Sabina Ali - Healthcare Disparities in IBD Care

In this episode, hosts Drs. Jennifer Lee and Temara Hajjat talk to Dr. Sabina Ali about healthcare inequities and disparities related to the care of patients with pediatric inflammatory bowel disease. We review recent literature and discuss ways to improve clinical practice.

This episode is eligible for CME credit!  Once you have listened to the episode, click this link to claim your credit.  Credit is available to NASPGHAN members (if you are not a member, you should probably sign up).  And thank you to the NASPGHAN Professional Education Committee for their review!
 
Learning Objectives:

1.     Understand the definition of healthcare disparities, social determinants of health, equality and equity 

2.     Recognize disparities in care amongst patients with pediatric gastroenterologists

3.     Understand the resources and strategies available to improve inequities of care

Produced by: Jennifer Lee

Transcript

0:07

Welcome to another episode of Vow Sounds, a pediatric GI podcast, the official podcast of North American Society for Pediatric Gastroenterology, hepatology and Nutrition. My name is Jen Lee, and I am joined by Tamara Hija, both pediatric gastroenterologist, in Ohio. Hey, Tamara. Hello. Hello. How are you, Jen, how are you feeling, first of all? Oh, I'm feeling so good. We have one announcement to do. Any of our listeners who are planning to go to nasp, again, it's in San Diego, The link is up to reserve your hotel. And yes, the abstract deadline is coming up. So that will June 1st. June 1st. So submit your abstract. Uh, really looking forward to seeing everyone out in San Diego. And you can go ahead and reserve your rooms too. Right, right. I already did. Did you? Uh, nope. But that was also a reminder to myself. Remember last, last began, when was when it was, in San Diego and I reserved a room like on Car, Coronado Beach, one of those rooms. Mm-hmm. Which I was like, oh my gosh, this is, I need to wait for a bus it was a little far. Yeah, a little far. Yeah. And then like this time I'm like, I'm just gonna stay where the conference is. Yeah. So much closer. But then a couple hotel options there. So, um, second announcement is there is a brand new podcast that's coming out of NAS again that everybody should go look for. It's called Nutrition Pearls, the Pediatric GI Nutrition Podcast, and it is put on by the Council of Pediatric Nutrition Professionals. Because honestly, nutrition is a very important part of gi. So I'm excited to learn a lot from the lovely dieticians from naspa again. Exactly, and the introductory episode has come out and I think the content specific ones are coming out soon, so hopefully we can do a collaboration with them. Yes, I'm excited to listen. Um, and the person we're interviewing today is somebody that I met through nasp. Again, but it's Dr. Sabina Ali. And her birthday just happened. She has a Cinco de Mayo birthday, so we wanna give her a shout out for that happy birthday. That's pretty cool. That's pretty cool. Dr. Sabina Ali is the medical director of the I B D program at U C S F Benioff Children's Hospital in Oakland and we are gonna talk to her today about healthcare disparities in I B D care. Yes. So a very important topic This also plays into this new terminology that was just really put out there about a year or so ago called the Quintuple Aim, or Quintuple aim. we had a conversation today in Grand Rounds have you heard of this? Oh, was that, no. Yeah, so it, it started with the triple aim, right? Uh, which is improving population, health enhancing care experience, and reducing cost. And then there was the quadruple aim a few years ago, which added clinician burnout. And now it's this concept that's out there called the quintuple or quintuple aim. Which also includes advancing health equity. And so this episode really plays into that quintuple aim, and I think it's so important because we have a long way to go. That's true. That's true. Super awesome episode and we hope you get as much out of it as we did. Yes. Yes. Onto the show. Onto the show. Welcome, Dr. Hallie to Bow Sounds. We're excited to have you today. Thank you. I'm so excited to be here when I. Received that email. I was like, that song was going in my head. I'm so excited. Can't hide. I'm so excited and I can't just hide it or something like that. Yeah. We're not gonna go forward in that song, so just stop. We're gonna ask our first question that we ask every guest, and for our listeners who don't know you, how would you describe yourself in one sentence? Okay, so I'll say I am a foodie, which happens doing great. I'm a pediatric gastroenterologist and I love to travel, which helps my food interest because I try all these new foods in these new places. Oh, I love food. And actually this next question goes along with that. So this season we've started to ask some of our guests about the city where they live. And if we were to come to San Francisco, what do you recommend that we check out that the traditional tourist may not know about? Okay. So have you been to San Francisco? I have. Oh yes, I love it. Okay, love it. So you probably know about. The Crooked street Lombard, right? With everybody goes there. But do you know