Impact of a Population Health Management Intervention on Disparities in Cardiovascular Disease Control

  • Aisha James
  • Seth A. Berkowitz
  • Jeffrey M. Ashburner
  • Yuchiao Chang
  • Daniel M. Horn
  • Sandra M. O’Keefe
  • Steven J. Atlas
Original Research



Healthcare systems use population health management programs to improve the quality of cardiovascular disease care. Adding a dedicated population health coordinator (PHC) who identifies and reaches out to patients not meeting cardiovascular care goals to these programs may help reduce disparities in cardiovascular care.


To determine whether a program that used PHCs decreased racial/ethnic disparities in LDL cholesterol and blood pressure (BP) control.


Retrospective difference-in-difference analysis.


Twelve thousdand five hundred fifty-five primary care patients with cardiovascular disease (cohort for LDL analysis) and 41,183 with hypertension (cohort for BP analysis).


From July 1, 2014–December 31, 2014, 18 practices used an information technology (IT) system to identify patients not meeting LDL and BP goals; 8 practices also received a PHC. We examined whether having the PHC plus IT system, compared with having the IT system alone, decreased racial/ethnic disparities, using difference-in-difference analysis of data collected before and after program implementation.

Main Measures

Meeting guideline concordant LDL and BP goals.

Key Results

At baseline, there were racial/ethnic disparities in meeting LDL (p = 0.007) and BP (p = 0.0003) goals. Comparing practices with and without a PHC, and accounting for pre-intervention LDL control, non-Hispanic white patients in PHC practices had improved odds of LDL control (OR 1.20 95% CI 1.09–1.32) compared with those in non-PHC practices. Non-Hispanic black (OR 1.15 95% CI 0.80–1.65) and Hispanic (OR 1.29 95% CI 0.66–2.53) patients saw similar, but non-significant, improvements in LDL control. For BP control, non-Hispanic white patients in PHC practices (versus non-PHC) improved (OR 1.13 95% CI 1.05–1.22). Non-Hispanic black patients (OR 1.17 95% CI 0.94–1.45) saw similar, but non-statistically significant, improvements in BP control, but Hispanic (OR 0.90 95% CI 0.59–1.36) patients did not. Interaction testing confirmed that disparities did not decrease (p = 0.73 for LDL and p = 0.69 for BP).


The population health management intervention did not decrease disparities. Further efforts should explicitly target improving both healthcare equity and quality.

Clinical Trials #: NCT02812303 (


population health management racial and ethnic disparities in care hypertension hyperlipidemia cardiovascular disease 



Funding for this program, including the IT tool and personnel, was provided by the Massachusetts General Physicians Organization and Partners HealthCare. These funders were involved in creating and implementing the program, but the authors were responsible for design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, and submission of the manuscript without funder approval. Seth A. Berkowitz’s role in the research reported in this publication was supported by the National Institute Of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under Award No. K23DK109200. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with Ethical Standards

Conflict of Interest

Massachusetts General Hospital entered into a royalty arrangement on June 27, 2013, to commercialize the population management system with SRG Technology, a for-profit company. Dr. Atlas is a beneficiary of this royalty arrangement but has not received any payments to date. Dr. Atlas has received payments as a consultant for the company. All other authors declare that they have no disclosures.

Dr. Berkowitz had full access to all of the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis.

Prior Presentation

A version of the study was presented as an Oral Abstract at the Society for General Internal Medicine Meeting in Washington, DC, on April 21, 2017.

Supplementary material

11606_2017_4227_MOESM1_ESM.docx (99 kb)
ESM 1 (DOCX 99 kb)


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Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Aisha James
    • 1
  • Seth A. Berkowitz
    • 2
    • 3
  • Jeffrey M. Ashburner
    • 2
    • 3
  • Yuchiao Chang
    • 2
    • 3
  • Daniel M. Horn
    • 2
    • 3
    • 4
  • Sandra M. O’Keefe
    • 4
  • Steven J. Atlas
    • 2
    • 3
  1. 1.Harvard/Massachusetts General Hospital Medicine-Pediatrics Residency ProgramBostonUSA
  2. 2.Division of General Internal Medicine Massachusetts General HospitalBostonUSA
  3. 3.Harvard Medical SchoolBostonUSA
  4. 4.Massachusetts General Physicians Organization, Massachusetts General HospitalBostonUSA

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