Mayo Clinic experts from the otolaryngology, gynecology, nephrology and anesthesiology specialties discuss health care disparities in their respective fields and how they relate to coronavirus disease 2019 (COVID-19). The panel members discuss health care disparities before COVID-19 as well as what they are seeing in the middle of the pandemic.
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Welcome to Mayo Clinic Cove in 19 expert insights and strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with a C CMI guidelines. And welcome to our panel discussion, which is part of the Cove in 19 Expert Lecture Siri's. Today we will discuss health care disparities in Covert 19 with a particular emphasis on surgical subspecialty perspectives. I am your host, Dr Angela Donaldson. I'm a right knowledge is and Interest called a surgeon here at the Mayo Clinic in Jacksonville, and I'm also assistant professor of otolaryngology here in the Jacksonville campus. I'm joined today by my Panelists, Doctor Christer for DeStefano, Dr Beth Gladly Dr Archer Martin and Dr Haney Watty. We have no financial disclosures. The objective of today's panels include describing health disparities in health outcomes in covert 19 and minority groups. We'll discuss health care disparities singing surgical specialties such as otolaryngology transplant surgery and obstetrics and gynecology prior to the cove it 19 pandemic. And then we'll discuss protocols and procedures put in place here at the Mayo Clinic Jacksonville campus to protect staff and patients during aerosol generating procedures. such as innovation and endoscopy. I'd like to start the panel discussion by discussing the census data in regards to the demographic breakdown here in the United States. As of July 2000 and 19 the U. S population was approximately 328 million people. Whites made up 76.3% of the population. Those who are white of non Hispanic descent make up 60.1% of the population. Blacks and those of African American descent make up 13.4% of the population, and Latino and Hispanic persons make up 18.5% of the population. Thes statistics are important as we delve into health care disparities as relates to quit. But 19 this graph is from the CDC, and it shows the cases of covert 19 based on race and ethnicity. As of September 2000 and 20 it shows that whites make up the majority of cases of covert 19. How are blacks and those of African American descent make up 18.5% off Covad cases, and again they only make up 13.4% of the actual population. Hispanic and Latino persons make up 29.5% of the cases of covert 19 and again, they only make up 18.5% of the actual population. When we look at deaths due to covert 19 as of September 4 21st, 2000 and 20 we find that whites make up the majority of death do the cove. In 19 however, blacks make up 21% of death due to covet 19. And as we just discussed, they only make up 13.4% of the actual population. Hispanic and Latino persons make up 16.7% of deaths due to Cova 19 but they only make up 18.5% off the actual population. As you can see, there is a significant disparity in the frequency of hospitalizations and deaths due to Cova, 19. For black and Hispanic people. This slide is from the CDC, and it breaks down cases, hospitalizations and death based on ethnicity and race. What they found was that American Indians have a hospitalization rate that is 5.3 times higher than whites. They also have a death rate that is 1.4 times higher than whites. Blacks have a hospitalization right? That's 4.7 times higher than whites, and the death rate that is 2.1 times higher than whites and Hispanic and Latino persons have a hospitalization rate of 4.6 times higher. And a death rate that is 1.1 times higher than whites thes are important statistics. As we look at the factors associate it with death due to Kobe as we double further, we now all understand that air certain underlying conditions that make you more vulnerable to covert 19 especially when it comes to hospitalizations. This graph from the CDC shows that certain co morbidity such as asthma, hypertension, obesity, diabetes and chronic kidney disease are all associated with having a higher risk. Ah, hospitalization. Do you cover 19? These communities are important, as we all know, that they are statistically are found more commonly and those of minority groups. With this information, we find it significantly valuable toe have a frank discussion about health care disparities as relates to surgical entities, as well as emphasized the importance of a better understanding of how race and ethnicity plays a part in our health care system. If you like more information on the statistics. Discuss. Please go to the CDC dot gov website. Thank you. Well, now discuss otolaryngology and healthcare disparities. So I'm going to start by talking about my specialty Otolaryngology. We're gonna talk about the health disparities in this particular, um, subspecialty head and neck is one of the more significant studied areas for healthcare disparity Larry and Joe Cancer, endocrine tumors and HPV Positive or fair. And Joel tumors are all types of conditions that have been studied. Associate it with health care disparities for Larry and Joe cancer. We found that, um, blacks and Latinos are more likely to be treated with surgery meaning a total or inject to me where the Lawrence is taken out surgically and the patient is left with a stone mama which affects their ability to speak cough, smell and swallow. Normally, these patients who are in stage three or four typically should be considered candidates for a combination of chemotherapy and radiation. However, when we look at the statistics from 2000 and 1 to 2000 and 10 you find that blacks and Hispanics are more likely to be offered surgery rather than chemo radiation, which is considered to have the same overall survival and endocrine tumors. We found that patients of black descent are more likely to have complications from their surgery, meaning thyroid and parathyroid surgery, because they're more likely to be treated by those who have low volumes, meaning surgeons who are in um, who specialize in otolaryngology but do not have more than 75 cases per year of doing these types of surgeries. We've also found that HPV, which has changed our world as we see it as far as head and neck cancer because it's more likely to be sensitive to chemotherapy and radiation with better. Overall survivals is actually less prevalent in the black community. So whether they smoke or don't smoke, which has traditionally been how we assessed the likelihood they're going to have the diagnosis of a Orel Fair and Joel cancer and whether or not they