Population Segmentation is the process of dividing a population into groups based on criteria identified to meet the needs of each group. Population Segmentation groups individuals in the population with similar characteristics.
In Cwm Taf Morgannwg, the population is grouped using data on healthcare use and co-morbidities. As shown in the figure below, there are ten unique segments Cwm Taf Morgannwg, which have been developed in-house using Primary and Secondary Care datasets. There is some variation within segments, grouping 427,000 patients into just 10 groups. Segments range broadly from low need without chronic conditions to highest need in most settings with multiple chronic conditions (see figure).
Risk Stratification groups individuals according to their risk of experiencing an adverse event, such as a particular health outcome or their healthcare utilisation. In CTM, our primary outcome of interest is risk of emergency hospital admission in the following 12 months.
Typically, the population at highest risk usually makes up a small percentage of the total population, for example around 5%. The groups at medium and low risk are much larger, for example 15% of the overall population might be in the medium risk group and 80% in the low risk, although the proportions can be predefined and set according to population.
Why is Population Segmentation and Risk Stratification useful?
The need for healthcare varies within populations. Understanding patient populations, groups or clusters by characteristics related to their need and use of health care resources can help Primary Care Clusters and GP Practices to decide how best to use limited time and resources to deliver anticipatory and pre-emptive care for patients.
A key benefit is that interventions/services are targeted to individuals who are the most likely to benefit from them, at the time they are most likely to be effective, taking preventative action before further conditions develop; this helps to reduce demand for unscheduled, primary and secondary care and helps to ease the pressure on appointments. It could also help to prevent unplanned emergency admissions to secondary care and keep people healthy and at home for longer.
General Practices will be able to identify individual patients within practices who are at high risk of needing further healthcare in future; providing an opportunity to intervene earlier.