NURS 8310 Assignments – Epidemiology and Population Health Papers

NURS 8310 Assignments – Epidemiology and Population Health Papers

???????Epidemiology is the study of the distribution and determinants of health or disease in populations to respond to and control health problems.

The Epidemiology and Population Health Department provides training in quantitative methods, which can be used to understand population health needs and the patterns and etiology of disease, as well as to evaluate health interventions in the community. It also offers courses in methods of epidemiological surveillance and in methods of research design, data collection, analysis, as well as courses in population theory and methods of analysis that examine the link between health and population concerns.

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Epidemiology is the study of disease in populations. Veterinarians and others involved in the preventive medicine and public health professions use epidemiological methods for disease surveillance, outbreak investigation, and observational studies to identify risk factors of zoonotic disease in both human and animal populations. Knowledge of these risk factors is used to direct further research investigation and to implement disease control measures. The use of hazard analysis critical control point (HACCP) systems depends greatly on information produced by epidemiological studies. Epidemiological methods are used for disease surveillance to identify which hazards are the most important. Epidemiological studies are also used to identify risk factors which may represent critical control points in the food production system.

NURS 8310 Assignments – Epidemiology and Population Health Papers

Introduction to Epidemiology and Public Health

Although the role for epidemiology is widely accepted in public health programs in general, its role in chronic disease programs is not as widely recognized. One possible barrier to improving epidemiological capacity in chronic disease prevention and health promotion programs is that chronic disease program managers and public health decision makers may have a limited understanding of basic chronic disease epidemiology functions. We describe the assessment process of data collection, analysis, interpretation, and dissemination, and, using examples from two states, illustrate how this approach can be used to support program and policy development in three areas: by defining the problem, finding programs that work, and evaluating the effects of the program over time. Given the significant burden of chronic diseases in the United States, the scientific guidance provided by epidemiology is essential to help public health leaders identify priorities and intervene with evidence-based and effective prevention and control programs.

Epidemiology is the study and analysis of the distribution (who, when, and where) and determinants of health and disease conditions in defined populations.

It is the cornerstone of public health, and shapes policy decisions and evidence-based practice by identifying risk factors for disease and targets for preventive healthcare. Epidemiologists help with study design, collection, and statistical analysis of data, amend interpretation and dissemination of results (including peer review and occasional systematic review). Epidemiology has helped develop methodology used in clinical research, public health studies, and, to a lesser extent, basic research in the biological sciences.^[1]

Major areas of epidemiological study include disease causation, transmission, outbreak investigation, disease surveillance, environmental epidemiology, forensic epidemiology, occupational epidemiology, screening, bio monitoring, and comparisons of treatment effects such as in clinical trials. Epidemiologists rely on other scientific disciplines like biology to better understand disease processes, statistics to make efficient use of the data and draw appropriate conclusions, social sciences to better understand proximate and distal causes, and engineering for exposure assessment. NURS 8310 Assignments – Epidemiology and Population Health Papers

Epidemiology Epidemiology, literally meaning “the study of what is upon the people”, is derived from Greek, Modern epi, meaning ‘upon, among’, demos, meaning ‘people, district’, and logos, meaning ‘study, word, discourse’, suggesting that it applies only to human populations. However, the term is widely used in studies of zoological populations (veterinary epidemiology), although the term “epizoology” is available, and it has also been applied to studies of plant populations (botanical or plant disease epidemiology).^[2]

The distinction between “epidemic” and “endemic” was first drawn by Hippocrates,^[3] to distinguish between diseases that are “visited upon” a population (epidemic) from those that “reside within” a population (endemic).^[4] The term “epidemiology” appears to have first been used to describe the study of epidemics in 1802 by the Spanish physician Villalba in Epidemiología Española.^[4] Epidemiologists also study the interaction of diseases in a population, a condition known as a endemic.

The term epidemiology is now widely applied to cover the description and causation of not only epidemic disease, but of disease in general, and even many non-disease, health-related conditions, such as high blood pressure and obesity. Therefore, this epidemiology is based upon how the pattern of the disease causes change in the function of everyone. 

NURS 8310 Assignments – Epidemiology and Population Health Papers

Principles of Epidemiology

Public health workers use epidemiological principles as the foundation for disease surveillance and investigation activities.

Epidemiology is the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems.

Every public health worker should be familiar with the basic principles in this definition and how they are useful.

• Distribution – Epidemiology is concerned with the frequency and pattern of health events in a population. Frequency includes not only the number of events in a population, but also the rate or risk of disease in the population. Determining the rate of disease occurrences (number of events divided by size of the population) is critical for making valid comparisons across different populations.
• Determinants – Epidemiology is also used to search for causes and other factors that influence the occurrence of health-related events. The occurrence of a health-related event is usually related to multiple determinants that should be considered. Examples of determinants include host susceptibility to a disease, and opportunity for exposure to a microorganism, environmental toxin, insect vector or other infected individual that may pose a risk for acquiring disease.
• Specified populations – Epidemiologists are concerned with the collective health of people in a community or other area and the impact of health events on that population.
• Application – Epidemiology provides data for directing public health action. An epidemiologist uses the scientific methods of descriptive and analytic epidemiology in “diagnosing” the health of a community, but also must call upon experience and creativity when planning how to control and prevent disease in the community.

Disease surveillance usually begins with descriptive epidemiology — defining the what, who, when and where of health-related events.

• what – Define the disease events and/or its determinants
• who – Descriptions of demographic characteristics are helpful in determining which groups are at risk for some outcome. The demographic characteristics usually include age, sex and race/ethnicity. Other categories include socioeconomic status, history of occupation, or smoking habits, which provide useful information about exposures that may present a risk. A history of underlying diseases may be useful for determining susceptibility to certain conditions.
• when – Following changes in disease rates over time, following long-term disease trends and knowledge of the seasonality of certain diseases helps identify unusual occurrences that may define epidemics. Temporal associations between particular exposures on illness give information about incubation periods and exposures posing a risk to others. NURS 8310 Assignments – Epidemiology and Population Health Papers
• where – Insight into the geographical extent of health-related events gives an idea of where the agent that causes a disease normally lives and multiplies, what may carry or transmit it and how it spreads.

