title: Proposals for enhanced health risk assessment and stratification in an integrated care scenario.
abstract: OBJECTIVE
  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 (http://www.act-programme.eu). The second purpose was to elaborate on strategies toward enhanced health risk predictive modelling in the clinical scenario.
  
  
  METHODS
  The five ACT regions: Scotland (UK), Basque Country (ES), Catalonia (ES), Lombardy (I) and Groningen (NL).
  
  
  METHODS
  Responsible teams for regional data management in the five ACT regions.
  
  
  METHODS
  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.
authors.affiliation: Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pii Sunyer (IDIBAPS), CIBERES, Universitat de Barcelona, Barcelona, Spain Centre for Research in Environmental Epidemiology (CREAL), Universitat Pompeu Fabra, CIBER en Epidemiologia y Salud Pública (CIBERESP), Barcelona, Spain.
authors.forename: Ivan
authors.initials: I
authors.lastname: Dueñas-Espín
authors.affiliation: CatSalut, Servei Català de la Salut, Barcelona, Catalonia, Spain.
authors.forename: Emili
authors.initials: E
authors.lastname: Vela
authors.affiliation: Royal Philips Netherlands BV acting through Philips Research, Eindhoven, The Netherlands.
authors.forename: Steffen
authors.initials: S
authors.lastname: Pauws
authors.affiliation: Royal Philips Netherlands BV acting through Philips Homecare, Boeblingen, Germany.
authors.forename: Cristina
authors.initials: C
authors.lastname: Bescos
authors.affiliation: Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pii Sunyer (IDIBAPS), CIBERES, Universitat de Barcelona, Barcelona, Spain.
authors.forename: Isaac
authors.initials: I
authors.lastname: Cano
authors.affiliation: CatSalut, Servei Català de la Salut, Barcelona, Catalonia, Spain.
authors.forename: Montserrat
authors.initials: M
authors.lastname: Cleries
authors.affiliation: Departament de Salut, Generalitat de Catalunya, Barcelona, Catalonia, Spain.
authors.forename: Joan Carles
authors.initials: JC
authors.lastname: Contel
authors.affiliation: Kronikgune-Centro de Investigación en Cronicidad, Basque Country, Bilbao, Spain.
authors.forename: Esteban
authors.initials: E
authors.lastname: de Manuel Keenoy
authors.affiliation: Centre for Research in Environmental Epidemiology (CREAL), Universitat Pompeu Fabra, CIBER en Epidemiologia y Salud Pública (CIBERESP), Barcelona, Spain.
authors.forename: Judith
authors.initials: J
authors.lastname: Garcia-Aymerich
authors.affiliation: Department of Medicine, Karolinska Institute, Stockholm, Sweden.
authors.forename: David
authors.initials: D
authors.lastname: Gomez-Cabrero
authors.affiliation: Maccabi Health Services, Tel Aviv, Israel.
authors.forename: Rachelle
authors.initials: R
authors.lastname: Kaye
authors.affiliation: Department of Epidemiology, Health Technology Assessment, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
authors.forename: Maarten M H
authors.initials: MM
authors.lastname: Lahr
authors.affiliation: Eurecat, Barcelona, Catalonia, Spain Networking Department, Technical University of Catalonia (UPC), Barcelona, Spain.
authors.forename: Magí
authors.initials: M
authors.lastname: Lluch-Ariet
authors.affiliation: Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, Catalonia, Spain.
authors.forename: Montserrat
authors.initials: M
authors.lastname: Moharra
authors.affiliation: Institut Català de la Salut, Barcelona, Catalonia, Spain.
authors.forename: David
authors.initials: D
authors.lastname: Monterde
authors.affiliation: Kronikgune-Centro de Investigación en Cronicidad, Basque Country, Bilbao, Spain.
authors.forename: Joana
authors.initials: J
authors.lastname: Mora
authors.affiliation: Telbios (TLB), Milan, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Nalin
authors.affiliation: NHS 24, Scottish Centre for Telehealth and Telecare (SCTT), Edinburgh, UK.
authors.forename: Andrea
authors.initials: A
authors.lastname: Pavlickova
authors.affiliation: Badalona Serveis Assistencials (BSA), Badalona, Catalonia, Spain.
authors.forename: Jordi
authors.initials: J
authors.lastname: Piera
authors.affiliation: Kronikgune-Centro de Investigación en Cronicidad, Basque Country, Bilbao, Spain.
authors.forename: Sara
authors.initials: S
authors.lastname: Ponce
authors.affiliation: Badalona Serveis Assistencials (BSA), Badalona, Catalonia, Spain.
authors.forename: Sebastià
authors.initials: S
authors.lastname: Santaeugenia
authors.affiliation: Royal Philips Netherlands BV acting through Philips Homecare, Boeblingen, Germany.
authors.forename: Helen
authors.initials: H
authors.lastname: Schonenberg
authors.affiliation: Comprehensive Heart Failure Center (CHFC), Universität Würsburg, Würsburg, Germany.
authors.forename: Stefan
authors.initials: S
authors.lastname: Störk
authors.affiliation: Department of Medicine, Karolinska Institute, Stockholm, Sweden.
authors.forename: Jesper
authors.initials: J
authors.lastname: Tegner
authors.affiliation: Eurecat, Barcelona, Catalonia, Spain ViCOROB, Universitat de Girona, Girona, Spain.
authors.forename: Filip
authors.initials: F
authors.lastname: Velickovski
authors.affiliation: Royal Philips Netherlands BV acting through Philips Homecare, Boeblingen, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Westerteicher
authors.affiliation: Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pii Sunyer (IDIBAPS), CIBERES, Universitat de Barcelona, Barcelona, Spain.
authors.forename: Josep
authors.initials: J
authors.lastname: Roca
mesh_terms: D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D005060:Europe; D006305:Health Status Indicators; D006801:Humans; D011159:Population Surveillance / Q000379:methods*; D011446:Prospective Studies; D018570:Risk Assessment / Q000379:methods*
keywords: Health risk assessment; Patient stratification; case finding; chronic care; clinical decision making