Population Health Management

Article	Citations
Association Between Social Vulnerability and Postoperative Complications and Readmission Among Cardiovascular Surgery Patients	69
A Theoretically Grounded Chronic Illness Model Integrating Medical- and Community-Based Social Service Providers	69
COVID-19 Vaccination, Morbidity, and Mortality During a 12-Month Period in Israel: Can We Maintain a “Herd Immunity” State?	48
Health Equity Is Key to Better Population Health	31
A Population Health Proposal for Increasing Breast Cancer Screening to Reduce Racial Disparities in Breast Cancer: Getting the Village Back Together	21
Examining the Association of Social Needs with Future Health Care Utilization in an Older Adult Population: Which Needs Are Most Important?	20
More Patient Data? Be Careful What You Wish for…AI’s Role in Making Clinical Data Exchange Useful	19
Implementation of Medications for Alcohol and Opioid Use Disorders in a Value-Based Organization-Unlocking Value by Addressing Unmet Needs for Medicaid and Dually-Eligible Beneficiaries	19
Social Needs Screening in Academic Health Systems: A Landscape Assessment	18
Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates	18
Optimizing Hierarchical Condition Category-Risk Adjustment Factor Management in Population Health Using Rapid Process Improvement Methods	16
Patient Engagement with General Bulk Outreach: Impact of Primary Care Provider vs. Care Team Signature in General Bulk Patient Outreach	15
Chronic Care Management and Mortality Among Diabetic Patients with Multiple Chronic Conditions	15
The Impact of the Affordable Care Act on Disparities in Utilization of Cardiovascular Preventive Services by Socioeconomic Status	14
COVID-19 Deaths and the Impact of Health Disparities, Hospital Characteristics, Community, Social Distancing, and Health System Competition	14
Medicaid Acceptance Varies by Physician Seniority and Specialty in California	13
Prior Authorization: Process Redesign with a Focus on Value-Based Care	13
Operation Allies Welcome Medical Response Unit at Philadelphia International Airport: A Framework for Medical Triage of High Volume of Displaced Persons Arriving by Air	12
Transitional Care for Older Adults: Demonstration of the Role of a Partnership Payvider	12
Factors Influencing Learners’ Knowledge and Implementation of Value-Based Care Concepts Postcourse Certification	12
Ambulatory Care Utilization Among Medicare Beneficiaries with Depression	12
COVID-19 Vaccine Equity: Codesigning Public Health Interventions with Community Partners	11
The Impact of Personal and Historical Factors That Contribute to Medicare Readmissions	11
Successful Implementation of an All-or-None Diabetes Measure in 10 US Health Systems	11
Bridging the Digital Divide: A Practical Roadmap for Deploying Medical Artificial Intelligence Technologies in Low-Resource Settings	11

Cost-Effectiveness of Outreach Strategies for Stool-Based Colorectal Cancer Screening in a Medicaid Population	11
Impact of COVID-19 on Behavioral Health Services Use Among Medicaid Enrollees with Chronic Behavioral Needs by Race and Ethnicity	10
A Conceptual Framework for Building Individual and Team Capabilities to Provide Effective Longitudinal, Relationship-Based Clinical Case Management	10
What Are the Roles of Community Health Workers in Medicaid Managed Care? Results from a National Study	10
Innovations in Population Health: Improving Outcomes for Patients with Chronic Kidney Disease	10
Use of a Blood Biomarker Test Improves Economic Utility in the Evaluation of Older Patients Presenting with Cognitive Impairment	9
Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates	9
Screening for Social Needs in Health Care Systems: A Quality Improvement Framework and Two Case Studies	9
Using Quality Measures to Drive Improvements in Immunization Rates: Findings from a Real-World Evaluation from 3 US Health Care Organizations	9
Body Mass Index and All-Cause and Cardiovascular Mortality in United States Adults With and Without Atherosclerotic Cardiovascular Disease: Findings from the National Health Interview Survey	8
Implementation and Outcomes from a Post-Discharge Intervention Program in a Medicare ACO Population	8
Reimagining Diabetes Quality Measurement to Advance Quality Care	8
Leveraging Technology for Value-Based Kidney Care	7
Increasing Statin-Prescribing and Low-Density Lipoprotein Cholesterol Control in Secondary Atherosclerotic Cardiovascular Disease Prevention: A Collaborative Approach	7
What Is Old Needs to Be New Again	7
The Cost of Unhealthy Days: A New Value Assessment	7
Engaging Stakeholder Advisors Around Health-Related Social Needs Research, Policy, and Practice Priorities	7
