Ep. 11: Population Health: Advancing Equity Through Research and Community Partnership

Population health looks beyond the treatment of individual patients to understand the community, regional and system-level forces shaping health outcomes. That includes inequities driven by race, socioeconomic status, geography, and structural barriers that influence how people live, work, and access care. Chronic disease burdens remain high and social determinants continue to impact wellbeing across Western New York, but the Jacobs School is stepping forward with research, community partnerships, and equity-centered interventions that don’t just treat illness — they transform systems.

In this episode, host Allison Brashear, MD, MBA welcomes two guests who are leading this work nationally and here at UB, helping define the future of population health in our region. 

Leonard E. Egede, MD, is a nationally recognized expert in health disparities and chronic disease outcomes,  and Charles and Mary Bauer Endowed Professor and Chair of the Department of Medicine at the Jacobs School.   

Rebekah J. Walker, PhD, is chief of the Division of Population Health, whose research focuses on social determinants of health, structural barriers such as food insecurity, patient engagement, and equity-centered approaches to chronic disease management. 

Transcript

SPEAKER_02 0:02

Hello and welcome to the UB Medicine Podcast. I'm Dr. Allison Brashir, the Dean of the Jacobs School of Medicine and Biomedical Sciences, and Vice President for Health Sciences at the University at Buffalo. Today we're exploring population health, work that looks well beyond individual patients so that we can understand the community, regional, and system-level forces that are helping shape health outcomes. As chronic disease burden remains very high and the social determinants of health continue to impact the well-being across Western New York, the Jacobs School is stepping forward with research, community partnerships, and equity-centered interventions that just don't treat illness. They help transform systems and, near and dear to my heart, make sure that we intervene early, maybe before disease even starts. Today we have two guests that are leading this work in Buffalo and nationally, and here at UB. They're helping to find the future of population health for our region. I am so pleased to welcome two leaders driving innovation and health equity and community-engaged research. First is Dr. Leonard Agetty, nationally recognized expert in health disparities and chronic disease outcomes. He is the Charles and Mary Bauer Endowed Professor and Chair of the Department of Medicine at the Jacobs School here at UB. His work examines how race, socioeconomic status, and geography drive inequities and how evidence-based interventions can close those gaps. Also is Dr. Rebecca Walker, Chief of the Division of Population Health, whose research focuses on the social determinants of health, structural barriers such as food insecurity, patient engagement, and equity-centered approaches to chronic disease management. Leonard and Rebecca, welcome to our UB Medicine podcast. So we're going to start at a really high level here. What is population health and why does it matter? Leonard, we'll start with you.

SPEAKER_00 2:16

Yeah, so uh population health is really the idea of looking at health from a uh broad base as opposed to the individual uh patient. This is really about systems, it's about about communities, it's about uh groups uh across the board.

SPEAKER_02 2:31

Great. And Rebecca, what does population health mean to you and your work?

SPEAKER_01 2:35

Well, population health to me really talks about how we can understand trends in health, differences in healthcare, subgroups that are maybe having disparate impact of care, and being able to look at that at a big level.

SPEAKER_02 2:49

So, how do we have uh help our community understand why this is important? Because the health outcomes here in Buffalo are not good. Um, and we're so glad both of you joining us here at UB and at Buffalo. Um, let's think about um the individual patients and how they can understand how important this work is.

SPEAKER_00 3:11

Yeah, so uh I think uh when a patient comes to the clinic, uh usually they're coming for one uh individual uh case. When we think of population health, we're thinking about groups. So, for example, East Buffalo, Western New York. And what we're able to do is we're actually able to gather data across multiple groups and use that to inform where there are gaps. So, for example, are there gaps by race, are there gaps by gender, are there gaps by educational attainment? And the most important way we gather that information is through research. So patients who engage in research allow us to actually do that type of work and gives us data that we can actually report back about the health of populations.

SPEAKER_02 3:51

That's excellent. So, um, Rebecca, what are some things about like food insecurity and things that you focused on? Help us understand how population health gets to that issue.

SPEAKER_01 4:04

Yeah, so food insecurity we often think about at the individual level. And so when we're thinking about it from a population health standpoint, what we're thinking about is food access in the neighborhood. How does the food get to people? What communities have access to certain types of food? And we also look at the drivers of that food insecurity. So food insecurity is not just a matter of having food, it's usually a matter of the resources that you have as a family. So we can start doing interventions that focus on poverty, which in turn impacts food insecurity instead of just focusing on the food.

