Dr. charles modlin nma new orleans urology presentation july 30 2012

Charles Modlin, M.D., MBACharles Modlin, M.D., MBACharles Modlin, M.D., MBACharles Modlin, M.D., MBA

• Staff UrologistStaff Urologist• Kidney Transplant Kidney Transplant

SurgeonSurgeon• Founder & Founder &

Director, Minority Director, Minority Men’s Health Men’s Health CenterCenter

• Cleveland ClinicCleveland Clinic

Overview & ExamplesOverview & Examples Health DisparitiesHealth Disparities in in Racial/ Ethnic Minority Racial/ Ethnic Minority PopulationsPopulations

Discuss Discuss Causes of Causes of Health DisparitiesHealth Disparities

Health DisparitiesHealth DisparitiesPreventionPrevention

Highlight Cleveland Highlight Cleveland Clinic ProgramsClinic Programs Designed to Address Designed to Address Multifaceted Health Multifaceted Health DisparitiesDisparities

DisclosuresDisclosuresDisclosuresDisclosures

• I do not have any significant financial I do not have any significant financial interest or other relationship with the interest or other relationship with the manufacturers of any products or manufacturers of any products or providers of services I intend to providers of services I intend to discuss.discuss.

•   

Cleveland ClinicCleveland ClinicMinority Men’s Health CenterMinority Men’s Health Center

Cleveland ClinicCleveland ClinicMinority Men’s Health CenterMinority Men’s Health Center

Cleveland Clinic Minority Men’s Cleveland Clinic Minority Men’s Health Center/ Health Fair Health Center/ Health Fair

Established 2003Established 2003

Cleveland Clinic Minority Men’s Cleveland Clinic Minority Men’s Health Center/ Health Fair Health Center/ Health Fair

Established 2003Established 2003

Special Health Concerns in Special Health Concerns in Minority MalesMinority Males

HealthHealthHealthHealth

• In 1947, The World Health Organization In 1947, The World Health Organization defined health as: defined health as:

• ““a state of complete a state of complete

- physical, physical,

- mental, and mental, and

- social well-being and social well-being and

- not merely the absence of disease and not merely the absence of disease and infirmity” infirmity”

U.S. Minorities Increasing in U.S. Minorities Increasing in Numbers & Percentage PopulationNumbers & Percentage Population

U.S. Minorities Increasing in U.S. Minorities Increasing in Numbers & Percentage PopulationNumbers & Percentage Population

• Minorities: Minorities:

- African Americans (Blacks), AA African Americans (Blacks), AA

- Hispanic/ Latinos, H/LHispanic/ Latinos, H/L

- Asian, AAsian, A

- Native American, (American Indians), NANative American, (American Indians), NA

- Pacific Islander, PIPacific Islander, PI

• 1970: All U.S. Minorities 12.3% population1970: All U.S. Minorities 12.3% population

• 2003: All U.S. Minorities 25%2003: All U.S. Minorities 25%

• 2006: All U.S. Minorities 30%2006: All U.S. Minorities 30%

• 2050: Projected 50%2050: Projected 50%

Population of the United States by Race and Hispanic/Latino Origin, Census 2000 and 2010

Race and Hispanic/Latino origin

Census 2010, population

Percent of population

Census 2000, population

Percent of population

Total Population 308,745,538 100.0% 281,421,906 100.0%

Single race

White 196,817,552 63.7 211,460,626 75.1

Black or African American 37,685,848 12.2 34,658,190 12.3

American Indian and Alaska Native 2,247,098 .7 2,475,956 0.9

Asian 14,465,124 4.7 10,242,998 3.6

Native Hawaiian and other Pacific

Islander 481,576 0.15 398,835 0.1

Two or more races 5,966,481 1.9 6,826,228 2.4

Some other race 604,265 .2 15,359,073 5.5

Hispanic or Latino 50,477,594 16.3 35,305,818 12.5

NOTE: Percentages do not add up to 100% due to rounding and because Hispanics may be of any race and are therefore counted under more than one category. Source: U.S. Census Bureau: National Population Estimates; Decennial Census.

Read more: Population of the United States by Race and Hispanic/Latino Origin, Census 2000 and July 1, 2005 — Infoplease.com http://www.infoplease.com/ipa/A0762156.html#ixzz1yins01sM

Race in Medicine & ResearchRace in Medicine & ResearchRace in Medicine & ResearchRace in Medicine & Research

• Active debateActive debate about meaning, importance about meaning, importance• Possibility of improving prevention and Possibility of improving prevention and

treatment of treatment of diseasesdiseases by predicting hard-to- by predicting hard-to-ascertain factors on the basis of more easily ascertain factors on the basis of more easily ascertained characteristics ascertained characteristics

• Race: surrogate marker of increased Race: surrogate marker of increased likelihood of certain medical conditionslikelihood of certain medical conditions

Health Disparities in AA’sHealth Disparities in AA’sHealth Disparities in AA’sHealth Disparities in AA’s

• Compared to general Compared to general population, each year:population, each year:

• 44% more AA’s die from cancer 44% more AA’s die from cancer • 30% more die from heart disease30% more die from heart disease• 180% more die from stroke180% more die from stroke

http://www.cdc.gov/cancer/dcpc/data/race.htmhttp://www.cdc.gov/cancer/dcpc/data/race.htm

http://www.kff.org/minorityhealth/index.cfmhttp://www.kff.org/minorityhealth/index.cfm

African Americans Life African Americans Life ExpectanciesExpectancies

African Americans Life African Americans Life ExpectanciesExpectancies

• AA’s AA’s 6-8 year shorter life expectancy6-8 year shorter life expectancy than whitesthan whites

• AA’s have not benefited equally from AA’s have not benefited equally from medical advances medical advances

• AAs economically advantaged do not enjoy AAs economically advantaged do not enjoy in equal measure with whites expected +++ in equal measure with whites expected +++ influence of affluence on their health. influence of affluence on their health.

Life Expectancy at Birth (in Life Expectancy at Birth (in years), by Race/Ethnicity, 2007 years), by Race/Ethnicity, 2007

Life Expectancy at Birth (in Life Expectancy at Birth (in years), by Race/Ethnicity, 2007 years), by Race/Ethnicity, 2007

U.S.U.S. OhioOhio

WhiteWhite 78.778.7 78.078.0

AAAA 74.374.3 73.373.3

H/LH/L 83.583.5 80.480.4

AsianAsian 87.387.3 83.483.4

NANA 75.175.1 NSDNSD

Copyright restrictions may apply.

Harper, S. et al. JAMA 2007;0:297.11.1224-1232.

