>>THANK YOU,
FOR JOINING US FOR NIH HEALTH
DISPARITIES AND OSTEOARTHRITIS
WORKSHOP. I'M CHRISTY NIX. BONE
BIOLOGY, METABOLIC BONE
DISORDERS AND OSTEOPOROSIS
PROGRAM DIRECTOR AT NIAMS. WE
PLANNED THE NEXT TWO DAYS AN
INTERESTING AND INFORMATIVE
AGENDA. VISIT THE WORKSHOP
WEBSITE TO FIND RELEVANT
INFORMATION INCLUDING THE
PARTICIPANT LIST AND SPEAKER
BIOGRAPHIES. IN ORDER TO STAY ON
TIME IN OUR BUSY AGENDA WE WILL
GET STARTED. I WOULD LIKE TO
TURN THINGS OVER TO OUR DIRECTOR
OF THE NATIONAL INSTITUTE OF
ARTHRITIS, MUSCULOSKELETAL AND
SKIN DISEASE, DR. LINDS SHY
CRISWELL TO OPEN THE WORKSHOP.
SHE BECAME THE NIAMS DIRECTOR
FEBRUARY OF 2021. DR. CRISWELL,
FLOOR IS YOURS.
>> THANK YOU, CHRISTY. GOOD
MORNING, EVERYBODY IT IS A
PLEASURE TO WELCOME YOU TO THIS
TWO DAY NIH WORKSHOP ON HEALTH
DISPARITIES IN OSTEOARTHRITIS. I
WOULD LIKE TO BEGIN BY THANKING
THE CO-CHAIRS DR.S ARLENE BROWN,
LEIGH CALLAHAN, KENT KWOH
ANDERNIST MOY FOR LEADING THE
WORKSHOP HELPING TO IDENTIFY
SPEAKERS AND THEIR CONTRIBUTIONS
TO OUR AGENDA. WE KNOW THAT YOU
ALL WORKED VERY HARD ON THIS
MEETING AND WE APPRECIATE YOUR
PARTICIPATION IN OUR TEAMS
MONTHLY CONFERENCE CALLS. NEXT
SLIDE. YOU SEE THE NIAMS MISSION
IS SUPPORT AND CONDUCT RESEARCH
INTO THE AWE CAUSES TREATMENT
AND PREVENTION OF ARTHRITIS, AND
MUSCULOSKELETAL AND SKIN
DISEASES, TO TRAIN THE NEXT
GENERATION OF SCIENTISTS TO
CARRY OUT THIS RESEARCH, AND
PROVIDE INFORMATION TO THE
PUBLIC ABOUT RESEARCH PROGRESS
IN OUR MISSION AREAS AND HOW IT
CAN BE APPLIED TO IMPROVE
HEALTH. CONSIDERING THE
OSTEOARTHRITIS IS BOTH THE MOST
COMMON FORM OF ARTHRITIS AND
LEADING CAUSE OF DISABILITY
ADDRESSING DISPARITIES IN
OSTEOARTHRITIS IS A CRITICAL
COMPONENT OF EFFORTS TO FULFILL
THE NIAMS MISSION AND IMPROVE
THE PUBLIC HEALTH. DOCUMENTED
HEALTH DISPARITIES IN OA INCLUDE
THOSE IN OUTCOMES AS WELL AS IN
ACCESS TO QUALITY CARE. FOR
EXAMPLE, AFRICAN AMERICAN OA
PATIENTS WHO UNDERGO TOTAL KNEE
REPLACEMENT ARE TWO AND A HALF
TO FIVE TIMES MORE LIKELY THAN
WHITE PATIENTS TO BE DISCHARGED
TO AN INPATIENT REHABILITATION
OR SKILLED NURSING FACILITY
RATHER THAN TO HOME HEALTHCARE
OR SELF CARE. ONE POSSIBLE
EXPLANATION FOR THESE
DIFFERENCES IS THAT AFRICAN
AMERICAN PATIENTS ARE MORE
LIKELY THAN WHITE PATIENTS TO
DELAY THEIR TOTAL KNEE
REPLACEMENT AND THUS EXPERIENCE
MORE SEVERE DISEASE. SO BETTER
UNDERSTANDING THESE DISPARITIES
AND THE ROLES SOCIAL
DETERMINANTS OF HEALTH PLAY IS
VITAL TO ADDRESSING THIS OFTEN
DEBILITATING CONDITION AND THIS
WAS THE PRIMARY GOAL IN
DEVELOPING THIS WORKSHOP. THE
NEXT SLIDE HIGHLIGHTS OUR
PARTNERSHIP WITH THE NATIONAL
INSTITUTE ON AGING, AND THE
NATIONAL INSTITUTE ON MINORITY
HEALTH AND HEALTH DISPARITIES TO
EXPLORE WAYS THAT BEHAVIORAL AND
BIOMEDICAL SCIENCES TOGETHER CAN
BE LEVERAGED TO REDUCE
DISPARITIES IN MORBIDITY
OUTCOMES AND OTHER FACTORS
INFLUENCING QUALITY OF LIFE
AMONG OA PATIENTS. I WANT TO
ACKNOWLEDGE DR. CHRISTY NIX AND
MS. JANNA ISENSTEIN OF NIAMS,
DR. LYNDON JOHNSON AND PATRICIA
JONES ON NATIONAL INSTITUTE ON
AGING, AND DR.S RADHA AND RICK
BURSON NATIONAL INSTITUTE ON
MINORITY HEALTH AND HEALTH
DISPARITIES FOR LEADING THE
DEVELOPMENT OF THIS WORKSHOP ON
BEHALF OF THE NIH. AND ALL THOSE
THREE NIH COMPONENTS FOCUS
SPECIFICALLY ON OA WE HOPE THE
WORKSHOP SERVES AS A MOLD FOR
OTHER NIH ENTITIES AND FEDERAL
AGENCIES COMMITTED TO REDUCING
DISPARITIES IN AND THE OVERALL
IMPACT OF DISEASES ACROSS THE
NIH MISSION. N MISSION. ON TH,
THE NIH IS WIDELY RECOGNIZED AS
THE LEADING GOVERNMENT AGENCY
THAT SUPPORTS BIOMEDICAL
RESEARCH. THUS WE MUST CONTINUE
TO LOOK HOLISTICALLY AT THE
OPPORTUNITIES TO WORK ACROSS THE
MANY FIELDS OF SCIENCE IN ORDER
TO EQUITABLY REDUCE IMPACT OF
DISEASE CAUSED BY
OSTEOARTHRITIS. WHILE THE
FEDERAL GOVERNMENT SHOULD BE A
PART OF ANY NATIONAL ENDEAVOR TO
IMPROVE AMERICAN JOINT HEALTH,
THE GOVERNMENT CANNOT AND
SHOULDN'T DO IT ALONE.
LEADERSHIP MUST BE SHARED AMONG
THE MANY PUBLIC PRIVATE
NON-PROFIT ACADEMIC AND
SCIENTIFIC STAKEHOLDERS.
THEREFORE I'M PARTICULARLY
LOOKING FORWARD TO THE SESSIONS
TOMORROW WHERE WE HEAR THE
PATIENT CLINICIAN AND SOCIETAL
VOICES FOR THEIR INSIGHTS IN TO
THE PRESSING ISSUE OF HEALTH
DISPARITIES IN OSTEOARTHRITIS.
I'M ALSO LOOKING FORWARD TO
TODAY'S SESSIONS THAT FOCUS ON
INTERACTIONS THAT SHAPE
DISPARITIES IN OSTEOARTHRITIS AS
WELL AS THE SOCIAL DETERMINANTS
OF THE HEALTH THAT SYSTEMATIZE
THESE DISPARITIES. LASTLY, THIS
WORKSHOP IS BEING VIDEOCAST AND
WE WILL POST A SUMMARY ON THE
NIAMS WEBSITE. AND WE WILL LET
ALL OF YOU WHO REGISTERED FOR
THE MEETING KNOW WHEN THAT
SUMMARY IS AVAILABLE. NOW I
WANT TO TURN THE MEETING BACK TO
DR. NIX FOR THE FIRST SESSION.
>> THANK YOU, DR. CRISWELL, WE
WILL MOVE TO INTRODUCTION TO
OSTEOARTHRITIS TO SET THE STAGE
FOR DISCUSSION TODAY. SESSION
ONE IS MODERATED BY WORKSHOP
CO-CHAIR DR. KENT KWOH,
UNIVERSITY OF ARIZONA. DR. KWOH
IS FIRST SPEAKER OF THE SESSION
WHERE HE WILL DISCUSS THE
CLINICAL MANIFESTATIONS AND
EPIDEMIOLOGY OF OSTEOARTHRITIS.
I WILL TURN THE SESSION TO YOU
DR. KWOH.
>> THANK YOU. I WOULD LIKE TO
THANK THE NIH FOR THE HONOR AND
PRIVILEGE TO PARTICIPATE IN THIS
WORKSHOP. O OSTEOARTHRITIS IS
THE MOST COMMON FORM INVOLVING
CHRONIC INFLAMMATION BREAK DOWN
AND STRUCTURAL ALTERATION OF
WHOLE JOINTS. IMPORTANT TO
REALIZE OSTEOARTHRITIS IS A
DISEASE THAT IS CHANGES IN JOINT
STRUCTURE AND ILLNESS AND THAT
IS A PERSON EXPERIENCE OF OA
PAIN IS THE REASON PATIENTS SEEK
CARE FOR OA. THERE IS A TYPO ON
FORMATTING ON THIS SLIDE. THE
SYMPTOMS SHOULD BE ON THE LEFT
AND THE SIGN SHOULD BE ON RIGHT.
SYMPTOMS OF OSTEOARTHRITIS IS
USEFUL RELATED PAIN OR
STIFFNESS, WORST WITH ACTIVITY
BETTER WITH REST AND LATE STAGE
PATIENTS EXPERIENCE PAIN AT
NIGHT. THEY MAY HAVE STIFFNESS
OR JELLING AFTER ACTIVITY
JELLING WOULD BE AFTER YOU SAT
HERE AND LISTEND TO THE WORKSHOP
FOR A FEW HOURS AND HAVE A
LITTLE BIT OF DIFFICULTY GETTING
OUT OF YOUR CHAIR, THAT'S THE
SENSATION OF JELLING. MORNING
STIFFNESS IS USUALLY LESS THAN
30 MINUTES WHEREAS INFLAMMATORY
ARTHRITIS IS OVER AN HOUR.
PATIENTS ALSO EXPERIENCE LOSS OF
MOBILITY DIFFICULTY WITH CERTAIN
TASKS SUCH AS WALKING, CLIMBING
STAIRS. PATIENTS MAY ALSO HAVE
FEELINGS OF INSECURITY OF
INSTABILITY DUE TO LACKSTY
AROUND THEIR JOINTS. THERE IS
FUNCTIONAL LIMITATION AND
HANDICAP FOR DAILY ACTIVITIES
SUCH AS ADL OR INSTRUMENTAL
DAILY ACTIVITIES. IN TERMS OF
SIGNS OF OSTEOARTHRITIS, THEY
MAY HAVE TENDER SPOTS AROUND
JOINT MARGIN, FIRM OR SWELLING
ON THE JOINT MARGIN, CRACKING OR
LOCKING RICE CRISPY SEN STATION
THAT CAN BE PALPABLE OR AUDIBLE
WHEN PATIENTS MOVE THEIR JOINTS.
THERE MAYBE SIGNS OF MILD
INFLAMMATION THAT IS THAT THE
FUSION OR SWELLING IS COOL
COMPARED TO RED HOT SWOLLEN
JOINTS ONE SEES IN INFLAMMATORY
TYPES OF ARTHRITIS SUCH AS
RHEUMATOID ARTHRITIS. PATIENTS
HAVE RESTRICTED RANGE OF MOTION
AND MAYBE HURTS AT THE EXTREMES
IN MOTION. AND INSTABILITY THAT
WE TALKED ABOUT BEFORE WHEN
THERE IS OBVIOUS SEVERE WON'T OR
JOINT DESTRUCTION.
OSTEOARTHRITIS IS NOW RECOGNIZED
AS JOINT FAILURE. A DISEASE
PROCESS INVOLVING THE ENTIRE
JOINT. USED TO BE MORE CARBON
CENTRIC AND CENTRIC IN TERMS OF
BONE IN TERMS OF OSTEOPHYTE BUT
WE KNOW THERE IS BONE REMODELING
SCLEROSIS, CARTILAGE BREAK DOWN,
SYNOVIAL HYPERTROPHY, IMPORTANT
THERE IS MILD INFLAMMATION
OCCURRING WITHIN THE JOINTS.
LIGAMENTS CAN BE -- THERE IS
DYSFUNCTION AND LOSS OF
STRUCTURSTRUCTURSTRUCTURAL. ALSE
IMPORTANT COMPONENT OF
OSTEOARTHRITIS AND OSTEOPHYTES
USED TO DEFINE OSTEOARTHRITIS
RADIOGRAPHICALLY. THE COMMON
SITES INCLUDE JOINTS CLOSE TO
YOUR NAIL OR DIP. AND THEN THE
JOINTS NEXT TO THOSE IN TERMS O
PROXIMAL INTERPHALANGEAL JOINTS,
HIPS KNEES AND FIRST MTP AT THE
BASE OF YOUR GREAT TOE ARE ALSO
COMMONLY INVOLVED. ALSO IN TERMS
OF C SPINE CERVICAL SPINE OR
LUMBAR SACRAL SPINE MAYBE
INVOLVED. LESS COMMONLY YOU CAN
HAVE THE KNUCKLES OF THE HAND OR
META CARPAL FLAN JOEL JOINTS OR
JOINTS IN SHOULDERS OR THE
FOLLICULAR JOINTS MAYBE
INVOLVED. NEXT. SO YOU MAY
WONDER IS OSTEOARTHRITIS A
SERIOUS DISEASE? IT HAS BEEN BY
THE FDA AND WHY THIS IS BECAUSE
OA IS COMMON AND GROWING,
AFFECTS 240 MILLION PEOPLE
WORLDWIDE WITH WOMEN EFFECTED
MORE -- TWO TIME MORRIS LIKELY
THAN MEN. OA ALSO LIMITS LIFE,
25% OF INDIVIDUALS CAN'T DONOR
MALL ACTIVITIES SUCH AS WALKING
OR CLIMBING STAIRS. THEY MAY
HAVE LIMITED MOBILITY. AND WE
ALSO KNOW NOW THAT THERE IS
INCREASE RISK OF CARDIOVASCULAR
DISEASE, DIABETES, HYPERTENSION,
EVEN PREMATURE MORTALITY RELATED
TO OSTEOARTHRITIS. IT IS
IMPORTANT TO REALIZE THAT
OSTEOARTHRITIS IS NO KNOWN CURE.
WHILE TREATMENTS CAN REDUCE PAIN
AND WE KNOW THERE IS CERTAINLY
SIDE EFFECTS TO NON-STEROIDAL
ANTI-INFLAMMATORY DRUGS, I DON'T
NEED TO TELL YOU ABOUT THE
OPIATE EPIDEMIC. WE DON'T HAVE
GOOD DRUGS FOR OSTEOARTHRITIS.
THERE ARE NO APPROVED DRUGS TO
PREVENT OA OR SLOWER HEALTH
PROGRESSION OF OA. SURGERY CAN
REPLACE BUT NOTTER RES NOT RESTL
JOINTS H. EVERYONE SHOULD
RECEIVE EDUCATION BE ACTIVE
EXERCISE TO MAG, SOME BENEFIT
FROM DRUGS OR INJECTIONS AND A
FEW MAY NEED SURGERY. THIS WAS
AN INFO GRAPHIC DEVELOPED BY THE
OSTEOARTHRITIS RESEARCH SOCIETY
INTERNATIONAL AND ONE GETS MORE
INFORMATION ON IN IN THE
OSTEOARTHRITIS SERIOUS WHITE
PAPER IS AVAILABLE AND HAS BEEN
DISTRIBUTED. SO THIS SLIDE SHOWS
OLDER DATA THAT IS LIMITED DATA
ON AGE AND SEX SPECIFIC
INCIDENCE OF SYMPTOMATIC
OSTEOARTHRITIS. YOU CAN SEE
THAT LOWER AGES STARTING AT AGE
20 WHEN THEY DEVELOP
OSTEOARTHRITIS, IT IS THE
INCIDENCE IS LOWEST IN THE HAND,
NEXT IS THE HIP AND THEN THE
KNEE. AND AFTER AGE 50 WE CAN
SEE INCREASE IN THE INCIDENCE OF
OSTEOARTHRITIS IN ALL THESE
JOINTS AND IN PARTICULAR AFTER
AGE 50 FOR WOMEN, AND WE CAN SEE
A DRAMATIC RISE IN INCIDENCE OF
HAND HIP AND KNEE OSTEOARTHRITIS
MUCH HIGHER THAN IN MEN
PARTICULARLY AFTER AGE 50. THIS
SLIDE SUMMARIZES AGE AND SEX
SPECIFIC PREVALENCE OF OA FROM
2005 TO 2006 TO 2017 AND 2018
USING N HAYNES DATA YOU CAN SEE
THAT REGARDLESS OF RACE OR
ETHNICITY, THAT FOR THE HISPANIC
POPULATION, NON-HISPANIC
CAUCASIANS, NON-HISPANIC AFRICAN
AMERICANS AN NON-HISPANIC OTHER
WE HAVE RISES IN THE PREVALENCE
OVER THESE YEARS. BOTH IN MEN
AND WOMEN IMPORTANTLY, THIS
SLIDE SUMMARIZES IN TERMS OF THE
ACTUAL NUMBERS AND PREVALENCE
RATES OF SELF-REPORTED ARTHRITIS
WHICH IS MAINLY OSTEOARTHRI OST.
AMONG NON-HISPANIC WHITES,
AFRICAN AMERICAN AND AMERICAN
INDIAN THE PROBLEMS ARE NOT THAT
DIFFERENT AND LOWER IN PACIFIC
ISLANDERS BUT WHEN LOOKING AT
SELF-REPORTED ACTIVITY
LIMITATIONS IT IS HIGHER AMONG
MINORITY GROUPS SUCH AS AFRICAN
AMERICANS AND AMERICAN INDIANS
COMPARED TO WHITES. THEN LOOK AT
PROPORTION WITH ARTHRITIS WITH
ACTIVITY LIMITATION ATTRIBUTABLE
TO ARTHRITIS, HERE WE CAN SEE
THE DRAMATIC EFFECT ON ARTHRITIS
ON PEOPLE'S LIFE PARTICULARLY
MINORITY POPULATIONS WHEREAS
PROPORTION WITH ACTIVITY
LIMITATION ATTRIBUTABLE TO
ARTHRITIS IS ACTUALLY HIGHER IN
AFRICAN AMERICANS AND AMERICAN
INDIANS COMPARED TO NON-HISPANIC
WHITES. IF WE LOOK BY ETHNICITY,
SELF-REPORTED ARTHRITIS ACTUALLY
IS HIGHER AMONG NON-HISPANIC
WHITES AND NON-HISPANIC BLACKS
COMPARED TO HISPANICS BUT
SELF-REPORTED ACTIVITY
LIMITATION IS SIMILAR BUT LOOK
AT PROPORTION AGAIN ON FAR
RIGHT, WHERE ARTHRITIS IS
ATTRIBUTABLE ACTIVITY LIMITATION
TO ARTHRITIS WE CAN SEE
HISPANICS AND NON-HISPANIC
BLACKS HAVE HIGHER ACTIVITY
LIMITATION ATTRIBUTABLE TO
ARTHRITIS THAN NON-HISPANIC
WHITES. WHEN LOOKING AT
PREVALENCE OF RADIOGRAPHIC
OSTEOARTHRITIS, DEFINED BY A
DEFINITE OSTEOPHYTE AS GROWTH OF
THE BONE ON X-RAY THIS IS IN THE
LAUREN SCALE DATING BACK TO 1957
USED IN CLINICAL EPIDEMIOLOGIC
STUDIES WE CAN SEE THAT FOR
AFRICAN AMERICANS THEY MAY HAVE
DECREASE PREVALENCE OF
RADIOGRAPHIC OA BUT WE KNOW
THEIR FEATURES ON RADIOGRAPHIC
OA AND PATTERNS ARE ACTUALLY
DIFFERENT COMPARED TO WHITES.
AND IN TERMS OF AFRICAN
AMERICANS HAVE HIGHER PREVALENCE
OF NEOA ALSO MORE SEVERE AND
LIKELY BILATERAL. THOUGH
DECREASED PREVALENCE OF
RADIOGRAPHIC HIP OA BUT WE SEE
THE PATTERN OF OA IN THESE
INDIVIDUALS IS DIFFERENT AND
FEATURES ARE DIFFERENT COMPARED
TO WHITES. THERE IS LIMITED
DATA ON HIS FA NIX SUGGEST THAT
IN TERMS OF -- HISPANICS SUGGEST
THAT THERE IS NOT A DIFFERENCE
IN HISPANICS AND NON-HISPANIC
WHITES. THERE'S LIMITED DATA ON
ASIANS BUT THERE WAS ONE STUDY
IN TERMS OF COMPARING WHITES IN
THE U.S. AND FRAMINGHAM TO THE
BEIJING OA STUDY SUGGESTING
RADIOGRAPHCAL OA IS DECREASE
PREVALENCE IN CHINESE IN BEIJING
COMPARED TO WHITES IN THE U.S.
BUT THEIR KNEE OA PARTICULARLY
IN WOMEN IS INCREASED AND WILL
IS ALSO DIFFERENCES IN
MORPHOLOGY IN WELCOME PAIR IN
CHINESE WELCOME PAIRED TO WHITE
WOMEN AND MORE OFTEN BILATERAL.
THESE DIFFERENCES WERE NOT
NECESSARILY SEEN IN WHITE MEN.
IN HIP OA WE SEE THERE MAYBE
DIFFERENT DECREASES IN
PREVALENCE IN CHINESE AND
BEIJING COMPARED TO WHITES BUT
AGAIN WE SEE THERE'S DIFFERENCES
IN MORPHOLOGY IN THE HIP IN
CHINESE COMPARED TO WHITES.
WHEN WE LOOK AT PREVALENCE OF
SYMPTOMATIC OSTEOARTHRITIS,
SYMPTOMATIC OA DEFINED DEPENDING
USUALLY ON N HAYNES DEFINITION
ON PAIN ON BOTH DAYS OF AT LEAST
ONE MONTH THE PAST 12 MONTHS
WHICH IS SOMETIMES AN AWKWARD
DEFINITION BUT MOST
EPIDEMIOLOGIC STUDIES WE LOOK AT
PAIN ON MOST DAYS THE PAST 30
DAYS AS DEFINING SYMPTOMATIC OA
WHEN RADIOGRAPHIC OA IS ALSO
PRESENT. YOU CAN SEE IN AFRICAN
AMERICANS THE PREVALENCE OF
SYMPTOMATIC HAND OA IS DECREASED
COMPARED TO WHITES, BUT KNEE OA
IN AFRICAN AMERICANS IS
INCREASED IN TERMS OF PREVALENCE
AND MORE SEVERE IN TERMS OF
SYMPTOMATIC OA COMPARED TO
WHITES. HIP OA IS DECREASED IN
AFRICAN AMERICANS IN TERMS OF
SYMPTOMATIC OA COMPARED TO
WHITES. FOR HISPANICS WE HAVE
INCREASE IN SYMPTOMATIC HAND OA
AND INCREASE IN SYMPTOMATIC KNEE
OA COMPARED TO WHITES. DATA FROM
THE BEIJING OSTEOARTHRITIS STUDY
PREVALENCE OF SYMPTOMATIC HAND
OA DECREASED IN CHINESE AND
DECREASED IN HIP OA COMPARED TO
WHITES BUT KNEE OA IS INCREASED
IN CHINESE PARTICULARLY IN WOMEN
BUT NOT MEN. THIS WAS VERY
INTERESTING DATA FROM THE
JOHNSTON COUNTY OSTEOARTHRITIS
PROJECT. IT SHOWS THE PA TERM OF
ENVIRONMENTAL OA WHETHER HAND
HIP KNEE, LS, SPINE, IS
DIFFERENT IN AFRICAN AMERICANS
COMPARED TO WHITES IN THAT
THERE'S CERTAIN PATTERNS OF
JOINT INVOLVEMENT THAT ARE LEAST
LIKELY IN AFRICAN AMERICANS AND
YOU CAN SEE AS WE MOVE FROM LEFT
TO RIGHT THAT THERE ARE OTHER
PATTERNS OF JOINT INVOLVEMENT
ARE MOST LIKELY IN AFRICAN
AMERICANS. THIS IS IMPORTANT TO
SHOW THAT WE NOW KNOW THERE ARE
DIFFERENT PHENOTYPES OF KNEE
OSTEOARTHRITIS AND THAT THIS MAY
BE RELATED TO JOINT INVOLVEMENT
ALSO IN TERMS OF WHETHER
PATIENTS HAVE DIFFERENT
UNDERLYING PATHOPHYSIOLOGY IN
TERMS OF THEIR ARTHRITIS AND
THIS IS IMPORTANT TO CONSIDER
WHEN THINKING ABOUT ETHNIC AND
RACIAL DISPARITIES IN OA. THIS
IS DATA THAT FROM THE
OSTEOARTHRITIS INITIATIVE THAT
OUR GROUP DID USING DATA FROM
THE FIX FLEX KNEE X-RAYS USED TO
MEASURE JOINT SPACE WITH BETWEEN
FEMUR AND TIBIA, BONES IN YOUR
LEGS AS SURROGATE OF CARTILAGE
THICKNESS AND WHAT YOU CAN SEE
HERE IS IN TERMS OF PROGRESSION
OF KNEE OSTEOARTHRITIS THAT ODD
AVERAGE AT BASELINE AFRICAN
AMERICAN MEN AND WHITE MEN HAVE
MORE JOINT SPACE, THAT IS
PRESUMABLY MORE CARTILAGE THAN
WHITE FEMALES OR AFRICAN
AMERICAN FEMALES. OVER FOUR
YEARS OF ANIMAL FOLLOW-UP OF
KNEE X-RAYS THERE IS LOSS OF
JOINT SPACE WITH PROGRESSION OF
THEIR KNEE OSTEOARTHRITIS AND
THE RATES OF LOSS IN WHITE MEN,
WHITE WHEN AND AFRICAN AMERICAN
WOMEN ARE SIMILAR BUT THERE IS A
SUGGESTION OF GREATER LOSS IN
AFRICAN AMERICAN MEN COMPARED TO
THE OTHER GROUPS. I WILL CAUTION
THAT THIS IS DUE TO A SMALLER
NUMBER OF AFRICAN AMERICAN MEN
THAT IS AVAILABLE BUT WE ARE
DOING OTHER STUDIES TO TRY TO
BETTER UNDERSTAND IF THERE ARE
RACIAL AND ETHNIC DIFFERENCES IN
TERMS OF PROGRESSION OF
OSTEOARTHRITIS. IT IS IMPORTANT
TO NOTE AFTER FOUR YEARS WITH
THE LOSS THAT MEN ON AVERAGE,
WHITES AND AFRICAN AMERICANS
HAVE LARGER JOINT SPACE COMPARED
TO WOMEN. THIS MAY BE IN PART
WHY THERE IS DISPARITY OF WOMEN
HAVING HIGHER INCIDENCE AND
PREVALENCE OF OSTEOARTHRITIS
COMPARED TO MEN. THIS IS A META
ANALYSIS OF RACIAL ETHNIC
DIFFERENCES MANY PAIN AND
DISABILITY AND YOU CAN SEE HERE
THAT AFRICAN AMERICANS COMPARED
TO WHITES HAVE HIGHER REPORTS
AND MORE SEVERE PAIN. WESTERN
ONTARIO MCMASTER OUTCOME
MEASURES THAT GENERALLY USED IN
EPIDEMIOLOGIC AND CLINICAL
STUDIES TO MEASURE PAIN,
STIFFNESS AND DISABILITY RELATED
TO LOWER EXTREMITY
OSTEOARTHRITIS. WE WILL FOCUS
NON-MODIFIABLE RISK FACTORS. YOU
HAVE SEEN AGING IS A POTENT
NON-MODIFIABLE RISK FACTOR FOR
THE DEVELOPMENT OF
OSTEOARTHRITIS. THAT FEMALE SEX
AROUND MENOPAUSE PERI AND MOST
MENOPAUSAL PERIOD IS IMPORTANT
RISK FACTOR. GENETICS AND JOINT
SHAPE. WE KNOW PARTICULARLY IN
HIP AND KNEE POTENT
NON-MODIFIABLE RISK FACTORS.
