Public Health Cubed Fall 2017 Awardees

October 10, 2017

The Institute for Public Health has awarded Public Health-Cubed (PH3) grants to nine projects this fall.

PH3 is a rapid seed funding mechanism to support cross-disciplinary projects from the Institute’s faculty Scholars. For this cycle 2.0, we sought projects that focus on health equity and community and social disparities. Projects address issues specific to, or with potential impact in, our local St. Louis region. Funding for fall 2017 projects were awarded to:

Assessing the Indirect Costs of Clostridium Difficile Infection: A Survey of Caregivers of BJC Patients

Team: Derek Brown, PhDErik Dubberke, MD, MSPH; Abigail Barker, PhD

This project will to inform a scientific gap in evidence on the burden of clostridium difficile infection (CDI) caregiving. The goal is to influence professional practice in favor of prevention by reinforcing existing data on direct costs with new information on the substantial indirect costs that occur in the form of caregiver burden. Prevention may be shown to represent a net savings to society and will likely have disproportionate benefit for those demographic groups at risk for prolonged or multiple episodes. The team will develop, administer, and analyze a survey of caregivers (usually adult children) of BJC patients infected with CDI (usually aging parents) to estimate the indirect costs associated with the infection. The outcomes are estimated indirect costs stratified by different demographic categories, which can in turn be used to estimate the total societal value of prevention of (in the form of a vaccine against) the infection. To the extent permitted by sample size, the study team will test for disparities in the economic and quality of life burden of CDI caregiving along racial/ethnic and sociodemographic strata. If disparities are identified, the study will inform ways to reduce these through social and public health policies around caregiving and CDI treatment and post-ambulatory care. Funding: Institute for Public Health

17-Hydroxyprogesterone Caproate and Preterm Birth Prevention: Patterns of Utilization and Efficacy

Team: Ebony Carter, MD, MPH; Molly Stout, MD, MSCI; Derek Brown, PhD

African-American women bear a disproportionate burden of preterm birth (PTB) in the United States. It is the single greatest predictor of infant mortality. North St. Louis city zip codes have infant mortality rates that parallel the developing world. Optimizing PTB prevention strategies targeting women at high risk has the potential to significantly impact rates of PTB and infant mortality. The Resident Obstetrics and Gynecology Clinic at Barnes-Jewish Hospital serves a high-risk community of low-income women, of which 80% are African-American. This observational, retrospective study of pregnant women enrolled in Missouri Medicaid from 2007-2016 includes those who: 1) experienced a prior spontaneous PTB; and 2) are taking 17-hydroxyprogesterone caproate (17-OHPC) for recurrent PTB prevention. The goal is to elucidate some of the important epidemiological considerations that could make use of this drug more efficient. The recommended 17-OHPC regimen includes weekly injections from 16 through 36 weeks gestation. This study’s central hypothesis is that there is still a significant benefit for PTB prevention when women start 17-OHPC after 20 weeks and/or take fewer than the recommended 20 weekly injections for the duration of the pregnancy, and that the gestational age of the prior PTBs is an important considerations in the efficacy of 17-OHPC. The expected outcome of this study will be high-quality, population-level data to suggest ways to optimize prevention of PTB through efficient use 17-OHPC treatment in low-income women in Missouri. Funding: Institute for Public Health and Institute of Clinical and Translational Sciences

Modeling the Cost Per HIV Infection Averted with Pre-Exposure Prophylaxis (PrEP) Using an Innovative Simulation Approach

Team: Zachary Feinstein, PhD; Timothy McBride, PhD, MS; Rupa Patel, MD, MPH, DTM&H

In recent years, a new method of human immunodeficiency virus (HIV) prevention has entered the medical arena (i.e. pre-exposure prophylaxis, aka PrEP, one pill taken once a day) offsetting the per patient lifetime treatment cost of $400K per year. PrEP is over 90% effective, but a barrier to PrEP use among at risk persons is access to a physician to prescribe the medication. Expanding access to PrEP could potentially save millions of dollars statewide by averting new infections every year. The cost savings of PrEP has historically been difficult to assess using a randomized-controlled trial. The primary outcome of this project is to determine the cost savings achieved by increasing access to PrEP and quantifying the cost per new HIV infection averted. This proposal utilizes modeling to simulate how behaviors and decisions at an individual-level impact system-level dynamics of HIV transmission across the state of Missouri. It will determine cost savings of PrEP compared to status quo and has potential to influence large-scale biomedical HIV prevention efforts in Missouri, as well as other Medicaid non-expansion states in the southern US, where the national HIV burden is especially high. Funding: Institute for Public Health & Center for Health Economics and Policy

Mixed Methods Analysis of Interdistrict School Transfer Program Participation and Student Health

Team: Erin Linnenbringer, PhD, MS; Darrell Hudson, PhD, MPH; Odis Johnson Jr., PhD 

The St. Louis voluntary interdistrict school desegregation program (VICC) has been in existence for nearly 35 years, and is the largest program of its kind in the country. While academic achievement and other socioeconomic outcomes of participating students have been examined, scant attention has been paid to the health impact (both positive and negative) of participation in interdistrict school desegregation programs, particularly the behavioral, physical, and/or mental health for either children or their parents/guardians. The project team will integrate empirical and thematic results with existing education policy, school health, and racism and health literatures to generate a conceptual model of the mechanisms by which interdistrict school desegregation program participation may influence health among children and adolescents. The ultimate goal of this project and subsequent research is to develop a much deeper understanding of the health impact that various types of interdistrict transfer and school choice programs may have on minority and underserved populations to inform policies, programs, and interventions reduce both health and education disparities in the St. Louis region. Funding: Institute for Public Health and Institute of Clinical and Translational Sciences

Is There a Link Between Socioeconomic Status and Infection Risk?