there's actually another crooked street. It's actually more crooked and oh, even the locals don't know about it. It's quite ver Vermont Street. It's actually the most crookedest street in the country. It has the more tighter turn radius and it's more steeper than lobar and oh, the best part is there is no tourists. Even locals don't know about it, so it's always good to just go and drive through that street. There's one more place which you may have visited, but if you did not, then the next time you go do stop by. In the mission area, there's the mission murals. It's the most wonderful. Outdoor Alternative Art, Gar Gallery, and it's also the area where the food is great. So you get both. I was gonna go there and I didn't have time to go there. I was like, oh, I should go back to San Francisco to, there's a lot of stuff that I wanted to visit there. My favorite, honestly was Redwoods. Oh my gosh. Those are amazing. Those are amazing. Well, I feel like whenever I go to San Francisco, I love to run. So some of the listeners may know this and like I feel like depending on which way you go, you can make a big mistake because you end up going like straight uphill for so long. Yes. Well, the next time you come, you have new too neat things to look at. Yes. The Mormon Street and the murals now. We'll definitely check that out. Absolutely. So, going on to our topic, our topic today is about disparities in healthcare, and specifically today we're talking about disparities in patients with inflammatory bowel disease. And a lot of people recommended you because you work with patients in the Oakland area in California. So we want to start off with how did you get involved and interested in working in healthcare disparities? Yeah, so it's naturally happened because I work at Children's Hospital Oakland. It serves a very large, diverse population like any other large center does. But it's also a safety net hospital for our region. So it just naturally happened for me and I think like a few more definitions I think would be helpful just to set the stage. So what are health disparities? And another term I hear a lot is social determinants of health, especially how they relate to inflammatory bowel disease. Yes. So there are a few definitions out there, but the one that is mostly in the literature is the one C D C has, which basically it's preventable differences in the burden of disease or injury or violence or opportunities where you can achieve optimal healthcare. That experience by socially disadvantaged population. There is another definition that is by healthy people 2020. So basically it's a particular type of health difference that is closely linked to either a social, economic or environmental disadvantage and notes that disparities affect adversely. People who are have systematically experience these obstacles to health. And you may also hear the terms health inequality or inequity, and they prefer to disparities and they are used interchangeably, but very completely different terms. So equity means that each person has what they need to be as healthy as possible. But then equality means that each individual gets the same thing. So even though we, it's used interchangeably, but when you. Think about it deeper. They are a little different and they can arise from multiple factors. As we said, environmental threats, inadequate access, healthcare to healthcare, education or poverty. The other term you asked about was social determinants of health. So these are the conditions in the environment where people are born. We live, we learn, we work, we play the age we are in. That affects the wide range of health and. Our functioning, they're five big domains. So economy, economic stability, access to education, quality of healthcare, access, your neighborhood, your environment you are in, the social and community. So that affects all of that. Um, so for example, let's safe housing, transportation in the neighborhood, racism, discrimination. Y the job you hold, education opportunities or income access to nutritious food or physical activity. We in pediatrics, think about this so much, right? I mean, not even just I b D, but your obese population, physical activity, can they even leave? Uh, And their house and run in their neighborhood, right? Because it may not be a safe neighborhood to go out for a walk even. And people may don't, who don't have access to grocery stores with have, which have healthy foods, right? Or are less likely to have good nutrition that that raises the other health conditions and even lowers life expectancy. Just promote promoting. So just promoting healthy choices sometimes doesn't eliminate. Because of these, all these other disparities around them. Um, just to summarize, so health equity is the state in which everyone has fair and just opportunity for the highest level of health. And then the social determinants of health are really those five domains, which are conditions in which people are born or live in that affect their health. Right. The other thing I think is also we forget and may not come across which we encounter every day, is language and literacy skills. Right? People and families who have limited. English proficiency face barriers to health services and experience