Population Health Programs Research Articles

Application of the Informatics Stack framework to describe a population-level emergency department return visit continuous quality improvement program

IntroductionPopulation health programs are increasingly reliant on Health Information Technology (HIT). Program HIT architecture description is a necessary step prior to evaluation. Several sociotechnical frameworks have been used previously with HIT programs. The Informatics Stack is a novel framework that provides a thorough description of HIT program architecture. The Emergency Department Return Visit Quality Program (EDRVQP) is a population-level continuous quality improvement (QI) program connecting EDs across Ontario. The objectives of the study were to utilize the Informatics Stack to provide a description of the EDRVQP HIT architecture and to delineate population health program factors that are enablers or barriers. Materials and MethodsThe Informatics Stack was used to describe the HIT architecture. A qualitative study was completed with semi-structured interviews of key informants across stakeholder organizations. Emergency departments were selected randomly. Purposive sampling identified key informants. Interviews were conducted until saturation. An inductive qualitative analysis using grounded theory was completed. A literature review of peer-reviewed background literature, and stakeholder organization reports was also conducted. Results23 business actors from 15 organizations were interviewed. The EDRVQP architecture description is presented across the Informatics Stack levels. The levels from most comprehensive to most basic are world, organization, perspectives/roles, goals/functions, workflow/behaviour/adoption, information systems, modules, data/information/knowledge/wisdom/algorithms, and technology. Enabling factors were the high rate of electronic health record adoption, legislative mandate for data collection, use of functional data standards, implementation flexibility, leveraging validated algorithms, and leveraging existing local health networks. Barriers were privacy legislation and a high turn-around time. DiscussionThe Informatics Stack provides a robust approach to thoroughly describe the HIT architecture of population health programs prior to program replication. The EDRVQP is a population health program that illustrates the pragmatic use of continuous QI methodology across a population (provincial) level.

Homocysteine and education but not lipoprotein (a) predict estimated 10-year risk of cardiovascular disease in blood donors: a community based cross-sectional study

BackgroundWith aging of the population, screening and prevention health programs for blood donors will increasingly be a priority. We aimed at: assessing the 10 year-cardiovascular disease (CVD) risk in blood donors, according to Italian CUORE risk score (CRS); determining the association of homocysteine (Hcy), lipoprotein (Lp)(a) and socio-demographic or lifestyle variables with estimated 10-year CVD risk.MethodsBetween June 2015 and July 2017, 1,447 (61.2% men) unselected blood donors (aged 18–69 years) were enrolled at the Blood Transfusion Service of the Pescara General Hospital, Italy. The project entailed evaluation of unalterable (age and gender) and modifiable CV risk factors (total cholesterol, HDL, LDL, triglycerides, fasting glucose, smoking, hypertension). The educational attainment, socio-demographic and lifestyle behavior information were obtained through a structured self-report questionnaire, and Health-related quality of life (HRQoL) through the Short Form Survey (SF-12). Plasma Hcy and Lp(a) were determined in the fasting state.ResultsA CRS within the moderate-high risk range was reported in 21.7% donors. Multivariate logistic regression, after adjustment for clinical and demographic variables, showed that Hcy [OR (95% CI): 1.09 (1.04–1.13); p < 0.001) and low educational attainment [1.71 (1.09–2.73); p = 0.019] are independent risk factors for moderate-to-high CVD risk. Instead, Lp(a), evaluated in 774 donors, was > 30 mg/dL in 22.4% of the examined population, but without any significant correlation with CRS.ConclusionsOur study highlights a previously unappreciated need for CV risk assessment in blood donors, which may include evaluation of educational attainment as a non-traditional risk marker.

Healthcare Providers Are Missing Opportunities to Capture Data that Support Population Health Programs

Data aggregation is important at every stage of population health management. A surprisingly simple (and often overlooked) way healthcare teams can collect data and gain the insights they need to successfully execute population health plans is to leverage healthcare surveys like health risk assessment surveys, medication adherence surveys, remote health monitoring surveys and gaps in care surveys. A West study found many providers and healthcare organizations can do a better job using surveys to prop up their population health initiatives. In particular, teams can take advantage of opportunities to use surveys to help prevent and manage chronic conditions across high-risk, rising-risk and low-risk subpopulations of patients.

