>> I’M DAVID MURRAY FROM THE OFFICE OF DISEASE PREVENTION THIS OFFICE IS HOSTING TODAY’S MEETING I WANT TO CALL THE MEETING TO ORDER AND MOVE IMMEDIATELY TO INTRODUCE OUR NEXT SPEAKER IT’S MY PLEASURE TO INTRODUCE DR. ELISEO PEREZ-STABLE AND NIN SUPPORTS KNOWLEDGE AND MECHANISMS TO IMPROVE MINORIY HEALTH AND DEVELOPS EFFECTIVE INTERVENTIONS TO REDUCE THE DISPARITIES IN COMMUNITY AND CLINICAL SETTINGS HIS RESEARCH IS CENTERED ON IMPROVING THE HEALTH OF RACIAL AND ETHNIC MINORITIES AND UNDER SERVED POPULATIONS IMPROVING COMMUNICATION SKILLS AMONG HEALTH PROFESSIONALS AND EXPANDING DIVERSITY HE JOINED NIH IN 2015 DR. PEREZ-STABLE BUILT A CAREER AT THE CALIFORNIA UNIVERSITY SAN FRANCISCO WHERE HE WAS CHIEF OF THE DIVISION OF INTERNAL MEDICINE AND DIRECTOR OF THE CENTER FOR AGING AND DIVERSE COMMUNITIED AND WAS — COMMUNITIES AND WAS ISSUES FOR AFRICAN AMERICANS AND LATINOS IN THE FIELD OF AGING AND REPRODUCTIVE HEALTH AND HAS RECEIVED MANY AWARDS INCLUDING KAISER AWARD FOR EXCELLENCE IN TEACHING THE JOHN M. EISENBERG ACHIEVEMENT IN RESEARCH AND NATIONAL ACADEMY OF MEDICINE HE WAS HONORED WITH THE UCSF LIFE TIME AND MENTORING AWARD IN 2015 HE WAS BORN IN CUBA, GREW UP IN MIAMI OBTAINED HIS UNDERGRADUATE DEGREE FROM THE UNIVERSITY OF MIAMI AND COMPLETED HIS RESIDENCY AT UCSF JOIN ME IN WELCOMING DR. ELISEO PEREZ-STABLE >> THANK YOU VERY MUCH, DAVID I WAS CHARGED WITH GIVING INTRODUCTORY REMARKS AND SETTING THE STAGE I’LL BE ABLE TO STAY FOR MUCH OF TODAY AND LOOK WARD TO SEEING OTHER PARTS ON — LOOK FORWARD TO SEEING OTHER PARTS ON VIDEO FULL DISCLOSURE, NO CONFLICTS AS AN EMPLOYEE YOU’RE NOT ALLOWED AND AS A DIRECT YOU’RE EVEN MORE NOT ALLOWED BUT I NEVER HAD CONFLICTS SO I’M PROUD TO LAY THAT OUT I WANT TO EMPHASIZE THAT WE HAVE THREE OTHER INSTITUTES SUPPORTING THIS EFFORT MY COLLEAGUE AND FRIEND DEREK GIBBONS WILL PRESENT A VIDEO FROM THE NHLBI PERSPECTIVE AND A LONG-TIME FRIEND AND COLLEGIATE NCI AND DIRECTOR OF THE DIVISION OF CANCER CONTROL AND POPULATION SCIENCES, WHICH BY THE WAY, HAS A BIGGER BUDGET THAN OUR INSTITUTE, WILL ALSO TALK BY VIDEO AND FINALLY WE’LL HAVE AN R — REPRESENTATIVE FROM THE NATIONAL KIDNEY INSTITUTE WILL HAVE A VIDEO AND I WANT TO START WITH MINORITY HEALTH AND HEALTH DISPARITIES AND WE LOOK AT WHAT’S MECHANISTIC AND PROMOTING EQUITY WE ALSO ENDORSE THE IDEA THAT ALL RACE ETHNIC MINORITY GROUPS AND POPULATIONS SHARE A COMMON THEME SUBJECT TO DISCRIMINATION IN OUR SOCIETY AND THIS HAS LET TO A CERTAIN AMOUNT OF SOCIAL DISADVANTAGE THOUGH IT VARIES BY GROUP THIS ARE THE OFFICE BUDGET AND MANAGEMENT CENSUS CATEGORIES THE CENSUS WILL BE DISTRIBUTED NEXT YEAR WE’RE A FEDERAL AGENCY, WE ENDORSE THIS, BUT MORE IMPORTANTLY WE NEED TO BE STANDARDIZING HOW WE USE TERMINOLOGY A COUPLE QUICK POINTS, NATIVE HAWAIIANS ARE AND PACIFIC ISLANDERS ARE NOT ASIAN AND WE

SHOULD ABANDON THE TERM CAU CAUCASIAN IT COMES FROM THE ANTHROPOLOGISTS IN THE 19th CENTURY WHO BELIEVED HUMANS ORIGINATED IN THE CAUCUSES AND WE NOW KNOW IT’S SCIENTIFICALLY INCORRECT AND THE CENSUS OFFERS ONE RACE C CATEGORY 2% TO 3% ENDORSE THAT BOX AND HISPANICS ARE THE ONLY ETHNIC GROUP AND I STILL GET THAT QUESTION FROM THIS AUDIENCE IT PREDICTS LIFE EXPECTANCY AND MORTALITY AND DIRECTIONS NOT FULLY UNDERSTOOD WHILE WHITES AND U.S. OVERALL HAS BEEN LOSING LIFE EXPECTANCY AT A GREAT CONCERN, I MIGHT ADD, FOR OUR SOCIETY WHO HAS NOT RECEIVED SUFFICIENT EXPECTATION AND LATINOS CONTINUE TO BE UNEXPLAINED BETTER LIFE EXPECTANCY THAN OTHER GROUPS OUR MANDATE ON DISPARITIES INCLUDES OTHER POPULATIONS BESIDES RACE, ETHNIC MINORITIES ALL POOR PEOPLE REGARDLESS OF RACE ARE INCLUDED IN OUR TARGET POPULATION WE’RE ALSO INTERESTED IN UNDER SERVED AND IN OCTOBER OF 2016 ALONGSIDE THE RESEARCH WE DECLARED SEX GENDER MINORITIES A DISPARITY GROUP FOR RESEARCH PURPOSE AND I THINK THIS HAS STIMULATED MORE RESEARCH IN THIS AREA A HEALTH OUTCOME THAT IS WORSE THAN ANY OF THE FOUR POPULATION GROUPS COMPARED TO A REFERENCE GROUP WILL DEFINE HEALTH DISPARITIES FROM OUR PERSPECTIVE WE ENDORSE THE THEME OF SOCIAL DISADVANTAGE DUE TO DISCRIMINATION AND MANY POPULATIONS, IF NOT MOST, ARE UNDER SERVED IN HEALTH CARE WHY DOES SOCIOECONOMIC MATTER? IT PREDICTS MORTALITY AS WELL INCOME THIS IS ADAPTIVE DATA FROM THE CENSUS AND HAS LOOKED AT VARIOUS WAYS IF YOU ARE AT THE POVERTY LEVEL YOU’RE THREE TIMES MORE LIKELY TO DIE AND IF YOUR HOUSEHOLD IS $115,000 THIS IS AS ROBUST A PREDICTOR AS BLOOD PRESSURE, BMI AND CIGARETTE SMOKING WHICH WE PAY A LOT OF ATTENTION TO AND A MESSAGE WHY WE NEED TO INCORPORATE THESE DEMOGRAPHIC DETERMINATES AND WE DEVELOPED A FRAMEWORK THAT’S INTENDED TO IDENTIFY SORT OF THE DIRECTION AND THE FACTORS INVOLVED IN DEVELOPMENT OF DISPARITIES AND ASCERTAINING MINORITY HEALTH OUTCOMES I WANT TO EMPHASIZE AT DIFFERENT LEVELS AND DOMAINS OF INFLUENCE BOTH IN BIOLOGICAL, BEHAVIORAL AND ENVIRONMENTAL AND HOW THEY INTERACT WITH THE HEALTH CARE SYSTEM WE’RE TALKING ABOUT SERVICES, I THINK AGAIN WE EMPHASIZE AS A FORMER PRIMARY CARE DOCTOR I VERY MUCH APPRECIATE THE IMPORTANCE OF WHAT CAN HAPPEN IN THE CLINICAL SETTING THE MESSAGE OF SUCCESS HAS BEEN VACCINATIONS IN CHILDREN WE SEE THE DATA IS DATED IF NICK NICK — IF ANYTHING WE’LL SEE AFFLUENT WHITES DECREASING VACCINATIONS REFLECTED IN MEASLES THIS YEAR BUT WE DON’T DO AS WELL WITH ADULT VACCINATIONS WHICH IS SOMETHING WE NEED TO PAY ATTENTION TO SO IN THINKING ABOUT GLOBAL ISSUES ABOUT PROMOTING HEALTH EQUITY AND PREVENTIVE SERVICES I HAVE FIVE POINTS TO MAKE ONE IS THEY CLEAR IF YOU’RE GETTING SERVICE US NEED MORE ACCESS AND ACCESS IS NOT JUST INSURANCE BUT CLINICIANS HAVE BEEN FUNDAMENTAL DRIVERS OF THIS THIS IS COMBINING THE CLINICAL AND PUBLIC HEALTH PERSPECTIVES AND INCORPORATING EVERY DAY PUBLIC HEALTH INTO CLINICAL MEDICINE SINCE MORE PEOPLE GO TO SEE A CLINICIAN WITH THEIR CHRONIC DISEASE ISSUES I THINK IT’S A FUNDAMENTAL ISSUE WE ALSO NEED TO CONSIDER DIFFERENCES BY RACE AND PREVALENCE IN SEVERITY NOT ALL PREVENTION IS EQUAL, IS AN EQUAL OPPORTUNITY ISSUE

HYPERTENSION I’LL COME BACK TO IN TERMS OF PREVALENCE AND SEVERITY IS DIFFERENCE BY RACE NEGATIVE CLINICAL TRIALS WITHOUT DIVERSE PARTICIPANTS CANNOT BE THE FINAL WORD I’LL MAKE THIS POINT ABOUT PROSTATE CANCER SCREENING INDEPENDENT OF WHAT YOU BELIEVE IS THE RIGHT THING TO DO WITH PSAs AND WE’VE SEEN THE DEVELOPMENT OF THE EXPANSION OF BIOLOGICAL KNOWLEDGE ASSOCIATED WITH SOCIAL CONSTRUCTS PARTICULARLY AROUND RACE NEED TO BE CONSIDERED IN DEVELOPING PREVENTION GUIDELINES AND I THINK WE HAVE NOT BEEN AS NUANCES AND ASTUTE ON THIS TOPIC AS WE COULD BE AND IT’S ONE OF THE GOALS I WANTED TO SEE THIS WORKSHOP TO PUSH THE FIELD MOVE IN THIS DIRECTION FINALLY, I’M A FUNDAMENTAL BELIEVER IN PRIMARY CARE I WAS PLEASED TO SEE DATA THAT PRIMARY CARE SAVES LIVES THERE’S A LOT TO BE DONE IN THE SETTING OF CLINICIAN/PATIENT RELATIONSHIP OVER TIME PARTICULARLY WHEN THERE’S CHRONIC DISEASE AND THE INFLUENCE OF EFFECTIVE COMMUNICATION AND PRECISION AND CUTURAL COMPETENCE AND CARE AND HAVING THESE KINDS OF SYSTEMS THAT COORDINATE CARE AND NOT DEPEND ON SOME SPECIALTY AND AN EXAMPLE OF HYPERTENSION IS A GOOD ONE AFRICAN AMERICANS HAVE A HIGHER PREVALENCE THE LARGE COHORT STUDY IN THE SOUTH HAS SHOWN FOR THE SAME LEVEL OF HYPERTENSION IN AFRICAN AMERICAN PERSON HAS TWO TIMES THE RISK MUCH STROKE THIS IS BLOOD PRESSURE IN THE MILD RANGE OR STAGE ONE COMPARED TO WHITES THOUGH WE KNOW IT’S MORE COMMON AND MORE SEVERE AND HAS A HIGHER RISK OF A BAD OUTCOME, BLACKS ARE LESS LIKELY TO BE CONTROLLED BASED ON NATIONAL DATA EXCEPT IN THE WEST WHERE THERE IS MORE POPULATION HEALTH APPROACHES KAISER PUBLISHED A STUDY YOU CAN GET 80% OF PATIENTS CONTROLLED AND YET WE DON’T DO IT I THINK THIS SAY CHALLENGE FOR OUR HEALTH CARE — IS A CHALLENGE FOR OUR HEALTH CARE SYSTEM AND IF YOU GET TO 80%, YOU SAY LET’S PUSH TOIS A CHALLENGE FOR OUR HEALTH CARE SYSTEM AND IF YOU GET TO 80%, YOU SAY LET’S PUSH TO 90% WE KNOW CANCER VARIES BY OU CONSTRUCT OF RACE, PROSTATE CANCER STANDS OUT AT DOUBLE THE RATE FOR BLACKS COMPARED TO LA LATINOS AND HIGHER THAN BLACKS AND ASIANS LUNG CANCER IS HIGHER I’LL RUN THROUGH EXAMPLES WHERE IS THE EVIDENCE ABOUT PSA SCREENING FOR AFRICAN AMERICANS? LAST YEAR THERE WAS A PUBLICATION ABOUT A U.K. TRIAL THAT WAS NEGATIVE A CLUSTER RANDOMIZED TRIAL IT WAS A WELL DONE STUDY, 10-YEAR FOLLOW AND OVER 640,000 PARTICIPANTS A GRAND TOTAL OF 4.4% WERE BLACK 4.4% IN THE U.S. AND THE U.K AND EUROPEAN STUDY HAD NEGLIGIBLE AMOUNTS WE RECOMMEND CANCER BE A SUBJECT AND YET CANCER IS TWICE AS COMMON AND OCCURS IN YOUNGER AGES AND IS MORE AGGRESSIVE AND DO WE CONCLUSIVELY SAY IT’S NOT USEFUL IN AFRICAN AMERICANS WE HAVE TO BE MORE CREATIVE HOW WE LOOK AT THE RECOMMENDATIONS TO OUR POPULATIONS IN THE CASE OF LUNG CANCER IS ALSO IMPORTANT WE NOW HAVE REASONABLE EVIDENCE THAT IT’S A DIFFERENTIAL EFFECT OF SMOKING BY RACE AND ETHNICITY IN THE FOLLOW-UP FROM THE MULTI-ETHNIC COHORT STUDY 5,000 CASES AND LOOKING AT RISK OF SMOKING 50 YEARS AT 10 CIGARETTES PER DAY 25 PACK EQUIVALENT NATIVE HAWAIIANS HAD THE HIGHEST RISK AND COULDN’T BE EXPLAINED AND LATINOS HAD A MUCH LOWER RISK UNEXPLAINED AND FOR AFRICAN AMERICANS THE RISK WAS THOUGHT TO BE EXPLAINED ON NICOTINE EQUIVALENT PRESENT IN THE SUBSTUDY ANALYSIS DONE AND ALSO FOR JAPANESE AMERICANS AND PERHAPS THIS IS PARTLY DUE TO METABOLISM DIFFERENCES THIS IS A KNOWN CARCINOGEN AND BAD OUTCOME AND PREVENTIBLE INTERVENTION YET LUNG CANCER SCREENING RATES ARE NOT GREAT WE HAVE EVIDENCE OF A 20% DECREASE IN OVERALL MORTALITY

FOR RANDOMIZED TRIAL OF SCREENING CT SCAN WE DON’T HAVE UPTAKE AND THAT’S A CHALLENGE WHY ARE WE NOT DOING THIS? THERE’S OTHER EXAMPLES IN THE PAST I’LL GET INTO WE DON’T SEE 3%, 5% OF ELIGIBLE SMOKES BEING SCREENED SO LET ME COME BACK AND FINISH WITH PATIENT CLINICIAN COMMUNICATION IT’S LINKED TO SATISFACTION SCORES WE HAVE GOOD EVIDENCE ABOUT AFRICAN AMERICAN AND VISITS FOR NON-ENGLISH SPEAKING PATIENTS AFRICAN AMERICAN AND LATINO PHYSICIANS ARE MORE LIKELY TO SEE IMMIGRANT AND LIMITED ENGLISH PATIENTS THOUGH THEY ONLY MAKE UP ABOUT 12% OF ALL PHYSICIANS IN THE U.S THIS IS A CRISIS THAT NEEDS TO BE ADDRESSED WE HAVE ENOUGH EVIDENCE TO SAY IT’S INTERVENTION THAT CAN WORK TO PROMOTE EQUITY IN HEALTH CARE MY FINAL COMMENTS WOULD BE WE SHOULD SHIFT THE MODELS OF CARE PO POPULATION HEALTH WITH PRIMARY CARE IN THE CENTER AND WE SHOULD COLLECT AND USE STANDARDIZED MEASURES OF SOCIAL DETERMINATES OF HEALTH AND SHOULD LEVERAGE THE ELECTRONIC HEALTH RECORDS TO PROMOTE EQUITY AND THINK HOW THE BURDEN HAS FALLEN ON CLINICIANS HOW WE ENGAGE IN COMMUNITY ROFRS RVRSS IN — RESOURCES IN PROMOTING HEALTH THANK YOU FOR YOUR ATTENTION IN PROMOTING HEALTH THANK YOU FOR YOUR ATTENTION PROMOTING HEALTH THANK YOU FOR YOUR ATTENTION IN PROMOTING HEALTH THANK YOU FOR YOUR ATTENTION >> MY NAME’S DAVID MURRAY FROM THE OFFICE OF DISEASE PREVENTION OUR OFFICE HAS A MISSION TO IMPROVE PUBLIC HEALTH BY THE IMPACT OF PREVENTION RESEARCH SUPPORTED BY NIH IN PARTNERSHIP WITH THE INSTITUTES AND CENTERS WHO CONTROL ALL THE RESOURCES WE JUST PROVIDE ENCOURAGEMENT AND IDEAS WE’VE RECENTLY RELEASED OUR SECOND STRATEGIC PLAN YOU CAN FIND ON OUR WEBSITE WE HAVE STRATEGIC PRIORITY LISTED HERE AND CROSS-CUTTING THEMES ONE IS HEALTH DISPARITIES IT’S QUITE NATURAL FOR US TO BE INVOLVED IN THIS WORKSHOP THE WORKSHOP IS ON ACHIEVING HEALTH EQUITY AND PREVENTATIVE SERVICES THIS ADDRESSES OUR INTEREST UNDER OUR SECOND STRATEGIC PRIORITY IDENTIFYING RESEARCH GAPS AND TO ADDRESS SCIENTIFIC EVIDENCE TO IDENTIFY FUTURE RESEARCH GENES TO ACHIEVE HEALTH — NEEDS TO ACHIEVE FIGHTING CANCER, HEART DISEASE AND DIABETES ALL 10 OF THE CLINICAL SERVICES RECEIVED IRB RECOMMENDATIONS FROM THE TASK FORCE AND UNDER THE AFFORDABLE CARE ACT AND AVAILABLE TO PATIENTS AT NO CHARGE THE WORKSHOPS BEGIN WITH A SYSTEMIC EVIDENCE REVIEW THIS GOT UNDERWAY 10 YEARS AGO IT TAKES A WHILE TO GET ONE OF THESE WORKSHOPS GOING THE SYSTEMIC EVIDENCE REVIEW IS PROVIDED TO OUR PANEL THEY ALSO OVER THE COURSE OF TWO DAYS HEAR A NUMBER OF INTERESTING PRESENTATIONS FROM OUR SPEAKERS WE ENCOURAGE AUDIENCE PARTICIPATION BOTH FROM THOSE HERE IN THE ROOM, YOU CAN STEP TO MICROPHONES IN THE AISLES AND ASK QUESTIONS AND THOSE ONLINE CAN SUBMIT QUESTIONS VIA E-MAIL AND TWITTER THE INDEPENDENT PANEL I WARNED THEM THIS MORNING I HOPE THEY GOT PLENTY OF SLEEP BECAUSE THEY WON’T GET THAT MUCH BEGINNING THIS MORNING THEY’LL BE WORKING LATE TONIGHT AND WORKING LATE TOMORROW NIGHT PUTTING TOGETHER THEIR SYNTHESIS OF THE EVIDENCE AND REPAIRING A DRAFT PANEL REPORT IT WILL BE POSTED ON OUR WEBSITE AND OPEN FOR 30 DAYS FOR PUBLIC COMMENT AND THE PANEL WILL THEN REVISE THE REPORT BASED ON THE COMMENTS AND IT WILL BE PUBLISHED IN APPROXIMATELY SIX MONTHS IN THE ANALES ANNALS OF INTERNAL MEDICINE AND IT’S DRAWN WIDESPREAD

ENGAGEMENT AND THE PANEL GRAPHIC SHOWS RELATIVE CITATION RATIOS FROM PUBLICATIONS FROM TWO OF OUR RECENT WORKSHOPS ALL OF THESE WERE IN THE TOP 5% OF PUBLICATIONS IN PUB MED AND THE LAST TWO ON THE OPIOIDS PANEL WERE IN THE TOP 1% THE RESEARCH GAPS STIMULATE NOT ONLY PUBLIC DISCUSSION BUT RESEARCH FUNDING OPPORTUNITIES FROM NIH THE WORKSHOP HAS A NUMBER OF KEY PARTICIPANTS REPRESENTATIVES FROM MY OFFICE HAVE BEEN INVOLVED IN PLANNING THE WORKSHOP FOR THE LAST TWO YEARS WORKING CLOSELY WITH INSTITUTE COORDINATORS AND WE HAVE FOUR INSTITUTES HERE AT NIH INVOLVED WITH THIS WORKSHOP I’VE IDENTIFIED THEM AT THE END OF MY REMARKS THEY WORKED WITH EXPERTS TO PLAN THE MEETING AND IDENTIFY THE QUESTIONS THAT THE MEETING IS STRUCTURED AROUND THEY COMMISSIONED THE EVIDENCE-BASED PRACTICE THROUGH ARC TO DO THE EVIDENCE REVIEW THEY NOMINATED INDEPENDENT PANEL MEMBERS AND OUR OFFICE VETTED THEM AND RECRUITED THEM AND I’LL INTRODUCE THEM IN A MOMENT AND IDENTIFIED WORKSHOP SPEAKER WE’RE GRATEFUL TO HAVE YOU ALL HERE IN THE ROOM AND PARTICIPATING ONLINE AND WE LOOK FORWARD TO WORKING WITH OUR FEDERAL PARTNERS TO IMPLEMENT ACTIVITIES TO ADDRESS RECOMMENDATIONS ONCE WE HAVE THEM THE EVIDENCE-BASED PRACTICE CENTER DOES CONDUCT A SYSTEMIC EVIDENCE REVIEW THROUGH A CONTRACT WITH AHRQ WE FUND THAT THROUGH AN INTERAGENCY AGREEMENT THE PACIFIC NORTHWEST EVIDENCE BASED CENTER AT OREGON UNIVERSITY IS THE CENTER THAT PERFORMED THE EVIDENCE REVIEW FOR THE WORKSHOP AND WE’LL HEAR FROM THEM ABOUT THE RESULTS UP THEIR REVIEW THE INDEPENDENT PANEL’S AN IMPORTANT PART THEY ARE RECRUITED BECAUSE THEY DON’T HAVE FINANCIAL OR INTELLECTUAL CONFLICT OF INTEREST PEOPLE ASK ME WHY DON’T HAVE YOU EXPERTS ON THE PANEL NOR WORKSHOPS — FOR THE WORKSHOP WE WANT PEOPLE WHO HAVE NOT SPENT THEIR CAREERS IN THE CONTENT AREA TO BE INDEPENDENT AND OPEN-MINDED AND NOT HAVE BIASES INTO HEARING THE EVIDENCE THEY’RE MULTIDISCIPLINARY AND HAVE EXPERTISE AND PRODUCE AN IMPORTANT REPORT THAT SYNTHESIZE THE FINDINGS AND MAKE RECOMMENDATIONS FOR FUTURE RESEARCH THE CHARGE TO THE PANEL IS SHOWN HERE WE ASK THAT YOU LISTEN TO ALL THE WORKSHOP PROCEEDINGS AND ATTEND ALL THE EXECUTIVE WRITING SESSIONS AND HEAR THE DRAFT REPORT IMPORTANTLY, WE ASK YOU GATHER AT LEAST VIRTUALLY IN ABOUT A MONTH OR SIX WEEKS TO REVIEW AND INCORPORATE PUBLIC COMMENTS INTO THE DRAFT AND FINALIZE THE REPORT BEFORE IT’S SUBMITTED TO ANALYSTS FOR PUBLICATION THE PANEL MEMBERS, I’M HAPPY TO IDENTIFY, AND INTRODUCE AT THIS POINT AND WOULD ASK THEM TO COME UP ON THE STAGE SO THE AUDIENCE CAN SEE THEM DR. TIM CAREY FROM THE UNIVERSITY OF NORTH CAROLINA CHAPEL HILL SCHOOL OF MEDICINE IS OUR WORK SHOP AND CHAIR DR. BETTY BECKMIRE FROM THE UNIVERSITY OF WASHINGTON CENTER FOR PUBLIC HEALTH PRACTICE DR. DOUG CAMPOS ATHALT AND DR VASER FROM TUFTS UNIVERSITY AND DR. UNDERWOOD FROM THE UNIVERSITY OF WISCONSIN MILWAUKEE COLLEGE OF NURSING AND DR. STEVEN TWITCH FROM THE SCHOOL OF PUBLIC HEALTH THE SPEAKER HAVE BEEN ASKED TO DISCLOSE ALL RELATIVE FINANCIAL CONFLICTS AND READ DISCLOSURES ALLOWED PLEASE REFER TO DISCLOSURE STATEMENTS ON THE WEBSITE AND FOR BIOS THE PANELISTS HAVE NO CONFLICTS WE HAVE STUDIED THAT CAREFULLY AND A WOULD MAKE A FEW OTHER COMMENTS BEFORE I TURN THINGS OVER TO OUR CHAIR WE HAVE OVER 1400 PEOPLE REGISTERED AND HAVE ABOUT 100 IN THE ROOM BUT I EXPECT THAT WILL GROW AS PEOPLE WORK THEIR WAY THROUGH THE CENTER MANY PEOPLE PROBABLY ARRIVED AT NIH THINKING THEY CAN COME THROUGH IN 30 SECONDS WE HAVE HUNDREDS WATCHING THE

VIDEOCAST AND HUNDREDS MORE WILL WATCH OVER THE NEXT SEVERAL WEEKS OUR OPENING PANEL IS COMPRISED OF DISTINGUISHED SPEAKERS WE HAVE FOUR NIH INSTITUTES AND CENTERS CO-SPONSORING AND THREE DIRECTORS WILL SHARE THEIR PERSPECTIV PERSPECTIVES VIA VIDEO FINALLY, WE HAVE A CLOSING KEY NOTE SPEAKER DR. JOHN ARANIAN A ADVANCE MY SLIDES. I FORGOT TO – I DO WANT TO THANK THE INSTITUTE COORDINATORS FROM MANY AGENCIES WE’VE HAD IMPORTANT HELP FROM AHRQ AND PACIFIC NORTHWEST’S TEAM AND WORKSHOP SPEAKERS AND INDEPENDENT PANELISTS AND I WANT TO THANK OUR SUPPORT SERVICES CONTRACT PROVIDING LOGISTICAL SUPPORT FOR THE MEETING AND I WANT TO THANK THE STAFF AND MY OFFICE WHO HAS WORKED SO HARD TO PUT THE MEETING TOGETHER PARTICULARLY THOSE WHO LED THE EFFORT AND NOW, I WANT TO THANK THE PANEL MEMBERS FOR COMING UP AND YOU’RE WELCOME TO TAKE YOUR SEATS AND A WANT TO INTRODUCE THE PANEL CHARG, DR. TIMONEY CAREY FROM THE UNIVERSITY OF NORTH CAROLINA HE’S BEEN A FACULTY MEMBER SINCE 1985 AND RESEARCHER AND REMAINS ACTIVE AS A CLINICIAN IN IN PATIENT AND OUT PATIENT CARE AND SENIOR ADVISE ARE TO THE UNC PRACTICE CENTER AND SERVES ON THE ETHNICITY, CULTURE AND HEALTH OUTCOMES AND DOES WORK IN EFFECTIVENESS RESEARCH, EXAMINATION OF TREATMENT PATTERNS AND CHRONIC MUSCULOSKELETAL PROBLEMS AND FOLKS ON TYPE 2 RESEARCH AND CROSS-DISCIPLINARY COLLABORATION AND PART OF THE COMPARATIVE EFFECTIVENESS RESEARCH AND HAS DONE RESEARCH AND TRAINING GRANTS FOR A NUMBER OF AGENCIES INCLUDING AHRQ AND FOUNDATIONS AND SERVED AS A CONSULTANT FOR PCORI AND WORK WITH MEDICAL STUDENTS AND POST-DOCTORAL FELLOWS PLEASE WELCOME OUR CHAIR, DR TIMOTHY CAREY >> GOOD MORNING I’LL BE VERY BRIEF I DO NOT HAVE DISCLOSURES YOU MET OUR PANEL MEMBERS THE BIOS ARE IN THE WEBSITE AND THAT’S TRUE OR ALL SPEAKERS WE’LL TRY TO KEEP INTRODUCTIONS AUTHORITY TO SPEND OUR TIME ON CONTENT THE PANEL ACTIVITIES YOU ALREADY HEARD WE’LL DRAFT A REPORT SUMMARIZING THE LITERATURE AND ADDRESS STATEMENTS FROM SPEAKERS AND COMMENTS AND FROM THOSE ONLINE WE’LL DO A DRAFT REPORT AND THE FINAL REPORT AFTER PUBLIC COMMENT IS POSTED FOR A MONTH AND IT WILL BE PUBLISHED IN THE ANNALS OF MEDICINE THE REVIEW WILL BE AVAILABLE FOR YOU ALL TO READ IT LOOKING AT 10 SERVICES THAT ARE RECOMMENDATIONS FROM THE USDF EACH SESSION WILL FOCUS ON ONE OF THE KEY QUESTIONS AND YOU’LL HEAR ABOUT THOSE TODAY AND TOMORROW FROM THE OREGON EPC SUMMARIZING THE RATHER LENGTHY WORK SO EACH SESSION WILL START WITH A SPEAKER AND THEN HAVE SOME SUBSEQUENT TALKS ADDRESSING SOME OF THE CUTTING RESEARCH, PERCEIVED GAPS IN THE LITERATURE, ETCETERA THE SPEAKERS WILL INTRODUCE THEMSELVES AND THE PRESENTATION WILL BE FOLLOWED BY A 40 MINUTE DISCUSSION NOT EACH PRESENTATION BUT EACH BUNDLE OF QUESTIONS AND SO WE’LL HAVE FIVE 40-MINUTE DISCUSSION PERIODS THE FIRST QUESTIONS MAY COME FROM PANEL MEMBERS IF THEY HAVE CLARIFYING QUESTIONS AND THEN WE’LL GO TO QUESTIONS FROM MEMBERS IN THE AUDIENCE HERE AND PEOPLE WATCHING ONLINE NOW, MEMBERS OF THE AUDIENCE WILL GO TO THE MICROPHONE

HOWEVER 40 MINUTES SAY GOOD PERIOD OF TIME — IS A GOOD PERIOD OF TIME WE WANT TO HEAR FROM AS MANY AS POSSIBLE WE’RE ASKING YOU TO RESTRICT YOUR QUESTION OR COMMENT TO TWO MINUTES AND I WILL SAY THANK YOU VERY MUCH AT TWO MINUTES TO BEAR WITH US ON THAT WE WANT AS MANY PEOPLE TO SUBMIT COMMENTS AS POSSIBLE IF YOU HAVE MORE TO SAY, FEEL FREE TO COMMENT ONLINE WE WILL TRY TO GET COMMENTS IN FROM FOLKS SENT VIA TWITTER OR E-MAIL TO DISCUSS DURING THE CONFERENCE HERE AND THE PANEL MEMBERS WILL GET THOSE COMMENTS TONIGHT AND TOMORROW WE WILL HAVE BREAKS OF SO MINUTES OF SESSIONS BUT WE WANT TO START AND END ON TIME SO THE LAST SPEAKER OF THE DAY WILL HAVE SUFFICIENT TIME AS THE FIRST SPEAKER OF THE DAY DOES AND WE WANT TO HEAR FROM YOU ON THE WEBSITE THERE’S VARIOUS ADDRESSES AND TWITTER HANDLES >> GOOD MORNING I’M RICH BERZON AT THE NATIONAL INSTITUTE OF MINORITY HEALTH AND HEALTH DISPARITIES I’D LIKE TO PROVIDE BRIEF BACKGROUND AND CONTEXT FOR THE NIH PATHWAYS TO PREVENTION WORKSHOP WHY CLINICAL SERVICES IS SO IMPORTANT TO THE NIH AND SISTER SRVICES I HAVE NO CONFLICT OF INTEREST TO DISCLOSE SO EVIDENCE-BASED PREVENTIVE PRACTICE SCREENING AND COUNSELLING SERVICES PREVENTED BY THE U.S. PREVENTIVE SERVICES TASK FORCE AND THE ADVISORY COMMITTEE ON IMMUNIZATIONS TASK FORCE AND ARE DESIGNED TO HELP ALL AMERICANS STAY THE AND AVOID OR DELAY THE ONSET OF DISEASE AND IMPROVE LONGEVITY AND REDUCE SOCIETAL AND FINANCIAL BURDEN DESPITE THE PROVEN VALUE, AMERICANS USE PREVENT TIF SERVICE INCLUDING CANCER SCREENING AND INJURY PREVENTION RECOMMENDATIONS AND VACCINATIONS AT ONLY HALF THE RECOMMENDED RATE CURRENT DISEASES SUCH AS HEART DISEASE, CANCER AND DIABETES ARE RESPONSIBLE FOR 7 OF EVERY 10 DEATHS AND ACCOUNT FOR 75% OF THE NATION’S HEALTH SPENDING MANY OF THESE CHRONIC CONDITIONS CAN BE PREVENT ORDER DELAYED AND DETECT AND TREATED EARLY WHILE PATIENTS WORK CLOSELY WITH THEIR PRIMARY CARE PROVIDERS THERE’S PARTICULAR PUBLIC HEALTH CONSEQUENCE FOR AT-RISK POPULATIONS DESPITE CLINICIAN GUIDANCE, SUBSTANTIAL RACIAL AND ETHNIC VARIANCE AND COMPREHENSION OF RISK EXISTS WITH RESPECT TO HOW PATIENTS MANAGER HEALTH-RELATED INFORMATION AS AN EXAMPLE, MORE THAN $2 MILLION AMERICANS HAVE CARDIOVASCULAR DISORDERS AND 800,000 DIE FROM MYOCARDIAL INFARCTION A YEAR THESE INCIDENT ARE THE LEADING CAUSES TO DISPARITIES AN LIFE EXPECTANCY AFRICAN AMERICANS ARE TWICE AS LIKELY AS WHITES TO DIE FROM HEART DISEASE AND STROKE AND AMERICAN INDIANS AND ALASKAN NATIVES DIE OF HEART DISEASES THAN OTHER RACIAL AND ETHNIC GROUPS IN THE UNITED STATES MANY DEATHS CAUSED BY CARDIOVASCULAR DISEASES ARE PREVENTIBLE PRIMARY CARE PRACTICES HAVE THE EVIDENCE TO ADOPT THE ABCs OF CARDIOVASCULAR DISEASE PREVENTION, ASPIRIN AND HIGH BLOOD CONTROL AND CHOLESTEROL AND CARDIOVASCULAR MANAGEMENT IT CAN PREVENT THE LOSS OF MORE THAN 2 MILLION LIFE YEARS ANNUALLY AND RESULT IN SAVINGS OF $3.7 BILLION HOWEVER, ADOPTION BY PROVIDERS AND IMPLEMENTATION BY PATIENTS

OF SUCH PREVENTIVE PRACTICES VARIES FOR MULTIPLE REASONS INCLUDING SOCIOBEHAVIORAL, ECONOMIC AND ENVIRONMENTAL CONSIDERATIONS AMONG OTHERS THE U.S. PREVENTIVE SERVICES TASK FORCE MAKES RECOMMENDATIONS TO CONGRESS ABOUT THE EFFECTIVENESS OF SPECIFIC PREVENTIVE CARE SERVICES IN 2016 THE TASK FORCE’S REPORT TO CONGRESS ON HIGH PRIORITY EVIDENCE GAPS FOR CLINICAL PREVENTIVE SERVICES IDENTIFIED SPECIFIC POPULATIONS FOR WHICH EVIDENCE GAPS EXIST INCLUDING SKRIENG — SCREENING FOR BREAST CANCER IN AFRICAN AMERICAN WOMEN AND SCREENING FOR COLORECTAL CANCER IN ALASKAN AND AMERICAN INDIANS AND THEY ADD SCREENING FOR PROS TATE WILL CANCER FOR AFRICAN AMERICAN MEN AS ANOTHER GAP THAT PREVENTS MAKING RECOMMENDATIONS FOR THIS POPULATION THERE’S A NEED FOR RECOMMENDATION TO IMPROVE THE HEALTH AND HEALTH CARE OF AMERICANS DR. KRISTEN BIBBENS DOMINGO IS WITH US TODAY AND WILL MODERATE THE OPENING PANEL DIFFERENCES IN THE USE OF HEALTH CARE PREVENTIVE SERVICES BETWEEN RACIAL AND ETHNIC MINORITY AND WHITE POPULATIONS CONTRIBUTE TO DISPARITIES IN CLINICAL HEALTH OUTCOMES AND HEALTH STATUS AND UTILIZATION OF HEALTH SERVICE TO CLINICAL NEED IMPROVE THE HEALTH OF MINORITY GROUPS AND HELP ELIMINATE DISPARITIES LOW LEVELS OF CANCER SCREENING, FOR EXAMPLE, MAMMOGRAPHY SCREENING AND PAP SMEARS AND COLORECTAL SCREENING CAN RESULT IN MORE LIMITED TREATMENT OPTIONS, GREATER DISPARITY AND HIGHER MORTALITY SELECTED CHALLENGES TO RECEIVING PREVENTATIVE SERVICES ARE REVEALED BY THESE BULLETS BLACKS AND HISPANICS HAVE LOWER PREVENTIVE SERVICES THAN WHITES AND ASIAN PACIFIC ISLANDERS WITH HIGH BLOOD PRESSURE AMERICAN IVEND ANDAND ALASKAN NATIVES HAVE THE LOWEST USE LEVELS OF ALL THE SERVICES HISPANIC POPULATIONS MADE OF UP NUMEROUS SUBPOPULATIONS AND NATION OF ORIGIN IS NOT CONSISTENTLY ASSOCIATED WITH DIFFERENCES IN RECEIPT OF PREVENTATIVE SERVICES BUT MEXICAN AMERICANS WHEN COMPARED TO BLACKS AND NON HISPANIC WHITES HAVE FOUND HAVE HIGHER AWARENESS — SORRY, LOWER AWARENESS AND TREATMENT OF HYPERTENSION RURAL RESIDENTS WHETHER HISPANIC OR NON-HISPANIC WHITE ARE LESS LIKELY TO RECEIVE PREVENTATIVE SERVICES LACK OF CARE HAVE BEEN FOUND TO BE THE STRONGEST PREDICTORS OF FAILURE TO RECEIVE SERVICES HISPANICS ARE SIGNIFICANTLY LESS LIKELY THAN WHITES TO REPORT HAVING RECEIVED MANY PREVENTATIVE SERVICES AND INCOME AND EDUCATION WERE HELD EQUAL IN MULTIVARIATE ANALYSIS THE FOLLOWING FEW SLIDES ILLUSTRATE VARIANCE IN PREVENTIVE SERVICES ACROSS RACIAL AND ETHNIC POPULATIONS UNDIAGNOSEDCATIONS OF HYPERTENSION — UNDIAGNOSED CASES OF HYPERTENSION, DIABETES, CHOLESTEROL AND KIDNEY DISEASE HAVE FOUND TO BE HIGHER IN HEALTH DISPARITIES POPULATION IN COMPARISON WITH NON HFR HISPANIC WHITES — NON-HISPANIC WHITES THE BLACK BARS AT THE TOP ILLUSTRATE THE UNDIAGNOSED CASES NATIONALEST PANTS OF UNDIAGNOSED KIDNEY DISEASE IN BLACKS IS ESPECIALLY STRIKING PREVENTIVE SCREENING AND COUNCILING SERVICES CAN PREVENT OR DELAY MANY OF THESE TYPES OF CHRONIC CONDITIONS ASSUMING EQUITY AND DIAGNOSIS UNDIAGNOSED DIABETES IN ADULTS BY RACE ETHNICITY IS HIGHLIGHTED IN THE SLIDE HERE WE SEE THE LARGEST PERCENTAGE OF UNDIAGNOSED IS HISPANIC FOLLOWED BY MEXICAN AMERICANS AND NON HISPANIC BLACKS AT 35% THE LOWEST PERCENTAGE OF UNDIAGNOSED DIABETES IS HISPANIC WHITES AT 31%

THE DIFFERENCES BETWEEN HISPANICS AND MEXICAN AMERICANS, NON-HISPANIC BLACKS AND NON-HISPANIC ASIAS ARE SIGNIFICA SIGNIFICANT ACCORDING TO THE SURVEY IN 2011 THROUGH 2014 NON-HISPANIC WHITES HAVE THE HIGHEST PERCENTAGES OF SOME KINDS OF COLORECTAL CANCER SCREENING THE PERCENTAGE OF NON HISPANIC BLACKS IN THE TRIANGLE AND HISPANICS LOOKING AT THE DIAMOND LINE, OBTAINING COLORECTAL SCREENING WERE LOWER THOUGH CANCER TEST USE INCREASED AMONG RACIAL ETHNIC MINORITIES AND HEALTH DISPARITY GAP BETWEEN BLACKS AND WHITES ARE CLOSING THOSE WITHOUT HEALTH INSURANCE OR THOSE WITH INCOMES OF LESS THAN $35,000 OR LESS THAN A HIGH SCHOOL EDUCATION HAVE A LOWER OCCURRENCE OF COLORECTAL CANCER SCREENING USE AND THIS SHOWS HIGH RATES OF CURRENT SMOKING IN THE SOUTH CENTRAL AND PARTS OF THE NORTH CENTRAL REGIONS OF THE U.S. WHEN COMPARED TO OTHER REGIONS GEOGRAPHIC AND DEMOGRAPHIC DISPARITY DIFFERENT AND WARRANT MORE INVESTIGATIVE RESEARCH REGARDING THE INADEQUATE PREVENTIVE CASE GUIDELINES AND PRACTICE AMONG PRIMARY CARE PROVIDERS AND MINORITY AND HEALTH DISPARITY PATIENTS THERE ARE A VARIETY OF STRUCTURAL AND NON-STRUCTURAL BARRIERS KNOWN AND HYPOTHESIZE TO THE USE OF PREVENTATIVE HEALTH SERVICES IN DISPARITY POPULATIONS THESE EXIST AT THE COMMUNITY, PROGR PROGRAMMATIC AND INDIVIDUAL LEVELS THERE’S SIGNIFICANT INTERACTIONS AMONG THE CAT FRIZZ — CATEGORIES TO BARRIERS AND THE EFFECTS OF PREVENTATIVE SERVICES WILL BE EXAMINED DURING THE WORKSHOP THE PATHWAYS TO PREVENTIVE WORKSHOP WILL ADDRESS RESEARCH GAPS, IMPEDIMENTS TO BARRIERS WITH THE ADOPTION AND IMPLEMENTATION BY PROVIDERS AND UPTAKE BY HEALTH DISPARITY POPULATIONS OF EVIDENCE-BASED PREVENTIVE SERVICES THE WORKSHOP WILL SEEK TO ANSWER A NUMBER OF RESEARCH QUESTIONS ABOUT THE EFFECTIVENESS OF DIFFERENT APPROACHES AND STRATEGIES BETWEEN PATIENTS AND PROVIDERS THAT COULD INCREASE THE USE OF SUCH PREVENTIVE SERVICES THE NATIONAL INSTITUTE ON MINORITY HEALTH AND HEALTH pCANCER INSTITUTE, THE NATIONAL HEART, LUNG AND BLOOD INSTITUTE AND THE NATIONAL INSTITUTE OF DIABETES AND DIGESTIVE AND KIDNEY DISEASES AS WELL AS THE NIH OFFICE OF DISEASE PREVENTION AND AGENCY FOR HEALTH CARE RESEARCH AND QUALITY COLLABORATED TO FOCUS ON THE IMPORTANCE OF ACHIEVING HEALTH EQUITY AND PREVENTATIVE SERVICES THERE ARE FIVE KEY TOPIC QUESTIONS THAT WILL BE ADDRESSED DURING THE WORKSHOP THESE QUESTIONS ARE LISTED IN THE NEXT TWO SLIDES AND APPEAR ON THE ODP WEBSITE AS WELL AS IN YOUR AGENDA TOPIC RANGE FROM AN EXAMINATION OF BARRIERS TO THE ADOPTION OF CLINICIANS AND HEALTH DISPARITY POPULATIONS AND BEST PRACTICES FOR INTEGRATION AND SHARED DECISION MAKING BETWEEN PROVIDERS AND PATIENTS TO EXAMINING HEALTH INFORMATION TECHNOLOGIES AND DIGITAL ENTERPRISES AND SERVING HEALTH DISPARITIES POPULATIONS TO CONSIDERING THE ROLE OF HEALTH CARE ORGANIZATIONS AND SYSTEMS WITH RESPECT TO REDUCING DISPARITIES AND PREVENTATIVE SERVICE USE I’D LIKE TO END MY REMARKS BY NOTING 10 UNIQUE SERVICES RECOMMENDED THAT WILL BE DISCUSSED DURING THE WORKSHOP THESE ARE CHARACTERIZED AS WELL ESTABLISHED CURRENT AND EVIDENCE-BASED PRACTICES IN PRIMARY CARE WITH A HIGH LEVEL OF EVIDENCE WOULD JUSTIFIED A CHANGE IN GRADE THE PREVENTIVE SERVICES INDICATE THERE’S A HIGH CERTAINTY THE NET BENEFIT OF THE SERVICE IS SUBSTANTIAL OR MODERATE THE SERVICE LISTED IN THE NEXT TWO SLIDES ARE LIST ON THE ODP WEBSITE HERE’S THE REMAINING PREVENTIVE SERVICES TO BE ADDRESSED DURING THE WORKSHOP I’D LIKE TO ACKNOWLEDGE THOSE INDIVIDUALS FROM OTHER I.C.s AND OTHER AGENCIES HELPING SPONSOR THE WORKSHOP WITH NIHHD AND I’D

LIKE TO INTRODUCE DR. KIRSEN BIBBENS DOMINGO THE PANEL IS CATALYZING HEALTH EQUITY INNOVATIONS THE BIO FOR HER AND ALL SPEAKERS CAN BE FOUND ON THE ODP WEBSITE THANK YOU THE INVITATION AND FOR PUTTING ON THIS TRAFFIC WORKSHOP MY NAME IS KIRSTEN BIBINS-DOMINGO I WAS A VICE CHAIR AND CHAIR DURING THE END OF MY TIME PERIOD I WANT TO OFFER A FEW REMARKS BEFORE WE START THE PANEL DISCUSSION WHEN I STARTED ON THE TASK FORCE IN 2010 WAS RIGHT AFTER OUR MAMMOGRAPHY RECOMMENDATION CAKE — CAME OUT IN 2009 AND WERE ENGAGED AT THAT TIME AND ENHANCING OUR ABILITY TO COMMUNICATE WITH STAKEHOLDER GROUPS WE DID A LOT OF MORE LISTENING TOURS AND TALKING WITH ORGANIZATIONS WE WANTED TO ENGAGE IN THE WORK THAT WE WERE DOING AND SO THAT WAS MY FIRST INTRODUCTION TO BEING ON THE TASK FORCE AND I REMEMBER THE ONE MEETING WE HAD WITH HEADS OF SEVERAL PATIENT ADVOCACY GROUPS THAT REPRESENTED DIFFERENT RACIAL AND ETHNIC PRIORITY GROUPS WITHIN THE U.S. AND THESE WERE THE NATIONAL LEADERS AND THEY MET WITH US WITH MEMBERS OF THE TASK FORCE AND I STILL REMEMBER VERY DISTINCTLY ONE OF THE LEADERS OF THE GROUPS SAYING TO ME WHEN WE CAME AROUND THE ROOM TO TALK ABOUT THE DIFFERENT RECOMMENDATIONS SAYING WITHOUT ANY ANIMOSITY OR SNARK OR IRONY, I HAD NO IDEA THE TASK FORCE WITH YOU WRITING RECOMMENDATIONS FOR MY COMMUNITY I THOUGHT THAT WAS A BIG PUNCH TO THE GUT FOR ME BECAUSE I HAD JOINED THE TASK FORCE THINKING WE WERE DOING ALL THIS GREAT WORK AND TO HEAR SOMEONE WHO REALLY HAD COME TO ENGAGE WITH US SAYING THERE WAS NOTHING WE WERE COMMUNICATING AT THAT TIME THAT WAS REALLY RELEVANT TO THE COMMUNITY SHE REPRESENTED WAS QUITE [INDISCERNIBLE] I THINK THAT INFORMED MUCH OF WHAT WE DID OVER A PERIOD OF TIME TO TRY TO ENGAGE WITH STAKEHOLDER ORGANIZATIONS EARLY TO TRY TO ENLIST THEIR INPUT IN HOW WE THOUGHT ABOUT RECOMMENDATIONS FROM START TO FINISH AND TO HELP US IN THE PROCESS BOTH OF UNDERSTANDING WHETHER OUR FRAMEWORKS RELATED TO THIS SPECIFIC ISSUES THAT WERE RELEVANT IN THEIR COMMUNITIES AS WELL AS TO HELP US DISSEMINATE AS WE GOT TO THE END OF OUR PROCESS SO GETTING THE WORD OUT WAS CEARLY SOMETHING WE VIEWED AS IMPORTANT AND STILL DO WE STILL TAKE IT VOUGSLY I THINK THERE’S THREE QUESTIONS BECAUS CLEARLY GETTING THE WORD OUT IS NOT ENOUGH AS THE THREE BIG CATEGORIES OF QUESTIONS I HOPE DURING THE COURSE OF TODAY WE CAN DISCUSS MORE AND CERTAINLY THE PANEL WILL PROVIDE MORE INSIGHTS ON THE FIRST IS SO YOU HAVE THE EVIDENCE, YOU GET THE WORD OUT, BUT HOW DO WE ACTUALLY DO THIS IN ACTUAL PRACTICE? THERE’S NOTHING LIKE YOUR HOME FAMILY TO KEEP YOU HONEST SO WHEN I WOULD FLY BACK FROM WASHINGTON, D.C. AND THE TASK FORCE MEETINGS TO MY COLLEAGUES WHERE I PRACTICE AT ZUCKERBERG SAN FRANCISCO GENERAL HOSPITAL WHICH IS A SAFETY NET HOSPITAL IN THE CITY AND COUNTY OF SAN FRANCISCO THEY WOULD SAY WE CANNOT IMPLEMENT THESE RECOMMENDATIONS WE HAVE NO IDEA HOW WE’RE GOING APPROACH WHAT YOU’RE RECOMMENDING MY COLLEAGUES WERE OUTSTANDING AND ARE OUTSTANDING CLINICIANS THEY WORK IN THE RESOURCE ADMITTING SETTING THERE’S NOTHING IN THE GUIDELINES AS WE ISSUED THEM EXCEPT FOR A FEW PARAGRAPHS ON GENERAL APPROACHES TO IMPLEMENTATION AND MY COLLEAGUES WERE TRAFFIC AND VERY VOCAL IN PROVIDING THE TASK FORCE FEEDBACK I REMEMBER IN PARTICULAR ON THE LUNG CANCER SCREENING RECOMMENDATION SAYING THIS WE CANNOT IMPLEMENT THIS WE ARE BASICALLY TRADING SMOKING

CESSATION PROGRAMS WITH C.T LUNG CANCER SCREENING AND THIS RECOMMENDATION AS WRITTEN IS NOT USEFUL AND WAS IMPORTANT IN MANY OF THE WAY THE TASK FORCE THOUGHT ABOUT HOW WE SHIFT THE RECOMMENDATIONS TO TRY TO PROVIDE ADDITIONAL LANGUAGE SO HOW WE ACTUALLY IMPLEMENT HOW WE STUDY, WHAT’S EFFECTIVE IN IMPLEMENTATION AND HOW WE DISSEMINATE BEST PRACTICES AND IMPLEMENT IS AN IMPORTANT PART OF WHAT WE’LL BE DOING TODAY A SECOND QUESTION IS REALLY WHEN IS THE EVIDENCE JUST REALLY NOT ENOUGH TO MAKE RECOMMENDATIONS FOR THE PARTICULAR POPULATIONS THAT WE’RE TALKING ABOUT ELISEO ALLUDED TO THIS AND YOU ALL KNOW THAT OUR EVIDENCE BASED IS STILL FROM A SPECIFIC SET OF POPULATIONS NOT ALL THE COMMUNITIES AND POPULATIONS WE’D LIKE TO REACH WITH OUR RECOMMENDATIONS ARE ACTUALLY REPRESENTATIVED ACTUALLY REPRESENTED IN THE EVIDENCE BASED AND EVERYONE DESERVES EVIDENCE BASED RECOMMENDATIONS ON PEOPLE THAT LOOK LIKE THEM, WHAT EVIDENCE IS ENOUGH TO SAY SOMETHING BEFORE THE EVIDENCE EXISTS IS EPIDEMIOLOGY ENOUGH? ENOUGH TO KNOW WE HAVE PATTERNS OF DISEASE THAT DIFFER AND THEREFORE WE SHOLD MAKE RECOMMENDATIONS FOR DIFFERENT POPULATIONS IF THE DISEASE STARTS EARLY OR MORE AGGRESSIVE? HOW DO WE THINK ABOUT THAT EVIDENCE BASED IN THE FACE OF THE URGENT NEED TO ADDRESS THE DISPARITIES WE’RE TALKING ABOUT? AND FINALLY, WE ARE TALKING ABOUT PREVENTION GENERALLY BUT ABOUT A PARTICULAR SLICE CLINICAL PREVENTION AND THERE ARE MANY PLAYERS IN THE PREVENTION SPACE PUBLIC HEALTH ORGANIZATIONS THINK ABOUT PREVENTION AS WELL AS WE UNDERSTAND AND INTERVENE MORE AT ALL DIFFERENT LEVELS ON SOCIAL DETERMINATES OF HEALTH HOW DO WE THINK ABOUT CLINICIAN EVEN IN THE CLINICAL SPACE IN A WAY THAT RECOGNIZES THESE BROADER INSTITUTIONAL PLAYERS AS WELL AS WAYS IN WHICH WE MAY INTERVENE ON THE SOCIAL DETERMINATES OF HEALTH THAT ULTIMATELY PLAY A ROLE IN OUR ABILITY TO PREVENT WHAT WE WANT TO PREVENT PUCKLY F PUCKLY — LUCKILY FOR ME I DON’T HAVE TO COME UP WITH THE ANSWERS I JUST HAVE TO INTRODUCE THIS LOVELY PANEL YOU’LL HEAR GISELLE CORBIE SMITH, SUSAN STRONG AND HERMAN A. TAYLOR AND BRUCE LEE AND I’LL ASK THEM TO COME UP AND THEN WE’LL HAVE A MODERATED PANEL DISCUSSION THANK YOU THANK YOU, KIRSTEN I SHARED WITH ANOTHER PANELISTS I’M NOT SURE I’LL GIVE YOU ANSWERS BUT PROBABLY MORE QUESTIONS FOR TO US THINK ABOUT I HAVE NOTHING TO DISCLOSE AND AM A GENERAL INTERNIST AND NEVER HAS DISCLOSE, UNFORTUNATELY THE FIRST TWO SPEAKERS, ELISEO AND RICK TALKED WHAT WE THINK ABOUT AS WE THINK OF CLINICAL SERVICES I’LL GIVE THE FLIP SIDE AND THINK OF HEALTH EQUITY I WAS GRATEFUL TO SEE IT IN THE TITLE OF THE TWO DAYS HEALTH EQUITY IS THE ASSURANCE OF CONDITIONS FOR OPTIMAL HEALTH FOR ALL PEOPLE THIS IS A DECEPTIVELY SIMPLE STATEMENT IT REQUIRES WE VALUE ALL INDIVIDUALS AND POPULATIONS EQUALLY, THAT WE RECTIFY AND RECOGNIZE HISTORICAL INJUSTICES THAT LEAD TO HEALTH INEQUALITIES AND PROVIDE RESOURCES ACCORDING TO NEED IT’S NOT A SITUATION WHERE WE FLOAT ALL BOATS BUT UNDERSTAND WHAT EACH BOAT NEEDS AND A FUNDAMENTAL SHIFT IN HOW WE THINK ABOUT THOSE AT THE MARGINS AND IN THE DISPARITY POPULATIONS THAT ELISEO DESCRIBED AND RICK TALKED ABOUT THOSE HEALTH D ABOUT THOSE H EALTH INEQUALITY IT REQUIRES CONSISTENT MONITORING OF THE CONDITIONS AND CHANGES WE PUT IN PLACE TO ACHIEVE HEALTH EQUITY IT’S NOT A ONE AND DONE SITUATION AND WE CAN LOOK AT HEALTH

EQUITY WE FOCUSSED FOR AS LONG AS WE COLLECTED DIFFERENCES ON RACE AND ETHNICITY AND USED THE DEFICIT MODEL TO THINK ABOUT HEALTH I WOULD SAY THERE’S MANY STRENGTHS WE NEED TO THINK ABOUT AND IN THE CRITIQUE OF THE FEMINIST MOVEMENT THINKING ABOUT WOMEN AT THE MARGINS THAT WERE NOT REFLECTED IN THE FEMINIST MOVEMENT THE NEW INTEREST AND PUSH TO THINK ABOUT DISPARITY POPULATIONS I WOULD SUGGEST WE CENTER THOSE AT THE MARGINS THAT WE PRIORITIZE AND THE WANTS AND NEEDS OF THOSE PATIENTS AND COMMUNITIES WE HOPE TO SERVE IN THIS WORK WE THINK ABOUT A WAY TO DEMOCRATIZE THE PROCESS TO INCLUDE DIRECT PARTICIPATION I THINK AT THE PROCESS HAS BEEN REFLECTED IN THE WORK THAT’S GONE INTO THE WORKSHOP BY DIRECT PARTICIPATION OF STAKEHOLDERS AND MAKE SURE THEY’RE GIVEN A MEANINGFUL VOICE I THINK YOU’LL SEE THAT REFLECTED EVEN IN OUR PANEL TODAY YOU DESIGN AND EVALUATE THE IMPACT OF OUR RESEARCH IN THIS AREA ACCORDING TO THE STAKEHOLDERS OUTCOMES AS CLINICIANS AND RESEARCHERS WE KNOW THE LITERATURE AND KNOW THE OUTCOMES BUT WE NEED STAKEHOLDERS AND PROVIDERS ON THE GROUND TO HELP US GROUND OUR WORK TO MAKE SURE IT REFLECTS WHAT THE REALITY IS IN COMMUNITIES AND POPULATIONS THIS CURRENT EMPHASIS ON PATIENT AND COMMUNITY ENGAGEMENT I THINK REFLECTS THE IDEA OF CENTERING THE MARGINS BUT THOUGH REFLECT AS A RADICAL SHIFT IN POWER DYNAMICS AND WE HAVE TO BE WILLING TO ACCEPT THAT SHIFT IF WE WANT SOMETHING DIFFERENT WE NEED TO HAVE A DIFFERENT WAY OF DOING THINGS I SEE I HAVE ONE MINUTE THAT WAS A QUICK FOUR MINUTES THERE’S A GROWING INTEREST IN ENGAGING COMMUNITIES, PATIENTS, FAMILIES AND STAKEHOLDERS AS PARTNERS IN THE PROCESS OF RESEARCH AND WE OFTEN USE THIS APPROACH TO ADDRESS THE HEALTH OF POPULATIONS TO IDENTIFY WITH UNDER SERVED MINORITY COMMUNITIES IT SHIFT THE ROLE OF THE RESEARCHER FROM SOLE CREATOR OF KNOWLEDGE TO CO-CREATOR WITH STAKEHOLDERS AND LOOK AT EXPERTISE PATIENTS, FAMILIES AND OTHER STAKEHOLDERS BRING AS CRITICAL TO SOLVING WHAT HAS BEEN IN REALITY WILL ALWAYS BE A COMPLEX PROBLEM IN HEALTH AND HEALTH CARE IT CREATES A BETTER PROCESS AND OUTCOMES BY INTEGRATING AND HIGHLIGHTING DIVERSE PERSPECTIVES THE HEALTH SYSTEMS THEN LEAD TO DRESS THINGS THAT MATTER TO PATIENTS, FAMILIES, CAREGIVERS AND COMMUNITIES AND THERE’S EVIDENCE OF IMPROVED HEALTH OUTCOMES AND PATIENT SAFETY AND PATIENT CENTERED PRACTICE IMPROVEMENTS AND SUSTAINED POLICY AND PARTNERSHIPS CHRIST KRISTEN TALKED ABOUT THE OUTREACH TO SHARED LEADERSHIP I THINK WHAT WE STARTED TO SEE IS THE OUTREACH AND STILL HAVE PLACE TO MOVE ON THE CONTINUUM THERE’S BEEN ATTENTION TO SOCIAL DETERMINATES OF HEALTH WHERE PEOPLE ARE BORN, WORK, GROW, LIVE AND AGE AND MOST THIS WORK I THINK NEEDS TO REALLY CENTER AT THE MORE UPSTREAM AREA MOST OF THE WORK CURRENTLY THOUGH IS STILL FOCUSSED DOWNSTREAM WHAT HAPPENS IN THE CLINICAL PRACTICE BUT RATHER I THINK IF WE’RE HOPING TO SHIFT AND ADVANCE HEALTH EQUITY WE NEED TO START PUSHING FURTHER UPSTREAM SO WITH THAT I’LL END AND THANK YOU AND LOOK FORWARD TO THE DISCUSSION >> GOOD MORNING, MY NAME IS SUSAN STRONG AND I HAVE NO DISCLOSURES I’M A PATIENT ADVOCATE AND SPEAKER AND ENGAGEMENT DIRECTOR FOR [INDISCERNIBLE] I’M BEEN A PRACTICING PATIENT FOR 36 YEARS THAT ILLUSTRIOUS CAREER STARTED WHEN I WAS 17 AND DIAGNOSED OF HODGKIN’S LYMPHOMA AND RECEIVED

CHEMOTHERAPY WITH 36 G.I.s OF RADIATION FIVE YEARS AGO I LEARNED ABOUT RADIATION INDUCED HEART DISEASE AND I DID WANT TO GIVE A SHOUT OUT TO MY PEDIATRICIAN WHO DIAGNOSED THE HODGKIN’S LYMPHOMA AFTER A YEAR OF SEEING SPECIALIST I WAS EMBARRASSED TO GO BACK TO HIS OFFICE WHEN HE WAS 17 BUT HE DID THE TRICK SO THANK YOU FROM — DR. SIMON FROM OKLAHOMA AND MY PRIMARY CARE PHYSICIAN NOTICED A CHANGE IN MY HEART MURR MURRER — MURRER AND WENT ON — MURMUR AND I’M GRATEFUL FOR THAT MEDICAL INTERVENTION AND TWO YEARS AGO NEXT MONTH I WAS DIAGNOSED WITH BREAST CANCER AND HAD A DOUBLE MASTECTOMY AND HAD CHEMOTHERAPY SO FIVE YEARS AGO I LEARNED ABOUT THE IMPORTANCE OF PREVENTIVE CARE FRANKLY IT’S SAVED MY LIFE TWICE LEARNING ABOUT PREVENTATIVE CARE THE VALUE OF PREVENTATIVE CARE SERVICES IS IMMEASURABLE AND IT SAVES LIVES AND MONEY AS WELL WHAT’S THE PROBLEM? WHY ARE WE HEAR ALL TALKING ABOUT IT BECAUSE WE KNOW IT’S A GOOD THING AND KNOW IT’S UNDER UTILIZED THAT’S A PROBLEM WE’RE HERE TO SOLVE I’M SORRY, I DON’T HAVE THE ANSWER FOR YOU TODAY IT’S A COMPLEX ISSUE WE’RE DEALING WITH INDIVIDUALS THAT ARE MEMBERS OF GROUPS WHO ARE EXPERIENCING BARRIERS TO CARE AND I WAS READING AND REALIZE ONLY 12% OF ADULTS HAVE PROFICIENT HEALTH LITERACY AND I CONSIDER MYSELF TO BE ONE OF THE 12% ACTUALLY AND I STILL EVEN AFTER I’VE BECOME A PATIENT ADVOCATE AM NOT AWARE OF THE PREVENTIVE SERVICES COVERED UNDER MY INSURANCE THERE’S A LOT OF OPPORTUNITY FOR EDUCATION FOR PATIENTS FROM ALL GROUPS TO LEARN MORE ABOUT HOW TO UTILIZE PREVENTIVE CARE TO LEARN ABOUT WHAT SCREENINGS THEY NEED TO HAVE AND THAT SORT OF THING COMMUNICATION IS BIG PARTS OF THAT AND COMMUNICATION OUTBOUND FROM PROVIDERS IS IMPORTANT INITIATING CARE AND THE E-MAILS, TEXTS, PATIENT PORTAL MESSAGES THAT ENCOURAGE PATIENT TO MAKE AN APPOINMENT AND THEY’RE DUE FOR PREVENTIVE CARE THAT’S EXTREMELY IMPORTANT I THINK THOSE ARE THE MAIN THINGS I WANTED TO MENTION AGAIN, JUST GRATEFUL FOR PREVENTIVE SERVICES AND WHAT IT DOES AND THE LIVES IT SAVES BECAUSE IT SAVED MY LIFE MULTIPLE TIMES THANK YOU ALSO NIH FOR INCLUDING THE PATIENT VOICE IN THIS DISCUSSION IT’S VERY IMPORTANT AND I’M ALWAYS HAPPY TO SEE THAT DONE THANK YOU >> THANK YOU VERY MUCH I REALLY APPRECIATE THE PRECEDING TALKS AND THEIR DIFFERENT PERSPECTIVES I WANT TO OFFER PERHAPS A SLIGHTLY DIFFERENT PERSPECTIVE THAN YOU MAY BE USED TO HEARING IN THIS CONTEXT THAT IS WE’RE IN THE HABIT OF FOCUSSING ON RISK AND NOT THE FLIP SIDE WHICH MIGHT BE ENCAPSULATED THE TERM RESISTANCE TO DISEASE AS YOU MIGHT EXPECT IT TO OCCUR IN CONDITIONS OF ADVERSE RISK, ADVERSE EXPOSURES AND PROPOSE THERE’S A BLACK PARADOX THAT IS MAYBE UNDER APPRECIATED IN TERMS OF THE

EXPECTED OUTCOMES FOR AFRICAN AMERICANS WHO VERY OFTEN REVIEW BLACK HEALTH AS MONOLITHICLY BAD OR CHARACTERIZED BY SHORT LIFE SPAN AND LEVELS OF MORBIDITY I HAVE NOTHING TO CLOSE — DISCLOSE I’M A CARDIOLOGIST WHICH IS NOTHING TO DISCLOSE AND HEALTH DISPARITIES IS A TRAGIC REALITY WE TALK ABOUT 83,000 EXCESS DEATHS AMONG AFRICAN AMERICANS EACH YEAR AS CALCULATED BY A FORMER SURGEON GENERAL AND HIS COLLEAGUE AND OTHERS AND BACK AT THE TURN OF THE 20th CENTURY IT WAS SAID WE SHOULD FIND A HIGHER DEATH RATE PRESENT AMONG NEGROS THAN WHITES AND HAVE DIFFERENT CONDITIONS AND STILL DO SO WE ALL KNOW THE SORT OF CONSEQUENCES, IF YOU WILL, AS IT MANIFESTS IN THE LITERATURE WE’RE ALL IMMERSED IN DAY IN AND DAY OUT THESE CONCLUSIONS THAT YOU SEE IN A VARIETY OF STUDIES THAT WIND UP SOMETHING LIKE CONTROLLING FOR ALL CONCEIVABLE RISK FACTORS AND WE STILL COULDN’T RESOLVE THE EXCESS MORBIDITY OR MORTALITY WE SAW IN THE BLACK POPULATION THESE THINGS ARE SEEN AGAIN REPEATEDLY IN THE LITERATURE, WE’RE ALL AWARE OF THEM THEY STIMULATE THINGS LIKE WHAT’S BEEN INVOLVED IN FOR MANY YEARS AND DIRECTED MANY YEARS AND THERE’S TWO EMPHASIS ON RISK AND IT WAS THE PRECIPITANT FOR THE STUDY AND APPROPRIATELY SO THERE’S ASPECTS OF HETEROGENEITY IT WILL SHED LIGHT ON BUT WE NEED TO KEEP AWARENESS IN LOOKING AFTER PUBLIC HEALTH ONE AMONG SEVERAL OF INTERESTING UNEXPECTED FINDINGS IS THE HEART STUDY I THINK MANY ARE FAMILIAR WITH WHEREIN THIS RURAL COMMUNITY OUT IN GEORGIA IT WAS FOUND THAT HEART DISEASE PREVALENCE WAS DRAMATICALLY LESS AMONG AFRICAN AMERICAN WHO HAD RISK FACTOR PROFILES WHO WOULD HAVE PREDICTED HIGHER DISEASE AND IN THE ACCOUNT BLACKS OCCUPIED THE RANKS OF WHITES MORE DISPLACED TOWARDS SHOP KEEPERS AND OTHER SEDENTARY PROFESSIONS BUT I DON’T BELIEVE WE UNDERSTAND THAT FULLY IN OUR OWN WORK AND WE’VE SEEN THE SURPRISING RESULT OF CONTROLLING FOR SEF DIFFERENCES IN THE BLACK COMMUNITY WE SEE DRAMATICALLY DIFFERENT LEVELS OF CARDIOVASCULAR DISEASE AND DIFFERENCES IN MORTALITY RATE AND EMERGENCY ROOM VISITS AND ADMISSION RATES IN ROOMS AND WE DON’T HAVE A REASON AND WE MAY HAVE AN OPPORTUNITY TO LOOK AT THE CURRENT STATE OF AFFAIRS AND FIND PROMOTERS OF HEALTH WE PERHAPS ARE OVERLOOKING PRESENTLY I’D LIKE TO ENDORSE THE IDEA OF CENTERING MARGINS IN THE REALM OF TECHNOLOGICAL APPROACHES TO THE PUBLIC’S HEALTH WE’LL GET TO TALK IT MORE IN THE DISCUSSION AND THERE’S A COMMUNITY DRIVEN IN CODE DESIGN AND DATA COLLECTION WE HOPE TO LAUNCH IN THE ATLANTA METROPOLITAN AREA WITH POSSIBILITIES BEYOND THE IDEA IS RATHER THAN AFRICAN AMERICANS AND OTHER

TRADITIONALLY MARGINALIZED AMERICANS THEY’RE LAST TO BENEFIT FROM TECHNOLOGICAL APPROACHES AND I.T. FOR GATHERING DATA ON A NON-TIME RESTRICTED FASHION AS LAUNCH AS OTHER STUDIES HAVE DONE AND OPEN UP AN OPPORTUNITY TO LOOK FOR THE GRANULAR NEW POSSIBILITIES AND COMMUNITY DRIVEN AND SOMETHING THAT SINCE I’M OUT OF TIME SOMETHING WE CAN TALK ABOUT FURTHER IN TERMS OF THE TYPES OF DATA WE’RE ABLE TO COLLECT AND AGAIN AND HOPEFULLY SEE NEW RESOLUTIONS FOR THE DISPARITY PATHWAYS THANK YOU >> THANK YOU AGAIN FOR THE OPPORTUNITY TO SPEAK ON THE PANEL MY NAME’S BRUCE LEE WE TALK ABOUT SYSTEM APPROACHES AND METHODS FOR HEALTH EQUITY THE ONLY THING I HAVE TO DISCLOSE IS I’VE NEVER BEEN IN ANY MARTIAL ART MOVIES MYSELF I WANT TO TALK ABOUT HOW EVERYBODY IN THE SOCIETY SEES EACH OTHER THROUGH A COMPLEX SYSTEM WE TEND TO FORGET WE’RE ALL CONTACTED AND ALL PART OF COMPLEX SYSTEMS AND ECONOMIC SYSTEMS, BEHAVIORAL SYSTEMS WE OURSELVES ARE COMPLEXES OURSELVES THERE’S A TENDENCY TO THINK WE’RE INDIVIDUAL ISLANDS THAT DON’T REALLY DEPEND ON EACH OTHER AND DON’T EFFECT EACH OVER THE OPPOSITE IS TRUE WHEN YOU DON’T REALLY APPRECIATE AND UNDERSTAND THE COMPLEX SYSTEMS, THERE’S TREMENDOUS RISKS FIRST YOU COME UP WITH BAND-AIDS RATHER THAN SOLUTIONS THERE’S A TENDENCY TO THINK SINGLE CAUSE AND EFFECT THERE’S A SINGLE REASON WHY THIS F PHENOMENON IS BEING CAUSED AND IF YOU TRY TO ADDRESS THE CAUSE THEN YOU’VE SOLVED THE PROBLEM AS A RESULT WE DEVELOP BAND-AIDS RATHER THAN SOLUTIONS BECAUSE WE’RE NOT FIXING THE PROBLEM AND SOMETHING MAY LOOK GREAT FOR A YEAR OR TWO BUT IT’S LIKE PUSHING A WATER COOLER IF YOU PUSH DOWN A PROBLEM IN ONE PART IT WILL SHOW UP ELSEWHERE ADDITIONALLY, YOU CAN MISS SECONDARY AND TERTIARY EFFECTS SOMETIMES IT CAN HAVE WELL MEANING INITIATIVES OR EFFORTS BUT THEN IT RESULTS IN NEGATIVE QUENCES FOR SOME PEOPLE OR ALL THE PEOPLE BECAUSE YOU DIDN’T UNDERSTAND THE SYSTEM OND — AND ON THE FLIP SIDE, PREVENTIVE MEASURES ARE AN INVESTMENT UP FRONT AND THE EFFECTS CAN OCCUR OVER A LIFE TIME OR MANY YEARS AND IF YOU DON’T UNDERSTAND THE SYSTEM OR APPRECIATE THE WHOLE SYSTEM YOU CAN UNDER VALUE OR UNDERESTIMATE THE POLICY OR PREVENTION FOR PREVENTIVE MEASURES AND SPEND TIME AND RESOURCES IF YOU DON’T UNDERSTAND THE SYSTEM BECAUSE IT COULD BE THROWING MONEY INTO THE OCEAN YOU’RE HOPING SOMETHING WILL HAPPEN WHEN YOU’RE NOT SURE LET ME GIVE YOU EXAMPLES OF SYSTEMS APPROACHES AND METHODS THEY’RE TECHNIQUES USED TO BETTER UNDERSTAND THE COMPLEX SYSTEMS SO AS HUMAN BEINGS REGARDLESS OF HOW SMART OR HOW MUCH EXPERIENCE OR EDUCATION WE HAVE, WE’RE LIMITED IN TERMS OF WHAT WE CAN SEE WE CAN SEE THE CHAIR AND I CAN MOVE IT ALONG THE STAGE BUT THAT’S A DIRECT EFFECT SECONDARY AND TERTIARY EFFECTS CAN BE DIFFICULT TO SEE THIS IS WHERE WE BUILT A COMPLEX SIMULATION MODEL IN WASHINGTON, D.C. AREA REPRESENTING ALL INDIVIDUALS IN THE LOCATION AND YOU LOOK AT THE SPREAD OF FLU DURING THE PANDEMIC AND WE TRIED TO DETERMINE IF THERE’S LIMITED AMOUNT OF VACCINES AVAILABLE, WHO SHOULD GET THEM FIRST? AND I’LL GO TO THE PUNCH LITHE SINCE WE’RE SHORT ON TIME, IF YOU VACCINE THE LOWEST INCOME NEIGHBORHOODS AND POPULATIONS FIRST, THAT’S WHERE YOU BENEFIT SOCIETY OPPOSED TO HIGHER INCOME POPULATIONS BECAUSE LOWER INCOME POPULATIONS TEND TO BE GE GET

DENSELY POPULATE AND YOU DON’T GET PEOPLE FROM HIGH-INCOME NEIGHBORHOODS WORKING IN LOW-INCOME NEIGHBORHOODS SO PROTECTING THEM BENEFITTED THEIR POPULATION A SECOND EXAMPLE WE BUILT A SIMULATION MODEL IN THE UNITED STATES AND WE SIMULATE WHAT WOULD HAPPEN IF YOU PHYSICAL ACTIVITY ON KIDS WHICH IS APPALLINGLY LOW THESE DAYS AND SHOWED THE SAVINGS AND DIRECT MEDICAL COSTS AND THEY’RE TREMENDOUS EVERY COHORT CAN SAVE BILLIONS ON PHYSICAL ACTIVITY THIS BENEFITS EVERYONE IN THE UNITED STATES EVEN IF YOU ARE ALREADY PHYSICALLY ACTIVE THIS IS AN EXAMPLE OF THE SYSTEMS BENEFITING AND THE THIRD EXAMPLE IS A SIMULATION MODEL OF WASHINGTON, D.C. AND FOUND THE IMPACT OF CRIME WAS SIGNIFICANT IN TERMS OF PREVENTING PEOPLE FROM GETTING EXERCISE AND GETTING PHYSICAL ACTIVITY THIS IS CONNECTING ONE SOCIAL PROBLEM OR ISSUE, WHICH IS CRIME, TO HEALTH AS WE THINK OF THESE PROBLEMS AS SEPARATE BUT THEY’RE INTERCONNECTED YOU CAN’T ASK THE POPULATION TO SAY OH, YOU GUYS NEED TO GET MORE PHYSICALLY ACTIVE WITHOUT CHANGING THE SYSTEM IF YOU HAVE A SITUATION WHERE THERE’S CRIME OR OTHER IMPEDIMENTS TO PHYSICAL ACTIVITY, WE HAVE TO TRY TO FIX THOSE SYSTEMS AS WELL SO HAPPY TO GO THROUGH THESE IN GREATER DETAIL BUT IN SUMMARY, EVERYONE IN SOCIETY IS INTERCONNECTED THROUGH COMPLEX SYSTEMS WE CAN’T THINK OF OURSELVES AS SEPARATE WE’RE ALL IN IT TOGETHER SECONDLY, INEQUITY CAN EFFECT AND THERE’S UTILITARIAN BENEFITS EVEN IF YOU DON’T CARE IN EQUITY FOR YOURSELF YOU’RE AFFECTED BY IT AND WE’VE SHOWN THAT IN OUR WORK SO THERE’S A SELFISH REASON TO SOLVE THE PATHWAY PROBLEMS FINALLY, SYSTEMS APPROACH AND METHODS CAN HELP UNDERSTAND AND REDUCE DISPARITIES WITH THAT I’M HAPPY TO ENGAGE IN THE SESSION THANK YOU >> SO THANK YOU SO ALL OF OUR SPEAKERS THE RANGE OF PERSPECTIVE IS GREAT WE HAVE A FEW QUESTIONS TO GUIDE OUR DISCUSSION TODAY THE FIRST ONE IS IT’S EITHER COMPLETELY SELF-EVIDENT BUT I WANT YOU TO MAKE IT EVIDENT TO THE AUDIENCE, WHY SHOULD PREVENTION BE THE TARGET WHEN WE TALK ABOUT HEALTH EQUITY? WE CAN MAKE SURE EVERYONE GETS TREATMENTS FOR THE DISEASES THEY GET BUT MAKE THE CASE PREVENTION IS THE THING AND BEING A CHEERLEADER FOR PREVENTION BUT MAKE THE CASE FOR US PREVENTION IS IMPORTANT >> THE SECOND STUDY I MENTIONED IS AN EXAMPLE OF WHAT HAPPENS IF YOU INCREASE FISCAL ACTIVITY AMONG — PHYSICAL ACTIVITY AMONG YOUTH AND THE RESULTING SAVINGS SAY CASCADE EFFECT WE SAID WHAT HAPPENS IF YOU INCREASE PHYSICAL ACTIVITY AMONG CHILDREN AND WHAT HAPPENS YEAR BY YEAR IN TERMS OF THEIR BODY MASS INDEX AND SUBSEQUENT DEVELOPMENT OF DIABETES AND CARDIAC DISEASE AND CANCER, ETCETERA SO IF YOU AREN’T INTERVENING EARLY ON YOU START GOING DOWN THIS CASCADE AND ESPECIALLY WHEN ONCE YOU HAVE CHRONIC DISEASE DEVELOP IT’S CHALLENGING BECAUSE IT STARTS BUILDING UPON EACH OTHER AND EFFECTS WORK AND YOU DON’T WANT TO GET CAUGHT IN THE COMMUNITIES START OFF AT HOME.NY THEY DON’T HAVE PREVENTIVE SERVICES OR THE OPPORTUNITY TO ENGAGE IN HEALTHY BEHAVIORS BECAUSE THEY HAVE OTHER THINGS WEIGHING THEM DOWN AND THEN IF YOU WAIT UNTIL LATER IN THE CYCLE AND WE’VE SHOWN THROUGH OUR MODELS AND YOU’RE INTERVENING LATER ONCE THE DISEASES DEVELOP OR PROBLEMS DEVELOP YOU CAN NEVER GO BACK LIKE YOU CAN NEVER RECLAIM THOSE COST SAVINGS IF YOU LOOK

STRICTLY ECONOMICALLY THE RETURN ON INVESTMENT FOR PREVENTIVE SERVICES IS SO HIGH IF YOU MEASURE THE SYSTEM WIDE EFFECTS AND BY A HEALTH BENEFITS STANDPOINT YOU CAN’T GO BACK >> I TOTALLY AGREE I THINK I MENTIONED GEORGE RUST PRIOR TO THIS BECAUSE I ADMIRE HIS WORK BUT HE’S MADE A VERY GOOD CASE, AS HAVE OTHERS, THAT DISPARITIES SEEM TO AMPLIFY AT EVERY STAGE AS YOU GO ALONG THE CONTINUUM OF ACCESSING CARE AND GETTING GOOD CARE IF YOU ARE NOT DIAGNOSED OR HAVE HIGH BLOOD PRESSURE LATE IN THE GAME THE ORGAN DAMAGE IS HIGHER IF PEOPLE ARE SCREENING YOU FOR TARGET ORGAN DAMAGE LATER IN THE PROCESS, THE CHANCES OF YOUR GOING ON TO THINGS LIKE STROKE AND KIDNEY DISEASE AND SO FORTH ARE AMPLIFIED THE HUMAN COSTS AMPLIFY AS YOU GO ALONG HE ALSO USED THE BREAST CANCER ANALOGY WHEREAS IF YOU LOOK AT AFRICAN AMERICAN WOMEN WHO MAY GET SCREENED LATER AND HAVE MORE ADVANCED DISEASE AND HAVE A MORE DIFFICULT COURSE FROM THAT POINT FORWARD THAT HAS HUGE ECONOMIC CONSEQUENCES AS WELL AS PERSONAL VIEW CONSEQUENCES >> I WOULD ADD WHILE I’M A GENERAL INTERNISTS AND SEE ADULT PEOPLE THAT ARE NOT PREGNANT, THAT’S HOW I HAVE TO CHARACTERIZE MY PRACTICE, AND THIS IS A MULTI — MULTIPLY MULTIPLYCATIVE STATE AND AS WE THINK OF WHAT THE FUTURE HEALTH CAN LOOK LIKE FOR AN ADULT AND THE HUMAN TOLL NOT JUST FOR AN INDIVIDUAL BUT FOR A COMMUNITY WHAT DOES IT MEAN TO HAVE MULTIPLE CHRONIC CONDITIONS IN A COMMUNITY AND WHAT’S IT MEAN FOR A COMMUNITY WELL BEING AND BEING ABLE TO THRIVE IN THE SOCIETY I THINK IT SEEMS LIKE ONE OF THE [INDISCERNIBLE] OF TASK FORCE FOCUSSED ON INDIVIDUAL PREVENTIVE SERVICES BUT IF WE THINK OF IT AS A CLUSTER AND LIFE COURSE PERSPECTIVE THE AMPLIFICATION BRUCE DESCRIBES IN HIS STUDY IS COMPELLING >> SO AS A PRIMARY CARE PROVIDER I LOVE YOU SHOUTED OUT YOU’RE A PEDIATRICIAN AND HEALTH CARE PROVIDER TALK TO US FOR A SECOND ABOUT WHEN YOU THINK ABOUT PREVENTION, IS THAT SOMETHING YOU THINK OF AS STARTING IN THE DOCTOR’S OFFICE OR SOMETHING YOU THINK ABOUT AS TAKING PLACE OUTSIDE THE DOCTOR’S OFFICE >> I THINK PREVENTION HAS TO START IN INDIVIDUALS MAKING GOOD CHOICES IN THEIR LIVES ABOUT EXERCISE AND EATING AND FOLLOWING UP WITH THE DOCTOR IT’S A GROUP EXPERIENCE FOR EDUCATING THE POPULATION ABOUT WHAT GOOD PREVENTION LOOKS LIKE BUT IT’S NOT THE DOCTOR’S RESPONSIBILITY IT’S INDIVIDUAL RESPONSIBILITY BUT WE HAVE TO WORK TOGETHER IN PARTNERSHIP >> IT WAS NATURAL FOR YOU THE DOCTOR WOULD BE MAKING RECOMMENDATIONS ABOUT PREVENTION >> ABSOLUTELY THE PREVENTATIVE SERVICES AND THE SCREENING AND NOT ONLY PREVENTION BUT EARLY DETECTIONS WAS MENTIONED BEFORE I THINK IS SO CRUCIAL HIGH RISK IN VULNERABLE POPULATION >> BUT IN THE PREVENTION LANDSCAP THE DOCTOR’S OFFICE IS ONLY ONE PIECE OF IT AND THAT IS TRUE ALL THE TIME IT’S PARTICULARLY TRUE WHEN WE

THINK ABOUT PATTERNS OF YEG INEQUITIES BECAUSE AS LONG AS YOU LOOK UPSTREAM WE HAVE TO THINK OF THE BROADER CONTEXT HOW DO WE THINK ABOUT CLINICAL PREVENTION KNOWING PREVENTION HAS A BROADER CONTEXT? >> I THINK A CHALLENGE IS THERE’S BEEN A FOCUS IN THE DOCTOR’S OFFICE IN PURE EDUCATION SOMEONE COMES IN AND SAY YOU SHOULD QUIT SMOKING, ETCETERA AND MANY PATIENTS UNDERSTAND WHEN HAVE YOU UNHEALTHY BEHAVIOR FEW PEOPLE SAY I DON’T GET ENOUGH EXERCISE AND A REALLY WANT TO DECREASE MY EXERCISE IT’S USUALLY BECAUSE THEY MAY HAVE TWO JOBS TO WORK AT OR TOO BUSY AND STEP OUTSIDE AND LIKE I CAN’T EXERCISE IN THIS ENVIRONMENT I HAVE TO GO FIVE MILES TO THE BASEBALL FIELD WHERE I DON’T KNOW ANYONE TO EXERCISE THERE SO YOU TELL A PATIENT WHAT TO DO AND THEY GO OFF AND DO IT AND IF THEY DON’T DO IT, IT’S BECAUSE THEY DON’T UNDERSTAND BUT IF YOU DON’T FIX THE ENVIRONMENT, IF YOU DON’T CHANGE THE ENVIRONMENTAL SITUATION, THE ECONOMIC SITUATION, HEALTHY FOOD IS MORE EXPENSIVE IT’S MORE COSTLY IF YOU WANT TO EAT FRUITS AND VEGETABLES YOU CAN EAT A LOT OF FAST FOOD YOU CAN BASICALLY SUBSIST ON FAST FOOD EVERY COLLEGE STUDENT BUT IT’S MORE EXPENSIVE TO LIVE THESE HEALTHY LIFE STYLES THERE COULD BE ECONOMIC BARRIERS, GEOGRAPHICAL BARRIERS AND ALL THE DIFFERENT THINGS IF THEY’RE NOT FIXED OR ADDRESSED IT’S HARD TO REALLY HAVE AN IMPACT >> SO WHAT’S OUR ROLE IN DOING THAT? >> I’M SITTING HERE THINKING ABOUT JACK GEIGER WHO HIS WORK IN THE MISSISSIPPI DELTA AROUND COMMUNITY HEALTH CENTERS AND I PRACTICE IN A COMMUNITY HEALTH CENTER TALKED ABOUT IN THE ’70s AS HUNGER BEING A SOCIAL DETERMINATE OF HEALTH AND WRITING PRESCRIPTIONS FOR FOOD FOR THE PEOPLE HE WAS SERVING IN THOSE COMMUNITIES WE’RE COMING AROUND TO JACK’S GENIUS IN SOCIAL DETERMINATES OF HEALTH AND WHILE WE MAY BE ABLE TO WRITE A PRESCRIPTION FOR A FOOD PANT TRY — PANTRY AND THERE’S WORK AROUND THE COUNTRY INCLUDING THAT IN ELECTRONIC HEALTH RECORD AND ADDRESS WHAT’S NEEDED AT THAT MOMENT IN TIME, TO HAVE THE EQUAL OPPORTUNITY TO BE HEALTHY WHETHER IT’S PARKS AND RECREATIONAL FACILITIES WE MUST AS THOSE OF US WITHIN THE FIELD THINK I BELIEVE FURTHER UPSTREAM IT’S IMPORTANT BUT IT’S SUFFICIENT TO THINK ABOUT IT WITHIN THE CLINICAL CONTEXT WE HAVE TO MOVE FURTHER UPSTREAM AND THAT’S WHERE COMMUNITY VOICES CAN HELP US THINK ABOUT WHERE ARE THOSE PLACES THAT WE CAN ACTUALLY KEEP MOVING IT’S JACK TALKED ABOUT HUNGER 50, 60 YEARS AGO IT MAY BE IN LIFE TIMES IT MAY BE OVER A TIME WE NEED TO BE WILLING TO LOOK AT THIS BUT WE NEED TO GET THE PERSPECTIVE PERFECT THE COMMUNITIES WE’RE HOPING TO SERVE FROM THIS WORK TO UNDERSTAND HOW THE ENVIRONMENT THAT THEY’RE WORKING AND LIVING AND PLAYING IN AFFECTS THEIR ABILITY TO AVAIL THEMSELVES OF CLINICAL PREVENTIVE SERVICES AND ALL THE OTHER THINGS THAT HAPPEN OUTSIDE OF OUR OFFICES >> I AGREE WITH THE STATEMENTS THAT HAVE BEEN MADE WHOLEHEARTEDLY ONE OF THE EARLY FINDINGS AS WE ARE LOOKING FOR PROMOTERS OF HEALTH TO HELP EXPLAIN THE HETEROGENEITY ACROSS ATLANTA, ONE OF THE INTERESTING FINDINGS EARLY ON IS THAT COMMUNITIES, THOSE NEIGHBORHOODS LIKE THE BLUE ZONES IF YOU GO WITHIN THE METRO AREA, ONE OF THE KEY THINGS THAT WE SEE IS THAT THOSE COMMUNITIES HAVE RESIDENTS IN THOSE COMMUNITIES RESPOND POSITIVELY TO THE QUESTION, HOW MANY GET-TOGETHERS AND SOCIAL INTERACTION CHARACTERIZES YOUR NEIGHBORHOOD

THOSE THAT RATED HIGH IN ANSWER TO THAT QUESTION WERE THE HEALTHIEST NEIGHBORHOODS BY AND LARGE AND THAT FACTOR WAS AT LEAST AS IMPORTANT AS THE SENSE OF AMBIENT CRIME AS THE PRESENCE OR ABSENCE OF AVAILABILITY OF NUTRITIOUS FOODS THOSE THINGS WERE IMPORTANT BUT WE WERE SURPRISED THAT THE LEADING INDICATOR WAS THIS SOCIAL NETWORKING WITHIN THE COMMUNITY AND I THINK THAT SPECKS TO THE COMMUNITY VOICES POINT AND YOUR POINT THAT WE’RE ALL EMBEDDED IN SYSTEMS AND IF WE HAVE POSITIVE INTERACTIONS THESE THINGS CAN LEAD TO DOWNSTREAM IMPACT ON HEALTH >> CAN I JUMP IN THANK YOU, HERMAN FOR THE WORK ON THAT AND ALSO CALLING IT OUT THE IDEA OF SOCIAL CAPITAL AND WHAT HAPPENS BETWEEN NETWORKS NOT SOLELY THE CONNECTIVENESS BUT THE SOURCES THAT MOVE BETWEEN NETWORKS AND I WANT TO HIGHLIGHT WORK IN LOOKING AT COMMUNITY WELL BEING AND SOCIAL CAPITAL AS ONE OF THOSE ANCHOR CONCEPTS >> YOU’VE POINTED OUT THE INDIVIDUAL RISK AND ALSO INDIVIDUAL RESILIENCE AND THEN UNDERSTANDING THE CONTEXT OF COMMUNITY AND SYSTEM CONNECTIVITY WHICH HAS ELEMENTS OF RISK AS WELL AS THESE COMMUNITY WELL BEING AND RESILIENCE AND THINGS THAT CAN BE POWERFUL FORCES FOR HEALTH WE HAVE A QUESTION ASKING YOU EACH AS LEADERS IN YOUR AREA, WHAT’S THE MOST EXCITING OR INNOVATIVE THING YOU’RE EXCITED ABOUT WHEN IT COMES TO PREVENTION PARTICULARLY AS IT RELATES TO REACHING MORE VULNERABLE COMMUNITIES AND POPULATIONS AND THEN WE’LL OPEN IT UP >> I’LL START I THINK THERE’S A LOT OF EXCITING THINGS WE POINTED TO MOYO A TERM FOR HEART AND IT’S AIMED AT ENGAGING YOUNG PEOPLE AROUND HEALTHFUL BEHAVIORS AND INFORMATION I THINK MORE GENERALLY TECHNOLOGY AS AN EXPANDER OF THE IMPACT OF THE CLINICAL SETTING IS AN IMPORTANT CONCEPT AND COMMUNITY HEALTH WORKERS AND INDIVIDUALS TRAINED NOT TO THE LEVEL OF NURSING OR DOCTORS BUT PEOPLE WHO HAVE HIGH SCHOOL EDUCATIONS IN FACT, WE EVEN HAVE HIGH SCHOOLERS DOING SOME OF THIS WHO ARE ASSISTED IN DELIVERING EDUCATION, DELIVERING SCREENING IDEAS OR STRATEGIES TO THE POPULATION IF THEY CARRY A CELL PHONE IT’S A SIMPLE WAY AND TAKES THEM THROUGH STEPS IN GIVEN SITUATIONS FOR INDIVIDUALS WHO MAY BE AT RISK FOR A VARIETY OF DISEASES I THINK THAT’S A VERY POWERFUL THING IF WE PUT THAT IN THE HANDS OF PEOPLE WHO MAY HAVE HIGH SCHOOL EDUCATIONS WE AMPLIFY THE POTENTIAL IMPACT FOR SPREADING PREVENTIVE SERVICES OR ENCOURAGING PEOPLE TO ACCESS THOSE SERVICES >> I LIKE THAT MORE AS WELL I THINK JUST TO AMPLIFY THAT THAT OFTEN TIMES WE THINK OF TECHNOLOGY THAT IN MORE RESOURCE-LIMITED SETTING IS NOT APPLICABLE AND WE FOUND’S EASILY BOTH APPLICABLE AND A VERY COST-EFFICIENT WAY TO SCALE SO WHEN IT IS ADOPTED >> I WOULD AGREE MY HOMELESS PATIENTS HAVE CELL PHONES I DON’T HAVE FOYT — HAVE TO PUT IT IN THEIR HANDS THEY BRING IT WITH THEM SO HIGH TOUCH AND HIGH TECH AND BRINGING THAT TOGETHER AND UNDERSTAND NOT ONLY HOW WE CAN USE IT TO SUPPORT PATIENTS BUT HOW CAN PATIENTS USE IT TO CONNECT WITH OTHERS HOW CAN WE THINK ABOUT SOCIAL INNOVATION WITHIN COMMUNITIES TO ADDRESS SOME OF THE MORE UPSTREAM IDEAS THROUGH TECHNOLOGY THE IDEA OF HOW WE BRING TECHNOLOGY TO BEAR ON THE UPSTREAM FACTORS IS REALLY EXCITING TO ME >> OVER THE PAST DECADE I’VE SEEN A SIGNIFICANT SHIFT IN TERMS OF THE CONVERSATIONS IT USED TO BE THE FOCUS WAS SINGLE CAUSE OR EFFECT AND HOW

DO WE DEVELOP A PILL TO ADDRESS THESE OR WHAT’S THE MAGIC DIET OR PHYSICAL ACTIVITY PROGRAM THERE’S INCREASING UNDERSTANDING THAT THESE SYSTEMS ARE ACTUALLY LIKE YOU CAN SEE THE SHIFT THROUGH DIFFERENT ORGANIZATIONS WHERE YOU TALK ABOUT THE SYSTEMS AND HOW TO FIX THESE THINGS PART IS WE’VE HAD THE PROBLEMS SINCE THE ’70s AND ’80s OBESITY IS ONE EXAMPLE AND NON HFR NON-COMMUNICABLE DISEASE AND PEOPLE ARE REALIZING A SINGLE CAUSE WILL NOT WORK YOU’RE SEEING IT EXPAND HEALTH CARE BEYOND THE OFFICE AND HOSPITAL THERE’S MORE TALK OF SAYING, OKAY, YOU HAVE TO GET TO KNOW THE COMMUNITIES AND HAVE TO DO SITUATIONS AND FIGURE OUT WHAT’S THE SOCIAL STATUS OF THE COMMUNITY AND ASK MORE QUESTIONS AND I WAS CHATTING WITH THE PREVIOUS SURGEON GENERAL TALKING ABOUT THE NEED TO INCREASE AND EXPAND THE DEFINITION OF HEALTH CARE OUT TO THE COMMUNITY WE’RE MOVING IN THE RIGHT DIRECTION SO THAT’S EXCITING >> I SEE A THEME BECAUSE WHAT I’M MOST EXCITED ABOUT AS WELL IS THE OPPORTUNITY FOR PATIENT TO DEVELOP MEANINGFUL COMMUNITY IN VIRTUAL WAYS BE IT ONLINE OR ON TELEPHONE APPS SNA COMMUNITY IS A — THAT COMMUNITY IS A PLACE OF SUPPORT AND I’M EXCITED IT’S CONTINUING TO IMPROVE AND GROW >> THANK YOU FOR THAT COMMENT, SUSAN THE WORD COMMUNITY HAS BEEN SAID OVER AND OVER AND I HOPE THAT’S NOT LOST ON ANYONE THE CO-DESIGN OF SOME OF THESE INTERVENTIONS WITH COMMUNITY MEMBERS USING PRINCIPLES THAT YOU MIGHT GROUP TOGETHER AS COMMUNITY-BASED PARTICIPATORY RESEARCH TYPE PRINCIPLES BUT SEEKING THEIR INPUT AND HAVING THEM SHOULDER TO SHOULDER WITH YOU AS YOU DEVELOP THE POSSIBLE INTERVENTIONS IS REALLY CRITICAL AND SOMETHING THAT WE’VE EMPHASIZED TO GOOD EFFECT IN ATLANTA >> ONE QUICK THING AS WELL SPEAKING ABOUT THE MERGING OF TECHNOLOGY, WE NOW HAVE THESE METHODS AND COMPUTATIONAL APPROACHES TO HELP US BETTER UNDERSTAND THESE THINGS SO FIND WAY TO LEVERAGE ALL THE TECHNOLOGIES, THAT’S EXCITING SO WE CAN SEE THINGS WHICH WE PREVIOUSLY WERE NOT ABLE TO SEE >> CAN YOU GIVE AN EXAMPLE >> WHEN WE’RE BUILDING COMPUTER AND SIMULATION MODELS WE HAVE MORE DATA AVAILABLE WE’RE IN THE ERA OF BIG DATA AND HAVE WEARABLES WHERE WE CAN FIGURE OUT WHAT’S GOING ON AND THEN THE YOU COMPUTATIONAL APPROACHES CAN VANCE — ADVANCE AND SIMULATE BEHAVIORS AND WE CAN CREATE SIMULATION MODELS TO SEE WHAT’S HAPPENING AND THEN TARGET YOUR EFFORTS AND BUILD DIFFERENT STRATEGIES THE WHOLE SPACE IS MOVING FORWARD I WAS JUST IN A COUPLE OTHER MEETINGS AT NIH WHERE WE’RE DISCUSSING HOW YOU CAN LEVERAGE THIS AND IT DOVETAILS WHAT WE’RE TALKING ABOUT HERE >> WE’RE ALL EXCITE ABOUT A LOT OF THINGS IN THE SPACE OF SYSTEM SCIENCE WORK GROUP MODEL BUILDING AND PARTICIPATORY MODEL BUILDING IS ANOTHER EXCITING SPACE WHERE PATIENTS AND OTHER STAKEHOLDERS ARE PART OF BUILDING THE MODELS SO THEY’RE WE FLECT — REFLECT REALITY >> I WANT TO MAKE SURE THAT WE HAVE TIME FOR THE AUDIENCE IF YOU HAVE QUESTIONS >> MY NAME’S LEE THANK YOU FOR YOUR PRESENTATION I HAVE A QUESTION AND SOME COMMENTS MY QUESTION IS TO PROVIDE THE READING MATERIAL IS THAT HELPFUL

OR WHY DON’T THEY DO SOMETHING LIKE THAT THE PHYSICIAN CAN COMMUNICATE WITH THE HEALTH PROVIDERS DIRECTLY OR INDIRECTLY I THINK YOU KNOW SOME PARENTS REFUSE THEMSELVES OR THEIR CHILDREN TO HAVE VACCINES MAYBE STLA EXPERIENCE THAT SOME HEALTH PROVIDER DIDN’T REALLY PROVIDE THE HEALTH INSTEAD THEY VICTIMIZED THE PATIENTS >> THANK YOU VERY MUCH SO I THINK FOR THE QUESTION I WANT TO MAKE SURE I UNDERSTAND YOU ARE ASKING US FOR WAYS TO COMMUNICATE WITH THE DOCTOR ABOUT HEALTH >> YEAH >> DO WE HAVE EXAMPLES WHERE THAT’S BEEN EFFECTIVE? I KNOW IN MY HOSPITAL WE’VE BEEN INTERESTED IN THE USE OF PATIENT PORTALS WHERE PATIENTS CAN ENGAGE WITH DOCTORS VIA ESSENTIALLY AN ONLINE WAY OF COMMUNICATING MORE DIRECTLY I WORK IN A SAFETY NET SETTING AND THE PATIENT PORTALS WE START WITH THE PRESUMPTION THIS HIGH TECH IS NOT GOING TO WORK WITH OUR LOWER-INCOME PATIENTS BUT WE FOUND WE HAVE TO DO MORE IN THE PLATFORMS BUT AFTER WE DO THAT THEY’VE BEEN ENGAGED WE ALSO WORKED WITH TECH COMPANIES FOR EXACTLY THE SAME TYPES OF THINGS IF THERE’S LOTS OF TOOLS FOR CHRONIC DISEASE MANAGEMENT AND TO HELP PATIENTS THINK OF MANAGING THEIR DISEASES AT HOME AGAIN, THE BARRIER UP FRONT TAKES A LITTLE BIT MORE WORK UP FRONT TO MAKE SURE EVERYONE KNOWS HOW TO USE THE PLATFORM AND IS COMFORTABLE USING THE PLATFORM IN HOUR EXPERIENCE IT’S BEEN REALLY IMPORTANT AND IN FACT HAS IMPROVED ON HEALTH MEASURES AND IN ENGAGEMENT MEASURES FOR LOTS OF THINGS RELATED TO PREVENTION AND MANAGEMENT >> I WOULD SAY YOU’RE RIGHT ON THE CUTTING EDGE IN TERMS OF LIBRARIES AS TRUSTED ENTITIES WITHIN COMMUNITIES AND THERE’S A GROWING INTEREST IN HOW DO WE LEVERAGE THAT NOT ONLY THE TRUST BUT THE INFORMATION TECHNOLOGY THAT OFTEN EXISTED WITHIN LIBRARIES TO REACH COMMUNITIES AROUND HEALTH PREVENTION I’VE SEEN A LOT OF INTEREST RECENTLY AND EVEN OUR COMMUNITY ACADEMIC PARTNERSHIPS WE MEET IN THE LIBRARY IN THE COMMUNITY SO IT SPEAKS TO THE POTENTIAL FOR THAT ANCHOR IN ORGANIZATION >> SO WE’RE IN SORT OF A STRANGE PERIOD WHERE THERE’S BEEN AN EXPLOSION OF INFORMATION THAT’S AVAILABLE NOW ONLINE SO PREVIOUSLY THERE WAS LESS INFORMATION THAT WAS READILY AVAILABLE AND NOW THERE’S AN EXCESS OF INFORMATION THAT’S POTENTIALLY AVAILABLE I THINK ONE OF THE CHALLENGES RIGHT NOW IS ONE, HOW DO YOU CURATE THAT INFORMATION AND HOW DO YOU IDENTIFY WHAT ARE THE TRUSTED SOURCES VERSUS THE NOT-TRUSTED SOURCES AND THE THIRD SITUATION IS SOME SOURCES ARE WRITTEN TO PARTICULAR PEOPLE AND DO NOT RESONATE WITH EVERYONE ELSE AND THE TROUBLE HAVE YOU MESSAGES ON SOCIAL MEDIA AND INTERNET DESIGNED TO RESONATE WITH COMMUNITIES NOT BEING INCLUDED AND THEN THAT MIGHT BE INFORMATION THAT’S INCORRECT OR SPREAD WITH AN AGENDA I THINK WE’RE IN A VERY INTERESTING TIPPING POINT WHERE THE NEXT STEPS IS TO FIGURE OUT HOW DO YOU THEN MAKE INFORMATION THAT’S RELIABLE THAT’S BACKED BY STRONG SOURCES THAT’S ALSO UNDERSTANDABLE BY ALL COMMUNITY AND RESONATE WITH THEM >> IT’S A GREAT QUESTION JUST TO REITERATE WHAT’S BEEN SAID, THIS ISN’T A HOSPITAL AS PART OF WHAT WE DID IN THE JACKSON HEART STUDY AND STILL ONGOING, WE HAD TRAINED COMMUNITY HEALTH WORKERS SO THEY BECAME MORE LIKE LIVING BROCHURES, IF YOU WILL, ABOUT INFORMATION PARTICULARLY REGARDING CARDIOVASCULAR HEALTH AND THE ISSUE OF RELIABILITY

THAT’S BEEN MENTIONED ARE SORT OF NOT COMPLETELY NECESSARILY IN EVERY CASE BUT ARE LARGELY ADDRESSED BY HAVING A HUMAN BEING WELL INFORMED AND TIED INTO GREATER SOURCES OF INFORMATION SO I THINK THAT MODEL OF HAVING INDIVIDUALS AND BEST COMMUNITY HEALTH ORGANIZATIONS WERE LIBRARIANS AND PEOPLE OF OTHER BACKGROUNDS AND HAVING THEM LEARN ABOUT CARDIOVASCULAR RISK FACTORS AND HAVE TEAS OR GET-TOGETHERS AFTER CHURCH OR WHATEVER WHERE THEY ANSWER QUESTIONS AND WHERE THEY REACHED THE POINT WHERE THEY COULDN’T REACH THE QUESTION THEY HAD IMMEDIATE RESOURCES >> I’M ROBERT HINE I LEAD A TEAM AT THE CDC THAT CONDUCTS SYSTEMIC REVIEWS ON HEALTH EQUITY AND PUBLIC HEALTH WE’VE DONE THIS THE PAST 10 YEARS I HAVE TWO POINTS THEMES THAT COME OUT OF THE DISCUSSION THAT WILL MAKE YOUR LIFE DR BIBBINS-DOMINGO MORE DIFFICULT WHAT IS THE DIMENSION AND DR ROBERT JACKSON DEMONSTRATED IF YOU DESEGREGATE SCHOOLS AND DID A SYSTEMATIC STUDY OF 850 DESEGREGATION CASE AND SHOWED BLACK KIDS WHO GO TO A DESEGREGATED SCHOOLS ARE MORE LIKELY TO FINISH SCHOOL HAVE BETTER HEALTH OUTCOMES AND OTHER STUDIES HAVE INDICATED THAT IF KIDS GRADUATE FROM HIGH SCHOOL YOU PROMOTE AS MUCH LONGEVITY AS YOU DO BY GETTING RID OF TOBACCO WE SHOULD THINK OF PREVENTION MORE THAN JUST IMMUNIZATION AND COLORECTAL SCREENING AND THE BARRIERS TO PREVENTION AND I THINK OF A FAMILY WITH THREE KIDS AND THE TRANSPORTATION IS TERRIBLE AND SHE’S CONCERNED ABOUT VIOLENCE SHE HAS A HARD TIME GETTING HER KIDS TO PLACES WHERE SHE CAN GET IMMUNIZATION SHE HAS OTHER THINGS TO WORRY ABOUT I THINK WE SHOULD THINK ABOUT BARRIERS TO PREVENTION NOT ONLY IN THE HEALTH SYSTEM ITSELF BUT MORE BROADLY OR MAYBE THINK ABOUT THE HEALTH SYSTEM MORE BROADLY THANK YOU >> THANK YOU VERY MUCH I THINK YOUR FIRST POINT SPEAKS TO WHAT WE HAVE BEEN TALKING ABOUT HERE THE SOCIAL STRUCTURAL FACTORS THAT ULTIMATELY THE MOST UPSTREAM FACTORS THAT ULTIMATELY DETERMINE HEALTH I THINK THE SECOND POINT YOU’RE SPEAKING TO IS MUCH MORE GRANDPA YOU LAR AT THE — MORE GRANULAR AT THE INTERFACE OF THE HEALTH SYSTEM WHAT DO WE NEED TO KNOW ABOUT THE MORE IMMEDIATE SOCIAL DETERMINATES AND WHAT’S THE INVENTION TO MAKE IT BETTER >> THIS MAY BE A BIT PROVOCATIVE BUT LET ME INTRODUCE I THINK PERHAPS ANOTHER COMPLEMENTARY POINT OF VIEW WHEN WE THINK OF SOCIAL DETERMINATES OF HEALTH ESPECIALLY LIKE THE ONES MENTIONED LIKE SCHOOL DESEGREGATION EVEN RESIDENTIAL DESEGREGATION AS THESE BEING AWFUL AND POWERFUL DETERMINATES OF HEALTH, IT BEGINS TO GET OVERWHELMING THESE THINGS HISTORICALLY HAVE CHANGED WITH A GLACIAL REPEATEDITY AND IT’S NOT EVEN LINEAR YOU DESEGREGATE A SCHOOL? 20 YEARS LATER IT’S RE-SEG REG GAITED IT’S — RE-SEGREGATED AND WE HAVE TO BE CONSTANTLY ATTENTIVE TO AND VIGOROUS IN ADDRESSING SOCIAL DETERMINATES OF HEALTH IT’S IMPORTANT AND IN THE MIDST OF ALL OF THIS THROUGH 12 GENERATIONS OF SLAVERY, JIM CROW, RACIAL DISCRIMINATION THAT IS STILL APPARENT EVEN TODAY, THERE ARE REMARKABLE EXAMPLES OF HETEROGENEITY AND POSITIVE OUTCOMES HOW DOES THAT HAPPEN?

