Income inequality and mortality in 282 metropolitan areas of the United States. Mortality is correlated with both income and inequality.
Population health has been defined as "the health outcomes of a
group of individuals, including the distribution of such outcomes
within the group".
According to Akarowhe (2018), the working definition of population
health is expressed thus; population health is an art, process, science
and a product of enhancing the health condition of a specific number of
people within a given geographical area - population health as an art,
simply means that it is geared towards equal health care delivery to an
anticipated group of people in a particular geographical location; as a
science, it implies that it adopt scientific approach of preventive,
therapeutic, and diagnostic service in proffering medical treatment to
the health problem of people; as a product, it means that population
health is directed toward overall health performance of people through
health satisfaction within the said geographical area; and as a process
it entails effective and efficient running of a health
management/population health management system to cater for the health
needs of the people. It is an approach to health that aims to improve the health
of an entire human population. This concept does not refer to animal or
plant populations. It has been described as consisting of three
components. These are "health outcomes, patterns of health determinants,
and policies and interventions".
A priority considered important in achieving the aim of Population
Health is to reduce health inequities or disparities among different
population groups due to, among other factors, the social determinants of health,
SDOH. The SDOH include all the factors (social, environmental, cultural
and physical) that the different populations are born into, grow up and
function with throughout their lifetimes which potentially have a
measurable impact on the health of human populations. The Population Health concept represents a change in the focus from the individual-level, characteristic of most mainstream medicine. It also seeks to complement the classic efforts of public health
agencies by addressing a broader range of factors shown to impact the
health of different populations. The World Health Organization's
Commission on Social Determinants of Health, reported in 2008, that the
SDOH factors were responsible for the bulk of diseases and injuries and
these were the major causes of health inequities in all countries. In the US, SDOH were estimated to account for 70% of avoidable mortality.
From a population health perspective, health has been defined not
simply as a state free from disease but as "the capacity of people to
adapt to, respond to, or control life's challenges and changes". The World Health Organization (WHO) defined health in its broader sense in 1946 as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity."
Healthy People 2020
Healthy People 2020 is a web site sponsored by the US Department of Health and Human Services,
representing the cumulative effort of 34 years of interest by the
Surgeon General's office and others. It identifies 42 topics considered social determinants of health
and approximately 1200 specific goals considered to improve population
health. It provides links to the current research available for selected
topics and identifies and supports the need for community involvement
considered essential to address these problems realistically.
The human role of economic inequality
Recently, human role has been encouraged by the influence of population growth there has been increasing interest from epidemiologists on the subject of economic inequality and its relation to the health of populations. There is a very robust correlation between socioeconomic status and health. This correlation suggests that it is not only the poor who tend to be sick when everyone else is healthy, heart disease, ulcers, type 2 diabetes, rheumatoid arthritis, certain types of cancer, and premature aging. Despite the reality of the SES Gradient,
there is debate as to its cause. A number of researchers (A. Leigh, C.
Jencks, A. Clarkwest—see also Russell Sage working papers) see a
definite link between economic status and mortality due to the greater
economic resources of the better-off, but they find little correlation
due to social status differences.
Other researchers such as Richard G. Wilkinson,
J. Lynch, and G.A. Kaplan have found that socioeconomic status strongly
affects health even when controlling for economic resources and access
to health care. Most famous for linking social status with health are
the Whitehall studies—a series of studies conducted on civil servants in London.
The studies found that, despite the fact that all civil servants in
England have the same access to health care, there was a strong
correlation between social status and health. The studies found that
this relationship stayed strong even when controlling for
health-affecting habits such as exercise, smoking and drinking. Furthermore, it has been noted that no amount of medical attention will help decrease the likelihood of someone getting type 1 diabetes or rheumatoid arthritis—yet
both are more common among populations with lower socioeconomic status.
Lastly, it has been found that amongst the wealthiest quarter of
countries on earth (a set stretching from Luxembourg to Slovakia) there is no relation between a country's wealth and general population health—suggesting
that past a certain level, absolute levels of wealth have little impact
on population health, but relative levels within a country do.
The concept of psychosocial stress attempts to explain how psychosocial phenomenon such as status and social stratification can lead to the many diseases associated with the SES gradient.
Higher levels of economic inequality tend to intensify social
hierarchies and generally degrades the quality of social
relations—leading to greater levels of stress
and stress related diseases. Richard Wilkinson found this to be true
not only for the poorest members of society, but also for the
wealthiest. Economic inequality is bad for everyone's health.
Inequality does not only affect the health of human populations. David
H. Abbott at the Wisconsin National Primate Research Center found that
among many primate species, less egalitarian social structures
correlated with higher levels of stress hormones among socially
subordinate individuals. Research by Robert Sapolsky of Stanford University provides similar findings.
Research
There
is well-documented variation in health outcomes and health care
utilization & costs by geographic variation in the U.S., down to the
level of Hospital Referral Regions (defined as a regional health care
market, which may cross state boundaries, of which there are 306 in the
U.S.).