Patient Outreaches for Clinical Pharmacy Services: A Population Health Management Program Assessment

Background: Pharmacists in ambulatory care can utilize population health approaches to identify patients needing disease management and improve outcomes. However, population health is only effective when identified patients are successfully outreached and show to appointments. Objective: Describe a population health approach utilized by pharmacists in primary care, report outcomes of outreach attempts and scheduled appointments, and determine whether patient and referral characteristics predict no-show appointments. Methods: Retrospective cohort study of patients referred for pharmacist management of hypertension or chronic pain through population health between 2013-2016. Outreach attempt and appointments outcomes were collected. Patient and referral characteristics were analyzed to determine whether predictive of no-show appointments using logistic regression. Results: Of 450 outreach attempts, 250 (56%) patients were not reached, 164 (36%) scheduled appointments, and 36 (8%) were reached but declined an appointment. Of 164 patients with appointments, 71 (43%) no-showed. Patients with higher systolic blood pressure were more likely to no-show (OR: 1.02, 95% CI: 1.00-1.04). Other characteristics were not predictive of no-show appointments. Conclusion: Successful outreach and showed appointments are essential components of successful population health programs. Using multiple outreach modalities and further identifying factors predictive of no-show appointments to refine the current approach may lead to increased efficiency.

P127: Health information technology and the Ontario emergency department return visit quality program - A population level continuous quality improvement program

Introduction: Emergency department (ED) return visits are used for quality monitoring. Health information technology (HIT) has historically supported return visit programs in the same hospital or hospital system. The Emergency Department Return Visit Quality Program (EDRVQP) is a novel population level continuous quality improvement (QI) program connecting EDs across Ontario that leverages HIT. We sought to describe the EDRVQP HIT architecture, experience of participants, enabling program factors and barriers. Methods: The Informatics Stack conceptual framework was used to describe the HIT architecture. A literature review of peer-reviewed background literature, and stakeholder organization reports was conducted. Purposive sampling identified key informants. Semi-structured interviews were conducted until saturation. Common themes were identified by inductive qualitative thematic analysis. Results: Twenty-three participants from 15 organizations were interviewed. The EDRVQP architecture description is presented across the Informatics Stack. The levels from most comprehensive to most basic are world, organization, perspectives/roles, goals/functions, workflow/behaviour/adoption, information systems, modules, data/information/knowledge/algorithms, and technology. Enabling factors were a high rate of EHR adoption, provincial legislative mandate for data collection and program membership, use of functional and data standards, local variability, phased deployment, and QI and patient safety culture. Two main barriers were increased case turnaround time and privacy legislation. Conclusion: The Informatics Stack framework provides a robust approach to thoroughly describe the HIT architecture of this population health programs. The EDRVQP is a population health program that illustrates the pragmatic use of continuous QI methodology across a population (provincial) level.

New partnerships, new perspectives: The relevance of sexual and reproductive health and rights for sustainable development

In the light of the opportunities presented by the Sustainable Development Goals (SDGs) debate is being reignited to understand the connections between human population dynamics (including rapid population growth) and sustainable development. Sustainable development is seriously affected by human population dynamics yet programme planners too often fail to consider them in development programming, casting doubt on the sustainability of such programming. Some innovative initiatives are attempting to cross sector boundaries once again, such as the Population Health and Environment (PHE) programmes, which are integrated programmes encompassing family planning service provision with broader public health services and environmental conservation activities. These initiatives take on greater prominence in the context of the SDGs since they explicitly seek to provide cross-sector programming and governance to improve both human and planetary wellbeing. Yet such initiatives remain under-researched and under promoted.

