Evidence Check - Targeted Integrated Care

Evidence check

Targeting integrated care: social and clinical risk factors

An Evidence Check rapid review brokered by the Sax Institute for the NSW Agency for Clinical Innovation

Duration: March – June 2015


A rapid review examined the evidence concerning risk factors which may be significant predictors of hospital service utilisation. Risk factors have been used in predictive models to stratify and select patients for integrated care interventions with the view to reducing potentially preventable hospitalisations. This review also critically examined the evidence as to whether the use of such risk models and factors to target integrated care programs was effective in reducing hospitalisations and associated costs.

What we did

A comprehensive search of electronic research databases combined with internet searches for other relevant literature was conducted. A total of 1,064 records were identified for possible inclusion in the review. There were 256 articles selected which were related to predictors of hospital utilisation or were studies that examined interventions associated with risk stratification.

Targeting integrated care coverThe review indicated that age; gender; socio-economic status or social disadvantage; living alone; rural and remote location; and Aboriginal and Torres Strait Islander status and ethnicity had good evidence for inclusion as predictors in risk stratification models. Important clinical risk factors included comorbidity; severity of illness; key diagnoses; self-rated health; falls history; functional status; physical activity; long term disability; cognitive impairment; and multiple medication use.

However, the predictive accuracy of current risk stratification tools was only moderate. The adverse effects of false positive and false negative results and the benefits of true positive and true negative results required further consideration. Otherwise targeted individuals may receive programs that are not appropriate or fail to receive programs that are appropriate for them. The benefits of these models need to outweigh their costs.

Many of the integrated care interventions based on risk stratification appeared to increase cost and few interventions showed a reduction in hospital admissions.

Final report

Sansoni JE, Grootemaat P, Seraji MH, Blanchard M and Snoek M (2015) Targeting integrated care to those most likely to need frequent health care: A review of social and clinical risk factors. Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong.

Last reviewed: 22 August, 2016

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