Accessible Type 2 Diabetes Interventions, with Sarah LaPointe and Dr. Michael Merrill

Join Sarah Robinson as she interviews Dr. Sarah LaPointe and Dr. Michael Merrill about type 2 diabetes, health equity, and more. We discuss the importance of bridging the gap in diabetes care, making interventions inclusive for all communities. Our expert guests share valuable insights on empowering the health care system and promoting health equity in diabetes management.

Dr. Sarah LaPointe is a Researcher at Brook Health and a Postdoctoral Research Fellow in the Department of Epidemiology at Emory University. She received her Master's in Public Health and PhD in Epidemiology from the Department of Epidemiology and Environmental Health at the University at Buffalo, State University of New York. Broadly, her research interests lie at the intersection of social and environmental determinants of health with a particular passion for improving the health and well-being of marginalized communities. In her free time, Sarah enjoys being outdoors with her dogs, tennis or pickleball, and exploring her new surroundings in Atlanta, GA.

Dr. Mike Merrill is chief medical officer for Brook Health, headquartered in Seattle.  Prior to Brook Health, he served as chief medical officer at United Memorial Medical Center, Rochester Regional Health, and as a medical director for Independent Health. 

Resources: 

• Brook website: https://www.brook.health/ (We are hiring!) 
• Weight loss in Brook's digital diabetes prevention program

Credits: 
Host/Writer: Sarah Robinson, MPH
Guests: Sarah LaPointe, MPH, PhD | Michael Merrill, MD, MS, MS, MBA 
Production Assistant/Audio Editor: Sarah Robinson, MPH 
Theme Music: Dr. Sungmin Shin, DMA 

Follow us!
Official Webpage
Buzzsprout
Spotify
Apple Podcasts
Youtube
Instagram
Facebook
Twitter

Transcript

Sarah Robinson  0:03 
All right, hi everyone. Welcome to Buffalo HealthCast, the official health equity podcast of the UB School of Public Health and Health Professions. My name is Sarah Robinson and today I'm joined by Dr. Sarah LaPointe and Dr. Michael Merrill. We're going to talk with these two experts today about type two diabetes and health inequities, and how they can determine outcomes associated with the disease. So just to start, let's learn a little bit more about our guests. Let's start with Sarah, can you tell us a little bit more about your background and where you went to school and what got you into this research?

Dr. Sarah LaPointe  0:34 
Sure. I'm Sarah LaPointe. I currently work as a researcher with Brook. I received my master's of public health as well as my PhD at the University at Buffalo in the Department of Epidemiology and Environmental Health. And currently, along with my work with Brook, I am a postdoctoral research fellow at Emory University. I came to Brook as a person in search of more research during my doctoral program and have stayed on since and, as we'll share, it's a very impactful program and you see real world results. And as a researcher, it's great to be a part of that. So that's how I came to be here.

Sarah Robinson  1:14 
Awesome. Thank you. And then Mike, would you want to share a little bit about your background?

Dr. Michael Merrill  1:18 
Yeah, I'm a physician. I'm board-certified in internal medicine. I also have a master's from the program there at UB in epidemiology. I've worked at a psychiatric hospital as a hospitalist, as a primary care doctor, I was the head doctor of a small hospital for a while. And I worked for a payer, a not-for-profit payer for a while. I've had some experience in data analytics. And I was approached because Brook needed a chief medical officer and I decided that it was a super interesting group of people to work with, and so I said yes.

Sarah Robinson  1:53 
All right, wonderful. So just to dive into our topic. So we're talking about type two diabetes and health equity today. And then we'll get into a little bit more about a study that you two conducted, to see how these things are related. So first, to start, how would you define health inequities in the context of diabetes management and diabetes care?

Dr. Sarah LaPointe  2:14 
I think a comprehensive response to that would start with the prevalence of diabetes, it's an issue for everybody across the board, across the world. And here in the United States, it's the eighth leading cause of death, and it affects roughly 37 million people, probably more than that. And a handful of those people do not know that they have the disease. When we look even more deeply into that, looking at the experiences and burden of diabetes in racial and ethnic groups, as well as socioeconomic status groups, we find a disproportionate burden that's concentrated amongst individuals that belong to minority racial and ethnic groups. And also individuals that have lower or tend to live below the poverty line or live in poverty, as well as individuals that have less education. And when we take that, then the experiences that come from diabetes, comorbidities, complications, and even death are even worse off in these groups. So we need to take that into consideration when we are trying to effectively prevent and treat diabetes and diabetes related complications.