Life Expectancy at Birth Among Black and White Males and Females in the United States and the Black-White Life Expectancy Gap, 1975-2003

Number of Deaths per 100,000 Number of Deaths per 100,000 Population by Race/Ethnicity, Population by Race/Ethnicity,

2005 2005

Number of Deaths per 100,000 Number of Deaths per 100,000 Population by Race/Ethnicity, Population by Race/Ethnicity,

2005 2005

United StatesUnited States OhioOhio• WhiteWhite 785.3 785.3 White 850.4White 850.4• Black 1,016.6Black 1,016.6 Black 1,078.1 Black 1,078.1• OtherOther 476.5 476.5 Other 291.2Other 291.2

20082008 United StatesUnited States OhioOhio WhiteWhite 750.3750.3 White 828.0 White 828.0 BlackBlack 934.9934.9 Black 1,029.2 Black 1,029.2 OtherOther 445.8445.8 Other 325.7 Other 325.7

Infant Mortality Rate (Deaths per 1,000 Live Infant Mortality Rate (Deaths per 1,000 Live Births) by Race/EthnicityBirths) by Race/Ethnicity

2003-20052003-2005

Infant Mortality Rate (Deaths per 1,000 Live Infant Mortality Rate (Deaths per 1,000 Live Births) by Race/EthnicityBirths) by Race/Ethnicity

2003-20052003-2005

• United StatesUnited States Ohio Ohio

• Non-Hispanic White 5.7Non-Hispanic White 5.7 6.4 6.4

• Non-Hispanic Black Non-Hispanic Black 13.613.6 15.6 15.6

• HispanicHispanic 5.6 5.6 6.5 6.5

• 2007 Non-HW NH-Black Hispanic

• United States 5.7 13.4 5.5

• Ohio 6.4 15.3 6.6

Number of Deaths Due to Firearms Number of Deaths Due to Firearms per 100,000 Population by per 100,000 Population by

Race/Ethnicity, 2005Race/Ethnicity, 2005

Number of Deaths Due to Firearms Number of Deaths Due to Firearms per 100,000 Population by per 100,000 Population by

Race/Ethnicity, 2005Race/Ethnicity, 2005

• United StatesUnited States OhioOhio

• WhiteWhite 8.98.9 WhiteWhite 7.77.7

• BlackBlack 19.419.4 BlackBlack 22.322.3

• OtherOther 4.14.1 OtherOther NSDNSD

http://www.statehealthfacts.org/comparebar.jsp?ind=115&cat=2&sub=32&yr=63&typ=3http://www.statehealthfacts.org/comparebar.jsp?ind=115&cat=2&sub=32&yr=63&typ=3

High Blood Pressure Levels Vary High Blood Pressure Levels Vary by Race and Ethnicityby Race and Ethnicity

High Blood Pressure Levels Vary High Blood Pressure Levels Vary by Race and Ethnicityby Race and Ethnicity

Race of Ethnic Group

Men (%)

Women (%)

African Americans 43.0 45.7

Mexican Americans 27.8 28.9

Whites 33.9 31.3 All 34.1 32.7

http://www.cdc.gov/bloodpressure/facts.htm

HypertensionHypertensionAfrican AmericansAfrican Americans

HypertensionHypertensionAfrican AmericansAfrican Americans

• HTN risk factor for:HTN risk factor for:

- Kidney, eye, heart, vascular diseaseKidney, eye, heart, vascular disease

- 7.5 million Blacks7.5 million Blacks

- High salt diets, urban living, poverty, High salt diets, urban living, poverty, psychosocial factors: stress, genetic psychosocial factors: stress, genetic predispositionpredisposition

- Greater likelihood of being untreatedGreater likelihood of being untreated

Cardiovascular Disease and Cardiovascular Disease and Heart Failure in AA’sHeart Failure in AA’s

Cardiovascular Disease and Cardiovascular Disease and Heart Failure in AA’sHeart Failure in AA’s

• CVD leading cause of death in all U.S. CVD leading cause of death in all U.S. pts.pts.

• Greater incidence in AA’sGreater incidence in AA’s

• Race and ethnicity influence a patient's Race and ethnicity influence a patient's chance of receiving many specific chance of receiving many specific procedures and treatments:procedures and treatments:

- AA 13% less likely to have coronary AA 13% less likely to have coronary angiography, 1/3 less to have bypassangiography, 1/3 less to have bypass

Screening & Treatment Screening & Treatment Differences by Race & GenderDifferences by Race & Gender

Screening & Treatment Screening & Treatment Differences by Race & GenderDifferences by Race & Gender

• Blacks are less likely Blacks are less likely to receive major to receive major procedures procedures diagnosing and diagnosing and treating coronary treating coronary heart disease than heart disease than whiteswhites

• Black women are the Black women are the least likely to have least likely to have such procedures such procedures recommended recommended

Paula A. Johnson, MD, Paula A. Johnson, MD, MPHMPH

Brigham and Women’s HospitalBrigham and Women’s Hospital

Sources:Sources: Schulman KA et al, Schulman KA et al, N Engl J Med 1999;340(8); N Engl J Med 1999;340(8); Ayanian JZ et al, JAMA, Ayanian JZ et al, JAMA, 1993;269,20; Giles et al, 1993;269,20; Giles et al, Arch Intern Med Arch Intern Med 1995;155(3); Johnson PA 1995;155(3); Johnson PA et al, Ann Intern Med et al, Ann Intern Med 1993;119(8))1993;119(8))

Heart Disease in AAHeart Disease in AAHeart Disease in AAHeart Disease in AA

• Heart failure from HTN is > in Blacks (40%) than Heart failure from HTN is > in Blacks (40%) than Whites (7%). Whites (7%).

• Major risk factors: smoking, HTN, high Major risk factors: smoking, HTN, high cholesterol, physical inactivity. cholesterol, physical inactivity.

• AA’s: AA’s:

- less knowledge about risk factors than whites, less knowledge about risk factors than whites, even per age and education. even per age and education.

• AA diet consumption of meat, fried foods, high in AA diet consumption of meat, fried foods, high in cholesterol and saturated fats. cholesterol and saturated fats.

• Physician Decision-makingPhysician Decision-making

Cerebrovascular Disease in AACerebrovascular Disease in AACerebrovascular Disease in AACerebrovascular Disease in AA

• Blacks higher incidence of and Blacks higher incidence of and >>mortality from stroke than whites>>mortality from stroke than whites

- Blacks more hemorrhagic vs. Blacks more hemorrhagic vs. ischemicischemic (Stroke 1991^22:299-304)

• Race and ethnicity influence a patient's Race and ethnicity influence a patient's chance of receiving many specific chance of receiving many specific procedures and treatments.procedures and treatments.

