FEMALE SPEAKER: Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with ACCME guidelines.

ANGELA DONALDSON: Hello and welcome to our panel discussion, which is part of the COVID-19 expert lecture series. Today, we will discuss health care disparities in COVID-19 with a particular emphasis on surgical subspecialty perspectives. I am your host, Dr. Angela Donaldson. I'm a rhinologist and [INAUDIBLE] surgeon here at the Mayo Clinic in Jacksonville. I'm also assistant professor of otolaryngology here in the Jacksonville campus. I'm joined today by my panelists, Dr. Christopher Destephano, Dr. Beth Ladlie, Dr. Archer Martin, and Dr. Hani Wadei. We have no financial disclosures.

The objective of today's panels include describing health disparities and health outcomes in COVID-19 in minority groups. We'll discuss health care disparities seen in surgical specialties such as otolaryngology, transplant surgery, and obstetrics and gynecology prior to the COVID-19 pandemic and then we'll discuss protocols and procedures put in place here at the Mayo Clinic Jacksonville campus to protect staff and patients during aerosol generating procedures such as intubation and endoscopy.

I'd like to start the panel discussion by discussing the census data in regards to the demographic breakdown here in the United States. As of July 2019, the US population was approximately 328 million people. Whites made up 76.3% of the population. Those who are white of non-Hispanic descent make up 60.1% of the population. Blacks and those of African-American descent make up 13.4% of the population. And Latino and Hispanic persons make up 18.5% of the population. These statistics are important as we delve into health care disparities as it relates to COVID-19.

This graph is from the CDC and it shows the cases of COVID-19 based on race and ethnicity as of September 2020. It shows that whites make up the majority of cases of COVID-19. However, Blacks and those of African-American descent make up 18.5% of COVID cases. And again, they only make up 13.4% of the actual population. Hispanic and Latino persons make up 29.5% of the cases of COVID-19. And again, they only make up 18.5% of the actual population.

When we look at deaths due to COVID-19 as of September 21, 2020, we find that whites make up the majority of death due to COVID-19, however Blacks make up 21% of death due to COVID-19. And as we just discussed, they only make up 13.4% of the actual population. Hispanic and Latino persons make up 16.7% of deaths due to COVID-19, but they only make up 18.5% of the actual population. As you can see, there is a significant disparity in the frequency of hospitalizations and deaths due to COVID-19 for Black and Hispanic people.

This slide is from the CDC and it breaks down cases, hospitalizations, and death based on ethnicity and race. What they found was that American Indians have a hospitalization rate that is 5.3 times higher than whites. They also have a death rate that is 1.4 times higher than whites. Blacks have a hospitalization rate that's 4.7 times higher than whites and a death rate that is 2.1 times higher than whites. And Hispanic and Latino persons have a hospitalization rate of 4.6 times higher and a death rate that is 1.1 times higher than whites. These are important statistics as we look at the factors associated with death due to COVID.

As we delve a little further, we now all understand there are certain underlying conditions that make your more vulnerable to COVID-19, especially when it comes to hospitalizations. This graph from the CDC shows that certain comorbidities, such as asthma, hypertension, obesity, diabetes, and chronic kidney disease are all associated with having a higher risk of hospitalization due to COVID-19. These comorbidities are important as we all know that they statistically are found more commonly in those of minority groups.

With this information, we find it significantly valuable to have a frank discussion about health care disparities as it relates to surgical entities as well as emphasize the importance of a better understanding of how race and ethnicity plays a part in our health care system. If you'd like more information on the statistics discussed, please go to the CDC.gov website. Thank you. We'll now discuss otolaryngology and health care disparities.

So I'm going to start talking about my specialty, otolaryngology. We're going to talk about the health disparities in this particular subspecialty. Head and neck is one of the more significant studied areas for health care disparity. Laryngeal cancer, endocrine tumors, and HPV positive oropharyngeal tumors are all types of conditions that have been studied associated with health care disparities.

For laryngeal cancer, we found that Blacks and Latinos are more likely to be treated with surgery, meaning a total or laryngectomy, where the larynx is taken out surgically and the patient is left with a stoma, which affects their ability to speak, cough, smell, and swallow normally. These patients who are in stage three or four typically should be considered candidates for a combination of chemotherapy and radiation. However, when we look at the statistics from 2001 to 2010, you find that Blacks and Hispanics are more likely to be offered surgery rather than chemoradiation, which is considered to have the same overall survival.