RETURNING TO THE RIGHT SIDE IN
TERMS OF MODIFIABLE RISK
FACTORS, OBESITY IS IMPORTANT
PARTICULARLY IN KNEES BUT ALSO
IN OTHER JOINTS SUCH AS HINT AND
HANDS THOUGH LESS SO THAN FOR
THE KNEES. UNFORTUNATELY JOINT
INJURY IS A VERY POTENT RISK
FACTOR SO JOINT PROTECTION IS A
VERY IMPORTANT PREVENTATIVE
STRATEGY FOR OSTEOARTHRITIS.
REPETITIVE STRESS DUE TO CERTAIN
OCCUPATIONING YOU CAN SEE HERE
WITH REPETITIVE SQUATTING OR
KNEELING PUTS STRESS ON KNEES
AND HIPS AND THIS CAN BE
IMPORTANT MODIFIABLE RISK FACTOR
FOR OSTEOARTHRITIS AND MAL
ALIGNMENT OF JOINTS, IF YOU ARE
KNOCK KNEED OR BOWLEGGED THAT
ALSO INCREASES YOUR RISK OF
OSTEOARTHRITIS. SO IN TERMS OF
SUMMARY AND RESEARCH GAPS MUCH
EPIDEMIOLOGY IS FOCUSED ON THE
KNEE WITH LIMITED INFORMATION ON
OA AND OTHER JOINTS. THERE'S
LIMITED DATA ON EPIDEMIOLOGY IN
AFRICAN AMERICANS ESPECIALLY
AFRICAN AMERICAN MEN. LACK OF
INCIDENCE AND PREVALENCE ON KNEE
HIP AND HAND OA AND FOOT AND
OTHER RACIAL ETHNIC GROUPS SUCH
AS LATINO AFRICAN AMERICAN AND
INDIGENOUS POPULATION AND LACK
OF DATA AND RISK FACTORS FOR
KNEE HIP HAND AND FOOT OA OTHER
RACIAL ETHNIC GROUPS SUCH AS
HISPANICS LATINOS, ASIAN
AMERICANS AND INDIGENOUS
POPULATIONS. THESE ARE THE
REFERENCES THAT MAY BE HELPFUL
FOR LATER DISCUSSION. THANK YOU
WE CAN MOVE TO THE NEXT TALK
THEN. I'M PLEASED DO INTRODUCE
DR. AMANDA NELSON, ASSOCIATE
PROFESSOR DIVISION OF
RHEUMATOLOGY ALLELE ANY
RHEUMNOLOGY AT THURSTON
ARTHRITIS CENTER UNIVERSITY OF
NORTH CAROLINA CHAPEL HILL.
I'M CHARGED TO TALK
ABOUT HEALTHY
PEOPLE OSTEOARTHRITIS
2030. WE KNOW OA IS A COMMON
SERIOUS DISEASE AND HEALTHY
PEOPLE 2030 FOCUSES ON COMMON
SERIOUS DISEASES IN GENERAL. IT
INCLUDES GOALS FOR ARTHRITIS
AROUND REDUCING JOINT PAIN,
REDUCING WORK LIMITATION AND
INCREASING PHYSICAL ACTIVITY.
THERE ARE SIMILAR GOALS FOR
CHRONIC PAIN, THERE IS CHRONIC
PAIN MANAGEMENT MODULE ALSO,
VERY SIMILAR TO ARTHRITIS. THE
PLAN INCLUDES FOCUS ON SOCIAL
DETERMINANTS OF HEALTH. THESE
INCLUDENATE ENVIRONMENT SOCIAL
CONTEXT, ECONOMIC STABILITY,
EDUCATION AND HEALTHCARE ACCESS
THERE IS A NEXT ANIMATION. THAT
IS THE SOCIAL DETERMINANTS OF
HEALTH FROM HEALTHY PEOPLE 2030.
WE SEE MAPS FROM THE CDC THAT
HIGHLIGHT AREAS WHERE PEOPLE ARE
FROM THE TOP. LIVING IN POVERTY
IN THE CENTER, THOSE WITHOUT
HIGH SCHOOL EDUCATION, AND
BOTTOM THOSE UNDER 65 AND DON'T
HAVE INSURANCE MEANING NOT
COVERED BY MEDICARE. THESE
BARRIERS TO HEALTHY AGING
DIRECTLY IMPACT RISK AND
PROGNOSIS OF OSTEOARTHRITIS AND
OTHER CHRONIC DISEASES. THE
IMPORTANCE OF SOCIAL
DETERMINANTS OF HEALTH AND OA
AND OTHER COMMONLY CO-MORBID
DISEASE HIGHLIGHTED IN THE NEXT
THREE SLIDES. SO NEXT. TWO
MORE. SO HERE ARE SEVERAL MAPS
FROM THE CDC WEBSITE. ON THE TOP
IF YOU CAN CLICK NEXT. THERE IS
THE PREVALENCE OF DIABETES OVER
THE LAST TWO DECADES. YOU CAN
SEE FROM 2004 TO 2019 THERE IS
AN OBVIOUS CONCENTRATION IN THE
SOUTHEAST AND WE SEE SIMILAR
PATTERNS FOR STROKE IN PURPLE,
HART DISEASE IN RED, AND EVEN
PHORIA THEY AT THIS. DOCTOR
DIAGNOSED ARTHRITIS IN BROWN.
YOU CAN SEE THESE MAPS OVERLAP
WITH HIGHEST RISK IN THE SAME
AREAS. AGAIN FROM THE CDC WE
SEE MAPS DEMONSTRATING OBESITY
OVERALL IN THE TOP LEFT. OBESITY
AMONG NON-HISPANIC BLACKS ON THE
TOP RIGHT, PHYSICAL INACTIVITY
OPT BOTTOM, INVERSE WALKING AS
THE MAIN SOURCE OF PHYSICAL
ACTIVITY ON THE BOTTOM RIGHT.
YOU CAN SEE THIS PREPONDERANCE
SOCIAL DETERMINANTS OF HEALTH
BARRIERS OVERLAPPING MOSTLY
SOUGHT EAST BUT SEVERAL OTHER
STATES A WITH LARGE UNDERSERVED
MINORITY POPULATIONS.
HIGHLIGHTED SOME OF THE
DIFFERENCES PREVALENCE AND
INCIDENCE OF OSTEOARTHRITIS A
PAIN AND FUNCTION BY RACE AND
ETHNICITY. WOMEN AND BLACK
PATIENTS WITH OA REPORT MORE
PAIN AND POORER FUNCTION BY
VARIOUS MEASURES. THESE ARE
SHOWN ON THE RIGHT WHERE THE
BLUE LINE REPRESENTS BLACK
INDIVIDUALS, PAIN ON THE TOP,
VAS PAIN THE LAST 30 DAYS, PAIN
MOST DAYS THE LAST 30 DAYS AND
WOMAC FUNCTION ON THEWOMAN SO
ON THE BOTTOM, SOBLACK INDIVIDUN
AND FUNCTION IN ALL THESE
CATEGORIES OVER TIME.
PERFORMANCE BASED FUNCTION IS
ALSO CORE IN BLACK COMPARED TO
WHITE PARTICIPANTS IN MOST
STUDIES THOUGH THIS IS AT LEAST
PARTIALLY EXPLAINED BY
SOCIOECONOMIC STATUS AND OTHER
HEALTH VARIABLES. THESE ARE
LISTED HERE. OTHER FACTORS
ASSOCIATE -- HIGHER AMONG BLACK
PARTICIPANTS IN THESE STUDIES
INCLUDE PAIN CATASTROPHIZING AND
RESILIENCE REDUCED. SO DIFFERENT
ASPECTS CONTRIBUTE TO DISPARITY
WE SEE IN PAIN AND FUNCTION JUST
BEGINNING TO BE UNDERSTOOD.
OSTEOARTHRITIS HAS DIFFERENT
EFFECTS ACROSS LIFE COURSE.
WORKPLACE MODIFICATIONS CAN
MITIGATE SOME OF THE IMPACT OF
DISABILITY FROM OA BUT THESE ARE
OFTEN NOT AVAILABLE OR NOT FULLY
UTILIZED, PARTICULARLY AMONG
INDIVIDUALS WITH LOWER CON LOGIC
AGE OR LOWER ORGANIZATIONAL AGE
WHICH MEANS THEY HAVE BEEN IN
COMPANY OR SETTING A SHORTER
TIME AND DON'T HAVE ACCESS OR
DON'T WANT TO TAKE ADVANTAGE OF
ADDITIONAL MODIFICATIONS. OA
AFFECT ROLES OUTSIDE OF WORK
PARTICULARLY DIFFICULT IN
YOUNGER ADULTS WHO MAY BE
RAISING FAMILY AND CARING FOR
OLDER RELATIVES WHILE WORKING SO
WE THINK AGE IS A STROBING RISK
FACTOR FOR OA BUT ALSO AFFECTS
YOUNGER INDIVIDUALS IN DIFFERENT
WAYS OVER THE LIFE COURSE.
BUILT ENVIRONMENT CAN BE A
BARRIER OR FACILITATOR FOR
THESE. IF THERE IS AN ACCESSIBLE
WALKABLE SAFE ENVIRONMENT THAT
COMPENSATES FOR DISEASE RELATED
-- THOSE LOSSES CAN BE SIMILAR
TO EXACERBATED BY LACK OF THESE
BENEFICIAL FEATURES SO THIS
PAPER BY JILLIAN BOWDEN ET AL
TALKS ABOUT THE VARIOUS ASPECTS
OF THE BUILT ENVIRONMENT AND HOW
THEY CAN EITHER HINDER OR
BENEFIT THOSE WITH
OSTEOARTHRITIS. YOU CAN SEE THE
IMPACT THAT MIGHT VARY BY LIFE
STAGE. ACCOUNTING FOR SOCIAL
DETERMINANTS OF HEALTH ACROSS
THE CARE PATHWAY CAN BENEFIT IN
OA AS WELL AS OTHER CONDITIONS.
FROM THE ARTICLE THIS FIGURE
DEMONSTRATES PREVENTION EFFORTS
TARGETED TO THOSE ENGAGED IN
HIGH RISK JOBS OR SPORTS WE
TALKED ABOUT REPEATED SQUATTING
OR OTHER OCCUPATIONS THAT MIGHT
BE HIGHER RISK. LIFESTYLE
INTERVENTIONS INCLUDE SUPPORT IN
THE WORKPLACE FOR THE
NEIGHBORHOOD AND SHOULD ALSO
ACCOUNT FOR SOCIAL CULTURAL
CONSIDERATIONS. THE ARTICLE HAS
OBVIOUSLY SUBSTANTIALLY MORE
DETAIL IN THESE NICE FIGURES TO
HIGHLIGHT THESE ISSUES. OA
INTERVENTIONS ARE OFTEN NOT
STUDIED IN DIVERSE POPULATIONS.
EXCELLENT REVIEW DESCRIBE LACK
OF DATA IN GENERAL BUT
HIGHLIGHTED REDUCE ACCESS IN
GREATER BARRIERS FOR DIVERSE
POPULATIONS. AND DR. IBRAHIM
WILL TALK ABOUT ARTHROPLASTY IN
THE NEXT TALK BUT THIS KEY
REFERENCES TALKS ABOUT LOWER
SES, HAVING -- GET LESS
EDUCATION ABOUT OA AND REDUCE
PARTICIPATION AND SELF
MANAGEMENT PROGRAMS, BLACK
HISPANIC INDIVIDUALS WITH OA
MIGHT HAVE LESS ACCESS OR LESS
ABILITY TO USE PT, LESS
PHYSICALLY ACTIVE AND EXPERIENCE
ADDITIONAL BARRIERS. ONE WAY TO
COMBAT LACK OF DATA AROUND OA
MANAGEMENT IN DIVERSE
POPULATIONS IS THROUGH COMMUNITY
BASED PARTICIPATORY RESEARCH.
THIS IMPROVES VALUE OF STUDIES
FOR RESEARCHERS AND COMMUNIT CO.
HERE EXEMPLIFIED BY STAFF IN
JOHNSTON COUNTY YOU HEARD
EARLIER, THIS IS THE HOME OF THE
JOHNSTON COUNTY PROJECT AND
STUDY, WE HAVE LOCAL STAFF AND
BUILT A LOT OF INFRASTRUCTURE
WITHIN THE COMMUNITY TO
FACILITATE THIS TYPE OF WORK.
INTERVENTIONS CAN BE TAILORED
FOR SPECIFIC POPULATIONS. THE
START STUDY STAART LED BY DR.
ALAN WHO IS ON THE CALL I PUT
HER PICTURE THERE, SURE SHE IS
THRILLED WAS FOCUSED ON ENGAGING
BLACK INDIVIDUALS WITH OA AND
PAIN COPING PROGRAM. THE STUDY
FOUND THIS PROGRAM IS FEASIBLE
AND ACCEPTABLE, IMPROVED PAIN
COPING SKILLS, SELF-EFFICACY AND
PAIN CATASTROPHIZING IN THIS AT
RISK POPULATION. IN TAILORING
WE CAN ADAPT EXISTING TO MEET
CURL CHURL NEEDS. WALK WITH EASE
IS STUDIED BY A CO-CHAIR DR.
CALLAHAN, MY COLLEAGUE HAS BEEN
STUDIED SPECIFICALLY IN BLACK
INDIVIDUALS SO A SUB SAMPLE OF
THE ORIGINAL TRIAL ON BLACK
PARTICIPANTS AND SPECIFICALLY
ADAPTED TO MEET THE NEEDS OF
HISPANIC INDIVIDUALS WITH
OSTEOARTHRITIS THROUGH CAMINE
CON GUSTO TO BETTER FACILITATE
UPTAKE OF THAT INTERVENTION.
MANY GAPS REMAIN. THERE IS LACK
OF RESEARCH IN THIS AREA, THERE
ARE FEW AVAILABLE DIVERSE
COHORT. DIFFERENCES BY BASIC
FEATURES SUCH AS AGE AND SEX
REMAIN UNDER APPRECIATED THOUGH
GETTING BETTER. INTERVENTIONS
WILL NEED TO BE STUDIED AND
APPROPRIATE POPULATIONS IN ORDER
TO ALLOW THEM TO BE TAILORED TO
MEET THE NEEDS OF THOSE
POPULATIONS. FURTHER APPROVED
FOCUS ON UNDERLYING ISSUES THAT
ARE QUOTE RACE AS NEEDED. AND
OBVIOUSLY I MENTION AD FEW
STUDIES THAT FOUND ATTENUATION
OF THAT VARIABLE BY SES,
PSYCHOSOCIAL VARIABLES AND
OTHERS BUT MUCH MORE WORK IN
THAT AREA IS NEEDED. THOSE ARE
THE REFERENCES THAT I MENTIONED.
THANK YOU VERY MUCH.
>> THANK YOU, DR. NELSON. THE
NEXT TALK IS BY DR. SAID
IBRAHIM, SENIOR VICE PRESIDENT
FOR MEDICINE SERVICE LINE AT
NORTH WELL HEALTH. AND THE DAVID
GREEN PROFESSOR DONALD BARBARA
ZUCKER SCHOOL OF MEDICINE AND
DR. IBRAHIM WILL DISCUSS
INTERVENTIONS DISSEMINATION AND
IMPLEMENTATION. DR. IBRAHIM.
>> HELLO, EVERYONE, GOOD
MORNING. IT IS GREAT TO SEE YOU
ALL. MANY FAMILIAR FACES. THANKS
AGAIN FOR NIAMS AND NIA AND THE
NICNIMHD FOR SPONSORING THIS
WORKSHOP, THIS REALLY A NEEDED
THING. SO THANK YOU. I'M GOING
TO, I THINK DR. NELSON AND DR.
KWOH PROVIDED AN EXCELLENT
INTRODUCTION TO OA AND
DISPARITIES AS MANY OF YOU KNOW,
OA IS SORT OF ALMOST LIFE LONG
AMBITION. THE SPECTRUM OF
DISPARITIES OR VARIATIONS IN
BOTH EPIDEMIOLOGY AND TREATMENT
AND MANAGEMENT FROM SELF CARE TO
EXTREME END JOINT REPLACEMENT SO
I WILL TAKE YOU TO THAT EXTREME
END. I WILL TALK ABOUT THAT
PARTICULAR DISPARITY IN
MANAGEMENT OF END STAGE KNEE OR
HIP OA. SO I'M GOING TO QUICKLY
SUMMARIZE WORK THAT'S ONGOING
AND MOSTLY FUNDED BY NIAMS
CONDUCTED BY TEAM OF US
INCLUDING DR. KWOH. BUT I THINK
OUR FRAMEWORK FOR APPROACHING
RACIAL DISPARITIES IN THE USE OF
KNEE AND HIP REPLACEMENT HAS
SORT OF USED THIS APPROACH WHERE
WE FIRST TRIED TO LOOK AT FIRST
GENERATION STUDIES, WE DECIDE TO
REALLY LOOK AT THE EXISTENCE OF
DISPARITY ITSELF TO MAKE SURE
THAT WE ARE NOT CONFUSING
DIFFERENCES WITH REALLY SERIOUS
DISPARITIES. SECOND STUDIES
STRIVE TO IDENTIFY SOMETHING WE
CAN DO SOMETHING ABOUT. IDENTIFY
POTENTIAL MITIGATING FACTORS.
AND THE THIRD GENERATION STUDIES
ARE STUDIES THAT TEST
INTERVENTIONS AND I WILL PROVIDE
AN EXAMPLE OF SOME OF THE
INTERVENTIONS THERE THAT WE HAVE
TESTED. LASTLY OF COURSE IS THE
FOURTH GENERATION, IN A WAY THE
HORIZON, THAT IS DISSEMINATION
AND IMPLEMENTATION. NEXT. SO
JUST QUICKLY, THE FIRST QUESTION
ONE HAS TO ASK IS JOINT
REPLACEMENT EFFECTIVE? IT IS
TRUE WHEN ALL ELSE FAILS OA IS
NOT A CURABLE DISEASE OR
CONSERVATIVE MANAGEMENT FAILS,
PATIENTS EVENTUALLY SORT OF
REQUIRE MORE INVASIVE TREATMENT
AND TOTAL REPLACEMENT IS THERE.
FOR THAT PURPOSE. BUT HAS IT
BEEN EFFECTIVE? MANY OF YOU ON
THE WORKSHOP KNOW BETTER THAN I,
THIS HAS BEEN A SUBJECT OF
NUMEROUS NIH CONSENSUS
STATEMENTS AND SYSTEMIC REVIEWS
BY AHRQQ. IT IS EFFECTIVE FOR TE
RIGHT PATIENT AT THE RIGHT TIME
IN THE THE RIGHT HANDS, AT THE
RIGHT HEALTHCARE. I SHOULD SAY
OR HOSPITAL, IT IS VERY
EFFECTIVE TREATMENT, VERY COST
EFFECTIVE WITH LESS THAN 10-K
PER QUALITY ADJUSTED LIFE YEAR.
THE VAST MAJORITY OF PATIENTS
WHO UNDERGO THIS TREATMENT AND
DO WELL THROUGH THE OPERATIVE
PERIOD REPORT IMPROVEMENT IN
PAIN OR FUNCTION. IT IS
CONSIDERED ONE OF THE MOST --
SAFEST ELECTIVE SURGICAL
PROCEDURES IN HISTORY OF SURGERY
WITH LESS THAN 1% RISK OF
MORTALITY. WITH ADVANCEMENT OF
TECHNOLOGIES AND MAKING
PROSTHETICS, THE NUMBER OF YEARS
THESE PROSTHETICS LAST IS ON THE
INCREASE. THAT IS REALLY
REFLECTIVE BY THE UTILIZATION OF
KNEE AND HIP REPLACEMENT. THIS
SLIDE SHOWS THE PROJECTED LIVES
IN USE OF KNEE AND HIP
ARTHEROBLAST IN THE UNITED
STATES ALONE LET ALONE THE REST
OF THE WORLD. WHAT IS REMARKABLE
IS JOINT REPLACEMENT ELECTIVE
KNEE AND HIP REPLACEMENT IS BY
FAR THE MOST COMMON AND THE
FASTEST GROWING ELECTIVE JOINT
REPLACEMENT IN THE UNITED
STATES. THERE HAS BEEN NUMEROUS
STUDIES THAT HAVE DOCUMENTED
BEAUTIFULLY DISPARITIES IN USE
OF KNEE AND HIP REPLACEMENT BACK
TO 1993. THIS IS START WITH THE
WORK BY JOSE WHO IS NOW AT RAND
I THINK AND SANDY SHORTS WHO
PUBLISHED IN 1993 FIRST STUDIES
USING MEDICAL DATABASES TO
DOCUMENT BLACK AND WHITE
DIFFERENCES IN THE USE OF KNEE
AND HIP REPLACEMENT. SINCE THEN
NUMEROUS OTHER AUTHORS LOOKED AT
THIS ISSUE, USING MOSTLY LARGE
ADMINISTRATIVE DATABASES TO SHOW
THIS IS SIGNIFICANT DISPARITY.
NEXT SLIDE. THIS IS A WORK BY
JHA, OR COVID CZAR AT WHITE
HOUSE BUT BEFORE EXPERT ON COVID
HE WAS EXPERT ON KNEE AND HIP
REPLACEMENT DISPARITIES. THIS
IS HIS WORK LOOKING AT THE BLACK
WHITE DIFFERENCES IN AGE
ADJUSTED NATIONAL RATES OF TOTAL
HIP REPLACEMENT SHOWING
DIFFERENCES BY RACE AND BY
GENDER. NEXT SLIDE. THIS IS WORK
FROM THE CDC, BEFORE CDC WAS
DECREDITTED BY THE COVID WALL,
GO BACK ONE. THIS IS WORK
PUBLISHED IN 2009 SHOWING BLACK
WHITE DIFFERENCES IN AGE
ADJUSTED TOTAL KNEE REPLACEMENT,
YOU CAN SEE MINORITY PATIENTS
PARTICULARLY AFRICAN AMERICAN
MEN ARE ALMOST 40% LESS LIKELY
TO UNDERGO KNEE REPLACEMENT
THOUGH WE ALL KNOW, BACK TO DR.
KWOH BEAUTIFULLY ARTICULATED THE
PREVALENCE OF KNEE OA IS
BENEFITING SLIGHTLY HIGHER AMONG
AFRICAN AMERICAN MEN. JUST IN
CASE YOU WORRY THIS IS OLD DATA
THIS IS MORE RECENT DATA THAT
WORK FUNDED BY NATIONAL
INSTITUTE FOR MINORITY HEALTH
AND HEALTH DISPARITIES SHOW WHEN
WE WERE STUDYING ASSOCIATION OF
MEDICARE BUNDLED LIKELIHOOD OF
UNDERGOING ELECTED KNEE AND HIP
REPLACEMENT BY RACE AND
ETHNICITY, WE FOUND DISPARITY IS
PERSISTENT, GETTING WIDER. THIS
IS NOT AN OLD STORY, THIS IS A
MARKED DISPARITY, IN FACT MANY
PEOPLE CONSIDER IT THE LARGEST
SURGICAL DISPARITY, HISTORY OF
MEDICINE. ONE OF THE PROBLEMS IN
IN STUDYING DISPARITIES USING
DATABASES IS IT IS NOT ALWAYS
EASY TO LEVEL PLAYING FIELD IN
TERMS OF THE SEVERITY OF DISEASE
AND THE -- PEOPLE FOR WHOM THE
TREATMENT IS INDICATED. SO ONE
OF THE NICE STUDIES UNBY JEFF
KATZ AND HIS TEAM AT DONE BY
JEFF KATZ AND HIS TEAM IS
LOOKING AT COHORT OF PATIENTS
WITH KNOWN SEVERE KNEE OA THE
LIKELIHOOD OF UNDERGOING KNEE
REPLACEMENT OVER TIME AND WHAT
THEY HAVE SHOWN IS THE REALLY
SORT OF DIVERGENCE THAT ALMOST
MIRRORS WHO WHAT THE LARGE
DATABASES HAVE SHOWN US. THIS IS
A GOOD WAY TO METHOD LOGICALLY
CONFIRM THIS DISPARITY IS NOT
JUST CONFOUNDED BY DISEASE
SEVERITY AT TIME OF TREATMENT
CONSIDERATION. SO THE QUESTION
THEN BECOMES IF YOU ACCEPT WHAT
I SAID, THIS IS IS LARGE
DISPARITY, IT IS LONG LASTING,
IT HAS BEEN AROUND FOR A WHILE.
THE QUESTION IS WHAT -- FIRST
QUESTION IS WHAT ARE THE REASONS
FOR THIS? BEFORE WE THINK ABOUT
WHAT INTERVENTIONS SHOULD WE
CONSIDER. SO WE HAVE DONE OVER
THE YEARS NUMEROUS STUDIES
LOOKING AT PATIENT LEVEL FACTORS
THAT SHAPE THIS ISSUE, SOME
INSURANCE ISSUES THAT MAY SHAPE
DISPARITY, SOME STUDIES LOOKING
AT DOCTOR PATIENT COMMUNICATION
MITIGATION FACTORS THAT SHAPE
DISPARITY. FIRST I WANT TO SHOW
YOU WITH IS THAT THERE IS A
MARKED DIFFERENCES BY RACE IN
PATIENTS PERCEPTIONS ABOUT
USEFULNESS OF VARIOUS TREATMENTS
FOR KNEE OA. IF YOU THINK ABOUT
FROM PHYSICAL THERAPY TO
CHIROPRACTIC TO HERBAL MEDICINE
TO MASSAGE, PRAYER, AND SOME
SORT OF TRADITIONAL TREATMENT
FOR ARTHRITIS, AFRICAN AMERICANS
PATIENTS HOLD MORE FAVORABLE
VIEWS OF THOSE TREATMENTS. IF
YOU GO TO THE LAST YOU REALIZE
WHEN IT COMES TO SURGERY,
EVERYTHING IS DIFFERENT. AFRICAN
AMERICAN PATIENTS IN GENERAL DO
NOT CONSIDER TOTAL REPLACEMENT
AS A USEFUL TREATMENT OPTION FOR
ENDS STAGE KNEE OA COMPARED TO
WHITES. SO YOU MIGHT SAY WHY IS
THAT? MULTIPLE FACTORS, SOME HAS
TO DO WITH PATIENT EXPECTATIONS,
REGARDING SURGICAL OUTCOMES.
