AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
MANUAL FOR PARTICIPATS
Item
Page Number
1.
INTRODUCTION
2
2.
Part A:
STUDY: THEORY AND PRACTICE
7
3.
Part B:
STUDY: TECHNIQUE
12
4.
Part C:
STUDY: RISK ESTIMATION AND
HRA EFFECTIVENESS
19
STUDY: NEW METHODOLOGIES
24
5.
Part D:
6.
EXERCISE: (to follow)
7.
SIMPLIFIED GLOSSARY
27
8.
REGISTRATION AND FEEDBACK
40
9.
QUIZ ANSWER SHEETS
42
10.
SUMMARY LECTURE
51
Copyright 1981/5
R.G.A. Boland, M.D., M.P.H.
A.A. Lisiewicz, M.Sc., Ph.D.
M.E.M.Young, M.D., M.P.H.
-
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
1.0
1.1.
1.2.
INTRODUCTION
PROGRAM OBJECTIVES
a.
To use the language and concepts of the Robbins Technique of Health Hazard
Appraisal (HHA)
b.
To develop skills in making HHA computations of Risk Score and Health
Appraisal Age with Personal Data Sheets, Galler-Gesner Tables and
Computation Charts.
c.
To determine Interventions and calculate new Risk Score and Compliance Age.
d.
To evaluate existing and future HHA methodologies and their appropriateness to
individuals, groups and organizations.
e.
To motivate further study in the future.
MATERIALS
a.
b.
Retained by Participants:
(1)
Text – Prospective Medicine (Hall and Zwemer) including GellerGesner Tables by age, sex and race, Risk Factors, protocols, Weight
Analysis Tables and Health Appraisal Age Charts, etc.
(2)
Manual – including lecture notes, learning points, simplified glossary,
program learning, articles, references, worksheets, etc. (Abbreviation
given in Exhibit A)
(3)
Learning Recall Tape – cassette for future study summarizing each step
in the learning process.
Not retained by Participants:
(1)
Work Pack – case studies, questions on the cases, case solutions,
learning patterns, quizzes, exercises, etc.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
1.0
1.3
1.4
NOTE:
INTRODUCTION
AGL METHOD
a.
The AGL (Autonomous Group Learning Method) was developed in 1969 for
international management training programs. It is a way of learning in groups
without formal instruction. Participants use the materials and group resources to
develop answers to all the cases and questions arising from the learning
experience.
b.
The work will be done in various modes: IND – individually, PAIRS – in pairs,
SG – in small groups, CSG – in combined small groups, and MG – in main
group.
c.
Groups will be changed to enable participants to work with a variety of course
members.
d.
The Group Organizer assists the participants and groups to solve all the
problems and thus achieve rapid individual learning in the limited time
available.
e.
Work quickly to cover all the materials in the time allowed. Use the SG’s to
help you clarify difficult points and questions. Use your notebook to continually
record key learning points. Use the Glossary for new technical word definitions.
f.
After the program use the LRT (Learning recall Tape) for about one hour
weekly for a month. This should improve the quality of your learning and
convert short term into long-term learning.
ACKNOWLEDGEMENTS
a.
Acknowledgement is made to the following persons who have assisted us in
preparing this course on the Health Hazard Appraisal: Charles Althafer and
Richard Lasco of CDC, Lynn Hawkins and Paul Melia of
the Canadian
Department of Health and Welfare, Robert Spasof, Ian McDowell and many
others.
b.
We are very grateful for the encouragement and support offered us by Dr. L.
Robbins.
Now complete the Program Registration Form, briefly read the Prospective
Medicine Pamphlet, and then complete the Personal Data Sheet for yourself (the
first step in HHA) (Exhibit B)
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
EXHIBIT A
ABBREVIATIONS
AGL
Autonomous Group Learning
ASHD
Arteriosclerotic Heart Disease
BF
Black Female
BM
Black Male
BP
Blood Pressure
CRF
Composite Risk Factor
HA
Health Appraisal
HHA
Health Hazard Appraisal
IND
Individual
PDS
Personal Data Sheet
RF
Risk Factor
SG
Small Group
WF
White Female
WM
White Male
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
EXHIBIT A
ABBREVIATIONS
AGL
Autonomous Group Learning
ASHD
Arteriosclerotic Heart Disease
BF
Black Female
BM
Black Male
BP
Blood Pressure
CRF
Composite Risk Factor
HA
Health Appraisal
HHA
Health Hazard Appraisal
IND
Individual
PDS
Personal Data Sheet
RF
Risk Factor
SG
Small Group
WF
White Female
WM
White Male
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
2.0
2.1
METHOD OF STUDY
a.
In MG (main group) - follow the lecture notes
b.
In SG (small group) - read the lecture together as follows (A,B,C,D):
1.
2.
3.
4.
2.2.
PART A - STUDY: THEORY AND PRACTICE
(Time 30 minutes)
A reads the first section to the SG
B summarizes what A has said and reads the second section
C summarizes what B has said and reads the third section
The process is repeated by D, and the cycle is continued until the lecture is
covered completely.
c.
In SG - Summarize the key points of the lecture on one sheet of the flip chart.
d.
Work quickly to complete all the work in the time allowed. Key points will be
repeated many times during the program.
DEFINITION OF HHA
a.
Objectives:
- Assess the risks that affect the quality of life of an individual
- Quantify impact on the individual of the risk of death
- Determine Interventions to reduce risk
- Change behavior towards Compliance
b.
Quantification enables;
- Comparison between individuals
- Identification of significant risks
- Measurement of Intervention effectiveness
c.
Four types of information are needed for HHA:
- Personal and family history : for certain conditions or diseases
- Physical assessment: of weight, height, blood pressure, cholesterol
- Health style behaviors : smoking, drinking exercising, dangerous practices
(arrests, weapons, etc.)
- High risk groups : such as hypertensives, diabetics, cancer of the
breast/cervix/colon, etc.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
2.0
2.3
2.4
HISTORICAL REVIEW
a.
HHA was conceived by Robbins in 1968 at the Methodist Hospital of Indiana
b.
Geller-Gesner Tables for average probability of death per 100,000 population by
age, sex and race, were established in 1970. Deaths are expressed as expected
deaths over the next ten years for a unit population of 100,000. Limited U.S.
population only.
c.
Proliferation of HHA instruments with the concept of “Prospective Medicine”
including extensive studies by the Canadian Department of Health and welfare
and the CDC (USA).
d.
The Robbins method of HHA as modified by the CDC has been the most widely
used and adopted to date (1981). This is the method described in this program.
PROBLEM AREAS
a.
Data Base -
b.
Risk Factors –
1.
2.
3.
4.
c.
NOTE:
PART A - STUDY: THEORY AND PRACTICE
(Time 30 minutes)
needs continuous updating of risk assessment
difficult to get at
is based on mortality data
Originally related to cardio-vascular disease and cancer in the 1960’s.
Forecast morbidity but uses mortality data
Ranks the relative risks of the individual
Tends to sort individuals into risk groups rather than to predict specific
outcomes
System –
1.
Cannot stand alone as a health motivator
2.
Is only the first step in a chain of events to change beliefs, motivate
people, build skills in affecting lifestyle behaviors, changing social
environments
3.
Effectiveness not yet scientifically proven
(a)
(b)
(c)
(d)
Robbins model of HHA based upon limited U.S. population studies.
The Framingham Studies;
were limited to a white middle class population
showed the usefulness of long-term prospective (forward looking)
community study
The American Cancer Society studies:
were less useful for HHA because it involved volunteers and was
most useful for risk of lung cancer from smoking risk factors of
ASHD association of health status and risk factor estimates
called mainly on older population
HHA needs broad prospective studies for total population
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
2.0
2.5
HHA AS A HEALTH PROMOTER
a.
b.
c.
d.
e.
2.6
PART A - STUDY: THEORY AND PRACTICE
(Time 30 minutes)
Improves screening with risk assessment
Provides the basis for personal and quantitative prescriptions for health.
Makes decision-making for risk reduction more understandable in terms of
health.
Shows the relationship between individual lifestyle and the risk of death.
Focuses responsibility for health onto the individual.
METHOD
a.
HHA involves four stages:
1.
Data base development (Text)
2.
Personal Data Sheet (exhibit A)
3.
Computation Chart (Exhibit B)
4.
Intervention and Compliance planning
b.
Data base development:
1.
Health Appraisal Age Tables to compute the HA Age from the individual
Risk Score (Text 42-5)
2.
Geller_Gesner Tables (Text 87-293) show, for each age group, race and
sex, and for each of the ten major Disease/Injuries the number of expected
deaths/100,000 population corrected for prognostic Characteristics and
Risk Factors.
3.
Weight / Height Tables (Text 30-2) for computation of percentage excess
weight
4.
Protocols for assessing Risk Factors (Text 75-86) classifying lifestyle
factors (exercise, smoking and drinking behaviors) in standard categories.
c.
On Personal Data Sheet (Exhibit A) is recorded the baseline data from the
individual. Critical data MUST be checked (e.g. possible uncontrolled
Diabetes).
d.
Computation Chart (Exhibit C):
1.
Individual name, age, race, sex.
2.
For relevant Disease/Injuries: Average Risk (death/100,000), Prognostic
Characteristics, etc. (Geller-Gesner Tables)
3.
Relevant Risk Factors (high or low) for each Prognostic Characteristic
4.
Composite Risk Factor and Present Risk Score computed for each
relevant Disease/Injury
5.
Total (Present ) Risk Score and Health Appraisal Age
6.
Intervention and Compliance (Achievable) Age computations.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
2.0
2.7
PART A – STUDY: THEORY AND PRACTICE
(Time 30 minutes)
QUESTIONS
1.
The main objective of Health Hazard Appraisal (HHA) is to:
a.
reduce risk
b.
compute risk
c.
change behavior
d.
use mathematics to compute health status
2.
HHA risk analysis is based upon:
a.
total population
b.
limited U. S. population only
c.
multiple international sources
d.
astrology
3.
A prognostic characteristic is a:
a.
relevant disease/injury
b.
risk indicator
c.
evidence of bad character
d.
a CRF
4.
In the Framingham Study, the population sampled was:
a.
white, middle-class men and women
b.
a randomly selected population
c.
predominantly blank blue-color workers
d.
farmers from New Hampshire
5.
The American Cancer Society study is relevant to HHA for all of the following
except:
a.
smoking as a risk for lung cancer
b.
risk of cancer in a younger age group
c.
establishing risk factors for arteriosclerotic heart disease (ASHD)
d.
association of health status and risk factor estimates
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
HEALTH HAZARD APPRAISAL CHART
Quality control: Evaluate performance of a predetermined goal.
(Goal: “Get this patient safely through the next ten years.”)
AVERAGE TO INDIVIDUAL RISK
POPULATION AVERAGE
10 YEAR DEATUS PER
100.000
Disease/Injury
Average
Risk
From Manual
(1)
Heart Attack
From
Manual
(2)
1355
Cancer
Cirrhosis Liver
Accid Mot Veh.
317
274
255
Suicide
250
Stroke
142
Homicide
112
Cancer Col Rec
78
Pneumonia
61
Alcoholism
54
Other Causes
Total
1525
4423
INDIVIDUAL PROGNOSIS
RISK APPRAISAL
Prognostic
Characteristics
Risk
Factor
From Manual
Listed in Manual
Physician Select
(3)
Blood Pressure
Cholesterol
Diabetes
Exercise
Family History
Smoking
Weight
Smoking
Alcohol
Alcohol
Mileage
Seat Belts
Depression
Family History
Blood Pressure
Cholesterol
Smoking
Arrest
Weapons
Polyp
Rectal Bleeding
Ulcerative Col.
Stool exam bl.
Alcohol
Hist. Bact. Pn.
