACERATION
REPAIR, SOME OF THEM COME WITH
HEART ATTACKS OR ST ELEVATION
MIs, AND THAT AFFECTS THE
PROCESSES THAT GO ON IN THE
EMERGENCY DEPARTMENT.
SO WHETHER THEY SMOKE OR NOT,
MAYBE THAT SOMEHOW AFFECTS
PEOPLE'S BEHAVIOR BECAUSE MAYBE
THERE ARE PROVIDERS WHO FEEL
LIKE, OH, THIS IS SOMETHING THEY
BROUGHT UPON THEMSELVES OR THEY
HAVE DIABETES AND IT AFFECTS
BEHAVIOR, IF THEY'RE LOW ACUTE,
THAT AFFECTS THEIR E.D. WAIT
TIMES BECAUSE THERE'S TRIAGE
SYSTEMS, SO THAT AFFECT
OUTCOMES.
SO WE THINK ABOUT IF THERE ARE
REALLY ACUTE AND THEY HAD TO
WAIT A LONG TIME, THAT MIGHT
MEAN THEY HAVE POORER OUTCOMES,
THEY MAY HAVE COMPLICATIONS
BECAUSE OF THEIR COMORBIDITIES,
BECAUSE OF THE BEHAVIOR THEY
ENGAGE WITH, AND SOMETIMES
PATIENT FACTORS DIRECTLY AFFECT
THE OUTCOME.
SO WHETHER OR NOT THEY ARE
TAKING THEIR MEDICINES MIGHT
AFFECT THE OUTCOME OF THEIR
HOSPITAL STAY, WHETHER THEY HAVE
CERTAIN ACUITY, A VISIT WILL
CERTAINLY AFFECT YOUR OUTCOME.
SO I THINK THIS IS A VERY KIND
OF LINEAR MODEL AND SOMETHING AS
CLINICIANS, WE TEND TO THINK
ABOUT, THERE'S PATIENT FACTORS
THAT AFFECT PROCESSES THAT
AFFECT YOUR OUTCOMES.
BUT I THINK SOMETHING THAT WE'RE
NOW UNDERSTANDING MORE OF IS
THAT THERE ARE SYSTEM FACTORS
THAT NOT ONLY AFFECT PATIENTS,
SO FOR EXAMPLE, PATIENTS MAY NOT
BE PRESENTING TO THE EMERGENCY
DEPARTMENT BECAUSE THEY'RE
FARTHER AWAY THAN OTHER PEOPLE
WHO MIGHT HAVE THE SAME
CONDITION AND THE EXACT SAME
PRESENTATION BUT BECAUSE THEY
ARE LOCATED MORE PROXIMATELY TO
ANOTHER E.D., THAT AFFECTS THEIR
WILLINGNESS TO GO.
THERE'S SYSTEM FACTORS IN TERMS
OF INSURANCE CERTAINLY, IF YOU
ARE INSURED OR NOT INSURED, THAT
AFFECTS YOUR CALCULUS ABOUT
WHETHER OR NOT TO SEEK CARE,
WHETHER OR NOT YOU ARE GOING TO
HAVE A FINANCIAL CONSEQUENCE OF
THAT VISIT, AND THEN THERE ARE
SYSTEM FACTORS THAT AFFECT THE
PROCESSES.
SO FOR EXAMPLE, THE OWNERSHIP OF
A HOSPITAL MAY BE HIGHLY RELATED
TO WHETHER OR NOT THEY PROVIDE
CERTAIN SERVICES.
NOT JUST THINGS LIKE DERMATOLOGY
OR THINGS THAT WE TEND TO THINK
OF AS LUXURY KIND OF HEALTHCARE
SERVICES, BUT THINGS THAT ARE
EVEN VERY CRITICAL TO YOUR
HEALTH.
SO THERE ARE SYSTEM FACTORS THAT
WE'LL TALK ABOUT TODAY AND WHAT
I SHARE WITH YOU TO KIND OF
THINK MORE BROADLY ABOUT HOW
THOSE AFFECT PROCESSES BECAUSE
YOU DON'T HAVE CERTAIN
HEALTHCARE SERVICES AVAILABLE IN
YOUR AREA, THAT AFFECTS YOUR
ABILITY TO GET TREATED AND THAT
AFFECTS YOUR OUTCOME.
SO NOT ONLY DO THE SYSTEM
FACTORS AFFECT THE PROCESSES
THAT AFFECTS YOUR OUTCOME, THE
SYSTEM FACTORS CAN DIRECTLY
AFFECT YOUR OUTCOME, AND HOW CAN
THAT BE?
WELL, IF WE THINK ABOUT THINGS
LIKE -- IF YOU THINK BROADLY,
YOU THINK ABOUT CALIFORNIA IS
ONE OF THE ONLY STATES WITH
NURSING RATIOS THAT CAN AFFECT
YOUR OUTCOME, THERE ARE
OWNERSHIP FACTORS ABOUT WHETHER
OR NOT THEY HAVE CERTAIN
GUIDELINES OR PROTOCOLS IN THAT
HOSPITAL SYSTEM AND THAT CAN
AFFECT YOUR OUTCOME IF THEY'RE
NOT PROTOCOLIZED IN THE SAME
WAY.
FINANCIAL FACTORS CERTAINLY OF
THAT HOSPITAL SYSTEM CAN AFFECT
YOUR OUTCOME BECAUSE OF THE WAY
THEY DI DECIDE TO INCENTIVIZE CARE,
WHETHER IT'S THE WAY THEY PAY
THEIR PROVIDERS OR THE WAY
THEY'RE CAPITATED OR NOT AND
THEY TRY TO CONNECT WITH PRIMARY
CARE OR NOT.
SO THIS IS WHAT I WANT TO
ENCOURAGE US TO THINK ABOUT
TODAY, IS TAKING A LARGER VIEW
OF THE STRUCTURAL FACTORS THAT
ARE FACING OUR PATIENTS.
SO WE TEND TO THINK OF SOCIAL
NEEDS AND HEALTH INEQUITIES AS
VERY INDIVIDUAL ORIENTED, THINGS
LIKE INCREASED E.D. WAIT TIMES
OR LESS FREQUENT PAIN MEDICATION
ADMINISTRATION OR HE DECREASED
RATES OF IMAGING.
SO THERE'S PLENTY OF STUDIES,
HUNDREDS IF NOT THOUSANDS, OF
HOW THERE ARE DIFFERENT
RELATIONSHIPS OF WHETHER YOU
GET, FOR EXAMPLE, PAIN
MEDICATION WITHIN -- IF YOU HAVE
A LONG BONE FRACTURE, IF YOU ARE
BLACK OR AFRICAN AMERICAN, YOU
MAY HAVE TO WAIT LONGER FOR
THE -- TO GET YOUR PAIN
MEDICATION THAN A WHITE PATIENT
WHO HAS THE SAME LONG BONE
FRACTURE.
SO THOSE ARE EXAMPLES OF THINGS
WE TEND TO THINK OF, I THINK AT
LEAST I DO IN THE TBINNING, WE
TEND TO THINK OF THEM AS
INDIVIDUAL INEQUITIES.
THIS IS ONE PROVIDER WHO HAS
DECIDED TO TREAT A PATIENT
DIFFERENTLY BASED ON THE COLOR
OF THEIR SKIN OR THEIR INSURANCE
STATUS, OR WHETHER OR NOT --
THEY HAVE THEIR OWN BIASES,
WHETHER THEY'RE HOUSED OR
STRUGGLING WITH OTHER BEHAVIORS.
SO I THINK THIS IS A TRADITIONAL
MODEL OF THINKING ABOUT
INEQUITIES AND SOCIAL FACTORS,
VERY MUCH BASED ON THE
INDIVIDUAL, WHETHER IT'S THE
PROVIDER OR THE PATIENT.
I JUST WANT TO SHOW THIS SLIDE
BECAUSE WHEN I -- I REMEMBER
SEEING THIS A LONG TIME AGO IN
RESIDENCY AND I PICKED IT OFF
THE ACTUAL REPORT, SO HERE
YOU'LL SEE, THIS IS TAKEN FROM
THE CDC, NCHS, AND WE'RE GOING
TO TOMORROW DELVE IN TO THE DATA
RESOURCES ALREADY COLLECTED, WE
HAVE EXCITING WAYS TO THINK
ABOUT DATA.
BUT THIS IS SOMETHING THEY
PUBLISHED ABOUT 10 YEARS AGO,
I'D SAY.
SO THIS IS JUST SAYING WHAT IS
THE MEAN WAIT TIME TO SEE A
PHYSICIAN IN THE EMERGENCY
DEPARTMENT.
AND THIS ISN'T ADJUSTED, IT'S
JUST KIND OF A RAW OUTPUT.
SO LOOKING AT AGE, SEX, RACE AND
HISPANIC ORIGIN.
SO YOU'LL SEE HERE THAT WHITES,
NOT HISPANICS, HAD A MEAN WAIT
TIME OF 15 MINUTES AND BLACK
NON-HISPANIC HAD A MEAN WAIT
TIME OF 68 AND HISPANIC PATIENTS
HAD A MEAN WAIT TIME OF 60.
SO I THINK WHEN PEOPLE LOOK AT
THIS, THEY MAY SAY, WELL, THIS
IS CLEARLY INDIVIDUAL BIAS, THIS
IS ONE PHYSICIAN WHO HAS
DECIDED, WHEN THEY'RE LOOKING AT
WHO TO TREAT, WHETHER IT'S IN
THE WAITING ROOM OR WHETHER
THEY'VE BEEN ALREADY IN THE
E.D., AND I'M NOT SAYING
CLINICIANS WOULD NECESSARILY
THINK OF THIS, I WOULD SAY LAY
PEOPLE MIGHT LOOK AT THIS AND
SAY THIS IS AN EXAMPLE OF STRONG
INDIVIDUAL PIE BIAS.
I WANT TO ENCOURAGE US TO THINK
ABOUT WHAT THE STRUCTURAL
FACTORS MIGHT BE THAT HAVE
CREATED THESE INEQUITIES AND
THESE TYPES OF SOCIAL NEEDS.
SO I WANT TO KIND OF URGE US TO
THINK ABOUT THIS LEFT SIDE OF
THE SYSTEM FACTORS OF WHAT THESE
RELATIONSHIPS ARE.
SO HOW CAN WE GO BEYOND THE
INDIVIDUAL LEVEL OR EVEN THE
FACILITY LEVEL.
WHEN I SAY FACILITY LEVEL, I'M
TALKING ABOUT THINGS THAT ARE
LIKE HOSPITAL PRACTICES.
SO THERE MAY BE SURGEON
HOSPITALS THAT HAVE DIFFERENT
HOSPITALS THAT MIGHT HAVE
CERTAIN INEQUITIES BAKED IN
ABOUT HOW THEY TRIAGE PATIENT OR
HOW THEY REGISTER PATIENTS AND
THAT HAS DOWNSTREAM EFFECTS OF
WHETHER OR NOT THOSE PATIENTS DO
END UP HAVING AND EXPERIENCING
INEQUITY.
BUT I WANT TO THINK ABOUT
STRUCTURAL ISSUES.
I THINK OVER THE PAST FIVE
YEARS, WE MIGHT HAVE HEARD MORE
OF THIS BUT IT'S STILL NOT USED
THAT COMMONLY WHEN WE TALK ABOUT
INEQUITIES.
I THINK THE INEQUITY COMMUNITY
TALKS MORE ABOUT THIS AND THERE
IS A REALLY GREAT SERIES OF
STUDIES OR OF JUST EXPOSITIONS
BY THE NATIONAL INSTITUTE FOR
MINORITY HEALTH AND HEALTH
DISPARITIES, NIMHD AND THE
AMERICAN JOURNAL OF PUBLIC
HEALTH, I THINK THAT WAS IN 2019
OR 2020, BUT IT WAS A SPECIAL
ISSUE DEDICATED TO THINKING
ABOUT THIS.
WHEN WE TALK ABOUT STRUCTURAL
DISCRIMINATION, IT'S NOT SAYING
THERE'S ONE PERSON WHO IS
CHOOSING TO OVERLAY THEIR OWN
BIASES ON ANOTHER PERSON, BUT
IT'S -- AND IT'S MORE THAN JUST
A FACILITY.
