O • N • E Some of the most significant women in the history of nursing made their reputations by providing population-based care. Their influence on nursing has been such that their names live on and their achievements continue to be recognized because of their important contributions to nursing and to healthcare. A brief look at the stories of some of these women helps to provide a background for understanding population health. Although she started her career as a teacher, Clarissa (Clara) Barton won her greatest acclaim as a nurse. Horrified by the suffering of wounded soldiers in the American Civil War (many of them former neighbors and students) and struck by the lack of supplies needed to care for them, she worked to obtain various supplies and put herself at great risk by nursing soldiers on the front lines of several major battles. Her experience would eventually lead to her becoming the founder and first president of the American Red Cross (Evans, 2003). During the Crimean War, Florence Nightingale used statistical analysis to plot the incidence of preventable deaths among British soldiers. She used a diagram to dramatize the unnecessary deaths of soldiers caused by unsanitary conditions and lobbied political and military leaders in London for the need to reform. She worked to promote the idea that social phenomena could be objectively measured and subjected to mathematical analysis. Along with William Farr, she was one of the earliest healthcare practitioners to collect and analyze data in order to persuade people of the need for change in healthcare practices (Dossey, 2000; Lipsey, 2006). Mary Breckinridge started the Frontier Nursing Service (FNS) in Kentucky in 1925 and remained its director until her death in 1965. Educated as a nurse and midwife, she devoted her life to improving health in rural areas, especially among women and children. She believed in working with the communities that were served by the FNS, and formed and worked with committees composed of community members to help plan and provide care. Similar to Florence Nightingale, she believed in the use of statistics to measure outcomes. From its onset, the FNS was so successful that there was an immediate drop in infant and maternal deaths in the communities served by the FNS (January, 2009; Frontier Nursing Service, 2014). These three nurses all worked to improve the health of at-risk populations. They met with political leaders to advocate changes in polices to benefit those populations, and both Nightingale and Breckinridge used statistical analysis to both support the need for change and to evaluate their interventions. Breckinridge was an early advocate of engaging communities to help address community health issues. They were all pioneers of nursing and, although perhaps not in name, certainly in fact, among the first nurses working in advanced practice. For decades, community health nurses have recognized the importance and the impact of population-based care, but large segments of nursing practice have focused primarily on caring for individual patients. Nursing remains, and should remain, a practice-based and caring profession, but nursing practice is changing. There is a growing awareness of the need to provide evidence-based care and to design interventions that have a broad impact on the populations that nursing serves, no matter the setting. Population health obligates healthcare professionals to implement standard interventions, based on the best research evidence, to improve the health of targeted groups of people. It also obligates nurses to discover new and effective strategies for providing care and promoting health. Although clinical decision making related to individual patients is important, it has little impact on overall health outcomes for populations. Interventions at the population level have the potential to improve overall health across communities. This book addresses the essential areas of content for a doctorate in nursing practice (DNP) as recommended by the American Association of Colleges of Nursing (AACN), with a focus on the AACN core competencies for population-based nursing. The goal is to provide readers with information that will help them to identify healthcare needs at the population level and to improve population outcomes. Although the focus is on the essential components of a DNP program, the intent is to broadly address practice issues that should be the concern of any nurse in an advanced practice role. This chapter introduces the reader to the concept of population-based nursing. The reader learns how to identify population parameters, the potential impact of a population-based approach to care, and the importance of designing nursing interventions at the population level in advanced nursing practice. For all the scare tactics out there, what’s truly scary—truly risky—is the prospect of doing nothing. —President Barack Obama, The New York Times, August 16, 2009 The first two decades of the 21st century have been witness to a growing and contentious debate on healthcare reforms. President Barack Obama’s stated goals in pushing for reforming health insurance were to extend healthcare coverage to the millions who lacked health insurance, stop the insurance industry’s practice of denying coverage on the basis of preexisting conditions, and cut overall healthcare costs. There is ample evidence of a need for healthcare reform in the United States. The gross domestic product (GDP) is the total market value of the output of labor and property located in the United States. It reflects the contribution of the healthcare sector relative to all other production in the United. In 1960, the health sector’s proportion of the GDP was 5% (i.e., $5 of every $100 spent in the United States went to pay for healthcare services). By 1990, this figure had grown to 12% and by 1996, 14%. A report issued by the Committee on the Budget of the U.S. Senate in 2008 warned that unless changes were made in how the United States provides care to its citizens, the GDP for the healthcare sector would grow to 25% by 2025 and 49% by 2089 (Orszag, 2008). In 2014, the Centers for Medicare & Medicaid Services (CMS) published its forecast of healthcare