Population Based Risk Stratification and Case Finding

Identifying the most appropriate patients for whom an intervention is appropriate is critical to the delivery of a cost-effective health system. Risk Stratification tools can assist healthcare professionals in this assessment by identifying individuals who are likely to be high service users in the future and therefore will benefit from pro-active disease management and preventative services now.

Through the process of ‘case-finding’ patients can be referred to services that are appropriate for their condition(s) and personalised care can be delivered to agreed clinical standards and protocols.

Risk stratification can also be employed to assess the future healthcare needs of a population, and therefore can inform the planning of healthcare services.  Subsequent scenario planning based on these predicted healthcare needs can inform the allocation of healthcare resources to ensure that the objectives of the healthcare system are achieved both efficiently and effectively.

Our Approach

Health Intelligence can support any number of Risk Stratification techniques that profile a population and individuals through the following techniques:

• Threshold modelling: Customer defined inclusion criteria to identify patients and refer patients to a specific healthcare intervention
• Clinical review: Patients are identified for clinical review to confirm their appropriateness for a specific healthcare intervention
• Statistical modelling: Historical patient data is used to build a model that predicts future healthcare events or outcomes for individuals.

Examples of algorithms that Health Intelligence already use include CVD risk scores (QRisk2, Framingham); prediction of emergency hospital events (King’s Fund Combined Predictive Model); and we are able to support any local variations on these or other statistical models.  Health Intelligence are also working closely with academia and existing customers to develop and test new Risk Stratification models that are focused on specific conditions (for example, early detection of colorectal cancer) or predict different types of care events based on social care needs.

Key Features & Benefits

• Seamless process of case-finding and then referring patients to appropriate interventions
• Unlimited number of intervention criteria can be deployed
• Can support any statistical algorithm required to identify risk score
• Cost profiles available to report on costs of clinical pathway
• Re-admission reporting to identify ‘revolving door’ patients
• ‘High Climbers’ report to confirm those patients whose risk is increasing
• Scenario modelling available to support planning of services
• Economic evaluation to measure cost-effectiveness of interventions and to ascertain sensitivity for specific patient groups

Benefits to GP and GP Consortia

• GP’s and their Consortia are able to design a healthcare system that delivers personalised care to individuals
• Better management of healthcare budgets through the identification of high risk patients who are likely to be high service users in the future
• Pro-active disease management employing agreed clinical standards and protocols
• Pre-configured and bespoke reports can be easily generated and provided to Local Authority in support of Joint Strategic Needs Assessments.

Benefits to Providers of Healthcare Interventions

• Profiles a populations healthcare service needs that can inform future demand for services
• Easy identification of candidate patients for whom an intervention is appropriate
• Retrospective studies can be undertaken to measure the impact of interventions.

Case Study

A randomised trial in Primary Care called PINCER, identified patients taking several different sub optimal medications that resulted in 5% of all hospital admissions. These admissions were classified as avoidable.

Health Intelligence CDRIntell solution easily locates any patients taking these high risk medications and provides clinicians with the necessary information to prevent patients from being admitted into costly acute care bed.

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