Population Health Management最新文献

{"title":"Essential Workforce and Competencies for Effective Population Health Management: A Scoping Review.","authors":"Munirah K AlSaqabi, Majed Naif AlOsaimi, Nawaf H Albali, Rufaidah Dabbagh","doi":"10.1089/pop.2025.0043","DOIUrl":"https://doi.org/10.1089/pop.2025.0043","url":null,"abstract":"<p><p>The increasing demand for skilled professionals in population health management (PHM) has highlighted the need for a clear understanding of workforce requirements and competencies. This scoping review aims to address this gap by identifying key roles, responsibilities, and competencies necessary for effective PHM implementation. The review was conducted using PubMed and Google Scholar. Articles focusing on PHM workforce requirements, job titles, roles, responsibilities, and competencies were included. Data were extracted and synthesized to address the research questions. A total of 30 records were reviewed, revealing a diverse range of PHM leadership roles, the importance of interdisciplinary teams, and the need for strategic workforce planning. Five core competency domains were identified: Population Health Knowledge and Expertise, Leadership, Data Literacy and Analytics, Business and Operations, and InterpersonalCommunication Skills. Effective PHM implementation requires a diverse, skilled workforce with clearly defined roles and competencies. These findings provide a framework for workforce development and highlight the need for standardized competency-based training in PHM.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-05-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144143397","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Factors Associated with Health Care Costs in Older Adults with Type 2 Diabetes: Insights for Value-Based Payment Models.","authors":"Winston Liaw, Omolola E Adepoju, Jiangtao Luo, Bill Glasheen, Ben King, Ioannis Kakadiaris, Todd Prewitt, Pete Womack, Jess Dobbins, Mohammad Madani, Rajit Shah, Carlos G Fuentes, LeChauncy Woodard","doi":"10.1089/pop.2025.0054","DOIUrl":"https://doi.org/10.1089/pop.2025.0054","url":null,"abstract":"<p><p>Diabetes accounts for 1 in 4 health care dollars spent. Succeeding in value-based payment models depends on identifying those at risk for high costs and providing them with appropriate treatment. The objective was to determine factors associated with type 2 diabetes mellitus costs. In this cohort study, this study used longitudinal data from a national insurer between 2016 and 2020. The authors included individuals aged 65 and older with type 2 diabetes mellitus with at least 12 months of continuous enrollment in Medicare Advantage. Exclusions included those who died during the study period or had incomplete data. Factors included study year, demographics (age, sex, race/ethnicity, language, dual eligibility, rurality), and diabetes complications (Diabetes Complications Severity Index). The outcomes of interest were medical and prescription costs. The study included 49,843 individuals. Diabetes complications (coefficient = $3582.11, <i>P</i> < 0.001), year (coefficient = $1003.22, <i>P</i> < 0.001, 2020 vs. 2016), sex (coefficient = $238.35, <i>P</i> < 0.001, female vs. male), dual eligibility (coefficient = $618.61, <i>P</i> < 0.001, yes vs. no), and rurality (coefficient = $1242.38, <i>P</i> < 0.001, yes vs. no) were associated with higher medical costs. Age (coefficient = $-2851.67, <i>P</i> < 0.001), race/ethnicity (coefficient = $-1458.03, <i>P</i> < 0.001, Black vs. White; coefficient = $-1679.81, <i>P</i> < 0.001, Hispanic vs. White), and language (coefficient = $-2523.29, <i>P</i> < 0.001, Spanish vs. English) were associated with lower medical costs. Individuals who had complications, were female, were dually eligible, and lived in rural communities had higher medical costs. Black, Hispanic, and Spanish-speaking individuals had lower medical costs, mirroring well-known disparities. Policy makers and health care organizations can use these data to more efficiently deliver care to some while ensuring adequate access for others.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-05-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144120331","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Transforming Population Health in Saudi Arabia: Aligning Strategies with Vision 2030 for a Healthier Future.","authors":"Assim M AlAbdulKader, Mohammed Jabr","doi":"10.1089/pop.2025.0047","DOIUrl":"https://doi.org/10.1089/pop.2025.0047","url":null,"abstract":"","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-05-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143994828","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Increasing Statin-Prescribing and Low-Density Lipoprotein Cholesterol Control in Secondary Atherosclerotic Cardiovascular Disease Prevention: A Collaborative Approach.","authors":"Erin Leaver-Schmidt, Earlean Chambers, Elizabeth Ciemins, Cori