2005 Stroke Death Rates per 2005 Stroke Death Rates per 100,000 population 100,000 population

(Kaiser Family Foundation)(Kaiser Family Foundation)

2005 Stroke Death Rates per 2005 Stroke Death Rates per 100,000 population 100,000 population

(Kaiser Family Foundation)(Kaiser Family Foundation)

United StatesUnited States

RateRate

OhioOhio

WhiteWhite

44.744.7

WhiteWhite

48.248.2

BlackBlack

65.265.2

BlackBlack

60.360.3

OtherOther

3838

OtherOther

31.931.9

Cancer in African AmericansCancer in African AmericansCancer in African AmericansCancer in African Americans

• Cancer 2Cancer 2ndnd leading cause of U.S. leading cause of U.S. deathsdeaths

• AA’s highest death rates in U.S.AA’s highest death rates in U.S.• Contributing factors: Contributing factors: Tob, Tob,

occupations, diet, knowledge, attitudes occupations, diet, knowledge, attitudes and practices, health/medical and practices, health/medical resources, biological factors, resources, biological factors, socioeconomic status.socioeconomic status.

Smoking in African Smoking in African AmericansAmericans

Smoking in African Smoking in African AmericansAmericans

• AA tend to start smoking later in life and AA tend to start smoking later in life and fewer cigarettes/day than Whitesfewer cigarettes/day than Whites

• More likely smoke Tar and Nicotine More likely smoke Tar and Nicotine brands, 55% AA use only mentholated brands, 55% AA use only mentholated formform

• AA less likely than Whites to quitAA less likely than Whites to quit

• AA 30% higher Nicotine intake per AA 30% higher Nicotine intake per cigarette and differ in metabolismcigarette and differ in metabolism

• ClinClin ImmunolImmunol ImmunopatholImmunopathol.. 1991 May;59(2):187-200. 1991 May;59(2):187-200.

Cancer in AACancer in AACancer in AACancer in AA By Race, AA more likely develop and die of the By Race, AA more likely develop and die of the

4 most common cancers:4 most common cancers:

Breast, Breast,

Prostate, Prostate,

Colon, Colon,

Lung—Lung— Cancer Incidence and Death Rates* by Site, Race, and Ethnicity†, US, 2004-

2008. . American Cancer Society. Cancer Facts & Figures 2012. Atlanta: American Cancer Society; 2012.

Cancer Incidence Rates by Race Cancer Incidence Rates by Race (Kaiser Family Foundation)(Kaiser Family Foundation)

Cancer Incidence Rates by Race Cancer Incidence Rates by Race (Kaiser Family Foundation)(Kaiser Family Foundation)

2004 Rate2004 Rate Age-Adjusted per 100,000 Age-Adjusted per 100,000• United StatesUnited States OhioOhio• White 455.4White 455.4 White 426.1White 426.1• Black 469.6Black 469.6 Black 453.6Black 453.6• Hispanic 356.5 Hispanic 356.5 Hispanic Hispanic 403.7403.7

••

20072007

United States Rate 0.0 - 471.7

White 462.5

Black 471.7

Hispanic 350.1

Number of Cancer Deaths per Number of Cancer Deaths per 100,000 Population by 100,000 Population by

Race/Ethnicity, 2005 & 2007Race/Ethnicity, 2005 & 2007

Number of Cancer Deaths per Number of Cancer Deaths per 100,000 Population by 100,000 Population by

Race/Ethnicity, 2005 & 2007Race/Ethnicity, 2005 & 2007

U.S. 2005 2007U.S. 2005 2007 Ohio 2005 2007Ohio 2005 2007

WhiteWhite 182.6 182.6 174.7 Whites 194.2 190.5174.7 Whites 194.2 190.5

Black 222.7Black 222.7 209.1 209.1 Blacks 249.2 238.1Blacks 249.2 238.1

Other 112.4Other 112.4 108.5 108.5 Other 66.0 91.3Other 66.0 91.3

Cancer Mortality Trends Among Cancer Mortality Trends Among Men by Race/Ethnicity: ProgressMen by Race/Ethnicity: ProgressCancer Mortality Trends Among Cancer Mortality Trends Among Men by Race/Ethnicity: ProgressMen by Race/Ethnicity: Progress

Among white men in the United Among white men in the United States from 1999 to 2008, deaths States from 1999 to 2008, deaths from—from—- Colorectal cancer decreased Colorectal cancer decreased

significantly by 3.0% per year. significantly by 3.0% per year.

- Lung cancer decreased Lung cancer decreased significantly by 2.0% per year. significantly by 2.0% per year.

- Prostate cancer decreased Prostate cancer decreased significantly by 3.4% per year. significantly by 3.4% per year.

- Melanoma of the skin Melanoma of the skin increased significantly by increased significantly by 1.0% per year1.0% per year. .

• Among black men in the United Among black men in the United States from 1999 to 2008, deaths States from 1999 to 2008, deaths from—from—- Colorectal cancer decreased Colorectal cancer decreased

significantly by 1.9% per year. significantly by 1.9% per year.

- Lung cancer decreased Lung cancer decreased significantly by 2.8% per year. significantly by 2.8% per year.

- Prostate cancer decreased Prostate cancer decreased significantly by 3.7% per year. significantly by 3.7% per year.

- Melanoma of the skin Melanoma of the skin remained level. remained level.

Number of Diabetes Deaths per Number of Diabetes Deaths per 100,000 Population by 100,000 Population by Race/Ethnicity, 2005Race/Ethnicity, 2005

Number of Diabetes Deaths per Number of Diabetes Deaths per 100,000 Population by 100,000 Population by Race/Ethnicity, 2005Race/Ethnicity, 2005

United StatesUnited States OhioOhio  

• WhiteWhite 22.522.5 WhiteWhite 28.428.4

• BlackBlack 47.047.0 BlackBlack 58.358.3

• OtherOther 20.5 20.5 OtherOther NSDNSD

Kidney Disease andKidney Disease and African Americans African AmericansKidney Disease andKidney Disease and African Americans African Americans

• The incidence of ESRD in AA is 4 times The incidence of ESRD in AA is 4 times greater than in whites. greater than in whites.

• HTN and DM are the most commonly HTN and DM are the most commonly identified causes of kidney failureidentified causes of kidney failure

• National chronic kidney disease fact sheet, 2007. National chronic kidney disease fact sheet, 2007. http://www.cdc.gov/diabetes/pubs/factsheets/kidney.htmhttp://www.cdc.gov/diabetes/pubs/factsheets/kidney.htm

Total PopulationNew Cases of End-Stage

Renal DiseaseRate per Million

TOTAL 289

Race and ethnicity

American Indian or Alaska Native 586

Asian or Pacific Islander 344

Asian DNC

Native Hawaiian and other Pacific Islander DNC

Black or African AmericanBlack or African American 873

WhiteWhite 218

Data source: U.S. Renal Data System (USRDS), NIH, NIDDK.

Gender

Female 242

Male 348

Renal Transplantation: Renal Transplantation: DisparitiesDisparities

Renal Transplantation: Renal Transplantation: DisparitiesDisparities

• Currently approx. Currently approx.

