Objectives:
Risk stratification tools that predict healthcare utilisation are extensively integrated into primary care systems worldwide, forming a key component of anticipatory care pathways, where high risk individuals are targeted by preventative interventions. Existing work broadly focuses on comparing model performance in retrospective cohorts with little attention paid to efficacy in reducing morbidity when deployed in different global contexts. We review the evidence supporting the use of such tools in real-world settings, from retrospective dataset performance to pathway evaluation.

Methods:
A systematic search was undertaken to identify studies reporting the development, validation, and deployment of models that predict healthcare utilisation in unselected primary care cohorts, comparable to their current real-
world application.

Results:
Among 3897 articles screened, 51 studies were identified evaluating 28 risk prediction models. Half underwent external validation yet only two were validated internationally. No association between validation context and model discrimination was observed. The majority of real-world evaluation studies reported no change, or indeed significant increases, in healthcare utilisation
within targeted groups, with only one-third of reports demonstrating some benefit.

Discussion:
Whilst model discrimination appears satisfactorily robust to application context there is little evidence to suggest that accurate identification of high-risk individuals can be reliably translated to improvements in service delivery or
morbidity.

Conclusions:
The evidence does not support further integration of care pathways with costly population level interventions based on risk prediction in unselected primary care cohorts. There is an urgent need to independently appraise the safety, efficacy, and cost-effectiveness of risk prediction systems that are already widely deployed within primary care.