IT'S TALKING ABOUT HOW THE
SYSTEM IN AND OF ITSELF CONTAINS
ELEMENTS THAT AFFECT PEOPLE'S
OUTCOMES AND MAY NOT -- IT MAY
NOT AT ALL BE RELATED TO AN
INTENTIONAL DESIRE TO DO SO, BUT
THAT WE MAY BE WORKING IN
SYSTEMS THAT ALREADY HAVE A
STRUCTURAL FOUNDATION WHERE
INEQUITY IS THE OUTCOME OF THE
SYSTEM.
AND AGAIN, I WANT TO EMPHASIZE
THAT THIS IS NOT SAYING THAT
IT'S FINGER-POINTING AND SAYING
THAT THIS IS ONLY INDIVIDUALS
WHO ARE INVOLVED IN THIS, BUT
THAT IT'S BAKED INTO THE SYSTEM,
AND THAT'S WHAT I'LL TALK ABOUT
TODAY, SO THAT WHEN WE WORK IN
THE SYSTEM, IF WE AREN'T AWARE
OF THAT, THAT THE OUTCOME OF OUR
WORK CAN LEAD TO INEQUITIES.
SO I'M GOING TO JUST SHOW THIS
SLIDE HERE, WHICH IS A STUDY
THAT I DID A WHILE BACK WITH A
COLLABORATOR, SO THIS IS JUST
LOOKING AT AMBULANCE DIVER
VERSION.
I'M SURE A LOT OF YOU KNOW WHAT
AMBULANCE DIVERSION IS, BUT IT'S
WHAT HAPPENS WHEN YOUR HOSPITAL
DECIDES IT IS TOO FULL.
THERE CAN BE MANY REASONS FOR
THAT OR IT CAN DECIDE IT DOESN'T
HAVE CAPACITY, SO FOR EXAMPLE,
OTHER REASONS MIGHT BE IF THE CT
SCANNER IS DOWN, BUT IN GENERAL,
AMBULANCE DIVERSION HAPPENS WHEN
THERE IS A BOTTLENECK IN THE
E.D., AND USUALLY THAT
BOTTLENECK, AS MOST OF US KNOW,
ARE ON THE INPATIENT SIDE.
THEY HAVE PATIENTS WAITING BUT
THERE'S NO EMPTY BEDS SO THE
HOSPITAL BACKS UP.
SO WHEN THE HOSPITAL DECIDES
IT'S UNSAFE TO TAKE MORE
AMBULANCE TRAFFIC, THEY GO ON
AMBULANCE DIVERGENCE, SO THEY
CAN NO LONGER DROP OFF PATIENTS
THAT -- THAT HOSPITAL -- USUALLY
THE EMS SERVICE TAKES PATIENTS
TO THE NEAREST HOSPITAL BUT IF
YOU'RE ON AMBULANCE DIVERT, THE
HOSPITAL SAYS YOU CAN'T COME
HERE AND NOW THE AMBULANCE NEEDS
TO GO TO THE NEXT NEAREST
HOSPITAL, WHICH HAS
CONSEQUENCES.
NAT ONLY FOR THE PATIENT, NOW
THE PATIENT HAS TO WAIT LONGER
FOR CARE, AND WE KNOW THAT FOR
CONDITIONS THAT REQUIRE -- THAT
ARE TIME-SENSITIVE, YOU NEED TO
GET TO CARE AS SOON AS POSSIBLE.
BUT EVEN EVEN OUTSIDE OF THE
PATIENT, IT PUTS THAT AMBULANCE
OUT OF SERVICE.
SO OTHER PATIENTS WHO DEPEND ON
AMBULANCE SERVICES NOW, THEY
HAVE TO WAIT TOO.
SO YOU CAN DEFINITELY JUST SEE
THIS DOMINO EFFECT.
BUT AMBULANCE DIVERSION AT LEAST
IN HEALTH RESEARCH, WE USE IT AS
A PROXY FOR CROWDING.
AND SO WHEN WE THINK ABOUT E.D.
WAIT TIMES, THEN WE ALSO CAN USE
AMBULANCE DIVERSION AS KIND OF A
VERY ROUGH PROXY FOR CROWDING.
SO NOW WHAT WE SEE HERE IS WHEN
WE LOOK AT HOSPITALS BASED ON
THEIR PATIENTS THAT THEY SERVE,
SO NON-MINORITY SERVING
HOSPITALS -- EXCUSE HE --
MINORITY SERVING HOSPITALS,
THEY'RE THE ONES IN THE DOTTED
RED LINE.
SO WHEN WE LOOKED AT 10 YEARS OF
DATA, EVERY YEAR AND EVERY MONTH
OF DATA, WE SAW THERE'S A VERY
CONSISTENT PATTERN WHERE
NON-MINORITY SERVING HOSPITALS
HAD A MUCH HIGHER NUMBER OF
AMBULANCE DIVERSION THAN --
SORRY, MINORITY SERVING
HOSPITALS HAD A MUCH HIGHER MEAN
DAILY HOURS OF DIVERSION THAN
NON-MINORITY SERVING HOSPITALS.
SO YOU'LL SEE THAT EVEN THOUGH
OVER TIME THAT NUMBER HAS
DECREASED, AND THAT'S DUE TO A
LOT OF DIFFERENT INTERVENTIONS
WE'VE HAD, WE GET E.D. CASE
MANAGERS AND SOME PLACES, THIS
WAS LOOKING AT CALIFORNIA DATA,
I BELIEVE, SOME PLACES HAVE
BANNED DIVERSION, SO THAT'S WHY
IN GENERAL, THE NUMBERS ARE
LOWER, BUT YOU'LL SEE IT'S A
SIGNIFICANT PERCENTAGE EVERY
YEAR, THAT IS CONSISTENTLY
HIGHER FOR HOSPITALS THAT SERVE
MINORITY PATIENTS.
THIS IS THE SAME THING WHEN WE
LOOKED AT BLACK-SERVING
HOSPITALS, WE ALSO FOUND
BLACK-SERVING HOSPITALS HAD A
HIGHER NUMBER OF PATIENTS WHO
EXPERIENCE DIVERGENCE.
SO NOT ONLY IS IT THE NUMBER OF
HOURS, THE REASON WHY WE WANTED
TO LACK AT THIS, IF YOU LOOK
BACK AT THE SLIDE, THIS IS THE
NUMBER OF HOURS PER HOSPITAL.
BUT YOU COULD SAY, WELL, LET'S
SAY, FOR EXAMPLE, THAT THE
HOSPITAL IS NOT AS BUSY, SO
MAYBE MINORITY-SERVING HOSPITALS
ARE LESS BUSY SO IT DOESN'T
AFFECT AS MANY PATIENTS.
BUT IF WE LOOK AT THE NUMBER OF
PATIENTS WHO EXPERIENCE
DIVERSION, IT'S THE SAME THING,
AND WE ALSO WANTED TO LOOK AT
NOT JUST MINORITY STATUS BUT
BLACK SERVING HOSPITALS AS WELL,
YOU'LL SEE THE TOP LINE ARE THE
HOSPITALS THAT HAVE A HIGH
PROPORTION OF PATIENTS WHO ARE
BLACK, AND THERE'S A HIGHER
NUMBER OF PATIENTS ALSO WHO
EXPERIENCE DIVERSION.
SO IT'S NOT ONLY BY THE NUMBER
OF HOURS, BUT IT BY THE NUMBER
OF PATIENTS, THE PERCENTAGE OF
PATIENTS WHO ARE EXPERIENCING
DIVERSION.
NOW WHY IS IT WHEN WE LOOK AT
HOSPITALS THAT SERVE DIFFERENT
RATES OF MINORITY PATIENTS, WHY
DOES THAT MATTER?
SO I'M QUOTING THIS STUDY, BUT
YOU'LL SEE HERE, I'LL SHOW YOU
TWO SLIDES, SO THIS IS JUST
WHITE PATIENTS.
SOME PEOPLE SAY, WELL, MAYBE
WHEN WE LOOK AT THE GENERAL
LITERATURE, YOU'LL LOOK AT MAYBE
NEWSPAPER REPORTS THAT SAY BLACK
OR HISPANIC PATIENTS HAVE HIGHER
MORTALITY THAN WHITE PATIENTS.
THEN WE START TO WONDER IS THAT
BECAUSE OF INDIVIDUAL
DISCRIMINATION OR ARE THERE
ISSUES RELATED TO THE HOSPITALS
THAT THEY GO TO?
AND SO WHEN WE LOOK HERE, THIS
STUDY LOOKS AT DIFFERENT
CONDITIONS OF AMI, ACUTE
MYOCARDIAL INFARCTION, CHF,
CONGESTIVE HEART FAILURE,
PNEUMONIA, AND ALSO IT LOOKS AT
MORTALITY RATES, WHAT HAPPENS TO
YOUR 30, 90 DAY MORTALITY RATES,
BASED ON WHETHER YOU WENT TO A
BLACK-SERVING HOSPITAL OR A
NON-BLACK-SERVING HOSPITAL?
YOU'LL SEE THE FIRST NUMBER IS
14.9%.
IT'S YOUR MORTALITY RACE.
IF YOU'RE WHITE AND GO TO A
BLACK SERVING HOSPITAL, YOUR
FATALITY RATE -- SO YOU'LL SEE
THAT ACROSS CONDITIONS, FOR EACH
CONDITION AND FOR EACH MORTALITY
RATE, THE MORTALITY RATE IS
HIGHER FOR WHITE PATIENTS THAT
GO TO BLACK-SERVING HOSPITALS,
AND WHEN YOU LOOK AT THE ODDS
RATIO, YOU'LL SEE THAT
CONSISTENTLY, THERE'S ONLY ONE
THAT'S NOT STATISTICALLY
SIGNIFICANT FOR CHF, BUT THAT
ALL OF THEM HAVE HIGHER -- IF
YOU -- BASICALLY THE WAY TO
INTERPRET THIS IS IF YOU ARE A
WHITE PATIENT THAT GOES TO A
BLACK-SERVING HOSPITAL, YOU HAVE
A HIGHER ODDS OF DYING, WHETHER
AT 30 DAYS OR AT 90 DAYS, EVEN
WITH THE SAME CONDITION,
CONTROLLING FOR YOUR CONDITION,
YOUR AGE, AND HERE WE'RE LOOKING
AT WHITE PATIENTS AS A
STRATIFIED ANALYSIS, AND ALL
YOUR COMORBIDITIES, THAT YOU
HAVE A HIGHER RISK OF DYING IF
YOU GO TO A BLACK-SERVING
HOSPITAL THAN A
NON-BLACK-SERVING HOSPITAL.
THIS IS THE SLIDE LOOKING AT
BLACK PATIENTS -- IF YOU'RE
BLACK AND GO TO A BLACK SERVING
HOSPITAL, THE ONLY ONE THAT
ISN'T SIGNIFICANT HERE IS FOR
AMI, BUT FOR THE OTHER
CONDITIONS HERE, YOU'LL SEE THAT
FOR -- AND SORRY, HERE IT'S CHS
AND PNEUMONIA FOR 90 DAYS, THAT
NOT ALL OF THEM ARE SIGNIFICANT
HERE, BUT FOR BLACK PATIENTS,
THAT YOU HAVE A HIGHER RISK OF
DYING FOR CHF AT 30 DAYS AND CHF
AND PNEUMONIA AT 90 DAYS.
SO WHAT DOES THIS TELL US?
THIS TELLS US THAT IT'S NOT JUST
THAT BLACK PATIENTS AND WHITE
PATIENTS GO TO DIFFERENT
HOSPITALS.
WHILE THAT IS ALSO TRUE AND
IMPORTANT, BUT IT ALSO TELLS US
THAT THERE ARE DIFFERENT --
THERE'S DIFFERENT QUALITY AT
THESE HOSPITALS, SO IT'S NOT
NECESSARILY AN INDIVIDUAL ISSUE
OF DISCRIMINATION, BUT WHITE
PATIENTS WHO GO TO DIFFERENT
HOSPITALS GET DIFFERENT
TREATMENT AND WHITE PATIENT WHO
GO TO BLACK SERRING HOSPITALS
WILL HAVE SERVING HOSPITAL
WILL HAVE HIGHER MORTALITY THAN
IF THEY GO TO A NON-BLACK
SERVING HOSPITAL AND SAME FOR
BLACKS.
SO WHY IS THIS POSSIBLE, WHAT IS
THE MECHANISM BEHIND WHAT'S
HAPPENING HERE?
THIS IS A STUDY I DID AGAIN WITH
MY COLLABORATOR SHOWING THAT LOW
INCOME COMMUNITIES ARE MORE
LIKELY TO EXPERIENCE LARGE
INCREASES IN DRIVING TIME TO THE
NEAREST E.D. DUE TO E.D.
