References
- 1Maarse H, Jeurissen P, Ruwaard D. Concerns over the financial sustainability of the dutch healthcare system. DICE Rep. 2013; 11: 32–6.
- 2Birch S, Murphy GT, MacKenzie A, Cumming J. In place of fear: aligning health care planning with system objectives to achieve financial sustainability. J Heal Serv Res Policy. 2015; 20: 109–14. DOI: 10.1177/1355819614562053
- 3Porter ME, Lee TH. The strategy that will fix health care. Harv Bus Rev; 2013.
- 4Williams R, Colagiuri S, Almutairi R, Montoya PA, Basit A, Beran D, et al. IDF Diabetes Atlas. Ninth Ed. 2019. Brussels: International Diabetes Federation; 2019.
- 5WHO. Programmes and projects – Nutrition – Nutrition health topics. Available from
www.who.int Accessed 13 November 2019 [Internet]. Available from:http://www.who.int/entity/en/ . - 6Geurten RJ, Elissen AMJ, Bilo HJG, Struijs JN, van Tilburg C, Ruwaard D. Identifying and delineating the type 2 diabetes population in the Netherlands using an all-payer claims database: characteristics, healthcare utilisation and expenditures. BMJ Open. 2021; 11:
e049487 . DOI: 10.1136/bmjopen-2021-049487 - 7Smeets RGM, Elissen AMJ, Kroese MEAL, Hameleers N, Ruwaard D. Identifying subgroups of high-need, high-cost, chronically ill patients in primary care: A latent class analysis. PLoS One. 2020; 1: 1–16. DOI: 10.1371/journal.pone.0228103
- 8Geurten RJ, Struijs JN, Elissen AMJ, Bilo HJG, van Tilburg C, Ruwaard D.
Delineating the Type 2 Diabetes Population in the Netherlands Using an All-Payer Claims Database: Specialist Care, Medication Utilization and Expenditures 2016–2018 . PharmacoEconomics – Open [Internet]. Springer International Publishing; 2021. DOI: 10.1007/s41669-021-00308-0 - 9Struijs JN, Baan CA, Schellevis FG, Westert GP, Van Den Bos GAM. Comorbidity in patients with diabetes mellitus: Impact on medical health care utilization. BMC Health Serv Res. 2006; 6: 1–9. DOI: 10.1186/1472-6963-6-84
- 10Hazel-Fernandez L, Li Y, Nero D, Moretz C, Slabaugh L, Meah Y, et al. Relationship of diabetes complications severity to healthcare utilization and costs among Medicare Advantage beneficiaries. Am J Manag Care. 2015; 21: e62–70.
- 11Kanavos P, Aardweg S Van Den, Schurer W. Diabetes Expenditure, Burden of Disease and Management in 5 EU Countries. LSE Heal London Sch Econ [Internet]. 2012; 1–113. Available from:
http://eprints.lse.ac.uk/54896/1/__libfile_REPOSITORY_Content_LSE Health and Social Care_Jan 2012_LSEDiabetesReport26Jan2012.pdf . - 12Hertroijs DFL, Elissen AMJ, Brouwers MCGJ, Schaper NC, Ruwaard D. Relevant patient characteristics for guiding tailored integrated diabetes primary care: A systematic review. Prim Heal Care Res Dev. 2018; 19: 424–47. DOI: 10.1017/S146342361800004X
- 13Elissen AMJ, Hertroijs DFL, Schaper NC, Bosma H, Dagnelie PC, Henry RM, et al. Differences in biopsychosocial profiles of diabetes patients by level of glycaemic control and health-related quality of life: The Maastricht Study. PLoS One. 2017; 12: 1–17. DOI: 10.1371/journal.pone.0182053
- 14Schmittdiel JA, Gopalan A, Lin MW, Banerjee S, Chau CV, Adams AS. Population Health Management for Diabetes: Health Care System-Level Approaches for Improving Quality and Addressing Disparities. Curr Diab Rep. Current Diabetes Reports; 2017. 17. DOI: 10.1007/s11892-017-0858-3
- 15Agardh E, Allebeck P, Hallqvist J, Moradi T, Sidorchuk A. Type 2 diabetes incidence and socio-economic position: A systematic review and meta-analysis. Int J Epidemiol. 2011; 40: 804–18. DOI: 10.1093/ije/dyr029
- 16Zupa MF, Arena VC, Johnson PA, Thearle MB, Siminerio LM. A Coordinated Population Health Approach to Diabetes Education in Primary Care. Diabetes Educ. 2019; 45: 580–5. DOI: 10.1177/0145721719879427
- 17Mitri J, Gabbay R.