Rattelman, Parag Agnihotri, Danielle Casanova, John Kennedy","doi":"10.1089/pop.2024.0227","DOIUrl":"https://doi.org/10.1089/pop.2024.0227","url":null,"abstract":"<p><p>Despite ample evidence supporting their efficacy in atherosclerotic cardiovascular disease (ASCVD) management, statin-prescribing and low-density lipoprotein cholesterol (LDL-C) measurement are underused, especially for vulnerable populations. This study explores the impact of a Best Practices Learning Collaborative to improve the management of patients with ASCVD for secondary prevention. Conducted with the guidance of a subject-matter expert advisory committee, the ASCVD Collaborative convened a geographically diverse group of health care organizations (HCOs) over a 12-month implementation period to set goals, develop and implement interventions, collect and track quality performance measures, and share best practices. Interventions included provider/staff education, clinical decision support tools, care coordination, patient education and awareness, and the treatment of very high-risk patients. HCOs tracked three measures for patients with established ASCVD: any statin prescribed (stratified by sex and race/ethnicity), high-intensity statin prescribed, and LDL-C control (<70 mg/dL). After a 12-month implementation period, HCOs demonstrated improvement in one or more measures. The Collaborative model was shown to be an effective means for achieving improvement in the management of ASCVD, laying the groundwork for future more rigorous studies to identify the most impactful interventions.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-05-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144040809","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evaluation of an Interdisciplinary Hypertension Management Program at a Large Primary Care Practice.","authors":"Melanie Chalfin, Scott Orlov, Sheraz Qamar, Amy Cunningham, Geoffrey Mills","doi":"10.1089/pop.2024.0233","DOIUrl":"https://doi.org/10.1089/pop.2024.0233","url":null,"abstract":"<p><p>Hypertension control remains challenging for many primary care patients. The goal of this study was to implement an evidence-based team approach to improve hypertension control, self-reported health distress, and self-efficacy in adult patients with hypertension at a large academic family medicine practice. The 5-year intervention included team-based medication therapy management, patient-centered behavioral counseling, and home blood pressure monitoring. Pre- and post-intervention blood pressure and patient surveys were analyzed using paired <i>t</i>-tests. The authors observed significant decreases in systolic blood pressure (148.4 vs. 135.6, <i>P</i> = 0.001) and self-reported health distress over the enrollment period in participants who completed the study. The multidisciplinary intervention was associated with reduced systolic blood pressure and health distress in patients who enrolled and completed the program. A multidisciplinary blood pressure monitoring program can be implemented by providers referring patients with uncontrolled hypertension after pharmacologic interventions.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-04-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144028391","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Enhancing Machine Learning Explainability of Disaster Preparedness Models from the FEMA National Household Survey to Inform Tailored Population Health Interventions.","authors":"Taryn Amberson, Wenhui Zhang, Samuel E Sondheim, Wanda Spurlock, Jessica Castner","doi":"10.1089/pop.2024.0243","DOIUrl":"https://doi.org/10.1089/pop.2024.0243","url":null,"abstract":"<p><p>Devastating mortality, morbidity, economic, and quality of life impacts have resulted from disasters in the United States. This study aimed to validate a preexisting machine learning (ML) model of household disaster preparedness. Data from 2021 to 23 Federal Emergency Management Agency's National Household Surveys (<i>n</i> = 21,294) were harmonized. Importance features from the preexisting random forest ML model were transferred and tested in multiple linear and logistic regression models with updated datasets. Multiple regression models explained 42%-53% of the variance in household disaster preparedness. Features that improved the odds of overall disaster preparedness included detailed evacuation plans (odds ratios [OR] = 3.5-5.5), detailed shelter plans (OR = 4.3-11.0), having flood insurance (OR = 1.5-2.0), and higher educational attainment (OR = 1.1). Having no specified source of disaster information lowered preparedness odds (OR = 0.11-0.53). When stratified further by older adults with Black racial identities (<i>n</i> = 350), television as a main source of disaster-related information demonstrated associations with increased preparedness odds (OR = 2.2). These results validate the importance of detailed evacuation and shelter planning and the need to consider flood insurance subsidies in population health management to prepare for disasters. Tailored preparedness education for older adults with low educational attainment and targeted television media for subpopulation disaster-related information are indicated. By demonstrating a feasible use case to import ML model findings for regression testing in new datasets, this process promises to enhance population management health equity for those in sites that do not yet utilize local ML.