OOIR: Observatory of International Research

Papers

(The TQCC of Population Health Management is 4. The table below lists those papers that are above that threshold based on CrossRef citation counts [max. 250 papers]. The publications cover those that have been published in the past four years, i.e., from 2021-11-01 to 2025-11-01.)

Article	Citations
Examining the Association of Social Needs with Future Health Care Utilization in an Older Adult Population: Which Needs Are Most Important?	63
A Population Health Proposal for Increasing Breast Cancer Screening to Reduce Racial Disparities in Breast Cancer: Getting the Village Back Together	56
COVID-19 Vaccination, Morbidity, and Mortality During a 12-Month Period in Israel: Can We Maintain a “Herd Immunity” State?	43
Improve Patient-Centered Care, Decrease Provider Burnout, Maximize Z Codes, Minimize Hierarchical Condition Category Codes	36
More Patient Data? Be Careful What You Wish for…AI’s Role in Making Clinical Data Exchange Useful	34
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	24
One Year Out: The Five Ds of COVID-19	24
Health Equity Is Key to Better Population Health	23
A Scoping Review of Behavioral Interventions Addressing Medical Financial Hardship	22
Optimizing Hierarchical Condition Category-Risk Adjustment Factor Management in Population Health Using Rapid Process Improvement Methods	21
A Tale of 4 Babies: Health Equity at the Center of the Quadruple Aim	19
Social Needs Screening in Academic Health Systems: A Landscape Assessment	18
Letter to the Editor: Pivoting Care Coordination Efforts Based on Risk and Return	18
Perceived Stigma in Health Care Settings Mediates the Relationships Between Depression, Diabetes, and Hypertension	16
COVID-19 Deaths and the Impact of Health Disparities, Hospital Characteristics, Community, Social Distancing, and Health System Competition	16
Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates	16
The Impact of the Affordable Care Act on Disparities in Utilization of Cardiovascular Preventive Services by Socioeconomic Status	15
Medicaid Acceptance Varies by Physician Seniority and Specialty in California	15
What Are the Roles of Community Health Workers in Medicaid Managed Care? Results from a National Study	14
Prior Authorization: Process Redesign with a Focus on Value-Based Care	14
Ambulatory Care Utilization Among Medicare Beneficiaries with Depression	13
The Impact of Personal and Historical Factors That Contribute to Medicare Readmissions	12
Successful Implementation of an All-or-None Diabetes Measure in 10 US Health Systems	12
Impact of COVID-19 on Behavioral Health Services Use Among Medicaid Enrollees with Chronic Behavioral Needs by Race and Ethnicity	12
COVID-19 Vaccine Equity: Codesigning Public Health Interventions with Community Partners	11

