Web Log


Risk Stratification: Identifying High/Many Risk Patients and How to Help Them

6/23/2016 10:37 AM

A couple of days ago I ran across this from ChilMark Research, titled "Evolution To Total Active Risk Report Hits the Streets." It's a treatise on the move toward Risk Stratification or predicting which patients will be at high risk for expensive utilization patterns. That means "getting sick."

At Sentia, we created our first Risk Stratification report over a decade ago, and made it run without any other user input than clicking a button. In fact, the model we use now is intended to make the patient think about his or her behavior and make better choices. That means we do more than just draw and analyze blood. There are a couple of dozen lifestyle questions with the usual "how much do you exercise?" and the like, but there is also "How many friends can you share problems with?" and "How many fillings do you have/do your gums bleed when you brush your teeth?" These questions are designed to make the patient think about life choices that you wouldn't normally associate with a Health Risk Assessment. We go even further by using the Uth, Sørensen, Overgaard, Pedersen Equation to estimate maximum volumetric oxygen uptake (VO2Max) and therefore Body Age. We then modify this answer with the answers to his or her lifestyle questions to come up with a Body Age that shows how well they are doing overall. A lower Body Age indicates better health, and a higher one, specifically higher than his or her chronological age indicates less than healthy lifestyle choices and means the patient should seriously consider changing those choices.

We even go a couple of steps further and produce a Population Health Report that details all of the metrics we collect (there are dozens) and aggregates them to show the performance in each category and an overall Body Age of the population. Comparing these year to year gives us a good idea of how we are doing as a group. We also produce a Self-Comparison report that details how the population is doing when compared to itself during the patient's own last visit. That means that a year ago. We had, say, 15 individuals with 3 or more risk factors and this year, we have only 5. That is real, measurable progress. Even better, with the Patient List Generator talked about here we can single out those patients with either high risk factors or many risk factors and individually counsel them on reading and following the patient education that we generated for them. Or they are going to die.

So yes, once again, the industry has come up with a great idea that we have already implemented, and done so years and years ago.

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