>>MY NAME IS
DAVID MURRAY, ASSOCIATE DIRECTOR
FOR PREVENTION AT NIH AND
DIRECTOR OF THE OFFICE OF
DISEASE PREVENTION. PLEASED TO
WELCOME YOU TO THE 2023 ROBERT S
GORDON JR. LECTURE IN
EPIDEMIOLOGY. THE GORDON LECTURE
IS AWARDED EACH YEAR TO A
SCIENTIST WHO MADE MAJOR
CONTRIBUTIONS TO RESEARCHER
TRAINING IN THE FIELD OF
EPIDEMIOLOGY OR IN THE CONDUCT
OF CLINICAL TRIALS. THE SPEAKER
SELECTION IS COORDINATED BY THE
OFFICE OF DISEASE PREVENTION AND
THIS IS THE 28TH YEAR THAT ODP
HAS SPONSORED THE GORDON
LECTURE. THE LECTURE AWARD WAS
ESTABLISHED IN TRIBUTE TO ROBERT
S. GORDON JR. FOR HIS DEDICATION
TO FIELD OF EPIDEMIOLOGY AND
DISTINGUISHED SERVICE TO NIH.
OVER THE COURSE OF 30 YEARS DR.
GORDON SERVED IN NUMEROUS SENIOR
LEADERSHIP POSITIONS INCLUDING
SPECIAL ASSISTANT TO THE
DIRECTOR AND CHIEF ADVISOR FOR
CLINICAL PRACTICE AND RESEARCH.
DR. GORDON WAS EARLY ORGANIZER
OF EFFORTS TO ADDRESS EMERGING
PROBLEM OF HIV AIDS AND BECAME A
KEY COORDINATOR OF AIDS
RESEARCH.
TODAY'S SPEAKER IS DR. LISA
COOPER. DR. COOPER IS THE JAMES
F FRIES PROFESSOR OF MEDICINE
AND BLOOMBERG DISTINGUISHED
PROFESSOR AT JOHNS HOPKINS
UNIVERSITY SCHOOLS OF MEDICINE,
NURSING, AND THE BLOOMBERG
SCHOOL OF PUBLIC HEALTH. SHE IS
ALSO THE FOUNDER AND DIRECTOR OF
THE JOHNS HOPKINS CENTER FOR
HEALTH EQUITY. DR. COOPER
STUDIES HOW RACE AND
SOCIOECONOMIC FACTORS SHAPE
PATIENT CARE, AND HOW HEALTH
SYSTEMS WITH COMMUNITIES CAN
IMPROVE THE HEALTH OF
POPULATIONS THAT EXPERIENCE
HEALTH DISPARITIES. AN INTERNAL
MEDICINE PHYSICIAN
EPIDEMIOLOGIST AND HEALTH
SERVICES RESEARCHER DR. COOP E
AND HER TEAM WORK IN PARTNERSHIP
WITH HEALTH SYSTEMS AND
COMMUNITY BASED ORGANIZATIONS TO
IDENTIFY INTERVENTIONS THAT
ALLEVIATE HEALTH DISPARITIES AND
TRANSLATE THEM INTO PRACTICE AND
POLICY CHANGES THAT IMPROVE
COMMUNITY HEALTH. HER
PRESENTATION TODAY IS TITLED
GETTING TO HEART OF
CARDIOMETABOLIC HEALTH
DISPARITIES. PLEASE JOIN ME
WELCOMING THE 2023 ROBERT S
GORDON JR. LECTURE AWARD
RECIPIENT, DR. LISA ANGELINENE
COOPER.
>>THANK YOU VERY MUCH, DR.
MURRAY. I WOULD LIKE TO THANK
DR. MURRAY AND THE OFFICE OF
DISEASE PREVENTION AS WELL AS
ALL THE ORGANIZERS OF THE
WEDNESDAY AFTERNOON LECTURE
SERIES FOR INVITING ME TO GIVE
THIS 2023 ROBERT S GORDON JR.
LECTURE IN EPIDEMIOLOGY. THE
LAST TIME I SPOKE AT THE
WEDNESDAY AFTERNOON RECKTURE
SERIES IT WAS NOVEMBER 2020, FOR
THE DIRE LECTURE I HOPED TO BE
IN PERSON TODAY BUT ALAS
CIRCUMSTANCES MADE IT DIFFICULT
SO I AM AGAIN JOINING YOU MT.
VIRTUAL SPACE. IT IS AN HONOR
TO SPEAK TO YOU TODAY ABOUT
GETTING TO THE HEART OF
CARDIOMETABOLIC HEALTH
DISPARITIES. YOU HAVE SEEN MY
DISCLOSURES ON PREVIOUS SLIDES.
THE LEARNING OBJECTIVES AS WELL
WHICH WILL FOCUS ON LISTING
CONTRIBUTORS TO RACIAL AND
SOCIOECONOMIC DISPARITIES AND
CARDIOMETABOLIC HEALTH,
DESCRIBING EFFECTIVE
INTERVENTION APPROACH, AND
DISCUSSING KEY CHALLENGES AND
OPPORTUNITIES AND TRANSLATING
EVIDENCE INTO PRACTICE AND
POLICY. LET'S START WITH
UNDERSTANDING THE ORIGINS AND
CONTRIBUTORS TO HEALTH
DISPARITIES. WE HAVE HEARD A LOT
ABOUT HEALTH DISPARITIES IN
RECENT YEARS BECAUSE OF THE HUGE
DISPARITIES THAT WERE OBSERVED
DURING THE COVID-19 PANDEMIC BUT
HAVE EXISTED FOR QUITE A LONG
TIME. SO WHAT ARE HEALTH
DISPARITIES? THEY ARE
PREVENTABLE DIFFERENCES IN
BURDEN OF DISEASE, INJURY
VIOLENCE OR OPPORTUNITIES TO
ACHIEVE OPTIMAL HEALTH
EXPERIENCED BY SOCIALLY
DISADVANTAGED POPULATIONS AND
THAT IS ONE OF MANY DEFINITIONS
IN THE UNITED STATES THERE ARE
NUMEROUS POPULATIONS AND GROUPS
THAT EXPERIENCE HEALTH
DISPARITIES, THESE ARE THE ONES
LIVED ON THIS SLIDE HAVE BEEN
DESCRIBED IN THE NATIONAL
HEALTHCARE QUALITY AND
DISPARITIES REPORT AS WELL AS
DOCUMENTED IN NUMEROUS NATIONAL
SURVEYS AND COLLECTIONS OF DATA
AND EXTENTSIVE RESEARCH. SO WE
HAVE NUMEROUS POPULATIONS THAT
ARE AFFECTED BY DISPARITIES. WE
KNOW DISPARITIES ARE PERVASIVE
ACROSS CONDITIONS NUMEROUS
CONDITIONS AND POPULATIONS. THEY
COST OUR ENTIRE SOCIETY
SUBSTANTIAL AMOUNT IN DIRECT
MEDICAL COSTS BUT INDIRECT COSTS
IN TERMS OF LOSSES OF
PRODUCTIVITY DUE TO PREMATURE
DEATHS. THEY HAVE EXISTED FOR A
LONG TIME ONE OF THE THINGS WE
HAVE KNOWN IS THESE DISPARITIES
HAVE ACTUALLY PERSISTED THOUGH
WE MADE SOME PROGRESS IN SOME
AREAS THE PROGRESS HAS NOT BEEN
DRAMATIC. THEN WE HAD THE
COVID-19 PANDEMIC THAT BEGAN IN
2019, 2020, AND THAT HAS SHOWN A
BRIGHT SPOTLIGHT ON THESE
DISPARITIES AND MAGNIFIED THEM.
TODAY WE ARE GOING TO TALK ABOUT
CARDIOMETABOLIC HEALTH
DISPARITIES IN PARTICULAR. WHY
TALK ABOUT CARDIOVASCULAR AND
CARDIOMETABOLIC DISEASES?
BECAUSE THESE ARE EXTREMELY
COMMON CONDITIONS, THEY INCLUDE
CARDIOVASCULAR DISEASE, DIABETES
AND CHRONIC KIDNEY DISEASE AND
CARDIOVASCULAR DISEASE AS YOU
KNOW INCLUDES CORONARY HEART
DISEASE, STROKE, HYPERTENSION
CONGESTIVE HEART FAILURE AS WELL
AS MANY OTHER CARDIAC AND
VASCULAR CONDITIONS. THESE
COMBINED SHARE MULTIPLE COMMON
RISK FACTORS. INCLUDING
HYPERTENSION, OBESITY, HIGH
CHOLESTEROL AND DISLIPIDEMIA OR
ABNORMAL CHOLESTEROL LEVELS.
THEY ARE EXCEEDINGLY COMMON AND
WIDELY CONSIDERED TO BE THE
LEADING CAUSES OF DEATH
WORLDWIDE. FOR EXAMPLE JUST IN
THE UNITED STATES, WE HAVE
CARDIOVASCULAR DISEASE THAT
AFFECTS ABOUT 40% OF OUR ADULT
POPULATION OVER THE AGE OF 40.
CORONARY HEART DISEASE AFFECTING
20 MILLION INDIVIDUALS,
HYPERTENSION 116 MILLION PEOPLE,
STROKE CLOSE TO 800,000
INDIVIDUALS. DIABETES WE ARE
TALKING 8.7% OF THE ADULT
POPULATION OR 28.7 MILLION
PEOPLE IN CHRONIC KIDNEY DISEASE
ABOUT 37 MILLION PEOPLE. SO JUST
IN THE UNITED STATES ALONE,
THESE ARE DISEASES THAT INFLICT
A LARGE BURDEN OF ILLNESS AND
PREMATURE DEATH IN OUR
POPULATION. THEY ALSO AFFECT
SEVERAL GENERATIONS WITHIN
FAMILY, THEY CAN DEVELOP AND BE
MADE WORSE AT DIFFERENT POINTS
TOWARDS -- DURING A PERSON'S
LIFE SPAN. AND THEY ARE ALSO THE
LEADING CONTRIBUTORS TO RACIAL
AND INCOME DISPARITIES IN
MORBIDITY AND MORTALITY. IF WE
LOOK AT JUST THE CURRENT STATE
OF CARDIOVASCULAR HEALTH
DISPARITIES JUST OVER THE PAST
FEW YEARS, WHAT WE CAN SEE FROM
THIS STATEMENT PUBLISHED BY THE
AMERICAN HEART ASSOCIATION IS
THAT THE DEATH RATES FROM
CARDIOVASCULAR DISEASE HAVE
DECLINED OVER THE LAST DECADE OR
SO. THEY HAVE BEEN DECREASING
FOR ALL RACIAL GROUPS. HOWEVER
THE RATE OF DECREASE HAS SLOWED
AND IT IS NOT BEEN THE SAME
ACROSS RACIAL AND ETHNIC GROUPS.
