SCCM Resource Library-Critical Care Health Disparities: What Little We Understand

Video Transcription

Good morning, and welcome to this talk called Critical Care Health Disparities, What Little We Understand.  In this session, we have four different talks that we're going to hear on around the issues of health disparities, racism, and medicine, and how we can address it.  Dr. Michelle Gong, who is Chief of Critical Care Medicine at Mount Fiore, will be presenting on what we know and what we don't know in racial disparities in adult critical illness.  Dr. Barrett Rush will be presenting on racial disparities in critical illness, how can the research inform frontline care?  And Dr. Titus Chan from Seattle Children's will be presenting Pediatric Racial Disparities in Critical Illness.  I am Dr. Nneka Sederstrom, and I will be your moderator for this session, but I also will have a talk on COVID-19 disparities and the hidden blessings of a pandemic.  Thank you and enjoy your time. Hello, my name is Dr. Barrett Rush, and I'm an Assistant Professor of Critical Care Medicine  currently at the University of Manitoba up here in Winnipeg, Manitoba, Canada. My talk today is titled Racial Disparities in Critical Illness, How Can the Research  Inform the Frontline Care? My research program mainly revolves around the use of large databases, mainly American  data, and looking at disparities in critical care access outcomes and treatments, and I have a great interest in racial and ethnic disparities, and I'm thankful for the SCCM  organizers for inviting me to speak today, and thank you for listening to my talk. I have no disclosures that are relevant to this talk.  Just a bit of background about racial disparity in the ICU, and some of the other presenters  and colleagues will talk a lot about these issues, but race and ethnicity have been associated with numerous disparities across the health system, from access to care, inappropriate  care, substandard treatment of minorities, as well as associated with worse outcomes and higher complication rates.  The relationship between race and observed differences in care and outcomes is very complex.  There are often multiple factors influencing these findings, and really trying to understand these issues and outcomes is quite difficult.  I think it's really important to note, especially because we have mainly an American audience today, that these disparities observed of racial and ethnic groups is really observed  around the world, in different countries, different health systems, and different environments, and not just the United States.  For example, in Canada, there's a huge amount of disparity in critical illness in all health  outcomes for Aboriginal and Indigenous populations, as well as new immigrants and people that English is not their first language.  It's well described in Canada, but also in Europe, and in Asia, and throughout the world. Perhaps in the U.S., it's most noted because of the large amount of research on the subject  in the United States, but it is a worldwide problem. When you're trying to talk about racial disparities in the ICU, and I'll use the term race and  ethnicity interchangeably, but we'll talk about that a little bit later, that there's some ambiguity around those terms, we're trying to determine when differences that are observed  or reported are actual disparities, and how these factors contribute to differential health outcomes.  This is a very difficult topic, and really health inequity, which is rooted in social  injustice, and the inequitable distribution of social, environmental, and economic disadvantages  to certain population groups reflects in these poor differential health outcomes and treatments.  In attempting to study this problem, and identify targets for interventions to reduce or eliminate these differences and disparities within the health system is quite difficult.  Often a societal wide action is required to remove these fundamental inequalities from marginalized groups, and health outcomes are only one real part of the disadvantage that  these groups endure. Other issues such as access to housing, food security, educational attainment, and other  socioeconomic issues are really other burdens that these communities face. This is a great slide from Soto and colleagues from Critical Care Medicine in 2013, really  just showing you the spectrum of the continuity or continuity of disparity that these marginalized patients and groups experience.  There's differences in individual susceptibility, genetic differences, level of comorbidities,  and management levels of those comorbidities, as well as access to preventative health services,  as well as health behaviors and substance abuse, and lack of health insurance and lower socioeconomic status, making patients more susceptible to critical illness, as well as  all illnesses, as well as they have disparity in the presentation when they come to present to a hospital.  They have decreased access to pre-hospitalization care, a likely poor access to ambulatory preventative health measures.  They've got more comorbidity burden, as well as those comorbidities are maybe not managed as well as they don't have the finances for medications and other preventative health  services. Then we see disparities in the clinical management of these patients with minority preferences  and implicit bias, which we'll talk about further in the talk, as well as differences  in the healthcare delivery and differences in treatment that some minorities face, unfortunately,  as well as hospital-based factors, which I'll talk about again later in the talk, how hospitals  that serve a disproportionate minority populations really is a variable of the mechanism for disparities in outcomes and treatments.  Then we also see lots of reported differences in outcomes in these patient populations, which are all influenced from these previous domains, but it really is a symptom of all  of the effects that we have seen down here. In the slide here below, you can see some of the reported differences in quality and  access and outcomes and severity of illness that have been described in critical illness for ethnic minorities and racial minorities.  The mechanisms along this whole spectrum of disparity are hard to elucidate the cause of what is really causing these disparate outcomes, and understanding the complex relationship  of these factors is extremely challenging. As I said before, trying to identify targetable interventions and quality improvement remains  really a crucial part in the research around this area to date. This is just another caveat that even studying these types of interactions and outcomes is  very difficult because the terms race and ethnicity are controversial in and of themselves. The self-identification aspect of these terms is really also a large room for error and  ambiguity, and it makes it even more difficult to study accurately and reproducibly these types of groups.  