In endocrine tumors, we found that patients of Black descent are more likely to have complications from their surgery, meaning thyroid and parathyroid surgery because they're more likely to be treated by those who have low volumes, meaning surgeons who specialize in otolaryngology but do not have more than 75 cases per year of doing these types of surgeries.

We've also found that HPV, which has changed our world as we see it, as far as head and neck cancer, because it's more likely to be sensitive to chemotherapy and radiation with better overall survivals, is actually less prevalent in the Black community. So whether they smoke or don't smoke, which has traditionally been how we assess the likelihood they're going to have a diagnosis of a oropharyngeal cancer, and whether or not they have other comorbidities, having HPV is actually a positive thing for their overall survival. And African-Americans are less likely to have that diagnosis of HPV positive.

In the pediatric realm, we find that African-American and Hispanic children are less likely to be referred for surgical procedures, such as PE tubes and tonsillectomies, which means that they continue to suffer for longer periods of time before having appropriate definitive surgery. And in the rhinology and skull base world, we also find that they are more likely to have complications from their surgical procedures because they're more likely to be operated on at low volume centers.

So COVID has significantly impacted our practice. We are considered a procedural type of practice in both the OR and in the office. And we're also considered an aerosol generating procedure type of specialty. We also complicate this by the fact that many of the COVID symptoms are also symptoms that we see with many of our patients-- anosmia and hyponosmia, one of the most common symptoms in COVID, both for those who have mild to moderate symptoms and those who have severe symptoms, is a common symptom that we see in patients with chronic rhinosinusitis.

Things like sore throat and nasal congestion-- common things we see in our office and in our practice-- are now some of the things that are warning signs for COVID-19, which makes our specialty even more complicated in figuring out whether acute processes are their underlying condition or COVID. We have taken a major impact in specialties such as rhinology and laryngology where our patients are typically scoped using an endoscope or laryngoscope on a daily basis. These endoscopy procedures actually trigger cough and sneezing, which has been associated with increased risk of spread of transmission.

So what have we done in our practice to try and help protect patients and our staff? Well, number one, all of our patients are COVID tested prior to having outpatient visits. This is a challenge for those who are seen by us from outside the realm of the local Jacksonville area, but we've actually seen resilience with our patients who have been able to come early and on days opposite of their appointments to get these COVID tests. It's important because it protects them and it protects our staff.

We also are no longer using aerosolized topical anesthetic for preparation of our endoscopies. Instead, we're using nasal packing that has a similar medication. We're using telemedicine as appropriate, especially for those who have had head and neck procedures so they do not have to be exposed to the staff or to other patients who are waiting. And we're able to expedite any issues that they may have. And we also intermittently close our offices depending on the risk of aerosolization. We also have lots of controversy over when to do a tracheostomy, one of our primary procedures. And we found that the use of an N95 or a PAPR has been associated with a safer protection of our surgeons as we provide this necessary treatment.

Again, COVID-19 has impacted otolaryngology in many ways as it's a challenge as we are learning more and more about the condition and how it spreads and trying to keep our staff safe and trying to keep our patients safe as well, but we hope that these things will lead to improved quality of life for our patients. From the health care disparities standpoint, we here are lucky that we have all these precautions in place, but we understand that some patients don't have a car to come and get COVID tested.

They are concerned about the finances of getting these tests done with frequent appointments. And they don't have necessarily the internet access to have telemedicine, which does limit their ability to have any of these precautions even used. I thank you for your time as we discussed otolaryngology. Now I have the distinct pleasure of introducing our next panelist, Dr. Christopher Destephano. He's an MD/PhD and he's also the assistant professor of Obstetrics and Gynecology here at the College of Medicine in Florida. Thank you, Dr. Destephano.

CHRISTOPHER DESTEPHANO: Hi. Thanks for having me.

ANGELA DONALDSON: We are going to start with the question of, how have you noticed the health care disparities in the field of obstetrics or gynecology?

CHRISTOPHER DESTEPHANO: So thank you for that question. So I am predominately a gynecologic surgeon now. The OB and the GYN is separated at Mayo, and we really focus on gynecologic surgery on the Florida campus. And so I'll focus on gynecologic cancer specifically because that's where we've seen the most change with regards to disparities. Before COVID-19, disparities were prevalent in endometrial cancer and cervical cancers, and this was predominantly due to access.