Individual- and Community-Level Predictors of Hospital-at-Home Outcomes	7
Correction to : Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities, by Laura B. Beidler, et al. Popul Hea	6
What Is a Center of Excellence?	6
Limitations to Health Care Quality Measurement: Assessing Hospital Variation in Risk of Cardiac Events After Noncardiac Surgery	6
The Future of Population Health	6
The Role of Social Determinants of Health in Gastroenterology Care	6
Cost-Effectiveness of Screening and Early Diagnosis Strategies for Cancer in the General Adult Population in Low- and Middle-Income Countries: A Systematic Review	6
Medicaid Cost Savings from Provision of Contraception to Beneficiaries in South Carolina, 2012–2018	6
Interventions to Increase Affordable Care Act Marketplace Enrollment: A Systematic Review and Meta-Analysis	6
A Review of the MINDSPACE Framework for Nudging Health Promotion During Early Stages of the COVID-19 Pandemic	6
Cost Reduction and Utilization Patterns in a Medicare Accountable Care Organization Using Home-Based Palliative Care Services	5
Multisector Partnerships and Service Colocation to Increase Adoption of Influenza Vaccines and Address Food Insecurity	5
Mental Health Service Use and Equity in a Comprehensive Employer-Sponsored Benefit Program: A Retrospective Cohort Study	5
Assessing the Added Value of Blood Pressure Information Derived from Electronic Health Records in Predicting Health Care Cost and Utilization	5
Honoring the Past While Shaping the Future: Reflections From the Incoming Editor-in-Chief	5
Addressing Social Determinants of Health in Family Medicine Practices	5
Health Resources and Services Administration-Funded Health Centers Reduce Health Care Expenditures of California Medicaid Managed Care Beneficiaries with Complex Needs	5
Transitioning from In-Person to Telemedicine Within Primary Care Behavioral Health During COVID-19	5
The Academic Payvider Model: Commentary	5
An Increase in the Use of ICD-10 Z-Codes for Social Risks and Social Needs: 2015 to 2019	5
Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization	4
Assessing the Relationship Between Behavioral Health Integration and Alcohol-Related Treatment Among Patients with Medicaid	4
Implementation of E-Consults in an Integrated Health System for a Value Population	4
The Minority and Rural Coronavirus Insights Study: Design and Baseline Characteristics of a Minority Cohort	4
The Impact of Social Vulnerability and Race on Colorectal Cancer Screening	4
A Path to Risk: Critical Elements of a Structured Approach	4
Challenge of Managing Chronic Kidney Disease: Patient and Caregiver Perspectives	4
Major Economic Losses Associated with Inadequate Control of High Blood Pressure: Time for a Major Change	4
Acknowledgment of Reviewers 2025	4
Hospital Safety-Net Burden is Associated with Perioperative Outcomes in Primary Total Hip Arthroplasty: A Multistate Retrospective Analysis, 2015–2020	4
The Future of Chronic Disease Management	4
For Profit, but Socially Determined: The Rise of the SDOH Industry	4
Tackling Ethnic Health Disparities Through Community Health Worker Programs: A Scoping Review on Their Utilization During the COVID-19 Outbreak	3

Impact of Health Literacy on Medication Adherence Among Black Medicaid Beneficiaries with Hypertension in Delaware: A Cross-Sectional Study	3
Letter to the Editor: Public Health Reform Efforts Should More Effectively Engage Public Health Professionals and the General Public	3
Estimating Cost Savings of Care Coordination for Older Adults: Evidence from the Iowa Return to Community Program	3
It Is Time to Supersize Our Population Health Improvement Goals	3
Health Care Bricolage: A Method to Reduce High-Cost Medical Spend	3
Social Determinants of Hepatitis C Virus Infection in the United States, 2016–2021	3
The Impact of Public Health Funding on Population Health Outcomes	3
Participants in Medicare’s New Mandatory Bundled Payment Program	3
Rethinking Blood Pressure Quality Measurement: Accounting for Seasonal Variation in Value-Based Care	3
Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities	3
Future Trends to Watch for Value-Based Care	3
Reimagining Our Public Health Systems: The Robert Wood Johnson Foundation's National Commission to Transform Public Health Data Systems	3
The Impact of Expanding Telehealth-Delivered Dietary Interventions on Long-Term Cardiometabolic Health	3
Hospital-at-Home: The Good, the Bad, and the Ugly	3
Developing a Strategy to Increase Lung Cancer Screening in Areas of Need	3
The Unfortunate State of Population Health: Its Omnipresent Promise and Industry's Continued Failure of Vision and Commitment	3
