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Using Big Data to Solve Big Public Health Problems: Gillings faculty thrive on tackling complex public health issues. We’re Gillings. We’re on it! Powerful technologies and innovative methods fuel their work, while UNC’s uniquely collaborative environment empowers them to reach across disciplines for answers to some of the most pressing public health challenges of our time.

Successful data science hinges on the interplay between the questions that researchers want to ask, and the methods they use to find the answers. Researchers at the UNC Gillings School of Global Public Health are right in the middle of that intersection, working together to improve health and health-care outcomes locally and globally.

“We like to collaborate,” says Michael Kosorok, PhD, W.R. Kenan, Jr. Distinguished Professor and chair of biostatistics. “We often team up with clinicians and other biomedical researchers who have problems they want to solve and figure out how to open doors to get those answers — and sometimes, the methods we choose can help refine those questions or change those goals. It’s all in the interaction.”

Data science approaches like causal inference and machine learning are used increasingly in precision health, which aims to provide personalized solutions to public health problems. Precision health works in three different stages of increasing complexity:

• Prediction: Capturing information and characteristics of patients
• Causal Inference: A what-if analysis that estimates what will happen if an action or treatment is changed
• Decision Support: The development of computer algorithms to optimize actions or interventions to maximize health outcomes

“Think of those stages as what is, what might be, and how best to act to achieve our goals,” said Stephen Cole, PhD, professor of epidemiology. “We want the algorithms we develop for precision health to account for both the individual and the context so we can figure out better prevention and treatment strategies.”

Cole and Kosorok are working with Jeff Stringer, MD, professor of medicine, on the Limiting Adverse Birth Outcomes in Resource-Limited Settings (LABOR) study, a project funded by the Bill & Melinda Gates Foundation to evaluate 15,000 pregnant women in two or three developing countries.

The mothers in the LABOR study will wear patches on their abdomens — which are being developed specifically for this study — that will record oxygen saturation levels, heart rates and other real-time information about the women and their babies, since the patches are designed to discern signals from the baby and from the mother during the labor and birthing process. Researchers also will examine the mothers’ medical records and structural information about the clinics themselves, such as the actions of staff and events over time.

Using all these data sources, researchers will develop new algorithms and precision medicine tools that will help doctors better assess an individual woman’s risk of having adverse pregnancy outcomes or having a baby at risk for poor birth outcomes, and predict the health interventions they will likely need.

Though they teamed up for the LABOR study, Kosorok and Cole do not often get the opportunity to work together. Cole has focused much of his career on study designs about population health risks and infectious disease, while Kosorok’s application of data science to health problems has centered primarily on cancer and diabetes.

One of Kosorok’s recent priorities is using precision medicine to improve Type 1 diabetes treatments. He is working with Elizabeth Mayer-Davis, PhD, RD, the Cary C. Boshamer Distinguished Professor and chair of nutrition, and Eric B. Laber, PhD, professor of statistics at North Carolina State University, on artificial intelligence tools that allow researchers to analyze each patient and determine optimal treatments in real time. They’ve developed a mobile app prototype integrating an insulin pump, a glucose patch, and activity monitors to help diabetes patients manage their glucose levels.

For Cole, HIV and other infectious diseases has been at the heart of his work for several years. He’s currently involved in optimizing HIV treatment and exploring treatment as prevention for HIV infections. Cole recently teamed with Ada Adimora, MD, MPH, professor of epidemiology at Gillings and Sarah Graham Kenan Distinguished Professor of medicine, and others to develop new methods to project the benefit of HIV treatment as prevention among U.S. women, where a randomized clinical trial seems infeasible.

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“Humans are complex, but they are also precious, so we have to get it right.”

Michael Kosorok, PhD

W.R. Kenan, Jr. Distinguished Professor and Chair of Biostatistics

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Despite their distinct research interests, Cole and Kosorok occasionally walk around campus to bounce research ideas off each other and engage in discussions about science, learning and life. Kosorok is an accomplished music composer who originally planned biostatistics as a backup career, while Cole is an avid student of philosophy and history who is driven by learning.

“Reading various scholars and works in the historical record gives me context for what I’m doing now,” Cole says. “My project is to learn how to learn better.”

One of their shared philosophies is that although they delve deeply into math, machine learning and methods, their work is human-focused. “Being in biomedicine and working with real patients causes us to be really careful with the methods we use,” Kosorok says. “Humans are complex, but they are also precious, so we have to get it right.”