The Primary Applications of Epidemiology in Public Health

To set policy and plan programs, public health officials must assess the health of the population they serve and must determine whether health services are available, accessible, effective and efficient. Epidemiology provides data for directing public health action. The information is used when planning how to control and prevent disease in the community. Through public health surveillance, a health systematically collects, analyzes, interprets and disseminates health data on an ongoing basis. By knowing the ongoing pattern of disease occurrence and disease potential, a health agency can effectively and efficiently investigate, prevent and control disease in the community.

Uses of Epidemiology

• Count health-related events
• Describe the distribution of health-related events in the population
• Describe clinical patterns
• Identify risk factors for developing diseases
• Identify causes or determinants of disease
• Identify control and/or preventive measures
• Establish priorities for allocating resources
• Select interventions for prevention and control
• Evaluate programs
• Conduct research
  • risk factors and causes
  • drug trials / vaccine trials
  • operational research

Purposes of Communicable Disease Investigation and General Principles of Preventing Transmission.

Introduction

These guidelines have been written to assist public health staff engaged in investigating communicable diseases. Their intent is to provide basic, practical, up-to-date and easy-to-understand information which has been coalesced and interpreted from a variety of sources. These guidelines have been written as carefully as possible to balance the amount of work necessary to follow up a reported case against the probability of controlling spread of the disease. NURS 8310 Assignments – Epidemiology and Population Health Papers

Only certain diseases are included in these guidelines. This is based upon their frequency and complexity. For further information about these and other diseases, consult Control of Communicable Diseases in Man. 

Remember, these are only guidelines. All situations differ and best judgment should prevail. Some situations require a more stringent approach. Some require a less stringent approach.

Purposes of Communicable Disease Investigation

Nothing is less self-fulfilling than going through the motions of a task without understanding its purpose. When investigating a report of communicable disease, always keep in mind the purposes are to:

1. Prevent Transmission from Cases to Contacts: A full discussion of this topic begins below.
2. Identify the Source of the Disease: The source may be in the environment, a food, or another person. Its identification can lead to control. NURS 8310 Assignments – Epidemiology and Population Health Papers
3. Identify Other Cases: Each reported case should be regarded as a sentinel health event. Efforts to identify other cases which are not diagnosed and/or reported may uncover outbreaks and common sources. It is important to question the reported case about others who have been exposed or who have similar symptoms.
4. Conduct Surveillance: Information collected when investigating a reported disease can be examined on a state or regional basis to identify outbreaks or trends and to formulate policy. This information is collected on standardized forms and often is sent to the Centers for Disease Control and Prevention for surveillance on a national basis.
5. Ensure that the Patient has Adequate Medical Supervision: Our responsibilities include making sure the patient is well cared for and understands the consequences of his illness. Where medical care is inadequate, appropriate referrals should be made.

General Principles of Preventing Transmission

This section describes how cases and contacts can be managed to prevent transmission.

Case Management

1. Verify the Diagnosis: It is very important to promptly establish or verify the etiologic agent responsible for the disease. For many diseases reported by physicians or others, there are often little or no laboratory data initially available to verify the diagnosis. Since control efforts depend on the exact diagnosis, it is important to: (a) determine if this information exists; (b) arrange for laboratory tests if the information does not otherwise exist; or (c) make the best guess about diagnosis if it cannot be obtained.
2. Determine if the Case is Infectious or Possibly Infectious: If the case is still infectious, you must identify available measures for preventing transmission. There are two ways to assess the case’s interactivity:
   • estimation–uses the date of onset of illness, dates of known treatment, and known periods of infectiousness for an illness. For example, hepatitis A is no longer infectious after 1 week of the onset of symptoms. Strep throat is no longer infectious after 24 hours of treatment.
   • verification–requires laboratory testing of specimens for the case (for example, a stool specimen for a food handler with salmonellae). Which method you use depends upon the disease (the period of communicability for some diseases is precise; for others it is not precise), the quality of information about the case (e.g., is date of onset known?), and the need to know definitely whether the case is infectious.
     In practice, because of delays in diagnosis and reporting, many cases will have passed the infectious stage by the time they are reported. In this instance, the opportunity to prevent transmission is lost, but preventive efforts can be directed to the case’s contacts, and other purposes of case investigation can be fulfilled. You may need to contact the physician to fill in information about the case, determine results of laboratory tests, or arrange for tests. Also ask about similar cases for which a report may be pending. NURS 8310 Assignments – Epidemiology and Population Health Papers
3. Minimize the Duration of the Case’s Interactivity: Drugs (antimicrobial) are the most important means to shorten the duration of interactivity for many diseases. Usually, decisions about drug treatment will be made by the time you investigate. However, sometimes it may be necessary to work with the patient and physician to ensure the patient is appropriately treated.
4. Put into Effect Practices for Preventing Transmission: These practices depend upon the disease and other circumstances. If the disease warrants, the case may have to employ these practices while ill and for a period after recovery during which (s)he is still infectious:
   • disinfect and dispose of contaminated material (e.g., blood, saliva, feces, urine, eating utensils, bedding, clothes, toys, etc.)
   • disinfect the case, clothing, bedding, etc. (e.g., lice)
   • encourage behavioral practices of the case (e.g., hand washing, covering the nose and mouth when coughing/sneezing, protecting lesions from contact with another person. Also, there may be a need for changes if individual is a food handler.)
   • isolate the case — the duration and degree depends upon the illness

