Outside the Box:Health Disparities in Your Practice

Amy K Mosman, PA-C SLU Division of Nephrology American Academy of Nephrology PAs Disclosure: None

Objectives

1)Using a series of true life cases, recognize and discuss types of health disparities commonly found in practices

2) Discuss disparities found in race, gender, literacy, and disabilities

3)Identify opportunities within PA practices to reduce health disparities

Sylvester63 y/o, SCr 1.5mg/dL UACR 30mg/g Sylvester tells you he is Piscataway Indian which you know from reading Smithsonian is historically black farm hands intermarrying white household workers during the 1600s

What race do you use to calculate GFR? A. Indian* B. African American C. Caucasian D. Calculate AA and other; average

Blaine49 y/o male, AFAB (assigned female at birth) PMH: Chest reconstruction, metoidioplasty Meds: testosterone IM q2w Comes into office for annual visit, pre-op for knee scope

What gender do you use to calculate GFR for NSAID dosing?

A. Male* B. Female* C. Calculate both and average* D. Leave it up to Blaine* E. Since he is thin, use female*

Blaine49 y/o male, AFAB (assigned female at birth) PMH: Chest reconstruction, metoidioplasty Meds: testosterone IM q2w Comes into office for annual visit, pre-op for knee scope

What screening/s are important for Blaine? A. PSA B. Mammogram C. Pap Smear D. Colonoscopy E. B/C only*

Reggie65 y/o male PMH: HTN, CP, chronic leg edema Meds: lisinopril, lasix, metolazone Living at home with caretaker sister Sister frustrated that PCP office not handicapped accessed No follow-up for a year due to inability to get into office Presents to ED for blood work

What is the BUN/SCr? A) BUN 38/ SCr 2 B) BUN 58/SCr 3 C) BUN 68/SCr 4 D) BUN 219/SCr 10.5*

What could have been done to prevent this disaster? A) Give him an order for lab work for the hospital B) Transfer him to a different practitioner with access C) Arrange for a home visit D) Use a different medication*

Reggie

His BUN/SCr corrects to 3/1.4 with IV fluids However, he will be at continued risk of ESRD due to his AKI

AKI on CKD

52 y/o Indonesian female with HTN X 4mo Meds: none Labs: SCr 1.9mg/dL (GFR 55mL/min), UACR >30mg/g, BMI 23 Lisinopril started at 20mg/day

What lab test is important for Sally? A. Kidney biopsy B. A1C* C. Metabolic panel (CMP) D. Urine for protein electrophoresis E. Pregnancy test

Sally

SallySince Jan 2015 ADA Guidelines:

use BMI of 23 to screen Asian Americans for Diabetes

Asian is defined as: origins from the Far East (China, Japan, Korea, and Mongolia), Southeast Asia (Cambodia, Malaysia, the Philippine Islands, Thailand, Vietnam, Indonesia, Singapore, Laos, etc.), or the Indian subcontinent (India, Pakistan, Bangladesh, Bhutan, Sri Lanka, and Nepal)

http://care.diabetesjournals.org/content/39/Supplement_1

Isabella21 y/o self-identified Hispanic female presents for 1st prenatal visit PMH: G1P0 Meds: none PE: 5’5”, 125#, BMI 21, 124/72

Which of the following is true for Isabella? A)Since she is Hispanic, she has a lower incidence of miscarriage B)Since she was born in Mexico she has a lower infant mortality

rate* C)Since she was born in Nicaragua, the statistics for Hispanics do

not hold true for her D)Since she is Hispanic, she is more likely to develop preeclampsia

OR nurse with 30 years experienceWorks mainly as circulating RNMissing directions during surgerySurgeon throws her out after she did not retrieve gel foam and patient needed transfusionHas recently lost her father

Why does a brilliant experienced RN fail? A) Deafness* B) Depression C) Drugs D) Diabetes

Julia

Harry67 y/o diabetic who presents for routine

follow-up, student reports Harry has 2-3+ bilateral edema

PE: 135/80, bilateral BKAs, multiple ‘farting’ which causes student to snicker

Meds: Metformin, basal insulin, atorvastatin, metoprolol

What is most important issue to discuss at this visit? A) Not to try to trick students with prostheses B) Discuss fall risk with metoprolol* C) Discuss metformin and ‘farting’ D) Discuss disabilities and appropriate behavior*

Maria42 y/o self-identified Hispanic female presents for annual PE PMH: G3P3, s/p TAH Meds: daily ASA

Which of the following screening recommendations are true for Maria?

