9 April 2020
Congratulations to Helen Snooks and colleagues in PRIME Centre Wales' emergency and unscheduled care research team on the announcement that their paper looking at the effects and costs of implementing predictive risk stratification in primary care, has been awarded second place the top ten BMJ Quality and Safety articles of 2019.
Across the National Health Service (NHS), predictive risk tools are being implemented in general practice to identify patients for case management, in part in hope that these tools might reduce emergency admissions. Here, Snooks et al. performed a stepped wedge trial across 32 practices in one Welsh health board to evaluate the costs and effects of the introduction of an emergency admission risk prediction tool (PRISM).
This tool, which updates monthly, identifies the 0.5% of the practice population deemed highest risk for unplanned admission in the following year. The programme provided local education for proactive case management and support for the tool as it was introduced to each practice, but it did not specify how practices should manage care based on algorithm results.
Overall, 1.8 participants per practice used the tool 8.1 times over the 16-month study period. The tool had good technical performance for admission prediction, although it generally under-predicted risk of admissions in the higher risk categories. During the intervention period, each of ED attendances (3% higher), outpatient attendances (5%), and bed days (3%) increased per participant per year.
The programme was significantly less effective and significantly more costly than usual care. This sobering study highlights the importance of evaluating well-intentioned and apparently well-founded interventions to assess whether they meet their goals. Risk prediction tools require further study, particularly when the aim is to reduce emergency admissions.
Read the full publication here:
Snooks H, Bailey-Jones K, Burge-Jones D, Dale J, Davies J, Evans BE, Farr A, Fitzsimmons D, Heaven H, Howson H, Hutchings H, John G, Kingston M, Lewis L, Phillips C, Porter A, Sewell B, Warm D, Watkins A, Whitman S, Williams V, Russell I. Effects and costs of implementing predictive risk stratification in primary care: a randomised stepped wedge trial. BMJ Quality & Safety 2019;28:697-705. doi: 10.1136/bmjqs-2018-007976