Population Health Management

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
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
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
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
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 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
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
Estimating Cost Savings of Care Coordination for Older Adults: Evidence from the Iowa Return to Community Program	3
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
Assessing Barriers and Facilitators to Lung Cancer Screening: Initial Findings from a Patient Navigation Intervention	2
A Longitudinal, Relationship-Based Model for Managing Complex Chronic Disease in the Medicaid Population	2
The Academic Payvider Model: Care and Coverage	2
Social Determinants of Hepatitis C Virus Infection in the United States, 2016–2021	2
It Is Time to Supersize Our Population Health Improvement Goals	2
Future Trends to Watch for Value-Based Care	2
The Clinical and Economic Burdens of Obesity and the Value of Weight Loss for an EMR-Derived US Cohort: A Modeling Study	2
Toward a Continuum of Measures to Mitigate Primary and Secondary Impacts of COVID-19 and Other Public Health Emergencies	2
Interprofessional Intervention to Reduce Emergency Department Visits in Black Individuals with Diabetes	2
Opportunities and Challenges in Screening for Colorectal Cancer	2
Did the Affordable Care Act Promote Racial Equity in Pregnancy-Related Health? A Scoping Review	2
Treatment-Effect-Based Versus Risk-Based Targeting of Care Management Outreach in Medicaid: A Retrospective Cohort Study with Machine Learning	2
It’s Time to Build the Infrastructure that Makes Health Possible: Formalizing Accountable Communities for Health	2
Health Care Bricolage: A Method to Reduce High-Cost Medical Spend	2
The Unrecognized Impact of Anxiety in Complex and Costly Patients	2
Racial and Ethnic Disparity in Preference-Weighted Quality of Life: Findings from the Selenium and Vitamin E Cancer Prevention Trial	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
Enhancing Machine Learning Explainability of Disaster Preparedness Models from the FEMA National Household Survey to Inform Tailored Population Health Interventions	2
Data-Driven Leadership: Clinical Registries Drive Higher Value Health Care	2
Homelessness Among Acute Care Patients Within a Large Health Care System in Northern California	2
Feasibility of an Adaptive Food Insecurity Intervention for Patients with Uncontrolled Hypertension: A Pilot SMART	2
Single and Dual Sensory Loss and Cardiovascular Disease in US adults: Findings from the 2021 Behavioral Risk Factor Surveillance System	2
Molecular Testing for Women’s Gynecologic Health: Real-World Impact on Health Care Costs	2
Racial Disparities in Cardiovascular Health Among the Acute Coronary Syndrome Population	2
Electronic Health Data Quality and Population Health Management Algorithms	2
Postpartum Medicaid Eligibility Expansions and Postpartum Health Measures	2
Measuring Stakeholder Engagement in Statewide Primary Care Cardiovascular Health Improvement Cooperatives	2
Community Coalitions' Perspectives on Engaging with Hospitals in Ohio to Address the Opioid Crisis	2
Lessons Learned from the Camden Coalition's Work with High Needs, High Complexity Patients	1
A Call for Consistent Measurement Across the Social Determinants of Health Industry Landscape	1
Comparing Clinician Impression of Cognition with Standardized Screening in Medicare Annual Wellness Visits	1
Predictors of Interest in Offered Social Care Assistance Among People with Uncontrolled Diabetes	1
Validating and Improving Adjusted Clinical Group's Future Hospitalization and High-Cost Prediction Models for Dutch Primary Care	1
Evolution of Population Health Within US Schools of Medicine and Academic Medical Centers	1
The Coming Health Care Transformation: Empowered Patients and Better Value	1
Characteristics of Nonelderly Adult Health Care Persistent Super Utilizers in Utah	1
Pediatric Population Management Classification for Children with Medical Complexity	1
Strengthening the Public Health Partnership and Telehealth Infrastructure to Reduce Health Care Disparities	1
Impact and Continued Relevance of Medication Adherence Measurement	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
Changes in Health Care Utilization During the First 2 Years of Massachusetts Medicaid Accountable Care Organizations	1