have other co morbidity is having HPV. Um is actually a positive thing for their overall survival. And African Americans are, unless likely tohave that diagnosis of HPV positive in the pediatric realm. We find that African American Hispanic Children are less likely to be referred for surgical procedures such as P E tubes and Thanh selective use, which means that they continue to suffer for longer periods of time before having appropriate definitive surgery. And in this right knowledge in school based world, we also find that they're more likely to have complications from their surgical procedures because they're more likely to be operated on at low volume centers. So Covic has significantly impacted our practice were considered a procedural type of practice in both the O. R. And in the office, and we're also considered an aerosol generating procedure type of specialty. We also complicate this by the fact that many of the cove it symptoms are also symptoms that we see with many of our patients. A nausea and Hypo Naz Mia, one of the most common symptoms, and Covic, both for those who have mild or moderate symptoms, and those who have severe symptoms is a common ah, symptom that we see in patients with chronic or on your sinusitis, things like sore throat and nasal congestion. Common things we see in our office and in our practice are now some of the things that are warning signs for covert 19 which makes our specialty even more complicated and figuring out whether acute processes are there underlying condition or cove it. We have taken a major impact in specialties such as Ryan Ology and Larry Oncology, where patients are typically scope using an endoscope are a learning a scope on a daily basis. Thes industrial procedures actually trigger cough and sneezing, which has been associated with the increased risk of spread of transition transmission. So what we have we done in our practice to try and help protect patients in our staff? Well, number one, um, all of our patients are covert tested prior to having outpatient visits. This is a challenge for those who are seen by us and I, um, from outside the realm of the local Jacksonville area. But we've actually seen resilience with our patients who have been able to come early and on days opposite of their appointments to get this covert tests. It's important because it protects them, and it protects our staff. We also are no longer using aerosolized topical anesthetic for preparation of our endoscopy. Instead, we're using nasal packing that has that similar medication for using telemedicine as appropriate, especially for those who have had head and neck procedures. So they do not have to be exposed to the staff for two other patients who are waiting and were ableto expedite any issues that they may have, and we also intermittently close Our office is depending on the risk of our civilization. We also have lots of controversy over when to do a tracheostomy one of our primary procedures, and we found that the use of in 95 or a paper has been associated with a safer protection of our surgeons as we provide this necessary treatment again, Kobe, 19 has impacted otolaryngology in many ways as it's a challenge, as we're learning more about more about the condition and how it spreads and trying to keep our staff safe and trying to keep our patients safe as well. But we hope that these things will lead to improve quality of life for our patients. From the health care disparities standpoint, we're here are lucky that we have all these precautions in place, but we understand that some patients don't have a car to come and get cove it tested. They're concerned about the finances of getting these tests done with frequent appointments, and they don't have necessarily the Internet access to have telemedicine, which does limit their ability to to have any of these precautions even used. I thank you for your time. And, um, as we discuss otolaryngology. Now I have the distinct pleasure of introducing our next Panelist, Dr Christopher Distephano. He's an M D ph. D. And he's also the assistant professor of obstetrics and gynecology here at the College of Medicine in Florida. Thank you, Dr D. Stefana. Hi. Thanks for having me. We're going to start with the question of how has, um you have you noticed the health care disparities in the field of abstract tricks or gynecology? So thank you for that question. So I am predominantly a gynecologic surgeon. Now, the OBE and the G Y N is separated at at Mayo, and we really focus on gynecologic surgery in the Florida campus. And so I'll focus on, um, gynecologic cancer specifically because that's where we've seen the most change with regards to disparities. Before. Cove in 19 disparities were prevalent in endometrial cancer and cervical cancers, and this was predominantly due to access. So black women that developed in Dimitri all cancer are twice as likely to die from the endometrial cancer, which is the predominant form of uterine cancer, Uh, compared to white women. And so we were already working on some of this research. However, unfortunately, Cove in 19 has reduced screening for cancers mainly, I think, because it has reduced women coming in for symptoms of gynecologic cancers. And so we're setting up a number of different systems in order to reach out to women in order to bring them into the mix with regards to their cancer screening Again. Excellent. And the next question really has to do with How has Cove it impacted your practice to date. I think those first two months, because gynecologic surgery, even though it is often indicated and needed, is elective. And so those first few months after Cove in 19 we really shut down elective surgeries to get a handle of what was happening, and at this point we're ramping back up with new precautions like wearing mask universally, Um, what frequent hand washing, social distancing Andi and those have made it safe to see patients in clinic Aziz well, but we also have the option for telemedicine as we're often able to go through the symptoms that are associated with cancers even without a physical clinic visit. And often we can order different tests in order to evaluate for cancer, even with without being seen in a gynecologist office. You know, there's been a lot of differences in how we do screening for gynecologic cancers. Pap smears, which look for cervical cancer no longer recommended every year. However, we still recommend being seen by a women's health specialist every year to discuss symptoms. And the main symptom I want to bring up today is post menopausal bleeding or bleeding that happens after menopause. This is something that over 50% of women