The Unrecognized Impact of Anxiety in Complex and Costly Patients	3
Racial Disparities in Cardiovascular Health Among the Acute Coronary Syndrome Population	3
The Clinical and Economic Burdens of Obesity and the Value of Weight Loss for an EMR-Derived US Cohort: A Modeling Study	3
Data-Driven Leadership: Clinical Registries Drive Higher Value Health Care	2
Opportunities and Challenges in Screening for Colorectal Cancer	2
Composite Indices of Social Determinants of Health: Overview, Measurement Gaps, and Research Priorities for Health Equity	2
Feasibility of an Adaptive Food Insecurity Intervention for Patients with Uncontrolled Hypertension: A Pilot SMART	2
Electronic Health Data Quality and Population Health Management Algorithms	2
The Academic Payvider Model: Care and Coverage	2
Long Way to Go: Attitudes, Knowledge, and Perception of Artificial Intelligence in Health Care, Among a Racially Diverse, Lower Income Population in Houston, New York, and Los Angeles	2
Avoidance of Total Knee Replacement in a Population Health Setting: Introducing a Noninvasive Biomechanical Intervention for Patients with Knee Osteoarthritis	2
Factors Associated with Health Care Costs in Older Adults with Type 2 Diabetes: Insights for Value-Based Payment Models	2
AI and Falls Detection: Great Promise but Gaps in Evidence	2
Interprofessional Intervention to Reduce Emergency Department Visits in Black Individuals with Diabetes	2
A Longitudinal, Relationship-Based Model for Managing Complex Chronic Disease in the Medicaid Population	2
Racial and Ethnic Disparity in Preference-Weighted Quality of Life: Findings from the Selenium and Vitamin E Cancer Prevention Trial	2
Cervical Cancer and Sexually Transmitted Infections Screening Among Individuals with a Substance Use Disorder: A Retrospective Cohort Study	2
Molecular Testing for Women’s Gynecologic Health: Real-World Impact on Health Care Costs	2
Did the Affordable Care Act Promote Racial Equity in Pregnancy-Related Health? A Scoping Review	2
Comparing Clinician Impression of Cognition with Standardized Screening in Medicare Annual Wellness Visits	2
The Key to Success Tomorrow Is Leadership Transformation Today	2
Community Coalitions' Perspectives on Engaging with Hospitals in Ohio to Address the Opioid Crisis	2
Measuring Stakeholder Engagement in Statewide Primary Care Cardiovascular Health Improvement Cooperatives	2
Assessing Barriers and Facilitators to Lung Cancer Screening: Initial Findings from a Patient Navigation Intervention	2
Toward a Continuum of Measures to Mitigate Primary and Secondary Impacts of COVID-19 and Other Public Health Emergencies	2
Postpartum Medicaid Eligibility Expansions and Postpartum Health Measures	2
Single and Dual Sensory Loss and Cardiovascular Disease in US adults: Findings from the 2021 Behavioral Risk Factor Surveillance System	2
Homelessness Among Acute Care Patients Within a Large Health Care System in Northern California	2
Validating and Improving Adjusted Clinical Group's Future Hospitalization and High-Cost Prediction Models for Dutch Primary Care	2
A Call to Action to Increase Uptake of Follow-Up Colonoscopy After Initial Positive Stool-Based Colorectal Cancer Screening	2
Health Care Professionals' Perspectives on Universal Screening of Social Determinants of Health: A Mixed-Methods Study	2
Social Determinants of Health and After-Hours Electronic Health Record Documentation: A National Survey of US Physicians	2
Enhancing Machine Learning Explainability of Disaster Preparedness Models from the FEMA National Household Survey to Inform Tailored Population Health Interventions	2
A Call for Consistent Measurement Across the Social Determinants of Health Industry Landscape	1
A Multi-Intervention Approach to Blood Pressure Control: A Description of How a Large University Based Primary Care Clinic Tackled Hypertension	1
Changes in Health Care Utilization During the First 2 Years of Massachusetts Medicaid Accountable Care Organizations	1
Continuity of Care, Immigrant Status, and Emergency Department Use Among Seniors in Canada	1
Association Between Relative Fat Mass and New-Onset Arthritis Among Middle-Aged and Older Chinese Females	1
Do Refill Gaps Indicate Nonadherence? A Perspective on the Medication Adherence Metric for Quality Rating of Medicare Advantage Plans	1
Accountable Care Organizations and Health Disparities of Rural Latinos: A Longitudinal Analysis	1
Redesigning Diabetes Care for Treatment Inertia: A Population Health Model	1
The Coming Health Care Transformation: Empowered Patients and Better Value	1
Impact and Continued Relevance of Medication Adherence Measurement	1
Demographic and Clinical Correlates of the Cost of Potentially Preventable Hospital Encounters in a Community Health Center Cohort	1