Dr. Michael Merrill  3:29 
I'd add to that just from a sort of medical care on the ground perspective, if you're disadvantaged, for one reason or another, if you're poor, for example, you don't get a lot of primary medical care, you may just, and you have diabetes, maybe you go to the emergency room a couple times, and they say, Oh, your sugar is really high, you should get that taken care of. But you have other concerns on your mind, you don't go, so your diabetes is picked up late, you're not going to get it well treated, you're probably not going to see an endocrinologist, you're going to have complications, it starts to develop all at the same time, over the years, as this disease slowly eats away at your health and you're gonna maybe have a foot amputation and go on dialysis and have some visual impairment. If you're very advantaged, for example, you're wealthy, you're not going to lose your foot, you're probably not going to go on diabetes, diabetes will be picked up early, you're going to be on a lot of medications, including the expensive new medications, you're gonna have an endocrinologist and it might even be reversible for you. You know, diabetes is effectively reversible with adequate exercise and appropriate diet. So there's a tremendous difference in outcomes related to the care that these individuals receive as well.

Sarah Robinson  4:41 
Definitely. And we talk a lot about the social determinants of health in public health. And we define that as sort of a series of systemic and economic and social barriers that different people experience based on their circumstances. So it includes housing and financial security and food access and education access. So how do the social determinants of health impact diabetes outcomes and access to care?

Dr. Sarah LaPointe  5:11 
I would say in a major way, health and disease occur where we all live, eat, work, play, and pray. And starting with care, as Dr. Merrill had just alluded to, some people don't get the care that they need, or even get that entry point into the clinical and medical care system to know that they have diabetes. And then furthermore, once they do, perhaps, get that diagnosis, maybe they lacked the resources or the knowledge, or the opportunities to, say, access healthy foods, to have opportunities for physical activity, to have the health literacy to abide by the prescriptions of a clinician to manage their care. And also, there's also these cultural factors of reliance on certain foods, or certain behaviors and activities that align with culture that need to be integrated into our engagement with these individuals, and then insurance rolls over into it as well. If you're uninsured, you may not have that entry point into the system to begin with. So I would say it's, as a chronic disease, very much influenced by the social determinants.

Dr. Michael Merrill  6:21 
Yeah, and I think one of the things we see is that, you know, we, in the health care system can only do so much to compensate for these problems, you know, you can't, you know, putting the health care system in charge of eliminating social determinants is, you know, I don't think you should have the health care system build affordable housing and create a system for, you know, whatever, universal basic income, we're not in a position to do that. We need to work with others, we're just, we're fighting this gale force wind of inequality that we can't make go away on our own. We're just trying to compensate for it. And the first step, of course, is understanding, which is what we've been doing in the past few decades, understanding how bad this problem is.

Sarah Robinson  7:12 
Yeah. And it's really difficult because you can't put a BandAid on a systemic issue really. You said these issues just stem from so many different things that aren't related to the healthcare system. But somehow, they all trickle down to the healthcare system. And then we're just sort of left picking up the pieces and trying to help people live longer and healthier. And it's really difficult when everyone is just given such different circumstances. Leading off of that, what would you say are the major challenges that are faced by marginalized communities in managing diabetes effectively?

Dr. Michael Merrill  7:45 
Well, you know, certainly access to care is probably the big one. Another problem is, I think the time horizon, I mean, in in disadvantaged environments, your time horizon appears very, very short, you're trying to figure out how you're going to eat today, and how you can keep your electricity from being turned off. And it's really difficult for someone from a middle class or upper class background to understand the horror of trying to live a life like that. One tends to generalize from one's own experience. And if one doesn't have experience like that, it can just seem like a problem that, you know, fools just don't know how to solve. And that's just that's just absolutely not the case. But I think you can start with just access to care, you can start with having clinics in underserved areas, you can start with insurance products that eliminate copays. Copays are designed to reduce utilization, and they do that very well. Right. But if you want folks who are disadvantaged to get care, you probably don't want to have copays, you know, there are a lot of really intelligent things to be done on a system level, if we get some intelligence into the systemic planning process.

