From primary care to the revolving door of hospital readmission: Relevance of Geoffrey Rose's call for a population strategy.

The high-risk strategy in prevention has remained the preferred approach in health care. High-profile research predominantly emphasizes specific high-risk subgroups such as those who have extremely high cholesterol and super-utilizers of emergency departments. Dr. Geoffrey Rose's alternative population approach, though well established in principle, has failed to come to fruition in primary care research, aside from a few exceptions. The population approach extends intervention efforts to more moderate-risk people, attempting to shift the overall distribution in a positive direction, effecting change in more of the population. Despite requiring more initial investment due to the larger target group, the health-related gains and downstream cost savings through a population strategy may yield greater long-term cost-effectiveness than the high-risk strategy. We describe the example of extending prevention efforts from super-utilizers (e.g. those with ≥3 readmissions per year) to include those who readmit in moderate frequency (1-2 per year) in terms of potential hospital days and associated medical costs averted.