Population risk stratification tools and interventions for chronic disease management in primary care: a systematic literature review
Open accessAbstract
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.
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Inpatient and acute care settings commonly use inpatient diagnostic error triggers and EHR-based interventions, whereas outpatient and primary care settings rely more on population risk-stratification tools and ambulatory e-triggers targeting missed follow-up or unexpected ED visits.
“Inpatient and acute care settings commonly use inpatient diagnostic error triggers [375] and EHR-based interventions [376], whereas outpatient and primary care settings rely more on population risk-stratification tools [377] and ambulatory e-triggers targeting missed follow-up or unexpected ED visits [378].”
From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [377]
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- Authors
- Golinelli, D., Pecoraro, V., Tedesco, D., Negro, A., Berti, E., Camerlingo, M. D., Alberghini, L., Lippi Bruni, M., Rolli, M., & Grilli, R.
- Affiliations
- Azienda Unità Sanitaria Locale Della Romagna (IT)
- Regione Emilia-Romagna (IT)
- University of Parma (IT)
- Corresponding author
- Golinelli, Davide
- Venue
- BMC Health Services Research
- Published
- 2025-04-10
- Volume
- 25
- Issue
- 1
- Pages
- 526-526
- ISSN
- 1472-6963 (ISSN-L)
- PMC
- PMC11983763
- OpenAlex
- W4409289218
- Cited by
- 30
- References
- 33
- Citations by year
- 2026: 23 · 2025: 7
- FWCI
- 4.61
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Health Services Research (publishedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- Archivio istituzionale della ricerca (Alma Mater Studiorum Università di Bologna) (submittedVersion, cc-by-nc-nd)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Ministero dell'Università e della Ricerca (Complementary National Plan PNC-I.1 "Research initiatives for innovative technologies and pathways in the health and welfare sector” D.D. 931 of 06/06/2022, PNC0000002 DARE - Digital Lifelong Prevention." - CUP: G65E23000150006)
- Topics
- Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
- Keywords
- chronic disease management, primary care, targeted interventions, heart failure, chronic kidney disease, type 2 diabetes, chronic obstructive pulmonary disease, dementia, emergency department visits, hospitalization, mortality, health care utilization, health care costs, cost-effectiveness
- MeSH terms
- Chronic Disease, Humans, Primary Health Care, Randomized Controlled Trials as Topic, Risk Assessment, Disease Management
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