costs for 2013 to 2023. Its estimates are similar to those previously published by the Senate. The CMS has projected that healthcare spending will increase an average of 5.7% each year from 2013 to 2023, about 1.1% faster than the GDP. If accurate, healthcare spending would account for 19.3% of the GDP by 2023. According to the CMS, the state of the economy in the United States, the expansion of the Affordable Care Act (ACA), and the aging of the U.S. population are the three major factors driving healthcare costs at this time (CMS, 2014). The Organization for Economic Cooperation and Development (OECD) provides a global picture of healthcare spending. It reports that U.S. expenditures for healthcare as reflected by GDP are nearly double those of the average for OECD countries. One interesting fact that can be gleaned from that report is that the OECD attributes that the difference in costs (U.S. costs as compared to other countries) is due to private health sector prices, primarily pharmaceuticals (OECD, 2013). The rising cost of healthcare is reflected in the insurance industry. According to the Henry J. Kaiser Family Foundation (2014a), the average annual premium for employer-sponsored family health coverage in 2014 is $16,834 and the average annual contribution from employees is $4,823. They also report that the average deductible is $1,217. Since 2009, the average deductible has risen 47%. Unfortunately, although the United States ranks first in spending on healthcare among industrialized nations, it ranks lower than most industrialized countries in important health indicators. Two commonly used indicators for measuring a country’s health are infant mortality and life expectancy at birth. Worldwide, the United States is ranked 42nd for life expectancy at birth (life expectancy at birth in the United States is 79.56 years) and 55th for infant mortality (infant mortality rate in the United States is 6.17/1,000 live births; Central Intelligence Agency [CIA], 2014). A report issued by the Institute of Medicine (IOM, 2010a) argues that the system used in the United States for gathering and analyzing health measures is part of the problem. A second problem is the inadequate system used in the United States for gathering, analyzing, and communicating information on the underlying factors that lead to chronic health conditions and other risk factors that contribute to poor health. Readers can refer to Chapter 11 for a more detailed description of how the United States ranks among other countries in relation to health indicators. Driven by a need for change in how healthcare is paid for, the ACA was signed into law by President Obama in 2010. It went into effect over the span of 4 years beginning in 2011. The public option in the ACA proposed that an insurance plan be offered by the federal government for purchase by consumers and small businesses. This option was eliminated from the reconciled legislation. Currently, there are three different “markets” for insurance through the ACA. The federal marketplace is run solely by the federal government. The state marketplace is run solely by the state, and in partnership marketplaces, states run many of the important functions and make key decisions but the marketplace is operated by the federal government. The ACA includes an option whereby states can expand Medicaid eligibility. Although it is too early to determine whether the legislation has had an effect on health indicators, there is evidence that the ACA is impacting insurance rates. The Centers for Disease Control and Prevention (CDC) released a report based on the 2014 National Health Interview Survey in late 2014 (Cohen & Martinez, 2014). According to this report, 41 million people in the United States were without health insurance in the first 3 months of 2014. This number represents 13.1% of the U.S. population. The lowest uninsured rate (6.6%) is for children 17 years of age and younger as most states have state/federal-funded programs to cover children. (The State Children’s Health Insurance Program [SCHIP] was enacted in 1997 as a Medicaid expansion program to insure children whose families made too much to qualify for Medicaid but whose incomes did not permit private insurance coverage.) The report notes that adults younger than 65 were three times more likely to be uninsured (18.4%) than children, a disparity that many hope the ACA will diminish. Almost 10% of the total U.S. population was uninsured for more than a year. Although uninsured rates remain high, the report did find that the number of uninsured adults decreased from 20.4% in 2013 to 18.4% during the first quarter of 2014. A survey conducted by the Gallup Poll in the first quarter of 2014 found that the uninsured rate among adults in the United States for the fourth quarter of 2014 averaged 12.9%, a significant drop from the uninsured rate of 17.1% for the same period 1 year before (Levy, 2014). As noted earlier, it will take time to see whether insured rates for all ages will approach 100%, but the more important goal will be to see whether overall health improves. Of equal importance is to determine whether the ACA improves access to healthcare along with improved insurance rates. Differences in insurance rates are being observed based on the choices made by states as they relate to the ACA. In the first 3 months of 2014, uninsured rates decreased in states that opted for Medicaid expansion, but not in those states that did not opt for the expansion. In those states that expanded Medicaid, the insurance rate in people younger than 64 dropped from 18.4% to 15.7% in the first quarter of 2014. It did not change in states that did not expand eligibility. During the same time period, there were no decreases in uninsured rates for either state or federal marketplaces, but there was a decrease in the uninsured rate in people aged 64 and younger in partnership marketplaces (Cohen & Martinez, 2014). There is also evidence that the ACA has impacted the insurance rate of Latinos in the United States. Historically, Latinos have had the highest uninsured rates of any racial or ethnic group in the United States. Less than 1 year after the ACA was implemented, the overall Latino