Understanding Population Health Through Diabetes Population Management . Endocrinol Metab Clin North Am [Internet]. Elsevier Inc; 2016; 45: 933–42. DOI: 10.1016/j.ecl.2016.06.006 - 18Hertroijs DFL, Elissen AMJ, Brouwers MCGJ, Schaper NC, Köhler S, Popa MC, et al. A risk score including body mass index, glycated haemoglobin and triglycerides predicts future glycaemic control in people with type 2 diabetes. Diabetes, Obes Metab. 2018; 20: 681–8. DOI: 10.1111/dom.13148
- 19Struijs JN, Drewes HW, Stein KV. Beyond integrated care: Challenges on the way towards population health management. Int J Integr Care. 2015; 15: 7–9. DOI: 10.5334/ijic.2424
- 20Struijs JN, Drewes HW, Heijink R, Baan CA.
How to evaluate population management? Transforming the Care Continuum Alliance population health guide toward a broadly applicable analytical framework . Health Policy (New York) [Internet]. Elsevier Ireland Ltd; 2015; 119: 522–9. DOI: 10.1016/j.healthpol.2014.12.003 - 21Swarthout M, Bishop MA. Population health management: Review of concepts and definitions. Am J Heal Pharm. 2017; 74: 1405–11. DOI: 10.2146/ajhp170025
- 22Abraham M, Lim MJ, Tan WS, Cheah J.
Global Trends Towards Population Health Management and Key Lessons and Initiatives in the Singapore Context . Int. J. Integr. Care. Ubiquity Press; 2022. DOI: 10.5334/ijic.7016 - 23Hendrikx RJP, Drewes HW, Spreeuwenberg M, Ruwaard D, Struijs JN, Baan CA.
Which Triple Aim related measures are being used to evaluate population management initiatives? An international comparative analysis. Health Policy (New York) [Internet]. Elsevier Ireland Ltd; 2016. 120: 471–85. DOI: 10.1016/j.healthpol.2016.03.008 - 24Stiefel M, Nolan K. Measuring the triple aim: A call for action. Popul Health Manag. 2013; 16: 219–20. DOI: 10.1089/pop.2013.0025
- 25Copenhagen: WHO Regional Office for Europe. Populationhealth management inprimary health care:a proactive approach to improvehealth and well-beingseries. Primary heath carepolicy paper series [Internet]; 2023. Available from:
http://apps.who.int/ . - 26Elissen AMJ, Duimel-Peeters IGP, Spreeuwenberg C, Spreeuwenberg M, Vrijhoef HJM. Toward tailored disease management for type 2 diabetes. Am J Manag Care. 2012; 18: 619–30. DOI: 10.1080/1364557032000119616
- 27Arksey H, O’Malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol Theory Pract. 2005; 8: 19–32.
- 28Peters M, Godfrey CM, McInerney P, Khalil H, Parker D, Baldini Soares C.
Chapter 11: ScopingReviews . In: Aromataris E, Munn Z (eds), Joanna Briggs Institute Reviewer’s Manual. Available fromhttps://reviewersmanual.joannabriggs.org/ . Joanna Briggs Inst. 2017. - 29Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al.
PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation . Ann. Intern. Med. American College of Physicians; 2018. p. 467–73. DOI: 10.7326/M18-0850 - 30Steenkamer BM, Drewes HW, Heijink R, Baan CA, Struijs JN. Defining Population Health Management: A Scoping Review of the Literature. Popul Health Manag. 2017; 20: 74–85. DOI: 10.1089/pop.2015.0149
- 31Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev [Internet]. Systematic Reviews. 2016; 5: 1–10. DOI: 10.1186/s13643-016-0384-4
- 32Bouchonville MF, Hager BW, Kirk JB, Qualls CR, Arora S. Endo echo improves primary care provider and community health worker self-efficacy in complex diabetes management in medically underserved communities. Endocr Pract. 2018; 24: 40–6. DOI: 10.4158/EP-2017-0079
- 33Paul MM, Saad AD, Billings J, Blecker S, Bouchonville MF, Chavez C, et al. A telementoring intervention leads to improvements in self-reported measures of health care access and quality among patients with complex diabetes. J Health Care Poor Underserved. 2020; 31: 1124–33. DOI: 10.1353/hpu.2020.0085
- 34Blecker S, Lemieux E, Paul MM, Berry CA, Bouchonville MF, Arora S, et al. Impact of a primary care provider Tele-mentoring and community health worker intervention on utilization in Medicaid patients with diabetes. Endocr Pract. 2020; 26: 1070–6. DOI: 10.4158/EP-2019-0535
- 35Ali MK, Chwastiak L, Poongothai S, Emmert-Fees KMF, Patel SA, Anjana RM, et al. Effect of a Collaborative Care Model on Depressive Symptoms and Glycated Hemoglobin, Blood Pressure, and Serum Cholesterol among Patients with Depression and Diabetes in India: The INDEPENDENT Randomized Clinical Trial. JAMA - J Am Med Assoc. 2020; 324: 651–63. DOI: 10.1001/jama.2020.11747
- 36Kheniser KG, Aminian A, Kashyap SR. A Review of the Current Evidence: Impact of Metabolic Surgery on Diabetes Outcomes and Obesity-Associated Macrovascular Complications. Curr Diab Rep. Current Diabetes Reports; 2020; 20. DOI: 10.1007/s11892-020-01350-8
- 37Levitz C, Jones M, Nudelman J, Cox M, Camacho D, Wielunski A, et al. Reducing cardiovascular risk in patients with diabetes: An evidence-based, population health management program. J Healthc Qual. 2021; 1–10.