For the critical care population itself, ICU patients often present unconscious, intubated after cardiac arrest or found in the field, and they may die before they're able to  be interrogated or asked about their race or ethnicity, and often it's a clerk or a staff member at the hospital that's inputting this data into the health record, which then  is put into a database, which then is used to study these types of associations, and  that might be an incorrect labeling or a classification of these patients, including the lack of clarity  in the drop-down menus where you have to bin people into one race or ethnicity as opposed to another based on observation, and there's really a big problem and growing problem of  mixed race and how that is categorized and treated in these types of studies. So there's quite a bit of difficulty in accurately characterizing these types of variables in  these large database studies, and most of the research related to race and ethnicity are retrospective analyses of large databases, usually collected for administrative purposes,  not a priori set up to accurately categorize and question about race and ethnicity in relation to health outcomes, especially critical care.  So how can the research of racial disparities improve the clinical care and outcomes of these populations?  That's kind of a fundamental question of translating some of these findings and associations  of disparity in outcomes and treatments, how can we use that research to inform interventions in future practice and ways to bridge the gap between these populations and outcomes?  One of the main issues I'm going to talk about today, and there are many different avenues of research that have identified potential problems and ways we can improve the care  delivered to these patients and outcomes, but minority-serving hospitals is one that has been shown in numerous studies to be associated with worse outcomes for patients.  These minority-serving hospitals are hospitals that serve a disproportionate number of minority patients.  These are often, in the United States at least, inner city, urban, usually county, or not-for-profit  hospitals that treat an overwhelming majority of minority patients in their hospital. These are different healthcare facilities than, say, suburban, more white-serving hospitals  that often are for-profit, have more technology, more resources available to them. This was a paper that was involved with…we published in the Blue Journal in March.  We studied critical care delivery across the United States from 2006 to 2016 and showed that treatment in a minority-serving hospital, which was defined as a hospital that treated  twice the census area of minority patients, the improvement in survival in critical care  patients was lower compared to non-minority hospitals, and also there was a lack of improvement  over the time period, which was an improvement seen with the non-minority-serving hospitals.  This has been shown in other studies, including this one that we just published in Critical Care Medicine, looking at sepsis patients who were treated across the United States.  If you were in a minority-serving hospital, regardless of your race, adjusted for severity of sepsis, your mortality was significantly higher.  These are associations, not causations for sure, but I think that with a wide breadth  of research that's been published on minority-serving hospitals having worse outcomes, more complication  rates, less access to treatment, a standard of care treatment, this certainly is an area that is right for targeting.  So it was interesting in our first paper that I described that 50% of the care for African-American  patients in this study was delivered in only 7% of the hospitals, really highlighting the  fact that the vast majority of care for minority patients does occur at these minority-serving hospitals and is just an instrumental variable for poor outcomes.  These minority-serving hospitals suffer from a lack of stable funding and they often have  less ability to attract and retain quality health care professionals, as well as they have less resources for allied health, outpatient services, preventative medicine, all kind  of areas of the hospital that are cut when they have a lack of financial resources. They are more likely to have overcrowded emergency rooms and suffer from ambulance diversion,  both of which have been shown to delay time to antibiotic therapy and sepsis, for example,  has been well described. And the overcrowding of emergency rooms and ICUs, as everybody well knows, has been shown  to be associated with significantly higher rates of mortality and morbidity and complications for critically ill patients.  So the question is how we know that the care delivery at these minority hospitals, which represents a majority of the treatment that minority patients receive, how can we improve  the care? One of the big issues is the current pay-for-performance reimbursement models in the United States  where hospitals are measured on their benchmarks and outcomes and if they don't meet certain  standards or they don't hit targets, they get financial penalties from insurance companies  and the government, and this actually perpetuates the disparity for these minority-serving hospitals  as well as the patients that they serve, further restricting their financial resources and limiting access to clinical services inside critical care as well as outside critical  care. So looking at the model of how we renumerate and penalize hospitals is an important policy  decision that needs to be addressed going forward, and it's becoming increasingly clear that these types of hospitals maybe should be not included in these types of schemes  or certainly have a different approach than is currently used for many reimbursement insurance programs in the United States.  Switching gears a little bit here, this is just an interesting paper that was just recently published in the New England Journal looking at the technical accuracy of pulse oximetry  monitoring. Pulse oximetry, when it was developed decades ago, was all validated on mainly Caucasian  patients and research subjects, and this was a nice analysis done by a group at the University of Michigan which was validated in another large US-wide database where they  looked at the SAT monitoring and then the PO2 of arterial blood gases that were done at the same time, and there was a large and statistically significant discrepancy between  the SAT monitor and the PO2 for black patients as compared to Caucasian patients, alluding to the fact that the black patients' SATs may look normal but their PO2 might be lower  than the clinicians think, and that could potentially lead to not as judicious use of oxygen therapy and potential hypoxemia for some of these patients, which is just a very  fascinating example of a discovery of other avenues where the health system may be disproportionately interacting negatively with a certain patient population.  