uninsured rate dropped from 36% to 23%, according to the Commonwealth Fund Affordable Care Act Tracking Survey, conducted in 2014 (Rasmussen, Collins, Doty, & Beutel, 2014). Notably, the uninsured rate among Latinos in states that did not expand their Medicaid program at the time of the survey remained unchanged. These states are home to about 20 million Latinos, the majority of whom live in Texas and Florida (Doty, Blumenthal, & Collins, 2014). It is unclear if or how healthcare will be affected in the long term by the ACA, because the law is constantly being challenged by several groups and it is too soon to determine whether it will have an impact on any health indicators. As this book goes to print, Republicans, who have tried repeatedly to strike down the legislation, have taken control of the Senate as well as the House. The Supreme Court’s June 2015 decision in King v. Burwell preserves federal healthcare subsidies under the ACA for Americans who reside in states that have opted not to create their own health insurance exchanges. In so doing, it removes an immediate uncertainty for those who would have been left without coverage if the federal exchanges had been declared unconstitutional (King v. Burwell, June 25, 2015). The ACA currently specifies the maximum amounts people will have to pay in cost sharing based on their incomes, and federal subsidies make up the rest. Our healthcare system is complex, and there is no simple solution to lowering costs and improving access. The goal of this textbook is not to provide an overarching solution to the issues of cost, but to propose that nurses can contribute to improving the cost-effectiveness and efficiency of care through the provision of evidence-based treatment guidelines to identified populations with shared needs, and by advocating for policies that address the underlying factors that impact health and healthcare. To do this, we must change the way that we deliver healthcare and become politically active. In an ideal world, healthcare policies are created based on valid and reliable evidence and population need and demand. The ideal premise is that there is equitable distribution of healthcare services and that the appropriate care is given to the right people at the right time and at a reasonable cost. For 20 years, the American Nurses Association (ANA) has been advocating for healthcare reforms that would guarantee access to high-quality healthcare for all. The ANA supports the ACA and was an advocate for the public option (ANA, 2014). It is a function of individual choice to either support or not support healthcare reforms. The actions of professional organizations are driven by membership. Regardless of your political alliance, involvement in professional organizations as well as in local, state, and national political activities (even if only minimally as a registered and active voter) is part of the professional responsibility of advanced practice registered nurses (APRNs). The AACN definition of advanced practice nursing includes recognizing the importance of identifying and managing health outcomes at the population level (AACN, 2004). In 2006, the AACN specified that graduates of DNP programs have competency in meeting “the needs of a panel of patients, a target population, a set of populations, or a broad community” (AACN, 2006, p. 10). A core component of DNP education is clinical prevention (health promotion and disease prevention at individual and family levels) and population health (focus of care at aggregate and community levels and examination of environmental, occupational, cultural, and socioeconomic dimensions of health) (AACN, 2006; Allan et al., 2004). Regardless of whether DNP graduates practice with a focus on clinical prevention or population health, the ability to define, identify, and analyze outcomes is imperative for improving the health status of individuals and populations (AACN, 2006). The goal of population-based nursing is to provide evidence-based care to targeted groups of people with similar needs in order to improve outcomes. Population-based nursing uses a defined population or aggregate as the organizing unit for care. The American Heritage Dictionary of the English Language (“Population,” 2002, p. 1366) defines a population as “all of the people inhabiting a specified area.” A second definition is given as “the total number of inhabitants constituting a particular race, class, or group in a specified area” (p. 1366). Subpopulations may be referred to as aggregates. Many different parameters can be used to identify or categorize subpopulations or aggregates. They may be defined by ethnicity (e.g., African American or Hispanic), religion (e.g., Roman Catholic or Buddhist), or geographic location (e.g., Boston or San Diego). Aggregates can also be defined by age or occupation. People with a shared diagnosis (e.g., diabetes) or a shared risk factor (e.g., smoking) comprise other identifiable aggregates. Sometimes people may choose to describe themselves as members of a particular group (e.g., Democrat or Socialist). One person may belong to more than one such group (e.g., White, younger than 18 years, current smoker, etc.). A community is composed of multiple aggregates. The most common aggregate used in population-based nursing is the high-risk aggregate. A high-risk aggregate is a subgroup or subpopulation of a community that shares a high-risk factor among its members, such as a high-risk health condition (e.g., congestive heart failure) or a shared high-risk factor (e.g., smoking and sedentary behavior). The aggregate concept can be used to target interventions to specific aggregates or subpopulations within a community (Porche, 2004). The implementation of standard or proven (evidence-based) strategies to prevent illness and/or improve the health of targeted groups of people can have the effect of ameliorating health problems at the population and/or aggregate level. Making change at the population level may impact the health of a community not only in the present but for generations to come. As we learn how to approach and target populations using evidence, we improve our chance of long-term success and can strive to make lifelong