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Population health

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Income inequality andmortalityin 282 metropolitan areas of theUnited States.Mortality iscorrelatedwith both income and inequality.

Population healthhas been defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group".[1]It is an approach tohealththat aims to improve thehealthof an entire human population. It has been described as consisting of three components. These are "health outcomes, patterns of health determinants, andpolicies and interventions".[1]

A priority considered important in achieving the aim of population health is to reduce health inequities or disparities among different population groups due to, among other factors, thesocial determinants of health(SDOH). The SDOH include all the factors (social, environmental, cultural and physical) that the different populations are born into, grow up, and function with throughout their lifetimes which potentially have a measurable impact on the health of human populations.[2]The population health concept represents a change in the focus from the individual-level, characteristic of most mainstreammedicine.It also seeks to complement the classic efforts ofpublic healthagencies by addressing a broader range of factors shown to impact the health of different populations. TheWorld Health Organization's Commission on Social Determinants of Health reported in 2008 that the SDOH factors were responsible for the bulk of diseases and injuries, and that these were the major causes of health inequities in all countries.[3]In the US, SDOH were estimated to account for 70% of avoidable mortality.[4]

From a population health perspective, health has been defined not simply as a state free from disease but as "the capacity of people to adapt to, respond to, or control life's challenges and changes".[5]TheWorld Health Organization(WHO) defined health in its broader sense in 1946 as "a state of complete physical, mental, and socialwell-beingand not merely the absence of disease or infirmity. "[6][7]

Healthy People 2020[edit]

Healthy People 2020 is a web site sponsored by theUS Department of Health and Human Services,representing the cumulative effort of 34 years of interest by the Surgeon General's office and others. It identifies 42 topics consideredsocial determinants of healthand approximately 1200 specific goals considered to improve population health. It provides links to the current research available for selected topics and identifies and supports the need for community involvement considered essential to address these problems realistically.[8]

Economic inequality[edit]

Recently, there has been increasing interest fromepidemiologistson the subject ofeconomic inequalityand its relation to the health of populations. There is a very robust correlation betweensocioeconomic status and health.This correlation suggests that it is not only the poor who tend to be sick when everyone else is healthy, given that conditions such asheart disease,ulcers,type 2 diabetes,rheumatoid arthritis,certain types ofcancer,andpremature agingare present in all socioeconomic levels. Despite the reality of theSES Gradient,there is debate as to its cause. A number of researchers (A. Leigh, C. Jencks, A. Clarkwest—see also Russell Sage working papers) see a definite link between economic status and mortality due to the greater economic resources of the better-off, but they find little correlation due tosocial statusdifferences.

Other researchers such asRichard G. Wilkinson,J. Lynch, and G.A. Kaplan have found that socioeconomic status strongly affects health even when controlling for economic resources and access to health care. Most famous for linking social status with health are theWhitehall studies—a series of studies conducted oncivil servantsinLondon.The studies found that, despite the fact that all civil servants in England have the same access to health care, there was a strong correlation between social status and health. The studies found that this relationship stayed strong even when controlling for health-affecting habits such asexercise,smokinganddrinking.Furthermore, it has been noted that no amount of medical attention will help decrease the likelihood of someone gettingtype 1 diabetesorrheumatoid arthritis—yet both are more common among populations with lower socioeconomic status. Lastly, it has been found that amongst the wealthiest quarter of countries on earth (a set stretching fromLuxembourgtoSlovakia) there is no relation between a country's wealth and general population health[1]—suggesting that past a certain level, absolute levels of wealth have little impact on population health, but relative levels within a country do. The concept ofpsychosocial stressattempts to explain how psychosocial phenomena such asstatusandsocial stratificationcan lead to the many diseases associated with theSES gradient.Higher levels of economic inequality tend to intensify social hierarchies and generally degrades the quality of social relations—leading to greater levels ofstressand stress related diseases. Richard Wilkinson found this to be true not only for the poorest members of society, but also for the wealthiest. Economic inequality is bad for everyone's health. Inequality does not only affect the health of human populations. David H. Abbott at the Wisconsin National Primate Research Center found that among many primate species, less egalitarian social structures correlated with higher levels of stress hormones among socially subordinate individuals. Research byRobert SapolskyofStanford Universityprovides similar findings.

