Good morning, everyone. Hope all of you are able to gather, and welcome to this morning's session. We have an entire hour on this contemporary topic called healthcare disparities in pulmonary hypertension. And it's a privilege and it's a delight to be here, and this concept of this particular session was envisioned by my dear friend Roberto here. And the session is going to be basically consisting of three different sets of talks, followed by a session for discussion, which will be moderated by our dear friend Jean Elwing. So I'll be talking about lessons from 2020, representation of minorities, and Lana will be talking about race, ethnicity, and PAH. And the last topic will be social determinants of health by Roberto. And then we'll conclude with a good 15 to 20-minute discussion. Hopefully, we expect a robust participation from everyone on this very important concept. All right. So please, a couple of housekeeping details. Please, all sessions can be evaluated through the mobile app. Please don't forget to do that, and we will certainly be disclosing our relationships so that we don't end up in prison. And all rights are reserved, and please make room for attendees to have a seat by moving towards the center of the rows. And I see plenty of empty seats, so there is some disparity right there. So, all right. Okay. So my topic is to talk about lessons from 2020, representation of minorities and PAH. And these are my disclosures, and these are the objectives of this particular, it's more of an introduction. So what is health equity? CDC defines health equity as the state in which everyone has a fair and just opportunity to attain the highest level of health. Achieving this requires ongoing societal efforts to address historical and contemporary injustices, overcome economical, social, and other obstacles to health and health care, eliminate preventable health disparities. Obviously, we have to talk about Martin Luther King's famous quote, all forms of inequality, injustice in health care is the most shocking and inhumane. What is health care inequality? The WHO defines this as avoidable inequalities in health between groups of people within countries and between countries. So this cartoon illustrates what equal treatment is, and this one illustrates equitable treatment and what it would be to remove the systemic barriers. COVID pandemic has taught us a lot of things, hasn't it? So it really gave us a realization of what we have been blessed with here. It really threatened our way of life. In the process, it also uncovered a lot of the fatalities that was attributable to underlying comorbidities such as just being poor, being black, or being minority, or being a nursing home resident. So it pretty much opened up a whole can of worms with regards to all these disparities in the society. It unmasked and amplified numerous health inequalities that already existed within societies, led to disastrous and unjust consequences in mortality rates amongst the minority groups, and obviously even certain vulnerable groups such as asylum seekers and refugees. You can see that when you look at cases, hospitalization rates, and mortality, these are several fold compared to the traditional white population or non-Hispanic population amongst the minorities. And this was once again reflected in several other studies, and this is one of those reflections that basically tells us that we are not all in it together. Okay. So let's throw some light on some of the issues pertaining to racial inequalities or disparities in pulmonary hypertension. See various components in this cartoon, that is aspects such as genetic societal factors, mediable response, and adherence, advancing research efforts in ethnic data collection, and other novel culturally specific treatment strategies, and my dear friends Lana and Roberto will be talking more on those lines. This study, this was recently published, that actually was published in CHEST, illustrates the shocking discordance between registry demographics and trial enrollment, and basically there was such a striking predominance of white versus minority representation in the registries as well as in the clinical trials. Some randomized controlled trials do not even report or perform subgroup analysis based on racial, ethnic, or socioeconomic status. Ambition trial, for example, again if you look at the white and the non-white population, it's a very dominant kind of under-representation of minorities. The other aspect in pulmonary hypertension is also the different kind of phenotype that's happening over a period of time. The contemporary registries highlight how the people diagnosed with PAH are much older currently. For example, the Compera registry, the mean age was 71. And this ATS annals publication kind of illustrates how there has been some advancement and some recognition of this aspect with regards to the secular and the regional trends. And you can see that there's slightly enhanced participation of minorities over time. And 85% of the participants in early studies were non-Hispanic white, but this has decreased over time to 70%. But mind you, this is basically the contribution from the registries from Asia and Latin America. What about influence of race on mortality on pulmonary hypertension? And again, here if you look at all the other traditional risk factors and comorbidities associated with pulmonary hypertension, just being an African-American race can be an increased risk for pulmonary hypertension and can also predispose to an increased mortality. So amongst patients with PAH, African-American race was associated with a 26% increased adjusted mortality. What about the pulmonary hypertension registry demographics? That also reflects a very similar type of distribution. What about pulmonary hypertension in Native Americans? Obviously, one would think this is a pretty natural question, but