Emphysema
Smoking
Alcohol
X
Present
Risk
See Instruction
(2) x (5)
(5)
(6)
2.7
1.9
2.0
3659
602
548
2.2
561
1.0
250
2.8
398
1.0
112
3.0
234
3.3
1.0
201
54
+
(4)
180
94
220
Neg
Walk 1ml
Neg
1pkcig
15% +
1pk/day
18dr/wk
18dr/wk
1500 yr
80%
No
No
180/94
220
1 pk day
No
No
No
Yes
No
No
18dr/wk
No
No
1pk/day
18dr/wk
Composite
Risk Factor
1.0
1.0
0.7
1.0
1.0
0.5
1.0
0.9
1.0
1.0
1.0
1.0
0.7
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.7
0.2
1.0
1.0
1.0
1.0
1.0
2.0
0.5
0.9
1.0
1.0
0.5
1.6
0.2
2.0
0.3
1525
8144
Health Appraisal Age 47
Reappraise on assumption that physician’s prescription is complied with.
Columns (7) through (10) same as columns (3) through (6) except where the physician’s prescription changed
prognostic
characteristics.
**
Divide figures in column (11) by total of column (6)
*
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
Name
Street
City
John Doe
Patient No.
Blank Apartments
Middletown
State______Zip______
XXX
Birthdate
Race, Sex. Age
Date
12/17
RISK REDUCTION FOR INDIVIDUAL
PROGNOSIS AFTER INTERVENTION
RISK REAPPRAISAL
Prognostic
Risk Factor
Composite
New
Risk
Characteristics
Risk Factor
After Physician’s
From Manual
See
(2) x (9)
Prescription
Instructions
x
+
(7)
Reduce b.p. to 140.88
Prescribed exercise
Stop smoking
Reduce to ave
Stop smoking
Reduce to 3-6 d/wk
Reduce to 3-6 d/wk
Wear seat belts 100%
Reduce b.p. to 140/88
Stop smoking
Stool exam (3x/yr)
Reduce to 306d/wk
Stop smoking
Achievable Age
41
(8)
1.0
0.7
1.0
0.9
0.5
0.9
0.8
1.0
1.0
1.0
1.0
0.6
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
0.3
1.0
1.0
1.0
1.0
1.0
12/15/35
WM 41
19 76
SURVIVAL
ADVANTAGE
Amount
Per Cent
Reduction
Reduction
(6) – (10)
..
(9)
(10)
(11)
(12)
0.9
1.7
1.0
1220
539
274
2439
63
274
30.0
0.8
3.4
1.1
281
280
3.4
1.0
250
0
0.0
1.5
213
185
2.3
1.0
112
0
0.0
0.3
23
211
2.6
1.0
1.0
61
54
140
0
1.7
0.0
1525
4552
3592
44.1%
0.7
0.7
0.5
0.5
Appraiser_______________
(SIGNATURE)
Physician____________________________________________________________________
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
3.0
3.1
SOURCE DATA
a.
3.2
PART B – STUDY: TECHNIQUE
(Time 30 minutes)
Data base –
- health Appraisal Age Tables (Text 42-5)
-
Geller-Gesner Tables (Text 87-293)
-
Weight/Height Tables (Text 30-2)
-
Protocols (Text 75-86)
b.
Personal Data Sheet
c.
Computation Chart
METHOD
a.
Personal Data Sheet gives age, sex, race, and life style data for the individual.
b.
Computation Chart completed for the individual (Exhibit D) showing
1.
Relevant disease/injuries and Average Risk of Death/100,000 population
2.
Prognostic Characteristics for each Disease/Injury
3.
Risk Factors for each Prognostic Characteristic
4.
Composite Risk Factor and Risk Score for each Disease/Injury
5.
Total Risk Score and Health Appraisal Age
6.
Intervention and Compliance Age Computations
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
3.0
3.3
RELEVANT DISEASE /INJURIES
a.
For a 41 WM (41 year old white male) the Geller-Gesner Tables (Text 103-6)
show the following ten major Disease/Injuries and Average Risk of
death/100,000 population:
Rank
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
b.
3.4
PART B – STUDY: TECHNIQUE
(Time 30 minutes)
Disease/Injury
Deaths
Heart Attack (ASHD)
Cancer of the Lung
Cirrhosis 274
Motor Vehical Accidents
Suicide
Vascular Lesions – CNS
Homicide
Cancer of the Large Intestine
Pneumonia
Alcoholism
Other (not specified)
Total Average Risk Score
(deaths/100,000). Population)
1355
317
274
256
250
142
112
78
61
54
1524
4423
The average 41 WM has a Risk Score of 4423 (Age Specific Death Rate
4423/100,000). (Exhibit C)
PROGNOSTIC CHARACTERISTICS
a.
For a 41WM the Geller-Gesner Tables (Text 103-6) List for ASHD (heart
attack) the following eight (8) Prognostic Characteristics:
Blood pressure – systolic
Blood pressure – diastolic
Cholesterol
Diabetes
Exercise
Family History
Smoking
Weight
b.
This data is also recorded on the Computation Chart (Exhibit C).
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
3.0
3.5
PART B – STUDY: TECHNIQUE
(Time 30 minutes)
RISK FACTORS
a.
b.
c.
d.
For each Prognostic Characteristic a Risk Factor is determined from the
Personal Data Sheet, Geller-Gesner Tables (Text 103-6) and the protocols (Text
75-86).
Low Risk Factors (1.0 or less) are recorded on the Computation Chart column 4
(left) and are multiplied together.
High Risk Factors (Over 1.0) are recorded on the Computation Chart as follows:
Column 4 (left) – 1.0 (average risk)
Column 4 (right) – the excess over 1.0 (the excess above Average Risk)
Risk factors are combined together as follows:
Column 4 (left) – multiplied together
Column 4 (right) – added together
Exhibit D computes the Composite Risk Factor for Heart Attack (ASHD) as
follows:
Prognostic
Characteristics
Risk Factors
Colmn 4
left
Right
(low)
(high)
1.0
1.7
1.0
0.2
.7
1.0
1.0
.5
1.0
0.5
.9
Blood pressure – systolic
Blood pressure – diastolic
Cholesterol
Diabetes
Exercise
Family History
Smoking
Weight
Product of column 4 (left)
(1.0 x 1.0 x .7 x 1.0 x 1.0 x .5 x 1.0 x .9)
Sum of column 4 (right)
(1.7 plus .2 plus .5)
Composite Risk Factor (See Exhibit D)
e.
Personal
Data
BP 180/94 (RF 2.7)
(RF 1.2)
Cholesterol 220
No diabetes
Occasional activity
Parents both alive after 70
20 cigarettes daily (RF 1.5)
15% overweight
0.3
2.4
2.7
For an average 41 WM, all RF’s would be 1.0 (column 4-left), and thus the
CRF would be 1.0 and the Present Risk score would be Average Risk.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
3.0
3.6
PART B – STUDY: TECHNIQUE
(Time 30 minutes)
RISK SCORE
a.
A CRF (Composite Risk Factor)is calculated for each relevant Disease/Injury
b.
For each Disease/Injure the Present Risk Score is computed as: Average Risk
(deaths/100,000) times CRF
c.
For ASHD the Present Risk Score is computed: Average Risk 1355 times CRF
2.7 equals Risk Score 3659.
d.
The Total Present Risk Score is the sum of the Present Risk Scores of the ten (10)
relevant Disease/Injuries plus a given Risk Score for “Other Causes” from the
relevant Geller-Gesner Table (Text 103-6) for a 41WM
e.
Exhibit D shows a Total Risk Score of 8144 for the 41 WM computed as follows:
Disease/Injury
3.7
Risk Score
Heart Attack(ASHD)
Vascular Lesions – CNS
Cancer of the Lung
Pneumonia
Cirrhosis of the liver
Suicide
Homicide
alcoholism
Accidents
3659
398
602
201
548
250
112
54
561
Other
TOTAL RISK SCORE
1525
8144
HEALTH APPRAISAL AGE
a.
The Health Appraisal Age Table (Text 42-5) convert the Risk Score by race,
age, sex into Health Appraisal Age.
b.
The last digit of the individual’s age together with the Risk Score identifies the
Heath Appraisal Age pm the relevant table, e.g., 41 WM with Risk Score of
Appraisal 8144 gives an HA of 47 Years.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
3.0
3.8
3.9
PART B – STUDY: TECHNIQUE
(Time 30 minutes)
COMMENT ON THE METHOD
a.
Low Risk Factors (1.0 or lower) are multiplied together because they should not
cumulatively increase the Risk Score.
b.
High Risk Factors (over 1.0) added together after deducting 1.0 (average risk)
because they do cumulatively increase the risk of death.
c.
The CRF reflects the individual’s disposition to acquire risk and die from teh
relevant Disease/Injury. CRF is derived from the Prognostic Characteristics
described in the personal Data Sheet.
d.
The average risk for each Prognostic Characteristic is assumed to be 1.0.
e.
CRF’s exceeding 1.0 indicate above average risk, and CRF’s below 1.0 indicate
less than average risk.
INTERVENTION AND COMPLIANCE
a.
CRF’s exceeding 1.0 indicate potential for Intervention.
b.
The Significance of any Intervention for a particular Disease/Injury depends
more on the Average Risk than the size of the CRF (i.d. In Exhibit D a change
in the CRF of Heart Attack Cancer of the Colon (Average Risk only 78).
c.
Interventions and the new Risk Score and compliance (Achievable) Age are
computed on the right side of the Computation Chart using the same technique.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
3.0
3.10
PART B – STUDY; TECHNIQUE
QUESTIONS
1.
For and average 41 WM the least risk is:
a.
stroke
b.
alcoholism
c.
cancer of colon/rectum
d.
pneumonia
2.
In the HHA model alcohol relates to all relevant disease/injuries risks except:
a.
accidents
b.
ASHD]
c.
pneumonia
d.
cirrhosis
3.
In computing the CRF (Composite Risk Factor) RF’s above average 1.0 are :
a.
added before deducting 1.0
b.
added after deducting 1.0
c.
multiplied twice
d.
multiplied and then added
4.
The Risk Score for each disease/injury is computed:
a.
average risk times RF
b.
median risk times CRF
c.
average risk times CRF
d.
to one decimal place
5.
An average 40 WM has a risk score of:
a.
same as 40 BM
b.
more than a 40 BM
c.
less than a 40 BF
d.
under 8000
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
HEALTH HAZARD APPRAISAL CHART
Quality control: Evaluate performance of a predetermined goal.
(Goal: “Get this patient safely through the next ten years.”)
AVERAGE TO INDIVIDUAL RISK
POPULATION AVERAGE
INDIVIDUAL PROGNDSIS
10 YEAR DETAILS PER 100,000
RISK APPRAISAL
Average
Prognostic
Composite
Disease/Injury
Risk
Characteristics
Risk Factor
Factor
Present
Risk
From manual
From Manual
(1)
Heart
Attack
From
Manual
(2)
1355
Listed in Manual
Physician Select
(3)
Blood Pressure
x
+
(4)
180
1.0
1.7
94
1.0
0.2
220
0.7
Neg
Walk 1mt
1.0
1.0
Neg
0.5
Smoking
1PK/cig
1.0
0.5
0.9
Cholesterol
Diabetes
Exercise
Family History
Cancer Lungs
317
Weight
Smoking
15%+
1pk/day
0.9
1.0
Cirrhosis Liver
274
Alcohol
18dr/wk
1.0
Accid:Mot.Veh
255
Alcohol
18dr/wk
1.0
1.
0
1.0
Mileage
15000yr
1.0
0.5
Seat Belts
Depression
Family History
80%
No
No
0.7
1.0
1.0
Blood Pressure
180 94
1.0
220
1.0
Diabetes
Smokint
Neg
1pk/day
1.0
1.0
Arrest
Weapons
Polyp
No
No
No
1.0
1.0
1.0
Rectal Bleeding
Yes
1.0
Ulcerative Col.
No
1.2
Stool exam bl
No
Suicide
Stroke
250
142
Cholesterol
Homicide
112
Cancer col-rec
78
Pneumonia
Alcoholism
61
54
Others Causes
1525
Total
4423
*
**
Alcohol
18dr/wk
1.0
Hist.Bact.Pn
No
1.0
Emphysema
Smoking
No
1pk/day
1.0
1.0
Alcohol
18dr/wk
1.0
See
Instructions
(5)
(2) x
(5)
(6)
2.7
1.9
3659
602
2.0
548
2.2
561
1.0
250
2.8
398
1.0
112
3.3
201
1.0
54
1.6
0.2
2.0
2.0
0.3
1525
8144
Health Appraisal Age 47
Reappraise on assumption that physician’s prescription is complied with.
