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 2022-08-01 to 2026-08-01.)

Article	Citations
Association Between Social Vulnerability and Postoperative Complications and Readmission Among Cardiovascular Surgery Patients	51
COVID-19 Vaccination, Morbidity, and Mortality During a 12-Month Period in Israel: Can We Maintain a “Herd Immunity” State?	23
Health Equity Is Key to Better Population Health	20
A Population Health Proposal for Increasing Breast Cancer Screening to Reduce Racial Disparities in Breast Cancer: Getting the Village Back Together	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	18
A Theoretically Grounded Chronic Illness Model Integrating Medical- and Community-Based Social Service Providers	17
More Patient Data? Be Careful What You Wish for…AI’s Role in Making Clinical Data Exchange Useful	17
Examining the Association of Social Needs with Future Health Care Utilization in an Older Adult Population: Which Needs Are Most Important?	16
Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates	15
Optimizing Hierarchical Condition Category-Risk Adjustment Factor Management in Population Health Using Rapid Process Improvement Methods	14
Social Needs Screening in Academic Health Systems: A Landscape Assessment	14
Chronic Care Management and Mortality Among Diabetic Patients with Multiple Chronic Conditions	13
When Sleep Hurts the Joints: Longitudinal Associations of Sleep Quality and Duration with Incident Arthritis in the English Longitudinal Study of Aging	12
The Impact of the Affordable Care Act on Disparities in Utilization of Cardiovascular Preventive Services by Socioeconomic Status	12
Corrigendum to: Identifying and Measuring Caregiver Burdens: A Scoping Review	12
Patient Engagement with General Bulk Outreach: Impact of Primary Care Provider vs. Care Team Signature in General Bulk Patient Outreach	12
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
Prior Authorization: Process Redesign with a Focus on Value-Based Care	11
Factors Influencing Learners’ Knowledge and Implementation of Value-Based Care Concepts Postcourse Certification	11
Medicaid Acceptance Varies by Physician Seniority and Specialty in California	11
Ambulatory Care Utilization Among Medicare Beneficiaries with Depression	11
COVID-19 Deaths and the Impact of Health Disparities, Hospital Characteristics, Community, Social Distancing, and Health System Competition	11
Screening for Social Needs in Health Care Systems: A Quality Improvement Framework and Two Case Studies	11
Transitional Care for Older Adults: Demonstration of the Role of a Partnership Payvider	10
Impact of COVID-19 on Behavioral Health Services Use Among Medicaid Enrollees with Chronic Behavioral Needs by Race and Ethnicity	9