- 100,000100,000 pts. on Kidney Tx Waiting pts. on Kidney Tx Waiting listlist

•35% AA; 19%H/L35% AA; 19%H/L

•But AA’s only 12% U.S. But AA’s only 12% U.S. population; H/L 16% population; H/L 16%

• NIH News http://www.nih.gov/news/health/mar2012/niddk-08.htmNIH News http://www.nih.gov/news/health/mar2012/niddk-08.htm

•AA only get 26% of Deceased AA only get 26% of Deceased Donor Kidney TxDonor Kidney Tx

Renal Transplantation: Renal Transplantation: DisparitiesDisparities

Renal Transplantation: Renal Transplantation: DisparitiesDisparities

• Among Appropriate Candidates for Tx, Blacks Among Appropriate Candidates for Tx, Blacks are less likely: (UNOS Scientific Registry)are less likely: (UNOS Scientific Registry)

- referred for evaluation referred for evaluation

- listed for Tx (account for only 28% new listing)listed for Tx (account for only 28% new listing)

- receive Txreceive Tx

- Post Tx have higher rejection rates (50% Post Tx have higher rejection rates (50% higher), lower patient and graft survivalhigher), lower patient and graft survival

Blacks wait 2-4 times as long as whitesBlacks wait 2-4 times as long as whites

Why Healthcare Disparities?Why Healthcare Disparities?Why Healthcare Disparities?Why Healthcare Disparities?• Reasons:Reasons:• MultifactorialMultifactorial

• Patient and Provider FactorsPatient and Provider Factors• Culture/ Culture Competency/ CommunicationCulture/ Culture Competency/ Communication

• Education/ Health LiteracyEducation/ Health Literacy

• Historical Factors/ Distrust/ Racism/ Stereotyping/ BiasHistorical Factors/ Distrust/ Racism/ Stereotyping/ Bias

• Socio-EconomicSocio-Economic

• Lack of health insuranceLack of health insurance

• Lack of Access Lack of Access

• Environment/ NutritionEnvironment/ Nutrition

• Lack of Diverse Healthcare WorkforceLack of Diverse Healthcare Workforce

• Genetics/ Biologic/ Diff. Response to MedicationsGenetics/ Biologic/ Diff. Response to Medications

• Lack of Minority Patients in Research TrialsLack of Minority Patients in Research Trials

• Sub-specialization in Medicine & Lack of Awareness of DisparitiesSub-specialization in Medicine & Lack of Awareness of Disparities

Health Disparities Solutions: Health Disparities Solutions: MultifacetedMultifaceted

Health Disparities Solutions: Health Disparities Solutions: MultifacetedMultifaceted

-Based upon our Cleveland Based upon our Cleveland Clinic MMHC Observations Clinic MMHC Observations and Researchand Research

-Examples of our Cleveland Examples of our Cleveland Clinic Innovative Solutions/ Clinic Innovative Solutions/ ProgramsPrograms

Solutions: Step 1 Step 1

Health Provider Recognition, Acknowledgment of Existence, Causes & Impact of Health Disparities in Minority Populations

Solutions: Step 1 Step 1

Health Provider Recognition, Acknowledgment of Existence, Causes & Impact of Health Disparities in Minority Populations

Doctors on Disparities in Medical Care

Doctors on Disparities in Medical Care

• Doctors less likely than public to say disparities are happening “very often” or “somewhat often.”

• Kaiser Family Foundation Survey, March 2002. http://www.kff.org/minorityhealth/20020321a-index.cfm

Health Provider EducationHealth Provider EducationHealth Provider EducationHealth Provider Education

• Regarding:Regarding:

-Existence and Impact of Existence and Impact of Health Disparities in Health Disparities in Minority PopulationsMinority Populations

Congressman Louis Stokes Congressman Louis Stokes Health Equity Lecture Forum, Health Equity Lecture Forum,

Established 2006Established 2006

Congressman Louis Stokes Congressman Louis Stokes Health Equity Lecture Forum, Health Equity Lecture Forum,

Established 2006Established 2006

Cleveland Clinic Journal Medicine Cleveland Clinic Journal Medicine Special Series 2012: Special Series 2012:

Addressing Disparities in Health CareAddressing Disparities in Health CareGuest Editor: Charles Modlin, MD, MBAGuest Editor: Charles Modlin, MD, MBA

Cleveland Clinic Journal Medicine Cleveland Clinic Journal Medicine Special Series 2012: Special Series 2012:

Addressing Disparities in Health CareAddressing Disparities in Health CareGuest Editor: Charles Modlin, MD, MBAGuest Editor: Charles Modlin, MD, MBA

• Modlin CS. Modlin CS. Addressing Addressing Disparities in Health Disparities in Health CareCare Cleveland Clinic Cleveland Clinic Journal of Medicine Journal of Medicine January 2012 vol. 79 January 2012 vol. 79 (1): 44-45.(1): 44-45.

Disparities in prostate cancer in African American Disparities in prostate cancer in African American men: what primary care physicians can do.men: what primary care physicians can do.

Wu I, Modlin C. Wu I, Modlin C. Cleveland Clinic Journal of Medicine Cleveland Clinic Journal of Medicine May 2012 vol. 79 5 313-320May 2012 vol. 79 5 313-320

Disparities in prostate cancer in African American Disparities in prostate cancer in African American men: what primary care physicians can do.men: what primary care physicians can do.

Wu I, Modlin C. Wu I, Modlin C. Cleveland Clinic Journal of Medicine Cleveland Clinic Journal of Medicine May 2012 vol. 79 5 313-320May 2012 vol. 79 5 313-320

SOLUTION: Step 2SOLUTION: Step 2Vision & CommitmentVision & Commitment

Institutional/Self-Belief that YouInstitutional/Self-Belief that You

Can Make A Difference Can Make A Difference

SOLUTION: Step 2SOLUTION: Step 2Vision & CommitmentVision & Commitment

Institutional/Self-Belief that YouInstitutional/Self-Belief that You

Can Make A Difference Can Make A Difference

Solutions: Step 3:Solutions: Step 3:Health Provider Cultural Competency & Health Provider Cultural Competency &

SensitivitySensitivity

Solutions: Step 3:Solutions: Step 3:Health Provider Cultural Competency & Health Provider Cultural Competency &

SensitivitySensitivity

• All providers need to become sensitive All providers need to become sensitive to traditions, values, attitudes of ethnic to traditions, values, attitudes of ethnic groupsgroups

- Mandated in some states, i.e. New Mandated in some states, i.e. New Jersey first stateJersey first state

• Cultural sensitiveness indicates how culture can strongly influence the amount and type of communication between patients and their health providers

The African American Barber Shop, Beauty Salon and Church Initiative

A Tool in Development of Medical & Nursing Student & Health Provider

Cultural Competency/Sensitivity

The African American Barber Shop, Beauty Salon and Church Initiative

A Tool in Development of Medical & Nursing Student & Health Provider

Cultural Competency/Sensitivity

Step 4: Community Trust-BuildingStep 4: Community Trust-Building Step 4: Community Trust-BuildingStep 4: Community Trust-Building

• Key Lesson: Key Lesson: Barbershop, Salon, Church Barbershop, Salon, Church

InitiativeInitiative

• TrustTrust is single most important is single most important prerequisite necessary for healthcare prerequisite necessary for healthcare providers to have success in promoting providers to have success in promoting health in AA communitieshealth in AA communities. .