3222 University of Mississippi Center for Clinical and Translational Science (CCTS): A Catalyst for Clinical and Translational Sciences

OBJECTIVES/SPECIFIC AIMS: To introduce CCTS to the clinical and translational research community. METHODS/STUDY POPULATION: Established in the summer of 2017, the Center for Clinical and Translational Science (CCTS) fosters cooperative clinical and translational sciences between the University of Mississippi School of Pharmacy (UMSOP) and the University of Mississippi Medical Center (UMMC). CCTS facilitates the translation of basic research discoveries into clinically validated therapies to improve the health of populations in Mississippi and beyond. Priority areas of investigation in CCTS include Cardiometabolic disorders, Cancer, Neuroscience, Infectious diseases, Precision Medicine, and Community-Based Research. To accomplish CCTS mission three overarching goals have been defined: I) Develop progressive and sustainable capacity for clinical and translational research in Mississippi; II) Promote interprofessional engagement in clinical and translational science; and III) Foster research collaboration among stakeholders in and outside of Mississippi. RESULTS/ANTICIPATED RESULTS: To carry its CCTS’s mission three research units have been established: 1) The Pre-clinical Research Unit: Develops processes to move basic science discoveries towards translation into research in humans. This unit provides guidance in the development of Investigational New Drug (IND) applications; and identifies and pursues opportunities to develop progressive capacities for in vitro, ex vivo, in vivo, and in silico approaches for evaluating new pharmaceutical and therapeutic agents. 2) The Clinical Research Unit: Transitions projects that have received IND approval into the first phase of clinical trials. It also transitions clinical trials from Phase I to Phase II and to Phase III; develops standard operating procedures (SOPs), personnel training plans, and policies to guide clinical research; works with industry sponsors and governmental funding agencies; and assures compliance with regulatory requirements. 3) Community/population Research Unit: Develops, coordinates, and facilitates research activities and translation between clinical and community/population research stages. To do so, this unit works closely with community partners and Population Health programs on the Oxford and Jackson campuses. DISCUSSION/SIGNIFICANCE OF IMPACT: Since its inception, the CCTS has surpassed 1.5 million dollars in competitive funding. This early success positions the CCTS well to promote research collaboration between UMSOP and UMMC and to progress in becoming a national leader in clinical and translational investigation.

3342 Developing a population health learning system

OBJECTIVES/SPECIFIC AIMS: Population health research seeks to identify and address variation in needs, care experiences, and outcomes for a defined geography or subgroup. Solutions often require collective actions of complex interdependent health and social service systems in communities. System sciences focused on implementation and dissemination are vital for developing interventions that work at the intended scale in these “real world” environments; yet these approaches are often underutilized. METHODS/STUDY POPULATION: The UCLA Clinical Translational Science Institute (CTSI) co-developed a Population Health Program with the local health department to advance the practice and use of these system science methods. The vision is integrated training, methodological innovation, and real-world application in the region. One specific aim of the program is preparing investigators to apply suitable translational methods to solve population health problems in both health systems and in public health. Investigators from different parts of the university partnered with health services and public health leadership to develop and team-teach new curriculum in system sciences that integrates their disciplines (epidemiology, education, psychology, health policy and management). RESULTS/ANTICIPATED RESULTS: New curriculum in population and implementation/improvement sciences offers junior investigators effective modules and training opportunities that can support their career awards. The program is also increasing the receptivity and readiness of population health delivery systems to apply system science methods to pressing problems. Program metrics include total participants, research yielded by the collaboration, and skills and system science mindset acquisition among trainees, investigators, and health personnel. DISCUSSION/SIGNIFICANCE OF IMPACT: CTSAs can partner with health and public health agencies to develop shared infrastructure, developing capacity in the university and in the partnered local agencies so that investigators and the agencies that are responsible for population health can work together to apply suitable translational methods to solve population health problems in both health systems and in public health.

