What is the effectiveness of population health management in improving health delivery, health outcomes, and reducing inequalities? A Rapid Review

Population health management (PHM) is an approach that aims to improve health and reduce health inequalities by data-informed planning and delivery of proactive care. It uses linked datasets to identify local ‘at risk’ populations which are then targeted with personalised interventions that deliver proactive and proportionate care. The aim of this rapid review is to identify the effectiveness of PHM in improving healthcare delivery, health outcomes and reducing inequalities. 

An abbreviated systematic review methodology was used to conduct this review in order to provide the available evidence in a timely manner whilst maintaining attention to bias. The review included studies published between 2018 and 2025. Three comparative studies evaluating the effectiveness of a PHM approach in improving health delivery, health outcomes, or reducing inequalities were identified. Four further studies evaluated the effectiveness of specific interventions targeting high risk groups and were developed using a PHM approach. Included studies were conducted in the USA and the UK.

Key findings and certainty of the evidence:  The prevention focused integrated care models led to increased costs of secondary care per patient per year, and costs per user of secondary care and led to mixed findings for emergency admissions, with no significant differences in primary care utilisation and health-related quality of life. The social determinants of health focused care model led to reduced emergency department visits, hospital admissions and costs per patient and led to improved health-related quality of life. The community-based programme designed to improve care coordination and address clinical and social determinants of health, led to mixed findings in terms of costs and healthcare utilisation. The food supplementation intervention led to the successful provision of food supplementation, reduced emergency department visits and hospitalisations. The person-centred smoking cessation intervention led to increased quitline engagement, increased treatment engagement and increased abstinence. The clinic-to-community, physical activity referral intervention led to decreased body weight and systolic blood pressure. Those with hypertension were found to have decreased body weight, systolic and diastolic blood pressures. The revenue generated from the model was larger than the cost of scholarship provided to those in need of financial support. The social determinants of health screening and referral process intervention led to increased screening rates, social work referral and more patients accessing the FindHelp.org resources. Acceptability and satisfaction with both the models of care and interventions was generally high but integrated care models found no differences in patient perceptions of support.

While the evidence base was limited by a small number of low-quality studies, the findings may inform the development of PHM approach. Most PHM approaches were resource intensive, delivered across multiple care settings, involving multiple collaborating partners and a range of personnel to deliver the interventions, so complexity may impact feasibility and implementation of the interventions. PHM is a broad approach that can be implemented in various ways and at different levels of the healthcare system, depending on population needs and priorities. However, within the literature the impacts of the different PHM components are poorly reported, making it challenging to determine the effectiveness of PHM overall. There was a lack of high-quality evidence, particularly UK based. Further research is needed to draw firmer conclusions.