So I think that this is a very novel finding, obviously it was published in the New England Journal, but who knows what other technical factors are in this health system that may  be not being equal for different patients. This is the next topic I'd like to just briefly touch on is implicit bias or unconscious bias,  which I think if I would have given this talk 10 or 20 years ago very few people would have heard of this, but I think it's a more common thing that's being talked about, and this  is the concept of an unconscious bias towards certain people or certain things, and a study  of almost 300 medicine residents and ER residents showed that they reported no conscious racial  explicit bias, but after answering numerous clinical vignettes they showed a preference towards white patients who were thought to be more cooperative than black patients, as  well as patients with acute stroke in the vignettes, they were more likely to offer thrombolytic therapy to Caucasian patients than black patients, and this was an interesting  study and the difficulty with implicit bias is it's very hard to identify and measure and action upon because it operates below consciousness and below the provider's awareness  until it's really drilled down on and exposed through the implicit awareness test, association test.  This was a systematic review that was done in 2015 of dozens of studies of implicit bias in healthcare settings and these authors found that while there was not an increased level  of implicit bias in relation to race and ethnicity amongst healthcare providers compared to the  regular general population, there were significant levels of bias against non-white patients  and this was really shown to be significantly interacting in patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes, and this was  just a further confirmation that there is this level of bias in all people and we need to work better to identify it and try to improve it.  Now it's difficult to action on these things because measuring it is difficult and there's really very few strategies that have been shown in the health sciences to improve this  and mitigate this bias, although there is more evidence in social sciences, the education of criminal justice literature about how this can be improved.  The implicit association test which is available through Harvard for free and I'm sure some  of you have taken it, it's becoming more common in training programs as well as orientations  for new employment in health systems at hospitals across the world and it's increasingly being noted that this type of bias training and awareness training needs to be incorporated  into medical training not for just only physicians but nurses and other providers in the healthcare  team and it's increasingly more important that now that over 30% of the U.S. population  and rising is a visible minority whereas unfortunately only about 9-10% of our physicians are currently visible minorities.  I think with the increased uptake into medical schools of visible minorities the percentage will improve but we all, regardless of our ethnicity or race, need to be aware of these  types of biases and try to reduce the impact of these. Future research on race and ethnicity in the ICU and critical care and how we can minimize  the impact of the disparities that certain patient groups experience is fundamental. Unfortunately many of these associations and research findings have been based on retrospective  analyses, again with the caveat I had said, studying race and ethnicity is very difficult in these types of databases due to the ambiguity around the race and ethnicity information  and it may be assigned by someone that's not the person, self-identification and mixed race issues.  Really now I think with the last year or so the awareness of how much these minorities are disproportionately affected by the health system has increased and prospective studies  and data collection with accurate race and ethnicity information and health outcomes and covariates where we can get better modeling and approximations of the effects of the health  system at various levels across the continuum of disparity can be improved to close the  gap between the outcomes and access and treatments that these different patient populations experience is really fundamental.  Relying on these retrospective databases while crucial and hypothesis generating needs to be confirmed with prospective studies that have better collected data specifically relating  to race and ethnicity and understanding that the societal wide influences of employment status and education level attainment and English speaking status and other socioeconomic  factors which are not really captured accurately in a lot of these databases in order to adjust  for the severity of the comorbidities and how well patients are treated for the comorbidities and access to care.  There's so many variables that go into the impact of this health system and health outcomes for these patients that we really need to do better at measuring these things and doing  better modeling than we have traditionally in the past. Really many disparities in health outcomes that are observed for minorities will only  be fixed by interventions and change that come from outside of the ICU, the societal wide things I talked about, socioeconomic, educational, access to care, preventative  health measures, many of these other changes will be required for these marginalized populations to really have a better shot at equitable care and health equity.  The ICU, we obviously will need to work on our delivery of care, the standard of care is delivered to make sure we've minimized our implicit bias and work to correct any  type of injustice or inequality that occurs inside of our ICUs, but from a macro level many of the things that will be needed to fix these disparities will have to come from  outside the ICU and really outside the healthcare system. Thank you for listening to my talk and I hope we can all improve our care delivery to these  marginalized populations of any race or ethnicity no matter where we practice around the world. Thank you very much.  Good morning. Thank you to the organizers for inviting me to speak today. My name is Titus Chan. I am a pediatric cardiologist and cardiac intensivist at Seattle Children's Hospital  and I'm going to talk today about racial disparities in pediatric critical care. I have no disclosures with the exception that I am a pediatric cardiologist and cardiac  intensivist and so the majority of my research has been focused on cardiac intensive care.  There are some caveats that I have to start off with. First, there is a dearth of research in disparities in pediatric critical care and the research  that does exist is not well organized nor is it systematic. I have not focused too much on studies that document the lack of disparities, but they  are out there and the existence of these studies does not deny the fact that disparities do exist.  Now, I have a very primitive or basic understanding of health disparities, but the way I think  about it and the way I've approached research is to think about disparities as a result of two large driving forces.  So the first is disparities in access and essentially that is referring to the inability or prevention of families and patients of getting the outpatient and preventative care  that they need, which then results in having their disease process progress so that they present in extremis or in a heightened severity of illness to the hospital.  