So Black women that develop endometrial cancer are twice as likely to die from the endometrial cancer, which is the predominant form of uterine cancer, compared to white women. And so we were already working on some of this research, however, unfortunately, COVID-19 has reduced screening for cancers, mainly I think because it has reduced women coming in for symptoms of gynecologic cancers. And so we're setting up a number of different systems in order to reach out to the women in order to bring them into the mix with regards to their cancer screening again.

ANGELA DONALDSON: Excellent. And the next question really has to do with how has COVID impacted your practice to date?

CHRISTOPHER DESTEPHANO: I think those first two months, because gynecologic surgery, even though it is often indicated and needed, is elective. And so those first few months after COVID-19, we really shut down elective surgeries to get a handle of what was happening. And at this point, we're ramping back up with new precautions, like wearing masks universally, frequent hand washing, social distancing. And those have made it safe to see patients in clinic, as well. But we also have the option for telemedicine, as we are often able to go through the symptoms that are associated with cancers even without a physical clinic visit. And often, we can order different tests in order to evaluate for cancer even with without being seen in a gynecologist office.

You know, there's been a lot of differences in how we do screening for gynecologic cancers. PAP smears, which look for cervical cancer, are no longer recommended every year. However, we still recommend being seen by a women's health specialist every year to discuss symptoms. And the main symptom I want to bring up today is post menopausal bleeding or bleeding that happens after menopause. This is something that over 50% of women experience at some point, usually isn't cancer. However, 90% of women with uterine or endometrial cancers do have postmenopausal bleeding. And so that's the symptom I really want women that are over the age of 50 that have gone through menopause to think about and to seek medical care if they have that symptom.

We are an academic medical center and, therefore, it has been important to continue research during the pandemic. And actually, our research project deals with this issue of seeking medical treatment and from home, actually. So we're studying self-collected tampon tests to evaluate for endometrial cancer. And so one day, this may be able to decrease the need for being seen in a clinic. And so a patient could have a telemedicine visit and have an order for a self-collected tampon. And so we are still doing research, as well, on disparities in order to reach out to women that aren't necessarily coming into the clinic setting and are scared to come into the clinic visit.

So we're trying to reduce those barriers to seeking care because we know, again, that Black women have death rates that are twice as high as white women for uterine cancers. The diagnoses of uterine cancer are 35% lower during the first 12 weeks of the epidemic in California. This means that many patients are not presenting with symptoms of disease. They're probably at home not considering the possibility of cancer.

And so even though the pandemics important, we have mechanisms in order to reduce the risk of spread of the virus with universal masking, and we still recommend that women seek care for symptoms that are associated with cancer, especially postmenopausal bleeding. 90% of patients with endometrial cancer have abnormal vaginal bleeding, but only 9% with bleeding have endometrial cancer. So many women and providers outside of gynecology often don't bring up postmenopausal bleeding. We want patients to start to bring this up to their providers so that we can act on it.

And some of the things we're doing from Mayo is reaching out to community clinics, non-clinical community settings, like churches, like homeless shelters, like libraries-- anywhere we may be able to find women that have symptoms associated with cancer outside of the clinical setting. And then, finally, non-academic medical center settings because we know that most patients are not seen in the academic medical center and we need to help provide access to women that have symptoms associated with cancer. So this is just a map of how we're trying to cover Jacksonville with some of our work on symptoms associated with cancer during a pandemic.

ANGELA DONALDSON: Excellent. And we have a few minutes to talk still. How did you establish those communications between yourself and the non-academic institutions that you're partnering with right now?

CHRISTOPHER DESTEPHANO: Mayo clinic has dedicated themselves to health equity and work on disparities research. And so we have an Office of Health Equity at Mayo Clinic that helps establish partnerships both within Mayo with different departments like we're talking today and then also outside of Mayo clinic in the community, both at clinical settings with other physicians and in non-clinical community settings.

ANGELA DONALDSON: Excellent.

CHRISTOPHER DESTEPHANO: And so the other important piece is knowing what to expect if you come in with symptoms associated with endometrial cancer. First of all cancer, is a scary word. However, with uterine or endometrial cancer, it is highly curable if caught at an early stage. That's why I'm really reiterating that we want patients to come in. We think they need to come in early with symptoms so that we can do a biopsy. And a biopsy is about a less than 30 second procedure in the clinic, in the office, that sometimes we can do under anesthesia with our anesthesia colleagues if there's concern about the pain or discomfort. And so we have both options, both in clinic or in the operating room. And so I'm looking forward to hearing from our anesthesia colleagues about how to facilitate access for many of these cancer screenings.