HOW DOES AN AFRICAN AMERICAN MAN WHO IS SAY 80 YEARS OLD NOW GET TO THE AGE, HOW DOES HE NOT HAVE HIGH BLOOD PRESSURE GIVEN ALL THE TREVAIL HE’S EXPERIENCED UNDERSTANDING THOSE OUTCOMES WILL OPEN UP NEW INSIGHTS AND DOORS FOR US TO EXPLORE BECAUSE SOME PEOPLE IN THE WORDS OF THE ANTHEM OF THE CIVIL RIGHTS MOVEMENT, OVERCAME WHAT ARE THE SECRETS THERE? ARE THEY SECRET ARE THEY BEHAVIORAL OR A PSYCHOLOGICAL CONSTRUCT WE’RE TALKING ABOUT HERE OR ARE THERE PHYSIO LOGIC AND OTHER EPIGENETIC UNDERPINNINGS BECAUSE THE STORY OF AFRICAN AMERICANS SAY STORY OF SURVIVAL AND DESPITE INCREDIBLE ODDS OF COURSE THERE’S DISPARITIES BUT THESE EXAMPLES OF VIGOR BEAR INVESTIGATION MORE VIGOROUSLY THAN WE’VE DONE IN THE PAST >> I WANTED TO GIVE A FIVE-MINUTE WARNING I SEE MANY PEOPLE AT THE MIC >> I THINK WE TAKE AS MANY AS WE CAN >> IN THE SPIRIT OF THE FOCUS OF THE INITIATIVE AND ACHIEVING HEALTH EQUITY AND PREVENTIVE HEALTH SERVICES I WANT YOUR THOUGHTS RELATIVE TO RECOMMENDATIONS FOR FUTURE RESEARCH AND GIVEN THE FACT THAT ULTIMATELY WHAT WE’RE TRYING TO DO IS TO IDENTIFY INTERVENTIONS THAT ARE INDEED EFFECTIVE IN ADDRESSING THE NEEDS FOR THE DISPARATE POPULATIONS BUT AS YOU ALL HAVE EMPHASIZED THERE’S CHALLENGES WITHIN OUR COMMUNITIES CHALLENGES WITH THE LIVED EXPERIENCE AND TAKE ING — TAKING A LOOK AT THE RESEARCH DONE IN CONTROLLED ENVIRONMENTS WHERE THERE’S BEEN CORRECTION AND CONTROLS FOR IT DOESN’T REFLECT THE REALITY OF MANY INDIVIDUALS WE’RE SPEAKING OF THAT YOU’RE TALKING ABOUT IN THESE PRESENTATIONS ULTIMATELY AS IT RELATES TO SYSTEMS NEEDS AND MANY DISPARATE POPULATIONS WE’RE FOCUSSED ON, THEY’RE RECEIVING THEIR HEALTH CARE IN COMMUNITY CENTERS AND FEDERALLY QUALIFIED HEALTH CENTERS AND THE INDIAN HEALTH SERVICES WHAT ARE YOUR THOUGHTS RELATIVE TO ADVANCING SCIENCE IN THESE INSTITUTIONS AS WELL AS WE’RE TRYING TO REACH THESE POPULATIONS AT GREATEST RISK? >> IT’S A FANTASTIC QUESTION THANK YOU FOR IT MY IMMEDIATE THOUGHT IS AROUND MULTIPLE CHRONIC CONDITIONS WHEN WE WERE LOOKING AT THE IMPLEMENTATION OF PREMIER AN NNLBI EVIDENCE-BASED INTERVENTION IN EASTERN NORTH CAROLINA, PREMIER HAD STRICT INCLUSION CRITERIA WE SHARED THAT WITH OUR COMMUNITY PARTNERS AND THEY SAID THERE WAS NO WAY WE’LL FIND PEOPLE WITH ONE CARDIOVASCULAR RISK FACTOR WE HAD TO LOOSEN THE CRITERIA AS WE THINK OF DISPARITY POPULATIONS WE MUST THINK OF MULTIPLE CHRONIC CONDITIONS NOT ONLY AND WHEN IT COMES TO PREVENTION AS I CLINICIAN EACH TIME I’M AT THE CLINIC I HAVE TO MAKE A DECISION WHICH PREVENTIVE SERVICE WILL I ADVOCATE FOR AMONG THE MULTIPLE CHRONIC CONDITIONS INDICATE AND WHICH GUIDELINES AND HOW WILL I LEVERAGE THAT 15 MINUTE, 20 MINUTE VISIT TO ENSURE THEY HAVE THE BEST CARE AND THAT’S NOT ALWAYS CLEAR IN TERMS OF WHAT I CAN OFFER TO PATIENTS IN ADDITION TO ALL THE OTHER LIFE FACTORS I HAVE DEAL WITH HOUSING INSECURITY, FOOD INSECURITY, HOME HEALTH AID AND ALL THE OTHER THINGS >> I THINK WE SHOULD IN STUDYING MORE IN THOSE SYSTEMS WHERE A LARGE NUMBER OF THE POPULATIONS THAT WE’RE TALKING ABOUT IS SERVED IT DOESN’T MEAN THEY’RE NOT SYNONYMOUS WE NEED TO BE STUDYING THESE HEALTH DISPARITY POPULATIONS IN ALL THE MANY PLACES THAT THEY ARE SEEN IN THE SETTINGS YOU’RE TALKING ABOUT THEY HAVE THEIR OWN RESOURCE RESTRICTIONS AND FOR MANY POPULATIONS THEY DISPROPORTIONATELY SEE THE POPULATIONS WE’RE TALKING ABOUT IT’S THAT OVERLAP OF THE TWO

THAT WE NEED TO SEE MORE STUDIES IN THOSE CONTEXT THE STUDY ELISEO ALLUDED TO, KAISER GETTING 80% BLOOD PRESSURE CONTROL WE DECIDED TO DO THAT SAME THING IN OUR SAFETY NET SETTING WE HAD TO ADAPT EVERYTHING KAISER DID BUT WORKED WITH KAISER TO UNDERSTAND NOT HOW THEY DID IT BUT THE PRINCIPLES BEHIND THEIR APPROACH AND WENT TO OUR STAKEHOLDERS WE’RE NOT KAISER WHAT DO WE HAVE TO DO? WE ADAPTED EVERY OUR PATIENT POPULATION EVERY THING TO OUR PATIENT POPULATION AND THE FACT MANY PATIENTS DON’T HAVE INSURANCE AND YOU CAN’T START WITH DIURETICS AND THE PATIENTS HAVE DIFFERENT SCHEDULES BUT WE ALSO ACHIEVED 80% CONTROL RANGE THAT’S WHAT WE HAVE TO HAVE MORE OF STUDIES IN THE SETTINGS AND THE POPULATIONS WE’RE TALKING ABOUT >> AND POSSIBLY RECOMMENDATIONS FOR FUTURE RESEARCH THAT COLLABORATES WITH RESEARCH INTENSIVE ACADEMIC MEDICAL CENTER AND THESE TYPES OF CENTERS IN RESEARCH AND POSSIBLY MAKING THAT A STRONG RECOMMENDATION >> I WOULD STRONGLY RECOMMEND THAT >> IT’S MORE OF AN ANSWER THAN A QUESTION >> THIS IS A SITUATION WHERE YOU CAN COMBINE SYSTEMS METHODS WITH OTHER STUDIES AND THE GOAL IS TO ALSO UNDERSTAND THE MECHANISM AND THE DRIVERS BEHIND RESULTS AS YOU MENTIONED, YOU DO A STUDY IN ONE LOCATION AND EVERYTHING’S SET DOES THAT PLI TO OTHER LOCATIONS — APPLY TO OTHER LOCATIONS YOU CAN USE THE DATA FROM DIFFERENT STUDIES TO HELP INFORM THE MODELS WHICH THEN YOU CAN RUN AND FIGURE OUT THE KEY DRIVERS AND WHERE’S THE INFORMATION THAT’S LACKING AND THAT IN TURN CAN THEN DRIVE ADDITIONAL STUDIES IT’S THIS INTEGRATIVE APPROACH THAT CAN HELP ACHIEVE BETTER UNDERSTANDING I — >> I GOT THE SIGN THAT SAYS STOP BUT PLEASE JOIN ME IN ENDING THIS SESSION WE WILL RESTART PROMPTLY IN 10 MINUTES WE’LL JUST START THERE’S MANY REST ROOMS WHICH I THINK WE MAY NEED TO USE THANK YOU THANKS TO THE PANEL THIS WAS GREAT >> THIS IS THE FIRST OF FIVE PRESENTATIONS WE’LL PRESENT THE EVIDENCE REVIEW COMMISSIONED FOR THIS WORKSHOP MY NAME IS HEIDI NELSON AND OVER THE NEXT TWO DAYS YOU’LL HEAR EACH PIECE OF THE EVIDENCE REVIEW AS IT RELATES TO ONE THE FIVE QUESTIONS THE FIRST PRESENTATION WILL FOCUS ON THE METHODS OF EVIDENCE REVIEW AND RESULTS THE FIRST KEY QUESTION I HAVE NO INFORMATION TO DISCLOSE I WANT TO FIRST THANK THE MEMBERS ON THE SLIDE AND FIRST WE’LL TWO THROUGH THE PURPOSE, SCOPE AND KEY QUESTIONS OF THE REVIEW ITSELF FIRST TO PREVENT CANCER, CARDIOVASCULAR DISEASE IN ADULTS AND LOOK AT THE STRATEGIES AND INTERVENTIONS SECONDLY, THE REPORT WAS MADE SPECIFICALLY TO INFORM THE WORKSHOP ON ACHIEVING HEALTH EQUITY AND PREVENTION SERVICES THE TOPIC IS IMPORTANT TO IMPROVING HEALTH IN THE UNITED STATES AS DESCRIBED BY SOME OF THE PREVIOUS SPEAKERS OVERALL AMERICANS USE PREVENTIVE SERVICES AT HALF THE RECOMMENDED RATES AND ALSO IT’S WIDELY RECOGNIZED ACCESS TO UTILIZATION OF PREVENTIVE HEALTH CARE IS DIFFERENT ACROSS POPULATION GROUPS HOWEVER, EVIDENCE IS NOT

ENOUGH TO INFORM SERVICES AS CITED BY GAPS IN THE RESEARCH THE REVIEW REFLECTS THE INPUT OF MANY STAKEHOLDERS IN THE DEVELOPMENT AND THE SCOPE AND KEY QUESTIONS WERE BY THE SYSTEMIC REVIEW PROTOCOL IS FINALIZED WITH INPUT FROM NON-FEDERAL SUBJECT MATTERS AND EXPERT GROUP EARLIER DRAFTS OF THE REPORT HAVE BEEN REVIEWED BY NIH AND PARTNERS AND EXPERTS IN THE FIELD AND NOW YOU HAVE A CHANCE, EVERYONE HAS A CHANCE TO PROVIDE INPUT BECAUSE THE DRAFT EVIDENCE WAS POSTED TODAY ON THE WEBSITE AND I’LL GIVE YOU THAT LINK AT THE END MIFF TALK — OF MY TALK AND IT WILL BE POSTED FOR A FOUR-WEEK PUBLIC COMMENT PERIOD AND WE WELCOME YOUR INPUT AND REFERENCES AND ANY OTHER COMMENTS YOU HAVE TO MAKE AND HEALTH EQUITY AND DISPARITY IS THE ATTAINMENT OF THE HIGHEST LEVEL OF HEALTH FOR ALL PEOPLE HEALTH DISPARITY IS A HEALTH DIFFERENCE THAT AFFECTS POPULATIONS BASED ON ONE ORE MORE HEALTH OUTCOMES THE POPULATIONS ADVERSELY EFFECTED ARE DEFINED BY DEFINITIONS FROM THE NATIONAL INSTITUTE OF MINORITY HEALTH AND HEALTH DISPARITIES AND THE EARLIER TALK TODAY WENT WELL THE POPULATIONS INCLUDE RACIAL OR ETHNIC MINORITY POPULATIONS, ASSOC ECONOMICALLY STOCK EXCHANGED — AFFECTED POPULATIONS ACHIEVING HEALTH EQUITY AND PREVENTION IS PARTICULARLY CHALLENGES BECAUSE NEARLY EVERYONE IN THE POPULATION IS ELIGIBLE FOR A PREVENTIVE SERVICE AND HAS A PATHWAY FOR THE DIAGRAM LISTED IN THE SLIDE ALONG THE BOTTOM PART OF THE SLIDE IS THE PREVENTIVE SERVICES PATHWAY SERVICE MUST BE DETERMINED AND THEY’RE INTENDED FOR SPECIFIC POPULATION AND WE NEED TO IDENTIFY WHO BELONGS IN THE TARGET BEFORE MOVING ON TO THE DELIVERY OF THE PREVENTION SERVICE IT NEEDS TO BE FOLLOWED UP IF THERE’S ABNORMAL RESULTS ON FOLLOW-UP PLANS AND DIAGNOSIS OF ROUTINE SCREENING AT SPECIFIC INTERVALS IS INDICATED AFTER THAT EACH STEP IN THE PATHWAY REPRESENTS A POTENTIAL GAP OR BARRIER THAT MAY GIVE RISE TO DISPARITY AND MAY LEAD TO A DISADVANTAGE FOR GROUPS DIFFERENT SERVICES WOULD CREATE VARIATIONS OF THE PATHWAY IT’S MEANT TO BE A GENERIC EXAMPLE YOU CAN PLUG IN PRACTICALLY ANY CLINICAL SERVICE AND FIND OUT WHERE THE GAPS WOULD BE FOR THAT PARTICULAR ONE SUCCESSFUL NAVIGATION OF THE PATHWAY IS SUBJECT TO LEVELS OF INFLUENCE SHOWN BY THE ARROW COMING DOWN THE SIDE OF THE SLIDE THESE INCLUDE THE CLINICIAN AND PATIENT LEVELS SO WITH THIS DIAGRAM IN MIND, THE REVIEW ADDRESSES FIVE KEY QUESTIONS ON ACHIEVING HEALTH EQUITY AND PREVENTION SERVICES RATED TO THREE HIGH BURDEN DISEASES IN THE UNITED STATES CANCER, CARDIOVASCULAR DISEASE AND DIABETES THIS IS A THIN SLICE OF THE WHOLE ISSUE AND SO AT THE BEGINNING I WANT TO POINT OUT THE EVIDENCE REVIEW IS ONE DEEP DIVE INTO ONE SMALL PART OF THE PROBLEM BUT AN IMPORTANT SLICE OF THE PROBLEM SO AS I DESCRIBED WHAT THE EVIDENCE REVIEW DID WAS WELL AWARE AND KEEP IN MIND IT’S PART OF A MUCH BIGGER PICTURE THE SPECIFIC PREVENTIVE SERVICES THAT WERE CHOSEN TO BE EVALUATED ARE BASED ON 10A OR B LEVEL RECOMMENDATIONS FROM THE TASK FORCE THE RECOMMENDATIONS ESTABLISH STANDARDS OF CARE OF CLINICAL PRACTICE AND WITHOUT CHARGES THROUGH MOST INSURANCE AND PRIVATE PLANS UNDER THE AFFORDABLE CARE ACT THE FIRST TWO QUESTIONS EVALUATE THE IMPEDIMENTS AND BARRIERS TO PREVENTIVE SERVICE AND FOCUS ON PROVIDER-LEVEL BARRIER AND POPULATION-LEVEL BARRIERS FOR

KEY QUESTION TWO THE NEXT THREE QUESTIONS ARE ABOUT THE EFFECTIVENESS OF INTERVENTIONS TO REDUCE DISPARITIES THESE INCLUDE INTERVENTIONS CENTERED ON CLINICAL PROVIDERS AND PATIENT FOR KEY QUESTION THREE AND HEALTH INFORMATION TECHNOLOGIES AND DIGITAL ENTERPRISES FOR KEY QUESTION FOUR KEY QUESTION FIVE FOCUSES ON HEALTH CARE ORGANIZATION AND SYSTEMS INTERVENTIONS SO YOU’LL SEE THOSE IN SEPARATE PRESENTATIONS WITH SOME OF THESE BEING PRESENTED TOMORROW IN ORDER TO ANSWER THESY QUESTIONS WE NEED TO — KEY QUESTIONS WE NEED TO CLEARLY DEFINE THE SCOPE OF THE REVIEW SO ONE WAY TO DO THIS IS TO LOOK AT THE DIFFERENCE LEVELS OF DISPARITIES RESEARCH WHICH IS OFTEN CATEGORIZED INTO THREE PHASES THESE INCLUDE A FIRST PHASE STUDY THAT SHOW DISPARITIES EXIST AND THESE TYPES OF STUDIES ARE NOT INCLUDED IN THIS REVIEW THIS IS A BIG IMPORTANT LITERATURE OUTSIDE THE SCOPE OF THE REVIEW WARE LOOKING AT SECOND — WE’RE LOOKING AT SECOND PHASE STUDIES THAT EXPLORE POTENTIAL CAUSES OF DISPARITIES WE’RE LOOKING FOR EFFECTS OF THE DISPARITIES SO THESE ARE REVIEWED IN QUE QUESTIONS ONE AND TWO ON IN — I AM PED I AMS AND BARRIERS — IMPEDIMENTS AND BARRIERS AND THEN QUESTIONS THREE, FOUR AND FIVE THE REVIEW ILLUSTRATES HOW THE INTERVENTIONS AND OUTCOMES RELATE TO THE KEY QUESTIONS ESSENTIALLY IT’S A BIG PICTURE VIEW OF THE PROJECT TO COVER A ROAD MAP FOR THE SYSTEMIC REVIEW AND HOW THESE QUESTIONS WERE ADDRESSED SO THE FAR LEFT SIDE OF THE SCREEN YOU’LL SEE THE TARGET FOUR IN A MINUTE.LL DEFINE THOSE ALL THE ARROWS INDICATE STEPS OF INTERVENTIONS OR ACTIONS TO REDUCE DISPARITIES AND WE HAVE INTERMEDIATE LEVEL OUTCOMES MEASURES OF ACCESS TO PREVENTIVE SERVICES THEY’RE MORE AT THE FRONT END OF THE PATHWAY I SHOWED YOU AND WHAT WE’RE LOOKING FOR HERE ARE STUDIES OF RATES OF SCREENING AND FOLLOW-UP PROCEDURES, UTILIZATION OF SERVICES AND BEHAVIOR CHANGE AND IMPROVEMENT IN IMMEDIATE HEALTH OUTCOMES AND FINALLY IN THE BOX AT THE FAR END ARE HEALTH OUTCOMES WHEN CH ARE ALSO LOOKED AT IN THE SYSTEMIC REVIEW THAT MEASURE DISEASE SPECIFIC INCIDENT AND MORBIDITY AND FUNCTION OF QUALITY OF LIFE AND RELEVANT HEALTH OUTCOMES AND THEY’RE THE STRONGER STUDIES TO SHOW AN INTERVENTION LEADS TO IMPROVEMENT IN HEALTH SO WE’RE LOOKING FOR THOSE AS WELL IN THE SYSTEMIC REVIEW I THINK A PREVIOUS SPEAKER LIST THE SERVICES THERE’S FOUR PREVENTIVE SERVICES RELATED TO CANCER SCREENING INCLUDING COLORECTAL AND BREAST AND OTHERS AND IT VARIES BY AGE AND SOME ARE SPECIFIC TO WOMEN, BREAST CANCER SCREENING AND CERVICAL CANCER AND LUNG CANCER SCREENING IS SPECIFIC TO ADULTS WITH HEAVY SMOKING HISTORY WE ALSO INCLUDED BEHAVIORAL AND PHARMACO THERAPY FOR TOBACCO SMOKING CESSATION IN ADULTS ASPIRIN TO PREVENT COLORECTAL DISEASE AND CARDIOVASCULAR RISK WHICH IS A SPECIFIC TARGETED GROUP HEALTHFUL DIETS AND PHYSICAL ACTIVITY AND CVD PREVENTION FOR S WITH OBESITY AND OTHER DEFINED CARDIOVASCULAR RISK FACTORS AND GUE — GLUCOSE SCREENING FOR ADULTS AND SCREENING FOR OBESITY IN ALL DAULTS AND MANAGEMENT OF ADULTS OVERWEIGHT OR OBESE AS YOU CAN SEE EACH TARGET POPULATION VARIES A LITTLE BIT WITH EACH PREVENTIVE SERVICE THE NEXT STEP IN DEFINING THE FACTORS AND SCOPE OF THE REVIEW AND ANALYTIC FRAMEWORK AND LOOKING AT THE QUESTIONS WE CREATE INCLUSION CRITERIA AND THESE MORE EXPLICITLY DEFINE THE POPULATION WHICH INCLUDES ALL THE PATIENTS FROM THE TARGET POPULATIONS FROM THE 10 PREVENTIVE SERVICES AND THOSE ARE THOSE ADVERSELY AFFECT DIVERSITY THE FOCUSES OUR SEARCH IN THE LITERATURE FOR PAPERS TO THOSE POPULATIONS THE INTERVENTIONS ARE THOSE TO REDUCE DISPARITIES AND USE OF SERVICES COMPARISONS BETWEEN INTERVENTIONS OR NO INTERVENTIONS AND WERE LOOKING FOR EFFECT SIZES THERE THE OUTCOMES AS WE DESCRIBED IN

OUR ANALYTIC FRAMEWORK INCLUDE THE INTERIMMEDIATE OUTCOMES AND — INTERMEDIATE OUTCOMES AND MORTALITY AND MORBIDITY AND THE PREVENTION SERVICE ITSELF FOR THE TIMING WE TALK ABOUT ANY KIND OF FOLLOW-UPS AND DURATION OF FOLLOW-UP IN DIFFERENT STUDIES WE WANT TO MAKE SURE EACH STUDY IS RELEVANT TO CURRENT PRACTICE WE DON’T WANT TO FIND PRACTICES THAT ARE NO LONGER PART OF STANDARDS OF CARE AND THE SETTING IS BROADLY APPLICABLE TO U.S. PRIMARY CARE SO THOSE CRITERIA ARE VERY IMPORTANT AS WE SELECT ABSTRACT IN PAPERS AND INCLUDE STUDIES IN THE ACTUAL REPORT AND FACTORS THAT COMPLICATED OR DELAYS ACCESS TO OR COMPLETION OF SERVICE DIVIDING A POPULATION BARRIER IS SOMETIMES CLEAR BUT OFTEN TIMES NOT TEASING A PART THE STUDY TO SEE THE INTENTION OR THE MEASURES OR MEASURES OBTAINED FROM PATIENT OR PROVIDERS MAKES IT A DIFFICULT LITERACY TO SIFT THROUGH ELIGIBLE STUDIES FOR KEY QUESTIONS ONE AND TWO REPORTED THE EFFECTS OF BARRIERS AND IMPEDIMENTS AND THE PHASE TWO TYPE OF RESEARCH NOT JUST THE ASSOCIATION SO STUDIES WERE EXAMINED IF THE BARRIER IMPEDIMENT EXPLAINED DIFFERENTIAL USE OF SERVICE THOSE WERE SPECIFIC TYPES OF STUDIES WE WERE LOOKING FOR FINALLY, WE TRIED TO CLEARLY DEFINE THE SETTINGS OF DIFFERENT INTERVENTIONS TO OCCUR THE U.S. PREVENTIVE SERVICES TASK FORCE ARE INTENDED FOR PRIMARY CARE PRACTICE SETTINGS THOUGH THE TASK FORCE DESCRIBES PRIMARY CARE IN A BROAD SENSE AT TIMES AS WELL STUDIES OF THE EFFECTIVENESS OF CLINICIAN PATIENT INTERVENTIONS WHICH IS KEY QUESTION THREE WERE DIFFERENTIATED FROM STUDIES OF THE EFFECTIVENESS OF HEALTH SYSTEM INTERVENTIONS AND KEY QUESTION 5 BY HAVING A MAJOR COMPONENT OF CARE AND THE PAINT POINT IS IN THE CLINICIAN DOMAIN AND THESE WERE DIRECT LINK WERE MORE DEFINED BY THE SOLID LINE ARROWS AND INDIRECT LINK WAS ALSO CONSIDERED IF IT LED BACK TO A REFERRAL OR CONNECTION BACK TO A HEALTH SYSTEM AS MENTIONED IN THE PREVIOUS DISCUSSION THERE’S A BIG BODY OF RESEARCH OF COMMUNITY RESEARCH THAT DOESN’T CONNECT TIE HEALTH SYSTEM FOR THE PURPOSES OF THIS REVIEW THEY WERE NOT INCLUDED THIS IS PRIMARILY A REVIEW LOOKING AT ANY STUDIES THAT CONNECT TO THE HEALTH SYSTEM ENTERPRISE AND CLINICIAN DOMAIN AS WELL TO MAKE THAT CLEAR IT’S ANOTHER BIG BODY OF EVIDENCE THAT COULD BE ON THE REPORT THE REVIEW FOLLOWS A STANDARD METHODS FOR SYSTEMATIC REVIEWS AND BRIEFLY, THIS INCLUDES A RESEARCH LITERATURE SEARCH THAT INVOLVES STRATEGY TO DEVELOPED WITH LIBRARIANS AND GOES TO THE USUAL LARGE DATABASES OUR DATES INCLUDE JANUARY 12, 1996 TO MID JULY OF 2018 WE’RE DOING AN UPDATE IN A FEW WEEKS AND THE FINAL VERSION WILL HAVE PAPERS INCLUDED AND WHAT YOU SEE TODAY AND WHAT YOU CAN COMMENT ON IS THE MOST RECENT DRAFT SECONDARY SEARCHING WAS ALSO CONDUCTEDED TO LOOK AT OTHER STUDIES — CONDUCTED TO LOOK AT OTHER STUDIES WE HAD INDEPENDENT DUAL REVIEW OF ABSTRACTS, ARTICLES AND ARTICLES THEMSELVES USING PRE-DEFINED INCLUSION CRITERIA DATA EXTRACTED AVAILABLE IN THE REVIEW ITSELF AND DUAL REVIEWED FOR ACCURACY AND DUAL INDEPENDENT REVIEW OF THE STUDY QUALITY AND APPLICABILITY OF EACH STUDY USING CRITERIA AND WE’VE SEEN GRADES OF EVIDENCE IN THE TABLES OF RESULTS WE’LL SHOW YOU THE GRADING IS BASED ON SEVERAL CHARACTERISTIC AND WHAT STRENGTH OF EVIDENCE MEANS IS HOW CONFIDENCE ARE WE THE RESULTS ARE THE TRUTH A HIGH-LEVEL GRADE MEANS WE’RE VERY CONFIDENT THE EFFECT IS TRUE AND OTHER STUDIES PROBABLY WON’T CHANGE THINGS LOW MEANS UNLIMITED CONFIDENCE AND WE NEED MORE EVIDENCE AND INSUFFICIENT IS NO CONFIDENCE IN THE EVIDENCE GRADING APPLICABILITY INCLUDES THESE CHARACTERISTICS HIGH APPLICABILITY MEANS THE RESULT OF THE STUDIES APPLIES WIDELY TO THE UNITED STATES PRACTICE

LOW MEANS IT COULD APPLY TO SOME POPULATIONS IT’S STILL AVAILABLE BUT LIMITED IN ITS APPLICABILITY WE DOES STATISTICAL META-ANALYSES WE WON’T SHOW THESE UNTIL TOMORROW AND WE USED ESTABLISHED STANDARDS AND WELL DESCRIBED IN OUR REPORT META-ANALYSES CREATES SUMMARY RESULTS WHICH IS SOMETIMES EASIER TO INTERPRET SO WE IDENTIFIED OVER 16,000 ABSTRACTS, WE REVIEWED OVER 1800 FULL TEXT ARTICLES AND ENDED UP WITH 84 ARTICLES OF 80 UNIQUE STUDIES THE STUDIES MOSTLY ZEROED IN ON COLORE COLORECTAL AND CERVICAL AND BREAST SCREENS AND ON THE PART OF IMPEDIMENTS ON PROVIDERS YOU MAY HAVE NOTICED WE FOUND NO STUDIES THAT MET INCLUSION CRITERIA FOR KEY QUESTION ONE MANY STUDIES PROVIDED TREATMENT DECISION BUT NOT THE 10 PREVENTIVE SERVICES THERE ARE STUDIES ON PATIENT FACTORS AND MANY FIRST-PHASE ASSOCIATION STUDIES SO FUTURE RESEARCH NEEDS ARE KND OF OBVIOUS WE NEED RESEARCH TO FILL THE GAP THERE ARE NOT STUDIES THAT SHOWED THE EFFECTS OF PROVIDER BARRIERS ON THE SERVICES THAT WE DRAFTED IN THE INCLUSION CRITERIA SO I THINK MY TIME HAS ABOUT ENDED AND THE REPORT IS AVAILABLE AT THIS WEBSITE AND I ENCOURAGE YOU TO GIVE US COMMENTS SO WE CAN MAKE THIS REPORT MORE USEFUL FOR YOU THANK YOU I’M CAROL MANGIONE IN THE SCHOOL OF MEDICINE AT THE SCHOOL OF PUBLIC HEALTH AT UCLA AND APPRECIATE THE OPPORTUNITY TO TALK ABOUT PROVIDER AND HEALTH CARE PROVIDERS TO DELIVERY OF HEALTH SERVICES COMING BEHIND DR. NELSON’S TALK YOU MAY THINK MY TALK IS GOING TO BE VERY SHORT, RIGHT, BUT I HAVE THE LIBERTY OF MAKING SOME EXTRAPOLATIONS AND USING LOWER QUALITY EVALUATIONS SO THAT’S MY DISCLAIMER OFF THE BAT I DON’T HAVE CONFLICTS I AM A CURRENT MEMBER OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE AND THIS PRESENTATION REPRESENTS MY VIEW AND NOT THAT OF THE TASK FORCE AND I’M A PRACTICING PRIMARY CARE DOCTOR AND A LITTLE BURNED OUT AND BELEAGUERED AS I GO THROUGH THE PHYSICIAN LEVEL BARRIERS YOU MAY GET A HINT OF SOME OF THAT I’M FIRST TO GIVE YOU A DEFINITION OF THE PREVENTIVE SERVICES AND WE HAVE WILL HEAR ABOUT HIGH-LEVEL RECOMMENDATIONS BECAUSE YOU’LL HEAR MORE RECOMMENDATIONS TOMORROW THE ONE THING ABOUT MY TALK I WANT YOU TO KEEP IN MIND DR NELSON CLEARLY INDICATED WHEN WE LOOK FOR HIGH QUALITY STUDIES, LITTLE HAS BEEN STUDIED IN THE SPACE OF THE DRIVERS OF PHYSICIAN BARRIERS OR SYSTEM BARRIERS FOR NOT DELIVERING PREVENTIVE SERVICES SO I WENT TO THE LITERATURE TO LOOK AT THE BARRIERS TO ACCESS TO PRIMARY CARE YOU’LL NEED TO MAKE A BIT OF AN EXTRAPOLATION IF SOMEONE CAN’T GET TO A PRIMARY CARE VISIT I THINK YOU’LL HOPE THEY AREN’T GOING GET A CLINIC-BASED PREVENTIVE SERVICE AND I CAN MAKE THAT EXTRAPOLATION BECAUSE I’M NOT IN THE FRAMEWORK OF THE EVIDENCE REVIEW MAINLY I’LL FOCUS ON CLINICAL PREVENTIVE SERVICES INCLUDING IMMUNIZATIONS, SCREENING TESTS AND COUNSELLING AS NOTED BEFORE AND A LOT OF THIS LITERATURE ON CARE DELIVERY IS MORE IN CANCER PREVENTION AND IMMUNIZATION SO THAT WILL BE THE FOCUS OF THE TALK WE KNOW THERE ARE GAPS FOR CERTAIN POPULATIONS OR SOCIOECONOMICALLY DISADVANTAGED AND LOW ECONOMIC AND RACIAL AND ETHNIC MINORITIES AND PEOPLE IN RURAL AREAS ARE LESS LIKELY TO RECEIVE SERVICES SO I WON’T GO OVER THAT WE ALSO KNOW THE ELDERLY ESPECIALLY ELDERLY WHO ARE LOW INCOME AND LIVE IN RURAL AREAS

ARE LESS LIKELY TO RECEIVES THIS SO AGE IN ITSELF IS A RISK AND WE’LL HAVE MANY OF THESE PEOPLE IN THE NEXT DECADE OR SO SO WHAT ARE THE HEALTHY PEOPLE 2020 NATIONAL OBJECTIVES FOR RECEIVING PREVENTIVE SERVICES WE KNOW HALF THE SERVICES THE POPULATION SHOULD GET ARE BEING RECEIVED WHAT IS PROPOSED IS A RELATIVE INCREASE OF ABOUT 10% OR INCREASE OF ABOUT 5% FOR MEN AND WOMEN IN THE AGE GROUP AND THE CORE SERVICES ARE IMMUNIZATIONS, SCREENING FOR LIPID DISORDERS AND COLORECTAL SCREENING AND BREAST CANCER SCREENING IN WOMEN WE HAVE LOW RATES OF USE OF PREVENTIVE SERVICES OVERALL ONLY 25% OF ADULTS BETWEEN 50 AND 60 OF AGE AND LESS THAN HALF THE ADULTS OVER 65 ARE UP TO DATE ON THEIR SCREENING RECOMMENDATIONS SO I THINK AS WE THINK ABOUT DISPARITIES, REALIZE WE’RE THINKING ABOUT IT IN A CONTEXT WHERE WE’RE NOT DOING A VERY GOOD JOB WITH ANYBODY THIS IS TRUE DESPITE THE SERVICES ARE PAID BY ALL INSURANCE PLANS INCLUDING MEDICARE AND MEDICAID SO WE’RE TALKING ABOUT THOSE GRADE A AND B LEVEL SERVICES THAT ARE A COVERED BENEFIT BECAUSE OF THE ACA EVEN WITH THAT OVERLAY WE KNOW THERE’S PERSISTENT AND SIGNIFICANT RACIAL ETHNIC DISPARITIES VACCINATIONS 44% OF AFRICAN AMERICANS REPORT NOT GETTING INFLUENZA VACCINES COMPARED TO 55% OF WHITE A DIFFERENCE OF 15% WE ALSO KNOW THAT FOR OTHER GROUPS SUCH AS HISPANICS OR NATIVE AMERICANS THAT THE DIFFERENCE IS ABOUT 10% IN THOSE GROUPS TOO I’M GOING TO TALK ABOUT CERVICAL CANCER DISPARITIES BECAUSE THIS IS REALLY AN EXAMPLE AGAIN AS A PRIMARY CARE DOCTOR, WE CAN PAY FOR A PREVENTIVE SERVICE SUCH AS CERVICAL CANCER SCENE BUT — SCREEN BUT IF THE TREATMENT IS NOT COVERED WE’VE DONE LITTLE WITH REGARD TO CERVICAL CANCER AS WE THINK IN THE PREVENTION SPACE, FIXING THE GAP IN PREVENTION WILL NOT FIX THE DELIVERY FOR CANCERS WE KNOW THAT HAVE GOOD EVIDENCE-BASED TREATMENTS I THINK WE WANT TO KEEP THAT IN MIND WE KNOW MORTALITY RATES IN CERVICAL CANCER IN AFRICAN AMERICAN AMERICAN WOMEN IS TWICE THE RATE OBSERVED FOR WHITE WOMEN AND YET WE’RE GETTING VERY CLOSE TO HAVING THE SAME SCREENING RATE WHY IS THAT? WE KNOW THERE’S INADEQUATE FOLLOW-UP AFTER SCREENING AND WE ALSO KNOW IT’S POSSIBLE THAT AFRICAN AMERICAN WOMEN MAY HAVE POTENTIALLY A MORE AGGRESSIVE FORM WE ALSO KNOW THAT NATIVE-AMERICAN WOMEN HAVE HIGHER RATES OF CERVICAL CANCER MORTALITY THAN THE U.S. AVERAGE IN THIS CASE IT LOOKS LIKE LOWER SCREENING RATES IS A BIGGER CONTRIBUTOR THAN IT IS WITH AFRICAN AMERICANS AND THERE’S INADEQUATE FOLLOW-UP AND WE KNOW HISPANIC WOMEN HAVE HIGHER INCIDENT AND SLIGHTLY HIGHER MORTALITY ESPECIALLY HISPANIC WOMEN IN UNDER SERVED AREAS SUCH AS THE TEX-MEX BORDER WHITE WOMEN IN UNDER SERVED AREAS HAVE HIGHER MORTALITY IT POINTS TO THINGS OUTSIDE THE HEALTH CARE SYSTEM SUCH AS INCOME, RURAL AREAS, GEOGRAPHIC ISOLATION AS DRIVERS AS SOME DISPARITIES INSURANCE COVERAGE PLAYS AN IMPORTANT ROLE IN ACCESS TO SCREENING 23% OF WOMEN WITHOUT HEALTH INSURANCE AND 25% WITH NO REGUL REGULAR SOURCE OF CARE REPORT THEY DIDN’T RESOURCE A PAP SMEAR IN THE LAST FIVE YEARS COMPARED TO 11% IN THE GENERAL POPULATION AGAIN, THAT PRIMARY CARE EXTRAPOLATION IF YOU DON’T HAVE A USUAL SOURCE OF PRIMARY CARE WHETHER YOU’RE INSURED OR NOT YOU’RE LESS LIKELY TO GET SERVICES WHAT ABOUT COLORECTAL TAL CANCER SCREEN MALE SEX HAVE HIGHER INCIDENT

AND BLACK ADULTS HAVE A HIGHER MORTALITY RATE COMPARED TO OTHER GROUPS AND STUDIES HAVE DOCUMENTS INEQUALITIES IN SCREENING BUT ALSO IN DIAGNOSTIC FOLLOW-UP AND TREATMENT SO THIS IS IMPORTANT TO KEEP IN MIND SO WHAT ARE THE BARRIERS TO CLORECTAL CANCER SCREENING FOR AFRICAN AMERICANS AND THIS USED MORE LIBERAL CRITERIA THAN OUR EVIDENCE-BASED CENTERS AND PROVIDER LEVEL BARRIERS INCLUDE POOR KNOWLEDGE OF PATIENT BARRIERS SUCH AS FEAR, PATIENT’S LACK OF KNOWLEDGE ABOUT THE POTENTIAL BENEFITS OF SCREENING AND COMPETING DEMANDS FOR TIME THIS SYSTEMATIC REVIEW PROVIDED PROVIDERS WERE CONFUSED ABOUT INITIATING SCREENING AND IN GENERAL AS A PRIMARY CARE DOCTOR OFTEN TIMES FACED WITH A 15-MINUTE VISIT AND A LOT OF COMPETING ACTIVITIES FOR THAT VISIT, THAT MY OWN KNOWLEDGE DEFICITS ARE OFTEN A BARRIER TO GETTING TIMERY PREVENTIVE SERVICE — TIMELY PREVENTIVE SERVICES AND DID NOT DEVELOP SYSTEMS TO HELP PRIMARY CARE DOCTORS DO THAT BETTER WE KNOW THERE’S INSUFFICIENT PATIENT COUNSELLING THERE’S SYSTEM FACTORS TOO THOUGH SUCH AS INADEQUATE HEALTH INSURANCE COVERAGE PRE ACA AND HIGH OUT OF POCKET COST FOR PATIENT WE KNOW PATIENTS COME TO FEWER PCP VISITS ARE LESS LIKELY TO GET PREVENTIVE SERVICE AND THOSE WITH POOR ACCESS TO SPECIALISTS ARE LESS LIKELY TO GET SERVICES AS IS LACK OF CARE COORDINATION WHAT ABOUT BREAST CANCER MORTALITY? WHITE WOMEN ARE HIGHER RATES AN AFRICAN AMERICAN WOMEN BUT THE RATES HAVE BECOME CLOSER RECENTLY ABOUT 30% MORE AFRICAN AMERICAN WOMEN DIE EACH YEAR FROM BREAST CANCER THAN WHITE WOMEN WE HAVE SIMILAR INCIDENT BUT SIMILAR DEATH RATES WHY IS THAT? WE DON’T HAVE REALLY CLEAR EVIDENCE OF EXACTLY WHY THIS IS THERE’S SOME SIGNAL THERE’S MAY BE A DIFFERENCE IN BIOLOGY AFRICAN AMERICAN WOMEN ARE DISPROPORTIONATELY AFFECTED BY TREATMENT RESISTANT FORMS OF BREAST CANCER AND THERE’S HEALTH DIFFERENCES AND FAILURES SUCH AS DELAYS IN CARE, INAPPROPRIATE TREATMENT FOR NO TREATMENT AT ALL FOR MANY MUCH AMERICAN WOMEN THE — AFRICAN AMERICAN WOMEN THE USPF NOTES AFRICAN AMERICAN WOMEN ARE SUBSTANTIALLY UNDER REPRESENTED TRIALS OF MAMMOGRAPHY WE DON’T KNOW IF WE HAD MORE AGGRESSIVE OR MORE FREQUENT SCREENING IN THIS POPULATION THAT CLEARLY DOES POORER WITH THE DISEASE WHETHER THAT WOULD BEGIN TO MITIGATE THE DISPARITY THIS POINT WAS BROUGHT UP EARLIER AND A WANT TO EMPHASIZE WHEN WE’RE IN A SITUATION WITH NO EVIDENCE AND WHEN WE HAVE TO EXTRAPOLATE FROM ONE POPULATION TO ANOTHER WE’RE AT RISK FOR DRAWING THE WRONG CONCLUSIONS SO THIS IS A BIG EVIDENCE GAP WE DO NEED BETTER STUDIES OF MAM MAMMOGRAPHIC SCREENING I’LL START WITH HEALTH SOCIAL SERVICE BECAUSE IT’S SO IMPORTANT AT BASELINE 83% OF PERSONS IN THE U.S. IN 2008 HAD HEALTH INSURANCE AND SINCE THE ACA WE’VE SEEN BETTER COVERAGE AND YOU SEE THE HERE IN THE PICTURE BUT YOU ALSO SEE VARIATION BY RAGE AND ETHNICITY THE ACA LOWERED THE COST OF COVERING THE COST OF ROUTINE PREVENTIVE SERVICES GRADE A OR B AND THEY LOWERED THE COST FOR RECOMMENDED IMMUNIZATIONS THE PROBLEM IS TESTS AND PROCEDURES TOO EVALUATE A POSITIVE TEST RESULT COSTS ARE NOT LOWERED AND WE KNOW ESPECIALLY WE’RE HAVING REALLY AN EPIDEMIC OF HIGH DEDUCTIBLE HEALTH PLANS CREATE BARRIER IN THE COUNTRY FOR MANY PEOPLE EVEN WITH HEALTH INSURANCE TO BE ABLE TO AFFORD TREATMENT WHAT ABOUT BARRIERS TO HEALTH CARE UTILIZATION AMONG PUBLICLY INSURED PATIENTS? THERE’S A STATEWIDE SURVEY DONE IN MINNESOTA AND HAD A 44% RESPONSE RATE NOT WONDERFUL BUT AT LEAST SOME EVIDENCE AND THE GOAL OF THE VARE WAS TO ESTIMATE THE EFFECTS

OF PERCEIVED PATIENT PROVIDER AND SYSTEM LEVEL BARRIERS ON LACK OF PREVENTIVE SERVICES IN THE SURVEY, 29% OF PEOPLE HAD DELAYED NEEDED CARE 14 ADDITIONAL PERCENT HAD FOREGONE NEEDED CARE AND 24% HAD NOT HAD ANY PREVENTIVE SERVICES IN THE PAST YEAR AND BLACKS AT 50% AND SOCIOECONOMIC DISCRIMINATION WE’RE ALL ASSOCIATED WITH DELAYS AND FOREGONE CLAIR AS WELL AS LACK OF DELIVERY OF PREVENTIVE SERVICES IT IS SHOWING A SIGNAL AND A CALL FOR BETTER STUDIES TO CLOSE THE INFORMATION GAP AND CAN AND SIGNALS FOR HOW TO ADDRESS DISPARITIES AND PREVENTIVE SERVICE DELIVERY ON THIS SLIDE WE’RE COMPARING THE USE OF PREVENTIVE SERVICES FOR PEOPLE IN SURED EUROPEAN D N INSURED VERSUS UNINSURED AND IN TERMS OF INFLUENZA VACCINATION, 44% WHICH IS QUITE LOW COMPARED TO WHAT WE WOULD LIKE TO SEE, BUT COMPARED TO A STRIKING 14% AMONG UNINSURED PEOPLE HAVING HEALTH INSURANCE MATTERS I PROBABLY DON’T NEED TO TELL THIS GROUP THAT BUT WE STILL SEE PERSISTENT GAPS IN IMMUNIZATION RATES WHY IS THAT? THERE’S FREE PLACES TO GET IMMUNIZATIONS IF YOU DON’T HAVE INSURANCE YOU’RE UNLIKELY TO HAVE AN UNUSUAL SOURCE OF CARE UNLESS YOU’RE LUCKY TO BE NEARBY A HEALTH CENTER OR SOME OTHER GOOD SAFETY NET CLINIC I THINK THAT MAY BE ONE OF THE DRIVERS HERE AND THIS IS ABOUT A CLAIMS ANALYSIS THAT IDENTIFIED WOMEN OVER THE AGE OF 70 WHO HAD NOT HAD A MAMMOGRAM WITHIN TWO YEARS AND MEN AND WOMEN OVER THE AGE OF 70 AT INCREASED RISK FOR COLON CANCER WHO HAD NOT HAD A COLONOSCOPY IN FIVE YEARS PEOPLE IN THE PREVIOUS STUDY WERE IN THAT CATEGORY WHERE THEY WOULD HAVE HAD A FIVE-YEAR FOLLOW-UP AND FOR MAMMOGRAPHY RATES OF UPTAKE WERE LOWER FOR THE LOWEST ECONOMIC STATUS QUARTILE AND FOR COLON CANCER BOTH IN THE PRE AND POST ACA PERIODS, THERE WAS AN ASSOCIATION BETWEEN UPTAKE AND EDUCATIONAL STATUS THERE WERE NOT ANY CHANGES WITH COL COLONOSCOPY USE BY SOCIOECONOMIC STATUS THERE’S SOMETHING BIGGER THAN INSURANCE DRIVING THIS I THINK YOU HEARD EARLIER SPEAKERS TALKING ABOUT THE MULTIFACTORI MULTIFACTORIAL NATURE OF THIS AND THE LIKELIHOOD WE’LL HAVE TO INCONVENIENCE ON MANY FACTORS SIMULTANEOUSLY TO SOLVE THESE PROBLEMS IN 2017, THE NATIONAL ACADEMY OF MEDICINE AND OFFICE OF THE NATIONAL COORDINATOR FOR HEALTH INFORMATION GOT TOGETHER TO IDENTIFY BARRIERS FOR CLINICAL DECISION SUPPORT AND CAME TO THE CONCLUSION THERE WAS A LACK OF RELIABLE SHARED CLINICAL DECISION SUPPORT AND CONTENT AND ABILITIES THAT COULD BE ADOPTED ACROSS ORGANIZATIONS AND AN ABSENCE OF SYSTEMIC MEANS TO VALIDATE CONSENT FOR PROVISION ACROSS VENUES THAT WAS RELIABLE AND THERE WAS MANY TECHNICAL DIFFICULTIES YOU’LL HEAR MORE ABOUT WHAT CAN BE DONE IN THE SPACE LATER ON IN THE CONFERENCE THIS IS A SYSTEM LEVEL BARRIER TO CARE DELIVERY WE NEED TO KEEP IN MIND OTHER IMPORTAT BARRIERS AND THIS IS REALLY WHERE WE HAVE A GAP IN THE EVIDENCE BASE IS WE REALLY DON’T HAVE AN EASY WAY TO

IDENTIFY WHICH PATIENTS NEED WHICH SERVICES AND WE DON’T HAVE A WAY TO DO THIS QUICKLY IN MOST SETTINGS THAT HAVE ELECTRONIC HEALTH RECORDS AND I WOULD CONTEND AS A PRIMARY CARE DOCTOR SINCE THE ONSET OF THE ELECTRONIC HEALTH RECORD, I HAVE LESS TIME TO LOOK FOR THIS IN THE CHART AND ACTUALLY IDENTIFY WHERE PEOPLE HAVE GAPS AND HAVE MANY DEMANDS HOISTED ON ME BY THE ELECTRONIC RECORD WHICH TAKES UP THE APPRECIATION MINUTES RATHER THAN THE EHR TO DATE HELPING MOST OF US DELIVER SERVICES BETTER I WOULD SAY IN MANY SETTINGS IT HINDERS US AND WE’LL HAVE TO TACKLE THAT WITH INTERVENTIONS AND STUDY THOSE TO BE ABLE TO MAKE PROGRESS IT LACKS SIMPLE TRACKING TO IDENTIFY THOSE PERCEIVED SERVICES AND IN MANY SYSTEMS WE DON’T HAVE GOOD WAYS TO TRACK ABNORMAL RESULTS WHEN PREVENTIVE TESTS HAPPEN AND THE LACK OF WORK FLOWS THAT ENGAGE ALLIED HEALTH PROFESSIONALS TO MAKE IT SLARD AT THE PRACTICE LEVEL — SHARED AT THE PRACTICE LEVEL RATHER THAN HAVING A BOTTLENECK THAN GOING THROUGH THE PCP WILL BE NEEDED IF WE’RE GOING ADDRESS THE GAPS SO WHAT ABOUT PROVIDERS, WHY DON’T MORE PEOPLE GET PREVENTIVE SERVICES MANY LACK SYSTEMS OR FAIL TO USE SYSTEMS THAT TRACK PATIENTS THAT CONTACT PATIENTS AND REMIND THEM THEY NEED SERVICES THAT HAVE SYSTEMS IN PLACE TO REMIND THEMSELVES WHEN THEY NEED TO DELIVER SERVICES OR TO MAKE CERTAIN THAT PATIENTS UNDERSTAND WHY THEY NEED SERVICES SO PROVIDER LEVEL BARRIERS AND AGAIN THESE CAME FROM LOWER QUALITY STUDIES BUT TIME IS MENTIONED, COMPETING PRIORITIES, IMPLICIT RACIAL BIAS AND LACK OF KNOWLEDGE FACILITATORS OF DELIVERING SERVICE MENTIONED A LOT COMMUNITY-BASED RESOURCES, REDESIGN OF WORK FLOWS I’M GOING TO WRAP UP AND SKIP OVER THIS YOU CAN LOOK AT THE STUDY YOURSELF THE ROLE OF TRUST IS CLEARLY CRITICAL I WOULD SAY IN MOST CARE SETTINGS IT’S HARDER TO ESTABLISH TRUST POSSIBLE SOLUTIONS I’LL LEAVE FOR OTHERS TO DISCUSS SINCE WE’LL HAVE OTHER SESSIONS ABOUT AND THAT I’LL WRAP UP SO I DON’T STEP ON THE TIME OF MY OTHER PANELIST THANK YOU VERY MUCH FOR YOUR ATTENTION >> GOOD MORNING, EVERYONE I’M RAQUEL GREER I HAVE NO DISCLOSURES AND DURING MY TALK TODAY I’LL DESCRIBE THE BENEFITS OF EFFECTIVE PATIENT-CENTERED COMMUNICATION IN PRIMARY CARE AMONG DISADVANTAGED POPULATIONED AND SPEND THE BULK OF MY TIME DISCUSSING THE KEY CLINICIAN FACTORS CONTRIBUTING TO THESE DISPARITIES AND TALK ABOUT ENHANCING COMMUNICATION AND CONCLUDE BY PROVIDING DISCRETION FOR FUTURE RESEARCH — DIRECTION FOR FUTURE RESEARCH THERE’S GREATER EMPHASIS THE CARE BEING PATIENT CENTER AND IT’S KEY A STRATEGY FOR REDUCING PATRIOTS AND — DISPARITIES AND IS DEFINED OF CARE RESPECT WILL OF PATIENT PREFERENCES AND VALUES AND VALUES GUIDE ALL CLINICAL DECISION S SO WHAT DO WE MEAN WHEN WE SAY COMMUNICATION BETWEEN A PATIENT AND PROVIDER IS PATIENT CENTERED? PATIENT-CENTERED COMMUNICATION AIMS TO ACHIEVE FOUR GOALS TO ELICIT AND UNDERSTAND THE PATIENT’S PERSPECTIVE AND IDEAS,

CONCERNS AND NEEDS AND FEELINGS AND AIMS TO UNDERSTAND THE PATIENT WITHIN HIS OR HER UNIQUE PSYCHOSOCIAL CONTEXT AND AIMS TO ACHIEVE SHARED DECISION MAKING REACHING A SHARED DECISION OF THE PROBLEM AND ALIGNED WITH VALUES AND INVITING PATIENTS TO BE ACTIVE PARTICIPANTS IN ACTIVE DECISION MAKING TO THE DEGREE THEY WISH THERE’S INCREASING EVIDENCE THAT DEMONSTRATE PATIENTS IN COMMUNICATION IS ASSOCIATED WITH IMPORTANT OUTCOMES IT LEADS TO IMPROVED PATIENT KNOWLEDGE AND RECALLED KNOWLEDGE SHARED DURING THE VISIT AND IMPROVES PATIENT SELF-MANAGEMENT BEHAVIORS AND CONTINUITY OF CARE IT LEADS TO GREATER PATIENT SATISFACTION AND TRUST IN THEIR PROVIDERS AS WELL AS IMPORTANT HEALTH OUTCOMES RELATED TO HEALTH AND CHRONIC ILLNESS CONTROL SUCH AS HYPERTENSION AND ABOUT THE AND PART OF THE RESULTS EXIST AND HAVE BEEN DESCRIBED IN PATIENT-CENTERED COMMUNICATION AND DESCRIBED BY ETHNICITY, RACE, LITERACY, LANGUAGE CONCORDANCE AND RACIAL AND SOCIAL DISCORDANCE SO RACIAL DISPARITY IN PATIENT CENTERED COMMUNICATION IS WELL DOCUMENTED THE FIGURE ON THE RIGHT IS FROM A STUDY BY RACHEL JOHNSON AND LISA COOPER AND COLLEAGUES AT JOHNS HOPKINS WHERE THEY RECRUITED 450 PATIENTS AND USED QUESTIONNAIRE DATA TO ASSESS DIFFERENCES IN THE QUALITY OF PATIENT/PHYSICIAN COMMUNICATION DURING ENCOUNTERS AND SEE IF THERE WAS DIFFERECES BETWEEN BLACK AND WHITE PATIENTS THOUGH THE VISITS WERE THE SAME, WHEN THEY LOOKED AT THE PHYSICIAN/PATIENT CENTEREDNESS PROVIDERS WERE DOING MORE INFORMATION GIVING AND LOWER-PATIENT CENTEREDNESS WITH US LESS ENGAGEMENT DURING AFRICAN AMERICAN PATIENTS COMPARED TO WHITE AND FOUND WITH AFRICAN AMERICAN PATIENTS AN PROVIDERS THERE WERE LOWER POSITIVE AFFECT SCORES COMPARED TO WHITE PATIENTS AND HAVE BEEN DEMONSTRATED AND LITERACY AND LANGUAGE PROFICIENCY WERE FACTORS DUE TO THEIR LIMITED HEALTH LITERACY THEY’RE LESS ENGAGED IN CARE THIS IS NICELY ILLUSTRATED IN A STUDY OF 771 OUT PATIENTS WITH DIABETES AND/OR CARDIAC DISEASE IN SAFETY NET SETTINGS IN SAN FRANCISCO THE INVESTIGATORS CATEGORIZED PATIENTS ON THEIR HEALTH LITERACY STATUS AT THE TO THE FIGURE SO PATIENT WITH ADEQUATE HEALTH LITERACY ARE NOTED AND WITHOUT AND PATIENTS WITH GREATER HEALTH LITERACY HAD HIGHER RATINGS OF REPORTED POOR COMMUNICATION WITH PROVIDERS INCLUDING POOR COMPREHENSION OF PHYSICIAN INSTRUCTIONS AN POD POOR COMMUNICATION THEY ALSO LOOKED AT NATIVE ENGLISH SPEAKERS REPRESENTED IN LIGHT GRAY AND SPANISH CONCORDANCE VISITS REPRESENTED IN DARK GRAY AND SPANISH-SPEAKING PATIENTS VISITING SPANISH-SPEAKING PROVIDERS AND THERE WERE SPANISH-SPEAKING PATIENTS WITH PROVIDERS THAT WERE NON-SPANISH SPEAKING IN THE SPANISH DISCORDANT VISITS THERE ARE WITH HIGHER RATES OF POOR COMMUNICATION AND LOW HEALTH LITERACY HAS BEEN ASSOCIATED WITH LOWER SATISFACTION WITH CARE THERE’S ALSO SYSTEMIC REVIEWS THAT SHOW RACIAL DID — DISCORDANCE IS AN A FACTOR AND WHERE PATIENTS AND PROVIDERS ARE OF DIFFERENT RACES TEND TO BE SHORTER AND HAVE LESS POSITIVE AAFFECT AND MORE INFORMATION GIVING AND LESS ENGAGEMENT OF PATIENTS THANE CARE IN THAT CASE WITH CHARACTERISTICS SUCH AS RACE, GENDER, ETHNICITY AND EDUCATION HAS SHOWN TO REFLECT PATIENT’S

