Monday, November 3, 2025 11/3/2025

Hotspotting Cardiometabolic Disparities for Simulated Advances in Population Care

Award Number: R01AG052533
ORGANIZATION: NATIONAL INSTITUTE ON AGING
OPDIV: NIH
AWARD CLASS: DISCRETIONARY
AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)
PERIOD OF PERFORMANCE START DATE: 09/01/2018
PERIOD OF PERFORMANCE END DATE: 06/30/2024

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Hotspotting Cardiometabolic Disparities for Simulated Advances in Population Care - 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 approach, this study will provide useful insights into the impact, cost-effectiveness, and sustainability of programs to reduce CVD disparities that are currently supported only by pilot data.


Issue Date FY	Funding FY	Legal Entity Name	Legal Entity Address	Legal Entity City	Legal Entity State	Legal Entity Zip Code	Legal Entity COUNTY	Legal Entity COUNTRY	Assistance Listing	Award Code	Budget Year	Action Date	Action Type	Action Amount

Issue Date FY: 2025 ( Subtotal = -$1,184 )
2025	2021	HEALTHPARTNERS INSTITUTE	8170 33RD AVE S	MINNEAPOLIS	MN	55425	HENNEPIN	USA	Aging Research	000	4	1/3/2025	NON-COMPETING CONTINUATION	-$1,184
														Subtotal = -$1,184

Issue Date FY: 2023 ( Subtotal = $0 )
2023	2021	HEALTHPARTNERS INSTITUTE	8170 33RD AVE S	MINNEAPOLIS	MN	55425	HENNEPIN	USA	Aging Research	000	4	7/6/2023	NON-COMPETING CONTINUATION	$0
														Subtotal = $0

Issue Date FY: 2021 ( Subtotal = $500,581 )
2021	2021	HEALTHPARTNERS INSTITUTE	3311 E OLD SHAKOPEE RD	BLOOMINGTON	MN	55425	HENNEPIN	USA	Aging Research	000	4	5/27/2021	NON-COMPETING CONTINUATION	$500,581
														Subtotal = $500,581

Issue Date FY: 2020 ( Subtotal = $496,463 )
2020	2020	HEALTHPARTNERS INSTITUTE	3311 E OLD SHAKOPEE RD	BLOOMINGTON	MN	55425	HENNEPIN	USA	Aging Research	000	3	7/13/2020	NON-COMPETING CONTINUATION	$496,463
														Subtotal = $496,463

Issue Date FY: 2019 ( Subtotal = $500,646 )
2019	2019	HEALTHPARTNERS INSTITUTE	3311 E OLD SHAKOPEE RD	BLOOMINGTON	MN	55425	HENNEPIN	USA	Aging Research	000	2	7/26/2019	NON-COMPETING CONTINUATION	$500,646
														Subtotal = $500,646

Issue Date FY: 2018 ( Subtotal = $535,442 )
2018	2018	HEALTHPARTNERS INSTITUTE	3311 E OLD SHAKOPEE RD	BLOOMINGTON	MN	55425	HENNEPIN	USA	Aging Research	001	1	9/21/2018	NEW	$35,557
2018	2018	HEALTHPARTNERS INSTITUTE	3311 E OLD SHAKOPEE RD	BLOOMINGTON	MN	55425	HENNEPIN	USA	Aging Research	000	1	8/23/2018	NEW	$499,885
														Subtotal = $535,442

Grand Total All Awards = $2,031,948

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Hotspotting Cardiometabolic Disparities for Simulated Advances in Population Care

Award Number: R01AG052533

ORGANIZATION: NATIONAL INSTITUTE ON AGING

OPDIV: NIH

AWARD CLASS: DISCRETIONARY

AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)

PERIOD OF PERFORMANCE START DATE: 09/01/2018

PERIOD OF PERFORMANCE END DATE: 06/30/2024

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