ANGELA DONALDSON: Great. Thank you so much. Thank you, Dr. Wadei for joining us today for the panel on COVID-19 and health care disparities and surgical procedures. Dr. Wadei is an assistant professor in medicine and has a joint appointment in transplant and is part of the transplant and hypertension center here in the Florida campus. Again, thank you for joining us today.

HANI WADEI: OK. Thank you for inviting me. So that's a little bit of a different topic than the previous ones discussed, but again, I just want to highlight that there is a big history here. And I think it's appropriate to talk about kidney disease, kidney failure, and racial disparity because it's a perfect example of the blind spot phenomenon in the American health system. So I will explain this a little bit further. Basically, race was not mentioned anywhere in the end-stage renal disease literature or the chronic kidney disease literature until probably 1984 when the first time they discussed that there is increased risk of kidney failure in African-American population.

Back then, there was limited access to dialysis. And there was a committee that actually prioritized dialysis patients and based on what worthiness-- their net income, are they married or not, they have kids or not, their contribution to society, but race was not mentioned as one of the criteria to prioritize people on dialysis back then. And you wonder if some people were denied dialysis actually because of the race.

As far as the kidney transplant is concerned, again, early reports dating before 1970 did not even consider race as a criteria even to mention whether when it comes to the recipient or when it comes to the donor, they did not mention it. It's not until '77 when they said, well, there's 11.9% of the people who actually get transplanted turn out to be African-Americans. So it took them 50 years to recognize that there is racial differences. And that's, again, why it's a perfect example of the racial blind spot, as I just said.

So what have we learned since we start looking at race and end-stage renal disease? We learned very important facts. We learned fact number one, that chronic kidney disease is seven times more common in African-American compared to Caucasians. End-stage renal disease, meaning being on dialysis because of the chronic kidney disease, is three times higher in the African-American population. We learned that renal transplant is a life saving procedure for anybody irrespective of race because it prolongs years of life and gives better quality of life.

But we learned, too, it has been reproduced in multiple different studies that African-Americans have limited access to kidney transplant compared to Caucasians. And there definitely, when it comes to living donor, they're at disadvantage because they're less likely to receive a living donor kidney, which is the best quality kidney compared to the deceased donor. And even if they get transplanted, their post-transplant outcome has been inferior when compared to Caucasians. So the patient does not live as long as long and the kidney does not stay as long compared to Caucasian population.

So this is a graph, here, showing the lifetime risk of end-stage renal disease by race in the US. And this is just published in 2018. And this source is an available one for everybody to check. It's an online database that has all the information regarding dialysis patient. As you can see, in African-American men, 8% of African-American men will end up being on dialysis compared to only 2% or 3% in Caucasian. Same thing with African-American women-- 7% lifetime risk of being on dialysis.

So that's what I'm saying-- three times higher. You expect that if there is more people on dialysis and more people would get the kidney transplant and that's not the case. So here's the transplant rate-- percent people who got transplanted by race. The red line here is a Caucasian and the greenish line is African-American. And you can say that over the years, 10% of the people who received a transplant are of African-American race compared to between 20% and 30% of the people who received a transplant are Caucasian despite the reverse as far as dialysis is concerned. Three times higher dialysis and three times less African-American are receiving transplant.

So what happened in the COVID-19? We know that this virus came to us out of nowhere. Highly contagious virus causes severe acute respiratory distress syndrome. And it received various kinds of names. First report in China at the end of December. Spread across the whole globe. Did not spare anybody. Cause major disruption on multiple levels. And we were not spared from this disruption.

But I will say, personally, I attribute this disruption to many things. One of them is the high mortality rate we received from the European counterparts who, especially in Italy, and the conflicting media reports that get us totally puzzled, we did not know what the mode of transmission is. Until now, the CDC is still debating, is asymptomatic carriers or asymptomatic people can transmit the infection or not. The surfaces, the doorknobs-- all these things kind of created a lot of fear. And there was a lack of knowledge on how best to manage this patient and there was a big fear that the medical system will collapse actually.

So all this kind of led our efforts, here in the transplant center, to change our practice. And we did many things and we did not do things, other things, which I think we're proud of. So the things that we did is that we stopped all living donor kidney transplant. We considered those to be an elective surgery. And since all elective surgeries have been postponed, we postponed them. Deceased donors and the kidney offers, we delayed-- we did not accept any for seven to 10 days but after that, we catched up. And compared to other centers, that's kind of unheard of because other centers stopped doing transplants for a couple of months.

