Environmental Scan - Health Risk Appraisals in Primary Care
Project Objective: to inform AHRQ planning and decision-making related to the use of Health Risk Appraisal (HA) information in primary care settings.
Methods: environmental scan including a literature review and interviews with nine key informants, plus an expert panel meeting.
Results by Research Question
How are HAs currently being used in primary care settings? Information on this topic is limited. A 2001 survey reported that more than 20 percent of large medical groups and IPAs used HAs and provided the results to the patient's physician. The Expert Panel, however, was skeptical of these results.
How might HAs be used more effectively to improve the delivery of preventive services in primary care settings? Understanding and intervening in lifestyle factors is critical to health promotion. Effective HA use requires physician links to capable providers of preventive follow-up services and may work best if para-professionals review HA findings with patients. Widespread HA adoption in primary care is unlikely without standardized HA instruments and risk scoring and protocols to elicit high completion rates and guide follow-up referral. HA integration into electronic health records (EHRs) or the Medical Home seems desirable.
How is information derived from the use of HAs in other settings, such as worksite health promotion programs shared with primary care providers? HAs are widely used by health plans and employers. Confidentiality issues, data ownership, and patient uncertainty about primary care provider identity impose formidable barriers to sharing. Even without those barriers, current HA data vary so much in content, format and scoring that busy clinicians could not readily use them.
How are HAs being used (in any setting) to provide care to individuals that integrates preventive services and care management for chronic conditions? HA use with chronically ill patients, especially ones with multiple diseases, is uncharted territory except in two nascent Centers for Medicare and Medicaid Services (CMS) demonstrations on HA use in primary care with people over age 65. AHRQ should consider working with CMS to assure the data elements AHRQ needs are being captured.
What strategies might improve the delivery and coordination of clinical preventive services when HAs are used, regardless of setting? The National Committee for Quality Assurance (NCQA) is working to document, evaluate, and increase the quality and consistency of HA practice, an effort that AHRQ may wish to join. Major system redesign based on a team approach, would be necessary to coordinate preventive care and follow-up services in primary care. Self-care management and the effect of cultural factors and work environment on HA completion rates also merit exploration.
What knowledge and evidence gaps exist regarding the use of HAs? Studies recommended included analyses of: best practices; linkages between the clinical and community setting; HA effects on costs of care, patient functioning, and productivity; HA design (e.g., coverage, reading level, risk scoring); and risk behavior in racial and ethnic populations and people with chronic conditions.
Other Recommendations to AHRQ. Programmatic needs include developing demographically tailored HA instruments, risk scoring, and practice guidelines tailored to primary care and documenting best practices in HA use in primary care. The potential role of health information technology (IT) and EHRs in HA standardization and use needs further study. AHRQ also should consider (1) collaborating with CMS, Department of Defense (DoD), Department of Veterans Affairs (VA), or the private sector to demonstrate the value of linking HAs into primary care and (2) monitoring or participating in NCQA's efforts. A more probing survey of HA use in large practices and an initial survey of smaller practices are needed to determine how often they use HAs and how they integrate the results into primary care. Another desirable study would analyze claims and HA data from large users of HAs in primary care to determine how often primary care providers deliver or refer patients to preventive follow-up in response to different risks (e.g., do reports of balance problems or falls elicit greater referral than reports of memory lapses?).