# Hotspotting Cardiometabolic Disparities for Simulated Advances in Population Care

> **NIH NIH R01** · HEALTHPARTNERS INSTITUTE · 2021 · $500,581

## Abstract

Project Summary
Cardiovascular disease (CVD) is a major public health problem, particularly for patients and neighborhoods
with low socioeconomic status. Growing evidence has encouraged health systems to explore the use of
community health workers (CHWs) to improve screening and management of CVD and cardiometabolic risks
(CMR) among patients and communities with disparate disease burden. Yet broad systems change has been
limited by a lack of outcome and cost data of sufficient scope and duration.
We propose using innovative systems-science methods to model and analyze the effectiveness and cost of
individually-targeted and neighborhood-targeted CHW interventions to reduce CVD disparities. The results will
provide sought-after guidance for health systems implementation of optimally targeted programs to improve
population health disparities. Public health in general will benefit significantly from the creation and validation of
a systems-based framework for targeting communities experiencing CVD disparities with coordinated clinic-
and community-based CHW programs. By merging spatial hotspot analysis with established microsimulation,
this study's innovative methodology will provide novel and actionable knowledge based on simulated large-
scale implementation of CHW interventions currently supported by small-scale trial data, yielding a replicable
means for health systems and policymakers to identify, model, and improve health disparities in the future.
The project has five stages. Stage 1: Data collection, geocoding, and spatial aggregation of de-identified data;
Stage 2: identification of geographic hotspots of CVD and spatial statistical analysis to determine factors of
neighborhood risk; Stage 3: adaptation of our established microsimulation model to the disease, demographic,
and social characteristics of hotspots and to the parameters of CHW interventions; Stage 4: microsimulation
modeling of clinic-based CHW interventions targeted to patients with individual and neighborhood CVD risks
and community-based CHW programs targeted to neighborhoods according to disparate burdens of CMR and
CVD; Stage 5: comparison of the disease outcomes, geographic clustering of CVD, cost-effectiveness, and
sustainability for CHW interventions for CMR and CVD along 2-, 10-, and 20-year time frames.
We will collect, de-identify, and aggregate service data from the 2 safety-net health care systems serving most
patients and high-risk communities in a Midwestern metropolitan area. That data will provide a granular view of
the neighborhood distribution of CVD and CMR illness burden across the metropolitan area to allow for robust
spatial analysis and microsimulation modeling. Microsimulation analyses informed by empiric data will allow us
to compare the effects of targeted clinic- and community-based CHW programs on disparities within
communities across the metropolitan area. By melding spatial hotspot analysis with microsimulation in an
innovative systems-science appr...

## Key facts

- **NIH application ID:** 10215376
- **Project number:** 5R01AG052533-04
- **Recipient organization:** HEALTHPARTNERS INSTITUTE
- **Principal Investigator:** Bjorn Christopher Westgard
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2021
- **Award amount:** $500,581
- **Award type:** 5
- **Project period:** 2018-09-01 → 2024-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10215376

## Citation

> US National Institutes of Health, RePORTER application 10215376, Hotspotting Cardiometabolic Disparities for Simulated Advances in Population Care (5R01AG052533-04). Retrieved via AI Analytics 2026-05-25 from https://api.ai-analytics.org/grant/nih/10215376. Licensed CC0.

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