We postponed some of the new kidney transplant evaluations, basically, clinic visits for evaluating patients for kidney transplants, especially if they're coming from out of state, especially New York, which was at the time a hot spot. We tried to go with the virtual format and overnight all our offices were filled up with the speakers and the mics and all the things to facilitate this to happen. Then, we start to work on a patient specific level by creating protocols to help manage these COVID infected kidney transplant patients who are immunosuppressed and at risk of having worse disease than others.

As has been mentioned before, chronic kidney disease itself is a risk factor for severe COVID infection. And many of our patient also has hypertension, has diabetes, and are obese and, as we said, African-American. So all of these people-- all the risk factors are concentrated in the kidney transplant patients. So we had to develop protocols on how to manage those. We also wanted to split the medical teams. Some would come even days, some would come odd days so we avoid infection between them.

And we had to deal with, like, staff quarantines and half time [INAUDIBLE] coverage and all the rest. But what we did not do, we really did not change, overall, our immunosuppressant regimen or any protocols that we're using. We kept trying to keep the patient's social support together and we allowed at least one caregiver to be present with each patient. And that was something we had to discuss with the hospital because the policy at the time was not to get any visitor or any caregivers in the hospital. So we had allowed this to happen. Overall, we survived and we did not collapse, which is a very good thing.

I will just tell you, too, that we looked at our experience with COVID-19 and how it affected our practice. So COVID-- this is kind of the overall graph showing how the growth of our transplant center, as far as kidney transplant patient's concerned from 2014 to now. So there is continuous growth and COVID, it kind of came and knocked us down or slowed us down a little bit. And the surprising fact that it didn't slow down or disfavor the African-American community more for unclear reasons or reasons that we need to look for cause of.

So basically, if you look at people who came for kidney transplant evaluations-- I told you what we did overall, and we did not discriminate based on race of who will come and who will not come for kidney transplant evaluation. But if you look for the 90 days before COVID and the 90 days starting from March 2 after COVID, there was a 30% drop in patients coming to us for kidney transplant evaluation if they're African-American. Caucasian did not drop that much, only 4% drop in the Caucasian race for some reason compared to 29% in the African-American population.

And if you look at transplants-- so all transplants kind of dropped-- again, 90 days before COVID we did 21 transplants is African-American patients and 36 in Caucasian. After COVID, there was a drop in both races, but the rate of the drop was more pronounced also in the African-American community compared to the Caucasian-- 33% decline in transplant compared to 22%. So reasons for that is not clear. You can only speculate about it.

Maybe some of those patients were, again, from more out of state or from heavily infected areas and they did not get the kidney offer, like people from New York or other areas which were initially heavily hit. Maybe we had some people who could not come because their caregivers were actually sick or they could not find somebody to drive them in a reasonable amount of time to get the deceased donor kidney. Probably some people lost their insurance. We have to dig deep and find out what the true reasons are.

But I think this is, again, an example that COVID not only has effects on mortalities, the numbers that everybody-- the CDC is tracking, the media is tracking-- but it does have other effects that we kind of would be surprised if we see it and we just don't have the answers for. So I just want to conclude that CKD, which is chronic kidney disease, end-stage renal disease, renal transplant patient are a clear example of how race and racial disparity is affecting the American health care system. And because of COVID, major disruption happened overall in our transplant program but it seems, for some reason, it magnified this racial disparity. So we can even conclude that COVID killed us even without infecting us. And with that, I will just have no more things to say.

ANGELA DONALDSON: Amazing. Fantastic. That was very enlightening and we'll talk about this when we come together because I think this is a challenging thing, not only for our institution, but I think around the country everyone is trying to figure out. I think there's a lot of concern and information and misinformation that's put out in the community about whether we're doing transplants. If we're not doing transplants, are you now not a candidate because you're high risk in regards to COVID in general?

Should you be taking your medications or should you not be taking your medications? These are huge things that I think that everyone who's a health care provider, a patient, an advocate for patients really needs some clear instruction and information so that, again, as you said so eloquently, we don't let the virus kill us and we're letting our transplant and our kidney kill us because we're in fear.

HANI WADEI: I just want to say that people are still confused and they come to the clinic and they say, we don't want to get transplanted until this virus is over. Or, we don't want to get transplanted until there is a vaccine available. And what's going to happen if there is a vaccine? Should we take the-- I mean, our immune system, how is it going to handle that? There's lots of questions and proliferating about this.