Contact Management

1. Determine the risk of infection to contacts: What is the frequency, duration and dosage of the exposure? Often, these characteristics can only be described vaguely. It is usually reasonable to assume persons living in the same household had opportunity for exposure.
   Is the contact susceptible? Has the person been vaccinated, or previously infected? Is there evidence of a compromised immune system (surgery, steroids, etc.)? Does the disease result in immunity or are people generally susceptible? NURS 8310 Assignments – Epidemiology and Population Health Papers
2. Determine if the contact is ill or infected: Look for clinical signs or symptoms. It is important to know if the contact is in the early stages of an illness or asymptomatic infected, you must rely on the laboratory. If you determine that a contact is ill or infected, manage him/her as a case.
3. Prevent illness in susceptible: It may be useful for you to think of contacts in two ways: Those who have been exposed, and those who might yet be exposed, either to the original source or to a contact who subsequently acquires an infection.
   The choice of the preventive measure depends upon the disease. Rapid identification of susceptible s is important. Remember, vaccines usually require a time period greater than one incubation period to develop antibody. Therefore, they rarely prevent illness in the first generation of contacts. They can, however prevent illness in later generations. Immune globulin must be given within a few days of contact to prevent or modify an infection, but they provide only short-term protection. Antimicrobial are particularly important for contacts exposed to strep, tuberculosis and meningitis.
   Limit the activities of exposed persons — sometimes it may be prudent to recommend cessation of contact between the contact and the source. Another example is quarantining exposed persons to protect others not yet exposed.
   Conduct personal surveillance of the exposed person — it may be important to call an exposed person by the end of the maximum incubation period to see if (s)he is ill (e.g., for hepatitis A), or simply ask the contact to call you if (s)he develops symptoms. The intensity of the surveillance depends upon the importance attached to preventing transmission from that person.

The primary focus of Harbor Branch population health and epidemiology research is the interplay of marine mammal, human, and environmental health, as embodied in the One Health concept.  The resulting research on marine mammal health, infectious disease and environmental epidemiology has illustrated the role of marine species as sentinel organisms for human and ecosystem health. Bolstered with staff expertise in epidemiology study design, statistical analysis and data management in both wildlife and human research, the program recently produced one of the pioneering studies connecting animal and human health, which demonstrated elevated mercury concentrations in dolphins and humans who consume fish from Florida’s Indian River Lagoon. NURS 8310 Assignments – Epidemiology and Population Health Papers

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Sentinel Species Health Assessments

Our previous research has identified human health hazards such as mercury, organic contaminants and antibiotic resistance in our local environment. This research includes the integration of environmental data to understand how natural and anthropocentric changes to the ecosystem impact the health of keystone species. We collect samples from wild dolphins, sharks, rays and penguins for clinical pathology parameters or hematology and serum chemistry, contaminant concentrations, viral screening, microbiology/antibiotic resistance and immunology from both live and deceased individuals for this research.

We are at the dawn of a data deluge in health that carries extraordinary promise for improving the health of populations. However, current associated efforts, which generally center on the “precision medicine” agenda, may well fall short in terms of its overall impact. The main challenges, it is argued, are less technical than the following: (1) identifying the data that matter most; (2) ensuring that we make better use of existing data; and (3) extending our efforts from the individual to the population by exploiting new, complex, and sometimes unstructured, data sources. Advances in Epidemiology have shown that policies, features of institutions, characteristics of communities, living and environmental conditions, and social relationships all contribute, together with individual behaviors and factors such as poverty and race, to the production of health. Examples are discussed, leading to recommendations that focus on core priorities for data linkage, including those relating to marginalized populations, better data on socioeconomic status, micro- and macro-environments, collaborating with researchers in the fields of education, environment, and social sciences to ensure the validity and accuracy of multilevel data, aligning research aims with policy decisions that must be made, and heightening efforts to protect privacy. NURS 8310 Assignments – Epidemiology and Population Health Papers

The growing abundance of data on the factors that produce health, and the capacity to link these to data from individuals, afford tremendous potential for improving population health. Although public health is built on a long history of creatively using health data going back to the pioneering work of Langmuir¹ and Snow,² the full potential of contemporary rich data sources is not being fully realized. Instead, the impact of this revolution is being seen mainly in the burgeoning precision medicine agenda, globally, and through the Precision Medicine Initiative (PMI) in the United States.³ In that context, linkage of omits data to phenotype information from health records is being exploited as new research platforms, with the hope that this will transform clinical practice.⁴ Similar momentum has not yet been achieved for the population health sciences.

We propose that there are two challenges for the population health agenda. First, ensuring that we make better use of existing data, and in some cases, enhance data linkage and methods to do this. Second, in extending our efforts from the individual to the population by exploiting new complex, and sometimes unstructured, data sources. NURS 8310 Assignments – Epidemiology and Population Health Papers

We recognize that there are major technological challenges when dealing with the massive and rapid flows of data that come from both traditional data sources, such as large administrative databases, and new sources, such as genomics, land-use, neighborhood and climate data, and unstructured social media feeds. However, we argue that the more important challenge is conceptual and perhaps ideological. How do we identify the data that matter most to improve health for the whole population? In some cases, these are existing data and we need to determine how to enrich, link, and analyze these routinely collected data to maximize their value. We also need to think about new sources of big data that can improve our understanding of health, and how we better integrate these in our approaches to studying population health while avoiding the temptation to analyze everything that may present itself as a new opportunity. Distinct from personalized medicine, the “what matters most” question can be addressed through an understanding of the pressing health challenges of our time and an understanding of how factors across economic, social, behavioral, and biological domains may interact.

The past 2 decades have shown how factors at multiple “levels of influence” are associated with both individual and population health.⁵ Multilevel causal frameworks suggest that policies, features of institutions, characteristics of neighborhoods and communities, living conditions, and social relationships all contribute, together with individual behaviors and individual factors such as genotype poverty and race, to the production of health.⁶ For example, quality of the built environment has been shown to be associated with mental ill health and diabetes.⁷,⁸ Certain social network characteristics are associated with the risk of obesity.⁹ It is a logical extension of the goals of big data collection to introduce measures that can capture potential risks at multiple levels of influence. The feature that turns these into “big data” is the coverage and complexity of this information, which enables the population health approach, across geographies, time, and the life course.