IN PARTICULAR YOU CAN SEE THAT
BLACK AMERICANS CONTINUE TO HAVE
THE HIGHEST RATES OF AGE
ADJUSTED DEATH RATES FROM
CARDIOVASCULAR DISEASE. WHEN WE
LOOK AT WHAT THE RISK FACTORS
ARE THAT CONTRIBUTE TO
CARDIOVASCULAR DISEASE AS WELL
AS SOME OF THE OTHER
CARDIOMETABOLIC CONDITIONS YOU
CAN SEE THEY ARE HYPERTENSION
OBESITY, DIABETES AND TOTAL
CHOLESTEROL. SO THIS SNAP SHOT
FROM 2015 THROUGH 2016 USING
DATA FROM THE NATIONAL HEALTH
AND NUTRITION EXAMINATION SURVEY
OR N HAYNES REALLY SHOWED THAT
FOR HYPERTENSION NON-HISPANIC
BLACKS WERE MOST LIKELY ALL
OTHER ETHNIC GROUPS TO HAVE
HYPERTENSION. FOR OBESITY THAT
WAS THE CASE FOR HISPANIC AND
NON-HISPANIC BLACK INDIVIDUALS
MORE LIKELY TO HAVE OBESITY.
SAME FOR DIABETES. THOSE TWO
ETHNIC GROUPS HISPANICS AN
NON-HISPANIC BLACKS AND FOR HIGH
TOTAL CHOLESTEROL THE ETHNIC
GROUPS WERE EQUALLY LIKELY TO
HAVE HIGH CHOLESTEROL. THIS
ANALYSIS WAS DONE BASICALLY TO
LOOK AT TRENDS AND DISPARITIES
IN CARDIOMETABOLIC HEALTH SO
INSTEAD OF LOOKING AT DISEASE WE
ARE LOOKING AT WHAT IS THE STATE
OF HEALTH WITH REGARD TO
CARDIOMETABOLIC RISK FACTORS
OVER THE PAST 20 YEARS OR SO. SO
WHAT WE SEE IS THAT
CARDIOMETABOLIC HEALTH IF YOU
LOOK AT THESE LINES ON THE
SCREEN YOU CAN SEE THAT IT HAS
BEEN POOR. IF YOU LOOK AT PEOPLE
WITH OPTIMAL CARDIOVASCULAR
HEALTH YOU CAN SEE ALL OF THESE
GRAPHS START AT LIKE 20% OR 15%
SO VERY LOW PERCENTAGES OF THE
OVERALL POPULATION HAVE OPTIMAL
CARDIOMETABOLIC HEALTH. THIS IS
WORSENING AND IN 2017 TO 2018
THE MOST RECENT PERIOD ONLY
ABOUT 6% OF U.S. ADULTS HAD
OPTIMAL CARDIOMETABOLIC HEALTH.
THEY ARE ALSO DISPARITIES IF YOU
LOOK, THESE GRAPHSES ARE SHOWING
DISPARITIES BY AGE ON THE FAR
LEFT. THEN BY RACE AN ETHNICITY
AND THEN BY EDUCATION AND
INCOME. THE WAY THE AUTHORS
ACTUALLY MEASURED THIS WAS THAT
THEY USED THE AMERICAN HEART
ASSOCIATION HEALTH SCORE AND
THEY INCLUDED UPDATES TO THAT.
SO THAT INCLUDES THINGS LIKE
MEASURE OF BODY MASS INDEX,
BLOOD PRESSURE CONTROL H BLOOD
LIPIDS AND THE ABSENCE OF
PREVIOUS CARDIOVASCULAR DISEASE
EVENTS. SO WHAT YOU CAN SEE HERE
IS THAT THERE ARE DISPARITIES BY
AGE, BY RACE ETHNICITY, BY
EDUCATION LEVEL AS WELL AS BY
INCOME LEVEL. THAT WE ARE NOT
REALLY SEEING MUCH IN THE WAY OF
CLOSING OF THOSE GAPS. IN FACT
IN SOME CASES THEY ACTUALLY
WORSENED. SO WHY DO WE HAVE
HEALTH DISPARITIES? IF BEREALLY
WANT TO ADDRESS -- IF WE WANT TO
ADDRESS THEM WE WANT TO
UNDERSTAND THE CAUSAL CHAIN,
SOMETIMESES IT'S WHAT HAPPENS ON
THE INDIVIDUAL LEVEL BUT THIS
SCHEMATIC IS HERE TO REMIND US
THAT THERE IS A CAUSAL CHANGE
THAT BEGINS WITH SYSTEMS OF
POWER. WHEN YOU THINK ABOUT
FACTORS THAT ACTUALLY INFLUENCE
OUR LIVES AND OUR HEALTH THEY
ACTUALLY BEGIN AT A VERY LARGE
LEVEL, IT HAS TO DO WITH OUR
SOCIAL NORMS AND BELIEFS AND
VALUES AND WHERE WE INVEST OUR
RESOURCES. SO THINGS LIKE
RACISM AND SEXISM CLASSISM
ABLEISM AND HOMOPHOBIA, THESE
SORT OF GENERAL BELIEFS AND
VALUES AROUND WHO IN OUR SOCIETY
OUGHT TO HAVE CERTAIN
OPPORTUNITIES AND RESOURCES,
THEY SHAPE BASICALLY WHO GETS TO
BE INVOLVED AND THEY PROVIDE
HIERARCHIES OF POWER WITHIN OUR
INSTITUTIONS SO WE CALL THOSE
STRUCTURAL DRIVERS SO THESE
NORMS AND BELIEFS DETERMINE WHO
IS AT THE TOP OF THE HIERARCHY
OF OUR INSTITUTIONS AND AS Y'ALL
KNOW OUR INSTITUTIONS DETERMINE
HOW WE ARE GOVERNED, WHAT
PRACTICES AND POLICIES WE
SUPPORT, AND WHAT OUR
REGULATIONS AN LAWS ARE. SO
THOSE ARE THE FACTORS. THESE
STRUCTURAL DRIVERS ARE THE
FACTORS THAT DETERMINE WHAT OUR
LIVING CONDITIONS ARE. SO OUR
LIVING CONDITIONS ARE THINGS
LIKE THE PHYSICAL AND SOCIAL
ENVIRONMENT, THE ECONOMIC
ENVIRONMENT, AND THIS SERVICE
ENVIRONMENT WHETHER WE HAVE
ACCESS TO RESOURCES LIKE
HEALTHCARE OR SOCIAL SERVICES
FOR EXAMPLE WHETHER WE HAVE
OPPORTUNITIES TO WORK, WHETHER
THERE ARE GOOD RELATIONSHIPS
AMONG GROUPS OF PEOPLE IN
SOCIETY, WHETHER OR NOT WE WERE
EXPOSED TO DIFFERENT TOXINS. WE
CALL THESE SOCIAL DETERMINANTS
BUT THEY ARE REALLY SHAPED BY
THE STRUCTURAL AND SYSTEMS OF
POWER. AND THAT IS WHAT
DETERMINES WHAT BEHAVIORS WE ARE
ABLE TO ENGAGE IN AS
INDIVIDUALS. WHAT OPPORTUNITIES
DO WE HAVE TO MAKE DECISIONS
REGARDING WHETHER WE ARE GOING
TO CHOOSE TO SMOKE OR ENGAGE IN
HEALTHY EATING BEHAVIORS,
PHYSICAL ACTIVITY WHETHER WE ARE
GOING TO USE ALCOHOL OR DRUGS AT
UNHEALTHY LEVELS. THOSE
INDIVIDUAL ACTIONS ARE NOT
THINGS THAT OCCUR IN THE VACUUM,
THEY OCCUR AS A RESULT OF WHAT
OPPORTUNITIES WE HAVE BASED ON
WHERE WE LIVE AND THE OTHER
SORTS OF RESOURCES WE HAVE IN
OUR LIVES. IT IS THOSE
INDIVIDUAL ACTIONS THAT
ULTIMATELY DETERMINE WHETHER OR
NOT WE BECOME ILL. THAT TERMS
OUR EXPOSURES, THAT IMPACT OUR
PSYCHOLOGICAL AND BIOLOGICAL
RESPONSES. AND SHAPE HOW WELL WE
ARE, WHETHER WE DEVELOP
DISEASES, WHETHER WE ARE INJURED
AND WHETHER WE DIE SOONER THAN
WE WOULD IF WE HAD OPTIMAL
EXPOSURES SO IS H IS THE FULL
CAUSAL CHAIN AND UNTIL WE
UNDERSTAND THIS AND UNDERSTAND
WE NEED TO INTERVENE AT EACH OF
THESE POINTS, WE ARE NEVER GOING
TO SOLVE DISPARITIES PROBLEM.
KEEP THIS IN MIND AS WE MOVE
FORWARD AND TALKING ABOUT THE
FIELD OF HEALTH DISPARITIES
RESEARCH. BECAUSE IT REALLY HAS
EVOLVED. EARLY ON IN DISPARITIES
RESEARCH THERE WAS A LOT OF
RESEARCH THAT BASICALLY
DESCRIBED THE PROBLEM. COLLECTED
DATA FROM PEOPLE OF DIFFERENT
RACIAL ETHNIC GROUPS. FOR A LONG
TIME WE DIDN'T HAVE DATA ON
CERTAIN GROUPS SO WE COULDN'T
DESCRIBE WHAT WAS GOING ON BUT
FOR A LONG TIME RESEARCH WE DID
HAVE WAS VERY DESCRIPTIVE. THEN
WE MOVED TO MECHANISTIC WORK
WHERE WE ARE LOOKING AT THE
DIFFERENT DISTRIBUTORS AND --
CONTRIBUTORS AND WHAT PART THEY
PLAYED. THE FIELD HAS NOW MOVED
TO THE DIRECTION OF
INTERVENTIONS BECAUSE THERE IS
URGENCY FOR US TO INTERVENE.