lower healthcare because limited English proficiency is an independent driver of health disparity and can be another social determinant of health. I definitely feel that my grandmother doesn't speak English, and when she went to the hospital most recently, we had such a hard time communicating to understand what was going on and so luckily we had family members to go be with her, but it would've, it was very challenging. Yeah, exactly. And I can have days when none of my patients may be English speaking and finding a interpreter. Sometimes I personally feel like in-person interpreters make such a big difference than one on the video or audio because you can see the body language, you know, they just interact differently and sometimes you don't know what. You know, with just being on audio of what they're saying, if the family is actually understanding, because the dialects may be a little different, right? So it can make a huge difference. Absolutely. And sometimes the interpreters are trained to convey medical terms and knowledge, but a lot of times, like I have to use an Arabic interpreter. I'm Arabic speaking, but I have to use an Arabic interpreter because I'm not certified, especially for procedures. And the interpretation is not a hundred percent what I said. And I think that also is a barrier. In kind of receiving like healthcare for non-English speaking patients. Yeah, I agree. That's so fascinating because sometimes I feel that, right? Like I ask a question and there's a lot of back and forth dialect and then I get one line back. Yeah. Like I'm like, is that exactly? I know. Yeah. The answer is no. And you're like, Sounds like it's more than just one word. Great. So, so now, oh, wait, before we move on, Tamara, real quick. I, I wanna, I, there was another term that you brought up that I think is so important and that's equality. And I think there's this PowerPoint slide I remember from a grand rounds from a few years ago with these children under a tree. Mm-hmm. And they're all trying to get an apple and equality is everyone having the same size ladder? But the tree is too tall for some people to reach, and so I think that's another important term. So I'm so glad that you brought that up. Yeah. The other way I felt this, it was some I heard from someone, which I loved was think about it like we all are invited to a party, but some of us are. Having a conversation, but not all of us are included in the conversation. Right? So it's like, yes, you may be invited to a party, but doesn't mean you're really having a conversation at that party. So that's, yeah. Yeah. That makes, that makes good, that makes perfect sense. So Sabina, we'd like to turn to your clinical experience with managing patients, and we wanna hear from you what specific challenges you have or you face for carrying your patients with inflammatory bowel disease. And how do you overcome these challenges? Yeah, so I think I would start with saying I can't imagine having a clinic without our social workers. We have a wonderful social work program at our hospital, and I think if they all disappear, I don't know if we'll all show up to work the next day because we just can't function. The big challenge is access. It's access to a lot of things for our patients. Simple as access to transportation. Can my patient even get here? That makes it access to their care. We talked a little bit about food safety, food insecurity and safety, where they live, and again, safety in their environment, access to their medical team, who speaks their language. And also the other part is understand their culture. As we mentioned, Arabic culture may be different than a South Asian culture, and understanding that part because you have to include. Them and their family in some of these decision making, which sometimes we forget in certain cultures, the whole family helps in the decision making, right? So I think those are the things that we have to think about and ex that goes along with my daily clinical experience when seeing patients with such a. Big diverse backgrounds. Yeah, absolutely. And I feel that when I manage a patient that is, has like a Middle Eastern background or a different background from somebody who is born and raised here in the United States and I, I grew up in the Middle East and I understand how the culture is, so I adjust my recommendations based on how their understanding is and how I know the culture is. But it might be challenging to know. Everybody's culture. So I think that's a good way where you would ask and listen really well and educate yourself about different cultures and not just be single-minded about managing all the patients in one way. Yeah. So don't make an assumption. Right? Don't make an assumption. Yeah. Yeah. And I think it applies to not just us who you know as physicians or nurse practitioners or physician assistants, but also I always kinda mention it's also to our dieticians, right? They have to adjust. Their discussion about food, right? I mean, we have all these I B D related dietary therapies. There are some guidelines, but adjustments have to be made based on what's on their dinner table, right? So absolutely. It's gonna be hard to convince a South Asian patient saying, eat avocado