SOME OF IT HAS TO DO WITH
PATIENTS FAMILIARITY AND KNOWING
RELATIVES OF COMMUNITY MEMBERS
WHO HAD THE TREATMENT AND THIS
SLIDE SHOWS A STUDY WE DID IN
CLEVELAND, WHAT WE FOUND WAS
AFRICAN AMERICAN PATIENTS WERE
MORE LIKELY TO HAVE CONCERNS
ABOUT WALKING AFTER THE
PROCEDURE. MORE CONSENSUS ABOUT
PAIN POST PROCEDURE. THEY
THOUGHT RECOVERY TIME WOULD TAKE
MORE THAN SIX MONTHS COMPARED TO
WHITES. MORE WORRIED ABOUT LONG
HOSPITAL COURSE, MORE THAN TWO
WEEKS, WE WILL COME BACK TO THIS
ISSUE BECAUSE IT MAY BE RELATED
TO SOMETHING THAT DR. CRISWELL
SAID WHICH IS MINORITY PATIENTS
ARE MORE LIKELY TO BE DISCHARGED
TO AN INSTITUTION AFTER
UNDERGOING KNEE OR HIP
REPLACEMENT WHICH MAY SHAPE THE
THOUGHTS ABOUT HOW LONG IT TAKES
TO BE IN A HOSPITAL. AFTER ALL
ACUTE HOSPITAL IS NO DIFFERENT
THAN A SNIFF IN THE MINDS OF
MANY OF THE PATIENTS. NEXT
SLIDE. IN SOME OF THOSE STUDIES
ONE OF THE THINGS WE ASK IN
COHORT OF PATIENTS WITH KNEE OA
OR HIP OA CANDIDATES FOR
TREATMENT, WE WANT TO KNOW WHAT
PATIENTS WOULD DO OR LIKE TO DO
IF DOCTOR RECOMMEND THE
TREATMENT. ONE OF THE THINGS YOU
REALIZE IS THAT AFRICAN AMERICAN
PATIENTS WERE ABOUT ALMOST 50%
LESS LIKELY TO BE WILLING TO
CONSIDER TOTAL REPLACEMENT EVEN
IF DOCTOR RECOMMENDED IT. WHEN
WE ADJUSTED FOR FACTORS SUCH AS
EDUCATIONAL LEVEL AGE ANNUAL
HOUSEHOLD INCOME AND RADIOLOGY
AND GERIATRIC SCORE AND
FAMILIARITY IT DOESN'T MAKE A
LOT OF DIFFERENT BUT WHEN WE
INCLUDE INTO THE MODEL PATIENT
CONCERNS ABOUT SURGICAL
OUTCOMES, EXPECTATION ABOUT
SURGERY THE ODD RATIO MOVED
CLOSER TO ONE THAT WAS NO LONGER
STATISTICALLY SIGNIFICANT
SUGGESTING THAT PART OF PATIENT
CONCERNS ABOUT SURGERY HAS TO DO
WITH CONCERNS ABOUT OUTCOMES.
WHAT ABOUT ORTHOPEDIC SURGERY IN
PATIENTS, THIS STUDY FUNDED BY
ROBERT WOOD JOHNSON FOUNDATION
WE INTERCEPTED PATIENTS AFRICAN
AMERICAN AND NON-AFRICAN
AMERICAN PATIENTS WHO REFERRED
TO ORTHOPEDIC SURGERY AND WANTED
TO KNOW HOW DID THEY COMMUNICATE
TO THE DOCTORS AND WHAT WAS THE
RECOMMENDATIONS AFTERWARDS. WE
AUDIOTAPED THE CONVERSATIONS ONE
THING WE FOUND IS THAT MINORITY
PATIENTS WERE SIGNIFICANTLY LESS
LIKELY TO BE RECOMMENDED FOR THE
JOINT REPLACEMENT, BUT THAT IS
ALMOST ALL ENTIRELY DUE TO THE
FACT THAT THAT BASELINE
PREFERENCE FOR THE TREATMENT WAS
VERY LOW TO BEGIN WITH. SO IN
OTHER WORDS, PHYSICIANS
ORTHOPEDIC SURGEONS ARE
CALIBRATING THE RECOMMENDATIONS
BASED ON WHERE PATIENTS ARE. AND
AFRICAN MESH PATIENTS LISTED
WHAT ARE DIFFERENT PLACES
COMPARED TO WHITE PATIENTS. SO
THE QUESTION THEN BECOMES YES,
IT LOOKS LIKE PATIENTS PLAY A
SIGNIFICANT ROLE, INSURANCE IS
NOT A DISPARITY, AFTERALL
STUDIES WE HAVE DONE IN THE VA
HEALTHCARE SYSTEM WHICH CLOSEST
WE HAVE IN THE UNITED STATES FOR
EQUAL ACCESS HEALTHCARE SYSTEM,
WE FOUND THAT DISPARITIES IN
JOINT REPLACEMENT USED TO BE
EXACTLY IDENTICAL WHAT WE FOUND
IN THE MEDICARE DATABASES. MORE
IMPORTANTLY SIGNIFICANT ALMOST
60% JOINT REPLACEMENT IN UNITED
STATES ARE PAID FOR BY MEDICARE
SO WE DON'T THINK ACCESS IS A
HUGE OR INSURANCE IS A HUGE
FACTOR IN DISPARITY, IT'S LITTLE
IF SOME. SO WHAT IS CLEAR TO US
FROM THIS STUDY IS PATIENT AND
THEIR PERCEPTION AND THEIR PLACE
IN TERMS OF THEIR THINKING, IS
IMPORTANT SOURCE OF SOURCE FOR
POTENTIAL TARGET FOR
INTERVENTION. SO IN A RANDOMIZE
CONTROL STUDY WE IDENTIFY
PATIENTS WHO ARE CANDIDATES FOR
JOINT REPLACEMENT AT THE PRIMARY
CARE LEVEL AND WE RANDOMIZE INTO
TWO POTENTIAL WAYS OF EDUCATING
THEM ABOUT THE RISKS AND THE
BENEFITS OF THE TREATMENT, WE
USE THE DECISION MADE THAT
REALLY WELL DEVELOPED OUT OF
BOSTON. AND WE USE MOTIVATIONAL
INTERVIEW, ANOTHER WAY OF
BEHAVIOR HELPING PATIENTS REALLY
FRAME THEIR OWN CHOICES. WE ALSO
WE HAVE DONE ASSESSED
WILLINGNESS AFTER UNDERGOING
THESE INTERVENTIONS AND THEIR
LACK OF RECEIVING DISCUSSING
THEIR PROBLEM WITH PRIMARY CARE
DOCTOR, PARTICULARLY WILLINGNESS
TO UNDERGO JOINT REPLACEMENT.
ONE OF THE THINGS WE FOUND THE
DECISION MADE WHICH ACTUALLY A
45 MINUTE LONG VIDEO TA TALKS
BEAUTIFULLY ABOUT DIFFERENT
OPTIONS AND TREATMENT OPTIONS
FOR KNEE OA, SIGNIFICANTLY
CHANGED. INITIALLY PATIENTS
WILLINGNESS AFRICAN AMERICAN
PATIENTS TO CONSIDER KNEE
REPLACEMENT IF OFFERED. AS YOU
CAN SEE BY ONE MONTH AND BY
THREE MONTHS HIGH. BUT OF COURSE
THIS WAS A ONE TIME INTERVENTION
SO THINGS WILL TAPERING OFF. SO
CLEARLY USING EDUCATIONAL TOOLS
PARTICULARLY EVIDENCE BASED DEAD
SESSION AIDS, COULD BE ACTUALLY
AN INTERVENTION FOR ELECTIVE
TREATMENT OR PREFERENCE
SENSITIVE TREATMENTS LIKE KNEE
AND HIP REPLACEMENT IN OUR
OPINION. BUT THE QUESTION THAT
WAS RAISED AFTER WE SUBMITTED
THIS PUBLISHED THIS STUDY WAS IT
IS ONE THING TO CHANGE A
PERSON'S THINKING ABOUT
TREATMENT, IT IS ALL TOGETHER IF
THEY UNDERGO THE TREATMENT. SO
WE ARE FUNDED BY NIAMS TO DO A
RANDOMIZE CONTROL STUDY. LOOKING
AT THE WHETHER THE DECISION MADE
WOULD CHANGE LIKELIHOOD OF
UNDERGOING KNEE OR HIP
REPLACEMENT. FOR COHORT OF
AFRICAN AMERICAN PATIENTS WHO
REFERRED TO ORTHOPEDIC SURGEON
IN PHILADELPHIA. AND TREMBLE
UNIVERSITY. WHAT WE FOUND IS CUT
TO THE CHASE IS THAT MINORITY
PATIENTS WHO VIEWED DECISION
MADE BEFORE SEEING ORTHOPEDIC
SURGEON WERE MORE LIKELY TO
UNDERGO KNEE REPLACEMENT AT 12
MONTHS. THAT WAS THROUGH
ANALYSIS PROTOCOL OR WHETHER WE
DID ANALYSIS OF INTENTION TO
TREAT ANALYSIS. SO THIS WAS A
UNEXPECTED ACTUALLY FINDING ON
OUR PART. NEXT SLIDE. SO THAT
IS REALLY ONE POSSIBLE
INTERVENTION IN OUR OPINION
READY FOR POTENTIALLY
IMPLEMENTATION AND DISSEMINATION
EDUCATIONAL TOOL, MANY OF YOU
KNOW HEALTH SYSTEMS ARE ADOPTED
SOME EDUCATIONAL TOOLS OR
PATIENTS NOT NECESSARILY AFRICAN
AMERICAN PATIENTS BUT ANYONE
CONSIDERING SURGERY BUT NOT
WIDELY USED AND IT IS NOT
SOMETHING PATIENTS APPLIES TO
PROCEED. ANOTHER POSSIBLE
INTERVENTION IDEA DOWN THE ROAD,
IS SORT OF EXPANDING ON A WORK
STARTED BY THIS GROUP OF PEOPLE
LED BY EMMA PEERSON WHO USE AI
TECHNOLOGY APPROACH TO
ASSESSMENT OF KNEE PAIN, AFTER
ALL PAIN IS AN IMPORTANT FACTOR
FOR QUALITY OF LIFE, WHICH IS A
KEY INDICATION FOR JOINT
REPLACEMENT. THERE ARE
DIFFERENCES IN DISPARITIES IN
PAIN ASSESSMENT MINORITY AND
NON-MINORITY PATIENTS IT IS
POSSIBLE THAT COULD HAVE
IMPLICATIONS TO WHO UNDERGOES
KNEE OR HIP REPLACEMENT. THEY
COMPARED ALGORITHM THEY
DEVELOPED USING AI MEEK NICHE
MANY WAYS TO ASSESSING OA
SEVERITY, IT IS A VALIDATED
SCALE THAT HAS BEEN DEVELOPED
OVER 30 YEARS AGO IN NORTHERN
ENGLAND. SO WITH VERY DIFFERENT
SAMPLE SO THEY USED THE SORT OF
SAMPLE TO RECALIBRATE AND CREATE
A DEVELOPED ALGORITHM AND THEY
FOUND REALLY ABLE TO POTENTIALLY
NARROW ASSESSMENT OF PAIN WITH
BLACKS AND AFRICAN AMERICANS AND
FIRST PART OF THIS SLIDE WE SEE
KNEE ELIGIBLE FOR SURGERY BY
RACE IS ON THIS CHANGED MARKEDLY
USE ALG VERSUS THE ALGORITHM
THEY DEVELOPED. THEY LOOKED
ALSO HOW NOT JUST RACE BUT LOW
INCOME AND LOW EDUCATION IMPACTS
THESE VARIATIONS. IN A
FOLLOW-UP I WAS ASKED TO WRITE
EDITORIAL TO ACCOMPANY THIS
PUBLICATION AND I APPLAUDED THE
TEAM FOR REALLY USING EMERGING
TECHNOLOGY TO HELP COME UP WITH
POTENTIAL WAYS TO INTERVENE,S
THAT IS NOT NECESSARILY FOCUSED
ON THE PATIENT BUT ALSO ON THE
HEALTH SYSTEM AND HOW WE ARE
ASSESSING PAIN. INDICATION FOR
TREATMENT. I DID IN THIS
EDITORIAL POINTED OUT THAT WE
SORT OF NEED TO UNDERSTAND PAIN
IS NOT THE ONLY INDICATION FOR
KNEE OR HIP REPLACEMENT BUT
OTHER PA FACTORS SUCH AS OTHER
THINGS THAT NEED TO BE LOOKED
INTO. EVERYBODY ALSO KNOWS HOW
PATIENTS EXPRESS PAIN FIRST BY
RACE ETHNICITY AND CORRELATION
PAIN AND PATIENTS RADIO LOGIC
EVIDENCE OF KNEE OA IS NOT VERY
GOOD. NEXT SLIDE. THIS IS A
PIECE THAT I BROUGHT WHICH I
MAKE THE CASE BY EDUCATING
PATIENTS, ABOUT THESE ELECTIVE
TREATMENTS WE MAY REDUCE
DISPARITIES. I WANT TO END BY
TAKING US WHERE WE THINK THIS
WORK NEEDS TO GO. THAT IS -- WE
NEED TO BE ABLE TO IMPLEMENT
WHAT WE FIND EVEN IF IMPACT IS
SMALL. THAT IS REALLY THE
FRONTIER OF THE FILL. I HAVE
BEEN TRYING TO GET MY HEALTH
SYSTEM TO ADOPT SOME OF THESE
HIGHLY VALIDATED EVIDENCE BASED
EDUCATIONAL TOOLS FOR SHARED
DECISION MAKING FOR PATIENTS
WITH KNEE OA. THAT IS THE WORK
WE NEED TO DO MORE. IN MY
OPINION. THANK YOU. I WILL STOP
HERE AND HAPPY TO TAKE QUESTIONS
LATER ON. I SEE THERE ARE SOME
QUESTIONS IN THE CHAT ALREADY
BUT BACK TO DR. KWOH.
>> IT IS TIME FOR THE PANEL
DISCUSSION. THANK YOU, DR.
NELSON AND DR. IBRAHIM. WE ARE A
LITTLE OVER TIME SO WE WOULD ASK
FOR SHORT QUESTIONS AND SHORT
ANSWERS. FROM DR. MARY ANN HAHN
NON, DISCONNECT BETWEEN
TREATMENT PROVIDERS, ARE
PHYSICAL THERAPISTS BETTER ABLE
TO COMMUNICATE OUTCOMES TO
PATIENTS? I DON'T RECALL IF WE
HAVE STUDIES LOOKING AT
COMMUNICATION BETWEEN PHYSICAL
THERAPISTS AND DIFFERENCES BY
RACE. SAID, DO YOU RECALL THOSE
STUDIES?
>> EXCELLENT QUESTION. IT IS ONE
OF THOSE AREAS THAT NEED MORE
RESEARCH. I AM NOT FAMILIAR WITH
THAT RESEARCH AT THE MOMENT.
>> ANOTHER PLACE TO INTERVENE IN
TERMS OF HEALTH DISPARITIES, A
GOOD POINT. QUESTION IN TERMS OF
LOW BONE DENSITY AFFECT DECISION
O HAVE JOINT REPLACEMENT, I
DON'T THINK THAT'S THE CASE.
AMANDA, DO YOU KNOW OF ANYTHING?
TERMS OF BONE DENSITY AND
DECISIONS OF JOINT REPLACEMENT?
>> I DON'T. CERTAINLY THERE IS
ASSOCIATION BETWEEN BONE DENSITY
AND OA. BUT I DON'T THINK IT
AFFECTS THE DECISION.
>> I DON'T THINK SO. DECISION
ITS IMPLEMENTATION, SAID YOU
TALKED ABOUT THIS, TOUCHED UPON
IT. ARE YOU ABLE TO MENTION IN
TERMS OF LITTLE BIT MORE HEALTH
SYSTEMS AND HOW IT'S SUCCESSFUL?
PARTICULARLY SAY ARE THESE
DISSEMINATION EFFORTS COST
EFFECTIVE FOR HEALTH SYSTEM?
>> THAT IS REALLY A GOOD
QUESTION. FIRST I THINK MANY OF
YOU PROBABLY KNOW CMS HAS BEEN
ENCOURAGING HEALTH SYSTEMS TO
ADOPT SHARED DECISION MAKING
TOOLS IN GENERAL. IN FACT
ACTUALLY OA MANAGEMENT SPECIFIC
ONE IS TMS HAS IDENTIFIED AS A
SCRIBE FOR SHARED DECISION
MAKING. THERE ARE DIFFERENT WAYS
OF DOING IT. DECISION AIDS IN MY
OPINION ARE JUST ONE WAY TO DO
IT. IN OUR STUDIES, WE USE THE
DECISION AID AS A SORT OF
VEHICLE FOR EVIDENCE BASED
INFORMATION. WE DIDN'T REALLY
USE AS A SHARED DECISION MAKING
TOOL. WE JUST WANTED TO EDUCATE
OUR PATIENTS USING A VALID
APPROACH ABOUT RISKS AND
BENEFITS AND WHO SHOULD AND WHO
SHOULDN'T. BUT IT IS REALLY --
THE OTHER CHALLENGE THAT I FIND
ABOUT THE IMPLEMENTATION OF
DECISION AIDS AS A FORM OF
SHARED DECISION MAKING, TOOL,
THERE'S SO MANY OF THEM. SOME
ARE BETTER THAN OTHERS. THE ONE
WE USE, COCHRAN APPROVED
DECISION AID WHICH BY THE WAY IS
NO LONGER AVAILABLE OR
ACCESSIBLE BECAUSE IT BECAME A
BILLION DOLLAR THING AND IT WAS
BOUGHT BY WALGREEN'S NOW SO IT
IS GONE. IT WEPT TO WALL STREET
SO WE CAN ACTUALLY USE THAT, IT
IS VERY TOO EXPENSIVE BUT OUR
OTHERS THAT ARE OUT THERE, THAT
COULD BE USEFUL, QUESTION IS HOW
EVIDENCE BASED ARE THEY AND HOW
RELIABLE ARE THEY. SO NOT UNLESS
I THINK -- NONETHELESS IT IS
REALLY IMPORTANT WE PROVIDE SOME
SORT OF EDUCATION AT A SYSTEM
LEVEL POPULATION LEVEL FOR IN
ORDER FOR US TO MAKE DIFFERENCE
IN THIS DISPARITY.
>> INTERESTING QUESTION, COMMENT
FROM JEFF KATZ, DECISION AIDS
ARE OFTEN USED TO DECREASE
UTILIZATION, WHEREAS IN TERMS OF
HEALTH DISPARITIES IT INCREASED
UTILIZATION. I DON'T KNOW IF
YOU WANT TO COMMENT.
>> THAT WAS -- THAT IS A
BEAUTIFUL QUESTION, JEFF,
BECAUSE THAT WAS ONE OF THE
REASONS WE PICKED THE DECISION
AID WE PICKED. IT WAS DECIDED
THROUGH USE UTILIZATION BUT NOT
NECESSARILY AFRICAN AMERICANS,
FOR EVERYBODY. THAT WAS CRITICAL
IN OUR DECISION MAKING AS TO
WHETHER TO USE IT OR NOT BECAUSE
WE DIDN'T WANT TO BE PERCEIVED
AS OVERSELLING THE TREATMENT. SO
WE KNEW IT WAS CONSERVATIVE WAY
OF COMMUNICATING. SO YES WE WERE
AWARE OF THAT. IN FACT ONE OF
THE THINGS THAT WE ALSO DID IS
THAT THE SYSTEM AID WE USED HAD
FIVE PATIENTS TWO DECLINED THREE
SAID YES TO KNEE REPLACE. , THEY
TALKED ABOUT THEIR EXPERIENCE,
THEY WERE ALL INTERVIEWED BY
MINORITY ORTHOPEDIC SURGEON. SO
WE ASKED THEM TO EXPAND NUMBER
OF PEOPLE, FOR MORE AFRICAN
AMERICANS SO WE CAN SEE A MORE
BALANCED DIVERSE GROUP. THEY DID
THAT. THEY RECREATED THE
DECISION AID, ADDED AFRICAN
AMERICAN PATIENT WHO REFUSED TO
HAVE THE TREATMENT AFTER KNOWING
ALL THE THINGS THEY NEED TO
KNOW. SO THAT IS A WELL DONE,
TOO BAD IT IS NOT ACCESSIBLE AND
TOO EXPENSIVE TO USE BUT IT IS A
GOOD STRATEGY FOR EDUCATING
PATIENTS.
>> THAT IS ALSO IMPORTANT POINT,
SAID, THAT WHEN WE TALK ABOUT
DECISION AIDS, LOOKING AT THERE
IS A LOFT THEM BUT ALSO NEED TO
BE CULTURALLY APPROPRIATE. YOU
AND I HAVE TALKED, IT WASN'T
BALANCED BEFORE SO SOMETHING TO
THINK ABOUT AS WE DO
DISSEMINATION.
>> ABSOLUTELY. THAT IS A KEY I
DIDN'T MEAN THE INTERRUPT, BUT I
DO RECALL BACK IN PITTSBURGH
USING THIS DECISION AID WE WERE
FUNDED BY NIA IN A SMALL GRANT
TO DO A FOCUS GROUP MAKE SURE
DECISION AID WAS ACCEPTABLE TO
MINORITY PATIENTS. AND THAT IT
IS CULTURALLY REASONABLE TO
THEM. SO WE RECRUITED MINORITY
PATIENTS AND DID FOCUS GROUPS,
SHOWED THEM DECISION AID AND
MADE SURE IT WAS ACCESSIBLE AND
FEASIBLE TO USE.
>> KEY POINT. THERE IS A
QUESTION IN TERMS OF BIOLOGICAL
MECHANISMS AND WORSE PAIN IN
RACIAL ETHNIC MINORITIES. AMANDA
YOU WERE ANSWERING THAT
QUESTION?
>> IONSED IN THE CHALET BECAUSE
TIME IS RUNNING SHORT. I DID
MENTION THERE ARE SOME FEATURES
MINORITY INDIVIDUALS TEND TO
HAVE MORE PAIN QUAS THAT STRAY
FIES, MORE CATASTROPHIZING.
REASONS TO REPORT GREATER PAIN
BUT THERE'S UNEXPLAINED
CONFOUNDERS IN THESE ANALYSES WE
HAVE NOT ASSESSED WELL.
>> I THINK WE PROBABLY SHOULD
PAUSE HERE. WE HAVE PEOPLE TIME
FOR BIO BREAK BEFORE WE MOVE TO
THE NEXT SESSION. I WOULD LIKE
TO THANK DR. IBRAHIM, DR. NELSON
AND ALL THE OTHER PARTICIPANTS
FOR GREAT DISCUSSION. THANK
YOU.
>> THANK YOU.
>> THANK YOU, EVERYONE FOR OUR
SESSION 1 DISCUSSIONS AND THE
ROBUST DISCUSSION WE HAD. I KNOW
WE DIDN'T HAVE TIME FOR ALL THE
QUESTIONS SO IF THE SPEAKERS ARE
WILLING AND YOU HAVE MORE
QUESTIONS TO PUT IN THE CHAT
MAYBE THEY WILL FOLLOW-UP WITH
YOU DURING THE BREAK AND WE WILL
STOP HERE AND RESUME AT 12:15.
>>WELCOME BACK, EVERYBODY. WE
WILL GET STARTED WITH SESSION 2
WE WILL HEAR FROM A DIVERSE
GROUP OF SPEAKERS ON FACTORS
THAT IMPACT DISPARITIES IN
OSTEOARTHRITIS. SESSION 2 WILL
BE MODERATED BY CO-CHAIR DR.
LEIGH CALLAHAN, UNIVERSITY OF
NORTH CAROLINA. DR. CALLAHAN, I
WILL TURN IT OVER TO YOU.
>> THANK YOU VERY MUCH, CHRISTY.
WELCOME BACK, EVERYONE. I WANT
TO OFFER MY THANKS TO THE
OUTSTANDING SPEAKERS WE HAD IN
SESSION ONE. SESSION 2 WE WILL
FOCUS ON PERSONAL INTERPERSONAL
INFLUENCES ON OA CARE AND WE
HAVE THREE WONDERFUL SPEAKERS
FOR THIS SESSION AS WELL. THEIR
COMPLETE BIO EGG ARE IN YOUR
MEETING MATERIALS AND I WILL
GIVE A BRIEF OVERVIEW OF THE
SPEAKER BEFORE THEY SPEAK. THE
FIRST SPEAKER IS DR. JEFF KATZ,
PROFESSOR MEDICINE ORTHOPEDIC
SURGERY AT HARVARD MEDICAL
SCHOOL AND PROFESSOR
EPIDEMIOLOGY HARVARD SCHOOL OF
PUBLIC HEALTH. HE HOLDS A CLINIC
SLEDGE DISTINGUISHED CHAIR IN
ORTHOPEDIC SURGERY AT BRIGHAM
AND WOMEN'S HOSPITAL. DR. KATZ
IS GOING TO GIVE AN OVERVIEW OF
SOCIOECONOMIC STATUS AND
DISPARITIES. JEFF.
>> THANK YOU, LISA. I WILL WAIT
TO SEE MY FIRST SLIDE. THANK
YOU. SO SUBTITLE HOW
SOCIOECONOMIC FACTORS IMPACT
DISPARITIES WHICH I THOUGHT WAS
A VERY CHALLENGING QUESTION
WHICH I WILL COME BACK TO IN THE
END, IT IS A FAIRLY SUBTLE
QUESTION. NOT SURE I HAVE THE
ANSWER BUT IF WE GO QUICKLY TO
THE NEXT SLIDE O FOR DISCLOSURES
FUNDED BY NIAMS. SO WHAT I WILL
DO AS DR. CALLAHAN SAID IS TO
DELINEATE SOCIAL DETERMINANTS OF
HEALTH THAT MAY INFLUENCE RISK
OF OA ONSET AND OUTCOMES TO TALK
A LITTLE BIT ABOUT MEASUREMENT
AND DATA SOURCES. TO GIVE COUPLE
OF EXAMPLES WE HAVE SEEN MANY
ALREADY SO THIS WILL BE LIGHT OF
ASSOCIATIONS OF SOCIAL
DETERMINANTS WITH OA ONSET OR
OUTCOMES AND THEN TO DELVE INTO
THIS QUESTION OF WHETHER SOCIAL
DETERMINANTS INFLUENCE
DISPARITIES IN OUTCOME SAND I
WILL MAKE COUPLE OF METHOD LOGIC
POINTS WITH RESPECT TO THAT
ISSUE IN THE END. SO WE WILL GO
TO THE NEXT SLIDE PLEASE. DR.
NELSON PRESENTED THIS ALREADY
JUST TO GET US STARTED, THE
HEALTHY PEOPLE 2030
CONCEPTUALIZATION OF SOCIAL
DETERMINANTS OF HEALTH ARE THE
CONDITIONS IN THE ENVIRONMENT.