THESE PROBLEMS HAVE BEEN GOING
ON FOR DECADES AND EVEN MORE
THAN A CENTURY FOR MANY OF THESE
CONDITIONS MORE THAN SEVERAL
CENTURIES. SO IT IS TIME FOR US
TO INTERVENE ESPECIALLY AS OUR
COUNTRY BECOMES MORE AND MORE
DIVERSE AND OUR INEQUITIES BY
THESE SOCIAL CONDITIONS HAVE
GROWN. SO ONE THING, THIS IS A
SLIDE I SHARED BEFORE AT THIS
LECTURE BUT JUST I THINK IT IS A
GOOD REMINDER FOR US THAT WE
NEED A LOT OF KNOWLEDGE IN ORDER
TO SOLVE THESE REALLY COMPLEX
PROBLEMS AND THAT IS WHY WE ARE
FORTUNATE TO HAVE INSTITUTES
LIKE THE NIH AND OTHER FUNDERS
THAT SUPPORT RESEARCH ON
CLINICAL EFFICACY AND
EFFECTIVENESS ON BASIC
BIOMEDICAL AND BEHAVIORAL
SCIENCE DISCOVERIES AND ON
EPIDEMIOLOGY. THIS SLIDE IS
SHOWING WE HAVE DEVELOPED A
SUBSTANTIVE KNOWLEDGE BASE
RELATED TO HEALTH DISPARITIES
BUT WE HAVE A GAP BETWEEN WHAT
WE KNOW AND WHAT WE DO TO
ACHIEVE EQUITY. SO THAT GAP IS
REALLY IN THE AREA OF -- THAT WE
NEED MORE TRANSDISCIPLINARY
RESEARCH. AS I MENTIONED TO YOU,
BECAUSE THE PROBLEM IS SO
COMPLEX, AFFECTS SO MANY
DIFFERENT SYSTEMS AND ASPECTS OF
OUR SOCIETY, THAT IT IS GOING TO
TAKE SCIENTISTS FROM A VARIETY
OF DIFFERENT DISCIPLINESS. IT IS
ALSO GOING TO TAKE EFFORTS TO
REALLY DISSEMINATE AND TRANSLATE
THE KNOWLEDGE WE DO HAVE. HOW DO
WE GET THAT KNOWLEDGE JUST OUT
OF SCIENTIFIC JOURNALS AND OUT
OF MAYBE THE MOST HIGHLY
RESOURCED INSTITUTIONS AND HOW
DO WE GET THEM OUT TO THE
COMMUNITIES THAT ARE REALLY
AFFECTED BY INIQUITIES? HOW CO--
INEQUITIES? HOW DO WE KNOW
APPROACHES ARE SUSTAINABLE
OUTSIDE THE SETTING OF THE REAL
WORLD AND HOW TO EFFECTIVELY
ENGAGE WITH COMMUNITIES, IT IS
NOT JUST THE SCIENTISTS OR THE
PEOPLE WHO ARE IN POSITIONS OF
INSTITUTIONAL POWER, BUT IT IS
ALSO ABOUT THE PEOPLE WHO LIVE
IN THE COMMUNITIES THAT ARE
AFFECTED BY DISPARITIES BECAUSE
THEY KNOW ONLY TOO WELL WHAT THE
PROBLEMS ARE, AND WHAT SOME OF
THE BARRIERS ARE TO SOLUTIONS,
THEY ALSO KNOW WHAT THE
STRENGTHS ARE MUCH MORE SO THAN
SCIENTIST WHOSE MAY NOT COME
FROM THOSE COMMUNITIES OR NOT
HAD THE LIVED EXPERIENCES OF
THOSE GROUPS. SO THIS APPROACH
WE WROTE ABOUT IN A BOOK
PUBLISHED BY THE NATIONAL
INSTITUTE ON MINORITY HEALTH AND
HEALTH DISPARITIES, BASICALLY ON
THE HEALTH SCIENCE OF HEALTH
DISPARITIES RESEARCH. SO WHAT
ARE SOME OF THE APPROACHES WE DO
HAVE THAT WE DO KNOW BASED ON
EVIDENCE COLLECTED BY SCIENTISTS
OVER MANY, MANY DECADES? WE KNOW
THREE BROAD CATEGORIES OF
APPROACHES THAT REDUCE
INEQUITIES IN HEALTH IF WE
SIMPLY IMPLEMENTED THEM. SO THE
THREE BROAD CATEGORIES ARE
CREATING COMMUNITIES OF
OPPORTUNITY, INFUSING MORE
HEALTH INTO THE DELIVERY OF
MEDICAL CARE, AND BUILDING
POLITICAL WILL. SO WE WILL GO
THROUGH MORE DETAIL WHAT DO WE
MEAN CREATE OPPORTUNITY? DR.
DAVID WILLIAMS MY COLLEAGUE AND
I WROTE ABOUT THIS A FEW YEARS
AGO. WE KNOW EARLY CHILDHOOD
INITIATIVES ARE AFFECTED AT
IMPROVING THE HEALTH AND THE
DEVELOPMENTAL OUTCOMES OF
CHILDREN. WE NODE TO IMPLEMENT
THEM, REDUCE CHILDHOOD POVERTY,
WE KNOW THAT THAT PLEADS TO
BETTER HEALTH IN ADULTHOOD. WE
KNOW ENHANCING INCOME AND
EMPLOYMENT OPPORTUNITIES AMONG
YOUNG PEOPLE IN ADULT -- AND
ADULTS IMPROVE IT IS HEALTH OF
THOSE INDIVIDUALS AND THEIR
FAMILIEFAMILIES. WE JUST KNOW Y
THINGS LIKE INCREASING THE
MINIMUM WAGE FOR EXAMPLE. WE
KNOW IMPROVING NEIGHBORHOOD AND
HOUSING CONDITIONS CONTRIBUTES
TO BETTER HEALTH. THAT'S BEEN
SHOWN BY BEHAVIORAL SCIENTISTS.
THAT MANY OF WHOM HAVE BEEN
FUNDED BY THE NATIONAL
INSTITUTES OF HEALTH AND
NATIONAL SCIENCE FOUNDATION.
THE OTHER THING WE KNOW IS ABOUT
INFUSING MORE HEALTH INTO THE
DELIVERY OF HEALTHCARE. WE KNOW
FOR EXAMPLE THAT IMPROVING
ACCESS TO CARE IMPROVES HEALTH
OUTCOMES. WE HAVE SEEN THAT.
FROM THE CHILDREN, INSURANCE
PROGRAM FOR CHILDREN, CHIPS. WE
HAVE SEEN THAT FROM THE
AFFORDABLE CARE ACT WHEN
INSURANCE IS PROVIDED THAT IT
DOES IMPROVE HEALTH. WE KNOW IT
IS NOT THE ONLY THING BUT WE
KNOW IT IS AN IMPORTANT
COMPONENT. WE KNOW THAT
EMPHASIZING PREVENTION AND
PRIMARY CARE IS IMPORTANT.
RATHER THAN WAITING UNTIL PEOPLE
GET SICK THEN TRYING TO TREAT
ALL THE COMPLICATED ISSUES THEY
HAVE AT THAT POINT, THERE IS SO
MUCH SCIENCE THAT WE HAVE ABOUT
WHAT -- HOW WE -- HOW TO EAT
HEALTHY, HOW TO KEEP OUR BLOOD
PRESSURE DOWN, WHICH KNOW WHICH
MEDICATIONS WORK, WE KNOW WE
SHOULD WEAR OUR SEAT BELTS WHEN
WE DRIVE, WE KNOW WE SHOULD WEAR
HELMETS WHEN WE RIDE A BICYCLE,
ALL THOSE ARE PREVENTION. WE
KNOW HOW TO PREVENT AND SCREEN
FOR CANCER. BUT IT IS NOT
ACTUALLY BEING EMPHASIZED AND
PROVIDED TO EVERYONE. WE KNOW
THERE ARE DISPARITIES IN THE
QUALITY OF CARE, WE KNOW SOME OF
THE FACTORS THAT CONTRIBUTE TO
THAT, WHETHER IT BE POOR PATIENT
PROVIDER COMMUNICATION. OR
INADEQUATELY RESOURCED
INSTITUTIONS AND CERTAIN
COMMUNITIES. WE KNOW WE DO A
BETTER JOB OF ADDRESSING
PATIENTS' SOCIAL RISK FACTORS BY
CONNECTING HEALTHCARE WITH OTHER
RESOURCES WITHIN COMMUNITIES.
WE KNOW THAT DIVERSIFYING THE
HEALTHCARE WORK FORCE IMPROVES
OUTCOMES. SO THERE'S SO MANY
THINGS WE KNOW ABOUT THAT WE
JUST ACTUALLY NEED TO DO. WHEN
IT COMES TO BUILDING POLITICAL
WILL, A LOT OF THESE THINGS
HAVEN'T BEEN DOCUMENTED YET BUT
CERTAINLY THERE IS A LOT OF
WISDOM AROUND THE FACT THAT IF
WE INCREASE AWARENESS OF THE
INEQUITIES THAT WE CAN MOBILIZE
COMMUNITIES. INTO SUPPORTING
POLICIES AND POLICY MAKERS THAT
WOULD ADDRESS INEQUITIES. WE
KNOW GETTING PEOPLE MORE
CIVICICALLY ENGAGED IS BETTER
FOR THEIR HEALTH, INDIVIDUAL
HEALTH AS WELL AS HEALTH OF
ENTIRE COMMUNITIES. WE KNOW
REDUCING STEREOTYPES AND
PREJUDICE WILL REDUCE THINGS
LIKE VIOLENCE, CRIME AND OTHER
FORMS OF HARM. THESE ARE BROAD
APPROACHES. THE OTHER THING WE
KNOW IS THAT IT IS GOING TO TAKE
MORE THAN ONE THING. SO THIS
DIAGRAM, THIS IS AN
INTERVENTIONS MODEL THAT IS
MULTI-LEVEL INTERVENTION MODEL.
IT IS BASICALLY -- IT IS BASED
ON THE SOCIO ECOLOGICAL MODEL.
WHICH SORT OF ACKNOWLEDGES THE
FACT THAT HEALTH IS INFLUENCED
BY FACTORS AT MULTIPLE LEVELS.