PER SHARE CEPTION PERCEPTION OF CARE AND THIS TABLE IS FROM DATA FROM THE COMMONWEALTH FUND ON HEALTH CARE QUALITY SURVEY WHERE THEY ASKED PARTICIPANTS THEIR BIAS AND ASKED THEM IF THEY’D AGREE WITH THE STATEMENTS WOULD I HAVE RECEIVED BETTER CARE IF I WAS A DIFFERENT RACE OR ETHNICITY AND TREATED UNFAIRLY DUE TO THESE OR TREATED UNFAIRLY BASED ON HOW I SPEAK ENGLISH COMPARED TO WHITES WHICH ARE REPRESENTED HERE IN THESE RED NUMBERS BLACK, HISPANIC AND ASIAN PATIENTS ALL REPORTED HIGHER RATES OF PERCEIVING MORE BIASSED TREATMENT IN THEIR HEALTH CARE AND ALL OF THESE COMPARISONS WERE STATISTICALLY SIGNIFICANT >> WE LOOKED AT A NUMBER OF FACTORS SO WHAT ARE THE KEY CLINICIAN FACTORS THAT CAN CONTRIBUTE TO PATIENT CENTERED COMMUNICATION AND LOOKING AT CULTURAL COMPETENCY AND COMMUNICATION SKILLS AND IMPLICIT BIAS AND LIMITED MEDICAL KNOWLEDGE IMPACTED THE DEGREE TO WHICH PROVIDER’S CARE AND THERE’S PREFERENCES IN CARE AND FACT SUCH AS WORKFORCE DIVERSITY, LIMITED RESOURCE SUCH AS ACCESS TO AVAILABLE INTERPRETERS INFLUENCED HOW WELL THEY’RE ABLE TO BUILD EFFECTIVE COMMUNICATION AND PROVIDER CULTURAL COMPETENCE AND CARE FOR PATIENTS WITH DIVERSE POPULATIONS HAS BEEN RECOGNIZED AS A KEY STRATEGY TO REDUCING HEALTH CARE DISPARITIES THERE’S THE ABILITY TO RESPOND TO THE LINGUISTIC NEEDS BROUGHT BY PATIENTS TO THE HEALTH CARE ENCOUNTER THIS INCLUDES SERVICES AVAILABLE AND ASSOCIATED WITH THE PATIENT RELATIONSHIP AND OUTCOMES FOR CULTURAL COMPETENCE THEY PERCEIVED PROVIDERS ENGAGED THEM IN CARE AND THERE’S EVIDENCE THEY RECEIVED MORE EQUITABLE CARE AND OUTCOMES IN TERMS OF LINGUISTIC COMPETENCE USING MEDICAL INTERPRETERS IT’S ALSO BEEN ASSOCIATED WITH IMPROVED PATIENT SATISFACTION FEWER UTILIZATION DISPARITIES AND MORE PREVENTIVE CARE SUCH AS RESET OF COLORECTAL SCREENING PROVIDERS ARE OFTEN IL-EQUIPPED TO PROVIDE PATIENT CENTERED CARE THIS IS A SURVEY OF RESIDENTS IN TRAINING FROM U.S. ACADEMIC MEDICAL CENTERS AND THEY DESCRIBED RESIDENTS RECEIVING LITTLE OR NO INSTRUCTION IN CROSS-CULTURAL CARE AND THE PERCENTAGES ARE QUITE HIGH RESIDENTS FELT UNSKILLED TO PROVIDE ASPECTS OF CULTURAL CARE INCLUDING PATIENT’S UNDERSTANDING OF THEIR ILLNESS, NEGOTIATING A TREATMENT PLAN, IDENTIFYING DECISION MAKING STRUCTURE AND WORKING WITH AN INTERPRETER THE CHALLENGES THEY FACE IS ONCE THEY LEAVE MEDICAL SCHOOL THEY REPORT SUB OPTIMAL TRAINING THERE’S ALSO A LACK OF ROLE MODELS FROM MENTORS TO IMPROVE THEIR SKILLS IN THIS AREA

ALSO IMPORTANT IS COMMUNICATION SKILLS ALSO DETERIORATE OVER TIME MANY PROVIDERS ARE RECEIVING THEIR SKILLS IN MEDICAL SCHOOL AND YOU CAN IMAGINE THEY DEGRADED SOMEWHAT ALSO PROVIDERS REPORT POOR ACCESS TO SERVICES AND ACCESS TO INTERPRETERS OR SUFFICIENT TIME DURING THE 15, 20 PRIMARY CARE VISITS TO DELIVER CULTURALLY COMPETENT CARE CLINICIANS EXPRESS DIFFICULTIES AND THERE WAS A STUDY OF CLINICIANS IN SAN FRANCISCO THEY FOUND WHEN USING INTERPRETER, 85% OF CLINICIANS SO MOST WERE SATISFIED WITH THEIR ABILITY TO DIAGNOSE AND TREAT DISEASE BUT FEWER WERE SATISFIED WITH THEIR ABILITY TO EMPOWER PATIENTS THE FIGURE ON THE BOTTOM DESCRIBES SOME PROBLEMS CLINICIANS REPORTED IN THEIR ABILITY TO PROVIDE QUALITY CARE DURING THE ENCOUNTER AND JUST TO FOCUS ON THE TOP THREE THE TROUBLE WAS SYMPTOMS AND TROUBLE WITH TREATMENT PREFERENCES SO AGAIN, DIFFICULTY WITH EMPOWERING PATIENTS AND THOSE WITH LIMITED ENGLISH FOUND IT DIFFICULT TO ACHIEVE SHARED DECISION MAKING AND UNDER UTILIZATION OF INTERPRETERS AND THERE’S OFTEN RELIANCE ON FAMILIES AND FRIENDS TO DO INTERPRETING DURING MEDICAL VISITS AND RELYING ON LIMITED ENGLISH SKILLS AND TIME CONSTRAINTS MAKE IT DIFFICULT TO USE INTERPRETERS APPROPRIATELY AND THERE’S IMPLICIT BIAS AND THE WAY IT MAY IMPACT PATIENT-CENTERED COMMUNICATION IMPLICIT BIAS IS ASSOCIATION MAY NEGATIVELY INFLUENCE PROVIDER’S JUDGMENT OR DECISION MAKING THE FIGURE ON THE RIGHT IS A CONCEPTUAL MODEL HOW IT MAY NEGATIVELY INFLUENCE HYPERTENSION CONTROL AMONG DISADVANTAGED SITUATIONS A PROVIDER MAY SEE AN AFRICAN AMERICAN PATIENT ON A NUMBER OF HYPERTENSION MEDICATIONS TO CONTROL BLOOD PRESSURE BUT DURING THE VISIT THEY NOTE THE PATIENT’S BLOOD PRESSURE IS ELEVATED THE PROVIDER MAY PERCEIVE THE PATIENT MAY BE RESISTANT TO ADDING ANOTHER MEDICATION OR MAY THINK THAT PATIENT MAY HAVE DIFFICULTY PAYING THE CO-PAY SO THEY DECIDE I WILL NOT INTENSIFY THE BLOOD PRESSURE MANAGEMENT DURING THIS VISIT THEY MAY THINK THEY CAME TO THE BEST DECISION FOR THE PATIENT GIVEN THE CONTEXT AND MAY NOT REALIZE THAT DECISION THEY CAME TO WAS BASED ON UNCONSCIOUS BIAS THERE’S EVIDENCE TO SHOW THAT PROVIDERS HAVE THESE IMPLICIT BIASES INCLUDING BY RACE ETHNICITY AND SOCIOECONOMIC STATUS AND IT IMPACTS PATIENT PROVIDER INTERACTS AND ASSOCIATED WITH LOWER PROVIDER CARE AND TRUST SO WHAT ARE STRATEGIES TO INCLUDE DELIVERY OF PATIENT CENTERED AND CULTURAL COMPETENT CARE THAT TARGET CLINICIAN FACTORS? COMMUNICATION SKILLS ARE LEARNABLE PROVIDERS CAN BE TAUGHT HOW TO GATHER INFORMATION FROM PATIENTS USING OPEN-ENDED QUESTIONS AND COUNSELLING PATIENTS BY PROVIDING INFORMATION IN SHORT METHODS AND ASSESSING THE PATIENT’S UNDERSTANDING AND BE TAUGHT HOW TO ENGAGE PATIENTS IN PROBLEM SOLVING AROUND VARIOUS MEDICAL DECISIONS AND TO BUILD RAPPORT AND SUPPORT PATIENTS DURING VISITS IN ADDITION, PATIENTS CAN ALSO BE TAUGHT SKILLS IN HOW TO BETTER ENGAGE DURING THE MONTHLY VISITS AND HOW TO ASK QUESTIONS AND EXPRESS OPINIONS AND SHARE FEELINGS AND FEEL MORE CONFIDENT IN DOING SO THERE’S BEEN A NICE SYSTEMATIC REVIEW THAT SHOWS INTERVENTIONS TO PROMOTE PATIENT-CENTERED COMMUNICATION THIS HAS BEEN SHOWN TO IMPROVE PROVIDER SKILLS IN THIS COMMUNICATION BUT THE RESULT MIXED ON INTERMEDIATE AND CLINICAL OUTCOMES BUT THERE’S PROMISING NEWS THAT INTERVENTIONS THAT TARGET BOTH PATIENTS AND PROVIDERS AND INCLUDE CONDITION-SPECIFIC MATERIALS MATERIAL SPECIFIC TO COLORECTAL CANCER SCREENING HAVE BENEFICIAL

EFFECTS ON THEIR SATISFACTION AND HEALTH STATUS THERE’S BEEN A REVIEWS RELATED TO THE EFFECTIVENESS OF CULTURAL INVENTIONS AND TARGETS PROVIDER EDUCATION AND TRAINING AND THOSE HAVE BEEN SHOWN TO CONSISTENTLY HAVE A POSITIVE EFFECT ON PROVIDER KNOWLEDGE AND ATTITUDES AND PATIENT SATISFACTION WITH CARE AND DOES NOT DEMONSTRATE AN EFFECT ON OTHER TREATMENT OUTCOMES FEWER SETTINGS FOCUS ON INTERVENTIONS TO EMPOWER PATIENTS TO BE ACTIVE PARTICIPANTS IN THEIR CARE AND THOSE STUDIES THAT EVALUATED THIS HAVE BEEN SHOWN TO IMPROVE PATIENT SATISFACTION AND SOME EVIDENCE IT MAY INCLUDE ADHERENCE BEHAVIORS BUT AGAIN THERE HASN’T BEEN EVIDENCE TO SHOW IT IMPROVES CLINICAL OUTCOMES IT’S IMPORTANT TO NOTE NONE OF THESE STUDIES EVALUATE THE EFFECT OF CULTURALLY COMPETENT INTERVENTIONS IN REDUCING DISPARITIES THE FINAL STRATEGY IS AN AREA THAT HASN’T HAD AS MUCH AS ATTENTION THE STRATEGY TO IMPROVE OR REDUCE THE EFFECT OF RACIAL BIAS FOCUSES ON PROVIDING PHYSICIANS WITH TRAINING TO MAKE THEM AWARE OF THE SKILLS TO NAVIGATE THAT DURING A MEDICAL ENCOUNTER AND PATIENT REGISTRIES AND COMPUTERIZED SUPPORT MAY ALSO HELP REDUCE BIAS BY HELPING IDENTIFY PATIENT WITH GAPS AND PROMPTING PROVIDERS TO ENGAGE THE PATIENT IN DECISIONS IT’S A KEY MEDIATOR TO IMPROVE HEALTH OUTCOMES HOPEFULLY I’VE DEMONSTRATED CLINICIANS HAVE EXPERIENCE LIMITED TRAINING IN CULTURAL COMPETENCE AND HAVE SUB OPTIMAL SKILLS AND UNCONED BIAS HIRND — HINDER ENGAGEMENT PROMOTING THIS HOLDS PROMISE FOR PATIENT’S PERCEPTION OF CARE HOWEVER EVIDENCE IS LIMITED TO CLINICAL OUTCOMES AND WHETHER THE INTERVENTIONS REDUCE DISPARITIES WHAT I ALSO WANT TO MENTION IS MOST STUDIES THAT ASSESS PATIENT CENTERED COMMUNICATION OCCUR DURING A SINGLE ENCOUNTER UNDERSTANDING THE CONTEXT IN WHICH IS OCCURS AS WELL AS NON VERBAL COMMUNICATION THAT MAY COMPLUNS MAY INFLUENCE THE QUALITY OF PATIENT-CENTERED COMMUNICATION IN TERMS OF KEY RECOMMENDATIONS, FLRD — IN ORDER FOR THERE TO BE HIGH CENTERED COMMUNICATION AND BE EQUITABLE INTERVENTIONS NEED TO TARGET PATIENTS, PHYSICIANS AND THE HEALTH CARE SYSTEM AND BE TRANS-DISCIPLINARY AND THEORETICALLY BASED TARGET THE RIGHT BEHAVIORS AND ASSESS THE RIGHT OUTCOMES IN ADDITION RESEARCH DESIGNS THAT USE VALID PATIENT MEASURES ARE NEEDED TO PROVIDE INTERACTIONS AND THE RESEARCH DESCRIBING THE IMPACT OF INTERVENTIONS ON DISPARITIES AND THE COST OF THE INTERVENTIONS WILL HELP INFORM PRACTICE AND POLICY THANK YOU I LOOK FORWARD TO THE DISCUSSION >> GOOD MORNING I’M MICHAEL PARCHMAN IT’S A PLEASURE TO BE HERE TODAY I WANT TO THANK THE CONFERENCE ORGANIZERS I WAS ASKED TO HELP CREATE SOLUTIONS FOR HEALTH EQUITY IN PREVENTIVE SERVICES

I THINK I MAY HAVE PROMISING DIRECTIONS I’D LIKE TO POINT TO SOME I HAVE NOTHING TO DISCLOSE AND WE’LL TALK ABOUT DRIVERS AND TALK ABOUT CAPACITY ADDS — AS A CONCEPT AND IMPLICATIONS AND TELL YOU A STORY ABOUT A PROJECT WE RECENTLY COMPLETED THAT WE CALL HEALTHY HEARTS NORTHWEST AND CARDIOVASCULAR AND TALK ABOUT EQUITY AND CAPACITY BUILDING AND TALK ABOUT FUTURE DIRECTIONS FOR RESEARCH AND IMPLEMENTATION SO THOSE FROM RURAL AREAS KNOW OUR COMMUNITIES DESERVE OUR ATTENTION RURAL RESIDENTS ARE LESS LIKELY TO RECEIVE OUR SERVICES I SHARE THIS SLIDE AND PARDON THE RODEO SYMBOL BUT I’M REMINDED OF A NURSE PRACTITIONER WHO TOLD ME THE ONLY WAY SHE REACH HER POPULATION IS BY CONSISTENTLY GOING TO THE LOCAL RODEO IN FEED LOT TO ENGAGE WITH FARMERS AND RANCHERS IN HER COMMUNITY RURAL POPULATIONS FACE MANY BARRIERS THE REASONABLE — REASON THERE’S NOT EYE LINE — A LINE AND NOT A CIRCLE IS THEY INTERACT WITH EACH OTHER AND THIS IS A THEME WE’LL COME BACK TO THERE’S NON-LINEAR INTERACTION BETWEEN FACTORS OF MULTIPLE LEVELS IN RURAL COMMUNITIES THAT ARE DRIVERS WHETHER OR NOT CLINICAL SERVICE DELIVERED ESPECIALLY FROM THE PRIMARY CARE CLINICAL OR PROVIDER PERSPECTIVE WE KNOW THERE’S LACK OF ACCESS AND WE KNOW RURAL AREAS HAVE HIGHER RATES OF OBESITY, SMOKING, SEDENTARY BEHAVIORS AND HIGHER NUMBERS OF CHRONIC ILLNESSES THE REASON THAT IS IMPORTANT IS MANY PRIMARY CARE PROVIDERS WHEN YOU SEE A PATIENT WITH FIVE OR 10 CHRONIC ILLNESSES YOUR MANAGING AND A LIST OF 8 OR 10 CHRONIC MEDICATIONS, THERE’S A LOT OF COMPETING DEMANDS IN THE EN COUNTER FOR SERVICE DELIVERY BEYOND REMEMBERING TO GIVE THEM [INDISCERNIBLE] THOSE WHAT MAY BE FAMILIAR WITH THE ANDERSON MODEL OF HEALTH CARE UTILIZATION THIS IS WORK IN WHICH THEY MODIFIED HEALTH SEEKING BEHAVIOR MODEL FOR VULNERABLE POPULATIONS I WANT TO POINT OUT SHE DID THIS WORK IN THE HOMELESS POPULATION IN LOS ANGELES MANY ARE RELEVANT WHEN YOU CARE RURAL VERSUS OTHER COMMUNITIES, RAGE, SOCIAL ISOLATION, INSURANCE, INCOME, TRANSPORTATION AND GREAT DISTANCES THAT HAVE TO BE TRAVELED IN ORDER TO REACH HEALTH CARE, GEOGRAPHIC ACCESS AND OTHER FACTORS THAT ALL COMBINE IN WAYS THAT I POSTULATE RESULT IN EMERGENT PHENOMENON OF PREVENTIVE SERVICE RECEIVE — RECEIPT I DO NOT LIKE THE LINEAR ARROWS ON THIS DIAGRAM BECAUSE I DON’T THINK IT’S A LINEAR PHENOMENON AND THERE’S APPROACHES TO ADDRESSING PREVENTIVE SERVICE DELIVERY SO LET’S TALK ABOUT PRIMARY CARE

CLINICAL PERSPECTIVE FOR A MINUTE IF YOU’RE A PRIMARY CARE PROVIDER AND PRACTICING IN A RURAL COMMUNITY YOU DON’T HAVE ACCESS TO A LOT OF SPECIALIST COLLEAGUES THERE’S A SENSE OF ISOLATION AND RESPONSIBLE FOR SEEING 20 TO 30 PATIENTS A DAY AND BEING ON CALL FOR YOUR LOCAL EMERGENCY DEPARTMENT FOR ROUNDING ON YOUR PATIENTS IN RURAL HOSPITAL AND FOR PROVIDING COVERAGE FOR YOUR LONG-TERM CARE FACILITY IN YOUR COMMUNITY ALL AT THE SAME TIME THERE’S ALSO A LACK OF A DEEP BENCH IN YOUR COMMUNITY IN TERMS OF STAFFING YOUR CLINIC WE HAVE SEEN STAFFING SHORTAGES IN CLINICS AND THESE CLINICALS AND THESE PEOPLE ARE DEEPLY EMBEDDED IN THEIR RURAL COMMUNITY AND FEEL A SENSE OF BELONGING TO THEIR COMMUNITY, A COMMITMENT TO SERVING THEIR COMMUNITY WHICH SAY REAL STRENGTH — IS A REAL STRENGTH THEY HAVE A RELATIONSHIP WITH THEIR PATIENTS AND CAN DEVELOP A LEVEL OF TRUST OFTEN TIMES EXISTS IN OTHER COMMUNITIES FINALLY THERE’S PATIENTS THAT ARE ELDER AND SICK TODAY I’D LIKE TO TALK WITH THE CONCEPT OF CAPACITY AND ILLUSTRATE IT THROUGH A RECENT STUDY THAT WE WERE INVOLVED IN ABOUT CARDIOVASCULAR DISEASE RISK REDUCTION IN PRIMARY CARE CLINIC SETTINGS CAPACITY IS THE SKILLS, MOTIVATION AND KNOWLEDGE NECESSARY TO IMPLEMENT INTERVENTION THIS EXISTS AT THE INDIVIDUAL LEVEL AND SAYING A PROVIDER OR STAFF LEVEL AND ORGANIATION LEVEL WHICH IS THE ORGANIZATION OF THAT CLINIC OR ORGANIZATION THAT CLINIC BELONGS TO AND OUTSIDE THE CLINIC THE COMMUNITY IN WHICH THEY’RE EMBEDDED THERE’S CAPACITY AT MULTIPLE LEVELS I APOLOGIZE FOR THE SMALL PRINT BUT THERE’S CAPACITY AT THE LEVEL OF INNOVATION AND GENERALLY CAPACITY AT EACH LEVEL OF THE INDIVIDUAL ORGANIZATION AND COMMUNITY THAT INTERFACES WITH THE INNOVATION IN TERMS OF THE IMPLEMENTATION WE CAN LOOK AT THE DIFFERENCE IN CAPACITY IN THE RURAL AND URBAN LEVEL IN TERMS OF IMPLEMENTATION AND ABILITY TO IMPLEMENT INNOVATION OR DELIVER SERVICE SO THERE’S STORY ONCE UPON A TIME, THE AGENCY FOR RESEARCHER HEALTH CARE DID A CRAZY THING THEY FOUNDED SEVEN COOPERATIVES ACROSS THE UNITED STATES AND GAVE THEM 36 MONTHS OF FUNDING TO ADDRESS THE DELIVERY OF CARDIOVASCULAR PREVENTIVE CARE SERVICES IN PRIMARY CARE PRACTICES AT A REGIONAL LEVEL WE WERE THE NORTHWEST COOPERATE I WAS PRIVILEGED TO BE THE PRINCIPLE OF AN AMAZING TEAM OF PEOPLE WHO DID REMARKABLE WORK IN THE PACIFIC NORTHWEST TO ENGAGE SMALLER PRIMARY CARE PRACTICES AROUND THE DELIVERY OF FOUR CLINICAL PREVENTIVE SERVICES ASPIRIN, CHOLESTEROL AND SMOKING AND THESE WERE THE PRACTICES THAT WERE ENGAGED WITH US AND THE DISTANCES WE COVERED ACROSS THE THREE STATES IS THE EXACT SAME DISTANCE AS IT IS FROM WHERE WE’RE SITTING TODAY TO ORLANDO, FLORIDA THERE’S A MOUNTAIN RANGE DOWN THE MIDDLE WITH PASSES THAT ARE FREQUENTLY CLOSED THESE WERE THE PRACTICES THAT AGREED TO PARTICIPATE IN THE STUDY THEY WERE VERY BRAVE AND COURAGEOUS AND I JUST WANT TO POINT OUT 43% OF WHOM WERE LOCATED IN A RURAL AREA WE’RE TRYING TO ASSESS CAPACITY BUILDING TO DO IT WELL WITH THE FOCUS ON THE FOUR CARDIOVASCULAR RISK FACTORS AND WE USED

PRACTICE FACILITATION AS A SINGLE UNIFYING STRATEGY TO HELP PRACTICES WHEN BUILDING THEIR Q.I. CAPACITY TO INTERVENE AND IMPROVE THE PREVENTIVE SERVICES EACH PRACTICE EFFECTIVELY HAD ONE WE PROVIDED WITH 15 MONTHS OF SUPPORT AT LEAST QUARTERLY VISITS IN PERSON AND PHONE CONTACT IN BETWEEN SO WHAT IS FACILITATION? IT’S THAT SUPPORT PROVIDED BY SOMEONE WHO SERVES AS A CHANGE AGENT FROM THE OUTSIDE OF THE PRACTICE AND SAYS HOW’S IT GOING? WHAT ARE YOU WORKING ON? WHAT DO YOU MEAN? HOW CAN WE HELP YOU? THEY INTRODUCE NEW IDEAS FOR CHANGE IN THE PRACTICE IT HELP THEM IDENTIFY AND REMOVE BARRIERS THEY ESTABLISHED EFFECTIVE COMMUNICATION CHANNELS BETWEEN PEOPLE WHO WORK IN THE PRACTICE AND MONITOR CHANGE AND ARE GENERALLY AN ACCOUNTABILITY AGENT FOR THE PRACTICE THIS PERSON IS THAT PERSON THAT ONE DAY THE OFFICE MANAGER COMES INTO THE PRACTICE AND SAYS, OH, MY GOSH, BRIGITTE, OUR PRACTICE COACH IS COMING NEXT WEEK AND WE HAVEN’T DONE ANYTHING WE SAID WE WERE GOING TO DO SINCE THE LAST VISIT WE NEED TO GET OUR BUTTS IN GEAR AND CHANGE SOMETHING TO WE HAVE SOMETHING TO TELL HER I WANT TO COMPARE THE PRACTICES FOR A MINUTE AND MAKE A COUPLE [INDISCERNIBLE] FIRST, IT WAS EASIER TO RECRUIT ROLE PRACTICES THAN OTHER PRACTICES 1 OF 4, THOSE WE APPROACHED PARTICIPATED VERSUS 1 OF 10 IN URBAN PRACTICED S AND THEY WERE MORE LIKELY TO STAY ENGAGED AND COMPLETE THE STUDY LOWER DROP-OUT RATES AND HAD MORE IN-PERSON TOUCHES WITH THEIR PRACTICE COACH THEY WERE OPEN TO MORE IN-PERSON VISITS I THINK THIS POINTS TO THE RELATIONSHIP ASPECT OF DOING THIS WORK IN RURAL COMMUNITIES AND THE IMPORTANCE THAT THESE PEOPLE IN RURAL COMMUNITIES PLACE ON HAVING THAT RELATIONSHIP WITH SOMEONE WHO WILL COME BY AND INTERACT WITH THEM IT’S A WAY THAT ADDRESS THEIR ISOLATION IN DOING THEIR WORK WHAT WE HEARD WAS, YOU KNOW, THAT DOESN’T ALWAYS HELP TO HAVE THE EXPERT IN A RURAL AREA YOU’RE ASKED TO DO MANY THINGS ONE DAY YOU’RE IN THE EMERGENCY ROOM, THE NEXT DAY YOU’RE IN THE CLINIC GENERAL PRACTICE YOU HAVE TO REALIZE YOU MAY BE THE ONLY OPTION FOR THAT PATIENT THEMES ABOUT ISOLATION AND RESOURCES BECAUSE WE’RE RESEARCHERS, WE ASKED THESE PRACTICES TO COMPLETE WAY TOO MANY SURVEYS BUT ONE OF THE SURVEYS WE ASKED THEM TO COMPLETE WAS A SURVEY ABOUT THEIR SELF-ASSESSED ABILITY TO DO QUALITY IMPROVEMENT WELL AND WE IDENTIFIED THESE SEVEN WHAT WE CALLED HIGH-LEVERAGE CHANGES AND AREAS WE THOUGHT WERE IMPORTANT FOR PRACTICES TO ENGAGE IN THIS WAS FILLED OUT IN A ROOM AND THEY DISCUSS EVERY ITEM IN THE VARE AND TALKED ABOUT — SURVEY AND TALKED BEFORE WHERE THEY WERE IN THE AREAS AND THERE’S TWO YEARS I WANT TO POINT OUT TO YOU AND THE SELF-MANAGEMENT SUPPORT AND COMMUNITY RESOURCES BOTH I THINK POINT TO THE CONTEXT IN WHICH RURAL PRACTICES DELIVER CARE VAIR VARE — IN AND THEIR SETTING AND ENVIRONMENT THEY LACK THE RESOURCES AND COMMUNITY SUPPORT THEY NEEDED TO DO THIS WELL I WANT TO SHOW THE PROPORTION OF PATIENTS WHO’S BLOOD PRESSURE WAS LESS THAN 140/90

AT THE START IN 2015 THERE WAS A SIGNIFICANT GAP IN PATIENTS IN RURAL PRACTICES VERSUS URBAN PRACTICES AND THE PROPORTION OF PATIENTS TARGETED AND TWO YEARS LATER BY 2017, RURAL PRACTICES HAD SIGNIFICANTLY CLOSED THAT GAP WE’RE TALKING ABOUT THE CAPACITY TO IMPLEMENT THINGS WELL IN THE PRACTICES I WANT TO POINT TO THIS WORK BY LEWIS AND FLEMING FROM THE UNIVERSITY OF NORTH CAROLINA IT TALKS ABOUT THE IMPORTANCE OF BUILDING RELATIONSHIPS AND BUILDING CAPACITY IN THE RURAL COMMUNITY AND RURAL PRACTICE IF WE’RE TO IMPLEMENT EFFECTIVE DELIVERY OF SOMETHING LIKE CLINICAL PREVENTIVE SERVICES INVEST IN RELATIONSHIPS IN RURAL COMMUNITIES FIRST YOU NEED TO FUND AND BUILD CREATIVE INDIVIDUAL AND ORGANIZE ORGANIZE — ORGANIZATIONAL ASPECTS BECAUSE OF THE CAPACITY ISSUE SO WHAT DOES THIS MEAN FOR EQUITY? I WOULD POSTULATE CAPACITY BUILDING HAS TO OCCUR AT MANY LEVELS THE RURAL CLINICS AND COMMUNITIES NEED SUPPORT AND BECAUSE IT’S A COMPLEX SYSTEM IT CAN RESULT IN BIG IMPROVEMENTS I THINK IT’S IMPORTANT FOR TO US GET CREATIVE ABOUT THIS I WOULD THINK ABOUT HOW WE CAN PARTNER WITH OUR COLLEAGUES TO CO-CREATE INNOVATIONS IN THE RURAL SETTING THEY’RE ACTUALLY REVIEW IN FACT I COULD NOT FIND ANY EVIDENCE-BASED MODELS FOR IMPLEMENTING CLINICAL PREVENTIVE SERVICES TO DEVELOP DE NOVO IN REAL WORLD SETTING MOST ALL WERE DEVELOPED ELSEWHERE AND THEN ADAPTED TO THE RURAL SETTING WHERE ATTEMPTS WERE MADE TO ADAPT THEM TO THE REAL WORLD SETTING WE NEED TO PROVIDE LONGER RAMP UP SUPPORT TIME FOR THE CLINICALS AND TO BUILD THE RELATIONSHIPS AND WE SHOULD THINK ABOUT CONVENING MORE GOODS TO DEVELOP STRATEGIES ACROSS LEVELS THE COMMUNITY AND THE ORGANIZATION AND THE INDIVIDUAL I WANT TO THANK YOU TODAY FOR INVITING ME AGAIN I WANT TO CLOSE BY SAYING BE INNOVATIVE, BE DARING AND BE PATIENT DON’T EXPECT RURAL COMMUNITIES TO BE YOUR STUDY SESSIONS I THINK IF WE ESTABLISH A RESPECTFUL PARTNERSHIP AND LISTEN TO OUR COLLEAGUES WITH UNCONDITIONAL POSITIVE REGARD WE’LL MAKE GREAT PROGRESS IN DELIVERING SERVICES THANK YOU VERY MUCH >> IF OUR OTHER PANELISTS CAN COME UP THANK YOU VERY MUCH >> LET’S START WITH ANY CLARIFYING QUESTIONS FROM OUR PANEL >> THANK YOU THOSE WERE FASCINATING AND YOU DID PULL A LOT OUT FROM THE RESEARCH I HAVE ONE QUESTION ABOUT CLINICIANS AND PROVIDERS I’M WONDERING IF ANY OF YOU LOOKED AT SOMEHOW MANY THESE ASPECTS — HOW SOME OF THESE AC — ASPECTS OF CARE WERE AFFECTED BY NURSE PRACTITIONERS AND PROVIDERS BECAUSE THEY’RE TRAINED DIFFERENTLY AND MIGHT THERE BE DIFFERENCES WE CAN LEARN FROM AND HIGHLIGHT >> I THINK YOU BRING UP AN

IMPORTANT POINT A LOT OF THE VISITS ARE WITH DIVERSE PROVIDERS, PHYSICIANS, NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS I DIDN’T COME ACROSS THAT BUT IT DOESN’T MEAN IT DIDN’T EXIST I WOULD WARRANT LOOKING MORE DEEPLY AT CAPTURING THE INFORMATION TO ASSESS DIFFERENCE MY INITIAL IMPRESSION IS COMMUNICATION IS IMPORTANT REGARDLESS OF WHAT TYPE OF PROVIDER YOU ARE AND WHILE THERE’S DIFFERENCES, I THINK THE GOALS ARE THE SAME AND ENSURING INTERACTIONS THAT HAVE YOU WITH PATIENTS YOU’RE ABLE TO DEVELOP THOSE EFFECTIVE PARTNERSHIPS WOULD TRANSLATE ACROSS PROVIDER TYPE >> WE DID WORK BY THE RODWAY JOHNSON FOUNDATION LOOKING AT AMBULATORY PRACTICES AND THE LEAP PROJECT CHIN WE LOOKED AT — IN WHICH WE LOOKED AT HIGH FUNCTIONI FUNCTIONING TEAMS IN PRIMARY CARE AND A CHARACTERISTIC OF A TEAM WITH DISTRIBUTED TASK AND RESPONSE AND THE ACROSS EVERYONE WHO WORKED IN THE CLINIC DID BETTER WE DIDN’T QUANTIFY THAT IN TERMS OF COLLECTING DATA BUT WE LOOKED AT THE CLINICS WE VISITED AND IT WAS PRETTY IMPRESSIVE EVERYONE FROM THE FRONT DESK TO THE M.A.s TO THE BILLING STAFF FELT RESPONSIBILITY FOR DELIVERING APPROPRIATE CARE TO THE PATIENT AND TOOK ON THE TASKS OF SAYING, OH, YEAH, THIS PATIENT IS HERE >> WHERE YOU SEE LITERATURE ON THE VALUE OF THE ALLIED HEALTH PROFESSIONAL MULTIDISCIPLINARY TEAM IN THE MANAGEMENT OF CHRONIC CONDITION SPACE WHEN I LOOKED AT PREN — PREVENTIVE SERVICES AND LOOKED ACROSS PROVIDERS IT’S SCANT LITERATURE AND A BIG EVIDENCE GAP >> I HAD A QUESTION IN REGARD TO APPROACH AND HE HETEROGENEITY AND WE LIKE THINGS DONE ON A RESEARCH BASIS AND RIGOROUSLY AND MORE QY APPROACH CAN BE JUST AS INFORMATIVE AND MAYBE TAILORED BETTER I WONDER IF YOU CAN COMMENT HOW WE GET TO REAL LEARNINGS THAT MAKE A DIFFERENCE IN THE DIFFERENT SETTINGS AND SORT OF THE VALUE OF QI VERSUS MORE RIGOROUS ACADEMIC STUDIES I THINK THERE’S EMERGING METHODOLOGY FOR STUDYING METHODS AND A CONSORTIUM THE NIH AND PCORI FUNDS TO EXAMINE NATURAL EXPERIMENTS LIKE DELIVERY OF DIABETES CARE I THINK AS THE METHODOLOGY EMERGE, ONE OF THE THINGS THAT’S CLEAR IS THAT YOU NEED ROBUST COMPARITOR POPULATIONS EVEN WHERE THERE’S NATURAL EXPERIMENTS WITH CARE MANAGEMENT IF YOU CAN BUILD IN THOSE ROBUST COMPARITOR POPULATIONS THAT’S COMPARABLE IT’S VERY IMPORTANT THE OTHER THING THAT’S REALLY IMPORTANT IS CONSENSUS TO TRACK ACROSS HETEROGENEOUS SETTING AND INFORMATION TECHNOLOGY HOLDS PROMISE TOWARDS GETTING TO MANAGEABLE REAL-TIME CLINICAL DATA SETS THAT CAN BE REPURPOSED FOR THAT WE’RE AT THE FRONT END OF THAT METHODOLOGY AND BEST PRACTICES FOR HOW TO STUDY THOSE THINGS I WOULD SAY THAT’S THE DIRECTION WE’RE GOING HAVE TO MOVE BECAUSE WE CAN’T REALLY DO RANDOMIZED CLINICAL TRIALS AT THE SYSTEM LEVEL FOR MANY OF THE THINGS WED LIKE TO DO TO IMPROVE CARE >> TO PIGGY BACK ON THAT THERE’S A GROWING [INDISCERNIBLE] IN THE COMMUNITY ABOUT TWO HYBRID TYPE THREE TRIALS THAT IS AN ATTEMPT TO BUILD RIGOR AND GUARDRAILS AROUND STUDY DESIGN THAT I THINK HOLDS GREAT PROMISE

IT’S DIFFICULT TO ENGAGE HEALTH SYSTEMS AND CLINICS AND COMMUNITIES IN RESEARCH IF YOU TELL THEM WELL, YOU MAY BE RANDOMIZED WE FOUND THAT IN OUR RECENT OPIOID STUDY IN WHICH WE TOLD THEM WE’D DO A STEP WEDGE STUDY DESIGN AND WHEN WE GOT THE FUNDING AND WENT BACK TO THEM THEY SAID WE’RE NOT IN IT’S A CRISIS >> AS YOU SPOKE ABOUT CREATING SOLUTION FOR HEALTH EQUITY AND SERVICE IN RURAL AREAS AND I LOOKED AT THE MAP AND YOU’RE AREA IS IN THE NORTHWEST OF THE UNITED STATES WHICH OF COURSE IS VERY RURAL WHEN I THINK OF RURAL I THINK SOUTHEAST THE SOLUTIONS YOU’RE SUGGESTING TO FOR THE NORTHWEST, WOULD THEY BE APPROPRIATE FOR OTHER RURAL COMMUNITIES WITHIN OUR COUNTRY AS WELL OR DOES THAT NEED TO BE CONSIDERED >> I THINK RURAL COMMUNITIES MAY QU QUALITATIVELY BEAR CONSIDERATION I THINK SOME PRINCIPLES ABOUT NEEDING TO THINK ABOUT MULTILEVEL CAPACITY BUILDING ARE THE SAME SO BUILDING CAPACITY AT THE COMMUNITY LEVEL, THE ORGANIZATIONAL LEVEL AND INDIVIDUAL LEVEL IS IMPORTANT TO THINK ABOUT IF WE’RE GOING TO ADDRESS EQUITY SO I DON’T THINK THAT’S DIFFERENT BUT I THINK THE WAY IN WHICH WE GO ABOUT IT WOULD BE DIFFERENT IN THE SOUTHEAST BECAUSE OF THE DIFFERENCES IN CULTURE AND VALUES THAT WOULD BE A REALLY IMPORTANT CONSIDERATION, YES >> THANK YOU, ONE MORE DR. PARCHMAN CAN YOU ADDRESS THE ISSUE OF SUSTAINABILITY OF YOUR INTERVENTIONS AND HOW YOU FORESEE THAT BEING ADDRESSED? >> NO, BECAUSE IT’S REALLY DIFFICULT TO GET ANYBODY TO FUND A STUDY OF SUSTAINMENT NOBODY WANTS TO STUDY SUSTAINMENT THOUGH THEY CLAIM TO SO WE REALLY DON’T KNOW ABOUT SUSTAINABILITY IN IMPLEMENTING CHANGES IN SYSTEMS UNLESS YOU CAN LOOK BACK AND REFLECT BACK ON THINGS DOING A RETROSPECTIVE LOOK BACK AND SAY, HUH, THAT WASN’T SUSTAINED, I WONDER WHY LET’S THINK ABOUT IT AND LOOK AT VARIABLES THAT WOULD BE A MEDIATOR OR MODERATOR OR SUSTAINABILITY IT IS TERRIBLY DIFFICULT TO STUDY SUSTAINMENT >> THE INTERVENTION YOU HAD WHICH IS BASICALLY DETAILING ON A CRITICAL LEVEL HAS TO BE FUNDED TO BE SUSTAINED ANY IDEAS ON THAT >> THERE AGAIN I’M GRIEVING THE FACT THAT THE IDEA OF HEALTH EXTENSION AGENTS SUPPORT PRIMARY CARE PRACTICE WERE AUTHORIZED IN THE ACA BUT NOT FUNDED IN THE UNITED STATES THAT BEING THE SAME PRACTICE FACILITATOR MODEL OF PEOPLE WHO ARE REGIONALLY BASED WHO ARE AN EXTENSION AGENT FOR PRIMARY CARE PRACTICES WHICH IS SO DESPERATELY NEEDED ESPECIALLY IN RURAL AREAS >> IF WE CAN GET FOLKS FROM THE AUDIENCE LINED UP AT THE MIC IN THEORY CRITICAL CARE ORGANIZATIONS COULD SUPPORT SOME OF THOSE PRACTICES BUT ARE THEY AC ADAMS >> IN SOME PLACES TO A LIMITED FASHION IT’S NOT WIDESPREAD YOU CAN SEE A FEW EXAMPLES OF VARIOUS GEOGRAPHIES AROUND THE

U.S. BUT NOT AS ROBUST OR AS SIGNIFICANT AS AN IDEA GIVEN THE LEVEL OF THE EFFECTIVENESS OF THE PRACTICE DON’T SEE IT >> ON THE LEFT >> MY QUESTION IS FOR DOCTOR GREER I WAS WONDERING WHEN YOU TALK ABOUT CULTURAL COMPETENCY AMONG PROVIDERS IF THEY LOOKED AT BREAKING DOWN LOCATION OF RESIDENCY IN TERMS OF COMPETENCE LEVEL TO SUPERCEDE THE GAP >> WHEN YOU SAY LOCATION OF RESIDENCY BY REGION OR? >> YES >> WE LOOK AT TYPE OF PROVIDERS IN TERMS OF CULTURAL COMPETENCY TRAINING WHERE SURGEONS MAY FEEL LESS CULTURAL COMPETENT AND RECEIVE LESS TRAINING THAN PRIMARY CARE PROVIDERS BUT THAT’S TO ARE WHERE THEY BREAK IT DOWN AND NOT BY REGION FROM THE COUNTRY >> OKAY >> TO CONCERNS ONE IS WITH THE NOTION OF EQUITY THAT YOU MENTIONED DR. NELSON AND THIS IS A WIDESPREAD NOTION OF EQUITY AS QUOTE THE HIGHEST ATTAINABILITY QUALITY OF LIFE FOR ALL PEOPLE MY CONCERNS ARE THREE ONE, I HAVE NO IDEA WHAT THE HIGHEST LEVEL OF HEALTH MEANS AND IT’S IMPOSSIBLE TO MEASURE TWO, IT IGNORES THE MOTION OF INJUSTICE WHICH I THINK IS FUNDAMENTAL TO THE MOTION OF EQUITY AND THIRD, MOST IMPORTANT IT ILS FOR — IGNORES WE CAN ALL HAVE EQUAL HEALTH BUT IF WE DON’T ALL HAVE THE RESOURCES TA PROMOTE HEALTH — THAT PROMOTE HEALTH THE HEALTH WILL DISAPPEAR FAIRLY QUICKLY THE SECOND ISSUE THAT I’M CONCERNED ABOUT IS THE NOTION OF DISCORDANCE, RACIAL DISORDERANCE WHICH IS IMPORTANT BECAUSE IT SHOWS THE EFFECT OF RACE ON HEALTH CARE I’M CONCERNED ON WHAT THE INFERENCE IS FROM THAT ONE WAY TO DEAL WITH THAT WOULD BE TO HAVE SEGREGATED HEALTH CARE SYSTEM IN WHICH BLACK PHYSICIANS TREATED BLACK PATIENTS WHICH I THINK WOULD PROMOTE MORE EQUITY THAN IT WOULD SOLVE AND THE OTHER WOULD BE TO BUILD INTO THE HEALTH CARE EDUCATIONAL SYSTEM THE ANTI-BIAS CULTURAL SENSITIVITY APPROACHES YOU TALKED ABOUT TWO QUESTIONS THANK YOU >> STARTING WITH DR. NELSON AND THEN MAYBE DR. GREER >> WELL, DESCRIBING HEALTH EQUITY IN A BROAD SENSE IS AN ENTRY INTO THE DISCUSSION AND APPLYING THAT IN REVIEWS AND WHAT WAS INTENDED >> YOU BRING UP IMPORTANT POINTS AROUND RACIAL DISCORDANCE AND TO RECOGNIZE THAT ETHNIC RACE MINORITIES AND HISPANIC CULTURES WILL SEE PEOPLE A DIFFERENT CLASS SO THERE SHOULD BE EFFORTS FROM A HEALTH SYSTEM LEVEL THAT THEY ARE HAVE MORE FORCE ARE DIVERSE THAT’S ONE WAY TO PROMOTE PATIENT-CENTERED AND DIRECT THAT CONCERN THE OTHER IS TO ENSURE VISITS WHERE THERE IS SUPPORT THAT WOULD TRAIN THE PROVIDERS TO DELIVER PATIENT CENTER AND CULTURALLY COMPETENT CARE AND THAT TRAINING NEEDS TO OCCUR IN MEDICAL SCHOOL AND BE ENFORCED BECAUSE THE COMMUNICATION INCREASES OVER TIME >> I WOULD LIKE TO SUGGEST WE HAVE A BIG RESEARCH GAP BECAUSE FROM OBSERVATION IN SETTINGS WITH A DIVERSE PHYSICIAN WORKFORCE AND WITH TRAINING THAT WE PROBABLY GET THE BEST OUTCOMES BECAUSE I THINK WHEN HAVE YOU COLLEAGUES FROM DIFFERENT GROUPS THERE IS HEIGHTENED SENSITIVITY

AND KNOWLEDGE THAT ISN’T PRESENT IF YOU JUST HAVE A HOMOGENEOUS GROUP OF PHYSICIANS THE BIAS TRAINING IS BETTER THAN NOTHING BUT I THINK WE SHOULD ASPIRE TO HAVE A MORE DIVERSE WORKFORCE AND DO BIAS TRAINING AND IT WOULD BE WONDERFUL IF SOMEBODY WOULD STUDY THAT BECAUSE I THINK THAT’S ANOTHER BIG EVIDENCE GAP ON WHAT YOU’RE GETTING ON THE MARGIN AND FOR MANY WHO WORK IN DIVERSE SETTINGS WE FEEL ON THE MARGIN IS HUGE BUT I THINK IT HASN’T BEEN STUDIED WELL >> THANK YOU NEXT QUESTION >> THANK YOU FOR THE PRESENTATION WE TALK ABOUT OUR HEALTH AND WANT ACCESS TO HEALTH SPECIFICALLY OR THE HEALTH PROVIDER GO TO THE COMMUNITY I THINK THERE COULD AN ECONOMIC BEHAVIOR IF PEOPLE GO BACK TO THE PARENTS’ HOUSE AND IF THEY DON’T HAVE TRANSPORTATION IN THE CAR OR VEHICLE THEIR CAR IS STOLEN OR ROBBED AND THE SYSTEM IS A BIG PROBLEM ESPECIALLY CURRENTLY IT CHANGES TO THE DIRECTION OF PRIVATE PARTNERSHIP BY ALL AGENCIES PRACTICALLY BUT PPP IS NOTORIOUS IT REFLECT [INDISCERNIBLE] AND WE SAY [INDISCERNIBLE] CONSPIRACY WITH POLICE AND ATTORNEYS AND THERE’S NO RECOURSE FOR THEM TO COMPLAIN AND ALL THEY CAN DO IS SLEEP OUTSIDE THEY DON’T EVEN HAVE SHELTER AND IF THEY DON’T GO TO THEIR PARENTS’ HOUSE AND THEIR HEALTH SAY PROBLEM GETTING LESS HEALTH AND GO TO JAIL THEN [INDISCERNIBLE] MAKES THE HEALTH EVEN WORSE WE HAVE TO THINK ABOUT SYSTEM PROBLEM PROMOTE HEALTH AND PROMOTE THE FAMILY RELATIONSHIP OTHERWISE EVERY TIME IF POLICE WANT THE MONEY YOU GIVE THEM MONEY AND TRAINING AND TRAINING AND ASKED THEM TO KILL RATHER THAN TRAINING TO HELP PEOPLE SO I THINK WE HAVE TO THINK ABOUT OUTSIDE BOX HOW TO PROMOTE HEALTH AND REDUCE MASS INCARCERATION, HOW TO IMPROVE THE HAPPINESS RATHER THAN SAY THE FAMILY RELATIONSHIP AND EVERYBODY IS LONELY AND HAVE PARENTS NOBODY’S TAKING CARE OF AND THEY WILL BE ROBBED BY THIS KIND OF PPP GROUP I HOPE WE CAN THINK ABOUT OUTSIDE THE BOX FOR REAL CHANGE OTHERWISE OR SOCIETY IS IN VICIOUS CYCLE >> THANK YOU MAYBE OUR FOCUS CAN BE UPON THE VERY SPECIAL POPULATIONS BROUGHT UP OF INCARCERATED, HOMELESS, ETCETERA WHICH BRINGS TO LIGHT SOME OF THE POPULATION PROBLEMS >> WE SAW IN RURAL COMMUNITIES PEOPLE DIDN’T REALLY KNOW EACH OTHER BUT KNEW WHEN SOMEONE INCARCERATED WAS RELEASED THEY KNEW [INDISCERNIBLE] THEY MET WITH EACH OTHER THEY TALKED WITH EACH OTHER ABOUT THE COMMUNITY THEY TALKED ABOUT DEVELOPING PARTNERSHIPS AROUND ADDRESSING THE DRIVERS OF HEALTH CARE IN THEIR COMMUNITY AND FELT A COMMITMENT >> THANK YOU >> LARRY McNEIL WITH THE AMERICAN DIABETES ASSOCIATION AND GREAT PANEL AND PRESENTATIONS, THANK YOU MY QUESTION IS FOR DR. PARCHMAN AND OTHER MAY WANT TO WEIGH IN I’M INTERESTED IN THERE’S BEEN A LOT OF BUZZ ABOUT THE PROJECT ECHO MODEL AND SPECIALISTS WITH PRIMARY CARE AND SHARED

KNOWLEDGE AND WORKING THROUGH DISSEMINATION OF BEST PRACTICES, ETCETERA FOR A NUMBER OF DISEASE STATES INCLUDING DIABETES MY QUESTION IS HOW PRACTICE FACILITATION AS YOU PRESENTED EITHER FITS, COMPLEMENTS OR COMPETES WITH THAT EITHER FOR RESOURCES FROM POLICY MAKERS OR FROM A PRIMARY CARE PHYSICIAN >> MAYBE START WITH TELLING THE AUDIENCE WHAT PROJECT ECHO IS >> SO PROJECT ECHO WAS DEVELOPED ORIGINALLY FROM THE UNIVERSITY OF NEW MEXICO TO ADDRESS I THINK HEPATITIS C IN RURAL COMMUNITIES WHERE AN ACADEMIC EXPERT WAS LIVE VIDEO CONFERENCING WITH RURAL PRIMARY CARE PROVIDERS AND PRESENTING COMPLEX AND DO THIS WELL THE PATIENTS WERE NOT GOING TO THE ACADEMIC HEALTH CENTER TO RECEIVER CARE AND REALIZED THEY’D HAVE DO — TO DO PROJECT ECHO OUTREACH AND WERE REGULAR SERIES WITH TELEHEALTH BETWEEN THE ACADEMIC HEALTH CENTER AND THE RURAL PROVIDERS IN THE COMMUNITY THE QUESTION IS SO WE WERE DOING SOMETHING KIND OF LIKE THAT EXCEPT IT WAS MORE REMOTE ACADEMIC DETAILING AROUND CARDIOVASCULAR RISK CALCULATION IN PRIMARY CARE AND TRYING TO REACH OUT TO HALF THE CLINICS IN THE STUDY TO GET A PROVIDER TO JOIN A WEBINAR LIVE WITH ME OR SOMEONE ELSE CALCULATING CARDIOVASCULAR RISK AND USING THAT IN SHARED DECISION MAKING WITH PATIENTS WE DISCUSSED CASES AND BLAH, BLAH, BLAH WE COULDN’T GET ANYBODY TO SIGN UP FOR IT I THOUGHT, OH, NO, WE HAVE PRACTICE FACILITATION IS WE DON’T WANT TO TELL PRACTICE FACILITATORS ABOUT THE CONTENT OF THE OUTREACH WE’RE DOING AND FINALLY, WE SAID, THIS IS CRAZY IT’S NOT GOING HAPPEN BECAUSE THE FACILITATORS WITH THE TRUST AND RESPECT OF THE PROVIDERS IN THE CLINICALS WE TURNED TO THE FACILITATORS AND SAID YOU HAVE TO RECRUIT THE PROVIDERS TO GET THEM ON THE LINE TO DO WEBINARS WITH US AND THEY TRUST YOU AND RESPECT YOU AND THAT’S THE ONLY WAY WE’RE ABLE TO GET THEM TO PARTICIPATE IN THAT ARM OF OUR STUDY IT’S THROUGH THE PRACTICE FACILITATOR DOING THE OUTREACH AND IN SOME CASES PHYSICALLY BEING IN THE CLINIC TO DIAL UP THE CONNECTION AND GET THEIR COMPUTER TO WORK SO THEY CAN MAKE THE VIDEO CONNECTION THE PROVIDERS WERE USUALLY LATE AND RUNNING BEHIND THEY COULDN’T GET THERE IN TIME TO PARTICIPATE SO THE COACH WAS THERE TO FACILITATE THE WHOLE PROCESS THANK YOU >> GOOD MORNING I’M WITH LATINO CONNECTION I’M CURIOUS AND CONCERNED WITH THE FINDINGS ESPECIALLY IN THE AREA OF CULTURAL COMPETENCY AMONG CLINICIANS WHAT ROLE DOES IT PRESENTLY PLAY DO NATIONAL CLASS STANDARDS PLAY AND WHAT IS BEING DONE TO TRACK HOW CLASS STANDARDS ARE BEING IMPLEMENTED IN HOSPITALS AND CLINICS WHEN I SAY CLASS STANDARDS I MEAN CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES JUST CURIOUS >> I THINK YOU BRING UP AN IMPORTANT POINT AGAIN, THERE IS A NATIONAL CALL THAT THOSE SERVICES BE AVAILABLE AND IS IMPORTANT FOR THOSE TO BE MEASURED AND ASSESSED AND FOR ORGANIZATIONS TO BE HELD ACCOUNTABLE FOR THAT FORTUNATELY I’M NOT SURE OF THE EVIDENCE AROUND THAT AREA AND DON’T KNOW IF ANY OF MY COLLEAGUES ARE MORE FAMILIAR WITH THAT BUT I DO AGREE THAT’S A VERY IMPORTANT POINT THAT SHOULD BE TRACKED >> I’M CURIOUS AS TO WHETHER HOSPITALS AND CLINICS AND

CLINICIANS ARE AWARE IT’S FEDERALLY RETIRED AND REGULATED AND — REQUIRED AND REGULATED AND ACROSS FEDERAL STANDARDS IT’S CONCERNING TO ME OVER 50% OF RESIDENTS FEEL THEY’RE NOT CULTURALLY COMPETENTLY TRAINED WHEN IT’S FEDERALLY REQUIRED SO JUST CURIOUS >> UNSUBSTANTIATED OPINION BUT UNTIL THERE’S AUDIT AND PENALTIES, IT’S UNLIKELY WE’LL SEE BROAD ENFORCEMENT WE HAVE SOME BIG FEDERAL PAYERS LIKE MEDICARE AND MEDICAID AND WE COULD HAVE PUBLIC POLICY THAT WOULD LEAD TO BETTER ENFORCEMENT >> I WILL SAY THAT I CAN SPEAK AT LEAST FOR THE TRAINING PROGRAMS AND ACADEMIC STANDARDS IN FACT THERE’S CURRICULUM AT THE RESIDENCY LEVEL AS WELL THERE’S EFFORTS ENCOURAGING TO GO IN THAT DIRECTION AND ENSURE ALL PROVIDERS THAT COMPLETE THEIR TRAINING HAVE THAT APPROPRIATE INFORMATION BUT AGAIN I THINK YOU’RE RIGHT, IT SHOULD BE TRACKED BUT ULTIMATELY DIFFICULT TO ENFORCE >> I’M A RESIDENT AND INTERESTED IN HEALTH CARE WORKFORCE DIVERSITY I HAD A COMMENT AND THEN A QUESTION THE PRESENTATION THAT INCLUDE THE DIFFERENTIAL AND OUTCOMES FOR AFRICAN AMERICAN WOMEN WITH REGARDS TO BREAST CANCER MORTALITY, THERE WAS A PART OF THE BULLET THAT TALKED ABOUT TREATMENT RESISTANT FORMS WHICH IS AN INTERESTING PHRASING AND WHAT THAT SAYS TO ME AS A PERSON OF COLOR IS THE TREATMENT HAVE BEEN DEVELOPED FOR WHITE WOMEN AND SO BASED ON WHAT WE WERE TALKING ABOUT BEFORE WITH THE IDEA OF CULTURAL COMPETENCE WHICH I THINK WAS THE FIRST ITERATION THAT EVENTUALLY LEADS WORKFORCE DIVERSITY, WHAT ROLE DO YOU THINK LANGUAGE PLAYS IN HOW WE PRESENT THESE ISSUES AND SECONDLY, WHAT ROLE DOES A RESEARCHER HAVE WITH COMPILING EVIDENCE AND ALSO SPEAKING TO THEIR OWN EXPERIENCE AS RESEARCHERS AND CLINICIANS IN COMMUNICATING THAT WITH THE PUBLIC AND WHAT ROLE RESEARCH HAS IN ADVOCACY >> FIRST, THANK YOU FOR BRINGING UP THE POINT THE CATEGORY OF TREATMENT RESISTANT BREAST CANCER WAS REALLY SOMETHING THAT CAME UP NOT SO MUCH IN THE RACIAL TEXT BECAUSE IT’S SOMETHING NOTED IN THE CLINICAL TRIALS AND THOSE PATTERNS OF BIOLOGIC MARKERS DON’T JUST HAP EN IN AFRICAN AMERICAN WOMEN THEY HAPPEN IN WHITE WOMEN AND OTHER GROUPS BUT THEY SEEM TO BE MORE PREVALENT IN AFRICAN AMERICAN WOMEN WITH POOR OUTCOMES WORDS ARE POWERFUL AND I COULDN’T AGREE WITH YOU MORE THE EVIDENCE GAP WE HAVE NOT DEVOTED SUFFICIENT RESOURCES TO IDENTIFY BEST TREATMENTS FOR PEOPLE WHO DON’T HAVE ESTROGEN POSITIVE RECEPTORS ON THEIR TUMORS YOUR POINT IS WELL TAKEN AND IS A CALL FOR RESEARCH TO TO STUDY BREAST CANCERS MORE AND THINK ABOUT WHEN WE SAY TREATMENT RESISTANT WE MEAN BY THE TYPICAL WAYS WE TREAT, RIGHT? SO PROBABLY THERE’S A DIFFERENT WAY TO REFER TO THOSE TUMORS MUCH LIKE THERE WOULD BE FOR SAY LYMPHOMA WHO MAY HAVE MARKERS WITH A PROGNOSIS >> THANK YOU IT’S 12:31 SO I THINK WE HAVE AN OPPORTUNITY FOR LUNCH WE WILL RESUME AT 1:30 SEE YOU THERE WE’LL START WITH KEY QUESTION NUMBER TWO, SAME TYPE OF FORMAT