CLOSURES.
SO WE KNOW THAT HOSPITALS
ACTUALLY IN THE UNITED STATES,
THERE'S NO MANDATE FOR THEM TO
HAVE AN EMERGENCY DEPARTMENT.
I MEAN, THERE ARE FEDERAL
FACILITIES LIKE V.A. FACILITIES
THAT MIGHT HAVE CERTAIN
MANDATES, BUT IN GENERAL, ALL
OTHER HOSPITAL THE, SO HOSPITALS, WHETHER YOU'RE
FOR PROFIT, NON-PROFIT, THERE'S
NO MANDATE THAT SAYS YOU HAVE TO
HAVE AN E.D.
AND SO HOSPITALS CAN CHOOSE TO
CLOSE THEIR E.D.s.
THERE MIGHT BE GOOD REASONS TO
CLOSE, YOU MIGHT HAVE REDUNDANT
SERVICES, THERE MIGHT BE SO MANY
HOSPITALS IN THE AREA, YOU DON'T
NEED EMERGENCY DEPARTMENTS, BUT
THIS IS TO SHOW WHO'S BEING
AFFECTED AND WHAT ARE THE RISK
FACTORS FOR CLOSURE.
SO YOU'LL SEE THE GREEN DOTS
HERE, THOSE ARE DECREASES IN
DRIVING TIME.
SO THOSE ARE PLACES THAT HAVE
ACTUALLY EXPERIENCED E.D.
OPENINGS.
SO NOW BEFORE, WHERE THEY MIGHT
HAVE HAD TO DRIVE 30 MINUTES TO
THE NEXT EMERGENCY DEPARTMENT,
NOW THEY HAVE TO DRIVE 15.
SOME MIGHT SEE THAT AS A GOOD
THING.
I WILL TALK ABOUT THAT A LITTLE
LATER WHETHER MORE IS BETTER AND
THAT'S NOT ALWAYS THE CASE.
BUT YOU'LL SEE THE RED IS WHERE
THERE'S MORE -- THESE CLOSURES
HAVE AFFECTED THEM SUCH THAT
PATIENT WHO USED TO BE ABLE TO
DRIVE X AMOUNT OF TIME NOW
ACTUALLY NEED TO DRIVE X PLUS 30
MINUTES TO GET TO THEIR NEAREST
E.D.
WHEN YOU LOOK AT THIS, I'LL SHOW
YOU THE ADJUSTED ANALYSIS IN A
LITTLE BIT, BUT THERE HAVE BEEN
MORE RURAL AREAS AND THESE TEND
TO BE MORE LOW INCOME AREAS TOO,
AND THEY'RE NOT NECESSARILY
HAPPENING IN BIG METROPOLITAN
AREAS, AND A LOT OF THESE PLACES
ALREADY DO NOT HAVE ADEQUATE
SERVICES.
SO THIS IS WHEN WE STARTED TO
LOOK MORE CAREFULLY, WHAT WE DID
IS WE DID A SURVIVE ANALYSIS.
WE TEND TO THINK OF SURVIVAL
ANALYSES, WE WERE THINKING ABOUT
BREAST CANCER PATIENTS, SOME OF
THEM HAD A HIGHER SURVIVAL AND
SOME OF THEM HAD LOWER SURVIVAL,
WHETHER IT DUE TO SMOKING,
ESTROGEN USE, THESE ARE THE
COMMON EXAMPLES THAT ARE USED.
NOW WHAT WE DID IS WE LOOKED AT
DATA FROM 2001 TO 2013, AND WE
LOOKED AT EVERY E.D. IN THE
UNITED STATES THAT REPORTED TO
THE AMERICAN HOSPITAL
ASSOCIATION, AND WE LOOKED AT
EACH YEAR THEY HAD AN E.D., WE
LOOKED THE THEIR ZIP CODES, WHEN
THEY WERE OPENING AND CLOSING.
THE RED LINE SHOWS YOU OPERATING
E.D.s.
OF COURSE WHILE YOU HAVE
CLOSURES, THERE ARE ALWAYS
OPENINGS AS WELL.
WE FOUND ABOUT -- ON AVERAGE
ABOUT 80 CLOSURES PER YEAR, BUT
IT'S NOT 80 TIMES 13 YEARS OF
DATA.
THERE ARE SOME OPENINGS AS WELL.
BUT WHEN YOU ASK IS IT POSSIBLE
THAT THESE E.D.s ARE CLOSING
IN REDUNDANT AREAS, YOU'LL SEE
THAT IT'S NOT -- IF THEY WERE
CLOSING IN REDUNDANT AREAS, YOU
WOULD HAVE A SMALL NUMBER OF THE
PERCENT POPULATION AFFECTED BY
THE E.D. CLOSURE, IT WOULD
PACEICALLY IT WOULD
BASICALLY NOT BUDGE.
IF YOU HAD 10 E.D.S -- IT
WOULDN'T REALLY AFFECT THE
PERCENT POPULATION BECAUSE THEY
STILL HAVE ACCESS.
BUT WHAT WE SEE HERE IS THAT
OVER TIME, IT'S AFFECTED UP TO
14% -- 14.5% OF THE POPULATION
IN THIS PERIOD OF THE STUDY.
SO WHAT WE DID IS, WE LOOKED AND
WE ASKED THE QUESTION, WHAT ARE
THE RISK FACTORS THAT ARE
ASSOCIATED WITH E.D. CLOSURE?
SO WE WANTED TO LOOK AT HOSPITAL
FACTORS, SO WHAT HE WITH FOUND,
THIS ISN'T ROCKET SCIENCE, BUT
IF YOU HAVE LOW PROFIT MARGINS,
THE STEPLADDER DOWN IS MUCH
LOWER THAN THE GREEN AND THE RED
LINE.
SO THEY HAD A HIGHER TETHER
RATE.
HOSPITALS WITH LOW PROFIT
MARGINS HAD A MUCH HIGHER DEATH
RATE.
THEY WERE MUCH LESS LIKELY TO
SURVIVE.
30 TO 40% LESS LIKELY TO SURVIVE
THAN HOSPITALS WHO HAD HIGH
PROFIT MARGINS OR EVEN WERE IN
THE MIDDLE.
WE ALSO FOUND THAT IF YOUR
HOSPITAL WAS TAKING CARE OF A
HIGH PERCENTAGE OF PATIENTS WHO
ARE IN POVERTY, THEN YOU HAD A
HIGHER DEATH RATE AS WELL.
SO HERE THE GREEN AT THE VERY
BOTTOM ARE HOSPITALS THAT TOOK
CARE OF A HIGH SHARE OF PATIENTS
IN POVERTY.
SO THOSE HOSPITALS WERE ALSO AT
A HIGHER LIKELIHOOD OF DYING OR
CLOSING.
WHEN WE LOOKED AT SAFETY NET
HOSPITALS TOO, SO SAFETY NET IS
A DEFINITION WE USE FOR
HOSPITALS THAT TAKE CARE OF A
CERTAIN NUMBER OF UNINSURED OR
MEDICAID PATIENTS, THOSE
HOSPITALS THAT ARE DEPICTED HERE
IN RED ALSO HAD A HIGHER DEATH
RATE.
AND THEN FINALLY, THIS IS AN
INTERESTING FINDING, THAT
HOSPITALS WHO ARE FOR PROFIT, SO
THEY -- WITH THEIR MONEY, THEY
ACTUALLY PAY IT OUT TO
SHAREHOLDERS, SO THESE ARE
FOR-PROFIT HOSPITALS, ACTUALLY
HAVE A HIGHER DEATH RATE.
SOME PEOPLE THINK WHY IS THAT
THE CASE?
YOU'LL FIND HOSPITALS CAN MAKE
DECISIONS ABOUT CLOSING THEIR
E.D.s TO PROTECT THEMSELVES
FROM HAVING TO ADMIT OR CARE FOR
PATIENTS THAT MAY NOT BE
FINANCIALLY PROFITABLE.
A LOT OF US HAVE HEARD OF THE
EMERGENCY MEDICAL TREATMENT AND
LABOR ACT, THAT WAS INACTED IN
1986 TO PREVENT PATIENT DUMPING.
BEFORE IF YOU SHOWED UP AND WERE
UNINSURED, THEY THEY'D SAY GO DOWN
THE STREET.
AND IT SAYS YOU HAVE TO TREAT
PATIENT REGARDLESS OF THEIR
ABILITY TO PAY.
SO WHAT HAPPENED IS THAT
HOSPITALS SAY, WELL, IF YOU'RE
GOING TO DO THAT, THEN I'M
PROBABLY GOING TO CLOSE MY E.D.
BECAUSE I DON'T WANT TO OPEN MY
DOORS UP TO PATIENTS THAT DON'T
PAY, AND SO I'M GOING TO NOW BE
JUST A SPECIALTY-SPECIFIC
HOSPITAL, I AM GOING TO BE ONLY
A CANCER HOSPITAL OR ONLY AL
CARDIAC HOSPITAL OR ONLY A
HOSPITAL FOR SPECIAL SURGERY OR
ONLY AN ORTHOPEDIC HOSPITAL.
SOL THAT'S WHAT'S HAPPENING
HERE, THAT'S WHAT'S BEHIND THIS
SIGNAL HERE.
AND WHAT HAPPENS IS, AS WE HAVE
THESE DIFFERENTIAL CLOSURES, YOU
HAVE MORE CLOSURES IN POOR
AREAS, AND YOU ACTUALLY HAVE
OPENINGS IN RICH AREAS THAT THIS
IS ANOTHER STUDY THAT I DID, TO
ACTUALLY LOOK AT DOES THIS
AFFECT YOUR ABILITY TO GET TO
THE HOSPITAL IF YOU ARE LOW
INCOME AND HIGH INCOME?
SO WE LOOKED AT ACTUALLY
AMBULANCE DATA TO LOOK AT
RESPONSE TIME, AND WE LOOKED --
FOR THIS STUDY, WE LOOK AT
PATIENTS WHO WERE IN LOW INCOME
VERSUS HIGH INCOME, BUT WE ALSO
HAVE DONE THIS FOR CARDIAC
ARREST PATIENTS ALSO.
SO NOT JUST LOOKING AT
ALL-COMERS BUT EVEN FOR CARDIAC
ARREST, IT TRUE THAT IF YOU ARE
IN A LOW INCOME AREA, THAT YOUR
RESPONSE TIME IS LONGER BECAUSE
YOUR RESPONSE TIME, ON-XENOTIME,
YOUR TOTAL TIME IS MUCH LONGER,
IT 10% LONGER, THIS IS NOT
JUST -- YOU JUST NEEDED TO GET
YOUR EARS CHECKED OR -- YOU'VE
HAD CARDIAC ARREST, YOU MAY OR
MAY NOT HAVE HAD CPR AND YOU
NEED TO GET TO THE NEAREST
HOSPITAL RIGHT AWAY, AND NOW WE
FIND IT IS INDEED TRUE THAT IT
TAKES YOU LONGER TO GET TO THE
HOSPITAL WHEN YOU CALL AN
AMBULANCE.
SO HERE'S WHAT WE FIND.
"THE NEW YORK TIMES" WHEN I --
COVERAGE ABOUT HOW THERE'S FEWER
EMERGENCY DEPARTMENTS, REUTERS
LOOKED AT THAT TOO, "U.S.A.
TODAY," SAYING THERE'S A LOT OF
CLOSURES.
ONE OF THE THINGS THAT I THINK
PEOPLE ARE CONFUSED ABOUT IS
THAT THERE'S THIS CRY FOR HELP
FOR EMERGENCY SERVICES.
YOU ALSO SEE SOMETHING ELSE
THAT'S A LITTLE OF A TALE OF TWO
CITIES.
YOU ALSO LOOK AT THIS, WHETHER
IT'S MAGAZINES OR -- ON THE
HIGHWAY, YOU'LL SEE PEOPLE
TRYING TO ADVERTISE YOUR
EMERGENCY SERVICES, WE CAN
GUARANTEE YOU'LL SEE THE ER
DOCTOR IN 60 MINUTES OR LESS, O
YOU'LL SEE THESE BILLBOARDS, AND
NOW IT'S JUST 9 MINUTES.
AND THIS IS UCSF, SO I WORK
ACTUALLY AT THE PUBLIC HOSPITAL,
THE SAN FRANCISCO GENERAL
HOSPITAL BUT THIS IS WHAT I SAW
ACTUALLY WHEN I WAS WALKING DOWN
THE HALL FOR A MEETING A PFAU
YEARS AGO.