Columns (7) through (10) same as columns (3) through (6) except where the physician’s prescription changed
prognostic characteristics.
Divide figures in column (11) by total of column (6).
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
RISK REDUCTION FOR INDIVIDUAL
PROGNOSIS AFTER INTERVENTION
RISK REAPPRAISAL
Prognostic
Composite
Risk Factor
New Risk
Characteristics
Risk Factor
From
Manual
After Physician’s
x +
See Instructions
(2)x(9)
(7)
(8)
(9)
(10)
Reduceb.p.to140 88
1.0
0.7
0.7
1.0
Prescribed exercise
0.9
0.5
Stop smoking
0.9
Reduce to av
0.8
0.9
1220
Stop Smoking
1.0
0.7
1.7
539
Reduce to 3-6 d/wk
1.0
1.0
274
Reduce to 3-6d/wk
1.0
1.0
0.5
Wear Seat belts 100%
0.6
1.1
281
1.0
1.0
1.0
250
Reduceb.p.to 140/88
1.0
0.5
1.0
1.0
Stop smoking
1.0
1.5
213
1.0
1.0
1.0
112
1.0
1.0
1.0
Stool exam(3x/yr)
0.3
0.3
23
Reduce to 3-6d/wk
1.0
1.0
1.0
Stop smoking
1.0
1.0
61
1.0
1.0
54
1525
4552
Achievable Age 41
SURVIVAL
ADVANTAGE
Amount
Percent
Reduction
Reduction
(6)-(10)
(11)
**
(12)
2439
63
274
30.0
0.8
3.4
280
3.4
0
0.0
185
2.3
0
0.0
211
2.6
140
0
1.7
0.0
3592
44.1%
Appraiser_______________
(SIGNATURE)
Physician____________________________________________________________________
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
4.0
4.1
CHOICE OF PROGNOSTIC CHARACTERISTICS
a.
b.
c.
d.
4.2
A Prognostic Characteristics is a risk indicator
The choice of risk indicators is limited by availability of well-defined studies
(see note on Framingham and American Cancer Society studies in lecture 3.3)
Criteria for selection of indictors include:
1.
Strength of association between risk and disease.
2.
Duration/dose response between risk and disease outcome
3.
Biological support and experimental evidence of association between risk
and Disease/Injury.
4.
Evidence that risk removal reduces the probability of Disease/Injury
outcome
The more information available, the more predictable (Bayes rule).
QUANTIFYING THE RISK
a.
b.
c.
d.
4.3
PART C – STUDY: RISK ESTIMATION AND HRA EFFECTIVENESS
(Time 30 minutes)
The HHA model in this program used the Robbins “Actuarial Model” which
avoids inflating composite risks.
Risk factors are treated differently:
 high risk (greater than 1.0) – promoters of death
 low risk – protectors from death
The model works well with a limited number of Risk Factors
The model tends to overestimate risk (with highly correlated prognostic
characteristics) and to underestimate risk with prognostic characteristics that are
mutually independent and have large values.
METHODOLOGICAL ISSUES
a.
b.
c.
Should HHA be appropriate for individuals with early disease onset? Can a
successfully treated cancer patient be considered “healthy” compared with a
successfully treated hypertensive?
How can HHA be adapted to individuals with special occupational or ethnic or
environmental risks?
Since HHA is for “healthy” people, should the underlying data base be for
average mortality? What about the high mortality for chronically ill individuals?
The overall risk must be elevated by the chronically sick:
Technical example: If 90%of the population have a mortality or M and the remainder
2M, then the total mortality:
Mt = .9M + .1 (2M) = 1.10 M (overestimate of 10%)
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
4.0
4.4
4.5
4.6
PART C - STUDY: RISK ESTIMATION AND HRA EFFECTIVENESS
(Time 30 minutes)
RISK TAKING AND THE HEALTH PARTICIPANT
a.
The “healthy” worker will tend to take a more risky occupation thus the
probability of injury is higher in the younger population.
b.
Older workers tend to have supervisory and less risky positions
c.
Thus, the age distribution of the population influences the average probability of
death.
COMPOSITE RISK FACTOR COMPUTATION
a.
The Actuarial (“Debit/Credit”) method is arbitrary and makes no provision for
total disease interaction (High “debits” are added but low “credits” are effected by
multiplication).
b.
Is multiplication of low risk factors as if they were “Relative Risks” really
justified (Spas off and McDowell,1976)
c.
Competing risks are ignored thus overestimating the risk.
d.
Corrections are needed for all of the above only if they are high risk factors
(Chang, 1970).
e.
There is a need to do sensitivity analysis to determine whether any specific
assumption significantly affects the resulting Risk Score.
PROBLEM OF THE YOUNG MALE RISK COMPUTATIONS
a.
The assumption that increasing age increases risk of death is not true for young
males.
b.
The average risk from accidents is higher at age twenty and forty years than it is
for thirty years. Thus, there are two ages with equivalent probabilities. This can
be corrected by:
c.
1.
Regression, or
2.
Calculations which ignore traumatic causes of death (this leaves a linear
relationship between age and death but lowers young males to unrealistic
risk levels).
Thus, in computations of HHA for young males:
1.
Users of computerized HHA should be wary of what is measured
2.
Users should know what models and assumptions are being used and what
corrections have been made.
3.
Users should be able to adjust programs to compensate for unrealistic
results.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
4.0
4.7
HHA EFFECTIVENESS
a.
Change of lifestyle is difficult due to: beliefs, motivation, social, cultural and
economic environments.
b.
Beliefs may be based on objective or subjective data but “belief change” is
complex and on must in any case be “relatively pleasant” for acceptance (Roberts
1975).
c.
Motivation related to complex factors including:
d.
e.
4.8
PART C - STUDY: RISK ESTIMATION AND HRA EFFECTIVENESS
(Time 30 minutes)
1.
Intention to achieve desired goals
2.
Intention to move away from disliked situations
3.
Pressures against harmful habits
4.
Gratification or release of fear (Jarvis 1967, Kas1 1975, Leventhal 1971,
1973).
The social, cultural and economic environment affects:
1.
Values of life, health, sickness and death
2.
Peer pressures
3.
Social engineering
4.
prestige of healthy life styles in the social hierarchy.
Planning for Intervention must therefore involve a complex mix of motivational
factors.
PROSPECTIVE MEDICINE
a.
Prospective Medicine involves four stages:
1.
HHA to determine ten year survival chances
2.
Planned reduction of risk and plotting a survival course
3.
Health management program with family members and social organizations
4.
Choice of the right time to act on Interventions.
b.
Thus, HHA is a vital part of a total scheme of prospective Medicine which is a
new approach to patient care that begins before illness strikes.
c.
The key to prospective Medicine is its Epidemiological Approach.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
4.0
4.9
PART C - STUDY: RISK ESTIMATION AND HRA EFFECTIVENESS
(Time 30 minutes)
QUESTIONS
1.
For an average 45-year-old white male the major HHA risk factor is:
a. Jogging downtown at night
]
b. Stroke
c. cardiac disease]
d. diabetes and hypertension
2.
If the CRF if 2.00 and the average probability of death from ischemic heart
disease is 1405/100,000, the risk score is about:
a. 700
b. 1400
c. 2800
d. 4200
3.
In the Robbins HHA model the risk factor for cancer of the lung for a 50 year old
woman smoker is the same as for a 50 year old man.
a. true
b. not true because of ERA
c. true for BF’s
d. not true
4.
How is the Risk Score for each relevant disease/injury calculated?
a. CRF’s are added together
b. CRF’s are multiplied together
c. CRF is each multiplied by the average projected mortality
d. none of the above
5.
In HHA the (“credit/debit”) approach for risk assessment:
a. accounts for protective risk factors
b. all risk factors are either added or subtracted to calculate the composite risk
c. all risk factors are multiplied together
d. high risk factors have values greater than one, and are added together after
one is subtracted from each
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
5.0
5.1
PART D - STUDY: NEW METHODOLIGIES
(Time 30 minutes)
TRENDS FOR THE EIGHTIES:
a)
b)
c)
Questions on the future of HHA

How accurate should it be?

Is too much should it being placed on prediction of results?

How closely is prospective Medicine being turned into predictive medicine?
HHA Potential:

Adopted country-wide in Canada

Sponsored by CDC in the U.S.A

Microcomputers will facilitate updating data bases and computing results.
HHA methodology:

Specificity of data bases will be improved]

Will be adjusted to fit special cases

New models will be added when the debit-credit system of analysis breaks
down (ethnic, cured cancer patient, controlled hypertensive).

New methodology might be developed by the 1990;s.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
5.0
5.2
PART D – STUDY: NEW METHODOLOGIES
(Time 30 minutes)
ALTERNATIVE MODELS FOR HHA ANALYSIS
a)
Most popular methods:
Debit-credit (Actuarial Method which does not use logarthmic rule factors)
Log-linear
Logistic
Branching method
b)
Log-linear model
Permits direct estimation of conditional probabilities of outcome events.
Allows for interaction.
Permits the analysis to incorporate new risk indicators.
Rejects old low associated ones.
Does not deal with continuous variables.
Technical note:
Condition probabilities given by: p(D/jik), where i, j, k, are three risk factors, D is
death from disease, S is survival from disease; then p(D/ijk) = p(Dijk)/p(Dijk)+p(Sijk)
The log linear equation is given by:
Ln p(Dijk) = Uo+Ui+Uj+Uk
+ Uij+........
+ Uijk..
c)
The logistic model:
Accommodates continuous variables.
More powerful than present methods.
Will take time to incorporate into common usage.
Cannot be hand tabulated.
Requires computer facilities for operation.
Technical note: Logistic model can be written as follows:
P (D/ijk) = 1/(1+e-bx) , where x is a dummy variable vector for the intercept and
values for risk indicators at levels i,j,k; b is a vector consisting of intercept and
regression weight.
d)
The “Branching” model:
Based on the epidemiological concepts of screening.
Both sensitivity and specificity measures are involved.
IR (or intermediate risk) will be determined by the number of screenings
performed (Exhibit F)
Probabilities worked out are based on Bayes’ Rule
Tests are sequenced form the simple to complex, from the cheap to
expensive.
Most advanced methodology.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
5.0
PART D – STUDY: NEW METHODOLOGIES
(Time 30 minutes)
5.2
ALTERNATIVE MODELS FOR HHA ANALYSIS (cont’d.)
Model could rely on physical measurement (lab, anthropomorphic, radiology,
etc.)
Risk estimates would be individually assessed.
Technical note: Bayes Rule can be summarized by saying the more information is
available, the more predictable the probability measure.
5.3
WHAT ARE THE QUALITATIVE ISSUES
a)
Ethical Issues:
What information should be presented to the participant?
Should the report be in two parts, one for health professional, other to the
client?
Should damaging information be released?
What happens if the risk is racially biased?
b)
Formatting:
-
Should non-reducible risks be included in the analysis?
How should the client’s report be written?
How long is the permissible period for writing?
Does an interactive model justify the expense?
c)
Role of HHA:
An educational tool only.
Should it be more predictive?
Who is the best person to do the HHA?
Should HHA be incorporated with hypertensive screening?
d)
Motivation:
Do certain results motivate people to change?
When is “the teachable moment”?
What should the presentation be to create optimum motivation?
e)
Methodology:
Should the orientation change towards risk assessment?
How can the instrument be changed for young and old?
What sort of measures should be used to measure “wellness” in the
elderly? (Katz Scale is not enough in HHA)
What alternative is there for achievable age in the young?
HHA should be scientific and accurate.
HHA is not a cult or a pseudoscience; data used must be epidemiologically
based.
Scientific rigor must be maintained.
A dichotomy must be established between research and application.
