Interventions in the Real World

by ANNA WILLIAMS

Investigators are working closely with community partners to address healthcare challenges.

It’s estimated that academic medical centers see less than one percent of the American population over the course of a month. Yet much of the clinical research that informs broad, far-reaching medical policy is conducted within this small subset of the population.

For scientists like Abel Kho, MD, director of the Center for Health Information Partnerships (CHiP) at Feinberg’s Institute for Public Health and Medicine (IPHAM), this is a problem — not just for the patient groups that are consequently overlooked, but for the pursuit of science overall.

“In order to do statistically sound science, you need to get at larger data sets. And to do that you need to get out into that much larger real-world community,” says Kho, also an associate professor of Medicine in the Division of General Internal Medicine and Geriatrics and of Preventive Medicine in the Division of Health and Biomedical Informatics.

Kho is one of an increasing number of Feinberg investigators dedicated to what’s known as community-engaged research — research that involves direct collaboration with communities to identify and address health concerns. By taking such an approach, scientists hope to not only reduce health disparities, but also to deepen discovery.

“It’s not just that this type of research is more representative. It also bubbles up good ideas,” Kho explains. “By engaging people where they are, you move past just the priorities of science happening within the ivory tower. You end up getting at the real health priorities of people.”

By engaging people where they are, you move past just the priorities of science happening within the ivory tower.

Across the medical school, investigators are leading grants for community-engaged research projects that tackle a wide range of specific health challenges in Chicagoland and beyond — from interventions to prevent diabetes through collaboration with Hispanic-serving community organizations in Humboldt Park and South Lawndale, led by Matthew O’Brien, MD, assistant professor of Medicine and Preventive Medicine, to programs that address mental health and post-partum depression in at-risk women in Illinois, led by Darius Tandon, PhD, associate professor of Medical Social Sciences.

The landmark “All of Us” research program at Northwestern, part of a national precision medicine initiative that aims to recruit one million people, is also uniquely focused on reaching patient populations not traditionally connected to academic medical centers. Investigators hope the broad scope will lead to discoveries that might not otherwise be possible.

“For us, community-engaged research is just doing good science,” Kho says. “It’s one reason why we’re seeing a shift in this direction, both in funding and in national legislation.”

In fact, over the decade from 2007-2016, while research grants focused on “community” or “practice” research increased 66 percent nationally, they grew more than 200 percent at Feinberg.

“At Northwestern, we’ve made a commitment to engaging communities and stakeholders in our research, in the hopes of developing and evaluating more complete and implementable solutions for health’s challenges,” says Ronald Ackermann, MD, MPH, senior associate dean for public health and director of IPHAM and the Center for Community Health. “We take pride in this evolution of the way we conduct research, and we continue striving to expand this work to have the biggest impact we can on the health of Chicago and beyond.”

TRANSLATING FINDINGS TO COMMUNITIES

Namratha Kandula, MD, MPH, has long been dedicated to identifying solutions to health disparities by collaborating closely with underserved populations.

“Over the last 60 years, we’ve learned a lot about what promotes health and what causes disease — yet we are still seeing large health disparities in terms of some communities benefiting from the advances, and others not. Community-engaged research is a way to close the disparities gaps,” says Kandula, an associate professor of Medicine in the Division of General Internal Medicine and Geriatrics and of Preventive Medicine. “The question is, how do you take interventions that were developed in a very highly controlled setting, with a narrow population, and actually implement them in the real world?”

Kandula is now the principal investigator of a study to answer that question specifically within the South Asian community around Chicagoland.

South Asians, the second-fastest growing ethnic group in the United States, suffer a disproportionately high rate of cardiovascular disease. But the majority of research on the development of heart disease, and appropriate interventions, has been mostly conducted in populations of white men.

Namratha Kandula, MD, MPH

“It’s usually not as effective to take an intervention developed in one population and drop it into another,” Kandula explains. “There are a lot of cultural and social factors that determine how people think about their own health, how they think about prevention and how behavior change might work.”

With community partners, Kandula and her team have developed a program, the South Asian Healthy Lifestyle Intervention (SAHELI), that translates established lifestyle interventions — focused on diet, physical activity and stress management — to the community’s specific cultural context and needs. The program uses concepts and values that are culturally relevant to South Asians to inspire behavior change and includes established behavior change strategies, such as motivational interviewing, self-monitoring diet and physical activity. Key to the program is that it was developed using a community-based participatory research process, which involved investigators and community members throughout.

Kandula partners with Chicagoland community organizations such as Universal Metro Asian Services to test the efficacy of culturally relevant lifestyle interventions. Pictured are some of the events organized for her South Asian Healthy Lifestyle Intervention (SAHELI) study.

For example, through her research with community members around Devon Avenue — a largely South Asian area of Chicago — it became clear that exercising for personal benefit was not something inherently valued. As such, traditional exercise counseling, which emphasizes working out for 30 minutes a day for your own health, was not proving effective.