experience at some point usually isn't cancer. However, 90% of women with uterine or endometrial cancers, uh, do have post menopausal bleeding. And so that's the symptom. I really want women that are over the age of 50 that have gone through menopause to think about and to seek medical care. If if they have that symptom, you know we are an academic medical center, and therefore it has been important to continue research during the pandemic, and actually our research project deals with this issue of seeking medical treatment and from home actually So we're studying self collected, a tampon test to evaluate for endometrial cancer. And so one day this may be able to decrease the need for being seen in a clinic, and so a patient could have a telemedicine visit, um, and have in order for a self collected tampon. And so we are still doing research as well on disparities in order to reach out to women that aren't necessarily coming into the clinic setting and are scared to come into the clinic. Visit eso. We're trying to reduce those barriers to seeking care because we know again that black women have death rates there twice. A Zayas White Women for uterine cancers. The diagnoses of uterine cancer 35% lower during the 1st 12 weeks of a pan of the pandemic in California. This means that many patients are not presenting with symptoms of disease. They're probably at home not considering the possibility of cancer. And so we want, even though the pandemics important, we have mechanisms in order to reduce the risk of spread of the virus with universal masking on DWI, still recommend that women seek care for symptoms that are associated with cancer, especially post menopausal bleeding. 90% of patients with endometrial cancer have abnormal vaginal bleeding, but only 9% with bleeding. Havin Dimitriou CANCER So many women and providers, um, in outside of gynecology often don't bring up post menopausal bleeding. We want patients to start toe, bring this up to their providers so that we can act on it. And some of the things we're doing is from Mayo is reaching out to community clinics, non clinical community settings like churches, like homeless shelters like libraries anywhere we may be able to find women that have symptoms associated with cancer cancer outside of the clinical setting and then finally, non academic medical center settings. Because we know that most patients are not seen in the Academic Medical Center and we need toe help. Provide access to women, uh, that have symptoms associated with cancer. So this is just a map of how we're trying to cover Jacksonville with some of our work on symptoms associated with cancer during a pandemic. Excellent on we have a few minutes to talk. Still, Do you? How did you establish those communications between yourself and the non academic, um, um, institutions that you're partnering with. Right now, Mayo Clinic has dedicated themselves to health equity and work on disparities research. And so we have an office of health equity at Mayo Clinic that helps establish partnerships both within Mayo with different departments, like we're talking today and then also outside of Mayo Clinic, uh, in the community, both at clinical settings with other positions in the non clinical community settings. Excellent. Oh, and so the the other important pieces, uh, knowing what to expect, Uh, if you come in with symptoms associated with endometrial cancer. First of all, cancer is a scary word. However, with uterine or, uh, in Dimitri, all cancer, uh, the it is highly curable if caught at an early stage. That's why I'm really reiterating that we want patients to come in. We think they need to come in early with symptoms so that we can do a biopsy and the biopsies about a less than 32nd procedure in the clinic in the office that sometimes weaken do under anesthesia with our anesthesia colleagues if if there's a concern about the pain or discomfort. And so we have both options both in clinic or in the operating room on DSO I'm looking forward to hearing from our anesthesia colleagues about how to facilitate access for many of these cancer screenings. All right, thank you so much. Thank you, Dr Wati, for joining us today for the panel on Covert 19 and health care disparities and surgical procedures. Doctor Watty is a assistant professor and medicine and is has a joint appointment in transplant and is part of the transplant and hypertension center here in the Florida campus. Again. Thank you for joining us today. Okay. Thank you for inviting me. So that's a little bit off. Different topics and the previous ones discussed. But again, I just want to highlight that there is a big history big here. And I think it's inappropriate to talk about kidney disease, kidney failure and racial disparity because it's a perfect example off the blind spot phenomenon, uh, in the American health system. So I will explain this a little bit further. Basically, race was not mentioned anywhere in the end stage renal disease, literature or the chronic kidney disease literature until probably 1984. When the first time they discussed that there is increased risk off kidney failure in African American population there was. Back then there was limited access to dialysis, and there was a committee that actually prioritized dialysis patients and based on worthiness, how they're like net income. How is the are married or not? How they have kids or not? Their contribution to society but race was not mentioned is one of the criteria to prioritize people on dialysis back then. And you wonder if some people would deny Dallas is actually because of the race. As Faras kidney transplant is concerned again. Early reports dating before 1970 did not even consider race as a criteria, even to mention whether, when it comes to the recipient or when it comes to the donor, they did not mention it. It's not only till 77 when they said, Well, there's 11 0.9% off. The people who actually got transplanted turned out to be African Americans, so it took them 50 years. Toe recognized that there is racial differences, and that's again why It's a perfect example off the racial blind spot, as I just said. So what have we learned since we start looking at trace and end stage energies were learned very important facts we learned that number one that so correctly disease is seven times more common in African American compared to Caucasians. End stage renal disease meanings Being analysis because of the chronic disease is three times higher in the African American population. Re not. We learned that renal transplant is a life saving procedure for anybody, a respectable phase and because it belongs years off life and gives