Authors

Unfulfilled Home Health Referrals Lead to Higher Mortality Among Medicare Advantage Members

Medicare Advantage members referred to home health after acute hospitalization who did not receive home health services had higher mortality at 30, 90, and 180 days.

Assessment of Structured Data Elements for Social Risk Factors

An expert panel identified and assessed electronic health record and health information exchange structured data elements to support future development of social risk factor computable phenotyping.

Patient Satisfaction With Letter-Based Communication of LCS Pulmonary Nodule Results

Patients were satisfied with receiving their lung cancer screening (LCS) pulmonary nodule results via letter and considered the amount of information provided in the letter appropriate.

A Cue-to-Action Pilot Project to Increase Screening Mammography

A targeted cue-to-action campaign of outreach, education, and incentive can improve uptake of screening mammography.

More Employers Offer Preventive Drug Lists Over Time

More large employers with high-deductible health plans with health savings accounts offer preventive drug list benefits over time.

Adjusting Starting Points for Initial Price Offers: The Example of Ibrutinib

Ibrutinib has been selected for Medicare price negotiation under the Inflation Reduction Act. The authors summarize the House Oversight Committee investigation to be considered by CMS during the price negotiation process.

Access to Consultative Dermatologic Care via Physician-to-Physician Asynchronous Outpatient Teledermatology

Direct access of primary care physicians to dermatologists via asynchronous teledermatology improves a health system’s ability to increase patient access to dermatologic care.

Prevention and Management of COVID-19 in Hemodialysis Centers

This article gives recommendations for individual hemodialysis centers worldwide to ensure the safety and effectiveness of patients receiving maintenance hemodialysis based on the experience of such a patient with coronavirus disease 2019 (COVID-19) in the Sichuan province of China.

Overcoming Weight Bias in Health Care Systems

This commentary calls for health care systems to deliver equitable care for people living with obesity by addressing weight bias and updating standards in obesity care.

Impacts of Community-Based Care Program on Health Care Utilization and Cost

A community-based care management program in Rhode Island reduced hospitalizations and inpatient costs. There were stark differences across subgroups based on intensity of care.

Potential Health Literacy Resources for Health Plans: A Narrative Review

Several evidence-based health literacy resources may be beneficial in health plan settings to improve organizational health literacy, personal health literacy, and health equity.

Driving Healthier Outcomes Through Comprehensive, Team-Based Care: Q&A With Marisa Rogers, MD, MPH

In 2025, each issue of Population Health, Equity & Outcomes will feature a profile of a health system leader transforming care in their area of expertise. This issue spotlights a conversation with Marisa Rogers, MD, MPH, chief medical officer at Oak Street Health.

Collaborative Care Implementation: Lessons Learned

The authors drafted a “Shared Values of Collaborative Care” document with fundamental principles to make better group decisions in implementing collaborative care.

Equity and AI Governance at Academic Medical Centers

This study identifies limited engagement with equity among academic medical centers as they develop governance processes for artificial intelligence (AI)/machine learning and predictive technologies.

Health Equity in the Era of Large Language Models

This article presents challenges and solutions regarding health care–focused large language models (LLMs) and summarizes key recommendations from major regulatory and governance bodies for LLM development, implementation, and maintenance.

AI Seen as Key to Reducing Health Care Claim Denials, Survey Finds

Experian Health’s 2025 State of Claims survey shows rising denial rates, data errors, and low artificial intelligence adoption despite providers’ belief in its potential.

Emergency Department Risk Model: Timely Identification of Patients for Outpatient Care Coordination

The authors created a machine learning–based model to identify patients with major depressive disorder in the primary care setting at high risk of frequent emergency department visits, enabling prioritization for a care coordination program.

Contingency Management: Promises, Gaps, and Philosophical Limitations

This editorial reviews the promises, gaps, and philosophical limitations of contingency management for pregnant people who use drugs.

Reducing Readmissions in the Safety Net Through AI and Automation

Artificial intelligence (AI) and electronic health record–based automation tools helped a safety-net health system meet performance-based readmission metrics, thereby retaining critical funding while improving clinical and equity outcomes.

Revisiting Conclusions on the Empiric Segmentation of High-risk Patients

The authors provide feedback on generalizations made regarding interventions for high-risk populations in previous research.

End-of-Life Values and Value-Based Care

An editorial in response to the editor in chief’s December 2021 letter discusses evidence supporting the cost-effectiveness of an innovative advance care planning initiative.

Using Electronic Health Records and Claims Data to Identify High-risk Patients Likely to Benefit From Palliative Care

Deep learning algorithms could improve palliative care by predicting mortality from electronic health records and claims data.

Effective Prevention and Management of COVID-19 in Outpatient Hemodialysis Patients

The authors introduce a mobile phone app that may effectively prevent and manage coronavirus disease 2019 (COVID-19) in outpatient hemodialysis patients in Sichuan Province, China.

US Spending on High-Revenue Rare Disease Drugs in 2022

One in 5 of the highest-revenue drugs of 2022 was exclusively approved for rare conditions, accounting for more than 7% of US pharmaceutical spending.

Geographical Variation in Kidney Function Testing and Associations With Health Care Costs Among Patients With Chronic Kidney Disease and Type 2 Diabetes

Assessing the Impact of Transplant Case Management on Clinical Outcomes

This article examines the effect of a transplant case management program on clinical outcomes following transplant surgery.

Contemporary Care Patterns in the Management of Small Renal Masses

An investigation of management patterns after initial radiographic diagnosis of small renal masses showed that early urologist referral was associated with guideline-concordant care.

Improving Pulmonary Embolism Outcomes in Intermediate-Risk Patients: Krunal Patel, MD

Krunal Patel, MD, pulmonary and critical care fellow, Temple University Hospital, discusses how early intervention within 12 hours improved hemodynamic measurements and clinical outcomes in patients with pulmonary embolism.

Appropriate ED Utilization Leading to Better Care Coordination

Addressing avoidable emergency department (ED) utilization takes interventions in partnership with providers.

Glucose-Lowering Treatment Patterns in Patients With Diabetic Kidney Disease

Real-world treatment of diabetic kidney disease in the United States, based on national-level health care claims and electronic health records data, is inconsistent with the current guidelines.