every day. So it's not, it's not at that dinner table, right? So, right. Although they were on sale at the grocery store this week, so we have They're good too. They're good too. Right. But I think you brought up another concept that has come up time and time again as we've been talking about care for patients with inflammatory bowel disease, and that's really that multidisciplinary care. So having access to a social worker to help with those things is so important and I'm so glad you brought that up. So if I were going. To meet a family? Are you the one having conversations to assess a family's needs, or does the social worker do that? And what advice do you have for us to maybe help recognize some of these social determinants? What's a good process? Yeah, I, that's a great question, and I think we were just talking about it. This week, actually, in my clinic, we had a resident and we were talking about, so who does these assessments? Right. I'll start with something that we also have to think about is a quote from an epidemiology expert or of Europe. Dr. Professor Sir Michael Marma, he just always says is, why treat people and send them back to the conditions that made them sick in the first place? Right? So, Most of us know it is important to identify and address and achieve this as a whole person, but the challenge is how do we put it in the system, how we implement it in our so busy practice, right? As you said, who does it so, Our social workers, this is their second nature, right? They are just having a conversation and they're going through it. But you and I have to think about those five domains every time, right? In a healthcare setting that we are in our busy practice, there are some screening tools available. They are long and it's hard to accomplish them in a busy practice. It's actually, if you have an emr, some of the EMRs have it epic. Has it, it's, I don't know if you have Epic, it's actually shows up on the corner of your screen. It's, and you click on it and actually opens two questions for each domain, which is nice. It's short and you can just go through it. It also is, it's part of their medical records and if they're followed in another clinics at GI now, rheumatology or dermatology or primary care. Everyone can see it, right? That is a concern expressed by another physician, and so it's nice to have those in your E M R and see if kind of you can use that in your daily practice. The other is, as we said, we acknowledge it now we document it, right? But then we also need to say, what are we gonna do about it, right? Because every patient practice and community is so different, it's not a one size fit all to address their social needs. So, Including a social worker or a community health worker in the practice will be definitely a place to go in so they can provide and help resources, get resources to our patients. So me and in the emr, that's like my domain and what I love. But I think the way our hospital has implemented this is interesting. We have this social determinants. Of health screening that goes out to every single patient who's seen, regardless of your clinic, but it's sent to the family as a questionnaire. So it does not necessarily have, like, I don't have a conversation about it. Mm-hmm. With my patient necessarily. But if there's a certain score, then that patient is automatically added to a list that a group of social workers maintain to contact them. And if there's any medium risk, high risk, what have you, we provide education right there. Mm-hmm. But I have some inherent challenges with this at baseline because when it's a questionnaire within the E M R, it's actually in English and we don't have a lot of other language opportunities, and so you have to take additional steps. So it almost, it's nice in one way, but again, you mentioned the language barrier. It comes up time and time again. And it's hard to do it in a busy practice. And I find it challenging too because I've also had instances where families will say, yes they are, they're having issues, but they don't wanna talk about it. Right. How do you address that? Yeah. I think that's where I think our social workers place such a unique role because over time they also develop a relationship with the families and they spend a longer time. Talking about these things when you and I are in and out trying to get through our day and we'll start a conversation, but we may not be the people who have the right resources, right? So we have to still connect them with the right resources. So we are some of us who are fortunate to have social workers in our practice. It works out. But I think it's challenging for private practices out there who don't have access and they may need the community health workers in those situations. And one more question before we move on. So our practice standardly, is to do this once a year. But as we've we're going to talk about, and I know it's come up in the past in conversations with inflammatory bowel diseases, are we have a very unique patient population. So we've talked about the diet, but a lot of the treatments are quite costly also within our inflammatory bowel disease population. Is there a different recommendations for how frequently we should be asking social