better quality off life. But we learned to it has Bean really produced multiple different studies. That African American has limited access to kidney transplant compared to Caucasians, and they're definitely when it comes to living donor. Their disadvantage because they're less likely to receive a living donor kidney, which is the best quality kidney compared to the disease donor. And even if they get transplanted, their post transplant outcome has bean inferior when it compared to Caucasians, so the patient does not live as long, and the kidney does not stay as long compared to Caucasian population. So this is a graph here showing the the lifetime risk off end staging these by race in the US, and this is just published in 2018 and the sources isn't available. One for everybody to check. It's an online database that grasp all the information regarding dialysis. Patient. As you can see in African American men, the 8% off the African American men will end up being unbalances, compared to only two or 3% in Caucasian. Same thing with African American women. 7% lifetime risk off. Being on Dallas is so that's what I'm saying three times higher. You expect that if there is more people in Dallas is and more people will get a kidney transplant and that's not the case. So here's the transplant rate present off people who got transplanted by race. The red line here is a Caucasian, and the greenish line is African American. And you can say that over the years, 10% of the people who received a transplant off African American race compared to between 20 and 30% off the Caucasians who had off. The people who receive transplants are Caucasians. Despite the reverse, as faras Dallas is concerned, mawr three times higher dialysis and three times higher, sometimes less African Americans are receiving can spent. So what happened in the covert 19? We know that this virus came to us out of nowhere. Highly contagious virus caused severe acute respiratory distress syndrome and it received various kind off names first reported in China at the end of December. Spread across the whole globe, did not spare anybody, cause major disruption on multiple levels and we will not spared from this disruption. But I will say personally, I attribute this disruption too many things. One of them is a high mortality rate we received from the European counter parts who, especially Italy and the conflicting media reports who kept us totally puzzled. We did not know what the mode of transmission is. We didn't want to. Now the CDC is still debating is. Does asymptomatic carriers or asymptomatic affected people can transmit the infection, amount, the surfaces, the door knobs? All these things kind of created a lot off fear and there was a lack off knowledge on how best to manage this patient, and there was a big fear that the medical system will collapse actually. So all this kind of flood our efforts here in the 10th Stint center to change our practice and we did many things on. We did not do things, other things which I think we're empowered off. So the things that we did is that we stop all living donor kidney transplant. We consider those to be an elective surgery. And since all elective surgeries have been postponed with postponed them deceased donors and the kidney offers we delayed. We did not accept any for seventh 10 days. But after that, we catched up, and that's compared to other centers. That's kind off unheard off because other centers stopped doing transplants for a couple of months. Hm. We postponed some off the new kidney transplant evaluations basically clinic visits for evaluating patients for kidney transplant, specially if they're coming from out of state, especially in New York, which was at the time ah, hot spot. We tried to go with the virtual format, and overnight all our officers were filled up with speakers and the mix and all the things to facilitate this to happen. Then we start toe work on a patient specific level by creating protocols toe How to manage this over infected any transplant patients who are immuno suppressed and at risk off having worse disease than others, as has been mentioned before, Chronic kidney disease itself is a risk factor for for severe cov infection and many off. Our patient also has hypertension, has diabetes and are obese. Uh, and as we said, African Americans. So all these people are like all the risk factors are concentrated in the kidney transplant patients, So we had to develop protocols on how to manage those. We also wanted to split the medical teams. Some would come even they some would come out day. So we avoid co infection between them, and we had to deal with, like, staff quarantines and hard time when coverage and all the rest. But what we did not do, we really did not change overall are immune suppressive regimen or any protocols that we're using. We kept trying to keep the patients social support together, and we allowed at least one caregiver to be present with each patients. And that was something we had to discuss with the hospital because the policy at the time was not to get any visitor or any caregivers in the hospital. So but we had to allow this to happen. Overall, we survived, and we did not collapse, which is a very good thing. Okay, I will just tell you to that we looked at our experience with Covert 19 and how it affected our practice. So go with this is kind off overall draft showing how the growth off our transplant center assed faras kidney transplantation is concerned from 2014 now. So there is continuous growth and cove it kind of came and knocked us down or slowed us down a little bit. And the surprising fact that it did slow down or this favor of the African American community more for unclear reasons or the reasons that we need Thio look for cause off. So basically, if you look at people who came for penny transplant evaluation, so I told you what we did overall and we did not discriminate based on race, who will come and who will not come for kidney transplant evaluation? But if you look for the 90 days before Cove in in the 90 days starting from March 2nd after co vid, there was 30 30% drop in patients coming to us for kidney transplant evolution. If there are African American Caucasian did not drop that much. Only 4% drop in the Caucasian race for some reason, compared to 29% in the African American population. And if you look at fresh, tense plans, so all transplant kindof dropped again 90 days before, covered with 21 transplants in the African American patients and 36 Caucasian after Cove it there was a drop in both races. But the drop was more pronounced also in the African American community, compared to the Caucasian, 