Implementation research for comprehensive cardiometabolic care in Guatemala

PROJECT SUMMARY Candidate: David Flood, MD, MSc, is a general internist and fellowship-trained health services researcher at the University of Michigan and the Institute of Nutrition of Central America and Panama (INCAP) in Guatemala. Dr. Flood’s long-term career goal is to become an independent physician-scientist who uses expertise in implementation research to improve the adoption of evidence-based interventions for the prevention, treatment, and control of cardiometabolic diseases (e.g., hypertension, diabetes, and dyslipidemia) in resource-limited health systems in the U.S. and globally. Background: Pharmacologic and behavioral interventions are effective in improving cardiometabolic disease outcomes. However, limited implementation of these interventions in low- and middle-income countries (LMICs) leads to substantial excess morbidity and mortality. The Hearts Technical Package for Cardiovascular Disease Management in Primary Health Care is the model recommended by the World Health Organization to address this implementation gap (“HEARTS”: Healthy lifestyle counseling, Evidence-based protocols, Access to medicines, Risk-based care, Task sharing, and Systems monitoring). Despite compelling supporting evidence, HEARTS has not been implemented in most LMICs. Training Plan: To achieve research independence, Dr. Flood requires additional training in (1) applying implementation research methods, (2) human-centered design of interventions, and (3) mixed methods design and evaluation of clinical trials. Dr. Flood will be mentored by an outstanding, multinational team including Co-Primary Mentors Dr. Michele Heisler (University of Michigan) and Dr. Manuel Ramírez-Zea (INCAP) who have extensive mentoring experience and expertise implementing chronic disease interventions. His Co-Mentor will be Dr. Gretchen Piatt (implementation research). Dr. Flood’s advisors will include Drs. Sanjay Saint (consensus design methods), Mark Huffman (translating research between global and U.S. settings), Vilma Irazola (implementation research in Latin America), and Timothy Guetterman (mixed methods). Research Plan: With guidance from his mentors and advisors, Dr. Flood will carry out a detailed study of HEARTS implementation in a single country, Guatemala, which can serve as a generalizable implementation template for use in other LMICs. The research plan will build and expand on an ongoing NHLBI-funded hypertension implementation study in Guatemala (of which Co-Primary Mentor Dr. Ramírez-Zea is Co-PI). Using a stepwise approach, Dr. Flood will (1) identify barriers and facilitators to expanding an ongoing hypertension intervention in Guatemala to also include diabetes and dyslipidemia treatment, as recommended in WHO Hearts; (2) co-design a delivery model of integrated treatment of cardiometabolic diseases using human-centered design, and (3) evaluating the feasibility and acceptability of the delivery model using a mixed-methods evaluation of a cluster randomized pilot study. Findings from this award will position Dr. Flood to submit an R01 application to evaluate effectiveness and implementation outcomes in a type 2 hybrid trial.