Measurement of health organisation performance across multiple sector services: a population health analytic perspective

Introduction: In measuring the activity and indeed the performance of health organisations it is important to consider not only the case-mix of the organisation and technical efficiency, but also what inter-dependencies may exist between organisations, or whether they are covering different services and extent of services. This study seeks to measure and provide a population health analytic approach to recognising the effects of substitution and overlap of activities of primary and secondary care. Challenges to measure true performance of organisations exist where sectors of care exist across different organisations, and where health care is divided across silos and are reviewed without consideration of interrelationships. In addition, with the increased policies worldwide to introduce integrated health services e.g. accountable care organisations, local health community and population health programs, assessing cost and health quality improvements will need an adequate a framework to understand where improvements are attributed across multiple contributing organisations. Methods: The data sources include multiple studies from different countries. Primary Care and secondary care data were combined to create population databases, and casemix measurement was made using the Johns Hopkins ACG System. The distribution of the populations were analysed observing the share of activity and cost between primary, outpatient and inpatient services. The triple aim reporting framework suggested by Seow 2014 will be adapted to look at both temporal changes in cost distribution by health sector, and looking to identify and classify different organisation models. The Johns Hopkins ACG Adjusted Clinical Groups system was used to control for casemix complexity and multimorbidity. Results: Analysis of total costs across all sectors inpatient, outpatient, emergency care and primary care showed the increased costs associated with higher complexity and multimorbid patients. The distribution of utilisation and cost were different according to the complexity of patients but also by organisation. For example, the proportion of spend on primary care services was generally higher for lower complexity patients, with the proportion reducing with increased complexity, and in association, the increased spend on hospital services could be seen as complexity increased. But regional analyses also highlighted that these proportions of spend were different even when casemix complexity was held constant. The population level analyses showed different results with respect to cost efficiency than those shown in individual sectors. Discussion: In measuring organisational performance it is important to consider the extent of vertical integration in health services in fully understanding the cost effectiveness and efficiency of health systems. Isolating individual sectors of health care for measurement may lead to incorrect interpretation of results where interdependencies between services across different sectors exist. Policy makers need to be aware of the effect of activity shifting between health sectors, which can lead to increased complexity in all sectors, increases in average costs per sector, whilst the potential lower costs and convenience to patients are unmeasured Technical v Allocative efficiency. Casemix adjustment is an important consideration in measuring health care organisations, but to reduce confounding the inter and intra organisational dynamics and dependencies need to be considered.

Payor Reform Opportunities for Spine Surgery: Part III: Population Health Programs and Converging Strategies.

As the cost of health care continues to rise, government and commercial payors are implementing strategies as a means of reducing the overall expenditure of health care dollars. The largest savings will be not just in more cost-effective treatments but in strategies that can avoid the need for treatments in the first place. Although the savings from popular payor reform strategies like bundled payments are tied to the initiation of the clinical episode, population health programs utilize a variety of tactics to decrease the need for health care utilization overall. However, the payor reform landscape is seeing some convergence of strategies as varying tactics can be complimentary. Given the dramatic rise in expenditures on spine surgery and related services, spine surgeons should understand how population health and other efforts will inevitably influence spine health care delivery going forward.

‘Structural Competency’ Approach Takes Into Account Patients’ World

‘Structural Competency’ Approach Takes Into Account Patients’ World

How U.S. children\u2019s hospitals define population health: a qualitative, interview-based study

BackgroundThe literature suggests that although adult hospitals are establishing population health programs around the country, there is considerable definitional ambiguity regarding whether interventions are aimed at the social determinants of health or the management of existing patient populations. U.S. children’s hospitals also undertake population health programs, but less is known about how they define population health. The purpose of this study is to understand how U.S. children’s hospitals define population health, and how institutions are adjusting to new preventive health care models.MethodsWe conducted semi-structured interviews with key stakeholders at ten hospitals with the highest amount of staff time dedicated to population health activities as reported in the 2016 Children’s Hospital Association’s population health survey. Using a semi-structured interview guide, we interviewed representatives from each hospital. Verbatim interview notes were coded and analyzed using the data analysis software Dedoose. Data analysis followed a modified constructivist grounded theory approach.ResultsOur results suggest that even population health innovators employ a variety of approaches that span both population health management and public health. We present further evidence that U.S. children’s hospitals are actively debating the definition and focus of population health.ConclusionsDefinitional debates are ongoing even within children’s hospitals that are dedicating significant resources to population health. Increased clarity on the conceptual boundaries between population health and population health management could help preserve the theoretical differences between the two concepts, especially insofar as they mark two quite different long-term visions for health care. Without agreement about the meaning of population health within and among institutions, hospitals will not be able to know whether projects aimed at addressing the social determinants of health are likely to improve the health of populations.