And one last thing I should say is that we published a paper looking at, we summarized all the literature until the end of July discussing COVID-19 from the whole literature. We included, like, more than 300 cases of COVID-19 in the kidney transplant patient has been reported from all over the world. And the mortality rate in the kidney transplant patient was 24% compared to 10% in the general population. So that tells you that the more severe disease and more higher mortality are problematic in the kidney transplant patients. We did not look for race particularly because, again, this is reported from all over the world, including China and Iran, Italy, France, and the US. So not every report included race as part of the reporting criteria. But that's something we should look into.

ANGELA DONALDSON: Absolutely.

HANI WADEI: The mortality in the kidney transplant patient differs by race.

ANGELA DONALDSON: Yes. Excellent. Thank you so much and we look forward to hearing from you after our next speakers. Our next speaker is Dr. Beth Ladlie. She's an MD/ MPhD. And she's also the assistant professor of anesthesiology here at the Mayo Clinic in Florida. She's also the medical director for our Office of Equity Inclusion and Diversity. And I'm really excited to hear her perspective on not only diversity initiatives here but also how anesthesia has been affected by-- or health disparities have been affected by anesthesia. Thank you, Dr. Ladlie.

BETH LADLIE: Thanks for having me, Dr. Donaldson. And I'd like to start my talk off the same way that you did. I want to give people a bird's eye view of what health care disparities look like in anesthesia. And I can do that very easily in a small panel discussion because almost all the information that we have on health care disparities and in a reasonable fit on this first slide. So anesthesia, sometimes we feel like we're sort of a subsection of medicine, where our patients are sort of just brought to us by other providers. And so I think, sometimes, we're a little bit late to the game as far as looking at outcomes differences.

So there is still a lot of questions to ask, but what we know so far are these things. So in analgesia, no matter where you look at it-- perioperative, pediatrics, labor and delivery, especially in fact, as Dr. Destephano already mentioned, there's a lot of information on health care disparities in maternal fetal outcomes. And analgesia during labor and delivery is no exception for that. There is a perception that people of other ethnicities may perceive pain or anxiety differently and for that reason, it may be under treated. So as you can imagine, the disparity is that it's more highly treated in white patients in the United States than it is in any people of color.

And along that same line, because many of the treatments are opioids, there can be more complications of opioid over treatment in white patients as well. When you look at general anesthesia for cesarean section, so general anesthesia is generally something we try very difficult to avoid. The risk of complications and significant morbidity and mortality is double when you have to receive general anesthesia versus a spinal anesthesia for cesarean section. So it's an obvious indicator on how we're handling things if your risk of general anesthesia is 1.7 times higher if you are a person of color.

Post-operative nausea and vomiting is an issue that's really recently recognized. So there was a huge study based on a national database outcome. And this includes more than-- this is 50,000 plus cases of anesthesia where they're are kind of able to separate by socioeconomic status. And who knows what the details of the reason why, but lower socioeconomic status is associated with under treatment and under prophylaxis of post-operative nausea and vomiting, which is a major cause for delayed discharge, prolonged length of stay, prolonged PACU length of stay, all things that are sort of indicators of care.

General anesthesia for hernia repair and regional anesthesia for orthopedic procedures-- those are sort of linked. So regional anesthesia tends to be more accessible for white patients than patients of color. And again, it's sort of hard to tease this out because some of this is sort of regional variation in practice. But the take home point remains, any time you ask the question, is there a difference between how we take care of people of different ethnicities, the answer is almost always yes.

Let me move on a little bit to critical care specifically because critical care is a multidisciplinary field but, as you know, anesthesiologists are highly involved. And I really feel like the health care disparities in critical care are what are most closely related to COVID-19. So you've already expanded very nicely on the difference in death rates, the difference in hospital admissions for different ethnicities.

And that literature isn't specifically available yet in anesthesia critical care literature but prior to the COVID-19 pandemic, there is a difference in outcomes if a patient has acute lung injury or ARDS. There is a higher incidence for people of color for respiratory failure. There's a higher risk of venous thromboembolism for people of color. And venous thromboembolism is certainly an exacerbating factor in morbidity and mortality when it comes to COVID-19 treatment specifically. And then, finally, community acquired pneumonia, which we normally think of as a streptococcal pneumonia, right now is highly associated with viral pneumonia related to the COVID-19 virus.