A Multi-Intervention Approach to Blood Pressure Control: A Description of How a Large University Based Primary Care Clinic Tackled Hypertension	1
Evaluating a Care Management Program for Dual-Eligible Beneficiaries: Evidence from Rhode Island	1
Redesigning Diabetes Care for Treatment Inertia: A Population Health Model	1
Development of Digital Algorithms for the Early Identification of Rare Clinical Outcomes Using Electronic Medical Records: A Case Study of Hidradenitis Suppurativa	1
Demographic and Clinical Correlates of the Cost of Potentially Preventable Hospital Encounters in a Community Health Center Cohort	1
Health Systems Need to Transform Data Collection to Advance Health Equity	1
A Comparison of Emergency Room Visits and Hospital Admissions Between People with Prediabetes and Diabetes	1
Progression to the Mean: Reconciling Traditional and Modern Professional Values in Medicine	1
A Call to Action to Increase Uptake of Follow-Up Colonoscopy After Initial Positive Stool-Based Colorectal Cancer Screening	1
Postpartum Medicaid Coverage Expansion and Changes in the Risk of Health Insurance Loss Within the Second Year After Birth	1
The Key to Success Tomorrow Is Leadership Transformation Today	1
Chronic Kidney Disease, Diabetes, and Population Health: From Primary Care to Transplant	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
Evaluation of the Electronic Health Record-Support Social Support Score in Breast Cancer: Comparison of Count and Item Response Theory Scores	1
Adopting Health Technologies in Israel and England	1
Impact of Income Disparity on Utilization of Home-Based Care Services Among Older Adults in Japan: A Retrospective Cohort Study	1
Reflections on the Connection Between Health Care Quality and Population Health	1
Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups	1
Future Role of the Clinical Lab in Population Health	1
Association Between Relative Fat Mass and New-Onset Arthritis Among Middle-Aged and Older Chinese Females	1
Evaluation of an Interdisciplinary Hypertension Management Program at a Large Primary Care Practice	1
Trends in Mental Health Utilization Before and During the COVID-19 Pandemic: Federally Qualified Health Centers As a Case Study	1
To Win We Must Change the Game: A Formula for Health Care Transformation	1
Perspectives on Obesity Management and the Use of Anti-Obesity Medicine from US Employees and Employers: Results from the OBSERVE Study	1
Employer Strategies for Health Care Price Transparency	1
Global Challenges with Oral Antivirals for COVID-19	1
From Patient Goals to Team Action: A Qualitative Analysis of Student Capstone Projects from a Complex Care Curriculum	1

Impact of Social Needs in Electronic Health Records and Claims on Health Care Utilization and Costs Risk-Adjustment Models Within Medicaid Population	1
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	1
Corrigendum to: “Single and Dual Sensory Loss and Cardiovascular Disease in US Adults: Findings from the 2021 Behavioral Risk Factor Surveillance System”	1
Avoidance of Total Knee Replacement in a Population Health Setting: Introducing a Noninvasive Biomechanical Intervention for Patients with Knee Osteoarthritis	1
Gun Violence Prevention Policies Are Not Political: They Are Just Part of Good Public Health	1
Chart Review Is Dead; Long Live Chart Review: How Artificial Intelligence Will Make Human Review of Medical Records Obsolete, One Day	1
Collateral Damage from the COVID-19 Pandemic: Pediatric Obesity	1
Continuity of Care, Immigrant Status, and Emergency Department Use Among Seniors in Canada	1
Population Health: Staying Focused through the Pandemic and Beyond	1
Building for Value: A Foundational Structure to Support Population Health	1
Disparities in Recombinant Zoster Vaccine Coverage in the United States	1
Z Codes for Social Determinants of Health: A Better Predictor of Risk for Value-Based Care	1
A Call for an American Social Care System: Social Services Reimbursement to Address Fragmented Care	1
Application of Narrative Nursing Combined with Psychological Resilience Training in Patients and Their Families in Hospice Care	1
Comparing “Meaningful Use” of Health Information Technology in Pennsylvania: Electronic Prescription Rates of Metropolitan and Rural Counties	1
Hospital Outcomes for Patients with Psychiatric Comorbidities: A Comparison of an Integrated Medical-Psychiatry Unit and Traditional Medical Units	1