HHA should routinely be used in Health Promotion activities.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
5.0
PART D – STUDY: NEW METHODOLOGIES
(Time 30 minutes)
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
5.0
5.4
PART D – STUDY: NEW METHODOLOGIES
(Time 30 minutes)
QUESTIONS
1.
A deficiency of the Geller-Gesner Tables is the:
a.
actual method
b.
absence of special additional risk factors for the same previously
diagnosed illness
c.
absence of probabilities for blacks
d.
too many tables
2.
Which of the following HHA model is used in this program?
a.
Log-linear model
b.
Branching model
c.
Robbins model
d.
Log stic model
3.
The logarithm of the risk factor is used in the Robbin’s model of HHA is:
a.
to make the extrapolation linear
b.
to take into account variability of estimate
c.
to make it easier for computerization
d.
No. Robbins does not use logs
4.
HHA computation takes how many minutes to complete:
a.
8
b.
20
c.
40
d.
60
5.
If a 42-year-old BM smokes 15 cigaretts per day (RF=1.5), is 50 lbs. overweight
(RF=1.5) and has no family history of ischemic heart disease (RF=0.9), what is
his composite risk factor?
a.
3.9
b.
1.9
c.
2.2
d.
3.0
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
7.0
SIMPLIFIED GLOSSARY
Age – present
Chronological age - - the age calculated from
the birth date.
Age – Achievable
The age that an individual can achieve is the
lifestyle changes are adopted and risk score
reduced. Computed from health Appraisal
Age Tables (Text 42.5).
Age - Health Appraisal
The appraised age as reflected by the risks
reported and the lifestyle recorded. The sum
of all the risks and their effects on specific
causes of death in an age-risk group which
shares the individual’s appraised probability
of death. Calculated on the Computation chart.
Appraised probability of Dying
This is the Composite Risk Factor (see
below)multiplied by the average risk of death.
Average Probability of Death
This is the average mortality rate based on 12
causes of death.
Bayes Rule
P (D/S) = P(S/D) P(D) which the probabilities
P(S)
of an event occurring is dependent on the
amount of information that is available. The
more information available, the more
predictable the probability measure.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
7.0
SIMPLIFIED GLOSSARY
Blood Pressure
The force of blood on the sides of the arterial
vessel as it passes through the circulation. This
is subdivided into Systole – the maximum
pressure attained when the heart is contracting
and Diastole- the minimum pressure when the
heart is relaxing. Prognostic characteristic
affecting several disease/injuries. GellerGesner Tables require two R.T. ‘s for serious
hypertensive individuals.
Cause
A Shorthand notation for cause of death, cause
of cause of illness or birth. It refers to outcome
events rather than precursors.
Cholesterol Levels
The amount of cholesterol, a fatty deposit or
sterol found in all animal tissues, measured in
the blood. Prognostic characteristic for heart
disease, stroke and diseases of the arteries.
Cohort
A population that is selected because of certain
characteristics and followed over time.
Composite Risk Factor (CRF)
The value for risks accumulated by calculating
individual risks ( precursors of death ) and
combining them together using a mathematical
formula to get the total value. Each precursor
is assigned a numerical weight known as a risk
factor. Low R.F. ‘s are multiplied and high
R.F.’ s are added ( after deducting 1.0). The
sum of low and high R.F. ‘s is the CRF.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
Conditional Probability
Applies to the situation where the change of a
particular event’s occurrence depends on the
outcome of some other event.
Crisis Medicine
Medicine that responds to problelms at hand
and tries to solve them immediately.
Death – Average Probability
This is the chance of death of whole
population based on the number of deaths
occuued irrespective of other variables.
Environmental Risk
Those precursors of death (or risk factor) that
are found in the environment.
Formula
-
Odds Ratio
is the ratio that describes the odds in favor of
having the disease with the risk present over
odds of having the disease with the factor
absent.
-
Odds Ratio Standard Error
gauges the precision of the estimated odds
ratio.
Frequency Table
The number of people with a certain attribute
with a population – percentage distribution.
Geller-Gesner Tables
Thsi is an example of a frequency distribution
within a population of a hundred thousand.
Tables by age, sex and race do indicae: ten
simplified disease/injuries with average risk,
prognostic characteristics, risk factors and risk
score.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
Health Hazard Appraisal
See HHA
HHA – Age
This is equivalent to the appraised age (see
above).
HHA – Definition
Health Hazard Appraisal is an instrument to
establish the probability of an individual dying
in the next ten years. Part of Prospective
Medicine.Enables qualification of potential
interventions to achieve improved health
states.
HHA – History
Intorduced by L.Robbins in 1960’s as a health
screening device for family physicians.
HHA – Intervention
The prescription for change in lifestyle for
achieving an optimum probability of death is
the intervention.
HHA – Manual/computerized
HHA can be done by hand (manually) or the
analysis can be made via a suitable
programmed computer system.
HHA – Tables
Geller-Gesner Tables are actuarial tables that
give the survival probabilities. Health
Appraisal Age Tables connect Risk Scores
into HA Ages by sex and race.
Health Risk – American Cancer
The establishment of health risks using
Society Sample the American Cancer Society
population sample as the population at risk;
mainly an older middle class sample, not
representative of the U.S. population.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
Health Risk – Framingham Sample
Framingham population sample as the first
major large scale prospective community
study. Needed to study cardiovascular risk;
middle
class
rural
population
and
representative of the U.S. population.
Independence
The occurrence of two events in which the
occurrence of one does not affect the
occurrence or non-occurrence of the other.
Intervention
See HHA – Intervention.
Level
A risk indicator may be continuous or assume
two (absent/present) or more levels. (e.g.,
number of drinks drunk/day may classify an
individual at different levels).
Multiplier
The quantitative weitht attached to a risk
indicator to describe the amount by which risk
increases or decreases.
Morbidity
A measure of the amount of illness.
Mortality
A measure of death rates.
Logarithmic Coefficients
If a number “a” is expressed as a power of
another number “b”, i.s. a = bn, where the “n”
is the logarithm to the base “b”.
Methodology – Current
The methodology as practiced at present.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
New Risk
See Risk
Odds Ratio
See Formula “Odds Ratio”.
“Other Causes of Death”
Others deaths not due to the ten major disease/
injuries in the Geller-Gesner Tables.
Overall Appraised Probability of Death
The sum of appraised probabilities of death.
Probable Risk
Is the average mortality rate multiplied by the
composite risk factors.
Probability – Single
One single probability of survival.
Probability – Composite
The sum of many probabilities.
Probability - Conditional
See Conditional Probability.
Predictive - Medicine
The basis of signs and symptoms predicts the
survival of the individual.
Prospective Categories
Those categories that have a probabilistic influence
on survival.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
Prognostic Characteristics
Those characteristics that classify individuals into
prognostic categories. (e.g. blood pressure,
cholesterol level, exercise, smoking, alcohol,
family history, etc.).
Prognostic Risk Factors
Risk factors that affect change of survival.
Rate
The frequency of a disease or characteristic
expressed per unit of size of the population or
group to which it is observed.
Relative Risk
The ratio of the rate of the disease (usually
incidence or mortality) among those exposed
to the rate among those not exposed.
Risk
The chance of dying within 10 years is
dependent on the magnitude of the risk.
Risk Components
The different parts that make up a total risk:
By Credit/Debit method
All risks that are beneficial are multiplied
together and added to the sum of the amounts
of the other risks that are greater than one.
Risk Factor (RF)
See Galler-Gasner Tables in Text Probability
of a Prognostic Characteristic. How risk
factors (under 1.0) are protective, average risk
factor (1.0) or high risk factor (over 1.0) which
are hazardous. See Composite Risk Factor.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
Risk Factor Profile
A set of risk indicator values or levels,
describing and individual.
Risk Indicator
Prognostic characteristic, a variable which
modified the probability of occurrence of
disease or death from that of the general
population.
Risk Intervention
Activity that changes the value of risk and
should reduce the Risk Score. Health
Appraisal Age.
Risk Variable – Single/Composite
Single risk variable is one that has one
component. Composite risk variable has more
than one component.
Sensitivity
The extent to which patients who truly
manifest a characteristic are so classified.
Specitivity
The extent to which patients who do not
manifest a characteristic are correctly
classified.
Standard Error
The limits of the accuracy of a prediction.
Standard Error of Odds Ration
(See Odds Ratio). The limits of the accuracy
of the odds ratio.
Survival Advantage
That amount that is less than would be
expected if the prescribed lifestyle change had
not been undertaken.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
8.0
REGISTRATION AND BACKGROUND DATA
COURSE DATE & LOCATION :
PARTICIPANT’S NAME :
TITLE :
ADDRESS :
PREVIOUS PHC EXPERIENCE :
QUIZ RESULTS :
DAY I
DAY II
50
DAY II
19
50
PERSONAL OBJECTIVES IN TAKING THE COURSE :
NOTE:
1)
2)
3)
4)
COMPLETE ONE SHEET OF THE COURSE DIARY FOR EACH DAY
INDICATING :
Key Points learned
Reactions t AGL
Questions which are not satisfactorily answered
Results of any quizzes given during the day.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
8.0
1.
FEED BACK SUMMARY
NAME :
TITLE :
ADDRESS :
2.
PREVIOUS PHC BACKGROUND :
3.
QUIZ SCORES :
DAY I
DAY II
Out of 50
DAY II
out of 19
out of 50
4.
DID THE PROGRAM COMPLETELY SATISFY YOUR PERSONAL OBJECTIVES?
5.
WHAT SUGGESTIONS COULD YOU MAKE FOR IMPROVING THE PROGRAM?
6.
WHAT OTHER AGL PROGRAMS COULD BE DEVISED WHICH WOULD BE
USEFUL?
7.
WHAT IS YOUR OVERALL EVALUATION OF THE COURSE IN TERMS OF:
Excellent
1
Content
Presentation
Administration
Usefulness
Note : Mark the appropriate item with an X
Good
2
Fair
3
Poor
4
Terrible
5
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
9.0
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(b)
(b)
(b)
(b)
(b)
(b)
(b)
(b)
(b)
(b)
(b)
(b)
(b)
(b)
(b)
(b)
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(b)
(b)
(b)
(b)
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(c)
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(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
QUIZ ANSWER SHEET
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
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(b)
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(b)
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(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(c)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
(d)
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
10.0
SUMMARY LECTURE
INDEX
Item
1.
Introduction
2.
What is HRA
3.
HRA Computation
4.
The Robbins Model
5.
Criticism of the Robbins Model
6.
HRA in Business
7.
Industrial Applications – Alternatives
8.
Industrial Applications – Planning
9.
Industrial Applications – Criticism
10.
Summary
11.
Bibliography
12.
HRA Computerized Report
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
1.
INRODUCTION
Health Risk Appraisal was used by John Manion at Temple University in 1959
and was developed by Robbins and Hall at the Methodist Hospital in Indiana in the
1960’s. It was associated with Prospective Medicine in the 1970’s with extensive
studies summarized under U.S. Government Contract No. 23-78-3008 (Reference No.
1 in Bibliography).
This brief report outlines the basic concepts of HRA and its potential for
industrial applications.
2.
WHAT IS HAR?
HRA is a technique which uses epidemologiacal data to quantify an individual’s
risk of death and health age (compared to calendar age), in order to motivate lifestyle
changes to reduce the risks.
HRA may be used as: a screening technique, an educational tool, a personal
behavior change agent, a reinforcer of the impact of short and long term behavioral
change, etc.
The original HRA model was called Health Hazard Appraisal (not to be confused
with the NIOSH meaning of these words). Robbins and Hall, at the Methodist
Hospital in Indiana, used the data from the Framingham study and the American
Cancer Association study to set up the first Geller-Gesner tables for health risk.
HRA has been used to screen large numbers of the general population since 1974.
In the USA over 400 organizations screened more than 1,000 person each in 1980.
3.
HRA COMPUTATION
In 1982 there are about 25 HRA models…………., and so the health risk
computations will depend upon the model chosen. Models vary from simple one-page
questionnaires to long and complex instruments processed by computers. They may
be general models for healthy people 16-60 years of age or specialized models dealing
with the special risks of cardiovascular disease, stress, fitness, obesity smoking,
alcohol, etc. Except for the Robbins model which has been adapted by the
Government in Canada and by the CDC in the USA, most of the models have not
been substantially tested.
