1. Roncarolo F, Boivin A, Denis JL, Hébert R, Lehoux P. What do we know about the needs and challenges of health systems? A scoping review of the international literature. BMC Health Serv Res. 2017;17(1):636.
2. Kindig D, Stoddart G. What is population health? Am J Public Health. 2003;93(3):380–3.
4. Lynn J, Straube BM, Bell KM, Jencks SF, Kambic RT. Using population segmentation to provide better health care for all: the “Bridges to Health” model. Milbank Q. 2007;85(2):185–208; discussion 209.
5. Vuik SI, Mayer EK, Darzi A. Patient Segmentation Analysis Offers Significant Benefits For Integrated Care And Support. Health Aff (Millwood). 2016;35(5):769–75.
6. Yan S, Kwan YH, Tan CS, Thumboo J, Low LL. A systematic review of the clinical application of data-driven population segmentation analysis. BMC Med Res Methodol. 2018;18(1):121.
7. Eissens van der Laan MR, van Offenbeek MAG, Broekhuis H, Slaets JPJ. A person-centred segmentation study in elderly care: towards efficient demand-driven care. Soc Sci Med. 2014;113:68–76.
8. Vuik SI, Mayer E, Darzi A. A quantitative evidence base for population health: applying utilization-based cluster analysis to segment a patient population. Population health metrics. 2016;14:44.
9. Berra S, Borrell C, Rajmil L, Estrada MD, Rodríguez M, Riley AW et al. Perceived health status and use of healthcare services among children and adolescents. Eur J Public Health. 2006;16(4):405–14.
10. T. Caliński & J Harabasz. A dendrite method for cluster analysis. Communications in Statistics. 1974;3(1):1–27.
11. Hair JF, Black WC, Babin BJ, Anderson RE.. Multivariate Data Analysis. Vectors. 2010;6:816.
12. Croezen S, Haveman-Nies A, Alvarado VJ, Van’t Veer P, De Groot CPGM. Characterization of different groups of elderly according to social engagement activity patterns. J Nutr Health Aging. 2009;13(9):776–81.
13. Ward JH. J. Hierarchical grouping to optimize an objective function. Journal of the American Statistical Association. 1963;58:236–44.
14. Everitt B. Cluster analysis. Kluwer Academic Publishers; p. 75–100.
15. Duda R, Hart PE, Stork DG.. Pattern Classification. 2nd ed ed. New York: Wiley; 2001.
16. StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC..
17. Bodenheimer T. Coordinating care—a perilous journey through the health care system. N Engl J Med. 2008;358(10):1064–71.
18. Kern LM, Seirup JK, Rajan M, Jawahar R, Miranda Y, Stuard SS. Extent of Health Care Fragmentation in Different Payer Populations: Evidence from the Hudson Valley of New York. Population health management. 2019;22(2):138–43.
22. Low LL, Kwan YH, Liu N, Jing X, Low ECT, Thumboo J. Evaluation of a practical expert defined approach to patient population segmentation: a case study in Singapore. BMC Health Serv Res. 2017;17(1):771.
23. Reid RD, Mullen KA, Slovinec D’Angelo ME, Aitken DA, Papadakis S, Haley PM et al. Smoking cessation for hospitalized smokers: an evaluation of the “Ottawa Model”. Nicotine Tob Res. 2010;12(1):11–8.
24. Marcus SC, Chuang CC, Ng-Mak DS, Olfson M. Outpatient Follow-Up Care and Risk of Hospital Readmission in Schizophrenia and Bipolar Disorder. Psychiatr Serv. 2017;68(12):1239–46.
25. McFall M, Saxon AJ, Malte CA, Chow B, Bailey S, Baker DG et al. Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial. JAMA. 2010;304(22):2485–93.
26. Pillutla V, Maslen H, Savulescu J. Rationing elective surgery for smokers and obese patients: responsibility or prognosis? BMC Med Ethics. 2018;19(1):28.
27. Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009;7(2):100–3.
28. Hayes SL, Salzberg CA, McCarthy D, Radley DC, Abrams MK, Shah T et al. High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? A Population-Based Comparison of Demographics, Health Care Use, and Expenditures. Issue Brief (Commonw Fund). 2016;26:1–4.
29. Charlton J, Rudisill C, Bhattarai N, Gulliford M. Impact of deprivation on occurrence, outcomes and health care costs of people with multiple morbidity. J Health Serv Res Policy. 2013;18(4):215–23.
30. Collins PF, Stratton RJ, Kurukulaaratchy RJ, Elia M. Influence of deprivation on health care use, health care costs, and mortality in COPD. Int J Chron Obstruct Pulmon Dis. 2018;13:1289–96.
31. Baker A, Leak P, Ritchie LD, Lee AJ, Fielding S. Anticipatory care planning and integration: a primary care pilot study aimed at reducing unplanned hospitalisation. Br J Gen Pract. 2012;62(595):e113–20.
32. Hochman M, Asch SM. Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations. Journal of general internal medicine. 2017;32(4):392–7.
34. Jean-Baptiste D, O’Malley A, Shah T.. Population Segmentation and Tailoring of Health Care Resources: Findings from a Literature Review. Working Paper 58. Mathematica Policy Research. 2017;
35. Chong JL, Matchar DB. Benefits of Population Segmentation Analysis for Developing Health Policy to Promote Patient-Centred Care. Ann Acad Med Singapore. 2017;46(7):287–9.
36. Low LL, Yan S, Kwan YH, Tan CS, Thumboo J. Assessing the validity of a data driven segmentation approach: A 4 year longitudinal study of healthcare utilization and mortality. PloS one. 2018;13(4):e0195243.