Data Science Basics

• Causal Inference is a set of new approaches to address the age-old problem of induction. The problem of induction is the problem of how to justifiably infer causal relationships from observations. For example, will HIV-related mortality differ under plan A, compared to plan B? A key aspect of modern causal inference is the use of potential, or counterfactual, outcomes, as well as observed factual outcomes.
• Machine Learning is a set of analytical methods from computer science and statistics which analyze data to produce predictions and to support decisions (e.g., given all of my medical data, which therapy should my doctor choose for me).

By Penny Gordon-Larsen, PhD

Associate Dean for Research and Professor of Nutrition

‍Using Big Data to Solve Big Public Health Problems: Gillings faculty thrive on tackling complex public health issues. We’re Gillings. We’re on it! Powerful technologies and innovative methods fuel their work, while UNC’s uniquely collaborative environment empowers them to reach across disciplines for answers to some of the most pressing public health challenges of our time.

So why does the same nutrition plan work for some people and not for others? A transdisciplinary team of researchers at the UNC Gillings School of Global Public Health is working together to find out using a precision health approach. The Obesity Hub, an innovative team-based approach in the Gillings School involving more than two dozen faculty members from all parts of UNC campus, is using big data to study animals, people and populations to understand why different people can consume the same diets and have different weight gain patterns — and using data-driven strategies to transform behavioral weight loss.

Hub leader Penny Gordon-Larsen, PhD, associate dean for research and professor of nutrition, says most weight studies look at the average effects of weight interventions. Focusing instead on the tails (those most likely to gain or lose, for example) of the distribution rather than averages can highlight the most (and least) successful weight loss in individuals and answer key questions about weight loss.

“If you take the full data in any kind of weight intervention — for example, low fat, low carb, surgery — and look at the population, you see a normal curve where some people on that therapy actually gain weight and for some people it works beautifully, but most people are in the middle with very little weight loss,” she says. “You want to figure out what it is about the person who is very successful on a particular treatment — whether it’s their biology, their behavior, or other factors — and what it is about that intervention that produces a really good result for a specific person or type of person. If you can match the right therapy with the right person, then you will have good results.”

Using several different study designs and analyzing thousands of data points, Hub researchers aim to delve into that variability to find out what factors predict success. A central hypothesis is that a genetic defect could lead to metabolic inefficiency, disrupting a person’s ability to process energy from food and leading that person to gain weight instead of lose it.

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“We do a series of experiments in the first few weeks to hone the right prescription, and then we follow that tailored prescription, adjusting as needed, to see if we can maximize successful weight loss.”

Deborah Tate, PhD

Professor of Health Behavior and Nutrition

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Analyzing genetic, bacterial and molecular information from 10,000 individuals followed over 30 years, these same markers found in animal models, and behavioral data from people who volunteered for a weight-loss treatment, the researchers’ goal is to find molecular and genetic signals that will help doctors personalize and tailor more effective therapies to people. Stephen Hursting, PhD, a professor of nutrition who is part of the team studying animals, says, “The exciting work is really in the translation of findings from animal to human.”

In the clinic, mobile monitoring devices and behavioral strategies are being integrated to personalize interventions for people who want to lose weight. Initially, 40 patients will try out different dietary compositions and intervention strategies, while researchers glean real-time glucose, exercise, and sleep data and other information so they can adjust recommendations for each person as an individual.

“We do a series of experiments in the first few weeks to hone the right prescription, and then we follow that tailored prescription, adjusting as needed, to see if we can maximize successful weight loss,” says Deborah Tate, PhD, professor of health behavior and nutrition. “Our goal is to get away from the one-size-fits-all approach that we’ve done historically — using identical diet and activity prescriptions and behavioral strategies across the board, even though it may not be the right approach for everyone.”

The Obesity Hub Leadership Team

The Obesity Hub is an exciting collaboration of 32 scientists working to develop weight-loss treatment and prevention approaches that go far beyond the common “one-size-fits-all” approach. The team won a Creativity Hub award from the University last year to spur the kind of novel, collaborative science that helps keep UNC at the forefront of research and discovery. The hub has published two position papers, has nine grants in progress, three spin-off grants, and a grant from the NIH valued at more than $6 million.

