Implementation of risk triaging in primary healthcare facilities in Sub-Saharan Africa: A systematic review

Background One challenge facing treatment programs for HIV and other chronic conditions in sub-Saharan Africa (SSA) is how to target interventions to optimize retention in care and other outcomes. Most efforts to target interventions have identified predictive features among high risk patients after negative outcomes have already been observed. An alternative for identifying patients at high risk of negative outcomes is “risk triaging,” or identifying vulnerable or higher risk patients before they experience an interruption in care or other negative outcome. We conducted a systematic review of the use of risk triaging tools at the primary healthcare (PHC) level in SSA. Methods We searched PubMed and other databases for publications after 1 January 2012 that reported development or implementation of risk triaging tools for PHC use in SSA. We extracted information on three outcomes: 1) characterization of the risk triaging tools; 2) tool performance metrics (sensitivity, specificity, positive and negative predictive value, area under the curve); and 3) health system effects (efficiency, acceptability, resource utilization, cost). We report outcomes for each eligible study and identify lessons for use of risk triaging. Results Of 1,876 articles identified, 28 were eligible for our review. Thirteen addressed HIV, 10 TB, 1 TB/HIV, and 4 other conditions. Approximately 60% used existing, retrospective data to identify important risk factors for an outcome and then construct a scoring system, but no implementation of these tools was reported. The remaining 40% designed a tool using existing data or experience and reported implementation results. More than half (16/28, 58%) of the tools achieved sensitivities >80%; specificity was much lower. Only one tool, the World Health Organization’s 4-symptom screen for tuberculosis, had been scaled up widely. While most studies claimed that their tools could increase the efficiency of healthcare delivery, none of the studies provided examples of tangible health system impacts. Conclusion Most of the tools identified were at least somewhat successful in identifying potential risks but uptake by health systems has been minimal. Although well-designed risk triaging tools have the potential to improve health outcomes, implementation will require commitment at the policy, operational, and funding levels. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Protocols ### Funding Statement Funding for the study was provided the Bill & Melinda Gates Foundation through INV-031690 to Boston University. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript.