Why Aren’t There More Population Health Initiatives in Otolaryngology?

A Google Scholar search for “population health diabetes” quickly turns up more than two million articles. “Population health cardiology” points to nearly 1.5 million articles. Search for “population health otolaryngology,” though, and you’ll only receive 640,000 results, including “Independent risk factors for atrial fibrillation in a population-based cohort: the Framingham Heart Study” (the No. 1 result) and “Domestic violence against women: incidence and prevalence in an emergency department population” (result No. 2).

In contrast, the “population health diabetes” articles examine the population health significance of gestational diabetes, health-related quality of life deficits, and the association of health illiteracy with diabetes outcomes. “Population health cardiology” includes articles on hospital readmission of Medicare patients, risk factors for atrial fibrillation, and vitamin intake as a determinant of homocysteinemia in elderly people.

Why are there so few population health articles and initiatives in otolaryngology? According to Kevin Sykes, PhD, MPH, director of clinical research in otolaryngology–head and neck surgery at the University of Kansas Medical Center in Kansas City, “pediatric and family medicine tend to be far ahead of us when it comes to population health because those providers are more interested in a prevention approach rather than a treatment approach.”

As a surgical specialty, otolaryngology has long focused on one-on-one interventions. Patients seek the services of an otolaryngologist when they have a problem they want fixed; otolaryngologists fix it. And although there have been some efforts to improve the otolaryngologic health of particular populations—most notably, the push toward newborn hearing screening—population health research and initiatives are still relatively rare in otolaryngology.

“You don’t see a lot of population health research or initiatives in surgical specialties,” said Elizabeth Calhoun, PhD, MEd, executive director of the Center for Population Health at the University of Arizona Health Sciences in Tucson. “They aren’t preventionists; they’re interventionists.”

But as healthcare moves away from the fee-for-service model of care toward models of care that reward providers for maintaining patient health rather than treating patient illness, there’s an economic incentive to prioritize prevention and population health. Providers and the public are also realizing that social determinants, such as income and access to care, drastically affect health. This realization points to an obligation to adapt treatment to the needs of particular populations.

Population Health Defined

Generally speaking, population health considers the health outcomes of a group of individuals, including the distribution of those outcomes within the group. “You can define a population according to geography, demographic, genetics, or anything else,” Dr. Sykes said.

Population health and public health are closely linked. “Public health involves taking large amounts of data, looking specifically at the health of the population, analyzing contributors to health, and understanding how to prevent disease,” said Steven S. Chang, MD, an otolaryngologist and co-lead of the Cancer Epidemiology, Prevention and Control Research Program at the Henry Ford Health System in Detroit. Vaccination and hearing screenings are two healthcare initiatives that grew out of the public health sciences.

Population health “is a newer buzz-word,” Dr. Chang said. It drills down into the whys that influence health outcomes within a population. “Population health looks at the social determinants that lead to whether a person gets vaccinated or not,” he added. “Is it health literacy? Their understanding of why vaccination is important? Is it transportation?” The answers to those questions are imperative because an intervention that aims to increase vaccination rates by emphasizing the potential harm of infection will never succeed if lack of transportation is the primary cause of sub-par vaccination rates.

Population Health in Otolaryngology

Stephanie Smith, MD, assistant professor of otolaryngology–head and neck surgery at Northwestern Medicine in Chicago, believes that population health is more prevalent within the specialty than many people realize. “I think there is a fair amount of population health research being done within otolaryngology, but it may not be defined as such,” she said. “For instance, over the past decade, we’ve seen a lot of research emerging on HPV and its relationship to oropharyngeal cancer, and that has affected vaccination campaigns,” she said. “I think that over the next few years and decades, we’ll see the impact of vaccination on head and neck cancer rates.”

Dr. Smith’s research into antibiotic prescription patterns for sinusitis is an example of population health research that may fuel population health initiatives. “The impetus for my research came from national data that shows we prescribe antibiotics for sinusitis more than [for] any other diagnosis for adult outpatients in this country,” she said. Given the fact that unnecessary antibiotic usage may contribute to the rise of antibiotic-resistant bacteria, minimizing over-prescription is one way to protect public health. Dr. Smith dug more deeply into the data and learned that primary care physicians and otolaryngologists prescribe most of the antibiotics used to treat sinusitis; she also discovered that primary care physicians are more likely to prescribe antibiotics than otolaryngologists. “Whenever you find a disparity, it points to an opportunity for quality improvement,” she said. “Someone is doing it differently and, perhaps, better.”