SO WE WANT TO INTERVENE ON A
PARTICULAR PROBLEM, WE NEED TO
MOVE BEYOND ADDRESSING
INDIVIDUAL PATIENT BEHAVIORS FOR
EXAMPLE. THIS IS A MODEL THAT
FOCUSES ON HEALTHCARE BUT THIS
MODEL COULD BE REPLICATED FOR
ANY OTHER SETTING FOR
EDUCATIONAL SETTING FOR AN
EMPLOYMENT SETTING. FOR
COMMUNITY BASED SETTING. SO THE
FACT IS THAT THERE ARE PEOPLE'S
BEHAVIORS ARE SHAPED BY THEIR
SOCIAL CONNECTION AND SOCIAL
NETWORKS. BY THE ORGANIZATIONS
IN WHICH THEY OPERATE AND WORK
AND OBTAIN SERVICES. AND BY THE
POLICIES AND THE COMMUNITY
RESOURCES THAT ARE AVAILABLE TO
THEM AND THEIR COMMUNITIES. WE
DON'T HAVE TO INTERVENE ON ALL
AT THE SAME TIME, BUT WE KNOW
AND THE RESEARCH HAS SHOWN US
THAT INTERVENING ON ONLY ONE
LEVEL VERY RARELY ACCOMPLISHES
THE GOAL OF REDUCING
DISPARITIES. SO THE FIELD IS NOW
MOVED TOWARDS TESTING
MULTI-LEVEL INTERVENTIONS AND
THANKS TO NIH IN PARTICULAR MANY
OTHER FUNDING AGENCIES BUT NIH
IN PARTICULAR, HAS BEEN VERY
SUPPORTIVE OF THE TESTING OF
MULTI-LEVEL INTERVENTIONS AND
LOOKING AT HOW THOSE
INTERVENTIONS INFLUENCE KEY
INTERACTIONS WITHIN THE
ENVIRONMENT OR IN THE
ORGANIZATION IN WHICH WE ARE
OPERATING AND THEN SUBSEQUENTLY
HOW THOSE INTERACTIONS THEN
INFLUENCE OUTCOMES. IT IS
IMPORTANT TO NOTE THAT WE ARE
NOW FOCUSED NOT ONLY ON CLINICAL
OUTCOMES BUT ON ORGANIZATIONAL
OUTCOMES SUCH AS COSTS, ON
PATIENT EXPERIENCES, EQUITY OF
SERVICES, ALL THOSE THINGS THAT
MATTER TO INDIVIDUAL PEOPLE, TO
COMMUNITIES AND TO DECISION
MAKERS. SO WHEN WE LOOK AT
CARDIOMETABOLIC DISEASE IN
PARTICULAR YOU LOOK AT ALL THESE
MULTIPLE LEVELS OF INFLUENCE YOU
CAN SEE WE GET MORE SPECIFIC ONE
MIGHT CHOOSE ON INDIVIDUAL
PATIENT LEVEL TO FOCUS ON AN
ISSUE SUCH AS ADHERENCE TO
MEDICATIONS. ON THE PROVIDER OR
CLINICAL TEAM LEVEL, THERE MIGHT
BE A FOCUS ON SOMETHING RELATED
TO COMMUNICATION SKILLS OR
RELATED TO SOME OTHER TECHNICAL
SKILLS IN THE DELIVERY OF CARE.
AT THE LOCAL COMMUNITY LEVEL ONE
MIGHT CHOOSE TO FOCUS ON
SOMETHING RELATED TO FOOD
AVAILABILITY. IF IT IS NOT
CHANGING THE ACTUAL AVAILABILITY
OF FOOD, LIKE CHANGING HOW
INDIVIDUALS CAN OBTAIN ACCESS TO
FOOD WITHIN THEIR ENVIRONMENTS
AND SIMILARLY ON THE OTHER SIDE
DIAGRAM YOU CAN SEE MULTIPLE
AREAS IN WHICH ONE MIGHT CHOOSE
TO FOCUS ON AND OBVIOUSLY THE
CHOICE OF WHAT TO INTERVENE UPON
IS INFLUENCED BY WHAT IS KNOWN
IN THE EXISTING RESEARCH. THAT
RESEARCH ON ON CONTRIBUTORS TO
HEALTH DISPARITIES AND MEDIATORS
WILL LET YOU KNOW WHICH FACTORS
CONTRIBUTES THE MOST AND IS MOST
AMENABLE TO CHANGE. THAT IS
WHERE YOU WANT TO THEN DIRECT
YOUR EFFORTS. I WAS FORTUNATE IN
2010 TO BE AWARDED A P 50 GRANT
FROM THE NATIONAL HEART LUNG AND
BLOOD INSTITUTE TO ESTABLISH A
CENTER FOCUSED ON HEALTH EQUITY
SO WE HAVE BEEN IN EXISTENCE
SINCE 2010 AND NOW SO WE ARE IN
OUR 23RD YEAR. OUR MISSION IS TO
PROMOTE EQUITY AND HEALTH IN
POPULATIONS THAT HAVE BEEN
SOCIALLY MARGINALIZED BY A THREE
PRONGED APPROACH. ADVANCING
SCIENTIFIC KNOWLEDGE, HE BELIEVE
KATEING AND TRAINING LEADERS --
EDUCATING AND TRAINING LEADERS
AND PARTNERING WITH COMMUNITIES
SO THIS PHOTO SHOWS OUR
COMMUNITY ADVISORY BOARD WHICH
HAS ALSO BEEN ACTIVE SINCE 2010
SO BACK IN 2010, WE WROTE A
PAPER ABOUT WHAT WAS INVOLVED IN
CREATING THIS TRANSDISCIPLINARY
RESEARCH CENTER. SOME OF OUR
EARLY LESSONS LEARNED. WE WROTE
THE MULTI-LEVEL INTERVENTIONS WE
TESTED AND SO SOME OF THEM, THIS
PARTICULAR CENTER WE WERE
FOCUSED AT THIS TIME ON
HYPERTENSION DISPARITIES. . WE
HAD ONE PROJECT RED CHIP WHICH
WAS PRIMARILY FOCUSED ON HEALTH
SYSTEM APPROACHES. BUT WE
INTERVENED AT THE LEVEL OF
CLINICAL AND FRONT LINE STAFF AS
WELL AS ON THE LEVEL OF
PATIENTS. WE INTERVENE ON THE
ORGANIZATIONAL LEVEL BY
PROVIDING ADDITIONAL STAFFING
THROUGH REGISTERED DIETITIAN AND
PHARMACIST. TO ADDRESS
UNCONTROLLED HYPERTENSION IN
PRIMARY CARE PATIENTS. THE FIVE
PLUS NUTS AN BEANS TRIAL
INTERVENED MORE ON THE FOOD
ACCESSIBILITY ISSUE IN BALTIMORE
CITY. WE HAD PEOPLE FROM A FOOD
DESERT WHICH IS AN AREA WHICH
LACKS HEALTHY FOOD OPTIONS FOR
PEOPLE. SO WHAT WE DID IS
PROVIDED DIETARY COACHING AND A
FOOD DELIVERY TO THE LOCAL
LIBRARY BECAUSE MANY OF THE
FOLKS THAT WERE PARTICIPATING IN
THIS TRIAL HAD NO ACCESS TO
FRESH FRUITS VEGETABLES NUTS AND
BEANS, PART OF THE DASH DIET
WHICH WE KNOW IS EFFECTIVE FOR
REDUCING BLOOD PRESSURE. WE HAD
A THIRD STUDY CALLED THE ACT
STUDY WHICH INCLUDED COMMUNITY
HEALTH WORKER OUTREACH TO
PATIENTS WITH UNCONTROLLED BLOOD
PRESSURE, PROVISION OF HOME
BLOOD PRESSURE MONITORS AND SOME
FOCUS ON PROBLEM SOLVING. SO
INTERVENING THERE ON THE SOCIAL
SUPPORT ENVIRONMENT AS WELL AS
ON THE HEALTHCARE ENVIRONMENT
AND THE INDIVIDUAL. WE HAD SOME
INTERESTING LESSONS LEARNED. L
WE SHOWED SOME EFFECTIVENESS IN
THOSE THREE STUDIES. NOT AS
DRAMATIC AS WE WOULD HAVE LIKED
AND SOME OF THE LESSONS WE
LEARNED WERE APPLIED TO OUR NEXT
GENERATION OF STUDIES WHICH NOW
WHAT WE ARE DOING IS FOR
EXAMPLE, THE HEALTH SYSTEM
APPROACH NOW ALSO INCORPORATES
THE COMMUNITY OUTREACH BECAUSE
WE DIDN'T REACH SO MANY OF THE
PEOPLE WHO WERE ELIGIBLE FOR OUR
PROGRAM. BY FOCUSING ONLY ON THE
HEALTH SYSTEM OR THE PEOPLE THAT
WERE ALREADY ENGAGE MISDEMEANOR
THE HEALTH SYSTEM. ON THE FOOD
-- ENGAGE MISDEMEANOR THE HEALTH
SYSTEM. ON THE FOOD DELIVERY
APPROACH WE LEARNED PARTICULAR
PEOPLE AT HIGHER RISK COULD
BENEFIT MORE FROM THE HEALTHIER
DIET SO WE ARE T FOCUSING ON THE
HIGHER RISK INDIVIDUAL WHOSE HAD
EARLY KIDNEY DISEASE AND JOINED
THE DIETARY COACHING FOOD
DELIVERY WITH THAT HIGHER RISK
POPULATION. SO THESE ARE OUR
THREE MOST RECENT TRIALS ARE THE
RICH LIFE PROJECT, THE FIVE PLUS
NUTS AND BEANS FOR KIDNEYS
TRIAL, AND THEN WE ALSO HAVE A
TRIAL THAT WE CONDUCTED IN GANA
WHICH TESTED TASK SHIFTING FROM
PHYSICIANS TO COMMUNITY HEALTH
NURSES IN A SETTING WHERE THERE
WERE -- THERE WAS A LIMITED
NUMBER OF PRIMARY CARE
PHYSICIANS TO CARE FOR PATIENTS
WE ALSO PROVIDED HOME BLOOD
PRESSURE MONITORS AND CELL PHONE
APP FOR TRACKING OF PATIENTS
BLOOD PRESSURE AND DIABETES
OUTCOMES, USING HEALTH
INFORMATION TECHNOLOGY. WE WERE
DOING THIS BEFORE THE PANDEMIC
AND SO MANY LESSONS LEARNED FROM
THAT STUDY THAT CAN BE APPLIED
NOW IN THE UNITED STATES. SO AS
I MENTION OUR CENTER HAS A THREE
PRONGED APPROACH, OUR ENGAGEMENT
WITH COMMUNITY THROUGH OUR
COMMUNITY ADVISORY BOARD AND
WITH NUMEROUS HEALTH SYSTEM
PARTNERS. OUR RESEARCH ARM AND
THEN OUR TRAINING ARM WHICH
FOCUSES ON PROVIDING COURSES AND
SYMPOSIUM AND INDIVIDUALIZED
MENTORING OPPORTUNITIES FOR THE
NEXT GENERATION OF RESEARCHERS
AND LEADERS IN HEALTH EQUITY. SO
I'M GOING TO TELL YOU NOW FOCUS
MORE ON THE SPECIFIC STUDY ON
THE RICH LIFE PROJECT. SO THAT
YOU CAN GET A LITTLE BIT MORE
IDEA OF EXACTLY WHAT I'M TALKING
ABOUT. SO THIS STUDY RICH LIFE
WAS FUNDED BY PCORI AND NHLBI.