changes in the health of a group of people. The collection and analysis of data provide healthcare professionals and policy makers with a starting point for identifying, selecting, and implementing interventions that target specific populations and aggregates. Many of the leading causes of death in the United States are preventable. One in three American adults has cardiovascular disease, and it is the leading cause of death among both men and women in the country, killing an average of one American every 37 seconds (American Heart Association [AHA], n.d.). On the basis of data from 2010, the CDC has identified, in descending order, the 10 leading causes of death in the United States They are heart disease, cancer, chronic lower respiratory tract diseases, accidents, stroke, Alzheimer’s disease, diabetes, influenza and pneumonia, renal diseases, and intentional self-harm (e.g., suicide) (CDC, 2014a). Several factors, such as the physical environment, healthcare systems, personal behaviors, and the social environment, can have a deleterious impact on individual and community health. The negative consequences of these factors are researched and well documented. Life expectancy for smokers is at least 10 years shorter than for nonsmokers. It is a leading cause of preventable morbidity and mortality, causing nearly one of every five deaths annually in the United States. This figure includes heart attack deaths and lung cancer deaths among nonsmokers who are exposed to secondhand smoke. It is estimated that smoking contributes $96 billion to healthcare costs in the United States (CDC, 2014b). The CDC used the 2012–2013 National Adult Tobacco Survey (NATS) to estimate adult smoking prevalence rates in the United States. The findings indicate that 21.3% of U.S. adults use a tobacco product every day or some days. Smoking rates are higher among men, younger adults, non-Hispanic adults, those living in the Midwest and South, those with less education and income, and LGBT (lesbian, gay, bisexual, and transgender) adults (Agaku et al., 2014). Although higher rates are seen in younger adults, a reduction in smoking by school-age children should result in reductions in tobacco-related deaths in the future, and there is good news related to smoking rates among this group. Cigarette smoking rates for high school students have dropped to the lowest levels since the National Youth Risk Behavior Survey (YRBS) began in 1991. The U.S. teen smoking rate of 15.7% has met the national Healthy People 2020 objective of reducing adolescent cigarette usage to 16% or less (CDC, 2014c). Another very popular trend is the use of hookahs. Hookahs are water pipes used to smoke specially flavored tobaccos. More and more youth are drawn toward this social trend in which groups of people share a hookah usually in a café setting (American Lung Association, 2007, n.d.). Although hookahs have been around for hundreds of years, they are not a safe alternative to smoking. A Monitoring the Future survey found that as many as 17% of high school seniors have tried hookahs. The numbers are even higher for college-age students (U.S. Department of Health and Human Services, 2012). The tobacco and smoke from hookahs have toxic properties and have been linked to various cancers, including lung and oral cancers. Many of the same effects of cigarette smoking are found with smoking hookahs, and very little is being done to educate youth on the health effects of hookahs (Cobb, Ward, Maziak, Shihadeh, & Eissenberg, 2010). As with any potential threat to health, education of our youth and adult populations regarding the deleterious effects of hookahs is paramount to reducing the potential morbidity and mortality of long-term exposure to these flavored tobaccos. More recently, newer electronic forms of hookahs have been introduced, and little research has been conducted to determine the long-term health effects of these products. Regardless, the use of hookahs is another growing epidemic of health behaviors that an APRN can attempt to modify by evidence-based prevention education. For more on the effects of hookahs, refer to the CDC’s site (http://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/index.htm#overview). There is huge potential for cost savings by preventing smoking-related illnesses, and one cannot overlook the effects of secondhand smoking on the health of family members and coworkers. It is well known that secondhand smoke has long-lasting effects on the unborn fetus, infant, and child. These effects can manifest as low birth weight in newborns (Ventura, Hamilton, Mathews, & Chandra, 2003), increased respiratory infections and higher risk of asthma exacerbations (U.S. Environmental Protection Agency [EPA], 2014), sudden infant death (Anderson & Cook, 1997), and a lower intelligence quotient (Yolton, Dietrich, Auinger, Lanphear, & Hornung, 2005). Thus, it is important to recognize not only the direct effects of smoking on health but also the indirect effects on the fetus, infants, children, and family members. The effects of secondhand smoke are not specific to smoking cigarettes. Exposure to hookah smoke is also associated with very similar effects on the fetus, infants, and family members. Education of pregnant mothers is just as important as with other family members as they may not realize the negative effects of secondhand exposure to hookah or cigarette smoke. As with other smoking-related diseases, the cessation of smoking early on can reverse or ameliorate the potential long-term harmful effects of secondhand smoke exposure. These data provide a starting point for targeting specific high-risk groups for intervention based on parameters such as age, education, income, and geographical location. Another pertinent fact is that many insurance companies are now charging higher premiums for smokers than for nonsmokers. This has led to increasing interest in cessation programs, but whether this will have a long-term impact on smoking rates is unknown. Smoking cessation and smoking prevention programs are not the only areas that offer opportunities for improving the health of people in the United States and for saving money. Other health problems, such as obesity, are also