Epidemiology is an integral component of public health practice. The discipline aims to provide the basis to prevent disease and to promote the health of populations through the study of the occurrence and distribution of health-related states or events, including the study of determinants influencing such states. Professional epidemiological methods, defined as the application of epidemiological methods to public health practice, entail the combination of analytical methods and applied epidemiology oriented to problem solving in public health. The principal areas of professional epidemiology include epidemiological assessment of public health data, health situation and trend analyses, public health surveillance and health program impact assessment. These areas are closely linked to the essential public health function and services. This certificate program is intended to provide the concepts, methods and tools needed for the assessment of health situations and trends of population groups. NURS 8310 Assignments – Epidemiology and Population Health Papers

Epidemiology is the study of diseases in given populations. Epidemiologists examine how and where disease outbreaks start, how diseases are transmitted among individuals in a population and how to effectively treat those diseases. The information gathered and analyzed by epidemiologists is then used to develop or improve clinical and medical research, as well as improve preventative healthcare. It’s safe to say that countless lives have been saved due to the work of epidemiologists.

In order to become an epidemiologist, a master’s degree is the minimum educational requirement. The most common master’s degree is in public health with a specialization in epidemiology; however, the public health degree is not a requirement and many epidemiologists obtain master’s degrees in other fields and specialize in other areas. Many epidemiologists have doctorate and/or medical degrees, especially if they plan on teaching at the post-secondary level or overseeing medical research studies. On the undergraduate level, most epidemiologists have backgrounds in public health, biology, medicine and statistics. The high level of education required and the technical nature of the educational requirements to become an epidemiologist are reflected by a median salary of $66,330, which is well above the national average.

Typical careers for epidemiologists revolve around either conducting research or applying information and conclusions gathered from the research. Epidemiologists that conduct research are usually employed by universities or in conjunction with government organizations, such as the Centers for Disease Control and Prevention and the National Institutes of Health. Epidemiologists who apply knowledge obtained from research usually work with local governments and organizations directly tackling public health issues.

NURS 8310 Assignments – Epidemiology and Population Health Papers

The Role of Data in Population Health

Population health, the interdisciplinary field focused on the analysis of health outcomes of large groups of people, is becoming a more common and increasingly effective way of combating medical problems on a vast scale. In the United States, the use of population health data is becoming an effective and increasingly utilized tool in efforts to treat widespread health problems such as diabetes and heart disease. Population health data has also played an important role in the design and implementation of community-wide health initiatives implemented to promote good health practices, discourage drug and alcohol abuse, and promote safe sex behaviors. As the influence of population health and data analytics grows, health informatics – and the professionals who specialize in fields related to health data – have begun to play an increasingly important role.

Population health data is broadly defined as information related to the health outcomes of specific groups of people, namely nations, communities, or ethnic groups. While the concept of population-wide health surveys is not new, advancements in information technology and data interpretation have breathed new life into a data set once considered too unwieldy to make accurate use of. NURS 8310 Assignments – Epidemiology and Population Health Papers

Types of Population Health Data

As the fledgling population health discipline continues to grow in scope and influence, so too are the breadth of populations with which specific health data can encompass. While population health data always includes large sets of people or patients, the particular scope of what defines a “population” in health care terms is ever-evolving.

Population health data can include groups such as employees, individuals with a specific disease, students of a particular city or campus, military veterans, disabled persons and prisoners, just to name a few. Populations have also been delineated on lines of race, gender, income, and education. Determinants of population health data may also not be exclusive to specific groups, but also to physical environments that include a wide range of people, such as medical care systems, and social, physical, biological and geographic environments. In fact, global research dedicated to the health impact of issues such as climate change often has close ties to the arena of population health. NURS 8310 Assignments – Epidemiology and Population Health Papers

While the specific groups of focus in population health studies are continually changing, so too are the types of data utilized in population health surveys, scholarly research and medical study. From specific clinical data to widely-completed surveys, public health stats and census data, the range of influence as to what defines population health data is considerably broad.

Claims data can include patient demographics, diagnosis codes, dates of specific care, and cost parameters. The main value of claims data is its assistance in helping health informatics professionals act as a basis for healthcare professionals to better gauge who they are treating, which major health issues they are facing, and what and how these specific groups are paying for treatment.

Electronic health records, commonly referred to as EHR, provide data to population health professionals that offers direct insight into clinical findings. In addition to offering new perspectives into care processes, EHR data also includes patient-oriented information including vital signs, lab data and imaging, immunization and allergy history, and other key detailed metrics.

Socioeconomic data is also a rich resource for population health professionals. Environmental, social and communal factors can play a key role in the development of health management programs that address the specific spectrum of needs for a certain group, whether delineated by age, income, education or employment status. Socioeconomic data also allows health informatics professionals to consider incidents of interpersonal violence, type and frequency of illegal drug use, and economic disparities at the state, county, and city levels.

Another realm of key socially-rooted data for health informatics professionals is prescription medication data. This type of information allows healthcare professionals and policy makers to determine how patients are managing chronic health problems and diseases, a realm of health data also commonly referred to as medication adherence. NURS 8310 Assignments – Epidemiology and Population Health Papers

While the sources and kinds of population data are plentiful, plenty of debate remains among healthcare providers, government and non-governmental organizations, and healthcare related companies as to how such data should be utilized effectively in the public sphere without disrupting patient confidentiality. Similarly, data related to private companies and medical insurance providers is often proprietary, which has led to high-level discussions among population health data stakeholders by the global bodies such as the World Health Organization.

Population Health Analytics: Emerging Trends & Professions

The healthcare industry is still in the beginning stages of developing infrastructure, IT tools, computer programs and strategic methods that can bring together the disparate types data available to them in a reliable and consistent basis. As such, companies and organizations dedicated to collecting, storing, scoring, protecting and targeting interventions based on population health data are among the most rapidly growing in the healthcare industry.