33% in transplant declining transplant, compared to 20%. So reasons for that is not clear. You can only speculate about it. Maybe some of those patients were again from more out off state and or from heavily infected areas. And we just they did not get a kidney after, like people from New York or other areas which were initially heavily head. Uh, maybe we had some people who could not come because their caregivers were actually sick or they could not find somebody to drive them in a reasonable amount of time to get their deceased donor kidney. Um, probably some people lost their insurance. We have to dig deep and find out what two reasons are. But I think this is again an example that coal over it not only has effects on mortality, the numbers that everybody the CDC is tracking, the media is tracking. But it does have other effects that we kind off would be surprised if we see it. And we just don't have the answers for. So I just want to conclude that CKD, which is character newsies and stages these renal transplantation, are a clear example off how race on racial disparity is affecting the American health care system and because of covert major disruption happened overall in our transplant program. But it seems to for some reason, it magnified this racial disparity. So we can even conclude that cove it killed us even without infecting us. And with that, I would just I have no more things to say Amazing, fantastic. That was very enlightening. And we'll talk about this when we come together, because I think this is a challenging thing, not only for our institution, but I think around the country everyone is trying to figure out. I think there's a lot of concern and information in this information that's put out in the community about what? Whether we're doing transplants if we're not doing transplants, are you now and not a candidate because you're high risk in regards to covet in general, should you be taking your medications or you should you not be taking your medications thes air, huge things. So I think that everyone who is a health care provider ah, patient of advocate for patients really need some clear instruction and information. So that again, as you said so eloquently, we don't let the virus kill, you know, kill us. And we're letting our translating our kidney kill us because we're in fear. That's why I say that people are still confused and they come to the clinic and they say, We don't wanna get transplanted to lose. This virus is over. We don't wanna get transplanted, there's a vaccine is available. And what's gonna happen if we there's a vaccine? Should we take the I mean, our new system. How is gonna handle that? There's lots off questions and public creating about this one. Our Lessing, I should say, is that we published the paper looking at We summarized all the literature till the end of July discussing covert 19 from, like the whole literature we included, like more than 300 cases off over 19 in the kidney transplant patient has Bean reported from all over the world, and the mortality rate and the kidney transplant patient was 24% completed 10% in the general population. So that that was you, that the more severe disease and more higher mortality are are problematic in the kidney transplant patient. We did not look for race, particularly because again, this is reported from all over the world, like including China and Iran, Italy, France and the U. S. So not every report included race as as part of the, uh, reporting criteria. So but that's something we should look into. Absolutely mortality in the kidney transplantation differs by grace. Yes, excellent. Thank you so much. And we look forward to hearing for you after our next speakers. Our next speaker is Dr Beth Ladell. She's an M B PhD, and she's also the assistant professor of anesthesiology here at the Mayo Clinic in Florida. She's also the medical director for our Office of Equity, Inclusion and Diversity, and I'm really excited to hear her perspective, but not only diversity initiatives here, but also how anesthesia has been affected by, um, our health disparities have been affected by anesthesia. Thank you, Dr Ladan. Thanks for having me, Dr Donaldson. And I'd like to start my talk off the same way that you did. I want to give people a bird's eye view of what health care disparities look like an anesthesia. And I could do that very easily in a small panel discussion because almost all the information that we have on health care disparities in anesthesia will fit on this first slide. Mhm. So, uh, you know, anesthesia? Um, sometimes we feel like we're sort of a subsection of medicine. Where are our patients are sort of just brought to us by other providers. And so I think sometimes we're a little bit late to the game as far as looking at outcomes differences. So there is still a lot of questions to ask. But what we know so far are these things. So in an analgesia, no matter where you look at it, peri operative, pediatrics, labor and delivery especially in fact, when, as Dr Distephano already mentioned, there's a lot of information on health care disparities and maternal fetal outcomes. Um, and analgesia during labor and delivery is no exception for that. There is a perception that people of other ethnicities may perceive pain or anxiety differently, and for that reason it may be undertreated. So as you can imagine, the disparity is that it's more highly treated, um, in white patients in the United States than it is in any people of color and along that same line. Because many of the treatments are opioids. There can be mawr complications of opioid overtreatment in white patients as well. When you look at general anesthesia for Caesarian section, so general anesthesia is generally something we try very difficult to avoid. The risk of complications and significant morbidity and mortality is double when you have to receive general anesthesia versus a spinal anesthesia for caesarian section. So it's a It's an obvious indicator on how we're handling things. If your risk of general anesthesia is 1.7 times higher if you are ah, person of color, the postoperative nausea, vomiting, um, is an issue that's really recently recognized. So there was a huge study based on a national database outcome, and this includes more than, uh, this is 50,000 plus cases of anesthesia where they're kind of able to separate by socioeconomic status and who knows what the details of the reason why. But lower socioeconomic status is associated with under treatment and under prophylaxis of postoperative nausea, vomiting, which is a major cause for delayed discharge. Prolonged length of stay prolonged pack you length of