• Nutrition: Penny Gordon-Larsen, PhD (Associate Dean for Research and Professor of Nutrition)
• Computer Science: Stan Ahalt, PhD (Professor of Computer Science and Director of the Renaissance Computing Institute)
• Biology: Vicki Bautch, PhD (Beverly Long Chapin Distinguished Professor of Biology)
• Endocrinology: Sriram Machineni, MD (Assistant Professor of Endocrinology and Metabolism and Director of UNC Medical Weight Clinic)
• Epidemiology: Kari North, PhD (Professor of Epidemiology)
• Nutrition/NRI: Steve Zeisel, MD, PhD (Professor of Nutrition and Director of UNC Nutrition Research Institute)
• Health Behavior: Deborah Tate, PhD (Professor of Health Behavior and Nutrition)

By Jill Stewart, PhD (Professor of Environmental Sciences and Engineering) and Will Vizuete, PhD (Associate Professor of Environmental Sciences and Engineering)

Using Big Data to Solve Big Public Health Problems: Gillings faculty thrive on tackling complex public health issues. We’re Gillings. We’re on it! Powerful technologies and innovative methods fuel their work, while UNC’s uniquely collaborative environment empowers them to reach across disciplines for answers to some of the most pressing public health challenges of our time.

Interdisciplinary collaboration between chemists, biologists, epidemiologists and engineers is helping Will Vizuete, PhD, associate professor of environmental sciences and engineering, find ways to better understand the effects of the atmosphere’s chemical makeup on air pollution toxicity and which populations are most affected.

“Anything that’s emitted into the air, like wildfires or automobile exhaust or power plant emissions, is harmful,” says Vizuete, whose background as a chemical engineer has helped inform his work.

“We don’t know the extent of how that harm changes once it enters the atmosphere.”

His approach includes using high-performance computers, developing new three-dimensional models to simulate the atmosphere, and testing air toxicity using living cells. The ultimate use of the data he generates is to influence policy changes and create more effective pollution controls.

Although air pollution affects everyone, children and older people are especially susceptible to air pollution mortality and morbidity, as are individuals of low socioeconomic status who may live near polluted areas. These issues also are important for low- and middle-income countries, where indoor cookstoves and coal burning are common.

Examining how things like power plant or car emissions interact with the chemicals already in the atmosphere will shed light on the best ways to protect those who are most vulnerable, Vizuete says.

“Everyone is impacted by air pollution, but our exposure is far more complicated than what we knew before,” Vizuete says. “What we’re trying to investigate and highlight is: What are the true drivers of toxicity in the atmosphere that we haven’t looked at yet that we need to look at down the line?”

“Unfortunately, a long history of social and environmental injustices has resulted in circumstances where poor and minority communities are disproportionately impacted by degraded environmental conditions.”

Jill Stewart, PhD

Professor of Environmental Sciences and Engineering

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Jill Stewart, PhD, professor of environmental sciences and engineering, is exploring similar questions about water. Growing up on Chesapeake Bay, Stewart always has felt a connection to water. “Water is essential to life. People should be able to drink water, swim in water or fish from water without getting sick,” says Stewart, whose contributions to beach-related epidemiological studies helped form the scientific basis for revising U.S. recreational water-quality criteria.

Stewart is working to better understand how environmental conditions can affect human health, and how humans themselves influence this process. Her goal is improving the health and well-being of those affected by poor environmental conditions such as waste products, industrial hazards, and flood-prone development. “Unfortunately, a long history of social and environmental injustices has resulted in circumstances where poor and minority communities are disproportionately impacted by degraded environmental conditions,” she says.

Instead of culturing bacteria as they’ve done in the past, scientists now use molecular and genetic methods to measure pathogens and track contamination back to its original source. Stewart combines microbiology with geospatial and risk modeling to pinpoint when and where people are exposed to bacteria and to identify strategies to help prevent the exposures.

“It is a really exciting time to be an environmental microbiologist because the molecular biology tools we use keep advancing so quickly,” Stewart says. “The data are giving us a much better understanding of the ecology of antibiotic-resistant bacteria and the role of the environment in the spread of resistance among humans, animals, and the environment.”

In addition to working across disciplines in her own research, Stewart promotes collaboration as deputy director of the UNC Galápagos Initiative, where she leads campus research directors in identifying critical research questions, and as a member and co-teacher in the NC One Health Collaborative, which promotes dialogue about the interconnectedness of people, animals, and the environment.

“Collaborations are a really important part of the work I do,” Stewart says. “Traditional, disciplinary approaches will not be effective in addressing the major environmental challenges facing our generation.”

Quick facts:

• 35% of NC population relies on unregulated private wells for water (the 3rd most of any state)
• 1,991 community water systems in NC
• $17B-$26B in estimated water and wastewater infrastructure needs for North Carolina over the next 20 years

Aaron Salzberg, PhD, the Don and Jennifer Holzworth Distinguished Professor, has joined the UNC Gillings School of Global Public Health in the Department of Environmental Sciences and Engineering.