The term population health is much more widely used now than in 2003 when Greg Stoddart and I proposed the following definition: “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” The term is often seen in policy discussion, research, and in the name of new academic departments and institutes.

The term’s growing use, most notably in the Triple Aim and in clinical settings, has resulted in a conflicting understanding of the term today. In this post, I discuss the evolution of the term population health, and argue that going forward multiple definitions are needed. While the traditional population health definition can be reserved for geographic populations, new terms such as population health management or population medicine are useful to describe activities limited to clinical populations and a narrower set of health outcome determinants.

Origins Of Population Health Terminology

The most influential contemporary contribution to how we understand population health is Why Are Some People Healthy and Others Not? The Determinants of Health of Populations, a 1994 book by Evans, Barer, and Marmor. No definition of the term appears there, although the concept is described as, “the common focus on trying to understand the determinants of health of populations.” NURS 8310 Assignments – Epidemiology and Population Health Papers.

In my 1997 book, Purchasing Population Health: Paying for Results, I proposed the definition as, “the aggregate health outcome of health-adjusted life expectancy (quantity and quality) of a group of individuals, in an economic framework that balances the relative marginal returns from the multiple determinants of health.” This definition included the specific measure of population health (health-adjusted life expectancy) as well as consideration of the relative cost-effectiveness of resource allocation to multiple determinants.

This definition emphasized that there are investment trade offs, which required “an economic framework that balances the relative marginal returns from the multiple determinants of health.” While less appreciated as a hallmark of population health thinking, the economic trade offs are equally important. If resources were unlimited we wouldn’t have to make investment choices, but they are limited. A critical component of population health policy has to be how the most health return can be produced from the next dollar invested, such as expanding insurance coverage or reducing smoking rates or increasing early childhood education. This is important for clinical populations as emphasized by the Triple Aim, but also for geographic populations needing resources from both public and private sectors.

In our 2003 article, Stoddart and I simplified the definition to focus on general health outcomes. We were thinking broadly about groups of individuals and suggested that “these populations are often geographic regions, such as nations or communities, but they can also be other groups, such as employees, ethnic groups, disabled persons, or prisoners.” At the time, the term typically referred to local geographic populations and had not yet been applied to the realm of medical care.

Multiple Determinants And Investment Trade offs

By 2003, Stoddart and I believed that the increasing emphasis on social determinants had led to an under-emphasis on specific measures of health. In response, we developed our shortened, simplified definition without the earlier emphasis on the multiple determinants of health and economic trade offs among them.

Some may argue that multiple determinants are so fundamental to population health that they deserve definitional status. I believe, however, that including multiple determinants in the definition could lead to confusion between the outcome goal and the determinants needed to achieve that outcome. This point is so important that the County Health Rankings grade the health of America’s counties on two components: reported outcomes (such as low birth weight), and factors determining that outcome (in the case of low birth weight, access to care and child poverty rates). NURS 8310 Assignments – Epidemiology and Population Health Papers.

Health Disparities

The second phrase in the 2003 definition, “including the distribution of such outcomes within the group” deserves serious attention. We often state that our national and local goals are improving overall health and reducing disparities. Unfortunately in measurement, policy, and research, we often emphasize the average or overall, such as setting future life expectancy targets, but without such attention and specificity to the disparity reduction component.

A common assumption is that improving overall population health also reduces gaps by race, socioeconomic status (SES), and geography, but this is not always the case. Many times these goals compete with each other, such as quicker take up in health behaviors by more educated persons actually increasing disparities. Often policy trade offs are required. If we truly believe that reducing disparities by race and SES is just as important as improving overall health, we need to give them equal attention, as we did in the original 2003 definition.

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The Triple Aim And Population Health Management

The past six years have seen the prominent development of the Triple Aim, which proposes three linked goals – improving the individual experience of care, reducing per capita cost of care, and improving the health of populations. This framework provided a boost in the use of the term population health.

In particular, its promotion by the Institute for Healthcare Improvement and the Centers for Medicare and Medicaid Services has led many health care organizations to use it to describe the clinical (often chronic disease) outcomes of enrolled patients. And many clinicians and medical managers have begun to use the terms population health management or population medicine. For example, the Symphony care website defines population health management as “the iterative process of strategically and proactively managing clinical and financial opportunities to improve health outcomes and patient engagement, while also reducing costs.” NURS 8310 Assignments – Epidemiology and Population Health Papers

Top Public Health Issues Impacting Healthcare Organizations

While the vast majority of diseases certainly do have genetic or biological underpinnings, environment also plays a critical role in determining who is most likely to fall sick—as well as who is most likely to get well once afflicted.  Public health research addresses the many issues that can influence the overall health and well-being of individuals and the greater community at large.

“Understanding these issues and how they affect patient populations is key to providing more efficient and effective healthcare,” says Joshua Gordon, MD, PhD, director of the National Institute of Mental Health. “Not only will it help improve the health of patients but it will also reduce healthcare costs and increase healthcare organizations’ ability to negotiate with private insurance sectors.”

Here are the top five public health issues currently impacting healthcare organizations.

1. Behavioral health integration. Julia Andrieni, MD, vice president of Population Health and Primary Care at Houston Methodist Hospital in Houston, says that, too often, proper assessments of mental health conditions aren’t done. As these conditions can significantly impact a patient’s physical health status, she believes more healthcare organizations need to integrate behavioral health assessments into primary care.

“Assessments of a population for anxiety, depression, addiction, and with our aging population, cognitive ability, is really important,” she explains. “It’s very difficult to be effective in treating chronic conditions if you have an unaddressed behavioral health issue. For example, a diabetic with unaddressed anxiety or depression likely won’t be motivated to go to appointments, check blood glucose levels, or change their diet or exercise plan to stay healthier. Behavioral health is a vital part of a person’s whole health status.” NURS 8310 Assignments – Epidemiology and Population Health Papers.