Solutions: Step 5African American Physician Leadership,African American Physician Leadership,

Visibility & Availability: Visibility & Availability: Very Important To The African American CommunityVery Important To The African American Community

Solutions: Step 5African American Physician Leadership,African American Physician Leadership,

Visibility & Availability: Visibility & Availability: Very Important To The African American CommunityVery Important To The African American Community

Become Part of the Community:Become Part of the Community:Build Trusting RelationshipsBuild Trusting Relationships

Become Part of the Community:Become Part of the Community:Build Trusting RelationshipsBuild Trusting Relationships

Become Part of the Community:Become Part of the Community:Build Trusting RelationshipsBuild Trusting Relationships

Become Part of the Community:Become Part of the Community:Build Trusting RelationshipsBuild Trusting Relationships

TEAMWORK & VOLUNTEERISM: TEAMWORK & VOLUNTEERISM: Step 6Step 6

TEAMWORK & VOLUNTEERISM: TEAMWORK & VOLUNTEERISM: Step 6Step 6

• Dept. UrologyDept. Urology• Dept. NephrologyDept. Nephrology• Medicine InstituteMedicine Institute• Cleveland Clinic Interdepartmental Cleveland Clinic Interdepartmental

Clinical CollaborationsClinical Collaborations• Wellness InstituteWellness Institute• Dept. Pastoral Care ServicesDept. Pastoral Care Services• Dept. Social WorkDept. Social Work• PharmacyPharmacy• Division of NursingDivision of Nursing• Nutrition ServicesNutrition Services• Institutional Services (Pt. Education, Institutional Services (Pt. Education,

OPSA, Sponsored Research, etc.)OPSA, Sponsored Research, etc.)• Corporate CommunicationsCorporate Communications• Governmental & Community RelationsGovernmental & Community Relations• DiversityDiversity• BioethicsBioethics• BiostatisticsBiostatistics• Cleveland Clinic Lerner College of Cleveland Clinic Lerner College of

MedicineMedicine• Lerner Research InstituteLerner Research Institute

Community & Corporate Community & Corporate Partners and Sponsors: Step 7Partners and Sponsors: Step 7

Community & Corporate Community & Corporate Partners and Sponsors: Step 7Partners and Sponsors: Step 7

Solutions: Step 8Solutions: Step 8Solutions: Step 8Solutions: Step 8

• Facilitated Patient AccessFacilitated Patient Access

• Financial/ Charity Assistance ProgramsFinancial/ Charity Assistance Programs

Cleveland Clinic Cleveland Clinic Financial Assistance ProgramFinancial Assistance Program

Cleveland Clinic Cleveland Clinic Financial Assistance ProgramFinancial Assistance Program

• Under Ohio Hospital Care Assurance Program (HCAP) Under Ohio Hospital Care Assurance Program (HCAP) Cleveland Clinic offers basic, medically necessary hospital-Cleveland Clinic offers basic, medically necessary hospital-level services free of charge to individuals who are residents level services free of charge to individuals who are residents of Ohio, and who are currently eligible recipients of the of Ohio, and who are currently eligible recipients of the General Assistance or the Disability Assistance Programs or General Assistance or the Disability Assistance Programs or whose income is at or below the Federal Poverty Income whose income is at or below the Federal Poverty Income Guidelines.Guidelines.

• In addition, Cleveland Clinic provides financial assistance on In addition, Cleveland Clinic provides financial assistance on a sliding scale to patients who do not have insurance at a sliding scale to patients who do not have insurance at family income levels up to four (4) times the Federal Poverty family income levels up to four (4) times the Federal Poverty Income Guidelines, and to all patients, including patients with Income Guidelines, and to all patients, including patients with insurance coverage, if there are exceptional circumstances.insurance coverage, if there are exceptional circumstances.

Financial Assistance ProgramFinancial Assistance ProgramFinancial Assistance ProgramFinancial Assistance Program

• 2008 Federal 2008 Federal Poverty Income Poverty Income GuidelinesGuidelines

Family SizeFamily Size HCAP 2008 HCAP 2008 Federal Federal Poverty Poverty Income Income LevelLevel

CC Financial CC Financial Assistance Assistance Program Program (Family (Family Income up to Income up to 400% of 400% of Federal Federal Poverty Level)Poverty Level)

11 $10,400$10,400 $41,600$41,600

22 $14,000$14,000 $56,000$56,000

33 $17,600$17,600 $70,400$70,400

44 $21,200$21,200 $84,800$84,800

55 $24,800$24,800 $99,200$99,200

66 $28,400$28,400 $113,600$113,600

77 $32,000$32,000 $128,000$128,000

88 $35,600$35,600 $142,400$142,400

Facilitated Patient Access:Facilitated Patient Access:Step 9: Preventive Health Step 9: Preventive Health

Screenings & Health EducationScreenings & Health Education

Facilitated Patient Access:Facilitated Patient Access:Step 9: Preventive Health Step 9: Preventive Health

Screenings & Health EducationScreenings & Health Education

““Every Life Deserves World Class Care”Every Life Deserves World Class Care”““Every Life Deserves World Class Care”Every Life Deserves World Class Care”

1010thth Annual Minority Men’s Annual Minority Men’s Health FairHealth Fair

1010thth Annual Minority Men’s Annual Minority Men’s Health FairHealth Fair

Health Fair VideoHealth Fair VideoHealth Fair VideoHealth Fair Video• Courtesy Mr. Greg LockhartCourtesy Mr. Greg Lockhart

- Frame By Frame Video Frame By Frame Video ProductionsProductions

http://www.youtube.com/wathttp://www.youtube.com/watch?v=3L4zEnecs9Mch?v=3L4zEnecs9M

Health Screenings: Identification of Health Screenings: Identification of Diseases in Early Treatable StatesDiseases in Early Treatable States

Health Screenings: Identification of Health Screenings: Identification of Diseases in Early Treatable StatesDiseases in Early Treatable States

0

100

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600

Dental Screenings & Oral Hygiene

Instruction

Blood Pressure Screening

Stress Management

Urinalysis Reviewed Medications

DRE Blood draws

Series1 120 153 200 217 400 422 439

120153

200 217

400 422 439

Axis

Title

MMHC Health Fair Screenings 2007

Solutions: Step 10: Dedicated Solutions: Step 10: Dedicated Health Literacy EducationHealth Literacy Education

Solutions: Step 10: Dedicated Solutions: Step 10: Dedicated Health Literacy EducationHealth Literacy Education

• Health Education/ Outreach to Health Education/ Outreach to Promote/ Improve Health Promote/ Improve Health LiteracyLiteracy

- Increase awareness of Increase awareness of preventive healthpreventive health

- Increase health Increase health screeningsscreenings

- Promote healthy lifestylesPromote healthy lifestyles

- Promote participation in Promote participation in clinical trials by minoritiesclinical trials by minorities

- Promote awareness of Promote awareness of family medical historyfamily medical history

• Health Literacy Health Literacy Saves LivesSaves Lives

Minority Men’s Health CenterMinority Men’s Health CenterHealth FairHealth Fair

Minority Men’s Health CenterMinority Men’s Health CenterHealth FairHealth Fair

Health Information You Need To Health Information You Need To Know!Know!