stay, all things that are sort of indicators of care. General anesthesia for honey repair and regional anesthesia for orthopedic procedures. Those air sort of late so regional anesthesia tends to beam or accessible for white patients than patients of color. And again, sort of hard to tease this out because some of this is sort of regional variation in practice. But the the take home point remains Anytime you ask the question, Is there a difference between how we take care of people of different ethnicities? The answer is almost always, yes, let me move on a little bit, Thio critical care, specifically because critical care is a multidisciplinary field. But as you know, anesthesiologists are highly involved, and I really feel like the health care disparities in critical care are what are most closely related to Cove in 19. So you've already you've already expanded very nicely on the difference in death rates. The difference in hospital admissions for different ethnicities. Andi. That literature isn't specifically available yet in anesthesia critical care literature. But prior to the Cove in 19 Pandemic, there is a difference in outcomes. If a patient has acute lung injury, or RDS, there is a higher income for people of higher incidence for people of color. For respiratory failure, there's a higher risk of Venus thrombosis and embolism for people of color and Venus Rambo embolism is certainly an exacerbating factor in morbidity and mortality when it comes to cope in 19 treatment specifically and then finally, community acquired pneumonia, which we normally think of as a streptococcal pneumonia right now, is highly associated with viral pneumonia related thio, the Cove in 19 virus. If there was already a difference in community acquired pneumonia treatment, we can expect those to be augmented based on the health care disparities that have even been uncovered with Cove in 19 specifically, and I think part of the reason why this happens is because representation matters. So this, um, this is this is from census data and from unaudited of anesthesia practice from 2019 that was given Thio, the American Society of anesthesiologists. So you can see that while according to the census, maybe 52% of Americans or white 80% of Americans are. 80% of anesthesiologists are white. So there's data in other fields that patient provider concordance so that patients and providers can have things in common, like race like gender like, um, sexual orientation. It's sort of automatically increases the level of connectivity right from the get go. And so patient provider concordance is something that anesthesia struggle with struggles with because we don't have good representation amongst our staff amongst our providers for minority patients. Eso What What do I think are the solutions to this? I'm just gonna throw a few things out there that I that are that are in the literature. So protocol use really eliminates some of the implicit bias that providers bring to the table because you're no longer really dependent on your own brain for remembering post op nausea and vomiting prophylaxis. Regardless of who the patient is, it's sort of already systemically laid out in how you practice medicine, and so that's easy to apply to all patients. And there is definitely data in the literature that this works particularly well for areas protocol. So if you look at enhanced recovery after surgery, the studies that have been done that look at race and those feel like the protocol sort of eliminate, Um, there's there's no longer bias that's obvious between people of color and white patients and that unconscious bias training. Probably everyone who's listening to this knows already that regular and routine unconscious bias training where you really make those unconscious biases mawr conscious allows you. So, for example, if I knew that I had, ah, bias against a particular type of patient, if I know that and that that means I'm have, um at risk for under treating them for nausea and vomiting, I can now pay special attention to that subgroup of patients when I see them and consciously make an intentional effort to improve that post op nausea and vomiting. Third, we need to ask the question. So I already told you I could tell you about all the health care disparities of anesthesia in one or two slides. So we're not asking questions about racial and ethnic disparities when it comes to peri operative glycemic control. When it comes to transfusion, when it comes to link the stay in the pack. You even, um, length of operation Time has been looked at once or twice, and Operation Time tends to be different, depending on payer mix or racial. So every time we ask the question, we learn something. So we need to get better asking the questions and then back to that patient and provider concordance. That's about building a pipeline. That's about finding out why women don't go into anesthesia, because women do. You make up 50% plus now of medical student populations. So what about anesthesia? Causes them to lose interest and people of color are already under representative medical school. So the pipeline for them is broken prior to that. So really repairing the pipeline is gonna yield providers that have greater insight into creating sort of, um, or fair health care system for for users when they come when they interface with our with our healthcare environment and I'm going to turn it over to Dr Martin because Dr Martin I worked together also on sort of developing the anesthesia response team here at Mayo, and he is going to be ableto shine some light on some of the experiences that we had. Excellent. Thank you so much. Well, Dr Lalli, thank you so much for that insight. Thank you to Dr Donaldson for hosting this and really thank you to all my fellow Panelists. So we were tasked to answer the question. What was the impact of Cove in 19 on our specialty? What are some of the safety concerns that we've had? And what are the protocols that we have to find throughout this pandemic? Really were driven by our goals. These don't change. I'm going to discuss those. But we're guided by principles that also never changed. But sometimes the application does. Finally, I'm gonna take each one of you on a multidisciplinary cove in 19 journey going through time to tell you exactly how we've handled it and where we are in the current day. Now, when we examined the goals that are in the forefront of our mind, these never changed. The first, which is foundational to Mayo Clinic, is that the needs of our patient come first. But we're facing a pandemic where there is a threat to health care providers who are taking care of these patients. It's