SPEAKER_02 4:39

That's excellent. And you know, nutrition here is incredibly important as a Jacob School, and all of our medical students are involved early on in working with community-based organizations. And I know you've been involved with several of them because you know, food is the basic, you know, sustenance of the of health, right? Um it's so, so important. Um, tell me about the structural challenges, you know, about patients when they show up. How can we help them? Um, and and Leonard, maybe that it goes to your point about research and geographics, because there's all this chronic illness, right? Um, I'm a neurologist, uh, we have a lot of stroke here. Um, and uh, how can we help use your work to really drive down the number of chronic illnesses we have, which of course increase the cost of care dramatically?

SPEAKER_00 5:32

Yeah. So we uh uh uh we tend to approach this uh from multiple, what we call multiple levels. So you have at the individual level, uh, where you are focused on the on what's happening at the individual level, things like you know, diet, exercise, what people actually do on their own. Then you go to the next level, which is more about neighborhoods. What's your neighborhood like? Uh you know, housing, transportation, access to care, how far do you have to drive to get to healthcare? And then we go to what we call the macro level, which is really policy. Uh, what are the policies in place? So, whether it's local government policy, whether it's state policy, whether it's federal policy. So, as you can see, a lot of those things are all connected. And so most of what we try to do and what we are trying really focusing on right now is how do we link the individual to the neighborhood to the policy, and how do we change policy that then comes down to actually improve the health of individual patients.

SPEAKER_02 6:25

That's great. Um, Dr. Walker, can you talk a little bit about the research and how you've been redesigning um and you both uh Leonard, as the new chair, you developed a new section about community-based health. So maybe Rebecca, you can jump in and Leonard can can also tag in.

SPEAKER_01 6:44

Yeah, absolutely. So one of the things that we are are doing is really making sure that the research we are doing is available to all communities. And that involves moving the research out of the medical space and into the community. One of the big ways that we've redesigned to do this is what we call field sites. So we have community partners throughout Buffalo and Niagara Falls that serve as sites for research. So our team goes to the community instead of asking the community to come to us. What that does is it allows people who have never participated in research before see that the research is important to them. And once they can understand how it's going to impact their family, their community, they're more interested in participating. But it also makes it easier. They don't have to take off of work for to come in for research study. Um, they can participate in the evenings or the afternoons, or they can stop over because it's close to where they are.

SPEAKER_02 7:41

That's great. And for, you know, here at UB, we want to build our research portfolio, particularly clinical trials. And so, so give us a just a very short nugget of what one of your research trials is that you would enroll maybe in a community organization, both here in Erie County and up in Niagara.

SPEAKER_01 8:02

Yeah, so an example would be one of our NIH-funded studies. Um, so this is a study that is looking at lowering cardiovascular risk by uh in individuals who are food insecure by combining uh financial incentives to help them purchase healthy food with education on cardiovascular risk. So individuals can come in for their assessments, which they complete at these field sites. Our health educators deliver the education over the phone, so they don't need to come in for that education, and then their financial incentives are delivered over a reloadable card. So they can then go use that immediately at the grocery store, any grocery store of their choice. And hopefully what we will see is that they're able to change their habits, lower their cardiovascular risk over time.

SPEAKER_02 8:49

So, Leonard, how do we track that? So you have a uh a patient population, um, they have healthy food, which they may not have access to because we have several food deserts here in our region. And then how do we measure that to say that this intervention works and needs to be scaled?

SPEAKER_00 9:10

So, what we have uh systems in place now is using census track data. So uh we set up baselines with census track data to look at, and we have uh multiple indices you use to track uh, you know, kind of what's happening at that level. There are actually measures of food access, the measures of health outcomes at the population level. But we also do tracking at the individual level. So we since we've been here now, we've actually recruited more than 600 individuals into research studies in a very short period of time. We gather that information, we link that data at the individual level to more of the census track. So we can then say uh if we took people who actually got this intervention, here's what it did for them on an individual level. But then at the population level, we are seeing trends and we're seeing changes. So an example of work like this we did was in South Carolina, where the goal for diabetes was to reduce amputations. And we actually went in and said, let's provide education at the at a local level, and then we actually were able to track amputation risk over time. And what we found was that by providing that intervention, over a three to five year period, amputation risk went down. So we're expecting that when we rule out these types of intervention, cardiovascular risk will go down and health uh outcomes will improve at the population level.