determinants of health screening questions? Knowing that the medications are so costly and some of the other treatments like diet therapy may not be covered by insurance and as costly, is there a different guidance there? Yeah, I don't think there is like specific guidance, but you know, I. Challenging as it is definitely on diagnosis, right? Where is the baseline here? Every hospitalization, because that leads to more cost of care change in third therapy, and I think when you change that therapy, that's another time to think about it, right? Now it's access. What if they live far away and there's transportation to get a to an infusion center? Will that make a decision change for you? Finding a local infusion center, injectable medicine, who's in the household? Can somebody even do this injection right? Some families are large and they have younger kids and parents work two jobs. We saw that during the start of the pandemic, right? I mean, those families really struggled when. Those parents had to leave the house every day to work still, and these kids couldn't go to school. And who's taking them at care for them when they are at home and the parents still have to go out and work and they're not in school. That's true. Yeah. So Sabina, what I'm hearing is that be infested in your patients. Listen to them, ask the right questions. Have a social worker. If you can have a good relationship with your social worker. Know the resources that are available to help your patients with I B D. Kind of get the. Medical care that they need and one switching from one medication to another. Just make sure that this, there's no challenges for them to access this care. But I do wanna know, like I do wanna ask a question about even before diagnosing patients with I D D. Um, some studies talk about unequal health experiences when seeking care for kind of abdominal pain and that there are some disparities in actually getting the diagnosis of I b D. Can you tell us a little bit more about why that is and how to overcome this kind of challenge? Yeah, so there's, it is a good kind of examples from our ER colleagues who have done a lot of work in this. In the ER setting of even acute appendicitis based on race and socioeconomic status, there's always disparity in outcomes. Just for example, patient, a child coming with abdominal pain, with differences in their background appendicitis, how cha can be challenging in their diagnosis, and it may lead to access maybe. Complication like perforation, maybe longer length of stay or time until surgery. We also know that incidence of IBDs increasing in minority groups and there has been a trend of seeing that in 1970s it's high in the minority as increased almost like 134% in some studies and there's, there is variation in the phenotypes or African American patients have increasing renal know penetrating disease may have less, I only disease may have more perianal disease. Our, our Hispanic population may have less upper GI tract disease than our Asians may have upper, more upper GI tract disease. And I think it's also, it's under the provider's understanding that i b D is not a disease only of certain population anymore. So when you're seeing a patient. Broader differential. So, and think about I V D and not dismiss that child's pain or weight loss to think we'll see you back or not assess it. Thinking about I V D as part of the differential, I. Absolutely. Yeah. Yeah. And uh, what I think about is it's just so easy with just a simple stool sample to possibly exclude something that is very big and can affect the health of a patient. And like you said, taking out. Maybe educating yourself more about the presentation of inflammatory bowel disease in minority groups, because not one presentation fits all. So that's what I'm hearing. Jen, do you wanna go into the next question? Yeah, no, I think that makes sense. I think it just reminds me of all of those question stems when you're studying for your medical school exams, right? And like the classic example is that you have a Caucasian male and then they end up with cystic fibrosis. Well, I even think. Even going back to that level of question stem, I know that they're trying to teach something there, but I, I agree that in the real world, like everybody presents so differently and we can't just like assume based on somebody's race or ethnicity that. They do or do not have a certain thing. Right. And I think the other way is also as we increase this awareness and maybe help our patients, encourage them, right about self-advocacy is like ask questions even after the diagnosis. Ask as many questions as you want. The other part we are all struggling with is research. I idea continue. So we, it's, it's now, it's seemingly very important to then ever to disaggregate, break down the data, right? According to race and ethnicity. It's important for us to separate the data so we can see each group and, but unfortunately we still don't have an ideal data source. But I think there is awareness that we need to start doing that. I agree, and I think that's a really good transition to our next question, which is really going into the topic of patients who have known inflammatory bowel disease. So there was a paper published by one of