ENVIRONMENTS WHERE PEOPLE ARE
BORN LIVE LEARN WORK PLAY
WORSHIP AND AGE THAT AFFECT WIDE
RANGE OF HEALTH FUNCTIONING AND
QUALITY OF LIFE OUTCOMES AND
RISKS AND THEY CREATED THE FIVE
DOMAINS THAT AMANDA POINTED OUT
ALREADY. HOW ARE SOCIAL
DETERMINANTS MEASURED? DEPENDS
ON THE DATA SOURCE. WE CAN AT
THE INDIVIDUAL LEVEL LEVEL OF
INDIVIDUAL RESEARCH SUBJECT OR
PATIENT LOOK AT INSURANCE STATUS
INCOME EDUCATIONAL ATTAINMENT
USING SOURCES THAT PROVIDE DATA
AT THE INDIVIDUAL LEVEL SUCH AS
MEDICAL RECORDS, INSURANCE
CLAIMS, HOSPITAL DISCHARGE
ABSTRACTS OR SURVEYS THAT ARE
ADMINISTERED ROUTINELY OR AS
PART OF RESEARCH. THERE IS A
GROWING TRADITION AS WELL OF
MEASURING SOCIAL DETERMINANTS AT
HE CAN LOGIC LEVEL OFTEN THE
NEIGHBORHOOD USING CENSUS DATA
OR SEVERE STATE OR NATIONAL
DATABASES, AND HERE ONE CAN LOOK
AT NOT INDIVIDUAL LEVEL BUT AREA
LEVEL VARIABLES SUCH AS INCOME
HOUSING EDUCATION SEGREGATION.
TO MAKE IT MORE CONCRETE ON THE
LEFT WE HAVE A FEW OF MANY
EXAMPLES OF INDIVIDUAL LEVEL
SOCIAL DETERMINANTS THAT CAN BE
OBTAINED FROM QUESTIONNAIRES OR
CLAIMS OR MEDICAL RECORDS
EMPLOYMENT STATUS INCOME OR
INCOME CATEGORY EDUCATIONAL
ATTAINMENT INSURANCE STATUS AND
THEN DATA CAN BE OBTAINED AT THE
ECOLOGICAL OR AGGREGATE LEVEL
PERCENT PLOYED MEANING THE
SUBJECT OR PATIENT LIVES IN AN
AREA WHERE THE PERSON EMPLOYED
EXCEED A CERTAIN NUMBER OR WHERE
THE PROPORTION OF PEOPLE WITH
INCOME GREATER THAN THE POVERTY
LEVEL EXCEED CERTAIN PERCENTAGE,
ET CETERA, AND THEN OTHER
DATABASES BEYOND CENSUS GATHER
ECOLOGICAL DATA SUCH AS LEAD
LEVELS IN WATER HOMICIDE PER
CAPITA AND OTHER EXAMPLES. I
THINK THAT SOME RESEARCHERS WILL
TURN TO AREA LEVEL INDICATORS AS
PROXIES FOR INDIVIDUAL LEVEL
INDICATORS BECAUSE INDIVIDUAL
LEVEL INDICATORS ARE UNAVAILABLE
IN MANY DATABASES BUT THAT IS
CERTAINLY NOT THE ONLY OR I
WOULD SAY PREFERRED USE OF AREA
LEVEL INDICATORS, THERE IS A
RICH SOCIAL SCIENCE THEORY THAT
EMPHASIZES ROLE OF INDIVIDUAL
NEIGHBORHOOD IN THEIR
ENVIRONMENT IN AFFECTING
INDIVIDUAL BEHAVIOR AND HEALTH
INCLUDING HOUSING EMPLOYMENT,
EDUCATIONAL OPPORTUNITIES THAT
SURROUND THEN, ENVIRONMENTAL
TOXINS OR GLUTIN, CULTURAL
FACTORS OBSERVED IN THEIR
NEIGHBORS AND I HAVE GIVEN PA
GRAPHIC FROM THAT PAPER IS ON
THE RIGHT OF THE SLIDE, THAT
GIVES A SENSE HOW FACTORS CAN BE
MEASURED AT INDIVIDUAL
ORGANIZATIONAL A AND COMMUNITY
LEVEL AND THESE DIFFERENT LEVELS
OF INFORMATION INFORM EACH OTHER
TO CREATE VECTORS OF USED IN
MEASUREMENT
A. CXFC I WON'T DELVE INTO THAT
HERE BUT DO RECOMMEND THIS PAPER
TO YOU. ONE FAIRLY FREQUENTLY
USED WAY OF AGGREGATING AREA
LEVEL DATA IS SOCIAL
VULNERABILITY INDEX THE CDC HAS
PUT TOGETHER THAT USES CENSUS
DATA, 15 VARIABLES ARE SHOWN ON
THE RIGHT RIGHT. MOST PART OF S
SLIDE THAT AGGREGATE TO FOUR
DOMAINS WHICH IS MIDDLE PART OF
THE SLIDE WHICH ARE FURTHER
AGGRAVATED INTO OVERALL
VULNERABILITY AND INVESTIGATORS
USED DOMAIN LEVEL AS WELL AS
OVERALL LEVEL VULNERABILITY
INSIGHTS TO GAIN INSIGHT TO
SOCIAL DETERMINANTS. A VALIDITY
CHECK FOR KNOW BOSTON A BIT,
DARK BLUE AREAS ARE THE AREAS OF
GREATEST SOCIAL VULNERABILITY
AND TRACKED VERY WELL WITH SOME
OF OUR MOST VULNERABLE
NEIGHBORHOODS FROM SOUTH TO
NORTH, NOR CHESTER ROCKS BURY
WHICH HE IS SEE AN WINTHROP SO
THIS FOR PEOPLE WHO KNOW THE
AREA IS REALLY NICE VALIDITY
CONFIRMATION. THERE IS RICH
LITERATURE THAT LINKS, WE
PRESENTED EARLIER NICE EXAMPLES
AS DID DR. IBRAHIM SO HERE IS
ONE MORE FROM NORTH CAROLINA
GROUP, BECK KY CLEVELAND'S PAPER
WHICH I LIKE BECAUSE OF THE
INFERENCES WE CAN MAKE SO THIS
IS A TABLE SHOWING ASSOCIATION
DIFFERENT SOCIAL DETERMINANTS OF
HEALTH WITH TOTAL WOMAC SCORE
AMONG PERSONS WITH SYMPTOMATIC
RAID YES GRAPHIC OA IN JOHNSTON
COUNTY OA PROJECT. THE SCORE
RANKS FROM 0 TO 96 POINTS WITH
96 BEING WORSE AND MEAN 34,
STANDARD DEVIATION WITH THIS
COHORT. FIRST YOU CAN SEE WHAT
WE ARE LOOKING AT ARE COUPLE OF
INDIVIDUAL LEVEL INDICATORS,
EDUCATIONAL ATTAINMENT AND
OCCUPATION AND AGGREGATE LEVEL
INDICATORS IN TERMS OF POVERTY
RATE EACH CONTRIBUTES TO HIGHER
OR WORSE WOMAC SCORE COMPARED TO
PERSONS WHO DON'T HAVE THE
INDICATOR WHO HAVE GREATER THAN
12 YEARS EDUCATION, ALSO NOTABLE
THESE DIFFERENCES FROM SMALL.
THREE OR FOUR POINTS WHICH IS
ABOUT A FIFTH STANDARD
DEVIATION. IN ANALYSES IT JUST
AS YOU CAN SEE THE BOTTOM OF THE
SLIDE FOR VARIETY OF FACTORS,
SOCIAL DETERMINANTS INFLUENCE
REPORT OF PAIN AND FUNCTION BUT
MILDLY SO. AT THE BOTTOM HALF OF
THE TABLE EACH INDICATOR ADJUST
FOR ONE ANOTHER YOU CAN SEE
EFFECTS ARE ATTENUATED
SUGGESTING NO SURPRISE
INDICATORS ARE CORRELATED WITH
ONE ANOTHER, THAT HAS LED TO
CREATE ADDITIVE INDICES TO AVOID
THE PROBLEM OF INTERCORRELATION.
SO THESE ARE INDIVIDUAL LEVEL
DATA FROM CDC BEHAVIORAL RISK
SURVEILLANCE SURVEY, AND WHAT WE
HAVE IN 36,000 INDIVIDUALS 26%
REPORT ARTHRITIS AND PREVALENCE
OF SELF-REPORTED ARTHRITIS
INCREASES FROM 12% AMONG THOSE
WITH 0 OF THESE SOCIAL
DETERMINANTS TO ABOUT TWICE THAT
AMONG THOSE WITH FOUR WITH DOSE
RESPONSE. SO THIS IS A NICE WAY
TO HANDLE THE DATA AND FROM THE
SAME STUDY, IN THE TABLE THE
FOUR COLUMNS SHOW ADDITIONAL
OUTCOMES THE AUTHORS LOOKED AT,
LIMITED ACTIVITIES, LIMITED
WORK, ET CETERA AND IN EACH SEE
THE SAME PATTERN PEOPLE WITH
FOUR OR FIVE SOCIAL DETERMINANTS
OF HEALTH HAVE TWO OR THREE
TIMES THE LIKELIHOOD OR RISK OF
HAVING THESE ADVERSE OUTCOMES,
DISPOSED WITH ZERO. TO THE NEXT
SLIDE. HERE IS THE CONUNDRUM I
DISCUSS AT THE OUTSET. I WAS
LOOKING CAREFULLY FOR DATA THAT
ILLUSTRATE THE AFFECT OF SOCIAL
DETERMINANTS OF HEALTH ON
DISPARITIES RACIAL ETHNIC
DISPARITIES AND OUTCOME. I
BELIEVE THE LITERATURE IS SPARSE
AND INTERESTED IN OTHERS ARE
AWARE OF EXAMPLES IN OUR FIELD,
I FOUND A NICE EXAMPLE FROM THAT
RELATES TO COMPLICATIONS OF
CORONARY ARTERY BYPASS GRAFT OR
CABBAGE OWN SURGERY SO ON THE Y
ACCESS WE SEE RISK OR THE
PREVALENCE OF SERIOUS
COMPLICATIONS OF BYPASS SURGERY,
ON THE X AXIS WE SEE THE SOCIAL
VULNERABILITY INDEX FROM 0 TO
100, 100 BEING MOST VULNERABLE.
THE DARK LINE ARE NON-WHITES AND
WHITE LINE THE DASHED LINES ARE
WHITES. SO COUPLE OF
OBSERVATIONS THE DARK LINE IS
SITUATED ABOVE THE DASH LINE. SO
THIS IS ANOTHER DISPARITY WHERE
NON-WHITES HAVE MORE
COMPLICATIONS THAN WHITES.
ANOTHER OBSERVATION IS THAT BOTH
LINE VERSUS A POSITIVE SLOPE
MEANING THERE ARE GREATER
COMPLICATIONCATIONS FOR THOSE
WHO ARE MORE VULNERABLE THAN
THOSE WITH LESS VULNERABILITY
AND A THIRD OBSERVATION IS THAT
THE LINES ARE NOT PARALLEL SO IF
YOU LOOK AT THE DISPARITY THE
RISK IN NON-WHITES COMPARED TO
WHITES AT HIGHEST END OF SBI
ABOUT 1.24, AT LOWEST 1.1 SO
THERE IS A DIFFERENCE, TO ME
THOUGH WE DON'T SEE HERE THESE
STATISTICAL SIGNIFICANCE OF THIS
DIFFERENCE BUT JUST ON THE
SURFACE IN TERMS OF MAGNITUDE OF
EFFECT IS IT DOES APPEAR
INFLUENCE OF SOCIAL DETERMINANT
OF HEALTH SBI ON THE
DISPARITIES. I WILL CLOSE WITH
A COUPLE OF METHOD LOGIC POINTS,
I WOULD LIKE MOTIVATE THESE BY
PRESENTING/I MADE THIS UP A
COHORT OF A THOUSAND INDIVIDUALS
WHO DO OR DO NOT DEVELOP
INCIDENCE OA, 23% IN THIS
EXAMPLE DO DEVELOP IT. ABOUT 150
OR 15% COHORT ARE BLACK. THE
OTHERS NON-BLACK. AS I DEVELOPED
THIS 40% OF THE BLACKS DEVELOP
OA, 20% NON-BLACKS SO RISK RATIO
IS 2.0. SO IF WE GO TO THE NEXT
SLIDE, ONE ANALYSES THAT IS
OFTEN HELPFUL TO DO IN TRYING TO
DISENTANGLE THE ROLE OF RACE OR
ETHNICITY, OUTCOME OF INTEREST
IS TO DO ADJUSTMENT FOR IN THIS
CASE SIMPLE STRATIFICATION.
THIS IS A MADE UP EXAMPLE, I
STRATIFIED BY INCOME AND FIND
THE RISK RATIOS ARE CLOSE TO 1.
FOR BOTH HIGH INCOME AND LOW
INCOME GROUPS. SO THERE IS
WITHIN THE HIGH INCOME GROUP NOT
A RACIAL DISPARITY OR NOR LOW
INCOME GROUP SO WHAT WE CAN
CONCLUDE IS INCOME IS RELATED TO
INCIDENCE OF IA LOW INCOME
RELATED TO INCIDENCE OA BLACKS
ARE MORE LIKELY TO HAVE LOW
INCOME AND THIS NEED TO BE
ASSESSED FORMALLY AND CONFIRMED
WITH ANALYSIS BUT WHAT WE LEARN
FROM THIS ANALYSIS, IS A PATHWAY
WHERE DISPARITY IN RACE CAN BE
EXPLAINED IN THIS EXAMPLE BY
INCOME. I WILL CONTRAST THAT
WITH THE NEXT SLIDE WHERE WE DO
SIMILAR EXERCISE BUT DIFFERENT
FINDINGS. SO HERE THIS IS WHERE
REMINISCENT OF CABBAGE EXAMPLE I
SHOWED YOU A MOMENT AGO. HERE
STRATEGY PHID BY SOCIAL
DETERMINANT OF HEALTH, YOU HAVE
HIGH INCOME GROUP RELATIVE RISK
IS .9 BUT IN THE LOW INCOME
GROUP THE BLACKS ARE 2.3 TIMES
MORE LIKELY THAN WHITE PERSONS
TO HAVE OSTEOARTHRITIS, SO WE
SEE A MARKED DISPARITY. SO THIS
IS AN EXAMPLE WHERE WE
ESSENTIALLY PERFORM ANALYSIS
LOOKING FOR INTERACTION AND UPON
FINDING IT COULD INDEED CONCLUDE
THAT SOCIAL DETERMINANT INCOME
DOES INFLUENCE DISPARITY IN OA
BY INCIDENCE BY RACE. IF I CAN
CONCLUDE ON THE FINAL SLIDE
SOCIAL DETERMINANTS IS ADJUSTED
CAN BE MEASURED AT THE
INDIVIDUAL HE CAN LOGIC OR AREA
LEVEL AND THAT WHILE THE HE CAN
LOGIC MEASURES ARE OFTEN
PROXIES, INDIVIDUAL BEHAVIOR
DOES IN RARE INSTANCES MIRROR
THOSE OF NEIGHBORS AND
INFLUENCED BY HE CAN LOGIC
FACTORS HOUSING, ET CETERA, AS I
HAVE SHOWN AMANDA SHOWED. SOCIAL
DETERMINANTS ARE INTERCORRELATED
SO USING ADDITIVE INDICES CAN BE
HELPFUL WAY TO APPRECIATE THE
CUMULATIVE IMPACT. THERE ARE
NUMEROUS EXAMPLE SOCIAL
DETERMINANTS INFLUENCE OA
INCIDENCE AN OUTCOMES AND THERE
ARE EXAMPLES AND I SHOWED YOU A
FICTITIOUS ONE BUT THERE ARE
MANY EXAMPLES SOCIAL
DETERMINANTS MEDIATE RACE AND
ETHNICITY. I THINK IT IS UNUSUAL
TO FIND PUBLISHED EXAMPLES WHERE
SOCIAL DETERMINANTS INFLUENCE
DISPARITIES MEANING THAT THE
RESEARCHERS HAVE DONE
STATISTICAL INTERACTIONS TO
DESCRIBE THESE DISPARATE RISK
RATIOS DEPENDING ON THE LEVEL OF
SOCIAL DETERMINANT. SO THE FIRST
GAP I WOULD POINT TO IS TO TRY
TO UNDERSTAND WHETHER THERE IS
RESEARCH OR TO SUGGEST RESEARCH
THAT EXAMINES WHETHER SOCIAL
DETERMINANTS INFLUENCE
DISPARITIES AND INCIDENCE OR
OUTCOME. THAT HAS REALLY
IMPORTANT IMPLICATIONS FOR HOW
WE AND WHERE WE WOULD TARGET
INTERVENTIONS. I THINK IT IS
ALSO USEFUL TO DISTINGUISH AMONG
THOSE OUTCOMES THAT APPEAR
INFLUENCED PRIMARILY BY
INDIVIDUAL LEVEL IN PARTICULAR
THOSE THAT APPEAR INFLUENCED
PRIMARILY BY HE CAN LOGIC OR
AREA LEVEL SOCIAL DETERMINANTS
BECAUSE THAT WOULD HAVE SOME
IMPORTANT IMPLICATIONS FOR
INTERVENTION. FINALLY THE THIRD
GAP, THIS WILL FOLLOW DR.
IBRAHIM'S COMMENTS, IS WE HAVE
REACHED THE STAGE IN THIS ARENA
WHERE WOULD BE EXTREMELY USEFUL
TO FIELD INTERVENTIONS, BOTH THE
INDIVIDUAL AND WHERE APPROPRIATE
AREA LEVEL TO TRY TO ADDRESS
SOME OF THE RACIAL ETHNIC
DISPARITIES SO WELL DOCUMENTED.
>> THANK YOU VERY MUCH, JEFF,
THAT WAS AS USUAL VERY THOUGHT
PROVOKING TALK. OUR NEXT WE WILL
MOVE TO THE NEXT SPEAKER, IN
THIS SESSION, AND THAT IS DR.
SANDRA SOTO, UNIVERSITY OF NORTH
CAROLINA CHAPEL HILL H. SHE IS
ASSISTANT PROFESSOR IN SCHOOL OF
NURSING AND ALSO MEMBER OF THE
FIRST ARTHRITIS RESEARCH CENTER
AND SHE WILL FOCUS ON PATIENT
PROVIDER RELATIONSHIP
COMMUNICATION.
>> THANK YOU. I HAVE NO
CONFLICTS OF INTEREST TO
DISCLOSE. FIRST I WILL BRIEFLY
COVER SOME OVERARCHING PATIENT
PROVIDER COMMUNICATION ISSUES
AND CARE OCCUR ACROSS PATIENTS
NOT SPECIFIC TO HEALTH DIVISION
PARITIES YET. SO IN THIS
COMMUNICATION HAPPENS BETWEEN
PATIENTS WITH OA AND PROVIDERS
DUE THE MISALIGNED EXPECTATIONS
AROUND PRESCRIPTION MEDICATIONS
AND REFERRALS. WE SEE THIS BREAK
DOWN LEADS TO DECLINES AND
TREATMENT ADHERENCE. HOWEVER
BREAK DOWNS IN COMMUNICATION GO
BEYOND DISAGREEMENT ABOUT
TREATMENT OPTIONS THEY INCLUDE
INCONSISTENT EDUCATION AND
DISCUSSION AROUND OA MANAGEMENT.
IN A META ANALYSIS OF STUDIES
ASSESS THE CARE PROVIDED TO
PATIENTS WITH OA THE AUTHORS
PAYMENT PROVIDER ADHERENCE TO
SIX QUALITY INDICATORS IN OA
CARE. THE TWO QUALITY INDICATORS
WITH LOWEST ADHERENCE WERE
OFFERED EDUCATION AND/OR SELF
MANAGEMENT WITH ADHERENCE RATE
OF 35%. INFORMED ABOUT POTENTIAL
RISKS IF N SAID PRESCRIBED WITH
ADHERENCE RATE OF ONLY 34%. THIS
META ANALYSIS AND OTHER RESEARCH
LED TO DEVELOPMENT OF CORE
CAPABILITY FRAMEWORK FOR
PROVIDERS CARING FOR PATIENTS
WITH, OA WHICH IS WHERE THIS
INFO GRAPHIC ON THE RIGHT COMES
FROM. THE FRAMEWORK HIGHLIGHTS
13 BROAD SKILLS AREAS THAT
PROVIDERS SHOULD DEVELOP TO
PROVIDE QUALITY CARE TO THEIR
PATIENTS. NOTE THAT
COMMUNICATION IS LISTED FIRST
AND NO THIS IS NOT BECAUSE THE
LIST IS ALPHABETICAL ORDER.
COMMUNICATION WAS LIKELY PUT AT
THE TOP OF THE LIST TO EMPHASIZE
IMPORTANCE OF SKILL HAS ON
QUALITY OA CARE AND HOW IT
RELATES TO OTHER SKILLS ON THE
LIST. NOW WE WILL FOCUS IN ON
HOW DIFFERENT PATIENT
CHARACTERISTICS PLAY A ROLE IN
PATIENT PROVIDER COMMUNICATION.
HERE ARE EXAMPLES, I WILL
HIGHLIGHT A FEW. LIMITED HEALTH
LITERACY COMES INTO PLAY BECAUSE
IT COMPLY CASE COMMUNICATION
ESPECIALLY REGARDING OA AND
OTHER CHRONIC DISEASE MANAGEMENT
THAT REQUIRE ONGOING CARE.
RACIAL ETHNIC MINORITIES
EXPERIENCE COMMUNICATION
DISPARITIES EVEN WHEN THERE ARE
NO HEALTH LITERACY OR LINGUISTIC
BARRIERS. RESEARCH SHOWS THAT
AFRICAN AMERICAN PATIENTS
EXPERIENCE LOWER QUALITY
COMMUNICATION WITH PROVIDERS
THAN WHITE PATIENTS. AFRICAN
AMERICAN, LATINOS AND OTHER
MINORITIES HAVE INDIVIDUALLY AND
HISTORICALLY EXPERIENCED
INFERIOR QUALITY OF CARE
RESULTING IN DISTRUST AND
MISTRUST OF HEALTHCARE PROVIDERS
AND THE HEALTHCARE SYSTEM. WE
KNOW LESS ACULTUREATED LATINOS
ARE SKEPTICAL OF PHARMACEUTICALS
AND PREFER ALTERNATIVE
TREATMENTS. CRITICAL OR PROVIDER
RELATIONSHIP WITH PHARMACEUTICAL
INDUSTRY AND THEY HAVE LESS
PREFERENCE FOR SURGICAL
TREATMENT. AS DO AFRICAN
AMERICANS. SO I WANT TO NOTE
THAT I HAVE NOT LISTED HERE
PROVIDERS SPECIFIC FACTORS SUCH
AS RACIAL ETHNIC STEREOTYPES AND
PROVIDER DISCRIMINATION BECAUSE
THIS WILL BE COVERED IN SESSION
3. SO I MENTION THIS A FEW TIMES
BUT I WANT TO PROVIDE A
DEPICTION OF WHY PATIENT
PROVIDER COMMUNICATION IS SO
IMPORTANT. FROM THIS PHI YOUR WE
SEE POOR COMMUNICATION CAN
RESULT IN POOR PATIENT
SATISFACTION WHICH LEADS TO LOW
TREATMENT ADHERENCE AND THUS
POOR HEALTH OUTCOMES THIS TABLE
COMES FROM A STUDY THAT IDENTIFY
HIGH PRIORITY RESEARCH QUESTIONS
FOR OA SYSTEMATIC REVIEWS,
WITHIN SCOPE OVERLET EQUITY AND
SOCIAL DETERMINANTS OF HEALTH.
ONE ASPECT WAS TO SURVEY
PATIENTS AND ASK THEM TO RANK
TOP TEN RESEARCH QUESTIONS AND
HERE YOU SEE THE TOP RANKED
PRIORITY BASED ON IMPORTANCE AND
POTENTIAL IMPACT ON EQUITY WAS
COMMUNICATION INTERVENTION TO
APPROVE QUALITY AND LEVEL OF
COMMUNICATION BETWEEN OA
PATIENTS AND THEIR HEALTHCARE
PROVIDERS. SO WHERE ARE
OPPORTUNITIES FOR INTERVENTION
WHERE COMMUNICATION CAN BE
ENHANCED? MANY HERE MAY ALREADY
THINK ABOUT THE OPPORTUNITIES
HIGHLIGHTED IN THE RED BOX WHERE
PATIENTS PROVIDERS AND PATIENT
PROVIDER DYADS ARE TARGETED TO
IMPROVE COMMUNICATION. AND YES,
THERE ARE INDEED INDIVIDUAL
PATIENT PROVIDER DIATIC
INTERVENTIONS THAT HAVE SHOWN
SUCCESS. HOWEVER I WANT TO
FOCUS ON OTHER DIATIC CLINIC AND
COMMUNITY LEVEL OPPORTUNITIES
BECAUSE WHEN WE TALK ABOUT
HEALTH DISPARITIES, NOT ONLY
TALKING ABOUT INDIVIDUAL LEVEL
BARRIERS TO COMMUNICATION. WE
ARE ALSO TALKING SYSTEMATIC
INSTITUTIONAL AND COMMUNITY
LEVEL BARRIERS THAT NEED TO BE
ADDRESSED. SO LET'S STAY AT
THIS TOP LEVEL OF POTENTIAL
INTERVENTION TO WORK. DIRECT
SERVICES MEANS PROVISION OF
VERBAL WRITTEN PATIENT
COMMUNICATION DESIGNED TO MEET
DISPARATE LANGUAGE NEEDS.
INTERPRETERS, AND HEALTH
EDUCATION MATERIALS THAT
TRANSLATED PROFESSIONALLY OR AT
LEAST NATIVE SPEAKER SO NOT
GOOGLE, OR SOMEONE WHO HAD BASIC
LANGUAGE SKILLS AND DEVELOPED AT
A SIXTH GRADE READING LEVEL OR
BELOW. THESE SOUND OFTEN AND
WELL HANGING FRUIT BUT CAN BE
DONE LAST MINUTE WITHOUT
ATTENTION THAT THEY NEED TO BE
EFFECTIVE. INCORPORATING
CULTURAL HOMOPHYLY CREATING
CULTURE OF PATIENTS WE ARE
TRYING TO REACH. DOING SO CAN
IMPROVE COMMUNICATION BY HELPING
PATIENTS FEEL UNDERSTOOD, SEEN
AND HEARD AND THEREFORE BUILT
TRUST BETWEEN PATIENTS AND
PROVIDERS THAT LEAD TO IMPROVED
COMMUNICATION. THIS INSLIDES
HIRING PROVIDERS AND STAFF WHO
SHARE CULTURAL BACKGROUND OF
THESE PATIENTS, ANOTHER EXAMPLE
IS CREATING ENVIRONMENT THAT
PROMOTES INCLUSION OF FAMILY,
SINCE MANY MINORITY CULTURES
PLACE MYVALUE ROLE OF FAMILY IN
HEALTH AND MAILLOT HEALTH
BEHAVIORS INCLUDING MEDICATION
ADHERENCE. SO THIS MAY LOOK LIKE
MAKING EFFORT TO INCLUDE FAMILY
MEMBERS AND CLINIC VISITS IN
PERSON, VIA VIDEO OR BY PHONE.
NEXT INCLUDING ALTERNATIVE
TREATMENTS DOESN'T MEAN
PROMOTING QUESTIONABLE
TREATMENTS THAT LACK EVIDENCE
BUT DOES MEAN BEING AWARE OF THE
OTHER TREATMENT OPTIONS PATIENTS
ARE INTERESTED IN, SUCH AS
DIETARY SUPPLEMENTS AND CHANGES,
AND HAVING RESOURCES AND
INFORMATION ON THIS TREATMENT
AVAILABLE FOR THESE PATIENTS.
FINALLY, IN INCLUDING COMMUNITY
HEALTH WORKERS IN CLINIC
SETTINGS MAY INCREASE CULTURAL
HOMOPHYLY NEEDED TO IMPROVE
COMMUNICATION. COMMUNITY HEALTH
WORKERS HAVE A DEEP
UNDERSTANDING OF COMMUNITY THEY
SERVE BECAUSE THEY ARE MEMBERS
OF THAT COMMUNITY TOO.