There is ongoing debate as to the relative contributions of race,
gender, poverty, education level and place to these variations. The
Office of Epidemiology of the Maternal and Child Health Bureau
recommends using an analytic approach (Fixed Effects or hybrid Fixed
Effects) to research on health disparities to reduce the confounding
effects of neighborhood (geographic) variables on the outcomes.
The importance of family planning programs
Family planning programs (including contraceptives, sexuality education, and promotion of safe sex) play a major role in population health. Family planning is one of the most highly cost-effective interventions in medicine. Family planning saves lives and money by reducing unintended pregnancy and the transmission of sexually transmitted infections.
For example, the United States Agency for International Development lists as benefits of its international family planning program:
- "Protecting the health of women by reducing high-risk pregnancies"
- "Protecting the health of children by allowing sufficient time between pregnancies"
- "Fighting HIV/AIDS through providing information, counseling, and access to male and female condoms"
- "Reducing abortions"
- "Supporting women's rights and opportunities for education, employment, and full participation in society"
- "Protecting the environment by stabilizing population growth"
Population health management (PHM)
One
method to improve population health is population health management
(PHM), which has been defined as "the technical field of endeavor which
utilizes a variety of individual, organizational and cultural
interventions to help improve the morbidity patterns (i.e., the illness and injury burden) and the health care use behavior of defined populations". PHM is distinguished from disease management by including more chronic conditions and diseases, by use of "a single point of contact and coordination", and by "predictive modeling across multiple clinical conditions".
PHM is considered broader than disease management in that it also
includes "intensive care management for individuals at the highest level
of risk" and "personal health management... for those at lower levels
of predicted health risk". Many PHM-related articles are published in Population Health Management, the official journal of DMAA: The Care Continuum Alliance.
The following road map has been suggested for helping healthcare
organizations navigate the path toward implementing effective population
health management:
- Establish precise patient registries
- Determine patient-provider attribution
- Define precise numerators in the patient registries
- Monitor and measure clinical and cost metrics
- Adhere to basic clinical practice guidelines
- Engage in risk-management outreach
- Acquire external data
- Communicate with patients
- Educate patients and engage with them
- Establish and adhere to complex clinical practice guidelines
- Coordinate effectively between care team and patient
- Track specific outcomes
Healthcare reform and population health
Healthcare reform is driving change to traditional hospital reimbursement models. Prior to the introduction of the Patient Protection and Affordable Care Act (PPACA), hospitals were reimbursed based on the volume of procedures through fee-for-service models. Under the PPACA, reimbursement models are shifting from volume to value. New reimbursement models are built around pay for performance,
a value-based reimbursement approach, which places financial incentives
around patient outcomes and has drastically changed the way US
hospitals must conduct business to remain financially viable.
In addition to focusing on improving patient experience of care and
reducing costs, hospitals must also focus on improving the health of
populations (IHI Triple Aim).
As participation in value-based reimbursement models such as accountable care organizations (ACOs) increases, these initiatives will help drive population health.
Within the ACO model, hospitals have to meet specific quality
benchmarks, focus on prevention, and carefully manage patients with
chronic diseases. Providers get paid more for keeping their patients healthy and out of the hospital.
Studies have shown that inpatient admission rates have dropped over the
past ten years in communities that were early adopters of the ACO model
and implemented population health measures to treat "less sick"
patients in the outpatient setting.
A study conducted in the Chicago area showed a decline in inpatient
utilization rates across all age groups, which was an average of a 5%
overall drop in inpatient admissions.
Hospitals are finding it financially advantageous to focus on
population health management and keeping people in the community well.
The goal of population health management is to improve patient outcomes
and increase health capital. Other goals include preventing disease,
closing care gaps, and cost savings for providers.
In the last few years, more effort has been directed towards developing
telehealth services, community-based clinics in areas with high
proportion of residents using the emergency department as primary care,
and patient care coordinator roles to coordinate healthcare services
across the care continuum.
Health can be considered a capital good; health capital is part of human capital as defined by the Grossman model. Health can be considered both an investment good and consumption good.
Factors such as obesity and smoking have negative effects on health
capital, while education, wage rate, and age may also impact health
capital.
When people are healthier through preventative care, they have the
potential to live a longer and healthier life, work more and participate
in the economy, and produce more based on the work done. These factors
all have the potential to increase earnings. Some states, like New York,
have implemented statewide initiatives to address population health. In
New York state there are 11 such programs. One example is the Mohawk
Valley Population Health Improvement Program (http://www.mvphip.org/).
These programs work to address the needs of the people in their region,
as well as assist their local community based organizations and social
services to gather data, address health disparities, and explore
evidence-based interventions that will ultimately lead to better health
for everyone. Following a similar approach, Cullati et al. developed a
theoretical framework for the development and onset of vulnerability in
later life based on the concept of "reserves".
The advantages to use the concept of reserves in interdisciplinary
studies, as compared with related concepts such as resources and
capital, is to strengthen the importance of constitution and
sustainability of reserves (the “use it or lose it” paradigm) and the
presence of thresholds, below which functioning becomes challenging.
Statistics
In the United States, the National Center for Health Statistics is responsible for the collection of data on the health of citizens.