significant public health concerns. In 2009, researchers published their analysis of the cost of obesity in the United States, taking into account separate categories for inpatient, outpatient, and prescription drug spending. They estimated that the medical costs of obesity may have been as high as $147 billion/year by 2008 (including $7 billion in Medicare prescription drug costs). According to their findings, the annual medical costs for people who are obese were $1,429 higher than those for normal-weight people (Finkelstein, Trogdon, Cohen, & Dietz, 2009). Ogden, Carroll, Kit, and Flegal (2014) studied the prevalence of obesity in children and adults in the United States. They also looked at trends between 2003 and 2012 and found no significant changes in obesity rates for youths or adults between 2003 and 2012. They did find that there was a significant decrease in obesity among children aged 2 to 5 (from 13.9/1,000 to 8.4/1,000). This good news was somewhat tempered by the fact that the rate increased for children aged 2 to 19 (from 16.9/1,000 to 19.34/1,000). They also reported that older non-Hispanic Blacks have the highest age-adjusted rates of obesity (47.8%), followed by Hispanics (42.5%), non-Hispanic Whites (32.6%), and non-Hispanic Asians (10.8%). Among age groups, obesity is higher among middle-age adults (39.5% for people aged 40–59), than among younger adults (30.3% for people aged 20–39), and highest among older adults (35.4% for 60 years or older). As part of Healthy People 2020, the United States set an objective to decrease the proportion of obese adult Americans (20 years of age or older) to 30.5%. Healthy People 2020 uses the baseline of 33.9%, which was the percentage of persons aged 20 years and older who were obese in 2005 to 2008. The target objective for children (aged 2 to 19 years) is 14.5%. The baseline data for this objective is 16.1%, which was the percentage of children who were considered obese in 2005 to 2008 (HealthyPeople.gov, 2014). Obesity is associated with increased morbidity and mortality rates. For example, Borrell and Samuel (2014) found that obese adults, when compared with normal-weight adults, had 20% higher all-cause and cardiovascular disease mortality rates, even when controlling for demographic and behavioral characteristics. Although people are familiar with the association between heart disease and obesity, many are just learning about the relationship between obesity and cancer. Obesity is associated with an increased risk for many cancers, including esophageal, pancreatic, colon and rectal, breast (after menopause), endometrial, kidney, thyroid, and gallbladder. It has been estimated that the percentage of cases attributed to obesity (although it varies) may be as high as 40% for some cancers, particularly endometrial and esophageal cancers (National Cancer Institute, 2014). Jacobs et al. (2010) published a study that helps to illustrate the complexity of understanding risk factors and their relationship to the development of poor health. They studied the association between waist circumference and mortality among 48,500 men and 56,343 women 50 years or older. They determined that waist circumference as a measure of abdominal obesity is associated with higher mortality independent of body mass index (BMI). They note that waist circumference is associated with higher circulating levels of inflammatory markers, insulin resistance, type 2 diabetes, dyslipidemia, and coronary heart disease. In recent years, the constellation of these factors has been described as the metabolic syndrome. Metabolic syndrome is a complex syndrome that encompasses many conditions and risk factors, particularly abdominal obesity, high blood pressure, abnormal cholesterol and triglyceride levels, and insulin resistance, and is known to be associated with an increased risk of stroke, heart disease, and type 2 diabetes (Grundy et al., 2005). The increasing prevalence of metabolic syndrome is becoming a tremendous public health concern, and more evidence is appearing in the literature to better define the treatment as well as preventive measures needed to reduce the incidence. Although it is ill defined in children and adolescents, it is clear that early interventions to reduce obesity and sedentary behavior and to improve nutrition can have long-term effects and can improve overall life expectancy. The metabolic syndrome, similar to many conditions, demonstrates the complexity of interactions that occurs in disease development and that no one factor in and of itself can be targeted alone. Our understanding of obesity is also becoming more complex, as new studies have identified independent associations between sitting time/sedentary behaviors and increasing all-cause and cardiovascular disease mortality risk. This phenomenon highlights the importance of avoiding prolonged, uninterrupted periods of sitting time (Dunstan, Thorp, & Healy, 2011). The APRN needs to take into consideration the many facets of health and disease, genetics and environment, including human attitudes, attributes, and behavior when determining how to implement a population-based intervention. One cannot talk about the epidemic of obesity and not mention its concomitant relationship to diabetes mellitus (DM). The number of American adults treated for DM more than doubled between 1996 and 2007 (from about 9 to 19 million). This includes an increase from 1.2 to 2.4 million among people aged 18 to 44 years. During this time period, the treatment costs for DM climbed from $18.5 to $40.8 billion (Soni, 2010). In June 2014, the American Diabetes Association released the results of the National Diabetes Statistics report (CDC, 2014d). The report highlights the importance of tracking morbidity rates and the need to be aware of trends in order to target groups for interventions. The percentage of Americans with DM aged 65 and older is estimated to be as high as 25.9% (accounting for over 11 million seniors), which includes those who are undiagnosed. The incidence rate of diabetes in 2012 was 1.7 million new diagnoses per year. The rise in both incidence and prevalence rates for DM is closely tied to rising obesity levels, which is a preventable