Team: Karen Joynt Maddox, MD, MPHMargaret Olsen, PhD, MPH; Center for Health Economics and Policy, Institute for Public Health

The Hospital-Acquired Conditions Reduction Program (HACRP) is a mandatory Medicare pay-for-performance program that penalizes hospitals with high rates of adverse patient safety events. Prior studies have shown that teaching hospitals and safety-net hospitals are particularly likely to be penalized. One critical, yet poorly-understood risk factor for hospital infection is social risk. This project will fill this gap by using national inpatient data to identify social risk factors associated specifically with surgical-site infection and determine how adjusting for these factors might influence hospital performance on measures of hospital-acquired infection. Social risk factors examined include Medicaid status, uninsured status, race/ethnicity, residence in a low-income zip code, and residence in a remote rural zip code. Questions answered are: a) whether there is a relationship between social risk and infection; and b) whether this risk is related to higher comorbidity burden, or whether it is independent. If there is an association, the project team will pursue broader research on other types of hospital-acquired infection, as well as research using local hospital data and more policy-oriented research using claims data and policy simulations. Funding: Bradley-Hepner Fund for Faculty Research in Community Health & Health Policy in the Institute for Public Health & Center for Health Economics and Policy

A Baseline Study on Senior Housing with Services for Low-Income Older Adults in St. Louis

Team: Sojung Park, PhD; M. Carolyn Baum, PhD, OT; Community Partner, St. Louis Covenant

Evidence demonstrates the relationships between income and healthcare expenditure, hospital admission, and preventable hospitalization. Health and Long-Term Services and Supports (LTSS) reform efforts focus on high-risk populations, particularly the socioeconomically vulnerable who have complex health situations and are at higher risk for excessive use of costly health and LTSS. One policy option yet to be tested for low-income residents of subsidized senior housing communities is to provide health and supportive services on site in collaboration with health and social service providers. This study will analyze the extent to which senior housing with services influences the health and wellbeing of aging residents in one large senior housing complex in St. Louis, Covenant Place. Findings of this research will add baseline empirical knowledge on factors and mechanisms that enable a long-term examination of benefit to health and wellbeing among housing residents. Findings will also provide a much-needed empirical underpinning for public health policy-making efforts regarding vulnerable elders. Funding: Institute for Public Health & Institute of Clinical and Translational Sciences

Public Access to Enriched Conditions (PARC) Initiative

Team: Diana Parra Perez, PhD, MPH; Ross Brownson, PhD; Debra Haire-Joshu, PhD, RN, MS, MA 

Environmental Enrichment consisting of physical and social stimulation to the brain and peripheral systems improves health outcomes across a variety of animal models for human disease, injury recovery, and substance abuse/addiction. This project will apply this concept to public health. It will assess how access to and engagement in enriched outdoor recreational spaces can be improved. Two parks in St. Louis offering open-air exercise equipment or fitness zones and two parks that do not offer these amenities, both located in low socioeconomic areas, will be the site of systematic observation to assess use, estimated user age, gender, level of physical activity, social interaction, and other characteristics of the area and the equipment. The team will also conduct interviews on reasons for park use, barriers, and facilitators. They will offer complementary activities to engage the community including yoga and health fairs and then their assess impact on park use and sense of ownership/belonging to the park. The results from this study will inform policymaking and implementation efforts in St. Louis as it relates to the presence of parks in socioeconomically disadvantaged areas and understanding of which resources and activities within the parks best promote physical activity and social interaction. Funding: MTM, Inc., Community Health Access Fund within the Institute for Public Health

Child Human Trafficking in the St. Louis Region: Policy Implementation to Impact the Most Vulnerable

Team: Rumi Kato Price, PhD, MPE, MA; Mary McKay, PhD, MSWCenter for Community Health Partnership and Research, Institute for Public Health

Despite a growing acceptance of public health approaches to human trafficking, policy development has not been guided by research evidence to date. This project will: 1) incubate public discourse on the commercial sexual exploitation of children (CSEC); 2) advance evidence-based policy solutions to combat CSEC in the St. Louis region; and 3) provide effective and impactful policy recommendations to reduce underlying social justice disparities and improve CSEC-related negative health consequences. Key partners involved include the Human Trafficking Collaborative Network (HTCN), Clark Fox Policy Forum in the Brown School, and a wide coalition of community groups, legislators, service providers, criminal justice representatives and others. Funding: Institute for Public Health