Because many patients think that antibiotics are the best treatment for sinusitis, and expect their providers to write a prescription, Dr. Smith is currently working to develop a mobile health platform that will tailor information to patient populations. She plans to test whether or not such a platform can effectively shape patient expectations of antibiotics and interactions with primary care providers. If so, routine use of such a tool could decrease antibiotic over-prescription.

At the Henry Ford Health System, Dr. Chang has integrated population health into the clinical care of patients with head and neck cancer. All new patients attend a pretreatment clinic to help them prepare for their upcoming cancer treatments. During this appointment, clinicians also administer some basic screening tests to better understand how well patients will do during treatment,” Dr. Chang said. Clinicians use standardized tools to assess patient health literacy, alcohol and tobacco use, and social determinants of health. The information garnered helps healthcare providers tailor treatment to patients’ specific needs. It also drives additional population health research.

“Because we use standardized tools, we can look across our data and records and compare outcomes for early stage vs. late stage head and neck cancer, socioeconomic status, cognitive status, and type of cancer,” Dr. Chang said.

Pediatric and family medicine tend to be far ahead of [otolaryngology] when it comes to population health because those providers are more interested in a prevention approach rather than a treatment approach. —Kevin Sykes, PhD, MPH

Data Quality Is Crucial

Huge troves of digitized data can reveal valuable information about patient populations, but researchers and clinicians must carefully evaluate the quality of available data. The proliferation of electronic medical records (EMRs) means that healthcare researchers have access to more data points than ever before, but experts call for caution. “Networked electronic health records are potentially a very powerful research tool, but we have to be careful in terms of how we collect, interpret, and analyze the data,” Dr. Smith said.

Hospitals, healthcare centers, and insurance companies maintain large databases of patient information, but much of that data is collected to satisfy payors’ requirements. “Most databases today are all actuarial designed,” said Chester Griffiths, MD, an otolaryngologist at Providence Saint John’s Health Center in Santa Monica, Calif.

Better sources of data include national health projects such as the National Cancer Institute’s Surveillance, Epidemiology, and End Result (SEER) database, which includes data from population-based cancer registries, and the National Cancer Database, which is jointly sponsored by the American College of Surgeons and the American Cancer Society and includes data on more than 70% of all newly diagnosed cancer cases in the United States. The All of Us Research Program, a National Institutes of Health effort to collect personal health and genomic information from one million Americans, will also produce tremendous quantities of valuable data.

Reviewing the data present in such large databases is a great way to generate hypotheses, said Dr. Sykes. However, additional data is usually necessary to test those hypotheses.

An analysis of the information contained in a database may reveal, for instance, that African American patients with oropharyngeal cancer typically experience poorer outcomes than white patients with the same type of cancer, despite identical treatment. “That’s good to know, but the data can’t tell us why,” Dr. Sykes said. “Is it because of systemic bias? Or is something genetic going on? Is there some other component of the disease itself that we don’t understand?”

Dr. Sykes frequently encourages the otolaryngologists in his department to add a population health focus to their research questions. “I ask them to think about what additional data points they might want to consider to make sure planned interventions are sensitive to particular populations, such as people that live further away or have less income,” Dr. Sykes said.

Incorporating Population Health into Practice

Otolaryngologists who are interested in adopting a population health approach to their practices would do well to begin with an analysis of their patient charts. “Look at your records. Look at the populations you’ve treated. Does anything stand out?” said Dr. Calhoun.

Interested otolaryngologists can also connect with their local departments of public health. “Have conversations with them about what they’re seeing that may relate to otolaryngology,” Dr. Sykes said. Public health officers are typically well versed in the health concerns and challenges of various populations within the community; they may have already identified an area of need that dovetails with your clinical practice or research interests.

To move the profession forward, otolaryngologists should partner with epidemiologists, nurses, and other healthcare professionals. Academic departments should consider hiring PhD-prepared researchers to help them study prevention strategies and population health challenges.

“Rather than creating a research team composed strictly of surgeons, add professionals with a population health perspective as well,” Dr. Sykes said. “It’s important to have these conversations about what your work means to all populations—not just the people who come through your door, but also those populations who may not have access to your services or the interventions you’ve developed.”

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Jennifer Fink is a freelance medical writer based in Wisconsin.