LOGISTICALLY COMMUNITY HEALTH
WORKERS PROVIDE PATIENT
EDUCATION LANGUAGE ASSISTANCE
AND INFORMAL COUNSELING AND
IMPROVED CONTINUITY AND
COORDINATION OF CARE. THEY
LITERALLY SPEAK THE SAME
LANGUAGE. AND UNDERSTAND
CULTURAL NUANCES AN RATIONALE
BEHIND PATIENT VALUES BELIEFS
AND BEHAVIORS. THIS IS WHY THEY
MAKE SUCH GREAT LIAISONS BETWEEN
PATIENTS AND PROVIDERS. THIS IS
AN IMPORTANT POINT BECAUSE
COMMUNITY HEALTH WORKERS ARE NOT
ONLY VALUABLE TRANSLATORS AND
EFFECTIVE MESSENGERS OF
EDUCATION BUT PROVIDER WANTS TO
RELATE TO THE PATIENT BUT MORE
IMPORTANTLY THEY ARE ABLE
TEENING KATE PROVIDERS ABOUT
COMMUNITY NEEDS AND THE CULTURE
OF THE COMMUNITY SO THAT THE
PROVIDER CAN DEVELOP GREATER
UNDERSTANDING OF THEIR PATIENT
NEEDS. FINALLY COMMUNITY HEALTH
WORKERS HELP INCREASE USE OF
COMMUNITY RESOURCES WHICH WE
WILL DISCUSS NEXT. INSTITUTIONAL
ACCOMMODATIONS TO IMPROVE
COMMUNICATION GO BEYOND STAFFING
DECISIONS AND TYPES OF RESOURCES
MADE AVAILABLE TO PATIENTSS. THS
INCLUDES LOCATION OF CLINICS AN
SERVICES PROVIDED BY THE CLINIC.
MOBILE CLINICS. THE HOURS OF
OPERATION WITH THE PHYSICAL
ENVIRONMENT LOOKS AND FEELS LIKE
AND INCREASING CULTURAL HUMILITY
OF ALL PROVIDERS AND STAFF WHO
INTERACT WITH PATIENTS IN A
CONCERTED EFFORT THAT GOES
BEYOND HIRING PEOPLE WITH THE
SAME BACK GROWN AS THEIR
PATIENTS. SOME OF THESE ARE
OBVIOUS AND EASIER TO MODIFY
THAN OTHERS. I WANT TO SPEND
TIME ON THE LAST EXAMPLE.
COMMUNITY PARTNERSHIPS. CLINIC
COMMUNITY PARTNERSHIPS ARE
IMPORTANT BECAUSE WHILE AN
INDIVIDUAL PROVIDER LACKS SKILLS
AN RESOURCES TO ADDRESS TRUST
ISSUES THAT MAY IMPEDE
COMMUNICATION WITH PATIENT, THEY
CAN PARTNER WITH ORGANIZATIONS
THAT ALREADY HAVE THAT TRUST.
EXAMPLES INCLUDE PARTICIPATING
IN HEALTH FAIRS MOBILE CLINICS
AND EDUCATING THE PUBLIC IN
PLACES LIKE RELIGIOUS
INSTITUTIONS LOCAL GROCERY
STORES BARBERSHOP AN COMMUNITY
CENTERS. THESE PARTNERSHIPS
INCREASE PATIENT HEALTH
KNOWLEDGE, IMPROVER COMMUNITY
IMAGE OF CLINIC AND ENHANCE
PROVIDERS AND STAFF MEMBERS
UNDERSTANDING OF CULTURE THAT I
SHALLS COME FROM. TO END I WILL
REVIEW A FEW GAPS AND POTENTIAL
RESEARCH FUTURE RESEARCH THAT
CAN ADDRESS THESE GAPS. FIRST
MULTI-LEVEL INTERVENTIONS THAT
TARGET VARIOUS LEVELS OF
INFLUENCE INFLUENCE PATIENT
PROVIDER COMMUNICATION. THERE'S
HEALTH LITERACY INTERVENTION
THAT TARGETS PATIENTS AND THEIR
FAMILIES WHICH HELP PROMOTE
TREATMENT ADHERENCE IN PATIENTS
WHO CULTURE PLACES HIGH VALUE ON
FACILITATE OA MANAGEMENT.
ANOTHER EXAMPLE IS OA
SELF-MANAGEMENT INTERVENTION
DELIVERED VIA PARTNERSHIP
BETWEEN EMPLOYER COMMITTEEOR
CLINIC AND COMMUNITY CENTER.
SUCH INTERVENTION TARGET SELF
MANAGEMENT BEHAVIORS AND WORK
ENVIRONMENT BY PROMOTING
OCCUPATIONAL ACCOMMODATIONS, BY
ENHANCING PATIENT PROVIDER
COMMUNICATION SKILLS, AND IN
COMMUNITY CENTER BY OFFERING
EVIDENCE BASED PROGRAM. ANOTHER
AREA OF INTEREST MAY INCLUDES
HOW TO MEASURE SUCCESS AT EACH
OF THESE LEVELS. HOW MUCH WE
EXPECT HIGHER LEVEL OF
MULTI-LEVEL INTERVENTION TO
IMPACT PATIENT OUTCOME SUCH AS
PAIN AN FUNCTION. HOW LONG DO WE
EXPECT UPSTREAM VARIABLES LIKE
TRUST WILL TAKE TO MAKE AN
IMPACT ON INDIVIDUAL MEASURES
LIKE MEDICATION ADHERENCE.
FINALLY, CROSS CULTURAL
EDUCATION FOR STUDENTS SUCH AS
MEDICAL AND NURSING STUDENTS CAN
GO BEYOND ACTIVE LISTENING
SKILLS TO BUILD AN AWARENESS OF
BIASES AND STEREOTYPES AN
INCREASING CULTURAL HUMILITY TO
ENHANCE PATIENT PROVIDER
COMMUNICATION. THANK YOU.
>> THANK YOU, SANDRA. NOW WE
MOVE RIGHT INTO OUR THIRD TALK
IN THIS AREA, SOCIAL
DETERMINANTS OF HEALTH QUALITY
AND ACCESS AND THIS IS PRESENTED
BY DR. CATHERINE MACLEAN, CHIEF
MEDICAL OFFICER AND SENIOR VICE
PRESIDENT AT HOSPITAL TO HAVE
SURGERY AND PROFESSOR MEDICINE
AT WEILL CORNELL MEDICAL
COLLEGE.
>> GOOD MORNING OR AFTERNOON,
EVERYBODY, DEPENDING WHERE YOU
ARE, PLEASURE TO HAVE THE
OPPORTUNITY TO SPEAK WITH YOU
SOME HEALTHCARE QUALITY ISSUES
AS RELATED TO SOCIAL
DETERMINANTS. MY HAT IS OFF TO
THE ORGANIZERS, THIS IS A GREAT
SESSION SO FAR. I CERTAINLY
LEARNED A LOT AND HOPE TO DEPLOY
IN OUR HEALTH ORGANIZATION.
NOTHING TO DISCLOSE. SO I WANT
TO START WITH FIRST PRINCIPLES,
ONE IS QUALITY OSTEOARTHRITIS
WHAT IS QUALITY AND ONE IS
VALUE. THIS IS THE CLASSIC MODEL
OF HEALTHCARE QUALITY FROM BACK
IN THE '80s, HASN'T CHANGED.
WHEN WE THINK OF QUALITY OF
HEALTHCARE, IT IS WHAT WE DO TO
PATIENTS WITHIN OUR HEALTHCARE
SYSTEM THAT AFFECT HEALTH
OUTCOMES SO WE HAVE HAD A LOT OF
DISCUSSION TODAY ABOUT THE
IMPACT, SOCIAL DETERMINANTS OF
HEALTH OUTCOMES SO I THINK WE
KNOW THAT THAT IS A GIVEN.
HEALTHCARE QUALITY, HEALTHCARE
QUALITY IS ABOUT WHAT WE DO AND
HOW THAT AFFECTS THE HEALTH
OUTCOMES. SO WE CON SIP
ACTUALIZE QUALITY MEASURE IN
STRUCTURE PROCESS AND OUTCOME
MEASURES. THAT'S ARE THINGS LIKE
COMPLICATION RATES, REVISION
RATES, MORTALITY RATES
READMISSION RATES ET CETERA,
STRUCTURAL MEASURES ARE THINGS
THAT GET INTO PHYSICAL
STRUCTURE, ORGANIZATIONAL
STRUCTURE, SO THE PROPORTION OF
PHYSICIANS FACILITY THAT ARE
BOARD CERTIFIED. WHETHER A
HOSPITAL HAS A STROKE UNIT.
STROKE UNITS ASSOCIATED WITH
BETTER OUTCOMES. STRUCTURE
MEASURES AN PROCESS MEASURES ARE
THE MOST COMMON TYPES OF QUALITY
MEASURES, THOSE MEASURE WHAT WE
DO TO PATIENTS PROPORTION OF
PATIENTS WHO ARE ELIGIBLE FOR A
MAMMOGRAM THAT GOT THAT
MAMMOGRAM. PROPORTION OF
PATIENTS UNDERGOING SURGERY WHO
GOT THE PROPHYLACTIC ANTIBIOTICS
THEY WERE SUPPOSED TO HAVE
GOTTEN. SO THESE ARE WHAT
QUALITY MEASURES ARE. WE THINK
ABOUT VALUE, REPORTER HAS A NICE
MODEL WHICH IS REALLY JUST
TALKING ABOUT HEALTH OUTCOMES
WHICH ARE INTEGRAL TO QUALITY
AND RELATIONSHIP TO COST. SO
VALUE WE THINK ABOUT VALUE, WE
MAKE VALUE JUDGMENTS EVERY DAY
AS CONSUMERS AND THAT OUTCOME
WHAT YOU WILL GET OUT OF IT OVER
THE COST OF CARE. NEXT SLIDE.
WHY MEASURE QUALITY? WHY BOTHER?
THERE IS THREE MAIN REASONS TO
DO IT WE MEASURE TO DIRECT
QUALITY IMPROVEMENT ACTIVITIES,
MEASURE QUALITY FOR PURPOSES OF
PUBLIC REPORTING AND
ACCOUNTABILITY. AND LASTLY MORE
RECENTLY TO ENABLE VALUE BASED
PURCHASING PROGRAM. I WANT TO
EMPHASIZE, AT THE BOTTOM HERE
THE REASON WE DO ANY OF THIS
STUFF, IS IMPROVE HEALTH OF
INDIVIDUALS AND POPULATIONS. WE
CANNOT LOSE SIGHT OF THAT. THAT
IS THE PURPOSE OF QUALITY
MEASUREMENT AND REALLY THE
PURPOSE OF VALUE BASED
PURCHASING. RISK ADJUSTMENT OF
QUALITY MEASURES. WHY DO WE DO
THAT? IN GENERAL REASON WE RISK
ADJUST IS FACILITATE FAIR
COMPARISONS ACROSS PROVIDERS. WE
WANT TO ENSURE THE MAIN
DIFFERENCES WE ARE LOOK AT FOR
QUALITY MEASUREMENT ARE RELATED
TO DIFFERENCES IN PERFORMANCE.
DIFFERENCES IN THE WAY
HEALTHCARE IS DELIVERED. THEY
ARE NOT RELATED TO PATIENT
FACTORS OVER WRITE PROVIDERS
DON'T HAVE MUCH CONTROL OR DON'T
HAVE ANY CONTROL. MOST CURRENT
RISK ADJUSTMENTS FOCUS ON
PHYSICAL CHARACTERISTICS IN
PATIENTS AND IMPACT OF HEALTH
OUTCOMES. DISEASE SEVERITY. AGE,
GENDER, WE KNOW THOSE THINGS
AFFECT HEALTH OUTCOMES AND IN
THE CONTEXT OF LOOKING AT
QUALITY MEASURE, WE WANT TO MAKE
SURE WE ADJUST FOR THOSE THINGS
TO MAKE SURE WE ARE DOING A FAIR
COMPARISON ACROSS DIFFERENT
PROVIDERS. WHAT ARE SOCIAL
DETERMINANTS? WE HAD A WHOLE
DISCUSSION THIS MORNING, I DON'T
THINK I NEED TO PROVE THE POINT
SOCIAL DETERMINANTS CERTAINLY
AFFECT HEALTH OUTCOMES AND THE
PROS FOR ADJUSTING FOR SOCIAL
DETERMINANTS IN THE CONTEXT OF
QUALITY MEASUREMENT IS THAT
MEASURE PERFORMANCE TIDE TO
SOCIAL DETERMINANTS IN WAYS
BEYOND PROVIDER CONTROL. FOR
EXAMPLE, WE KNOW DUAL
ELIGIBILITY IS TIGHTLY
CORRELATED WITH OUTCOMES AND
WITH QUALITY. ANOTHER PROSE TO
LEVEL PLAYING FIELD VALUE BASED
PURCHASING CONS OF ACTUALLY RISK
ADJUSTING FOR SOCIAL
DETERMINANTS WITHIN QUALITY
MEASURES IS TO MASSK DISPARITIES
AN LIMIT ABILITY TO IDENTIFY
PROBLEMS AND IMPROVE IT. THEY
MAY ON ON FEW SKATE POOR
PERFORMANCE, BIAS OR
DISCRIMINATION. WE WANT TO
UNDERSTAND IF THEY ARE INSURANCE
COMPANIES DOING THAT THAT FALL
INTO THAT BUCKET. ANOTHER CON IS
THAT THE SAME CON IS ONE OF THE
PROS, COULD REDUCE INCENTIVES TO
PARTICIPATE VALUE BASED
PURCHASING DEPENDING WHERE YOUR
ORGANIZATION SITS ON SPECTRUM IN
TERMS OF DELIVERING CARE WITH
THE PROPORTION OF POPULATION. OF
PATIENTS WHO ARE DISADVANTAGED.
SO WILL IS A LOT OF THOUGHT
ABOUT THIS, I THINK CMS HAS BEEN
A REALLY NICE THOUGHTFUL JOB IN
THINKING ABOUT HOW SOCIAL
DETERMINANTS OUGHT TO BE THOUGHT
ABOUT IN TERMS OF VALUE BASED
PURCHASING PROGRAM, UNDER THE
IMPACT ACT, ASPE WAS TASKED WITH
RELATIONSHIP BETWEEN SOCIAL
DETERMINANTS AND MEDICARE VALUE
BASED PURCHASING PROGRAMS. IN
THE CENTER I LAID OUT MEDICARE
VALUE BASED PURCHASING PROGRAMS
SO THERE ARE A LOOT. SOME FOCUS
ON -- A LOT. SOME FOCUS ON CARE
DELIVERY SYSTEM, SOME INSURANCE
COMPANIES SO HOSPITAL
READMISSION REDUCTION PROGRAM,
HOSPITAL PURCHASING PROGRAM TO
THE BIGS, THE HOSPITAL ACQUIRED
CONDITIONS REDUCTION PROGRAM,
ANOTHER BIG ONE, MEDICARE
ADVANTAGE STAR PROGRAM. SO THERE
IS A LOT OF MONEY TIED TO
QUALITY PERFORMANCE ON MEDICARE
ADVANTAGE STAR PROGRAM AND SOME
INSURANCE COMPANIES THE MONEY IS
IN THE BILLIONS. WITH A B OF
DOLLARS IN TERMS OF QUALITY. SO
THESE ARE SOME OF THE -- VALUE
BASED PROGRAMS. A COUPLE OF
STUDIES WERE DONE, THE FIRST
RELEASED IN 2016, SECOND WAS
RELEASED IN 2020. THE KEY
FINDINGS FROM THESE STUDIES FROM
THE FIRST STUDY WAS THAT
BENEFICIARIES WITH SOCIAL RISK
FACTORS HAD WORSE OUTCOMES. AND
INEQUALITY MEASURES. THAT DOES
NOT A SURPRISING FINDING. AND
THE DUAL ELIGIBILITY WAS REALLY
HIGHLY CORRELATED WITH THAT POOR
PERFORMANCE. ADDITIONALLY
PROVIDERS WHO DISPROPORTIONATELY
BENEFICIARIES WITH SOCIAL RISK
FACTORS TENDED TO HAVE WORSE
PERFORMANCE ON THESE QUALITY
MEASURES EVEN AFTER ADJUSTING
FOR BENEFICIARY BUT NOT ALL THE
TIME, I WILL GO THROUGH A COUPLE
OF SLIDES ON THAT. FINDINGS FROM
THE MORE RECENT STUDY INCLUDE
THAT BENEFICIARY SOCIAL RISK FOR
INFORMATION, IS NOT ROUTINELY
SYSTEMATICALLY COLLECTED. SO IT
IS HARD TO EVEN UNDERSTAND WHAT
IS GOING ON. AGAIN AFTER
ACCOUNTING FOR LOTS OF DIFFERENT
RISK FACTORS OR PATIENT
CHARACTERISTICS THIS DUAL
ELIGIBILITY RISES TO THE SURFACE
AS BEING A KEY FACTOR THAT IS
ASSOCIATED WITH POOR QUALITY
PERFORMANCE, IN SOME CASES
FUNCTIONAL STATUS MATTER AS
WELL. AND THAT ALTHOUGH LOTS OF
ORGANIZATIONS ARE WORKING ON
THIS IN DIFFERENT WAYS THERE IS
NOT A COMMON WAY WE HAVEN'T
DETERMINED WHAT IS REPUTABLE IN
TERMS OF REDUCING THESE SOURCE
OF DISPARITIES. I WANTED TO PULL
OUT STUDIES OUT OF THE ASPE
WORK. THE REPORT IS REFERENCED
AT BOTTOM AND REALLY BIG BODY OF
REALLY ELEGANT VARIABLE DONE
RESEARCH LOOK AT SOCIAL
DETERMINANTS, BUT TO ME TWO OF
THE KEY FINDINGS OR THE TWO KEY
FINDINGS KEY STUDIES ARE IN THE
NEXT SLIDE. THEY LOOK AT
RELATIONSHIP BETWEEN
DISPROPORTIONATE SHARE HOSPITAL
INDEX AND HOSPITAL BABIES
PURCHASING TOTAL PERFORMANCE
SCORES. ON THE LEFT IS
PERFORMANCE SCORES, QUALITY
SCORE AND ON THE X AXIS WE SEE
THE DISPROPORTIONAL SHARE
HOSPITAL INDEX. SAFETY NET
HOSPITALS IN RED, NON-ARE IN
BLUE. THERE IS A CLEAR
CORRELATION WEAN THE PROPORTION
OF PATIENTS WHO ARE
DISADVANTAGED, IN THESE
HOSPITALS AND THE QUALITY
SCORES. NEXT SLIDE. THIS TO ME
WAS THE MOST FASCINATING RESULT
OF ALL RESEARCH THEY DID, THIS
WAS FOR MEDICARE ADVANTAGE IN
THIS STUDY THEY LOOK AT
RELATIONSHIP BETWEEN THE
PROPORTION OF DUALLY ELIGIBLE
ENROLLED SLASH LOW INCOME
SUBSIDY STATUS AND MEDICARE
ADVANTAGE QUALITY STAR RATING.
THIS MEDICARE ADVANTAGE QUALITY
STAR RATING IS WORTH A LOT OF
MONEY HEALTH PLANS. ON THE Y
AXIS WE SEE UNROUNDED OVERALL
MEDICARE STAR, SCORE, 0 TO 5.
AND ON THE X AXIS WHICH SEE
PROPORTION OF DISADVANTAGED --
PEOPLE IN THE POPULATION. THERE
IS A BIMODAL OUTCOME HERE. SO
FAR LEFT PART OF THE SLIDE TOP
PART WE SEE THAT PLANS WHO HAVE
FEW DISADVANTAGE PATIENTS IN
THEIR POPULATION HAVE MUCH --
PRETTY HIGH SCORES. FOR MEDICARE
ADVANTAGE. BUT WE SEE THAT ON
THE RIGHT HAND SIDE THERE ARE
NUMBER OF PLANS WHERE THERE IS A
HIGH PROPORTION OF PATIENTS WHO
ARE DISADVANTAGED AND DOING
WHITE WELL. THESE ARE PROBABLY
SPECIAL NEEDS PLANS AND WHAT
THIS SAYS IS HEALTH PLANS WHO
FOCUS ON THOSE PATIENTS, THESE
ARE MEDICARE ADVANTAGE PLANS
HAVE SOME THAT HAVE DONE A VERY
GOOD JOB IN DELIVERING HIGH
QUALITY CARE. IT IS NOT
IMPOSSIBPOSSIBLE. THIS IS SOMETG
THAT CAN BE DONE. BASED ON ALL
THE STUDIES DONE AS PART OF THE
EVALUATION ASPE MADE
RECOMMENDATIONS ON WHEN WE
SHOULD OR SHOULDN'T ADJUST FOR
SOCIAL DETERMINANTS IN TERMS OF
QUALITY MEASUREMENT. THE TOP
GRAPHIC IS SCHEMATIC IS
STRUCTURE PROCESS MEASURES,
PROBABLY NOT ADJUSTING THOSE BUT
RESOURCE USE MEASURES AN PATIENT
EXPERIENCE MEASURES MAKES MORE
SENSE SO ON THE BOTTOM RIGHT ARE
THE RECOMMENDATIONS ON WHETHER
TO ADJUST FOR SOCIAL RISK
FACTORS IN TERMS OF QUALITY
REPORTING, AND ALSO IN TERMS OF
VALUE BASED PROGRAMS. SO WHEN WE
ARE PAYING OUT. PROCESS MEASURES
NO, OUTCOME MEASURES NO, PATIENT
EXPERIENCE MEASURES YES, IN
SCENARIOS, RESOURCE USE
MEASURES, YES, WHEN PAYING OUT
AND PROGRAM PERFORMANCE SCORES
IN EITHER SITUATION. NEXT SLIDE
THIS JUST THE FRAMEWORK HERE FOR
YOUR REFERENCE BUT THE CONCEPT
IS WE OUGHT TO ACCOUNT FOR
SOCIAL RISK IN MEDICARE
PURCHASING PROGRAMS AND DO BY
MEASURING AND REPORTING QUALITY
FOR BENEFICIARIES WITH SOCIAL
RISK FACTORS SENDING HIGH FAIR
QUALITY STANDARDS FOR EVERYONE
IS NOT OKAY TO HAVE A LOWER
STANDARD FOR DISADVANTAGED
PEOPLE. AND THEN LASTLY TO
REWARD AND SUPPORT BETTER
OUTCOMES. GO QUICKLY THROUGH
SOME STUDIES DONE REALLY THROUGH
THE LANDS INSTITUTE AND U.S.
NEWS REPORT THAT LOOK AT
RELATIONSHIP BETWEEN ACCESS TO
HOSPITALS AND THE TYPE OF CARE,
DELIVERED TO PATIENTS BASED ON
RACE. SO THE U.S. NEWS WORLD
REPORT BUILDING ON SOME OF THE
WORK THE LANSETT INSTITUTE HAD
DONE, PUT TOGETHER THIS
INTERESTING METRIC THAT LOOKS AT
THE RELATIONSHIP BETWEEN
PATIENTS THIS IS ALL BASED ON
MEDICARE PATIENTS PATIENTS IN A
HOSPITAL HOW THEIR RACE REFLECTS
THE RACE IN THE CATCHMENT AREA
AROUND THAT HOSPITAL OR IN THAT
COMMUNITY. WHAT WE SEE,
VARIATION HERE YOU CAN SEE ON
THE GRAPH ON THE TOP LEFT BUT
BOTTOM RIGHT LOOKING AT
DIFFERENT TYPES OF HOSPITALS WE
SEE HOSPITALS OVERALL THEY ARE
NOT -- THEY DON'T REPRESENT
COMMUNITIES THAT ARE SURROUNDING
THEM. WHEN WE LOOK DOWN ON THE
BOTTOM WE SEE THAT IT IS NOT FOR
PROFIT, IT IS LOWER STATE OWNED
HOSPITALS AND END UP HAVING
REPRESENT MORE PATIENTS MINORITY
POPULATIONS THAN DO OTHER
HOSPITALS. WE DID ANOTHER
ANALYSIS AND LOOKED AT RACE AS
INDEX AT THE LANDS INDEX --
INSTITUTE PUT TOGETHER ON RACE
INCLUSIVITY AND LOOKED AT IT IN
RELATIONSHIP TO U.S. NEWS WORLD
REPORT TOP 20 HOSPITALS I FOCUS
ON ORTHOPEDIC HOSPITAL AND
TALKING OSTEOARTHRITIS. WHAT YOU
SEE HERE IS AMONG THESE TOP 20
HOSPITAL THERE IS IS A
DIVERGENCE, THERE ARE NUMBER OF
HOSPITALS WHO HAVE HIGH
INCLUSIVITY INDEX, NOT RACIALLY
INCLUSIVE, AS THE ONES ON TOP
BUT THERE ARE SOME SHINING STARS
AMONG THAT TOP 20 LILLED DOWN AT
THE BOTTOM. CALL OUT FOR MASS
GENERAL UCSF. JUST WANTS TO CALL
OUT THAT THE U.S. NEWS REPORT
NUMBER 1 AND 10 AND 11 RATED
HOSPITALS, ARE NOT INCLUDED
HERE, SPECIALTY HOSPITALS, THAT
WAS NOT CALCULATED BY THE INDEX
THIS IS REALLY THE FINAL SLIDE,
THIS GRAPHIC BACKGROUND IS
TAKING FROM -- TAKEN FROM
HOSPITAL COMPARE AND CMS LOOKS
AT HIP AND KNEE REPLACEMENT THE
RELATIONSHIP BETWEEN TOTAL HIP
KNEE REPLACEMENT 90 DAY
COMPLICATION RATES ON THE X AXIS
AND THE 90 DAY PAYMENT ON THE Y
AXIS. SO YOU WANT TO BE IN THE
BOTTOM LEFT AND SO AGAIN I HAVE
TAKEN THE TOP 20 U.S. NEWS
REPORT HOSPITALS AND PLOTTED
THEM ON THIS AND YOU CAN SEE
WHERE THEY PAN OUT. AGAIN THERE
ARE FOUR HOSPITALS ON HERE,
THREE THAT I MENTION PREVIOUSLY,
HHS, SCRIP, THEY ARE SPECIALTY
HOSPITALS THEY HAVEN'T GOTTEN
THIS RATING IN TERMS OF RACIAL
INCLUSIVITY. MAYO CLINIC WASN'T
RATED BECAUSE COMMUNITY IN WHICH
MAYO CLINIC IS LOCATED IS NOT
VERY HETEROGENOUS POPULATION IN
TERMS OF RACE. SO YOU CAN SEE
HERE IN THE GREEN THESE ARE
INSTITUTIONS THAT ARE IN THE --
AT THE FAVORABLE 50% OF THE
LANDS RACIAL INCLUSIVITY INDEX
AND THE RED ARE ONES IN THE
LOWER LEAST FAVORABLE PROPORTION
AT THE RACIAL INCLUSIVITY INDEX.
SO THERE IS A MIX HERE. SIMILAR
TO THAT SLIDE EARLIER IT IS
POSSIBLE TO DELIVER HIGHER
QUALITY CARE AND DO IT
EFFICIENTLY REGARDLESS OF THAT
INDEX. NOT GOING TO SPEND A LOT
OF TIME ON THIS, LOTS OF QUALITY
MEASURES FOR OA, SELECTIVE ONES
AND I WANT TO POINT OUT MOST ARE
NOT ADJUSTED FOR SOCIAL
DETERMINANTS OF HEALTH. THERE IS
A NEW MEASURE SOON COMING MANY
IN THE NEXT SEVERAL YEARS, BASED
ON PATIENT REPORTED OUTCOMES.