there is zero data, zero data on this. And my dear friend Roberto dug out this particular article, which was actually a dissertation that was submitted in University of Oklahoma from 2000. What was interesting is about 562 participants in the Oklahoma Native American population, predominantly women. But look at the PAH prevalence, I mean obviously I can't validate, but it was just striking to see a 56% PAH prevalence reported. And right ventricular dilatation was strikingly predominant in men as well as in right ventricular hypertrophy predominantly in men. Perhaps PAH in this cohort is a distinct phenotype. I do not know. I don't think we know the answer. Here is another interesting study which looks at donor-recipient race matching on survival after lung transplantation, an analysis over 11,000 patients. And again, about 43% of patients died in this kind of study. What was interesting was race matching decreased the 30-day, 90-day, one-year, two-year unadjusted mortality. And this is a paper that is coming from us. We have submitted it. It's unpublished at this point, but it's under consideration. But this is looking at basically IPH hospitalizations over, you know, with a gap of a decade in between, from 2007 and 2017. And this is derived from the nationwide inpatient sample, NIS. And basically, again, if you look at the demographics, there was a substantial underrepresentation of minorities, even over a decade apart. Recognizing this important issue, NIH created this body called National Institute on Minority Health and Health Disparities. And a strategic plan that was focused on three key elements, which are conduct and support intensive research on the factors underlying healthcare disparities, expand and enhance research capacity to create culturally sensitive and culturally competent workforce, engage in aggressive, proactive community outreach, information dissemination, and public education. The American Thoracic Society also came up with their first statement on this in 2017. And the top five takeaways are PAH registries must be organized to reliably capture information concerning race, ethnicity, and socioeconomic status of patients. Genetic screening of large populations should include patients within the minority groups to kind of address the existence of unique genetic determinants. Socioeconomic status should be included in the risk stratification to help identify patients with PAH who may be at greatest risk for noncompliance. Hospitals, health insurers, and providers should be educated on the importance of data on key determinants of health. And obviously, partnership with public health divisions, community-based health centers, and outreach programs to help with further advancing the data. Therefore, conclusions are healthcare disparities are very apparent in PAH. Mass control trials and registries should incorporate more racial, ethnic, socioeconomic data in their analysis. Proposed solution is, for example, if you take our panel here, I'm from California, and we have Roberto from Oklahoma, and then Lana from New Mexico. So if we have state-based registries, and then if we can feed that into one large registry, then that will hopefully throw some more light for a better understanding of local populations, healthcare access, challenges, phenotypes, outcomes, so on and so forth. With that, just a very 10-second, not even a 10-second video. This is a video that I was able to watch on one of the sessions, and he was kind enough to let me take a little segment, which I thought was very prudent for us to listen to. So I want to make a specific challenge to our medical professionals and educators as relates to this conversation. Make sure that your professional associations and the schools in our state who educate our healthcare providers are intentionally building a cultural competence that allows them to see the humanity in the people they serve. So if you look at where I come from, which is Fresno, and there is a majority minority, which is a very dominant Hispanic presence out there, and you can see the different subpopulations, which is very different compared to the registries and the randomized control trials that we spoke about. And this is the clinic that I had started more than a decade ago to make sure that there is equality of care and a high-quality pH care for all populations, no matter what background, what socioeconomic status. We are continuing to provide, and we call this the Faith Clinic. We came up with that name. And this is the support group that was just less than two or three weeks ago, and that's my team. Thank you for the opportunity. All right, well, first, hi, how's everybody doing? It is tremendously wonderful to be here because it is a rare opportunity for me to have a chance to sort of marry two things that I'm very passionate about, obviously, pulmonary hypertension, but I am very excited because I get to bring diversity, equity, inclusion into the conversation in terms of pH. And for me, this has been sort of a mission returning to New Mexico, which is where I am from, and starting a program there mainly because prior to 2012, all of our patients left the state of New Mexico to get their care outside of there. And if any of you know New Mexicans, we don't leave New Mexico, so they didn't go outside of New Mexico to get care. And for me, this has been such a journey in understanding my population, and it's lovely to sit up here today with good friends to talk about it. So our learning objectives for today's session, and for me specifically, I'm going to address more in terms of race, ethnicity, and the potential association in the clinical outcomes for pH. And I always feel like we should all at least start on level ground, as Vijay was showing, so that we have the opportunity to kind of learn from there. And one of the things that I was able to understand for