IT IS A CLUSTER RANDOMIZED
PRAGMATIC TRIAL THAT INCLUDED 30
PRACTICES IN MARYLAND AN
PENNSYLVANIA. WE ENROLLED 1,820
ADULT PATIENTS, APPROXIMATELY 63
PER PRACTICE. THE PATIENTS HAD
TO HAVE UNCONTROLLED
HYPERTENSION PLUS AT LEAST ONE
OTHER CO-MORBID CONDITION WHICH
INCLUDED DIABETES, DEPRESSION,
HIGH CHOLESTEROL, HEART DISEASE
OR TOBACCO SMOKING AND WE
COMPARED TWO INTERVENTION, ONE
STANDARD OF CARE PLUS
INTERVENTION, WHICH ACTUALLY
FOCUSED ON PROVIDING SKILLS AND
KNOWLEDGE AND RESOURCES TO FRONT
LINE CLINIC STAFF AND SYSTEM
LEADERS. AND THEN THE SECOND
APPROACH COLLABORATIVE CARE
STEPPED CARE WHICH INCLUDED ALL
THE COMPONENTS OF STANDARD OF
CARE PLUS BUT ALSO INCORPORATED
A CARE MANAGER COMMUNITY HEALTH
WORKER AND A SPECIALIST TEAM
THAT WOULD BE AVAILABLE
VIRTUALLY TO DELIVER
INDIVIDUALIZED CARE TO PATIENTS
SO LET ME TELL YOU A LITTLE BIT
MORE ABOUT THOSE INTERVENTIONS
IN A FEW MINUTE BUS OUR MAIN
OUTCOMES AT 12 AND 24 MONTHS
WERE BLOOD PRESSURE CONTROL AND
CHANGE IN PATIENT AGGRAVATION.
WE DID POLICIES THAT WERE
PLANNED PRE-PLANNED SUBGROUP
ANALYSIS WITH PRIMARY ONE BEING
LOOKING TO SEE IF WE COULD -- IF
THE INTERVENTION WOULD REDUCE
DISPARITIES IN CARDIOVASCULAR
DISEASE AND HYPERTENSION LEVELS
THAT WERE PRESENT AT BASELINE.
SO BRIEFLY, THE STANDARD OF CARE
PLUS INTERVENTION INCLUDED
STANDARDIZED BLOOD PRESSURE
MEASURING TRAINING FOR ALL FRONT
LINE STAFF AND CLINICIANS,
INCLUDED A HYPERTENSION BEST
CARE AN BEST PRACTICES TRAINING
DELIVERED BY AUDIO-VISUAL
WEB-BASED TRAINING PROGRAM. ALSO
INCLUDED A LEARNING NETWORK FOR
HEALTH SYSTEM LEADERS SO THIS
WAS LIKE A SERIES OF ORDERLY
SEMINARS ON KEY TOPICS. THEN WE
HAD A HYPERTENSION DASHBOARD
THAT WAS PROVIDED TO ALL
PRACTICES, EXTRACTING DATA FROM
ELECTRONIC MEDICAL RECORDS AND
GIVING FEEDBACK ON HOW PROVIDERS
AND HOW THE CLINIC OVERALL WAS
PERFORMING WITH REGARD TO
ACHIEVING BLOODS FROM SURE
CONTROL METRICS BROKEN DOWN BY
RACE AND ETHNICITY. THIS IS A
VERY ACTIVE COMPARATOR ARM. SO
HERE IS WHAT WE DID FOR THE
STANDARDIZATION OF BLOOD
PRESSURE MEASUREMENT, WE HAD A
SCREEN AND CONFIRM PROTOCOL, WE
INTRODUCED AUTOMATED BLOOD
PRESSURE DEVICES TO ALL THE AT
THISES. WE HAD STAFF TRAINING
IN PERSON FOR THE TRAINERS AND
THEN THE TRAINERS CAN TRAIN THE
FRONT LINE STAF STAFF. E WE ALSD
OBSERVATION VISITS OR A FIDELITY
AUDIT OVER THE PERIOD OF THE
STUDY. THEN AS I MENTIONED TO
YOU, THE HYPERTENSION BEST
PRACTICES TRAINING. SO THE
SCREEN AND CONFIRM PROTOCOL IS
BASICALLY THAT EVERY PATIENT IS
SCREENED FOR BLOOD PRESSURE
USING AUTOMATED BLOOD PRESSURE
DEVICE. AND USING THESE STEPS
FOR POSITIONING THE PATIENT
USING THE DEVICE CORRECTLY. THE
CONFIRMATION PIECE IS DONE ONLY
FOR PATIENTS WHO HAVE A
SCREENING BLOOD PRESSURE THAT IS
ABOVE THE THRESHOLD. WE USE AT
THE TIME WE USE THE THRESHOLD OF
140 SYSTOLIC BECAUSE THAT IS
WHAT THE GUIDELINES SAID AT THE
TIME. NOW THEY CHANGED TO 130.
THAT IS WHERE WE STARTED OUT. IF
PEOPLE HAD A HIGH SCREENING
BLOOD PRESSURE, THE STAFF WERE
TRAINED TO THEN CONFIRM IT, THE
CONFIRMATORY MEASUREMENT
BASICALLY ALLOWS THE DEVICE TO
COLLECT THREE BACK TO BACK
READINGS WITH A FIVE MINUTE WAIT
IN BETWEEN. EACH READING AND
THOSE READINGS ARE AVERAGED.
THEN IF THE PATIENT STILL HAD A
HIGH BROOD PRESSURE READING
AFTER CONFIRMATORY MEASURE THEY
ARE DEEMED UNCONTROLLED BLOOD
PRESSURE. SO AGAIN, THE
LEADERSHIP INTERVENTION INVOLVED
INTRODUCTORY SESSION, QUARTERLY
WEBINARS, AS WELL AS COACHING
CALLS, BUT THE COACHING CALLS
WERE ONLY FOR THE MORE INTENSIVE
ARM OF THE STUDY, NOT FOR THE
STANDARD ARM. AGAIN, SEVERAL
TOPICS ALL WAY FROM THINGS LIKE
ADDRESSING INEQUITIES, ON YOUR
DASHBOARD, WORKING WITH
COMMUNITY PARTNERS, ADDRESSING
PATIENT SOCIAL NEEDS,
PSYCHOLOGICAL SAFETY FOR YOUR
EMPLOYEES. ADDRESSING IMPLICIT
BIAS, SEVERAL TOPICS OF INTEREST
THAT WE DEVELOPED BASICALLY
BASED ON INPUT FROM OUR
STAKEHOLDERS. ARM TWO OF THE
TRIAL HAD ALL OF THOSE STANDARD
OF CARE ELEMENTS PLUS THE
MONTHLY COACHING CALL FOR THE
CLINIC BASED CHAMPIONS. A
DASHBOARD REVIEW FACILITATED BY
THE CLINIC CHAMPION SO NOT JUST
HAVING THE DASHBOARD AVAILABLE
BUT HAVING A PROCESS BY WHICH TO
REVIEW THAT DASHBOARD AND COME
UP WITH IMPROVEMENT PLANS. THEN
THE ADDITION OF A CARE MANAGER
TO THE TEAM. SO THE CARE MANAGER
WAS ADDED TO THE TEAM WHICH
INCLUDED THE PRIMARY CARE
PROVIDER AND THE PATIENT AND THE
CARE MANAGER THEN HAD THE OPTION
OF ALSO WHAT WE CALL STEPPING
THE PATIENT UP. IF THE PATIENT
WAS NOT IMPROVING IN BLOOD
PRESSURE OR OTHER ASSOCIATED
CONDITION OVER TIME CARE MANAGER
COULD INCORPORATE THE SUPPORT OF
A COMMUNITY HEALTH WORKER. OR
ENGAGE WITH A SPECIALIST CORE
AVAILABLE THROUGH VIRTUAL
CONSULTATION THE CARE MANAGER
ALSO HAD ACCESS AT ALL TIMES TO
A BEHAVIORAL HEALTH SPECIALIST.
SO IN MOST CASES IN THIS TRIAL
WE USED EXISTING STAFF WITHIN
THE PRACTICES AND TRAIN THEM
BECAUSE WE WANTED THIS TO BE AS
PRAGMATIC AND REALISTIC AS
POSSIBLE SO IT CUB AS
SUSTAINABLE AS POSSIBLE. THE
ORGANIZATIONSES WE WORKED WITH
WERE RESPONSIBLE FOR IDENTIFYING
AND HIRING THESE INDIVIDUALS AND
THE RESEARCH TEAM WORKED WITH
THEM TO TRAIN THEM AND OVERSEE
THEM OVER THE COURSE OF THE
PROJECT. SO THE COMMUNITY HEALTH
WORKERS REALLY PROVIDED
COMMUNITY BASED
CONTEXTUALIZATION OF CARE FOR
PATIENTS IN THIS INTENSIVE ARM.
THEY WOULD SUPPORT PATIENTS
REACHING THEIR SELF MANAGEMENT
GOLDSBY HELPING THEM TO ADDRESS
ANY SOCIAL AND ENVIRONMENTSAL
ISSUES, WE ARE THINKING ABOUT
THINGS LIKE FOOD INSECURITY OR
HOUSING INSECURITY OR FINANCIAL
PROBLEMS WITH GETTING
MEDICATIONS COVERED. THEY WOULD
ALSO SUPPORT PATIENTS IN
ADVOCATING FOR THEMSELVES WITH
THEIR HEALTHCARE PROVIDERS.
HELP NAVIGATE THE HEALTHCARE
SYSTEM SO SOME OF OUR PATIENTS
IN THIS INTERVENTION ARM
RECEIVED THIS MORE STEPPED UP
INTENSIVE APPROACH. OTHERS WITH
MORE MEDICALLY COMPLEX SITUATION
IT IS CARE MANAGER WOULD OPT TO
CONSULT WITH A SPECIALIST TEAM
SO WE HAD SPECIALISTS IN HYPE
TENSION, DIABETES, PSYCHIATRY,
PREVENTIVE CARDIOLOGY AND
SPOKING CESSATION AND DISCUSS
THE PATIENTS CASE AND PROVIDE
RECOMMENDATIONS BACK TO PRIMARY
CARE TEAM. SO I WILL TELL YOU
ABOUT SOME OF THE IMPLEMENTATION
PROCESS MEASURES. THEN MOVE ON
TO RESULTS. WHAT DID WE DO TO
DETERMINE WHETHER OR NOT OUR
IMPLEMENTATION WAS ACTUALLY
SUCCESSFUL? FOR THE BLOOD
PRESSURE MEASUREMENT PIECE WE
HAD A NUMBER OF MEASURES. ONE
WAS CALLED THE TERMINAL DIGIT
ZERO PREFERENCE. THAT LETS YOU
KNOW IF YOU CAN THINK OF BLOOD
PRESSURE DEVICES AS HAVING
NUMBERS ON THEM AND BETWEEN EACH
NUMBER THERE IS NUMBERS FROM
ZERO TO 10. YOU HAVE 130, 131,
132, 135, 137. 140. WE KNOW WHEN
PEOPLE DON'T USE AUTOMATED
DEVICES, THAT OFTEN TIMES IN
MEASURING BLOOD PRESSURE THERE
IS UNCERTAINTY AROUND WHAT THE
MEASURE IS SO PEOPLE TEND TO
ROUND NUMBERS TO ZERO. WHAT WE
WERE LOOKING FOR IN OUR MEASURES
OF BLOOD PRESSURE WE OBTAIN FROM
ELECTRONIC MEDICAL RECORD IS
ZERO PREFERENCE WOULD GO DOWN.