Computation of HRA may be “self-marked”, marked manually by professional
staff or processed by computer in batch or “in line” systems. The cost of HRA varies
from $2 p.c. (Canadian Government) to $600 p.c. (Control Data) depending upon the
counseling and preventive medicine follow-up provided.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
4.
THE ROBBINS MODEL
The Robbins Model, as adapted by the CDC, can be used manually or by computer. It
involves the following steps:
a.
Personal Data Sheet:- giving baseline data on medical history, blood pressure,
lifestyle, etc.
b.
Geller – Gesner Tables – for each age group, by race and sex, giving the average
probability of death within 10 years for the appropriate ten leading
Disease/Injuries. The Tables also give the relevant prognostic characteristics for
each Disease Injury, and rules for computing compsite Risk Factors.
c.
Computation Chart
d.
(1)
Using the individual Personal Data sheet and the Geller-Gesner Tables, the
Computation Chart is used to calculate the individual’s Health Age.
(2)
Risk Factors for each prognostic characteristic are combined into a
Composite Rick factor (CRF) for each of the ten leading Disease/Injuries.
(3)
The CRF is multiplied by the average risk of death/100,000 population to
give a Risk Score for that Disease/Injury.
(4)
The total Risk Score allows computation of the individual’s Health Age
from the Health Tables.
(5)
Interventions are the selected according to significant Disease/Injuries and
Composite Risk Factors (exceeding 1.0 average risk) so as to compute a
revised Achievable Risk Score and Achievable Health Age.
Example for a 41 year old white male follows:
Average risk score for a 41 WM
4423
(Exhibit C)
Individual risk score
8144
(Exhibit D)
Individual Health Age
47 yrs
(Exhibit E)
Proposed intervention – BP, smoking, alcohol
(Exhibit D)
Achievable life style, risk score
(Exhibit D)
Achievable health age
41
(Exhibit E)
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
5.
CEITICISM OF THE ROBBINS MODEL
All HRA models have been criticized and the following are typical objections to the
Robbins Model:
a.
Input – the Model is based on the old studies at Framingham and the American
Cancer Society which are not representative of the general U.S. population. It
deals with mortality rather than morbidity. The data base is being updated by
CDC, but the results will not be available until 1982.
There is no provision for the special risks or for increased risk due to
occupational exposure or previous history of disease. The model is essential
appropriate to healthy people and not for those who suffer from chronic disease
or are at the extremes of age.
There is no opportunity to introduce laboratory or other medical/health
information and no “branching” for special study for persons of high risk.
The method of combining of low and high risk factors is simplistic and does
not clearly adjust for the additive effect of certain types of risks without more
sophisticated computer based models, but the latter have not yet been subjected
to the same degree of research study as the Robbins model.
b.
Process – the Model is sometimes accepted by only 50% of the individuals
tested, for a variety of reasons including: lack of interest, fear, confidentiality,
low socio-economic status, etc. Thus it may be necessary to adapt the technique
to encourage special groups to participate.
c.
Output – HRA provides the individual with knowledge which is not necessarily
an effective motivation to change to a healthier life style. It is extremely
difficult to devise the “mix” of motivations to ensure compliance to
interventions.
d.
Outcome – Compliance with interventions is presumed to reduce risk, improve
health and prolong life, but no studies are available to substantiate this claim. In
any case such outcome cannot be easily associated solely with the HRA since
health depends upon so many different factors.
Overall, despite criticism of the Robbins Model, if it succeeds in motivating
individuals towards life styles that reduce risk, then it could be achieving its
objectives. Thus the success of the HRA may not depend purely on the development
of increasingly scientifically valid models (the objective of the current research), but
rather on the motivational problems.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
6.
HRA IN BUSINESS
Reports of applications in three companies are given
These are not objective scientific studies but they do indicate some
degree of corporate satisfaction with the quantitative and non-quantitative results of
HRA.
7.
INDUSTRIAL APPLICATIONS – ALTERNATIVES
Alternative uses of HRA include the following:
a.
Screening for health risks – HRA is quick, low cost ($ 10 or less), and noninvasive screening without the need for physical examinations or laboratory
tests. It provides the individual with useful data on his health status. The data
can be presented with or without counseling and “follow-up”. Health facilities
do not have to be provided by the company since extensive public facilities
(programs for : smoking reduction, diet control, alcohol, exercise, etc.) are
usefully available.
b.
Management data – HRA can provide a health profile for the work force by
department; this data may justify changes in the work conditions, fringe
benefits, health plans, exercise at work programs, and the general personnel
policies. Such summary data can be provided without loss of the personal health
confidentiality.
c.
Preventive medicine – HRA data may be a useful entry point and motivator for
preventive medicine for the individual or the organization. Repeated annual
HRA’s may be a cost effective substitute for annual physical examinations with
a more effective health education effect.
d.
Cost reduction – data on health and health risks may facilitate marked reduction
in the costs of health care by reason of improved health status. There may also
be some improvement in absenteeism and productivity, but these are complex
matters not related purely to the HRA activity. No objective data or justification
is presently available.
e.
Personal relations – the offer of HRA as a fringe benefit may improve the
company image with Trade Unions as regards continuous concern for the
employee health status.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
8.
INDUSTRIAL APPLICATIONS – PLANNING
Application of HRA in an industrial organization may required some months of
negotiation and planning to include the following steps:
a.
Objectives: clear definition of what is to be achieved by HRA including:
individuals to be assessed, counseling, preventive medicine activity,
management information, cost saving, etc. for defined groups of employees.
b.
Method: selection of the HRA model which involves decision as to the level of
sophistication (questionnaire, laboratory tests, physical examinations, etc.);
decisions as to use of consultants or training of company staff for HRA
administration, counseling, etc. It may be better to start with a relatively simple
system and limited follow-up, until the relevant cost becomes apparent, ie., the
cost of employee time as well as the HRA “out of pocket” expenses.
c.
Coordination: discussion with employee associations and development of
appropriate information sheets and meeting arrangements to explain the
program.
d.
HRA staff: recruitment of HRA supervisor and counsellors (possibly an RN or
Social Worker or personnel staff), training and development of routines and
protocols.
e.
Testing: Choice of a small department or executive group to test the procedures
and HRA processing (must be rapid feedback) before working with large
numbers.
f.
General application: using established routines and protocols on a scheduled
program to an increasing number of employees including: introductory talks to
small groups, completion and audit of personal data sheets, computation chart
calculations, feedback counseling, follow-up and preventive medicine activities.
g. Control: monthly and quarterly reviews of progress in relation to objectives and
appropriate change in relation to cost/benefits.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
9.
INDUSTRIAL APPLICATION – CRITICISM
The general criticisms of the Robbins Model of HRA (section 5) are appropriate
except to the extent that more sophisticated models are used. The general lack of
occupational risk data and additive risk due to occupation may be questioned,
although even a limited HRA model may still be motivational in changing life styles,
especially for executives and office workers. It may be less effective with lower
socio-economic class, but good data is not yet available.
The direct cost of HRA may vary from $2 to $600 per capita, depending upon the
level of counseling and preventive medicine benefits made available. To this must be
added the opportunity cost of employee time during HRA activities. Furthermore, if
HRA produces savings in reduced executive absenteeism and increased executive
productive time, the opportunity cost of such time may be a better justification for
HRA than preventive medicine activities. Thus HRA application may be more
cost/effective to executives than to lowered paid staff.
HRA may be interpreted by employees as an attempt by the company to “off-load
responsibility” for work-related disease/injury by putting the responsibility of
employee health on to the individual. Again the choice of HRA method and extent to
which it changes the traditional occupational medicine department routines may result
in some conflict.
However, overall with appropriate management and coordination with employee
organizations, the above criticisms can be handled and HRA can form part of
preventive medicine routine for most industrial organizations. This can be done either
by selecting “appropriate” employee groups or by selecting “appropriate” services.
There is a wide flexibility in using HRA.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
10.
SUMMARY
From this brief review of the basis of HRA and its potential for industrial
application, the following key points are emphasized:
1.
HRA can be a low-cost rapid screening technique to quantify individual health
risk and provide and entry for preventive medicine activities.
2.
HRA can be useful to management by providing data on the overall health risk
status of company employees, which is relevant for setting personnel policies on
working conditions, health services, improvement of morale and productivity,
etc.
3.
The four stages of HRA (input, process, output and outcome) although already
applied extensively in Canada and the USA are not yet scientifically validated.
4.
CDC is actively engaged in providing an improved general data base. However,
the existing and proposed data bases do not yet include occupational risk or
increased risk from occupational exposure, although a whole series of new
models to deal with this problem are being developed.
5.
The cost of HRA varies from $2 to $600 per capita depending on the extent of
the counseling and preventive medicine activities. New versions of HRA which
include laboratory data and medical history information are coming with
sophisticated computer processing.
6.
Planned HRA application should enable it to become a routine in most
organizations in the future.
7.
Occupational Medicine training should include some background in HRA.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
11.
BIBLIOGRAPHY
1.
Description, Analysis, and Assessment of Health Hazard/Risk Appraisal
Programs: A Final Report. Prepared under contract No. 23-79-3008 for the
National Center for Health Services Research; Office of Health Policy, Research
and Statistics; U. S. Department of Health and Human Services.
2.
Hall, Jack H. and Zwemer, Jack D. Prospective Medicine. Indianapolis, IN:
Methodist Hospital of Indiana, 1979.
3.
Proceeding of the Annual Meeting of the Society of Prospective Medicine 19741979.
Health and education resources.
Bethesda, MD. 20014
4.
Health Risk Appraisals Inventory
Public Health. Service – National Health Information Clearing House P. O. Box
1133, Washington, D. C. 20013
5.
Farquhar, John W. The American Way of Life Need Not Be Hazardous to your
Health. New York: W. W. Norton, 1978
6.
Sorochan, Walter D. Personal Health Appraisal. New York: John Wiley & Sons,
Inc., 1976.
7.
Vickery, Donald M. Life Plan for your Health. Reading, MA: Addison-Wesley
publishing Company, 179.
8.
Bauer, C. “Improving the Chances for Health.” Report to the Robert Wood
Johnson Foundation (December 1978). Published and distributed by the
National Center for Health Education, 211 Sutter St., 4th Floor, San Francisco,
CA 94104.
9.
Faber, M., ed. “Risk Reduction for Health promotion and Maintenance.” Family
and Community Health 3 (May 1980): 1-113
10.
Goetz, A.; Duff, J.; and Bernstein, J. “Health Risk Appraisal:
The Estimation of Risk.” Public Health Reports 95 (March-April 1980): 119126.
11.
Hall, J. “Which Health-Screening Techniques are Cost-Effective?” Diagnosis 2
(February 1980): 60-82.
12.
“Special Report: Health Hazard Appraisal in the Workplace.” Employment
Health & Fitness 2 (February 1980): 21-26.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
10.0 SUMMARY LECTURE
SHARE EMPLOYEE PROGRAM
YOUR HEALTH RISK DATA BEEN ANALYZED AND THE RESULTS ARE SUMMARIZED BELOW
AS THEY RELATE TO THE 12 MOST FREQUENT CAUSES OF DEATH FOR WHITE FEMALES AGED 44.
?
?
?
CHANCES OF DYING PER 100, 000 WITHIN THE NEXT 10 YEARS
?
?
?
Rank
?
CAUSE OF DEATH
?
COL.1
?
COL.2
?
COL.3
?
?
AVERAGE
?
APPRAISAl
ACHIEVABLE
?
?
ARIERIOSCLEROTIC HEART DISEASES
?
494
??
8526
?
2875
?
1
?
BREAST CANSER
464
??
464
232
?
2
?
?
3
?
LUNG CANCER
?
248
??
744
?
595
?
4
?
STROKE
?
211
??
2025
?
1076
?
5
?
CIRRHOSIS OF THE LIVER
?
190
??
2375
38
?
6
?
