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Transcript of Population health management anderson
Population Health Management
The Population Health Sciences Perspective How it helps us address health needs
Roger T. Anderson, Ph.D. Professor of Public Health SciencesChief, Division of Health Services and Behavioral ResearchAssociate Director for Population Sciences, Penn State Hershey Cancer InstituteDirector, Penn State MPH ProgramPenn State College of Medicine, Hershey PA
Population Health Management
Improving the systems and policies that affect health care quality, access, and outcomes, ultimately improving the health of an entire population.
Individual-focused Patient Care Policies
HbA1C < 7 BP < 130/80 LDL cholesterol < 100 Aspirin, ACE, statin use
Individual-focused Patient Care Policies
e.g., Breast cancer.
Use of adjuvant chemotherapy is defined as appropriate in the following settings:
node negative invasive cancer with tubular or colloid histology that is 3 cm or larger in size
node negative invasive cancer with ductal, lobular, or mixed histology that is larger than 1 cm in size
any node positive (N1) tumor
Population-focused policieswhat do they add?
Goal: Improve Access or use of services:
8.4
12.3
4.6
High education area Medium education area
Low education area
Percent decrease in mammography due to copays
Population-focused policieswhat do they add?
Goal: Overcome non-medical barriers to maximize health outcomes
Percent of patients with diabetes with self-management barriers
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Limiting Food Mindful of Schedule Meal Planning Organize day aroundTx
Some Hassle
Major Hassle
Adherence: Recognition of the Problem
12-Month Persistence by Drug Class
64.9
62.1
60.7
56.5
54.8
50*
83
0 20 40 60 80 100
Proportion of Days Covered (%)
ACE=angiotensin-converting enzyme.Shrank WH et al. Arch Intern Med. 2006;166:332-337; Partridge AH et al. J Clin Oncol. 2003;21:602-606.
Dru
g C
lass
Oral contraceptives
Calcium-channel blockers
Angiotensin-receptor blockers
Statins
ACE inhibitors
Adjuvant endocrine therapy for breast cancer
Adjuvant endocrine therapy - 48 month data
Burden of
Treatment
Theme 1 Work
patients must do to care
for their health
Theme 3Challenge
s/ stressors
that exacerbat
e felt burden
Learn about conditions & care
Medications
Medical appointments
Monitoring health status
Health behaviors
Other treatments (non-medication)
Enlisting support
Routinizing self-care
Planning for future
Using technology
Preserving autonomy /
independence
Exerting control over providers
Theme 2 Problem-focused
strategies to
facilitate self-care
Challenges with taking medication
Interpersonal challenges
Financial challenges
Confusion about medical
information
Healthcare provider obstacles
– individual provider
Role & social activity limitations
Physical & mental exhaustion of self-
care
Barriers to self-care
Healthcare provider obstacles
– system issues
Conceptual Model
Demands
Enablers
Theme 4Impacts
of burden
Population-focused policieswhat do they add?
Goal: Coordinate care and provide meaningful integration
Population-focused policieswhat do they add?
Goal: Monitor and address health disparities
Received Dr. Instruc-tions
Full Insurance
Married
Cost Problems
Activity Limitation
Equipment Needed
0 10 20 30 40 50 60 70 80 90 100
69.0
94.8
53.3
7.0
35.1
17.9
64.6
88.9
41.9
14.5
40.2
24.1
Non-white White
“RISK” Assessment to Ascertain level of Cultural Influence
Resources of patient and family – Tangible resources, e.g., level of education, SES, social support,
past experiences
Identity and Ability to navigate health care services –
Individual circumstances, place of birth, language
Skills available – Ability to navigate the HCS and cope w/ disease emotionally,
physically, socially and spiritually
Knowledge about ethnic group – Family structure, decision-making, truth-telling, preferences,
modes of providing social support
Broad view – Geographic Patterns
Breast cancer in Appalachia
Population Health Management
An Application
Tracking patient outcomes from risk factor identification through receipt of care
Stroke Risk Screening Development of a Sustainable and Effective Program in the ‘Stroke
Belt’ of NC
Roger T. Anderson, Ph.D1.,
James Toole, M.D2., Rong Tang, M.D.2
Beth Parks3
1 Pennsylvania State University College of Medicine2 Wake Forest University, Department of Neurology3North Carolina Stroke Association, Winston-Salem, NC. USA
GeographySmoothed Age-Adjusted Stroke Mortality
Rates by US County
WM 1996
Importance
2001-2005 Stroke Risk Screening Regions2000-2006 NCSA Stroke Screening Regions
Health care supply
NCSA + Community Hospital Partners
2001-2005 Stroke Risk Screening Regions2000-2006 NCSA Stroke Screening Regions
Community Stroke Risk Screening Program
Challenge - Build a community-based stroke risk screening program to reduce stroke risk in the community.
Community lead: North Carolina Stroke
Association Stakeholders: Community Hospitals Reach 1000’s of high risk persons across all
regions of North Carolina. Sustainable (1999 – ongoing).
Must have low operational cost: use existing outreach resources and volunteer staffing.
Work with Community Partners to:
Develop brief, sensitive screening tool. Provide health education and stroke risk
awareness to participants. Identify patient barriers to access. Quantify program effectiveness.
