Reverse the odds: a national primary care-embedded cardiometabolic risk identification and care linkage program in Saudi Arabia: an early implementation evaluation
Abstract
BackgroundCardiometabolic disease prevention requires integrated approaches that connect risk identification with timely confirmation, care linkage, and long-term management within routine healthcare. Saudi Arabia developed the Reverse the Odds (RTO) program, a national electronic health record (EHR)-enabled initiative embedded in primary healthcare (PHC). This study describes the program and evaluates its early implementation using routinely collected aggregate data.Program description and early implementation findingsRTO was implemented through all 20 health clusters and 2,048 activated PHC centers. The Phase 1 operational model used opportunistic cardiometabolic risk assessment during routine healthcare encounters, rather than universal screening of the general population, with diabetes and cardiovascular risk tools embedded in the national EHR. Positive findings triggered confirmatory assessment, referral, and multidisciplinary management, with eligible individuals entering structured lifestyle and/or medical pathways. Between July 2025 and March 2026, 911 certified health coaches were deployed nationwide. Among 632,948 adults in the Phase 1 operational target population, 580,941 (91.8%) responded to screening invitations, 498,096 (78.7% of the target population) attended a PHC visit, and 429,209 (67.8% of the target population) completed screening. Among screened individuals, 366,445 (85.4%) had at least one positive cardiometabolic finding, and 224,007 (61.1% of those with a positive finding) completed at least one follow-up visit, here termed initial care linkage. Obesity was the most frequently detected condition, followed by hyperlipidemia, hypertension, prediabetes, and previously undiagnosed type 2 diabetes; 89.8% of individuals with a positive finding had two or more of the five cardiometabolic conditions/risk states assessed. These figures represent implementation detection yield within a selected, healthcare-engaged population and are not estimates of national disease prevalence. Implementation strategies included phased cluster onboarding, stakeholder engagement, patient outreach, EHR-based flagging, PHC activation, workforce deployment, dashboard monitoring, and workflow adaptation.ConclusionsThe first 9 months of RTO implementation show that an EHR-enabled cardiometabolic risk identification and care-linkage workflow was deployed at national health-system scale within the defined PHC rollout population. The evaluation describes reach, adoption, screening completion, detection yield, and initial care linkage, but does not establish clinical effectiveness, sustained engagement, equity, or cost savings. Longitudinal evaluation is required to determine whether early implementation translates into durable clinical, behavioral, implementation, and economic outcomes.
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BibTeX
@article{albattal2026reverse,
title = {{Reverse the odds: a national primary care-embedded cardiometabolic risk identification and care linkage program in Saudi Arabia: an early implementation evaluation}},
author = {Saad Albattal and Abdullah M. Alarifi and Amal Almughthim and Lamis Alghamdi and Hussam Alghamdi and Maryam Almuhib and Ali Alhamad and Fahad Almutiry and Dhafer Al Zulayq and Nourah Aljowhri and Alhanouf Aloufi and Najwa Alqurashi and Saleh Ali Alsagti and Mutasim Almuayqil and Abdullah M. Assiri and Najim Z. Alshahrani},
journal = {Frontiers in Public Health},
year = {2026},
month = nov,
doi = {10.3389/fpubh.2026.1969770},
url = {https://www.frontiersin.org/articles/10.3389/fpubh.2026.1969770},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Reverse the odds: a national primary care-embedded cardiometabolic risk identification and care linkage program in Saudi Arabia: an early implementation evaluation
AU - Saad Albattal
AU - Abdullah M. Alarifi
AU - Amal Almughthim
AU - Lamis Alghamdi
AU - Hussam Alghamdi
AU - Maryam Almuhib
AU - Ali Alhamad
AU - Fahad Almutiry
AU - Dhafer Al Zulayq
AU - Nourah Aljowhri
AU - Alhanouf Aloufi
AU - Najwa Alqurashi
AU - Saleh Ali Alsagti
AU - Mutasim Almuayqil
AU - Abdullah M. Assiri
AU - Najim Z. Alshahrani
PY - 2026
DA - 2026/11/11
JO - Frontiers in Public Health
DO - 10.3389/fpubh.2026.1969770
UR - https://www.frontiersin.org/articles/10.3389/fpubh.2026.1969770
AB - BackgroundCardiometabolic disease prevention requires integrated approaches that connect risk identification with timely confirmation, care linkage, and long-term management within routine healthcare. Saudi Arabia developed the Reverse the Odds (RTO) program, a national electronic health record (EHR)-enabled initiative embedded in primary healthcare (PHC). This study describes the program and evaluates its early implementation using routinely collected aggregate data.Program description and early implementation findingsRTO was implemented through all 20 health clusters and 2,048 activated PHC centers. The Phase 1 operational model used opportunistic cardiometabolic risk assessment during routine healthcare encounters, rather than universal screening of the general population, with diabetes and cardiovascular risk tools embedded in the national EHR. Positive findings triggered confirmatory assessment, referral, and multidisciplinary management, with eligible individuals entering structured lifestyle and/or medical pathways. Between July 2025 and March 2026, 911 certified health coaches were deployed nationwide. Among 632,948 adults in the Phase 1 operational target population, 580,941 (91.8%) responded to screening invitations, 498,096 (78.7% of the target population) attended a PHC visit, and 429,209 (67.8% of the target population) completed screening. Among screened individuals, 366,445 (85.4%) had at least one positive cardiometabolic finding, and 224,007 (61.1% of those with a positive finding) completed at least one follow-up visit, here termed initial care linkage. Obesity was the most frequently detected condition, followed by hyperlipidemia, hypertension, prediabetes, and previously undiagnosed type 2 diabetes; 89.8% of individuals with a positive finding had two or more of the five cardiometabolic conditions/risk states assessed. These figures represent implementation detection yield within a selected, healthcare-engaged population and are not estimates of national disease prevalence. Implementation strategies included phased cluster onboarding, stakeholder engagement, patient outreach, EHR-based flagging, PHC activation, workforce deployment, dashboard monitoring, and workflow adaptation.ConclusionsThe first 9 months of RTO implementation show that an EHR-enabled cardiometabolic risk identification and care-linkage workflow was deployed at national health-system scale within the defined PHC rollout population. The evaluation describes reach, adoption, screening completion, detection yield, and initial care linkage, but does not establish clinical effectiveness, sustained engagement, equity, or cost savings. Longitudinal evaluation is required to determine whether early implementation translates into durable clinical, behavioral, implementation, and economic outcomes.
SN - 2296-2565
ER -