Acknowledging Social Determinants of Health - APSA Practice Gaps 2019

All right, we're going to move to Dr. Islam. We'll be changing uh shifting gears a bit and this topic was chosen after the uh recent uh APsa meeting in Boston in May where uh this has come up as an issue which surprisingly uh pediatric surgeons are interested in. And you'll see what we mean. So we'll start with the vignette. So that is of a seven week old boy who presents to the emergency room with a three week history of projectile emesis, weight loss, and dehydration. He's had three trips to the emergency room in the past few weeks and been sent home each time. The ultrasound that was done this time around reveals hypertrophic pyloric stenosis. Um, you admit him for hydration because he's severely hyperchloremic metabolic alkalotic, and he has to have three days of this hydration uh before a pyloromyotomy can actually be performed safely or before anesthesia will take him to the OR. So the question of this is common common disease, common presentation. Which of the following factors may be playing a role in this infant's delay in presentation and resultant severe dehydration for pyloric stenosis? Is it the fact that he's a boy? That he has commercial insurance for his uh healthcare, public insurance for the family, Caucasian in race, because maybe he's an Asian, Asian uh ethnicity, or maybe it's because where he lives, residential zip code. So as you wait for it, it's either it's a boy, is it because of commercial insurance, public insurance? Is it Caucasian or white, uh colored race individual, Asian ethnicity, or is it because where he lives? While while we're waiting, can I ask you a question, what did you rehydrate this patient with? That's a great question actually. We hydrated with normal saline, sir. Uh, no, but uh good point. Number of before you what's that? Number of boluses. Yeah, the St. St. Peter's study uh that looked at a good algorithm that we presented a few years ago on how to know how much fluid to give. Um, and I don't know it off the top of my head. I think it's 16, 17, 18 is the cutoffs of the you have to look that up. I don't remember the numbers for the chloride uh for the bicarb. But it's basically, we can find that for you. We'll write it down, but it's a a nice algorithm tells you exactly how much fluid to give. It probably goes by how what's the percent dehydration and it calculates the amount of water or and sodium and chloride requirements. Yeah, so what they did is they retrospectively looked back to see based on what parameters ended up correcting them. The main cutoff was chloride I believe and I think if it was like less than 88, you gave three boluses before checking. If it was less than like uh 96 then it was two boluses and like between 96 and 100, you give one bolus before you check. Okay. So that's that's great. I mean, um, uh you know, question is why did they need that many boluses? And why do others need just one bolus or none. Um and so the answers here on the on the um uh survey, uh 23% said it's because the child may have had public insurance, 11% think it's because they have commercial insurance. Whereas the majority thought, 67% thought it was where they lived uh had the biggest impact. So the answer is actually the fact that this child had Medicaid or public insurance. And the data on this, this relates to and it's an example of uh what we call the social determinants of health or the non disease part of it, which impacts substantially on the child's uh or even adults outcomes and uh their ability to seek care. As an example, um there's multiple studies out there that have now shown that race and ethnicity. So if you're African-American or black, um and or Hispanic, that um you tend to have poorer outcomes. Disease severity for disease severity being equal when compared to Caucasians. In the United States. All these studies in the United States for now. And then similarly, if you look at those who had public or or limited or no insurance, those also had poorer outcomes. They have decreased access to care. They have um uh and they have uh decreased ability to necessarily get the appropriate care that's needed. And there's multiple studies. So this this is just an example. There's studies that have been looked at appendicitis. Uh they've looked at uh traumatic injuries. They've looked at all kinds of different uh diseases that pediatric surgeons take care of. And in fact, they've all showed a strong and pervasive link between uh either black or Hispanic race and outcomes as well as poverty. So poverty in it of itself. And so public insurance is basically a a marker for degree of poverty. And so poverty has a big deal uh to explain. So I think it's it's it it's been shown in these studies that uh it decreases the peri operative length of stay. You need to get hydration longer. Uh a study that we did showed in fact that their chloride levels for those who had Medicaid tended to be about eight to 10 lower than those who had commercial insurance. to the pediatrician in the last month or last two three weeks, they had gone the commercial insurance patients had gone to the pediatrician and been seen by a pediatrician three times more often. Um, so they they just many different markers for how um patients are treated differently. So, for years we keep publishing this, right? W we had a paper, we showed that there was this there's appendicitis. What are we have still not I am not aware of any changes we can make that will show a measurable difference in this. That's that's a great point. And I think that was the next thing to discuss is that first off, is this even our lane, right? We've a lot of talk to talks about, you know, #stay in your lane and so on and so forth. Is this