Results from a Population Health Strategy for Diabetes in a Large Health Care System

Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. Awareness of population health management is increasing but the concept is not clearly defined or understood. Nevertheless, the overarching goal is to keep the patient population as healthy as achievable. Since diabetes is a chronic and progressive illness, population health management strategies hold promise and can be measured using health outcomes, disease burden or metabolic status. University of Washington Medicine, a large healthcare system in the greater Seattle area comprised of academic and community-based primary care clinics, recently initiated a diabetes population health (DPH) program. The is a centralized outlier management and surveillance system where a specialized team (endocrinologist and certified diabetes educator) remotely supports care teams (primary care providers, nurses) in diabetes management. In this pilot initiative, focus was on the highest risk patients with type 2 diabetes such as individuals who had chronically elevated A1C &amp;gt;9% over the past 12 months. The DPH team identified these individuals from an internal database, conducted chart reviews to identify potential areas for improvement, reached out to clinical care teams and offered individualized patient management strategies for the identified patients. Care of all identified patients remained with primary care teams. In 6 months there was a 1.4% point reduction in A1C (10.8% to 9.4%, n=34, p&amp;lt;0.01) primarily through the team’s work with care management nurses who in turn conducted outreach to patients to enable engagement, offered diabetes self-management support and improved care coordination. Thus, the number of individuals with diabetes and elevated A1C at any given period in the past 8 months was decreased by 60%. These early results suggest that an active diabetes surveillance program has the potential to improve health outcomes in diabetes. Disclosure S. Subramanian: Advisory Panel; Self; Intarcia Therapeutics, Inc., Akcea Therapeutics. I.B. Hirsch: Research Support; Self; Medtronic MiniMed, Inc.. Consultant; Self; Abbott, Bigfoot Biomedical, Roche Diabetes Care Health and Digital Solutions, ADOCIA. A. Evert: None.

Mapping the Gaps: Gender Differences in Preventive Cardiovascular Care among Managed Care Members in Four Metropolitan Areas

Prior research documents gender gaps in cardiovascular risk management, with women receiving poorer quality routine care on average, even in managed care systems. Although population health management tools and quality improvement efforts have led to better overall care quality and narrowing of racial/ethnic gaps for a variety of measures, we sought to quantify persistent gender gaps in cardiovascular risk management and to assess the performance of routinely used commercial population health management tools in helping systems narrow gender gaps. Using 2013 through 2014 claims and enrollment data from more than 1 million members of a large national health insurance plan, we assessed performance on seven evidence-based quality measures for the management of coronary artery disease and diabetes mellitus, a cardiac risk factor, across and within four metropolitan areas. We used logistic regression to adjust for region, demographics, and risk factors commonly tracked in population health management tools. Low-density lipoprotein (LDL) cholesterol control (LDL<100mg/dL) rates were 5 and 15 percentage points lower for women than men with diabetes mellitus (p<.0001), and coronary artery disease (p<.0001), respectively. Adjusted analyses showed women were more likely to have gaps in LDL control, with an odds ratio of 1.31 (95% confidence interval, 1.27-1.38) in diabetes mellitus and 1.88 (95% confidence interval, 1.65-2.10) in coronary artery disease. Given our findings that gender gaps persist across both clinical and geographic variation, we identified additional steps health plans can take to reduce disparities. For measures where gaps have been consistently identified, we recommend that gender-stratified quality reporting and analysis be used to complement widely used algorithms to identify individuals with unmet needs for referral to population health and wellness behavior support programs.