So the team developed an exercise intervention specifically for South Asian women that involved exercising with their children. “It turned out to be very successful,” Kandula says. “The whole family was on board, which was critically important to making it happen — and the only way we learned what might work was through working with the community.”

In a pilot study, participants enrolled in SAHELI saw significant improvements in weight and blood sugar levels at six months, when compared to a control group.

Now Kandula is launching a $3.5 million-National Institutes of Health-funded study to test the efficacy of SAHELI in a larger, more generalizable group of South Asians who all have at least two cardiovascular risk factors.

As part of SAHELI, the team is also forming a stakeholder advisory board, to help govern how the study should be conducted, as well as partnering with organizations such as the Skokie Department of Health, Metropolitan Asian Family Services and NorthShore University HealthSystem, to ensure that the program can be sustained.

“In addition to working with community members, we also like working with stakeholders, business owners, public health departments, policy makers — people from different sectors who bring a different perspective and can help us with longer-term sustainability of the intervention we are testing,” Kandula explains. “Our research does not happen in a silo.”

Kandula is also involved in research projects exploring the roots of cardiovascular disease disparities. She is a principal investigator for the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study, the first longitudinal study to understand heart disease etiology and risk factors specific to this group.

There are a lot of cultural and social factors that determine how people think about their own health, how they think about prevention and how behavior change might work.

So far the study has shown that Americans of South Asian descent are twice as likely as whites to have risks for heart disease, stroke and diabetes when their BMIs were in the normal range. Such data from MASALA, published in the Annals of Internal Medicine, has helped lead to a proposed congressional bill, introduced in late July, that would increase funding for medical research on cardiovascular disease in South Asians.

“My research is not successful just because I’m able to receive grant funding or complete the aims of a project. My research is successful if there is a community, clinical or policy impact,” Kandula says. “The ultimate goal of the research is to reduce health disparities by improving the care that people receive and working with communities to improve people’s lives.”

IMPROVING PRIMARY CARE FOR ALL

Kho, meanwhile, is leading a research project that aims to improve cardiovascular health by reaching a different group: primary care physicians in small practices around the Midwest.

After all, just as heart disease interventions proven in controlled settings may have limited success when applied to diverse sociocultural groups, strategies for physicians developed in large healthcare systems are not always as effective when applied to small medical practices with limited resources.

In 2015, Kho was awarded a $15 million grant to establish a consortium called Healthy Hearts in the Heartland. Funded by the Agency for Healthcare Research and Quality, the group assists independent clinics in Illinois, Indiana and Wisconsin in improving care around what’s known as the “ABCS” of heart health. These key measures focus on the importance of providing patients with aspirin therapy when appropriate, controlling blood pressure, cholesterol management and smoking cessation counseling.

Quality improvement strategies have been shown to increase these measures in academic medical centers and well-resourced healthcare systems, but it was unclear how these might be implemented in small, independent practices. Kho is aiming to find out in his study.

Abel Kho, MD

“There are a lot of resources that we take for granted in academic medical centers,” he says.

As part of the study, practice facilitators are working closely with individual clinics to tailor a program around improving ABCS measures with hands-on coaching, tools and strategies. Although the study is ongoing, the team has already discovered that this process of practice facilitation has led to noticeable increases across a majority of the study quality measures.

In many cases, the improvements are largely driven by helping primary care providers make better use of their electronic health records (EHRs).

“Once you put quality measures in front of people — for example, showing your current rate of patients who are eligible for aspirin who are actually on aspirin — that in and of itself drives change and is probably where we see the biggest benefit,” Kho explains.

The team also built a novel data reporting system, hosted at Northwestern, that enables the independent small practices to dynamically track and compare their quality measures through electronic feeds of EHR data.

It’s part of the reason why, beyond the immediate impact of Healthy Hearts in the Heartland, Kho and his collaborators see the study also kickstarting related research in the future.

“We hope that this opens the door to continue engaging with that much broader community of providers, rather than just those who are within large centers,” Kho says. “Both in terms of the relationships and the tools that we’re building, I think this can greatly increase the efficiency of how we do future research and engage unseen populations.”

Beyond the clinical impact of this approach, there’s also a bonus benefit to conducting research that so closely collaborates with different communities. For investigators like Kho and Kandula, it’s also intensely invigorating to their lives as clinicians and scientists.

“Community-engaged research is really what keeps me going. I find it to be a great antidote to burnout,” Kandula says. “To be able to work with these wonderful partners who are excited about the work that we do, and to see the way that it impacts people’s lives, has been so incredibly rewarding.”

For more information about community-engaged research at Feinberg, view the latest report from the Center for Community Health.

Healthy Hearts in the Heartland

Kho’s consortium covers a region that is home to more than 16 million people. About 34 percent live in areas considered medically underserved. The Healthy Hearts in the Heartland project provides small, independent clinics in those areas with quality improvement services for cardiovascular care that are typically not available to practices with limited resources.