our lane? And I I'd have to say convincingly, yes. We need to address this. This is firmly within what we need to be doing. And as you pointed out, every single study has said there's a problem. But we haven't done the next step, which is what are we going to do about this problem? Right. And what should we do about it? Right. I think that as pediatric surgeons right now, uh what we need to do is first off and perhaps these studies have helped with this, is we need to universally recognize and agree that social determinants of health matter. So the first thing is we need to do is we need to acknowledge that this is a problem. The second thing is we need to get involved. We need to get involved in advocacy. So the second A would be advocacy. We need to be aware of what the current efforts are on a statewide basis, on a federal basis, on an institutional basis. So the AAP uh or the American Academy of Pediatrics is incredibly uh involved with all these efforts at a regional level, at a district level, at a state level, and certainly at a federal level. And they have they have tremendous advocacy outreach programs that we can link into. So it behooves us to kind of get involved with that. Find out what's going on and how can we help in that. Um third, we need to educate. We need to educate students, we need to educate residents, we need to educate other faculty that this is a problem. We need to raise awareness. So we acknowledge, we advocate and we increase awareness. And finally, I mean, this is not going to get better unless something concrete is done. Right. And that concrete is unfortunately going to cost money. allocation of resources. So those allocations could be at an institutional level. Maybe we need to hire more social workers. Maybe we need to hire more discharge planning people. Maybe we need to fund the schools of public health so that they can actually carry out more surveys and and other issues where they can pinpoint areas that we can improve things. Mhm. This goes down so far down. I mean so we look at uh babies who are born, African-American babies or black babies, uh if you look at their gestational age for gestational age counterparts, they do poorly. So being black as a premature baby is a risk factor. Where does that even start? Right. That starts even before the baby's born. So it's the. It's the mom. It's prenatal care. It's the mom who's undereducated who who who can't seek prenatal care who there's poverty in that situation. Right. So we need to this is this goes beyond what we are talking about and into societal norms and how society needs to change. I just can't believe yet I have not seen a study you may have where someone's reporting an improvement in this. Like we did go ahead. Yeah. So, um not that I'm advocating one thing, but in this being an international Yeah. the broadcasted um event. I'm curious to see what other countries have faced with this because we did a study a number of years ago in the Kaiser system where everybody has insurance and with with respect to appendicitis and we clearly showed that uh we eliminated those disparities as far as um uh education, um uh income level and race that those patients all had the similar rates of uh perforated appendicitis. So that's maybe one way. Um obviously we're that's far off from what we can do, but but starting the process and that's just one one uh disease process that we're looking at. So. Well, you're absolutely right. I think if you look at it from a um international standpoint, um you know, it goes well beyond that is so it brings to for the global surgery and the global need for pediatric surgery and and what do we do about that? And and if you eliminate all those things like you said, these disparities, it's it's about poverty and lack of resources and the ability to get those resources to those who need them. I I think one of the things that we use a lot in in global health and in global surgery that we don't use in the US and in our system is really thinking about community health workers. And you know, are there opportunities for us to take skill, you know, we we have community health workers in SubSaharan Africa and other places that that go door-to-door, right, that help families with adherence to medications. The medication rate adherence is actually significantly higher in those settings than it is in our resource rich settings because we use those tools. And are there opportunities in disenfranchised communities in places where people have less access to use that as a kind of resource and a way to help get people into the system more in a more timely fashion um with recognition at a community level. Well, at least Pakistan says they have the same problem. So um it's it's I think it's Artur said this is basically going to be everywhere. Yes, Pakistan does have the same problem. I can attest to that. Yeah. Yeah. All right. That was pretty provocative. So um thanks for talking about that. Again, I'm just I would love for in two years for you to present. We found it, we found an improvement. We were able to fix the problem. Another plug for this is there is a lot of interest in social determinants of health at APsa this year and we up we updated that podcast where we interviewed That's right. uh the speaker and we have the full length uh presentation available. So you Put the link to that podcast. Yeah, absolutely. And the That was amazing. What were the names of the speakers? It was Adam Foster Squire. Yeah. It was incredib. APsa sent out a survey actually inquiring about which APsa members are interested in this kind of thing and I think they're creating a committee and hopefully will be continued movement in this direction. Okay. From pediatric surgeons. That's awesome. It's great. Uh