A long-established leader in water policy, Salzberg has been the lead water adviser to five secretaries of state, negotiated major international agreements, and created partnerships that strengthened the United States’ and international community’s capacity to address global water challenges.

Salzberg was the Department of State’s first special coordinator of water and chief of the Water Division within the Bureau of Oceans and International Environmental and Scientific Affairs. During his tenure, U.S. development assistance for drinking water and sanitation increased more than tenfold in countries of significant need.

At UNC, Salzberg wants to change how the world works on water through scientific discovery, technical innovation and policy leadership. He plans to merge policy and practice to focus the Institute on

real-world solutions to water and sanitation challenges.

“People must have access to sustainable supplies of water of the right quantity and quality to survive and thrive,” Salzberg says. “Diarrheal diseases due to unsafe drinking water and poor sanitation are one

of the leading causes of death in children worldwide — this is wholly preventable. What’s more, without water, local livelihoods are lost and this becomes a source of migration and conflict and supports

terrorist recruitment.”

Salzberg succeeds Jamie Bartram, The Water Institute’s first director, who retired in June. Bartram launched The Water Institute in 2010 to “provide global academic leadership for economically, environmentally, socially and technically sustainable management of water, sanitation and hygiene for equitable health and human development.” The Institute is well-respected for policy-relevant research on drinking water, sanitation and hygiene (WaSH) and for facilitating international efforts to solve global WaSH issues.

Driving Health Solutions for Under-represented Groups: Too often, the populations who are most burdened by or vulnerable to diseases are underrepresented in research studies and underserved in access to care. We’re Gillings. We’re on it! Equity is a core Gillings value, and our faculty work to find ways to better deploy health-care data and resources to help those who need them most.

However, most genomics studies include data on populations of European descent. That makes it more difficult to understand how best to reduce chronic disease inequities among racial and ethnic groups. UNC Gillings School of Global Public Health faculty members are working to narrow this data gap. One of the strategies is to gain a better understanding of population groups that are more susceptible to chronic diseases yet are underrepresented in existing research.

Kari North, PhD, professor of epidemiology, analyzes multi-omics data to show how genomic underpinnings in diverse populations relate to health outcomes. She leads the UNC Department

of Epidemiology’s Cardiovascular Genetic Epidemiology Computational Laboratory, a collaborative, interdisciplinary research group focusing on family- and population-based genetic epidemiological research.

“We typically study European populations for things like heart disease, hypertension, and diabetes, but these populations are not the ones most burdened by those diseases,” North says. “Our goal is to ensure that genetic advancements are equitable for all populations. We need more diversity in research across all race and ethnic groups to alleviate health disparities.”

North and a team of researchers from institutions across the country recently analyzed health outcomes among nearly 50,000 racially and ethnically diverse populations and identified 65 new genetic associations — locations on a chromosome where genetic variants are found — many of which can be transferable to other groups that share components of genetic lineage, such as African ancestry, which can be found in African-Americans, Hispanics and Latinos.

One key finding from the group’s work is the association between lower HbA1c levels — which often is used as a marker for glucose control — and the gene for sickle cell anemia. While this association had been reported in African-American populations, researchers found that the sickle cell variant also is important in some Hispanic/Latino populations. The gene can affect the reliability of glucose test results and could lead to the misdiagnosis of Type 2 diabetes.

Making sure genetic studies reflect more diverse populations will help doctors and researchers better understand the genetic nuances that can influence the course of diseases and the effectiveness of treatment and prevention strategies.

“Diversity is such an important part of the picture,” says North, whose interest in health equity dates to her dissertation project on American Indians. “Precision medicine moving forward means you can personalize the treatment. But that can change based on what population you’re in — the individual lives in the context of the population.”

Since multi-omics involves the sequencing of vast amounts of biological data, a major challenge of working with multi-omics is figuring out how to integrate across big data, such as genomics, microbiomics, and metabolomics. North works with Danyu Lin, PhD, Dennis Gillings Distinguished Professor of biostatistics, who is a leader in statistical approaches to integrating these big data. “We’ve been laying the groundwork for these new approaches for some time,” Lin says.

“Fortunately, the technology and software have advanced rapidly. I am very excited about the promises of these new approaches to integrate across multiple types of omics data.”

