Population Health Management最新文献

{"title":"Validating and Improving Adjusted Clinical Group's Future Hospitalization and High-Cost Prediction Models for Dutch Primary Care.","authors":"Shelley-Ann M Girwar, Marta Fiocco, Stephen P Sutch, Mattijs E Numans, Marc A Bruijnzeels","doi":"10.1089/pop.2023.0162","DOIUrl":"10.1089/pop.2023.0162","url":null,"abstract":"<p><p>The rise in health care costs, caused by older and more complex patient populations, requires Population Health Management approaches including risk stratification. With risk stratification, patients are assigned individual risk scores based on medical records. These patient stratifications focus on future high costs and expensive care utilization such as hospitalization, for which different models exist. With this study, the research team validated the accuracy of risk prediction scores for future hospitalization and high health care costs, calculated by the Adjusted Clinical Group (ACG)'s risk stratification models, using Dutch primary health care data registries. In addition, they aimed to adjust the US-based predictive models for Dutch primary care. The statistical validity of the existing models was assessed. In addition, the underlying prediction models were trained on 95,262 patients' data from de Zoetermeer region and externally validated on data of 48,780 patients from Zeist, Nijkerk, and Urk. Information on age, sex, number of general practitioner visits, International Classification of Primary Care coded information on the diagnosis and Anatomical Therapeutic Chemical Classification coded information on the prescribed medications, were incorporated in the model. C-statistics were used to validate the discriminatory ability of the models. Calibrating ability was assessed by visual inspection of calibration plots. Adjustment of the hospitalization model based on Dutch data improved C-statistics from 0.69 to 0.75, whereas adjustment of the high-cost model improved C-statistics from 0.78 to 0.85, indicating good discrimination of the models. The models also showed good calibration. In conclusion, the local adjustments of the ACG prediction models show great potential for use in Dutch primary care.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"430-437"},"PeriodicalIF":2.5,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71426250","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":"Examining the Association of Social Needs with Future Health Care Utilization in an Older Adult Population: Which Needs Are Most Important?","authors":"David M Mosen, Matthew P Banegas, Erin M Keast, John F Dickerson","doi":"10.1089/pop.2023.0171","DOIUrl":"10.1089/pop.2023.0171","url":null,"abstract":"<p><p><b>Abstract</b> Social needs, such as social isolation and food insecurity, are important individual-level social determinants of health, especially for adults ages 65 years and older. These needs may be associated with future health care utilization, but this research area has not been studied extensively. The objective of this study was to examine the <i>independent association</i> of 5 individual social needs with future (1) emergency department (ED) visits and (2) hospital admissions. This observational study included 9649 Kaiser Permanente Northwest (KPNW) Medicare members who completed the Medicare Total Health Assessment (MTHA) quality improvement survey between August 17, 2020 and January 31, 2022. The 5 social needs assessed by the MTHA, defined as binary measures (yes/no), included (1) financial strain, (2) food insecurity, (3) housing instability, (4) social isolation, and (5) transportation needs. ED utilization (yes/no) and hospitalization (yes/no), the current study outcome measures, were measured in the 12 months after MTHA assessment. In multivariable analyses, 3 of the 5 social needs were significantly associated with higher ED utilization: financial strain (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.11-1.76, <i>P</i> < 0.05), housing instability (OR = 1.43, 95% CI = 1.02-1.99, <i>P</i> < 0.05), and social isolation (OR = 1.19, 95% CI = 1.05-1.34, <i>P</i> < 0.05), and 1, financial strain, was significantly associated with hospital admissions (OR = 1.66, 95% CI = 1.23-2.23, <i>P</i> < 0.05). The study results identified which social needs are most strongly associated with future ED utilization and hospital admissions. Further research is needed to better understand whether addressing social needs is associated with improved patient-level health outcomes over time.