INDEED IT DID, THE ZERO
PREFERENCE OF THE MEASURES
BEFORE WE PRODUCED OUR TRAINING
WAS AROUND 16%, IT WAS REDUCED
TO ABOUT 11% AFTER OUR TRAINING
WHICH IS MORE EXPECTED BECAUSE
IF YOU HAVE NUMBERS FROM 0 TO 9
YOU EXPECT ZERO DIGIT PREFERENCE
TO BE SOMEWHERE AROUND 10% SO
11% IS NOT BAD. WE HAD A MEDIAN
BLOOD PRESSURE MEASUREMENT
PERFORMANCE SCORE OR PREPARATION
SCORE LIKE THINGS LIKE WHETHER
THE PATIENT WAS SEEDED CORRECTLY
-- SEATED CORRECT WITH FEET ON
THE FLOOR AND WHETHER ARM WAS
ELEVATED AT LEVEL OF HEART.
WHETHER OR NOT THE PATIENT WAS
NOT SPEAKING AND HAD EMPTIED
THEIR BLADDER, SO WE LOOK AT
MEDIAN BLOOD PRESSURE
MEASUREMENT PREPARATION SCORE
BEFORE, MIDWAY THROUGH TRAINING
AND A YEAR LATER AND WE FOUND
IMPROVEMENTS IN ALL OF THOSE
SCORES. NOW, THERE WERE SOME
SIDES WHERE WE DIDN'T SHOW
IMPROVEMENTS IN THE MIDDLE OF
THE STUDY, IN THAT CASE WE WOULD
SEND OUR TEAM OUT TO DO
TROUBLESHOOTING AND SOME
RETRAINING AS NEEDED. SO AT THE
END OF THE STUDY WE DID SHOW
IMPROVEMENT IN PRETTY MUCH
ACROSS THE BOARD IN OUR
PRACTICES. WE ALSO SAW HIGH
LEVELS OF ADHERENCE TO THE FIVE
MINUTE REST PERIOD. BEFORE THE
CONFIRMATORY MEASUREMENT. SO
THAT WAS SOMETHING THAT THERE
WERE PEOPLE NOT ALLOWING THAT
FIVE MINUTE REST WHEN WE FIRST
DID THE TRAINING AND AFTER TIME
WE SAW THEY DID IMPROVE WITH
THAT AND WE ALSO SAW IMPROVED
ADHERENCE THREE READINGS
CONFIRMATORY MEASUREMENT SO THE
BLOOD PRESSURE MEASUREMENT
PROGRAM IS A SUCCESS STORY.
THERE ARE SOME PRACTICES THAT
WERE SCORE -- CERTAINLY SCORED
BETTER THAN OTHERS SO WE KNOW
THERE IS SOME UNIQUE
ORGANIZATIONAL FACTORS THAT
COULD CONTRIBUTE TO THAT, FOR
EXAMPLE WE HAD A CHAMPION WHO
WAS REALLY ENGAGING THIS PROCESS
WE DEFINITELY SAW GREATER
IMPROVEMENTS IN THE BLOOD
PRESSURE SCORE. SO HERE ARE SOME
OTHER MEASURES OF
IMPLEMENTATION. FOR CARE
MANAGEMENT WE SAW THAT OUR
CARING MANAGERS CONDUCTED OVER
4,000 VISITS. SO 88% OF THE
PATIENTS WHO WERE ASSIGNED TO
THIS ARM DID ATTEND ONE CARE
MANAGEMENT VISIT AND 77%
ATTENDED TWO OR MORE. MOST OF
THESE VISITS WERE BY THEM PHONE.
AS BUT KNOW THE STUDY BEGAN
BEFORE THE PANDEMIC BUT IT DID
OCCUR DURING THE PANDEMIC SO I
BELIEVE THAT THAT PROBABLY
INFLUENCED THE MODE OF DELIVERY
OF THE INTERVENTION IN SOME
WAYS. BUT PEOPLE WHO COULDN'T
MEET THE CARE MANAGER IN PERSON
DID MEET BY PHONE AND CARE
MANAGER SPENT NOST TIME TALKING
MEDICAL CONDITIONS WHICH MAKES
SENSE BECAUSE MOST WERE NURSES.
SOME CLINICAL SOCIAL WORKERS AND
THEN THEY SPENT LOWER AMOUNT OF
TIME TALKING ABOUT LIFESTYLE
BARRIERS AND SOCIAL DETERMINANTS
OF HEALTH. THESE TERMS OF
REFERRALS TO THE STEPPED CARE
PROGRAM, WE HAD EXPECTED ABOUT
THE NURSE CARE MANAGERS WOULD
REFER HALF THE PATIENTS TO A
COMMUNITY HEALTH WORKER WHILE WE
SAW ABOUT REFERRAL RATE OF 30%
IN TERMS OF REFERRAL TO
SPECIALIST INTERVENTION WE SAW
REFERRAL RATE OF 2%%. YOU CAN SE
IT VARIED QUITE A BIT ACROSS
HEALTH SYSTEMS SO THE 30
PRACTICES IN FIVE DIFFERENT
HEALTH SYSTEMS AND YOU CAN SEE
THERE IS ONE HEALTH SYSTEM WHERE
THERE WAS A HIGH REFERRAL RATE
FOR COMMUNITY HEALTH PATIENTS TO
COMMUNITY HEALTH WORKERS, THAT
WAS A FEDERALLY QUALIFIED
COMMUNITY HEALTH CENTER AND
THERE WERE PATIENTS WITH HIGH
SOCIAL NEEDS BUT THERE IS ALSO
RECEPTIVITY TO HAVING COMMUNITY
HEALTH WORKERS BE PART OF THE
PRIMARY CARE TEAM. SOME OF THE
BARRIERS WE HEARD ABOUT WERE
RELATED TO THINGS LIKE PEOPLE
NOT BEING USED TO WORKING WITH
COMMUNITY HEALTH WORKER, FEELING
LIKE THE NURSES FEELING LIKE
THEY COULD ADDRESS A LOT OF
ISSUES THE COMMUNITY HEALTH
WORKERS BEFORE ADDRESSING JUST
INERTIA IN CHANGING EXISTING
PRACTICES. FOR THE SPECIALIST
REFERRAL PIECE, WE LEARNED A LOT
OF NURSE CARE MANAGERS WERE
CONCERNED THAT SUGGESTING A
REFERRAL TO SPECIALIST CORPS
MIGHT BE OFFENSIVE TO THE
PRIMARY CARE PROVIDER.
ESPECIALLY IF THEY SAW THAT THE
PATIENT WAS ALREADY RECEIVING
CARE FROM SPECIALISTS SO
HESITANT TO MAKE REFERRALS AND
DESPITE THE FACT THAT WE DID A
LOT OF EXPLAINING TO THEM AROUND
THE FACT THE SPECIALIST CORE WAS
NOT TO REPLACE THE PATIENT USUAL
CARE BUT PROVIDE ADDITIONAL
SUPPORT THERE WERE STILL LACK OF
UPTAKE OF THAT INTERVENTION. SO
LET'S TALK PATIENTS WHO WERE
REFERRED TO THE COMMUNITY HEALTH
WORKERS. A COMMUNITY HEALTH
WORKERS CONDUCTED 600 VISITS,
91% PEOPLE WHO WERE REFERRING TO
COMMUNITY HEALTH WORKER HAD AT
LEAST ONE VISIT WITH THE
COMMUNITY HEALTH WORKER AND JUST
OVER HALF OF THEM HAD TWO OR
MORE. MOST VISITS WERE DONE BY
PHONE, WE DID HAVE SOME
COMMUNITY HEALTH WORKERS
ACTUALLY GO OUT TO PEOPLE'S
HOMES TO TAKE THEM BLOOD
PRESSURE MEASUREMENT DEVICES OR
TRY TO FIND THEM IF THEY HADN'T
HEARD FROM THEM. TO ACCOMPANY
THEM TO OTHER APPOINTMENTS AND
THINGS LIKE THAT. AGAIN WITH THE
PANDEMIC IT WAS MUCH LESS THAN
WE HAD EXPECTED. ON THE
COMMUNITY HEALTH WORKERS TALKED
ABOUT A VARIETY OF DIFFERENT
THINGS, SURPRISINGLY A LOT OF
BIOMEDICAL CONDITIONS BUT THIS
WAS PROBABLY MORE ABOUT THINGS
LIKE HOW PEOPLE COULD GET ACCESS
TO THEIR MEDICATION AND TO OTHER
MEDICAL SUPPLIES. AND NOT SO
MUCH ABOUT THE MEDICAL CONDITION
ITSELF. A LOT OF THOSE
CONVERSATIONS WERE HOW TO USE A
HOME BLOOD PRESSURE MONITOR
WHICH THE COMMUNITY HEALTH
WORKERS WERE VERY HELPFUL IN
TEACHING PATIENTS HOW TO USE
HOME BLOOD PRESSURE MONITORS.
