OOIR: Observatory of International Research

Papers

(The TQCC of Population Health Management is 3. 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 2022-05-01 to 2026-05-01.)

Article	Citations
A Theoretically Grounded Chronic Illness Model Integrating Medical- and Community-Based Social Service Providers	69
Examining the Association of Social Needs with Future Health Care Utilization in an Older Adult Population: Which Needs Are Most Important?	68
Association Between Social Vulnerability and Postoperative Complications and Readmission Among Cardiovascular Surgery Patients	48
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	30
Health Equity Is Key to Better Population Health	21
More Patient Data? Be Careful What You Wish for…AI’s Role in Making Clinical Data Exchange Useful	19
A Population Health Proposal for Increasing Breast Cancer Screening to Reduce Racial Disparities in Breast Cancer: Getting the Village Back Together	19
Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates	18
COVID-19 Vaccination, Morbidity, and Mortality During a 12-Month Period in Israel: Can We Maintain a “Herd Immunity” State?	18
Chronic Care Management and Mortality Among Diabetic Patients with Multiple Chronic Conditions	15
Social Needs Screening in Academic Health Systems: A Landscape Assessment	15
Optimizing Hierarchical Condition Category-Risk Adjustment Factor Management in Population Health Using Rapid Process Improvement Methods	15
The Impact of the Affordable Care Act on Disparities in Utilization of Cardiovascular Preventive Services by Socioeconomic Status	14
Medicaid Acceptance Varies by Physician Seniority and Specialty in California	14
Patient Engagement with General Bulk Outreach: Impact of Primary Care Provider vs. Care Team Signature in General Bulk Patient Outreach	14
COVID-19 Deaths and the Impact of Health Disparities, Hospital Characteristics, Community, Social Distancing, and Health System Competition	13
Prior Authorization: Process Redesign with a Focus on Value-Based Care	13
Transitional Care for Older Adults: Demonstration of the Role of a Partnership Payvider	12
Impact of COVID-19 on Behavioral Health Services Use Among Medicaid Enrollees with Chronic Behavioral Needs by Race and Ethnicity	12
Innovations in Population Health: Improving Outcomes for Patients with Chronic Kidney Disease	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
The Impact of Personal and Historical Factors That Contribute to Medicare Readmissions	11
Ambulatory Care Utilization Among Medicare Beneficiaries with Depression	11
Use of a Blood Biomarker Test Improves Economic Utility in the Evaluation of Older Patients Presenting with Cognitive Impairment	11