(With Pre & Post Test Options)(With Pre & Post Test Options)

Kidney Disease and Kidney Kidney Disease and Kidney TransplantationTransplantation

Kidney Disease and Kidney Kidney Disease and Kidney TransplantationTransplantation

• Diabetes and high-blood pressure cause Diabetes and high-blood pressure cause most kidney disease and kidney failure.most kidney disease and kidney failure.

• Control of your blood pressure and blood Control of your blood pressure and blood sugar may prevent kidney disease.sugar may prevent kidney disease.

• Kidney transplantation is a way to treat Kidney transplantation is a way to treat kidney failure. More AA are needed to kidney failure. More AA are needed to donate their kidneys while living or after donate their kidneys while living or after death.death.

DiabetesDiabetesDiabetesDiabetes

• Risk factors for diabetes are:Risk factors for diabetes are:

- GeneticsGenetics

- ObesityObesity

- Lack of exerciseLack of exercise

- Other predisposing factorsOther predisposing factors

Solution: Step 11: Solution: Step 11: CommunicationsCommunications

Health Disparities Public Media CampaignHealth Disparities Public Media Campaign

Solution: Step 11: Solution: Step 11: CommunicationsCommunications

Health Disparities Public Media CampaignHealth Disparities Public Media Campaign

• TV Media/ NewsTV Media/ News• Print MediaPrint Media

Media AwarenessMedia AwarenessMedia AwarenessMedia Awareness

Solutions: Step 12Solutions: Step 12Solutions: Step 12Solutions: Step 12

Patient Compliance: Patient Compliance: How To Improve ItHow To Improve It

Solutions:Solutions: Step 13 Step 13Community Empowerment:Community Empowerment:

Cleveland Clergy Ambassadors Cleveland Clergy Ambassadors Health Education ProgramHealth Education Program

Solutions:Solutions: Step 13 Step 13Community Empowerment:Community Empowerment:

Cleveland Clergy Ambassadors Cleveland Clergy Ambassadors Health Education ProgramHealth Education Program

2012 Minority Men’s Health Center2012 Minority Men’s Health Center Health AdvocatesHealth Advocates

2012 Minority Men’s Health Center2012 Minority Men’s Health Center Health AdvocatesHealth Advocates

Solutions: Step 14Solutions: Step 14Translational Medicine to Benefit Translational Medicine to Benefit

Health Disparity PopulationsHealth Disparity Populations

Solutions: Step 14Solutions: Step 14Translational Medicine to Benefit Translational Medicine to Benefit

Health Disparity PopulationsHealth Disparity Populations

Solutions: Step 15Solutions: Step 15Encourage Minority Patient Encourage Minority Patient

Participation in Clinical Participation in Clinical Research TrialsResearch Trials

Solutions: Step 15Solutions: Step 15Encourage Minority Patient Encourage Minority Patient

Participation in Clinical Participation in Clinical Research TrialsResearch Trials

Response to Medications Response to Medications African AmericansAfrican Americans

Response to Medications Response to Medications African AmericansAfrican Americans

• Differences in genetics, environmental and cultural factors may Differences in genetics, environmental and cultural factors may lead to racial differences in response to medications.lead to racial differences in response to medications.

• Studies and Examples:

• AA respond better to Calcium Antagonists AA respond better to Calcium Antagonists

- Whites respond better to ACE and B-BlockersWhites respond better to ACE and B-Blockers

- BiDil—New Med to treat CHF in AABiDil—New Med to treat CHF in AA

- RACE-BASED MEDICINERACE-BASED MEDICINE

- Immunosuppressive Medications in AAImmunosuppressive Medications in AA

Etiology of Heart Failure Etiology of Heart Failure in Black Patientsin Black Patients

Etiology of Heart Failure Etiology of Heart Failure in Black Patientsin Black Patients

LVH=left ventricular hypertrophy.

Adapted from Yancy CW. J Card Fail. 2003;9(suppl 5):S210-S215.

HFMore common cause of HF cases in blacks

MI

More common cause of HF cases in whites

LVH

HTN CAD

A-HeFT: Additional A-HeFT: Additional 43%43% Reduction in Mortality Beyond Current Reduction in Mortality Beyond Current Standard TherapiesStandard Therapies

A-HeFT: Additional A-HeFT: Additional 43%43% Reduction in Mortality Beyond Current Reduction in Mortality Beyond Current Standard TherapiesStandard Therapies

*Reduction refers to relative risk in mortality 1 – (hazard ratio) =1 – 0.57 =0.43. Reduction represents full length of follow-up.BiDil [prescribing information]. Lexington, MA: NitroMed, Inc.; 2005.

0 100 200 300 400 500 600

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rviv

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%)

43% Reduction*P=.012 by Log-Rank Test

BiDil + Standard Therapies

Event rate=6.2%

Event rate=10.2%

Placebo + Standard Therapies

518 463 407 360 314 253 16532 466 401 340 285 233 25

BiDil, n =Placebo, n =

Time (days)

Solutions:Solutions:Step 16: Mentorship: Developing Step 16: Mentorship: Developing

Future Healthcare LeadersFuture Healthcare Leaders

Solutions:Solutions:Step 16: Mentorship: Developing Step 16: Mentorship: Developing

Future Healthcare LeadersFuture Healthcare Leaders

Increasing Diversity of Health Increasing Diversity of Health Provider WorkforceProvider Workforce

Increasing Diversity of Health Increasing Diversity of Health Provider WorkforceProvider Workforce

Solutions: Step 17: Solutions: Step 17: Develop Community PartnershipsDevelop Community Partnerships

Solutions: Step 17: Solutions: Step 17: Develop Community PartnershipsDevelop Community Partnerships

Community Leadership & Community Leadership & Celebrity Endorsement of Celebrity Endorsement of

MMHC: Step 18MMHC: Step 18

Community Leadership & Community Leadership & Celebrity Endorsement of Celebrity Endorsement of

MMHC: Step 18MMHC: Step 18

Bill Cobbs: Hollywood ActorBill Cobbs: Hollywood Actoron Disease Prevention & Early Detectionon Disease Prevention & Early Detection

Bill Cobbs: Hollywood ActorBill Cobbs: Hollywood Actoron Disease Prevention & Early Detectionon Disease Prevention & Early Detection

• http://www.yhttp://www.youtube.com/outube.com/watch?v=-HEwatch?v=-HE7I_J-q98&fea7I_J-q98&feature=relatedture=related

Health Policy Advocacy:Health Policy Advocacy:Step 19:Step 19:

UnitedUnited States Congressional Black Caucus, States Congressional Black Caucus, U.S. Capital, U.S. Capital,

Washington, D.C.Washington, D.C.