2. The suicide epidemic. Gordon says that the suicide in the United States is currently a national public health emergency.

“Suicide rates continue to go up—and we know there are things we can do to reduce suicide risk,” he explains. “Healthcare organizations have a large role to play in rolling out the kind of risk identification and intervention measures that can be effective to address this issue.”

3. The opioid crisis. According to the CDC, approximately 115 Americans are dying each day from opioid-related overdoses. Through integrated models of care, Andrieni argues, healthcare organizations are in a unique position to identify and treat individuals who may be suffering from a substance misuse disorder.

“So often, with opioids, alcohol, and tobacco misuse, we see that people are self-medicating and that’s what leads to addiction,” she says. “We need to be addressing the other issues that commonly appear with substance abuse, those potential dual diagnoses, or diagnoses of physical or behavioral health conditions with substance misuse disorders, to better get a handle on this growing issue.”

4. Social determinants of health. Andrieni says that two patients may present with the same physical symptoms of a disease—but if they differ in socioeconomic status, education level, healthcare accessibility, family support, or other non-clinical factors, their diseases are likely to progress in very different ways.

“Healthcare providers need to address the non-clinical as well as the clinical factors when we treat a patient. Because they do impact health,” she says. “Think of a diabetic patient again.  If that patient has no transportation, food insecurity, an inability to pay for medicine, and a low literacy level, it will be a challenge to be effective in treatment. We have to address the disparities in social determinants of health so we can help our patients get healthier.”

5. The obesity epidemic. Research study after research study has shown the relationship between obesity and conditions like cardiovascular disease, diabetes, sleep apnea, and osteoarthritis.

“This is a public health issue that not only impacts adults but also is important to childhood health,” Andrieni says. “Understanding how a healthy weight can help set people toward a path of good health is critically important.”

There are, of course, many more public health issues that influence population health in the United States—and some have more impact in certain communities over others. But Gordon says that, especially regarding behavioral health issues, collaborative care models can help healthcare organizations develop the right strategies to keep their patient communities healthy and whole.

“When primary care doctors work with mental healthcare professionals of all different persuasions, we see a big difference. I would encourage hospital executives to think about integrating care across departments,” he says. “If we saw more of that in the private healthcare industry, we could see more cost-efficient and higher quality patient care.” NURS 8310 Assignments – Epidemiology and Population Health Papers.

The goal: to assess the current state of population health management while distilling insights and best practices for the road ahead. Participants ranged from fully capita ted west coast organizations to east coast systems just beginning to dip their toes into the waters of risk.

“The opportunity for population health to address healthcare disparities is huge,” said the chief medical quality officer from a Midwest organization. “We’re trying to do more and more, but I still struggle with explaining our population health strategy.”

Here are five of the key insights that emerged.

1. Big data doesn’t equal actionable insights

Forty-three percent of executives selected data aggregation as their highest priority IT investment for population health.

Multiple EHRs, claims data, quality metrics, the overwhelming surge of big data. It’s great to have access to this data, but what do organizations do once they have all that data? How to make sense of the tsunami of zeroes and ones staring back at them from their health IT systems? Data without insight or actionable strategy to move the needle of both quality and cost is nearly useless.

Or, as one executive put it: “Without a single, integrated record of clinical and financial information, regardless of provider or care site we’ll never move the needle on population health.”

But, once organizations have aggregated the necessary information to succeed as the first step on this new reimbursement model journey, the real opportunity to make a difference on health outcomes is to help make sense of that data. NURS 8310 Assignments – Epidemiology and Population Health Papers

2. Delivering quality care is not the same as financially succeeding under new reimbursement models

Common wisdom suggests that to succeed under value-based reimbursements and new care delivery models, organizations must effectively care for the top five to 10% of their riskiest patients. What isn’t quite known or understood is the most effective game plan for doing so.

As one executive said, there is a delta between the quality measures used to determine successful outcomes, in programs such as PQRS and the like, and true patient quality delivered from providers.

“How can we say ‘use this compass to provide quality care with a straight face?’” wondered one executive. Pay for performance incentives make little sense for certain specialties or emergency department physicians, executives said, and it becomes increasingly difficult to succeed financial and clinically as organizations move toward fully capita ted risk. Checking off quality measures like they are boxes on a test will ultimately lead many to game the system for financial advantage.

Until organizations have a better sense of what actually moves the needle on keeping the high-risk patients healthy and therefore total costs down, there will be a lot of experimentation and waste to figure out the successful value-based blueprint.

3. Financial incentives aren’t there yet

Payers routinely come up as one of the most significant roadblocks for provider organizations to make the switch to value-based reimbursement. Of course, each regional market and payer mix differs, but the general sentiment from executives was that payers are “dragging their feet,” as one executive put it. “They don’t want to work with us on these types of new care models,” the executive added.

One of the primary reasons is that when provider organizations move to a fully integrated, total cost of care model, then they can dictate the care delivery method. But, until that happens, provider organizations have to figure out how to care for the patient based on the rules and regulations of each payer. NURS 8310 Assignments – Epidemiology and Population Health Papers.

4. Patient access is an important and key variable

Once organizations are financially responsible for maintaining the health of its patient panels, much of the ability to do so depends on the patients themselves. Are patients adhering to their care plans? Do they have access to care in the right setting when they need it? Are they getting care outside the network? Convenient access – whether through a physical location or via digital communication mechanisms – is such a crucial piece to keeping the costs of caring for patients low.

Some organizations are working to build their own urgent care and retail experiences for patients, or to extend hours, but wherever existing organizations have gaps, there will be “companies that come in and expose our gaps to compete with us.”

Further, by not reacting quickly enough and allowing disruptive entrants to the care delivery system, some executives view patient-friendly competitors as “fictionalizing what we are trying to pull together under our pop health strategies.”

