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Risk stratification in Catalonia

January 12, 2016

The Catalan Health System covers the health needs of more than 7.4 million citizens through an integrated public health care network based on primary care centres and community hospitals. A population perspective has been a constant in health policy making through the different health plans issued over the past decades. Risk stratification (RS) has become a cornerstone in the making of the new Health Plan 2011-2015 as a lever of healthcare transformation towards a more chronic and proactive oriented care.


The Catalan Health Institute (ICS, the main healthcare provider in Catalonia) was the first to use the Clinical Risk Groups (CRG) as a stratification tool up until 2014. Concurrently, another RS tool has been designed and implemented in the region in collaboration with CatSalut (the Catalan healthcare authority and commissioner): the Morbidity-Adjusted Groups (GMA in Catalan).

In 2011, Catalonia initiated a new healthcare programme called PPAC (Prevention and Chronic Care Program) whose aim was (i) to improve the quality of care provided to complex chronic patients (ii) to refine the provider payment mechanism in order to acknowledge heterogeneity within the patient population in terms of clinical complexity. Its ultimate goal was to guide the health system in changing towards a better chronic care. RS was seen as a resourceful tool to achieve PPAC goals. Initially, CRG was deployed to stratify the population in order to (i) identify complex chronic patients who require a personalized intervention, and (ii) define the risk-adjusted reimbursement in primary healthcare contracts. In this respect, since early 2015, all primary care contracts are issued based on risk-stratified populations. During the same period, GMA was deployed to achieve those objectives. PIAISS represents the continuation of the PPAC programme and it investigates the use of new independent variables in the RS model as well as its recalibration. PIAISS (Interdepartmental Plan on Health and Social Integration) and PPAC share the same RS tools.

The GMA morbidity grouper is based on statistical methods applied to mortality, hospital admissions, pharmaceutical use and GP contact information. It provides a quantitative assessment of the patient's disease complexity. The RS tools have been deployed in all districts within Catalonia (Spain). In addition, GMA is currently being evaluated by the Spanish Ministry of Health (MoH) as a potential RS tool for the Spanish National Health System. A recent agreement has led to the implementation of GMA RS tools in 13 out of 17 Spanish regions (92% of the Spanish population). Madrid is among these regions, its population being 6 million people, and it was chosen as the pilot region to perform the pre-intervention test.

Both the GMA and the CRG were tested as morbidity groupers during the validation of the RS model of the Catalonia region. Their predictive power was evaluated together with other covariates (i.e. age, sex and socio-economic status) to predict different healthcare outcomes: mortality, unplanned admissions, emergency department consultations, total healthcare expenditure, pharmacy costs, costs related to drugs strictly dispensed by hospitals (e.g. AIDS treatment, oncology treatments, etc.), contacts with GPs and number of outpatient consultations. To achieve this aim, different multiple linear regression models were designed and tested (see section "Performance of the model"). The data from the entire patient population from Catalonia were used during the validation. In addition to the statistical validation of the tool, a clinical validation was performed through a pilot test surveying GPs.

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This webpage arises from the project ASSEHS which has received funding from the European Union, in the framework of the Health Programme (2008-2013).