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Gordon K. Norman, MD, MBA
Chief Medical Officer
xG Health Solutions
Graphical Lessons in Population Health
Graphical Lessons in Population Health
As a physician dedicated to improving population health for several
decades, I have...
1. Determinants of Health / Premature Death
The first of these are a pair of graphs that vividly demonstrate the dominant ...
2. Rule of Halves
The successive gaps in our case finding, diagnostic confirmation, evidence-based
treatment, persistent a...
2. Rule of Halves (cont.)
A different depiction of this phenomenon of successive shortfalls in diabetes control is
shown b...
3. Medication Adherence
A key part of the shortfall problem above is the challenge of long-term medication
adherence. As p...
3. Medication Adherence (cont.)
3. Medication Adherence (cont.)
Clinical Inertia
4. Clinical inertia
Clinical inertia is defined as lack of treatment intensification in a patient not at
...
5. Diffusion of new knowledge
From the work of Balas & Boren and Paul Glasziou come the following 2 graphics
showing how s...
5. Diffusion of new knowledge (cont.)
While the leaks in translating new research into routine care are real and many, we
...
6. Changing health behaviors
A large literature has been developed about
why we behave as we do and how to change
unhealth...
7. Social contagion
Research from Christakis and Fowler has demonstrated that our social networks
influence our behavior i...
8. Health literacy
We have long known that variability in health literacy impacts one’s wellbeing and
may limit the effect...
8. Health literacy (cont.)
This is a multifactor societal challenge that the health professions or public health
alone can...
9. Personal health ecosystems
Aside from our genetic
and familial heritage, our
health is influenced by a
complex combinat...
10. Holistic health care
Our specialty-oriented,
high-tech medical care
today is often perceived
by patients as fragmented...
11. Squaring the Morbidity Curve
Jim Fries, MD depicted lifetime morbidity in the graphic below showing how the
default cu...
12. Value Chain for Accountable Care
Clearly there is no single, unique
chain of interdependent steps that
all health care...
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Graphical lessons in Population Health

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Show Me, Don't Tell Me!

