The Institute convened the present Think Tank to obtain advice regarding the objectives and design of the next generation of research that will address health inequities in the US. The Think Tank was convened to both identify the causes of health inequities and advise the NHLBI on T4 translation and intervention research that would reduce the unacceptable high burden of disease among at-risk populations.
Selected Highpoints of Discussions
The determinants of health inequities are thought to be the same across diseases, including heart, lung, blood, and sleep disorders, and strongly influenced by social determinants, environmental factors and geography in addition to race and ethnicity. Geographic location can contribute to inequities through influences on social policies, safety, and access to recommended dietary resources such as fresh foods and vegetables as well as environmental pollution.
In addition to social determinants that affect to some degree entire at-risk populations albeit with larger negative health effects on minority and ethnic groups, factors that produce health inequities can also be assessed at the individual level. Health literacy, immigrant status, poverty, employment, income, insurance status, family support, personal habits and lifestyle, among others, can erode healthy functioning and undermine the will to engage in preventive self-care. The long, slow accumulation of emotional and physical trauma resulting from social disadvantage can be hard for health practitioners to recognize as part of the process of disease causation and more importantly, as part of regular provision of healthcare. Adverse experiences during childhood have even been strongly linked to disease later in life, particularly stroke. Together, these considerations suggest that the first line of intervention should be broad and inclusive to capture poverty status, access to healthcare, and other upstream factors that are not well captured within healthcare systems, in an attempt to achieve primary prevention at the population level, while more focused strategies must be developed to address the needs of subgroups.
Experience from efforts in hypertension control programs suggests that attention to the cultural environment, the community in which the targeted individuals live, and a sustained commitment of health systems, health providers, and community-based organizations are essential for intervention design. Thus, multilevel interventions are necessary to meet the challenge posed by the complex matrix of causes leading to health inequities.
Sustainability of effective interventions was acknowledged to be an important consideration in T4 translation research. Early engagement of a broad range of stakeholders in the design of the interventions and their implementation was also seen as essential for long-term success. Community involvement with empowerment likewise should inform the research design and are directly linked to sustainability. Research planning should take into account not only financial considerations but the concept of utility in intervention design, with an important emphasis on community context including infrastructure to support continual research to improve health. Community involvement will also increase the likelihood of including individuals who are outside of clinical care and therefore not reflected in EHRs. Community involvement can increase the likelihood for early intervention for the young or asymptomatic persons who may be seeking non-clinical services and may, therefore, be identifiable as persons "eligible" for interventions.
Due to the breath and scope of the determinants of health inequities and the similarity of influences on access and uptake of health care, creating a disease agnostic infrastructure for T4 translation research would inform healthcare in a manner that is applicable to any or many disease-specific categories and might afford a cost-effective yet health impactful approach. Importantly, shared resources also offer the advantage of evaluating whether interventions across multiple conditions are more effective than a series of disease-specific interventions.
Health care, policy, and economic circumstances will likely undergo significant changes in the coming years, resulting in opportunities to obtain data from "natural experiments." Specific changes are difficult to predict and thus, appropriate and timely responses may pose challenges to implement. If policy changes can be anticipated and planned, a phased roll out is desirable in order to collect comparative effectiveness data, such as employing a stepped-wedge or other relevant designs.
The need to train a new cadre of individuals with knowledge and skills to apply dissemination and implementation (D&I) research using integrated approaches is critical to improve the delivery of health and health care services, to improve the public's health, and particularly to evaluate interventional strategies to address health inequities. To address the complexity of health inequities, training must be trans-disciplinary with a strong integration of social sciences and other disciplines (e.g., marketing models, business acumen in health systems efficiency). Training in the use of big data science, predictive modeling, and research design to advance implementation science was encouraged. Training in public health research, including epidemiology and community health assessment and planning, will be important to effectively translate research to address health inequities. Training linkages with practice settings across disciplines and mentors connected to the D&I community and community partners were stated as critically important. Thus, T4 implementation research training environment is expected to have unique features.
Creation of a research platform for cost-effective implementation of protocols that can execute multi-level interventions using holistic approaches in collaboration with health care systems, community, local health departments, academia and Federally Qualified Health Centers and individuals was a repeated theme.
