Proposals for enhanced health risk assessment and stratification in an integrated care scenario

Ivan Duenas-Espin, Emili Vela, Steffen Pauws, Cristina Bescos, Isaac Cano, Montserrat Cleries, Joan Carles Contel, Esteban de Manuel Keenoy, Judith Garcia-Aymerich, David Gomez-Cabrero, Rachelle Kaye, Maarten M. H. Lahr, Magi Lluch-Ariet, Montserrat Moharra, David Monterde, Joana Mora, Marco Nalin, Andrea Pavlickova, Jordi Piera, Sara PonceSebastia Santaeugenia, Helen Schonenberg, Stefan Stoerk, Jesper Tegner, Filip Velickovski, Christoph Westerteicher, Josep Roca*

*Bijbehorende auteur voor dit werk

    OnderzoeksoutputAcademicpeer review

    46 Citaten (Scopus)
    293 Downloads (Pure)


    Objectives: Population-based health risk assessment and stratification are considered highly relevant for large-scale implementation of integrated care by facilitating services design and case identification. The principal objective of the study was to analyse five health-risk assessment strategies and health indicators used in the five regions participating in the Advancing Care Coordination and Telehealth Deployment (ACT) programme ( The second purpose was to elaborate on strategies toward enhanced health risk predictive modelling in the clinical scenario.

    Settings: The five ACT regions: Scotland (UK), Basque Country (ES), Catalonia (ES), Lombardy (I) and Groningen (NL).

    Participants: Responsible teams for regional data management in the five ACT regions.

    Primary and secondary outcome measures: We characterised and compared risk assessment strategies among ACT regions by analysing operational health risk predictive modelling tools for population-based stratification, as well as available health indicators at regional level. The analysis of the risk assessment tool deployed in Catalonia in 2015 (GMAs, Adjusted Morbidity Groups) was used as a basis to propose how population-based analytics could contribute to clinical risk prediction.

    Results: There was consensus on the need for a population health approach to generate health risk predictive modelling. However, this strategy was fully in place only in two ACT regions: Basque Country and Catalonia. We found marked differences among regions in health risk predictive modelling tools and health indicators, and identified key factors constraining their comparability. The research proposes means to overcome current limitations and the use of population-based health risk prediction for enhanced clinical risk assessment.

    Conclusions: The results indicate the need for further efforts to improve both comparability and flexibility of current population-based health risk predictive modelling approaches. Applicability and impact of the proposals for enhanced clinical risk assessment require prospective evaluation.

    Originele taal-2English
    Aantal pagina's10
    TijdschriftBMJ Open
    Nummer van het tijdschrift4
    StatusPublished - 2016


    Duik in de onderzoeksthema's van 'Proposals for enhanced health risk assessment and stratification in an integrated care scenario'. Samen vormen ze een unieke vingerafdruk.

    Citeer dit