  1. 1. Gordon K. Norman, MD, MBA Chief Medical Officer xG Health Solutions Graphical Lessons in Population Health
  2. 2. Graphical Lessons in Population Health As a physician dedicated to improving population health for several decades, I have relished and often reused a number of graphs and graphics that depict salient issues in population health far better than words can convey, at least for me, an admitted visual learner. The following dozen are from my “greatest hits” collection, and I invite readers to reuse these as appropriate. “One look is worth a thousand words.” Frederick Barnard, Printer's Ink, December 1921
  3. 3. 1. Determinants of Health / Premature Death The first of these are a pair of graphs that vividly demonstrate the dominant influence of personal lifestyle and health behaviors on health and premature death. Whenever I get too focused on EHRs, CINs, PCMHs, ACOs, etc., these data remind me that until we impact health behaviors and lifestyles for a population, we will not optimize health outcomes. Schroeder S. N Engl J Med 2007;357:1221-1228
  4. 4. 2. Rule of Halves The successive gaps in our case finding, diagnostic confirmation, evidence-based treatment, persistent adherence to treatment all compound to yield a disappointing net result in our population health management throughput. This is vividly demonstrated by the “Rule of Halves” which applies to diabetes and some other chronic conditions.
  5. 5. 2. Rule of Halves (cont.) A different depiction of this phenomenon of successive shortfalls in diabetes control is shown below. However illustrated, serial drop-offs in our ability to render high quality care and optimal outcomes to all who need it are an indictment of the current system which is often characterized by “compounded mediocrity”.
  6. 6. 3. Medication Adherence A key part of the shortfall problem above is the challenge of long-term medication adherence. As pithily noted by former U.S. Surgeon General, C. Everett Koop, “Drugs don’t work in patients who don’t take them.” No portrayal of this challenge is more dramatic to me than the following graphics that show how quickly after hospitalization for a heart attack that many patients stop using life-savings drugs. After escaping the grim reaper in a scary CCU attached to cardiac monitors and IV drips while contemplating one’s mortality, one might think the survivors of this experience would be devoutly committed to their physician’s care plan, particularly prescribed medications. Shockingly, almost one quarter of patients had not filled their cardiac prescriptions in one week after discharge, one third of patients stopped at least one of 3 indicated medications, while 12% stopped all 3 within one month of hospital discharge! The data clearly demonstrate that in as little as one year later, those quitting all 3 meds suffered a 10% survival disadvantage compared to those who remained adherent.
  7. 7. 3. Medication Adherence (cont.)
  8. 8. 3. Medication Adherence (cont.)
  9. 9. Clinical Inertia 4. Clinical inertia Clinical inertia is defined as lack of treatment intensification in a patient not at evidence-based goals for care, and it occurs commonly in clinical practice, exposing patients to avoidable morbidity and mortality risk. Because of the multifactorial nature of this problem, it is not a simple or easy one to tackle yet must be addressed for optimal population health. Systems of care which embed workflows, reminders, order sets, thresholds for action, etc. are key for treating to target reliably.
  10. 10. 5. Diffusion of new knowledge From the work of Balas & Boren and Paul Glasziou come the following 2 graphics showing how slow and inefficient we are in deploying new health science into routine practice. If it takes on average 17 years for new, proven knowledge to become adopted by more than half of all practicing clinicians, yet the half-life of medical knowledge these days is on the order of 10 years, what prognosis does this portend for the future? Adoption Half-life = 17y Knowledge Half- life = 10y %ofpopulation
  11. 11. 5. Diffusion of new knowledge (cont.) While the leaks in translating new research into routine care are real and many, we must find ways to leverage EHRs and clinical decision support technology to do significantly better than this. 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21 Aware Accept Apply Able Act Agree Adhere Valid Research If leakage is only 20% at each stage of pipeline …patients get only ~1/5 of full potential benefit We experience successive “leaks” between research & clinical practice that significantly dilute clinical benefit
  12. 12. 6. Changing health behaviors A large literature has been developed about why we behave as we do and how to change unhealthy lifestyles and behaviors, but no single model has emerged as superior to others for population health improvement. One of the more useful and practical is the Information-Motivation-Behavioral Skills (“IMB”) model from Fisher & Fisher, endorsed by WHO and shown to be effective in changing sexual behavior in teenagers, ART adherence in AIDS patients, and in diabetic self-care in multiple cultures. Sensibly, if you know what you should change and why, decide you want to make the change, and are equipped with the necessary behavioral tactics to support the change, then you are much more likely to be successful with long term behavior change.
  13. 13. 7. Social contagion Research from Christakis and Fowler has demonstrated that our social networks influence our behavior is subtle ways that may not be obvious but can be measured in many settings. Understanding these behavioral influences may give us another lever to use in population health improvement.
  14. 14. 8. Health literacy We have long known that variability in health literacy impacts one’s wellbeing and may limit the effectiveness of many approaches to improving population health.
  15. 15. 8. Health literacy (cont.) This is a multifactor societal challenge that the health professions or public health alone cannot solve without broader, grassroots initiatives.
  16. 16. 9. Personal health ecosystems Aside from our genetic and familial heritage, our health is influenced by a complex combination of forces, beliefs, habits, and other environmental and societal factors that are portrayed in the following graphic. These myriad influences often work at a subconscious rather than conscious level, making it challenging to even identify what they are for a given individual, much less change them.
  17. 17. 10. Holistic health care Our specialty-oriented, high-tech medical care today is often perceived by patients as fragmented and organ-centric. Many believe that to help patients convert unhealthy behaviors into healthy ones, change unhealthy beliefs to healthier ones, and to slow morbidity while enhancing quality of life, we need a more holistic approach to health care that takes a person- centric perspective.
  18. 18. 11. Squaring the Morbidity Curve Jim Fries, MD depicted lifetime morbidity in the graphic below showing how the default curve should be “squared” to represent improved quality of life for a greater percentage of our lifespan than currently - a worthy goal for population health management that harmonizes well with the Triple Aim.
  19. 19. 12. Value Chain for Accountable Care Clearly there is no single, unique chain of interdependent steps that all health care organizations must follow in order to be successful in accountable care, but the following schematic is based on observing several that have been able to achieve Triple Aim outcomes while remaining financially viable. Working backward from the desired health outcomes, the key is determining the population health behaviors that need to change and all the necessary steps required to produce those changes at scale and with persistence. Complete Population Health Data Integration & EBM Gap Analyses Impactful Health Decision SupportShared Care Plans w/ Better Use of What Works Information, Motivation, Behavioral Skills Better Health Behaviors Improved Health Outcomes

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