important also note that one of our primary goals, the safety of our staff in order to achieve these goals, we have guiding principles and I think that there's been threefold. First is an appropriate level of education as well as coordination and communication amongst all of our colleagues. Now I've taken this and gone through time. I note phase one, phase two and in current day, and I'll define those time eras. But I want to take you back to early 2020. Let's say February to March and I would turn the phase one soon. There were reports coming out of China either on Twitter or medical case reports that my colleagues were picking up of a new emerging pandemic and from the education. But we were trying to figure out what exactly were we dealing with. So we had to look back toe literature from 2000 and five, predominantly out of our colleagues in Canada and in fact, Toronto with the initial stars pandemic that initial literature discussing the threat to the providers who were taking care of the patients, as well as some of the techniques to use PPE as well as attenuate the risk of fertilizing generating procedures were vital for us in terms of our starting point during this pandemic. From a communications standpoint, we had to learn how to identify the problem. Testing was relatively limited and often slow in the very beginning phases of the pandemic, and we realized fairly quickly, Doctor loudly, myself and many other colleagues from our department that we had to figure out how to coordinate together as a team. We had to really defend ourselves, our entire department, and we decided to do the best we could in terms of concentrating, available PPE and expertise by forming a covert anesthesia response team. Now, if we moved out of Phase One, we moved into Phase two, and some of the education that we received both through literature and other colleagues, experiences where the pandemic was. Ah, little tougher at the time, helped us in terms of understanding how to use appropriate PPE. We form video and put it online. We digitize our protocols where we discussed appropriate donning and doffing procedures for air slides and generating procedures. After our team had interaction with these patients, we had debriefs both within ourselves in via email, and we incorporated that experience to reinforce the digital protocols. Now, this time, testing had improved. So our communication piece. We aim to disseminate that information as quickly as possible. And we used our electronic medical record in order to communicate the covert status either positive, negative or unknown, and each one of the patients presenting for a surgical procedure. And whereas on the first phase in February and March, I would say we were on defense. Our coordination now became one of offense, and we coordinated with our multidisciplinary colleagues, and I see you in particular and we integrated into their team to provide support for a GPS or procedural support or if they became overwhelmed, such as our colleagues did, and not find out in New York form our own standing. I see you team to take care of these patients as we move past. Phase two were in current day, and this has been the same since about June 2020. From an education standpoint, we have dissolved the Koven Anesthesia response team and I would say that we're all in this together. We've done the best we can to ensure a departmental wide proficiency so that any provider in our department anesthesiologist or nurse in Estes now is appropriate training and availability for the dawning Adopting of PPE. In terms of communication, we have aims to have rapid identification of patients presenting for procedures. We have hospital wide testing policies. Any colleague who presents for work has to attest every day, whether or not they have symptoms. They're screening at all of our entrances, and we have rapid testing available for emergency procedures. In terms of coordination, we've moved back out of ice you more into the operative face and any patient who is either suspected or known covert positive. We have time outs with all team members and we coordinate before we start the anesthetic. I found that to be very, very helpful in improving safety. As for our patients as well as for ourselves kind of high all of this together, I want to give you an example of a procedure that I would probably say is one of the highest risk that we do in these patients. Now I'm division chair of cardiovascular, a drastic anesthesiology, but we have many different colleagues who are involved in taking care of patients who have refractory respiratory distress secondary to cope in 19. In that case, oftentimes they present to the operating room for rapid the employment of vino Venus ECMO, or extracorporeal membrane oxygenation, which provides oxygenation for their blood as well as the car box elation. When we look at our three guiding principles, we looked from an education standpoint. What are the latest principles, both in terms of ECMO protocols, which may come from the also organization, as well as ensuring that every team member has appropriate knowledge for donning and doffing? From a communications standpoint, we've gone beyond the M R. We have a cardiogenic shock team who is available. This cardiogenic shock team is notified anytime. A potential BB ECMO either comes from an outside institution or within our own. Within five minutes, we're all expected to be on a zoom call, and we coordinate and discuss the best plan for the patient. Subsequent to that we've built into our M R. A secure chat system. The secure chat is key because oftentimes we communicate via phone or be a pager. But when we're fully dawned with a paper or in 95 we can use secure chat directly from the workstation in the operating room to communicate with colleagues outside of the operating room. From a coordination standpoint, as I mentioned, we're outside of the I C U. Now and really, this is a matter of coordination amongst the I. C U cardiothoracic surgery, TV, anesthesia and the profusion departments. And there are multiple colleagues within their respective departments that work together. So what can we see? A conclusion about Kobe. 19th impact on our specialty, the safety adjustments we've had to make a swell of the protocols we've created, Whether we're discussing health care disparities or emerging pandemic, these sort of challenging problems require solutions, solutions that air guided by goals that we all share together as well as principles. But we need to have flexibility to create these ongoing solutions. Our goals, as I noted before, should always remain the same. The needs of our patients