myself was that this idea and these terms, race and ethnicity, really didn't come into play until about 1997 when the U.S. Census Bureau said, we need boxes that everybody should be checking so that we can try to figure out who lives here and classify them in some way. And for me, in science, we sort of then needed to catch up, because we needed to be able to say, okay, now how do we define it in terms of research? And when you look at it, you're really indicating that for race, these are physical characteristics. So do you look like me? Do I look like you? And thereby, now we are classified into potentially the same racial classification. Where ethnicity is really more of a cultural heritage, I think more of what we would all say defines who we are, right? What are our traditions? What are our clothing? What do we eat? How does that kind of indicate who we are as a people? And so when you start to then break that down and say, okay, now we have these five established categories for race and two categories for ethnicity. You are either Hispanic, Latino, Spanish origin, or you're not. Which to me, you know, is I think somewhat difficult to sort of then say, we're classifying these so broadly, and yet we're trying to find understanding within those groups. And like pH, over the past 20 to 25 years, the amount of evolution and understanding that we have continues to grow. And when we talk about race and ethnicity, we've had to figure out how to catch up as well. So it presents this dilemma. And I think some start to look at it and say, well, should we be, instead of thinking of race and ethnicity, thinking of ancestry? Where did we come from? And that is now how we have gotten to where we are. Part of the biggest problem for us here in the United States is going to be that we are a melting pot. And I say a problem only because then our understanding is so much, there are so many more variables to it. Just like Vijay was mentioning. When I look at my population in New Mexico, I'm saying, all right, this is the breakdown of race, ethnicity, but wait, we live at a moderate to higher elevation. Does that play into it? Everybody is completely rural. Does that play into it? And so because our actual demographic across the entire United States is so expansive, when we try to then compare ourselves to our European colleagues and their registries, you're saying, can I actually extrapolate anything from what I'm seeing there to my patient population? And we continue to change in America. We are, I think, amazing in that. What we will see and are projected to see by 2050 is that 30% of our population will be Hispanic, 14% will be black, and that we as a country will actually be a minority majority population. And so then having to understand how we can take information that doesn't reflect that and apply it to the patients that we're caring for. And there's one other piece that I want to present, which is in New Mexico, we have one of the largest Native American populations. I think many people may not have known that until COVID, when all of a sudden the Navajo Nations was at the forefront of understanding the disparities that we saw in terms of our access to care and healthcare. But that one in four Native Americans continue to this day, this is from 2018, live under the poverty line. So trying to figure out how I was going to present this, right? You have your 10,000 foot view, which looks like this from the top of the Sandia Mountains. These are two of my littles who are not so little anymore. But this is actually at 10,000 feet on the top of our tram, looking down, and you can get a good idea of what your landscape looks like, what the geography sort of is. But in reality, it isn't until you look in your own backyard, where I start to see the blades of grass, the pine needles, each individual thing that makes up something so beautiful. And for me, I try to take every single one of my patients and say, you are my individual. How am I going to apply the information that I have to be able to treat you in the best way that I can? So what is the impact of race and ethnicity in pH? First, we actually don't have any specific treatment recommendations. And this is unlike so many of our other cardiovascular diseases. In heart failure, in hypertension, we have data to look at. Part of that is that these are huge trials and registries that we're able to collect this information. We are able to get a little glimpse of what sort of the demographics and the common etiologies are for when we consider race and ethnicity due to the reveal registry. We know that our white patients are significantly older at the time of their diagnosis. When we look at it, our Hispanic population, they're usually in their early 40s, which is definitely not reflective or what I usually am talking about when I say this is the age that most people present. In terms of our black patients, two and a half times more likely to develop PAH associated with a connective tissue disease. So should we be looking more at that? Should there be more screening in certain areas of our country? In terms of congenital heart disease, more common in Asians and Hispanics. So because we use all of our registry data and our clinical trials to try and come up with our treatment guidelines, we're in a position that for me, we are unfortunately seeing this under-representation of racial and ethnic minorities in these clinical trials and registries. It truly is actually astounding. I don't think that we ever necessarily look at every trial at the same time because they're telling us different things, different medications, different therapies. And instead, when you actually pull that information out, as Vijay showed, it's just specifically for the ambition trial. You're able to start to see that we're getting ourselves in trouble because all of the information that we're utilizing really