my colleagues at Nationwide, Dr. Dotson and, and several others talking about how when it comes to outcomes, previous healthcare disparity research shows that. In adults with minority status, female gender, lower socioeconomic status, some of those things are related to poorer outcomes. And so what do we know about the disparities in pediatric I B D care and why do we think that these disparities are there? You know, as you mentioned, Jen Dodson at all, they have done great work on this and looking at. The differences in hospital readmissions, complications, procedures among hospitalized children's related to race. I mean, they looked at, African American children, had shorter time for first readmission and higher probability of readmission in a maybe a longer state. They also used proof care. Now, the Learning Health Network for I B D ensured that African American. Children had more active disease on presentation and likely more anemia, and that could be because of diagnostic delay and limited access to a specialist. The other is health literacy. Sometimes insurance coverage can be an issue, and even after diagnosis is helpless received leading to adherence or treatment. So it can just all link together at times. Oh, okay. The other I would mention is they just finished enrolling patients is is the study called safir. It's this, it stands for a relation of social factors and racial disparities in pediatric I B D. The purpose of that study is to compare social constructs, like we talked a little bit about like household income, parental health literacy, distrust in the healthcare system. Even and time needed to travel to see an IBD specialist among children of different races and ethnic group within us. I am looking forward to see the results and we were one of the centers who recruited patients. It was like a survey the parents had to finish complete. So I think it'll be interesting to see what they learned at the end. Yeah, that's very interesting. And you talked about like the time to travel to see an I B D specialist, and I'd like to talk a little bit about kind of access to care and particularly telemedicine. Telemedicine kind of became more widely known during Covid, and I think you and Jen worked on a project, right? Yeah. I think that's the first time we met, actually. Yes. Was with the telemedicine webinar right at the beginning of Covid with Be and the rest of that group of amazing individuals. Right. On a Zoom. On a Zoom, and we're still on a Zoom. So I'd like to talk a little bit more about that and ask about access to care disparities in I B D and if telemedicine has done anything positive or maybe negative in that area. Um, and then have we seen a digital divide specific to telemedicine care and I b D or really has it improved access to certain patients but not other? Yes. So the answer for the digital divide is, has it helped to improve access? Yes and no. So TE Telehealth has shown, right, in terms of there has been patient physician communication that worked out during the early part of the pandemic. There was patient satisfaction, right? We were able to get them access and they, there was engagement. But it also at times worsened that, socioeconomic factors that created that barrier. And I think that's another social determinant of health now. So effective virtual care, as we know, is depends on, you have to be digitally fluent, meaning that you. Need to be able to engage these, all of these digital technology. Can I access the internet? Can I access that platform? Can I troubleshoot And I'm not able to. So many people still cannot do it. A and they still have significant barriers to care and creating Still a pretty large population that is still having trouble. Telehealth. I mean, a perfect example, just like we talked about with the questionnaires is some hospital systems require you to access your telehealth through your electronic medical record. Well, if your electronic medical record patient portal does not support additional languages, then there's an already inherent disparity right there. Right, and if you don't have access to internet, that's also a disparity because honestly, internet is expensive and not everybody can afford it. And some people have to go to a coffee shop or Target or Walmart to access internet. So that's a disparity as well. Right? And as Jen, you said it's accessing simple thing, right? These EMRs have, how do you send a message to your medical team all that process of getting, just for example, MyChart for Epic. If I look at just my. Patient panel. My patients who don't have English at their first language, their access or getting connected to MyChart is, the numbers are so low. Then my patients who are English proficient and we still see that and it's wonderful. I'll go back to our social workers. They actually now carry a cell phone and the patients, we have them. Text families and the families text them back who are non-English speaking as their first language is csi. I, oh, I'm having trouble with my medication. I cannot get through to the phone lines in the or. So our social workers with their cell phones have become our contacts at times. To connect with these families. Well, and for those are listeners who are not aware, MyChart