If there was already a difference in community acquired pneumonia treatment, we can expect those to be augmented based on the health care disparities that have even been uncovered with COVID-19 specifically. And I think part of the reason why this happens is because representation matters. So this is from census data and from an audit of anesthesia practice from 2019 that was given to the American Society of Anesthesiologists.

So you can see that while according to the census maybe 52% of Americans are white, 80% of anesthesiologists are white. So there's data in other fields that patient provider concordance, so that patients and providers can have things in common like race, like gender, like sexual orientation, it's sort of automatically increases the level of connectivity right from the get go. And so patient provider concordance is something that anesthesia struggles with because we don't have good representation amongst our staff, amongst our providers for minority patients.

So what do I think are the solutions to this? I'm just going to throw a few things out there that are in the literature. So protocol use really eliminates some of the implicit bias that providers bring to the table because you're no longer really dependent on your own brain for remembering post op nausea and vomiting prophylaxis. Regardless of who the patient is, it's sort of already systemically laid out in how you practice medicine and so that's easy to apply to all patients. And there is definitely data in the literature that this works particularly well for errors protocols. So if you look at enhanced recovery after surgery, the studies that have been done that look at race in those feel like the protocol sort of eliminate-- there's no longer bias that's obvious between people of color and white patients in that.

Unconscious bias training-- probably everyone who's listening to this knows already that regular and routine unconscious bias training where you really make those unconscious biases more conscious allows you-- so for example, if I knew that I had a bias against a particular type of patient, if I know that and that means I'm at risk for under treating them for nausea and vomiting, I can now pay special attention to that subgroup of patients when I see them and consciously make an intentional effort to improve that post op nausea and vomiting.

Third, we need to ask the question. So I already told you I could tell you about all the health care disparities of anesthesia in one or two slides. So we're not asking questions about racial and ethnic disparities when it comes to perioperative glycemic control, when it comes to transfusion, when it comes to length of stay in the PACU. Even length of operation time has been looked at once or twice and operation time tends to be different depending on payer mix or race. So every time we ask the question, we learn something. So we need to get better at asking the questions.

And then back to that patient and provider concordance, that's about building a pipeline. That's about finding out why women don't go into anesthesia because women do make up 50% plus now of medical student populations. So what about anesthesia causes them to lose interest? And people of color are already underrepresented in medical school. So the pipeline for them is broken prior to that. So really repairing the pipeline is going to yield providers that have greater insight into creating sort of a more fair health care system for users when they interface with our health care environment. And I'm going to turn it over to Dr. Martin because Dr. Martin and I worked together also on developing the anesthesia response team here at Mayo and he is going to be able to shine some light on some of the experiences that we had.

ANGELA DONALDSON: Excellent. Thank you so much.

ARCHER MARTIN: Well, Dr. Ladlie, thank you so much for that insight. Thank you to Dr. Donaldson for hosting this. And really thank you to all my fellow panelists. So we were tasked to answer the question what was the impact of COVID-19 on our specialty? What are some of the safety concerns that we've had? And what are the protocols that we have defined throughout this pandemic? Really, we're driven by our goals. These don't change. I'm going to discuss those, but we're guided by principles that also never change but sometimes the application does. Finally, I'm going to take each one of you on a multidisciplinary COVID-19 journey, going through time to tell you exactly how we've handled it and where we are in the current day.

Now, when we examine the goals that are in the forefront of our mind, these never change. The first, which is foundational to Mayo clinic, is that the needs of our patients come first. But when we're facing a pandemic where there's a threat to health care providers who are taking care of these patients, it's important to also note that one of our primary goals is the safety of our staff. In order to achieve these goals, we have guiding principles. And I think that they have been threefold.

First is an appropriate level of education as well as coordination and communication amongst all of our colleagues. Now, I've taken this and gone through time. I note phase one, phase two, and then current day. And I'll defined those time eras. But I want to take you back to early 2020. Let's say, February to March. And I would term this phase one. Soon, there were reports coming out of China either on Twitter or medical case reports that my colleagues were picking up of a new emerging pandemic. And from the education bit, we were trying to figure out what exactly were we dealing with?

We had to look back to the literature from 2005 predominately out of our colleagues in Canada and, in fact, Toronto with the initial SARS pandemic. That initial literature discussing the threat to the providers who were taking care of the patients as well as some of the techniques to use PPE as well as attenuate the risk of aerosolizing generating procedures were vital for us in terms of our starting point during this pandemic.