is looking at a very specific demographic of people. And not only that, we do a little better when it comes to our registries, but when you look at the information here, you can see that in terms of Hispanics, they either weren't included or described or they just weren't even a part of that trial. And so when you break it down a little bit further with some of these registries, I just wanted to point out that when you're looking at each of them, you can see in terms of the ethnicity or race in terms of being white and just this huge predominance of that population. So I wanted to pull up what my registry in New Mexico looks like. This is our publication from our population from 2016. And when I look at it, I see almost 36% of my patients are Hispanic and 10% are Native American. And I am utilizing all the same information that all of my other colleagues are using to try and take care of them. We're currently doing a follow-up in terms of that because what we actually found from that data also was that our prevalence and incidence was higher than anywhere else in the world and not by just small amount. And so now to follow up on those patients and who continues to survive, and maybe this is a, unfortunately, they develop this disease, but yet they have response to therapies and management of care. And so again, just pulling this, I called up my research coordinator. I said, well, Lisa, can you please pull it? And she, in like 10 hours, had the data for me. But the thing is, I never thought going back to New Mexico that there would be such a need. I thought, we're small. We have two million people in our state. And so to think that we would be doubling in size. Last year alone, we had 70 new incident cases of PAH, which is not what is supposed to happen. So how do I get to the root of why it is? Part of what I'm up against, and I don't, I use New Mexico more as a case study because for me, it's we have to all look in our own backyard. We have to understand that population. And when I do, one, we are ginormous when it comes to like land mass. We have no people in that land mass, but we are huge, right? We could just cover the whole Eastern side of the country. We are all rural. Everybody lives just kind of out in the middle of nowhere. I travel frequently out to areas in and near the Navajo Nation, and they don't have street signs. They have dirt roads. They describe how you get somewhere by saying, take a right at the stump that is in this location. These are my Pueblos and my reservations. And every one of these tribes and people are different, tremendously different. Every language is different. Every tradition is different. And yet we are trying to manage them the same. During the COVID pandemic, we actually realized and recognized that our Navajo patients had much worse survival and outcomes between the hours of 5 p.m. and 8 a.m. because we no longer had in-house Navajo translators. So nobody could speak to them. And so they, in their own land, were in a foreign country. This is a breakdown of the poverty rate within New Mexico. And you can see that the little blue spot is up kind of near Taos and Santa Fe and areas that do have wealth. But everywhere else, we're looking at most people somewhere between 25 and 35% are below the poverty line. So what do I do? How do I treat these patients? And I think that to Vijay's point, we don't even have anything published on Native Americans. I pulled a case series of my patients, my Native American patients who had systemic sclerosis. And I had a fellow working on it. And I said, let's pull the data. I mean, there was nothing, like truly not even a statement anywhere about PAH in a Native American. So what we could see from the reveal registry, and I am so fortunate because Sarah Medrick is, I stole her from Sandeep a few years back, which I'm very fortunate for because she's brilliant and she's done several publications when it comes to race and survival and PAH. And what they found was that non-surviving Hispanic patients had a reduced use of ERA therapy within six months prior to their death. That black patients were less likely to be on a PDE5. And that Hispanic patients were less commonly treated overall with PAH specific medications. So it's unclear. Are these observations indicative of differences that are pathophysiologic, distinct phenotypes, genetic differences? Or as Roberto will be up here momentarily to discuss about, is this more of a socioeconomic access to care and disparities within the environment? So then we have a little bit more information, but it kind of backs up what the reveal data showed, which is that once again, when looking at the PAH specific medications, our Hispanic population just don't seem to be receiving them the way that our other individuals are. And then when it comes to survival, well, it's all over the place. It's conflicting. I mean, I will let Roberto talk a bit about things because this is from his in terms of the FAR, but Sarah Medrick looked at it and said, really, there's no differences between race and ethnicity, which if this is the case, that's fantastic, right? I mean, if that's truly what is happening, then I can look and treat them based off the information that potentially is coming out in a different demographic of patient. But then we looked at a meta-analysis of four independent cohorts, two of those being very strongly Hispanic, being Stanford and the University of Arizona, both very good friends of mine that I've collaborated with trying to further our knowledge on this. And what we found was that there were a higher PVR, a reduced prostacyclin use, and this question of a Hispanic paradox where they were surviving despite potentially a higher PVR and less therapies being given to them. Now, Roberto, and it's so amazing to be able to just sit and talk with the people who have written all of these manuscripts to