ArticleJournal of health care for the poor and underserved2018
A Practical Risk Stratification Approach for Implementing a Primary Care Chronic Disease Management Program in an Underserved Community.
Article in Journal of health care for the poor and underserved, 2018. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 7 papers, 1 of them a synthesis that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
7 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Population risk stratification tools and interventions for chronic disease management in primary care: a systematic literature review.BMC health services research · 2025Pooled it
- Intelligent risk prediction in public health using wearable device data.NPJ digital medicine · 2022Article
- A systematic review of risk stratification tools internationally used in primary care settings.Health science reports · 2021Review
- Community Engagement of African Americans in the Era of COVID-19: Considerations, Challenges, Implications, and Recommendations for Public Health.Preventing chronic disease · 2020Review
- Identifying subgroups of high-need, high-cost, chronically ill patients in primary care: A latent class analysis.PloS one · 2020Article
- Interventions to Reduce Ethnic and Racial Disparities in Dyslipidemia Management.Current treatment options in cardiovascular medicine · 2019Review
- Community-Based Participatory Research in Action: The Patient-Centered Medical Home and Neighborhood.Journal of primary care & community healthArticle
Corrections and comments
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Authors and funding
5 authors.
Funding
Abstract
The use of value metrics is often dependent on payer-initiated health care management incentives. There is a need for practices to define and manage their own patient panels regardless of payer to participate effectively in population health management. A key step is to define a panel of primary care patients with high comorbidity profiles. Our sample included all patients seen in an urban academic family medicine clinic over a two-year period. The simplified risk stratification was built using internal electronic health record and billing system data based on ICD-9 codes. There were 347 patients classified as high-risk out of the 5,364 patient panel. Average age was 59 years (SD 15). Hypertension (90%), hyperlipidemia (62%), and depression (55%) were the most common conditions among high-risk patients. Simplified risk stratification provides a feasible option for our team to understand and respond to the nuances of population health in our underserved community.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.