Successful Implementation of an All-or-None Diabetes Measure in 10 US Health Systems	10
Cost-Effectiveness of Outreach Strategies for Stool-Based Colorectal Cancer Screening in a Medicaid Population	10
Factors Influencing Learners’ Knowledge and Implementation of Value-Based Care Concepts Postcourse Certification	10
Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates	9
COVID-19 Vaccine Equity: Codesigning Public Health Interventions with Community Partners	9
Using Quality Measures to Drive Improvements in Immunization Rates: Findings from a Real-World Evaluation from 3 US Health Care Organizations	9
What Are the Roles of Community Health Workers in Medicaid Managed Care? Results from a National Study	9
Bridging the Digital Divide: A Practical Roadmap for Deploying Medical Artificial Intelligence Technologies in Low-Resource Settings	9
Cost-Effectiveness of Screening and Early Diagnosis Strategies for Cancer in the General Adult Population in Low- and Middle-Income Countries: A Systematic Review	8
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
Limitations to Health Care Quality Measurement: Assessing Hospital Variation in Risk of Cardiac Events After Noncardiac Surgery	8
Reimagining Diabetes Quality Measurement to Advance Quality Care	8
A Review of the MINDSPACE Framework for Nudging Health Promotion During Early Stages of the COVID-19 Pandemic	7
What Is Old Needs to Be New Again	7
Individual- and Community-Level Predictors of Hospital-at-Home Outcomes	7
Interventions to Increase Affordable Care Act Marketplace Enrollment: A Systematic Review and Meta-Analysis	7
The Cost of Unhealthy Days: A New Value Assessment	7
Medicaid Cost Savings from Provision of Contraception to Beneficiaries in South Carolina, 2012–2018	6
Leveraging Technology for Value-Based Kidney Care	6
Assessing the Added Value of Blood Pressure Information Derived from Electronic Health Records in Predicting Health Care Cost and Utilization	6
Health Resources and Services Administration-Funded Health Centers Reduce Health Care Expenditures of California Medicaid Managed Care Beneficiaries with Complex Needs	6
Increasing Statin-Prescribing and Low-Density Lipoprotein Cholesterol Control in Secondary Atherosclerotic Cardiovascular Disease Prevention: A Collaborative Approach	6
Transitioning from In-Person to Telemedicine Within Primary Care Behavioral Health During COVID-19	6
Implementation and Outcomes from a Post-Discharge Intervention Program in a Medicare ACO Population	6
Engaging Stakeholder Advisors Around Health-Related Social Needs Research, Policy, and Practice Priorities	6
An Increase in the Use of ICD-10 Z-Codes for Social Risks and Social Needs: 2015 to 2019	5
What Is a Center of Excellence?	5
Cost Reduction and Utilization Patterns in a Medicare Accountable Care Organization Using Home-Based Palliative Care Services	5
Addressing Social Determinants of Health in Family Medicine Practices	5
The Role of Social Determinants of Health in Gastroenterology Care	5
Multisector Partnerships and Service Colocation to Increase Adoption of Influenza Vaccines and Address Food Insecurity	5
The Academic Payvider Model: Commentary	5
The Future of Population Health	5
Correction to : Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities, by Laura B. Beidler, et al. Popul Hea	5
Mental Health Service Use and Equity in a Comprehensive Employer-Sponsored Benefit Program: A Retrospective Cohort Study	5
The Future of Chronic Disease Management	4
Implementation of E-Consults in an Integrated Health System for a Value Population	4
Impact of Health Literacy on Medication Adherence Among Black Medicaid Beneficiaries with Hypertension in Delaware: A Cross-Sectional Study	4
Developing a Strategy to Increase Lung Cancer Screening in Areas of Need	4
Challenge of Managing Chronic Kidney Disease: Patient and Caregiver Perspectives	4
For Profit, but Socially Determined: The Rise of the SDOH Industry	4
Estimating Cost Savings of Care Coordination for Older Adults: Evidence from the Iowa Return to Community Program	4
Acknowledgment of Reviewers 2025	4
Honoring the Past While Shaping the Future: Reflections From the Incoming Editor-in-Chief	4
Major Economic Losses Associated with Inadequate Control of High Blood Pressure: Time for a Major Change	4
Assessing the Relationship Between Behavioral Health Integration and Alcohol-Related Treatment Among Patients with Medicaid	4
The Impact of Expanding Telehealth-Delivered Dietary Interventions on Long-Term Cardiometabolic Health	3
The Impact of Social Vulnerability and Race on Colorectal Cancer Screening	3
Rethinking Blood Pressure Quality Measurement: Accounting for Seasonal Variation in Value-Based Care	3
Feasibility of an Adaptive Food Insecurity Intervention for Patients with Uncontrolled Hypertension: A Pilot SMART	3

Letter to the Editor: Public Health Reform Efforts Should More Effectively Engage Public Health Professionals and the General Public	3
Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization	3
A Path to Risk: Critical Elements of a Structured Approach	3
Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities	3
The Impact of Public Health Funding on Population Health Outcomes	3
Molecular Testing for Women’s Gynecologic Health: Real-World Impact on Health Care Costs	3
Reimagining Our Public Health Systems: The Robert Wood Johnson Foundation's National Commission to Transform Public Health Data Systems	3
Hospital Safety-Net Burden is Associated with Perioperative Outcomes in Primary Total Hip Arthroplasty: A Multistate Retrospective Analysis, 2015–2020	3
The Unfortunate State of Population Health: Its Omnipresent Promise and Industry's Continued Failure of Vision and Commitment	3
Hospital-at-Home: The Good, the Bad, and the Ugly	3
Health Care Bricolage: A Method to Reduce High-Cost Medical Spend	3
Racial Disparities in Cardiovascular Health Among the Acute Coronary Syndrome Population	3
Tackling Ethnic Health Disparities Through Community Health Worker Programs: A Scoping Review on Their Utilization During the COVID-19 Outbreak	3
The Minority and Rural Coronavirus Insights Study: Design and Baseline Characteristics of a Minority Cohort	3