From a communications standpoint, we had to learn how to identify the problem. Testing was relatively limited and often slow in the very beginning phases of the pandemic. And we realized fairly quickly, Dr. Ladlie, myself, and many other colleagues from our department, that we had to figure out how to coordinate together the team. We had to really defend ourselves, our entire department. And we decided to do the best we could in terms of concentrating available PPE and expertise by forming a COVID anesthesia response team.

Now, as we moved out of phase one, we moved into phase two. And some of the education that we received both through literature other colleagues experiences where the pandemic was a little tougher at the time helped us in terms of understanding how to use appropriate PPE. We formed a video and put it online-- we digitized our protocols-- where we discussed the appropriate donning and doffing procedures for aerosolizing generating procedures. After our team had interaction with these patients, we had debriefs both within ourselves and via email and we incorporated that experience to reinforce the digital protocols.

Now, at this time, testing had improved so our communication piece, we aimed to disseminate that information as quickly as possible. And we use our electronic medical record in order to communicate to COVID status, either positive, negative, or unknown in each one of the patients presenting for a surgical procedure. And whereas on the first phase in February and March I would say we were on defense, our coordination now became one of offense, and we coordinated with our multidisciplinary colleagues in the ICU in particular and we integrated into their team to provide support for AGPs, for procedural support, or if they became overwhelmed, such as our colleagues did in Mt. Sinai New York, formed our own standing ICU team to take care of these patients.

As we moved past phase two, we're in current day. And this has been the same since about June 2020. From an education standpoint, we have dissolved the COVID anesthesia response team and I would say that we're all in this together. We've done the best we can to ensure a departmental wide proficiency so that any provider in our department, anesthesiologist or nurse anesthetist, now have appropriate training and availability for the donning and doffing of PPE.

In terms of communication, we have aims to have rapid identification of patients presenting for procedures. We have hospital wide testing policies. Any colleague who presents for work has to attest every day whether or not they have symptoms. They're screening at all of our entrances and we have rapid testing available for emergency procedures. In terms of coordination, we've moved back out of ICU more into the operative phase. And any patient who is either suspected or known COVID positive, we have time outs with all team members and we coordinate before we start the anesthetic. I've found that to be very, very helpful in improving safety for our patients as well as for ourselves.

To kind of tie all of this together, I want to give you an example of a procedure that I would probably say is one of the highest risk that we do in these patients. Now, I'm division chair of cardiovascular and thoracic anesthesiology but we have many different colleagues who are involved in taking care of patients who have refractory respiratory distress secondary to COVID-19. 19 In that case, oftentimes they present to the operating room for rapid deployment of veno-venous ECMO or extracorporeal membrane oxygenation, which provides oxygenation for their blood as well as decarboxylation.

When we look at our three guiding principles, we looked from an education standpoint, what are the latest principles, both in terms of ECMO protocols, which may come from the ELSO organization, as well as ensuring that every team member has appropriate knowledge for donning and doffing. From a communication standpoint, we've gone beyond the EMR. We have a cardiogenic shock team who is available. This cardiogenic shock team is notified any time a potential VV ECMO either comes from an outside institution or within our own.

Within five minutes, we're all expected to be on a Zoom call and we coordinate and discuss the best plan for the patient. Subsequent to that, we've built into our EMR a secure chat system. Secure chat is key because oftentimes we communicate via phone or via pager, but when we're fully donned with a PAPR or N95, we can use secure track directly from the workstation in the operating room to communicate with colleagues outside of the operating room.

From a coordination standpoint, as I mentioned, we're outside of the ICU now and really this is a matter of coordination amongst the ICU, cardiothoracic surgery, TB anesthesia, and the profusion departments. And there are multiple colleagues within their respective departments that work together. So what can we see in conclusion about COVID-19's impact on our specialty, the state the adjustments we've had to make, as well as the protocols we've created?

Whether we're discussing health care disparities or an emerging pandemic, these sort of challenging problems require solutions. Solutions that are guided by goals that we all share together as well as principles, but we need to have flexibility to create these ongoing solutions. Our goals, as I noted before, should always remain the same. The needs of our patients come first, as well as the safety of our colleagues. And I think it's so important that we work together not just within our own specialty, but multidisciplinary colleagues. And together, we can solve these issues. Thank you Dr. Donaldson. I'd like to give my time back to you.