1. Population Health Management
The Population Health Sciences Perspective
How it helps us address health needs
Roger T. Anderson, Ph.D.
Professor of Public Health Sciences
Chief, Division of Health Services and Behavioral Research
Associate Director for Population Sciences,
Penn State Hershey Cancer Institute
Director, Penn State MPH Program
Penn State College of Medicine, Hershey PA

2. Population Health Management
 Improving the systems and policies that affect
health care quality, access, and outcomes,
ultimately improving the health of an entire
population.

3. Individual-focused Patient Care Policies
 HbA1C < 7
 BP < 130/80
 LDL cholesterol < 100
 Aspirin, ACE, statin use

4. 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

5. Population-focused policies
what 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

6. Population-focused policies
what 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 around
Tx
Some Hassle
Major Hassle

7. 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.
DrugClass
Oral contraceptives
Calcium-channel blockers
Angiotensin-receptor blockers
Statins
ACE inhibitors
Adjuvant endocrine therapy for breast cancer
Adjuvant endocrine therapy - 48 month data

8. Burden of
Treatment
Theme 1
Work
patients
must do to
care for
their
health
Theme 3
Challenges
/ stressors
that
exacerbate
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
D
e
m
a
n
d
s
E
n
a
b
l
e
r
s
Theme 4
Impacts of
burden

9. Population-focused policies
what do they add?
 Goal: Coordinate care and provide meaningful
integration

10. Population-focused policies
what do they add?
 Goal: Monitor and address health disparities
69.0
94.8
53.3
7.0
35.1
17.9
64.6
88.9
41.9
14.5
40.2
24.1
0 10 20 30 40 50 60 70 80 90 100
Received Dr. Instructions
Full Insurance
Married
Cost Problems
Activity Limitation
Equipment Needed
White Non-white

11. “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

12. Broad view – Geographic
Patterns

13. Breast cancer in Appalachia

14. Population Health Management
An Application
Tracking patient outcomes from risk factor
identification through receipt of care

15. 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 Medicine
2 Wake Forest University, Department of Neurology
3North Carolina Stroke Association, Winston-Salem, NC. USA

16. Geography
Smoothed Age-Adjusted Stroke Mortality Rates
by US County
WM 1996

17. Importance
2001-2005 Stroke Risk Screening Regions
2000-2006 NCSA Stroke Screening Regions

18. Health care supply

19. NCSA + Community Hospital Partners
2001-2005 Stroke Risk Screening Regions
2000-2006 NCSA Stroke Screening Regions

20. 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.

21. 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

22. 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

23. 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)

24. NCSA Central
Site
 Protocol/Manual
 Survey
 Training
 Funding Sources
 Database/Reports
Local Employer
Local Health
Center
Local Facility
Regional
Sites
Stroke Risk Screening Program

25. 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

26. 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 Bruits 137 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 communities
Screened 8,579 Persons

27. 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%
5
6
70
10
0.82%
0.12%
8579 100%

28. 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

29. 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

30. 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.

31. 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.

32. 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.

33. Follow-up at 3 months
Attention Control Motivational
Intervention
p-value
MD visit after screening date (recorded
at 3 months) %52.9 70.1 0.0156
% Concern over risk factors
59.0 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

34. % 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
%PrescribedMedications
Visit to Dr. after screening No Visit
95% Confidence Intervals shown

35. 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

36. Overall Summary

37. 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

38. 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

40. Thank you