- 38Ashburner JM, Horn DM, O’Keefe SM, Zai AH, Chang Y, Wagle NW, et al. Chronic Disease Outcomes From Primary Care Population Health Program Implementation. Am J Manag Care. 2017; 23(12): 728–35.
- 39Baer HJ, De La Cruz BA, Rozenblum R, Nolido N V, Orav EJ, Metzler K, et al.
Integrating an online weight management program with population health management in primary care: Design, methods, and baseline data from the PROPS randomized controlled trial (Partnerships for Reducing Overweight and Obesity with Patient-centered Strate) . Contemp Clin Trials [Internet]. Elsevier; 2020. 95: 1–9. DOI: 10.1016/j.cct.2020.106026 - 40Baer HJ, Rozenblum R, De La Cruz BA, Orav EJ, Wien M, Nolido N V, et al. Effect of an Online Weight Management Program Integrated with Population Health Management on Weight Change: A Randomized Clinical Trial. JAMA – J Am Med Assoc. 2020; 324: 1737–46. DOI: 10.1001/jama.2020.18977
- 41Bouchonville MF, Paul MM, Billings J, Kirk JB, Arora S. Taking Telemedicine to the Next Level in Diabetes Population Management: a Review of the Endo ECHO Model. Curr Diab Rep [Internet]. Current Diabetes Reports; 2016; 16: 1–7. DOI: 10.1007/s11892-016-0784-9
- 42Fischer HH, Villacres A, Durfee MJ, McCullen K, MacKenzie TD. Diabetes population management by telephone visits. Telemed e-Health. 2011; 17: 396–8. DOI: 10.1089/tmj.2010.0191
- 43Grant RW, Hamrick HE, Sullivan CM, Dubey AK, Chueh HC, Cagliero E, et al. Impact of population management with direct physician feedback on care of patients with type 2 diabetes. Diabetes Care. 2003; 26: 2275–80. DOI: 10.2337/diacare.26.8.2275
- 44Grant RW, Cagliero E, Sullivan CM, Dubey AK, Estey GA, Weil EM, et al. A Controlled Trial of Population Management. Diabetes Mellitus: Putting Evidence into Practice (DM-PEP). Diabetes Care. 2004; 27: 2299–305. DOI: 10.2337/diacare.27.10.2299
- 45Heider AR, Maloney N, Satchidanand N, Allen G, Mueller R, Gangloff S, et al. Developing a Community-Wide Electronic Health Record Disease Registry in Primary Care Practices: Lessons Learned from the Western New York Beacon Community. eGEMs (Generating Evid. Methods to Improv. patient outcomes). 2014; p. Art.7 p. 1–8. DOI: 10.13063/2327-9214.1089
- 46Kimura J, DaSilva K, Marshall R. Population management, systems-based practice, and planned chronic illness care: Integrating disease management competencies into primary care to improve composite diabetes quality measures. 2008; 11: 13–22. DOI: 10.1089/dis.2008.111718
- 47Lewinski AA, Patel UD, Diamantidis CJ, Oakes M, Baloch K, Crowley MJ, et al. Addressing diabetes and poorly controlled hypertension: Pragmatic mHealth self-management intervention. J Med Internet Res. 2019; 21: 1–13. DOI: 10.2196/12541
- 48Mcconnell KJ, Zadvorny EB, Denham AM, Kasten SL, Hutka KA, Koetting CR, et al. Angiotensin-converting Enzyme Inhibitor Therapy for Coronary Artery Disease and Diabetes Mellitus. Am J Manag Care. 2007; 13: 560–6.
- 49Muraywid B, Butkievich LE, Myers B. Effect of a virtual pharmacy review program: A population health case study. J Manag Care Spec Pharm. 2020; 26: 24–9. DOI: 10.18553/jmcp.2020.26.1.24
- 50Rana JS, Karter AJ, Liu JY, Moffet HH, Jaffe MG.