Geographic Inequality[edit]

There is well-documented variation in health outcomes by geographic variation in many countries around the globe. This includes the U.S., with the addition of health care utilization & costs geographic variation, down to the level of Hospital Referral Regions (defined as a regional health care market, which may cross state boundaries, of which there are 306 in the U.S.).[9][10]However, data availability of health indicators for sub-national geographies is limited in both number, data source and geographic scale. Across the 38 OECD countries, region, or equivalent large subnational entities, is the predominant geographic level for both mortality and morbidity indicators. Health indicator availability at smaller geographies was sparse, and varied considerably by geographic definition, health indicator, age range of population and years available. In all cases, geographic boundaries used only administrative definitions.[11]

There is ongoing debate as to the relative contributions of race, gender, poverty, education level and place to these variations. The Office of Epidemiology of theMaternal and Child Health Bureaurecommends using an analytic approach (Fixed Effects or hybrid Fixed Effects) to research onhealth disparitiesto reduce the confounding effects of neighborhood (geographic) variables on the outcomes.[citation needed]

Critiques[edit]

Population health has been subject to ongoing critiques and its assumptions.[12][13]

Subfields[edit]

Family planning[edit]

Family planningprograms (includingcontraceptives,sexuality education,and promotion ofsafe sex) play a major role in population health. Family planning is one of the most highly cost-effective interventions in medicine.[14]Family planning saves lives and money by reducingunintended pregnancyand the transmission ofsexually transmitted infections.[14]

For example, theUnited States Agency for International Developmentlists as benefits of its international family planning program:[15]

  • "Protecting the health of women by reducing high-risk pregnancies"
  • "Protecting the health of children by allowing sufficient time between pregnancies"
  • "Fighting HIV/AIDSthrough providing information, counseling, and access tomaleandfemale condoms"
  • "Reducingabortions"
  • "Supporting women's rights and opportunities for education, employment, and full participation in society"
  • "Protecting the environment by stabilizing population growth"

Mental health[edit]

There are three main kinds of population-based approaches to mental health: health care system interventions; public health practice interventions; and social, economic, and environmental policy interventions. Health care system interventions are mediated by the health care system and hospital leaders. Examples of these interventions include enhancing the efficacy of clinical mental health services, providing consultations and training for community partners, and sharing aggregate health data to inform policy, practice, and planning for public mental health. Public health practice interventions are mediated by public health department officials. These interventions include advocating for policy changes, initiating public service announcements to reduce the stigma of mental illness, and conducting outreach to increase the accessibility of community mental health resources. Elected officials and administrative policy makers implement social, economic, and environmental policy interventions. These can include reducing financial andhousing insecurity,changing thebuilt environmentto increaseurban green spaceand decrease nighttimenoise pollution,and reducing structural stigma directed at those with mental illness.[16]

Population health management (PHM)[edit]

One method to improve population health is through population health management (PHM), which has been defined as "the technical field of endeavor which utilizes a variety of individual, organizational and cultural interventions to help improve themorbiditypatterns (i.e., the illness and injury burden) and the health care use behavior of defined populations ".[17]PHM is distinguished fromdisease managementby including morechronicconditions and diseases, by use of "a single point of contact and coordination", and by "predictive modelingacross multiple clinical conditions ".[18]PHM is considered broader than disease management in that it also includes "intensive care management for individuals at the highest level of risk" and "personal health management... for those at lower levels of predicted health risk".[19]Many PHM-related articles are published inPopulation Health Management,the official journal ofDMAA: The Care Continuum Alliance.[20]

The following road map has been suggested for helping healthcare organizations navigate the path toward implementing effective population health management:[21]

  • Establish precisepatient registries
  • Determine patient-provider attribution
  • Define precise numerators in the patient registries
  • Monitor and measure clinical and cost metrics
  • Adhere to basicclinical practice guidelines
  • Engage in risk-management outreach
  • Acquire external data
  • Communicate with patients
  • Educate patientsand engage with them
  • Establish and adhere to complex clinical practice guidelines
  • Coordinate effectively between care team and patient
  • Track specific outcomes

Healthcare reform and population health[edit]

Healthcare reform is driving change to traditional hospital reimbursement models. Prior to the introduction of thePatient Protection and Affordable Care Act (PPACA),hospitals were reimbursed based on the volume of procedures throughfee-for-servicemodels. Under the PPACA, reimbursement models are shifting from volume to value. New reimbursement models are built aroundpay for performance,a value-based reimbursement approach, which places financial incentives around patient outcomes and has drastically changed the way US hospitals must conduct business to remain financially viable.[22]In addition to focusing on improving patient experience of care and reducing costs, hospitals must also focus on improving the health of populations (IHI Triple Aim[23]).

