Dalio Center for Health Justice

Sri Lekha Tummalapalli, MD, MBA, MAS; Will Simmons, MPH; Sumit Mohan, MD, MPH; Jeffrey Silberzweig, MD; Jonathan T. Lin, MD; Deirdre Sawinski, MD

Chronic kidney disease (CKD) disproportionately affects marginalized populations, including Black individuals and those with low socioeconomic status. Recent evidence shows significant racial and ethnic disparities in the receipt of guideline-recommended therapies for CKD, including sodium-glucose cotransporter 2 inhibitors (SGLT2i). Since receiving the 2021 Health Justice Research Grant, the team has created an electronic health record-based cohort of over 100,000 patients with CKD seen in the NewYork-Presbyterian system. They are examining disparities in the use of guideline-recommended therapies by race, ethnicity, insurance status, and neighborhood-level social deprivation and are developing a clinical decision support tool within the electronic health record to improve evidence-based prescribing. This research aims to improve the quality and equity of CKD care across the NYP healthcare system.

Lauren K. Groner, DO (PI); Erica Phillips, MD; Rulla Tamimi, ScD, Bradley Pua, MD; Stephen Peterson, MD; Rishikesh Dalal, MD, Nathalie Moise, MD

Lung cancer is the leading cause of cancer-related death in the U.S., although screening for lung cancer with a low-dose CT scan can save lives by catching lung cancer early when it's potentially curable. Unfortunately, participation in lung cancer screening (LCS) is much lower than for other screening exams, such as breast and colon cancer screening, and there are significant racial inequities regarding LCS rates, as well as diagnosis, staging, treatment, and outcomes. Although there are significant patient-, provider-, and organizational/institutional-specific barriers to LCS, there is also much overlap and influence of barriers across categories. Screening recommendation and referral by primary care providers are especially important determinants of screening uptake among patients. Thus, IBREATHE is focused on implementing strategies to mitigate barriers to LCS at the provider-level, and to some extent patient- and organization-levels, and facilitate increased screening rates among eligible high-risk adults, with the long-term goal of improving early detection and outcome disparities.

Since receiving the 2021 Health Justice Grant Dalio Center for Health Justice Grant in February, the team has conducted multiple nominal group sessions with primary care providers from around the country to understand physicians’ most prominent barriers to implementing guideline concordant lung cancer screening uptake/referral in their daily practice, particularly regarding minoritized patients. They have begun devising a multicomponent strategy to mitigate barriers to screening in the primary care setting based on the data from these sessions. Pilot testing of the final strategy will begin in early 2023.

Shashi Kapadia, MD, Alexis Vien, MD, Matt Scherer, MD

The team is focused on collecting data that will provide a local understanding of disparities in treatment for this population. The overall goal is to enable developing intervention at NYP that will improve care for people who inject drugs hospitalized with serious infections. With the support provided by the Dalio Center award, they have begun conducting qualitative interviews with providers across the NYP enterprise about this topic, including their perspectives on interventions that would help to improve care. Additionally, they have started design of a survey that will go to a wider range of provider, with a plan to launch this survey in early 2023.

Randolph Marshall, MD, Olajide Williams, MD, MS, Amelia Boehme, PhD, Patricia Peretz, MPH, Yvonne Stennett

This pilot randomized clinical trial aims to address known disparities in stroke outcomes for minoritized, underserved populations. Community health workers (CHWs) represent an untapped resource that has the potential to revolutionize mitigation of social determinants of health (SDoH). The study uses CHWs with hospital privileges and ties to a local community-based organization (CBO) to help mitigate SDoH needs arising from systemic racism and discrimination (SRD), including transportation, housing insecurity, food insecurity, poor health literacy, and challenges in health system navigation.

The initial funding from the Dalio Center was distributed to Community League of the Heights (CLOTH) in October 2022 to support the hiring of a new Director of Social Services, fulfilling plans for capacity building within the CBO. With the team fully in place, they began screening for enrollment in October 2022. Patients were randomized to the CHW intervention arm and to the Standard of Care arm. In the CHW intervention, the CHW has been able to assist with health care access, housing, and food insecurity. The team plans to continue to enroll approximately 4 patients per month to reach our goal of 40 patients in each arm by late Summer or early Fall 2023.

