What is the approach to risk stratification?

From the Guidelines

Risk stratification should be a systematic and ongoing process, incorporating validated tools and considering multiple factors, including medical, surgical, and social history, to accurately identify patients at high risk of developing complications or adverse outcomes, as emphasized in the most recent guidelines 1.

Key Considerations

• Risk stratification is crucial for guiding clinical decision-making and ensuring proportionate care for patients with varying levels of risk.
• The process should involve the use of validated tools specific to the condition being evaluated, such as the CHA₂DS₂-VASc score for stroke risk in atrial fibrillation patients or the HEART score for chest pain evaluation.
• Factors to consider in risk stratification include age, comorbidities, laboratory values, vital signs, and clinical presentation, as well as social and family factors that may impact neurodevelopmental outcomes 1.
• Risk stratification should be repeated at regular intervals as patient conditions change to maintain appropriate management strategies.

Implementation

• Clinicians should use a systematic approach to risk stratification, with clear documentation of risk factors and the resulting stratification level (low, moderate, or high risk).
• High-risk patients may require more aggressive interventions, closer monitoring, or hospitalization, while low-risk patients might be safely managed in outpatient settings with less intensive therapy.
• The goal of risk stratification is to improve patient outcomes by ensuring proportionate care and optimizing healthcare resource utilization, as highlighted in the American Heart Association guidelines 1.

Ongoing Evaluation

• Risk stratification should occur before hospital discharge and periodically throughout childhood and adolescence for individuals with congenital heart disease, as recommended in the latest scientific statement from the American Heart Association 1.
• Accurate risk stratification requires identification of factors that increase neurodevelopmental risk, including social and family factors that have not been consistently assessed within pediatric health care despite their demonstrated impact on child outcomes.

From the FDA Drug Label

Inclusion in the trial required 1) a baseline LDL-C level ≥190 mg/dL or 2) a baseline LDL-C level ≥160 mg/dL and positive family history of FH or documented premature cardiovascular disease in a first or second-degree relative.

The approach to risk stratification involves considering the following key factors:

• LDL-C level: a baseline level of ≥190 mg/dL or ≥160 mg/dL
• Family history: positive family history of familial hypercholesterolemia (FH)
• Premature cardiovascular disease: documented premature cardiovascular disease in a first or second-degree relative 2

From the Research

Approach to Risk Stratification

The approach to risk stratification involves categorizing patients into distinct subgroups based on their health risks to tailor interventions and improve health outcomes.

• Risk stratification methods used by primary care practices include practice-developed algorithms, clinical algorithms, payer claims and electronic health records, and clinical intuition 3.
• Patient stratification is essential in managing heterogeneous diseases like Alzheimer's, where it helps physicians tailor therapeutic interventions and optimize care management 4.
• Different risk stratification tools are used in primary care settings, including the Adjusted Clinical Groups (ACG), Charlson Comorbidity Index (CCI), and Hierarchical Condition Categories (HCC) 5.

Implementation of Risk Stratification

Implementing risk stratification in primary care involves several challenges and strategies, including:

• Choosing established versus self-created algorithms or heuristics, clinical intuition, or a combination 6.
• Selecting mechanisms for assigning risk scores and determining how to integrate risk stratification approaches into care delivery 6.
• Displaying risk scores to the care team and obtaining buy-in from care team members are major issues in implementing risk stratification 6.

Assessment and Identification of High-Risk Patients

Accurate assessment of patients is crucial in identifying those at risk of deterioration, and tools like the National Early Warning Score (NEWS) can be used to track and trigger timely interventions 7.

• The ABCDE (airway, breathing, circulation, disability, and exposure) approach to assessment is a comprehensive framework for evaluating patients 7.
• Risk stratification tools like ACG, CCI, and HCC have been shown to have good statistical performance, with ACG being the most flexible and valid 5.