CANCER IF THE OVERY
?
136
??
136
?
136
?
7
?
SUICIDE
?
134
??
236
?
402
?
8
?
INTESTINAL CANCER INCL. RECTUM
?
131
??
131
?
131
?
9
?
MOTOR VECHICLE ACCICDENTS
?
91
??
800
?
400
?
10
?
NON-MOTOR VECHICLE ACCIDENTS
?
73
??
73
?
73
?
11
?
CANCER OF THE CERVIX
?
69
??
345
?
27
?
12
?
DIABETES
?
62
??
532
?
202
?
?
ALL OTHER CAUSES
?
1335
??
1335
?
1335
?
?
ALL CAUSES OF DETATH
?
3638
??
18022
?
7254
AGE:
ACTUAL
APPRAISED
ACHIEVABLE
DIFFERENCE
44
52.2
52.2
11.7
?
?
?COL. 2-COL. 3??
??DIFFERENCES??
??
5651
??
232
??
??
??
??
??
??
??
??
??
??
??
??
149
949
2337
0
402
0
400
0
318
0
??
??
??
??
??
??
??
??
??
??
??
10768
FOR HEIGHT 68 INCHES AND MEDIUM FRAME, 450 LBS IS APPROXIMATELY 214%---DESIRABLE WEIGHT IS 143 LBS
***************************************COMLIANCE****************************************
*AVERAGE CHANCES OF DYING ARE BASED ON 1975-1977 U. S. MORTALITY DATA. (CDC VERSION 1.1)
*APPRAISED AGE (DR “HEALTH AGE”) IS AN ESTIMATE OF HOWHEALTHY YOU ARE COMPARED TO OTHERS OF YOUR RACE AND SEX.
*ACHIEVABLE AGE IS AN ESTIMATE OF HOW HEALTHY YOU COULD BE BY MAKING THE FOLLOWING CHANGES IN YOUR CONDITION/LIFEESTYLE:
SMOKING
FROM
STILL SMOKES 40
TO:
STOPPED SMOKING
BP: SYST
FROM
250 MM.
TO:
140 MM.
BP: DIAS
FROM
120 MM.
TO:
88 MM
ALCOHOL
FROM
41 DR MORE/WEEK
TO:
STOPPED
FH/BREST
FROM
NO FAMILY HIST.
TO:
NO FH SELF-EXAM
PAPSMEAR
FROM
NOT HAD/NOT SURE
TO:
AS RECOMMENDED
WEIGHT
FROM
450 LBS
TO:
220 LBS.
S-SCALE
FROM
ABOVE AVERAGE RISK
TO
****= = = = ***************************************************= = = =****
NOTE—SUICIDE RISK IS PRTLY BASED ON ANSWERS TO QUESTIONS ABOUT PHYSICAL HEALTH, LIFE SATISEACTION, SOCIAL TIES, HOURS OF SLEEP, RECENT LOSS MISFORTUNE AND
MARITAL STATUS.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
National Academy of Sciences Institute of Medicine:
Preventive services for the well population. Report of Ad Hoc
Advisory Group on Preventive Services to Julius Richmond,
MD, Assistant Secretary for Health, DHEW. Washington,
D.C., 1978.
Tufo H, Bouchard RE, Rubin AS: Problem oriented
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Somers AR: Preventive health care and its effect on
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Lewis CE, Lewis MA, et al: Child-intiated care: the use
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Brody JE: Heart disease goes out of stule N.Y. Times,
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Rosenstock IM: Why people use health services.
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experiments on adherence to mediciation. Paper
presented at Association for Advancement of Behavior
Therapy, San Francisco, 1975.
Tylor SE, Levin S: The psychological impact of breast
cancer; Theory and Research. In Psychological Aspects
of Breast Cancer: A Review of the Literature, Technical
Report No. 1. San Francisco, West Coast Cancer
Fountation, 1977, pp 1-40.
Lewin K: Group decision and social change. In
Proshansky H, Seidenberg B. (des.) Basic Studies in
Social Psychology. New York, Holt, Rinehart, and
Winston, 1966.
MeDill MS: Structure of social systems determining
attitude, knowledge, and behavior toward disease: microsocial structures. In enelow AJ, Henderson JP (eds.).
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Dallas, American Heart Associating, 1975.
Roberts DF, Maccoby N: Information proessing and
persuation: counter-arguing behavior, Vol. 2. In Clarke P
(ed.): New Models for Mass Communication Research,
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Beverly Hills, Sage Publications, 1973.
Jordan HA, Levitz LS, Kimbrell GM: Eating is OK.
New York, Ross and Associates, 1976.
Stuart RB, Davis B: Slim Chance in a Fat World:
Behavioral Control of Obesity. Champaign, III., Reseach
Press, 1972.
Podell RN: Physician’s Guide to Compliance in
Hypertension. Merck, 1975.
Allen WA, Angerman G, Fackler WA:
Learning to Live without Cigarettes. New York, Dolphin,
1973.
So You Want to Give Up Cigarettes? New Ferster CB,
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Psychol 1:87-109, 1962.
Mahoney MJ: The behavioral treatment of obesity. In
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Science to Cardiovascular Risk. Dallas, American Heart
Association, 1975, pp 121-132.
Bandura A: General Learing Theory. Morristown, N.J.,
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Janis IL: Discussants’ Reaction. In Enclow AJ,
Henderson JP (eds.): Applying Behavioral
Science to Cadiovascular Risk. Dallas, American Heart
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Lathem W, Newbery A (eds,): Community Medicine:
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Breslow L., Somers A: The lifetime health monitoring
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medical technologies. Washington, D.C., GPO, 1978.
Cross JN: Guide to the Community Control of
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Jackson EW, Tashiro M, Cunningham GC:
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A guide to medical Care
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AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
The use of mortality data in setting priorities for disease prevention
H. N. Colburn, M. D.* and P. M. Baker, Ottawa, Ont.
Summary: The examination of specific
disease mortality by five-year age
groups helps identify health problems
as problems of people and how they
live. Traditional methods of examining
data in broad classifications tend to
obscure etiological factors and the
importance of behavior. Violence, a
major cause of death in young adults,
gives way to so-called diseases of
indulgence in middle age, especially
among men who have a much higher
death rate than women. Male life
expectancy at age 40 has increased
only marginally in the past 40 years.
Health-related human behaviour must
be considered within an ecological
framework since social, cultural and
physical environmental differences as
well as personal factors influence lifestyle. The responsibility for prevention
rests more with the individual and
society at large than with health
workers. Probability tables, Health
Hazard Appraisal (a system of personal
risk
assessment)
and
personal
counseling can reinforce healthful lifestyles and help correct hazardous ones.
Resume: Les donnees de mortalite et
leur valeur pour etablir les priorites en
matiere de prevention de la morbidite
Letude de la mortalite par maladies
specifiques et dans des statistiques
portent sur des groupes d’age de cinq
en cinq ans, permet de reconnaitre les
problemes de sante
comme des
problemes individuals et d’identifier le
mode de vie de ces indivudus. Les
methods classiques d’evaluation des
donnees en des categories larges ont
pour effet d’obscurcir les facteurs
etiologiques et l’importance du
comportement
individual. Si la
violence est une cause importante de
mort chez les jeunes adultes, chez les
gens d’age mur cest surtout labus des
bonnes choses qui les rend malades,
en particulier les homes
Non-Medical use of Drugs Directorate.
Health Protection Branch. Health and
Welfare Canada
Statistics Canada: formerly Health and
Welfare Canada
Reprint requests to: Dr. H. N. Colburn,
9th Floor, the Journal Building. 365
Laurier Avenue W., Ottawa, Ont, KIA
1B6
don’t is mortalite est deja tres
superieure a ceile des femmes. Depuis
les 40 demieres annees l’esperance de
vie des homes de 40 ans n’a guere
augmente. II faut envisager le
comportement de l’homme a l’egard de
sa sante d’une maniere globale, dans
un cadre ecologique complet, car on
sait que les differences de milieu, au
point de vue social, culturel et
physique, et des facteurs strictement
personnels influencent le mode de vie.
La responsabilite de la prevention
repose donc bien plus sur l’individu et
la societe en general que sur les
specialists de la sante. Les tables de
probabilite, le “Health Hazard
Appraisal” ou Reieve des risques
personnels (systeme d’estimation des
risques personnels de maladie) et les
conseils personnels peuvent modifier
les modes d e vie dans un sens
favorable et contribuer a corriger ou a
eliminer les facteurs dangereux.
The examination of rates of mortality
due to specific diseases by rank within
five-year age groups, as described by
Robbins and Hall, helps to put in
perspective for each stage of life the
most important potential health
problems. Health problems can thereby
be more clearly seen as problems of
people and how they live. This
knowledge can then offer guidance in
determining the means of improving an
individual’s chances not only of long
life, but also of enjoying healthful and
disease-free living.
The traditional methods of examining
data in broad classifications such as
heart disease, cancer, accidents, etc.
Omitting reference to small age
groupings, tend to obscure etiological
factors. The importance of behaviour
and the potential for its alteration with
attendant lowering of the risk disease
and early death – the true role of
preventive medicine – are all too often
overlooked.
A glance at the 12 leading causes of
death for the next 10 years for
Canadian men and women now at age
20 (Table 1)** shows the role of
violence in the deaths of young people,
tragedies of
particular concern
because of the loss of human potential.
Jumping to the 45-year age group
(Table II). One sees a change to what
might be considered diseases of
indulgence. Heart attacks, lung cancer,
cirrhosis of the liver and stroke join
motor vehicle accidents and suicide to
reduce the chances of individuals
reaching and enjoying retirement. Two
of the major smoking-related diseases,
heart attack and lung cancer, are now
first and second causes of male deaths
and remain so between 45 and 64. The
other leading diseases influenced by
smoking,
chronic bronchitis and
emphysema, move quickly up the
ranks after age 45 and join heart
attacks and lung cancer among the top
five causes of death for men aged 55 to
70. For women aged 45, breast cancer,
heart attack and stroke are the three
leading causes of mortality with
suicide, lung cancer, cirrhosis of the
liver and motor vehicle accidents in 6th,
7th, 8th and 9th places respectively.
Lung cancer may be expected to
assume more importance among
female deaths as women’s exposure to
cigarette smoking increases.
By age 65 (Table III) heart attack,
stroke, lung cancer and chronic
bronchitis and emphysema are the
leading causes of death for men. The
impact of diseases attributable mainly
or in part to cigarette smoking is
striking. For women at age 65 the
order is heart attack, stroke, cancer of
the intestine includingrectum, and
breast cancer.
The tables show the marked excess of
mortality in men over that in women.
Much of the difference is attributable
to the greater risks men assume in the
way they live. It is noteworthy that,
despite improvements in medical care
and social conditions, male life
expectancy at age 40 increased by only
one year between 1930-32 and 196567 while that of women increased by
five years.
Reliable and complete data on
morbidity are not available. For this
reason
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
One is compelled to use data as indicators of potential
health problems. The mortality data are only the
disability and the destruction of the quality as well as the
quantity of life.
The leading causes of death in south and middle age –
motor vehicle accidents and heart attack, respectively –
are associated with specific types of human behaviour, as
are lung cancer, cirrhosis of the liver and chronic
bronchitis and emphysema. Human behaviour must be
considered within an ecological framework rather than in
isolation. There are social, cultural and physical
environmental difference as well as personal factors that
help determine whether individuals eat and drink too
much, smoke or physically inactive. Ultimately,
however, it is the human response to feelings and
environment that determines the outcome. Truly, we so
often do not die – we kill ourselves, and the
responsibility for prevention rests more with the
individual and society at large than with the health
worker.
The importance of behaviour and environment is
emphasized in the four primary divisions (human biology
environment, life-style and health care organization) of
the health field concept developed by the long-range
health planning branch of the Department of National
Health and Welfare. In describing the health field
concept, Laframboise said, “It is humbling to realize that
all the technological advances of clinical medicine, the
prepayment and organization of health services and the
removal of health pollutants, have little effect on the
decision of an obese person to reach for another place of
strawberry shortcake”.