THERE WILL BE A ADJUSTMENT FOR
HEALTH LITERACY THAT PARTICULAR
MEASURE. AND THE NOT ON THE
SLIDE BUT IN RECENT NEWS CMS IS
STARTING NEXT YEAR GOING TO BE
COLLECTING OR PUTTING INTO PLACE
MEASURES ON COLLECTION OF
INFORMATION ON SOCIAL
DETERMINANTS OF HEALTH AT LARGE
NOT SPECIFIC TO OSTEOARTHRITIS.
WRAPPING UP SUMMARY POINTS,
THERE IS EVIDENCE SOCIAL RISK
FACTORS ARE ASSOCIATED WITH POOR
OUTCOMES. QUALITY SCORES
PROVIDERS DISPROPORTIONATE
SHARES OF PATIENTS WITH SOCIAL
RISK FACTORS ARE LOWER FOR MOST
BUT NOT ALL. VARIATION IN THE
RACIAL INCOME AND EDUCATIONAL
INCLUSIVITY OF HOSPITAL SUGGEST
THAT ACCESS TO SOME TOP QUALITY
HOSPITALS IS LIMITED. BY SOLE
DETERMINANTS AND POLICY MEMBERS
ADJUST FOR QUALITY MEASURES OF
THE SOCIAL DETERMINANTS OF
HEALTH. OPEN QUESTION AND
RESEARCH IDEAS AND WILL THE
QUALITY INEFFICIENCY REPORTING
STRATIFIED SOCIAL DETERMINANTS
CHANGES IN SCORES WHAT QUALITY
IMPROVE INTERVENTIONS ARE
EFFECTIVE IN IMPROVING
HEALTHCARE QUALITY AMONG
DISADVANTAGED POPULATION AND DO
MEASUREMENT METHODS INTRODUCE
BIAS IN RESULTS AS A CONSEQUENCE
OF SOCIAL DETERMINANTS. THAT
LAST ONE IS REALLY QUITE
IMPORTANT. THAT IS IT. HAND IT
BACK OVER TO THE CHAIR.
>> THANK YOU, VERY MUCH. THANKS
TO ALL OUR SPEAKERS. WE HAVE
RUN UP UNTIL LUNCHTIME SO WE ARE
GOING TO JUST TAKE A COUPLE OF
QUESTIONS NOW. THEN WE WILL
SUGGEST THAT IN THE ATTENDEES
HAVE SPECIFIC QUESTIONS IF THEY
JUST PUT THEM IN THE CHAT AND
THE SPEAKERS CAN ANSWER
DIRECTLY. ONE COMMENT CAME IN,
NOTES WE WANT PEOPLE TO LOOK AT
POSTERS AT THE END OF THE DAY
BECAUSE THEY WILL BE BUILDING ON
FIND,. HERE WAS A QUESTION
SPECIFICALLY FOR NEWS. HOW DO WE
BALANCE INCLUSION OF FAMILY FOR
CULTURAL HOMOPHYLY WHEN PATIENT
PRIVACY AND ANY RESERVATIONS
PATIENTS THEMSELVES MAY HAVE
WITH DISCUSSING MORE SENSITIVE
BUT RELEVANT INFORMATION IN THE
PRESENCE OF THE FAMILY?
OPERATOR: THAT IS A GREAT
QUESTION. I THINK I WILL BEGIN
SAYING OUR NORMS ARE US-BASED
CULTURAL NORMS, MIGHT BE VERY
DIFFERENT IN THIS ASPECT FROM
OTHER CULTURES. I RUN INTO THIS
WHEN IT COMES TO OUR IRB
PROTOCOLS AND DOING CONSENT
ESPECIALLY NOW DURING THE
PANDEMIC WHERE WE ARE EXPECTED
TO TELL PARTICIPANTS MAKE SURE
YOU ARE IN A PRIVATE LOCATION,
AND WE SEE IF THEY ARE ON THE
SCREEN WE SEE THE WHOLE FAMILY,
WE HEAR THE WHOLE FAMILY AROUND
SO THEY HAVE A VERY DIFFERENT
SENSE OF WHAT IS PRIVATE AND
WHAT REQUIRES PRIVACY, I THINK
WE DO IN OUR OUR CULTURE
US-BASED CULTURE, SO THAT IS MY
MAJOR POINT, OUR UNDERSTANDING
OF WHAT SHOULD BE THE NORM OF
WHAT IS THE NORM COULD LOOK
DIFFERENT AND THEN OF COURSE
HAVING PROVIDERS EXPLAIN UP
FRONT IF THERE IS ANOTHER PERSON
IN THE ROOM OR VIRTUALLY ON THE
PHONE TO SAY ABOUT ANY POINT IF
THE PATIENT WANTS TO HAVE SOME
PRIVACY THAT THE EXPECTATION I
AM LATINA AND I HAVE BEEN
INVOLVED IN MANY, MANY VISITS
WITH MY PARENTS SEPARATELY AND I
HAVE BEEN KICKED OUT OF THE
ROOM. AND IT WAS EASY. SO I
THINK THE MORE IT BECOME IT IS
NORM TO HAVE PATIENT FAMILIES IN
THERE EASIER IT WILL BE TO FOR
PATIENTS TO BE DELINEATE THIS
PART IS PRIVATE. I WANT PRIVACY
HERE.
>> THANK YOU. I DON'T SEE ANY
OTHER QUESTIONS. MAYBE PEOPLE
ARE GETTING HUNGRY ON THE EAST
COAST. SO CHRISTY, DO YOU HAVE A
CHARGE FOR PEOPLE? WE START BACK
AT 1:30. WE WILL STAY ON
SCHEDULE. I THINK THAT'S --
>> SORRY I WAS TRYING TO UNMUTE
MYSELF. WE WILL RETURN AT 1:30,
THANKS TO EVERYONE FOR
DISCUSSION IN SESSION 2 AND IF
YOU DO HAVE QUESTIONS THESE ARE
ALSO TOPICS WE ARE HOPING TO
DISCUSS DURING THE BREAK OUT
SESSION SO PLEASE FEEL FREE TO
HOLD ON TO THEM AND TALK WITH
YOUR BREAK OUT SESSIONS ABOUT
THESE TOPICS AS WELL. SO WE WILL
SEE EVERYONE BACK AT 1:30 FOR
THE START OF SESSION 3.
>>WELCOME BACK, EVERYBODY. WE
ARE GOING TO GET STARTED WITH
SESSION 3 WHERE WE WILL CONTINUE
OUR DISCUSSIONS RELATED TO
FACTORS THAT IMPACT DISPARITIES
IN OSTEOARTHRITIS FOCUSING HERE
ON THE MANY SOCIAL DETERMINANTS
OF HEALTH. SESSION 3 WILL BE
MODERATED BY ONE OF OUR WORKSHOP
CO-CHAIRS DR. ERNES MOY,
EXECUTIVE DIRECTOR VA OFFICE OF
HEALTH EQUITY. DR. MOY, OVER TO
YOU.
>> THANK YOU SO MUCH, IT IS A
PLEASURE TO BE HERE AND I'M
LEARNING SO MUCH. WE HAVE A VERY
PACKED AGENDA SO I WILL TURN IT
OVER TO TALK MULTIPLE
DETERMINANT OF HEALTH RELATING
TO OSTEOARTHRITIS. OUR FIRST
SPEAKER IS DR. MESSIER,
PROFESSOR DIRECTOR J B
BIOMECHANICS LABORATORY WAKE
FOREST, PRINCIPAL INVESTIGATOR
OF WEIGHT LOSS AND EXERCISE
COMMUNITIES IN EARTHIEST AT THIS
NORTH CAROLINA CHILD AND THE
OSTEOARTHRITIS PREVENTION TRIAL.
WE WILL PRESENT ON EXAMINING HOW
RURAL AND URBAN POPULATIONS WITH
OSTEOARTHRITIS RESPOND TO
LIFESTYLE INTERVENTIONS. DR.
MESSIER.
>> THANK YOU, APPRECIATE IT. SO
AS DR. MOY SAID I'M GOING TO
DISCUSS PART OF OUR TRIAL ON
RURAL AND YOU CAN URBAN
POPULATIONS AND HOW THEY RELATE
TO LIFESTYLE INTERVENTIONS OF
DIET AND EXERCISE. HEALTH
BEHAVIOR DIFFERENCES BETWEEN
RURAL AND URBAN COMMUNITIES
INCLUDE ACCESS TO PROPER
NUTRITION, ABILITY TO EXERCISE,
AND ACCESS TO SPECIALIZED
HEALTHCARE. HEALTH DISPARITIES
BETWEEN THESE COMMUNITIES
INCLUDE MEDICAL INSURANCE
ACCESSIBILITY, INCREASE
PREVALENCE OF OBESITY, AND OTHER
CO-MORBIDITIES. THE PURPOSE OF
THE STUDY WAS TO DETERMINE THE
EFFECT OF GEOGRAPHY WHETHER YOU
RESIDE IN RURAL OR URBAN
COMMUNITIES, ON CLINICAL
OUTCOMES IN A PRAGMATIC
RANDOMIZE CLINICAL TRIAL OF DIET
AND EXERCISE. THE WEIGHT LOSS
EXERCISE COMMUNITIES WITH
ARTHRITIS IN NORTH CAROLINA WAS
PHASE 3 PRAGMATIC ASSESSMENT
BLINDED RANDOMIZE CONTROL TRIAL.
THAT COMPARED 18 MONTHS DIET AND
EXERCISE TO CONTROL AND OLDER
ADULTS WITH NEO'S SKYLAR
ARTHRITIS, OVERWEIGHT AND
OBESITY. WE RANDOMIZE 823
PARTICIPANTS THAT WERE RECRUITED
FROM THREE NORTH CAROLINA
COUNTICOUNTIES. FORCYTE COUNTY 0
PEOPLE PER SQUARE MILE,
CLASSIFIED AS URBAN, THEY WOOD
COUNTY HAS 100 PEOPLE FOR SQUARE
MILE, CLASSIFIED RURAL. AND
JOHNSTON COUNTY HAS 200 PEOPLE
PER SQUARE MILE, IT WAS ALSO
CLASSIFIED RURAL. 413
PARTICIPANTS WERE RECRUITED FROM
FORSYTHE COUNTY AND COMBINED 410
PARTICIPANTS RECRUITED FROM
THEYWOOD AND JOHNSTON COUNTIES.
SO THIS NEXT PAIR OF SLIDES
REPEATED FOR EACH OF THE
OUTCOMES I'M GOING TO DISCUSS.
AT BASELINE RURAL GROUP SHOWN IN
THE DARKER BOXES SIGNIFICANTLY
MORE PAIN THAN URBAN GROUP. THIS
FIGURE SHOUGHS THE DIFFERENCE
BETWEEN THE DIET AND EXERCISE
AND CONTROL GROUP IN PAIN FOR
BOTH URBAN AND RURAL
COMMUNITIES. A POSITIVE
DIFFERENCE CONTROL HAD LESS
PAIN. NEGATIVE DIFFERENCE MEANT
DIET AND EXERCISE HAD LESS PAIN
WHAT YOU CAN SEE HERE IS THAT
DIET AND EXERCISE HAD THE SAME
POSITIVE EFFECT ON BOTH URBAN
AND RURAL GROUPS OVER 18 MONTHS
WITH NO SIGNIFICANT DIFFERENCE
BETWEEN THE TWO. AT BASELINE THE
RURAL GROUP HAD SIGNIFICANTLY
WORSE FUNCTION THAN URBAN GROUP.
THIS SHOWS DIFFERENCE BETWEEN
DIET AND EXERCISE AND CONTROL
AND FUNCTION FOR BOTH URBAN AND
RURAL GROUPS. POSITIVE
DIFFERENCE MEANT THAT CONTROL
HAD BETTER FUNCTION. NEGATIVE
DIFFERENCE MEANT DIET AND
EXERCISE HAD BETTER FUNCTION.
YOU CAN SEE DIET AND EXERCISE
HAS THE SAME POSITIVE EFFECT ON
BOTH URBAN AND RURAL GROUPS.
WITH A TREND THAT TENDED TO
FAVOR THE RURAL GROUP. AT
BASELINE THE RURAL GROUP
SIGNIFICANTLY WORSE MOBILITY
QUANTIFYD BY SIX MINUTE WALK
DISTANCE. COMPARED TO URBAN
GROUP. THIS IS THE DIFFERENCE
BETWEEN DIET AND EXERCISE
CONTROL AND SIX MINUTE WALK FOR
BOTH URBAN AND RURAL GROUPS.
POSITIVE DIFFERENCE MEANT THAT
DIET AND EXERCISE HAD BETTER
MOBILITY, NEGATIVE DIFFERENCE
MEANT CONTROL HAD BETTER
MOBILITY. YOU CAN SEW DIET AND
EXERCISE ARE THE SAME POSITIVE
EFFECT ON BOTH RURAL AND URBAN
GROUPS WITH NO SIGNIFICANT
DIFFERENCE BETWEEN THE TWO.
NEXT PLEASE. AT BASELINE THE
RURAL GROUP SIGNIFICANTLY WORSE
PHYSICAL HEALTH RELATED QUALITY
OF LIFE. THAT WAS MEASURED BY
THE SF 36. COMPARED TO THE
URBAN. THE DIFFERENCE BETWEEN
DIET AND EXERCISE AND CONTROL
AND SF 36 BETWEEN URBAN AND
RURAL COMMUNITIES SHOW DIET AND
EXERCISE HAD THE SAME POSITIVE
EFFECT ON BOTH RURAL AND URBAN
GROUPS, NO SIGNIFICANT
DIFFERENCE BETWEEN. FINALLY THE
RURAL GROUP AT BASELINE RURAL
BROWN HAD SIGNIFICANTLY MORE
DEPRESSIVE SYMPTOMS COMPARED TO
THE URBAN GROUP AS MEASURED BY
THE CESD. THIS SHOWS THE
DIFFERENCE BETWEEN DIET AND
EXERCISE AND CONTROL IN CESD FOR
URBAN AND RURAL COMMUNITY.
POSITIVE NUMBER OR POSITIVE
DIFFERENCE MEANT CONTROL HAD
FEWER DEPRESSIVE SYMPTOMS.
NEGATIVE DIFFERENCE MEANT DIET
AND EXERCISE HAD FEWER
DEPRESSIVE SYMPTOMS AND ONCE
AGAIN YOU CAN SEE DIET AND
EXERCISE HAVE THE SAME POSITIVE
EFFECT ON URBAN AND RURAL GROUPS
WITH NO SIGNIFICANT DIFFERENCE
BETWEEN. AT SUMMARY AT BASELINE
RURAL RESIDENTS HAD MORE PAIN,
POORER FUNCTION, WORSE MOBILITY,
POOR PHYSICAL HEALTH RELATED
QUALITY OF LIFE, AND MORE
DEPRESSIVE SYMPTOMS THAN THE
URBAN RESIDENTS. HOWEVER BOTH
RURAL AND URBAN GROUPS RESPONDED
IN A SIMILAR FASHION TO THE DIET
AND EXERCISE AND CONTROL
INTERVENTIONS. THOUGH YOU CAN
ARGUE THERE WAS A DEFINITE TREND
THAT FAVORED THE RURAL GROUP. SO
THIS BRINGS US BACK TO OUR
ORIGINAL QUESTION. DOES
GEOGRAPHY MATTER? IS IT
IMPORTANT TO HAVE BOTH RURAL AND
URBAN RESIDENTS IN YOUR CLINICAL
TRIALS? PERHAPS WE CAN DISCUSS
THIS AT OUR BREAK OUT SESSION.
THANK YOU.
>> THANK YOU
>> DR. MESSIER. I WILL NOW MOVE
TO DR. KIM. DR. KIM IS A HEALTH
ECONOMIST CENTER FOR HEALTH
SYSTEM EFFECTIVENESS AT OREGON
HEALTH AND SCIENCE UNIVERSITY.
HER RESEARCH INTERESTS INCLUDE
RACIAL ETHNIC DISPARITIES IN
HEALTHCARE AND MEDICARE MEDICAID
PAID REFORM, AND DR. KIM WILL
PRESENT ON MOVEMENT OF JOINT
REPLACEMENT SURGERIES FROM
INPATIENT TO OUTPATIENT SETTINGS
AND IMPLICATIONS OF THE MOVEMENT
FOR DISPARITIES. DR. KIM.
>> HI, EVERYONE. I WILL TALK
ABOUT HUGE CHANGE IN SURGICAL
SETTING FOR JOINT REPLACEMENT
SURGERIES AND WHAT IT MEANS IN
TERMS OF DISPARITIES. SO THERE
ARE THREE REPLACEMENTS, HIP AND
KNEE. PRIMARILY THEY RECEIVE IN
HOSPITAL AT PATIENT SETTING, BUT
INCREASINGLY PEOPLE ARE
RECEIVING SURGERY AT HOSPITAL
OUTPATIENT DEPARTMENT, OR
AMBULATORY SURGICAL CENTER ASC.
SO HOSPITAL OUTPATIENT
DEPARTMENT IS STILL AFFILIATED
HOSPITAL, PEOPLE STAY THERE LESS
THAN 24 HOURS AFTER SURGERY,
THEY GO BACK HOME AS SOON AS
POSSIBLE. IN SAME AM BRATORY
SURGICAL CENTER MAY OR MAY NOT
BE AFFILIATED TO HOSPITAL,
PEOPLE STAY LESS THAN 24 HOURS
AND GO BACK HOME AFTER THE
SURGERY. SO SURGICAL SETTINGS
CHANGING SO THIS SPEAKER SHOWING
THE SURGICAL SETTING CHANGE MORE
MEDICARE FEE FOR SERVICE JOINT
REPLACEMENT PATIENTS. THERE IS
NO OUTPATIENT WHATSOEVER UNTIL
2017 AND OUTPATIENT SURGERIES
ARE STARTING TO SHOW UP FROM
2018 BECAUSE MAINLY BECAUSE
MEDICARE SORRY TO PAY -- STARTED
TO PI FOR OUTPATIENT KNEE
REPLACEMENT FROM 2018. SO WE NOW
KNOW WHY OUTPATIENT REPLACEMENT
SHOWED UP AMONG MEDICARE FEE FOR
SERVICE POPULATION BUT THERE ARE
-- THE MORE INTERESTING FINDING
IS THERE WAS A STRONG FACT FROM
MED CAROL POPULATION TO PRIVATE
-- MEDICARE POPULATION TO
PRIVATE INSURED POPULATION. SO
THIS FIGURE SHOWING THE JOINT
REPLACEMENT IN STATE OF FLORIDA.
LET'S LOOK AT THE SOLID LINE
FIRST. TWO SOLID LINES AND FIRST
DARKER BLUE IS MEDICARE FEE FOR
SERVICE POPULATION AND IN
PATIENT REPLACEMENT VOLUME. THE
LIGHTER ONE IS SAME BUT FOR
PRIVATE INSURANCE POPULATION. AS
YOU CAN SEE THE NUMBER HAS BEEN
GRADUALLY INCREASING NOTE THAT
INTERESTING BUT IF YOU LOOK AT
THE BAR GRAPH DOWN THERE, THAT
SHOWS THE CHANGE IN VOLUME
YEAR-TO-YEAR. SO LOOK AT 2014.
DARKER BLUE IS FEE FOR SERVICE.
INPATIENT KNEE REPLACEMENT
INCREASE BY 1% AMONG MEDICARE
FEE FOR SERVICE POPULATION. BUT
9% AMONG PRIVATE POPULATION BUT
IF YOU MOVE TO 2017 AND 18 AS
YOU CAN SEE THERE IS A HUGE DROP
IN IN PATIENT MEDICARE
POPULATION AN PRIVATE INSURANCE
POPULATION. I REALLY WISH I
COULD SHARE THE GRAPH MY TEAM
PRODUCED, I COULDN'T DO IT
BECAUSE WE GETTING PERMISSION
FROM DATA VENDOR BUT WE LOOK AT
HOW THING CHANGE AMONG
COMMERCIAL POPULATION FROM 18 TO
26 YEARS OLD POPULATION. THERE
IS A HUGE INCREASE IN HOSPITAL
DEPARTMENT OPERATION JOINT
REPLACEMENT SURGERY FROM 2017
AND 2020. BY 2020 DURING COVID
TIME THE PROPORTION OF INPATIENT
JOINT REPLACEMENT SURGERY WAS
LESS THAN HALF. SO THERE IS A
HUGE CHANGE.
NEXT SLIDE. AGAIN I BELIEVE
THIS HUGE CHANGE WAS DRIVEN BY
MEDICARE PAYMENT POLICY, AS I
SAID BEFORE, MEDICARE STARTED TO
PAY FOR HOSPITAL OUTPATIENT
DEPARTMENT KNEE REPLACEMENT FROM
18 HIP REPLACEMENT FROM 2020.
ALSO IT IS NOT PROVEN
SCIENTIFICALLY BUT IN COVID-19
MAYBE PLAY A ROLE. IN 2020 WE
FOUND LESS THAN 50% JOINT
REPLACEMENT SURGERY IN PATIENT,
WE THOUGHT MAYBE PATIENT DON'T
WANT TO STAY IN HOSPITAL, SO
THEY WANT TO GO BACK AS SOON AS
POSSIBLE AND THAT IS WHY WE SEE
HIGH PROPORTION OF OUTPATIENT
SURGERIES IN 2020. JUST COMPARE
OUTPATIENT INPATIENT
REPLACEMENT, NOT SURPRISING
OUTPATIENT SURGERY ARE CHEAPER
BY 50 TO 70% BUT WE FOUND
PATIENTS OUT OF POCKET COST 70%
HIGHER IN ASC. SCHOOL SETTING IN
PATIENT. WE DON'T HAVE ANY
ROBUST EVIDENCE SURGICAL
OUTCOMES BETWEEN OUTPATIENT AND
IN PATIENT SURGERY YET. NEXT
SLIDE. SO WHAT THIS MEANS IN
TERMS OF DISPARITIES? THERE IS
LIMITED DATA BUT THERE IS
EMERGING EVIDENCE THAT PATIENTS
LESS LIKELY TO RECEIVE
OUTPATIENT KNEE REPLACEMENT
SURGERY THAN WHITE PATIENTS.
THIS FIGURE IS LOOKING AT
NATIONWIDE DATA INCLUDE MEDICARE
AND COMMERCIAL INSURANCE AND
EVERYONE, LOOK AT 2019 ABOUT 6%
OF PATIENTS, PATIENT REPLACEMENT
SURGERY HAPPEN AT OUTPATIENT AND
FOR WHITE WAS HIGHER AROUND 8%.
YOU SEE EMERGING TREND BETWEEN
WHITE AND BLACK. WE SEE THE SAME
TREND IN HIP REPLACEMENT, SOL WE
DON'T -- THIS IS EMERGING
EVIDENCE WE DON'T KNOW WHY THIS
IS HAPPENING. MAYBE IT IS
BECAUSE STRUCTURAL RACISM OR
MAYBE BECAUSE THERE IS DIFFERENT
IN ACCESSIBILITY TO OUTPATIENT
SURGERIES WE HEARD IN RURAL AR
AREA, HARD TO RECEIVE OUTPATIENT
SURGERY, MAYBE THAT IS WHY. WE
NEED MORE EVIDENCE WITH THAT. I
WILL SKIP THIS ONE. NEXT SLIDE.
I LISTED WHAT EVIDENCE WE NEED
SO WE WANT TO UNDERSTAND
DISPARITIES IN THE ACCESS TO
OUTPATIENT JOINT REPLACEMENT. WE
WANT TO KNOW WHY THAT IS THE
CASE. AND THIRD WE DEFINITELY
NEED MORE EVIDENCE FOR
DISPARITIESES IN POST SURGICAL
OUTCOME FOR OUTPATIENT JOINT
REPLACEMENT PATIENT REPLACEMENT.
THE BUNDLE PAYMENT PROGRAMS LIKE
COMPLETE JOINT REPLACEMENT
MODEL, IT STARTED TO INCLUDE
OUTPATIENT JOINT REPLACEMENT IN
ITS BUNDS L. SO WE WANT TO
UNDERSTAND WHAT IT MEANS ON THE
CARE QUALITY OF CARE, WHAT IT
MEANS IN TERMS OF DISPARITIES OF
CARE. THANK YOU.
>> THANK YOU, DR. KIM. I'M GOING
TO PUSH ON TO OUR THIRD SPEAKER.
DR. ENDSLEY, A CLINICAL
PSYCHOLOGIST AND DIVERSITY
EQUITY INCLUSION PROGRAM MANAGER
AT THE VA NORTHERN CALIFORNIA
HEALTHCARE SYSTEM. HE IS CO-LEAD
FOR VA YOU KNOWVATION SUPPORTED
PROJECT TO SPREAD RISK-BASED
STRESS AND TRAUMA BASED
INTERVENTION TO SUPPORT VETERANS
OF THE COLOR. HE WILL PRESENT ON
RACIAL DISCRIMINATION AND
PATIENT PROVIDER COMMUNICATION.
DR. ENDSLEY. THANK YOU. TODAY I
WANT TO TALK ABOUT WHAT ARE WAYS
AS MEDICAL PROFESSIONALS WE CAN
COMMUNICATE BETTER WITH PATIENTS
EXPERIENCE RACIAL DISCRIMINATION
MAYBE LEADING TO INCREASE
HEALTHCARE DISPARITIES FOR THEM,
ALSO TALK ABOUT WHAT ARE
CONSIDERATIONS WHEN THINKING
ABOUT DOING SHARED DECISION
MAKING, IN ADDITION IF YOU
NOTICE THERE'S SOMETHING CHANGED
IN THE ROOM MAYBE YOU ACCIDENTLY
COMMITTED A MICROAGGRESSION,
WHAT ARE SOME STEPS YOU CAN
RECOVER. AND MAYBE IMPROVE THE
RELATIONSHIP. MANY OTHER
FANTASTIC SPEAKERS SO FAR
INDICATED THERE ARE SOME
HEALTHCARE DISPARITIES, I ALWAYS
GO BACK TO THIS INSTITUTE OF
MEDICINE QUOTE. THAT TALKS ABOUT
WHEN YOU CONTROL FOR CONFOUNDING
FACTORS THERE'S RACIAL
DIFFERENCES IN VARIOUS AREAS OF
CARE. DISEASE SEVERITY AND SITE
OF CARE. IN OA WE SEE THAT LOT
OF PATIENTS EX-- BLACK PATIENTS
TALK ABOUT HAVING LOWER
SATISFACTION WITH COMMUNICATION.
THEY ALSO MAY REPORT DIFFERENT
DESCRIPTIONS OF THEIR QUALITY OF
KNEE OR HIP PAIN IN ADDITION
THERE'S OTHER COPING TOOLS THAT
BLACK AND INDIGENOUS PEOPLE MAY
USE WHEN IT COMES TO MANAGING
PAIN, OTHERS IN ENVIRONMENT
FRIENDS FAMILY FOR ADVICE IN
DIFFERENT WAYS THAN OTHER GROUPS
SO IT IS IMPORTANT TO HIGHLIGHT
THOSE BRIEFLY. SO THIS IS A
MODEL OF HOW DISCRIMINATION CAN
HAVE VARIOUS IMPACT ACROSS
RELATIONSHIP WITH THE PATIENT
AND THE PROVIDER AND THEIR
ENGAGEMENT WITH CARE.