A FEW
YEARS AGO.
THIS IS A PLACE WHERE YOU CAN
HOLD YOUR PLACE ONLINE, THEY'D
GIVE YOU A TEXT AND MAKE YOUR
WAY IN SO YOU CAN WAIT IN THE
COMFORT OF YOUR OWN HOME AND
SAID THERE'S NO PLACE LIKE HOME,
NO NEED TO WAIT IN THE RATING
ROOM, COME IN AND REGISTER
ONLINE AND WE'LL SEE YOU THERE.
SO THIS IS -- WHAT WE FIND IS
THAT GEOGRAPHY REALLY IS DESTINY
IN EMERGENCY SERVICES AND OTHER
SERVICES AS WELL, SO I'LL TALK
ABOUT THAT TOO, BUT IF YOU ARE
AN E.R. THAT IS IN A AFFLUENT
AREA, THEN YOU ARE A REVENUE
CENTER.
I TRAINED AT STANFORD HOSPITAL,
WHERE MOST OF THE PATIENTS IN
THAT AREA IN PALO ALTO ARE
INSURED, SO STANFORD NEEDS THAT
E.D., BECAUSE MOST ADMISSIONS
COME FROM THE E.D.
SO YOU NEED YOUR ED IN THOSE
CASES BECAUSE YOU NEED A WAY FOR
PEOPLE TO GET IN THE DOOR TO BE
ADMITTED BUT IN OTHER PLACES,
YOUR E.D. MAY BE A COST CENTER
IF YOU LIVE IN AN AREA WHERE
THAT HOSPITAL IS LOCATED IN AN
AREA THAT HAS A LOT OF PATIENTS
WHO ARE UNINSURED.
AND SO I THINK IT'S IMPORTANT
FOR US TO RECOGNIZE THAT WHEN
PEOPLE COME TO THE E.D. WITH
SOCIAL NEEDS, THAT THERE ARE
FACTORS THAT HAVE AFFECTED THEIR
ABILITY TO EVEN OBTAIN EMERGENCY
SERVICES OR OTHER SERVICES THAT
ARE VERY TIME-SENSITIVE.
SO THEY ALREADY COME WITH THE
BURDEN OF NOT BEING ABLE TO
ACCESS CARE IN THE SAME WAY THAT
OTHERS DO.
AND I THINK IT'S IMPORTANT
BECAUSE THERE'S A COMMON THEME
WHEN POLICY MAKERS MAKE POLICY
OR -- AND I'M NOT SAYING ALL,
BUT YOU TEND TO SEE THIS KIND OF
VICTIM BLAMING OF WHERE WE SHIFT
THE BLAME ON THE PATIENT,
WHETHER OR NOT THEY'RE COMING IN
FOR AN INAPPROPRIATE VISIT, OR
AVOIDABLE VISIT.
THESE ARE ALL TERMS TO TEND TO
MAKE YOU THINK THE PATIENT HAD A
CHOICE AND THEY JUST HAD OTHER
OPTIONS BUT THEY DECIDED TO COME
TO THE E.D.
SO I JUST THINK IT'S IMPORTANT
FOR US TO UNDERSTAND THE CONCEPT
THAT PATIENTS COME TO THE E.D.
AND E.D.s ARE NOT ALL THE SAME
AND PATIENT DON'T HAVE ALL THE
SAME ACCESS TO E.D.s, SO WHEN
THEY PRESENT AND WE SEE THEM,
THIS IS THE CONTEXT THAT THEY
COME FROM.
THIS IS A PICTURE OF -- I GREW
UP IN TEXAS AND MY PARENTS STILL
LIVE THERE SO WHEN I VISIT THEM,
I WILL NOTICE WHAT'S GOING ON IN
HEALTHCARE.
TEXAS IS NOT UNIQUE, THERE ARE
OTHER STATES THAT DO THIS, BUT
THEY ALLOW FOR SOMETHING CALLED
FREE-STANDING E.D.s.
WHAT A FREE-STANDING E.D. IS,
USUALLY WE'RE USED TO HAVING AN
E.D. ASSOCIATED WITH A HOSPITAL,
IT'S THE BOTTOM FLOOR, THERE'S
AN AMBULANCE SIGN AND THAT'S
WHERE PATIENTS COME IN.
BUT WHAT A FREE-STANDING E.D.
IS, IT'S NOT TIED TO A HOSPITAL,
THERE'S NO HOSPITAL THAT'S
ATTACHED TO IT.
IT'S FREE-STANDING, IT CAN BE
ANYWHERE, AND THEN IF THEY
DECIDE THEY NEED TO ADMIT
PATIENTS, THEN THEY PUT THEM IN
AN AMBULANCE AND GO TO THAT
OTHER HOSPITAL.
NOW FREE-STANDING EDs ARE
LUCRATIVE, BECAUSE OF THE WAY WE
IN AMERICA HAVE DECIDED TO
FINANCE AND PAY FOR CARE.
I WON'T SPEND TOO MUCH TIME ON
IT, BUT ANOTHER THREAD OF MY
RESEARCH IS LOOKING AT THE
INCENTIVES OF HEALTHCARE, AND
PLJ DEPARTMENTS ARE ALLOWED TO
CHARGE A FACILITY FEE.
THAT MEANS ONCE YOU STEP IN THE
DOOR, EVEN IF YOU COME OUT WITH
A BAND-AID, I'M SURE YOU'VE SEEN
STUDIES OF THIS AND REPORTS OF
THIS IN THE "NEW YORK TIMES" AND
EVERYWHERE ELSE, WHERE PATIENTS
GO IN WITH A SPRAINED ANKLE AND
THEY COME OUT WITH A $10,000
BILL.
I MEAN, IT ALL SOUNDS VERY
CRAZY, BUT MOST OF THOSE ARE
BECAUSE OF FACILITY FEES WHICH
ARE LAWFUL TO CHARGE, AND ONLY
EMERGENCY DEPARTMENTS CAN CHARGE
THEM.
SO URGENT CARES CANNED CHARGE
THEM.
SO THERE USED TO BE A BIG FLOOD
OF URGENT CARES, BUT NOW
PEOPLE -- IT DOESN'T MATTER WHAT
HAPPENED IN THE HOSPITAL, COME
IN, I'VE GOT HIM, THAT'S ALREADY
LIKE $2,000 OFF THE TOP.
SO IN TEXAS, YOU'LL SEE THE D.
JUST TWO-DOOR DOWN IS AN
AMBULANCE BAY.
THIS AMBULANCE BAY IS TIED TO --
I THINK I MIGHT HAVE BEEN
DRIVING IN THE PASSENGER'S SIDE
OR SOMETHING SO I DIDN'T GET A
GREAT PICTURE, BUT THIS IS FIRST
CHOICE EMERGENCY ROOM.
IT'S AN EMERGENCY ROOM, IT'S NOT
A DEPARTMENT.
YOU CAN DROP THE PATIENT OFF
THERE, BUT IF YOU ACTUALLY NEED
TO GET ANOTHER PLANS TO GO.
AND SO WHAT WE SEE HERE IS
ANOTHER EXAMPLE OF INEQUITY.
SO THERE ARE OTHER STATES THAT
DO THIS AGAIN, BUT OTHER PEOPLE
HAVE LOOKED AT WHAT -- IT MAKES
YOU MORE LIKELY TO HAVE A
FREE-STANDING E.D.
BECAUSE A LOT OF THE TIME, WHEN
FREE-STANDING E.D.S APPLY FOR
LICENSURE IN THE STATE, THEY
WILL SAY WE ARE PROVIDING CARE
TO PEOPLE WHO NEED IT.
WE ARE PROVIDING MILLIMETER
CARE, IF YOU SAY THAT, SURE, YOU
GET THE STAMP OF APPROVAL, BUT
WHERE ACTUALLY ARE THESE PLACES
LOCATED?
THEY'RE IN DALLAS-FORT WORTH,
AUSTIN AND HOUSTON.
THEY'RE NOT ACTUALLY IN PLACES
THAT NECESSARILY NEED THEM.
YOU CAN SEE THESE DOTS ARE JUST
PILING UPON EACH OTHER.
SO WHAT THEY'VE FOUND IS WHEN
THEY DID AN ADJUSTED ANALYSIS
AND REGRESSION, THEY FOUND
THERE'S MORE FREE-STANDING
E.D.s IN AREAS WITH HIGHER
INCOME, LOWER RATES OF MEDICAID
SERVICES AND ALREADY AT
BASELINE, HAD MORE HEALTHCARE
SERVICES.
SO AGAIN, WHEN WE THINK ABOUT ED
SERVICES, AND I DON'T WANT
PEOPLE TO THINK -- I'M NOT
SAYING THAT THEY DON'T PROVIDE
GOOD SERVICES.
I'M JUST SAYING OVERALL THE
CONTEXT IS IMPORTANT TO
UNDERSTAND THAT THERE ARE AREAS
THAT HAVE A LOT OF EMERGENCY
SERVICES AND THERE'S SOME THAT
DO NOT, AND I THINK THAT'S VERY
SIMILAR WHEN WE THINK ABOUT HOW
WE CONNECT PEOPLE TO SOCIAL
SERVICES, WE ARE ALREADY WORKING
IN ENVIRONMENTS THAT DON'T HAVE
A LOT OF RESOURCES AVAILABLE.
SO THIS IS AN INTERESTING --
JUST A LITTLE GRAPH.
THE BLUE ARE NON-FREE-STANDING
EDs.
THESE ARE BASICALLY
HOSPITAL-BASED EDs.
THEN THE RED ONES ARE
FREE-STANDING EDs.
YOU'LL SEE AT THE TOP HERE, THE
TOP IS PRIVATE INSURANCE, RIGHT?
IF YOU'VE GOT AN AREA WITH A ZIP
CODE THAT HAS A LOT OF PRIVATE
INSURANCE, YOU HAVE A MUCH
HIGHER CHANCE OF GETTING A
FREE-STANDING ED THAN DOWN HERE,
BECAUSE NOBODY WANTS TO OPEN IN
YOUR NEIGHBORHOOD BECAUSE
THEY'RE NOT GOING TO GET PAID.
AND SO HERE IS ANOTHER EXAMPLE
OF HOW HEALTHCARE IN THE UNITED
STATE, LIKE MANY THINGS, IS PUT
IN THE MARKET AND THERE ARE
THESE VERY REAL CONSEQUENCES OF
WHO GETS CARE AND WHO DOESN'T.
AND THIS IS JUST A BRIEF STUDY
JUST SHOWING THAT FREE-STANDING
EDS ARE RAPIDLY EXPANDING, THEY
ACTUALLY CHARGE HIGHER PRICES TO
THE UR VANT CAR EVEN THOUGH A
LOT OF ACUTES ARE ACUTITIES ARE URGENT
CARES.
SO I THINK IT'S IMPORTANT TO
UNDERSTAND THAT THE Es ARE NOT
ALL THE SAME AND THAT
FREE-STANDING -- REGARDLESS OF
WHAT WE WORK IN, MOST OF THE
SOCIAL VCHS
SOCIAL SERVICES -- IF YOU GO
THERE, I'VE BEEN -- IT'S KIND OF
MY HOBBY WHEN I VISIT MY PARENTS
WHEN I DO THESE FIELD
INVESTIGATIONS KIND OF ON THE
SIDE, BUT THEY ARE REALLY,
REALLY NICELY EQUIPPED, THERE'S
NO ONE IN THE WAITING ROOM OR
THE E.D. BECAUSE US HAVE ONE
PHYSICIAN AND FIRSTS WAITING FOR
PATIENTS, BUT IT'S BECAUSE IT'S
A HIGHLY PROFITABLE SERVICE, SO
SIMILAR STORY WITH TRAUMA
CENTERS.
I'LL GO THROUGH THIS A LITTLE
MORE QUICKLY PAUSE I WANT TO
SPEND TIME ON ANOTHER PART WHEN
WE TALK ABOUT DISPARITIES IN
SOCIAL MEANS.
BUT I WANTED TO SHOW THAT IT'S
NOT JUST LIMITED TO EDs BUT
IT'S THE SAME SORE STORY WITH
TRAUMA CENTERS, THEY'RE VERY
PROFITABLE IN SOME AREAS AND NOT
PROFITABLE IN OTHERS.
THAT SIMILAR THING, SO HAVE A
LOWER -- IF YOU TREAT A HIGHER
PROPORTION OF MINORITIES YOU'RE
MORE LIKELY TO CLOSE.