is the patient portal that's specific to Epic. Yes. And I think Cerner and some of the others have other brand names for that. Right. But Right. But that is what they call the one specific to Epic. Um, okay, so yeah, sorry. I got, I just get so riled up about telemedicine because I think that there's such a potential here and it can do so much good, but you know, there's still so much that we need to learn in this, in this aspect. And one of the things that have been shown with telemedicine is that improves transportation and it doesn't take as long to reach people, which kind of leads us into that conversation of cost. And for those who haven't listened. In January, we released an episode where we talked about biologics and small molecules beyond anti TNFs, Dr. Raj. Yay, Dr. Raj. And there. And there's an excellent Twitter chat about that. Yes. No, but you know, you go back and listen to the episode and read the Twitter chat, hashtag hashtag P g I chat that, yes, but you know, these medications are not cheap. And actually even the dietary treatments, like if we even look at the Crohn's disease exclusion diet that we had an episode about that's not covered by your insurance, that's not cheap either. And so I was a little bit blown away when I looked at this. Paper that published, I guess a year or so ago about the cost of inflammatory bowel disease. So can you talk a little bit about direct and indirect cost and what resources we have available for our patients to help with that? Yeah. Thank you for bringing that up. So the cost of healthcare for I V D patients is almost doubled, and those who don't have I b D and out of pocket can be two times. They have also looked at children with I B D. Can have 46% higher cost burden. So there are, as you said, direct indirect costs, right? So direct cost. Just think about direct costs is expenses for hospitalization, seeing your medical team, prescription drugs. Don't forget the over-the-counter drugs, supplements, vitamin D. A lot of supplements. Omega three s cucu. Then meeting skill nursing, starting in iv, getting to infusion nurses and the expensive diagnostic procedures. I'm so glad ultrasound is coming our way. It will help relieve some of these rise and the indirect cost are, The lost of earnings in productivity. You're going to an infusion center. As a child, your pa, one of the parent has to go, so now they have to leave work. You have to miss school for infusions, your medical appointment, hospitalizations. The other is you're also losing time for fun activities, right? Your leisure time, sometimes you have to adjust your vacations because your infusions may be falling in that time. And it impacts your social activities, not just yours, your family members. The other cost we also have to think about is the comorbidity with this is anemia, right? Another infusion, maybe you may be needing IV iron. Unfortunately, if some patients get thrombosis, their hospital stays are longer. Um, or they may need i c U. The other big thing is mental health. That therapy, which is something may not be covered by a lot of insurances and that is something so important. So there was a study other than the one you mentioned, there was another one by the Crohn's and Colitis Foundation with, they looked at a 10 year period of direct and indirect cost. And that's what kind of also they showed that it's, the cost is increasing as we continue to use more biologics. But also if we have to start looking at clinically risk certifying our patients, right? How the true impact is the financial bottom line. Not just as clinician, but also the policymakers need to take a note when we are, when we are asking for certain medication, right? And we are in these long peer-to-peer sessions. Infusion therapy we know is the key cost contributor and hopefully these biosimilars may come out a little bit. Cheaper in the long run, but I think it's important for payers who mandate the standard dosing, ignoring the robust data right now in pediatric, I mean there is a reason we are requesting a higher dose. Maybe in the hoping in the long run, these patients may go into remission faster, not another hospitalization or so risk of saving a relatively small number up just upfront dollars. Right? May not only may. Adversely affect the long-term medical outcomes. So it's, it's a unique opportunity to change the natural history for, especially for us as pediatric i b D for a potentially highly complicated. Long-term disease for these patients. There are resources, right? There are some patient cost saving programs. How do you facilitate better access through that, through the drug, these cost saving, and then getting early mental health and cycles looking at those for these patients because it's really impacts their I B D journey. Well, and I think that they talk a lot about that first year, which makes sense to a lot of us, right? You got the scopes, you got all the other, you have more appointments. But the burden, at least according to this study, does seem to go down. But I worry like if you don't catch some of those things early, it can escalate and get worse. That's really challenging. And you may have mentioned this and maybe I forgot, but can you talk about is there a difference