Sarah Robinson  9:03 
And then going off of just basic health, how would you describe any specific examples of health disparities that you've seen related to diabetes, either in your work or just in some of the research that you've done?

Dr. Michael Merrill  9:17 
Sure. I mean, you know, I'll think of a patient I had who worked at a McDonald's. She was obese, she probably weighed about 250 pounds, she had diabetes, and  she couldn't afford her insulin. So we had her on some other medications. She had trouble working because she was obese and had bad arthritis and had trouble sitting at the McDonald's window for eight hours at a time. And she had a high deductible. So how do you find your way out of that problem? This is someone who has to pay a lot of medicines for the diabetes, a lot of money for the medicines for the diabetes, but also has to, you know, pay rent on nearly minimum wage salary, how do you do that? It's just not possible. So something's got to give. And lots of times what gives is the long term goal, the long term goals of remaining healthy are given up. And the short term goal of trying to make it through the day is the primary thing. There are people who, sort of middle income people who don't understand the necessity, that just, through health literacy, do not understand the necessity of keeping their sugars under control, and just sort of live there. Oh, I feel better if my sugar's 250. And okay, but you probably also feel better if you still had your feet in five years, right. So sometimes, you know, that may not be the best way to explain it to someone, but that's the truth. And so, some careful attention by an endocrinologist for some of these difficult diabetes patients will add years to their life, will reduce heart attacks and strokes, let them keep their feet, let them stay off dialysis, and make them feel better, too. And it's just, they're just so many barriers to that. That's what I see. And it's something I deal with every day. I still see patients, I do some house calls. And you know, every day, I see people who have trouble getting the care they need due to, for example, cost or transportation or depression or unsupportive family or whatever, you know, there's tons of reasons.

Sarah Robinson  11:24 
And what specific strategies or interventions do you think could help reduce these health inequities in diabetes care? We see this every day, you see this every day? Are there any specific things that can be done to, you know, slow this problem down?

Dr. Michael Merrill  11:39 
Well, there's a lot of work being done across the across the healthcare system on this, I mean, things like providing transportation to people so they can get to places, having telemedicine visits, reducing copays is really critical. I mean, $10 doesn't sound like much if you're an executive in a health insurance company sitting there thinking about it, but $10 to someone on Medicaid or on, you know, some exchange insurance, is a huge amount of money that will keep you from getting care. Culturally sensitive care, translators, you know, and I think if I was going to do one thing to improve care, it would be to stop underfunding the primary care system. You know, primary care gets about 6%, maybe 7% of the budget in Western New York and across most of the United States of the healthcare spend. In other countries with more functioning healthcare systems, it gets about 12%. And right now, the working conditions in primary care, the amount of work you have to do are just untenable. It's not - you can't do it, you know, and because there's not enough money to hire enough people to support you, and you have to see so many patients that you don't have enough time. So I think if I was going to do one thing, I'd support the primary care system better through increasing the mandated spend by insurance on the primary care system. An infectious disease specialist, or an endocrinologist does not make a whole lot more than a primary care provider. So it's not about the salary, it's about the working conditions. You know, I am unable, as a primary care doctor to do 45 minutes work in 15 minutes - it's just not possible. And I'm not exaggerating, that's how much work has to be done every 15 minutes. And so it creates this moral horror, this moral injury to have to sort of cut something out. What part of your health care would you like me to cut out because I don't have enough time? You know, and people just are repelled by that.  You spend vacation time, like a friend of mine did on a ship in the middle of the Pacific Ocean, bouncing around three hours a night, while scuba diving, doing paperwork from his practice at home, they don't want to do that. And if you have an option to get away from bad working conditions, you get away. So I would say that it's not necessarily the money. It's the working conditions. That's quite irrelevant, I suppose. But, you know.

Sarah Robinson  13:59 
No, it's totally relevant!

