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