between private payer insurance versus like commercial insurance? And is there any like additional assistance that we can give to patients or we can work with our social workers? Yeah, so definitely there is the commercial insurance, the, the cost saving programs from the companies itself that is available. Also for certain specialized labs, there are some cost saving programs available that usually I, it's important when you are starting someone on a biologic to definitely mention it to a patient saying, go and sign up for it to, because a lot of time they look at their income and and see where they fit. So do you direct them to the website of that biologic? Yeah, so you can, so for that biologic and now for even biosimilars, right? So definitely direct them. Sometimes there's a long list we put in our after visit summaries, which they may or may not read. But I think it's also important to keep mentioning them, not just for infusion, but also for injectables. So it'd be great if you can provide us with that. Yeah, definitely. That's a great idea. Mm-hmm. So, Dr. Ali Savina, it's been great having you today. We really appreciate your time and we appreciate you also joining the peds g I Chat back in January so. Since we have you here on our podcast, we really wanna ask you about the most valuable advice that you've received in your career, and what advice do you have for our listeners? Yeah, so I really thought about this and definitely something is so be focused, but yet be a little flexible. It is important for us as, as our career moves in, to have a plan to know what you want, to understand, what you, what is good for you, and get all of that focus, right? That's part of focus, but I think it's equally important to be flexible because sometimes opportunities come that are not planned for you. That has happened to me so many times. That make you nervous and makes you a little uncomfortable, but those can be the most interesting decisions you make. Like step outside of your comfort zone. Yeah. Right. It's so challenge yourself sometimes lines, right? Yeah. It's scary to step out with your comfort zone, but sometimes it's really worth it. You guys cha you, you did, you challenged yourself to start this podcast. Look at it. Well, Jen, and that's true. It's like the very first episode we had literally like a piece of paper like this and it had all the questions on it and we just passed it around like no preparation. And look how far we've come. It's just, it's been incredible. So I appreciate that you like listening to the episodes. Yeah, I love listening. Appreciate all listeners too. I listen to all of them. That's my one hour, that's how long my commute is sometimes to work with the Bay Area, just like I go through it. The whole thing. Yeah. So that is just such great career advice and I think one that everyone can benefit from. So we have a new question that a fan of the podcast actually asked us to include, and that is, and you can think about this for a minute, but if you have three takeaways for our listeners, what would that be? Right. So I think that three takeaways is, is as a provider, look at your practice, look at your community where you are practicing, understand the barriers of your patients. Talk to your patients. Have a have a team. So your team is not just you, right? It starts from your medical assistant. You have to train your team to work with this patient population. Have a social worker that's your best friend, I would say, and kind of gather resources. It takes time to gather these resources, but in the long run, they can be the key that can help your patients. That's great. So learn about your community, have a team of supportive people, and know your resources. That is amazing. Yeah. So can you tell us what, any final words for our listeners? Okay, so I'll say so find your passion and challenge yourself. And remember when you get to the top. Send that elevator down. Uh, and remember to not just mentor, but also sponsor someone. So be a mentor, not just a mentor. Oh, I love that. Hashtag spend. That's, I love that. Thank you very much. Well, what a great episode. I hope I have a chance to like have coffee with her when we all go to San Diego in a few months for this conference. Happy birthday. You don't already. Be sure to follow us on Twitter and Instagram at Bell Sounds and on Facebook, pediatric GI Podcast for the latest news and updates on upcoming episodes. if you like what you heard and want to support the podcast, it would really help us if you did one or all of the following things. One, tell one person about the podcast to leave a review on Apple Podcast to help others discover our podcast. And three on our Buzz brow page, there is a link to support the show by making a donation to the NASP Foundation. You can also get there through www dot. N A s p g h a n.org. The money you donate has support some of the amazing things that the NASPA began Foundation is doing, including supporting pediatric GI research and public education programs. And as always, the discussion views and recommendations of the podcast are the sole responsibility of the host and guest, and are subject to change with advances in the field. Thanks for listening. Thank you for listening.