T4 research should emphasize proven, evidence-based interventions such as those recommended by the US Preventive Services Task Force (USPSTF), US Community Guide Recommendations, American Heart Association, other authoritative sources and organizations with the mission to reduce health inequities. In the main, however, some existing recommendations and goals from key stakeholders provide insufficient guidance to meet this complex change.
T4 translation research aims to drive adoption of proven, evidence-based interventions in populations that would significantly benefit from their implementation. As such, T4 translation research is team science and will require a multidisciplinary approach facilitated by teams composed of traditional academicians and non-traditional fields including, health economists, behaviorists, engineers and other groups that can contribute to developing a rigorous understanding of the problems and identifying innovative solutions in the T4 space. These diverse teams will require transparent decision making framework(s) to allow for reconciliation of differing viewpoints.
T4 translation research offers the opportunity for observational and intervention studies that document the outcomes of natural experiments. The implementation of the Affordable Care Act could allow researchers to gain significant insight into about how policy affects community and population health.
Efforts to engage collaboration by other NIH Institutes and Centers should be initiated early; CTSAs, Federal and non-federal agencies including state, local, and tribal health departments, health care organizations, community-based organizations, and other relevant foundations should also be engaged and specific goals for efforts to reduce inequities should be set. Furthermore, stakeholders including community-based organizations which are the lynchpin of T4 research should be adequately funded to fully participate in implementation and dissemination research.
Data needs and potential new sources of data will become increasingly important components of this work and should receive substantial early attention. For example, electronic health records (EHRs) are a rich source of data but EHRs and EHR systems are not yet interconnected with each other or with health information exchanges (HIEs). Primary care EHRs may be inadequate sources of data because individuals may seek episodic, fragmented care in emergency departments. These departments may be sources of data for individuals not otherwise in the health care system; although as currently constructed EHRs may provide insufficient individual-level data to be useful in efforts to reduce inequities. In addition, social service providers may be additional sources of data (opportunities to identify and target) that may describe individuals who are not interacting with health care systems. Developing a screening tool for social determinants of health that could be incorporated into the EHR will give providers and healthcare systems a granular sense of their minority patients' issues related to their care. Furthermore, setting metrics for relevant outcomes could drive the process of improving the value of health systems data. Linking practice settings to community-based resources will also make it possible to engage health care systems in evidence-based self-management strategies to reduce inequities.
Training and sustaining the complex workforce required for T4 translation research on health inequities will require unique programs that must be trans-disciplinary and include broad partnerships to sustain a robust research program over the coming years. Research capacity should be strengthened for mentors, individuals across the career trajectory, including those in various allied health professions and community health workers. Funding of small grant programs would make it possible to assemble teams to generate and vet innovative new plans for T4 research.
Training programs should also be considered within the curriculum of health professional schools, as these provide additional opportunities to develop a workforce competent in addressing health inequities.
Continued high level NHLBI leadership was deemed vital due to the complexity of the issues and the high level of engagement needed among Federal agencies, academe, the private sector and community. NHLBI could lead the way by initiating and executing signature studies in conjunction with other Federal agencies, academic medical Center for Translation Research and Implementation Sciences and other partners. In this framework, NHLBI and other Federal partners can create capacity for long-term monitoring and surveillance of health inequities within these signature studies and the progress toward reducing them. These studies could also demonstrate data sharing across federal agencies and institutions creating common databases for health inequities research. NHLBI can assure objectivity in data collection, inclusion of mixed methods when needed, and sustained follow-up.