The other part of that is disparities in geography in the sense that if patients are referred  to poor hospitals or hospitals that are not high performers, then of course they're going to have worse outcomes.  The other part of this are disparities in decision-making and so do we as healthcare providers make differential decisions or make different decisions based upon the race and  ethnicity of our patients and that is informed to some extent by our own implicit bias as well as how the family, how different families and patients interact with the healthcare  system in the sense of is there an underlying sense of mistrust for the healthcare system. And now all of these different things interact with one another in the sense that mistrust  for the healthcare system may also delay detection. Implicit bias may influence how we refer our patients.  And all of this is underneath a overarching environment of structural and systemic racism that has been present in the United States for the past 400 years.  I wanted to talk first starting about disparate outcomes in pediatric critical care and again I will warn you that the number of studies and the disease process that are examined  in pediatric critical care is relatively sparse and so there are big gaps in our knowledge. But I wanted to take out three examples of disparate outcomes as it pertains to pediatric  critical care. Now this first study uses the virtual pediatric systems and looks at about 23,000 admissions to the ICU in children who have cancer.  And you can see here that African-American children and Hispanic children have anywhere  between a 24 to 37% increased odds of mortality when they're in the ICU for a cancer diagnosis. Most of this can be seen in terms of hematologic as well as solid tumor malignancies.  But on top of that there's also some regionalization involved as well too in the sense that African-American  children had a higher risk in southern states whereas Hispanic children had a higher risk of mortality in western states. Another example is in pediatric cardiac surgery.  As you can see here there are a multitude of different studies over the past two decades which have demonstrated that children who are undergoing congenital heart surgery have  differential survival after congenital heart surgery. And as most people know pediatric cardiac surgery takes up a fair proportion of our critical care population.  Me and my collaborators have focused on examining this disparity and understanding the reasoning behind this.  But overall what we have found is that black children have anywhere between a 25 to 75% increased odds of mortality whereas Hispanic children have anywhere between a 0 to 45%  increased odds of mortality after undergoing congenital heart surgery. And then finally the last area that I want to pull out is children who require ECLS for whatever reason.  Now Ravi Thiyagarajan has written many papers that look at ECLS as it is used to support children of various diseases.  And in many of these papers, white race is a protective factor and non-white race is a risk factor for mortality.  ECLS, at least in pediatrics, continues to be a very complex and high-risk therapeutic. There are a lot of subspecialists involved. There are multiple organ systems involved.  And there are multiple layers of complexity. And these multiple layers of complexity provide multiple opportunities for people to make individual decisions.  And those individual decisions are open to areas of implicit bias. And so if you have multiple opportunities where you can make differential decisions,  those can culminate and add up to larger overall outcomes where certain races and ethnicities have poor survival.  We explored this further by looking specifically at race and ethnicity. We looked at children, again, who needed cardiac support, and that was the reason why they were on ECLS.  And again, we found that black and Hispanic patients had the highest risk of mortality while supported by ECLS.  And this is, as I said before, due to probably the multiple complexities and the multiple decision points that are used within ECLS.  Now, I've talked briefly about health outcomes, and I will acknowledge that there are many areas that have not yet been examined, but I wanted to talk quickly about disparities  in access. And the first area that I think about is detection. And like we talked about before, detection, to me, is my understanding of if you can get  to your primary care provider at a fast enough time interval when your disease process is relatively mild, and can they treat and refer you at an appropriate time period to prevent  your disease process from progressing? If that can't happen, then there's a high risk that your disease process will continue  to deteriorate, and then you'll present an extremis to the ICU or to the emergency department.  And as you can imagine, if you have a higher severity of illness when you enter the ICU, then your risk of mortality is subsequently higher in terms of surviving in the ICU.  Now there is some data that suggests that this is actually the case. David Epstein and the group out of the Children's Hospital of Los Angeles looked at all of their  ICU admissions as well and correlated it to the 2010 census data. And what they found was that Hispanic children had a higher severity of illness in their ICU.  And on top of that, Latino children who were in a Latino enclave or a neighborhood that had a very high Latino population had a higher severity of illness.  Additionally, what they also found is that increasing neighborhood income was associated with decreasing severity of illness.  And that suggests that the neighborhood itself, the characteristics of the neighborhood in terms of having public transportation, having health outreach, having health literacy,  can contribute to how families can get to see their doctor and get the preventative care that they need. Me and my colleagues have also looked at this.  Dr. Lee Chung recently published this paper where she examined severity of illness using the three main severity of illness scores that we have in pediatric critical care, which  is the PIM-2, PRISM-3, and PICSIM, which is specific to cardiac surgery. And here the red triangles represent a statistically significant higher severity of illness.  And we broke these patients down into preoperative surgical patients as well as postoperative surgical patients.  And what we found was that African-American children had two out of three of their severity scores were statistically significantly higher than their white counterparts.  And in the postoperative patients, what we also found was that severity of illness was a main contributor and driver of disparities in terms of overall survival, which again  suggests that if we can improve access to care, decrease severity of illness, we may be able to improve survival for some of our patients.  The other part that may also contribute to disparities is geography. And so as you can imagine, most patients are likely to be referred to their nearest hospital.  And obviously if you live near a hospital that is a poor performer or that has poor  outcomes and you're referred to that hospital, you can imagine that your outcomes are subsequently – your, as in your own patient level outcomes – are going to be that much poorer.  