Modern disease prevention is not confined to doing
things for an to people, for example, ensuring for them
safe food and water and immunning them against
infectious diseases. Increasingly, doctors and other
Health workers can use knowledge about personal health
risks to advise individuals and society how they can alter
environments and change attitudes and acorns to ensure
healthful living. For example, physical activity requires
places to walk, run, and cycle and so forth, as well as
personal motivation. Similarly a child may not be able to
resist smoking in an environment that does not support
nonsmoking behaviors.
McKeown, who has written intensively in this v vein,
has concluded that “Past improvement has been mainly
due to modification of behaviour and changes in the
environment and this to these same influences that we
just look particularly for further advantage.”
It is suggested that programs of
Table 1-Causes and probability of death within the next 10 years (from 1971)
Men, age 20
Rank
1
2
3
4
5
6
7
8
9
10
11
12
Women, age 20
Rank
1
2
3
4
5
6
7
8
9
10
11
12
Cause of death
Probability
Motor vehicle accidents
Suicide and self-inflicted injury
Accidental drowning and submersion
Accidental poisoning
Homicide
Tambours of lymphatic and hemtopoietic tissue
excluding leukemia
Accidental falls
Cerebrovascular disease
Air and space transport accidents
Accident caused by fire
Ischemic heart disease
Accidents caused by firearm missiles causes
All other causes
All causes of death
Cause of death
Probability
Motor vehicle accidents
Suicide and self-inflicted injury
Cerebrovascular disease
Accidental poisoning
Homicide
Pneumonia
Leukemia
Tambours of lymphatic and hematopoietic tissue
excluding leukemia
Breast cancer
Chronic rheumatic heart disease
Congenital anomalies of the heart and circulatory
system
Accidental drowning and submersion
All other causes
All causes of death
661
225
106
47
46
33
25
20
20
19
17
16
387
1622
170
57
23
23
18
15
14
14
13
11
9
8
227
602
*Per 100,000
Table II-Causes and probability of death within the next 10 years (from 1971)
Men, age 45
Rank
Causes of death
Probability
1
Ischemic heart disease
2653
2
Lung cancer
477
3
Motor vehicle accidents
322
4
Cirrhosis of liver
316
5
Cerebrovascular disease
309
6
Suicide and self-inflicted injury
302
7
Intestinal cancer including rectum
180
8
Other forms of heart disease
131
9
Stomach cancer
121
10
Tumours of lymphatic and hematopoietic tissue
111
excluding leukemia
11
Chronic bronchitis and emphysema
106
12
Pneumonia
104
All other causes
2132
All causes of death
7264
Women, age 45
Rank
Causes of death
Probability
1
Breast cancer
2
Ischemic heart disease
3
Cerebrovascular disease
4
Intestinal cancer including rectum
5
Cancer of ovary, fallopian tube or broad ligament
6
Suicide and self-inflicted injury
7
Lung cancer
8
Cirrhosis of liver
9
Motor vehicle accidents
10
Cancer of the cervix
11
Chronic rheumatic heart disease
12
Tumours of lymphatic and hematopoietic tissue
excluding leukemia
All other causes
All causes of death
*Per 100,000
516
496
266
196
151
145
122
122
117
116
97
70
1357
3771
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
health promotion and disease prevention might give more
attention to helping people under 65 reach retirement
safely and enjoyable. Such programs may be developed
around mortality tables for five-year age groups and
concentrate on helping young and middle-aged
individuals to understand their own risk-taking forms of
behaviour and their relationships to potential health
problems in the immediate and more distant future. For
example, a 25-year-old man can see his risks for the next
10 years, as well as his risks at 45 if he continues his
current life-t\style. This review can reinforce healthful
life-styles as well as
draw attention to hazardous ones.
The higher level of risk-taking
behaviour among
men indicates where priorities lie.
The physician in his role as personal counselor can
influence the individual’s response. The this end the
system of personal risk assessment termed Health Hazard
Appraisal, developed by Drs. Lweis Robbins and Jack
Hall at the Methodist Hospital of Indiana, Indianapolis, is
particularly relevant.. The experimental use of Health
Hazard Appraisal in Canada ha been described in recent
articles.
Physicians or other health workers wishing to have a
set of tables showing chances jof dying in the next 10
years for each five-year age group or further
information a bout Health Hazard Appraisal may write
to: Smoking and Health, Non-Medical Use of Drugs
Directorate, Health Protection Branch, Health and
Welfare Canada, Ottawa. Those wishing more detailed
information about Canadian mortality probabilities by
age group should write to Dr. W. H. Cherry, Associate
Professor of Statistics, University of Waterloo, and
Waterloo, Ontario.
The assistance of Dr. W. H. Chery, Dr. Gaston Coquette,
Miss L Craig, Mr. R. Lauzon, Dr. A. B. Morrison and
Mr. B Sawka, is gratefully acknowledged.
Reference
1.
Table III-Causes and probabilityj of death within the
Men, age 65
Rank
Cause of death
Probability
1
Ischemic heart disease
2
Cerebrovascular disease
3
Lung cancer
4
Chronic bronchitis and emphysema
5
Intestinal cancer including rectum
6
Diseases of arteries, arterioies and capillaries
7
Stomach cancer
8
Cancer of prostate
9
Pneumonia
10
Other forms of heart disease
11
Diabetes mellitus
12
Cancer of pancreas
All other causes
All causes of death
13623
3160
2724
1522
1220
1048
872
827
765
645
630
527
7791
35354
next 10 years (from 1971)
Women, age 65
Rank
1
2
3
4
5
6
7
8
9
10
11
12
Cause of death
Probability
Ischemic heart disease
Cerebrovascular disease
Intestinal cancer including rectum
Breast cancer
Diabetes mellitus
Diesease of arteries, Arterioles and
capillaries
Other forms of heart disease
Stomach cancer
Pneumonia
Cancer of pancreas
Cancer of ovary, fallopian tube or broad
ligament
Lung cancer
All other causes
All causes of death
6966
2502
1025
913
840
518
447
392
362
331
326
319
5555
20496
Robbins L Hall J: How to practice Prospective
Medicine. Methodist Hospital of Indiana. 1970
2. Laframbose Hl. Health policy: breaking the
problem down into more manageable
segments. Can MED ASSOC j 108: 388. 1973
3. mCkFOWN t. A historical appraisal of the
medical task, in Medical history and medical
care published for the Nuffield provincial
hospitals trust by oxford university press, 1971
4. CHOOUETTE G: Evaluation des risques
personnels. Med que 8: 38, 1973
5. Idem: Popullations exposees et ennemis a
combattre Ibid jp 42
6. Idem: Role des media dinformation et des
centres de medicine prenvention Ibid p 34
7. COLBURN HN: Health Hazard Appraisal: a
possible tool in healthj protection and
promation. Can Jj Public Health 64. 490.
1973
8. CHERRY
WH.
COLBURN
HN:
Tabulations of the chancej of dying from 52
selected causes for Canadian residents.
Department of statistics, Universityj of
Waterloo, Waterloo. Ont 1973
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
Prospective medicine–
improving the patient’s survival odds
One way for an AMN editor to explore prospective
medicine for a story assignment is to put himself through
the examination. That’s what Associate Editor Bill
McCulloch did.
Here is his report.
Your average 32-year-old newspaper reporter has every
reason to feel confident-and maybe even a little bit smugabout his chances of making it through the next 10 years.
The so-called Geller Mortality Tables indicate that for
every 100,000 white males in their early 30’s, 97, 780,
will live to see their early 40’s. Only 2,20 of us will fall
by the wayside, or one man in 45.
Now those are pretty good odds.
According to Nancy Gilbert, though, my odds aren’t
quite that good. She’s the registered nurse who gave me
my Health Hazard Appraisal at Methodist Hospital in
Indianapolis. And what she found, basically, was this.
If we could find 100,000 white males in their early 30’s
who smoke and drink as much as Bill McCulloch does,
we’d probably lose about 4,450 of them over the next 10
years.
FOR A HORSEPLAYER, those are still pretty
attractive odds: only one chance in 22 to come a cropper.
Trouble is, horseplayers gamble with their money, not
their lives. The plain simple truth of it is that Bill
McCulloch’s risk of dying within 10 years is –
statistically speaking – about double the average in his
peer group.
Now here’s the real topper. Let’s s ay Bill McCulloch
has a bad chest cold and goes to see a doctor. The doctor
probably will tell him to get plenty of rest, take aspirin,
and drink lots of fruit juice. Oh yes, and call again if that
cough gets any worse.
Here’s a patient whose habits make him five times
more likely than average to die in an auto accident. His
risk of dying of cirrhosis is more than 12 times the
average; of pneumonia, three times average; of lung
cancer, nearly two times. In other words, this guy has
health risks that make his chest cold look like nothing.
And some doctor is going to tell him to get plenty of
rest, take aspirin, and drink fruit juice. What is going on?
“We’re sitting around waiting for people to get sick
when we should be trying to identify the things that make
them sick,” says Kenneth F. Kessel, M.D., director of the
Family Practice Center at McNeal Memorial Hospital in
west-suburban Chicago. “Really, it is amazing to see the
fantastic resources medicine can draw on in order to get
someone through a crisis. But there are no similar
resources invested in trying to prevent the crisis.”
THIS CONCERN in shared by Lewis C. Robbins,
M.D., former director of the Health Hazard Appraisal
project at Methodist Hospital, Indianapolis. “Our
situation
in medicine today,” he says, “reminds me of a few
baseball games I’ve seen. Right now, we’re relying
almost completely on spectacular, game-saving catches
by the outfielders.
“I’d rather see us get a new pitcher in there, some
fellow who can keep the batters from getting such good
wood on the ball in the first place. We ought to be
making things easier for those outfielders.”
The fellow that Dr. Robbins wants to bring in from the
bullpen is a physician whose “out pitch” is something
called prospective medicine, the science of solving
problems before they become crises.
Prospective medicine first began to take shape as a
clinical discipline about 15 years ago. It was initiated in
the U.S. Public Health Service and was viewed-at the
time anyway-as a weapon in the war on cancer. Dr.
Robbins, then chief of cancer control for the Public
Health Service, was instrumental in developing the
prospective-system.
PROSPECTIVE MEDICINE has since outgrown its
original categorical emphasis; nowadays it is
multidisciplinary. Its advocates say it has been adopted
by hundreds of primary care physicians throughout the
U.S. and Canada. In addition, the prospective approach
to medicine is being taught in several family practices
training programs, among them the residency program
headed by Dr. Kessel and MacNeal Memorial outside
Chicago.
Judged by prevailing standards, prospective medicine
is not particularly dramatic or exciting. It is doubtful, for
example, that prospective medicine will ever serve as the
basis for a popular TV series. Television’s doctor dramas
usually offer at least one tense medical crisis per week.
And that is exactly what prospective medicine aims to
avoid, which may be one of the reasons why some
doctors resist the prospective approach. “Our activities
during the clinical phase of training clearly reinforce
management of the dramatic,” says Jack H. Hall, M.D.,
director of Medical education at Methodist Hospital in
Indianapolis. “We enter practice expecting minute-tominute excitement.”
AS DRS. ROBBINS AND HALL explains in their
1970 manual How to Practice Prospective Medicine, the
prospective system differs from orthodox medicine in
three respects. It is continuous instead of episodic. It is
comprehensive, not fragmented by specialties. And as its
name clearly implies, it is initiated before, not after, the
onset of disease.
Prospective medicine has at least two familiar aliases –
predictive medicine and preventive medicine. Neither
name is 100% accurate, though, for the same reason that
it would be misleading to refer to orthodox practice as
curative medicine.
No physician can guarantee to cure his patients of
disease. He can only promise to apply his knowledge in a
way that will secure the greatest possible healing
advantage for a given patient. This is essentially the same
promise made by prospective medicine. It cannot predict
disease; it
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
cannot prevent disease. It merely seeks to establish what
Dr. Robbins calls a “survival advantage.” It does this by
offering each patient a plan for the management of his
“disease precursor,” meaning his harbingers of trouble.