Improved Cardiovascular Risk Factors Control Associated with a Large-Scale Population Management Program Among Diabetes Patients . Am J Med [Internet]. Elsevier Inc.; 2018; 131: 661–8. DOI: 10.1016/j.amjmed.2018.01.024 - 51Shahady E. The Florida Diabetes Master Clinician Program: Facilitating increased quality and significant cost savings for diabetic patients. Clin Diabetes. 2008; 26: 29–33. DOI: 10.2337/diaclin.26.1.29
- 52Tsui EW, Wang G, Zahler A, Simoyan OM, White MV, Mckee M. A multilingual population health management program. J Ambul Care Manage. 2013; 36: 140–6. DOI: 10.1097/JAC.0b013e31828596fa
- 53Zai AH, Grant RW, Estey G, Lester WT, Andrews CT, Yee R, et al. Lessons from Implementing a Combined Workflow-Informatics System for Diabetes Management. J Am Med Informatics Assoc. 2008; 15: 524–33. DOI: 10.1197/jamia.M2598
- 54Clarke M, Fursse J, Gokalp H, Sharma U, Jones RW. Whole population management of patients with diabetes. IEEE EMBS Spec Top Conf Healthc Innov Point-of-Care Technol. 2014; 197–8. DOI: 10.1109/HIC.2014.7038908
- 55Kozlowska O, Attwood S, Lumb A, Tan GD, Rea R. Population health management in diabetes care: Combining clinical audit, risk stratification, and multidisciplinary virtual clinics in a community setting to improve diabetes care in a geographically defined population. An integrated diabetes care pilot in the North East Locality, Oxfordshire, UK. Int J Integr Care. 2020; 20: 1–11. DOI: 10.5334/ijic.5177
- 56Kowalski A, Poongothai S, Chwastiak L, Hutcheson M, Tandon N, Khadgawat R, et al. The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study: design and methods to address mental healthcare gaps in India. Physiol Behav. 2017; September: 113–24. DOI: 10.1016/j.cct.2017.06.013
- 57Lewinski AA, Drake C, Shaw RJ, Jackson GL, Bosworth HB, Oakes M, et al. Bridging the integration gap between patient-generated blood glucose data and electronic health records. J Am Med Informatics Assoc. 2019; 26: 667–72. DOI: 10.1093/jamia/ocz039
- 58Alton DM. Population health management: from principal to practice. J Integr Care [Internet]. 2023; Available from:
https://www.emerald.com/insight/content/doi/10.1108/JICA-05-2023-0033/full/html . DOI: 10.1108/JICA-05-2023-0033 - 59Tsiachristas A, Rutten-van Molken MPMH.
Evaluating complex interventions . Handb Integr Care. Springer International Publishing; 2017. p. 297–313. DOI: 10.1007/978-3-319-56103-5_18 - 60Singer SJ, Kerrissey M, Friedberg M, Phillips R.
A Comprehensive Theory of Integration . Med Care Res Rev. SAGE Publications Inc.; 2020; 77: 196–207. DOI: 10.1177/1077558718767000 - 61Wei H, Horns P, Sears SF, Huang K, Smith CM, Wei TL.
A systematic meta-review of systematic reviews about interprofessional collaboration: facilitators, barriers, and outcomes . J. Interprof. Care. Taylor and Francis Ltd.; 2022. p. 735–49. DOI: 10.1080/13561820.2021.1973975 - 62Zupa MF, Krall J, Collins K, Marroquin O, Ng JM, Siminerio L. A Risk Stratification Approach to Allocating Diabetes Education and Support Services. Diabetes Technol Ther. 2022; 24: 75–8. DOI: 10.1089/dia.2021.0253
- 63Munch L, Arreskov AB, Sperling M, Overgaard D, Knop FK, Vilsbøll T, et al.
Risk stratification by endocrinologists of patients with type 2 diabetes in a Danish specialised outpatient clinic: A cross-sectional study . BMC Health Serv Res [Internet]. BMC Health Services Research; 2016. 16: 1–10. DOI: 10.1186/s12913-016-1365-y - 64Karter AJ, Warton EM, Lipska KJ, Ralston JD, Moffet HH, Jackson GG, et al. Development and validation of a tool to identify patients with type 2 diabetes at high risk of hypoglycemia-related emergency department or hospital use. JAMA Intern Med. 2017; 177: 1461–70. DOI: 10.1001/jamainternmed.2017.3844
- 65Hodgson S, Cheema S, Rani Z, Olaniyan D, O’Leary E, Price H, et al. Population stratification in type 2 diabetes mellitus: A systematic review. Diabet Med. 2022; 39: 1–13. DOI: 10.1111/dme.14688
- 66Ardesch, FH, Meulendijk, MC, Kist, JM, Vos, RC, Vos, HMM, Kiefte-de Jong, JC, et al.
A data-driven population health management approach: The extramural LUMC academic network data infrastructure . Health Policy (New York). Elsevier Ireland Ltd; 2023; 132. DOI: 10.1016/j.healthpol.2023.104769