Adopting Health Technologies in Israel and England	1
Disparities in Recombinant Zoster Vaccine Coverage in the United States	1
Strengthening the Public Health Partnership and Telehealth Infrastructure to Reduce Health Care Disparities	1
Postpartum Medicaid Coverage Expansion and Changes in the Risk of Health Insurance Loss Within the Second Year After Birth	1
Hospital Outcomes for Patients with Psychiatric Comorbidities: A Comparison of an Integrated Medical-Psychiatry Unit and Traditional Medical Units	1
Comparing “Meaningful Use” of Health Information Technology in Pennsylvania: Electronic Prescription Rates of Metropolitan and Rural Counties	1
Health Systems Need to Transform Data Collection to Advance Health Equity	1
A Call for an American Social Care System: Social Services Reimbursement to Address Fragmented Care	1
Rural, Underserved, and Minority Populations' Perceptions of COVID-19 Information, Testing, and Vaccination: Report from a Southern State	1
Evolution of Population Health Within US Schools of Medicine and Academic Medical Centers	1
Lessons Learned from the Camden Coalition's Work with High Needs, High Complexity Patients	1
Z Codes for Social Determinants of Health: A Better Predictor of Risk for Value-Based Care	1
Profiling Social Needs Activities in Publicly Traded Medicare Advantage Organizations	1
Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups	1
Evaluating a Care Management Program for Dual-Eligible Beneficiaries: Evidence from Rhode Island	1
Building for Value: A Foundational Structure to Support Population Health	1
Gun Violence Prevention Policies Are Not Political: They Are Just Part of Good Public Health	1
Application of Narrative Nursing Combined with Psychological Resilience Training in Patients and Their Families in Hospice Care	1
Future Role of the Clinical Lab in Population Health	1
Progression to the Mean: Reconciling Traditional and Modern Professional Values in Medicine	1

A Comparison of Emergency Room Visits and Hospital Admissions Between People with Prediabetes and Diabetes	1
Collateral Damage from the COVID-19 Pandemic: Pediatric Obesity	1
Chart Review Is Dead; Long Live Chart Review: How Artificial Intelligence Will Make Human Review of Medical Records Obsolete, One Day	1
From Patient Goals to Team Action: A Qualitative Analysis of Student Capstone Projects from a Complex Care Curriculum	1
Chronic Kidney Disease, Diabetes, and Population Health: From Primary Care to Transplant	1
Global Challenges with Oral Antivirals for COVID-19	1
Evaluation of an Interdisciplinary Hypertension Management Program at a Large Primary Care Practice	1
Impact of Social Needs in Electronic Health Records and Claims on Health Care Utilization and Costs Risk-Adjustment Models Within Medicaid Population	1
Predictors of Interest in Offered Social Care Assistance Among People with Uncontrolled Diabetes	1
Development of Digital Algorithms for the Early Identification of Rare Clinical Outcomes Using Electronic Medical Records: A Case Study of Hidradenitis Suppurativa	1
Accelerating Success in Value-Based Care and Population Health: Learnings from a High-Performing Physician Organization	1
Characteristics of Nonelderly Adult Health Care Persistent Super Utilizers in Utah	1
Put All Your Health Investments Under the Same Lens	1
Pediatric Population Management Classification for Children with Medical Complexity	1
Trends in Mental Health Utilization Before and During the COVID-19 Pandemic: Federally Qualified Health Centers As a Case Study	1
Impact of Income Disparity on Utilization of Home-Based Care Services Among Older Adults in Japan: A Retrospective Cohort Study	1
Employer Strategies for Health Care Price Transparency	1
Reflections on the Connection Between Health Care Quality and Population Health	1
The Impact of Continuous Use of Home Health Care Resources on End-of-Life Care at Home in Older Patients with Cancer: A Retrospective Cohort Study in Fukuoka, Japan	1
Population Health: Staying Focused through the Pandemic and Beyond	1
Evaluation of the Electronic Health Record-Support Social Support Score in Breast Cancer: Comparison of Count and Item Response Theory Scores	1
Perspectives on Obesity Management and the Use of Anti-Obesity Medicine from US Employees and Employers: Results from the OBSERVE Study	1
To Win We Must Change the Game: A Formula for Health Care Transformation	1
Review of “Lifelines: A Doctor's Journey in the Fight for Public Health”: A Doctor's Account of Public Health's Invisible and Indispensable Effects	1
Factors Associated with Chronic Disease and Health Care Utilization Among Young Adults in South Korea	1