Graphical lessons in Population Health

1. Gordon K. Norman, MD, MBA
Chief Medical Officer
xG Health Solutions
Graphical Lessons in Population Health

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. 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. 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. 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. 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. 3. Medication Adherence (cont.)

8. 3. Medication Adherence (cont.)

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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