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The promise of population health

August 19th, 2013

by Kent Bottles

As a lecturer at The Thomas Jefferson University School of Population Health in Philadelphia, I sometimes forget not all hospital and medical leaders really understand population health.

It is one of those phrases--like accountable care organization or value-based payment or patient-centered medical home--you hear all the time. But what does population health really mean?

It should not surprise me that front-line hospital administrators and practicing physicians are confused by the term because the academics have not really provided us with a workable definition.

What is population health and why has it become such an important healthcare term?


The population health concept seems to have originated in Canada where investigators tried to understand why some populations of people were healthier than others. In discussing the issue they attempted to identify determinants of health, public policies that contributed to health, and resource allocations that made some communities healthy. Social scientists contributed to the field by emphasizing an individual's health is affected by family and community networks, living and working conditions, and broad public policies.

A 2002 Health Affairs article titled "The Case for More Active Policy Attention to Health Promotion" famously made the point that access to and quality of medical treatment only accounted for 10 percent of a person's health status. Behavioral choices such as diet, physical activity, substance abuse and stress contributed 40 percent, and social circumstances such as education, employment, housing, crime exposure and social cohesion accounted for 15 percent of the health of individuals. Genetics came in at 30 percent and environmental conditions 5 percent.

The study that years ago really caught my attention investigated the relationship between emotional support and heart attack mortality. Patients who reported no emotional support from friends or religious community had almost three times the risk of death, compared to those people who had a rich emotional support network of family, neighbors and religious community members.

When one really starts thinking about what makes a community healthy or unhealthy, healthcare leaders expand their thinking far beyond the hospital, the doctor's office and the emergency room.

For example, a 2011 Health Affairs issue was devoted to "Linking Community Development & Health." The articles in this special issue looked at topics such as community health impact assessments, programs to create new jobs, housing, transportation and hospital partnership models, and community development financial institutions.

Two facts from the special Health Affairs issue have stuck with me about how important population health has become—1) Life expectancy can vary by 14 years based on one's county of residence and 2) Life expectancy increases by nine years when one travels on the Blue Line of Washington, D.C.'s Metro system from downtown D.C. to Fairfax County, Va.

These far-ranging discussions about population health open up new avenues for communities to become healthier. A 2005 British Medical Journal study found higher levels of greenery and lower levels of graffiti and litter correlated with higher levels of physical activity and lower levels of obesity. Another study documented cities with sidewalks have fitter individuals than suburbs without walking paths. Social contagion theories of disease have demonstrated that obesity, smoking, depression and suicide can spread from friend to friend to friend in a community like a virus.

All of this new information can be used to affect change in one's community by using population health methods.

Activating a community to become healthier still faces challenges and difficulties, notwithstanding the new concept of population health. Health is poorly defined. Communities are in disarray. The biomedical model does not provide the language necessary to address the problems. Health promotion is complex, and it is difficult to encourage populations to embrace agendas such as the Healthy People campaign. In many communities leadership is fragmented and nonprofit politics can be disruptive.

However, population health holds the promise of improving the health of more people--even more so than improving the access and quality of care we healthcare professionals provide to our patients.

I consider it a tragedy the public health and medicine fields seem to have gone their separate ways sometime in the early 20th century. The new emphasis on population health could link the important discoveries in medicine to the important insights from public health and create better communities where we could live longer, happier lives.

Kent Bottles, M.D, is a lecturer at the Thomas Jefferson University School of Population Health and chief medical officer of PYA Analytics.


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