I WANT TO THANK OUR PANEL FABULOUS DISCUSSION WHICH GOES TO SHOW EVEN IF THERE’S NO LITERATURE WE CAN GET A LOT OUT OF IT THANKS A LOT WE’RE GOING TO START THE AFTERNOON WITH A BRIEF VIDEO VIGNETTE FROM DR. GARY GIBBONS, DIRECTOR OF THE INSTITUTE >> THE NHLBI IS PURSUING A RESEARCH AGENDA THAT ENGAGES PATIENTS, RESEARCHERS PURSUING IMPLEMENTATION SCIENCE PO PROVIDE A LINK BETWEEN INTERVENTIONS THAT WILL HAVE A POSITIVE IMPACT ON THEIR COMMUNITIES AND ADDRESS HEALTH INEQUITIES WE BELIEVE THE AIMPORTANT APPROACH TO ADDRESS — AN IMPORTANT APPROACH IS PREVENTION SERVICES FOR EXAMPLE, WE FUNDED A STUDY THAT RECOGNIZED BARBERSHOPS ARE AN IMPORTNT PLACE OF CONVENING AND COMMUNICATION SHARING IN CERTAIN COMMUNITY AND THE INVESTIGATORS WERE ABLE TO LEVERAGE THAT COMMUNITY RESOURCE TO PROMOTE HEALTH AND PREVENTION SERVICES RELATED TO HYPERTENSION AND IT SHOWED A KEY BENEFIT TO THAT COMMUNITY OUR INSTITUTE IS COMMITTED TO SHOWING A DIRECT IMPACT ON THE HEALTH OF EVERYONE IN EVERY COMMUNITY IT’S IMPORTANT WE ENGAGE COMMUNITIES TO ENSURE THAT EACH INDIVIDUAL FEELS EMPOWERED AND THE COMMUNITY REALLY IS A PARTNER WITH US AS WE PROMOTE RESEARCH THAT DEVELOPED INNOVATIVE STRATEGIES TO REALLYISM PROF AN INDIVIDUAL HEALTH AND THE HEALTH OF THE OVERALL COMMUNITY WE HOPE AS PART OF OUR RESEARCH EFFORTS WE CAN DEVELOP BEST PRACTICES AND MODEL THAT EMPOWER PEOPLE TO TAKE CONTROL OF THEIR HEALTH AND TO ACT ON KNOWLEDGE IN WAYS THAT IMPROVES HEALTH OUTCOMES WE NOW HAVE THE CAPABILITY OF CONNECTING WITH HEALTH AND PROMOTING INTERVENTION THAT GOES BEYOND THE WALLS AND PERP — PERMEATES TO COMMUNITIES AND CAN CONNECT PEOPLE AND PATIENTS TOGETHER AND GROUPS TOGETHER QUICK — WITH FLOWS OF INFORMATION THAT ARE UNPRECEDENT ALL THE TOOLS AND TECHNOLOGIES CAN EXTEND SERVICES IN WAYS WE COULDN’T IMAGINE BEFORE IT’S AN OPPORTUNITY TO DEMOCRATIZE INFORMATION AND PUT IT IN THE HANDS AND EMPOWER PEOPLE AND PATIENTS AND COMMUNITIES WE THINK THIS COULD BE INCREDIBLY TRANSFORMATIVE IN ADDRESSING HEALTH INEQUITIES AS WE EVOLVE AND ENGAGE COMMUNITY TO WORK TOWARDS IMPROVING HEALTH >> I’M HEIDI NELSON FROM OREGON SCIENCE AND UNIVERSITY I’M GIVING THE SECOND PART OF OUR EVIDENCE REVIEW RESULTS FOR KEY QUESTION NUMBER TWO IMPEDIMENTS AND BARRIERS TO POPULATIONS I HAVE NO INFORMATION TO DISCLOSE I WANT TO ALSO ACKNOWLEDGE THE MEMBERS OF THE EVIDENCE-BASED PRACTICE AND TEAM LISTED IN THE SLIDE ALL RIGHT, IF ANYONE MISSED OUR FIRST PRESENTATION ON THE METHODS OF THE EVIDENCE REVIEW I WANT TO LET YOU KNOW THE DRAFT REPORT IS CURRENTLY POSTED ONLINE AND YOU’RE WELCOME TO LOOK AT THE REPORT IT WILL BE UP AT THE NEXT FOUR WEEKS AND SHOW YOU THE LINK AT THE END OF THE TALK AND WE OUTLINE THE METHODOLOGY AND THE DETAILS AND IN THE NEXT FEW MINUTES I’LL WALK YOU THROUGH THE RESULT FOR KEY QUESTION NUMBER TWO THIS QUESTION IS ABOUT THE EFFECT OF IMPEDIMENTS AND BARRIERS ON POPULATIONS AFFECTED BY SERVICE CONTRIBUTE TO DISPARITIES AND PREVENTATIVE SERVICES AND WHICH ARE MOST COMMON ONE HAD TO DO WITH IMPEDIMENTS AND BARRIERS IN THE PARTS OF MOW — PROVIDERS AND INCLUSIONS AND FOUND NO CITE TEAR — CRITERIA THAT MET QUESTION TWO

WE HAD 13 STUDIES THAT MET INCLUSION CRITERIA THESE INCLUDE COHORT STUDIES AND INCLUDED BEFORE AND AFTER STUDIES THESE ARE OFTEN USED IN DEMONSTRATING A NEW DIFFERENT INTERVENTION OR CHANGE AND WANTED TO INCLUDE THOSE AND SECONDARY ANALYSES OF RANDOMIZED TRIALS I WANT TO POINT OUT A COUPLE DESIGNS BEFORE AND AFTER STUDIES, SECONDARY ANALYSES OF DATA HAVE NO QUALITY REINING CRITERIA AND WE DON’T HAVE QUALITIES FOR THE DESIGNS THEY WON’T HAVE THOSE IN THE REPORT MOST OF THESE STUDIES HAD TO DO WITH CANCER SCREENING, THREE FOR COLORECTAL CANCER AND SEVEN FOR BREAST CANCER AND TWO ON SMOKING CESSATION SOME STUDIES REPORT A COUPLE KINDS OF CANCER SCREENING THEY’RE LISTED FOR EACH ONE SEPARATELY POPULATIONS WERE DEFINED IN MANY DIFFERENT WAYS THE MOST COMMON DESCRIPTION WAS A LOW-INCOME POPULATION THAT’S KIND OF VAGUE IN SOME SITUATIONS WE HAVE SOME RURAL POPULATIONS, STUDIES DONE IN HISPANIC POPULATIONS, AFRICAN AMERICAN, KOREAN AMERICAN AND CHINESE AMERICAN TRYING TO REFER TO THOSE AS WE GO OUR GOAL TO TRY TO HAVE ANY KIND OF CONCLUSIONS BASED ON A POPULATION FALLS APART WHEN WE ONLY HAVE 13 STUDIES AND PRACTICALLY EVERY STUDY IS IN A DIFFERENT POPULATION WE CAN’T REALLY DO THAT FOR THIS KEY QUESTION A REMINDER HOW WE GRADE THE STRENGTH OF EVIDENCE AND APPLICABILITY IT’S IT’S A SCORE HOW WELL AND CONFIDENT THE EFFECT IN THE STUDIES IS TRUE LOW MEANS LIMITED CONFIDENCE AND MORE EVIDENCE IS NEEDED BEFORE MAKING A STRONG CONCLUSION AND THE OTHER IS NO EVIDENCE IN THE CONFIDENCE WE HAVE AND THE OTHER IS HOW IT PLAYS OUT IN THE MAIN STREET OR REAL WORLD IF IT’S HIGH THE STUDIES WOULD BE APPLICABLE LOW MEANS IT APPLIES TO SELECTED POPULATION AND STILL USABLE BUT EXTRAPOLATING COULD BE EVIDENT AND WE’LL SHOW THE SCORES IN THE TABLES THAT STOLLO OR EACH SERVICE I’LL SHOW TABLE SET LOOKED LIKE THIS AND DESCRIBE THE SUMMARY OF EVIDENCE ON THE FAR LEFT SIDE OF THE TABLE WE LIST IMPEDIMENTS AND BARRIERS DESCRIBED IN THE STUDY THE NUMBER OF STUDIES, THE TYPE OF STUDY DESIGN AND NUMBER OF PARTICIPANTS LISTED IN THE NEXT COLUMN THE OVERALL EFFECT AND THEN FINALLY AT THE FAR END THE STRENGTH OF EVIDENCE IS THE FIRST LETTER IN THE APPLICABILITY OF THE SECOND LETTER SO L WOULD CORRESPOND TO LOW AND INS, INSUFFICIENT IT’S NOT TOO PROMISING IN REGARDS TO THE STRENGTH OF EVIDENCE I’LL WALK YOU THROUGH WHAT WE FOUND SOME STUDIES HAVE MULTIPLE IMPEDIMENTS AND BARRIERS AND ADDED UNDER EACH SOME REPORT MORE PREVENTIVE SERVICES IN COLORECTAL CANCER BUT FOR SCREENING THERE WERE THREE STUDIES LOOKING AT A BEAR — BARRIER OF LOW INCOME AND THE DISCREPANCIES OF INCOME ACROSS A POPULATION GROUP MAY NOT BE ENOUGH TO SHOW A LOW END HAD A BIG DIFFERENCE FROM THE HIGH END OF INCOME AND IT’S A SMALL STUDY WE GAVE IT A LOW LEVEL OF EVIDENCE CERTAINLY THERE’S MORE STUDIES THAT CAN BE DONE THAT WILL ANSWER THIS QUESTION FOR US LOOKING AT INSURANCE AS A POTENTIAL IMPEDIMENT OR BARRIER WE HAD TWO TRIALS WHICH INCLUDES THE FIRST I MENTIONED AND REPORTED INSURANCE STATUS IN ONE STUDY THERE WAS LESS SCREENING WITH MEDICARE COVERED PATIENTS COMPARED WITH DIFFERENT HEALTH PLANS OTHERWISE NO DIFFERENCE IN OTHER TYPES OF INSURANCE WITH THE COUNTY HEALTH PLAN OTHER TRIAL SHOWED NO TYPE OF INSURANCE WE HAD A MIXED ANSWER THERE SO EVIDENCE STRENGTH IS LOW APPLICABILITY LOW AND A THIRD BARRIER THAT WAS EVALUATED AND A DIFFERENT RANDOMIZED TRIAL WAS ATTITUDES TOWARDS SCREENING IN

AN AFRICAN AMERICAN POPULATION FOR COLORECTAL CANCER SCREENING AND FOUND HIGHER SCORES ON THE ATTITUDE SCALE WHICH MEANS THEY HAD A BETTER ATTITUDE WERE ASSOCIATED WITH A HIGHER RATE AND THEY MADE THE SCALE UP IT’S NOT A VALIDATED SCALE AND AN INDIRECT MEASURE IT’S HARD TO KNOW IF THAT MEANT WHAT WAS INTENDED SO THAT WOULD BE A STUDY THAT WOULD BE GOOD TO HAVE FOLLOW-UP OR ANOTHER STUDY VALIDATING WHAT THE ATTITUDES ARE ON THE SCALE NOT A STRONG SET OF STUDIES BUT AT LEAST THERE’S SOME AND THERE’S TRIALS I PROMISE THE PANEL IT GETS BETTER AS WE GO SO SOMETHING TO TALK ABOUT AS WE GO TO BREAST CANCER SCREENING WE HAVE MORE STUDIES I BELIEVE THERE’S SIX OR SEVEN OF BREAST CANCER SCREENING THAT LOOK AT IMPEDIMENTS AND BARRIERS ONE TRIAL OF OVER 1,000 WOMEN SHOWED AMONG NON-U.S. BORN LATINAS WOMEN WITH PUERTO RICAN COUNTRY OF ORIGIN HAD HIGHER SCREENING RATES THAN THOSE FROM MEXICO OR DOMINICAN REPUBLIC THERE WAS SOME EFFECT OVER THOSE GROUPS HOWEVER IT WAS ONE TRIAL SO EVIDENCE IS LOW LOOKING AT AGE IN ONE TRIAL OF LOW-INCOME CHINESE IMMIGRANT OLDER WOMEN WERE LESS LIKELY TO GET BREAST CANCER SCREENING THAN JUST ONE TRIAL A VERY SPECIFIC POPULATION LOW INCOME IN TWO TRIALS SHOWED NO EFFECT PROBABLY AMONG NOT A WIDE RANGE OF INCOME SO MAY NOT HAVE BEEN THE BEST STUDY AND WE HAD MORE ON INSURANCE YOU’LL SEE WE GOT MORE SCREENING VERSUS NO COVERAGE AND IS WHAT YOU’D EXPECT AND MORE SCREENING WHEN YOU’RE COVERED OTHER STUDIES SHOWED LOWER SCREENING WITH INSURANCE AND TWO STUDIES SHOWED NO EFFECT SO IT’S HARD TO SORT OUT THE REAL ANSWER AS MENTIONED BREAST CANCER SCREENING ARE CURRENTLY COVERED WITH NO DEDUCTIBLE WITH NO PUBLIC INSURANCE PLANS THE NUMEROUS STUDIES MAY NOT BE GOOD AT PULLING THIS OUT AND MAY NOT MEAN AS MUCH BUT WE GOT MIXED STUDIES FOR THE QUESTION AND THE FURTHER YOU LIVED FROM THE RADIOLOGISTS OFFICE THERE WAS LESS SCREEN AND WHEN YOU LIVED IN AN ECONOMICALLY DEPRIVED AREA THAT WAS A DISTANCE FROM THE RADIOLOGIST OFFICE THEY LOOKED AT THE EFFECT OF MAMMOGRAPHY VANS AND FOUND IT FIXED THE PROBLEM THAT’S THE KIND OF STUDY THAT’S USEFUL DISTANCE FROM SERVICE HAD AN EFFECT BUT THAT’S ONE STUDY LOOKING AT THE EFFECT OF A PROVIDER HAVING NO PROVIDER TWO STUDIES SHOWED THERE WAS LESS SCREENING WITH NO REGULAR PROVIDER AND NO EFFECT IN THE OTHERS THEN THE STUDY OF LOW INCOME CHINESE AMERICAN IMMIGRANT SAME LOOKED AT AGE LOOKED AT LANGUAGE AS A BARRIER AND FOUND NO EFFECT AMONG THAT GROUP OF WOMEN FOR SCREENING FOR BREAST CANCER SO WE HAVE SIX STUDIES OF CERVICAL CANCER SCREENING CONFINED TO WOMEN SOME ARE SAME STUDIES AR — AS FOR BREAST CANCER AND THE STUDY OF PUERTO RICAN BORN WOMEN SHOWED A HIGHER RATE FOR CERVICAL CANCER WHICH IS THE SAME WE FOUND FOR BREAST CANCER SO THAT WAS EFFECT THERE AS WELL ANOTHER STUDY OF LOW INCOME RURAL SHOWED NO EFFECT OF RATE AND COUNTRY OF ORIGIN SOME INFORMATION WAS HARD TO PULL OUT SO NOT SURE HOW HELPFUL IT WAS LOOKING AT OLDER AGE RURAL LOW-INCOME WOMEN AND FOUND LESS SCREENING FOR OLDER WOMEN IN THAT COHORT AMONG THAT GROUP OF PEOPLE WAS LOWER SCREENING FOR CERVICAL CANCER LOW INCOME IN ONE TRIAL SHOWED NO EFFECT AMONG LOWER INCOME WOMEN AND INSURANCE STATUS WE HAD FOUR STUDIES AND WITH ANY INSURANCE IN TWO STUDIES LESS SCREENING WITH NO INSURANCE SO THERE’S A MIXED MESSAGE

REGARDING INSURANCE SO ALL OF THESE REALLY WERE ONLY REACHING STRENGTH OF EVIDENCE OF A LOW LEVEL WE THOUGHT THE APPLICABILITY WAS SIMILAR LOW AND SMALL IN SMALL SPECIALIZED POPULATIONS AND RESULTS WERE UNCLEAR HOW TO APPLY THEM BUT IT’S A START WE HAD TWO STUDIES OF SMOKING CESSATION AND BOTH WERE DONE IN AFRICAN AMERICAN POPULATIONS ONE STUDY WAS THE ANALYSIS OF BASELINE DATA OF THE TRIAL INCLUDED BOTH AFRICAN AMERICAN AND WHITE SMOKERS AND ONE STUDY THAT COMPARED GROUPS THEY FOUND MOTIVATIONS FOR SMOKING DELIVERED BETWEEN AFRICAN AMERICAN AND WHITE SMOKERS BUT MOTIVATION DID NOT EXPLAIN THE LOWER QUIT RATE AMONG AFRICAN AMERICAN PARTICIPANTS WE GAVE IT AN INSUFFICIENT LEVEL AND THERE WERE DIFFERENCES MAYBE THEY’RE ON TO SOMETHING THERE AND LOOKING AT THE E OF NO PROVIDER THIS SHOWED HAVING A REGULAR SOURCE OF HEALTH CARE SHOWS ASSOCIATION WITH WANTING TO QUIT AND QUITTING AND LIGHT SMOKING THEY DIDN’T MEASURE QUIT RATES IN THE STUDY BUT THEY’RE GOOD SIGNS OF PERHAPS THINKING ABOUT QUITTING AS PART OF THE PROCESS OF QUITTING SMOKING THAT GOT A LOW LEVEL OF EVIDENCE THAT WAS ALSO IN AN AFRICAN AMERICAN POPULATION ADDING THESE UP, 13 STUDIES BUT THEY’RE KIND OF ALL OVER THE PLACE IN REGARDS TO WHICH IMPEDIMENTS AND BARRIERS THEY LOOKED AT AND SOME EFFECTS ON PREVENTIVE SERVICES AND LOOKING AT IMPEDIMENTS TO ONE CATEGORY AND ONE REGULAR PROVIDER AND NOT KNOWING WHERE TO GET SCREENED AND THE PROVIDER ISSUE SHOWED DECREASED SCREENING IN SOME STUDIES BUT NO EFFECTS IN OTHERS RESIDING IN DEPRIVED LOCATION FOR THE BREAST CANCER SCREENING STUDY SHOWED DECREASED IN THE STUDY LOW INCOME MOSTLY SHOWED NO EFFECT IF THE DIFFERENT STUDIES BUT WASN’T PARTICULARLY WELL EVALUATED IN THE STUDIES ATTITUDES AND PREVENTIVE SERVICES WE FOUND POSITIVE ATTITUDES FOR COLORE COLORECTAL SCREENING WAS A FACTOR AND SCREENING AMONG RURAL WOMEN AND CHINESE AMERICAN WOMEN COUNTRY OF ORIGIN DEPENDED IN ONE STUDY CONSISTENTLY SHOWED IT SHOWED INCREASED SCREENING WITH PUER PUERTO RICAN-BORN WOMEN SO WE HAD STUDIES TRYING TO GET TO OUR QUESTION MOST QUESTIONS REGARDED CANCER SCREENING AND IT’S THE RESEARCH WHERE PREVENTIVE SERVICES STUDIES DIFFERENT BY CAT GORE — CATEGORIZING THEM AND AS YOU KNOW THINGS CHANGE OVER TIME WE LOOKED AT HOW THEY WERE DEFINED BY INVESTIGATORS AND TOOK THE DATA AS THEY TOOK THEM BUT IF WE MAKE THEM MORE MEANINGFUL BY THE QUESTIONS WE HAVE ZA — TODAY WE’D PROBABLY DO IT DIFFERENTLY IT’S A STARTING POINT TO GET THE EVIDENCE BASED FILLED IN AND MOST RECRUITED HIGHLY SELECTIVE SAMPLES OF PATIENTS TO APPLYING THEM FOR MAKING GENERAL STATEMENTS ARE PROBABLY NOT WORTHY AT THIS POINT IT’S UNCLEAR HOW THEY APPLY TO OTHERS FUTURE RESEARCH INCLUDES RESEARCH TO TEST EFFECTS OF THE IMPEDIMENTS AND BARRIERS WE SAID WITH THE METHODS TALK

WE’RE NOT LOOKING AT ASSOCIATION STUDIES AND WANT TO KNOW AN EFFECT SIZE THE STUDIES WERE ABLE TO PROVIDE THOSE IN DIFFERENT WAYS THOSE ARE SUMMARIZED IN THE REPORT BUT TO GO THROUGH THE REPORT WOULD TAKE MORE TIME THAN WE HAVE AND WE NEED TO INCLUDE POPULATIONS OF SELECTIVE SERVICES NOT YET ADDRESSED IN THE MANY POPULATIONS INCLUDED YOU’LL SEE MORE INCLUDED IN THE DIFFERENT STUDIES WE HAVE SO WE DO HAVE GOOD REPRESENTATION OF SOME GROUPS BUT NO REPRESENTATION OF OTHER GROUPS WE NEED TO IMPROVE STUDY METHODOLOGY AND MEASURES TO OUTCOMES IT WILL CALL FOR UNIFYING CONSTRUCT AROUND THOSE OUR KEY MESSAGES AS A TAKEAWAY MOST COMMONLY SOMEONED PATIENTS WITH — EXAMINED WITH PATIENT STUDIES AND ADDITIONAL STUDIES SHOWED EVIDENCE THAT WAS INSUFFICIENT BECAUSE OF LACK OF STUDIES, SMALL AMOUNT OF PATIENTS AND SOME STUDIES WERE NOT RATED HIGHLY BY THEIR QUALITY MEASURES AS AN INDIVIDUAL STUDY EVIDENCE LIMITED BY THE HIGH HETEROGENEITY AND DIFFERENT OUTCOMES AND INCONSISTENT RESULTS I WANT TO GIVE YOU THE WEBSITE FOR THE FULL REPORT AND LOOK FORWARD TO YOUR REMARKS I HOPE WE CAN ADD A FEW MORE STUDIES TO THIS WE NEED TO SEE THE FINAL REPORT I’LL STOP HERE THANK YOU >> GOOD AFTERNOON THANK YOU VERY MUCH FOR THE ORGANIZERS INVITING ME HERE I’M NICO PRONK WITH HEALTH PARTNERS IN MINNEAPOLIS THE TOPIC IS TO TALK ABOUT THE ROLE OF BUSINESS AND INDUSTRY AND I MPROVING POPULATION HEALTH AND WELL BEING AND I HAVE NO INFORMATION TO DISCLOSE WE CAN GET STARTED RIGHT AWAY I’D LIKE TO START BY SETTING CONTEXT FOR HEALTH AND WELL BEING IN THE NATION ACROSS THE NEXT DECADE HEALTHY PEOPLE 2030 IS UNDERWAY AND THERE’S A DEFINITION OF HEALTH AND WELL BEING TO FOCUS IN ON THE ADDITIONAL CONCEPT OF WELL BEING IN ADDITIONAL TO THE EXISTING HEALTH DEFINITION ALREADY THERE HOW PEOPLE THINK, FEEL AND FUNCTION IN A PERSONAL AND SOCIAL LEVEL AND HOW TO EVALUATE THEIR LIFE AT A WHOLE IT HAS AN IMPACT ON HOW PRODUCTIVE THEY ARE AND WHAT THEIR PERFORMANCE IS LIKE AT WORK SO THE LINKAGE TO BUSINESS AND INDUSTRY AS A SECTOR IS EASILY MADE NEW TO HEALTHY PEOPLE 2030 IS A GROUPING OF FOUNDATIONAL PRINCIPLES THAT OUTLINE THE DECISIONS AND ACTIONS BY THE ADVISORY COMMITTEE IN THAT FRAMEWORK, YOU CAN TELL HEATH DISPARITIES AND EQUITY FEATURE PROMINENTLY AND THE CONTEXT OF HEALTH AND WELL BEING OF ALL PEOPLE AND COMMUNITIES BEING ESSENTIAL TO A THRIVING EQUITABLE SOCIETY SO THE LINKAGE TO BUSINESS IS EASILY MADE WHEN YOU THINK ABOUT THE GOALS FOR THE NATION FOR THE NEXT 10 YEARS AS THEY’RE BEING PUT FORTH IT’S ALSO IMPORTANT TO SEE HOW BUSINESS AND INDUSTRY ARE CONNECTED TO COMMUNITY IT’S CLEAR THAT WORK IS AN IMPORTANT SOCIAL DETERMINATE AND PEOPLE WHO ARE HEALTHY AND WELL TEND TO BE AT WORK MORE OFTEN THAN NOT THEY HAVE A HIGHER LEVEL OF PERFORMANCE WHILE AT WORK THEY HAVE MORE OF A PHYSICAL AND MENTAL CAPACITY TO DO WORK AND THEY’RE MOTIVATED TO DO THE JOB WELL BUSINESS ON THE OTHER HAND NEEDS PRODUCTIVE WORKERS SO THE CONNECTION BETWEEN THE TWO IS QUITE STRONG IN ADDITION TO THAT, BUSINESS IS THE MAIN ECONOMIC ENGINE FOR A COMMUNITY AS WELL THERE’S LINKAGE TO AN ECONOMICALLY THRIVING COMMUNITY AND SHOULD INCLUDE BUSINESS AND COMMUNITY AS A SECTOR AT THE TABLE NOW EVER ORGANIZATION WHETHER IT’S PROFIT OR NAUGHT — NOT FOR PROFIT OR PRIVATE IS AN

IMPACT ON HEALTH ONE WAY IS THROUGH COMMUNITY HEALTH AND WHAT’S THE RELATIONSHIP AN ORGANIZATION HAS TO THE COMMUNITY AND LOCATIONS AND EMPLOYEE HEALTH THE HEALTH AND SAFETY OF THE WORKERS THEMSELVES AND ENVIRONMENTAL HEALTH WHAT’S THE IMPACT OF THE BUSINESS AND FOOTPRINT, IF YOU WILL, BUSINESS EAVES BEHIND ON THE ENVIRONMENT AND CONSUMER HEALTH, HOW DOES THE BUSINESS EFFECT THE CONSUMERS OF ITS PRODUCTS AND SERVICES SO THINKING ABOUT WHAT BUSINESS AND INDUSTRY CAN DO TO BUILD IN A SENSE A CULTURE OF HEALTH AND WELL BEING INSIDE OF ITS OWN ORGANIZATIONS, WHEN A BUSINESS DOES THIS INTENTIONALLY THERE’S GOOD OUTCOME THERE’S LOTS OF INDICATORS SHOWING IN THE PROCESS OF BUILDING THERE’S A REDUCTION OF COST AND INCREASE IN REVENUE AND PROFITS SWELLS ENHANCEMENT OF — AS WELL AS ENHANCEMENT OF REPUTATION AND BUSINESS BECOMING THE EMPLOYER OF CHOICE A COUPLE EXAMPLES, ONE IS FOR EXAMPLE THE EMPLOYER THE EMPLOYMENT SECTORS WITH UNHEALTHY WORKFORCES TEND TO BE MORE LIKELY LOCATED IN COUNTIES WITH POOR HEALTH THIS ANALYSIS LOOKS ACROSS MORE THAN 3100 COUNTIES ACROSS THE UNITED STATES AND MANUFACTURING SECTOR THE RED DOTS ARE ASSOCIATED WITH HIGHER PREVALENCE OF SMOKING, OBESITY, DIABETES AND CARDIOASCULAR DISEASE RELATED DEATH IF YOU’RE IN THE MANUFACTURING SECTOR AS A BUSINESS BUT IN A COUNTY WITH HEALTH IS HIGHER THAN THE COUNTY OVER, YOU START WITH AN ADVANTAGE COMPARED TO YOUR COMPETITION IS HEALTH IS IMPORTANT AND HEALTH IS IMPORTANT IN TERMS OF PERFORMANCE OF THE COMPANY WITH THE MARKETPLACE THIS IS THE ANALYSIS USING WINNERS OF THE CORPORATE HEALTH ACHIEVEMENT AWARD HANDED OUT BY THE COLLEGE OF OCCUPATIONAL ENVIRONMENTAL MEDICINE WHEN BUSINESSES ARE AWARDED THE CORPORATE HEALTH ACHIEVEMENT AWARD, THEY WERE PUT INTO CATEGORY AND USING MODELING FOR OTHER COMPANIES IN THE S&P 500 AND MODELING OF PORTFOLIO OF INVESTMENT PLAYED OUT OVER THE COURSE OF 12 TO 13 YEARS BASICALLY THE ANNUALIZED RETURNS COMPARE TO THE S&P 500 ARE A 5% DIFFERENCE IN TERMS OF ANNUAL RETURNS THIS IS A STRONG FINANCIAL PERFORMANCE INDICATOR FOR BUSINESS THAT SUPPORTS THE IDEA OF BUILDING STRONG CULTURES OF HEALTH AND WELL BEING IN THE WORKPLACE AS A BACKDROP I’D LIKE TO WORK YOU THROUGH TWO EXAMPLES OF INTENTIONAL BUSINESS ATTORNEY GENERALS EMPLOYED BY HEALTH PARTNERS AS A HEALTH SYSTEM TO LINK EMPLOYERS TO COMMUNITY BUT ALSO WITH AN EYE ON IMPROVING HEALTH AND ADDRESSING HEALTH EQUITY THE FIRST IS AROUND PERSONALIZATION TO ADDRESS HEALTH DISPARITIES PARTICULARLY USING APPROACHES THAT INCORPORATE MACHINE LEARNING AND USE COLORECTAL SCREENING AND WHEREAS THE MEASUREMENT AND REPORTING OF POPULATION HEALTH AND WELL BEING USING MEASURES IS A STRATEGIC EXAMPLE AND AT ANY GIVEN TIME THERE’S MEMBER CAMPAIGNS GOING ON IN THE HEALTH SYSTEM NOW IN A HEALTH SYSTEM THAT’S INTEGRATED WHERE THEY’RE CONNECT HEAD TO FINANCING OF THE CARE THERE’S STRONG REASONS WHY YOU WANT PEOPLE TO COME IN FOR PREVENTIVE SCREENINGS IN THIS EXAMPLE WHILE THERE’S MEMBER CAMPAIGNS GOING ON, THE FOCUS WOULD BE ON THE FOUR THAT ARE HIGHLIGHTED IN BLUE AND I’LL HIGHLIGHT IN PARTICULAR THE KOL KOL — COLONOSCOPY REMINDER SEASON THINK OF THE ALERTS YOU GET ON YOUR CARS YOU GET MAIL THAT SAYS IT’S TIME TO GET YOUR STICKER AND YOU FOLLOW THE PROCESS AND EVERYTHING MOVES ALONG FINE IF YOU DON’T YOU END UP WAY

TICKET OR SOMETHING IS THIS SIMILAR HERE WE HAVE A POPULATION OF PEOPLE NOT IN ADHERENCE FOR THE CLINICAL SERVICES GUIDELINE SO THE HEALTH SYSTEM GENERATES A REMINDER, A NUDGE THEY’RE NOW SET UP TO OPTIMIZE MACHINE LEARNING SO AT EVERY INTERACTION AND ITERATION THE SYSTEM GETS SMARTER ABOUT HOW TO CONNECT WITH INDIVIDUALS AND THEY ARE CREATE AT THE LEVEL OF THE PERSON FOR COLONOSCOPY THERE’S A GROUP OF A LITTLE OVER 30,000 PEOPLE NOT IN COMPLIANCE WITH THE SCREENING WE KNOW THE BEST SCREENING TOOL IS THE ONE BEING USED WE SENT OUT A FIT KIT TO 35,000 AND OUT OF THE POSITIVE TESTS 186 FOLLOW-UPS THAT’S A 48% FOLLOW-UP RATE AND OF THOSE 128 SCREENING CONDUCTED AND 80 PEOPLE ENDED UP PREVENT CANCER WITH THE POLYPS OR TO TREAT CANCER IN THE MALIGNANCY CASES AT THE SAME TIME THE EFFORT NARROWED THE SCREENING GAP BETWEEN WHITE AND RACIAL AND ETHNIC MINORITY PATIENTS FROM 11.5% TO 7.6% IN A SINGLE YEAR IT NARROW THE GAP AS WELL AS INCREASING THE COLONOSCOPY SCREENING RATES WHICH SIT NOW AT 82% IN THE SYSTEM THE SECOND EXAMPLE IS MORE OF THAT STRATEGIC APPROACH IS RELATED TO USING SUMMARY MEASURES FOR HEALTH AND WELL BEING IN OUR SYSTEM THE MISSION STATEMENT NOR ORGANIZATION IS VERY MUCH CENTERED AROUND HEALTH AND WELL BEING AND IMPROVING THE HEALTH AND WELL BEING OF OUR MEMBERS, PATIENTS AND COMMUNITY WHEN YOU’RE ASKED TO REPORT ON THE PROGRESS OF THAT MISSION STATEMENT IT’S HARD TO DO IF YOU DON’T HAVE A SET OF MEASURES THAT CAN ACTUALLY REPRESENT THAT SO WE ENDED UP CREATING OUR SUMMARY MEASURES WHICH ENDED UP BEING THREE INDICATORS ONE AROUND CURRENT HEALTH WHICH IS REALLY AN INDICATOR BASED ON A CLAIMS-BASED MEASURE USING A GLOBAL DISEASE COEFFICIENT AND DIAGNOSIS FROM THE MEDICAL RECORD AND LINKING THAT TO MORBIDITY AND MORTALITY FUTURE HEALTH IS A SURVEY BASED MEASURE OF BEHAVIORS THE SUSTAINABILITY IS LINKED TO PHYSICAL ACTIVITY LEVELS, TOBACCO USE, SLEEP, HEALTHY THINKING WHICH WE ASKED PEOPLE TO REFLECT ON THE GOOD THINGS THAT HAPPED TO THEM IN THEIR LIFE — HAPPENED TO THEM IN THEIR LIFE AND ADHERENCE TO CLINICAL PREVENTIVE SERVICES BECAUSE WE DO HAVE THIS WELL BEING IN OUR MISSION STATEMENT, HOW DO WE REPORT ON WELL BEING? IT’S THROUGH LIFE SATISFACTION WITHOUT DOING DEEPER IN THE METHODOLOGY SOME LEARNING IS WE CAN MEASURE HEALTH BURDENS ACROSS THE ENTIRE ORGANIZATION AND UNPACK IT TO LOOK AT DIFFERENT POPULATIONS THIS IS THE EXAMPLE ACROSS THE MEMBERSHIP AND THE HEALTH BURDEN IS 31% SO 69% OF WHAT HEALTH COULD BE OF THAT 31% BURDEN IN THE ENGLISH-SPEAKING POPULATION, 45% OF THAT BURDEN COMES FROM THREE CATEGORIES, MUSCULOSKELETAL, PSYCHOSOCIAL AND NEUROLOGIC CONDITIONS AMONG OTHER POPULATIONS THE SAME DRIVERS OF BURDEN NEUROLOGIC CONDITIONS IS THE LARGEST

FOLLOWED BY MUSCULOEXCEL CAL — MUSCULOSKELETAL AND PSYCHOLOGICAL AND IN SPANISH SPEAK AT 40% OF THE BURDEN IS REPRESENTED BY THREE STARTING IN MUSCULOSKELETAL AND PSYCHOSOCIAL IT’S INTERESTING TO SEE THE DRIVERS ARE THE SAME BUT NOT IN THE SAME PRIORITY ON AVERAGE WE SEE HIGH RATING OF A 9 OR 10 OF A RATING OF 1 TO 10 THOSE ARE THE FOLKS THRIVING IN THEIR LIVES THE ONES SUFFERING ARE RATING BETWEEN 0 AND 6 WHEN WE LOOK ACROSS INSURANCE PRODUCTS NOTICE MEDICARE AND COMMERCIAL ARE ALMOST IDENTICAL BUT MEDICAID IS LAGGING THAT’S WHERE MOST THE BURDEN COMES FROM IN TERMS OF WELL BEING WE SEE THE SPANISH SPEAKING POPULATIONS DO BETTER IN TERMS OF INDICATORS THE [INDISCERNIBLE] POPULATION BECAUSE IT’S FAIRLY SMALL ARE SUFFERING 26% ACROSS THE BOARD HERE THIS IS AN EXAMPLE WHERE WE USED SUMMARY MEASURES AS AN INDICATOR TO SET STRATEGY ON THE BUSINESS SIDE OF RUNNING THE HEALTH SYSTEM SO POPULATION HEALTH STRATEGIES ACROSS THE SYSTEM HELP US IDENTIFY HEALTH AND WELL BEING DISPARITIES IN USING THE SUMMARY MEASURED KIND OF APPROACH AND UNPACKING THAT AND DELVING DEEPER INTO WHERE THE DISPARITIES ARE LOCATED IT ALSO HELPS US LOOK AT DATA ACCORDING TO POPULATIONS OF INTEREST ADDRESSING HEALTH EQUITY ISSUES AND ASSESS THE INTERVENTIONS OF POPULATION HEALTH THIS IS THE INCREASE IN PREVENTIVE SERVICES COMES IN AS AN INTERVENTION TO RELIEF BURDEN — RELIEVE BURDEN MOVING BACK TO THE BUSINESS AND INDUSTRY SECTOR INTEREST WE BELIEVE PUBLIC HEALTH CAN LEVERAGE BUSINESS AND INDUSTRY AS A WAY TO IMPROVE HEALTH AND WELL BEING ACROSS THE COMMUNITY FOR THAT TO HAPPEN, BUSINESS INDUSTRY HAS TO BE ACTIVELY ENGAGED IN THE PROCESS OF SHAPING A NARRATIVE AROUND HEALTH EQUITY THEY ARE AN IMPORTANT PARTNER IN PREVENT WIDENING OF HEALTH DISPARITIES WHAT WE NEED TO SEE GOING FORWARD IS MORE LEADERSHIP INITIATIVE LEADERSHIP ON THE BUSINESS SIDE CONNECTING WITH LEADERSHIP ON THE PUBLIC HEALTH SIDE TO CREATE PARTNERSHIPS THAT ARE FOCUSSED AND DESIGNED AROUND CREATING SHARED VALUE THE IDEA OF CREATING SHARED VALUE WOULD MAKE SURE THERE’S AB A SUBSTANTIAL SOCIETAL BENEFIT TO PARTNERSHIPS WHILE ADDRESSING THE VIABILITY OF THE BUSINESS ORGANIZATIONS AS WE’RE CONCLUDING WE SHOULD LOOK AT THE MASS PERSONALIZATION APPROACHES OF PREVENTIVE SCREENING SUDDENLY TO CONDUCT QUALITATIVE RESEARCH WITH PUBLIC HEALTH AND BUSINESS LEADERS ABOUT THE MOST IMPORTANT AREAS TO ADDRESS IN ACHIEVING HEALTH AND WELL BEING, ELIMINATING HEALTH DISPARITIES, ADDRESSING HEALTH EQUITY AND OBTAINING HEALTH LITERACY THIRD, TO MAKE DISEASE INCIDENT AND OUTCOME OF CHOICE TO HIGHLIGHT THE IMPACT OF DISEASE PREVENTION RATHER THAN SPENDING TOO MUCH TIME ON PREVALENCE ALONE FOURTH TO EXPLORE UNEXPLAINED VARIATION IN HEALTH DISPARITIES USING MIXED METHODS AND COMPLEX SYSTEMS SCIENCE APPROACHES AND TO THINK ABOUT THAT AS RESEARCH COULD BE DONE IN SYSTEMS THAT HAVE RESEARCH AND FINALLY TO DEPLOYED AN APPROACH TO LEARNING, KNOWING AND DOING TO CONNECT RESEARCH THROUGH EDUCATION AND PRACTICE AND FACILITATE A MORE RAPID CYCLE BETWEEN RESEARCH AND HOW TO APPLY THAT RESEARCH IN

PRACTICE WITH THAT I’M GOING CONCLUDE AND LOOK FORWARD TO DISCUSSION THANK YOU >> GOOD AFTERNOON MY NAME IS VANI SIMMONS OF THE MOFFE MOFFE MOFFETT CANCER CENTER LIKE TO THANK THE PLANNERS AND IN PARTICULAR THOSE IN PLANNING IT’S IMPORTANT TO LOOK AT WHERE SMOKING FALLS IN PREVENTIBLE CAUSES OF CANCER AS WE CAN SEE FROM THE SLIDE WHEN WE LOOK AT THE DIFFERENT PREVENTIBLE CAUSES OF CANCER, WE CAN SEE WHEREAS 2% OF ALL CANCER DEATHS ARE ATTRIBUTABLE TO SUN EXPOSURE OVER ONE THIRD OF ALL CANCER DIAGNOSES ARE FROM TOBACCO USE AND IF WE CAN GET EVERYONE TO QUIT SMOKING IT WOULD ELIMINATE ONE-THIRD OF ALL CANCER DEATHS THE GOOD NEWS IS WE’VE SEEN A DROP IN SEVERAL YEARS BUT ONE THING TO NOTE IS SMOKING PREVLENCE VARIES FROM RACE AND ETHNICITY IT’S HIGHEST AMONG AMERICAN INDIANS AND MULTIRACIAL INDIVIDUALS AND THE LOWEST SMOKING PREVALENCE RATES ARE AMONG ASIANS AND HISPANIC INDIVIDUALS IT’S NOTEWORTHY AMONG HISPANIC INDIVIDUALS THERE’S A DEAL OF VARIABILITY DEPENDING ON ETHNICITY CUBANS AND PUERTO RICANS HAVE HIGH RATES AND DOMINICAN INDIVIDUALS HAVE LOWER SMOKING PREVALENCE RATES IN ADDITIONAL TO OVERALL THERE’S DIFFERENCES IN SMOKING Y PATTERNS AS YOU SEE FROM THE BAR GRAPH, WHAT YOU’LL NOTE IS THERE ARE GREATER RATES OF NON-DAILY SMOKING AMONG PARTICULAR GROUPS SUCH AS HISPANICS AND BLACKS ON THE OTHER SIDE YOU’LL SEE THERE’S ALSO VARIABILITY WITH RESPECT TO CIGARETTES PER DAY IF YOU LOOK AT THOSE ADULTS SMOKING LESS THAN 10 CIGARETTES PER DAY YOU’LL NOTE THAT INDIVIDUALS WHO ARE HISPANIC OR ASIAN HAVE MUCH HIGHER PREVALENCE OF SMOKING AT THE LOWER SMOKING RATE IT MEANS THESE ARE DIFFERENCES IN SMOKING PATTERNS THAT MUST BE CONSIDERED AS WE THINK ABOUT DEVELOPING TARGET INTERVENTIONS FOR THESE POPULATIONS FORTUNATELY TO BE ABLE TO CONTINUE TO SUPPORT A DECLINE IN SMOKING PREVALENCE RATES, WE HAVE SEVERAL EVIDENCE-BASED SMOKING INTERVENTIONS OFFERED TO SMOKERS THEY’RE SUMMARIZED IN THE PUBLIC HEALTH CLINICAL GUIDELINES IMPORTANTLY, IMPLEMENTATION OF THESE GUIDELINES AND OF THESE EVIDENCE-BASED STRATEGIES CAN BE BEST THOUGHT OF IN TERMS OF THE FRAMEWORK AND WHAT THIS BRIEF CLINICAL INTERVENTION ADVISES IS ENSURING WE SHOULD ASK ABOUT INTERVENTION AND ADVISE SMOKERS TO QUIT SUCH AS A PROVIDER THE MOST IMPORTANT THING YOU CAN DO FOR YOUR HEALTH IS QUIT SMOKING WE NEED TO ASSESS AN INDIVIDUAL WILLINGNESS TO MAKE A QUIT ATTEMPT AND ASSESS IN THE QUIT ATTEMPT AND ARRANGE FOR FOLLOW-UP IN TERMS OF CLINICAL INTERVENTIONS WE HAVE HELP

INCREASE THEIR IMPLEMENTATION OF SMOKING CESSATION SERVICES FOR PATIENTS AND IMPROVES THE WAY THE ELECTRONIC HEALTH RECORD IS LEVERAGED THEY’RE IMPORTANT BECAUSE WE KNOW 25% OF SMOKERS ARE PROVIDED WITH SOME FORM OF COUNSELING IN THEIR ATTEMPTS TO QUIT SMOKING IN TERMS OF ASSISTING SMOKERS WE HAVE SEVERAL INTERVENTIONS WE KNOW THE MOST EFFICACIOUS INTERVENTION WILL BE A COMBINATION OF BEHAVIORAL COUNSELLING PLUS PHARMACO THERAPY IT CAN COME IN THE FORM OF SEVERAL FDA APPROVED NICOTINE REPLACEMENT THERAPIES SUCH AS GUM OR PATCH OR INHALERS AND PROVIDING EVIDENCE-BASED SERVICES GOES BACK TO THE E.H.R AS ONE PROMISING STRATEGY IN FACT ONE APPROACH THAT MANY HOSPITALS ARE NOW TAKING WHICH HAS BEEN SHOWN TO BE EFFECTIVE IS CREATING E-REFERRALS WITHIN THE ELECTRONIC RECORD THIS IS PARTICULARLY IMPORTANT IN SETTINGS IN WHICH RESOURCES ARE LIMITED DISPOI DISPOINT PIET — DESPITE THE FACT GUIDELINES APPLY TO ALL MINORITIES AND RACES WE KNOW THERE’S BARRIERS IN TERMS OF RECEIVING SERVICES ONE SUCH GROUP IS HISPANIC SMOKERS DESPITE BEING THE LARGEST AND FASTER GROWING MINORITY GROUP, THERE’S SURPRISINGLY FEW SPANISH ARE EVIDENCE BASED.SOURCES THAT WE ALSO KNOW FROM THE RESEARCH THAT HISPANIC INDIVIDUALS AND THOSE OF LOWER SOCIOECONOMIC BACKGROUND ARE LESS LIKELY TO RECEIVE TOBACCO SCREENING AND COUNSELLING AND INCREASED FINANCIAL STRAIN HAS BEEN SHOWN TO BE ASSOCIATED WITH POOR QUITTING RATES AMONG THOSE WHO ARE ATTEMPTING TO QUIT SMOKING WE KNOW HISPANIC SMOKERS ARE LESS LIKELY TO SEE THEMSELVES AS ADDICTED AND MAY BE RELATED TO MORE THE NON-DAILY OR INTERMITTENT SMOKING AND LESS LIKELY TO USE NICOTINE REPLACEMENT THERAPIES FINALLY, WITH GREATER ACCULTURATION HISPANICS SHOW LOWER LEVELS OF PERCEIVED RISK FROM THEIR CONTINUED SMOKING OUR RESEARCH GROUP HAS RECEIVED FUNDING THE NATIONAL CANCER INSTITUTE AND STATE OF FLORIDA BIOMEDICAL PROGRAM TO TEST THE EFFICACY OF A SMOKING CESSATION INTERVENTION FOR SPANISH-SPEAKING SMOKERS THE FIRST STEP IN THE INTERVENTION WAS A SYSTEMATIC PROCESS WE UNDERTOOK WHERE WE CONDUCTED FORMATIVE WORK WITH HISPANIC SMOKERS TO BE ABLE TO TRANS THIS IS CREATE A SET — TRANSCREATE EFFICACIOUS MATERIALS TO HELP SMOKING BY TRANS-CREATE IS NOT ONLY TRANSLATE THE INFORMATION BUT TO CULTURALLY ADAPT OUR INTERVENTION SPECIFICALLY FOR THIS POPULATION IN CONDUCTING OUR FORMATIVE WORK WITH THIS POPULATION SEVERAL KEY THINGS EMERGED THAT WERE CRITICAL TO ADAPTING OUR INTERVENTION SPECIFICALLY FOR THIS POPULATION FOR INSTANCE, ONE OF THE KEY THEMES THAT EMERGED WAS THE IMPORTANCE OF FAMILY FAMILY WAS SEEN TO BE BOTH A MOTIVATOR FOR HELPING PEOPLE TO QUIT SMOKING BUT ALSO IN TERMS OF DEALING WITH STRESS RELATED TO FAMILY WAS SEEN AS A STRESSOR RELIGION AND SPIRITUALITY WAS A COMMON THEME EXPRESSED BY OUR PARTICIPANTS IN THE FOCUS GROUP AND SEEN AS A SUPPORT WHEN QUITTING SMOKING IN TERMS OF TRIGGERS FOR SMOKING THERE WERE UNIQUE TRIGGERS EMPHASIZED FOR EXAMPLE, ONE WAS COFFEE WHICH WAS SEEN AS PART OF THE SOCIAL CULTURE AND WAS A STRONG ASSOCIATE AND CUE FOR SMOKING AMONG SEVERAL SMOKERS WE TALKED TO

AND KEY STRESSORS RELATE HEAD TO IMMIGRATION EXPERIENCE THESE RELATED TO DIFFICULTIES IN LANGUAGE, PROBLEMS WITH FINANCES AND TRANSPORTATION AND LACK OF COMMUNITY FELT TO BE A UNIQUE STRESS STRESSOR FOR THIS POPULATION SIMILAR TO PRIOR RESEARCH, OUR PARTICIPANTS HELD SEVERAL NEGATIVE PERCEPTIONS ABOUT PHARMACO THERAPY FOR SMOKING CESSATION AND HAD MYTHS ON NICOTINE REPLACEMENT THERAPY FOR EXAMPLE, THERE WAS CONCERN THEY’D BECOME ADDICTED TO WHATEVER REPLACEMENT PRODUCT THEY WERE USING AND A FEAR THAT THE NRT WOULD NOT BE EFFECTIVE BASED ON THINGS THEY HEARD THIS INFORMATION WAS VERY INFORMATIVE IN ADAPTING THE INTERVENTION FOR THE HISPANIC POPULATION OF SPANISH SPEAKING SMOKERS AND FOR OUR SPANISH INTERVENTION WHICH WAS EFFICACIOUS AND COST EFFECTIVE IN SMOKING CESSATION WE MADE TWO CHANGES WE CREATED A BOOKLET AS PART OF THE EXTENDED SELF-HEP INTERVENTION DESIGNED FOR FRIENDS OR FAMILY MEMBERS SUPPORTING AN INDIVIDUAL THE OTHER THING ABOUT THIS SELF-HELP INTERVENTION WE CHANGED BASED ON OUR FORMATIVE FEEDBACK WAS WE LEARNED SOME PIECE OF A PERSONAL CONNECTION WAS DISCOVERED WHERE OUR SPEAKING INTERVENTION WAS DONE THROUGH THE MAIL WE ADDED A BRIEF TELEPHONE CONTACT TO ESTABLISH A RAPPORT AND INTRODUCE PARTICIPANTS TO THE INTERVENTION WE ALSO GOT A LOT OF GREAT SUGGESTIONS WITH RESPECT TO THE VISUAL COMPONENTS OF THE INTERVENTION IN TERMS OF WANTING BOLD AND VIVID COLORS AND WANTING SIM BOWLS OF DIFFERENT — SYMBOLS OF DIFFERENT HISPANICS AND ETHNICITIES AND WITH A GREAT HETEROGENEITY AMONG THE POPULATION AND THINK OF INCREASING THE NUMBER OF INTERACTIVE COMPONENTS FOR PARTICIPANTS TO COMPLETE IN THE SELF-HELP INTERVENTION WE CURRENTLY COMPLETED RECRUITMENT FOR THE RANDOMIZED TRIAL WHERE WE’RE RANDOMIZING INDIVIDUALS TO USUAL EXISTING CARE AN NCI BOOKLET OR TARGETED INTERVENTION AND AFTER PARTICIPANTS ENROLL AND COMPLETE A BASELINE WE CONDUCT FOLLOW-UP ASSESSMENTS EVERY SIX MONTHS THEREAFTER TO CAPTURE SMOKING STATUS AND VERIFICATION OF SMOKING STATUS AMONG A SMALL SUBSAMPLE OF PARTICIPANTS WE RECRUITED OVER 1400 CIGARETTE SMOKERS ACROSS THE COUNTRY AND HALF OF OUR SAMPLE IS FEMALE AND WE BELIEVE WE REACHED QUITE AN UNDER SERVED POPULATION IN THAT ONE-THIRD HAS LESS THAN A HIGH SCHOOL EDUCATION AND 41% OF OUR SAMPLE HAS A HOUSEHOLD INCOME BELOW $10,000 WE HAVE A GREAT DEAL OF SUBETHNICITY VARIABILITY WHICH IS IMPORTANT TO US AND ADVANCES THE FIELD IN THAT WE HOPE TO BE ABLE TO LOOK AT HOW OUR INTERVENTION MIGHT BE EFFICACIOUS AMONG DIFFERENT ETHNIC GROUPS OUR POPULATION ALSO HAS A SIGNIFICANT TOBACCO SMOKING HISTORY BURY MOVE ON I WANT TO UNDERSCORE THIS REPRESENTS ONE OF THE FEW RANDOMIZED TRIALS IN THE POPULATION SO A GAP AND AREA IN FUTURE RESEARCH IS TO LOOK AT DEVELOPING TARGETED EFFICACIOUS INTERVENTIONS FOR THE POPULATION ANOTHER SPECIAL POPULATIONS THAT DESERVES PREVALENCE AMONG SEXUAL MINORITIES IT’S HIGHER, 20% OF LGB ADULTS SMOKE CIGARETTES COMPARED TO 15.3% OF HETEROSEX ULES THIS CAN — SEXUALS THIS CAN BE SEEN AS A HEALTH DISPARITY SEEN AND THE LANDSCAPE OF TOBACCO USE IS SHIFTING WITH THE TREND OF ELECTRONIC CIGARETTES INCREASING POPULARITY WHILE ETHNIC AND RACIAL MINORITIES ARE LESS LIKELY TO USE E-CIGARETTES, LGBTQ INDIVIDUALS HAVE HIGHER RATES OF USE THOUGH THERE’S A LACK OF DATA AMONG THE POPULATION, IT’S CLEAR THAT THERE ARE MANY BARRIERS TO TOBACCO CESSATION AND MOTIVATORS FOR SMOKING THAT HAVE BEEN