North also uses multi-omics and integrative analysis to study obesity and other risk factors for chronic illnesses that disproportionately affect minority populations. Through genomics, identifying genetic variants linked to obesity is critical in developing targeted interventions to reduce the risk of obesity-related chronic illnesses such as hypertension, Type 2 diabetes, and heart disease. Metabolomics — the study of small molecules such as sugars, fatty acids, and lipids — helps researchers explore the molecular processes that can affect disease development and progression.

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“Health equity, period, is the motivating factor of my work.”

Kari North, PhD

Professor of Epidemiology

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“People who are obese are at much greater risk for cardiovascular risk factors across the board, but we don’t understand the molecular mechanisms by which obesity causes downstream disease,” North says. “What can the data tell us about why some populations are at increased risk of disease?”

In trying to get past correlation and look for causation, North and her team collaborate with Lin. “Everything I do is big data. We talk to Danyu about the problem, and he helps us operationalize those problems in terms of statistical algorithms,” North says. “He’s an amazing collaborator.”

The spark behind North’s data-driven search for answers is simple: “Health equity, period, is the motivating factor of my work,” she says.

Driving Health Solutions for Under-represented Groups: Too often, the populations who are most burdened by or vulnerable to diseases are underrepresented in research studies and underserved in access to care. We’re Gillings. We’re on it! Equity is a core Gillings value, and our faculty work to find ways to better deploy health-care data and resources to help those who need them most.

“I’m looking into why young women get hysterectomies after being diagnosed with these really common gynecologic issues, like fibroids, endometriosis and painful periods. Hysterectomies are the second most commonly performed surgery among young and middle-aged women in the United States, but they’ve been understudied. My feeling is that this issue affects millions of women’s ability to attend work, have a satisfying sex life and raise a family, and that’s worth examining.”

The health issues that can lead to a hysterectomy have a variety of other possible treatments, ranging from hormonal birth control to more minor surgeries. For Robinson, the concern is: Who has access to these cheaper, less invasive treatments?

“That’s what we want to understand,” she says. “When a young woman opts for a hysterectomy, is it because her doctor pushed for it? If so, did the provider push because it’s an easily reimbursable procedure, or because their training highlighted it? Or, do minority women truly have more severe symptoms and clinical complexity? Maybe a woman chooses the more invasive treatment because she lives in a rural area and couldn’t stomach the possibility of many return visits to her provider if the less invasive treatments didn’t work. Or, maybe there’s a cultural element that influenced her.”

To understand this complex question, Robinson and her team are bringing together datasets from a nonprofit hospital system, the national census and a large registry of health professionals. Two years into a grant from the National Institute on Minority Health and Health Disparities, they are finally poised to analyze the immense amount of data they’ve collected and cleaned. Robinson is especially excited because the tens of thousands of data points include uninsured women.

“This is critical from a health equity lens,” she explains. “Many of the women who receive hysterectomies are too young to qualify for Medicare and can’t afford private insurance. Historically, data analyses have missed uninsured women of reproductive age, and they are a key population for this question.”

Robinson also is excited because the sheer size of the dataset — representing more than 10,000 women — reveals patterns that weren’t clear in earlier studies. For example, her team has already learned that, in North Carolina, young Native American women have even higher rates of hysterectomies than young African-American women.

The ultimate goal of this research is to inform action: Which public health interventions will advance women’s care? If the hysterectomy differences are due to higher clinical need among minority women, then improving care will require developing new uterine-sparing treatments that are more effective for treating their symptoms. On the other hand, if young women receive different treatments due to their race, interventions should prioritize more unbiased delivery of existing treatment options.

“Hysterectomies can be life-changing,” Robinson says. “For some women, they offer amazing relief from a host of symptoms. They also mean the end of a woman’s ability to have biological children and they can bring immediate menopause. For a young woman, getting a hysterectomy is a big decision — we want it to be the most informed, equitable decision possible.”

Robinson discusses other aspects of her research on AcaDames, the podcast that she co-hosts with Sarah Birken, PhD, assistant professor of health policy and management at the Gillings School. In each episode, they delve into the experience of being a woman in academia. The common thread between her research and this passion project, Robinson says, is her interest in women’s health and well-being. As she puts it: “Whatever it takes to ensure women feel confident and are fully engaging in life.”

Driving Health Solutions for Under-represented Groups: Too often, the populations who are most burdened by or vulnerable to diseases are underrepresented in research studies and underserved in access to care. We’re Gillings. We’re on it! Equity is a core Gillings value, and our faculty work to find ways to better deploy health-care data and resources to help those who need them most.