WHEN WE LOOK AT ACCESS TO LEVEL
ONE OR TWO TRAUMA CENTERS IF
YOU'RE UNINSURED, YOU HAVE A
VERY, VERY, VERY LOW ODDS OF
HAVING ACCESS TO A TRAUMA CENTER
WITHIN 60 MINUTES.
SAME THING WITH YOUR MEDICARE.
IT'S HIGHER BUT STILL, .69 ODDS
RATIO OF HAVING ACCESS TO A
TRAUMA CENTER WITHIN 16 MINUTES.
AND YOU HAVE ACTUALLY A POSITIVE
SIGNAL HERE, WHERE BLACKS AND
NON-WHITES HAVE A HIGHER
LIKELIHOOD OF ACCESS TO TRAUMA
CENTER, BUT I'LL GO INTO THAT IN
JUST A LITTLE BIT BECAUSE PEOPLE
SAY YOU'VE BEEN TALKING ABOUT
THERE'S DISCRIMINATION BUT
YOU'RE SAYING BLACKS AND
MINORITY -- I WILL TALK ABOUT IT
IN JUST TWO SLIDES BUT I WANT TO
KIND OF POINT OUT THE UNINSURED
AND A LOT OF -- IS WITH INCOME.
YOU'LL FIND THAT TRAUMA CENTERS
HAVE BEEN GROWING, THERE'S ALSO
BEEN A GROWING NUMBER OF TRAUMA
CENTERS THAT HAVE BEEN OPENING
ACROSS THE NATION, SO THE NET
NUMBER OF TRAUMA CENTERS HAS
BEEN INCREASING AS SO WHAT'S
HAPPENING HERE IS THAT TRAUMA
CENTER SAME THING AS EDS, THEY
HAVE ACTIVATION FEES SO THEY ARE
ABLE TO CHARGE THESE SOMETIMES
$10,000, SOME OF THEM ARE EVEN
HIGHER EVERYONE -- MEDICARE
TENDS TO -- IT DOESN'T HAVE A
HIGHER RATE OF PAYMENT BUT THEY
KNOW THAT IT'S WELL INSURED
BECAUSE YOU HAVE A LOT OF
RETIREES THERE, BUT YOU'LL SEE
LEFT, RIGHT, WHEN YOU'RE ON THE
HIGHWAY, YOU'LL SEE A TRAUMA
CENTER, ON THE OTHER SIDE YOU'LL
SEE A TRAUMA CENTER TOO, AND
YOU'RE WONDERING IF THAT'S A
GOOD USE OF RESOURCES.
IF YOU NEED A CARDIAC CATH
BECAUSE YOU HAVE A HEART ATTACK,
YOU'LL FIND THAT YOU HAVE LESS
ACCESS, THIS IS KIND OF THE
BACKWARDS WAY BUT UNTIMELY
ACCESS, MEANING POOR ACCESS TO
PCI, YOU'RE MUCH LESS LIKELY TO
HAVE POOR ACCESS IF YOU LIVE IN
A POOR AREA OR IF YOU HAVE LOW
INCOME OR IF YOU HAVE A HIGH
SHARE OF HISPANICS, BUT THEN
INTERESTINGLY HERE, AGAIN, THIS
IS -- WE FIND A LITTLE BIT OF A
STRANGE SIGNAL THAT IT LOOKS
LIKE BLACK PATIENTS, IF YOU HAVE
A HIGH SHARE OF BLACK PATIENTS
THAT YOU HAVE A LOWER ODDS OF
HAVING ACCESS TO PCI, SO WHAT
WE'RE FINDING THERE IS ACTUALLY
JUST -- IT'S AN ISSUE WITH URBAN
CITIES, SO IF YOU LIFE LIVE IN
KIND OF A CITY CENTER, YOU DO
HAVE A P KRI. CI CENTER.
IT'S NOT JUST ABOUT ACCESS BUT
IT'S TALKING ABOUT THE
CROWDEDNESS OF THAT HOSPITAL
BECAUSE WE KNOW FROM OTHER
STUDIES THAT BLACK SERVING
HOSPITALS TEND TO BE MORE
CROWDED.
SO IF YOU'RE IN AN AREA THAT,
YES, YOU HAVE ACCESS TO PCI BUT
IT'S A REALLY CROWDED HOSPITAL,
YOU STILL MAY HAVE POOR OUTCOMES
BECAUSE THERE'S NOT ENOUGH
RESOURCES FOR YOU.
SO I WON'T SPEND TOO MUCH TIME
HERE BUT THIS IS BASICALLY
SHOWING THAT PCI CENTERS TEND TO
PROLIFERATE IN AREAS WITH HIGHER
RATES OF PRIVATE INSURANCE,
WHERE THERE ARE ALREADY PCI
SERVICES.
BUT IT'S NOT JUST ABOUT
GEOGRAPHY.
I WANT TO GO INTO A LITTLE
ABOUT -- WHILE WE HAVE ABOUT
SEVEN MINUTES LEFT, EVEN IF YOU
LIVE CLOSE TO A HOSPITAL, THERE
ARE STUDYS THAT HAVE SHOWN THAT
IT'S NOT JUST SHOWN THAT YOU
LIVE CLOSE AND YOU GO THERE,
THERE ARE STUDIES SHOWING EVEN
IF YOU'RE CLOSE TO HOSPITALS,
YOU TEND TO GO TO LOW QUALITY
HOSPITALS.
HERE, THIS STUDY LOOKS AT BLACK
AND WHITE MEDICARE PATIENTS'
PROXIMITY AND ADMISSION TO LOW
QUALITY HOSPITALS.
SO ON THE LEFT, YOU'LL SEE
PROXIMITY TO AN AVERAGE OR HIGH
QUALITY HOSPITAL.
IF YOU ARE LESS THAN FIVE MILES,
THERE'S ACTUALLY MORE BLACK
PATIENTS, 15% OF PATIENTS WHO
ARE LESS THAN FIVE MALES TO A
CENTER THAN WHITE PATIENTS.
BUT FOR SOME STRANGE REASON,
EVEN THOUGH YOU'RE CLOSER TO
THAT HIGH QUALITY CBG CENTER,
YOU HAVE A HIGHER ODDS OF GOING
TO A LOW QUALITY CENTER IF
YOU'RE BLACK VERSUS WHITE.
SO THAT'S WHAT THIS SHOWING,
EACH AREA, WHETHER YOU'RE LESS
THAN LESS THAN FIVE MILES, FIVE
TO 20 MILES, GREATER THAN
20 MILES, YOU STILL HAVE A
HIGHER PROBABILITY OF GOING TO A
LOW QUALITY HOSPITAL.
SAME THING, WE FIND A HIGHER
RISK OF GOING TO A LOW QUALITY
HOSPITAL FOR EVEN THINGS LIKE
ELECTIVE SURGERIES, LIKE LUNG
CANCER.
SO FOR CERTAIN THINGS, THERE
MIGHT BE AN ELEMENT OF
INDIVIDUAL DISCRIMINATION.
IT MIGHT BE, FOR EXAMPLE, FOR
CBG, IF YOU'RE HAVING A BIG
HEART ATTACK AND IT'S MANY
VESSELS, MAYBE YOU NEED A CBG.
I HEAR IT IN THE HOSPITAL WHERE
THE MEDICS OR THE AMBULANCE
PROVIDERS WILL COME IN AND SAY,
WELL, YOU LOOK LIKE A GENERAL
PATIENT SO I BROUGHT HIM HERE
EVEN THOUGH HE WAS FARTHER AWAY
AND YOU WONDER WHAT DOES A
GENERAL PATIENT LOOK LIKE, AND
YOU KNOW THEY ALREADY HAVE IN
THEIR MINDS AN IDEA OF WHAT A
GENERAL PATIENT LOOKS LIKE, SF
GENERAL IS WHAT WE CALL OUR
HOSPITAL.
BUT THERE ARE OTHER THINGS
OUTSIDE OF THE SYSTEM TOO, SO IF
YOU LOOK AT LUNG CANCER
RESECTION, THIS IS PROBABLY NOT
SOME PATIENT WHO'S BEING BROUGHT
BY EMS FOR LUNG CANCER RESEC
SHUFNLT THIS
RESECTION.
IT'S LIKELY RELATED TO THEIR
ABILITY TO GET REFERRALS OR
THEIR PRIMARY CARE PHYSICIANS
ARE ASSOCIATED WITH HIGH QUALITY
HOSPITALS.
SO THIS IS AGAIN A ANOTHER
EXAMPLE OF HOW WE HAVE BAKED IN
STRUCTURAL INEQUITIES AND THAT
PATIENTS' SOCIAL NEEDS ARE
AFFECTED BY OUR ABILITY TO
MAINTAIN QUALITY CARE.
THIS IS MY LAST KIND OF SECTION
JUST ABOUT WHEN WE THINK ABOUT
STRUCTURAL DISCRIMINATION AND
SOCIAL NEEDS, THAT WHILE WE DO
WANT TO THINK ABOUT PROXIMITY
AND GEOGRAPHY, AND WE THINK,
WELL, LET'S JUST DISSEMINATE
TECHNOLOGY TO THESE PLACES SO
THAT THEY HAVE MORE PCI IN THESE
AREAS OR THAT WE HAVE BETTER --
YOU KNOW, THERE'S A LOT OF
STUDIES THAT SHOW THAT THERE ARE
ACTUALLY INEQUITIES IN THE WAY
WE DI DISSEMINATE TECHNOLOGY.
SO WE SEE THIS IN EMERGENCY
MEDICINE AS WELL.
THE QUESTION IS, DOES THE RISING
TIDE LIFT ALL BOATS?
SOME PEOPLE THINK IF THERE'S SEC
TECHNOLOGY, IT WILL HELP
EVERYBODY.
WE DON'T HAVE TO THINK ABOUT
DISSEMINATING IN A WAY THAT IT
HAS MORE FOCUS ON UNDERSERVED
AREAS BECAUSE EVERYONE WILL
BENEFIT.
THIS WAS A STUDY I DID THAT
LOOKS AT CARDIAC CARE
REGIONALIZATION, IF YOU HAVE A
HEART ATTACK YOU'RE USUALLY
BROUGHT TO THE NEAREST E.D.
NOW WE KNOW BECAUSE NOT ALL
E.D.s HAVE PCI OR PERCUTANEOUS
CORONARY INTERVENTION, THAT YOU
NEED TO GO TO THE NEAREST
HOSPITAL WHERE THEY HAVE PCI,
WHERE THEY CAN PUT A LINE IN
YOUR GROIN, GO UP TO YOUR HEART
AND OPEN UP THAT OBSTRUCTION.
SO THIS SAYS IN A CERTAIN EA WE
WILL MAKE AGREEMENTS THAT THE
ANNUAL SERVICE TAKES YOU TO THE
NEAREST PCI HOSPITAL, AND THAT
YOU WILL HAVE BETTER OUTCOMES.
SO WE'VE ACTUALLY LOOKED AT,
WELL, IS THAT TRUE, DID
REGIONALIZATION HELP ALL
COMMUNITIES THE SAME?
OR IS IT POSSIBLE THAT
REGIONALIZATION HELPED SOME
COMMUNITIES DIFFERENTLY?
I KNOW THE SLIDE IS HARD TO READ
SO I'LL JUST ZOOM IN ON ONE.
SO THIS PARTICULAR OUTCOME PANEL
B IS LOOKING AT THE RECEIPT OF
SAME-DAY PCI.
SO WHAT IS THE LIKELIHOOD OF
RECEIVING PERCUTANEOUS CORE CORONARY
INTERVENTION IF YOU HAD A HEART
ATTACK AND IS THAT DIFFERENT IF
YOU LIVED IN DIFFERENT
COMMUNITIES AND IF YOU WERE
DIFFERENTLY WHITE OR BLACK?
SO HERE'S WHAT WE FIND, WHICH I
FIND VERY SOBERING.
SO YOU HAD A MUCH HIGHER
LIKELIHOOD THAT TO RECEIVE
SAME-DAY PCI BASED ON
REGIONALIZATION'S EFFECT, IF
YOU'RE A WHITE RESIDENT IN A
NON-MINORITY COMMUNITY THAN IF
YOU WERE AT THE -- NO EFFECT AT
ALL IF YOU WERE A BLACK OR
HISPANIC RESIDENT IN A MINORITY
COMMUNITY.
