Reducing Disparities in Valve Replacement for Infective - PowerPoint Presentation

1. Reducing Disparities in Valve Replacement for InfectiveEndocarditis Among Patients with Histories of IV Drug Use:An Interprofessional ApproachBackground:Infective Endocarditis & PWIDObjective:Changing the NarrativeThe Role of StigmaEndocarditis Epidemiology & OutcomesPathogenesis of endocarditisCompromised endocardiumMicrobial adhesionUnfavorable hemodynamicsRisk factorsExisting heart damagePrevious endocarditisCongenital abnormalitiesForeign hardwareInjection drug useHemodialysisImpaired immunityHIVDiabetesMichael Lourie, MPH; Adam Marks, MD, MPH; Janice Firn, PhD, LMSW; Corey Telin, LMSW, CAADC The Opioid Epidemic & PWIDPrognosisUntreated  Fatal15-30% in-hospital mortalityCardiac, embolic, renal complicationsEffect of injection drug useNo evidence of poorer survivalLonger hospital staysMore likely to experience recurrenceManagementLong-term antibioticsValve replacementRole of surgical interventionNot universally indicatedImproved survival with surgery when compared to only medical treatment, early surgery versus late surgeryIndications for Valve Replacement SurgeryEvidence of heart failureInfection with resistant organism/fungiPersistent infection despite antimicrobialsRecurrent emboliSevere regurgitationHeart block, abscess, or penetrating lesionsVegetation >10 mmWhen can we say no?How can we say yes?Current literature largely framed in “negative” — to limit valve replacement surgery for PWIDGrowing population of people who inject drugs (PWID)Increases in opioid use disorder seen among all age and racial/ethnic demographics between 2002-2017Greatest increase amongYoung adults: Ages 18-34Non-Hispanic WhitesInconsistency in treatment of endocarditisAmbiguity in guidelines, variation between treatment centersOpportunity for introduction of bias against PWIDDebate regarding management of PWID with endocarditis This project aimed to demonstrate an opportunity for improved health equity for PWIDLiterature Review:Trajectory of the DebateLa Puma et al.Physicians as gatekeepers of resources; paternalism198819912009201420162019Cassel et al.Identification of two diseases: Addiction + endocarditisDiMaio et al.Patients as stewards of treatment versus undue judgment from providersHull & JadbabaieNeed for addiction treatment;Proposed “three-strikes” policy on valve replacementGansera et al.Victim-blaming leads to withholding of appropriate medical careElbatarny et al.Call for interdisciplinary management of PWIDProposed solutions present within the literature:Our research team has no disclosures of relationships with industry that could influence our involvement in this project.Conclusions: Identifying Bias & Interdisciplinary ManagementLimit number of valvesAbstinence contractsSubstance use treatmentInterdisciplinary involvementStigma (Goffman, 1963): Attribute, behavior, or reputation that is socially discreditingConsequences of stigma against PWIDLeads to worse mental and physical functioningDiminished empowerment  Poorer treatment outcomesPWID sense discrimination and employ strategies to avoid stigmaDelay healthcareAvoid disclosing drug useDownplay need for pain medicationExperience of treating PWIDPerceived as less cooperative and more disruptiveProviders have lower motivation and satisfaction caring for PWIDProviders who work with PWID have less discriminatory attitudesStigma and its PlayersHealthcare ProvidersPWID PatientsIndividual level: Discriminatory treatmentSocietal level: Unequal distribution of resourcesSelf-stigma: Internalized stereotypesPerceived stigmaEnacted stigmaProposed solution: Identify bias through interdisciplinary management and standardized protocolsWe must identify our bias to counter itRecognize situations that magnify biasIndividuate patients – don’t stereotype themPractice evidence-based medicine with a standardized approachReduce cognitive loadInterdisciplinary team approach (e.g. cardiothoracic surgery, infectious disease, addiction psychiatry, social work, ethics, etc.)Accountability and enhanced cultural competencyLimitation: Capacity for interdisciplinary management is limited by resources available at individual institutionsWork was presented at American Society for Bioethics & Humanities annual conference in October, 2019Researchers plans to continue working with interdisciplinary teams to further care of PWID at home institution