risk factor. This upward trend in the incidence rate for DM provides a clear direction for targeting prevention measures toward younger populations. There is, in fact, a huge potential for improving the health of populations by targeting children using primary prevention measures that go well beyond reducing diabetes rates. Implications for early interventions beginning in pregnancy and continuing through infancy and early childhood are clear. Evidence is increasing that early feeding patterns (e.g., breast-feeding versus formula feeding) as well as parental obesity and parental eating patterns are linked to the increased likelihood of developing obesity in children, which puts them at an increased risk for type 2 DM (Owen, Martin, Whincup, Smith, & Cook, 2005). There are many opportunities for APRNs to apply evidence-based, primary prevention interventions to improve the long-term outcomes of children at the beginning of pregnancy and at birth and thereafter. This approach may include targeting high-risk aggregates (e.g., parents with obesity and type 2 DM) and then expanding to communities through educational campaigns or changes in health policy. Most of the information discussed earlier exemplifies the biological and environmental factors that contribute to poor health in adults. However, it is becoming more apparent that social (e.g., psychological) factors starting as early as conception (e.g., maternal stress) may play a more significant role in adult health than was once thought. Having a comprehensive understanding of the underlying causes of adult diseases (including social, psychological, biological, and environmental) is necessary to successfully approach the problems seen in populations. Without this comprehensive understanding, it may be difficult to successfully implement a primary prevention program (the goal of which is to prevent disease before it occurs). Stress is a regular part of day-to-day life, and small amounts of stress are normal and necessary for developing coping skills. However, exposure to prolonged and severe stressors, such as abuse, neglect, or being a witness to or victim of violence, can lead to changes that occur in the brain and can lead to short-term and even long-term poor health outcomes. This type of stress is termed toxic stress. The effects of toxic stress are being rigorously studied, and in particular, studies looking at adverse childhood events (ACE) were some of the first to show a correlation between toxic stress exposures and high-risk behaviors and poor health outcomes in adults. The ACE study is an ongoing, joint project of the CDC and Kaiser Permanente that looks retrospectively at the relationships among several categories of childhood trauma. Childhood trauma exposures were broken down into three categories: abuse (e.g., physical or sexual), neglect (e.g., emotional or physical), and household dysfunction (e.g., having an incarcerated household member, family member with mental health issue and/or drug and alcohol problems, domestic violence, or parental divorce or separation). An ACE score is calculated based on past exposures to the subparts of each of the aforementioned categories. The higher the ACE score, the stronger the relationship to high-risk behaviors or poor health outcomes (ACE Study, 2011). In one widely cited ACE study (Felitti et al., 1998), people who experienced a score of four or more categories of ACEs, compared with those who had no history of exposure, had a 4- to 12-fold increased risk for alcoholism, drug abuse, depression, and suicide attempts. They also experienced a 2- to 4-fold increase in smoking and self-reported poor health. Subsequent research provides additional evidence to support the link between childhood trauma and adverse events and poor health outcomes. For additional information on the effects of childhood stress, refer to the CDC publication at www.cdc.gov/ncipc/pub-res/pdf/Childhood_Stress.pdf. Many additional studies have been conducted that demonstrate the destructive effects of exposure to toxic stress. Goodwin and Stein (2004) identified an increased risk of diabetes in adults who were neglected as children and an increased risk of cardiac disease in adults who were sexually abused as children. Smyth, Heron, Wonderlich, Crosby, and Thompson (2008) completed a study of students entering college directly from high school to investigate the association between adverse events in childhood and eating disturbances. They found that childhood adverse events predicted eating disturbances in college. Childhood adverse events have also been linked to drug abuse and dependence (Messina et al., 2008) and greater use of healthcare and mental health services (Cannon, Bonomi, Anderson, Rivara, & Thompson, 2010). Building on earlier studies that linked smoking in adulthood with ACEs, Brown et al. (2010) discovered a relationship between a history of ACEs and the risk of dying from lung cancer. Researchers have identified similar outcomes in studies carried out with populations in other countries. A study conducted in Saudi Arabia, where beating and insults are an acceptable parenting style, identified a correlation between beating and insults (once or more per month) and an increased risk for cancer, cardiac disease, and asthma (Hyland, Alkhalaf, & Whalley, 2012). Scott, Smith, and Ellis (2012) completed a study in New Zealand which found that adults who had a history of child protection involvement had increased odds of a diagnosis of asthma. More and more studies are being conducted to look at the relationship of sustained exposure to toxic stress to a variety of poor health outcomes and high-risk behaviors. These behaviors include such things as cutting, hypervigilance, promiscuity, eating disorders, poor school performance, depression, violence, suicidal ideation/attempts, and justice system involvement. These are just a few of the many behaviors found to be associated with sustained exposure to toxic stress. Studies such as these illustrate the importance of understanding the social determinants of poor health and the potential for doing good and preventing harm to aggregates and populations by targeting exposures to such things as child abuse and