“I wanted to get a better handle on why some mothers were struggling to make enough milk for their own babies, but others were pumping enough extra milk to feed two or three,” she says. “I was also curious about how parents dealt with the risks and why they decided to feed their babies this way rather than using formula or pasteurized donor milk from a milk bank.”

Palmquist enrolled in the Mary Rose Tully Training Initiative, the clinical lactation training program at the UNC Gillings School of Global Public Health, to prepare her to do more rigorous research on lactation and breastfeeding. After joining Gillings in 2017, Palmquist established a research agenda on infant feeding in emergencies: Emergencies create enormous challenges for infant nutrition. Palmquist’s training in medical anthropology and clinical lactation prepared her to examine how aid organizations can support recommended nutritional interventions in humanitarian settings, like sharing breastfeeding, sharing breastmilk, and reducing the risks of formula feeding. She collaborated with Dilshad Jaff, MD, MPH, assistant adjunct professor of maternal and child health and formerly, program coordinator for the Gillings School’s Research Innovation and Global Solutions office, on research to improve the quality of perinatal health services for displaced Yazidi families in Iraq.

Their work emphasizes the importance of including mental health support in any kind of health intervention for populations experiencing conflict and other crises. “We are trying to demonstrate that any trauma or mental health issues, especially among women, decreases breastfeeding rates and increases infections in children,” said Jaff, who recently took a new job with the International Committee for the American Red Cross. A native of Iraq who worked as a medical doctor during the Iraq war, Jaff will retain his affiliation with Gillings.

Drawing on the knowledge they gained from their work in Iraq and Jaff’s personal expertise as a physician during conflict, Palmquist and Jaff began working on ways to help vulnerable populations in North Carolina during emergencies.

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“How do we help them before, during and after evacuation to protect them from the short- and long-term negative social, economic, and health impacts of natural disasters?”

Aunchalee Palmquist, PhD

Assistant Professor of Maternal and Child Health

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“In emergency situations, the needs of people who are pregnant, birthing, or caring for babies are not at the top of the list,” Palmquist says. “We have to figure out how to provide more support to these people, who are at the greatest risk of neglect in emergencies. How do we help them before, during and after evacuation to protect them from the short- and long-term negative social, economic, and health impacts of natural disasters?”

After Hurricane Florence last year, Palmquist and others from the Carolina Global Breastfeeding Institute (CGBI) developed a resource kit for providers and patients in the hospitals the CGBI works with in North and South Carolina. It includes guides for health workers, frontline responders, shelter managers, and volunteers to help families with infants and young children (birth to age 2) in providing safe nutrition during emergencies.

In talking with providers and emergency response personnel across the state, Palmquist also stresses the importance of preparedness, which can provide a critical safety net for infants who are vulnerable to illness and food insecurity in emergency situations.

That means planning ahead and thinking through what families need to feed their babies when there isn’t power or clean water, and when stores are closed. “Most parents may not have thought about how they might prepare formula with no access to clean water or a way to wash bottles,” she says. “We have environmental disruptions year-round — flooding, snowstorms, hurricanes, power outages. It is so important to be prepared, particularly for families with young infants.”

Data and technology could help connect families with information about emergency readiness

and response, Palmquist says. Apps and mobile technology have great potential to use SMS messaging, real-time counseling, and other tools to link people with available resources and support — especially in cases where people are displaced by an emergency event.

Longer term, Palmquist’s goals include building capacity from within historically marginalized communities in North Carolina to improve emergency response in ways that better meet the needs of maternal, child, and family health.

“North Carolina can set the precedent nationally for what good practice looks like,” she says.

Translating Science into Practice: Doing great public health research means putting study results to work. Whether examining molecular-level data or facilitating large-scale organizational changes, we’re Gillings. We’re on it! Gillings faculty go beyond the literature and the lab to make real changes in health-care practice and policies — and real differences for patients.

From creating personalized health interventions to helping large health-care organizations implement widespread changes, UNC Gillings School of Global Public Health researchers are working to bring about meaningful results for patients, providers and communities throughout North Carolina.

For Stephanie Wheeler, PhD, MPH, professor of health policy and management, those results hinge on using big data to identify key underserved populations or regions where evidence-based interventions should be adapted and implemented to improve health equity.

In one series of studies, Wheeler and her colleagues linked insurance claims, cancer registry data, surveys and interviews to look for ways to address the financial strain of costly cancer treatments. They found that financial navigators — oncology support staff trained to support patients and reduce hardship related to treatment costs — were one effective solution: Patients at UNC’s Cancer Hospital who worked with navigators reported lower levels of out-of-pocket cost burden and less worry about their finances.