When we examined children who have congenital heart surgery, what we found was that black children had a 30 percent higher odds of being referred to a high mortality hospital than  their white counterparts. And so that in a sense sets them up for having poor outcomes because they're at a poorer performing hospital.  However, on top of that, what we also found was that when we examined the outcomes for patients who were just at high mortality hospitals, black patients continued to have a higher  odds of mortality at those high mortality hospitals than their white counterparts. So referral in and of itself alone is not the only driver for these disparate outcomes.  Now the other part of health disparities that I oftentimes think about are disparities in decision making.  And that means that – and that refers to kind of the decisions that we as healthcare providers make in terms of working up a patient, treating a patient, and deciding what's the  best clinical course for them. As you can imagine, that is influenced by our own implicit bias as well as by the interactions  that families may have with the healthcare system in the sense that the families may enter a healthcare system and have an underlying mistrust for the advice that we give them  or for the health recommendations that we would like to institute. And so a few examples of this can be found throughout kind of the pediatric critical care literature.  So this study looked at about 12,000 patients who had a history of blunt torso trauma. And what they found was that black patients were 20% less likely to get a CT of their  abdomen despite adjusting for their risk of intra-abdominal injury, which then suggests that our own decision making differs based upon the race and ethnicity of our patients.  This is slightly – this is kind of the – the next study is kind of the converse of that. And this looked at about 500 patients who were in the ICU for an acute head injury.  And so we as clinicians interpret data differently based upon the race and ethnicity of our patients.  And so in this setting, minority patients were more likely to be evaluated and reported for concerns regarding abuse in terms of abuse of head trauma than their white counterparts.  On top of that, that was driven almost entirely by patients who were – who when looked at it objectively had either a very low or no likelihood of having an abuse of head trauma.  And now I also want to mention that this – that these disparities in decision making are not relegated only to healthcare providers.  The group out of Philadelphia examined bystander CPR. And in that study, they found that black patients were 40% less likely to receive bystander CPR than their white counterparts.  Hispanic patients were about 25% less likely to receive bystander CPR. And then finally, this also happens in congenital heart surgery as well.  We examined the decision making around using ECLS to support patients who are at high risk of mortality.  And what we found was that black patients had a 30% higher likelihood of dying without ECLS, meaning that we as clinicians were choosing to not use ECLS in our black patients when  compared to our white – their white counterparts. And of course, this is adjusted for severity of heart disease as well as complexity of surgery.  So underlying this, we do make decisions that are different based upon the race and ethnicity of our child – of our patients, and that contributes to disparate outcomes.  I do want to make a mention that, again, as I said before, there are differences in terms of how families interact with the healthcare system, both in terms of us as providers,  but then also as a healthcare system as a whole. Linda Kiel published this paper recently where they examined whether or not families participated  in a discussion about limitation or withdrawal of care in the ICU. And they adjusted for severity of illness, disease process, as well as functional status.  And they found that black patients were much less likely to be invited or to participate in a discussion of withdrawal or limitation of life-sustaining therapies than their white  counterparts. Additionally, this paper down below documents that non-white patients or non-white families are more likely to not receive communication in their preferred format.  The different formats being rounds – on rounds, family meetings, or bedside meetings.  And what they found is compared to white families, non-white families were less likely to receive communication in their preferred style.  Now, finally, I also want to talk about how there are disparities in research as well, too. One of our most recent large center – large multi-center trials was the RESTORE study,  which looked at sedation. However, we found that black parents were less likely to be approached for consent compared  to white families. And on top of that, when they were actually approached for consent, they were more likely to refuse consent when compared to white and Hispanic families.  And when they broke it down and actually looked at the intervention arm, 40% of black families refused to participate in this research study.  And that is a reflection of not only how we as clinicians and investigators approach and  talk to black families, but also their – probably their underlying mistrust for the healthcare system and for healthcare research, which, to be honest, given the history that we all  know of, is not surprising.  I do want to pull out two quick things. So when I worked in the United Kingdom, what was interesting there was that South Asian  children – so children from India, Pakistan, and Bangladesh – were the – were the patient populations that were at increased risk of mortality when they were admitted to an ICU.  And the children who were from the most affluent neighborhood experienced this disparity the most.  And that tells me that race is – race, first of all, is a social construct, and that disparities are a product of the social and historical context of each society.  Now, finally, when I first started doing this, I thought that we would eventually come to  this place where we could figure out a national solution or an international solution to address  disparities and that through national efforts we would be able to improve the health of all of our patients.  That might still be a possibility, but it's become clear to me that, if anything, we need to start doing this at our own institution and working at the local level to improve  care for our patients before we can think about moving to a national solution. A great example of a center that did do this is a group out of Memphis, Tennessee, where  they found that their Latino patients had a higher risk of mortality compared to their white and African-American patients.  And through multiple interventions, they were able to improve the survival of their patients.  And these interventions centered around delivering culturally competent and culturally sensitive  care, increasing communication and communicating with families in their native language, and then also increasing awareness and promoting preventative and outpatient care for their  patients. And by doing this, you can see that they improve the quality of care and the survival for all of their Latino patients.  