>>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.