ValuedCare program: a population health model for the delivery of evidence-based care across care continuum for hip fracture patients in Eastern Singapore

BackgroundTo test a population health program which could, through the application of process redesign, implement multiple evidence-based practices across the continuum of care in a functionally integrated health delivery system and deliver highly reliable and consistent evidence-based surgical care for patients with fragility hip fractures in an acute tertiary general hospital.MethodsThe ValuedCare (VC) program was developed in three distinct phases as an ongoing collaboration between the Geisinger Health System (GHS), USA, and Changi General Hospital (CGH), Singapore, modelled after the GHS ProvenCare® Fragile Hip Fracture Program. Clinical outcome data on consecutive hip fracture patients seen in 12 months pre-intervention were then compared with the post-intervention group. Both pre- and post-intervention groups were followed up across the continuum of care for a period of 12 months.ResultsVC patients showed significant improvement in median time to surgery (97 to 50.5 h), as well as proportion of patients operated within 48 h from hospital admission (48% from 18.8%) as compared to baseline pre-intervention data. These patients also had significant reduction (p value < 0.001) of acute inpatient complications such as delirium, pneumonia, urinary tract infections, and pressure sores. VC program has shown significant reduction in median length of stay for acute hospital (13 to 9 days) as well as median combined length of stay for acute and sub-acute rehabilitation hospital (46 to 39 days), thus reducing the total duration of hospitalization and saving total hospital bed days. Operative and inpatient mortality, together with readmission rates, remained low and comparable to international Geriatric Fracture Centers (GFCs).ConclusionThe implementation of VC methodology has enabled consistent delivery of high-quality, reliable and comprehensive evidence-based care for hip fracture patients at Changi General Hospital. This has also reflected successful change management and interdisciplinary collaboration within the organization through the program. There is potential for testing this methodology as a quality improvement framework replicable to other disease groups in a functionally integrated healthcare system.