So in summary, racial disparities are found in pediatric critical care, and they span anywhere from the parts of access all the way through to research.  That research is still very, very patchy and incomplete for many disease processes and needs to be further understood. That being said, race is a social construct.  This is not a function of biology, and disparities are reflective of the surrounding social and historical context that contributes to this.  And finally, while we need a national solution and we should work on getting a national solution,  we also need to work on addressing disparities at our own institution, and that is the first step to making things better for everybody. Again, thank you very much. Good morning.  My name is Nneka Cedars-Strom, and today I'll be presenting COVID-19 Disparities, Hidden Blessings of a Pandemic.  I have nothing to disclose, but recently in giving talks about equity and racism, I have decided that disclosures about my lens makes the most sense.  So I am disclosing that I am the descendant of slaves, and I am considered a black woman in America, which is very relevant when giving these kinds of talks.  So it's good to start off with the hard facts. We know that COVID-19 has hit black and brown communities the worst since it began in the early stages of 2020.  At the point where I did these slides, we were at a nationwide, black people were dying at a 1.7 times more rate than white Americans.  These calculations came from the COVID racial data tracker in the U.S. Census Bureau. We also know that there are upwards of 40% of cases that have not yet been ascribed race  or ethnicity. So even though this number is still a big number, we don't definitely have a clear image of how many people of color are dying more than white Americans.  We just know that at the time of this talk, 1.7 times more were the mortality rate of black Americans.  Some other interesting data that I think is very relevant in how we look at how COVID has impacted the black and brown community, this slide and the next few are some data  that have been brought up from the Commonwealth Fund. What they looked at, and this one in particular, was the percent of African Americans, Latino  or Latinx community and white Americans who were hit heavily with financial or economic hardship during the pandemic.  We know that black and brown communities make up the most of the people who work in essential  jobs and who also have the hardest time with finding employment or maintaining employment.  This slide shows that across the board, being able to maintain some sort of financial economic  security has been problematic for these communities, especially the black community in regards to maintaining some sort of economic wellness during the COVID pandemic.  This next slide discusses how black people, women and people in lower incomes are most at risk for mental health concerns.  We've read across the news, there have been many conversations on in particular how the pandemic has affected the children in schools from a mental health perspective, but there  is a lot of data and evidence on how it is affecting general adult populations as well. You can see from this graph that black and Latino persons are affected the worst when  it comes to mental health and experiencing mental health anguish during the pandemic as opposed to their white counterparts and women are higher and people who are in below  average incomes are more significantly higher in their mental health anguish. And then finally, the last graph from the Commonwealth to help paint this picture is  a graph that looked at the feelings of positivity from black and Latino and white Americans with regards to leaders in the country on their response to the pandemic.  And from this graph, you can see that there are significant feelings of positivity for hospital doctors and nurses in this, but then when you get to political leaders at state  government and even the presidential level, the belief of positivity of doing a good or very good job dropped significantly, especially in the black community.  But we all know the why. We know that the reasons for the distrust and we know that the reasons for the outcomes  of what the pandemic is showing us is specifically due to the fact that the institution of medicine  in the United States has been built on this proverbial backpack of full of racism from all levels.  I have said in many of my talks before and in some of my writings that when a black person shows up at the door of a hospital, they're carrying already a proverbial backpack that  has multiple points allotted to them against them from systemic racism, institutional racism and structural racism.  And when they come in the door, they come in with those concerns and those issues. And when we have to address their wellness and outcomes, we have to do so in a manner  that takes into consideration the racism that is the reasons why a lot of their health outcomes are so tainted.  And if you don't quite understand the three different levels of racism, the other graphic on this slide is a great graphic that helps us better understand the definitions between  structural institutional and individual impact on racism. But I think that the majority of people are very clear on how these various versions of  racism impact their institutions and are clear that we need to pay attention to that because the story is not really a new one.  We know specifically in medicine and especially after reading the novel, The Medical Apartheid, the history of medicine in America was built on racism in multiple ways.  And so within our own field, we haven't done a really good job yet of addressing our history and moving things forward.  What we tend to do is we tend to just assume that if we look at what is considered the  surface level of how racism impacts and works within that, that we somehow are making adjustments  that truly impact the foundational level of racism, and it doesn't, which is why we're still moving forward with conversations on how to be anti-racist and conversations on  how to deal with microaggressions, looking at policy levels and having a little bit of a reckoning within our country and within our institutions on what really comprises  racism and how do we work within a culture of white supremacy and what does that actually mean and how does that affect our patients and their outcomes.  But the difference is now that we have a new way of addressing it. And so I believe that there is a bit of a blessing in disguise as a result of the pandemic.  And that blessing has come in the form of a bit of an awakening. White Americans across the country have had an opportunity to truly see things that have  been true in the black community and the brown community since their beginning. White Americans have had the opportunity to truly take this time to really understand  what does this all mean. It's no longer just something that people who think about this have to deal with.  