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-04-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143796215","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Perspectives on Obesity Management and the Use of Anti-Obesity Medicine from US Employees and Employers: Results from the OBSERVE Study.","authors":"Jamy Ard, Lee M Kaplan, Scott Kahan, Rekha Kumar, Hong Kan, Julia P Dunn, Tracy J Sims, Nadia N Ahmad, Kristen King-Concialdi, Sheila Drakeley, Adam Jauregui, Kimberly Gudzune","doi":"10.1089/pop.2024.0239","DOIUrl":"https://doi.org/10.1089/pop.2024.0239","url":null,"abstract":"<p><p>Personal health factors and direct and indirect costs of obesity affect employers and employees. This research aimed to understand perceptions of obesity management and anti-obesity medications (AOMs) among employers and employees. In 2022, people with obesity and employers completed cross-sectional surveys about perceptions of obesity and its management, including AOMs. Data were analyzed with descriptive statistics. Data from 461 employed people with obesity (EwO) and 51 employer representatives (ER) were analyzed. Both EwO and ER acknowledged the impact of obesity on future health problems (88.3%; 100.0%) and perceived obesity as a disease (60.5%; 80.4%) to varied degrees. Both groups perceived an incremental value in combining self-directed lifestyle changes and AOMs (57.5%; 66.7%) and perceived healthcare provider-guided lifestyle change alongside AOMs as the most effective approach for maintaining long-term weight reduction (56.4%; 66.6%). More than two-thirds (68.6%) of ER expressed willingness to revisit their AOM coverage decisions, though cost of medication coverage (72.5%) and affordability of medications for employees (68.7%) were identified as barriers. ER believed that data showing reductions in premiums and claims at their organizations (78.4%) would be helpful in supporting the coverage of AOMs. While EwO and ER were receptive toward AOMs, organization-level barriers existed with AOM coverage. Evidence demonstrating the benefits of evidence-based obesity care, direct/indirect cost reductions, and the impact of obesity may address barriers to AOM coverage and improve obesity care and outcomes of their workforces.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-04-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143764404","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Assessing the Relationship Between Behavioral Health Integration and Alcohol-Related Treatment Among Patients with Medicaid.","authors":"Lina Tieu, Nadereh Pourat, Elizabeth Bromley, Rajat Simhan, Weihao Zhou, Xiao Chen, Beth Glenn, Roshan Bastani","doi":"10.1089/pop.2024.0170","DOIUrl":"10.1089/pop.2024.0170","url":null,"abstract":"<p><p>Behavioral health integration (BHI) is increasingly implemented to expand capacity to address behavioral health conditions within primary care. Survey and claims data from the evaluation of the Public Hospital Redesign and Incentives in Medi-Cal program were used to examine the relationship between BHI and alcohol-related outcomes among Medicaid patients within 17 public hospitals in California. Key informant survey data measured hospital-level BHI at 3 levels (overall composite, infrastructure, and process domains, 10 themes). Multilevel logistic regression models estimated the relationship between BHI and outcomes indicating receipt of appropriate alcohol-related care (any primary care visit, any detoxification, timely initiation, timely engagement) and acute care (any emergency department [ED] visit or hospitalization, classified as alcohol-related or all-cause) in the year following an alcohol-related index encounter. Of 6196 patients, some had an alcohol-related primary care visit (33%), detoxification (16%), timely initiation (14%), or engagement in treatment (7%). ED visits resulting in discharge were more common (40% alcohol-related, 64% all-cause) than hospitalizations (15% alcohol-related, 26% all-cause). Controlling for patient-level characteristics, no significant relationships between overall BHI and these outcomes were observed. However, greater BHI infrastructure was associated with alcohol-related (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.14-3.05) and all-cause hospitalization (OR 1.25, 95% CI 1.01-1.55). Associations emerged between BHI themes (eg, related to support of providers) and greater likelihood of alcohol-related detoxification, primary care visit, timely initiation, and acute care utilization. Findings suggest that implementing specific BHI components may improve receipt of alcohol-related treatment, and warrant future research into these relationships.