Dr. Sarah LaPointe  14:02 
And that's why I appreciate having both Mike and I present here for this interview, because he offers that very insightful clinical perspective. But I guess my answer to that question, would be more of those comprehensive top down approaches. As much of this conversation has highlighted. there's no one specific approach, not to these very, very deep, chronic contributors to poor health. What we need to do is couple these changes in clinical care and probably providing incentives for people to be trickled into primary care so that we also have the presence of primary care practitioners that we need, which we currently don't have. There's this sparsity of primary care especially where it's needed most. And then you address that in concert with, say, environmental changes and policies that have greater density of parks green space, recreational and social engagement areas, as well as opportunities to purchase healthy foods. We're all well acquainted with this idea of food deserts, where some communities don't have an opportunity to have fresh produce or healthy foods to help with the management of their care or the prevention of the onset of diabetes and other chronic diseases. For instance, I believe it's present in New York State, but since moving down here to Georgia, we go to a lot of farmers markets, and you see heavily promoted, we take EBT. So they want people in the community to know that they can access using these social safety net programs, healthy foods. So incorporating that as well, that community aspect to it. And then also, as we'll touch on with the diabetes prevention is forming these partnerships and collaborations so that community members can have a stake in the improvement of their health as well.

Sarah Robinson  16:03 
And we touched on this a little bit with cultural barriers, but how can health care providers address cultural and linguistic barriers to help improve diabetes outcomes in diverse populations?

Dr. Michael Merrill  16:15 
Well, we need more providers, physicians of different backgrounds, I think there's a lot of data that shows that if you have a provider, a physician who's of your cultural, linguistic background, you do better, you know, and so that's crystal clear to me. You trust the person, that's more avenues of communication, there's more channels or dimensions of communication, the nonverbal communication, the cultural assumptions, the history, you know, and that's critical, but also having, obviously cultural sensitivity, cultural humility, you know, translators hirings, like Jericho Road locally is an example of that. They hire translators from the communities they serve, who work in the offices and are able to convey not only, you know, information linguistically, but also the cultural background of everything that's occurring. And I think they're much, much - it's much easier to take care of a population when you have a connection like that.

Dr. Sarah LaPointe  17:16 
Extension to the involvement of family members or caregivers, often these conversations happen one on one, but sometimes you need that mediator between the two. And that's a trusted individual on the part of the patient that can convey these messages and help them in their process for care and management.

Sarah Robinson  17:36 
What role would you say health literacy plays in addressing health inequities among individuals with diabetes?

Dr. Michael Merrill  17:43 
Well, I mean, it's a huge problem, as is everything else. You know, I mean, literacy itself is a problem. You know, I tell you, I've been a doctor for 25 years, I have never met anyone who can't read, which is obviously impossible since about 5% of the population, I think, has some illiteracy. And I think there is a bigger shame with illiteracy than there is, with almost anything else. You know, people are more ashamed of illiteracy than sexually transmitted diseases. They're more ashamed of illiteracy than almost anything, you know, but health literacy is a cousin to that and health literacy is, you know, I don't know how that's solved, I think it's solved by conversations. I think it's solved by giving providers enough time to talk to people and sit with them. I think it's solved with diabetes educators and written materials in the native language. And with cultural sensitivity for the individual involved.

Dr. Sarah LaPointe  18:45 
In the management of chronic disease, there's a lot of steps. So there's medication, there's these lifestyle recommendations that clinicians often make, you need to not only see a primary care physician, but an endocrinologist and these other specialties that are related to diabetes care, and also complications that also come with the diagnosis of diabetes. And that's a lot to manage for anybody, let alone somebody who is not having critical understanding what's going on at the onset with the primary care physician. And I think roadmaps would be incredibly helpful for these individuals. But that touches back on we are very limited in primary care. So at the onset, we are not providing the adequate understanding of what this care will look like for an individual with limited health literacy. And I guess that's identifying a problem more than providing a solution, but that's very limited where we are right now.

Sarah Robinson  19:43 
Yeah, understandably. And then, Mike, are there any innovative approaches or programs that you've come across in your practice that you think have successfully tackled health inequities and diabetes management or do you think we're still working on it?

Dr. Michael Merrill  19:56 
I think we're clearly working on it. I think there's a lot of people like, you know, Jericho Road and some of the other clinics out there that serve the underserved that have really gone way forward. And we can learn a lot from these folks about about how to do that. I think that New York State is very progressive in terms of its Medicaid benefits. I don't think it's good enough, because I think, you know, primary care doctors still lose money on every Medicaid patient. But it's a good start. And I think New York State has overall an enlightened and compassionate approach to taking care of people. Medicaid eligibility is very liberal in the state. Other programs for diabetes - I think a lot of endocrinologist are sensitive to health inequities and tried to take care of folks who really approach the office with fewer resources, and really try to give them some extra attention, walk the extra mile for them. And, you know, our program at Brook actually has, we'll talk about in a second, has great outcomes for diabetes prevention for the Medicaid population as well, actually, surprisingly good outcomes. So that's another one.