It is now something that even suburban housewives who have never felt any real need to understand the plight of what the black community is going through to join book clubs and read  books like White Fragility or How to Be an Antiracist. During the civil unrest post-murder of George Floyd, we saw many people across the country  joining forces all together and thousands and thousands and thousands of white people joining hands with thousands of black people to move through that painful time and better  understand why do these things happen. And then in our mainstream, Time magazine had this great picture that depicted the joining  together of everybody trying to understand the overdue awakening of America to its racist existence.  And that has led to even more conversations being put out in mainstream and within families and households.  These are just a couple of headers from a generic Google search in regular newspapers or on just regular online popularity websites on how this conversation has moved through  with 2020 and the fact that people can now have discussions, the fact that people are now learning how to have common terminology to be able to have these conversations.  We hear things like how to be an ally and whether allyship is truly the direction that we want America to go or do we need to become accomplices and what does that look like?  How to become Antiracist. These are all words now that you hear in generic spaces and even around the Thanksgiving table and families.  And that has led to a lot of positivity and a lot of insight on how to move this conversation forward. So are there particular blessings that have been associated with COVID?  And I think that there are. In particular, when we started looking at crisis standards of care, triage protocols  and how to deal with the equity issue, we were under the impression that recognizing the greatest good for the greatest number of people was the best philosophy but we have  since realized that there has been inherent racism in how that works and are now moving to create better philosophical outcomes to actually truly address how to be the greatest  good for the greatest number of people. Our triage protocols also within the scoring systems were problematic because they too  were inherently racist and now many, many people, many states are working on efforts  to create alternative options including looking at the area of deprivation index or vulnerability indexes, looking at a potential give back system.  There are many, many strategies that people are working through that will help with the triage protocols.  And then health equity is now no longer just a buzzword but actually things that people are trying to actively affect.  Institutions, organizations, and systems all across the country have moved to create equity  and inclusion positions and work on this reconciliation within the healthcare system with its sordid  past and try and figure out a way to truly affect outcome in a manner that is beneficial to all patients.  Being intentional with this reconciliation and intentional with equity and intentional in decision making I think is the way for us to move forward.  What it does is it helps us to engage in openly addressing the concept of affirmative action and knowing that it's actually not really a bad word and if we were being honest, the  reality is that affirmative action has always been in existence and it's been in existence  to help white Americans get ahead but it became a bad word when the idea was to help nonwhite Americans but if you look at our history, then that is exactly what it was created for  and it worked. So we need to be clear and have better conversations on what is truly an affirmative action and why we need to have them race specific.  Naming race is never a bad thing. We have sort of grown up in a society where it feels like you're doing the wrong thing  or it's a little icky to say that someone's white or black but that's not a problem. Naming race specifically is actually what we need to do and we need to get away from  proxies that make it feel like it's okay to talk about race without actually saying it. Proxies are a good beginning but they're definitely not the final answer.  We need to be explicit and deliberate. We also need to be able to provide the community with what we know they need in order to help raise them to net zero.  So this feeling that if we are intentional with helping black and brown communities excel that that somehow means that we will take away or withdraw things from the white community  and have them now be subservient is false. What it actually means is that we will be providing whatever is necessary to close the  gap to actually bring black and brown communities to the exact same level as white communities so we can then talk about equality.  We have to also acknowledge that racism has caused significant harm and we have to be bold and engage in anti-racist behavior at a policy level within every sphere of influence  that we have and we always will have to do some ongoing education and training evaluating and accountability for all members of our hospital communities to ensure that the culture  within the institution embraces equity as a pillar and a purpose and it's not just of course the latest buzzword. So what can you do?  There are many things that I believe people always get stuck on when they do this work because they're like oh this seems so big I don't know where to begin.  Well each and every one of us has a place to begin. First you can identify within your own institution where the health equity gaps lie.  Where are they within your critical care department? What are the outcomes of your patients?  Look at them and be clear on how you're evaluating them and make sure it's through an equity lens.  Identify barriers for why your patients have this these differences in their outcomes. You individually can you address your own sphere of influence.  Take a look around you and see how inclusive is your own personal inner circle at your department or your leadership.  Be true and honest about who are the people that you invite over to your family. Who are your kids friends and see how you can be more deliberate and intentional in  diversifying people around you. Take the opportunity to create something that I call equity rounds within your institutions  and look for ways to create to address the systemic barriers that have been created. Have open dialogues with some of your colleagues that are part of the black indigenous or people  of color community. Have them see if they're willing to talk about their personal experiences and if they are then just listen to them and believe them.  Don't try and justify or explain. Just listen and believe. And you can be intentional in your attempts to rebalance the scales.  It requires all of us to do this work so you can do it on your own in the way that you have the power to.  And lastly I want to end with this quote as my favorite poet Maya Angelou, do the best you can until you know better then when you know better do better.  I believe we all know better so it's in our power to now just do better. Thank you for your time.