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"88-97"},"PeriodicalIF":1.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142807776","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Transitional Care for Older Adults: Demonstration of the Role of a Partnership Payvider.","authors":"Alexis Kurek, Carlos Weiss, Kennedy M Boone-Sautter, Aiesha Ahmed","doi":"10.1089/pop.2024.0189","DOIUrl":"10.1089/pop.2024.0189","url":null,"abstract":"<p><p>A payvider organization provides both payer and provider services and has been linked to administrative and patient cost reduction by improving right-sized utilization of patient care services. A geriatric-focused transitional program was offered to patients covered under a value-based care risk contract formed by the payvider relationship of an integrated health system. This article describes a prospective study comparing utilization and cost metrics of patients enrolled in the transitional care program with the goal of analyzing utilization of services to better understand patient behavior patterns and care needs after hospital admission and consecutive enrollment in the program. Patients enrolled in the program incurred lower costs in all categories but home health care than the reference population. The cost avoidance achieved during the study period was estimated to be over $1.1 million. Individuals participating in the program had similar emergency department visit rates during the 90- and 180-days following the hospital as the reference population but had significantly lower inpatient readmissions (7.8% vs. 15.4%) even with a higher average readmission risk score (66.8 vs. 65.5). The implementation of the transitional care program led to reduced costs and more efficient utilization of services than those not enrolled in the program. The payvider relationship allows systems to think proactively about new initiatives and programs that will better serve their communities, especially when identifying groups with high projected costs and service utilization. Patients benefit from the assurance that the services they are receiving are covered by their insurer and their trusted organization.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"98-104"},"PeriodicalIF":1.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142886136","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hospital Safety-Net Burden is Associated with Perioperative Outcomes in Primary Total Hip Arthroplasty: A Multistate Retrospective Analysis, 2015-2020.","authors":"Margaret Darko, Virginia E Tangel, Abbey Gilman, Maressa Cumbermack, Deirdre C Kelleher, Tiffany Tedore, Robert S White","doi":"10.1089/pop.2024.0194","DOIUrl":"10.1089/pop.2024.0194","url":null,"abstract":"<p><p>Total hip arthroplasty (THA) is a widely performed surgical procedure in the United States, but disparities in THA outcomes related to hospital-level factors, such as safety-net burden, are underexplored. This study expands on previous research by analyzing multicenter, multistate data from 2015 to 2020 to investigate the impact of hospital safety-net burden-defined as the proportion of services billed to Medicaid and uninsured patients-on THA outcomes. This study is a retrospective analysis using data from the State Inpatient Databases for Florida, Kentucky, Maryland, New York, Washington, New Jersey, and North Carolina. The study cohort included 543,814 inpatient primary THA admissions, with patient demographics, comorbidities, and hospital characteristics analyzed across 3 categories of hospital safety-net burden (low, medium, and high). Generalized linear mixed models assessed the association between safety-net burden and in-hospital mortality and postoperative complications, whereas multilevel negative binomial regression evaluated the impact on hospital length of stay. The study findings indicate that patients undergoing THA at hospitals with high safety-net burden had significantly higher odds of in-hospital mortality (adjusted odds ratio [aOR]: 1.20, 95% confidence interval [CI]: 1.02-1.42), postoperative complications (aOR 1.33, 95% CI 1.20-1.48), and longer hospital stays (adjusted incidence rate ratio 1.15, 95% CI 1.10-1.21) compared with those at low-burden hospitals. These results suggest that hospitals with higher safety-net burden, often serving more vulnerable populations, may have suboptimal perioperative processes and protocols, leading to poorer outcomes. The study underscores the need for targeted interventions to improve THA outcomes in these hospitals.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"57-70"},"PeriodicalIF":1.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143010389","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}