The National Cancer Institute (NCI) has awarded Wheeler and Don Rosenstein, MD, professor of psychiatry and director of the Comprehensive Cancer Support Program, a five-year R01 grant to embed trained navigators in five rural oncology clinics across the state. “We’ve seen how this works at a large academic medical center,” Wheeler says. “The next step is adapting and implementing it in rural clinics.”

Wheeler has received another five-year R01 grant from the NCI to explore whether an evidence-based intervention to improve medication adherence — whether a patient continues to receive recommended treatment — among patients with chronic diseases like diabetes and cardiovascular disease can be adapted and used to improve endocrine therapy adherence in racially diverse breast cancer patients.

Wheeler and Katie Reeder-Hayes, MD, MBA, MSc, assistant professor of medicine, initially tested motivational interviewing, a counseling technique used in other health studies but not in cancer research, to see if it would help patients continue their treatment. It did. Adherence was high among participants, and so was patients’ confidence in sticking with their medication. The second NCI grant will scale-up the counseling intervention, adding a text messaging reminder, to be delivered remotely to more than 1,200 cancer survivors to understand how well it works in different settings and different sub-groups identified by race and age. This could revolutionize survivorship care for women who have had breast cancer and reduce inequities in health-care access and outcomes.

While Wheeler has focused on implementing innovative patient-focused interventions in medically underserved populations, Chris Shea, PhD, associate professor of health policy and management, studies implementation of organizational changes, many of which involve new technologies.

Shea has examined how technology has transformed health-care organizations over the years. This includes the adoption of electronic health records (EHRs), which increased about a decade ago with the introduction of the Centers for Medicare & Medicaid Services’ Meaningful Use program. This program gives providers financial incentives to promote adoption of EHRs and other technology-based care tools. Shea’s study of the UNC Health Care system’s readiness to implement Meaningful Use in ambulatory settings suggests the need for different implementation strategies for various roles and sites within a health system.

For example, Shea found that physicians were less willing than nurses and physician assistants to change their own work practices to meet Meaningful Use requirements. They were also less confident in their clinic’s ability to solve implementation problems. Additionally, practitioners in specialty clinics were more concerned than primary care practitioners about Meaningful Use activities diverting attention away from other important patient care activities.

In another study, Shea found that success in meeting the program’s requirements was highest when efforts were led by quality improvement teams, which are teams of diverse clinic staff who are charged with carrying out improvement efforts for that practice. “It’s important to integrate health technology implementation with quality improvement infrastructure and processes,” he says, “to connect those changes to ongoing efforts within the practice that clinicians think are important.”

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“It’s important to integrate health technology implementation with quality improvement infrastructure and processes.”

Chris Shea, PhD

Associate Professor of Health Policy and Management

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EHR data have potential benefits beyond the patient encounter, such as assisting with health system planning and predictive analytics. Health systems also are trying to determine how much to invest in novel approaches, such as machine learning.

Although new technology is a driver of many organizational changes in health care, changes that are not tech-driven also can affect how clinicians and administrative staff share information and do their work, Shea says. “We’re moving toward more information-oriented and technology-enabled health systems. It’s important to keep in mind that this movement may not affect all stakeholders the same way. We can’t lose sight of the implications for clinicians, patients and communities.”

Did you know? Cancer treatment is one of the most frequent causes of bankruptcy in the country, according to the President’s Cancer Panel. In 2015, new cancer drugs ranged in price from $7,484 to $21,834 per patient per month.

Translating Science into Practice: Doing great public health research means putting study results to work. Whether examining molecular-level data or facilitating large-scale organizational changes, we’re Gillings. We’re on it! Gillings faculty go beyond the literature and the lab to make real changes in health-care practice and policies — and real differences for patients.

UNC Gillings School of Global Public Health researchers are using those data to generate real-world evidence to improve knowledge about how prescription drugs affect patients.

Before new drugs reach the market, they must endure years of testing. But knowledge is limited about the benefits and harms of these treatments because of the small number of patients tested and how they are selected for trials. There also is a lack of information on long-term effects and potential interactions with other treatments.

That means drugs are being approved, prescribed, and used without a complete picture of their safety and effectiveness in the real world.

Til Stürmer, PhD, MD, MPH, Nancy A. Dreyer Distinguished Professor and chair of epidemiology; Jennifer Lund, PhD, associate professor of epidemiology; and Michele Jonsson Funk, PhD, associate professor of epidemiology and director of the Center for Pharmacoepidemiology (the branch of science that studies the effects of drugs in large numbers of people), are working to change that through rigorous research using big data such as insurance claims and electronic medical records, which can provide information on millions of patients compared to the smaller clinical samples in drug trials.