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"413-419"},"PeriodicalIF":1.8,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10698796/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71522417","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Put All Your Health Investments Under the Same Lens.","authors":"Ronald J Ozminkowski","doi":"10.1089/pop.2023.0175","DOIUrl":"10.1089/pop.2023.0175","url":null,"abstract":"","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"441-444"},"PeriodicalIF":2.5,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71413631","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":"Engaging Stakeholder Advisors Around Health-Related Social Needs Research, Policy, and Practice Priorities.","authors":"Marik Moen, Megan Doede, Alexandra Schweitzer","doi":"10.1089/pop.2023.0177","DOIUrl":"10.1089/pop.2023.0177","url":null,"abstract":"<p><p>As health care systems invest significant resources to address social needs associated with poor health such as food, financial, and housing insecurity, many eligible patients are still not obtaining the resources they need. The recently initiated PURPLE Project (Promoting Understanding in Social Needs Research Projects by Listening and Engaging) engages stakeholder advisors to help address 2 challenges: (1) many patients do not accept offered assistance, and (2) of patients who accept assistance, less than half have their needs addressed. This article presents the team's engagement with local advisors, garnering real-life insights from patients with social needs, staff and leadership in public health, health care, and community service organizations. The team shares these organizations' priorities and recommendations and how these can be applied to these major challenges. This article can assist others in the social care arena who seeks to involve local partners as advisors to improve practices and policies in addressing social needs.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"359-364"},"PeriodicalIF":2.5,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41168735","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":"A Conceptual Framework for Building Individual and Team Capabilities to Provide Effective Longitudinal, Relationship-Based Clinical Case Management.","authors":"Patrick Runnels, James Penman, Steve Schreiber, Trygve Dolber, Kipum Lee, Peter J Pronovost","doi":"10.1089/pop.2023.0165","DOIUrl":"10.1089/pop.2023.0165","url":null,"abstract":"<p><p>Individuals with complex, chronic diseases represent 5% of the population but consume 50% of the costs of care. These patients have <i>complex lives</i>, characterized by multiple chronic physical health conditions paired with a combination of behavioral health issues and/or unmet social needs. Unlike for most health problems, the problems faced by individuals with complex lives cannot be broken down into simpler parts to be solved independent from 1 another. In this article, the authors describe a 2-phase framework for improving outcomes in patients with complex lives, outline how the model works in more detail, and discuss lessons learned in this journey. In phase 1, a case manager carefully and deliberately focuses on building a relationship with the patient to first gain trust, and then identify, in partnership with the patient, how to best approach assisting the patient in improving their health. That pathway is often unknowable without a deep investment of time, a radical acceptance of the patient, faults and all, and an unwavering commitment to stay by their side, even when things are tough. Once the case manager and patient have established a trusting relationship, they enter phase 2-building a path toward wellness, including further emphasis on the relationship, solving prioritized issues, changing the health system approach, and engaging the patient in self-reflection and behavior change activities.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"408-412"},"PeriodicalIF":2.5,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89719291","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 Minority and Rural Coronavirus Insights Study: Design and Baseline Characteristics of a Minority Cohort.","authors":"Makella S Coudray, Shantoy Hansel, Lina V Mata-McMurry, Dora Il'yasova, LaTasha Lee, Nishanth Chalasani, Christina Edwards, Gary Puckrein, William A Meyer, Latrice G Landry, Gary Wiltz, Marian Sampson, Todd Brandt Dee, Paul Gregerson, Charles Barron, Jeffrey Marable, Ola Akinboboye","doi":"10.1089/pop.2023.0168","DOIUrl":"10.1089/pop.2023.0168","url":null,"abstract":"<p><p>The Minority and Rural Coronavirus Insights Study (MRCIS) is an ongoing prospective cohort study examining health disparities associated with SARS-CoV-2 infection among medically underserved populations. This report describes procedures implemented to establish the MRCIS cohort and