Health Policy Advocacy:Health Policy Advocacy:Step 19:Step 19:

UnitedUnited States Congressional Black Caucus, States Congressional Black Caucus, U.S. Capital, U.S. Capital,

Washington, D.C.Washington, D.C.

Healthy People 2000: Priority AreasHealthy People 2000: Priority AreasHealthy People 2000: Priority AreasHealthy People 2000: Priority Areas

• 1. Physical Activity and Fitness 1. Physical Activity and Fitness 2. Nutrition 2. Nutrition 3. Tobacco 3. Tobacco 4. Substance Abuse: Alcohol and Other Drugs 4. Substance Abuse: Alcohol and Other Drugs 5. Family Planning 5. Family Planning 6. Mental Health and Mental Disorders 6. Mental Health and Mental Disorders 7. Violent and Abusive Behavior 7. Violent and Abusive Behavior 8. Educational and Community-Based Programs 8. Educational and Community-Based Programs 9. Unintentional Injuries 9. Unintentional Injuries 10. Occupational Safety and Health 10. Occupational Safety and Health 11. Environmental Health 11. Environmental Health 12. Food and Drug Safety 12. Food and Drug Safety 13. Oral Health 13. Oral Health 14. Maternal and Infant Health 14. Maternal and Infant Health 15. Heart Disease and Stroke 15. Heart Disease and Stroke 16. Cancer 16. Cancer 17. Diabetes and Chronic Disabling Conditions 17. Diabetes and Chronic Disabling Conditions 18. HIV Infection 18. HIV Infection 19. Sexually Transmitted Diseases 19. Sexually Transmitted Diseases 20. Immunization and Infectious Diseases 20. Immunization and Infectious Diseases 21. Clinical Preventive Services 21. Clinical Preventive Services 22. Surveillance and Data Systems 22. Surveillance and Data Systems

Healthy People 2010Healthy People 2010Healthy People 2010Healthy People 2010

• Healthy People 2010 challenges individuals, communities, Healthy People 2010 challenges individuals, communities,

professionals, and institutions—all of us— to take specific professionals, and institutions—all of us— to take specific steps to ensure that good health, as well as long life, are steps to ensure that good health, as well as long life, are enjoyed by all.enjoyed by all.

• Healthy People is managed by the Healthy People is managed by the Office of Disease Prevention and Health PromotionOffice of Disease Prevention and Health Promotion, , U.S. Department of Health and Human ServicesU.S. Department of Health and Human Services

Step 20:Promotion of & Celebration Step 20:Promotion of & Celebration of Family Support Systems and of Family Support Systems and

Awareness of Family Medical HistoryAwareness of Family Medical History

Step 20:Promotion of & Celebration Step 20:Promotion of & Celebration of Family Support Systems and of Family Support Systems and

Awareness of Family Medical HistoryAwareness of Family Medical History

Solutions: Step 21Solutions: Step 21Outcomes ResearchOutcomes ResearchSolutions: Step 21Solutions: Step 21

Outcomes ResearchOutcomes Research

• Look at health outcomes in your own Look at health outcomes in your own practice and at your own institutionpractice and at your own institution

• Know how you are doingKnow how you are doing

• Develop strategies to improve your Develop strategies to improve your outcomesoutcomes

AAnalysis of Disparities in Kidney nalysis of Disparities in Kidney Transplantation by Race at Transplantation by Race at

Cleveland Clinic Cleveland Clinic

Section of Renal TransplantationSection of Renal TransplantationMinority Men’s Health CenterMinority Men’s Health Center

AAnalysis of Disparities in Kidney nalysis of Disparities in Kidney Transplantation by Race at Transplantation by Race at

Cleveland Clinic Cleveland Clinic

Section of Renal TransplantationSection of Renal TransplantationMinority Men’s Health CenterMinority Men’s Health Center

C. Modlin, C. Zaramo, J. Alster, L. Zhou, D. C. Modlin, C. Zaramo, J. Alster, L. Zhou, D. Goldfarb, S. Flechner, Goldfarb, S. Flechner,

and A. Novickand A. Novick

Living Related (LR)Living Related (LR)Cadaveric (CAD)Cadaveric (CAD)

Health Disparities in Renal Health Disparities in Renal Graph Survival in Tx Patients Graph Survival in Tx Patients

by Race and Source of by Race and Source of AllograftAllograft

Dialysis 1Dialysis 1stst Week Post-Tx Week Post-TxSignificant Disparities in Dialysis following the Significant Disparities in Dialysis following the First Week of Post Renal Transplantations First Week of Post Renal Transplantations (Post-Tx, p<0.001*)(Post-Tx, p<0.001*)

52.14%

15%

8.16% 5.14%

0

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100

Perc

en

tag

e (

%)

African American

(CAD)

Caucasian (CAD)

African American

(L)

Caucasian (L)

Race/ Ethnicity

*p< 0.0001 *p< 0.0001

Post-Tx Serum Creatinine (CAD)Post-Tx Serum Creatinine (CAD)Post-Tx Serum Creatinine (CAD)Post-Tx Serum Creatinine (CAD)Creatinine Levels from Cadaveric Donors, Significant Difference at 7

Days (p<0.0001), 1 month (p=0.005) and 2 Months (1 Year ) (p< 0.004)

0

1

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6

7

Day 7 1 3 6 12 36

Time

African American (CAD)

White (CAD* p=0.0001

* p=0.005

* p=0.004

P<.0001 @ 7 daysP<.0001 @ 7 daysP<.008 @ 12 mos.P<.008 @ 12 mos.