As participation in value-based reimbursement models such asaccountable care organizations(ACOs) increases, these initiatives will help drive population health.[24]Within the ACO model, hospitals have to meet specific quality benchmarks, focus on prevention, and carefully manage patients with chronic diseases.[25]Providers get paid more for keeping their patients healthy and out of the hospital.[25]Studies have shown that inpatient admission rates have dropped over the past ten years in communities that were early adopters of the ACO model and implemented population health measures to treat "less sick" patients in the outpatient setting.[26]A study conducted in the Chicago area showed a decline in inpatient utilization rates across all age groups, which was an average of a 5% overall drop in inpatient admissions.[27]

Hospitals are finding it financially advantageous to focus on population health management and keeping people in the community well.[28]The goal of population health management is to improve patient outcomes and increase health capital. Other goals include preventing disease, closing care gaps, and cost savings for providers.[29]In the last few years, more effort has been directed towards developing telehealth services, community-based clinics in areas with high proportion of residents using the emergency department as primary care, and patient care coordinator roles to coordinate healthcare services across the care continuum.[28]

Health can be considered a capital good; health capital is part ofhuman capitalas defined by the Grossman model.[30]Health can be considered both an investment good and consumption good.[31]Factors such as obesity and smoking have negative effects on health capital, while education, wage rate, and age may also impact health capital.[31]When people are healthier through preventative care, they have the potential to live a longer and healthier life, work more and participate in the economy, and produce more based on the work done. These factors all have the potential to increase earnings. Some states, like New York, have implemented statewide initiatives to address population health. In New York state there are 11 such programs.[32]These programs work to address the needs of the people in their region, as well as assist their local community based organizations and social services to gather data, address health disparities, and explore evidence-based interventions that will ultimately lead to better health for everyone.

See also[edit]

References[edit]