Sarah Robinson  21:07 
Great, and we're going to talk about an example of this. But just broadly, how would you say, or how can policymakers and healthcare organizations collaborate to reduce health disparities and improve diabetes care access and outcomes?

Dr. Sarah LaPointe  21:23 
I think provision or any measures to bolster the healthcare infrastructure and the health care workforce, particularly those working in primary care, but any stop along the way in care management, prevention, would all be useful. And there are some programs that have deployed community health workers, rather than bringing the patient to the clinic, bringing the practitioner to the community, and those have shown some meaningful changes in management of diabetes and reduction in some risk factors associated with diabetes, particularly when concentrated among those with the greatest need. And then I'll repeat the improved access to health, healthy foods, and opportunities for physical exercise and relaxation as well. You know, stress management also, I believe, that starts with policy that starts with implementing on a larger level - changes that cannot be made immediately within a community.

Sarah Robinson  22:25 
Great. So we're going to switch gears a little bit and talk about this great program that you two collaborated on and wrote a paper on. So it's the Brook Health Digital Diabetes Prevention Program. Tell us a little bit about it. What started the program? How does it work?

Dr. Michael Merrill  22:41 
So the CDC created a diabetes prevention program a number of years ago that was evidence based and originally was designed to be face to face. A little bit of a disadvantage there, because you have to actually take time away from your life and show up once a week or so with a group of people and work on diet and exercise and collaborating together. Over the years, especially during the pandemic, as we started to do more remote care, some digital diabetes prevention programs have been developed, including the one that Brook operates. And what this does is it's mostly through an app, and with the help of a health coach, and providing a means of technology, individuals are encouraged to examine their own social and psychological states, encouraged to be aware of what they eat, why they eat, what their motivations are, to have a goal, to be reflective, to track what they eat, to track their exercise, to cooperate and sort of compete in a happy way with each other. And it works. You know, the coaches seem to have some sort of supernatural ability, so to speak, to really engage people. The engagement of these patients with each other also seems to be a big predictor of it. And we see we see weight loss, which as far as we can tell now is somewhat sustained over a good deal of time. So it's very encouraging.

Sarah Robinson  24:16 
And who is eligible to participate in this program?

Dr. Sarah LaPointe  24:19 
We identify eligible individuals based on their health insurance status first. So the National Diabetes Prevention Program that was rolled out by the Centers for Disease Control and Prevention, partnered with different payers, which would be healthcare insurers, and first, that we need to ensure that they are covered for any digital diabetes prevention program. And then we assess those individuals for what's considered to be pre-diabetes risk. So based on a variety of different clinical factors, if they meet the definition of pre-diabetes, then we will enroll them if they are interested. It's a voluntary program.

Sarah Robinson  25:04 
And then for your study that you conducted to see how this program actually worked, what kind of data were you collecting? What were you looking at to see if the program was working? And what results did you get from that?

Dr. Sarah LaPointe  25:17 
So broadly, what we were interested in looking at is whether or not length of participation in the program was associated with greater reductions in weight. And we wanted to look at weight because weight loss is considered to be the most deciding factor, or strongest determinant of diabetes incidence reduction, as has been evidenced in previous studies. And the great thing about this program is once enrolled, and after some time, all eligible and enrolled individuals get a remote scale, and they receive a Fitbit physical activity tracker. And so every time they weigh themselves, every time they move, those data are immediately transmitted to our database. So we are getting their monitoring in real time. And those are the data that we used. So after enrolling individuals on a rolling basis, we also administer an intake survey just assessing baseline characteristics. And so we looked at, does length in the program in any way correlate with a reduction in weight? And we looked at weight in various ways.

Sarah Robinson  26:28 
What do the results show? What did you find, after collecting all this data?

Dr. Sarah LaPointe  26:33 
It suggests really positive impacts on the health of our eligible and enrolled members, on average, 94%, or 94 out of every 100 individuals lost weight. And we saw average weight loss of 12 pounds in the program, which also would correspond to a reduction in weight from baseline of 5.9% of their body weight. And 5% is what the CDC assesses as important body weight loss when we are working towards diabetes risk reduction. So to see that is also very meaningful. And then relatedly, the individuals in our study lost about two kilograms per meter squared of their starting BMI as well.