THEN YOU CAN SEE A LOT OF TIME
SPENT DEALING WITH SOCIAL
DETERMINANTS OF HEALTH. GETTING
ACCESS TO FOOD, TO HOUSING,
GETTING SIGNED UP FOR HEALTH
INSURANCE MAKING SURE THEIR
UTILITIES COULD BE PAID THINGS
LIKE THAT. SO WE WILL GO ON TO
RESULTS. BECAUSE WITH E DON'T
HAVE MUCH MORE TIME LEFT. SO WHO
ARE THE PATIENTS WE ENROLL? YOU
CAN SEE WE ENROLLED OVER 1800
PATIENTS, ON AVERAGE 60 YEARS
OLDS, 60% WOMEN. WE HAD ALMOST
60% WHO WORE BLACK. 33% WHITE,
ABOUT CLOSE TO 10% HISPANIC. WE
HAD ABOUT A QUARTER WHO WERE ON
MEDICAID INSURANCE. THERE WERE
NO DIFFERENCES BETWEEN OUR
INTERVENTION GROUPS WHEN WE
ADJUSTED FOR CLUSTERING, THOUGH
YOU CAN SEE THAT THERE IS A
LIGHTLY HIGHER PERCENTAGE OF
MEDICAID AND ENSURED PATIENTS IN
THE COLLABORATIVE CARE STEPPED
CARE ARM. THERE WERE ALSO NO
DIFFERENCES SUBSTANTIAL
DIFFERENCES CLINICALLY IN THE
INTERVENTION GROUPS WITH MOST
PATIENTS HAVING SLIGHTLY
ELEVATED SYSTOLIC BLOOD PRESSURE
DIASTOLIC BEING 85.5 ON AVERAGE,
TO BE IN THE STUDY YOU SIMPLY
HAD TO HAVE A SYSTOLIC BLOOD
PRESSURE OF 140 OR GREATER. YOU
CAN SEE THERE WERE CO-MORBID
CONDITIONS REPRESENTED WITH THE
MOST COMMON ONE BEING
HYPERLIPIDEMIA FOLLOWED BY
DIABETES. AND NO SUBSTANTIAL
DIFFERENCES BETWEEN THE TWO
GROUPS WHEN WE ADJUST FOR
CLUSTERING BUT SOMEWHAT A
DIFFERENCE IN THE PREVALENCE OF
CORONARY HEART DISEASE WITH THAT
BEING A LITTLE BIT HIGHER IN
STANDARD OF CARE GROUP THAN IT
WAS IN THE CC STEPPED CARE
GROUP. SO WHAT WERE OUR 12 MONTH
OUTCOME?
WE SUCCESSFULLY ENGAGED, 1800
PATIENTS OUR FOLLOW-UP RATES
WERE APPROXIMATELY 80% IN BOTH
GROUPS SO NO DIFFERENCES IN
FOLLOW UP. BETWEEN TWO
INTERVENTION GROUPS. WE DID HAVE
PEOPLE WHO SOME WHO WITHDREW
FROM THE STUDY, BUT MOST
PATIENTS WHO WE DIDN'T FIND WERE
THE ONES WHO WERE DECEASED OR
SIMPLY MOVED OUT OF THE AREA. SO
WHAT DID WE FIND? WE FOUND THAT
ABOUT 60% OF THESE PATIENTS
OBTAINED BLOOD PRESSURE CONTROL
OVER THE 12 MONTH PERIOD. SO OUT
OF THE 100% UNCONTROLLED, 60%
OBTAINED CONTROL OVER TIME. WE
DIDN'T SEE DIFFERENCES BETWEEN
THE TWO INTERVENTION GROUPS
ALTHOUGH YOU CAN SEE THAT AT
BASELINE BLOOD PRESSURE CONTROL
WAS BASICALLY LOWER AMONG BLACKS
HAHN IT WAS AMONG WHITES AND
HISPANICS. BUT WE DIDN'T SEE ANY
DIFFERENCES IN BLOOD PRESSURE
CONTROL OVER TIME. SORRY THIS IS
NOT AT BASELINE, THIS IS 12
MONTHS SO WE SAW DISPARITIES IN
BLOOD PRESSURE LEVELS AT
BASELINE. UNFORTUNATELY THOSE
WERE NOT CLOSED AT FOLLOW-UP
THOUGH EVERYONE DID OBTAIN BLOOD
PRESSURE CONTROL OVER FOLLOW-UP
NOT EVERYONE BUT SIMILAR
CONTROLS. RATES OVER TIME. WHAT
WE DID DO SOME PRE-PLANNED
SUBGROUP ANALYSES AND I'M ONLY
SHOWING A COUPLE HERE BECAUSE
THESE ARE THE ONES WHERE THERE
WAS A DIFFERENCE. SO AMONG
PATIENTS WITH MEDICAID WE SAW
THAT PATIENTS WITH MEDICAID HAD
A HIGHER LIKELIHOOD OF OBTAINING
BLOOD PRESSURE CONTROL WHEN IN
THE COLLABORATIVE CARE ARM THAN
PATIENTS WHO WERE NOT ON
MEDICAID. A SIMILAR PATTERN SEEN
FOR PEOPLE WITH CORONARY HEART
DISEASE, THOSE WHO HAD CORONARY
HEART DISEASE WERE MORE LIKELY
TO OBTAIN BLOOD PRESSURE CONTROL
IN COLLABORATIVE CARE ARM THAN
PEOPLE WHO DIDN'T HAVE CORONARY
HEART DISEASE. WHEN WE LOOK AT
REDUCTION IN SYSTOLIC BLOOD
PRESSURE OVER TIME IT WAS
CLINICALLY AND STATISTICALLY
SIGNIFICANT IN BOTH REDUCTION
ARMSES WITH REDUCTION IN 14 TO
15-MILLIMETERS OF MERCURY AND
SYSTOLIC BLOOD PRESSURE IN BOTH
GROUPS AND REDUCTION ANYWHERE
FROM 6 TO 7-MILLIMETERS OF
MERCURY FOR DIASTOLIC BLOOD
PRESSURE. THE DIFFERENCE BETWEEN
THE TWO INTERVENTION GROUPS WAS
ONLY SIGNIFICANT FOR DIASTOLIC
BLOOD PRESSURE WHERE PATIENTS IN
THE CC STEPPED CARE ARM HAD A
SLIGHTLY GREATER IMPROVEMENT IN
DIASTOLIC THAN THOSE FINAL
STANDARD ARM. IN TERMS OF
PATIENT REPORTED OUTCOMES WE SAW
IMPROVEMENT IN PATIENT
ACTIVATION. IN BOTH GROUPS THAT
WERE NOT SIGNIFICANTLY DIFFERENT
BETWEEN GROUPS. WE DID SEE
IMPROVEMENT IN PATIENTS
ASSESSMENT OF CHRONIC ILLNESS
CARE IN BOTH GROUPS THAT WAS
SLIGHTLY GREATER IN THE
COLLABORATIVE CARE STEPPED CARE
ARM. SO WHAT DID WE LEARN? WE
LEARNED ENHANCED STANDARD OF
CARE PROGRAM IMPROVED BLOOD
PRESSURE CONTROL SUBSTANTIALLY.
PATIENTS WITH HYPERTENSION AND
ASSOCIATED CO-MORBIDITIES. WHEN
WE ADDED A COLLABORATIVE CARE
PIECE TO THAT, WE SAW SIMILAR
BENEFITS FOR BLOOD PRESSURE
CONTROL. OVERALL BLOOD PRESSURE
LEVELS. WE DID SEE SOME GREATER
IMPROVEMENTS FOR PATIENTS WITH
MEDICAID INSURANCE AN PATIENTS
WITH CORONARY HEART DISEASE IN
THAT INTERVENTION. AND WE SAW
SOME GREATER IMPROVEMENTS IN
PATIENT EXPERIENCES OF CHRONIC
ILLNESS CARE. SO WE CONCLUDED
THAT O TO REDUCE DISPARITIES IN
HYPERTENSION HEALTH SYSTEM
LEADERS AND POLICY MAKERS SHOULD
SUPPORT MULTI-LEVEL
INTERVENTIONS AND RESERVE THE
MOST INTENSIVE APPROACHES FOR
PATIENTS WITH COMPLEX MEDICAL
AND SOCIAL NEEDS. THAT THERE IS
A NEED FOR FURTHER RESEARCH TO
ADDRESS AND ELUCIDATE
IMPLEMENTATION BARRIERS. SO WE
HAVE A FEW MINUTES LEFT, I'M
GOING TO TALK ABOUT SOME
CHALLENGES AND OPPORTUNITIES.
ONE OF OUR I THINK OUR REAL
STRENGTHS AND CONTINUED
OPPORTUNITIES IS IN THE
EXTENSIVE ENGAGEMENT WITH A
BROAD GROUP OF STAKEHOLDERS, WE
HAD PEOPLE FROM ALL LEVELS OF
HEALTH SYSTEM INVOLVED IN
GETTING INPUT TO THE DESIGN AND
IMPLEMENTATION OF THE TRIAL AS
WELL AS WE HAD PATIENTS AND
COMMUNITY MEMBERS ON OUR
ADVISORY BOARD AND LEADERSES OF
COMMUNITY BASED ORGANIZATIONS.
WE HAD THE INVOLVEMENT OF FIVE
HEALTH SYSTEMS THAT INCLUDED
FQHCs, WE INCLUDED DIVERSE
POPULATION AT HIGH RISK AND WE
USED EXISTING STAFF, SO THERE
ARE PLENTY OF OPPORTUNITIES HERE
TO USE EXISTING RESOURCES AND
STAFF TO BRING ABOUT CHANGES.
SOME OF THE CHALLENGES WERE
USING AN ACTIVE COMPARATOR GROUP
MADE IT SOMEWHAT DIFFICULT TO
DETERMINE, TO DETECT A
DIFFERENCE OFFERED BY ADDING THE
PATIENT FACING COMPONENT. THERE
MAY HAVE BEEN SOME CONTAMINATION
BETWEEN PRACTICES IN THE SAME
HEALTH SYSTEM. WE HAD SOME
IMPLEMENTATION BARRIERS WHICH WE
CAN GO INTO MORE DETAIL WITH IN
OUR DISCUSSION PERIOD. WE DID
USE CLINIC BASED MEASUREMENTS OF
BLOOD PRESSURE FOR OUTCOMES SO
WE DIDN'T HAVE RESEARCH STAFF
BUT USED CLINIC BASED
MEASUREMENTS BUT WE THOUGHT THAT
WAS A GOOD WAY TO HAVE -- TO USE
PRAGMATIC MEASURES, MEASURES
THAT WOULD BE USED IN CLINICAL
CARE AND WITH TRAINING WE
PROVIDED AND THE FIDELITY TO
TRAINING WE REALLY FELT
COMFORTABLE ABOUT QUALITY OF THE
BLOOD PRESSURE MEASUREMENTS. WE
DID HAVE SOME DISRUPTIONS DURING
THE COVID-19 ALL THESE ARE REAL
LIFE THINGS THAT HAPPEN. WE HAD
SOME LIMITED STATISTICAL POWER
FOR SOME OF OUR SUBGROUP
ANALYSES. WE KNOW RELATIONSHIPS
CENTERED APPROACHES AND
ENGAGEMENTS IS IMPORTANT AND
KNOW SOME ORGANIZATIONAL FACTORS
CAN CONSTRAIN SUCCESSFUL
IMPLEMENTATION SO WE WANT TO
LEARN MORE ABOUT THOSE THROUGH
OUR -- SOME OF OUR
IMPLEMENTATION MEASURES. WE KNOW
STAFFING AND FINANCIAL ISSUES
WERE PROBLEM FOR MANY OF OUR
SETTINGS. WE KNOW THERE WAS A
LOT OF TURN-OVER. THERE WERE
SOME COMPETING PRIORITIES
INCLUDING COVID-19. THERE IS
ORGANIZATIONAL INERTIA AND SOME
INDIVIDUAL ATTITUDE AND
BEHAVIORS OF STAFF MEMBERS THAT
HAVE TO BE ADDRESSED STILL. SO
I'M GOING TO WRAP UP WITH JUST A
SNAP SHOT OF SOME OF OUR CURRENT
RESEARCH TO ADVANCE
CARDIOMETABOLIC HEALTH EQUITY.