STEP 22: STEP 22: Putting it all together:Putting it all together:

Develop and Implement Develop and Implement Multifaceted Innovative Multifaceted Innovative

Programs to Address Health Programs to Address Health DisparitiesDisparities

STEP 22: STEP 22: Putting it all together:Putting it all together:

Develop and Implement Develop and Implement Multifaceted Innovative Multifaceted Innovative

Programs to Address Health Programs to Address Health DisparitiesDisparities

• Transplantation Transplantation ProceedingsProceedingsVolume 40, Issue 4Volume 40, Issue 4 , , Pages 1001-1004, May Pages 1001-1004, May 20082008

Solution: Promotion of Living Solution: Promotion of Living Kidney Donation in African Kidney Donation in African

AmericansAmericans

Solution: Promotion of Living Solution: Promotion of Living Kidney Donation in African Kidney Donation in African

AmericansAmericans

Living Unrelated Renal Living Unrelated Renal TransplantationTransplantation

Living Unrelated Renal Living Unrelated Renal TransplantationTransplantation

• http://www.youtube.com/watch?v=jy0CsHLL8YEhttp://www.youtube.com/watch?v=jy0CsHLL8YE

Living Related Renal Living Related Renal TransplantationTransplantation

Living Related Renal Living Related Renal TransplantationTransplantation

Standard Surgical Techniques Standard Surgical Techniques for Kidney Transplantationfor Kidney Transplantation

Standard Surgical Techniques Standard Surgical Techniques for Kidney Transplantationfor Kidney Transplantation

Renal AllograftRenal AllograftRenal AllograftRenal Allograft

Solutions:Solutions:Innovations in Healthcare:Innovations in Healthcare:

Look to see how Look to see how youyou can innovate can innovate to improve outcomesto improve outcomes

Solutions:Solutions:Innovations in Healthcare:Innovations in Healthcare:

Look to see how Look to see how youyou can innovate can innovate to improve outcomesto improve outcomes

• Utilization of Expanded Criteria Donor Kidneys for Utilization of Expanded Criteria Donor Kidneys for Transplantation:Transplantation:

- Single Pediatric Deceased Donor AllograftsSingle Pediatric Deceased Donor Allografts

- Pediatric Enbloc Deceased Donor AllograftsPediatric Enbloc Deceased Donor Allografts

- Kidneys with multiple arteriesKidneys with multiple arteries

- Dual Deceased Donor AllograftsDual Deceased Donor Allografts

- Kidneys with capsular injuriesKidneys with capsular injuries

- Kidneys with renal artery aneurysmsKidneys with renal artery aneurysms

Expanded Criteria Donor Expanded Criteria Donor Kidneys for TransplantationKidneys for Transplantation

Expanded Criteria Donor Expanded Criteria Donor Kidneys for TransplantationKidneys for Transplantation

• Modlin CSModlin CS, , Goldfarb DAGoldfarb DA, , NovickNovick AC AC. The use of . The use of expanded criteria expanded criteria cadaver and live cadaver and live donor kidneys for donor kidneys for transplantationtransplantation. Urol Clin North Am. 2001 2001 Nov;28(4):687-707.Nov;28(4):687-707.

Issues and Techniques Available to Expand Issues and Techniques Available to Expand the Pool of Kidneys Available For the Pool of Kidneys Available For

Transplantation. MODLINTransplantation. MODLIN

Issues and Techniques Available to Expand Issues and Techniques Available to Expand the Pool of Kidneys Available For the Pool of Kidneys Available For

Transplantation. MODLINTransplantation. MODLIN

• Chapter 10. In Chapter 10. In Kidney Kidney and Pancreas and Pancreas Transplantation: A Transplantation: A Practice Guide.Practice Guide.

Multiple Renal ArteriesMultiple Renal ArteriesMultiple Renal ArteriesMultiple Renal Arteries

End-To-Side Arterial End-To-Side Arterial AnastamosisAnastamosis

End-To-Side Arterial End-To-Side Arterial AnastamosisAnastamosis

Dual Mate Kidney with 3 ArteriesDual Mate Kidney with 3 ArteriesDual Mate Kidney with 3 ArteriesDual Mate Kidney with 3 Arteries

Dual Mate Kidney with 4 ArteriesDual Mate Kidney with 4 ArteriesDual Mate Kidney with 4 ArteriesDual Mate Kidney with 4 Arteries

Dual Deceased Donor AllograftDual Deceased Donor AllograftDual Deceased Donor AllograftDual Deceased Donor Allograft

Pediatric Deceased Donor Pediatric Deceased Donor Kidneys For TransplantationKidneys For TransplantationPediatric Deceased Donor Pediatric Deceased Donor

Kidneys For TransplantationKidneys For Transplantation

• Modlin C, Novick AC, Goormastic M, Hodge E, Modlin C, Novick AC, Goormastic M, Hodge E, Mastrioanni B, Myles J. Long-term results with single Mastrioanni B, Myles J. Long-term results with single pediatric donor kidney transplants in adult recipients. J pediatric donor kidney transplants in adult recipients. J Urol 1996 Sep;156(3):890-895. Urol 1996 Sep;156(3):890-895.

• Hobart MG, Modlin CS, Kapoor A, Boparai N, Mastroianni Hobart MG, Modlin CS, Kapoor A, Boparai N, Mastroianni B, Papajcik D, Flechner SM, Goldfarb DA, Fischer R, B, Papajcik D, Flechner SM, Goldfarb DA, Fischer R, O'Malley KJ, Novick AC. Transplantation of pediatric O'Malley KJ, Novick AC. Transplantation of pediatric enbloc cadaver kidneys into adult recipients. enbloc cadaver kidneys into adult recipients. Transplantation 1998 Dec 27;66(12):1689-1694. Transplantation 1998 Dec 27;66(12):1689-1694.

Pediatric Enbloc AllograftsPediatric Enbloc AllograftsPediatric Enbloc AllograftsPediatric Enbloc Allografts

Pediatric Enbloc KidneysPediatric Enbloc KidneysPediatric Enbloc KidneysPediatric Enbloc Kidneys

Pediatric Enbloc Kidney Pediatric Enbloc Kidney AllograftsAllografts

Pediatric Enbloc Kidney Pediatric Enbloc Kidney AllograftsAllografts

Pediatric Enbloc AllograftsPediatric Enbloc AllograftsPediatric Enbloc AllograftsPediatric Enbloc Allografts

Pediatric Enbloc Post PerfusionPediatric Enbloc Post PerfusionPediatric Enbloc Post PerfusionPediatric Enbloc Post Perfusion

Capsular Repair Vicryl MeshCapsular Repair Vicryl MeshCapsular Repair Vicryl MeshCapsular Repair Vicryl Mesh

Capsular RepairCapsular RepairCapsular RepairCapsular Repair

Renal Capsular RepairRenal Capsular RepairRenal Capsular RepairRenal Capsular Repair

• J Natl Med Assoc. 2012;104:199-201

Renal Angiomyolipoma Renal Angiomyolipoma in Living Donor Kidneyin Living Donor Kidney

Renal Angiomyolipoma Renal Angiomyolipoma in Living Donor Kidneyin Living Donor Kidney

Living Donor Kidney with Living Donor Kidney with Renal Artery AneurysmRenal Artery Aneurysm

Living Donor Kidney with Living Donor Kidney with Renal Artery AneurysmRenal Artery Aneurysm