neglect for prevention, early recognition, and intervention. Targeting evidence-based interventions toward aggregates in the acute care population also has the potential to improve health outcomes broadly. How can we improve the quality of care for our acute care patients by taking a population-based approach? When nurses apply evidence-based interventions to identified aggregates, they can improve outcomes more effectively than when interventions are designed on a case-by-case (individualized) basis. The following examples illustrate this point. Several organizations, including the Association for Professionals in Infection Control and Epidemiology and the CDC, have proposed a call to action to move toward elimination of healthcare–associated infections. The CDC and Agency for Healthcare Research and Quality (AHRQ) have published evidence-based recommendations for preventing central venous catheter-related bloodstream infections (CR-BSIs). These recommendations include hand hygiene, use of maximal barrier precautions, use of chlorhexidine gluconate for insertion site preparation, and avoidance of catheter changes. Catheters impregnated with antimicrobial agents are recommended when infection rates are high and/or catheters will be in place for a long time. Using these guidelines, hospitals have made good progress in reducing the incidence rate of CR-BSIs. In a report released by the CDC, CR-BSIs fell 46% between 2008 and 2013 (Steenhuysen, 2015). Another intervention that uses standard, evidence-based protocols to improve long-term outcomes addresses the treatment of stroke in an acute care setting. It was found that stroke patients taken to hospitals that follow specific treatment protocols have a better chance of surviving than patients taken to hospitals without specific stroke treatment protocols. A study evaluated the outcomes of the first 1 million stroke patients treated at hospitals enrolled in the Get With the Guidelines stroke program that was started by the AHA in 2003. The American Stroke Association guidelines require that hospitals follow seven specific evidence-based steps for treating stroke patients. Between 2003 and 2009, hospitals that followed these protocols lowered the risk of death by 10% for patients with ischemic stroke (Fonarow et al., 2011). Surveillance of poor health outcomes in acute care facilities is one way in which APRNs can identify causative factors and design interventions to reduce costs and improve care. For example, recognizing the causative factors that lead to increased rehospitalization rates and superutilization of emergency departments could be the first step in designing an intervention. Approximately 25% of all U.S. hospital patients are readmitted within 1 year for the same conditions that led to their original hospitalization. The AHRQ analyzed data from 2006 to 2007 on 15 million patients in 12 states. They found that among Medicare patients, 42% were readmitted to hospitals and 30% had multiple emergency department visits. Among Medicaid patients, 23% had multiple hospital admissions and 50% had multiple emergency department visits. According to the AHRQ, better outpatient care could prevent unnecessary repeat hospital admissions (AHRQ, 2010). Identifying and targeting populations with specific diagnoses for which there are high readmission rates offers great return on investment. Readmissions are costly in dollars to both consumers and hospitals and negatively impact the quality of life for patients. Noncommunicable diseases (NCDs) are the main cause of illness and disability in the United States and are responsible for the greater part of healthcare costs according to the CDC. About half (50.9%) of U.S. adults have at least one chronic condition, and 26% have two or more chronic conditions. Most chronic conditions result from preventable risk factors such as smoking, poor diet, sedentary behavior, excessive alcohol consumption, high blood pressure, and high cholesterol (Bauer, Briss, Goodman, & Bowman, 2014). In 2000, the U.S. Department of Health and Human Services (HHS) released a report outlining a strategic framework that includes goals to foster healthcare and public health system changes to improve the health of those with multiple chronic conditions. The intention of the framework is to create change in how chronic illnesses are addressed in the United States from an individual approach to one that uses a population-focused approach. The authors of the report point out that 66% of total healthcare spending is directed toward caring for the approximately 20% of Americans with multiple concurrent chronic conditions (e.g., arthritis, heart disease, and DM). One strategy proposed by the HHS is to define and identify populations and subpopulations with multiple chronic conditions broadly and to explore care models to target subgroups at high risk of poor health outcomes. Another proposed strategy addresses the need to develop systems to promote models to address common risk factors and challenges that are associated with many chronic conditions. The framework also addresses the need to create policies and interventions that identify populations and subpopulations at risk and to identify strategies and interventions that target these populations (U.S. Department of Health and Human Services, 2010). The problem of chronic diseases is not restricted to the United States. The World Health Organization (WHO) has published a report that documents the global problem of NCDs. NCDs now account for more deaths than infectious diseases even in poor countries. Director-General Dr. Margaret Chan of the WHO is quoted as saying, “[F]or some countries, it is no exaggeration to describe the situation is an impending disaster; a disaster for health, society, most of all for national economies” (WHO, 2011, p. v). Chronic diseases, such as heart disease, stroke, cancer, chronic respiratory diseases, and diabetes, are the leading cause of global mortality, representing 60% of all deaths. Out of the 35 million people who died from chronic disease in 2005, half were under 70 years old (WHO, 2014). Millions of people die each year as a result of modifiable risk factors that underlie the major NCDs. The