DOCUMENTED IN THE LITERATURE FOR THE POPULATION THAT VERY WELL CAN BE RELATED TO E-CIGARETTE USE AS WELL THE EXAMPLES INCLUDE FEELINGS OF DISCRIMINATION, NEGATIVE REACTIONS TO DISCLOSURE OF SEXUAL IDENTITY, DISCOMFORT WITH SEXUAL IDENTITY, GREATER RATES OF STRESS, DEPRESSION AND ALCOHOL USE AND TARGETING OF TOBACCO COMPANIES DIRECTLY TO THIS POPULATION WE HAD AN OPPORTUNITY TO USE BASELINE DATA FROM AN ONGOING RANDOMIZED CONTROL TRIAL THAT WE HAVE TESTING THE EFFICACY OF A SMOKING CESSATION INTERVENTION FOR DUAL USERS OF TOBACCO AND ECIGARETTES WE HAD OVER 500 PARTICIPANTS WHO IDENTIFIED AS LGB WE EXPLORED DIFFERENCES AMONG LGB AND HETEROSEXUAL PARTICIPANTS IN THE SAMPLE WE FOUND THE POPULATIONS DEMONSTRATED SIMILAR SMOKING AND VAPING PATTERNS, HOWEVER, THERE WERE SIGNIFICANT DIFFERENCES AS WELL SEXUAL MINORITY INDIVIDUALS IN OUR SAMPLE DEMONSTRATED SHORTER HISTORIES OF SMOKING AND LOWER NICOTINE DEPENDENCE HOWEVER, WE ALSO SAW THAT AFTER STARTING ECIGARETTES THEY DEMONSTRATED A LOWER REDUCTION OF TRADITIONAL CIGARETTE USE THAN WHAT WE SAW WITH HETEROSEXUALS WE FOUND SEXUAL MINORITY INDIVIDUALS REPORTED THEY WERE VAPING IN PLACES WHERE SMOKING WAS FORBIDDEN AND USING IT AS A SUBSTITUTE IN THOSE SITUATIONS AND LESS MOTIVATED TO QUIT SMOKING SO SEXUAL MINORITY INDIVIDUALS MAY BE AT GREATER RISK AND UNDER SCORE THE IMPORTANCE OF FUTURE RESEARCH AND DIFFERENCES BASED ON SEXUAL ORIENTATION S WE DEVELOP TARGETED INTERVENTION WE MAY NEED TO FACTOR IN ECIGARETTE PATTERNS AS WELL I’LL SWITCH GEARS AND TALK ABOUT LUNG CANCER BECAUSE IT REPRESENTS THE CANCER TYPE THAT’S MORE STRONGLY ASSOCIATED WITH SMOKING IN FACT, 90% OF MEN DIAGNOSED WITH LUNG CANCER HAVE A HIGHER PERCENTAGE OF SMOKING AND 80% OF WOMEN HAVE A HISTORY OF SMOKING THERE’S ALSO SIGNIFICANT HEALTH DISPARITIES AND AFRICAN AMERICANS ARE MORE LIKELY TO DEVELOP AND DIE FROM LUNG CANCER THAN PERSONS OF ANY OTHER RACIAL OR ETHNIC GROUP AS WE’VE TALKED ABOUT THE CAUSE OF THE POOR OUTCOMES ARE LIKELY MULTIFACTORIAL THERE’S HEALTH CARE SYSTEM BARRIERS SUCH AS LACK OF INSURANCE AND ACCESS TO CARE BUT AS A PSYCHOLOGIST, OTHER AREAS THAT CAN BE SEEN RELATED AS A BARRIER AND RESULT IN LATE PRESENTATION OF DISEASE HAVE BELIEFS AND ATTITUDES AND CULTURAL FACTORS FOR EXAMPLE, THERE’S A COMMON BELIEF AMONG MINORITIES AND INDIVIDUALS LACK POWER OVER ASPECTS AND THEY’RE LIKELY TO BELIEVE EVERYTHING THAT HAPPENS IS PART OF GOD’S PLAN AND THEY HAVE LESS POWER OVER THEIR HEALTH WE ALSO KNOW MEDICAL MISTRUST A COMMON BARRIER IN TERMS OF THINKING THE HEALTH CARE SYSTEM AND THE EMPLOYEES ARE UNTRUSTWORTHY WE KNOW MINORITIES ARE LESS LIKELY TO BELIEVE DOCTORS HAVE THEIR BEST INTEREST IN MIND AND THEY CAN RESULT IN DELAYS AND TREATMENT AND LESS LIKELY TO RECEIVE TREATMENT WHEN IT COMES TO SMOKING THERE’S AN UNFORTUNATE PARADOX DESPITE SMOKING FEWER CIGARETTES A DAY AND DAYS PER MONTH AND GREATER ATTEMPTS AT QUITTING SMOKING, AFRICAN AMERICAN ARE LESS LIKELY TO QUIT AND LIKELY TO DIE FROM CHRONIC DISEASES AND WE KNOW THEY’RE SUBJECT TO TARGETING MARKETING EFFORTS FROM THE TOBACCO INDUSTRY AS WELL ONE PROMISING NEW STEP TOWARDS PREVENTING LATE STAGE DISEASE PRESENTATION CAME WITH THE NATIONAL LUNG CANCER SCREENING TRIALS STUDY IN WHICH CURRENT OR FORMER SMOKERS WERE ENROLLED FORMER SMOKERS WHO QUIT WITHIN THE PREVIOUS YEARS AND THE RESULTS SUGGESTED SCANS AND LOW

DOZE CT SCANS RESULTED IN 15% TO 20% LOWER RISK OF DYING FROM CANCER COMPARED TO CHEST X-RAYS IT’S NOW GIVEN A B RATE INNING TERMS OF THE U.S. PREVENTIVE TASK FORCE OUR RESEARCH GROUP HAS LOOKED AT BARRIERS TO SCREENING AND WE TALKED TO HIGH RISK SMOKERS TO GET AN INFORMATION OF WHY UPTAKE IS SO LOW LESS THAN 2% OF SMOKERS THAT ARE ELIGIBLE HAVE RECEIVED SCREENING SOME OF THE KEY BARRIERS THAT EMERGED AS PART OF OUR WORK IS THERE’S A LACK OF KNOWLEDGE OR EXISTENCE THAT A LUNG CANCER CT SCREENING TEST EVEN EXISTS WHAT IS LUNG CANCER SCREENING SOME SAID TO US AND THERE’S A LACK OF KNOWLEDGE BETWEEN A CHEST X-RAY AND LOW-DOSE CT SCAN NONE WE INTERVIEWED WERE RECOMMENDED SCREENING BY PROVIDERS SO THERE WAS LACK OF PROVIDER INTERVENTION AND LACK OF KNOWLEDGE FOR WHO QUALIFIES FOR SCREENING CONCERNS ABOUT INSURANCE COVERAGE FEAR OF RESULTS AGAIN, RELATED TO THAT KNOWLEDGE BARRIER AND LACK OF COMMUNICATION WITH PROVIDERS ONE PARTICIPANT SAID I HAD ONE PHYSICAL THIS MORNING AND THE DOCTOR KNOWS I’VE BEEN SMOKING 60 YEARS HOW COME SHE DIDN’T SUGGEST A LOW-DOSE SCREENING CT WHY WOULDN’T THE DOCTOR SAY SOMETHING? WE ALSO NEED TO THINK ABOUT HOW THERE MAY BE INCREASED POTENTIAL FOR HEALTH DISPARITIES AS WELL FOR EXAMPLE, GIVEN THE CURRENT CRITERIA FOR LOW-DOSE CT SCREENING AND THE PATTERNS DESCRIBED FOR AFRICAN AMERICAN SMOKERS WE MIGHT WONDER IF THE CRITERIA RESULTS IN FEWER SCREENS WE KNOW ALSO FROM PRIOR RESEARCH AFRICAN AMERICANS ARE MORE RELUCTANT TO GET SCREENED FOR LUNG CANCER DUE TO FEAR OF DISEASE SO FINALLY, IN TERMS OF KEY RECOMMENDATIONS, THERE HAVE BEEN MANY COMMON BARRIERS ACROSS GROUPS SUCH AS DISCRIMINATION BUT ALSO VERY UNIQUE BARRIERS THERE’S REALLY A NEED FOR MORE CULTURALLY ADAPTED INTERVENTIONS AND WE NEED TO DO WORK TO DISPEL MYTHS ON NICOTINE REPLACEMENT THERAPIES AND AS THE LANDSCAPE CONTINUES TO CHANGE IN TOBACCO WE NEED TO TRACK AND KEEP ACCOUNT OF HOW MINORITY POPULATIONS ARE USING THE PRODUCTS AND WHAT IMPACT IT HAS ON SMOKING CESSATION THERE WAS A LACK OF KNOWLEDGE OF LUNG CANCER SCREENING CERTAINLY THERE NEEDS TO BE EFFORTS TOWARDS PUBLIC HEALTH CAMPAIGNS AND FINALLY AS NEWER SCREENING TOOLS BECOME AVAILABLE SUCH AS LUNG CANCER SCREENING WE NEED TO MAKE SURE THEY DON’T INCREASE HEALTH DISPARITIES DUE TO IMPLEMENTATION THANK YOU VERY MUCH >> GOOD AFTERNOON I’M MONICA BASKIN THE COMMUNITY DIRECT AT THE O’NEIL COMPREHENSIVE CENTER AND PROFESSOR AND VICE CHAIR OF CULTURE AND DIVERSITY DEPARTMENT OF MEDICINE ASSOCIATE AND FROM THE UNIVERSITY OF ALABAMA MANY OF WHAT I’M GOING IT TALK ABOUT TODAY WE HAVE GOTTEN SNIPPETS THROUGHOUT THE DAY I WANT TO HIGHLIGHT A FEW THINGS I THINK ARE RELEVANT TO QUESTION TWO I HAVE NO DISCLOSURE TO MAKE A LOT OF WHAT YOU HEARD ABOUT ARE ALL THE FACTORS THAT CAN INFLUENCE HEALTH WE KNOW MEDICAL CARE QUALITY AND ACCESS IS RELEVANT AND INDIVIDUAL BEHAVIORS LIKE SMOKING AND DIET AND PHYSICAL ACTIVITY AND SCREENING BEHAVIOR THERE’S OTHER THINGS THAT HAVE BEEN NOTED EARLIER THAT INFLUENCE OUR HEALTH THE COMMUNITIES AND ENVIRONMENTS WE LIVE IN, THE POLICIES AND THE INSTITUTIONS AND LARGER ISSUES WE CALL THE SOCIAL DETERMINATES OF HEALTH PLAY A SIGNIFICANT ROLE ONE THING I THINK IS REALLY RELEVANT TO OUR CONVERSATION TODAY IS THERE’S RESEARCH THAT SHOWS AS WELL AS 10% OF HEALTH IS RELATED TO MEDICAL CARE THERE’S A NEED TO IMPROVE THE

CARE AND TREATMENT INDIVIDUAL HAVE BUT THERE’S OTHER THINGS WE CAN INTERVENE ON THAT MAY BE JUST AS OR MORE EFFECTIVE IN TERMS OF GENERATING HEALTH EQUITY THIS IS HIGHLIGHTED LOOKING AT OTHER THINGS THAT WERE ATTRIBUTABLE TO DEATH IN THE YEAR 2000 YOU’LL SEE LOW EDUCATION, RACIAL SEGREGATION AND LOW SOCIAL SUPPORT ASSOCIATED WITH MORE DEATHS THAN LUNG CANCER IN TERMS OF MORTALITY IN THE YEAR THE STUDY WAS DONE AND THERE’S THREE BUCKETS THE SOCIAL ENVIRONMENT WHICH INCLUDES THINGS LIKE YOUR INCOME AND EMPLOYMENT AND SOCIAL ATTAINMENT AND THE PHYSICAL ENVIRONMENT THE PLACES WHERE WE LIVE, WORK, PLAY, WHETHER OR NOT THERE’S ADEQUATE INFRASTRUCTURE AVAILABLE IN THOSE AREAS THE AIR QUALITY AND WATER QUALITY THAT MAY BE INFLUENCING THE PHYSICAL ENVIRONMENT AS WELL AS ACCESS TO TRANSPORTATION AND THE LAST BUCKET AGAIN CLINICAL CARE BOTH DO YOU HAVE ACCESS TO IT AND THE QUALITY OF CARE WHEN YOU DO GO INTO RECEIVE SERVICES SO I THINK OVERARCHING THEME FOR pSO WE’RE TALKING ABOUT ALL THE WAYS THAT WE DEFINE PLACE AND FOR HERE I’M USING THE EXAMPLE OF CANCER INCIDENTS THIS LOOKED AT THE DIFFERENCE BETWEEN LIVING IN A METROPOLITAN AREA OR URBAN AREA VERSUS A RURAL AREA AND WHAT THE INVESTIGATOR SAW WAS THERE IS CLEARLY A DIFFERENCE DEPENDING ON WHERE YOU LIVE IN TERMS OF CANCER INCIDENTS SOMETIMES IN URBAN AREAS YOU HAVE A HIGHER CHANCE OF HAVING SOME TYPES OF CANCERS SOMETIMES YOUR RISK IS LOWER BUT IN GENERAL ACROSS THE CANCERS YOU SEE A DISTINCT DIFFERENCE IN TERMS OF PLACE VERSUS A RURAL AND URBAN AREA BUT WHEN YOU LOOK AT CANCER MORTALITY SO OVERALL THERE MAY BE DIFFERENCES IN TERMS OF CANCER INCIDENT BUT IN CANCER MORTALITY THE PICTURE’S MORE CLEAR IF INDIVIDUALS LIVE IN SPACES AND PLACES LIKE RURAL APPALACHIA THE CHANCES ARE MUCH HIGHER HAVE HIGHER RATES OF MORTALITY AND PLACES IN ALABAMA WHERE MY COLLEAGUE DR. VAN DERPOOL IS IN KENTUCKY YOU SEE HIGH RATES OF CANCER MORTALITY IN THESE AREAS BY WAY OF WHERE YOU LIVE THIS IS LOOKING AT IT AS THE OVERALL-STATE THERE’S ALSO DATA WHEN YOU LOOK BALTIMORE COUNTY YOU’LL SEE THE DARKER RED COUNTY ARE WHERE YOU SEE THE HIGHEST CANCER MORTALITY ACROSS THE U.S SIMILAR TO PREVIOUS SLIDES ABOUT OUR NATION THERE’S A CONCENTRATION OF WHERE WE SEE POOR PREVENTIVE BEHAVIORS AND DIABETES AND HEART DISEASE AND CANCER SO WE TALKED ABOUT PLACE WHERE YOU LIVE IN THE COUNTRY, WHICH COMMUNITIES YOU LIVE IN, EVEN WITHIN A PARTICULAR STATE BUT ONE OF THE OTHER THINGS THAT IS ALSO SIMILAR IN SOME OF THESE MAPS IS WHO IS LIVING IN THESE COMMUNITY THIS SAY MAP OF BLACK OR ARCH AMERICAN INDIVIDUALS LOOKING AT THE LATEST 2010 CENSUS DATA WE’LL SEE SOME OF THE SAME AREAS THAT WERE HIGHLIGHTED IN PREVIOUS MAPS OF THE U.S. ARE IN THESE REGIONS WHERE YOU HAVE HIGHER CONCENTRATIONS OF BLACKS OR AFRICAN AMERICANS WE CERTAINLY KNOW THAT THAT POPULATION IN PARTICULAR HAS HIGHER RATES OF CHRONIC DISEASES WE’VE TALKED ABOUT TODAY AND HAVE HIGHER MORTALITY AS A RESULT I HAD US THINK OF THE INTERSECTION BETWEEN RACE, PLACE AND CANCER AND THIS TABLE HIGHLIGHTS THAT NICELY I THINK THIS IS LOOKING AT CANCER MORTALITY LOOKING AT ALL CANCERS AND SELECT CANCERS WITH REGIONS CALLED THE DELTA REGIONS, 252 COUNTIES ACROSS THE COUNTRY THAT MAKE UP THE DELTA AND COMPARED NEXT TO THE U.S. AS A WHOLE AND THEN LOOKING AT NON-DELTA COUNTIES AND THEN NON-DELTA COUNTIES WITHIN THE DELTA REGION AND THEN THE APPALACHIAN

COUNTIES SEPARATE OUT YOU’LL SEE ACROSS EACH OF THESE DIFFERENT AREAS WITH VERY FEW EXCEPTIONS YOU’LL SEE IF YOU ARE A PERSON LIVING IN THE DELTA OR APPALACHIAN REGION YOU’RE LIKELY TO HAVE HIGHER RATES OF MORTALITY ACROSS THESE CANCERS THAN ANY OTHER GROUPS YOU’LL ALSO SEE THERE ARE OTHER DIFFERENCES THERE BY WHETHER OR NOT YOU’RE WHITE OR BLACK AS WELL SO IT’S HARD TO IT’S — TEASE OUT IS IT ONLY A RACIAL ISSUE OR PLACE IN TERMS OF TRYING TO FIGURE OUT WHERE THE DIFFERENCES ARE THE INTERSECTION I THINK IS ONE OF THE THINGS I WANT TO HIGHLIGHT FOR OUR DISCUSSION THE FIRST OF THE BUCKETS IN TERMS OF SOCIAL DETERMINATES THIS IS DATA LOOKING AT METRO AND WE SEE THE HIGHES RATES OF POVERTY ARE IN THE NON HFR METRO COMMUNITIES — NON-METRO AREAS AND WHERE I WORK IN THE ALABAMA BLACK BELT YOU’LL SEE THERE’S A GREATER PERCENTAGE OF INDIVIDUALS LIVING IN POVERTY INCOME, EMPLOYMENT, ALL THAT, WE KNOW INFLUENCES WHO IS HEALTHY AND WHO GETS SICK AND WHO’S GOING LIVE THE LONGEST IN TERMS OF THE PHYSICAL ENVIRONMENT SOME RESEARCH WE’VE DONE IN THE LAST SEVERAL DECADE WITHIN THE ALABAMA AND MISSISSIPPI AREAS HAS BEEN LOOKING AT THE PHYSICAL ENVIRONMENT THIS IS ONE STUDY WHERE WE USED A COMBINATION OF SOME MIXED METHODS STUDY WHERE WE LOOKED AT HAVING INDIVIDUALS IN THE COMMUNITY GO OUT AND TAKE PICTURES OF THEIR COMMUNITY ENVIRONMENT TO SEE WHAT WAS SUPPORTIVE OF A HEALTHY ENVIRONMENT AND PREVENTING CANCER AND USED MORE OBJECTIVE MEASURES TO LOOK AT WALKABILITY AND CONNECTIVITY WITHIN THE ENVIRONMENT OVERALL, WHAT WE SEE VERY MUCH IN GRM IS THERE’S A LOT HETEROGENEITY WITHIN RURAL COMMUNITIES ONE QUESTION THAT CAME UP IN AN EARLIER PANEL WAS DOES A RURAL COMMUNITY LOOK THE SAME IN THE NORTHWEST AS IT DOES IN THE SOUTHEAST AND THE CHANCES PROBABLY ARE THEY ARE NOT THE SAME RURAL IS A BROAD DEFINITION AND WE HAVE FRONTIER AREAS AND AREAS THAT ARE CONSIDERED TO BE MAYBE SMALLER TOWNS AND THOSE ARE VERY DIFFERENT IN THE COMMUNITIES WE HAVE WORKED IN LARGELY WITHIN THE CANCER CENTER AT UAB, WE FIND MANY COMMUNITIES THIS INFRASTRUCTURE IS NOT CONDUCIVE FOR THE PRESCRIPTIONS WE GIVE TO GET OUT IN THE COMMUNITY AND WALK WE HAVE INDIVIDUALS LIVING IN RURAL AREAS WHERE THERE’S HIGHWAY SYSTEMS AND NOT SIDEWALKS OR BUFFERS IT’S LITERALLY NOT SAFE TO WALK WE ALSO HAVE AREAS WHERE PEOPLE ARE LIVING IN AREAS THAT ARE NEAR SWAMPS AND SO FORH THINGS LIKE SNAKES AND OTHER THINGS COME OUT THAT ARE FACTOR TED IN THERE AND EVEN WHERE THERE’S RECREATIONAL FACILITIES AND EQUIPMENT YOU’LL SEE FROM PICTURES WHEN IT RAINS, THAT INFRASTRUCTURE IS NOT THERE AND YOU END UP WITH LOTS OF FLOODING AND IT MAKES IT DIFFICULT FOR PEOPLE TO UTILIZE THE RESOURCES AND ANOTHER WAS THE NUTRITION ENVIRONMENT WE KNOW ANOTHER WAY TO PREVENT CHRONIC CONDITIONS IS DIET AND pENVIRONMENT TO CONSUME AND R FOLLOW THE PRESCRIPTIONS AROUND DIET AND WE DISPENSED LOCAL COMMUNITY MEMBERS TO MEASURE WHAT WAS IN THEIR STORE AND THERE’S A GREAT DEAL OF VARIABILITY BUT IN GENERAL PEOPLE IN THESE COMMUNITY NOT ABLE TO FOLLOW THE PRESCRIPTIONS BECAUSE OF LACK OF ACCESS TO HEALTHY AFFORDABLE FOODS WITH VARIETY AND WE FIND OFTEN TIMES MANY OF US WHO DON’T LIVE IN RURAL AREAS WE HAVE THIS PERCEPTION OH, YOU’RE IN A RURAL COMMUNITY AND YOU HAVE ALL THE LAND AND CAN HAVE A GARDEN AND THAT’S NOT THE CASE IN MANY COMMUNITIES WE WORK IN THERE WERE SMALLER COMMUNITY GARDENS OR HOME-BASED GARDENS BUT OFTEN TIMES PEOPLE WERE CONSUME FROM STORES SMALLER GROCERY STORES AND CONVENIENCE STORES WHERE THERE WERE LOTS OF RED MEAT, ORGAN MEATS AND LOTS OF FATTY MEATS AND SO FORTH AND

ALSO AREAS WHERE THERE’S A LOT OF FAST FOOD RESTAURANTS NOT ON THE FOOD DESERTS IN NOT HAVING FRESH, AFFORDABLE FOODS BUT WHAT PEOPLE CALL FOOD SWAMPS WHERE THERE’S RESTAURANTS WHERE THERE’S HIGH-SALARY — HIGH-CALORIE AND HIGH FAT A LOT OF VARIABILITY BUT IN FOLLOWING PRESCRIPTIONS CHALLENGES IN THE COMMUNITY AND THE LAST BUCKET IS AROUND CLINICAL CARE WE ALREADY HEARD THEY’RE MISSING SPECIAL CARE AND IT’S IMPORTANT TO NOTE THAT OVER THE LAST COUPLE OF DECADES WE’RE SEEING THE CLOSURES OF RURAL HOSPITALS IN THE SOUTHEAST YOU SEE THE GREATEST NUMBER OF HOSPITAL CLOSURES HAPPENING WHEN PEOPLE DON’T HAVE PRIMARY CARE OR EXPERIMENT CARE OR EVEN IF THEY CAN’T GET IN IN THOSE URGENT AREAS TO HAVE PROCEDURES, THEY’RE STRONG DRIVE SEVERAL HOURS AWAY THAT PLAYS A ROLE IN TERMS OF LATE-STAGE DIAGNOSIS AND THEIR TREATMENT CULTURALLY RELEVANT STRATEGY AND WE HAVE AN ADVISORY MODEL FOR NEARLY TWO DECADES IN WHICH WE’VE SEEN A SIGNIFICANT DECLINE IN THE DISPARITY BETWEEN BLACK AND WHITE WOMEN RECEIVING MAMMOGRAMS IN THE SPAN OF TIME WE USED THE COMMUNITY HEALTH ADVISORS AND UTILIZED COMMUNITY HEALTH WORKERS PEOPLE MORE FORMAL AND HAVE MORE ADVANCED TRAINING CONNECT WITH THE HEALTH SYSTEM AND HELP NAVIGATE PATIENTS AND THAT HAS SHOWN TO BE ABLE TO IMPROVE THE TREATMENT AND IT’S BEEN SHOWN IN THE LARGER CMS GRANT TO REDUCE COST ESPECIALLY WHEN YOU THINK OF LATER STAGE CANCER AND HOSPICE CARE TO MINIMIZE INDIVIDUALS COMING IN FOR TREATMENT IN THE LAST MONTHS OR WEEKS OF THEIR LIFE WE HAVE SEEN MOBILE SCREENING UNIT MAMMOGRAPHY UNIT AND WE’VE SEEN LOW-DOSE CT UNITS TO GO OUT IN THE AREA MORE REMOTE SO INDIVIDUALS ARE NOT HAVING TO DRIVE MULTIPLE HOURS OR PARTICULARLY WHEN TRANSPORTATION IS LIMITED THOSE HAVE BEEN SHOWN TO BE EFFECTIVE IN INCREASING THE REACH OF THE MUCH NEEDED PREVENTIVE SERVICES IN THE RURAL COMMUNITIES ANOTHER STRATEGY THAT’S BEEN USED IS NON-TRADITIONAL SETTING OF HEALTH MESSAGES IT WAS MENTION THE IN THE VIGNETTE ABOUT UTILIZING BARBERSHOPS OR BEAUTY SALONS AND CHURCHES AND OTHER NON-TRADITIONAL PLACES IN DOING PREVENTIVE STRATEGIES WE HAVE TO GO WHERE THE POPULATION IS OPPOSED TO EXPECTING THEM TO COME TO OUR CLINIC THAT’S ANOTHER STRATEGY THAT’S BEEN SUCCESSFUL AND INNOVATIVE CHANNELS FOR DELIVERING MESSAGES THERE’S A NUMBER OF STUDIES THAT HAVE SHOWN RADIO DRAMAS OR FILM AND OTHER CREATIVE WAYS TO GET ACROSS MESSAGES BEYOND PAMPHLETS AND THINGS OF THAT NATURE HAVE BEEN VERY MUCH ABLE TO RESONATE WITH CERTAIN GROUPS PARTICULARLY IN OUR RURAL SMALLER COMMUNITIES WHERE THEY WANT TO GET TOGETHER AROUND A SOCIAL EVENT AND HAVE SOMETHING OR THE THAN SOMEONE GOING OVER AND OVER AGAIN THE CANCER MESSAGES WHAT I HIGHLIGHT HERE ARE THREE GAPS I THINK THAT EXIST IN THE POPULATION THE FIRST OF WHICH IS WHAT ROLE DOES INTERSECTIONALITY PLAY IN INTERVENTIONS FOR RURAL POPULATIONS SO THERE’S MORE STUDIES AND WE’RE GLAD BUT THE OVERWHELMING EVIDENCE IS IT WAS OF LOW QUALITY AND SO THERE WERE LOTS OF MIXED RESULTS ONE OF THE THINGS I WOULD POSIT BECAUSE WE’RE LUMPING EVERYONE TOGETHER THERE’S A GREAT DEAL OF HETEROGENEITY WITHIN POPULATIONS AND IF WE DON’T ACCOUNT FOR THAT WE MAY NOT KNOW WHAT WORKS WELL FOR WHOM THE SECOND BULLET IS WHAT ARE THE MOST IMPACTFUL INDIVIDUAL OR SOCIAL DETERMINATES TO INTERVENE ON FOR MAXIMUM UPTAKE

WE KNOW WE HAVE LIMITED RESOURCES WE WON’T BE ABLE TO HIT EVERYTHING THANE AROUND SOCIAL DETERMINA DETERMINATES AND WHAT GIVES THE MOST BANG FOR THE BUCK AND THE LAST IS WHAT INFRASTRUCTURE IS NEEDED TO SUSTAIN INTERVENTIONS IN RURAL AREAS AND AS HOSPITALS CLOSE AND THERE’S LIMITED CARE WHAT IS THE INFRASTRUCTURE THAT CAN BE EMBEDDED SO THE STRATEGIES ARE THERE AFTER THE GRANTS ARE OVER AND OTHER THINGS ARE NOT GOING TO BE AROUND WITH THAT MY RECOMMENDATIONS ARE ONE, CONDUCTING MORE COMMUNITY ENGAGED RESEARCH WE HEARD EARLIER HOW IMPORTANT TOSS HAVE — IT IS TO HAVE PEOPLE AROUND WITH INTERVENTION AND THE INTERSECTIONALITY ON PREVENTIVE SERVICE AND DEMONSTRATION PROJECTS SO WE CAN START TO TEASE OUT WHAT ARE THE THINGS MOST IMPACTFUL IN THOSE CULTURALLY ADAPTED INTERVENTIONS AND LASTLY I THINK TO THE POINT OF THE FIRST PRESENTATION WITHIN THIS PANEL WAS AROUND PERHAPS DOING MORE PUBLIC/PRIVATE PARTNERSHIPS HOW CAN BUSINESSES BE ENGAGED WITH ACADEMIC MEDICAL CENTERS AND CLINICIANS TO BE ABLE TO DELIVER MUCH NEEDED QUALITY, HIGH QUALITY MEDICAL CARE INTO REMOTE AREAS THAT WILL IMPROVE NOT ONLY THE BUSINESS IN TERMS OF THE WORKPLACE AND WORKFORCE BUT THE LARGER COMMUNITY WITH THAT, THANK YOU >> HOW TO THE SPEAKERS THAT WAS REMARKABLE LET’S START WITH QUESTIONS AND COMMENTS FROM OUR PANEL >> THANK YOU FOR EXCELLENT PRESENTATIONS AND THANK YOU DR BASKIN FOR ELABORATING FURTHER MY QUESTION IS RELATIVE TO THE HETEROGENEITY AMONG THE RURAL POPULATION MY QUESTION RELATES SPECIFICALLY TO WHAT YOU’VE MENTIONED I’M NOT FAMILIAR WITH YOUR DIRECT WORK AT UAB BUT I KNOW THE UNIVERSITY OF ALABAMA BIRMINGHAM AND TUSKEGEE AND OTHERS ARE LOOKING AT THE DISPARITIES IN THIS ARENA SO DO YOU SEE HETEROGENEITY IN TUSKEGEE AND ATLANTA AND BIRMINGHAM SIMILAR TO WHAT I SEE NORTH VERSUS SOUTH AND SOME INTERVENTIONS YOU’RE SUGGESTING WHETHER YOU’VE TRIED THEM IN THE THREE REGIONS OR NOT AND WHETHER YOU’VE SEEN SIMILAR OUTCOMES BECAUSE THE DISPARITIES ARE GRIEVOUS IN ALL THREE AREAS THOUGH THE CHARACTERISTICS OF THE POPULATIONS ARE VERY DIFFERENT >> THREW FOR THE QUESTION AND — THANK YOU FOR THE QUESTION AND CHANCE TO ELABORATE MORE AND I THINK THERE IS SOME HETEROGENEITY EVEN WITHIN THE TWO STATES AND WE WORKED IN MISSISSIPPI THINKING ABOUT THAT REGION, THERE ARE DISTINCT DIFFERENCES I THINK I’VE OBSERVED IN THOSE THREE AREAS SOME OF IT AND SOME OF MY THINKING IN HOW THINGS MAY BE DIFFERENT FROM THE NORTH-WEST RURAL AREAS IS THE MAKEUP OF THE RACIAL AND ETHNIC POPULATION THE HISTORY RELATED TO SAVORY AND DISCRIMINATION AND — SLAVERY AND DISCRIMINATION AND JIM CROW AND ISSUES AROUND RACIAL SEGREGATION AND HOW THAT’S STILL A MAJOR ISSUE IN TERMS OF IT’S ASSOCIATION WITH MORTALITY STILL IS ON TOP OF MIND IN COMMUNITIES WE WORK IN ACROSS PARTICULARLY IN ALABAMA AND MISSISSIPPI THE COMMUNITIES EVEN THE RURAL COMMUNITIES WHERE THERE MAY BE MORE DIVERSITY SO WE HAVE AN EQUAL DISTRIBUTION OF WHITES AND BLACKS YOU STILL SEE THE COMMUNITY AND PHYSICAL ENVIRONMENT IS STILL RACIALLY SEGREGATED THE AMENITIES AVAILABLE IN THE SIDE OF TOWN OR SIDE OF THE TRACKS THAT ARE FOR AFRICAN

AMERICAN COMMUNITIES THE MEN TIS ARE MUCH — AMENITIES ARE MORE LIMITED THOSE THE COMMUNITIES YOU SAW THE PICTURES WHERE THE INFRASTRUCTURE IS NOT AS NICE THERE’S SOME ISSUES THERE THE THINGS THAT I THINK ALMOST ALL THE PANELISTS HAVE BROUGHT UP AROUND MEDICAL MISTRUST YOU BROUGHT UP THE PARTNERSHIP WITH TUSKEGEE THERE’S STILL VESSAGES — VESTIGES WITH THE TUSKEGEE AND SYPHILIS STUDY AND BEING INVOLVED IN CLINICAL TRIALS THERE’S HETEROGENEITY WITHIN THE THREE STATES I’VE WORKED IN AND SOME THINGS ARE THE SAME AND IN ANY ROLE IN THE CANCER CENTER CAPTURING THE ENTIRE STATE WE’RE WORKING IN LARGELY WHITE RURAL COMMUNITIES WITHIN THE STATE OF ALABAMA AND SO THOSE ISSUES ARE ALSO DIFFERENT TO MY POINT IN THE RECOMMENDATION YOU HAVE TO HAVE COMMUNITY-ENGAGED RESEARCH GOU TO ONE COMMUNITY AND KNOW THAT ONE COMMUNITY SO THAT’S HOW THE RESEARCH HELPS YOU UNDERSTAND THE SUBTLE NUANCES AND HOW YOU NEED TO CULTURALLY ADAPT TO ENSURE THE UPTAKE >> THANK YOU THAT IS REALLY GREAT I THINK DR. SIMMONS GOT ME THINKING ABOUT THE ISSUE THAT’S A CONCERN OF MINE OFTEN WHEN YOU TALK ABOUT INCREASING THE AVAILABILITY OF LOW-DOSE CT SCANS AND THE DEGREE TO WHICH WE NEED TO BE CAUTIOUS ABOUT MAKING SOMETHING LIKE THAT WIDELY AVAILABLE SO AS NOT TO INCREASE DISPARITIES COULD YOU TALK ABOUT OR THE DEGREE TO WHICH HOW YOU THINK ABOUT INTERVENTIONS AND INTERVENTIONS YOU’RE DESCRIBING AND WHAT YOU RECOMMEND HOW YOU THINK ABOUT THAT AS THE SAME TIME WE MUST INCREASE DISPARITIES THROUGH THE INTERVENTIONS AND HOW YOU’D RECOMMEND US THINKING ABOUT THAT >> GREAT QUESTION I THINK IT RELATES TO SOME OF THE THINGS WE TALKED ABOUT IN PATIENT AND PROVIDER COMMUNICATION ONE THING I DIDN’T HAVE TIME TO TALK ABOUT WAS SOME DATA COLLECTED WITH PRIMARY CARE PROVIDERS AROUND THE TOPIC THERE WAS A LACK OF KNOWLEDGE AND PRIORITIZATION DEALING WITH HIGH RISK POPULATIONS WITH SEVERAL COMORBIDITIES AND THE CONVERSATIONS AROUND SCREENING AREN’T HAPPENING WHAT WE KNOW IN TERMS OF SMOKING CESSATION IS THOSE CONVERSATIONS TEND TO HAPPEN LESS FREQUENTLY WITH MINORITY POPULATIONS THAT’S SOMETHING I WORRY ABOUT IN THIS SPACE AS WELL AND THEN IN TERMS OF LOOKING AT THE ACTUAL ELIGIBILITY FOR SCREENING AND APPROPRIATE MINORITY REPRESENTATION AND TRIALS AND HOW SCREENING CRITERIA MAY NEED TO BE ADAPTED FOR POPULATIONS WITH DIFFERENT SMOKING PATTERNS THAT’S SOMETHING I THINK DESERVES FUTURE RESEARCH ATTENTION AS WELL >> I HAVE A QUESTION FOR A COUPLE PANELISTS AROUND THE ISSUE OF MASS CUSTOMIZATION THE LITERATURE BASE MORE ROBUST AS WE WORK THROUGH QUESTIONS SEVERAL SPEAKERS TALKED ABOUT THE NEED FOR ADAPTATION OF INTERVENTIONS AND INSTRUMENTS EITHER TO SUBETHNIC GROUPS OR COMMUNITIES OR GEOGRAPHICAL AREAS WHEN DOES THAT STOP BEING A RESEARCH STUDY NIH SHOULD SUPPORT AND START BEING IMPLEMENT IMPROVEMENT OF CARE AND IS THERE A RISK TO SLOW THING DOWN BY MAKING THIS A RESEARCH STUDY? >> ONE THING IN TALKING ABOUT ADAPTING INTERVENTIONS SIMILAR TO EFFORTS AROUND PRECISION MEDICINE WE MAY NEED TO THINK OF PREVENTION ARENA ALONG THE SAME LINES WITH POPULATION WITH UNIQUE NEEDS AND BARRIERS ADAPTION IS NEED AND LEVERAGING THE LENG ELECTRONIC HEALTH RECORD SYSTEM TO CREATE TARGETED INTERVENTION BASED ON UNIQUE

CONCERNS AS WELL >> THAT’S WHERE DISSEMINATION SCIENCE COMES INTO PLAY IN A REAL-WORLD SETTING TO UNDERSTAND THE PRINCIPLES THAT OPERATE WHATEVER IS HAPPENING OPPOSED TO FINDING OUT THERE’S ONE PLACE TO DO IT THIS WAY AND FIND IT DIFFERENTLY FIGURING OUT WHAT ARE THE CROSS-CUTTING DESIGN PRINCIPLES IS A VERY IMPORTANT AREA OF RESEARCH AND TO DO THAT WELL YOU ALMOST HAVE TO BE IN THE REAL WORLD SETTING TO FIGURE IT OUT >> AND IN PRECISION POPULATION HEALTH AS WELL I THINK THAT’S THE IDEA AND SPECIFICALLY MY WORDING ON THE RECOMMENDATION WAS DEMONSTRATION PROJECTS I DO THINK WE HAVE THE EVIDENCE AND TYPES OF ADAPTATIONS THAT AT LEAST I’M THINKING ABOUT ARE IN THE REALM OF DISSEMINATION AND IMPLEMENTATION HOW DO YOU GET THE EVIDENCE-BASED TREATMENTS OUT TO THE POPULATIONS THAT NEED THEM MOST AND DELIVERY MAY NEED TO BE CHANGED DEPENDING ON POPULATION >> THANK YOU LET’S GOOD TO MEMBERS OF THE AUDIENCE >> I WANT IT TURN TO THE LUNG CANCER SCREENING AND HEALTH EQUITY CONVERSATION I’M CONCERNED AS A PRIMARY CARE PHYSICIAN IN MY LIFE TIME IN CARING FOR VULNERABLE POPULATIONS IN THE PRIMARY CARE SETTING FOR PATIENTS WITH LIMITED RESOURCES WHAT WILL THEY CHOOSE TO REPLACE GETTING THE LUNG CANCER SCREENING WITH? IF YOU’RE LIMITED IN TRANSPORTATION AND TIME AND MONEY AND DECIDE TO GET THE LUNG CANCER SCREENING DO YOU ELIMINATE OTHER SERVICES BECAUSE YOU’VE USED UP YOUR TIME AND RESOURCES ON THAT PREVENTIVE SERVICE? HOW DO WE PRIORITIZE? >> I THINK THE ISSUE IS COMPETING DEMANDS FOR PROVIDERS AND INDIVIDUALS ARE REAL AND IN SPEAKING WITH SOME OF THE PROVIDERS WE FELT THERE WERE WAYS IN WHICH THE ELECTRONIC HEALTH RECORD CAN BE USED PRIORITIZE WHAT SCREENINGS MAY BEING MOST APPROPRIATE NOR PATIENT AND RECOMMEND — FOR THE PATIENT AND RECOMMENDED AND PRIME INDIVIDUALS TO HAVE CONVERSATIONS WITH PROVIDERS IT’S A REAL CONCERN AS ADDITIONAL SCREENINGS BECOME AVAILABLE AND TRYING TO PRIORITIZE I WILL NOTE IN SPEAKING TO HIGH-RISK INDIVIDUALS AND SMOKERS FELT A SCREENING WAS FINALLY AWARE FOR THEM AND WERE UNAWARE OF IT AND EAGER TO GET IT BUT THEY DIDN’T KNOW ABOUT IT BUT A LOT OF HOPE AROUND A SCREENING FOR THEM >> IF I CAN ADD TO THAT I THINK YOU’RE LOOKING TO A REPLACE MANY ISSUE OF ONE SERVICE IF YOU DO THIS ONE YOU’LL HAVE TO DO ANOTHER ONE NOT BECAUSE THERE’S NO ROOM FOR IT ANYMORE TO ME, IT BEGS THE QUESTION DOES IT CALL FOR A SYSTEM REDESIGN? THAT’S A TOUGHER QUESTION TO HANDLE BECAUSE THE SOLUTION ISN’T READILY AVAILABLE BUT THAT’S WHAT NEEDS TO HAPPEN >> I’LL BE DEVIL’S ADVOCATE AND DON’T QUITE BELIEVE WHAT I’LL PROPOSE BUT IT SEEMS THE WHOLE BUSINESS ORIENTATION OF THE BOTTOM LINE BEING FINANCIAL GAIN AND PROFIT IS ANTI-COMMUNITY AND ANTI-EQUITY IN THE SENSE THAT COMPANIES ARE MORE INTERESTED IN HAVING CHEAP LABOR AND MAKING PROFIT THAN IN PROMOTING EQUITY AND COMMUNITY

THE QUESTION I’D LIKE TO ASK YOU AND THERE’S COUNTEREXAMPLES AT THE GATES FOUNDATION BUT HOW DO WE CREATE AN ORIENTATION IN OUR BUSINESS COMMUNITY THAT MAKES THEM COMMUNITY ORIENTED THAT MAKES THEM VALUE EQUITY AS A PROJECT >> THANK YOU THIS IS A BIG ISSUE I THINK IT’S A DIALOGUE THAT NEEDS TO HAPPEN AND EVOLVE I THINK THERE ARE COMPANIES PUSHING THIS IDEA AND ALIGN THEIR EFFORTS WITH THINGS LIKE SOCIAL OR SUSTAINABLE DEVELOPMENT GOALS THE UNITED NATIONS APPROACH AND THE IDEA YOU CAN DO LOTS OF GOOD FOR SOCIETY AND THRIVE AS AN ORGANIZATION AS A COMPANY TO DO THAT YOU NEED A LONG VIEW WHICH FLIES IN THE FACE OF QUARTERLY RETURNS FOR SHAREHOLDERS THAT’S WHERE A LOT OF ORGANIZATIONS GET CAN’T DO THIS WE NEED TO CONTINUE THE DIALOGUE AROUND THE REASON FOR BUSINESS IN THE FIRST PLACE THOSE ARE LOFTY QUESTIONS TO PUT IN FRONT OF A SMALL BUSINESS OWNER BUT IF WE START THINKING ABOUT BUSINESS ORGANIZATIONS, CHAMBERS OF COMMERCE AND START A DIALOGUE THERE AND CONTINUE TO PUSH THAT FORWARD, I THINK THERE’S AN INTEREST THERE AND PENT-UP DEMAND, ALMOST, TO DO WELL AND GOOD FOR SOCIETY IN GENERAL THERE’S ANOTHER PHENOMENON IN THE MARKETPLACE WHICH IS YOUNGER GENERATIONS ARE COMING IN WITH A VERY DIFFERENT ATTITUDE THE YOUNGER GENERATIONS COME IN AND OFTEN TIME INTERVIEW THE COMPANY HOW ARE YOU OPERATING? WHAT KIND OF OPERATING ETHIC DO YOU HAVE? WILL YOU MAKE THIS PLACE BETTER OPPOSED TO ARE YOU JUST HERE FOR QUARTERLY SHAREHOLDER RETURN? THAT’S A VERY DIFFERENT KIND OF DYNAMIC AS WELL IF YOU’RE INTERESTED IN TOP TALENT AND YOU WANT TO ATTRACT THAT TO YOUR ORGANIZATION, YOU’LL HAVE TO PAY ATTENTION TO THAT SO LARGER ORGANIZATIONS TEND TO MAKE MORE EFFORT TO WORK WITH THAT KIND OF CONTEXT IN THE COMMUNITIES OPPOSED TO PERHAPS SMALLER COMPANIES THAT DON’T HAVE THE RESOURCES TO NECESSARILY RESPOND TO THEM ON THE OTHER HAND, SMALLER COMPANIES TEND TO BE MORE CONNECTED TO THEIR COMMUNITY IN THE FIRST PLACE SO I THINK THERE’S ROOM AND OPPORTUNITY TO REALLY CHANGE THE DYNAMIC I HAVEN’T EVEN TALKED YET ABOUT THE CHANGING NATURE OF THE COMMUNITY SOCIAL RESPONSIBILITY REPORTS AND THE CHANGING NATURE OF HOW ORGANIZATIONS ARE REPORTING IN GENERAL ON THE BUSINESS THEY ARE IN INCREASINGLY IT’S INCLUDING HEALTH AND SAFETY >> I HAVE AN ADDITIONAL THOUGHT ABOUT THAT WE’RE THINKING ABOUT WHAT’S GOOD FOR THE COMMUNITY WHETHER A BUSINESS WILL ENDORSE SOCIAL RESPONSIBILITY OR VALUE AROUND EQUITY, WE CAN PROBABLY PUT THAT ASIDE BUT IF THEY’RE HAVING WELLNESS PROGRAMS AND ENSURING THE WORKFORCE IS HEALTHY, THAT THEY HAVE A DIVERSE AND INCLUSIVE WORKFORCE WE KNOW LEADS TO A BETTER BOTTOM LINE, WHETHER THEY ENDORSE SOCIAL RESPONSIBILITY NORT IS GOOD FOR THE COMMUNITY — IS GOOD FOR THE COMMUNITY AND THAT STILL IS GOING TO BE A BENEFIT TO THE COMMUNITY AND TO THE OUTCOMES OF THE INDIVIDUAL WHETHER THAT COMPANY ENDORSES AND SAYS WE’RE EXPLICITLY DOING THIS FOR HEALTH EQUITY >> UNIVERSITY OF KENTUCKY I WANTED TO VISIT THE COMMENT MADE ABOUT HAVING PATIENTS

CHOOSE AND MADE ME THINK ABOUT TWO CONCEPTS WE HAVEN’T BROUGHT UP YET TODAY AND THAT’S OVERSCREENING AND DEIMPLEMENTATION AND NO MATTER HOW MANY TIMES I KEEP HEARING IN THE CLINICS AND PROGRAMS I’M IN THEY STILL DO ANNUAL PAP TESTS BECAUSE THE COMPANIES PAY FOR IT WE KNOW THE GUIDELINES HAVE CHANGED SOME WOMEN ONLY NEED DEPENDING ON THEIR AGE AND HPV STATUS BUT WE MAY BE MAKING PATIENTS CHOOSE AND SHUNT PUSH THEM — SHOULDN’T PUSH THEM OR CANCER SCREENING AT AN OLDER AGE AND I KNOW THAT’S A TALK FOR ANOTHER DAY BUT I’D LIKE THE PANEL TO TALK ABOUT WHERE WE MAY NEED TO DE-IMPLEMENT THE SERVICES TO CHEW ON FOR A WHILE.AT TOPIC ACTUALLY, THERE’S AN ENTIRE RESEARCH PORTFOLIO THERE TOO AROUND DE-IMPLEMENTATION WHAT YOU’RE ASKING IS HOW DO WE MAKE IT SIMPLE FOR PEOPLE TO MOVE THROUGH THE MEDICARE SYSTEM AND AFFORDABLE SO WE DON’T HAVE TO MAKE CHOICES ON WHAT TO GET OR NOT GET BASED ON THE $5,000 DEDUCTIBLE TO ALLOW YOU TO HAVE INSURANCE BUT YOU CAN’T AFFORD CARE? IT GETS ME TO THE NEED FOR REDESIGN AROUND THESE SYSTEMS THE SYSTEMS DON’T SEEM TO MAKE MUCH SENSE ANYMORE THAT’S WHERE I KEEP COMING >> SOME OF OUR PATIENTS EVEN IN THINKING OF COLORECTAL CANCER SCREENING AND TRYING TO HAVE A CONVERSATION MANY OF WHOM DON’T REALLY GO IN REGULARLY FOR PRIMARY CARE FOR SOMEONE TO HAVE THE CONVERSTION ABOUT WELL, IS THAT REALLY NECESSARY THAT INFORMED DECISION MAKING I AGREE WITH YOU AND IN COMMUNITIES WHERE THERE’S LOWER HEALTH LITERACY WHEN WE KEEP PUSHING CANCER MESSAGES AND SAY THERE’S A SCREENING OUT THERE BUT YOU DON’T NEED TO GET IT ANYMORE IT’S DIFFICULT OUR MESSAGING HAS TO ADJUST >> HOW DO YOU VERIFY YOUR DATA IS CORRECT AND PERSONNEL STAFF OR AIDE OR IN GOVERNMENT ANYONE INVOLVED ARE ACCOUNTABLE? AND IN SOCIETY OR COMMUNITY OR AREA YOU WANT TO DO THE RESEARCH [INDISCERNIBLE] EVERYBODY THOSE AREA ADVOCATING FOR PPP, PUBLIC PRIVATE PARTNERSHIP WHERE ARE THEY INVOLVED AND OFFICIAL MISCONDUCT [INDISCERNIBLE] AND WORK TOGETHER AND GO THE DETENTION CENTER AND TO THE JAIL OR THE MENTAL HOSPITAL FOR MONTHS WITHOUT CHARGE AND WHETHER THERE’S A SUGGESTION FOR UNIVERSITY STUDENT [INDISCERNIBLE] INSTEAD OF HELPING THE STUDENT INSTEAD OF LABEL IT A MENTAL HEALTH PROBLEM AND SOCIAL BENEFIT PROGRAM THEY DON’T TARGET THE POPULATION HAVE YOU EXAMINED THOSE TO MAKE SURE EVERY PERSON INVOLVED TO THE CEO OR NGO THEY USE THE PPP AND DO SOMETHING RIGHT >> THANK YOU BEI, VERY MUCH >> YOU MENTION ACADEMY OF

SCIENCE AND POLICE REPORT AND SOME PEOPLE TO JAIL [INDISCERNIBLE] >> COMMENTS FROM THE GROUP >> A COUPLE QUICK THINGS, WE USE WE HAVE A PROCESS WHERE WE HAVE PARTNERSHIPS WITH PEOPLE IN THE COMMUNITY WE HIRE LOCAL COMMUNITY MEMBERS AND USE VOLUNTEERS WE ALSO HAVE OVER THE COURSE OF 20 YEARS IN THE 20 OR 30 PLUS COUNTIES WE WORKED IN IN THE TWO STATES WE HAVE FORMED PARTNERSHIPS WITH LOCAL LEADERS FROM THE FAITH-BASED ORGANIZATIONS TO PUBLIC SAFETY TO GOVERNMENT TO SECONDARY EDUCATION AND PRIMARY EDUCATION AND SO FORTH WE HAVE PARTNERSHIPS WE DEFINITELY HAVE A PRACTICE AROUND BEING VERY TRANSPARENT AND EVACUATE CONVERSATIONS BEING OPEN TO BRING UP ISSUES THAT MAY BE VERY DIFFICULT AND CHALLENGING WE HAVE A COMMUNITY ADVISORY BOARD I TELL THE ADVISORY BOARD TO HOLD ME ACCOUNTABLE FOR THE THINGS I SAY I’M GOING MY RESPONSE TO YOUR LARGER COMMENTS IS YES WE ALL NEED TO HOLD ONE ANOTHER ACCOUNTABLE FOR WHAT’S HAPPENING AND WHEN WE ENGAGE THE COMMUNITY INSTEAD OF WORKING ON THEM OR TO THEM AND ARE PARTNERS YOU’RE LESS LIKELY TO HAVE THE ATROCITIES THAT MAY HAVE HAPPENED IN THE PAST TO REOCCUR >> IN TERMS OF CONDUCT AND ETHICS IT’S SOMETHING WE TAKE SERIOUSLY AND ENSURE THAT STAFF AND EVEN STUDENTS AND TRAINEES THAT WORK WITH US LEARN ABOUT CULTURE AND CONDUCTING ABOUT RESEARCH EARLY ON IN THE PROCESS >> THANK YOU A QUESTION FOR THE GROUP AND THIS IS A CLINICAL ANECDOTE FROM YESTERDAY CLINIC FOR ME A PATIENT WITH MULTIPLE CHRONIC CONDITIONS WAS TELLING ME HOW SHE’S HAVING DIFFICULTY COMING IN TO SEE ME AND ONE IS SHE’S A SCHOOL TEACHER IN AN ADJACENT UNNAMED COUNTY AND HAD TO HIRE A SUBSTITUTE FROM HER TAKE-HOME TO GET THE TIME TO GO TO A PHYSICIAN’S VISIT WHICH ARE PUBLICLY FUNDED FOLKS TO WHAT IS MORE THE GIG ECONOMY WHILE WE WOULD LIKE EMPLOYER TO SUPPORT HEALTHFUL BEHAVIOR I’M CONCERNED THE ENVIRONMENT IS MOVING IN THE OPPOSITE DIRECTION AND WHAT’S OUR ROLE AS HEALTH EQUITY RESEARCHERS IN THOSE ISSUES? I FIND IT HARD TO IMAGINE ONE WOULD RESEARCH THAT ONE COULD INVESTIGATE FROM AN OBSERVATIONAL STUDY HOW THAT DOES EFFECT CARE AND ACCESS IS THERE WORK BEING DONE IN TA AREA >> THERE ARE OTHER WAYS TO DO THIS THAT TAKE THE BURDEN AND THERE’S PROBABLY MORE MODELS THAT CAN BE TEST AND USED WE JUST HAVEN’T STRETCHED THAT FAR YET THEY’RE ENCOURAGING FIRST STEPS AND SEEM TO WORK WELL >> SO THE BURDEN IS ON SNUS >> WE HAVE EVIDENCE TO SHOW IT WORKS AND THE BARRIERS WITH GETTING OFF WORK WHICH IS HUGE, THAT CAN CHANGE THINGS >> AND MAKE SURE THE IMPACTS ARE VISIBLE WHETHER IT’S ON HEALTH OUTCOMES OR OTHER BURDENS OF THE POPULATION DOING RESEARCH IN THE AREA WOULD HELP MAKE

THE CASE AN IT’S A BURDEN ON MULTIPLE STAKEHOLDERS >> HAVING SCHOOL-BASED HEALTH CARE AND THAT’S WHERE WE HAVE MEDICAID SET THE SCHOOL BASED HEALTH CARE AS THE PRIMARY HEALTH CARE PROVIDER FOR PATIENTS AND TRYING TO OPEN IT UP FOR ADULTS AS WELL THANK YOU FOR THE INTERESTING AND COMPREHENSIVE TALKS I’M CURIOUS WHETHER YOU CAN SPEAK TO THE MECHANISMS THROUGH WHICH DISPARITIES INFLUENCE THE ULTIMATE OUTCOME AND RECEIPT OF PREVENTIVE SERVICE WHEN WE CHANGE AN APPROACH LIKE CHANGING THE DEFAULT AND CREATE OPT-OUT POLICIES AND THE INDIVIDUAL DECISION COMPONENT AS ONE MECHANISM AS OPPOSED TO MAKE MORE PROMOTING SHARED DECISION MAKING AND INFORMING THE PATIENT AND GOING THAT ROUTE TO ACHIEVING OUR ULTIMATE OUTCOME AND WHETHER DISPARITIES MAY PLAY A DIFFERENT ROLE IN EACH OF THOSE APPROACHES AND THE IMPORTANCE OF CONSIDERING DISPARITIES WHEN WE MAKE DECISIONS ABOUT THE INTERVENTION APPROACH WE TAKE >> AN OPT-OUT APPROACH IS WHAT WE’RE LOOKING FOR I CAN SPEAK TO OUR OWN CANCER CENTER IN TERM OF THE IMPACT WE KNOW SMOKING HAS ON CANCER OUTCOMES IT’S CRITICAL EVERY CANCER PATIENT IS PROVIDED EVIDENCE-BASED TREATMENT TO HELP THEM QUIT SMOKING AND RETAIN THEIR SMOKING ABSTINENCE ANDS WE HAVE AN OPT-OUT APPROACH WHERE EVERY PATIENT HAS THE OPPORTUNITY RATHER THAN OPT-IN WE THINK IT WILL HAVE A PBS TIF BENEFIT IN TERMS OF HEALTH DISPARITIES THE CONVERSATIONS AROUND TOBACCO CESSATION HAPPEN LESS FREQUENTLY WITH MINORITY POPULATIONS >> THANK YOU LAST QUESTION >> I’M SHV ANINA >> I’M A DOCTORAL STUDENT AT MORGAN STATE DR. BASKIN, YOU MENTIONED A RECOMMENDATION FOR ADDITIONAL EXPLORATION OF TELEMEDICINE, MOBILE UNITS, ETCETERA AND I THINK OTHERS MENTIONED IT AS WELL THERE’S CELL PHONE USAGE OR VIDEO CONFERENCING METHODS AS PART OF THE INTERVENTION >> DR. GARY BENNETT WILL TALK ABOUT HIS WORK IN PRIMARY CARE AROUND USING MORE MOBILE INTERVENTIONS BUT YES, THE EVIDENCE CLEARLY IS GROWING IN THAT AREA EVEN IN SOME OF THE MORE VULNERABLE POPULATIONS WE’VE BEEN TALKING ABOUT SO USUAL AREAS, AFRICAN AMERICAN WOMEN IN PARTICULAR AROUND OBESITY WHICH IS WHAT I THINK DR. BENN IT — BENNETT WILL BE TALKING ABOUT AND THE FINDINGS FROM THE RCTs ARE COMING OUT WITH PROMISING RESULTS AT OUR ACADEMIC CENTER WITH HOSPITAL HAVE CLOSED IT’S BEEN A MAJOR PUSH WE’VE BEEN PUT OUGHT AND IN THINKING ABOUT CANCER TREATMENT AND ONKOL GY THERE’S NOT — ONCOLOGY AND WE’VE GOT TRACTION TO TELL PEOPLE YOU DON’T HAVE TO DRIVE FOUR HOURS TO BIRMINGHAM TO GET THAT CARE OUR PROVIDERS CAN WORK WITH PROVIDERS THERE AND GIVE THEM CONTINUING EDUCATION AND CONSULT SO PEOPLE CAN GET CARE WHERE THEY ARE AS WE KNOW IT’S BETTER FOR THEM TO STAY IN THE SOCIAL SUPPORT SYSTEM THEY HAVE >> WE’RE GOING TO TALK ABOUT SOME OF THOSE STUDIES TOMORROW >> THERE’S CIRCUMSTANCES IN WHICH IT’S HELPFUL AND WE SHOULD GIVE ADVICE AND THEY’RE NOT THE SAME THING BECAUSE SOME OF THESE PREVENTIVE INTERVENTIONS WE’RE

