Health risk assessment: a standardized framework

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1 Health risk assessment: a standardized framework February 1, 2011 Thomas R. Frieden, MD, MPH Director, Centers for Disease Control and Prevention

2 Leading causes of death in the U.S. The 5 leading causes of death in 2007: 1. Heart disease 2. Cancer 3. Stroke 4. Chronic lower respiratory diseases 5. Unintentional injuries

3 Providers have an important part to play in winnable battles Tobacco prevention Nutrition, physical activity, obesity, and food safety Healthcareassociated infections Motor vehicle injury prevention Teen pregnancy prevention HIV prevention Question patients about use; offer/refer counseling and cessation; advocate for tobacco control Screen patients for obesity, diabetes, high blood pressure, cholesterol and offer/refer counseling, interventions Implement and track prevention guidelines Alcohol brief intervention; seat belt use counseling Offer/refer counseling and family planning services Implement routine HIV testing (ages 13-64); prevention with positives; partner services

4 Cardiovascular disease Leading cause of death in the U.S. 80 million people in the U.S. (1/3 adults) have some form of CVD Hypertension, heart attack, angina, heart failure, stroke CVD kills ~865,000 people/year (1/3 deaths), about 2,400/day 150,000 CVD-related deaths/year in people under 65 >1 million heart attacks and 700,000 strokes/year CVD accounts for largest proportion of racial disparities in life expectancy

5 On ABCS, U.S. gets an F Aspirin Blood pressure Cholesterol People at increased risk of cardiovascular disease who are taking aspirin People with hypertension who have adequately controlled blood pressure People with high cholesterol who have adequately controlled hyperlipidemia 33% 46% 33% Smoking People trying to quit smoking who get help Despite spending $1 out of every $6 on health care 20%

6 Large disparities in CVD mortality Rates 3x higher in some communities than others Source: CDC, Division for Heart Disease and Stroke Prevention

7 Health care providers can help reduce smoking Tobacco is the leading preventable cause of disease and death in the U.S. >46 million people 1 in 5 adults smoke ~443,000 die from tobacco-related causes/year Health care providers can Evaluate tobacco use at every visit Provide brief, personalized counseling Offer tobacco cessation services Medication (virtually all smokers who want to quit) Free online smokers quitline Use EHRs to improve clinical management Decision support, registry functions, quality measurement

8 Quitline counseling alone or with medication significantly increases 6-month abstinence rates % quit % 6-Month Quit Rate 3-5 minutes of personalized counseling increases quit rates 13% 28% 5 0 Minimal or no counseling or self-help With Quitline With Quitline and medication Source: Clinical Practice Guideline Meta-Analysis Results. Treating tobacco use and dependence: 2008 update. Rockville (MD): HHS 2008 May

9 Health care providers can help reduce alcohol misuse Excessive alcohol use in the U.S. Causes ~79,000 deaths/year Is the 3rd leading lifestyle-related cause of death Is responsible for 2.3 million years of potential life lost/year Accounted for >1.6 million hospitalizations and >4 million emergency room visits (2005) Providers can Screen patients Use behavioral counseling

10 Brief interventions can help people who drink excessively Used across the spectrum of alcohol problems Motivate dependent patients to seek specialized treatment Help non-dependent patients (who drink excessively) to reduce or stop drinking Inexpensive Effective For every 5 interventions, 1 patient decreases drinking One of the most important preventive clinical services

11 Standardized framework can help people manage diseases What people can do to prevent Heart disease and stroke Eat a healthful diet Maintain a healthy weight Exercise Chronic lower respiratory diseases, lung cancer Don t smoke Avoid secondhand smoke Road traffic injuries Use seat belt Don t drink and drive

12 New Medicare benefit includes individualized or personalized health risk assessment Annual Wellness Visit Includes Health Risk Assessment (HRA) to identify Chronic diseases Injury risks Modifiable risk factors Urgent health needs CDC and Centers for Medicare and Medicaid Services are collaborating on development

13 Need for a framework CDC recent systematic review of evidence Insufficient evidence to determine effectiveness of HRA alone HRA with tailored feedback is useful as a gateway intervention Strong evidence of effectiveness of HRA with feedback when used with health education provided >1 hour, multiple times Failed to address 65-year-old population most studies look at working adults

14 Need for a framework (cont.) Strong/sufficient evidence for meaningful effects on Tobacco Alcohol use Seatbelt non-use Dietary fat intake Blood pressure Cholesterol level Summary health risk estimates Worker absenteeism Health care service use

15 Need for a framework (cont.) Because of small or inconsistent effect estimates, insufficient evidence exists to determine effectiveness for Intake of fruits and vegetables Body composition Physical fitness Source: Soler, et al. American Journal of Preventive Medicine 2010;38(2S)S237-S262

16 Importance of standardization Differing assessments, interventions, and outcome measures make comparisons of changes of health status difficult Existing risk calculators offer only risk identification, no evidence-based intervention recommendations and/or support

17 Framingham Heart Study Hypertension risk prediction score using measures obtained in physician s office Can be used to Estimate an individual s absolute risk for hypertension on short term follow-up Identify person with pre-hypertension for additional follow-up Limitations Not generalizable to non-white race or ethnicity or people with diabetes Source: Parikh et al. A risk score for predicting near-term incidence of hypertension: The Framingham Heart Study. Annals of Internal Medicine January 15, 2008;148(2):

18 Standardized HRA Create a health assessment framework across purchaser/plan/payer groups Provide a platform for use of evidence-based health education Enhance health literacy Help people stay healthier longer Improve self-management skills for those with chronic conditions Measure preventive care use

19 Standardized framework improves health care and outcomes of care Consistent measure of quality of care and health outcomes between health plans/networks/providers/purchasers Decrease health disparities through development of patient-centeredness Use of linguistically and culturally appropriate tools Enhance efficiency and effectiveness of health care by triaging patients with High-risk behaviors that negatively affect health for goal setting and follow-up training and support Poorly controlled chronic diseases for selfmanagement training

20 Standardized tools benefit clinical care and public health Benefits for clinicians Clinicians can use tools to answer these questions: Is the health care I m providing achieving the desired results? Why or why not? Benefits for public health Provide near real-time surveillance health data through Electronic Health Record Serve as adjunct to existing health surveys (e.g., National Health Interview Survey and Behavioral Risk Factor Surveillance System)

21 Standardized tools benefit Medicare Assess member access to care Standardizes measure of preventive health services Decrease use of high-cost acute care by improving self-care chronic disease management skills Provide members with high-risk health behaviors individual attention through health goal planning tailored to need and support Improve patient/consumer satisfaction

22 Use of HRA in clinical care In clinical care and public health Benchmark individual patients against a reliable baseline Provide reliable information for personalized health, set goals, and measure progress Assess quality of care In public health Inform community-based prevention practice Community-level surveillance provides data to support further health studies Long-term outcome and impact Longitudinal on specific populations

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