Laura Gingras, M.D.; Elizabeth Baquero Ed.D.; Meena Seetharaman B.A.; Sanjai Sinha M.D.; Keith Roach, M.D.; Fred Pelzman, M.D.; Nathaniel Kratz, M.D.; Parag Mehta, M.D.; Alfred Leong, M.D.; Mangala Rajan, MBA; Monika Safford, M.D.

Effective patient education, engagement, and empowerment are essential prerequisites that allow patients to participate in shared-decision making regarding their medical care, which in turn increases the likelihood that they will adhere to long-term medications for chronic diseases and experience better health outcomes. However, effective education and empowerment often does not occur due to time and resource constraints, sub-optimal communication practices, or inadequate cultural competency on the part of clinicians, and limited health literacy on the part of patients, among other factors. This problem affects all patient populations, but is particularly prevalent and detrimental in the care of marginalized patients and patients with lower income. These groups in turn have worse control of cardiovascular risk factors (such as hypertension) and higher prevalence of poor outcomes such as heart attack and stroke. Clinicians may utilize a variety of tools, such as pre-written patient instructions included with EMR software, pamphlets, websites, or other resources to try to supplement their communication with patients, but many of these tools are sub-optimal due to the excessive health literacy demands of the material among other issues, and there has been little research into the effectiveness of such tools, or the best ways to incorporate them into patient care.

Recognizing this, the research team has previously utilized patient input to develop a novel online education and empowerment tool - the Patient Activated Learning System (PALS) – and is now seeking to engage patients and clinicians to understand how best to integrate this tool into the primary care setting, specifically for patients with hypertension. Since receiving the 2022 Health Justice Grant, the research team has begun conducting focus groups of patients and primary care clinicians at three different primary care sites at NYP, in order to understand their needs and preferences. The findings from these focus groups are being used to develop an intervention utilizing the PALS, with the goal of increasing patient knowledge, engagement, and empowerment. In the second year of the study, the team will conduct a pilot randomized controlled trial of this intervention to evaluate its acceptability to patients with hypertension and their primary care providers. The team will also preliminarily collect data on medication adherence and blood pressure control.

Jennifer Mootz, PhD, Alwyn Cohall, MD, Renee Cohall, LCSW-R, Milton Wainberg, MD, Myrna Weissman, PhD, Jane Chang, MD, Cori Green, MD

Young people are disproportionately impacted by mental health disorders and have the worst access to outpatient mental health care. Existing mental health disorder disparities among racial/ethnic minorities have been exacerbated through COVID-19 and presented great challenges for care. The use of technology to provide remote mental health services represents a shift in care delivery that could reduce the unmet mental health need among racial/ethnic minority young people. The purpose of this project is to adapt an evidence-based intervention called Interpersonal Counseling to meet the needs of racial/ethnic minority adolescents/young adults to include monitored, self-guided modules coached through an app to increase mental health care delivery. The study sites are primary care programs at CUIMC and Cornell which provide primary care and sexual/reproductive health services for young people 13-25, where over 95% of whom identify as racial/ethnic minorities.

Since receiving the 2022 Health Justice Grant, the team has conducted a systematic review of literature to understand effectiveness of apps designed to reduce mental distress for adolescents and/or young adults and are writing a manuscript for publication. The team has assembled a Youth Advisory Board and team of experts to provide community-based input on how to adapt an app to create self-guided modules that are engaging and appealing for adolescents and young adults. The team has been working with an app developer to develop the design and a strategic plan for inclusion of self-guided modules. Additionally, the team is working with another technology partner to build a chatbot that can help connect youth and parents to resources for linkage to mental health care following screening positive for a common mental disorder within a primary care setting. Next steps are to develop mock screens for the app and chatbot text and receive feedback about them from youth and providers.