A)Mammogram at age 40 due to increased risk of breast cancer in Hispanics

B)Pap smear does not need to be done due to previous hysterectomy

C)Due to increased risk of colon cancer in Hispanics, refer for colonoscopy

D)All of the above E)None of the above*

David52 y/o with h/o PE after knee surgery Placed on warfarin 5mg/day INR comes back at 4.5, ‘coumadin clinic’ called patient to hold x 2d, then restart at 5mg/2.5mg on alternating days M-Sat

Pt admitted with GI bleed, INR 7.9

What was the most likely cause of the GI bleed? A)Patient did not hold warfarin for 2 days B)Patient has an issue with numeracy* C)Patient ate a number of leafy greens D)Patient ignored staff instructions

Lacey50 y/o with LBP not relieved with NSAIDS Referred to ortho, X-rays of LS showed multiple lytic lesions of the spine and sacrum

Referred back to you for cancer workup

What type of cancer did Lacey have? A)Breast B)Multiple myeloma C)Prostate* D)Leukemia

Jose63 y/o male with severe knee pain, failed

conservative care X-rays: grade IV degenerative changes,

bone on bone, multiple osteophytes + deformity

Scheduled for surgery and pre-op instructions given, English and Spanish

Patient eats breakfast on day of surgery

What went wrong? A) Numeracy issues B) Cultural competence C) Literacy questions* D) Translation errors

What could have solved the issue? A) Use Emojis for pre-op directions* B) Require a family member to accompany the patient C) Read all directions out loud to patients D) Mail directions to house as well as giving them to

patients

Jose63 y/o male with severe knee pain, failed

conservative care X-rays: grade IV degenerative changes,

bone on bone, multiple osteophytes + deformity

Scheduled for surgery and pre-op instructions given, English and Spanish

Patient eats breakfast on day of surgery

Ibrahim63 y/o Iraqi male with PTSD, speech deficits, and HTN.

Takes 3 medications for BP, one of which is a diuretic

BP is 166/102 in clinic Translator reports that patient is frustrated with pills, doesn’t feel they make any difference

What should you check next? A) Treat the PTSD more aggressively B) Check his pharmacy use* C) Draw a sun/moon on each pill for when to take them D) Check for dietary indiscretion

Alvin58 y/o male with humeral fracture after a fall off ladder

Seen in ED and referred to orthopedics Meds: atorvastatin, nifedipine

What fact is vital to choosing a pain medication for Alvin? A)African American patients process narcotics faster and thus

need increased doses B)African American patients process narcotics slower and

thus need decreased doses C)African Americans have issues with metabolism of

oxycodone D)None of the above*

Mary59 y/o self-identified African American female presents for annual physical

PMH: HTN Meds: daily baby ASA, diltiazem Social HX: married X 23 yrs, 3 children

What screenings are important for Mary? A)Mammogram B)Colonoscopy C)HIV D)Pap smear E)All of the above F)Depends on whose recommendations you follow

Mary• CDC recommends HIV screen on every American at least

once • Heterosexual African American females in the South have

the highest incidence of new HIV infections • Colonoscopy is recommended at

45 y/o by Am College of Gastroenterology, 50y/o by Am Cancer Society & before 60y/o by USPSTF

• Mammogram recommended at age 50 until 74 by USPSTF>40y/o by American Cancer Society

• Pap smear recommended from age 21-65, Every 3 or 5 years per USPSTFEvery 3 years per American Cancer Society

Final Pearls of Wisdom

• Many EHRs will automatically calculate GFRs with the ‘legally recognized gender’…Monitor these patients clinically a little more closely

• Most of us have never been asked what Race we identify with…be the first clinician who does!

• Not all disabilities are visible • Some EHRs will allow you to list multi-racial identity…this can make race-based calculators hard

• Asian and Hispanic are two massive data sets and some screening guidelines may differentiate between them while others do not