SO WHAT THIS IS SHOWING TO US IS
THAT REGIONALIZATION, EVEN WHEN
WE HAVE TECHNOLOGY, IT'S NOT
DISSEMINATED IN THE SAME WAY,
AND PEOPLE DON'T HAVE THE
SAME -- WELL, WHAT I SHOULD SAY
IS, NOT THAT IT'S NOT
DISSEMINATED IN THE SAME WAY,
BUT BECAUSE WE HAVE THESE
UNDERLYING STRUCTURES OF HOW THE
PROVISION OF THE EMERGENCY
SERVICES IS ALREADY INEQUITABLE,
THAT MEANS WHEN YOU DISTRIBUTE
TECHNOLOGY, IT CONTINUES TO BE
INEQUITABLE BECAUSE THE BASELINE
STRUCTURE IS ALREADY DESIGNED
THAT WAY.
SO THAT'S WHY WE SEE THAT
ACTUALLY BLACK RESIDENTS IN
MINORITY COMMUNITIES, BLACK OR
HISPANIC RESIDENTS IN MINORITY
COMMUNITIES RECEIVE NO BENEFIT
FROM REGIONALIZATION, AND THAT'S
LIKELY BECAUSE THEY DIDN'T HAVE
A LOT OF THOSE SERVICES IN THE
BEGINNING AND I THINK THIS IS
VERY SOBERING.
WHEN WE LOOKED AT OUTCOMES TOO,
I'LL JUST SHOW YOU THIS SLIDE,
SAME THING WITH MORTALITY.
WHO BENEFITED FROM
REGIONALIZATION?
IT WAS WHITE RESIDENTS IN
NON-MINORITY COMMUNITIES, BUT
ALL OTHER RESIDENTS, WHETHER
THEY WERE BLACK OR HISPANIC,
WHETHER THEY WERE IN
NON-MINORITY COMMUNITIES OR
MINORITY COMMUNITIES, ONLY WHITE
RESIDENTS IN NON-MINORITY
COMMUNITIES HAD IMPROVED
MORTALITY.
STRATIFYING OUR ANALYSES TO LOOK
TO SEE WHO HAS BENEFITED IS
REALLY IMPORTANT, BECAUSE IF YOU
AVERAGE THEM ALL TOGETHER, THEN
YOU'LL THINK MAYBE THERE'S A
BENEFIT FOR EVERYBODY, BUT
ACTUALLY WHEN YOU SEPARATE THEM
OUT, THERE ARE DIFFERENT
POPULATIONS THAT ARE RECEIVING
BENEFIT AND THAT'S A
DIFFERENTIAL BENEFIT THAN
OTHERS.
SOME MAY RECEIVE A LOT, SOME MAY
RECEIVE NONE, WHEN WE AVERAGE
THEM OUT IT'S OKAY BUT IT'S
ACTUALLY A REALLY DIFFERENT
EXPERIENCE FOR PATIENTS ON
GROUND.
SO I THINK THIS IS JUST A WAY TO
CAPTURE, PEOPLE TEND TO THINK A
RISING TIDE LIFTS ALL BOATS.
IT'S GREAT NEWS IF YOU OWN A
BOAT, BUT IT'S NOT TRUE, WHAT WE
FOUND IN RESEARCH IS A RISING
TIDE DOES NOT LIFT ALL BOATS.
SO THIS IS JUST AN ENCOURAGEMENT
FOR US TO THINK ABOUT HOW EVEN A
WELL-INTENTIONED IMPLEMENTATION
OF REFORM ON A SICK SYSTEM CAN
LEAD TO GREATER GAPS IN HEALTH
OUTCOMES BETWEEN ADVANTAGED AND
DISADVANTAGED COMMUNITIES.
WHEN WE THINK ABOUT KIND OF
PEOPLE'S SOCIAL NEEDS, WHEN WE
THINK ABOUT PEOPLE'S PEOPLE'S SOCIAL
NEEDS THAT IT'S ALREADY WITHIN A
SICK SYSTEM, WE HAVE TO EXTEND
OUR -- WHETHER IT'S OUR
PROTOCOLS OR THE WAY WE THINK
ABOUT INTEGRATING THEM IN
TRANSITIONINGS OF CARE OR
HOUSING, THAT THEY ALREADY HAVE
THESE BARRIERS.
I WANT TO ENCOURAGE THE
RESEARCHERS OUT THERE, THIS IS A
STUDY THAT I FOUND THAT SAID,
IT'S A STUDY OF STUDIES, SO IT'S
A STUDY THAT SAYS THEY LOOKED AT
THE 50 HIGHEST IMPACT JOURNALS
IN SIX CATEGORIES REPRESENTING
THE PUBLIC HEALTH FIELD IN THE
U.S.
THE ENTIRE 14-YEAR PERIOD OF
2002 TO 2015 INCLUSIVE, THERE
WERE ONLY 25 ARTICLES THAT NAMED
INSTITUTIONAL RACISM IN THE
TITLE OR THE ABSTRACT.
SO I THINK IT'S IMPORTANT FOR US
TO THINK ABOUT THAT BECAUSE WE
NEED TO START INCORPORATING THIS
IN THE WAY THAT WE STUDY
INTERVENTIONS OR IN THE WAY WE
STUDY ACCESS TO CARE.
THIS IS JUST A SCREEN SHOT OF
KIND OF WHAT THEY FOUND, BUT
THIS IS VERY, VERY FEW, AND
YOU'LL FIND THAT SOME OF THEM
WERE JUST COMMENTARIES, THERE
WERE A FEW ORIGINAL RESEARCH
PIECES, A COUPLE LITERATURE VIEW
BUT NOT VERY MUCH.
SO WHEN WE THINK ABOUT NEXT
STEPS, I'M EXCITED TO KIND OF
THINK ABOUT ALL THE WAYS THAT I
HOPE THAT PEOPLE PARTICIPATING
IN THIS CONFERENCE, IN THIS
ROUNDTABLE L BENEFIT FROM
HEARING FROM THE SPEAKERS WHO
ARE TALKING ABOUT THINGS RANGING
FROM HOUSING AND THINKING ABOUT
SOCIAL SERVICES, THINKING ABOUT
DATA AND HOW WE KIND OF ATTACK
THIS PROBLEM OF SOCIAL NEEDS IN
THE EMERGENCY DEPARTMENT.
SO I'LL JUST STOP THERE SINCE MY
45 MINUTE RINGER WENT OFF, AND
I'M HAPPY TO TAKE QUESTIONS OR
WE CAN HAVE OTHER CONVERSATIONS.
THANK YOU VERY MUCH.
>> THANK YOU SO MUCH, DR. HSIA,
FOR YOUR VERY THOUGHTFUL
PRESENTATION.
NOW WE HAVE ABOUT 30 MINUTES FOR
DISCUSSION.
SO I WOULD REALLY LIKE TO
WELCOME EVERYONE WHO'S ATTENDING
TO USE THE RAISE HAND FUNCTION.
THAT'S LOCATED ON THE BOTTOM OF
YOUR SCREEN IN THE SECTION
CALLED REACTIONS NEAR THE LITTLE
SMILING FACE IMAGE IF YOU WOULD
LIKE TO ASK A QUESTION OR OFFER
A COMMENT, WE WILL CALL ON YOU
AND OUR TECHNOLOGY GEU GURUS GURUS ARE
GOING TO ENSURE PEOPLE ARE
UNMUTED AND ABLE TO PARTICIPATE
IN THE DISCUSSION.
SO WE'RE NOT GOING TO PUT
QUESTIONS IN THE CHAT AT THIS
POINT, SO PLEASE, I WOULD
ENCOURAGE YOU TO RAISE YOUR HAND
IF YOU HAVE A QUESTION.
I SEE MARY BETH, WOULD YOU LIKE
TO UNMUTE AND GO AHEAD?
>> THANK YOU.
FASCINATING PRESENTATION, THANK
YOU VERY MUCH.
ONE OF THE QUESTIONS I GUESS I
WAS THINKING ABOUT IN TERMS OF
STRUCTURAL DEFICITS DOES HAVE TO
DO WITH, YOU KNOW, HOW PCP
APPOINTMENTS ARE 9:00 TO 5:00.
SO I'M WONDERING ABOUT THE
ADVERSE IMPACT OF THAT STRUCTURE
WE HAVE FOR PRIMARY CARE BEING
9:00 TO 5:00 THAT ACTUALLY FEEDS
INTO THEN THE STRUCTURAL
INEQUITIES FOR PEOPLE HAVING TO
GO TO E.D.s, IF YOU'VE STUDIED
THAT OR THOUGHTS.
>> CAN YOU REPEAT THE QUESTION
AGAIN, THE PRECISE QUESTION?
>> SO THE QUESTION REALLY HAS TO
DO, HAS THERE BEEN MUCH RESEARCH
DONE LOOKING AT THE STRUCTURAL
INEQUITIES ASSOCIATED WITH HOW
PRIMARY CARE IS PROVIDED?
IT'S A 9:00 TO 5:00 MODEL, AND
HOW DOES THAT IMPACT OUR E.D.
USAGE AND/OR INEQUITIES?
>> YES.
SORRY, TOOK ME A LITTLE WHILE TO
KIND OF GET IN GEAR ABOUT THAT,
BUT I THINK THAT'S A GREAT
QUESTION.
I THINK THERE ARE A FEW STUDIES
I CAN CALL THAT LOOK AT
AVAILABILITY OF PRIMARY CARE,
AND ALSO NOT ALL PRIMARY CARE IS
THE SAME.
SO THERE ARE PRIMARY CARE
SERVICES THAT THEY CALL YOU
BACK, THEY'VE GOT AFTER HOUR
SERVICES, AND I THINK -- I DON'T
KNOW IF THERE'S A PARTICULAR
STUDY, BUT I WOULD BET THAT
THERE ARE MORE KIND OF ADVICE
NURSES IF YOU LOOK BASED ON
INCOME, BECAUSE THOSE ARE
PATIENTS WHO HAVE RESOURCES AND
HAVE GOOD CHOICE ARE GOING TO DO
THAT AND THAT'S GOING TO DO
MARKET PRESSURE FOR PRIMARY CARE
PROVIDER RS TO DO THAT.
THAT'S A LARGE REASON PEOPLE
COME.
>> THANK YOU.
>> OTHER FOLKS WITH QUESTIONS?
DON'T BE SHY.
IT'S A SMALL ZOOM.
OH, CARLY, GO AHEAD.
>> HELLO, YES.
SO MY QUESTION, I'M REPRESENTING
THE HISPANIC NURSES ASSOCIATION,
IS THE HAT I HAVE ON TODAY, AND
HAVE YOU NOTICED ANY --
ESPECIALLY WITH YOUR POPULATION
IN TEXAS, LOOKING AT DIFFERENT
AREA, TALKING ABOUT ACCESS TO
CARE FOR UNDOCUMENTED
INDIVIDUALS OR MY GRANT
POPULATIONS FOR PRIMARY CARE USE
OF THE E.R., SINCE THE LAW KIND
OF PROTECTS THAT, CAN YOU SPEAK
TO THAT A LITTLE BIT AND MAYBE
SOME INEQUITIES WE'RE FACING IN
TERMS OF THAT POPULATION?
>> MY COLLEAGUE DOES A LOT OF
WORK ON UNDOCUMENTED MIGRANTS
AND THEIR UNWILLINGNESS TO COME
TO THE E.D.
THREA MUCH MORE YEN RUSS
COVERAGE IN CALIFORNIA, BUT
THERE'S STILL THE SAME FEARS
THAT COMMUNITIES HAVE S BUT
MAYBE LESS ALSO EVEN WITHIN
DIFFERENT CITIES AND IN
CALIFORNIA, SAN FRANCISCO IS
REALLY DIFFERENT FROM OTHER
PLACES, SO I THINK THEY
DEFINITELY MAY NOT BE AS WILLING
TO -- I THINK THAT'S PART OF
WHAT'S DIFFICULT IN THINKING
ABOUT SOCIAL NEEDS, THERE'S
GOING TO BE A TALK TOMORROW
ABOUT DO PATIENTS WANT THEIR
NEEDS CARED FOR?
I THINK ANOTHER QUESTION IS
WHETHER THEY FEEL COMFORTABLE
ENOUGH TO EVEN SHARE THOSE OR
DISCLOSE THOSE, BECAUSE THEY MAY
NOT KNOW THAT THERE'S NO
RELATIONSHIP WITH THEIR
REGISTRATION HERE AND
REGISTRATION WITH THE
GOVERNMENT, ESPECIALLY IF IT'S A
GOVERNMENT HOSPITAL, RIGHT?