writers of a report by the WHO contend that 8% of premature heart disease, stroke, and diabetes can be prevented. Ten action points, including banning smoking in public places, enforcing tobacco advertising bans, restricting access to alcohol, and reducing salt in food, are listed. All of these actions require a population approach to be effective (WHO, 2011). Interventions that are evidence based and population appropriate can reduce the underlying causes of chronic disease. This approach has the potential to lower the mean level of risk factors and shift outcomes in a favorable direction. An example that is receiving a lot of recent attention is sodium intake. Excess sodium in the diet can put people at risk for stroke and heart disease. The CDC has reported that 9 of 10 Americans consume more salt than is recommended. Only 5.5% of adults follow the recommendation to limit sodium intake to 1,500 mg a day. Most sodium does not come from salt added to foods at the table but from processed foods. These foods include grain-based frozen meals, soup, and processed meat. In this report, the IOM concludes that reducing sodium content in food requires new government standards for the acceptable level of sodium. Manufacturers and restaurants need to meet these standards so that all sources in the food supply are involved (CDC, 2010; IOM, 2010b). A study published in the Annals of Internal Medicine (Smith-Spangler, Juusola, Enns, Owens, & Garber, 2010) estimates that reducing dietary salt 0.3 g/day could greatly reduce the yearly number of U.S. cases of coronary heart disease, stroke, and heart attacks, with a savings of up to $24 billion in healthcare costs each year. Although the IOM has published a report that it finds no evidence that a drastic reduction in reduces the risk of heart attacks, stroke, and mortality, the AHA and the CDC both contend that sodium is associated with high blood pressure, and therefore does put people at risk (Mitka, 2013). This discussion illustrates the need to promulgate laws and develop policies that can effect positive health outcomes. It also illustrates the difficulty involved in planning interventions when evidence is sometimes contradictory, and causation is not only multifactorial but sometimes outside of the control of the people whose health is compromised. Changing individual behavior is difficult and has little impact on population health. Using the power of legislation and regulation to make changes in the environment, such as banning smoking in public places, improving air quality, and reducing the amount of sodium in processed foods, has enormous potential for improving the overall health of populations. The basic sciences of public health (particularly epidemiology and biostatistics) provide tools for the APRN working with specialized populations to provide evidence for effective and efficient interventions. The care of specialized groups is the core of advanced practice. Evidence-based practice is defined as the conscientious integration of best research evidence with clinical expertise and patient values and needs in the delivery of quality, cost-effective healthcare (Burns & Grove, 2009). Population-based nursing requires APRNs to plan, implement, and evaluate care in the population of interest. The evaluation of outcome measures in populations begins with an identification of the health problems, the needs of defined populations, and the differences among groups. The rates calculated from these numbers can help the APRN to identify risk factors, target populations at risk, and lay the foundation for designing interventions. Prevention is best carried out at the population level, whether at the level of direct care or through the support and promotion of policies. For example, an evidence-based program to prevent hospital readmissions for congestive heart failure can lead to improved health and decreased health-related costs. The promulgation of policies and regulations to support primary prevention measures, such as decreased sodium in prepared foods, could potentially lead to decreased rates of hypertension and heart disease. Interventions that are appropriate at the individual level and applied at the population level can result in a far-reaching effect. Outcomes measurement refers to collecting and analyzing data using predetermined outcomes indicators for the purposes of making decisions about healthcare (ANA, 2004). Outcomes research in APRN practice is research that focuses on the effectiveness of nursing interventions. Outcomes measurement in population-based care begins with the identification of the population and the problem, followed by the generation of a clinical question related to outcomes. It is a measure of the process of care. An outcomes measure should be clearly quantifiable, be relatively easy to define, and lend itself to standardization. In outcomes measurement, the APRN is ultimately concerned with whether or not a population benefits from an intervention. The APRN also needs to be concerned with the question of quality, efficacy (Does the intervention work under ideal conditions?), and effectiveness (Does it work under real-life situations?). Other important considerations are efficiency (cost benefit), affordability, accessibility, and acceptability. The Robert Wood Johnson Foundation and the IOM have issued a report to respond to the need to transform the nursing profession. The committee developed four key messages: 1. Nurses should practice to the full extent of their education and should achieve higher levels of education training. 2. The education system for nurses should be improved so that it provides seamless academic progression. 3. Nurses should be full partners with physicians and other healthcare professionals. 4. Healthcare in the Unites States should be redesigned for effective workforce planning and policy making. (IOM, 2011)
Introduction to Population-Based Nursing
Ann L. Cupp Curley
BACKGROUND
DEFINING POPULATIONS
USING DATA TO TARGET POPULATIONS AND AGGREGATES AT RISK
Smoking
Obesity
Diabetes Mellitus
Health and the Social Environment
Population Strategies in Acute Care
Chronic Conditions
SUMMARY
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