examines the factors associated with the molecular and serological assessment of SARS-CoV-2 infection status at participant enrollment. Participants were recruited from 5 geographically dispersed federally qualified health centers between November 2020 and April 2021. At baseline, participants completed a detailed demographic survey and biological samples were collected for testing. SARS-CoV-2 infection status was determined based on the combined molecular and serological test results. Chi-squared and logistic regression analyses were conducted to examine associations between sociodemographic factors, COVID-19 safety measures, existing comorbidities, and SARS-CoV-2 infection status. The final cohort included 3238 participants. The mean age of participants was 50.2 ± 15.8 years. Most participants identified as female (60.0%), heterosexual or straight (93.0%), White (47.6%), and Hispanic or Latino (49.1%). Approximately 26.1% of participants had at least one positive SARS-CoV-2 test result. The main effect model included age, sex, and race/ethnicity. Compared with adults ≥65 years, participants in all other age groups had ∼2 times increased odds of a positive SARS-CoV-2 test result. In addition, racial/ethnic minorities had ∼2 times increased odds of a positive SARS-CoV-2 infection status compared with non-Hispanic Whites. A unique cohort of a traditionally medically underserved minority population was established. Significant racial and ethnic disparities in SARS-CoV-2 infection status at baseline were discovered.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"397-407"},"PeriodicalIF":1.8,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11074439/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41237913","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Changes in Health Care Utilization During the First 2 Years of Massachusetts Medicaid Accountable Care Organizations.","authors":"Meagan J Sabatino, Eric O Mick, Arlene S Ash, Jay Himmelstein, Matthew J Alcusky","doi":"10.1089/pop.2023.0151","DOIUrl":"10.1089/pop.2023.0151","url":null,"abstract":"<p><p>On March 1, 2018, the Massachusetts Medicaid and Children's Health Insurance Program (MassHealth) launched an ambitious accountable care organization (ACO) program that sought to integrate care across the physical, behavioral, functional, and social services continuum while holding ACOs accountable for cost and quality. The study objective was to describe changes in health care utilization among MassHealth members during the pre-ACO baseline (2015-2017) and post-implementation periods (2018 and 2019). Using MassHealth administrative data, the authors conducted a repeated cross-sectional study of MassHealth members enrolled in ACOs during 2015-2019. Rates of primary care visits, all-cause and primary-care sensitive emergency department (ED) visits, ED boarding, hospitalizations, acute unplanned admissions, and readmissions were reported during the baseline period (2015-2017) and year 1 (2018) and year 2 (2019). Primary care visit rates increased for adult members throughout the study period from a baseline mean of 7.2-9.2 per member per year (observed-to-expected [O:E]: 1.16) in 2019. Observed all-cause hospitalization rates fell below expected values with O:E ratios of 0.96 among adults and 0.79 among children in 2018, and 0.96 and 0.92 among adults and children, respectively, in 2019. All-cause ED visit rates increased slightly, and rates of pediatric asthma-related admissions, unplanned admissions for adults with ambulatory care sensitive conditions, and unplanned admissions and ED boarding for adults with substance use disorder and serious mental illness all declined for the study period. These findings are suggestive of utilization shifts to higher-value, lower-cost care under Massachusetts's innovative and comprehensive ACO model.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10698769/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71413629","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Use of Electronic Health Record Data to Identify Variation in Referral, Consent, and Engagement in a Pediatric Intervention for Overweight and Obesity: A Cross-Sectional Study.","authors":"Joshua S Yudkin, Marlyn A Allicock, Folefac D Atem, Carol A Galeener, Sarah E Messiah, Sarah E Barlow","doi":"10.1089/pop.2023.0120","DOIUrl":"10.1089/pop.2023.0120","url":null,"abstract":"<p><p>Clinical weight management programs face low participation. The authors assessed whether using electronic health record (EHR) data can identify variation in referral, consent, and engagement in a pediatric overweight and obesity (OW/OB) intervention. Using Epic EHR data collected between August 