DISCRIMINATION HAS IMPACT, OFTEN
TIMES LEADING TO MEDICAL
MISTRUST WHICH CAN LEAD TO CARE
NON-ADHERENCE DUE TO NOT
TRUSTING PROVIDERS, INCREASE
SATISFACTION. SOMEWHERE WE SEE
HERE DISCRIMINATION ALSO IMPACTS
THE PROVIDER COMMUNICATION WITH
THE PATIENT. WHICH ALSO GOES
INTO INFLUENCE ONGOING MEDICAL
MISTRUST, OFTEN TIMES I WORK
WITH VETERANS WHO ARE STUCK IN
CYCLE OF THEY HAVE HAD HISTORY
OF DISCRIMINATION SO THEY GET
STUCK AND MAY HAVE DIFFICULTY
TRYING TO OVERCOME SOME OF THOSE
BARRIERS OR MAYBE HAVE
EXPERIENCE A LOT OF
DISCRIMINATION HEALTHCARE SO
THEY NOTICE SIMILAR THINGS
HAPPENING FOR THEM AND HARDER TO
ENGAGE IN CARE. SO PART OF WHAT
I WANT TO TALK ABOUT TODAY IS
HOW DO WE HELP INTERRUPT THAT
CYCLE FROM HAPPENING. NEXT SLIDE
PLEASE. SO I THINK WHEN YOU ARE
CONSIDERING PATIENT PROVIDER
COMMUNICATION, I THINK IT IS
IMPORTANT TO ADAPT IT AND THINK
THROUGH WHAT IS SHARE DECISION
MAKING, MEAN FOR THAT PATIENT.
IT IS IMPORTANT TO ASK THEM.
SOMETIMES WHEN I WORK WITH
VETERANS THEY HAVE NOT
EXPERIENCED THAT, THEY FEEL LIKE
THEY ARE NOT BEING HEARD IN THE
ROOM SO THOSE DISCUSSION CAN BE
HOPEFUL. I LIKE THIS QUOTE
ENCOUNTERED THE EXPERIENCE
SHARED IT MUST OCCUR IN TRUSTING
PATTERN. SO THERE NEEDS TO BE
WORK OFTEN TIMES AT LEAST
MANUFACTURE THAT I EXPERIENCE A
LOT OF RACIAL DISCRIMINATION TO
OVERCOME AND MAYBE LESS LIKELY
TO SHARE INFORMATION, THEY CAN
FEELING, MAYBE PROBING FOR MORE
INFORMATION FROM YOU TO GET TO
KNOW YOU AND CREATE THAT FEELING
OF SAFETY AND TRUST WITHIN THE
CLINICAL ENCOUNTER. OFTENTIMES
MANY PATIENTS MAYBE PERCEIVED AS
INAPPROPRIATE OR ASKING
UNCOMFORTABLE QUESTIONS, ACTING
IN WAYS THAT SEEN AS NEGATIVE BY
PROVIDERS. SO IT IS A IMPORTANT
TO UNDERSTAND RACIAL TRAUMA AND
DISCRIMINATION MAYBE INFLUENCING
THAT BEHAVIOR AND NOT OTHER
PERSONALITY FACTORS. IN
ADDITION, THE PATIENT TELL,
SHARING INFORMATION BETWEEN BOTH
PATIENT AND MEDICAL
PROFESSIONAL, OFTENTIMES EVEN IN
MY PROFESSION AS CLINICAL
PSYCHOLOGIST CAN BE -- I WAS
TRAINED VERY MUCH WE DON'T SHARE
MUCH ABOUT OURSELVES. I LEARNED
WITH VETERANS I WORK WITH, WE
EXPERIENCE A LOT OF RACIAL
DISCRIMINATION IT IS HELPFUL FOR
ME TO BE A LITTLE OPEN ABOUT WHO
I AM, HELP THEM FEEL SAFER IN
THE ROOM AND OFTEN TIMES MAY
DISCLOSE THINGS THEY HAVE NOT
DISCLOSED OF OR HEALTHCARE
PROVIDERS. SO I THINK BEING
MINDFUL OF THAT RELATIONSHIP AND
BEING COMFORTABLE SOMETIMES
TALKING ABOUT YOURSELF A LITTLE
BIT MORE CAN BE HELPFUL FOR
FOLKS WHO EXPERIENCE RACIAL
DISCRIMINATION. ALSO TEACH FOLKS
HOW TO ADVOCATE FOR THEMSELVES
AND MAYBE NECESSARY TO STEP IN.
AND ADVOCATE FOR THAT PATIENT --
IF SOMEONE IS NOT HEARING THE
PATIENT CONCERNS, HAVING
CHALLENGES WITH OTHER HEALTHCARE
PROVIDERS AND HAVE A GOOD
TRUSTING RELATIONSHIP WITH YOU
THAT'S ANOTHER PLAY TO CONTINUE
TO BOND WITH THAT PATIENT AND
HAS PROFOUND IMPACT ON THEIR
ENGAGEMENT. I THINK WHILE SHARE
DECISION MAKING IS REALLY
IMPORTANT, MAY NOT BE WITH THE
PREFERENCE IS FOR EVERY PATIENT.
IT DOSE BACK TO MAKING SURE THAT
WE ARE ASKING ABOUT WHAT ARE
THEY LOOKING FOR, HOW TO ENGAGE
IN THEIR CARE, THIS COMES FROM
DATA THAT LOOK AT MOTIVATIONAL
INTERVIEWING AND FOUND THAT
MOTIVATIONAL INTERVIEWING IS
SOMETHING WE USE IN HEALTHCARE
TO HELP PATIENTS OR VETERANS
ENGAGE IN CARE, ENGAGE IN
BEHAVIORS, IT SHOWS THAT THERE
ARE CHALLENGES WHEN IT COMES TO
USING MOTIVATION WITHOUT
ADAPTING AND SOME PATIENTS MAY
PREFER MORE DIRECTIVE APPROACH.
SO THE OTHER PIECE THAT SOME OF
THE DATA SHOWED FOR SOME GROUPS,
REALLY IMPORTANT GOALS VALUES AN
PREFERENCES ARE DISCUSSED. AND
INCLUDE MISDEMEANOR THE
TREATMENT DECISION. NEXT SLIDE.
SO THESE ARE SOME QUESTIONS THAT
MIGHT BE IMPORTANT TO ASK ABOUT
THE PATIENT. HOW DOES A PATIENT
UNDERSTAND AND VIEW THEIR OWN
EXPERIENCE?
HOW DO OTHER IMPORTANT PEOPLE IN
THEIR LIVES ALSO RECEIVE THIS
PROBLEM AS WE SAW EARLIER ONE
STUDY NOTED THAT BLACK AFRICAN
AMERICAN PATIENTS MAYBE MORE
LIKELY TO ENGAGE FAMILY MEMBERS
AN FRIENDS AND ASK FOR ADVICE.
SOMETIMES IT CAN BE HELPFUL TO
ASK, WHO WOULD YOU FIND HELPFUL
IN THAT ADVICE. SO THEY LEARN
MORE ABOUT THAT PATIENT
ENGAGEMENT A LITTLE BIT MORE
ABOUT THE WORLD AROUND THEM,
WHAT STRUCTURAL BARRIERS ARE
IMPACTED. SO IT CAN BE IMPORTANT
TO ASK ABOUT THESE THINGS TO
HELP DEVELOP RELATIONSHIP,
RACISM AND DISCRIMINATION OFTEN
TIMES SOMETHING THAT THERE MAYBE
A NEED MORE QUESTIONING AROUND
TO GET FOLKS TO ENGAGE WITH THAT
AND SHARE MORE HOW HISTORIC PAL
DISCRIMINATION IMPACTED THE WAY
THEY RECEIVE. SO WHAT CAN YOU
DO? ONE OF THE IMPORTANT PIECES
IS THINKING WHAT CAN YOU DO IF
YOU MAKE A MISTAKE OR NOTICE
THAT SOMETHING IS CHANGED IN THE
RELATIONSHIP OR THE WAY THAT A
PATIENT INTERACTS WITH YOU, AND
RECOGNIZE THIS MAYBE INEVITABLE
IN SOME POINT AND SOMETIME YOU
WILL ENGAGE IN A MICROAGGRESSION
AND THERE ARE WAYS TO RECOVER
FROM THAT. THE RESEARCH SHOWS AT
LEAST THERAPY ENCOUNTERS AND TO
MAKE A ENCOUNTER THERAPEUTIC BY
ADDRESSING THE MICROAGGRESSION
AN RECOVERING FROM IT CAN UNDO
THE HARM CAUSED BY THAT
MICROAGGRESSION. SO THIS COMES
FROM DR. MONICA WILLIAMS,
SHARING STEPS YOU CAN DO THAT SO
THAT WILL INCLUDE ONE, NOTICE AT
WORK IF THE PATIENT BRINGS UP
SOMETHING AND SAYS HEY YOUR
STEREOTYPING ME, YOU ARE
ENGAGING IN A MICROAGGRESSION OR
YOU ARE NOT -- I'M FEELING LIKE
THERE IS A MISMATCH HERE WHEN IT
COMES TO RACE, SOMETIMES MAYBE
CLUES AS TO -- THERE'S SOMETHING
GOING ON MAYBE A MICROAGGRESSION
OCCURRED IN THE ENCOUNTER. SO I
THINK IT WOULD BE REALLY
IMPORTANT, FIRST TO ACKNOWLEDGE
SOMETHING HAPPENED. AND BE
CAREFUL ABOUT BECOMING DEFENSIVE
ABOUT IT OR BLAMING THE PATIENT
FOR WHAT HAPPENED OR MINIMIZING
THE IMPACT OF WHAT WAS SAID.
TRY TO AVOID EXPLAIN AWAY, WE
ARE SPENDING TIME TALKING ABOUT
YOURSELF IN THAT SITUATION.
INSTEAD FOCUS ON HOW IT IMPACT
LIMITATIONS. WHAT WAS IT LIKE
FOR THEM WHEN THAT HAPPENED?
NEXT SLIDE PLEASE. APOLOGIZE.
AND GENUINELY, IT IS IMPORTANT
TO APOLOGIZE AND RECOGNIZE THAT
BEHAVIOR HAD AN IMPACT. AND THEN
GGO AHEAD AND HIGHLIGHT WAYS THT
YOU ARE CONCERNED ABOUT WHAT
JUST HAPPENED. MAYBE IMPORTANT
TO DISCUSS WAYS TO PLAN TO
REMEDY THAT, AND SUCH AS GETTING
MORE EDUCATION OR TRYING TO GROW
AND LEARN TO PREVENT FROM
HAPPENING AGAIN. REMIND THEM YOU
ARE OPEN TO FEEDBACK. BE GENUINE
ABOUT THAT. ASK WAYS WHICH THEY
WOULD LIKE TO BE REMEDIED, ONE
WAY TO DO THAT, RECOMMIT TO THAT
HOPE FEEDBACK AND LISTEN TO
RESPONSE AND TRY NOT TO
INTERRUPT TOO MUCH AND TRY TO
FOCUS ON THEM, I KNOW THAT'S
HARD IN SHORT ENCOUNTERS BUT
EVEN THIS CAN TAKE A FEW SECONDS
TO REALLY WORK THROUGH SOME OF
THESE. RAIL DATION FOR THE
IMPACT, IT IS UNDERSTANDABLE,
ANGER AND FRUSTRATED WHEN THEY
EXPERIENCE A MICROAGGRESSION AND
RECOGNIZE THOSE EMOTIONS ARE
REAL RELEVANT. REMAIN OPEN TO
THEM ALERTING YOU TO MICROAGREG
IN THE FUTURE H. COMMIT TO
LEARNING AND CONTINUE TO LEAR L.
THOSE ARE WAYS TO SALVAGE THOSE
ENCOUNTERS, MANY VETERANS I WORK
WITH AROUND RACIAL DISCELL
NATION AND HOW IT IMPACTS
ABILITY TO ENGAGE IN CARE FOUND
WHEN THERE ARE PROVIDERS WHO
MADE MISTAKES OR MADE
MICROAGGRESSION THESE
CONVERSATIONS ARE REALLY HELPFUL
FOR THEM TO FEEL THEY CAN TRUST
THOSE HEALTHCARE PROVIDERS. SO
SOME EXTRA STEPS YOU CAN DO IS
CONTINUE TO LEARN MORE AND
ACCEPT THE UNFORTUNATE HISTORY
OF RACISM AND THE RACIAL
DISCRIMINATION AND EFFECT IT HAS
ON RACIAL DISPARITIES.
UNDERSTAND HOW RACISM SHAPES
DISPARITIESES NOT JUST RACE BUT
RACISM IS PLAYING A ROLE CAUSING
DISPARITIES. DEFINE AND NAME
RACISM, WHEN YOU SEE IT CALL IT
OUT. BE HONEST. IF THERE'S
SOMETHING GOING ON IT IS
IMPORTANT TO ENGAGE OTHER
HEALTHCARE PROVIDERS. YOU NOTICE
STEREOTYPING OTHER TYPES OF
ISSUES GOING ON WITH THE
PATIENT. IT IS IMPORTANT TO --
LOOK AT THE EXPERIENCE OF THOSE
WHO OFTEN TIMES WERE NOT THOSE
WE SEE AS THE NORM. WHO
OFTENTIMES MAYBE LARGER GROUP OF
FOLKS STUDIED IN OTHER GROUPS
MARGINALIZED OFTENTIMES ARE NOT
ENGAGED IN THAT CONVERSATION AND
RESEARCH OR ENGAGED IN THEIR OWN
CULTURAL VALUES AND HOW THAT
SHAPES THEIR HEALTHCARE RULES.
SO I THINK IT IS LEARNING IS
SOMETHING THAT HAS TO KEEP
GOING. SOMETIMES MIGHT ASK
YOURSELF WHAT WAYS ARE YOU
SUSTAINING THAT SYSTEM WHERE DO
YOU FIT IN THAT SYSTEM. ARE YOU
ADVOCATING AND HOW CAN YOU
ADVOCATE IF YOU NOTICE HEALTH
DISPARITIES GOING ON. AND IF YOU
ARE CURIOUS ABOUT HOW TO LEARN
MORE OF POEMS STORIES BOOKS ON
THIS TOPIC, OR EVEN DIGEST ASK
YOURSELF WHAT ARE YOUR
REACTIONS. THROUGHOUT THIS TALK
AND CONTINUE CONTINUE TO HAVE
THE CONVERSATION GOING, CONTINUE
TO TALK WITH COLLEAGUES AND
EDUCATE OTHERS.
>> THANK YOU, DR. ENDSLEY. NOW I
WILL TURN TO OUR LAST SPEAKER,
DR. THIRUKUMARAN. SHE IS HEALTH
SERVICES RESEARCHER ASSISTANT
PROFESSOR IN ORTHOPEDICS PUBLIC
HEALTH SCIENCES AT CENTER FOR
MUSCULOSKELETAL RESEARCH
UNIVERSITY OF ROCHESTER MEDICAL
CENTER. HER RESEARCH INTERESTS
ARE SECTION OF HEALTH POLICY OR
COMES DISPARITIESES IN
ORTHOPEDIC OUTCOMES AND SHE WILL
PRESENT RESEARCH EXAMINING
ASSOCIATION BETWEEN MEDICARE
BUNDLE PAYMENT PERFORM
COMPREHENSIVE CARE FOR DRUG
REPLACEMENT WITH DISPARITIES USE
OF ALKALINES WITH JOINT
REPLACEMENT SURGERIES. DR.
THIRUKUMARAN.
>> THANK YOU.
>> MANY THANKS TO THE DONE TO
PRESENT MY IMPORTANT WORK IN
THIS IMPORTANT SYMPOSIUM. I WILL
COVER ASSOCIATION OF FORMS WITH
DISPARITIES IN USE OF JOINT
REPLACEMENT AND THE OVERARCHING
TOPIC IS REALLY HOW SYSTEM LEVEL
MEDICARE POLICIES CAN BE
DETERMINANTS OF HEALTH
DISPARITIES IN TOTAL JOINT
REPLACEMENT FOR ARTHRITIS. I'M
GRATEFUL FOR THE FUNDING
RECEIVED FROM THE NIMHD AND NIA
AS MOST OF US HERE KNOW TOTAL
JOINT REPLACEMENT ARE HIGHLY
EFFECTIVE TREATMENT FOR END
STAGE ARTHRITIS. THEY ARE MOST
COMMONLY PERFORMED IN IN PATIENT
SETTING BUT AS DR. KIM MENTIONED
EARLIER NOW INCREASINGLY
CONSIDER IN THE OUTPATIENT
SETTING OFTEN REMOVAL OF THESE
SURGERIES FOR THE INPATIENT
PRIMARY CARE. DESPITE LARGELY
STANDARDIZED NATURE OF SURGERIES
THERE IS CONSIDERABLE
VARIABILITY IN THE USE OF
OUTCOMES AND SPENDING WITH JOINT
REPLACEMENT NOTABLY OUR
DISPARITIES IN USE OF OUTCOMES
OF THESE SURGERY AND
DISPARITIESES HAVE PERSISTED FOR
DECADES. THIS MAP SHOW AGE AND
SEX STANDARDIZE RATE OF HIP E
REPLACEMENT IN BLUE AND HIP
REPLACEMENT IN GREEN AS RECENT
AS 2017, THIS WAS A STUDY WE DID
RESPONDING FROM THE NIMHD. ON
THE LEFT SIDE ARE THE MAPS FOR
THE WHITE MEDICARE BENEFICIARIES
AND LEFT SIDE THE BLACK. ON THE
TOP RIGHT HAND SIDE THOSE WHO
ARE INTERESTED IN MORE DETAILS
ABOUT METHODOLOGY OF THE PAPER.
THE STARK CONTRAST BETWEEN THE
MAPS LEFT AND RIGHT SIDE
HIGHLIGHT THE PROFOUND
DISPARITIES IN JOINT REPLACEMENT
USE THAT EXIST IN 2017 USE OF
THESE SURGERIES WAS 38 TO 40%
FOR BLACK BENEFICIARIES COMPARED
TO WHITE BENEFICIARIES AND I
THINK DR. BRANNON MENTIONED
EARLIER FROM THE STUDIES JUST AS
MUCH IN THE FIRST DECADE AS
WELL. WHAT WOULD BE
INTERESTINGLY FOUND IS WHETHER
IT WAS A WHITE GROUP OR BLACK
GROUP USE OF SURGERY WAS NOWHERE
POORER FOR THOSE DULY ELIGIBLE
FOR MEDICARE AND MEDICAID
COMPARED TO THE ORIGINAL
BENEFICIARIES HIGHLIGHTS THE
DUAL ROLE IN ELIGIBILITY IN USE
OF THESE SURGERIES. GIVEN
IMPORTANCE OF JOINT REPLACEMENT
MEDICARE IMPLEMENTED SEPARATELY
DELIVERY OF FORMS OF PAST DECADE
TO INCREASE THE VALUE OF THESE
SURGERIES. SOME EXAMPLES INCLUDE
HOSPITAL READMISSION REDUCTION
PROGRAM THAT TARGETED
READMISSION IN JOINT REPLACEMENT
AND OTHER CONDITIONS IN
SURGERIES, AND COMPREHENSIVE
CARE JOINT REPLACEMENT MODEL
WHICH IS FOCUS OF MY RESEARCH
AND DR. KIM'S RESEARCH AS WELL,
AND IT IS A (INAUDIBLE) FOCUSED
EXCLUSIVELY ON JOINT
REPLACEMENT. ONE PAYMENT
RESPONSE SUGGESTS COMPREHENSIVE
CARE FOR JOINT REPLACEMENT OR
CGR ARE UNIQUE IN THE SENSE THAT
THE SPENDING ACUTE AND POST
ACUTE ARE EPISODES OF BUNDLED
TOGETHER. HOSPITALS OR OTHER
ENTITIES SUGGEST FACILITIES
MAYBE HEALTH ACCOUNTABLE FOR
QUALITY AND SPENDING DURING THE
EPISODE. THESE ENTITIES MAYBE
ASSESSED PENALTIES, DEPENDING ON
PERFORMANCE ON QUALITY AND
SPENDING METRICS. THESE REFORM
ARE NOT AIMED AT DISPARITIES
REDUCTION AND MAY
UNINTENTIONALLY WORSEN
PRE-EXISTING DISPARITIESES THIS
MAY OCCUR BECAUSE REFORMS DON'T
ADJUST SOCIAL RISK AND WE IN
PREVIOUS SESSION TODAY. WHY DOES
THIS HAPPEN? WELL ESTABLISHED
MINORITY INDIVIDUALS AND LOW
INCOME INDIVIDUALS ARE AT HIGHER
RISK OF ADVERSE EVENTS AND
SPENDING ON ACCOUNT OF THE
HEALTH AND OTHER SOCIAL RISK
FACTORS. HOWEVER PROVIDERS
TREATING THESE PATIENTS ARE NOT
CREDITED FOR HIGHEST SPENDING OR
EFFORT FOR THESE PATIENTS. HENCE
PROVIDERS ARE LIKELY TO EXCEED
SPENDING BENCHMARKS AND BE
PENALIZED. T THIS LEADS TO BEING
MORE CAUTIOUS IN SELECTING
MARGINALIZED OR DISADVANTAGED
PATIENTS FOR SURGERY, REDUCING
ACCESS TO SURGERY AND WORSENING
DISPARITIES. REPORTS FROM
SEVERAL AGENCIES INCLUDE
ASSISTANT -- INCLUDING ASSISTANT
SEC FOR PLANNING AND EVALUATION
AND NATIONAL ACADEMIES OF
SCIENCE ENGINEERING AND MEDICINE
RECOMMENDED THE ADJUSTMENT OF
SOCIAL RISK ADJUSTMENT OF
PAYMENT OR ADJUSTMENT OF THE
PERFORMANCE METRICS IN VALUE
BASED FOR CHOOSING PROGRAMS SUCH
AS CGR. THEY RECOMMEND IN AS A
WAY TO LEVEL PLAYING FIELD FOR
PROVIDERS WHO CARE FOR
MARGINALIZED PATIENTS. HOW CAN
THESE RECOMMENDATIONS BE APPLIED
IN THE CONTEXT OF TOTAL JOINT
REPLACEMENT? CGR WAS ABUNDANT
PAYMENT RESPONSE IMPLEMENTED IN
2016 IMPROVING QUALITY AND
REDUCING SPENDING FOR JOINT
REPLACEMENT, IT WAS MANDATED FOR
MOST HOSPITALS IN 67
METROPOLITAN AREAS AND HOSPITALS
ON PENALTIES OR WOULD BE
ASSESSED PENALTIES OR THEY WOULD
BUNDLE DEPENDING ON PERFORMANCE
IN THE PROGRAM. THE CGR WAS
REDESIGNED IN 2018, THEN IN
2021, WITH 2021 REDESIGN
INTRODUCING KEY DISPARITIES AND
CHANGES. SEVEN STUDIES HAVE BEEN
EXAMINE THE IMPACT OF CGR ON
DISPARITIES AND ALSO BE SPECIFIC
FOCUS ON SAFETY NET HOSPITALS
AND CARE THEY DELIVER IN THE
INTEREST OF TIME I WON'T GO
THROUGH THE DETAILS OF THIS TYPE
OF THESE STUDIES BUT HAPPY TO
SEND OUT REFERENCES AND ALSO
WANT TO ACKNOWLEDGE FANTASTIC
DISPARITIES FOCUSED CJR WHICH
DR. KIM AND COLLEAGUES ALSO
CONDUCTED AND SOME OF THOSE
CITATIONS ARE MENTIONED HERE.
FOCUS ON OUR WORK DUCTED IN 2021
WHICH WAS PUBLISHED IN THE JAMA
NETWORK QR CODE ON THE RIGHT
HAND SIDE FOR THOSE WHO MAYBE
INTERESTED. WHERE WE INVESTIGATE
IMPACT OF CGR DISPARITIES IN THE
NEWS TOTAL JOINT REPLACEMENT.
THIS IS A ONE SLIDE SUMMARY OF
THE LAST STUDY THAT -- DATA FOR
MILLIONS OF BENEFICIARIES FROM
2013 TO 2017. ON THE TOP LEFT
PANEL 8 IS THE PANEL FOR TOTAL
HIP REPLACEMENT AND CJR WAS NOT
ASSOCIATED WITH WORSENING OR
PREEXISTING DISPARITIES IN USE
OF TOTAL HIP REPLACEMENT.
HOWEVER IT DID WORSEN TO A MANY
DECEMBER EXTENT DISPARITIES IN
USE OF KNEE REPLACEMENT PANEL
BOTTOM RIGHT HAND SIDE AND
ENCLOSED IN RED BOX. NOTE IN
PANEL B THE FIRST BAR SHOWED CGR
IMPLEMENTATION KNEE REPLACEMENT
USED INCREASE WHITE RICH AND
WHITE POOR, DECREASED FOR BLACK
RICH AND BLACK POOR NOTED BY THE
TWO DOWNWARD FACING BARS AND
KNEE REPLACEMENT INCREASED WOULD
NOT SIGNIFICANTLY FOR HISPANIC
BENEFICIARIES. THE LIGHT GREEN
OR THE TEAL BAR SHOW HOW CHANGE
FOREFEET INCOME BASE GROUP
COMPARED TO THE WHITE, A KEY
REFERENCE POINT. AS YOU NOTE
FROM THE TWO DOWNWARD LIGHT
GREEN BARS THAT YOU HAVE
SUBSTANTIAL MAGNITUDE, CGR WAS
ASSOCIATED WITH DEEP LINE IN
KNEE REPLACEMENT FOR BLACK RICH
AND BLACK POOR BENEFICIARIES
COMPARED TO POOR WHITE
BENEFICIARYINGS THIS IS A
WIDENING IN THE GAP OF THE
SURGERIES AND CONSEQUENTLY THE
WORSENING OF DISPARITIES WITH
THE IMPLEMENTATION OF THE CJR.
OVERALL CJR WAS ASSOCIATED WITH
17 TO 19% FEW ERNIE REPLACEMENT
FOR BLACK RICH AND BLACK POOR
INDIVIDUALS COMPARED TO WHITE
RICH INDIVIDUALS.
THESE ARE STUDIES PROVIDE
EVIDENCE FOR THE CONSENT ABOUT
PATIENT SELECTION STEMMING FROM
PAIN IN CGR. THE WORSENING OF
KNEE REPLACEMENT DISPARITIES AND
NOT HIP REPLACEMENT DISPARITIES
-- PRIOR ADVERSE EVENTS AFTER
LONGER RECOVERY THERE BY
RESULTING IN PROVIDE EFFORT NOT
SELECTING IN KNEE REPLACEMENT.
SIMILAR EFFECTS MANNED OTHER
PAYMENT RESPONSE THAT DON'T
ACCOUNT FOR SOCIAL RISK MAY
CUMULATIVELY WORSEN STATE OF
PRE-EXISTING JOINT REPLACEMENT
DISPARITIES. THUS THERE IS A
NEED FOR RESPONSE TO RISK ADJUST
AND OTHER APPROACHES THAT
MITIGATE THE UNINTENDED
CONSEQUENCES OF (INAUDIBLE) THE
2021 CJR INTRODUCE ADJUSTMENT
FOR SOCIAL CLINICAL RISK WHICH
IS A STEP TOWARDS PROBABLY
TRANSFORRING THE CJR TO
DISPARITY REDUCTION AND
DIMENSION. ' IN 2021 JAMA
PROPOSED THE IDEA OF -- TO CJR
EXISTING N QUALITY AND SPENDING.
