Using Medtech to Close the Gaps in Care

In 2016, CDC released a report on its strategies to reduce inequities in healthcare, a major effort in public health and a step toward meeting the agency’s Healthy People 2020 goals. The report built on Health Disparities and Inequalities reports in 2011 and 2013 and a 2014 report from CDC’s Office of Minority Health and Health Equity.

This report examined health disparities in the United States associated with various characteristics, including race/ethnicity, sex, income, education, disability status, and geography. Health disparities were defined as “differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes.” 

Across several projects, such as reducing or preventing diabetes in American Indian Alaskan Native communities, interventions moved away from a common focus on changing individual behaviors to examining the biological and social factors that increase the likelihood of disease (eg, risk increased by high levels of stress), social factors, and types of interventions. Integration with traditional values, traditional meals, creation of community support networks, and community involvement in interventions were highlighted as methods for improving outcomes. In short, public health working within communities to reach patients in ways that are effective within those communities.

Cardiovascular care without patient burden

Medtech could be key in helping to understand healthcare usage, points for intervention, and effective methods for intervention, as well as ways to lessen patient burden. New York-based Feinstein Institutes for Medical Research, part of Northwell Health, has been working toward these community-based efforts with recent studies and device-driven interventions. In 2022, Feinstein launched a pilot trial aimed at lowering the rate of cardiovascular disease in the African American community. The goal of the study is to better understand the reasons for the lack of medication adherence across all patients (around 50% of all patients). Cardiovascular disease disproportionately impacts African Americans.

The study enrolled patients in a trial that used smart prescription bottles in order to track dosage and timing of medication usage. Smart bottles with weight sensors wirelessly deliver information to the study team when a dosage is taken, explained Mark Butler, PhD, an assistant investigator in the Institute of Health System Science and principal investigator. As a method to drive adherence, text message prompts are sent to trial participants. Data is being collected on the most effective messaging and frequency, and impactful medication dosage. The texts utilize the multi-behavioral change technique (BCT) method, which takes in feedback, helps to set goals, and plans actions to increase likelihood of adherence.

A key aspect of the research was the ease for patients. “We wanted to have a behavioral intervention delivered to individuals identifying as Black or African American which can be delivered entirely virtually, so we are talking enrolling, providing intervention, analyzing data,” said Dr. Butler. “Minimizing burden for participants as much as possible. The benefit of this is that once a person gets the medication bottle from their pharmacy, they don’t have to do anything. They don’t have to use their smartphone to link, the pill bottle sends it to us in real-time.”

Statins are linked to a reduction in cardiovascular disease exacerbation and risks, yet adherence is low across all patient populations. “We have a very useful medication for preventing cardiovascular disease not being taken by a population of people who would benefit from it, especially by African Americans and Blacks who also bear a disproportionate burden of cardiovascular disease,” said Dr. Butler. “It’s a one-two punch of people who need it more and take it less.” 

“Cardiovascular disease is a major driver of death, particularly among people in the Black community. Understanding how to promote adherence to life-saving medications is one of the best ways we have to shrink that disparity,” said Dr. Butler. “We hope to determine the best intervention strategies to help people stick to their prescribed treatments and improve their cardiovascular health.” The research also received backing from TD Bank with a $150,00 grant for the project.

Texts for obstetric intervention

Though not specifically targeted at diverse patients, Northwell Health has again used medtech to drive for better outcomes. The system, in late 2022, released AI-powered chatbot for obstetric outreach with its “Pregnancy Chats.” The platform links patients who are seen at any participating Northwell Health obstetrics practice (currently 30 practices since October 2022) with a text message service designed to answer their questions and let them know when to seek medical care.

The effort is part of Northwell’s initiative to reduce maternal morbidity and mortality in the US, a key reason for the launch of its Center for Maternal Health. In 2020, CDC’s National Center for Health Statistics reported the rate of maternal mortality increased to 861 women in 2020 (23.8 deaths per 100,000 live births) up from 754 in 2019 (20.1 deaths per 100,000 live births). Further, among non-Hispanic Black women, the 2020 rate was 55.3 deaths per 100,000 live births–close to three times that of non-Hispanic white women in the US.

The chatbot provides weekly information to patients during and after pregnancy and provides a lifeline to ask questions and share information that could highlight risk factors or a developing condition. The information is provided based on the patient’s stage of pregnancy and interactive questions are created to solicit information on possible changes in health, ideally heading off issues before they become detrimental.

So far, the chatbot, which is powered by dedicated nursing staff responding to patient questions, has been used by more than 1600 patients. Users have reported a 96% satisfaction rate (“satisfied” or “somewhat satisfied”), and a patient’s severe preeclampsia was identified.

“Far too many pregnant and birthing people in this country suffer harm or even die because of problems that are entirely preventable. Northwell is committed to doing whatever is necessary to reduce those risks,” said Dawnette Lewis, MD, MPH, director of the Center for Maternal Health. “By bringing together high-tech innovation and high-touch clinical care, the Northwell Health Pregnancy Chats will help keep women and babies safe.”

Dr. Lewis shared that the tool is hoped to provide information, and interventions when needed, for patients throughout and after their pregnancies, the entire antepartum period. “It’s really difficult to help when patients come in for [emergency] care without history,” explained Dr. Lewis. “The idea came, what if we can reach patients sooner in their care? If we can identify issues, then they can get the help that targets [their health issue].”

The effort initially came out of COVID when women were sent home more quickly than usual after giving birth and care teams were seeking to monitor them and to address health issues that resulted in readmission for postpartum care. As the program grows, it is intended to identify patients at risk, explained Dr. Lewis. “We are trying to come up with risk assessments for when they enter prenatal care,” she said, though these efforts are just beginning. This work could include the “use of AI to determine if a patient is at risk for preterm labor.”

Interventions that fit a purpose

Understanding when and how best to reach patients for interventions is also one of many points of research for Felicia Hill-Briggs, PhD, professor with the Institute of Health System Science at the Feinstein Institutes for Medical Research, Simons Distinguished Chair in Clinical Research, and professor of medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.

She works with national committees to better understand social determinants of health, interventions that reach at-risk populations, and increasing diversity in clinical trial enrollment. “All three of these areas: developing interventions, addressing social determinants of health, involving racial and ethnic minorities in research,” said Dr. Hill-Briggs. “All three of those are critical to addressing inequities, but they all are targeting different aspects of the problem because its complex, it’s multifaceted.”

Interventions, for instance, must first be determined by understanding when in a care continuum patients can best be identified. An observational study could help to determine when patients present with a particular set of symptoms. In the case of high maternal mortality for Black and African American women, for instance, when are pregnant women seeking care?

Once the point of breakdown in healthcare is determined, additional studies can help to identify interventions. Even something as simple as a checklist can improve outcomes. “[A physician thinks] ‘I don’t want to waste a resource that wasn’t necessary.’ A checklist gives them permission and reminds them,” said Dr. Hill-Briggs. “It also empowers the healthcare team whereas a physician makes the final decision about sending a patient home or for testing, it empowers a nurse to say ‘should we send her for additional tests?’”