Population Health Management最新文献

{"title":"Sex-Based Differences in Association Between Coverage Disruptions and Preventive Care.","authors":"Lauren Howard, Em Long-Mills, Dmitry Tumin, Adrianne Frech","doi":"10.1177/19427891261495777","DOIUrl":"https://doi.org/10.1177/19427891261495777","url":null,"abstract":"<p><p>Adults with part-year or year-round uninsurance are less likely to receive recommended preventive services. Sex differences in preventive care use have been documented, but it remains unclear whether sex moderates the association between insurance coverage disruptions and preventive care use. The current study analyzed data from 37,659 adults aged 18-64 in the 2019 and 2023 National Health Interview Survey. Insurance coverage over the past 12 months was categorized as continuous private, continuous public, coverage gap, or continuously uninsured. Outcomes included blood pressure and cholesterol tests, having a usual source of care, dental and eye exams, preventive care visits, and unmet need for medical care. Each outcome was analyzed using multivariate logistic regression interacting insurance category with sex. Continuously uninsured adults or adults with coverage gaps in the past 12 months reported lower preventive care utilization and higher unmet need for medical care than adults who were continuously insured. Relationships between part-year or year-round uninsurance and preventive care generally did not vary by sex. Female respondents with continuous public insurance were less likely to report a usual source of care but had lower unmet needs for medical care than female respondents with continuous private insurance. Health insurance coverage disruptions are associated with reduced use of preventive services regardless of sex. Policies promoting continuity of health insurance coverage may improve uptake of preventive services and reduce unmet needs for medical care.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"19427891261495777"},"PeriodicalIF":2.1,"publicationDate":"2026-10-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149169028","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":"Payment Reform Holds the Key to Impacting Complex Patients.","authors":"Patrick Runnels, Nicole Martin, Heather Byrne, Peter J Pronovost","doi":"10.1177/19427891261495771","DOIUrl":"https://doi.org/10.1177/19427891261495771","url":null,"abstract":"","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"19427891261495771"},"PeriodicalIF":2.1,"publicationDate":"2026-10-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149128182","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":"Census Tract Level Analysis of Stroke Burden and Social Vulnerability Index in Mississippi: Implications for Health Equity Policy.","authors":"Minhazul Abedin, Joshua R Mann, Benjamin H Walker, Tasnim Tabassum, Thomas Dobbs, Fazlay S Faruque","doi":"10.1177/19427891261481301","DOIUrl":"https://doi.org/10.1177/19427891261481301","url":null,"abstract":"<p><p>Stroke remains a leading cause of death and disability in Mississippi, accounting for approximately 1,844 deaths annually and substantial health care costs. Persistent geographical and racial disparities, driven by SDOH, contribute to an unequal burden. The publicly available CDC PLACES dataset and the CDC/ATSDR Social Vulnerability Index (SVI) provide opportunities to examine geographic disparities and identify communities at the greatest risk. An ecological analysis was conducted across 870 Mississippi census tracts (∼2.28 million adults) using CDC PLACES 2022 stroke prevalence estimates and SVI 2022 data across all four thematic domains. Stroke prevalence was categorized as low (0.7-3.8%, <i>n</i> = 225), moderate (3.9-5.9%, <i>n</i> = 433), or high (6.0-11.6%, <i>n</i> = 212). Spearman's rank correlation and bivariate choropleth mapping were used to assess associations between stroke burden and social vulnerability and their geographic concordance. An estimated 109,348 Mississippi adults have experienced a stroke, with 33,167 (30%) residing in highly vulnerable tracts. Stroke prevalence correlated strongly with overall SVI (ρ = 0.74), socioeconomic status (ρ = 0.75), and minority status (ρ = 0.60; all <i>P</i> < 0.0001). High-prevalence tracts showed extreme social vulnerability (median overall SVI = 0.82; socioeconomic SVI = 0.85), substantially higher poverty (50% vs. 15%), and predominantly minority populations (78% vs. 27%) compared with low-prevalence tracts. High-burden clusters were concentrated in the Mississippi Delta and central corridor, while Gulf Coast tracts showed comparatively lower prevalence. Stroke prevalence and social vulnerability are strongly and spatially co-patterned across Mississippi census tracts. Routinely updated CDC datasets provide actionable tools for identifying high-risk communities and guiding equity-focused stroke prevention that addresses social determinants alongside clinical risk factors.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"19427891261481301"},"PeriodicalIF":2.1,"publicationDate":"2026-10-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149128184","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":"Turning Compliance Into Action: An Augmented Intelligence-Enabled Framework for Advocacy Organizations to Drive Population Health Improvement.","authors":"Richard G Stefanacci","doi":"10.1177/19427891261450800","DOIUrl":"10.1177/19427891261450800","url":null,"abstract":"<p><p>Community Health Needs Assessments (CHNAs), mandated by the Affordable Care Act for tax-exempt hospitals, represent an underutilized yet rich data source for disease-specific advocacy. This commentary proposes a novel framework in which disease advocacy organizations-such as Alzheimer's Los Angeles, the American Heart Association, and the National Alliance on Mental Illness-deploy artificial intelligence (AI) agents to systematically analyze CHNAs, identify gaps in condition-specific care, generate personalized outreach to hospital leadership, and publicly score health systems on their responsiveness to identified needs. Using Alzheimer's disease and dementia care in Los Angeles County as a primary case example, this