SO WE HAVE BEEN FUNDED RECENTLY
BY NIMHD TO CONDUCT A SERIES OF
STUDIES IN THE MID ATLANTIC
REGION. THAT WILL ADDRESS NOT
ONLY HYPERTENSION BUT OTHER
CARDIOMETABOLIC CONDITIONS. SO
WE WILL BE TESTING THE
EFFECTIVENESS OF THESE
INTERVENTIONS USING COMMUNITY
BASED RESEARCH AND PATIENT
CENTERED OUTCOMES PRINCIPLES.
AND THEN AGAIN USING THIS
KNOWLEDGE TO PROMOTE CHANGES IN
PRACTICE AND POLICY IN -- ACROSS
MARYLAND AND THE MID ATLANTIC
REGION. WE ARE FOCUSING ON
SOCIALLY DISADVANTAGED
POPULATIONS IN A NUMBER OF
DIFFERENT COMMUNITIES ACROSS THE
STATE, RURAL AS WELL AS URBAN
LOOKING AT A VARIETY OF
DIFFERENT CARDIOMETABOLIC
FACTORS. WE HAVE THESE THREE
TRIALS, ONE FOCUSES ON PEOPLE IN
THE PREGNANCY AND POSTPARTUM
PERIOD, TRYING TO INTERVENE WITH
HEIGHT RISK GROUP. WE KNOW
MATERNAL MORTALITY DISPARITIES
ARE DRIVEN IN LARGE PART BY
CARDIOVASCULAR AND
CARDIOMETABOLIC INEQUITIES.
ANOTHER STUDY FOCUSED ON
INDIVIDUALS WITH EARLY HEART
FAILURE AND ONE AGAIN FOCUSED ON
HYPERTENSION DIABETES AND
CHRONIC KIDNEY DISEASE BUT THIS
TIME USING TELEMEDICINE AND
TELEMONITORING APPROACHES TO
ENGAGE PATIENTS AND TO IMPROVE
THEIR SELF-MANAGEMENT PROCED
PROCEDURES. SO WHEN WE ARE DOING
THIS WE HAVE TO BE MINDFUL OF
THE FACT THAT OUR WORK SHOULD BE
INFORMATIVE TO POLICY MAKERS AND
I JUST WANTED TO SAY THAT IT HAS
BEEN AN HONOR AND PRIVILEGE TO
PROVIDED A VICE TO POLICY MAKERS
IN MARYLAND AS WELL AS TO SERVE
ON NATIONAL ACADEMIES COMMITTEES
TO PROVIDE CONGRESSIONAL
TESTIMONIES ON THESE ISSUES, TO
PROVIDE BRIEFINGS, TO POLICY
MAKERS AT ALL LEVELS DURING
COVID-19 AND ALSO TO CONTRIBUTE
TO POLICY BRIEF AND REPORTS,
WHETHER IT IS ABOUT CHANGES IN
HOSPITAL PERFORMANCE AND
MEASUREMENT REWARD SYSTEMS AND
WHETHER IT IS LIKE ADVISING HOW
TO ADVANCING SUSTAINED COMMUNITY
HEALTH WORKER WORK FORCE. WE
HAVE -- WE SEE MULTIPLE
OPPORTUNITIES FOR FUTURE POLICY
ENGAGEMENT, FOR EXAMPLE IMPLICIT
BIAS TRAINING AREA. THAT'S BEEN
MANDATED IN SO MANY STATES, WHAT
CAN WE DO TO BE SURE
IMPLEMENTATION IS SUCCESSFUL?
LEGISLATION TO OFF LOAD
FINANCIAL BURDEN ON PATIENTS.
SUPPORT FOR COMMUNITY HEALTH
WORKERS AND THEN ALSO HEALTH
SYSTEM COLLECTION OF SOCIAL
DETERMINANTS DATA AND HOW THEY
USE IT. WE KNOW IT IS NOT ONLY
ABOUT RESEARCH BUT IT IS ABOUT
ENGAGEMENT TOWARDS ACTION
BECAUSE IT WILL TAKE TRANSLATION
OF SCIENCE INTO PRACTICE AND
POLICY IF WE WANT TO ACHIEVE
HEALTH EQUITY WHICH IS WHAT
EVERY PERSON HAS THE OPPORTUNITY
TO OBTAIN HIS OR HER FULL
POTENTIAL. I WANT TO JUST
ACKNOWLEDGE ALL THE MANY PEOPLE
COLLEAGUES ACROSS THE SPECTRUM,
COMMUNITY PARTNERS, STAFF
MEMBERS WHO DO A LOT OF DAY TO
DAY WORK, PARTNERS IN THE HEALTH
SYSTEM AND COMMUNITY WHETHER
ORGANIZATIONS MORE INVESTIGATORS
AND STAFF AND AGAIN OUR
COMMUNITY ADVISORY BOARD OVER 65
PEOPLE HAVE BEEN COMMITTED TO
THIS WORK FOR MORE THAN A
DECADE. I WILL CLOSE BY LEAVING
YOU WITH AN OPTION IF YOU ARE
INTERESTED IN READING MORE ABOUT
THIS OR LEARNING MORE ABOUT
THIS, IN MY BOOK WHY ARE HEALTH
DISPARITIES EVERYONE'S PROBLEM?
THERE IS A DISCOUNT CODE THAT IS
SHOWN ON THE SLIDE AND THAT WILL
BE PROVIDED TO YOU LATER. I WILL
CLOSE AND SAY THANK YOU.
>>THANK YOU, DR. COOPER.
TERRIFIC PRESENTATION. WE HAVE
TIME FOR ONE OR TWO QUESTIONS.
SPEAKER5: MIGHT BE A LITTLE
FEEDBACK DR. MURRAY. I DON'T
KNOW IF YOU CAN MUTE SOME
VIDEOCAST IF YOU MIGHT BE
WATCHING ON THAT.
>>I'M GOING TO TRY TO --
>>I THINK WE FIXED IT, WHATEVER
YOU JUST DID.
>>LET ME POST THIS -- POSE THIS
QUESTION. MULTI-LEVEL
ENTERRECOMULTI-LEVELINTERVENTIOE
COMPLICATED THAN AT THE
INDIVIDUAL LEVEL. WHAT ADVICE
YOU GIVE POST-DOCS GRAD STUDENTS
WHO WANT TO DEVELOP MULTI-LEVEL
INTERVENTIONS? WHAT ARE SOME OF
THE MOST IMPORTANT
CONSIDERATIONS?
>>I THINK WHAT IS IMPORTANT
FIRST OF ALL IS TO GET THE RIGHT
TRAINING. IN THE SCIENTIFIC
PRINCIPLES, THAT ARE -- THAT
WILL INFORM DEVELOPMENT OF THESE
INTERVENTIONS. GET THE RIGHT
TRAINING AND MENTORSHIP TO
REALLY IMMERSE YOURSELF NOT ONLY
IN DOING THE SCIENCE BUT ALSO
ENGAGING WITH THE PEOPLE WHO
WOULD BE IMPLEMENTING THE
INTERVENTIONS, WHO WOULD BE
USING THE INTERVENTIONS, SO YOU
ACTUALLY UNDERSTAND HOW TO APPLY
WHAT YOU HAVE LEARNED
CONCEPTUALLY IN A PRACTICAL
SENSE, THAT IS THE -- THOSE ARE
THE TWO MOST IMPORTANT THINGS I
WOULD SAY. OBTAIN FORMAL
TRAINING, MENTORSHIP AND
EXPERIENTIAL LEARNING.
>>HOW ABOUT LEARNING TO
EVALUATE MULTI-LEVEL
INTERVENTION?
THAT IS PERHAPS MORE COMPLICATED
THAN DEVELOPING MULTI-LEVEL
INTERVENTIONS. WHAT --
>>I AGREE.
>>ABOUT THOSE METHODS?
>>I THINK THEY CAN LEARN BY
COLLABORATING WITH
MULTI-DISCIPLINARY TEAMS. FOR
EXAMPLE, I LEARNED A LOT OF HOW
TO MEASURE COMMUNICATION QUALITY
FROM A SOCIAL BEHAVIORAL
SCIENTIST MENTOR AND I HAVE
LEARNED MORE ABOUT HOW TO
MEASURE ECONOMIC OUTCOMES FROM
MY COLLEAGUES WHO ARE HEALTH
ECONOMISTS. I HAVE A COLLEAGUE
WHO IS AN ORGANIZATIONAL
BEHAVIOR SPECIALIST AND I HAVE
LEARNED SO MUCH FROM HER ABOUT
HOW YOU MEASURE ORGANIZATIONAL
ATTITUDES AND PERFORMANCE. L YOU
KNOW, YOU CAN START OFF BEING AN
EXPERT IN ONE THING AND
COLLABORATING WITH OTHER PEOPLE
TO LEARN ABOUT THEIR METHODS AND
OVER TIME A JUNIOR PERSON IS NOT
GOING TO NECESSARILY BE ABLE TO
IMPLEMENT A MULTI-LEVEL
INTERVENTION IMMEDIATELY BUT YOU
CAN PUT PIECES TOGETHER AND
BECOME PART OF A TEAM SO THAT
YOU LEARN FROM THE OTHER PEOPLE
AROUND YOU.
>>I COULD NOT AGREE MORE. IT IS
A TEAM SPORT. AND ONE PERSON
CAN'T LEARN ALL THE PIECES. I
WANT TO THANK YOU, DR. COOPER,
FOR TERRIFIC PRESENTATION AND
THANK OUR AUDIENCE FOR GREAT
QUESTIONS AND A LIVELY
DISCUSSION.
I WANT TO
THANK EVERYONE FOR JOINING
TODAY'S LECTURE.