WE PROPOSE ADDING DISPARITIES
REDUCTION AS EXPLICIT -- MAKING
THE TRIPLE AIM OF KEEPING UNDER
CONCEPT OF TRIPLE AIM COULD
TRANSFORM CJR TO NATIONAL
DISPARITIES REDUCTION
INTERVENTION. WE SUGGESTED THIS
BECAUSE DISPARITIES DESPITE
IMPLEMENTATION OF SEVERAL WELL
INTENTIONED HIGHLY EFFECTIVE
LOCAL RESPONSE HIGHLIGHTING THE
NEED FOR NATIONAL INTERVENTION
WITH SCOPE, DESIGN DISPARITIES
REDUCTION INTERVENTION NATIONAL
INTERVENTION FROM SCRATCH
REQUIRE CONSENSUS BUILDING AND
POLITICAL WILL FOR THE
POSTPONING GOAL OF ACHIEVING
EQUITY IN CJR CARE. MODIFYING OR
REFINING EXISTING RESPONSE TO
CJR TO TARGET DISPARITIES MAYBE
FAIRLY ACHIEVABLE GOAL. MOREOVER
IT IS CURRENTLY HOE 400
HOSPITALS MAKING IT A GREAT TO
TEST MODIFICATIONS IN CJR BEFORE
SCALING TO A NATIONAL LEVEL. THE
2021 CJR UPDATE ADJUSTMENT FOR
SOCIAL RISK BUT JUST WHAT HAS
BEEN RECOMMENDED BY LEADING
NATIONAL AGENCIES. FINALLY WHAT
DOES RISK ADJUSTMENT DO?
MEDICAID CATEGORIES AGE INCREASE
LIKELIHOOD OF REWARDS, WITH
JOINT REPLACEMENT FOR BONES BY
MARGIN FOR MARGINALIZED PATIENT.
THIS IS A STEP IN THE RIGHT
DIRECTION USING CJR AS DISPARITY
INTERVENTION. RISK ADJUSTMENT
ARE NOT SURPRISE AND CONSIDERED
MANY THE FUTURE. THESE COULD
INCLUDE INCLUSION OF DISPARITY
SENSITIVE METRICS PUBLICLY
CHANGING THE SIZE OF INCENTIVES
AND ADJUSTMENT FUNCTIONAL STATUS
ARE OLD INITIATIVES THAT
POSSIBLY NEED TO BE CONSIDERED
IN THE FUTURE. WITH THAT I WOULD
LIKE TO THANK THE AUDIENCE FOR
THE ATTENTION. I LOOK FORWARD TO
QUESTIONS AND COMMENTS AND
DISCUSSING THIS IN THE BREAK OUT
SESSIONS. THANK YOU.
>> THANK YOU, DR. THIRUKUMARAN.
WE CAN TURN TO Q&A. I THINK WE
HAVE PLENTY OF TIME. THERE IS A
NUMBER OF QUESTIONS IN THE CHAT
WHICH I'M GLAD TO READ OUT BUT I
WANT TO START AND TAKE ON
BROADER QUESTION, I ENJOYED ALL
THE PRESENTATIONS, THE LAST
PRESENTATION I WAS FASCINATING
ABOUT THE MOTIONEN COLLUDING
DISPARITIES REDUCTION IN THE
BUNDLE PAYMENT METHODOLOGY. TWO
THINGS STRUCK ME. ONE, AS
PREVIOUSLY DISCUSSED ADJUSTMENT
WE TEND TO FINDING EFFECTS OF
DIFFERENT POPULATIONS, SOCIAL
DETERMINANTS ENTERING INTO
EQUATION. SO STRATIFICATION
ISN'T A PRODUCT THAT ALLOWS US
TO SEE THAT, TO BE ABLE TO
ADDRESS IT. WONDERING IF CURRENT
BUNDLE SYSTEMS REPORT THOSE DATA
INTERNALLY OR PUBLICLY, STRATIFY
FOR DIFFERENT KINDS OF GROUPS
NOT QUITE AT THE RELATIONSHIP TO
PAYMENT YET BUT PUBLIC REPORTING
OFTEN SHAME PROVIDERS INTO BEING
MORE EQUITABLE. I DIDN'T KNOW IF
CURRENT SYSTEM HAS THAT CONCEPT
BUILT INTO IT.
>> GREAT QUESTION THEN. THEY ARE
ABLE TO ACCOUNT FOR THIS. NOT
AWARE OF CURRENT PAYMENT
REFORMS, THAT STRATIFY AND
REPORT SOME OF THE METRICS WITH
DISPARITY FOCUS AND I THINK
PROBABLY MAYBE THE HOSPITAL
READMISSION REDUCTION PROGRAM, I
KNOW HAD SOME STRATIFICATION,
NOT TOO CLEAR AROUND THAT BUT
DEFINITELY CGR DOESN'T AS FAR AS
I CAN RECALL HAVE STRATIFICATION
MEEK NICHE PUBLICLY AVAILABLE
AND THAT SOMETHING WE THINK
WOULD BE QUITE AN IMPORTANT
INITIATIVE BUT THINGS CMS
RECOGNIZED AND INTRODUCE. THERE
IS ADJUSTMENT AS FIRST STEP,
LOOKING FORWARD TO SEEING WHAT
MORE IT HAS IN COMMON.
>> ARE THERE QUESTIONS FROM THE
AUDIENCE? AND WHILE YOU ARE
THINKING ABOUT THEM, I CAN READ
THE QUESTIONS THAT CAME THROUGH
ON THE CHAT. SO A QUESTION FOR
DR. MESSIER WAS ASKING ABOUT HOW
DO YOU ADJUST FOR SEX
DETERMINING PAIN MEASUREMENT
BETWEEN URBAN AND RURAL
COMMUNITIES FOR PATIENT
POPULATIONS.
>> WE ADJUST ANY DISCREPANCY IN
NUMBER OF MALES AND FEMALES
BETWEEN GROUPS AT BASELINE SO
ADJUSTING FOR THAT AT BASELINE.
WE DO THAT FOR OUR ANALYSIS.
>> QUESTIONS.
>> I HAD A QUESTION ABOUT HER
STUDY WHICH I THOUGHT WAS
INTERESTING. SIMPLY WHAT HAPPENS
WHEN PATIENTS AFTER THEY LEFT
YOUR TRIAL URBAN RURAL PATIENTS
MIGHT HAVE ACCESS TO DIFFERENT
KINDS OF EXERCISE CAPABILITIES
AND DIET OUTSIDE OF YOUR TRIAL
AND CURIOUS WAS THAT PART OF
WHAT YOU LOOKED AT LONGER TERM
AFTER NO LONGER RECEIVING?
>> THE TRIAL HAS JUST BEEN
FINISHED, IN FACT THE OUTCOME
PAPER IS UNDER REVIEW RIGHT NOW.
IT IS FRESH OFF THE PRESS. AS I
SPEAK. SO WE WOULD LIKE TO DO
THAT WITH 820 SOMETHING PEOPLE
IN THE STUDY, IT WOULD BE
POSSIBLE I THINK TO FOLLOW A
GOOD NUMBER OF THEM AFTERWARDS
AND THAT WOULD BE INTERESTING.
WE HAVE DONE THAT SMALLER SCALE
PREVIOUS STUDY THAT WECAN WAS
BASED ON, THE IDEA TRIAL WHICH
WAS MORE AN EFFICACY TRIAL. AND
WE GOT AFTER THREE AND A HALF
YEARS PEOPLE COMING BACK, WE GOT
ABOUT ONE QUARTER OF THEM BACK.
THERE WERE 400 SOMETHING IN THE
STUDY. WE GOT ABOUT A HUNDRED
BACK. SO IT IS TWICE AS MANY
HERE, HOPEFULLY WE CAN GET MORE
PEOPLE COMING BACK AFTER THREE
OR FOUR OR FIVE YEARS.
>> WONDERING IF THERE WAS
TARGETED COUNSELING OF THE THE
DIFFERENT GROUPS ABOUT THE
EXERCISE, WE SHOULD ENGAGE IN,
IMAGINE AGAIN WHAT THEY COULD DO
MIGHT DIFFER DEPENDING ON THE
TWO STUDIES.
>> WE USE SOCIAL COGNITIVE
THEORY, WE TRAIN OUR
INTERVENTIONISTS AND SOCIAL
COGNITIVE THEORY. SO BECAUSE THE
STUDY WAS REALLY LOOKING AT THE
EFFECT OF DIET AND EXERCISE,
VERSUS CONTROL IT JUST HAPPENED
OUR COMMUNITIES DIVIDED EVENLY
BETWEEN RURAL AND URBAN. IT
MAKES FOR NICE ANCILLARY STUDY.
>> DID SOMEONE HAVE A QUESTION
IN
>> THERE WAS COUPLE OF QUESTIONS
FOR DR. KIM IN THE CHAT.
>> IS THIS -- I SEE ONE, ANY
THOUGHTS ON ANALYZING ACCESS TO
REHAB, PHYSICAL THERAPY IN A
SIMILAR WAY TO JOINT
REPLACEMENT?
>> FOR ONE UNDER REVIEW WE DID
THAT AND WE FOUND FOR IN PATIENT
PATIENTS, THEY ARE SICKER, THEY
WERE MORE LIKELY TO USING USUAL
POST ACUTE CARE COMPARED TO
PEOPLE WHO RECEIVED OUTPATIENTS
OR (INAUDIBLE).
>> LOST IN THE CHAT, ANOTHER ONE
FOR DR. KIM?
>> IT IS HERE THE OUTPATIENT OP
ARE CHEAPER THAN IN PATIENT AND
THOSE MINORITIES RECEIVE MORE
OUTPATIENT. WOULDN'T THAT
INDICATE MORE ACCESSIBILITY
BECAUSE IT IS CHEAPER?
>> WHAT WE FOUND IS WHEN WE LOOK
AT OUT OF POCKET COSTS,
OUTPATIENT WERE MORE EXPENSIVE
THAN IN PATIENT BUT IF YOU LOOK
AT THE TOTAL PAYMENT THAT
INCLUDES OUTPATIENT OUTOF POCKET
COST AND THEN PAYMENT FROM -- TO
PROVIDER INPATIENT IS A LOT MORE
EXPENSIVE THAN OUTPATIENT BUT
LOOK AT THE PATIENT BURDEN
SURPRISINGLY OUTPATIENT WERE
MORE SEX PENS EXPENSIVE.
>> HERE IS A QUESTION FOR DR.
THIRUKUMARAN. IF YOU DEVISE A
PROGRAM TO TRIPLE BENEFITS,
OUTCOSTS VERSUS DISPARITIES,
WHAT WOULD YOU USE TO INCLUDE
DISPARITIES? WOULD YOU THINK
DATA SYSTEMS ARE ADEQUATE TO
SUPPORT INTERVENTION?
>> THANK YOU DR. KATZ FOR THAT
QUESTION. I HAVE -- SOME OF IT
COVERED IN -- SOME COVERED IN
TRIPLE E PIECE BUT YOU RAISE A
VERY IMPORTANT POINT ABOUT
WHETHER WE ARE GEARED TO BE ABLE
TO INCLUDE WHAT WE WANT TO
INCLUDE AND THIS IS IN
INTERVENTIONS AND THE DATA
SYSTEMS ARE SOMEWHERE WHERE WE
NEED A LOT MORE WORK TO BE DONE.
THAT IS GOING TO BE WORK IN
PROGRESS. BEING THE OPTIMIST I
AM, I WOULD LIKE START WITH WHAT
WE HAVE AND ADMINISTRATIVE DATA
WHICH WE HAVE ACCESS WHICH IS
FOUND TO GENERATE FAIRLY
SENSITIVE STANDARDIZED
COMPLICATION RATES, I THINK DR.
(INAUDIBLE) WORK HAVE SHOWN
SENSITIVITY OF IDENTIFYING
COMPLICATIONS THROUGH
ADMINISTRATIVE DATA ARE ABOUT
99% WHEN COMPARED TO MEDICAL
RECORD DATA AND AGAIN I THINK MY
OPINION THAT'S A GREAT PLACE TO
START OFF WITH WHAT WE HAVE.
THAT IS CERTAINLY NOT SUFFICIENT
AND GETTING GRANULAR CLINICAL
DATA PLACE TO GO. CJR HAS A
OPTION TO DO THAT, WE TALK ABOUT
THAT IN THAT PERSPECTIVE. CJR
HAS VOLUNTARY OPTION, TWO
ADDITIONAL POINTS FOR REPORTING
ON CERTAIN PATIENT REPORTED
OUTCOME METRICS. CJR DOESN'T
PUBLICLY -- IT PUBLICLY REPORTS
ON WHETHER OR NOT A HOSPITAL
SUBMITTED PROs AND WHAT THE
VALUE OF THOSE PRO. SO LOW
HANGING FRUIT TO BE ABLE TO MAKE
THAT DATA PUBLICLY VAILND AND
SURE THERE IS BIAS IN THAT
BECAUSE RESOURCE HOSPITALS ARE
MORE LIKELY TO BE ABLE TO
PREVENT -- PRESENT THAT DATA
THAN HOSPITAL DO NOT HAVE
RESOURCE TO REPORT ON THAT. THAT
POTENTIALLY IS THE NEXT SECOND
LOW HANGING FRUIT TO REPORT ON
USING WITHIN THE FRAMEWORK THAT
EXISTS IN THE CJR. BECAUSE WE
MOVE AHEAD METRICS FUNCTIONAL
VISIBILITY KEY IN RISK
ADJUSTMENT PIECE ON SOME
MEASURES SUCH AS CLINICAL USE,
GETTING REUSE ADMINISTRATIVE
DATA, WE ONLY ACCOUNT FOR
METRICS WHETHER OR NOT A PATIENT
HAD OA BUT NOT SEVERITY OF OA.
SO I'M HOPING THAT WITH YOUR
INSIGHTS THAT MAYBE A GREAT
PLACE TO MOVE AHEAD, GREAT PATH
TO TAKE TOWARDS GETTING MORE
GRANULAR CLINICAL DATA MADE
AVAILABLE BUT THERE ARE SOME
POTENTIALLY LEVERAGED TO HAVE
STRATIFIED REPORTING OTHER
DISPARITIES SENSITIVE METRICS,
WITHIN CJR POTENTIALLY COULD BE
TEMPLATE OF THAT REFORMS AS
WELL.
>> DR. MOY I HAD A QUESTION FOR
DR. ENDSLEY, THIS IS DAN, DR.
ENDSLEY I APPRECIATED YOUR TALK
TODAY BECAUSE WE HEARD A GOOD
BIT ABOUT DECISION AIDS WHICH
OBVIOUSLY PLACES BURDEN ON
PATIENTS TO LEARN MORE BEFORE
THEY SEE THEIR PROVIDER. WHAT
YOU TALKED ABOUT I THOUGHT
SOUNDED COULD BE SHAPED INTO AN
INTERVENTION FOR PROVIDER. SEEMS
LIKE WE ARE MISSING AN
OPPORTUNITY FOR THIS SHARE
DECISION MAKING APPROACH IF WE
ARE NOT PROVIDING AN
INTERVENTION FOR PROVIDERS AN
EXPECTING PATIENTS TO CARRY THE
BURDEN. WONDERING IF YOU MIGHT
COMMENT ON THAT. IN OTHER
MEDICAL -- MEDICALLY TREATED
DISORDERS DIABETES AND SO FORTH,
THE INTERVENTIONIST IS THE ONE
THAT'S THE TARGET FOR THE
INTERVENTION, NOT NECESSARILY
THE PATIENT. SO BONDING ARE IF
YOU MIGHT COMMENT ON THAT.
>> I THINK THAT OFTEN TIMES
UNFORTUNATELY MY WORK WITH
VETERANS OF COLOR IN PARTICULAR,
OFTEN TIMES FEEL LIKE A LOT OF
ONUS IS PLACED ON THEM, THAT CAN
BE CHALLENGING AS THEY MANAGE SO
MANY DIFFERENT THINGS, SO MANY
DIFFERENT HEALTH CONDITIONS. IN
A LOT OF WAYS WE HAVE -- WE HAVE
SORT OF INSTITUTIONAL POWER AND
WE HAVE THE KNOWLEDGE AND THE
OTHER THINGS TO BE ABLE TO DO --
TO MAKE THOSE CHANGES BROADLY.
SO I WOULD AGREE, SOMETIMES
USING TOOLS TO CHANGE PROVIDER
BEHAVIOR HAS SIGNIFICANT IMPACT
ON VETERAN ENGAGEMENT AND
HEALTHCARE FOLLOWING THROUGH ON
RECOMMENDATIONS, CLIENTS THERE
BUT I DO THINK THOSE CAN BE
REALLY IMPORTANT, SOMETIMES
THAT'S LEFT OUT OF THE
CONVERSATION. AND MANY VETERANS
FEEL LIKE THEY GET BLAMED FOR
THEIR HEALTHCARE CONDITIONS
VERSUS GET SUPPORT AND HELP THEY
ARE LOOKING FOR AT TIMES SO ONE
WAY IS TO TRY TO REVERSE THAT.
SOMETIMES ACTION ISN'T ABOUT
PATIENT, SOMETIMES INTERACTIONS
IS BECAUSE OF HISTORY OF RACISM
AND DISCRIMINATION AND HOW THEY
ARE PRESENTING MAKE MORE DUE TO
THAT THAN INDIVIDUAL
CHARACTERISTICS OR THINGS LIKE
THAT BUT THEY GET BLAMED FOR
REALISTIC CONCERNS WHEN IT COMES
TO HISTORY WITH RACISM AND
DISCRIMINATION. ON THE PROVIDER
SIDE IT IS IMPORTANT TO
RECOGNIZE THAT, I KNOW THAT
THAT'S CHANGED THE RELATIONSHIP
IN THERAPY MANY TIMES WHEN I
RECOGNIZE THOSE BEHAVIORS, TALK
THROUGH IT, IT COMES FROM A
PLACE OF HEY I HAVE HAD THESE
AWFUL EXPERIENCES IN HEALTHCARE.
LESS PROVIDERS ASKING ABOUT
THOSE THINGS IN THE SESSION IT
IS BEST. THERE IS A PLACE FOR IN
SOME WAYS BOTH, THERE IS A PLACE
FOR PATIENTS TO LEARN MORE BUT
THEY FEEL MOST COMFORTABLE
LEARNING FROM A TRUSTED
PROVIDER. JUST FOCUS ON THE
PATIENT WE LOSE A HUGE PART OF
THAT RELATIONSHIP WHICH IS
HEALTHCARE PROFESSIONAL WORKING
WITH VENDORS.
>> I APPRECIATE THAT, IN MY AREA
OF ARTHROPLASTY RESEARCH WE
THINK OF THE ORTHOPEDIC SURGEON
BEING TOO BUSY TO LEARN HOW BEST
TO CONVEY INFORMATION TO
PATIENTS ABOUT OPTIONS. IT IS A
LOST OPPORTUNITY. THANK YOU FOR
YOUR ANSWER.
>> THANKS FOR A NICE TALK.
QUESTION WHETHER URBAN RURAL
STUDY WHETHER YOU ARE ABLE TO
LOOK AT WIDER AFRICAN AMERICAN
-- WHITE AND AFRICAN AMERICAN IN
RESPONSE IF YOU HAD SIGNIFICANT
NUMBERS OF PATIENTS TO DO THAT.
>> WE DO. WE HAD A 48% AFRICAN
AMERICAN OUT OF 823. WHAT WE
DIDN'T DO WAS COLLECT ALL THE
SOCIAL DETERMINANTS THAT YOU
REALLY NEED TO BE ABLE TO
COMPARE BLACK VERSUS WHITE. SO
I'M HESITANT TO SHOW THOSE DATA
WITHOUT SOCIAL DETERMINANTS.
THAT'S HONEST ANSWER.
>> I WAS THINKING HARMONIZATION
ABOUT DR. KIM STUDY, IN DR.
KIM'S STUDY FOUND THAT AFRICAN
AMERICAN PATIENTS WERE LESS
LIKELY TO GET OUTPATIENT JOINT
REPLACEMENT AND MAY JUMP TO THE
CONCLUSION ACCESS ISSUE BUT ALSO
A TRUST ISSUE, VERY OFTEN FIND
THAT NEW TECHNOLOGIES ARE --
MAKE PEOPLE NERVOUS, UNLESS YOU
TRUST THE PERSON ADVOCATING THIS
NEW TECHNOLOGY MAYBE HESITANT TO
DO IT, JUST GIVE YOU THE OLD
FASHIONED I WANT TO DO IT
OUTPATIENT WAY AND ASK THE TWO
OF YOU, IF THAT MIGHT BE
HAPPENING OR IF THERE MIGHT BE
WAYS TO COMMUNICATE MORE
EFFECTIVELY FOR THE PATIENTS TO
MAKE TRUE INFORMED DECISION THAT
INCORPORATES PROS AND CONS OF
TECHNOLOGY.
>> WE NEED RESEARCH IN THIS
AREA, IT IS EMERGING EVIDENCE
AND WE NEED TO STUDY WHY THIS IS
HAPPENING. TRUST ISSUE I THINK
THAT MAYBE ONE PART DEFINITELY
BUT WE NEED EVIDENCE. THANK
YOU.
>> ARE THERE WAYS TO MEASURE
THIS, MEASURE THE TRAUMA,
HISTORY OF TRAUMA, LACK OF
TRUST, WHAT EXTENT BUILD THESE
INTO TRIALS IF THIS IS ANOTHER
SOCIAL DETERMINANTS OF HEALTH
ADJUSTOR PERHAPS TO UNDERSTAND
HOW THESE ARE CONTRIBUTING TO
OUTCOMES.
>> DEFINITELY.
>> WE HAVE TWO MINUTES LEFT IN
THE SESSION. WE DIP GET AN
OPPORTUNITY TO ASK QUESTIONS OF
ALL THE OTHER SPEAKERS. YOU CAN
PUT THEM IN THE CHAT. IF THEY
ARE STILL AROUND, IF THEY WOULD
BE SO KIND TO ANSWER THOSE
QUESTIONS AGAIN, WE ARE COMING
INTO THE -- WHAT WE THINK THE
MOST IMPORTANT PART OF THIS
CONVERSATION WHERE WE CAN HAVE
OUR DISCUSSION IN OUR BREAK OUT
SESSION SO YOU ARE MORE THAN
WELCOME TO BRING THOSE ISSUES UP
DURING THAT DISCUSSION. IT IS
ABOUT A MINUTE BEFORE WE WERE
SUPPOSED TO BREAK SO I WILL JUST
THANK DR. MOY AND ALL HIS
SPEAKERS FOR THIS WONDERFUL
SESSION AND WE WILL BREAK UNTIL
2:40 AND COME BACK AND GET OUR
CHARGE FOR THE BREAK OUT SESSION
AND HAVE VERY ROBUST DISCUSSIONS
DURING THE BREAK OUT SESSION.
THANKS, EVERYBODY EVERYBODY
>>WELCOME BACK, EVERYBODY TO
OUR BREAK OUT SESSIONS THAT WE
WILL HAVE THIS AFTERNOON. WE
HOPE THEY WILL BE VERY
INFORMATIVE FOR YOU AND ALLOW
FOR ROBUST DISCUSSION AND
EXCHANGING OF IDEAS. BEFORE WE
MOVE TO THE SPECIFIC SESSIONS,
DR. GAYLE LESTER, DIMES DIRECTOR
OF DIVISION OF EXTRAMURAL
RESEARCH WILL PROVIDE YOU WITH
THE CHARGE FOR THE SESSION. DR.
LESTER, TURN IT OVER TO YOU.
>> OKAY. CHRISTY, CAN YOU HEAR
ME?
>> YES, MA'AM.
>> GOOD. HELLO, EVERYBODY. I
THINK WE HAVE ALL ENJOYED A VERY
STIMULATING AND INFORMATIVE DAY.
NOW WE HAVE THE BREAK OUT
SESSION. WE ENVISIONED THIS
MEETING WOULD BE IN PERSON WHEN
WE FIRST STARTED PLANNING,
HOWEVER THAT WASN'T GOING TO BE
POSSIBLE FOR US AT THIS
PARTICULAR POINT IN TIME. SO
THESE BREAK OUT SESSIONS WHILE
VIRTUAL, ARE HOPEFULLY GOING TO
STIMULATE SOME OF THE TYPES OF
DISCUSSION AND INTERACTIONS
BETWEEN INDIVIDUALS IN THE
GROUPS THAT WE HOPED TO HAVE IN
PERSON. OUR GOAL IS WE STATED
IN THE DESCRIPTION PROVIDED TO
YOU IS TO PROVIDE PARTICIPANTS
IN THE WORKSHOP WITH DIVERSE --
WHO HAVE DIVERSE AREAS OF
EXPERTISE WITH OPPORTUNITIES TO
GET TOGETHER AND EXCHANGE IDEAS
ON HOW TO ADDRESS AND IMPROVE
ISSUES RELATED TO HEALTH
DISPARITIES IN OSTEOARTHRITIS. I
THINK WE HAVE HAD A TERRIFIC
START SO FAR. AND NOW WE ARE
GOING IN TO OUR FIVE DIFFERENT
GROUPS WHICHEVER ONE YOU SIGNED
UP FOR. HOWEVER, I DO THINK
THERE ARE OPTIONS TO MOVE
AROUND. THE QUESTIONS WE WOULD
LIKE TO WORK ON HERE ARE HOW
WEAKNESSES IN DISCUSSED FACTORS
AND DETERMINANTS INFLUENCE
HEALTH DISPARIT DISPARITIES. HAT
ON SOME THAT YOU ARE AWARE OF
THAT COULD BE INFORMATIVE. HOW
THESE FACTORS AND PROCESSES BE
MODIFIED TO ADDRESS DEFICIENCIES
THAT ARE OBVIOUS IN THE WAY
OSTEOARTHRITIS IS TREATED IN
UNDERSERVED OR UNDER-REPRESENTED
POPULATIONS. SO HERE ARE THE
TITLES OF THE BREAK OUT
SESSIONS. AND LIKE I SAID, YOU
HAVE ALREADY SIGNED UP FOR ONE,
AND DAVE IS GOING TO VERY
ADEPTLY PUT INTO DIFFERENT BREAK
OUT ROOMS IN THE BREAK OUT ROOMS
THERE ARE LEADS POINTED OUT
HERHERE. ALSO THERE WILL BE NOTE
TAKERS AND WE HOPE THERE WILL BE
SOME GENERAL CONSENSUS THAT COME
OUT OF THESE GROUPS RELATED TO
ISSUES THAT THE GROUP DECIDES
ARE THE MOST IMPORTANT TO BE
DISCUSSED FURTHER. IS THERE ANY
-- THAT'S THE LAST SLIDE WE HAD.
RIGHT? OH, ONE MORE. SO HERE ARE
SOME OF THE QUESTIONS JUST TO
GET YOU STARTED AND WE SHARED
THESE WITH THE BREAK OUT SESSION
LEADS JUST TO GET DISCUSSION
GOING BUT WE HOPE ONCE IT GETS
STARTED THAT THE CONVERSATION
WILL BE RATHER ORGANIC AND
CONTINUE IN THE DIRECTIONS THAT
ARE MOST APPROPRIATE FOR THE
GROUP. EVERYONE ENJOY THE TIME
AND AT THE END DON'T FORGET
THERE IS A SMALL POSTER SESSION
AND MEET AND GREET. PLEASE JOIN
YOUR GROUP AND THEN STAY ON FOR
THE POSTERS AND THE NETWORKING.