Using Electronic Health Records for Public Health Hypertension Surveillance

ObjectiveTo assess the equivalence of hypertension prevalence estimates between longitudinal electronic health record (EHR) data from a community-based health information exchange (HIE) and the Behavioral Risk Factor Surveillance System (BRFSS).IntroductionHypertension (HTN) is a highly prevalent chronic condition and strongly associated with morbidity and mortality. HTN is amenable to prevention and control through public and population health programs and policies. Therefore, public and population health programs require accurate, stable estimates of disease prevalence, and estimating HTN prevalence at the community-level is acutely important for timely detection, intervention, and effective evaluation. Current surveillance methods for HTN rely upon community-based surveys, such as the BRFSS. While BRFSS is the standard at the state- and national-level, they are expensive to collect, released once per year, and their confidence intervals are too wide for precise estimates at the local level. More timely, frequently updated, and locally precise prevalence estimates could greatly improve the timeliness and precision of public health interventions. The current study evaluated EHR data from a large, mature HIE as an alternative to community-based surveys for timely, accurate, and precise HTN prevalence estimation.MethodsTwo years (2014-2015) of EHR data were obtained from the Indiana Network for Patient Care for two major health systems in Marion County, Indiana, representing approximately 75% of the total county population (n=530,244). These data were linked and evaluated for prevalent HTN. Six HTN phenotypes were defined using structured data variables including clinical diagnoses (ICD9/10 codes), blood pressure (BP) measurements (HTN = ≥140mmhg systolic or ≥90mmHg diastolic), and dispensed HTN medications (Table 1). Phenotypes were validated using a random sample of 600 records, comparing EHR phenotype HTN to HTN as determined through manual chart review by a Registered Nurse. Each phenotype was further evaluated against BRFSS estimates for Marion County, and stratified by sex, race, and age to compare EHR-generated HTN prevalence measures to those known and in current use for chronic disease surveillance. Comparisons were made using the two one-sided statistical test (TOST) of equivalence, wherein the null hypothesis is the BRFSS and EHR prevalence estimates are different by +/-5% and the alternative is estimates differ by less than +/-5%. Rejection of the null resulted in the conclusion of equivalence of the estimates for use in population/public health.ResultsIn general, the performance of the EHR phenotypes was characterized by high specificity (&gt;87%) and low to moderate sensitivity (range 25.4%-95.3%). The false positive rate was lowest among the phenotype defining HTN by both clinical diagnosis and BP measurements (0.3%), and sensitivity was greatest for the phenotype combining all three structured data elements (95.2%). The prevalence of HTN in Marion County, Indiana (2014-2015) for the EHR sample (n=530,244) ranged between 13.7% and 36.2%, compared to 28.4% in the BRFSS sample (Table 1). Only one EHR phenotype (≥1 HTN BP measurement) demonstrated equivalence with BRFSS prevalence at the county level (difference 0.9%, 90% CI for difference -2.3%-4.0%). HTN prevalence by sex, race, age, sex and age, and sex and race (n=120 comparisons) failed to demonstrate equivalence between EHR and BRFSS measures in all but two comparisons, both among females aged 18-39 years. Differences between EHR and BRFSS HTN prevalence at the subgroup level varied but were particularly pronounced among older adults. As suspected, HTN prevalence precision was improved in the EHR sample with the largest subgroup 95% CI width of 0.7% for male African Americans compared to the BRFSS sample 95% CI width of 29.6%.ConclusionsThe applicability of the tested HTN phenotypes will vary based upon which EHR structured data elements are available to public health (i.e., ICD10, vitals, medications). We found that HTN surveillance using a community-based HIE was not a valid replacement for the BRFSS, although the HIE-based estimates could be readily generated and had much narrower confidence intervals.ReferencesMozaffarian D, et al. Heart Disease and Stroke Statistics — 2016 Update. Circulation. 2016; 133: e38-e360.Yoon S, Fryar C, Carroll M. HTN Prevalence and Control Among Adults: United States, 2011–2014. NCHS Data Brief No. 220. 2015; Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention, US Dept of Health and Human Services.

Schizophrenia and type 2 diabetes mellitus.

Schizophrenia is associated with increased risk for type 2 diabetes mellitus, resulting in elevated cardiovascular risk and limited life expectancy, translated into a weighted average of 14.5 years of potential life lost and an overall weighted average life expectancy of 64.7 years. The exact prevalence of type 2 diabetes among people with schizophrenia varies across studies and ranges 2-5fold higher than in the general population, whereas the aetiology is complex and multifactorial. Besides common diabetogenic factors, applied similarly in the general population, such as obesity, hyperlipidemia, smoking, hypertension, poor diet and limited physical activity, the co-occurrence of schizophrenia and diabetes is also attributed to unique conditions. Specifically, excessive sedentary lifestyle, social determinants, adverse effects of antipsychotic drugs and limited access to medical care are considered aggravating factors for diabetes onset and low quality of diabetes management. Schizophrenia itself is further proposed as causal factor for diabetes, given the observed higher prevalence of diabetes in young patients, newly diagnosed with schizophrenia and unexposed to antipsychotics. Furthermore, studies support genetic predisposition to diabetes among people with schizophrenia, suggesting shared genetic risk and disclosing a number of overlapped risk loci. Therefore, special attention should be paid in preventing diabetes in people with schizophrenia, through intervention in all possible modifiable risk factors. Implementation of careful antipsychotic prescription, provision of adequate motivation for balanced diet and physical activity and facilitating access to primary health care, could serve in reducing diabetes prevalence. On the other hand, increasing calls are made for early diagnosis of diabetes, application of the appropriate anti-diabetic therapy and strict inspection of therapy adherence, to limit the excess mortality due to cardiovascular events in people with schizophrenia. Moreover, population health programs could help counseling and preventing diabetes risk, additionally to early screening and diagnosis set, aiming to reduce disparities in populations. Finally, mental health-care providers might greatly promote offered health services to patients with schizophrenia, through a holistic individualized approach, considering additionally the physical health of the patients and working closely, preventively and therapeutically, in collaboration with the physicians and diabetologists.