5. When is the tipping point coming?

Though the majority in attendance acknowledged this particular moment in value-based health care is different from the managed care movement in the 90s, many were still skeptical of when the tipping point would come for the industry to fully shift from fee for service to fee for value. “When will the switch and market demand happen,” wondered one executive. “Are we just pushing out this switch every five years?”

The goal of PHM

There are several goals PHM programs seek to achieve.

One goal is financial improvement. PHM programs aim to mitigate costs by focusing on appropriate utilization of services to manage and coordinate care efficiently. PHM programs also seek to mitigate costs by effectively managing and preventing chronic diseases.

Another goal is clinical proficiency. This entails using PHM technologies to identify care gaps and also includes process metrics, such as the delivery of care services, and outcomes metrics, such as assessing the health of the patient population. Possessing and analyzing this data allows providers to identify the greatest needs of the patient population. For example, if the majority of a patient population is suffering from diabetes and hypertension, PHM technologies can help providers identify these problems.

Finally, another goal of PHM is better patient engagement. Patient engagement is an important aspect of PHM because in order to prevent disease and maintain wellness, patients need to be motivated to make healthy choices while outside the hospital or healthcare facility. NURS 8310 Assignments – Epidemiology and Population Health Papers

The benefits of population health management

The benefits of PHM include giving providers the ability to find care gaps, presenting providers with actionable steps on how to treat a patient or group of patients, and reducing cost for the healthcare organization.

Another benefit of PHM is its crucial role in aiding the American healthcare industry in transitioning over to value-based care or value-based reimbursement. A very important aspect to achieving value-based care is understanding the patient population and knowing the most effective ways to treat them. NURS 8310 Assignments – Epidemiology and Population Health Papers

PHM risk stratification

Risk stratification is the process of dividing a population of patients into groups based on their health, lifestyles and their medical histories. Risk stratification for PHM involves combining individuals’ risk scores, demographics and socioeconomic characteristics, and medical records to create a complete and comprehensive patient profile.

Risk stratification is important to PHM because it allows providers to predict and identify patients at risk for hospital admissions, allows providers to create patient-specific care plans, and helps providers understand their patient population health trends.

PHM data sources

In order for PHM to truly be successful and for healthcare to transition to value-based care, certain data is needed. At the absolute minimum, this data should include: patient-reported outcomes data, social determinants of health data, claims data and activity-based data. NURS 8310 Assignments – Epidemiology and Population Health Papers

Population health

A standardized definition for population health from a professional association does not currently exist. In the American Journal of Public Health in 2003, Kindig and Stoddart¹³ outlined a definition of population health that is commonly used in literature and practice. Reviewing a number of definitions from scholarly works and health policy organizations, they ultimately included both the health outcomes and the distribution of those outcomes within the group in the definition of population health. Importantly, Kindig and Stoddard noted the need to use population health measures that are dependent on a broad range of health determinants, such as Years of Health Life used in Healthy People,¹⁴ to accurately assess population health outcomes.

A key concept of population health is understanding how populations are defined. Some population health leaders may consider geographic areas, such as a county or select ZIP codes.¹⁵ Other population health stakeholders, like payers or health systems, may define a population based on the group of patients seeking care from a select group of primary care providers or a group of patients covered under a specific health plan. Still other population health initiatives focus on patients with similar diseases.

Understanding and defining populations are important for ensuring clarity. Populations can be defined by a variety of characteristics, such as patient age, payer group, primary care provider attribution, geographic region, or disease. Diez Roux¹⁶ cautioned that the narrowing of population health to groups of patients with specific conditions or providers may be missing the bigger picture of population health. She urged less focus on outlining what distinguishes population health from public health and noted that improving population health can only be achieved through a holistic focus on social determinants, biological determinants, and elements of health equity.

Sharfstein¹⁷ also discussed the widespread, often confusing, and colloquial use of the term population health in modern healthcare discussions. He provided lists of services that organizations are including under the umbrella term population health, and these lists include the terms pharmacy, pharmacy benefit management, and pharmaceuticals. Interestingly, pharmacists are not explicitly mentioned in the lists. Sharfstein challenged those working in population health to “define success or failure by not only those served but also those left behind.” For example, if population health efforts are focused on patients covered by a specific insurance type, uninsured patients may be unintentionally excluded from receiving services. NURS 8310 Assignments – Epidemiology and Population Health Papers

Population health encapsulates both health outcomes and determinants of health. There are published examples of service models that aim to improve determinants of health and optimize health outcomes. Due to ambiguity between the terms population health and population health management, it can be difficult to discern if the published models are examples of population health or population health management. The Community Aging in Place, Advancing Better Living for Elders trial is such an example.¹⁸ The study goals were to decrease hospitalizations and nursing home use in older adults by improving the health and quality of life for patients in their own home. The model involved pharmacists providing consultative services for patients on high-alert medications and for patients taking more than 15 medications. The trial involved a nurse, an occupational therapist, and a handyman. The approach of including a nontraditional team member, such as a handyman, to address the patient’s home environment conditions to improve activities of daily living is an example of some of the community-based partnerships the definitions of population health discuss. Studies have also demonstrated that pharmacists can play an important role in optimizing health behaviors and addressing underlying determinants of disease in populations. A longitudinal study conducted in a Veterans Health Administration clinic demonstrated that pharmacists can have a lasting effect on helping patients become tobacco free and live a healthier lifestyle.¹⁹ 

Population health management versus improvement

Understanding that the majority of proposed definitions of population health are conceptual frameworks, the terms population health management and population health improvement have been used to describe actionable population health activities. These terms are often used to outline pragmatic approaches to improve outcomes and optimize the health of populations and are sometimes used interchangeably. As noted previously, a primary goal of the IHI’s Triple Aim Initiative is to improve the health of populations.⁵ Once a population is identified and desired outcomes are defined, it is incumbent on healthcare organizations to work toward improving these outcomes for individual patients to maximize population health using population health management infrastructure and population health improvement techniques. NURS 8310 Assignments – Epidemiology and Population Health Papers