THESE PUBLIC HOSPITALS THAT TEND
TO SERVE A HIGH PROPORTION OF
THESE IMMIGRANTS, THEY'RE
PUBLIC.
SO THERE'S A LOT OF, I THINK,
FEAR AND WHILE WE MAY SAY THAT'S
UNJUSTIFIED FEAR BECAUSE WE
NEVER REPORT IT, BUT WHO KNOWS?
I THINK THAT'S A REALLY GOOD
POINT.
>> THANK YOU.
HOW ABOUT NATALIE?
>> THANK YOU SO MUCH FOR YOUR
EYE-OPENING PRESENTATION.
IT WAS ABSOLUTELY OUTSTANDING.
I WANTED TO HEAR FROM YOU A
LITTLE BIT ABOUT THE RESEARCH
CHALLENGES THAT YOU'VE
ENCOUNTERED, AND TO HEAR ALSO
ABOUT WHAT'S NEXT FOR YOU IN
TERMS OF YOUR RESEARCH
TRAJECTORY, IF YOU WOULDN'T MIND
SHARING THAT.
THANK YOU.
>> I THINK ONE OF THE THINGS
THAT I'VE BEEN INTERESTED IN
DOING IS WHEN THAT STUDY CAME
OUT IN 2011 ACTUALLY, IT WAS
SHOWING THAT HOSPITALS -- THAT
E.D.s TENDED TO CLOSE MORE
OFTEN IN POOR AREAS, AND THE
REPORTER SAID, OH, YOU KNOW, DR. HSIA, THA T'S UNFORTUNATE
THAT PATIENTS IN POOR AREAS ARE
MORE LIKELY TO LOSE THEIR
SERVICES, BUT HOW DOES THIS
AFFECT -- SERVICES?
I DON'T FAULT THAT QUESTION AT
ALL BUT I THINK SHE WANTS TO
WRITE A REPORT HER READERS WILL
CARE ABOUT.
SO I THINK THAT'S A COMMON
RESPONSE PEOPLE HAVE, IS THIS
IDEA THAT, WELL, THE POOR WILL
ALWAYS BE WITH YOU, THAT'S JUST
TOO BAD, THAT'S THE UNITED
STATES.
BUT WHAT I WANT TO LOOK AT MORE
AND WHAT I WOULD ENCOURAGE
PEOPLE WHO ARE INTERESTED IN
THESE AREAS IS TO SHOW HOW WE
ARE ALL DEPENDENT ON HEALTHCARE
SERVICES AND THAT IF YOU ARE IN
AN AREA WITH TOO MUCH, IT IS
VERY, VERY POSSIBLE THAT YOUR
OUTCOMES COULD BE WORSE BECAUSE
I'LL JUST GIVE YOU ONE EXAM, SO
PC I, IF YOU ARE AN
INTERVENTIONAL CARDIOLOGIST, YOU
ARE SUPPOSED TO HAVE A CERTAIN
NUMBER OF MINIMUM PROCEDURES PER
YEAR TO STAY CERTIFIED.
BUT WHEN YOU'VE GOT ALL THESE
HOSPITALS POPPING UP PCI CENTERS
AROUND YOU, YOU SHOULD HAVE A
FIXED VOLUME OF PCI IN A CERTAIN
EA YOU AREN'T CREATING OR
INDUCING HEART ATTACKS BY
PUTTING A HOSPITAL THERE.
BUT WHAT WE FIND IS BECAUSE YOU
HAVE MORE CARDIOLOGISTS AND MORE
HOSPITALS OFFERING THIS, YOUR
PER-INDIVIDUAL CARDIOLOGIST
NUMBER WILL DROP.
SO WHAT ACTUALLY ENDS UP
HAPPENING IS THEY START DOING
DISCRETIONARY PROCEDURES,
PROCEDURES THAT MAY NOT BE AS
BENEFICIAL BECAUSE THEY NEED TO
KEEP THEIR NUMBERS UP.
THESE ARE REAL MOTIVATIONS AND
REAL INCENTIVES THAT ARE OUT
THERE AND REAL PRESSURES.
SO THERE'S ACTUALLY A STUDY THAT
I'M IN THE MIDDLE OF WRITING UP
THAT SHOWS ACTUALLY THERE ARE
THE HIGHER NUMBER AS YOU HAVE
THE INTRODUCTION OF PCI SERVICES
IN THESE ALREADY SATURATED AREAS
THAT ARE PROPORTION OF PCI THAT
IS DONE FOR STABLE CORONARY
ARTERY DISEASE INCREASES.
AND YOU SHOULD REALLY NEVER HAVE
A PCI DONE FOR STABLE CORONARY
ARTERIES.
SO THAT'S JUST ONE EXAMPLE OF
KIND OF THE DIRECTION THAT I'M
WORKING IN, KIND OF JUST SHOWING
HOW CAN WE GET PEOPLE TO CARE
ABOUT THIS?
BECAUSE I THINK IT'S A LOT ABOUT
PEOPLE'S POLITICAL WILL, LIKE IF
THERE'S NOT POLITICAL WILL TO
MAKE THESE CHANGES, IT WILL
NEVER HAPPEN, SO HOW DO WE
PROVIDE EVIDENCE THAT GETS
PEOPLE TO SEE WHAT'S HAPPENING?
>> THAT'S VERY IMPORTANT.
REBEKAH.
>> I WANTED TO ASK YOU ABOUT
SOMETHING A LITTLE BIT OUTSIDE
OF THE NARROW CONFINES OF YOUR
RESEARCH, OR THE BROAD CONFINES
OF YOUR RESEARCH.
WHICH IS, HOW DO YOU THINK ABOUT
A LOT OF THE CLINICAL RESEARCH
THAT YOUR COLLEAGUES DO?
AND IN TERMS OF WHETHER WHAT
YOU'RE POINTING TO IN TERMS OF
TECHNOLOGY ACCESS, RESOURCE
ACCESS, IS THAT THE RESOURCE
ENTERPRISE ITSELF IS FOCUSING ON
A NARROW SECTOR OF THE
POPULATION TO DEVELOP IMPROVED
TREATMENTS THAT ARE AIMED AT
THAT NARROW SECTOR, AND IF
THERE'S A CERTAIN PAROCHIALISM
TO IT.
>> YEAH, I THINK -- I MEAN, I
THINK THERE'S IMPORTANT RESEARCH
BEING DONE IN MANY SPHERES, SO
IT'S HARD FOR ME TO COMMENT
SPECIFICALLY BECAUSE I DON'T --
I'M NOT AN EXPERT IN THEM AND
I'M NOT DESIGNING THOSE STUDIES.
I THINK I DO ENCOURAGE PEOPLE TO
THINK ABOUT -- I MEAN, I THINK
THAT'S WHY I CARE ABOUT WHAT I
DO, IS BECAUSE I THINK IT'S
IMPORTANT, NOT THAT IT'S NOT
IMPORTANT FOR OTHER PEOPLE,
THAT'S NOT MY PASSION, BUT I DO
WANT TO ENCOURAGE PEOPLE EVEN
LOOKING AT CLINICAL
INTERVENTIONS TO THINK ABOUT THE
BIGGER PICTURE OF WHEN WE
DISSEMINATE THESE, HOW CAN WE
DESEMI NATE THEM IN A WAY THAT
REALLY DOES DECREASE GAPS?
AS I SAID EARLIER, ACTUALLY,
IN -- IT IS POSSIBLE THAT IF YOU
JUST LOOKED AT THE GAP, WE
ACTUALLY KNOW THE GAP IS
INCREASING OVER TIME FOR MANY
CONDITIONS, BUT IN SOME AREAS,
FOR EXAMPLE, IF YOU LOOK AT PCI
AND YOU HAVE REDUNDANT SERVICES
IN REALLY RICH AREA, YOUR
OUTCOMES COULD BE WORSE IN THE
RICH AREAS BECAUSE YOU'RE GET
INAPPROPRIATE PROCEDURES SO IN
THAT SENSE, YOUR GAP IS
DECREASING NOT BECAUSE
UNDERSERVED PATIENTS ARE GETTING
BETTER TREATMENT BUT IT'S
BECAUSE OVERSERVED PATIENTS ARE
GETTING WORSE TREATMENT.
SO I THINK IT'S JUST IMPORTANT
TO HAVE THE MINDSET OF LET'S
LOOK AT THESE POPULATIONS AND
SEPARATE THEM OUT SO WE DON'T
AVERAGE OUT WHAT IS ACTUALLY
HAPPENING.
AND WE MISS THAT.
>> THANK YOU.
>> FANTASTIC.
IT'S REALLY IMPORTANT AND I HAVE
REALLY IMPORTANT STRATEGY FOR US
AS RESEARCHERS TO THINK ABOUT
INCORPORATING INTO OUR OWN WORK
FOR SURE.
OTHER THOUGHTS OR COMMENTS FROM
THE GROUP?
PEOPLE ARE QUIET.
ALL RIGHT.
I HAVE A COUPLE OF JUST
THOUGHTS/COMMENTS TO OFFER, BUT
THEN A QUESTION FOR YOU AS WELL.
ONE THING I WANTED TO SHARE WITH
THE GROUP IS THAT DR. HSIA HAD
MENTIONED SORT OF THIS DEARTH OF
ARTICLES PUBLISHED IN JOURNALS
THAT DIRECTLY CALL OUT
STRUCTURAL OR INSTITUTIONAL
RACISM IN THE TITLE OR THE
ABSTRACT.
SO IN A MUCH LESS RIGOROUS WAY,
THE PAPER THAT WAS PUBLISHED, I
TOOK A QUICK LOOK AT THE
LITERATURE THAT'S SPECIFIC TO
EMERGENCY NURSING, A COHORT OF
EMERGENCY NURSING FOCUSED
JOURNAL AND VERY UNFORTUNATELY,
THE SAME THING SEEMS TO HOLD
TREUL IN OUR OWN JOURNAL, SO I
QUICKLY SEARCHED THIS AFTERNOON
THE JOURNAL OF NJ EMERGENCY
NURSING, ACCIDENT AND EMERGENCY
NURSING, AND THE INTERNATIONAL
JOURNAL OF TRAUMA NURSING AND I
ONLY IDENTIFIED IN MY QUICK
PERUSE ONE PAPER THAT
SPECIFICALLY MENTIONED
STRUCTURAL OR INSTITUTIONAL
RACISM.
SO FOLKS ON THE CALL, AS A
COLLECTIVE, WE HAVE WORK TO DO
IN THIS VERY IMPORTANT SPACE AND
WE HAVE UNIQUE PERSPECTIVE.
I THINK THIS IS VERY MUCH SORT
OF IN OUR WHEELHOUSE AND ISSUES
THAT WE SHOULD CARE ABOUT, SO
I'D ENCOURAGE PEOPLE TO REALLY
THINK ABOUT WAYS THAT YOU CAN
INCORPORATE THESE KINDS OF
QUESTIONS INTO YOUR OWN
PORTFOLIO OF RESEARCH.
THE SECOND THING I WOULD LIKE TO
OFFER TO THE GROUP IS THAT SO IN
2008, DR. STANLEY WILLIS, PAM
GREYSON -- PUBLISHED A PAPER ON
THE CENTRAL UNIFYING FOCUS FOR
THE DISCIPLINE OF NURSING.
SO THEY PROPOSED THAT THE
CENTRAL UNIFYING FOCUS, THE CORE
OF THE DISCIPLINE OF NURSING FOR
ALL NURSES, IS FACILITATING
HUMANIZATION, MEANING, CHOICE,
QUALITY OF LIFE, AND HEALING AND
LIVING AND DYING.
SO I WOULD OFFER TO EACH OF YOU
HERE TODAY THAT WORKING TOWARDS
HEALTH EQUITY IS ABSOLUTELY
FOUNDATION
FOUNDATIONAL FOR US AS A
DISCIPLINE, IN TERMS OF BEING
ABLE TO ACHIEVE THAT CENTRAL
UNIFYING FOCUS.
THIS IS ONE OF MY FAVORITE
PAPERS EVER PUBLISHED, SO I LOVE
TO TALK ABOUT IT AND GET OTHER
PEOPLE TO READ IT.
WE CANNOT HELP OUR PATIENTS AND
COMMUNITIES TRULY FLOURISH AND
ACHIEVE THESE GOALS WITHOUT
HEALTH EQUITY, AND THAT MEANS
DISMANTLING STRUCTURAL AND
INSTITUTIONALIZED RACISM, RIGHT?