NOT IN EQ — EQUIS IN QUESTION OF THE AFTERNOON, THREE, WHAT IS THE THIS EVIDENCE AND APPROACH BETWEEN PROVIDERS AND PATIENT CONNECT PREVENTIVE BASED PRACTICES IN REDUCING DISPARITIES AND START WITH THE SYSTEMATIC REVIEW TEAM AMY CANTOR IS GOING TO BE UP NEXT AND THINK SHE’S ABOUT READY TO GO >> GREAT CAN EVERYONE HERE ME I’M AMY CANTOR AT FAMILY MEDICINE AND OBSTETRICS AND GYNECOLOGY AT OHSU AND HERE AS AN INVESTIGATOR FROM THE EVIDENCE-BASED PRACTICE CENTER I’LL TALK ABOUT KEY QUESTION THREE SO IT’S EVALUATING THE EVIDENCE AROUND PATIENT/PROVIDER INTERVENTIONS THIS WITH US INTERESTING BECAUSE I’M ALSO A PRIMARY CARE PHYSICIAN THOUGH I DON’T HAVE ANYTHING TO DISCLOSE IT’S A PERSPECTIVE THAT HELPS INFORM MY EXPERIENCE IN THIS PARTICULAR TOPIC HERE KEY QUESTION THREE I WANT TO READ IT AND AS I MOVE THROUGH I WANT TO TALK ABOUT WHAT WE MEAN AND WE TALKED ABOUT THIS AND PEOPLE MENTION THE IMPORTANCE OF THIS DIAD AND THE EFFECTIVENESS OF APPROACH AND STRATEGIES BETWEEN PROVIDER AND PATIENT CONNECT AND INTEGRATE EVIDENCE-BASED PRACTICES FOR REDUCING DISPARITIES IN PREVENTIVE SERVICES SO WHAT DO WE MEAN BY THAT? I WANT TO TALK ABOUT THE CRITERIA WE USE IN GENERAL AND SPECIFIC TO THIS KEY QUESTION WE’RE TALKING ABOUT POPULATIONS ADVERSELY EFFECT DISPARITIES AND PROVIDERS SERVING THESE POPULATIONS I WANT TO DIFFERENTIATE THIS QUESTION FROM FIVE WHERE WE’LL LOOK AT THE HEALTH SYSTEMS APPROACH FOR THEE CONNECTS — CONNECTS WHERE IN THIS WE’RE FOCUSSED ON INTERVENTIONS WERE A MAJOR COMPONENT OF CARE IS BASED IN THE CLINICAL PROVIDER SETTING WE’LL LOOK AT THOSE RECEIVING INVENTIONS VERSUS POPULATIONS WHO ARE NOT THE OUTCOMES ARE MEASURED IN SCREENING, ACCESS TO PREVENTIVE SERVICES AND CLINICAL OUTCOMES INCLUDING IN — INCIDENCE OF DECEASE AND OUTCOMES AND LOOKING AT THE MAJOR COMPONENT IN THE SETTING OR CONTEXT OF THE CLINICAL INTERACTION STUDY DESIGNS FOR THIS QUESTION ARE CONTROLLED CLINICAL TRIALS AND RANDOMIZED CONTROL TRIALS AND PERSPECTIVE COHORT STUDIES I’M BRINGING UP A SLIDE BROUGHT UP EARLIER TODAY WE’RE LOOKING AT THE BUBBLE WHERE CLINICIN INTERVENTIONS OCCUR THESE CAN BE CONNECTED TO THE COMMUNITY BUT WE WANTED TO MAKE SURE WE’RE RECOGNIZING THOSE AND INCLUDING THOSE CONNECTED TO THAT PATIENT PROVIDER INTERACTION FOR KEY QUESTION THREE IT LOOKED AT FOUR PREVENTIVE SERVICE THE MAJORITY ARE SIMILAR TO OTHER QUESTIONS RELATED TO CANCER SCREENING THERE WAS SEVEN RCTs THE ONE WAS NON-RANDOMIZED AND A STUDY AND YOU CAN SEE THE MAJORITY OF THE EVIDENCE WAS COLORECTAL SCREENING AND A COUPLE FOR BREAST CANCER AND ONE HAD AN OVERLAP OF CERVICAL SCREENING WHICH IS WHY THE NUMBERS DON’T ADD UP IN THE SAME WAY AND ONE STUDY WITH A FOLLOW-UP THAT WAS OBESITY MANAGEMENT

AND THE POPULATIONS INCLUDED IN THE STUDIES FOR THIS QUESTION INCLUDED VULNERABLE, LOW INCOME, RURAL SAFETY NET AND RURAL, ALASKAN AMERICAN AND OTHER MINORITIES AND REPORTED IN THE OUTCOMES LOOKING AT GRADING THE STRENGTH OF EVIDENCE AND APPLICABLE AND WE PROVIDE RATINGS FOR EACH INDIVIDUAL STUDY AND HAVE THEM ABBREVIATED YOU SEE HIGH, MODERATE OR LOW OR WHERE THERE WASN’T AN OUTCOME THERE WAS NO EVIDENCE THERE THOUGH WE’RE LOOKING AT THE CLINICAL SETTING WE WANTED TO MAKE SURE WE FOUND STUDIES THAT OFFERED INTERVENTIONS THAT CONNECTED PATIENTS TO PROVIDERS AND THAT CAN INCLUDE USING PATIENT NAVIGATORS, FOR EXAMPLE DEFINING THOSE HERE TO DIFFERENTIATE PATIENT NAVIGATORS FROM OTHER TYPES OF HEALTH WORKERS THE PATIENT NAVIGATORS ARE TRAINED HEALTH PROFESSIONALS WHO WORK IN CONJUNCTION WITH PHYSICIANS AND DIRECTLY COORDINATE SCREENING SOME STUDIES USE LAY HEALTH WORKERS WHICH WERE OFTEN COMMUNITY HEALTH WORKERS OR AIDS WITH INTERVENTION SPECIFIC TRAINING BUT HADN’T UNDERGONE FORMAL TRAINING IN THE PAST AND OTHER STUDIES UTILIZED HEALTH EDUCATORS SPECIFIC FOR LATINO AND HISPANIC POPULATIONS SOME STUDIES USE MAIL OR TELEPHONE BASED INTERVENTIONS IN STUDIES THAT USED SOMEONE OTHER THAN THE PHYSICIAN DIRECTLY IT SERVED AS LINK TO HELP FACILITATE SCREENING IN THAT CONTEXT NAVIGATORS WERE CONSIDERED HEALTH CARE COACHES AND HEALTH CARE WORKERS TRAINED TO GUIDE THROUGH THE HEALTH CARE SYSTEM WITHIN THAT CLINICAL SETTING I’M START WITH EVIDENCE AROUND COLORECTAL CANCER SCREENING THERE WERE FOUR STUDIOS THAT PROVIDED EVIDENCE AROUND PATIENT PROVIDER INTERVENTIONS TO FACILITATE COLORECTAL CANCERS AND TWO OF WHICH LOOKED AT PATIENT NAVIGATION ONE WAS A SMALL TRIAL THAT WAS A PILOT STUDY AND THEY LOOKED AT WHERE THE PRIMARY CARE PROVIDER REFERRED PATIENTS TO THE PATIENT NAVIGATOR AND THEY FACILITATED SCHEDULING THE COLONOSCOPY AND DISCUSSED RISKS AND BENEFITS AND COMPARED THAT TO SOMEONE WHO DIDN’T HAVE A NAVIGATOR SCREENING WAS INCREASED AND THERE WAS IMPROVED SCREENING COMPLIANCE AND COMPLETION OF THE COLONOSCOPY SO 13 RECEIVED THE INTERVENTION IN THAT PARTICULAR STUDY ANOTHER TRIAL OF PATIENT NAVIGATION AND THERE WERE OVER 400 OF PATIENTS IN LOW-INCOME SETTINGS AND RECEIVED A LETTER AND RECEIVED A FOLLOW-UP CALL WITH A LANGUAGE CONCORDANT PATIENT NAVIGATOR WHICH IS A LITTLE DIFFERENT BUT RECOGNIZED THE NEEDS OF THAT PARTICULAR POPULATION AND SCREENING WAS INCREASED IN BOTH STUDIES USING PATIENT NAVIGATION THERE WAS INCREASED SCREENING ANOTHER STUDY LOOKED AT POPULATIONS OF HISPANICS, LATINOS, ASIANS AND WHITES AND DID NOT FIND INCREASE SCREENING RATES FOR THAT GROUP IMPORTANTLY, THIS WAS A NARROW POPULATION BECAUSE THEY IDENTIFIED FIRST-DEGREE RELATIVES OF KNOWN CANCER CASES AND UTILIZED CULTURALLY APPROPRIATE COUNSELLING TO FACILITATE SCREENING AND CONNECT

THOSE PATIENTS TO CARE AND THEY WERE TAILORED FOR THAT STUDY ANY MODALITY WAS COMPLETED FOR SCREENING AND KOL COLONOSCOPY AND FOR THE LAST RCT FOR COLORECTAL CANCER SCREENING THERE WERE MAILED MATERIALS SENT TO A GROUP OF AFRICAN AMERICAN PATIENTS AS WELL AS WHITES AND THAT WAS THE COMPARISON GROUP THEY RECEIVED INTERVENTION FROM THEIR PROVIDER SO A LETTER FROM THEIR PROVIDER AS WELL AND ADDITIONAL TAILORED MESSAGES THAT INCREASED SCREENING AS WELL JOEFR OVERALL YOU SEE THE INTERVENTIONS THAT CONNECT THE PATIENTS TENDED TO LEAD TO INCREASED SCREENING OVERALL THERE WERE TWO TRIALS THAT UTILIZED LAY HEALTH WORKERS TO SEND REMINDERS AND BOTH WERE CONDUCTED IN A POPULATION OF LOW-INCOME WOMEN AND ONE USED A LETTER FROM THE PATIENT’S CLINICIAN AND ADDITIONAL COUNSELLING FROM LAY HEALTH WORKERS AND ANOTHER STUDY SET REMINDERS FROM LAY HEALTH AIDS ON THE FISSIPHYSICIAN’S BEHALF AND BOTH INTERVENTIONS INCREASED SCREENING RATES FOR MAMMOGRAPHY FOR CERVICAL CANCER SCREENING THERE WERE A COUPLE INTERVENTIONS TO INCREASE SCREENING AMONG A FEW TYPES OF POPULATIONS LAY HEALTH WORKERS AGAIN WERE EMPLOYED TO INCREASE SCREENING FOR LOW-INCOME WOMEN IN ONE TRIAL AND THIS WAS THE SAME TRIAL WHERE WE SAW BREAST CANCER IN THAT PARTICULAR STUDY THEY LOOKED AT THE EFFECTIVENESS OF LAY HEALTH WORKERS FOR INCREASING BREAST CANCER AND CERVICAL SCREENING BUT REPORT THE OUTCOME SEPARATELY AND THE REMINDERS FROM THE LAY HEALTH AID WERE EFFECTIVE FOR GETTING THOSE WOMEN REFERRED FOR CERVICAL CANCER SCREENING IN ANOTHER POPULATION OF RURAL LA TINA WOMEN AN INFORMATIVE VIDEO AND IT INCREASED SCREENING RATES FOR CERVICAL CANCER SCREENING AND THE TRIAL DEMONSTRATED USING PATIENT EDUCATION WITH PATIENT NAVIGATION INCREASED SCREENING RATES AMONG LOW-INCOME CHINESE WOMEN SO CERVICAL CANCER EDUCATION COMBINED WITH THE NAVIGATION VERSUS GENERAL HEALTH EDUCATION INCREASED SCREENING RATES IN THAT POPULATION AS WELL THE LAST IN THE GROUP OF STUDIES WITH YOU OBESITY MANAGEMENT ONE TRIAL REPORTED DATA AT SIX MONTHS AND A FOLLOW-UP STUDY THAT REPORT THE SAME DATA FROM THE SAME POPULATION OF PATIENTS AT NINE, 12 AND 18 MONTHS WHAT WAS INTERESTING ABOUT THIS PARTICULAR INTERVENTION A LITTLE BIT DIFFERENT FROM THE OTHER ONES IS THAT THE PROVIDERS WERE TRAINED THE PRIMARY CARE PROVIDERS ED FOUR HOURS OF TRAINING ON OBESITY MANAGEMENT GUIDED FROM THE NIH EDUCATIONAL OBESITY MODULE AND THEN OVER THE COURSE OF SIX MONTHS THEY HAD 15 EXTRA MINUTES WITH EACH PATIENT TO TALK ABOUT OBESITY MANAGEMENT EVERYTHING FROM DIET, EXERCISE AND ALL THE COMPONENTS THAT WOULD POTENTIALLY IMPROVE THEIR OBESITY AND THE TAILORED WEIGHT LOSS DELIVERED BY THE PRIMARY CARE PHYSICIANS IMPROVED WEIGHT LOSS AT THE SIX-MONTH MARK AND THREE-MONTH FOLLOW-UP AND NINE-MONTH MARK WAS EFFECTIVE WHEN THEY DID POST-INTERVENTION FOLLOW-UP AT 12 AND 18 MONTHS THERE WAS NO DIFFERENCE IN BMI AT THAT POINT INTERESTINGLY THERE WAS IMPROVED WEIGHT LOSS AND IT WAS NO LONGER SIGNIFICANT AT 12 AND 18 MONTHS IN SUMMARY FOR QUESTION THREE THERE WERE NINE INTERVENTIONS

WHICH INCLUDED DIFFERENT APPROACHES AND STRATEGIES TO INTEGRATE THE EVIDENCE-BASED PRACTICES AND FOUR PREVENTIVE SERVICE SO PATIENT NAVIGATION WAS EFFECTIVE FOR COLORECTAL CANCER SCREENING AND TELEPHONE CALLS AND PROMPT EFFECTIVE FOR COLORECTAL AND BREAST CANCER SCREENING LAY HEALTH WORKERS WERE HELPFUL AND PRIMA TORAS FOR SCREENING IT HELP OBESITY OUTCOMES IN THE SHORT TEM BUT AFTER THAT PATIENT CONTACT WAS LOST AND THERE WAS FOLLOW-UP AFTER THE INTERVENTION THOSE EFFECTS WERE NO LONGER SIGNIFICANT PRINTED MATERIALS ON THE PROVIDER’S BEHALF WERE EFFECTIVE FOR COLORECTAL CANCER SCREENING AND MAIL MATERIALS FROM TE PROVIDER WERE ALSO EFFECTIVE FOR COLORECTAL CANCER SCREENNG WE CAN SEE A NUMBER OF DIFFERENT TYPES OF INTERVENTIONS THAT CONNECTED THEM TO PROFESSIONALS OR TRAINED LAY PERSONS TO CONNECT THEM TO PROVIDERS AND IMPROVED SCREENING AND WHETHER OR NOT THAT WAS HIGH-TOUCH INTERVENTIONS OR SOME WAY PATIENTS WERE CONNECTED TO THEIR PROVIDERS, THEY ALL SEEMED TO WORK ON SOME LEVEL WE LOOKED AT POPULATIONS SOMEWHAT SPECIFIC POPULATIONS MANY POPULATIONS WE RECOGNIZED WERE NOT STUDIED IN THESE PARTICULAR TRIALS OR STUDIES AND MOST RECRUITED PATIENTS NOT ALL WERE ADDRESSED BY STUDIES THEY INCLUDED LUNG CANCER SCREENING, ASPIRIN USE TO PREVENT CPD AND COLORECTAL CANCER AND ACTIVITY FOR CPD PREVENTION AND SMOKING CESSATION FUTURE RESEARCH BASED ON CONVERSATIONS IN SHARED DITION — DECISION MAKING AND A MEDICAL HOME AND HOW TO HAVE PRIMARY CARE CLINICIANS AT THE HELM AND HOW THEY CAN BE EFFECTIVE FOR SERVICES THESE WOULD BE HELPFUL IN TERMS OF GUIDING FUTURE RESEARCH THEY SHOULD FOCUS ON EVALUATING THE EFFECTS OF SHARED DECISION MAKES ON PREVENTATIVE DECISIONS AND EFFECTIVENESS RESEARCH ON THE PATIENT/PROVIDER DIAD AND SEE WHICH ARE EFFECTIVE AND WHICH ARE APPLICABLE IN MORE THAN ONE POPULATION TO EVALUATE THE EFFECT OF BUNDLING PREVENTIVE SERVICES IF MAYBE YOU DON’T HAVE AS MUCH AS PATIENT CONTACT CAN YOU BUNDLE CERTAIN SERVICES TOGETHER? AND MEASURE PATIENT ADHERENCE AND HEALTH LITERACY, ETCETERA AGAIN LOOK AT THE PATIENT/PROVIDER DYAD FEW FOLK ON THE PATIENT/PROVIDER DYAD AND RELATED SERVICES SCREENING I AM PROECHLD WITH PATIENT NAVIGATORS OR LAY PERSONS AND STUDIES MAY HAVE BEEN OF NOT BEEN DEFINED OR HIGHLY SPECIFIC IN MOVING FORWARD AND LOOKING HOW THE INTERVENTIONS MAY WORK IN CERTAIN POPULATIONS AND THINKING ABOUT PATIENT-CENTERED INTERVENTIONS WHERE THE PRIMARY CARE PROVIDER IS USING SHARED DECISION MAKING AND THINKING HOW WE HEARD THE IMPORTANCE OF PRIMARY CARE AND COORDINATION OF CARE TO CONNECT PATIENT TO PROVIDERS THANK YOU FOR YOUR ATTENTION AND WE’LL LOOK FORWARD TO HEARING FROM THE REST OF THE SPEAKERS

>> HELLO AND THANK YOU FOR THE INVITATION TO THIS MEETING MAYBE BACKGROUND ABOUT MYSELF I’M A FAMILILEY DOCTOR ORIGINAL — FAMILY DOCTOR FROM THE U.K. AND BEEN AT DARTMOUTH NOW ABOUT SIX OR SEVEN YEARS WHEN I THOUGHT WITH THE TITLE I THOUGHT WHAT WOULD BE AN ALTERNATIVE I THINK I CAME AROUND TO THE IDEA THAT IF IT’S NOT IN THE ELECTRONIC HEALTH RECORD, FORGET ABOUT IT AND IF YOU CAN’T GET TO THE NEXT SCREEN YOU’RE STUCK AND LOTS OF PEOPLE HAVE LEFT BECAUSE OF THAT, AS YOU KNOW IT’S IMPORTANT I THINK THAT WE REALIZE THE IMPLICATIONS OF THAT LAST TALK WHICH IS THERE’S RELATIVELY LITTLE WORK WITH THE INTERACTION BETWEEN THE CLINICIAN AND PATIENT AROUND SCREENING ISSUES FOR THOSE INCLINED THERE’S A TWITTER HANDLE I TRY TO GET THING DONE IN THE REAL WORLD SO I GET CONFLICTED THE ACCESS COMMUNITY HEALTH NETWORK I WORKED WITH A GROUP OF FEDERALLY QUALIFIED CENTERS IN CHICAGO ONE OF THE POOREST AREAS, AS YOU KNOW AND THE TOOLS I IMAGINED A FEW YEARS AGO NOW CALLED OPTION GRIDS HAVE BEEN TAKEN UP I’LL MENTION BRIEFLY, EXCO MAKES [INDISCERNIBLE] AND I HAVE NON -FINANCIAL INTERESTS I’LL USE THIS TO SHARED DECISION MAKES BECAUSE IT APPLIES TO EVERY WALK OF LIFE AND THERE’S A DISCUSSION OF SHOULD WE ALLOW OPT-OUT OR OPT-IN TO PREVENTIVE OR SCREENING ISSUES IT’S A FASCINATING ISSUE BUT THE CHALLENGE IS EVEN IF IT’S OPT-OUT, SOMEBODY’S GOT TO TURN UP AND THEY’LL HAVE A COLORECTAL VACCINE OR PROCEDURE SO THERE’S NOT QUITE OPT OUT THERE’S ALWAYS AN OPT-IN MY FEELING IS THE SCREENING ISSUES AS WE HEARD MENTION OF OVERDIAGNOSIS AND OVER UTILIZATION THEY ALSO COME WITH HARMED I’M NOT SURE YOU CAN ALWAYS HAVE AN OPT-OUT SITUATION TO PREVENTIVE ISSUES IT’S MORE ACADEMIC DEFINITION OF SHARED DECISION MAKING THIS WORKING TOGETHER IS PRETTY CRITICAL AND UNDERSTANDING WHAT WE’RE GETTING INTO, WHY WE’RE DOING IT AND I BELIEVE A LOT OF PEOPLE DON’T FULLY UNDERSTAND THE INVITATIONS THEY GET ABOUT SCREENING ISSUES TO HAVE HARMED AND BENEFITS IS RELEVANT FOR A SITUATION LIKE LUNG CANCER SCREENING THE SMALL MODULES THAT LEAD TO OTHER INVESTIGATIONS AND THE COST OF OTHER INVESTIGATIONS WHICH IS NOT ALL BORNE BY YOUR INSURANCE IS SOMETHING PEOPLE WOULD WORRY ABOUT OR WOULD IF THEY KNEW ABOUT IT AND LOOK AT THE LAST SLIDE WHERE PATIENTS ARE SUPPORTED TO ARRIVE AT INFORMED PREFERENCES PEOPLE HATE MAKING DECISIONS IT BECOMES A RESPONSIBILITY THERE’S A DOMAIN OF UNKNOWN DESTINATION PLEASE TELL ME WHAT TO DO, MOST PEOPLE WILL SAY, UNLESS YOU SUPPORT THEM TO BALANCE THE

HARMED — HARMED — HARMS AND BENEFITS IN A WAY THEY CAN UNDERSTAND THIS IS WHAT MYSELF AND COLLEAGUES PUT TOGETHER TO SIMPLIFY THE IDEA OF SHARING DECISIONS WITH PATIENTS I WANT TO EMPHASIZE THE TOP TALK I THINK THERE ARE THREE BASIC TALKS THE FIRST IS TEAM TALK ESSENTIALLY SAYING WE HAVE AN OPPORTUNITY TO INVESTIGATE WHETHER YOU’RE AT RISK FOR A CANCER OR CARDIOVASCULAR RISK OF SOME SORT BUT LET ME HELP YOU UNDERSTAND WHAT WE’RE GETTING INTO AND I’M HERE TO HELP YOU MAKE THE RIGHT DECISION FOR YOU AND YOUR FAMILY I CALL THAT TEAM TALK IT’S LAYING OUT THE OPTIONS AND ALSO SAYING I’M NOT GOING TO ABANDON YOU TO MAKE THE DECISION ON YOUR OWN SECOND IS THE OPTION TALK THE DATA YOU NEED FOR THE PROBABILITIES OF HARM AND PROBABLES OF BENEFIT — PROBABILITIES ARE BENEFIT ARE DIFFICULT AND IF YOU LOOK AT TRANSCRIPTS AND WHAT WORLD YOU LIKE TO DO AND PAUSE LET THEM SPEAK THAT SIMPLE PAUSE AFTER THAT QUESTION IS VERY RARE IN TRANSCRIPTS THAT’S THE MODEL AND THE CHALLENGE WE HAVE I THINK IS NOT JUST IN SCREENING OR PREVENTIVE BUT TO DO THIS KIND OF APPROACH WHICH I THINK IS RELATIVELY SIMPLE BUT VERY DIFFICULT TO ACHIEVE AT CROSS MEDICINE OR PREVENTIVE SERVICES NOW, OVER THE LAST 20 YEARS IT STARTED IN THE ’80 IN BOSTON MAKING WHAT WE CALL SHARED DECISION MAKING PROGRAMS YOU MAYBE HEARD ABOUT PATIENT DECISION MAKING AT THE LAST COUNT THERE’S 105 OR 111 IT CHANGES DEPENDING ON THE CRITERIA, BUT THERE’S OVER 100 RANDOMIZED TRIALS OF USING THESE TOOLS BUT NOT ALWAYS IN THE ENCOUNTER NOT MANY IN THE SCREENING THEY’RE TOOLS ON THE PREEN COULDN’TER SIDE WHERE YOU SEND SOMETHING TO THE PATIENT AHEAD OF TIME A SCREENING PREVENTIVE SERVICE IS PERFECT FOR THIS THEN THERE’ ANOTHER GROUP CALLED ENCOUNTER BASED TOOLS I’LL SHOW THERE’S THINGS YOU SEND OR GIVE TO THE PATIENT TO COME WITH OR DISCUSS WITH THEIR FAMILY THERE’S ANOTHER SCIENCE ABOUT WHAT IT TAKES TO MAKE A GOOD ONE OF THESE AND THERE’S BEEN A QUESTION ON THE CONTENT AND THE WAY THEY LAY OUT RISK THAT’S IMPORTANT BECAUSE THESE INFLUENCE DECISIONS THE COCHRAN REVIEW TAKEN OVER SHOWN VERY CONCLUSIVELY THE KNOWLEDGE GAINED AMONGST PATIENT GOES UP ABOUT 15% TO 20% EASY THEY HAVE A BETTER RISK PERCEPTION AS WELL SO THEY REALLY UNDERSTAND THINGS BETTER THE CRITICAL ISSUE IS PEOPLE MAKE DIFFERENT DECISIONS ONCE THEY’VE GONE THROUGH THESE KINDS OF TOOLS THEY’RE POWERFUL SO THEREFORE YOU DON’T WANT CONFLICTED EVIDENCE IN THEM YOU WANT THE VERY BEST EVIDENCE IN THEM AND HE’S THE ISSUES I’VE CATEGORIZED INTO ENCOUNTER AND POST ENCOUNTER THE TRUTH IS MANY ENCOUNTER-BASED TOOLS ARE BRIEF BUT BEING USED PRE AND POST BECAUSE BELIEVE IT OR NOT PEOPLE WANT BREVITY AND WANT TO GET TO THE POINT AND GIST THEY’RE NOT INTERESTED IN LOOKING AT A WEBSITE THAT TAKES

40 MINUTES TO READ THEY’D RATHER WATCH NETFLIX HERE’S ONE IT’S A DECISION BOX IT’S DESIGNED FOR THE CLINICIAN AND PATIENT HAVING A CONVERSATION I THINK THIS FORMAT REALIZE ON THE CLINICIAN EXPLAINING SOME TERMS TO THE PATIENT IT’S QUITE A LOT OF DATA HERE’S ANOTHER TOOL THAT’S A VERY DIFFERENT APPROACH VERY MINIMAL COMPARING WHAT DIABETES MEDICATIONS YOU SHOULD TAKE ON THESE ISSUES OF WILL IT EFFECT THE BLOOD SUGAR, WILL IT EFFECT MY WEIGHT OR COST OR WHAT TIME OF DAY WILL I HAVE TO TAKE IT AND SO ON ONE ATTRIBUTE AT A TIME AND THEN COMPARING EACH OF THE MEDICATIONS AND THE PATIENT IS ASKED TO PICK WHICH THEY WANT TO FOCUS ON AND MAYBE A SECOND AND MAYBE A THIRD IT’S INTERESTING THAT PATIENTS NORMALLY HAVE ONE OR TWO VERY IMPORTANT ATTRIBUTES WHERE THEY WANT TO MAKE THE COMPARISONS HERE’S A TOOL THAT’S A DIFFERENT APPROACH WHICH SUCKS DATA OUT OF THE ELECTRONIC HEALTH RECORD INTEGRATED FULLY AND TAKES THE AGE, BLOOD PRESSURE, CHOLESTEROL LEVEL AND PUTS IT INTO THE PERSONALIZED RISK OF THE PATIENT AND CREATES WHAT’S CALLED AN ICON ARRAY THIS IS CALLED AN ICON ARRAY OR PICTOGRAPH BASICALLY ESTABLISHING THE RISK OF A BLOOD CLOT OR STROKE AND CHOOSE THE ASPIRIN AND SEE THE DATA CHANGE IN FRONT OF YOU BUT THE IMPORTANT DATA IS THE DEGREE OF INTEGRATION TYPE IN THE AGE, GENDER OR OTHER MORBIDITIES OF THE PATIENT AND THAT’S A STEP FORWARD CLINICIANS ARE EXCITED ABOUT THIS USED IN TESTING WITH PATIENT AS THE A WAY TO GO SOME PATIENTS MAY FIND THIS A BIT COMPLEX HERE’S A TOOL I’VE BEEN RESPONSIBLE FOR AND DISCLOSED THAT AND WE CALLED IT AN OPTION GRID HERE I FOCUSSED ON LUNG CANCER SCREENING THE DATA IS ON HAVING SCREENING OR NO SCREENING AND I KNOW YOU CAN’T READ IT AT THE MOMENT IT’S TOO SMALL BUT THE DATA COMES FROM THE LUNG SCREENING TRIALS WE’RE INTEGRATING THIS INTO THE MENU IN THE ELECTRONIC HEALTH RECORD SO IT’S AVAILABLE TO THE CLINICIAN AND YOU’LL SEE THESE BUTTONS AT THE TOP AND SEND THAT BY E-MAIL OR SMS TO READ AFTERWARDS OR WE CAN PRINT A PDF FOR THEM TO PRINT HOME IF IT’S WORKING IT’S NOT ALWAYS THE CASE EVEN IF THERE IS A PRINTER THE IMPORTANT THING HERE IS WE’VE GOT HIGH QUALITY EVIDENCE COMPARING NONE THAT ARE RELEVANT TO THAT PATIENT IN TIME AND OF COURSE THERE ARE RISK MODELS I TALKED EARLIER ON WHAT KIND OF RISK MODEL MIGHT MODIFY THIS RISK IF A PATIENT HAS BEEN A HEAVY SMOKE OR HAS GOT COPD THESE NUMBERS MAY CHANGE IF YOU CAN PLUG THAT IN SO WHERE ARE WE IN TERMS OF THESE KINDS OF TOOLS BEING INTEGRATED INTO HEALTH CARE DELIVERY SYSTEMS? NOT VERY CLOSE I WOULD SAY AND THERE ARE ISSUES I THINK IN CURRENT PRIMARY CARE OR INTERNAL MEDICINE IN THE U.S. THERE’S A CULTURAL RESISTANCE TO PREVENTIVE WORK IT’S NOT WHAT PEOPLE DO AS A ROUTINE THE IDENTIFICATION OF ELIGIBLE PEOPLE IS REALLY DIFFICULT UNLESS HAVE YOU A POPULATION REGISTERED AND FIXED YOU DON’T KNOW WHO THEY ARE IF YOU DON’T HAVE THEIR CONTRACT ADDRESS, HOW CAN YOU INVITE THEM? ARE WE INTO PERSUASION OR BALANCED INFORMATION? THERE’S A BIG DEBATE WHETHER WE LEAVE OFF THE HARMS OF SCREENING IN INVITATIONS AND DO WE HAVE ACCREDITED EVIDENCE-BASED ACCESSIBLE INFORMATION AT THE 6th GRADE READING AGE 10 OR 11 MOST MATERIALS ARE NOT THERE THEY’RE VERY FAR FROM THAT SOME WORK FLOW SOLUTIONS ARE YOU FIX A REGISTER IF YOU HAD A FIXED POPULATION A GOOD REGISTER OF HEAVY

SMOKERS YOU HAVE AN INVITATION SYSTEM SMOKERS ALIVED, NOT — ALIVE, NOT DEAD AND DON’T HAVE TERMINAL ILLNESS OR CANCER OR THOSE WITH DIFFICULT DEMENTIA AND SO ON THIS REGISTER IS DIFFICULT TO MAINTAIN YOU HAVE TO KEEP AN EYE ON THE RESULTS AND THE INTERVAL INVITATIONS BASICALLY WHEN YOU INVITE PEOPLE YOU NED TO SEND THEM VERY GOOD, IN MY VIEW, PATIENT DECISION AIDS OR DECISION-MAKING TOOLS WHICH ARE CERTIFIED, BALANCE AND EVIDENCE BASED AND USER TEST DID YOU SAY FIVE MINUTES? VERY GOOD YOU COULD TAKE THESE RESOURCE TO BUILD THEM INTO SYSTEMS IF YOU’RE IN PRIVATE PRACTICE IT’S PRETTY TOUGH BUT IF YOU’RE AT KAISER MAYBE IT’S MORE EASY OR AN ORGANIZED HEALTH CARE SYSTEM YOU CAN ACHIEVE THIS BUT THIS IS DIFFICULT IN THE CURRENT STATE IN THE U.S HAS THE EHR HELP ON SHARED DECISION MAKE ING? WE DID A VERY — REVIEW AND FOUND FIVE STUDIES THAT HAD LOOKED AT THIS ISSUE OF ELECTRONIC HEALTH RECORDS AND REMEMBER HOW WE STARTED, IF IT’S NOT IN THE HR IT DOESN’T HAPPEN IS THIS IS OUR CONCLUSION ANY APPROACH TO DECISION MAKING FEWER EVALUATIONS EXIST SO I DON’T HAVE MUCH DATA TO TELL YOU ABOUT HERE’S THE STUDIES IN PRE-DIABETES, ASTHMA, OSTEOPOROSIS I ASKED A PROMINENT PHYSICIAN IN A WELL KNOWN HEALTH SYSTEM ON THE EAST COAST YOU WILL KNOW THIS HEALTH SYSTEM IT’S WHAT THEY SAID, WE OFFER FIT, THE COLORECTAL BLOOD FECAL TEST AND I DON’T KNOW IF WE HAVE ANYTHING ELSE FORMAL BUILT YOU MENTION THE CARDIOVASCULAR WIZARD AND THE STRUCTURE THAT MADE THE CONVERSATION WORK IN THE CLINIC SO SOME CHALLENGES I THINK MOST HEALTH CARE IS CREATIVE AND YOU COME WAY PROBLEM AND WE’LL SORT IT OUT THERE’S THE ISSUE OF INFORMED CHOICE VERSUS PERSUASION AND PUBLIC HEALTH HAS TO GRAPPLE WITH THIS ARE WE PERSUADING PEOPLE FOR SCREENING OR DO THEY ELECT TO DO SO THIS ISSUE OF THE RIGHT PERSON AT THE RIGHT TIME, EVERY TIME THERE ARE TOOLS YOU NEED TO MAKE THE RIGHT INVITATIONS AND CERTIFIED AND HIGHLY ACCESSIBLE FOR REAL PEOPLE AND THEN THE SKILLED USE OF THESE TOOLS AS I MENTIONED IN THAT MODEL, VERY FEW PEOPLE OFFER THE PREFERENCE OF SOLICITATION IS THIS SOMETHING THAT SUITS YOU AND YOUR FAMILY AND THEN THE COHERENCE ACROSS TEAMS YOU NEED A TEAM APPROACH TO THIS BAYS THE MEDICAL RECORD AND UPDATING DOESN’T JUST HAPPEN BECAUSE ONE CLINICIAN WANTS IT TO HAPPEN I’LL FINISH WITH THIS KIND OF BULLET LIST IF YOU COULD HAVE A DREAM, THIS WOULD BE IT A FEDERAL LEVEL FOR DECISION SUPPORT NEED THESE TO BE GOOD AND REQUIRE THE TOOLS TO BE INTEGRATED INTO YOUR CHARTS MEANINGFUL USE, I HEARD ABOUT THAT REQUIRE POPULATION-BASED PREVENTION REGISTERS YOU CANNOT DO THIS WORK WITHOUT A REGISTER JUST CAN’T AND REWARD ETHICAL PREVENTIVE WORK THERE’S A LOT OF ETHICAL UNDERPINNING TO GOOD SCREENING THANK YOU >> OKAY THANK YOU FOR HANGING IN THERE

AND I THINK WE’LL DO A DEEPER DIVE INTO SOME OF THE SAME ISSUES OF DECISION SUPPORT IN COLORECT COLORECTAL CANCER IS WHERE I’VE WORKED IN MY FIRST JOB IN LATE ’90s TO PRESENT DAY I WANT TO LET YOU KNOW ABOUT THE FUNDING FOR SOME WORK I’VE HAD A NUMBER OF DIFFERENT FEDERAL AND NON-FEDERAL FUNDERS AS WELL AS THE INFORMED DECISIONS FOUNDATION I THINK THE TAKE HOME MESSAGE IS HIGH QUALITY DECISION AIDS ARE AN IMPORTANT MEANS OF IMPROVED DECISION MAKING AND REDUCE HEALTH DISPARITIES UNEQUAL ACCESS TO CARE CONTRIBUTING TO HEALTH DISPARITIES BUT AS A CARE PROVIDER I FEEL LIKE WE NEED TO DELIVER EQUITABLE CARE AS WELL WHAT THAT MAY ONLY INFLUENCE 10% OR 20% OF HEALTH OUTCOMES THAT PERCENTAGE IS IMPORTANT AS WELL THE GOAL I’VE DONE THROUGHOUT MY WORK IS IMPROVE ACCESS TO HIGH QUALITY CARE BY IMPROVING HIGH QUALITY DECISION MAKING AS GLYN IT RATED IN HIS TALK THERE’S ROOM FOR IMPROVEMENT IN DECISION MAKING AND CLINICAL CARE WE’LL DIVE INTO COLORECTAL CANCER IT’S AN IMPORTANT CAUSE OF MORBIDITY AND MORTALITY AND THERE’S IMPORTANT DISPARITIES THERE’S STRONG EVIDENCE COLORECTAL SCREENING IS EFFECTIVE BUT UNDEROUT — UNDER O SCREENING OPTION EVEN A DECISION TO SCREEN OR NOT SCENE FROM VENTIVE SERVICES IS CHALLENGES BUT WHEN HAVE YOU MULTIPLE OPTIONS IT BECOMES MORE CHALLENGING AND INTRODUCES SOME PARTICULAR FACTORS THAT NEED TO BE ACCOUNTED FOR WHEN YOU THINK OF HOW TO SUPPORT PATIENTS I WANT TO START WITH GOOD NEWS WE TALKED ABOUT PROBLEMS BUT COLORECTAL CANCER OVERALL IS AN AMAZING SUCCESS STORY NOW, I’VE BEEN GIVING THIS TALK FOR LIKE 20 YEARS AND HAVE BEEN TALKING ABOUT 50,000 DEATHS A YEAR IN THE UNITED STATES AND SECOND LEADING CAUSE OF DEATH AND YOU THINK WE’RE NOT MAKE PROGRESS BUT THE COUNTRY’S GROWING AND GROWING OLDER THE AGE TO ADJUSTED DEATH RATE THE BLUE BAR, THE DEATH ADJUSTED DEATH RATE SINCE THE MID ’70s DECLINED BY ABOUT 50% OR EVEN A LITTLE BIT MORE AS THE CASES HAVE STAYED SIMILAR REMEMBER, WE’RE MAKING PROGRESS IT’S JUST THERE’S STILL A LOT TO DO AS OUR POPULATION GETS BIGGER THIS WAS ALLUDED TO IN THE MORNING SESSION AND THEY’RE IMPORTANT RACE, ETHNIC DIFFERENCES IN COLORECTAL CANCER AND MORTALITY HERE I’M SHOWING HORE — MORTALITY RATES, MEN ON TOP AND WOMEN IN THE BOTTOM AND THE RED LINE GOING ACROSS IS AFRICAN AMERICANS THE YELLOW LINE IS WHITES AND THE GREEN LINE IS EVERYONE TOGETHER WHEN YOU SEE FROM THIS, FIRST OF HIGHER RATE AND EVERYONE’S GETTING BERTS OVER — GETTING BETTER OVER TIME AND THE DISPARITY CONTINUES TO PERSIST FOR A NUMBER OF REASONS THE OTHER RACE ETHNIC GROUPS ARE LOWER RATES THAN WHITES BUT THERE’S STILL PLENTY OF ROOM ACROSS THE RACE ETHNIC GROUPS FOR IMPROVEMENT FOR MEN AND WOMEN MEN AS IN MANY THINGS HIGHER RISK THAN WOMEN THERE’S BEEN GREAT MODELLING WORK THAT HAS SHOWN 50% OF THE OBSERVED REDUCTION IN COLORECTAL CANCER HAS BEEN DUE TO THE

INTRODUCTION OF SCREENING SOME IS DUE TO THE IMPROVEMENT OF RISK FACTORS SOME THOUGH NOT VERY MUCH THROUGH BETTER TREATMENT OF COLORECTAL CANCER BUT AGAIN ABOUT 50% IS THOUGHT TO BE DUE TO SCREENING THIS IS OBVIOUSLY A PRETTY IMPORTANT PART OF THE OVERALL ATTEMPT TO REDUCE COLORECTAL CANCER BURDEN IN THE UNITED STATES THIS IS DATA ON SCREENING FROM THE NATIONAL HEALTH INTERVIEW SURVEY FROM THE MID ’80s AND WHAT YOU SEE IS COLORECTAL CANCER SCREENING GOING FROM SOMETHING NO ONE GOT TO SOMETHING THAT’S NOW AT LEAST IN THE MAJORITY OF RACE ETHNIC GROUP OVER 50% LATINOS CONTINUE TO LAG OTHER RACE ETHNIC GROUPS THERE’S SOME DIFFERENCE BETWEEN AFRICAN AMERICANS AND WHITES AND JUST THE DIFFERENCE IN SCREENING ALONE DOES NOT ACCOUNT FOR THE DIFFERENCES OBSERVED IN COLORECTAL CANCER BETWEEN RACES IT’S MORE COMPLICATED THAN THAT AND NOT EQUALLY DISTRIBUTED ACROSS COUNTRY AN IMPORTANT POINT IS THIS SAY MAP OF THE UNITED STATES THE DARKER COLORS ARE STATES WITH HIGHER SCREENING RATES AND THERE’S IMPORTANT DIFFERENCES IN THE STATE LEVEL AND THE STATES IN THE GREAT LAKES AND NORTHEAST HAVE ACHIEVED HIGHER SCREENING RATES AND LOWER ACROSS THE SOUTH AND SOUTH CENTRAL PARTS OF THE COUNTRY ALSO NOT COINCIDENTALLY NO. MANY STATES THAT HAVE NOT ADOPTED MEDICATE EXPANSION — MEDICAID EXPANSION BUT THE TRENDS ARE IN A SIMILAR DIRECTION HIGHLIGHT THE IMPORTANCE OF INSURANCE COVERAGE THIS LOOKS AT DEMOGRAPHIC VARIABLES IF YOU’RE INCOME IS GREATER THAN 40% OF POVERTY IT’S ABOUT 3070% AS A PRIMARY CARE DOCTOR I’M SENSITIZED TO NOT HAVING A PRIMARY SENSE OF CARE IS A MARKER FOR LOW COLORECTAL SCREEN RATES IF YOU DON’T REPORT A USUAL SOURCE OF CARE YOU’RE ONLY SCREENED AT 60% RATE AND IT’S RELATED TO INSURANCE AND IF YOU HAVE PUBLIC OR PRIVATE INSURANCE THE SCREENING RATE IS RELATED AND SPECIALLY IMPROVE SCREENING RATES OVERALL THERE’S A CONSIDERABLE DIFFERENCE BETWEEN NON-HISPANIC AND HISPANIC POPULATIONS ON THE LEFT TABLE YOU SEE THE DIFFERENCE ABOUT 17 PERCENTAGE POINTS THOSE ARE NOT ADJUSTED SCREENING RATES AND A LOT OF THAT’S DUE TO DIFFERENCES IN INSURANCE STATUS LATINOS ALSO TEND TO HAVE HIGHER RATES OF UNINSUREDNESS AND THE LATINO POPULATION IS NOT MONOLITHIC THE TABLE ON THE RIGHT SHOWS DIFFERENT RATES ACROSS DIFFERENT SUBPOPULATIONS WITHIN THE LATINO POPULATION WITH HIGHER SCREENING RATES AND PUERTO RICANS LOWER AND MEXICAN AMERICANS AND CENTRAL AMERICANS IN BETWEEN I THINK SOLUTIONS TO REDUCING DISPARITIES IN COLORECTAL CANCER AND OTHER SKREENCREENING NEED TO IN INCORPORATE THE SCREENING RATES WHICH ARE THE BLUE BARS IN THE MIDDLE IS ABOUT 40% COMPARED TO USING BRFS DATA OVER 65% FOR THE ENTIRE POPULATION THE ONE IN THE QUARTERLY IS OUR LOCAL ONE WHERE WE’VE DONE WORK TO IMPROVE SCREENING AND STARTED LOWER NUMBERS PLENTY TO DO IN THE FQHC SETTING AND TO GIVE A GLIMPSE WHETHER WE’LL PROMOTE SCREENING COLORECTAL SCREENING HAS THE STRONGEST EVIDENCE IT RECEIVES AN A FROM THE PREVENTIVE SERVICES TASK FORCE AND I WON’T TALK ABOUT OLDER OR YOUNGER POPULATIONS WE NEED MORE INDIVIDUALIZED DECISION MAKING IN THOSE CASES BUT THE EVIDENCE IS STRONG IN SUPPORT OF SCREENING IN THAT 50 TO 75 AGE RANGE, HOWEVER, EVIDENCE ABOUT WHICH METHOD YOU SHOULD BE SCREENED BY IS MUCH MORE EYE

QUIV — EQUIVALENCE AND EQUIPOISE FOR SHARED DECISION MAKING MOST THE DECISIONS IN THE UNITED STATES TENDS TO BE WITH KOL KOLOSCOPY EVERY — COLONOSCOPY EVERY 10 YEARS AND SCREENING ARE DIFFERENT TOOL TESTING IS DONE AT HOME AND DONE ANNUALLY AND REQUIRES ONGOING ADHERENCE AND EASIER PER EPISODE OF TESTING COLONOSCOPY STREAK MORE INVOLVED AND YOU NEED SOMEONE TO DRIVE YOU BACK AND FORTH BECAUSE OF THE SEDATION YOU’LL RECEIVE AND IT HAS PROBABLY A HIGHER RATE OF COMPLICATIONS RATHER THAN STOOL TESTING AND IMPORTANTLY, WHAT MAKES IT MORE COMPLEX FOR SHARED DECISION MAKING IS YOU HAVE TO WON’T GET THE REDUCTION INS INCIDENT IN MORTALITY WE EXPECT WHEN WE OFFER SCREENING TO SOMEONE THAT’S IMPORTANT CAN WE DO SCHOOL — STOOL TESTING THERE’S AN INTRICATE DANCE GLYN DESCRIBED THAT NEEDS TO BE DONE AROUND THIS TOPIC THINGS HAVE HELP INCREASE SCREENING BUT NOT REDUCE DISPARITIES THEY INCLUDE INCREASED AWARENESS AND ADVOCACY AND MORE CLINICAL SYSTEMS AND MORE SCREENING OPTIONS THAN COVERAGE IN TERMS OF INCREASED AWARENESS WE’RE IN A DIFFERENT PLACE THAN 25 YEARS AGO THIS IS A CDC WITH KATIE COURIC AN IMPORTANT ADVOCATE THE EDUCATION IN THE POPULATION IS HIGHER THAN BEFORE BUT NOT BY ANY MEANS UNIVERSAL PARTICULARLY IN POPULATIONS THAT MAY BE MORE ISOLATED AND HAVE LESS EXPOSURE TO HEALTH MESSAGES AND LESS IN THE HEALTH CARE SYSTEM THERE’S STILL ROOM TO MOVE AND DELIVERING THAT MESSAGE THE CDC COMMUNITY GUIDE AND PREVENTIVE SERVICES HAS DONE WORK LOOKING AT THE TECHNIQUES TO IMPROVE CANCER SCREENING I’VE SHOWN A VARIETY HERE I DON’T HAVE TIME TO GO INTO ALL OF THEM THE MOST IMPORTANT THING I WANT TO EMPHASIZE IS WHAT’S IN YELLOW WHICH IS THE MULTI-COMPONENT VARIATIONS THAT HIT DIFFERENT BARRIERS SEEM TO BE AN EFFECTIVE WAYS TO ADDRESS SCREENING AND WHEN IMPLEMENTED INCREASE SCREENING BY 15 PERCENTAGE POINTS OVER SETTINGS THAT DON’T ADOPT THAT KIND OF AN INTERVENTION THE IDEA OF HITTING IT IN MORE THAN ONE PLACE IN THE HEALTH CARE DELIVERY AND PROVIDER PROVIDER/PATIENT INTERACTION SYSTEM IS A BIG ONE WE KNOW IF YOU OFFER STOOL TESTING YOU GET A HIGHER RATE OF SCREENING THAN IF YOU ONLY OFFER COLONOSCOPY IN SAN FRANCISCO PEOPLE HAD ACCESS TO BOTH FORMS OF SETTING AND THEY FOUND THOSE RESULTS LET’S TALK ABOUT HOW DECISION AIDS MAY HELP THAT’S THE OTHER PRELIMINARICATIONS OF THE FACT THAT OFFERING MORE TYPES OF SCREENING LEADS TO HIGHER SCREENING RATES SO THIS IS JUST A LITTLE BIT DIFFERENT CONCEPTION THAN GLYN USED BUT I THINK IS CONSISTENT DECISION AIDS ARE TOOLS THAT HELP PEOPLE UNDERSTAND THEY HAVE A DECISION THAT’S IMPORTANT IN PREVENTIVE CARE WHERE YOU DON’T COME IN WITH A SYMPTOM AND WE HAVE TO DISCUSS THE CONDITION YOU MIGHT BE AT RISK FOR YOU HAVE TO RECOGNIZE THE POSSIBLE OPTIONS AND KNOW THE PROS AND CONS THAT IS THE INFORMATION ABOUT THE OPTIONS GLYN MENTIONED YOU HAVE TO RECOGNIZE THE UNCERTAINTY IN THE DECISION THAT’S AN ADVANCED CONCEPT WE’VE NT DONE WELL IN WHEN IS THE EVIDENCE UNCERTAIN SERVICE THE CHOICE BALANCE THEY’RE DIFFERENT THINGS HELPING PEOPLE CLARIFY VALUES IS SOMETHING THAT DOESN’T HAPPEN ROUTINELY AND WITH DECISION AIDS IS MORE LIKELY TO HAPPEN AND IMPORTANTLY COME TO A DECISION AND COME TO THE HEALTH CARE SYSTEM TO MAKE THAT DECISION HAPPEN I WANT TO REINFORCE WHAT GLYN SAID, IF WE DON’T INTEGRATE THESE TOOLS INTO THE CARE ENVIRONMENT EFFECTIVELY THEY’LL NOT BE EFFECTIVE THERE’S BEEN OVER 21 TRIALS OF DECISION AIDS TO IMPROVE

COLORECTAL CANCER SCREENING DECISION MAKING LIKE THE OVERALL EVIDENCE THEY INVARIABLY INCREASE KNOWLEDGE IN MOST CASES THEY LEAD TO INCREASED SCREENING INTEREST AND INTENT IN SOME CASES THEY INCREASE SCREENING THERE’S ALMOST ALWAYS A VOLTAGE DROP BETWEEN INCREASED KNOWLEDGE AND THEN INTEREST AND THEN ORDERING AND THEN COMPLETION WE’VE NEVER BEEN PERFECT IN MAKING THE PATHWAY FROM A GOOD DECISION TO ACTUAL TEST COMPLETION SEAMLESS AND THEY TEND TO PRODUCE MORE VARIED TEST PREFERENCES AND UPTAKE IT MEANS PEOPLE EXPOSED TO DECISION AIDS THEY’RE LIKELY TO CHOOSE STOOL TESTING, AT LEAST IN THE UNITED STATES, THAN UP USUAL CARE THESE ARE SCREEN SHOTS AND WE HAVE WORK WE IT RATED THE FLORIDA — ENGLISH LANGUAGE IS CALLED CHOICE AND ANOTHER SPANISH VERSION WE TESTED THEM IN SETTINGS AND POPULATIONS THIS THEE ARE THE TRIALS — THESE THE TRIALS WE’VE DONE FIRST, TWO OF MY FORMER MENTEES, DAN ROILAND USED AN iPAD BASED DECISION AID IN PRACTICE FOLLOWED BY NAVIGATION BY NURSE IN THE SAME PRACTICE WE INCREASED COLORECTAL CANCER SCREENING BY 41 PERCENTAGE POINTS OVER USUAL CARE TO 68% AND THAT WAS EFFECTIVE AND ONE IN NEW MEXICO AND ONE IN NORTH CAROLINA WE DID ANOTHER TRIAL IN 2018 DAVE MILLER FROM THE WORKFORCE SYSTEM IN NORTH CAROLINA iPAD BASED AND ALLOWED PATIENT TO DIRECTLY ORDER THEIR OWN SCREENING IF THEY WANTED TO DISCUSS WITH THEIR PROVIDER THEY CAN DO SO AND USE TEXT MESSAGING FOR THE SCREENING QUITE VULNERABLE PATIENT POPULATION WITH A HIGH DEGREE OF MEDICAID OR UNINSUREDNESS AND INCREASE BY 15 POINTS NOT THE SAME AS WITH NAVIGATION BUT STILL A POSITIVE RESULT THIS IS FROM AN INTERN MEDICINE PAPER AND WHAT THIS SHOWS IS WE LOOKED AT WHETHER OR NOT THE EFFECT OF THE INTERVENTION VARIED BY A NUMBER OF DIFFERENT DEMOGRAPHIC GROUPS SO YOU CAN SEE OVERALL EFFECT IS IN THE DIAMOND AT THE TOP AND FOR EACH OF THE DEMOGRAPHIC CHARACTERISTICS THERE WERE DIFFERENCE IN THE VARIABLES AND THEY WERE MORE EFFECTIVE IN WOMEN THAN IN MEN BUT EFFECTIVE IN ALL THE RACE ETHNIC GROUP AND LATINAS SEEMED TO BENEFIT MORE WE WERE HARDEN THE FACT WE WERE ABLE TO MAKE IMPROVEMENTS ACROSS LTS AND LANGUAGE GROUPS AND INCOME GROUPS WHEN THERE WAS NAVIGATION SUPPORT THINKING OF LITERACY IN THE DIGITAL DIVIDE AND THE iPAD BASED INFORMATION HAS HELP OVERCOME LITERACY BARRIERS BUT PEOPLE DON’T HAVE COMPUTERS OR INTERNET ACCESS AND USING CELL PHONES AND TEXT MESSAGING HELPS OVERCOME BARRIERS THERE’S NOT THE SAME DIGITAL DIVIDE WITH CELL PHONE AND SMARTPHONE USAGE ANOTHER PLUG THIS HAS TO BE FIT WITHIN THE HR WORK FLOW IT’S NOT EASY TO DO ON THE FLY IT’S NOT OFTEN LIES MAN — EASILY MANIPULATABLE AND WE NEED TO LOOK AT HOW WELL IT FITS INTO PRACTICE AND HOW YOU MAKE SURE THE PATIENT HAS ACCESS TO OR GETS TESTING THEY PREFER IN CONCLUSION IN THE LAST MINUTE, WHAT I WOULD CONCLUDE IS IT CAN HELP IMPROVE THE PROCESSES FOR COLORECTAL SCREENING AND REINFORCING THE POINT OF WELL DESIGNED TO REACH VULNERABLE POPULATIONS BUT NEED TO BE DESIGNED WITH AND FOR THE POPULATION THAT YOU WANT TO IMPLEMENT THEM IN AND EFFECTIVE DECISION SUPPORT IS KEY FOR REDUCING OR AT LEAST NOT INCREASING HEALTH DISPARITIES AS WE IMPROVE BOTH GROUPS I THINK IF WE IMPLEMENT THESE TOOLS IN SETTINGS WITH LARGE