come first as well as the safety of our colleagues. And I think it's so important that we work together not just within our own specialty, but multidisciplinary colleagues. And together we can solve these issues. Thank you, Dr Donaldson. I like to give my time back to you. Excellent. Thank you so much. So we're gonna gather the group were just a few minutes, and there's just a few questions. I think there's a common thread that has come up between many of the speakers today that I'm just gonna ask, and so we're gonna gather into the panel form. I think one of the comments that kind of transcended multiple talks was the inequity in the representation of minorities within medicine itself and how that could lead to some of the ideas or misconceptions about the the difference of specialties that we have. So, for instance, from a transplant standpoint, the not having a large amount of community of, um, minority physicians kind of reduces trust because there's not that communication between the two that says no transplant is for everyone. There's lots of stigma says you can't come to these institutions. You have to move to a different state because that state is more likely to transplant than this status there. So there's a ah lot of mistrust, and that comes from many years starting, you know, to stick Gigi and and continuing on to 2020. So I think the discussion on pipeline has is an important one, and I know that we talked about that. From the anesthesia standpoint, I think the discussion on nausea, vomiting and how in the world weekend to say nausea, vomiting is something that's Kiefer anesthetic. Why is it something that is a discrepancy? We all kind of look at it superficially and scratch our head. But can I guess? The question is from your standpoint from your department. What are you doing or what plans do you have to try and help the pipeline so that we have more patients that see people that look like them that might reduce some of that barrier and trust? I could speak to that a little bit. The first thing is knowing where you are and knowing therefore where your deficits are. So it's possible that this is something that you it's been purposeful for. You purposeful with the people that you work around, and you've already really worked a lot on your own department. Diversity for most of us were not there. And so really taking the temperature of where you are right now and figuring out what your deficits are and then striving thio to kind of fill in those deficits, especially if you're a place that has learners. When those learners come and look at your institution, they're going to see a version of themselves where they're looking around. And it's the same thing for the patient when the patient walks in the door, they need to see a version of themselves when they spend time at the hospital. And so, um, I one of the things that I would recommend is take your temperature, figuratively figure out where you are now and therefore where you can go, how you can move forward. Excellent. Thank you, Yeah. Anyone else have a comment on that one? I think I have one comment. I think you're 100% correct. One of the reasons there is disparity in, uh, between African American Caucasian in as far as access to transplant that they have. There's a little bit off mistrust. Plus, they don't feel that they're being spoken to in a language. Did they understand or they relate to? And there is studies that looked at what if you hire an African American nurse or an African American coordinator in African American physician, and this has been associated with increasing the transplant rates and the kidney donation rate as well, so families who, when they relate to an African American nurse and she encourages them to donate a kidney, they arm or comfortable. And they say, Well, that's something that we can do and that's again That's one of the things that has been documented in the medical literature a t least one thing that we can do to narrow the gap as faras disparity is concerned. Another important thing. Disparities. Social economic aspect and the educational level. But even if you are just for those and when it comes to transplant, even if you are just for the socioeconomic factors and yet are just for the educational factors still African Americans have less access to kidney transplantation. Mhm. And I think, Dr Stefano, you've had Cem interactions and you talk to a little bit about that. But here in Mayo, we have some patient navigators and people who help us connect community to the Mayo campus itself. Faras those who may not have access. Can you speak a little bit to your experience with those who helped you connect to community to your practice here? Thank you. Yeah. Now, this is really important. As we move forward in the future. I think these kind of islands of healthcare facilities versus the community need toe start to become or, you know, connected, um, in some way. And we need to build Bridge. Bridge is outside of the health care facility because many of the disparities come from social determinants of health. And, you know, ways that aren't being addressed by health care facilities on DSO. That's where we're engaging with community members. And, you know, groups that look just like the patients And, um, you know, have similar kind of cultures and, you know, languages and education. And how do you engage that with the hospital between the hospital and the community and start utilizing those natural resource is that exist in the community? And we're just starting that, I'd say, in Florida, the Office of Health Equity and community engagement has been essential, and I think we'll see more and more, uh, role as we go forward toe meet patients and and women and men, um, you know, in the community and really educate outside of the facility. We've always kind of looked at patients, is needing to find us, but I think we there's a give and take there. And we also need toe help. Find the patients that are most at risk of some of these diseases and help help them obtain access, whether it's at Mayo or other community health centers. Hm. Excellent. Great. Well, our time has come, and I just want to again thank you all for your enlightening talks. I thank you for your time. And I really hope this has been valuable for our viewers in the future. Again, we're all here together. We're all trying to do the best both and co vid and outside of it, we're trying to uplift our community. So again, I thank you all for your phenomenal talks. Your time in your consideration. You guys have a great night. Thank you for joining us for this panel. Thank you. Thank you for inviting me off us. Thank you.