Increasing the use of research in population health policies and programs: a rapid review.

Although the body of literature on factors that impede and enhance the use of research in policy making continues to expand, there is limited evidence about strategies that are effective at fostering the use of research in population health policy and programs. Building on previous reviews, we reviewed the published literature to identify and assess papers describing intervention studies that had outcome measures relating to research use. Rapid review. We searched four academic databases and Google Scholar to identify papers published between 2009 and 2015. Our focus was on strategies relevant to population health policy and program delivery. For studies that tested strategies to increase the use of research, we extracted details about the intervention, participants, study sites and methods, and primary and other outcomes. We identified 14 articles reporting on 13 intervention studies. The studies were relatively weak methodologically and together provide few indications of effect. Only one study used an experimental design and one other used pre-/post-test design; the remaining studies were characterised by an absence of control groups, small sample sizes, and self-report data. Of the 13 studies: four intervention studies were related to the theme 'relevant, useful, accessible research'; five studies (described in six papers) tested strategies that facilitated interaction between researchers and research users; three studies assessed strategies aimed at enhancing the capacity of organisations to use research; and one intervention study was related to the theme 'funding research infrastructure and research projects'. The level of evidence for the effectiveness of strategies to improve the use of research in policy making is low, and there remains a need for well-designed empirical studies that evaluate interventions. In the absence of strong evidence, efforts to enhance research use should be tailored to organisational needs and may incorporate capability development, improved access to targeted research summaries and syntheses, and greater interaction and collaboration with researchers.

Ethical Issues in the Design and Implementation of Population Health Programs

Spurred on by recent health care reforms and the Triple Aim’s goals of improving population health outcomes, reducing health care costs, and improving the patient experience of care, emphasis on population health is increasing throughout medicine. Population health has the potential to improve patient care and health outcomes for individual patients. However, specific population health activities may not be in every patient’s best interest in every circumstance, which can create ethical tensions for individual physicians and other health care professionals. Because individual medical professionals remain committed primarily to the best interests of individual patients, physicians have a unique role to play in ensuring population health supports this ethical obligation. Using widely recognized principles of medical ethics—nonmaleficence/beneficence, respect for persons, and justice—this article describes the ethical issues that may arise in contemporary population health programs and how to manage them. Attending to these principles will improve the design and implementation of population health programs and help maintain trust in the medical profession.

Leveraging electronic medical record data for population health management in the Veterans Health Administration: Successes and lessons learned.

The process and operational elements to establish a population health program using electronic medical record data in a Veterans Health Administration region are described. Pharmacists are uniquely qualified to assume important roles in population health through the use of their clinical knowledge, assisted by electronic tools that consolidate and report patient-specific data for clinical care. Veterans Integrated Services Network (VISN) 21 has developed 300 dashboards and reports to improve the quality, safety, and value of healthcare to veterans. Within a group of specialty task forces, physicians, nurses, and pharmacists assist in the design and development of evidence-based tools to leverage timely electronic health information into metrics, benchmarks, and targets to assist with goal achievement. Examples of programs designed to improve care in 3 areas were selected for further description and review of outcomes. Population health improvement using Healthcare Effectiveness Data and Information Set and hepatitis C metrics were used to describe populations that may have an indication for evidence-based care but are not receiving it. Deprescribing efforts are described, as are medication safety monitoring efforts to prevent potential adverse events known to be associated with therapy. Quality, safety, and value outcomes are the measures of success for population health programs in VISN 21. Data-rich project dashboards and reports are developed by pharmacist data analysts and implemented and used by teams of clinicians who provide continuous feedback and support to improve population health. The use of task forces, metrics, benchmarks, targets, and teams is instrumental in the successful application of these tools.