2020 and April 2021, sociodemographic and clinical diagnostic data (ie, <i>International Classification of Disease</i> [ICD] codes from visit and problem list [PL]) were analyzed to determine their association with referral, consent, and engagement in an OW/OB intervention. Bivariate analyses and multivariable logistic regression modeling were performed, with Bayesian inclusion criterion score used for model selection. Compared with the 581 eligible patients, referred patients were more likely to be boys (60% vs. 54%, respectively; <i>P</i> = 0.04) and have a higher %BMI_p95 (119% vs. 112%, respectively; <i>P</i> < 0.01); consented patients were more likely to have a higher %BMI_p95 (120% vs. 112%, respectively; <i>P</i> < 0.01) and speak Spanish (71% vs. 59%, respectively; <i>P</i> = 0.02); and engaged patients were more likely to have a higher %BMI_p95 (117% vs. 112%, respectively; <i>P</i> = 0.03) and speak Spanish (78% vs. 59%, respectively; <i>P</i> < 0.01). The regression model without either ICD codes or PL diagnoses was the best fit across all outcomes, which were associated with baseline %BMI_p95 and health clinic location. Neither visit nor PL diagnoses helped to identify variation in referral, consent, and engagement in a pediatric OW/OB intervention, and their role in understanding participation in such interventions remains unclear. However, additional efforts are needed to refer and engage younger girls with less extreme cases of OW/OB, and to support non-Hispanic families to consent.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2023-10-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10698793/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41126861","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Associations of Mental Health and Experience of the COVID-19 Pandemic with United States Adults' Intentions to Be Vaccinated.","authors":"Briget da Graca,&nbsp;Monica M Bennett,&nbsp;Robert L Gottlieb,&nbsp;Megan E Douglas,&nbsp;Mark B Powers,&nbsp;Ann Marie Warren","doi":"10.1089/pop.2023.0136","DOIUrl":"10.1089/pop.2023.0136","url":null,"abstract":"<p><p>COVID-19 vaccine uptake in the United States has proved challenging. A deeper characterization extending beyond demographics and political ideologies of those hesitating or resisting is needed to guide ongoing conversations. This study examined associations between US adults' vaccination intentions and mental health history, experience of the COVID-19 pandemic, and mental health outcomes. An online population-based cross-sectional survey was administered nationwide during January 4-7, 2021. Participants were questioned about past and current mental health, and completed the Patient Health Questionnaire 8 (PHQ-8), Generalized Anxiety Disorder 7-item (GAD-7), and Posttraumatic Diagnostic Scale (PDS)-5 (to capture symptoms of depression, anxiety, and traumatic stress, respectively). Experience of the pandemic included cumulative county-level COVID case and death rates, self-reported COVID-19 testing/exposure/diagnosis, and self-reported impact on routines, resources, and relationships. Of 936 respondents, 66% intended to be vaccinated, 14.7% responded \"maybe,\" and 19.6% \"no.\" Past diagnosis of obsessive compulsive disorder, less impact on routines or social supports, not having been screened or tested for COVID-19, not knowing someone who tested positive, and not self-isolating were associated with less intention to vaccinate. After controlling for demographic and pandemic experience factors, symptoms of traumatic stress, but not other mental health outcomes, were associated with less intention to vaccinate. The apparent contradiction between less negative impact of the pandemic and symptoms of traumatic stress being associated with less intention to be vaccinated indicates the complex nature of barriers to vaccine uptake. Results from this study contribute to the evidence base needed to improve ongoing and future communications about, and strategies to increase uptake of, vaccination.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"317-324"},"PeriodicalIF":2.5,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10467734","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":"New Drugs for Obesity, Is the Excitement Affordable?","authors":"Ian Duncan,&nbsp;David Kerr,&nbsp;Rajesh Aggarwal,&nbsp;Nhan Huynh","doi":"10.1089/pop.2023.0086","DOIUrl":"10.1089/pop.2023.0086","url":null,"abstract":"","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"356-357"},"PeriodicalIF":2.5,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10611954/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9578923","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}