SPEAKER_02 10:24

That's excellent. And just to a final point, that was amputations. And that's a three to five year time frame. Over that time frame, and you may not know this, but does that decrease the cost of care as well as the outcome?

SPEAKER_00 10:40

Absolutely. So the expectation is that when you actually address some of these issues, you actually benefit the healthcare system. Because many of these individuals are having a difficult time, they have more complications, they are they are coming from multiple admissions, they are use the ED more frequently, emergency room more frequently. So by providing access, by providing uh uh resources, you decrease their use of resources. And so we saw a decline in uh in uh inpatient admissions, we saw a decline in uh cost of care because of those interventions.

SPEAKER_02 11:12

That's excellent. So, Rebecca, as your team is out and about in the communities, and we're so pleased that you both have come and have got everything up and running so quickly, what are some of the barriers? And and how can people who are listening to this, because people who listen to this are community members, medical students, patients, how can they understand the barriers that your team might and how can they participate?

SPEAKER_01 11:38

Yeah, well, one of the things that the team has done is they have made sure that people understand there's no need to be part of a certain healthcare system to participate. Um, and so you can come and participate in our studies regardless of what provider you go to. The information that we collect for our studies is not provided to insurance companies or anything that would change your benefits. And so that's very important. And it's a barrier that really a lot of times we address with our informed consent. We have a very detailed informed consent to make sure that people understand, especially if they've never participated in research, the risks, the benefits, and what the research is going to entail. So, what our team has really tried to do is just be very open, transparent, and make the process as easy as possible for people to participate.

SPEAKER_02 12:28

That's excellent. So I just left the AI and health symposium earlier this morning here at the Jacobs School, and we had experts both here locally, and what the keynote was from UCSF. And so, how does AI impact your ability to take your data? And how do you think we want our community to understand the benefits and risks of AI at this kind of research level?

SPEAKER_01 12:56

Well, so we really like to see AI as a tool and not as an outcome. And what we want to use is AI when it is the best tool for the process and not use it when it's not the best tool. We are very focused on ensuring that we're keeping up with the changes, with any kind of improvement in the process and when we might be able to bring that in. But then we also also want to be very clear and transparent when we're going to use it so that our participants understand whether they want to participate or not.

SPEAKER_00 13:28

Yeah, let me add to that just to give some concrete examples. So we have two large uh NIH grants right now using AI as a as a as a strategy. And what AI allows us to do is we are collecting data at multiple levels. We have like 30 years of data at the census track level, at the health systems level, and we're able to actually use those machine learning, neural networks, so deep AI methodology to crunch that data and come up with meaningful conclusions that cut across systems. So that uh that's more at the national level. The other area we're looking at right now is uh if you think about things like uh diabetes education and uh diabetes prevention, most of those uh systems right now are designed to be delivered face-to-face, one-on-one. It's very inefficient, it's very expensive, it takes a lot of time, and we are looking at uh AI uh models now that could actually do that training at the patients whenever they want it, at the time that's convenient to them, and allows them to actually get information in a very meaningful way. So that's going to shift the way we actually provide care because it allows patients to actually call on those models to actually ask questions and be able to get information without having to have someone be available at the time. So then the provider and the clinical team becomes more uh available to them to clarify things they can get where they actually have questions.

SPEAKER_02 14:47

So, how do we um take that work and deal with some of the social determinants of health? So people who don't have a uh smartphone, people who you know aren't as savvy. How do we how do we deal with that as we seek to make sure that everybody in Western York is able to participate?

SPEAKER_00 15:07

Yeah, so I think um there are a couple of strategies that actually need to uh play in. One is we actually need to increase digital literacy. So we have programs now where we actually how do we help community members learn how to use, learn about AI, learn about uh technology, how to use technology. So, for example, in diabetes right now, we have CGMs, which are continuous glucose monitors, which are phenomenal. But most patients, we did the focus group recently, and most patients don't even know what CGMs are, they don't know the benefits. So we're actually doing a lot of community education right now to address that. The second area is uh not just digital literacy, but the use of community health workers. These are individuals who are embedded in the community, they know the people, they understand the context, and they become the individuals who become ambassadors for us in terms of getting information and sharing that information with participants. So that has allowed us to have increased uptake in a lot of programs that we actually have.