article describes how AI-driven automation of data collection, natural language processing of CHNA documents, and coordinated advocacy campaigns can transform the current passive CHNA cycle into an active mechanism for population health improvement. The framework combines reputational accountability through public scorecards with constructive, evidence-based recommendations, creating a \"carrot-and-stick\" dynamic that existing literature on public performance reporting suggests can achieve engagement rates of 40%-70% and meaningful institutional change in 30%-60% of targeted systems. This approach is adaptable across chronic conditions and disease advocacy organizations, wherever publicly reported community needs data intersect with organized patient advocacy. Implications for population health management, health system quality improvement, and the responsible integration of AI in public health advocacy are discussed.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"340-344"},"PeriodicalIF":2.1,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148043468","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":"Screening for and Addressing Social Determinants of Health at Transitions of Care.","authors":"Shira Winter, Kimberly Mauer, Carl Jin, Arzellra Walters, Esther Pandey","doi":"10.1177/19427891261451491","DOIUrl":"10.1177/19427891261451491","url":null,"abstract":"<p><p>Transitions of care from hospital to home are a vulnerable time for patients, particularly so for those with social determinants of health (SDOH) needs that may impact their ability to manage their health in the outpatient setting. Traditional interventions focus on medication, continuity of care, health information, and red flags and do not necessarily address patients' SDOH needs. The objective was to evaluate the incorporation of an SDOH screening and intervention into transitions of care encounters (referred to here as CTI+). This is a retrospective analysis of electronic health record data of patients discharged from a large urban health system with a transition of care encounter between May 2022 and April 2024. Demographic characteristics of patients who participate in CTI + are presented, as well as the prevalence of screening positive for issues with health literacy, medical transportation, food insecurity, and financial resource strain. The 30-day readmission rates for patients with SDOH factors and those without were compared, as well as readmission rates in the year prior to and following implementation of CTI+. Of 5942 encounters, 31.9% screened positive for at least one SDOH. 25.6% reported issues with health literacy. Readmission rates rose slightly for each additional positive SDOH factor. After implementation of CTI+, readmissions dropped from 11.7% to 9.8%. These findings highlight the need to address health literacy and demonstrate that incorporating SDOH screening and interventions into transitions of care may help mitigate the effect of SDOH on readmissions.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"291-296"},"PeriodicalIF":2.1,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148259367","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":"Single and Dual Sensory Loss and Cardiovascular Disease in US adults: Findings from the 2021 Behavioral Risk Factor Surveillance System.","authors":"Heather F McClintock, Luis Enrique Espinoza, Amanda M Hinson-Enslin","doi":"10.1177/19427891261450803","DOIUrl":"10.1177/19427891261450803","url":null,"abstract":"<p><p>Prior work has shown that persons with disabilities have higher rates of poor cardiovascular outcomes than persons without disabilities. Little research has evaluated this relationship in persons with single and dual sensory loss. This study aimed to examine the association between single and dual sensory loss and cardiovascular disease (CVD). Data were obtained from 2021 Behavioral Risk Factor Surveillance System, a representative household survey of 234,394 noninstitutionalized civilian adults. The independent variable was sensory loss (neither, vision loss only, hearing loss only, both vision and hearing loss). The outcomes were self-reported angina/coronary heart disease, stroke, heart attack, and CVD (composite variable). Covariates were sex, age, race/ethnicity, education, employment, marital status, insurance, income, metropolitan status, body mass index, blood pressure, cholesterol, diabetes, depression, exercise, fruit and vegetable intake, smoking, and alcohol risk. Weighted multivariable logistic regression was used to evaluate the relationship between sensory loss and CVD, adjusting for covariates. In weighted and fully adjusted models, persons with vision loss only, hearing loss only, and dual sensory loss had increased odds of heart attack, stroke, angina/coronary heart disease, and CVD in comparison with persons without sensory loss. Additional research is needed to examine the underlying mechanisms influencing increased risk for CVD in persons with sensory loss. Initiatives are needed that aim to reduce the burden of CVD among persons with single and dual sensory loss.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"303-310"},"PeriodicalIF":2.1,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148006174","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":"It's Time to Build the Infrastructure that Makes Health Possible: Formalizing Accountable Communities for Health.","authors":"David S Buck, Haaris Mateen, Kenneth W Janda","doi":"10.1177/19427891261457303","DOIUrl":"10.1177/19427891261457303","url":null,"abstract":"","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"345-347"},"PeriodicalIF":2.1,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148212412","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":"Screening for Social Needs in Health Care Systems: A Quality Improvement Framework and Two Case Studies.","authors":"Megan Cahn, Shivonne Laird, Terrisca Des Jardins, Vaishali Patil, Jessica Shaffer, Tricia Bolender, Brynlee Vermillion","doi":"10.1177/19427891261454008","DOIUrl":"10.1177/19427891261454008","url":null,"abstract":"<p><p>Public health professionals have long understood the link