Successful Implementation of an All-or-None Diabetes Measure in 10 US Health Systems	9
What Are the Roles of Community Health Workers in Medicaid Managed Care? Results from a National Study	9
Innovations in Population Health: Improving Outcomes for Patients with Chronic Kidney Disease	9
COVID-19 Vaccine Equity: Codesigning Public Health Interventions with Community Partners	9
A Conceptual Framework for Building Individual and Team Capabilities to Provide Effective Longitudinal, Relationship-Based Clinical Case Management	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	7
Reimagining Diabetes Quality Measurement to Advance Quality Care	7
Bridging the Digital Divide: A Practical Roadmap for Deploying Medical Artificial Intelligence Technologies in Low-Resource Settings	7
Use of a Blood Biomarker Test Improves Economic Utility in the Evaluation of Older Patients Presenting with Cognitive Impairment	7
Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates	7
What Is Old Needs to Be New Again	7
Leveraging Technology for Value-Based Kidney Care	6
Limitations to Health Care Quality Measurement: Assessing Hospital Variation in Risk of Cardiac Events After Noncardiac Surgery	6
Interventions to Increase Affordable Care Act Marketplace Enrollment: A Systematic Review and Meta-Analysis	6
Implementation and Outcomes from a Post-Discharge Intervention Program in a Medicare ACO Population	6
A Review of the MINDSPACE Framework for Nudging Health Promotion During Early Stages of the COVID-19 Pandemic	6
The Cost of Unhealthy Days: A New Value Assessment	6
Individual- and Community-Level Predictors of Hospital-at-Home Outcomes	6
Increasing Statin-Prescribing and Low-Density Lipoprotein Cholesterol Control in Secondary Atherosclerotic Cardiovascular Disease Prevention: A Collaborative Approach	6
Engaging Stakeholder Advisors Around Health-Related Social Needs Research, Policy, and Practice Priorities	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
What Is a Center of Excellence?	6
The Future of Population Health	5
Optimizing Outcomes in the ACCESS Model: Why Provider Integration is Critical to Long-Term Success	5
Cost Reduction and Utilization Patterns in a Medicare Accountable Care Organization Using Home-Based Palliative Care Services	5
Medicaid Cost Savings from Provision of Contraception to Beneficiaries in South Carolina, 2012–2018	5
The Role of Social Determinants of Health in Gastroenterology Care	5
Correction to : Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities, by Laura B. Beidler, et al. Popul Hea	5
Transitioning from In-Person to Telemedicine Within Primary Care Behavioral Health During COVID-19	5
Health Resources and Services Administration-Funded Health Centers Reduce Health Care Expenditures of California Medicaid Managed Care Beneficiaries with Complex Needs	5
The Academic Payvider Model: Commentary	4
Challenge of Managing Chronic Kidney Disease: Patient and Caregiver Perspectives	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
Mental Health Service Use and Equity in a Comprehensive Employer-Sponsored Benefit Program: A Retrospective Cohort Study	4
The Future of Chronic Disease Management	4
A Path to Risk: Critical Elements of a Structured Approach	4
Honoring the Past While Shaping the Future: Reflections From the Incoming Editor-in-Chief	4
Addressing Social Determinants of Health in Family Medicine Practices	4
An Increase in the Use of ICD-10 Z-Codes for Social Risks and Social Needs: 2015 to 2019	4
Implementation of E-Consults in an Integrated Health System for a Value Population	4
Acknowledgment of Reviewers 2025	4
Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization	3
The Impact of Public Health Funding on Population Health Outcomes	3
Reimagining Our Public Health Systems: The Robert Wood Johnson Foundation's National Commission to Transform Public Health Data Systems	3
Rethinking Blood Pressure Quality Measurement: Accounting for Seasonal Variation in Value-Based Care	3
Composite Indices of Social Determinants of Health: Overview, Measurement Gaps, and Research Priorities for Health Equity	3
Assessing the Relationship Between Behavioral Health Integration and Alcohol-Related Treatment Among Patients with Medicaid	3
Hospital Safety-Net Burden is Associated with Perioperative Outcomes in Primary Total Hip Arthroplasty: A Multistate Retrospective Analysis, 2015–2020	3
Hospital-at-Home: The Good, the Bad, and the Ugly	3

Impact of Health Literacy on Medication Adherence Among Black Medicaid Beneficiaries with Hypertension in Delaware: A Cross-Sectional Study	3
The Benefit of Social Needs Programs: Hospital Reports of Associated Population Health Management Outcomes	3
When Administrative Requirements Shape Access: Medicaid Work Requirements and Mental Health Care	3
Letter to the Editor: Public Health Reform Efforts Should More Effectively Engage Public Health Professionals and the General Public	3
Developing a Strategy to Increase Lung Cancer Screening in Areas of Need	3
Participants in Medicare’s New Mandatory Bundled Payment Program	3
Tackling Ethnic Health Disparities Through Community Health Worker Programs: A Scoping Review on Their Utilization During the COVID-19 Outbreak	3
The Unfortunate State of Population Health: Its Omnipresent Promise and Industry's Continued Failure of Vision and Commitment	3
Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities	3
Cervical Cancer and Sexually Transmitted Infections Screening Among Individuals with a Substance Use Disorder: A Retrospective Cohort Study	3
Estimating Cost Savings of Care Coordination for Older Adults: Evidence from the Iowa Return to Community Program	3