The National Academy of Medicine favors the term population health improvement.²⁰ The National Academy of Medicine has an organized round table on the topic of population health improvement and conducts workshops with the goals of identifying and improving contributors to population health, specifically including education. The suggestion that population health can always be improved is similarly evoked in the IHI’s Triple Aim implementation tools.²¹

Many other organizations and articles use the term management as analogous to the word improvement, where population health management activities are intended to maintain and improve health.^22,–25 The term population health management was directly referenced in an article regarding the Triple Aim. In that article, Ber wick et al.⁵ used this term to describe how an integrator—or an organization that accepts responsibility for all 3 aims of the Triple Aim—would deploy its resources to address areas of need within its segmented population. Ber wick and colleagues proposed that organizations seeking to achieve the Triple Aim must develop population health management strategies, including preventive services, care models that detect and intercede when early signs of health deterioration are identified, and community-based programs that address determinants of mental health problems. Based on this definition, the term population health management should be used to describe the infrastructure devoted to delivering interventions.

Washington and colleagues²⁵ postulated that population health improvement is the “third curve” in the transformation of academic health systems, with the first curve being individual patient care and the second curve being population health management. They described population health management as using a capita ted budget to manage the health of a specific population that generally seeks care at a specific institution. They explained that the third curve of population health improvement extends further to reach patients who do not seek healthcare through traditional delivery models and includes greater emphasis on factors traditionally unrelated to healthcare, including education, employment, and the physical environment. The incentives for health systems to engage in these efforts include ensuring a healthy future workforce, having a deeper understanding of how health systems can influence broader health determinants, and facilitating compliance with growing regulations to focus on community needs. Steps that health systems can take to move toward population health improvement are provided, including making population health improvement part of the organization’s mission, forging new partnerships with other community sectors, creating healthy campuses, and leveraging other professional schools that may be affiliated with academic institutions.²⁵ 

There are numerous published examples of pharmacist-led population health management activities that span across diverse populations and care settings^26,–33; examples are provided in TABLE 2. Interventions may be provided to patients in the community setting through employer wellness programs or as extensions of primary care provider visits.^26,–30 Other examples align with Washington et al.’s²⁵ definition for the second curve of population health management, focusing on reducing preventable readmission’s for patients who were recently hospitalized.^31,–33 Some examples use pharmacists to promote healthy lifestyle behaviors and preventive wellness activities.^26,28 In other examples, pharmacists actively manage medication regimens through collaborative practice models.^27,29 Some models use a team-based approach that include pharmacists’ involvement.^28,31,32 Population health management as a domain under population health focuses on the identification of an at-risk population, the development of a strategy to improve specific health outcomes of the defined population, and the implementation of a pilot program to assess the feasibility and impact of the proposed strategy. NURS 8310 Assignments – Epidemiology and Population Health Papers

How to Move Population Health Management Forward and Improve Outcomes

With rare few exceptions, healthcare delivery systems have never had to deal with the socioeconomic and social determinants of health to the degree that public health systems have faced these issues. Healthcare delivery systems must add public health professionals and epidemiologists to their management and executive staff. They need to build the skills to interact with and develop health intervention strategies in concert with law enforcement; social support services in the community, including charitable and religious organizations; job growth and economic development in communities that ensures people can afford care when they need it; adequate affordable housing in the community; healthy options for eating in the community; adequate dental care; primary and secondary education programs that encourage healthy lifestyles; violent crime reduction; and environmental strategies to ensure that communities have clean air and water. These are the sorts of issues that public health professionals have been managing for years in the progressive reduction of infectious disease in communities. Now the U.S. needs to follow the lead of other countries and apply those public health skills to the new setting of chronic condition management in the community. NURS 8310 Assignments – Epidemiology and Population Health Papers

Three Important Data Sets Required for Population Health

While it’s true that healthcare is transitioning away from a traditional fee-for-service business model to a model that incorporates value into the payment equation (and thus encouraging efforts similar to public health strategies), it has a long way to go to equal its peers in the international community. Many health systems don’t have the data and technology to support this transition. The absolute minimal data sets required for this work include: 1) patient-reported outcomes data, 2) social determinants of health data, and 3) activity-based costing data that will allow accurate management of financial margins in per-capita reimbursement contracts. Without these three pieces of data, an organization can never achieve the aspirations of value-based care—managing populations of health and creating better patient outcomes for an efficient cost.

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What’s Missing in Most Population Health Solutions

EMRs currently on the market are designed for a fee-for-service world, running entirely on encounter-based medicine. This makes it difficult to manage the health of populations—and difficult to understand the cost of care. Fundamentally, in a population health environment, a health system is managing to margins on a per-member, per-month (PMPM) basis. And in this environment, everyone has to be aware of the cost of care, at the point of care; something not possible without major changes to the software of current EMRs.

Additionally, claims processing systems and revenue cycle software don’t address the issue because they are also encounter-based, adjudicating encounters on a line by line basis on procedures and tests (what’s allowed, what’s not allowed). These systems fail in a capitated PMPM environment because they don’t consider what care went into the encounter; that’s left up to the care providers. NURS 8310 Assignments – Epidemiology and Population Health Papers

Getting to Population Health Success

Population health assumes that healthcare organizations engage people beyond the shorter time frames often seen in today’s ACOs. Population health strategies will extend beyond the current episode-based framework of patient care. Part of this relationship building means that organizations will have to invest in people, then measure how well that investment is affecting the health of the person and the level of that person’s engagement in his/her own health.

Healthcare organizations starting population health will quickly discover that the highest-risk patients from a clinical perspective (for example, those in an obesity program) will not always return the most improved or best possible outcomes. In other words, the highest-risk patients are often those who are beyond the ability to intervene and actually change their outcomes. While new best practices that deliver better outcomes for these patients may (hopefully) be someday discovered, the reality is that—in a capita ted environment with limited resources—there are rising risk patients who will benefit more from those resources and higher levels of engagement.