L. Ebony Boulware, M.D., M.P.H., Duke University
Robert M. Califf, M.D., Duke University Medical Center
Lisa A. Cooper, M.D., M.P.H., F.A.C.P., Johns Hopkins University
Richard S. Cooper, M.D., Loyola University Chicago
Karina W. Davidson, Ph.D., Columbia University Medical Center
Ana V. Diez Roux, M.D., Ph.D., M.P.H., Drexel University School of Public Health
Kaytura Felix, M.D., Health Resources and Services Administration
John M. Flack, M.D., M.P.H., Wayne State University
J. Nadine Gracia, M.D., M.S.C.E., U.S. Department of Health and Human Service
Jeffrey A. Henderson, M.D., M.P.H,. Black Hills Center for American Indian Health
Robert M. Kaplan, Ph.D., U.S. Agency for Healthcare Research and Quality
Jerry A. Krishnan, M.D., Ph.D., University of Illinois College of Medicine
Tené T. Lewis, Ph.D., Emory University
Naomi L. Luban, M.D., Children's National Medical Center
James S. Marks M.D., M.P.H., Robert Wood Johnson Foundation
David Meyers, M.D., U.S. Agency for Healthcare Research and Quality
Olugbenga G. Ogedegbe, M.D., M.S., M.P.H., F.A.C.P., New York University School of Medicine
Letitia Presley-Cantrell, Ph.D., Centers for Disease Control and Prevention
Uchechukwu K. A. Sampson, MB.BS, MSc., M.B.A., M.P.H., F.A.C.C., Vanderbilt University School of Medicine
Eduardo Sanchez, M.D., M.P.H., American Heart Association
Viola Vaccarino, M.D., Ph.D., Emory University
Winston F. Wong, M.D., M.S., Kaiser Permanente
Jackson T. Wright, Jr., M.D., Ph.D., F.A.C.P., University Hospitals Case Medical Center
NIH Institutes and Centers
David Chambers, D.Phil., National Institute of Mental Health
Irene Dankwa-Mullan, M.D., M.P.H., National Institute on Minority Health and Health Disparities
Symma Finn, Ph.D., National Institute of Environmental Health Sciences
Mia R. Lowden, Ph.D., National Institute of Allergy and Infectious Diseases
Amy Patterson, M.D., Office of Science Policy, National Institutes of Health
William Riley, Ph.D., National Cancer Institute
Gary H. Gibbons, M.D., Director
Nakela L. Cook, M.D., M.P.H., F.A.C.C., Chief of Staff
George A. Mensah, M.D., F.A.C.C., Center for Translation Research and Implementation Science
Michael M. Engelgau, M.D., F.A.C.P., Center for Translation Research and Implementation Science
Peter G. Kaufmann, Ph.D. (Think Tank Lead), Center for Translation Research and Implementation Science
Chitra Krishnamurti, Ph.D. (Think Tank Co-Lead), Center for Translation Research and Implementation Science
Helena O. Mishoe, Ph.D., M.P.H., Center for Translation Research and Implementation Science
Robert S. Balaban, Ph.D., Division of Intramural Research
Glen C. Bennett, M.P.H., Center for Translation Research and Implementation Science
Jodi B. Black, Ph.D., Division of Extramural Research Activities
Allison T. Borst, Center for Translation Research and Implementation Science
Janita M. Chicquelo-Coen, Center for Translation Research and Implementation Science
Mishyelle I. Croom, M.A., Center for Translation Research and Implementation Science
Cynthia E. Dunbar, M.D., Division of Intramural Research
Lawrence J. Fine, M.D., DrPH, F.A.H.A., Division of Cardiovascular Sciences
Michelle M. Freemer, M.D., Division of Lung Diseases
Nara Gavini, Ph.D., Center for Translation Research and Implementation Science
Dinari A. Harris, Ph.D., Center for Translation Research and Implementation Science
W. Keith Hoots, M.D., Division of Blood Diseases and Resources
Joylene I. John-Sowah, M.D., M.P.H., Center for Translation Research and Implementation Science
Lenora E. Johnson, DrPH, M.P.H, Office of Health, Education, Communication and Science Policy
Michael S. Lauer, M.D., Division of Cardiovascular Sciences
Stephen C. Mockrin, Ph.D., Division of Extramural Research Activities
Mark E. Parker, Center for Translation Research and Implementation Science
Emmanuel Peprah, Ph.D., Center for Translation Research and Implementation Science
Catherine M. Stoney, Ph.D., Division of Cardiovascular Sciences
Rachael L. Tracy, M.P.H., Center for Translation Research and Implementation Science
Stephanie J. Webb, Ph.D., Division of Extramural Research Activities
Gail G. Weinmann, M.D., Division of Lung Diseases
Quanita L. Winters-Tyler, Center for Translation Research and Implementation Science
Shimian N. Zou, Ph.D., Division of Blood Diseases and Resources