SPEAKER_02 15:58

That's excellent. So um, you are a primary care doctor, um, still see patients. Um, I'm a neurologist, I saw patients uh Tuesday. Um, and so let's talk a little bit about primary care. And we have UBMD primary care, which I know you've both been very supportive of, and we are building the primary care group here uh with ECMC. So we have a large grant with ECMC to build more primary care students that'll stay here and work in Buffalo, and uh we're gonna build a health complex and all about trying to improve access for some of the people that I think we've talked about, right? Um, and we're building a new front door. So, how do we take kind of your work and partner that with primary care? I think you know, we've all said everybody in Buffalo needs a quarterback, not just the Bills. Um and how do we take your work and then um really operationalize it down to medical students wanting to go with primary care? Because if people have a primary care physician, maybe we'll get the diabetes and the hypertension and all these things that are risk factors taken care of really early.

SPEAKER_00 17:17

So we have uh uh in the populational health space, we have implementation scientists. And those individuals are individuals who their research is focused on how do you take evidence and make it actually uh usable in your clinical settings. So one of the things we're working on right now is integrating the evidence from studies into primary care settings. And what we have actually been able to do is to engage a lot of our physicians in some of the research areas, getting them involved, helping with recruitment, but also being able to disseminate that information. The other area is uh more of a systems approach. So we actually now with analytics, especially with what Rebecca and her team uh do, we're able to get information now at the analytic level. We can actually look across swords of a whole clinic uh and look at access to care. We can look at things where there are gaps and use uh evidence to actually fill those gaps as it relates to chronic disease uh management.

SPEAKER_02 18:09

That's excellent. And you know, these are models that you're doing in Buffalo and you've been in, you know, um Wisconsin and South Carolina. Can we scale these globally? Because we have significant outcomes here in Western York and in our country, but there's also significant health outcomes uh for everything we've talked around across the world. So how do we scale this globally?

SPEAKER_00 18:31

Yeah, so we uh we've we've been doing this now uh probably for 20. I have been doing it for 20, 20 plus years. Uh, we have programs in uh in Central America, we have programs in East Africa, we have programs in uh uh uh uh the Middle East. And what we've actually found is that a lot of the work we do in underserved populations in the US are very relevant to many of these global environments. And so we've actually created systems where we take trainees, we expose medical students and residents to these uh programs, we train faculty in those environments, we actually provide systems of care. Uh so for example, we had a program in Kenya where we're actually working with the Ministry of Health to actually provide care uh for uh for kidney patients and cardiovascular disease uh risk reduction in those environments. So we're taking things we learned here and taking it over there. But we're also finding now that as our immigrant population grows, we're also taking things we've learned in those countries and able to then uh uh use it to tailor care that is uh that is very culturally appropriate for the populations that actually have moved over here.

SPEAKER_01 19:34

I think another thing that we're able to do is we're able to take our expertise and help others apply it in their space. So we just met with a team in Uganda, um, provided information on how to use an implementation research strategy in the work that they're doing in emergency care. And so the expertise that we have here at UB can then be spread globally.

SPEAKER_02 19:55

That's excellent. So we're gonna wrap it up here, but I need just um we always do this. And if you have a one to two sentence uh message that you want to give to everyone about building a healthier, a more equitable Western New York, what would that be? And Ladrin, I'll start with you.

SPEAKER_00 20:11

Yeah, I think uh lifestyle intervention is the way to go. We need to spend more time really helping people understand the benefit of diet, exercise, and then also now the concept of uh you know digital literacy, because the more people, a lot of information today is out there on the web, it's out there on uh uh technology uh platforms, and people need to know how to access information and use information. So I would say lifestyle and then digital literacy will be things we really need to need to work on.

SPEAKER_02 20:38

And all those things help your brain too, right? It's really important. Yes.

SPEAKER_01 20:42

Um Rebecca, your closing thoughts. So I I think that the the next wave is really how do we integrate social and medical care together, um, whether it's in the same space or linking the groups that provide this, how do we do that in an efficient way so that the patient is the center of it? And then how do we scale it at a population level? That's excellent.

SPEAKER_02 21:01

Well, you've laid a tremendous groundwork for everything that we can change, the health in Buffalo, Western York, and as you mentioned, Leonard globally. I want to thank you both for your leadership and dedication to improving health equity and truly transforming the health of Western York and being just a bright light here at UB on how we're gonna make a difference and some of the most uh troubling health outcomes. So I just want to thank you again. And to our listeners, thank you for joining us. I'm Dr. Allison Brashir, and this is the UB Medicine Podcast. We look forward to more conversations about innovation, discovery, and the future of health of Western New York. Join us again and every time. Thank you.