  1. ^abKindig D, Stoddart G (March 2003)."What is population health?".American Journal of Public Health.93(3): 380–3.doi:10.2105/ajph.93.3.380.PMC1447747.PMID12604476.
  2. ^Social Determinants of Health overview tab.
  3. ^Meeting Report of World Conference of Social Determinants of Healthheld in Rio de Janeiro, Brazil, 2008.
  4. ^McGinnis JM, Williams-Russo P, Knickman JR (2002). "The case for more active policy attention to health promotion".Health Aff (Millwood).21(2): 78–93.doi:10.1377/hlthaff.21.2.78.PMID11900188.{{cite journal}}:CS1 maint: multiple names: authors list (link).See alsoNational Academies Press free publication: The Future of Public Health in the 21st Century.
  5. ^Frankish, CJ et al."Health Impact Assessment as a Tool for Population Health Promotion and Public Policy"Archived8 March 2010 at theWayback Machine.Vancouver: Institute of Health Promotion Research, University of British Columbia, 1996. Retrieved 12 October 2008.
  6. ^World Health Organization.WHO definition of Health,Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. InGrad, Frank P. (2002)."The Preamble of the Constitution of the World Health Organization".Bulletin of the World Health Organization.80(12): 982.PMC2567708.PMID12571728.
  7. ^World Health Organization. 2006.Constitution of the World Health Organization–Basic Documents,Forty-fifth edition, Supplement, October 2006.
  8. ^Health People 2020
  9. ^Chandra, A; Skinner, JS (2004).Geography and Racial Health Disparities, Chapter 16 of Critical Perspectives on Racial and Ethnic Differences in Health in Late Life(PDF).National Research Council.
  10. ^"Data by Region, the Dartmouth Atlas of Health Care".Retrieved16 November2013.
  11. ^Murray, Emily T.; Shelton, Nicola; Norman, Paul; Head, Jenny (1 January 2022)."Measuring the health of people in places: A scoping review of OECD member countries".Health & Place.73:102731.doi:10.1016/j.healthplace.2021.102731.ISSN1353-8292.PMID34929525.S2CID245322428.
  12. ^Coburn, David; Denny, Keith; Mykhalovskiy, Eric; McDonough, Peggy; Robertson, Ann; Love, Rhonda (2003)."Population Health in Canada: A Brief Critique".American Journal of Public Health.93(3): 392–396.doi:10.2105/AJPH.93.3.392.PMC1447750.PMID12604479.
  13. ^Raphael, Dennis; Bryant, Toba (1 June 2002)."The limitations of population health as a model for a new public health".Health Promotion International.17(2): 189–199.doi:10.1093/heapro/17.2.189.PMID11986300.
  14. ^abTsui AO,McDonald-Mosley R, Burke AE (April 2010)."Family planning and the burden of unintended pregnancies".Epidemiol Rev.32(1): 152–74.doi:10.1093/epirev/mxq012.PMC3115338.PMID20570955.International studies confirm that family planning is among the most cost-effective of all health interventions (80, 81). The cost savings stem from a reduction in unintended pregnancy, as well as a reduction in transmission of sexually transmitted infections, including HIV.
  15. ^USAID.Family planningArchived15 October 2008 at theWayback Machine.Retrieved 12 October 2008.
  16. ^Purtle, Jonathan; Nelson, Katherine L.; Counts, Nathaniel Z.; Yudell, Michael (2 April 2020)."Population-Based Approaches to Mental Health: History, Strategies, and Evidence".Annual Review of Public Health.41(1): 201–221.doi:10.1146/annurev-publhealth-040119-094247.ISSN0163-7525.PMC8896325.PMID31905323.
  17. ^Hillman, Michael.Testimony before the Subcommittee on Health of the House Committee on Ways and Means, hearing on promoting disease management in MedicareArchived8 May 2017 at theWayback Machine.16 April 2002. Retrieved 12 October 2008.
  18. ^Howe, Rufus, and Christopher Spence.Population health management: Healthways' PopWorksArchived17 December 2008 at theWayback Machine.HCT Project2004-07-17, volume 2, chapter 5, pages 291-297. Retrieved 12 October 2008.
  19. ^Coughlin JF, Pope J, Leedle BR (April 2006)."Old age, new technology, and future innovations in disease management and home health care"(PDF).Home Health Care Management & Practice.18(3): 196–207.doi:10.1177/1084822305281955.S2CID26428539.
  20. ^DMAA: The Care Continuum Alliance.Publications.Population Health ManagementArchived24 September 2008 at theWayback Machine.Retrieved 12 October 2008.
  21. ^Sanders, DaleA Landmark, 12-Point Review of Population Health Management Companies.Retrieved 17 March 2014.
  22. ^"The Revised Medicare ACO Program: More Options... And More Work Ahead".Health Affairs.2015.doi:10.1377/forefront.20150616.048573.Retrieved21 November2015.
  23. ^"The IHI Triple Aim".www.ihi.org.Retrieved21 November2015.
  24. ^DeVore S, Champion RW (2011). "Driving Population Health Through Accountable Care Organizations".Health Affairs.30(1): 41–50.doi:10.1377/hlthaff.2010.0935.PMID21209436.
  25. ^ab"Accountable Care Organizations, Explained".Kaiser Health News.14 September 2015.Retrieved21 November2015.
  26. ^Kutscher B.Outpatient care takes the inside track.Modern Healthcare. 2012. Retrieved 31 October 2015.
  27. ^"Where Have All The Inpatients Gone? A Regional Study With National Implications".Health Affairs.2014.doi:10.1377/forefront.20140106.035895.
  28. ^ab"Population Health Management: Hospitals' Changing Employer Role".www.beckershospitalreview.com.26 February 2014.Retrieved21 November2015.
  29. ^"What is Population Health Management?".Wellcentive.Retrieved21 November2015.
  30. ^Grossman M (1972). "On the Concept of Health Capital and the Demand for Health".Journal of Political Economy.80(2): 223–255.CiteSeerX10.1.1.604.7202.doi:10.1086/259880.S2CID27026628.
  31. ^abFolland S, Goodman A, Stano M. The economics of health and health care (Vol. 6): Upper Saddle River: Pearson Education; 2007.
  32. ^"Population Health Improvement Program".www.health.ny.gov.Retrieved10 March2022.

Further reading[edit]

External links[edit]

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