IT'S BAKED INTO THE SYSTEM THAT
WE HAVE, AS YOU SAID, SO THIS IS
VERY MUCH IN OUR LANE AS NURSES
AND EMERGENCY NURSES, AND WE
SHOULD REALLY, AGAIN, BE
THINKING ABOUT WAYS THAT WE CAN
INCORPORATE THIS INTO ALL THAT
WE'RE DOING.
SO FINALLY MY QUESTION FOR YOU.
SO I WOULD LIKE TO ASK YOU ABOUT
SOME OF THE WAYS THAT WE MIGHT
THINK ABOUT ACHIEVING A MORE
EQUITABLE HEALTH SYSTEM.
SO IN YOUR WORK, YOU AND YOUR
COLLEAGUES HAVE DONE SO MUCH TO
HELP US PINPOINT WHERE THESE IP
EQUITIES LIE AND THE STRUCTURAL
REASONS BENEATH THEM.
IN HIS BOOK HOW TO BE AN
ANTI-RACIST, DR. IBRIM KENNEDY
SHARES THAT RACE ILL POLICIES
AND RACIST IDEAS REALLY COMBINE
TO PRODUCE AND NORMALIZE THESE
RACIAL INEQUITIES.
HE GOES ON TO SAY THAT ALL
POLICIES ARE EITHER RACIST OR
ANTIRAY CYST, THAT THERE'S NO
SUCH THING AS A NEUTRAL POLICY.
THESE ARE HIS FABULOUS IDEAS.
SO RACIST POLICIES PRODUCE OR
SUSTAIN THESE INEQUITIES BETWEEN
RACIAL GROUPS AND ANTI-RACIST
POLICIES ARE ACTIVELY WORKING TO
PRODUCE AND SUSTAIN RACIAL
EQUITY.
SO I'M WONDERING IF YOU HAVE
IDEAS ABOUT THAT, AND HOW WE CAN
BEGIN TO MOVE BEYOND THE
INEQUITIES THAT YOU DESCRIBED
AND SO ELOQUENTLY UNCOVERED FOR
US TO A MORE EQUITABLE STATE
THROUGH STRATEGIC ANTI-RACIST
POLICY MAKING, PARTICULARLY AS
IT APPLIES TO EMERGENCY CARE.
>> THANKS FOR THAT QUESTION.
I THINK IT'S REALLY IMPORTANT TO
THINK ABOUT HOW -- ONE OF THE
THINGS I REALLY THINK WE CAN
FOCUS ON IS JUST HOW IF WE HAVE
THIS UNDERLYING INEQUITABLE
SYSTEM, ANYTHING THAT GOES
THROUGH THAT WILL END UP HAVING
INEQUITABLE OUTCOMES.
I THINK THAT'S WHAT DR. KENDY IS
SAYING IN HIS BOOK, AND I MEAN,
THERE'S OTHER LAYERS TO TALK
ABOUT THAT, BUT HE'LL BRING UP
THE EXAMPLE OF LIKE FOR EXAMPLE
IF THERE'S TAX ADVANTAGES FOR
MARRIED VERSUS UNMARRIED
FACILITIES, THESE ARE RACIST
POLICIES.
I MEAN, I DON'T KNOW IF I WOULD
ACTUALLY GO THAT FAR.
I THINK THEY END UP HAVING
RACIST OUTCOMES BUT I DON'T KNOW
WHETHER A TAX BASIS IS
NECESSARILY A RACIST POLICY, BUT
IT MIGHT JUST BE BECAUSE OF THE
UNDERLYING STRUCTURE.
REGARDLESS OF THOSE KIND OF
SEMANTICS, I THINK ONE OF THE
THINGS WE CAN THINK ABOUT OF AS
A SPECIALTY, IS THAT WE DON'T
GIVE UP HOPE ON HAVING THAT MORE
FUNDAMENTAL REFORM.
I THINK A LOT OF TIMES WE ARE
USED TO, IN THE E.D., EVERYONE
KIND OF JUST -- EVERYONE EXPECTS
THE E.D. TO PICK UP THE PIECES.
NOW WE PROVIDE HOUSING FOR
PEOPLE.
WE PROVIDE HOUSING, FOOD,
SHELTER, AND WE'VE GOT TO DIRECT
THEM TO THESE THINGS.
WE'RE USED TO THAT AND WE'RE
GOOD AT THAT, BUT I DON'T THINK
THAT WE SHOULD GIVE UP HOPE, AND
ALSO STOP WORKING IN THE AREAS
OF GETTING PEOPLE TO UNDERSTAND
THAT THE FUNDAMENTAL ISSUES OF
THE WAY WE PAY FOR AND DESIGN
FOR CARE, THE WAY WE FINANCE
CARE AND DELIVER CARE IS
STRUCTURED IN SUCH A WAY THAT
EMPLOYER-BASED HEALTHCARE IS A
GOOD EXAMPLE OF HOW THAT IS --
WHAT DR. KENNEDY WOULD PROBABLY
SAY IS A RACIST POLICY, WHICH I
WOULD AGREE WITH, BECAUSE
EMPLOYMENT WAS VERY RACIST AND
SO EMPLOYER-BASED INSURANCE IS
RACIST, RIGHT?
SO THAT'S AN EXAMPLE OF
SOMETHING THAT STRUCTURALLY
NEEDS TO BE REFORMED AND IS
REALLY DIFFICULT TO REFORM.
I THINK IN THE UNITED STATES,
MAYBE SINGLE PAIR IS POLITICALLY
FEASIBLE BUT THERE ARE OTHER
THINGS THAT MAY BE.
A PUBLIC OPTION VERY BRIEFLY IS
JUST SAYING WELL, WE CAN'T GET
EVERYONE ON THE SAME PLAN, BUT
PEOPLE CAN START OPTING --
ANYONE WHO IS IN CALIFORNIA CAN
OPT TO BE PART OF THIS PLAN AND
THAT THIS PLAN WILL START HAVING
POWER TO NEGOTIATE, BECAUSE IF
YOU'RE INTO THESE THOUSANDS OF
SMALL HEALTH PLANS THAT DON'T
HAVE POWER, THEN YOU'RE NOT
GOING TO BE ABLE TO GET MUCH
NEGOTIATING LEVERAGE.
SO I THINK THERE ARE WAYS THAT
WE SHOULD ENCOURAGE OURSELVES TO
NOT GIVE UP HOPE, BECAUSE WE
REALLY -- ALL THE INTERVENTIONS
THAT WE CAN DO WILL NOT REALLY
HAVE MUCH EFFECT IF THE
FUNDAMENTAL STRUCTURE OF OUR
HEALTHCARE SYSTEM STAYS AS IT
IS.
>> GREAT.
ARE THERE OTHER AREAS THAT YOU
CAN SEE AS CLEAR GAPS WHERE WE
SHOULD BE WORKING?
>> I THINK THERE ARE
INTERVENTIONS NOW THAT WHEN WE
THINK ABOUT EVEN JUST THE TYPES
OF WORK THAT WE DO THAT TEND TO
BE FOCUSED ON POPULATIONS AS
OPPOSED TO CONSIDERING THE WHOLE
CONTEXT OF WHERE THEY LIVE IN
TERMS OF THEIR ACCESS TO
RESOURCES, WHETHER IT'S THINGS
LIKE FOOD DESERTS, WHEN WE SAY
FOOD DESERTS, WE MEAN ACCESS TO
HEALTHY FOOD AND SCARCITY OF
FRESH VEGETABLES.
WE DON'T TEND TO NECESSARILY
CONNECT THEM WITH EMERGENCY
DEPARTMENTS BECAUSE WE TEND TO
THINK OF THOSE AS LIKE
PREVENTABLE HEALTHCARE,
HYPERTENSION, YOU KNOW, PRIMARY
CARE AND THAT'S KIND OF ON THE
OTHER END.
BUT THESE THINGS ARE ALL
CONNECTED SO HOW CAN WE START
THINKING ABOUT -- YOU KNOW,
THERE ARE OTHER METRICS THAT ARE
AVAILABLE THAT HAVE BEEN IN THE
LITERATURE FOR 20 YEARS, THINGS
LIKE THE AREA DEPRIVATION INDEX,
OTHER INDICES OF SEGREGATION.
HOW DO WE PUT THIS TOGETHER IN A
WAY THAT IS UNDERSTANDABLE AND
PALATABLE AND DIGESTIBLE FOR
POLICY MAKERS TO TAKE ACTION.
I THINK ONE OF THE THINGS IS AS
RESEARCHERS, A LOT OF TIMES WE
PUBLISH THINGS IN A JOURNAL THAT
NOBODY READS, SO HOW DO WE
ENGAGE MORE WITH THE MEDIA SO
THE PUBLIC AND POLICY MAKERS CAN
LEARN ABOUT IT AND MAKE CHANGE.
>> YEAH, THAT'S A REALLY GREAT
POINT.
THAT ES SO THERE'S SO MUCH GREAT WORK
AND IT DOES FEEL LIKE IT'S
FALLING ON DEAF EARS.
IT'S NOT GETTING OUT THERE IN A
WAY THAT THE SOCIAL MEDIA DOES.
VERY GOOD.
THANK YOU SO MUCH.
SO IF THERE ARE NO OTHER
QUESTIONS, DOES ANYBODY HAVE ANY
LAST QUESTIONS FOR DR. HSIA?
ALL RIGHT.
PEOPLE ARE QUIET AND IT'S
GETTING LATE.
SO THANK YOU VERY MUCH FOR
SHARING YOUR IMPORTANT WORK AND
YOUR ILLUMINATING REMARKS WITH
OUR GROUP.
WE VERY MUCH APPRECIATE YOUR
WILLINGNESS TO JOIN US HERE
TODAY, AND WE'RE VERY THANKFUL
ALSO TO OUR ATTENDEES TO SHARING
THEIR QUESTIONS AND ENGAGING IN
THIS IMPORTANT DISCUSSION.
I AM REALLY LOOKING FORWARD TO
CONTINUING THIS DIALOGUE WITH
YOU ALL TOMORROW, AND I WOULD
LIKE TO INVITE DR. ZENK TO OFFER
A FEW REMARKS BEFORE WE CLOSE
OUT FOR THE EVENING.
>> ABSOLUTELY.
THANK YOU, DR. STROUT, AND THANK
YOU SO MUCH, DR. HSIA.
REALLY ENJOYED YOUR KEYNOTE,
REALLY SET THE STAGE FOR OUR
CONVERSATIONS TOMORROW, SO THANK
YOU.
AND DR. STROUT, OF COURSE THANK
YOU FOR MODERATING OUR Q & A AND
FOR YOUR COMMENTS.
REALLY INSIGHTFUL.
SO I AGREE, I SEE SOMEONE IN THE
CHAT, WONDERFUL PRESENTATION, I
COULDN'T AGREE MORE.
SO WE'RE GOING TO WRAP UP FOR
THE EVENING.
BEFORE I DO THAT, I'M JUST GOING
TO GIVE A COUPLE COMMENTS ABOUT
WHAT WE'LL BE DOING TOMORROW.
SO TOMORROW, WE OPEN EVERYONE
WILL BE ABLE TO JOIN US.
WE'LL START AT 11:00 A.M.
EASTERN TIME WITH OPENING
REMARKS FROM DR. STROUT.
I'LL THEN SHARE AN UPDATE FROM
NINR AND OUR ACTIVITIES, AND
THEN WE'LL HEAR FROM OUR
COLLEAGUES ACROSS THE RESEARCH
SPECTRUM, INCLUDING THOSE
SPECIALIZING IN FAMILY AND
COMMUNITY MEDICINE, PUBLIC
HEALTH, HEALTH POLICY, AND
EMERGENCY MEDICINE.
OUR PRESENTERS WILL SHARE THEIR
OWN PROGRAMS OF RESEARCH AS WELL
AS PARTICIPATE IN A PANEL
DISCUSSION TO SYNTHESIZE FINDING
ACROSS THESE MANY FIELDS.
SO I AM REALLY CONFIDENT THAT
THE ROUNDTABLE AS WE DRAW TO A
CLOSE TOMORROW, THAT WE'LL HAVE
MANY NEW CONVERSATIONS AND
HOPEFULLY EVEN SOME FORMING NEW
COLLABORATIONS AND PARTNERSHIPS
IN THESE AREAS.
SO AGAIN, SO APPRECIATE EVERYONE
JOINING TONIGHT, AND I LOOK
FORWARD TO SEEING EVERYONE
TOMORROW MORNING.
THANKS AGAIN, DR. HSAI
GOODNIGHT, EVERYONE.