“These big, or real-world, data allow us to get timely answers to important clinical questions that cannot be answered quickly enough through any other means,” Stürmer says. “Being able to use these data is a prerequisite for assessing the real-world benefit and harm of drugs.”

For example, about 80 percent of pregnant women report nausea. When the generic version of Zofran, a drug developed to combat nausea in cancer patients, hit the market a few years ago, it was being prescribed to about 20 percent of pregnant women — despite inadequate data on its safety.

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“Using big data to conduct robust research … is truly a team science effort.”

Michele Jonsson Funk, PhD

Associate Professor of Epidemiology and Director of the Center for Pharmacoepidemiology

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Jonsson Funk and one of her graduate students, Elizabeth Suarez (who graduated in Fall 2019), analyzed de-identified health-care data and found that women using Zofran (or its generic form) during pregnancy did not have a higher risk of miscarriage, preterm birth, or gestational hypertensive disorders compared to women who used other drugs to treat their nausea.

“By using these big data, we can see the effects these treatments have on a diverse population of patients in the real world, not just the highly selected ones in the clinical trials,” says Jonsson Funk, who has studied several women’s health issues including medication use during pregnancy, pelvic floor disorder treatment, sex differences in statin benefits, and effects of diabetes medications on breast and endometrial cancer risk.

UNC is home to a uniquely rich resource: de-identified data from a nationwide 20 percent random sample — about 4.5 million individuals — of Medicare beneficiaries ages 65 years and older, including all medical encounters, procedures, and pharmacy-dispensed prescription drugs over time until the death of the beneficiary. Originally funded by a Gillings Innovation Laboratory, this dataset is now available to all UNC researchers.

The interdisciplinary diabetes working group led by Stürmer and Dr. John Buse, MD, PhD, chief of endocrinology at the School of Medicine, uses these big data to better understand the effects of various diabetes treatments. Stürmer also has used Medicare data for research on treatments after heart attacks, and on potentially inappropriate prescriptions that could put older patients at risk of adverse health outcomes.

“The introduction of Medicare drug plans (Part D) in 2006 was a game changer. UNC’s epidemiology department was at the forefront of using these data,” Stürmer says. “More recently, our ability to link multiple data sources, including insurance claims with clinical data from electronic health records, allows us to combine rich longitudinal records with clinical detail that was previously unavailable.”

Addressing questions of drug safety and effectiveness is not just about putting the right data together — it’s also about putting the right people together. Fortunately, the interdisciplinary environment at UNC is one that nurtures collaborations.

“We bring together pharmacoepidemiologists who understand the particular study designs that can increase the reliability of findings, clinicians who understand the condition so that the questions we ask are relevant, biostatisticians who ensure that our analytic tools are appropriate to the task, programmers who can efficiently manipulate terabytes of data, and patients who share which health outcomes are most important to them,” Jonsson Funk says. “Using big data to conduct robust research and produce meaningful results is truly a team science effort.”

Opioid Use

Opioid abuse in North Carolina has reached epidemic levels: In 2017, more than five North Carolinians died each day from an unintentional opioid overdose. To reduce the supply of unused, misused and diverted opioid pills, in 2017 the state legislature enacted the Strengthen Opioid Misuse Prevention Act, or STOP Act. Among other provisions, the law limits the legal prescription of opioid pain medications to a five-day supply for acute injuries and a seven-day supply post-surgery. It does not restrict opioid prescriptions for chronic pain.

While many states have implemented prescribing limits based on the number of days supplied, Gillings graduate student Jessica Young used national insurance claims data to examine other dimensions of opioid prescribing, such as the number of pills dispensed, and overall dosage (morphine milligram equivalents [MME]) dispensed. Her results show that these dimensions can yield a different perspective on patient use. Notably, one out of every 10 patients receiving opioids for postoperative pain received over 500 MMEs, putting them at 21 percent higher risk of having long-term opioid use following surgery compared to those receiving a dosage under 500 MMEs.

“The law uses ‘day supply,’ but there are other ways to characterize people who might be getting more opioids than needed,” said Young’s adviser, Michele Jonsson Funk, PhD, associate professor of epidemiology and director of the Center for Pharmacoepidemiology.

Young has received a $142,967 dissertation award from the National Institute on Drug Abuse to support completion of her doctoral dissertation in the field of drug use research.