Operation Allies Welcome Medical Response Unit at Philadelphia International Airport: A Framework for Medical Triage of High Volume of Displaced Persons Arriving by Air	11
A Conceptual Framework for Building Individual and Team Capabilities to Provide Effective Longitudinal, Relationship-Based Clinical Case Management	11
Factors Influencing Learners’ Knowledge and Implementation of Value-Based Care Concepts Postcourse Certification	11
Cost-Effectiveness of Outreach Strategies for Stool-Based Colorectal Cancer Screening in a Medicaid Population	11
Use of a Blood Biomarker Test Improves Economic Utility in the Evaluation of Older Patients Presenting with Cognitive Impairment	11
Innovations in Population Health: Improving Outcomes for Patients with Chronic Kidney Disease	10
Transitional Care for Older Adults: Demonstration of the Role of a Partnership Payvider	10
Bridging the Digital Divide: A Practical Roadmap for Deploying Medical Artificial Intelligence Technologies in Low-Resource Settings	10
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	9
Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates	9
Reimagining Diabetes Quality Measurement to Advance Quality Care	9
Using Quality Measures to Drive Improvements in Immunization Rates: Findings from a Real-World Evaluation from 3 US Health Care Organizations	9
A Review of the MINDSPACE Framework for Nudging Health Promotion During Early Stages of the COVID-19 Pandemic	8
Interventions to Increase Affordable Care Act Marketplace Enrollment: A Systematic Review and Meta-Analysis	8
The Cost of Unhealthy Days: A New Value Assessment	8
Individual- and Community-Level Predictors of Hospital-at-Home Outcomes	8
Limitations to Health Care Quality Measurement: Assessing Hospital Variation in Risk of Cardiac Events After Noncardiac Surgery	8
Increasing Statin-Prescribing and Low-Density Lipoprotein Cholesterol Control in Secondary Atherosclerotic Cardiovascular Disease Prevention: A Collaborative Approach	8
What Is Old Needs to Be New Again	8
Engaging Stakeholder Advisors Around Health-Related Social Needs Research, Policy, and Practice Priorities	8
Evaluating the Financial Sustainability of the School-Based Telemedicine Asthma Management Program	8
Reducing Health Disparities in Underserved Populations: A Spotlight on Health Inequities	8
Leveraging Technology for Value-Based Kidney Care	8
Health Resources and Services Administration-Funded Health Centers Reduce Health Care Expenditures of California Medicaid Managed Care Beneficiaries with Complex Needs	8
What Is a Center of Excellence?	7
Health Insurance Status of Adults with Hepatitis in the United States: Implications of Results from the National Health Interview Survey, 2013–2018	7
Transitioning from In-Person to Telemedicine Within Primary Care Behavioral Health During COVID-19	7
Health Inequality Among Older Adults with Percutaneous Coronary Intervention and Universal Health Coverage in Japan	7
The Future of Population Health	6
Value-Based Pay-for-Performance Gaps in the Care Delivery Framework for a Large-Scale Health System	6
Medicaid Cost Savings from Provision of Contraception to Beneficiaries in South Carolina, 2012–2018	6
Cost Reduction and Utilization Patterns in a Medicare Accountable Care Organization Using Home-Based Palliative Care Services	6
The Role of Social Determinants of Health in Gastroenterology Care	6
Correction to: Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities, by Laura B. Beidler, et al. Popul Health Manag 2023; (vol. 26, no. 5; 283-	6
Assessing the Added Value of Blood Pressure Information Derived from Electronic Health Records in Predicting Health Care Cost and Utilization	6
Major Economic Losses Associated with Inadequate Control of High Blood Pressure: Time for a Major Change	5
The Future of Chronic Disease Management	5
An Increase in the Use of ICD-10 Z-Codes for Social Risks and Social Needs: 2015 to 2019	5
Addressing Social Determinants of Health in Family Medicine Practices	5
Implementation of E-Consults in an Integrated Health System for a Value Population	5
Evidence and Implications of the Affordable Care Act for Racial/Ethnic Disparities in Diabetes Health During and Beyond the Pandemic	5
Mistrust, Neighborhood Deprivation, and Telehealth Use in African Americans with Diabetes	5
The Academic Payvider Model: Commentary	5
Multisector Partnerships and Service Colocation to Increase Adoption of Influenza Vaccines and Address Food Insecurity	5
Challenge of Managing Chronic Kidney Disease: Patient and Caregiver Perspectives	5
Neighborhood-level Social Determinants of Health Improve Prediction of Preventable Hospitalization and Emergency Department Visits Beyond Claims History	5
Patient Post-discharge Transitions and Inpatient Readmissions Impose Costly Burdens for Employers and Carriers	5
For Profit, but Socially Determined: The Rise of the SDOH Industry	4
A Path to Risk: Critical Elements of a Structured Approach	4
The Minority and Rural Coronavirus Insights Study: Design and Baseline Characteristics of a Minority Cohort	4

Systematic Review of Care Coordination Interventions Linking Health and Social Services for High-Utilizing Patient Populations	4
Impact of Health Literacy on Medication Adherence Among Black Medicaid Beneficiaries with Hypertension in Delaware: A Cross-Sectional Study	4
Honoring the Past While Shaping the Future: Reflections From the Incoming Editor-in-Chief	4
Home-Based Primary Care: A Solution for Our Frail Elderly Patients	4
Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization	4
Social Determinants of Health and Comorbidities Among Individuals with Atherosclerotic Cardiovascular Disease: The Behavioral Risk Factor Surveillance System Survey	4
Developing a Strategy to Increase Lung Cancer Screening in Areas of Need	4
Estimating Cost Savings of Care Coordination for Older Adults: Evidence from the Iowa Return to Community Program	4
Assessing the Relationship Between Behavioral Health Integration and Alcohol-Related Treatment Among Patients with Medicaid	4
Hospital Safety-Net Burden is Associated with Perioperative Outcomes in Primary Total Hip Arthroplasty: A Multistate Retrospective Analysis, 2015–2020	4
The Impact of Expanding Telehealth-Delivered Dietary Interventions on Long-Term Cardiometabolic Health	4