Sarah Robinson  27:25 
You implemented this program, it clearly worked really well. What do these results in this program - what do you think that can mean for tackling health inequities in the future with diabetes? Is this an accessible program that you think will be widely implemented across the country? Is that the hope eventually? Or where do you see this going?

Dr. Sarah LaPointe  27:44 
I think scalability is feasible. But it starts with having payers so those partnerships need to happen first. But in terms of health inequities, we are addressing those rural disparities, because as Mike had alluded to, these individuals don't need to come to some on site location. If you have difficulties in transportation or access to the more urban areas where the sites are concentrated, we can still give you the program components, you can still get coaching, you can still get monitoring all from home. So that convenience is great. And then also, Mike would know better the actual dates, but Medicaid and Medicare began to cover this as well. So we are starting to see and we have seen in different studies, meaningful and more powerful changes amongst these individuals who are Medicaid, who often come from disadvantaged backgrounds, and then Medicare who are older and thus more at risk for chronic diseases.

Sarah Robinson  28:46 
That's great that Medicare and Medicaid are starting to cover programs like this. That really means, I think, that we can see it continue to grow, that it's more accessible to the general population and more marginalized communities that would benefit from it most.

Dr. Sarah LaPointe  29:01 
For our study purposes, we used pretty much the digital data, but we do get insights and shared experiences through the health coaches and nurses. And overall, people share very positive experiences with Brook and these are individuals who have previously tried other weight loss programs and were perhaps unhappy or found them ineffective, but have switched over to Brook and find the comprehensive approach, the engagement with other members who are having similar experiences, the coach and nurse engagement as well, and then the empowering aspect of it where they are essentially taking control and doing it in a asynchronous manner that is convenient for them. They all seem to very much enjoy it.

Dr. Michael Merrill  29:52 
I'll just add one more point, which is that I think one of the reasons this program is accessible is that there's no copay. You know, it's just offered, at least by our main partner, just as a free benefit of being a member of the health plan. And so there's no friction going into it, you know? And, you know, that's a key point. So I think that this is a program that is, you know, I think it's innovative in that it translates an evidence based program from the CDC into a remote care format. And it works. And I think the most surprising thing to us is it seems to work for the wide variety of folks, including the disadvantaged. Very, very encouraging.

Sarah Robinson  30:41 
Yeah. And while we agreed that the answer to tackling health inequities like this probably starts from a higher up, top down approach, you know, something that's more systemic, we also recognize that that's not always possible, because it isn't up to the healthcare system to do that, and just a systemic issue in general. But maybe the answer is a collection of smaller programs like these for now that do make healthcare more accessible, especially through an asynchronous format. I think that's great, especially through the period of COVID, we've seen asynchronous programs more and more. And I think that we're starting to realize like, Oh, this is definitely what works for people, because it is on their own time, with their own devices, in their own homes. So yeah, maybe the future for now, tackling health inequities just looks like smaller programs like these that will hopefully expand so that everyone can access them if needed.

Dr. Michael Merrill  31:39 
Yeah, we're up against systemic inequities, huge social factors that are determinants of health. But we do what we can. And we're aggressive about that. And we're innovative about that. And there is an army of determined, idealistic people who are pushing towards better health outcomes despite the headwinds.

Sarah Robinson  32:02 
Absolutely. And we're so grateful to have you two spearheading part of that movement. Thank you both so much, for your time today, for talking to us about this. This has been really insightful and really important, and we will link the results of the study and the program and anything else that we feel is important in the show notes. So thank you all so much.

Dr. Michael Merrill  32:27 
Thank you.

Sarah Robinson  32:29 
This has been another episode of Buffalo HealthCast. Thank you to our guests, Dr. Sarah LaPointe and Dr. Michael Merrill for joining us today. Be sure to visit the show notes to learn more about their work. This episode was written, recorded, and edited by Sarah Robinson. Our theme music was written and recorded by Dr. Sungmin Shin of the UB Music Department. Buffalo HealthCast is produced by the University at Buffalo School of Public Health and Health Professions. To learn more about health equity in Buffalo, the US, and around the globe, visit our website, linked in the show notes to find more episodes. Thank you for listening to another episode of Buffalo HealthCast.