Data-Driven Population Health Management in Asia-Pacific


In conversation with Farhana Nakhooda, Senior Vice President, Asia Pacific, Health Catalyst

Asia-Pacific is facing an increasing prevalence of chronic diseases, or non-communicable diseases (NCDs), brought about by the increase in the aging of the population. In fact, 55% of all deaths in Southeast Asia are due to NCDs. In addition to having to fight infectious diseases such as Covid-19, NCDs represent a significant burden on the region’s health systems.

A data-driven approach to managing the health of NCD patient populations can significantly ease this burden. Biospectrum Asia spoke with Farhana Nakhooda, Senior Vice President, Asia Pacific at Health Catalyst, who shared additional information on the importance of population health management in Asia-Pacific, the challenges faced by health systems in population health management, and the opportunity for data and analytics to improve population health management, improve patient outcomes and reduce healthcare costs.

  • Why should health systems in Asia focus on population health management?

Chronic diseases are one of the biggest health problems in the world, claiming an estimated 40 million lives each year, of which 8.5 million reside in Asia. In Asia-Pacific, cardiovascular disease, diabetes, cancer and chronic respiratory conditions are among the most common chronic diseases. This is mainly due to the aging of the population and poor lifestyle choices such as lack of physical activity and consumption of tobacco and alcohol.

Healthcare spending generally follows the 80/20 rule, where 80% of healthcare costs are borne by 20% of the population – usually made up of cohorts with complex chronic conditions. The growing incidence of chronic diseases is putting a strain on health systems in the region, especially for developing countries that are already struggling with inadequate financial and human resources, poor service delivery and information systems. weak. A well-thought-out population health management strategy can help alleviate some of these burdens by actively identifying, enrolling, managing and monitoring those who may fall into this 20% of the population. It also involves screening high-risk patients who are prone to chronic disease and who are likely to end up with chronic disease and enrolling them in prevention programs. Finally, the rest of the population that is healthy today needs to ensure that they get regular health checkups to minimize the chances of ending up in the high-risk group. This holistic approach to population health management ensures that the health of the entire population is taken care of, while programs are tailored according to individual health needs.

Consider a group of diabetes patients from diverse socioeconomic backgrounds – providing a single care management approach may not effectively improve health outcomes for this group, as individuals may require different levels of attention and care. For example, accessibility to healthy food, stable employment, adequate housing, and family support are just a few key social factors that can affect whether patients improve or deteriorate. Being able to expertly manage these nuances is critical to both improving health outcomes and reducing healthcare costs.

Population health management takes into account the factors that make up the complete picture of individual and community health, including demographics, lifestyle, and social environment, among others. This leads to more responsive care delivery, which improves patient outcomes and enables more efficient allocation of healthcare resources.

  • How do you define effective population health management and associated struggles?

The biggest challenge is to provide and improve care for people with chronic conditions, while remaining vigilant against infectious diseases. Today, many health care providers are already under immense pressure in the fight against infectious diseases, such as Covid-19, which has severely disrupted the treatment of chronic conditions.

A significant amount of health care resources are required for the effective management of chronic diseases, including detection, screening, treatment and access to palliative care. Many healthcare systems lack the resources to meet these demands – in Asia-Pacific, for example, there are not enough doctors to meet this demand, and many patients are learning to self-manage their conditions and to minimize hospital visits.

Another major challenge is cost and affordability. Chronic disease management is costly for both healthcare providers and patients. Take the case of diabetes – the cost of care for a single patient amounts to a staggering average of US$16,752 per year. This has the potential to impact livelihoods. A study in Southeast Asia found that 48% of cancer patients experienced financial disaster, due to out-of-pocket expenses required for treatment. In countries where access to health care financing is limited, long-term treatment can even push people above the poverty line.

Also, one of the most important aspects of effective preventive and proactive health care is understanding behavioral science. Most overweight people know that they need to lose weight and that their weight can lead to diabetes and other chronic diseases. Likewise, most smokers know that smoking will shorten life expectancy. However, many continue to eat unhealthily and smoke. This can be attributed to a number of reasons including stressful lifestyles, depression, loneliness, among others, all of which impact mental state. The ability to understand and influence people to change their behavior is a science and an art in itself.

Finally, the lack of timely access to accurate near real-time data makes it difficult to actively identify at-risk cohorts and manage populations. Healthcare teams often make decisions based on outdated data and have limited ways to measure the effectiveness of their programs. It is essential to lay the foundation for care teams so that they can have access to the right data at the right time to measure the success of their population health strategies.

  • How can data and analytics address these challenges and create a more sustainable approach to population health management?

There is a huge opportunity for data and analytics to ease the burden of chronic diseases on Asia-Pacific health systems and also prevent the rest of the population from becoming chronically ill. With access to accurate, real-time data, healthcare providers will be better equipped to plan, allocate resources, and implement appropriate intervention strategies for patient populations.

Data and analytics can provide greater transparency into the population health journey by understanding what is happening beyond the four walls of a hospital. For example, in the case of diabetes, social determinants such as economic stability, education, social and community context all impact the effectiveness of diabetes self-management. Access to this data can allow healthcare providers to identify barriers to diabetes care and then design a program tailored to patients’ social backgrounds. This approach helped a healthcare provider in the United States reduce patient follow-up visits by 19%, as patients felt more confident and better equipped to manage their diabetes. By leveraging data and analytics, the hospital was able to understand individual barriers, such as lack of knowledge, poor transportation, or affordability of medication, and worked to make diabetes care more accessible to every patient. The same approach can be applied to most types of chronic disease.

Data can provide a more comprehensive view of the continuum of patient care inside and outside the healthcare system, providing greater insight into the environments in which patients live, work and play. This helps providers prevent chronic disease, personalize care, and help patients succeed in managing their own chronic conditions. This is critically important as healthcare systems in Asia-Pacific begin to consider the transition to value-based care, where success depends on improving patient outcomes rather than the volume of patients served alone. . As Asia-Pacific continues to struggle with its aging population and high incidence of chronic disease, this data-driven approach can create a more sustainable path to managing population health.

Hithaishi C Bhaskar

[email protected]


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