Environmental Scan - Health Risk Appraisals in Primary Care
Summary of Conclusions and Recommendations
The environmental scan found that the literature on health risk assessments (HAs) is extensive, but only a thin subset assesses HA use in or its integration with primary or chronic care. The Expert Panel concurred with this assessment. This section summarizes key conclusions from the scan and suggests actions that the Agency for Healthcare Research and Quality (AHRQ) may wish to take to move this area forward.
Priority Areas for Research
Although a survey found that one fifth of large medical groups and independent practice associations (IPAs) routinely used HAs in 2000, with findings typically reported to the primary care physician (Halpin et al., 2005), the panel was skeptical. They agreed that HA use is widespread in workplace and health plan settings, but felt the information very rarely reaches a primary care provider. Confidentiality and workload barriers can be substantial. Ongoing programs and randomized trials that incorporate strategies like informed consent or counseling to facilitate information transfer have not documented the yield from these strategies or the use that primary care physicians make of the HA information.
Wide variations in HA coverage, wording, and scoring also impose major barriers to efficient provider use of HA data. It is unrealistic to think a busy primary care provider would review patients' HA responses if those responses arrived in widely differing formats and inconsistent scoring. Thus, standardization is critical to integrating HAs into clinical care. Developing and demonstrating the effectiveness of practice guidelines or standards of care might help uptake and use.
It appears a more probing survey is needed of HA use in large practices. HA usage also should be assessed in smaller practices, and the content and format of HAs used in primary care should be probed. A study similar to that done by Eichler et al. (2007) in Austria is needed that details the services provided as a result of HA responses when HA results reach the primary care provider.
The literature clearly indicates that good outcomes are dependent on HA follow-up with appropriate preventive services and linkages between the primary care and community setting. Physicians often lack both the time and the training needed to coordinate effective preventive health services. In large practices, specialist staff members may be available to coordinate or deliver preventive services. This is a larger challenge for smaller practices.
Publicly available guidelines are needed for physicians to follow regarding HA administration, ways to process or evaluate HA data, and follow-up steps to take with patients who have completed an HA. Creating an automated HA link to electronic health records (EHRs) would facilitate HA integration into primary care and support inclusion of questions on care management services for people who have or are at high risk for chronic illnesses.
Two ongoing large Medicare preventive services demonstrations incorporate HAs. One has a strong component related to chronic care and is the first large-scale effort to use HAs in the care of chronically ill patients. The evaluative and descriptive data elements being collected should be reviewed to ensure that information needed by AHRQ and the U.S. Preventive Services Task Force (USPSTF) will be included.
Ensuring that questions on HAs are related to age-appropriate, evidence-based clinical preventive services has the potential to increase their impact. More culturally appropriate HA instruments also might raise response rates. Groups such as the National Commission on Prevention Priorities have developed evidence-based rankings of clinical preventive services that make the biggest impact on health and are most cost effective. Including questions on HAs related to these services could help clinicians prioritize their resources and ensure the patient is receiving appropriate care.
Recommendations to AHRQ
Actions that AHRQ may wish to consider to promote HA use in primary care include:
- Research current practices. Priorities include a Best Practices study of existing models that integrate HA use into primary care settings, an analysis of differences in content and format of HAs currently used in primary care settings, and data on use of HAs in smaller medical practices.
- Study health information technology (IT) and its role in HA use. Analyze how the Medical Home and the EHR can help standardize and promote HA integration into primary care, including transfer of HA data.
- Collaborate with partners such as the Centers for Medicare and Medicaid Services (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 explore the cost-effectiveness of that approach.
- Monitor or participate in the National Committee for Quality Assurance's (NCQA) work aimed at standardizing HA protocols and measures. It is impractical to use HA data in primary care unless providers receive consistent data across patients that cover the same topics, use the same questions, and generate comparable risk scores based on a methodology accessible to the provider. A forward-looking alternative to fully standardizing HAs that deserves deliberation is to standardize the subset of HA information that flows into the electronic medical record.
- Research and disseminate HA best-practice guidelines or standards of care specifically for primary care physicians and take other steps to increase the demographic tailoring, uniformity, and appropriateness of HA content areas, question wording, and scoring. Deciding on what domains of health risk the HA should cover, whether risk scoring is desirable, and the basic form of the risk scores seem appropriate questions for an expert panel.