Journal Article

Population risk stratification tools and interventions for chronic disease management in primary care: a systematic literature review

Golinelli, Davide, Grilli, Roberto, Rolli, Maurizia, Alberghini, Lucia, Lippi Bruni, Matteo, Pecoraro, Valentina, Negro, Antonella, Berti, Elena, Tedesco, Dario, Camerlingo, Maria Domenica

2025

Overview

Background Population risk stratification (RS) tools have been proposed to tailor interventions, prioritize resources, and proactively manage high-risk individuals with chronic diseases in primary care settings. This study aims to explore the available evidence on the use of population RS tools in primary care settings, specifically evaluating the impact of targeted interventions based on RS tools on selected chronic patients and healthcare utilization outcomes. Methods A systematic literature review was conducted across multiple electronic databases to identify relevant articles assessing the impact of targeted interventions based on RS tools in the management of chronic disease patients within primary care settings. We included studies meeting the following inclusion criteria: randomized controlled trials (RCTs), controlled clinical trials (CCTs) or before-after studies (BAs); adults with heart failure, chronic kidney disease, type 2 diabetes mellitus, chronic obstructive pulmonary disease, or dementia; interventions relying on RS tools; comparators with or without RS tools; and outcomes including Emergency Department (ED) visits, outpatient visits, hospitalizations, mortality, and costs. Results A total of seven studies met the inclusion criteria, comprising one RCT, two CCTs, and four controlled BAs. The findings revealed mixed effects of interventions on patients identified using RS tools. Among the included studies, four reported significant reductions in ED visits. Two studies reported an increase in outpatient visits. Hospitalization rates were reduced in three studies, and two studies reported significant reductions in overall mortality. However, the impact on healthcare costs was inconclusive. Conclusions The evidence on the effectiveness of RS tools for chronic disease management in primary care settings remains limited. While some studies demonstrated positive outcomes in reducing hospitalizations, ED visits, and mortality, the overall impact on outpatient service use and healthcare costs varied. Further high-quality studies are needed to evaluate the long-term benefits and cost-effectiveness of RS tools in chronic disease management within primary care.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Care and treatment / Chronic Disease - therapy / Chronic diseases / Chronic illness / Chronic illnesses / Chronic obstructive pulmonary disease / Dementia / Disease Management / Electronic health records / Health Administration / Health care / Health Informatics / Health risk assessment / Health services research / Health services utilization / Humans / Intervention / Keywords / Kidney diseases / Medical research / Medicine / Medicine & Public Health / Medicine, Experimental / Mortality / Nursing Research / Patients / Primary care / Primary Health Care / Public Health / Randomized Controlled Trials as Topic / Risk Assessment - methods / Risk factors / Risk stratification tools / Systematic Review / Systematic reviews / Technology adoption