NUMBERS OF VULNERABLE POPULATIONS ONES WITHOUT INSURANCE AND ONES THAT HAVE TYPICALLY NOT BEEN SERVED BY THE EXISTING HEALTH CARE SYSTEM WE CAN HELP REDUCE DISPARITIES BUT IT WON’T HAPPEN UNLESS WE HAVE EFFORTS TO BRING THAT ABOUT THANK YOU >> GOOD AFTERNOON THANKS FOR HANGING IN THERE WITH US SO ABOUT A YEAR AGO I WAS ACTUALLY STANDING ON THIS VERY STAGE I’M ROBIN VANDERPOOL FROM THE COLLEGE OF KENTUCKY AND THE COLLEGE OF PUBLIC HEALTH AND MARKEY CENTER AND WE WERE HOLD RURAL CANCER CONTROL CONFERENCE IT’S THRILLING FOR ME TO BE HERE AGAIN A YEAR LATER AND HAVE RURAL COMMUNITIES BE PART OF THIS WORKSHOP TODAY WITH THAT I’M THE LAST PRESENTATION OF THE DAY SO I HAVE TWO THOUGHTS, ONE, EVERYTHING IN MY TALK LITERALLY HAS ALREADY BEEN SAID TODAY BUT THEN TWO, IT’S REASSURING TO KNOW WE’RE ALL ON THE SAME PAGE AND THAT WE HAVE IDENTIFIED MANY OF THE SAME BARRIERS AND GAPS AND CONCERNS BUT ALSO MANY OF THE SAME OPPORTUNITIES AND STRATEGIES GOING FORWARD SO WITH THAT I’LL GO AHEAD AND GET STARTED I ONLY HAVE ONE DISCLOSURE IT’S A TEXTBOOK FOR PUBLIC HEALTH STUDENTS AND IT WAS NOT ON THE OPRAH BOOK CLUB LIST YOU CAN SEE IT’S QUITE [INDISCERNIBLE] RIGHT NOW I’LL GO OVER RURAL CANCER DISPARITIES AND WE HEARD MANY POINTS EARLIER TODAY THEN DIVE INTO THE CONTROLS WE USED IN PROVIDER RELATIONSHIPS AND IN APPALACHIAN, KENTUCKY IT’S ONE OF THE MOST MEDICALLY UNDER SERVED, UNDER RESOURCED LOW INCOME AREAS OF THE COUNTRY WE HAVE A LOT OF WORK TO DO BUT WE ARE IN IT TO WIN IT AND WE ARE IN IT TO CHANGE THESE OUTCOMES WITH UNIQUE, INNOVATIVE PARTNERSHIPS AND STRATEGIES WE’VE HAD A LARGE FOCUS ON RURAL COMMUNITIES AND PARTICULARLY OUR CANCER DISPARITIES CDC AMONG OTHERS HAVE PUBLISHED SEVERAL REPORTS THAT SHOW WHILE RURAL AREAS HAVE LOWER INCIDENT OF CANCER WE HAVE HIGHER CANCER MORTALITY RATES AND THE REDUCTIONS IN CANCER RATES OVER THE LAST FEW DECADE WE’VE SEEN THAT PROGRESS HAS BEEN MUCH SLOWER IN OUR RURAL COMMUNITIES AND THAT’S PARTICULARLY THE CASE FOR WHAT I CALL THE PREVENTIBLE AND SCREENABLE CANCERS LIKE LUNG, COLORECTAL AND CERVICAL AND WHAT I THINK IS REALLY CONCERNING IS WE’RE SEE HIGHER PREMATURE MORTALITY RATES IN AREAS AND DECREASES IN LIFE EXPECTANCY AND THAT COULD NOT BE MORE PRONOUNSD — PRONOUNCED WHERE EIGHT OF THE 10 TO 80% OF THE U.S. COUNTIES WITH THE LARGEST DECREASES IN LIFE EXPECTANCY ARE IN RURAL APPALACHIAN, KENTUCKY THESE MAPS, MONICA HAD SEVERAL MAPS IN HER TALK AS WELL YOU CAN SEE THE HOT SPOTS SITUATED PRIMARILY IN EASTERN KENTUCKY AND IN THE MISSISSIPPI DELTA REGION AND KENTUCKY HAS THE HONOR OF HAVING THE HIGHEST RATES OF HPV RELATED CANCER INCIDENT AMONG MEN AND WOMEN SO MUCH WAS PRESENTED IN THE TALKED AND IN REMARKS THAT WE HAVE HIGHER PREVALENCE OF THE RISK FACTORS THAT LEAD TO CANCER AND MANY OF OUR RURAL AREAS EVERYTHING FROM SMOKING TRADITIONAL CIGARETTES AND SMOKELESS TOBACCO AND ISSUES WITH OVERWEIGHT AND OBESITY, LOWER HPV I’LL ADVOCATE NEEDS TO BE ON THE NEXT ROUND OF SERVICES FOR THE NEXT REPORT CANCER SCREENING RATES ARE ALSO LOWER IN RURAL AREAS AND CONCERNS AROUND PHYSICAL INACTIVITY AND POOR DIET AND IT’S NOT JUST ABOUT HAVING HIGH CALORIE, HIGH FAT FOODS BUT ALSO

NOT ENOUGH FOOD AND THE RATES ARE AROUND 13% FOR FOOD INSECURITY INCREASED COMORBIDITY RATES I THINK WE KNOW IF YOU HAVE HIGH RATES OF CANCER YOU LIKELY HAVE HIGHER RATES OF OTHER CHRONIC CONDITIONS LIKE DIABETES AND HEART DISEASE AND I THINK YOU ALL CAN HAVE ME BACK IN 10 OR 20 YEARS AND WE COULD BE HERE TO TALK WITH THE RISING CASES OF LIVER CANCER IN OUR RURAL COMMUNITIES BECAUSE OF THE OPIOID EPIDEMIC AND THE HEPATITIS C INFECTION RATE AND ONCE RURAL PATIENT DIAGNOSED WE SEE LOWER QUALITY OF LIFE WITH STRESS AND DEPRESSION AMONG OTHERS WHAT’S THIS LOOK LIKE FOR KENTUCKY? WE HAVE THE SECOND HIGHEST ADULT SMOKING PREVALENCE A QUARTER ARE DAILY SMOKERS WE RANK SEVENTH ADULT OBESITY AND NUMBER ONE IN HEPATITIS C INCIDENT IN THE U.S IF OUR BEHAVIOR DIDN’T GET US THEN OUR GEOLOGY IMPACTS OUR CANCER OUTCOMES WE HAVE ELEVATED RADON LEVEL WHICH AFFECT OURS SMOKING AND CANCER RATES AND CONCENTRATIONS OF HEAVY METALS THAT ARE PART OF THE MOUNTAIN LANDSCAPE IN THE WE THINK ABOUT THE POSITION OF RURAL AMERICA YOU ALSO SEE AN MIGRATION OF YOUNGER INDIVIDUALS OR INMIGRATION OF OLDER INDIVIDUALS RETIRING TO RURAL AREAS AND HAVE YOU MORE DEATHS THAN BIRTHS SOCIOECONOMIC DISPARITIES WHICH WE COVERED REPEATEDLY TODAY THEN IF WE’RE GOING TO PROMOTE CANCER PREVENTIVE SERVICES WE NEED COMMUNITIES WITH HEALTHFUL POLICIES THAT SUPPORT THOSE SO IF I ASK YOU TO QUIT SMOKING AS A CLINICIAN AND I’M NOT A CLINICIAN, I ONLY PLAY ONE ON TV, I HAVE A DOCTORATE IN PUBLIC HEALTH BUT IF I ASK TO YOU QUIT SMOKING AND THEN YOU’RE COMMUNITY IS FOR EXAMPLE NOT SMOKE FREE, ONLY 30% OF COUNTIES IN KENTUCKY ARE SMOKE FREE ANYONE YOU DON’T HAVE A SUPPORTIVE ENVIRONMENT SO POLICY IS AN IMPORTANT PLAYER IN SUPPORTING SERVICES WE’RE TRYING TO PROMOTE CULTURAL BELIEFS WE HEARD EARLIER IN DR. SIMMONS’ TALK AND WHETHER IT’S A RELIGIOUS BELIEF AND/OR THE NOTION THERE’S A PHRASE CALLED CANCER COLLECTIVISM MEANING CANCER IS EVERY AND IN SOME COMMUNITIES THAT’S THE CASE EVERYONE THEY KNOW HAS BEEN IMPACTED OR DIAGNOSED WITH CANCER, FRIENDS, FAMILY, CHURCH MEMBERS, THE NOTION YOU GOT SCREENED AND THEY FOUND CANCER AND NOW YOU’RE GOING TO DIE IT’S SOMETHING IMPORTANT TO CONSIDER WE EVEN HAD A STUDY OF YOUNG WOMEN WITH HIGHER BELIEFS OF THESE DID NOT COMPLETE THE HPV VACCINATIONS AND THERE WAS MEDICAL DISTRESS AND DISCRIMINATION WHAT DO THIGH LOOK LIKE CONCERN — THEY LOOK LIKE IN KENTUCKY WE HAVE DIVERSITY IN APPALACHIAN, KENTUCKY WE HAVE LOWER MEDIAN INCOME ALMOST $20,000 LESS THAN THE NATIONAL NUMBERS A QUARTER OF OUR POPULATION LIVES BELOW THE POVERTY LEVEL AND ONLY THREE-QUARTERS ARE HIGH SCHOOL GRADUATES AGAIN, I WON’T REPEAT WHAT MONICA SAID BUT WE HAVE TO REMEMBER THERE’S AN INTERSECTIONALITY AND THIS MAPS OUT THE DISTRIBUTION OF DIFFERENT POPULATIONS AND WHERE THEY’RE CONCENTRATED IN OUR RURAL COMMUNITIES AND HOW COME TOGETHER TO IMPACT HEALTH AND THE LANDSCAPE OF OUR SITUATIONS AND THE TOPOGRAPHY AND MOUNTAINS AND DESERT AND WATER AND DIFFICULT CLIMATES AND WEATHER CONDITIONS WE HAVE TO THINK ABOUT GEOGRAPHIC ISOLATION AND THE DISTANCE AND TRANSPORTATION CHALLENGES YOU HAVE TO THINK WITH THE JOBS PRESENT IN MANY OF THESE COMMUNITIES AND THEN THE INFRASTRUCTURE THAT’S EVERYTHING FROM THE ROADS AND WATER AND SANITATION SERVICES IT HASN’T BEEN BROUGHT UP TOO MUCH TODAY BUT ALSO THIS PUSH THAT ACTUALLY HAVING ACCESS TO THE INTERNET OR BROWARD BROADBAND BROADBAND AND YOU CAN MAP RURALITY WITH LOW BROADBAND AND LOW ADOPTION.AND YOU CAN MAP RURALITY WITH LOW BROADBAND AND

LOW ADOPTION.YOU CAN MAP RURALITY WITH LOW BROADBAND AND LOW ADOPTION DISTANCE ZA — DOES MATTER AND IF YOU LIVE MORE THAN 50 MILES FROM A HOSPITAL YOU’RE ASSOCIATED WITH DECREASED QUALITY OF LIFE AND THIS HAS BEEN COVERED TODAY WE HEARD ABOUT THE HOSPITAL CLOSURES AND LIMITED ACCESS TO CARE AND A HOST OF SPECIALISTS AS WELL HERE’S A MAP THAT SHOWS AGAIN WHAT THIS LOOKS LIKE THE GREEN AREAS ARE RURAL NON-METRO AREAS IF ANYONE’S HERE FROM NEBRASKA, PLEASE LET US KNOW THIS COMES TOGETHER IN THE CONTEXT AND ENVIRONMENT OF THE COMMUNITIES AND COMPOSITION OF THE PEOPLE WHO LIVE THERE AND HEALTH OUTCOMES IT COMES TOGETHER IN A PERFECT STORM WE KNOW IF WE CAN GIVE EVERYONE EQUITABLE ACCESS TO PREVENTION EFFORTS AND HIGH QUALITY SCREENING AND TREATMENT FOR CANCER WE HAVE ALMOST A QUARTER REDUCTION THAT’S IF NOTHING ELSE WAS EVER INVENTED IF WE HAVE EQUITABLE ACCESS TO ALL THE SERVICES WE’VE TALKED ABOUT ALL DAY TODAY PARTICULARLY KNOWS IN THE CANCER DOMAIN AND WE’VE TALKED ABOUT WORKING WITH THE COMMUNITY AND LISTENING WITH THE COMMUNITY AND HAVING THEM DESIGN THE PROJECT AND IMPLEMENT THE WORK AND AGAIN I JUST CAN’T EMPHASIZE ENOUGH WORK THE COMMUNITY ACADEMIC COMMUNITY PARTNERSHIPS ARE VITAL, I THINK, IN PROMOTING THESE PREVENTIVE SERVICES WE JUST HEARD IT IN MICHAEL’S TALK WITH THE IMPORTANCE OF FEDERALLY QUALIFIED HEALTH CENTER I HAD A COLLEAGUE A CEO OF WHITE HOUSE FQHC WITH EIGHT SITES IN FIVE COUNTIES IN EASTERN KENTUCKY AND CAME TO ME AND SAID I WANT TO DO A PROJECT I KNOW WHAT I WANT TO DO AND HEARD ABOUT IT AT THE IHI CONFERENCE AND WANT TO COME HOME AND IMPLEMENT IT IN MY CLINIC SYSTEM AND HAVE MY DOCTORS PRACTICE MEDICINE AGAIN INSTEAD OF BEING IN THE EHR TRYING TO FIGURE OUT WHAT BUTTON TO PUSH AND TAKE CONTROL OVER THE CLINICAL GUIDELINES FOR CARE WE’RE A MEDICARE EXPANSION STATE IN KENTUCKY NOR TIME BEING — FOR THE TIME BEING AND HAD DIFFERENT PAYER GROUPS AND MANAGED CARE GROUPS AND DIFFERENT PROFESSIONAL ORGANIZATIONS EVEN NON-PROFIT GROUPS KNOCKING ON THE DOOR SAYING YOU NEED TO DO IT THIS WAY, NO, THIS GUIDELINE AND THAT GUIDELINE AND SHE SAID NO, I’M GOING DO WHAT WE NEED TO DO FOR OUR PATIENTS WE PUT PRIMARY CARE AT THE CENTER AND WHAT SHE WANTED TO PROMOTE IS WHAT’S CALLED A PRO-OFFICE ENCOUNTER AND DEVELOPED BY KAISER IN SOUTHERN CALIFORNIA THIS IS WHERE WE TAKE AN EVIDENCE-BASED PRACTICE AND ADAPTING IT FOR KENTUCKY AND ADAPTING IT TO THE SETTING AND POPULATION AND RESOURCES AT EVERY VISIT THEY SCREEN THE CHART AND GET A PIECE OF PAPER OUT AND CHECK OFF WHAT THE PATIENT’S NEED AND HAVE THE PROVIDER WORK FROM THAT PIECE OF PAPER WE CALL IT A SCRUB SHEET BECAUSE THEY SCRUBBED THE CHART TO FIGURE OUT THE GUIDELINES I’LL COME BACK TO THIS THEY HAVE THE PATIENT AND PROVIDER WORK ON THE LIST AND

THEN IT GETS INPUTTED BACK TO THE EMR IT PROMOTE THE PATIENT/PROVIDER RELATIONSHIP BECAUSE THEY’RE ABLE TO SIT AND TALK TO ONE ANOTHER BUT IT INVOLVES THE REST OF THE STAFF IT ALSO INVOLVES TASK SHIFTING WHERE THEY ACTUALLY HIRED WHAT WE CALL SCRUBBERS BUT THEY’RE CALLED PATIENT CARE COORDINATORS ON THE JOB TITLE THEIR OFFICE STAFF NOW SCRUB THE CHARTS AND LOOK FOR PREVENTIVE CARE GUIDELINE NEED TO BE MET AND ALERT THE PROVIDER TEAM ABOUT THAT AND IMPLEMENTED STANDING ORDERS IMMUNIZATIONS CAN BE ORDER OR FITBITS CAN BE ORDERED OR PREP THE ROOM ALL THINGS DONE AHEAD OF TIME IT DOES TAKE A CULTURE SHIFT TO DO THIS BUT THIS GROUP WAS COMMITTED TO DOING THIS AT EVERY APPOINTMENT THE CEO SAID I WANT THIS FOR ALL HEALTH CONDITIONS NOT JUST CANCER BUT SOMETIMES OUR SILOED FUNDING MECHANISM SO I WROTE A CDC GRARNT — GRANT ABOUT CANCER FOR THIS AND I MANAGES ALL THE ABOVE THIS IS A QUICK VIEW WHAT IT LOOKS LIKE WE EXPAND THE SCOPE OF PRACTICE AND HAVE STANDING ORDERS AND IT HAPPENS FROM PRE-ENCOUNTER THROUGH POST ENCOUNTER QUE TALKED ABOUT RURAL COMMUNITIES HAVE TRAVEL ISSUES THIS SAVES THE APPOINTMENT WHEN YOU SA COME BACK AND WE’LL DO ALL THAT WELLNESS STUFF WE KNOW THEY’RE NOT COMING BACK AND YOU MAY HAVE PATIENTS WITH 30 CARE GAPS BUT YOU CAN CHIP AWAY AT THOSE OVER TIME AND GET THE PATIENTS ON A REGULAR SCHEDULE WITHTHEIR WORK WE TALKED ABOUT DOING THIS IN THE REAL WORLD AND WE ATALKED TO PATIENTS IF YOU’RE GETTING YOUR ASTHMA PRESCRIPTION REFILLED AND YOU’RE GET FITBIT YOU’LL WANT TO KNOW WHY AND YOU WANT TO KNOW IF THE INSURANCE WILL PAY FOR ALL THAT AND WE WANTED THE PATIENT’S PERSPECTIVE I LIKE THE TERM MICHAEL PARCHMAN TALKED ABOUT PROVIDING SUPPORT AT THE ELBOW WE HELP WITH STRATEGIC PLANNING AND EVALUATION AND WE’RE ALL CREATURES OF HABIT AND YOU’LL GO BACK TO THE OLD WAY IF YOU CAN’T SHORE UP POLICIES AN PROCEDURES IF THE BACKUP GENERATOR BREAKS DOWN YOU NEED ANOTHER BACKUP GENERATOR AND THAT WAS THE PREPARATION — PREMISE TO PUT IT IN WRITING AND IF WE’RE TALKING TO PATIENT FITBITS AND TAKING ASPIRINS AND STATINS THIS IS A PATIENT EDUCATION SHEET AND THE PROVIDER CAN CIRCLE WHICH TEST WE TALKED ABOUT AND WHY YOU’RE HAVING IT WE HAVE NOW TRANSLATED IT INTO SPANISH I MAY NOT GET TO YOU GET A MAMMOGRAM TODAY BUT IF YOU’RE BACK IN A FEW WEEKS OR MONTHS I’LL BRING IT UP AGAIN AND AGAIN AND AGAIN THAT’S WHAT HAPPENED IN THE CASES WHERE WE HAVE DOCUMENTED CANCER DIAGNOSES THE PATIENTS TOLD US THE DOCTOR JUST KEPT BUGGING THE HECK OUT OF ME AND I FINALLY DID IT IT’S GOT CONTINUED REPETITIVE STRONG CONVERSATION TO HELP AGE APPROPRIATE SEX, APPROPRIATE, ALL THE RIGHT CRITERION TO DO THE SCREENING TEST AND HELP PATIENTS DO IT FOR THE TAKE OF NOT HAVING MORE DATA SLIDES I DID WANT TO SHARE WE HAVE OVER THE PAST FEW YEARS, 20% INCREASE FOR BREAST AND COLORECTAL SCREENING RATES ACROSS THE ORGANIZATION, 13% FOR CERVICAL CANCER AND EVEN THINGS LIKE IMPLEMENTING HEPATITIS C SCREENING NOR RIGHT AGE GROUP — FOR THE RIGHT AGE GROUP WENT UP 3,000 FOLD AND THAT WAS SIMPLY IMPLEMENTING A GUIDELINE SO I CAN’T ADVOCATE STRONGLY

ENOUGH WE BORROWED A LEADERSHIP MODEL TO RETROSPECTIVELY LOOK AT WHAT WAS WORKING AND NOT WORKING WITHIN THE ORGANIZATION AND IT GOES TO CREATING A CLIMATE YOU HAVE TO ENGAGE THE WHOLE ORGANIZATION AND SUSTAIN THE CHANGE TO SUPPORT THE PROVIDER HAVING THAT ONE-ON-ONE VERY TARGETED AND TAILORED CONVERSATION WITH THEIR PATIENTS AND I HELP SUPPORT SOME OF THIS WORK WITH THE GRANT FUNDING BUT FOR THE PAST THREE YEARS THIS FQFC HAS SUSTAINED IT AND PART OF THEIR ORGANIZATION AND CULTURE NOW AND WE’VE BEEN WORKING ON DISSEMINATING THIS TO SEVERAL OTHER HEALTH CARE SYSTEMS IN KENTUCKY IN CLOSING MY RECOMMENDATIONS ARE WE NEED MORE EVIDENCE-BASED HEALTH INTERVENTIONS SITUATED IN RURAL COMMUNITY AND DEVELOPED THERE TO BEGIN WITH AND IF NOT WE NEED TO ADAPT TO OUR SPECIFIC CONTEXT PREVENTIVE SERVICES CAN BE PROMOTED AT ALL CLINICAL ENCOUNTERS WE NEED TO LEVERAGE THOSE FQHCs AND ENGAGE ALL PARTIES IN THE DEVELOPMENT AND IMPLEMENTATION OF THESE STRATEGIES AND CONSIDER CONTEXT, CAPACITY, READINESS, QUALITY IMPROVEMENT WHICH WE HEARD ABOUT EARLIER AND SUSTAINABILITY WHEN WE GO ABOUT DOING THIS WORK [APPLAUSE] >> THANK YOU, THAT WAS MARVELOUS DISCUSSION OF COMPLICATED ISSUES LET’S TO OUR PANEL >> IS WE ALL KNOW COVERAGE SAY BIG ISSUE AND WITH U.S. PSTP RECOMMENDATIONS BEING COVERED FOR COMMERCIAL HEALTH PLANS, THERE ARE SOME NUANCES WHEN IT COMES TO COLON CANCER SCREENING YOU CAN GET A SCREENING TEST BUT THE POLYPECTOMY NOT COVERED AND YOU HAVE A SCREENING TEST WITHOUT THE KCOLONOSCOPY COVERED THEY CAN WORD YOUR RECOMMENDATION TO INCLUDE THOSE THINGS THE TASK FORCE HAS DONE SCREENING OR ACCOUNTING FOR GENETIC TESTING FOR BREAST CANCER THEY RECOMMENDED COUNSELLING BUT THEN THE TEST WASN’T COVERED AND THEY SAY WE RECOMMEND COUNSELLING AND IF A TEST IS DESIRED THE TEST IS NOW COVERED COULD THE TASK FORCE BE WILLING TO ADDRESS IT HIT AND DIDN’T WHEN THEY HAD A CHANCE A YEAR AGO >> IT’S A ROLE THE TASK FORCE WAS NOT ACTIVELY INVOLVED IN PUTTING ITSELF INTO I’D LOOK AT HHS AND CMS TO HELP RESOLVE THIS THROUGH BETTER LEGISLATION AS A CITIZEN NOW NOT AS A TASK FORCE MEMBER >> KENTUCKY SAW THAT AT THE STATE LEVEL THEY CHANGE THE POLICIES IF YOU’RE A PAYER IN KENTUCKY IF YOU FIND A POLYP ON A KOLOSCOPY HAS — COLONOSCOPY HAS TO BE CHARGED AND BUILD AND IF YOU HAVE A SUBSEQUENT COLONOSCOPY ALSO HAS TO BE MARKED AS SCREENING WE’VE WRITTEN THAT INTO STATE-LEVEL POLICY IN KENTUCKY.TO BE MARKE D AS SCREENING WE’VE WRITTEN THAT INTO STATE-LEVEL POLICY IN KENTUCKY >> OTHER COMMENTS FROM THE PANEL MEMBERS? I HAVE A QUESTION A FUTURE NEED BROUGHT UP BY AMY IS SHOULD WE TRY TO SHORT OUT THROUGH RESEARCH — SORT OUT THROUGH RESEARCH PROJECT THE BUNDLE VERSUS INDIVIDUAL COMPONENT OF THE INTERVENTIONS THERE MAY BE SOMETHING IN THE EMR AND NAVIGATOR AND THEN THE E-MAIL OR WHATEVER OFTEN YOU CAN FIND UP WITH A NEGATIVE STUDY WHICH IS A BUMMER

IF YOU’RE DOING A STUDY BUT ALSO IS THAT THE BEST WAY TO SPEND pULTIMATELY THAT’S NOT GOING TO BE UP TO US IT WILL BE UP TO STUDY SECTIONS AND OTHER GROUPS I THINK THERE’S SOME METHODS ISSUES OF WHEN IS IT WORTH WHILE TO DO THE DISENTANGLEMENT STUDIES COULD YOU COMMENT? WHEN DO YOU STOP DISENTANGLING? THE CULTURE OF THE ORGANIZATION THAT SAYS WHAT YOU WERE SAYING OF SCRUBBING THE RECORDS TO WHAT OPPORTUNITIES WE HAVE TODAY AND WHAT CAN WE PUT IN FRONT OF THE PATIENT LEGITIMATELY AND ALSO IN TERMS OF THE WORK IT TAKES TO HAVE AN ORGANIZATION THAT SIGNED UP TO INFORMED PREFERENCES ESSENTIALLY PUT THAT IN FRONT OF PEOPLE AND TO EVERY MEMBER TO LOOK FOR THOSE OPPORTUNITIES AND THE HRs AND THE COMMERCIAL HR ORGANIZATIONS ARE NOT WELL EQUIPPED TO DO THIS NOW AND FOLLOW THROUGH WITH THE SKILLED DEVELOPMENT IT TAKES TO USE THE TOOLS WELL AND THEN SOME HESITATE TO USE THEM BECAUSE THEY LOSE INCOME FROM A PROCEDURE BECAUSE PEOPLE ARE MORE CONSERVATIVE WHEN THEY GET INTO WHAT THEY WANT TO DO I AGREE WITH YOU BUT IT’S LIKE A SOCIAL ELOGICAL MODEL OF NOT JUST THE DYAD AND THE POLICY AND INCENTIVES AROUND ALL THAT I EITHER THE SYSTEMS THINKING TO TAKE CARE OF THIS AND NOT SURE HOW NIH CAN BET TO THE SYSTEM THINKING AT THE HEALTH STATUS RESEARCH LEVEL BUT I’D URGE THAT TO HAPPEN >> THANK YOU I DON’T THINK OUR STUDY OF A VERSUS B UNCHANGING IS THE BEST WAY TO LEARN GOING FORWARD PARTLY BECAUSE I THINK WHAT’S IN THE INTERVENTION PACKAGE OR NOT BUT FOR A NUMBER OF OTHER REASONS I THINK AN IMPLEMENTATION SCIENCE AND QUALITY IMPROVEMENT FRAMEWORK WE’RE TESTING REPEATED ITERATIONS MORE IN THE IHI MODEL IS BETTER AND ONE PERSONAL PIECE OF ADVICE I’VE OBSERVED OVER THE TIME OF DOING THIS KIND OF WORK, I’M SEEING A TREND TO LARGE STUDIES WITH SHORT TIME FRAMES AND I THINK THAT’S EXACTLY THE WRONG WAY TO GO I THINK WE NEED LONGER TIME FRAMES OFTEN TIMES THE START UP TO DOING THIS WORK IS INCREDIBLY TIME CONSUMING AND APPROPRIATELY TIME CONSUMING AND HAVING MORE TIME AND LESS MONEY YOU WOULD LEARN MORE THINGS I’D LOVE TO SEE SOME THOUGHT ABOUT THAT AT THE FUNDING AGENCIES >> I’M FROM THE UNIVERSITY OF MICHIGAN MY QUESTION FOR I GUESS ALL THE PANELISTS IS WHEN AN INTERVENTION WORKS IN THIS SPACE, DO WE KNOW WHY? WHAT I’M GETTING AT THERE IS WHAT IS THE ROLE OF THEORY AS ONE OF THE EXPLANATORY TOOLS WE MIGHT HAVE FOR HOW AN INTERVENTION ACTUALLY WORKS AND OBVIOUSLY THERE ARE SOME SHORT COMINGS WITH THE PREVAILING PE — BEHAVIORAL THEORIES GIVEN SOME WERE NOT MARGINALIZED IN GROUPS OR VALIDATED IN THEM AND CURIOUS WHAT YOU THINK OF THE ROLE OF THEORY GOING FORWARD AS WE TRY TO DEVELOP AND IMPROVE UPON INTERVENTIONS THAT WOULD BE MY FIRST QUESTION A RELATED ACQUISITION TO COLORECTAL SCREENING SO A QUESTION FOR DOCTOR PIGNONE COULD BE WHETHER YOU HAVE DISEN TANGLED THE ISSUES RELATED TO THE COMPLEXITY OF THE TYPE OF SCREENING SO COLORECTAL CANCER SCREENING CAN BE COMPLICATED AND A MULTIDAY PROCESS AND WONDERING WHETHER YOU LOOKED AT COMPLEXITY REDUCTION STRATEGY TO PROMOTE SCREENING AND ALSO WHETHER THERE’S WORK ARRANGEMENTS OR HOURS AND DISENTANGLE THE SOCIOECONOMIC STATUS ISSUES WITH

THE OCCUPATIONAL ISSUES THANKS >> THE CHARACTERISTIC OF THE UNSCREENED AND COLORECTAL CANCER ARE DIFFERENT TODAY THAN THEY WERE 20 YEARS AGO WE’RE MUCH FURTHER UP ON THE TREE OF FRUIT AND WE NEED TO EVOLVE OUR UNDERSTANDING AND BARRIERS WE HAVEN’T THOUGHT ABOUT SO THERE’S PLENTY OF WORK TO BE DONE STILL WITH RESPECT TO COMPLEXITY REDUCTION THERE’S AT THE HEART OF INTERVENTIONS THE MORE STEPS WHERE THINGS CAN FAIL THE MORE LIKELY THEY ARE TO FAIL AND THINKING ABOUT THAT AND MAKING THE SIMPLEST SYSTEM POSSIBLE, STANDING ORDERS RATHER THAN HAVING TWO PEOPLE HAVE TO SIGN OFF FOR IMMUNIZATIONS I FOUND TO BE HIGHLY EFFECTIVE AND I’LL LEAVE IT AT THAT MAYBE SOMEBODY ELSE CAN COMMENT ABOUT THEORY >> I’D LIKE TO ADDRESS THE THEORY PIECE A LITTLE BIT ONE OF THE FAVORITE THEORIES IS PROCESSING THEORY WHAT’S IT TAKE TO MAKE SOMETHING NORMAL? I THINK THE SMARTPHONE IS THE FASTEST TECHNOLOGY PIECE IMPLEMENTED EVER SO NOW WE HAVE 7 BILLION SMARTPHONES ON THE PLANET AND SOME PEOPLE HAVE TWO WHAT DOES IT MAKE TO MAKE SOMETHING NORMAL PRACTICE? THAT’S WORTH LOOKING AT AND LOOK AT THE IMPLEMENTATION WE’RE USING THE THEORIES IN OUR WORK WE HAVE TO WORK WITHIN COMPLEX SYSTEMS BECAUSE THE BEHAVIOR OF PEOPLE INSIDE THEM IS MODIFIED BY THE INCENTIVES AND PEOPLE MOSTLY BELIFE TO RESERVE ENERGY AND IN THEIR INTERESTS SO FIT TAKES A LOT OF ENERGY OR EFFORT TO DO IMAGINE IT’S UNLIKELY TO HAPPEN BUT IF THEY REALIZE IT’S IN THEIR INTEREST THEY’RE MORE LIKELY TO DO IT THERE’S ANOTHER COLLABORATION IF YOU INVOLVE PEOPLE THEY’RE MORE LIKELY TO DO IT AND THE FAVORITE OVER ARCHING THING FOR HEALTH CARE IS THE WORK OF THE ECONOMIST WHICH CAME UP WITH THE IDEA OF CO-PRODUCTION THE PEOPLE WHO LIVE IN FORESTS OR FISHERIES HAVE TO WORK TOGETHER OUR GET A TRAGEDY OF THE COMMONS IF YOU USE ALL THE AVAILABLE RESOURCES THERE’S NOTHING LEFT FOR ANYBODY WITH 18% OF GDP AT THE MOMENT THERE’S NOTHING LEFT FOR EDUCATIONAL ROAD AND THAT’S THE OVER ARCHING THEORY I’D URGE PEOPLE TO LOOK AT FOR THE HEALTH OF THE RESEARCH >> A FOLLOW-UP WOULD BE WITH REGARDS TO THOSE THEORIES >> WE NEED TO MOVE ON >> IN A PREVIOUS LIFE I WAS AN INTERNIST AND I WANT TO THANK THE ORGANIZERS AND SPEAKERS FOR A TREMENDOUS DAY THE QUESTION ON NAVIGATION OR HEALTH COACHES OR LAY HEALTH ADVISORS AND MAYBE FOR DR CANTOR OR FOR ANYTHING TO WEIGH IN AND THIS CAN LEAD TO CHANGES IN BLOOD GLUCOSE AND HIGH BLOOD PRESSURE AND THEY NEED TO MOVE FORWARD TO MAKE THIS A SUSTAINABLE PART OF OUR HEALTH CARE SYSTEM WRIT LARGE

>> I APPRECIATE THE QUESTION WE HAVE NINE STUDIES THAT SHOWED US VARIOUS ITERATIONS IN DIFFERENT POPULATIONS WERE EFFECTIVE WHETHER IT WAS A LAY HEALTH WORKER OR A PATIENT NAVIGATOR OR PROMOTORA AND WERE APPROPRIATE TO THE HEALTH CARE ENVIRONMENT AND CONNECTED THE PATIENT TO THE PROVIDER AND STRIVING FOR THE GOAL OF MEDICAL HOMES AND LOOKING AT OPPORTUNITIES TO EVALUATE THE IMPLEMENTATION PIECE SEEING EFFECTIVENESS IF PATIENTS ARE CONNECTED TO THEIR PROVIDER IT SEEMS TO BE MEANINGFUL AND THERE’S LOTS OF IT SEEMS LIKE SEEMINGLY LOTS OF OPPORTUNITIES TO CLOSE THAT COMMUNICATION LOOP AND THOSE WOULD BE OPPORTUNITIES TO EVALUATE THAT IMPLEMENT PIECE IT SEEMS LIKE WE HAVE THE GRAUND WORK TO MOVE FORWARD WITH GOOD QUESTIONS ABOUT THIS AND SO THAT CAN BE USED TO MAYBE INFORM WHAT MAY BE MOST EFFECTIVE AND HOW TO IMPLEMENT THAT ON A BIGGER SCALE OR POPULATIONS MORE BROADLY >> HAVING A WARM TOUCH FIRST BEFORE ENTERING INTO NAVIGATION IS MORE EFFECTIVE THAN A DISPLACED CALL CENTER THE NAVIGATOR MEANT THEM IN THE CLINIC AND NAVIGATED MOSTLY BY PHONE AFTER THAT BUT THERE WAS A WARM HAND-OFF FIRST AND THINK THAT’S IMPORTANT WE HAVE TO LEARN WHAT MAKES GOOD HEALTH NAVIGATORS BUT IF WE WE’RE GOING TO PUT SCALE HOW DO YOU TAKE SOMEBODY IN HIGH SCHOOL AND IDENTIFIED THEM AS THEY’RE A GOOD HELPING PERSON, GIVE THEM THE TRAINING THEY NEED TO BE GREAT AND BUILD THIS AS A CAREER MATH PATH — PATH WHERE THE PAY MODEL CHANGES FOR VALUE >> THESE SORTS OF RESEARCH OPPORTUNITIES AND INFORMATION NEEDS WILL BE HELPFUL FOR ALL OF US SO THANK YOU >> WE HAVE A PROGRAM IN KENTUCKY CALLED KENTUCKY HOME PLACE AND IT’S STATE FUNDED FOR THEY’RE WAITING FOR MEDICARE TO CHANGE SO THEY CAN BE COVERED ENTITIES BUT THEY SERVE AND I HEARD A STORY AND THEY SERVE AS THE INTERMEDIARY BETWEEN THE PATIENT AND HEALTH CARE SYSTEM AND THEY’RE THE TRUSTED LOCAL NEIGHBORS >> I’M FROM CORNEL MEDICAL COLLEGE IT’S GREAT TO HEAR THESE PERSPECTIVES I WANTED TO ASK ABOUT THE ROLE OF THE INCENTIVES IN HEALTH CARE SYSTEM THAT SIMPLY PROVIDING HEALTH INSURANCE COVERAGE IS NOT SUFFICIENT TO DEAL WITH IN A SO FAR UNSUCCESSFUL PROJECT IN MY MEDICAL CENTER WE’RE TRYING TO BUILD A MULTISTAGE INTERVENTION FACILITATE THE EHR TO DO SHARED DECISION MAKING AROUND LUNG CANCER SCREENING WE FOUND THE QUALITY OF THE SMOKING DATA IN THE EHR IS QUITE POOR WE HAVE ABOUT 20% OF PATIENTS WHO HAVE INTERNALLY CONTRADICTORY SMOKING STATUS SO IT’S HARD TO TELL WHO’S ELIGIBLE WRITE NOW MEDICARE PAYS FOR THE VISIT BECAUSE THE RISK IS SO LARGE AND THE RADIOLOGY TAKEN ON THE SHARED DECISION MAKING VISIT AND PRIMARY CARE IS LESS INTERESTED BECAUSE THEY’RE NOT GETTING REIMBURSED FOR THEIR SHARED DECISION MAKING VISIT AND WE ARE HOPING AN OUTCOME WOULD BE LOWER RATES OF INAPPROPRIATE LUNG CANCER SCREENING FROM LOW-RISK PATIENTS AT THE SAME TIME IT GETS TO DR. VANDERPOOL’S TERM OF DE-IMPLEMENTATION AND

HIGHER SCREENING AND RADIOLOGY WANTS MORE SCREENING THEY ENTIRELY OPTED OUT BECAUSE THE AMERICAN BOARD OF FAMILY PRACTICE HAS NOT ENDORSED LUNG CANCER SCREENING AS A PREVENTIVE MEASURE THESE ARE SNAP SHOPS ABOUT A LARGER MISALIGNED INCENTIVE PROBLEM THAT I’LL BE TALKING ABOUT HEALTH INFORMATION TECHNOLOGY TOMORROW AND SAYING THE EH WILL NOT FIX IT >> I THINK YOU SHOULD WRITE THAT UP EXPLICITLY BECAUSE IT’S VERY DIAGNOSTIC ON THE ISSUES THEY SHOULD BE EQUIPPED WITH THE TOOLS AND DATA AND I’M SURE MOST GENERALISTS DON’T KNOW THE PROBABILITIES OF INCIDENTAL FINDINGS THEY’RE NOT REALLY EQUIPPED RIGHT NOW AND SHOULD BE HEAVILY INCENTIVIZED IF THEY’RE THE RIGHT PLACE AND IDENTIFY THE RIGHT PATIENTS FOR RIGHT PROCEDURE I WANT TO ADVOCATE FOR WE’RE NOT GOING TO GET THIS RIGHT UNTIL WE HAVE A MEASURE OF THE PROCESS THE PROCESS IS THE CONVERSATION WHICH IS CAREFUL IT’S KIND AND GOT EVIDENCE IN IT I’M ADVOCATING FOR PATIENTS TO USE INTELLIGENCE TO ASSESS WHAT’S DOING ON IN THESE CONVERSATIONS THAT WILL CHANGE BECAUSE WE’RE SEEING WHY PEOPLE ARE DOING SOMETHING AND WHAT WHAT ARE THEY EXPLAINING FOR THOSE WHO HAVE DONE AUDIOTAPING STUDIES IT’S UGLY WE’RE NOT WHERE WE NEED TO BE IN REGULAR CARE AND SOME COLLEAGUES AT UNC RECENTLY PUBLISHED A PAPER LOOKING AT THE LUNG CANCER SCREENING CONVERSATIONS THAT HAPPENED IN A RANDOMLY SELECTED NUMBER OF AUDIOTAPE VISITS AND THEY WERE NOT WHERE WE NEED THEM TO BE BUT UNTIL WE HAVE A MEANS OF ASSESS BEING GOOD INFORMED DECISIONS VERSUS NOT GOOD INFORMED DECISIONS WE’LL STRUGGLE SUCH AS WE’RE STRUGGLING IN THE PAYMENT ENVIRONMENT WHERE WE ARE LIVING IN THE GOSH WE GET $1,000 FOR THAT CT SCAN AND THAT’S THE OLD SYSTEM’S PRETTY STRONGLY ENTRENCHED I DO THINK IT’S AN INTERESTING QUESTION ABOUT SMOKING STATUS AND THE FIELD WERE SET UP TO ENABLE SMOKING CESSATION AND THE QUESTIONS WE ASKED WERE ABOUT CURRENT OR NOT CURRENT WE NEED INFORMATION TO GUIDE THE LUNG CANCER SCREENING DECISION HALF OUR QI WORK WAS ABOUT IMPROVING THAT PART OF THE PROCESS BECAUSE EVERYTHING ELSE FLOWS FROM THERE WE HAVE TO BE HUMBLE THESE ARE NOT EASY THINGS TO CHANGE AND SOMETHING THAT’S NOT TECHNOLOGICALLY SEXY BUT FIGURES OUT WHAT PATIENTS WE WANT TOO ASK PATIENTS ABOUT THEIR SMOKING STATUS AND HOW WE TLOORD IS — HOW WE RECORD THAT IS VITALLY IMPORTANT >> THIS QUESTION COMES FROM THE ONLINE GROUP TO FOSTER DECISIONS CLINICAL DECISION SUPPORT AND TOOLS NEEDED OR RESEARCH ON SDM BE ENCOURAGED AND CONDUCTED RIGOROUSLY WITHOUT THE USE OF CDS TOOL? >> THINK GLYN MAY GET THAT >> YOU CAN DO RESEARCH OUTSIDE OF THE EHR BUT IF YOU WANTED TO HAVE LASTING OPPORTUNITY FOR IMPLEMENTED IT TO BE DONE WITHIN THE WORK FLOWS AT THIS POINT OR AT LEAST BE PREPARED TO BE IMPLEMENTED IN DHR WORK FLOWS SOMETIMES WHEN WE START A QI PROJECT WE START WAY PAPER VERSION BUT CAN CHANGE IT EVERY DAY IF WE NEED TO BUT ALWAYS THINK WILL THIS WORK IF IT’S NOT GOING TO EVER WORK WITHIN THE HR WORK FLOW WHAT WE CALL THE EHR NOW WE HAVE NOT INCORPORATE THE PATIENT PORTAL AND NEED TO EXPAND THE SPACE OF

WHAT WE CONSIDER TO BE OUR SHARED INTERACTION SPACE AND INCORPORATE THE PATIENT PORTAL AS WELL THEN HAVE YOU OPPORTUNITIES TO DO THINGS OUTSIDE OF THE REALITY OF THE CLINICAL BUT STILL WITHIN THE INFORMATION ENVIRONMENT OF THE SYSTEM >> TO ADDRESS THE QUESTION DIRECTLY, I DON’T THINK YOU NEED A TOOL IT’S REALLY HELPFUL BECAUSE YOU NEED SKILL LET ME START IN THE BEGINNING FIRST COMES ATTITUDE I WANT TO HELP THIS PATIENT MAKE AN INFORMED DECISION THAT’S THE FIRST THING SECONDLY IS YOU NEED GOOD DATA IN ABSOLUTE RISK TERMS AND WHAT HAPPENS IF YOU DO SOMETHING IN WAYS THE PATIENT CAN UNDERSTAND AND INTERESTINGLY ENOUGH WHEN WE MAKE GOOD DECISIONS YOU KNOW WHO LOOKS THEM BEST? IT’S THE GENERALIST WHO DIDN’T KNOW THE DATA IN THE FIRST PLACE THEY LEARN A LOT BY USING THESE TOOLS THEY’RE NOT NECESSARY OR SUFFICIENT BUT HELP A LOT WE’LL NEVER HAVE A TOOL FOR EVERY DECISION IN FACT ONCE YOU THINK THAT WAY YOU BEGIN TO GENERALIZE THE SKILL SET AND SEEK THE INFORMATION IF YOU’RE A GOOD PRACTITIONER TO HELP YOUR PATIENT >> THE EHR VENDORS ARE NOT IN THE DECISION AID BUSINESS THEY’RE IN THE EHR BUSINESS THEY SHY AWAY BECAUSE OF LIABILITY ISSUES YOU’RE THE PROVIDERS, WE JUST DO THE EHR YET THEY NEED TO BE ABLE TO SUPPORT THESE TOOLS AND HOW CLOSE ARE WE TO THOSE CONVERSATIONS HAVING FRUITION? >> YOU’LL NOTE THERE’S MAJOR EHR COMPANIES THEY RECOGNIZED THEY’RE NOT SKILLED AT THIS AND KEEP UP THE EVIDENCE OF THE TOOLS THEY CAN’T KEEP THEM UP TO DATE THERE’S COMMERCIAL PEOPLE WHO’S LIVELY HOOD DEPENDS ON THEED TOO AND OTHER ORGANIZATIONS ARE SAYING WHO’S GOING TO BE OUR THIRD-PARTY VENTER — VENDOR AND THERE’S A DISCUSSION I’M SURE GOING ON AS TO WE NEED LESS OF THE THIRD-PARTY VENDORS THAN WE HAVE AT THE MOMENT SO SOME CONSOLIDATION WILL HAPPEN I IMAGINE BUT A COMPANY CAN’T GO FORWARD WITHOUT THE TOOLS MADE EASY FOR PATIENTS AN CLINICIANS GIVEN THE IMPORTANT WORK WATCH THE SPACE THERE’S A LOT OF CONVERSATION GOING ON THERE’S AS MUCH CHALLENGE IN THE COME — CONTEXT IF YOU GIVE ME SIX HOURS I CAN GIVE YOU A DECENT TOOL IT’S NOT THAT CHALLENGING IT’S CHALLENGING TO DO ON THE FLY HOW DO YOU GET IT TO THE PERSON AT THE RIGHT TIME AND FOLLOW-UP WE CAN’T NEGLECT THE DOWNSTREAM FOLLOW-UP WE’VE BEEN ABLE TO FOLLOW DECISION SUPPORT AND MAKE DECISIONS AND THEN IT FALLS APART WITHOUT GOOD FOLLOW-UP THAT’S FOR THINGS DISCREET ACTIONS IF YOU IMAGINE WORK ON ALCOHOL SCREENING A LOT OF SCREENING RELATIVELY SMALL NUMBER WHO NEED INTERVENTION HOW DO YOU GET THEM TO THE RIGHT ONE AND FOLLOW THROUGH WITH THE RIGHT RESOURCES THAT’S THE CHALLENGE OF ORGANIZING THE SYSTEM >> ONE COMMENT ON THE GAP BETWEEN THE FACT EHR EXISTS BUT ONLY AS GOOD AS THE DATA YOU HAVE IF IT’S NOT ENTERED BY THE MA OR PROVIDER OR WHOEVER IS RESPONSIBLE FOR ENTERING THE DATA AND IF THE SMOKE DATA ISN’T CORRECT YOU WON’T IDENTIFY THE RIGHT PEOPLE IN THE SCREENING GROUP WAYS TO INFORM WHAT WE’RE DOING BUT NOT THE ONLY TOOL NECESSARY >> TIME FOR ONE ORE TWO MORE QUESTIONS >> THIS INFORMED DECISION MAKING PRESENTS A REAL DILEMMA IF YOU LOOK AT THE ETHICS OF IT

LET’S PRESENT ABSOLUTE RISK WHEN YOU TALK ABOUT CANCER SCREENING THE AVERAGE PERSON HAS VERY LITTLE CHANCE FOR SMALL CHANCE OF BEING HELP BY IT THEY HAVE A CHANCE OF BEING HARMED SOMETIMES THOSE ARE BALANCED BUT IF YOU SIT BACK AND LOOK AT IT TO THE AVERAGE PERSON WHO SAYS WELL, MY CHANCE OF GETTING COLON CANCER ARE X ABSOLUTE RISK IT’S A HIGHER RISK THAN A CHANCE I’M NOT GOING TO GET IT, IT’S A HASSLE TO GET SCREENED I’M WONDERING WHAT RESEARCH SHOWS WHEN YOU PRESENT DATA OBJECTIVELY LIKE THAT >> I CAN ANSWER THAT FOR COLORECTAL CANCER AND IN THE UNITED STATES IT’S ON THE ORDER OF 92% TO 95% ELECT TO HAVE SOME KIND OF ACTIVE FORM OF SCREENING AND IF YOU ASK THEM TO MAKE A SCREENING THEY CHOOSE AN ACTIVE SCREENING COMPARED TO NO SCREENING WHEN GIVEN GOOD INFORMATION OF THE PREVENTIVE SERVICES THAT ONE IS NOT AS MUCH EQUIPOISE AS OTHERS IN LUNG CANCER WE SEE 40% TO 55% IN DIFFERENT STUDIES ELECTING TO BE SCREENED AND OTHERS ELECTING NOT TO BE SCREENED >> I HAVE A FOLLOW-ON QUESTION WHAT ARE THE OUTCOMES WE SHOULD LOOK AT TO TAKE THE SHARED DECISION MAKING APPROACH OUTCOMES WERE INCREASES IN SCREENING RATE AND WE TALKED ABOUT THE INCENTIVE AND INFORMED CHOICES AND THAT MAY BE NOT TO GET SCREENED AND THE PRECISION WITH WHICH TO IDENTIFY THE POPULATIONS THAT SHOULD OR SHUNT BE SCREENED MAKE THOSE BASIC STATISTICS ABOUT WHAT PROPORTION OF PARTICULAR POPULATIONS ARE SCREENED MAYBE EVEN LESS USEFUL I’M CURIOUS WHAT RECOMMENDATIONS YOU WOULD MAKE ABOUT OTHER OUTCOMES AND WHAT IMPACT WILL THAT ULTIMATELY HAVE ON HEALTH DISPARITIES THAT’S WHY WE’RE ALL HERE TODAY >> THERE’S BEEN A BIG DEBATE BECAUSE IF YOU HAVE AN EQUIPOISE SITUATION BECAUSE NOTHING IS REMARKABLY SUPERIOR AND GYOU GO FOR B VERSUS A THE CHANCES OF THE HEALTH OUTCOME BEING DRAMATICALLY DIFFERENT ARE NOT THAT LOW IT STANDS TO REASON IN EQUIPOISE WHEN YOU HAVE A HEALTH IMPERATIVE, MAMMOGRAPHY, HAVE YOU A POPULATION BENEFIT THAT’S BEEN CALCULATED BY POLICIES BUT THE INDIVIDUAL MAY NOT STAND TO GAIN A LOT IN THAT SITUATION I THINK IT’S BALANCED MY OWN VIEW AND I’VE COME DOWN TO THIS IS YOU ALLOW THE INDIVIDUAL TO MAKE A CHOICE WHERE THE EVIDENCE IS PRETTY MUCH AN QUICK EQUIPOISE THE OUTCOME MEASURE THAT’S BEEN PROMOTED IN THE FIELD OF SHARED DECISION MAKING IS DECISION QUALITY DID THIS PERSON UNDERSTAND THE TRADE-OFF BETWEEN THE BENEFITS AND HARMS AND DID THEY ELECT TO DO THAT WHEN THEY WERE BETTER INFORMED THAT’S NOT BEEN DEVELOPED TO THE EXTENT IT’S EASY AND WIDELY USED IT’S SOMETHING WE SHOULD BE THINKING OF >> THE MAIN POINT BEING YOU CAN’T JUST AUTOMATICALLY GO TO MEASURE SCREENING RATES FOR ALL THESE DECISIONS BUT IN SOME YOU CAN I THINK IT’S A REASONABLE MEASURE IN COLORECTAL SCREENING AS LONG AS YOU HAVE INFORMATION AT THE SAME TIME >> FOLLOWING UP ON THAT DISCUSSION, DO YOU INCLUDE COST TO THE INDIVIDUAL AND THE DOWNSCREEN COST OF ALL THE PROCEDURES AND WHAT’S THE IMPACT THEN ON EQUITY FOR THE PEOPLE WHO REALLY WILL FIND THAT BURDENSOME? AND WON’T THAT IF WE BELIEVE THE SCREENING WILL OCCUR AND IT’S A MATTER OF WHAT TASK THEY MIGHT BE OPTING OUT TO A GREATER EXTENT WHAT EXTENT DO YOU INCLUDE THIS AND WHAT EXTENT DOES IT AFFECT EQUITY? >> I’VE WORKED A LOT ON THIS TOPIC AND IT’S NOT AEGS WE HAVE TO HAVE SOME ELEMENT ABOUT COST UNCERTAINTY IN YOUR

MATERIALS BECAUSE PEOPLE ARE GOING TO FACE CERTAIN COSTS AND IT’S A GREATER SIN TO NOT TELL PEOPLE THEY COULD BE GIVEN A SURPRISE BILL THAT BANKRUPTS THEM OR CAN’T PAY THE HEAT BILL THE NEXT MONTH IT’S HARD TO SAY FOR YOU THIS PERSON IN FRONT OF ME TODAY I KNOW EXACTLY WHAT COST YOU’LL FACE IT’S COMPLEX, PERIOD IT’S COMPLEX FOR HEALTH CARE PROVIDERS WE’VE TENDED IN OUR MATERIALS TO RECOGNIZE THERE MAY BE COSTS ASSOCIATED WITH DOWNSTREAM WORK IT’S BETTER THAN NOT SAYING THAT BUT HARD TO GET PRECISE IT WILL COST $325 >> I’VE LIVED IN A COUNTRY WHERE THAT DOESN’T MATTER SO MUCH >> WHERE AS IT NOT AT THE POINT OF CARE >> ONE LAST BRIEF COMMENT >> THANK YOU FOR YOUR EFFORT AND RURAL AREA HEALTH BUT SHOULD APPLY TO URBAN AREA LIKE THE NATIONAL CAPITAL AREA [INDISCERNIBLE] IF WE HAVE A SYSTEM IT GOES TO THE HIGHER BID [INDISCERNIBLE] IF YOU DON’T HAVE PROOF TO USE PPP PUBLIC PRIVATE PARTNERSHIP OR HAVE GOOD ANALYSIS OF COST BENEFIT YOU MUST USE GOVERNMENT ABUSE OF POWER OR MONEY OR DEFICIT OR GOVERNMENT BUDGET WHATEVER GO SKY HIGH SO HOW DO YOU SAY YOU WANT TO PROMOTE RURAL YARG WITHOUT CONSIDERATION THE URBAN AREA POPULATION? WOULD YOU BE ABLE TO PRESENT TO GOVERNMENT OFFICIALS SAYING MEDICATION SHOULD BE PUT TO PUT TO JAIL OR PROSECUTE ORDER EVEN PUT TO DEATH >> THANK YOU VERY MUCH ANY COMMENTS [OFF MIC] >> IF AN INTERVENTION WORKS AN RURAL AREA YOU CAN ADAPT IT TO AN URBAN AREA AND THAT’S WHAT IMPLEMENTATION SCIENCE IS ABOUT ANY GAINS ON EITHER SIDE OF RURALITY AND URBANICITY CAN BE SHARED ACROSS THE CONTINUUM >> I WANT TO THANK EVERYBODY HERE FOR STAYING PAST TIME AND A GREAT DISCUSSION IT SETS US UP WELL FOR TOMORROW WHERE WE’LL HAVE KEY QUESTIONS FOUR AND FIVE WHICH WILL BE ABOUT HEALTH TECHNOLOGY AND SINGLE MODAL INTERVENTIONS AND A COMPLETE DISCUSSION OF HEALTH SYSTEMS WHICH BRINGS IT ALTOGETHER AND HAS A ROBUST DATABASE WE’LL HEAR ABOUT TOMORROW I WANT TO THANK OUR SPEAKERS THINK OF QUESTIONS AND COMMENTS FOR TOMORROW IT WILL BE A FUN DAY WE START AT 8:30 SHARP AND EVERYBODY HAVE A GOOD NIGHT AND SAFE TRAVELS HOME AND THANK YOU