be able to say, is this really the case? And he looked at our FAR data and was able to say, listen, when we adjusted for social determinants of health, we weren't finding a difference in survival based on ethnicity. So where do we go from here? What's the future going to be? So in terms of where we need to be, as Vijay mentioned, it's a call to action. And ATS put out their call to action in their statement in 2017. And then I think across our community, the amount of people who have interest and are working toward this is fantastic. And whether it's looking at claims data, whether it be driven by investigator initiated trials, I think for us, the goal has to be, do we look at race, ethnicity, ancestry? Do we need to, or do we just need to do better in terms of social determinants of health? So everyone's welcome to come to New Mexico. This is technically my brother's backyard, but a picture from it. And so we would love for you to come and visit anytime. Thank you. That was a beautiful talk, Lana. Hi, my name is Roberto Bernardo from the University of Oklahoma, and I'll be talking about the social determinants of health in PAH. These are my disclosures, and I'm going to be reviewing what we know or what we don't know about socioeconomics and PAH. As Vijay and Lana highlighted, there is significant under-representation of minorities in registries and clinical trials. And after 2020, as Vijay highlighted, these differences matter, and we need to understand more about that. When we try to analyze the differences between race or ethnicity, there are so many small components that matter into that. The biology of the disease, socioeconomics, the type of exposure these patients get, and we are still getting to understand this in pulmonary vascular disease as compared to other cardiopulmonary disorders. When it comes to PAH, we can talk about the biology of the disease, and I think we know a fair lot about that, what is starting to know about race and ethnicity and how that interplays with PAH, and what is starting to get to know about socioeconomics. But a point I want to highlight is, when we talk about race, how does the color of the skin of an individual determines the care they will get? Are we talking about race, or are we talking about something else? And this is a map of 2020, as shocking as it is, about how segregated the United States are. In purple are the counties throughout the nation that are segregated, meaning locations where certain races are confined as compared to white populations. And if we look at the south of the country, those differences are shocking. If we go to Oklahoma, where I come from, Oklahoma City, the metropolitan area of Oklahoma City is highly segregated. If we look at Dallas, one of the largest metropolitan areas in the United States, those differences are shocking. And right here, we're in Nashville. Those differences exist. So are these differences due to the color of the skin of an individual, or are due to the different exposures they get? Because where you live may determine where do your kids go to school, what type of transportation you have, what's the rates of violent or crime on your neighborhood, if you have access to healthy food or all you have are fast food restaurants or so. So let's talk about socioeconomics, and socioeconomics is hard to describe, but it's a metric of the economic standing of an individual in a society. And it's difficult to measure, and there are different ways we can measure. We can talk about the individual components of socioeconomics, and that's what we refer as the social determinants of health, which include the annual income for a family, the type of job that you get, the level of education you get, what type of insurance you have. And these days, it also matters if you have access to technology or not, because that's another determinant of health. Other ways that we can assess socioeconomics is through scores that try to quantify what's your income and what type of education you get or so. And one interesting to me metric of socioeconomics is to use a geographic identifier, because if you use a zip code of an individual, you may know where they live. And if you know where they live, you may have an idea, again, to which school the kids of this patient go, what's the criminal rate in this area, and things like that. When it comes to socioeconomics, there are a few studies in PAH. This paper from the Blue Journal, using data from China, stratifies patients based on socioeconomic status. And as you can see, those with a lower socioeconomic status have a lower survival compared to wealthier individuals. And this goes through different adjustment models. This data is adjusted for age, gender, severity of disease, hemodynamics, the type of therapy. So regardless of those components, based on data from China, having a lower socioeconomic status was associated with a lower survival. Data from the US, this data from a large hospital system in New York showed that if you have a lower annual income, you will be more likely to have functional class three or four symptoms on presentation, which may suggest if you have a lower income, the referral to a center with expertise in PAH may be delayed. This paper of Gabriela Macias and a group of Brigham shows that rurality, meaning if you live far away from a metropolitan area, you may have a lower survival as compared to somebody who lives in a metropolitan town. Why is that? I don't know, but probably if you live four hours away and you have no access to technology and you don't have a lot of social support, you may not do as well as other individuals who are living nearby the PAH center. But as I mentioned before, if we're going to talk about race, it's important to account for the socioeconomic factors. And there are two studies that do that. This interesting paper using data from Duke and Cleveland, they