Video Summary

This video transcript highlights several talks on health disparities, racism, and medicine, and how to address them. The speakers discuss racial disparities in critical care among adults and children, as well as the impact of COVID-19 on minority communities. They emphasize the complex relationship between race, access to care, treatment decisions, and health outcomes. They also address the structural and systemic racism embedded within the healthcare system and the need for interventions to address these disparities. <br /><br />The speakers discuss the need for accurate data collection on race and ethnicity, as well as the importance of understanding and addressing implicit bias in healthcare. They also highlight the role of minority-serving hospitals in perpetuating disparities and the need to improve access to care and resources in these institutions. Additionally, the speakers discuss the disparities in mental health and the impact of racism on mental well-being during the pandemic.<br /><br />The speakers acknowledge the historical and ongoing racism in the healthcare system and call for a more intentional and inclusive approach to address health disparities. They highlight the need for reconciliation, equity, and inclusion within institutions and the importance of individual efforts to promote anti-racist behavior. They also encourage ongoing education and evaluation to ensure that healthcare institutions prioritize health equity.<br /><br />In conclusion, the speakers emphasize the need to recognize and address health disparities and racism within the healthcare system. They argue that the COVID-19 pandemic has brought these issues to the forefront and provided an opportunity for change. They emphasize the importance of intentional efforts to promote equity, inclusion, and anti-racism in healthcare practice and policy.

Asset Subtitle

Worldwide Data, Crisis Management, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives Review disparities in critical illness and clinical outcomes Construct a plan to improve our understanding of disparities in critical care delivery and outcomes through research Discuss potential barriers for generating meaningful discourse and research surrounding implicit bias and healthcare disparities

Racial Disparities in Critical Illness: How Can the Research Inform Frontline Care? Barret Rush Pediatric Racial Disparities in Critical Illness Titus Chan COVID-19 Disparities: Hidden Blessing of a Pandemic Nneka O. Sederstrom

Meta Tag

Content Type Presentation

Knowledge Area Crisis Management

Knowledge Area Worldwide Data

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag COVID-19

Tag Resource Allocation

Tag Epidemiology Outcomes

Year 2021

Keywords

health disparities

racism

racial disparities

COVID-19

access to care

implicit bias

minority-serving hospitals

mental health

health equity

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