between social determinants of health, health-related social needs (HRSN), and health outcomes. Recently, the integration of social care to address HRSN within the health care environment has increased, spurred by payers and health systems recognizing that they will be unable to improve health equity without addressing the underlying nonclinical causes of illness. However, the integration of social care and health care is complex, involving many stakeholders within health care and social care systems, as well as the community. From September 2021 to September 2022, the Institute for Healthcare Improvement, with funding from Pfizer, supported a Learning and Action Network (LAN) involving three integrated delivery networks (IDNs) from across the United States. During the LAN, the IDNs tested social care integration strategies within their patient populations and shared results both with one another and stakeholders in their own systems to enhance the rate of learning and improvement. Detailed here are practical examples from the LAN and learnings from the participating IDNs, with a focus on HRSN screening. This paper presents the quality improvement framework for the LAN, including the use of a three-part data review process and Plan-Do-Study-Act cycles, and documents the successes and challenges faced by each of the IDNs, which include dramatic improvements in HRSN screening rates. Success in this work can be realized with intentional engagement with health care system leadership and the community, closely monitoring implementation, and by evaluating what really matters at the core of this work-achieving health equity.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"319-329"},"PeriodicalIF":2.1,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148056128","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":"The Impact of Social Vulnerability and Race on Colorectal Cancer Screening.","authors":"Charlotte Blumrosen, Claire Clark, Myla Strawderman, Jennifer Maguire, Robert J Fortuna","doi":"10.1177/19427891261446802","DOIUrl":"10.1177/19427891261446802","url":null,"abstract":"<p><p>Colorectal cancer (CRC) is a leading contributor to morbidity and mortality in the United States, with documented disparities in screening rates across racial lines. This study examined the intersection of race and social vulnerability in CRC screening rates. We examined 117,424 patients eligible for CRC screening in New York State. We assessed CRC screening among individuals aged 45-80 based on Healthcare Effectiveness Data and Information Set guidelines. We used Social Vulnerability Indices (SVIs) geocoded to each patient's census track. We employed log-binomial multivariate regression models with interaction terms to evaluate the effects of race and social vulnerability on CRC screening rates, while controlling for age, sex, marital status, and community type. Among 117,424 patients eligible for CRC screening, 75.2% of patients (<i>n</i> = 88,276) were effectively screened. Screening rates varied based on race (White 76.2%; Black 64.4%; <i>P</i> < 0.0001). CRC screening rates declined with increasing social vulnerability among both Black and White patients. Among patients in the most socially vulnerable groups, the adjusted rate of screening was 3.8%-8.4% lower for Black patients compared to White patients. In contrast, within the least socially vulnerable (most affluent) group, there was no statistical difference in the rate of CRC screening by race (adjusted risk ratio = 0.981; <i>P</i> = 0.201). The impact of social vulnerability was experienced disproportionately by Black patients. Among patients living in the most vulnerable census tracts, Black patients were significantly less likely to be screened for CRC compared to White patients facing similar social vulnerability. In contrast, we did not observe a difference in screening rates by race in the most affluent (least socially vulnerable) group.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"297-302"},"PeriodicalIF":2.1,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147779271","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":"Continuity of Care, Immigrant Status, and Emergency Department Use Among Seniors in Canada.","authors":"Raaj Tiagi","doi":"10.1177/19427891261450755","DOIUrl":"10.1177/19427891261450755","url":null,"abstract":"<p><p>This study examines the relationship between continuity of care with a family doctor and the usual place of care for minor health problems among Canadian seniors, with a focus on differences between immigrants and the native-born. Data come from the Canadian Health Survey on Seniors (<i>n</i> = 40,848). The outcome identifies respondents' usual source of immediate care for minor problems: a doctor's office, hospital outpatient/community clinic/walk-in clinic, emergency department (ED), or another location. Multinomial logistic regression models estimate associations between continuity of care-measured as duration of attachment to a family doctor-and place of care, with and without interaction terms between continuity and immigrant status, adjusting for demographic, socioeconomic, health, and access-related factors. Seniors attached to a regular family doctor for more than 2 years are significantly less likely to rely on the ED as their usual source of care (OR = 0.89, <i>P</i> < 0.05). Immigrants are also less likely than native-born seniors to use the ED (OR = 0.69, <i>P</i> < 0.001). However, interaction models show that immigrants with short-term attachment (less than 1 year) have higher odds of ED use than native-born seniors with similar attachment (OR = 2.33, <i>P</i> = 0.031). Poor self-rated health, lower income, and access barriers are associated with greater ED reliance. These findings highlight the importance of sustained primary care relationships, particularly for newly attached and immigrant seniors, to reduce avoidable ED use and promote equitable access to community-based care in Canada.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"311-318"},"PeriodicalIF":2.1,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147974735","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}