are comparing African-American individuals and white individuals. And as you can see, based on an adjusted analysis, the survival of black individuals may be lower. However, if you adjust for the type of insurance these patients have, the difference disappears. What does this suggest? It may suggest that if you are a white individual but you do not have proper insurance, your outcomes may not be as optimal as somebody who has proper access to health care. Another problem when it comes to socioeconomics is that the registries, and Reveal is a great registry. We know a fair lot from Reveal, but most registries do not include data on socioeconomics. They were not designed to include data on socioeconomics. FAR, or the Registry of the PAH Association, is a beautiful registry. As you know, when Steve designed this, he wanted to include socioeconomics as a strong component of FAR. So FAR is a good database to analyze the impact of socioeconomics. Something I like about FAR is that the proportion of Hispanics is a little bit higher than Reveal. And that's important because if you are going to compare two groups, you want to have a sufficient number of individuals on each group so this comparison reflects the true differences or the true similarities they may exist. So with my partners in crime, Rohan Benicio and Stephen K. Wood, we used FAR to analyze what's the association between socioeconomics and Hispanic ethnicity. And the findings are shocking. I don't think they are surprising, but they are still shocking to see. But we saw that one out of 10 Hispanic patients was a college graduate or higher as compared to one-third of Hispanic individuals. When it comes to income, and think about this please, one out of three patients with PAH who was Hispanic had an annual income less than $20,000 per year for the entire family. And one-third of Hispanic patients had an income between $20,000 to $50,000 per year. And how do these patients can afford their care? How can they afford rent, paying for oxygen, paying for utilities, and on top of that, they may have some co-payments for their medications or so. For those on parenteral prostacyclines, they need a caregiver who can help them with a parenteral prostacycline, but that person needs to work to get this $20,000 per year. That's shocking to see. Hispanics were more likely to be unemployed. Interesting, the incidence of smoking or alcohol use or the frequency of smoking or alcohol use was lower in Hispanics. And health care insurance, 7% of Hispanics no insurance, 25% Medicaid as compared to non-Hispanic ones who were more likely to have a commercial insurance with all the benefits that brings or Medicare. And why is that important? Because if you, at least in Oklahoma, if you don't have Medicare or commercial insurance, you will not get pulmonary rehab, which is an important component of non-pharmacologic therapy for PAH. When it comes to survival, on the unadjusted analysis, maybe there was a better survival for Hispanics, again, suggesting this Hispanic paradox, but once we adjust for socioeconomics, the difference disappears. What does that mean? I guess it means that maybe Hispanics, under ideal conditions, have a better survival, but that survival benefit disappears if you have suboptimal health care because you have a more disadvantageous social profile. A beautiful paper that Gene was a co-author of is about what's our awareness about social determinants of health. And this nice study published this year, they are interviewing PAH providers trying to understand what's their awareness about social determinants of health. What I like about this paper is this figure. These are 10 questions that perhaps could be used in your routine practice by your nurse coordinator or so to screen and better understand what are the problems patients are facing on their daily life that we normally don't talk about it. And I don't want to politicize this, but I'm talking about socioeconomics and access to care in PAH, but another disparity is the access to reproductive health care. Why is that? Because in Oklahoma, if one of my patients needs an abortion that is medically indicated, I will have to refer that patient to a different state. Some patients can afford that, some patients cannot. Not surprisingly, minorities are the ones who face more barriers when it comes to access to reproductive health care due to the new legislation, and that's a disparity. So I do believe that we need to, professional societies and patient associations need to take everything in their power to help patients in states where there are more restrictive laws when it comes to reproductive health care. But there is a lot we don't know. We actually don't know much about Native Americans, and I think this needs to be, we need to work as a team, the different centers that have higher frequency of Native American patients to have and reach Native American data sets so we can better understand this historically neglected population. With PVD-omics, we're going to know more about the omics of the disease, and I'm hoping at one point, sometime in life, we will have enough granularity in our data that we can use machine learning to identify which combined factors predict barriers to accessing health care. But we are just talking about the U.S. and Europe. There is more PAH happening outside the world, and we need to talk about that. And I think institutions such as PVRI are starting to do a good job about this. Minorities are underrepresented. When we are going to talk about race and ethnicity, we need to include socioeconomics, and we all need to be more aware about this program. These are my collaborators, and thank you, and please evaluate our presentations in the app.

healthcare disparities

pulmonary hypertension

race

ethnicity

socioeconomic factors

health equity

COVID-19 pandemic

minority populations

PH