Operationally Feasible
Stroke Risk Assessment Tool
Easy to collect by trained volunteers
Age Height/ Weight (BMI) Blood pressure Lipids (LDL, HDL) Glucose (non fasting) and patient history of
diabetes Irregular heart beat Carotid Bruits
Predictors of an Ischemic Stroke Event (the ARIC study)
Variables Units of Measurement Odds Ratios Odds Ratios
Male Gender Binary(1 = Male) 1.63 (1.16,2.29)
Age Year 1.07 (1.04,1.11)
No Smoking History
Binary ( 1= No History) 1.10 (ns) (0.72,1.70)
Current Smoker
Binary ( 1 = Current) 2.20 (1.45,3.32)
Diabetes Binary 3.78 (2.61,5.46)
High Blood Pressure
Binary ( 1 if > 140/90 mmHG) 2.64 (1.87,3.71)
High Cholesterol
Binary (1 if >200 mg/dL) 2.02 (1.23, 3.31)
TIA Stroke Algorithm
Discrete 0 (low risk) – 8 (high risk) 1.26 (1.02,1.55)
Body Mass Index Kg / M*M 1.00 (ns) (0.96,1.03)
NCSA Central Site
Protocol/Manual
Survey
Training
Funding Sources
Database/Reports
Local Employer
Local Health Center
Local Facility
Regional Sites
Stroke Risk Screening Program
NCSA Stroke Risk Screening Program
Promote stroke risk screening
Make available standard protocol Regional health centers in high risk areas.
Provide technical assistance. Train volunteers Provide all materials needed Lab tests paid by small grant and donations Methods to encourage patients to seek health care All data analysis centralized
Quality Improvement Study screening effectiveness Research on optimal screening effectiveness
Risk factor # with Risk
Factor
% with Risk Factor
High Cholesterol > 200 3028 36%
High Glucose (non fasting >130) 1921
23%
High Blood Pressure >140/90
2954 35%
Carotid Bruits137
2%
Current Smoker 2237
27%
H/P: Irregular Heart Beat TIA symptoms detected1
1118 628
14% 7%
1 Unilateral numbness, paralysis
Goal: Identify mosifiable stroke risk in needy communitiesScreened 8,579 Persons
Levels of Stroke Risk in Population
# of Risk factors
Number of Individuals
% of Total
0 1626 18.95%
1 2,842 33.13%
2 2,408 28.07%
3 1220 14.22%
4 403 4.70%
56
70 10
0.82% 0.12%
8579 100%
Estimate potential effectiveness
Expected Ischemic Stroke Events in Screened Population (N=8,579)
ARIC Stroke Risk Score
N
Predicted no. of Subjects to have Stroke (20 year period)
0 - .0090 Lowest 1429 7
0.0090-.015 1843 19
.015-0.026 1968 38
.026 - .068 2143 102
.068-.14 563 48
.14+ Highest 187 29
If empirical model is correct: 74% of future stroke events in screened sample would occur among 33% of individuals
Proportion of persons found with risk who were unaware of this status, or who did not seek help for this risk factor during last six months (i.e.,TIA symptom or overweight):
High cholesterol 55.5%
High blood glucose 65.4% Hypertension 44.3%
Irregular heart beat 72.2% TIA Symptoms 83.3% Overweight 78.1%
Goal: Identify Barriers to Population Health Goal of RF Lowering
Barrier: Not aware of stroke risk
Barrier: low access and receipt of care following screening:
Of those with high risk, what proportion sought or received care after the NCSA screen?
_______________________________
n=461 with high risk followed 267 visited health provider (57%)
112 discussed results ( 26%) 63 were offered tests (9.5%)
_______________________________
DeLemos and colleagues (2002) found that after 3 months 73% of high risk individuals did not report any lifestyle changes to lower risk, and only 9% had
visited a doctor.
Barrier: Brief risk factor communication does not result in knowledge and awareness
90 days after screening After Screening: 40% could not correctly report the risk
factors found in screening. 30% talked to doctor/nurse about risk.
Participant support intervention
Randomized design: Usual care vs. telephonic coaching intervention
N- 227, followed 1 and 3 months post-screening
Intervention: review risk, assess patient contemplation and readiness to seek care, offer assistance with healthcare access. Send copy of stroke risk finding to patient physician by clinician co-investigator.
Outcome: proportion seeking medical care/advice, treatment.
Low cost to administer~ $10 per patient.
Follow-up at 3 months
Attention Control MotivationalIntervention
p-value
MD visit after screening date (recorded at 3 months) %52.9 70.1 0.0156
% Concern over risk factors59.0 72.0 0.0422
% Very Confident about lowering stroke risk
58.0 63.2 0.5466
% Planning to modify risk “on your own” 48.48 48.36 0.9853
% “With your doctor’s help” 52.58 68.60 0.0157
% with Medication Treatment for BP and Cholesterol at
Follow-up.
66.67
35.19
15.15
23.26
0
10
20
30
40
50
60
70
80
90
100
BP Chol
% P
rescri
bed
Med
icati
on
s
Visit to Dr. after screening No Visit95% Confidence Intervals shown
Conclusions
Low-cost follow-up phone call with counseling is effective in improving access in a high-risk community
Barrier needing more attention is self-help with risk factor lowering and support of healthy behaviors.
Requires community input and support
Overall Summary
Starting point – Define the Problem
Identify health needs of a community to facilitate prioritization and strategies to address them.
Morbidity and Mortality ‘Health’ = physical, social and emotional Treatment burden
Challenges
Collect and analyze data on patient/community health needs ‘Emic’ vs ‘etic’ the right balance?
Select health priorities for improvement Benchmark (e.g., Health People 2020) Notable high need or disparity in community Leading cause of health damage (i.e. smoking, obesity,
etc.) Basic Priority Rating System (BPSR) or variations
Thank you