According to Dr. Robbins, there are about 22 significant
precursors. The average “well” person, he says, carries
three of them, and they boost disease risks just as surely
as contaminated water used to increase the risk of
typhoid fever. Typhoid fever, notes Dr. Robbins, was not
brought under control by better disease treatment, but by
improved water and sewage (precursor) treatment. The
parallel is relevant to prospective medicine.
MANY PHYSICIANS say experience has trained them
to be on the lookout for important disease precursors in
their patients. They say they react automatically. And to
this extent, they claim, they’ve been practicing
prospective medicine for years.
But Dr. Robbins wants to go beyond that. He doesn’t
discount the importance of physician intuition, or savvy,
or whatever. But he does believe that prospective
medicine needs as organized format, a system. And this
is where the Health Hazard Appraisal comes in. Used
properly, explains Dr. Robbins, the Health Hazard
Appraisal can help the physician map out an effective 10year survival plan for any patient. Here’s how the
appraisal works:

It identifies average risks.
Average health risks are based on mortality
statistics. According to the Geller Mortality
Tables, for example, traffic accidents are the No.
1 killer of white males in their 30’s. The tables
tell us that in a group of 100,000 white males, age
30-34, we can expect 376 auto accident fatalities
over the next 10 years. The number 376 expresses
the average risk for this particular cause of death.
For atherosclerotic heart disease, the No 2 cause of
death, the average risk is 310. And so on down the list.
When all causes are lumped together, the average 10year death risk in this age/race/sex group is a composite
2,220.
The appraisal quantifies the patient’s risks.
The patient’s risks are expressed as deviations above
below the average risk. These deviations are noting more
than numerical extrapolations of personal health
characteristics, or to put it another way, precursors
translated into numbers.
People who drink a lot, for example, are believed more
likely to die in auto accidents than are teetotalers. But
how much more likely? Five times more, according to
the precursor tables that is used in conjunction with the
Health Hazard Appraisal. So the 32-year-old heavy
drinker would g et a factor of 5.0 on his No 1 risk. And
his 10-year risk of dying in an auto accident would be
expressed as five times the average risk of 376, or 1, 880.
By totaling the patient’s various risk figures, another
composite is determined, one that can be compared to the
average. American Medical News Associate Editor Bill
McCulloch has a composite 10-year death risk of 4,450as mentioned earlier-about twice the average.
*The appraisal establishes unmistakable goals.
“Like most human beings,” observes Methodist
Hospital’s Dr. Hall, “We doctors are reluctant to
establish goals. We don’t want everybody to know what
the target is, because then they can tell if we’re missing.”
But the Health Hazard Appraisal doesn’t leave much
room for hedging. Once the patient’s risks are spelled
out, the physician makes his commitment: “Get this
patient safely through the next 10 years.” That’s the goal;
and it is printed at the top of every appraisal form.
In reaching for that goal, the physician sets priorities
and does what he can to improve the patient’s survival
odds. He does his best to find the necessary survival
advantage.
* The appraisal offers a plan for survival.
If there is to be any improvement in the patient’s 10year survival chances, the physician must look for
appropriate ways to reduce the patient’s risks. This is
perhaps the most difficult part of the Health Hazard
Appraisal.
Obviously, the risk of ling cancer subsides if a
cigarette smoker quits smoking. The risk of dying in an
auto accident is reduced if the driver always buckles his
safety harness. The risks of cirrhosis declines if a
problem drinker goes on the wagon. The risk of
arteriosclerosis drops off it the patient controls what he
eats and gets regular exercise.
But these survival advantages may depend on the
modification of behaviour patterns that have been
established over years or even lifetimes. And as most
physicians are aware, you can lecture patients all you
want without having the slightest impact on behaviour.
“No, the parental approach just doesn’t work,” observes
MacNeal Memorial’s Dr. Kessel. “And you can’t use
scare tactics either or you’ll just push the patient into a
denial thing.
“About the best you can do,” he says, “is give the
patient as much information as possible about his
problems and hope that he’s motivated to do something
about them.
And maybe 25% follow through. That’s not a lot. But it’s
better than zero percent.”
Dr. Robbins believes strongly in the effect of
positive reinforcement. “I have good news!” is his usual
opening remark to an appraisal subject. “As of right now,
this year,” he’ll say, “you can importantly reduce your
risks of disease.”
The diminutive Indianapolis physician than outlines
a plan for reducing the risks. And after that, it’s up to the
patient. Dr. Robbins is never preachy. But the
information he presents does convey a sense of urgency.
The patient may fell fine, not a complaint in the world.
And yet, it suddenly seems important to reduce the risks
that Dr. Robbins is t talking about.
THE HEALTH HAZARD Appraisal helps to
illustrate the tasks at hand with its catalog of death
causes and risk figures. The appraisal also provides
incentives for behaviour modification by showing the
patient a sort of “before and after” picture of himself.
Bill McCulloch’s appraisal lists a composite patient
risk figure of 4450. Also listed, however, is a
hypothetical risk figure-it’s the carrot at the end of the
stick. It says, in effect, that if McCulloch will give up
smoking, cut way back on his drinking, and get a little
more exercise, his composite risk figure would drop
below 2,000.
The Health Hazard Appraisal also presents an
“appraisal age” and a “compliance age.” McCulloch, for
example, is said to be facing the same 10-year
probabilities of death that are faced by a 40-year- old
man. But if he
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
cleans up his act and starts living right, McCulloch’s
compliance age would be somewhere in the low 20’s.
And that’s pretty nice to think about.
SURE, THE AGE FIGURES are a numbers
game, a clever way of dramatizing an objective. That’s
all. But the people ho administer Health Hazard
Appraisals say it’s often the one thing that will really
make a patient sit up and take notice. It is a concept to
which everyone can relate.
So that’s how the health Hazard Appraisal
works. It is by no means a perfect instrument, and it is
not universally accepted. “We get shot at by some of the
purists in preventive medicine,” admits Dr. Kessel.
“They say the appraisal relies on a lot of things that
aren’t proven; they wonder if it’s applicable to inner-city
populations; they raise questions about what the risk
factors mean. And so on.
“But really, the Health Hazard Appraisal is just
and attempt to objectify. It forces us into a discipline we
didn’t have before.
“If you use the appraisal,” says Dr. Kessel,
“there’s no way you can ignore the leading causes of
death in a particular patient’s cohort group…. Also, the
appraisal makes you look for prescriptions that don’t
come out of bottles-physical therapy, counseling, diet,
that sort of thing.
“AND THE APPRAISAL is one hell of a good
teaching device.”
Drs. Robbins and hall also concede the Health
Hazard Appraisal’s imperfections. There is still a great
deal to be learned about precursors, they say, and some
of the risk factors should be taken with a grain of salt.
Alcohol has not yet been included as a precursor to heart
disease, for example, despite what some experts claim is
mounting evidence that it should be. In addition, the
health Hazard Appraisal does not yet list alcohol as a
precursor to suicide, even though alcoholics commit
suicide at rates four to five time higher than the general
population.
Both Dr. Robbins and Dr. Hall predict that the
data underlying the Health Hazard Appraisal will
improve with time. To that end, Dr. Robbins now works
full time coordinating the development and refinement of
disease precursor data. In the meantime, he says,
physicians need not be reluctant to make use of the
appraisal system.
Dr. Kessel agrees. “It’s choice between using
what we have or doing nothing,” he says.
PERHAPS BECAUSE of its imperfections,
though, the Health Hazard Appraisal loses much of its
usefulness when applied in a mass screening situation.
The appraisal does not make allowance to the possibility,
say, that the 32-year-old problem drinker may not even
own an automobile; the guy still gets a risk factor of 5.0
under fatal auto accidents.
“The subjective observations and little findings
made by the family physician are important in a Health
Hazard Appraisal,” notes Dr. Kessel. “Based on what he
knows about his patient, he can make adjustments here
and there in the appraisal.
“Plus which, the family physician is the guy
who can help the patient deal with his problems. I don’t
see any of these specialized preventive medicine clinics
really getting involved in patient management or patient
car. They’re just advisory,” Dr. Kessel says.
When the average family practitioner hears
about prospective medicine, though, one of his first
reactions is likely to be, Yes, but will it pay the rent?
“We believe it could be remunerative, but we’re not
really sure,” concedes Dr. Hall. “ Our biggest problem,
as I see it, is convincing the average guy in practice out
there that he can charge money for promoting health.
He’s been conditioned to think he can only charge for
treating sickness. Do you see what I mean? He hasn’t
yet learned to act as the patients advocate.”
OBSERVES DR. KESSEL: “This is why
episodic medicine is ‘where it’s at’ with the general
practitioner. You get fast turnover, and you make a good
back. Because of your tanning, you think you have to do
something to a patient…you can’t charge him if you just
talk to him.”
“And yet counseling should be a major
function of the family physician. Our curriculum here
includes a tremendous amount of behavioral science…”
According to Dr. Kessel, any physician who
does comprehensive prospective studies on his patients is
bound to uncover a variety of chronic condition’s “And
those ought to pay the rent,” he adds.
It is interesting to speculate about the potential
impact of prospective medicine. If it really does work,
for example, if we really could keep Bill McCulloch
from dying in an auto accident over the next 10 years,
maybe we’d merely be sparing him for a worse fate. He
might die of lymphatic cancer sometime during the next
ten-year cycle. Or he might have heart failure during the
10-years cycle after that. Death is inevitable, whether it
comes now or later.
And that, according to Dr. Robbins, is just the
point. Too many deaths come now instead of later. He
claims that 70-75% of all deaths recorded in this country
every year are premature.
Dr. Robbins wants to extend life-but not live
on is hospital bed with tubes running out of every orifice.
The part of a lifetime that concerns Dr. Robbins is the
useful, productive period. That’s what he wants to
extend, and that’s where he thinks medicine should begin
its battle against disease.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
PROGRAM MANAUAL
(used and retained by participants)
Copyright 1981 / 2 R.G.A Boland and A.A Lisiewicz
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
Content – Manual
Item
Page
1.
Program Schedule
2
2.
Program Objective
3
3.
AGL Method
4
4.
Acknowledgements
5
5.
Syllabus, readings, faculty
6-18
6.
Discussion I- Theory and practice of HHA
9-12
7.
Discussion II- Methodology
13-15
8.
Discussion III – Risk Estimation
16-18
9.
Discussion IV – New Methodologies
19-22
10. Bill Brown Cases
23-25
11. Excercise HHA and Cardiovascular Risk
26-28
Appendices
12. Simplified Glossary
30-36
13. Articles and Technical Notes
37
14. HHA Forms and Pre-Program Exercise (Separate package)
15. Tape for Learning Reinforcement
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
1.
Program Schedule
Time
Activity
Mode
9:00
Registration and Pre-Program Exercise
IND
9:15
Quiz
IND
9:45
Discussion I- Theory and practice of HHA
SG
10:15
Break
10.30
Case Study I - The Polish Sausage maker
SG
11:00
Discussion II - Methodology
SG
11:30
Case Study II – The Little Prince
SG
12:15
Bill Brown Cases
SG (new)
1:00
Lunch
1:45
Discussion III – Risk Estimation
SG
2:15
Case Study III – great expectations
SG
2:45
HHA and cardiovascular Risk
CSG
3:00
Case Study IV – The Crunch
Pairs
3:45
Discussion IV – New Methodologies
SG
4:15
Quiz and Review
Pairs
5:00
End
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
2.
Program Objectives
2.1
The major emphasis of the program is to improve the practical competence of health
professionals in completing and using the HHA instrument (as developed by Robbins
Hall and adapted by CDC).
2.2
Specifics learning objectives include:
a. to recognize the language and concepts of Health Hazard Appraisal
b. to develop skills in using the HHA Form B, HHA Chart and Geller-Gesner Tables
in computing HHA Present risk (risk score),Health Appraisal Age, New risk Score,
and Compliance Age
c. to evaluate the appropriateness of HHA for Varying individual groups, populations
and organizations
d. to criticize the existing and future methodology of HHA
e. to motive further study in the future
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
3.
AGL Method
3.1
The AGL (Autonomous Group Learning Method) was developed min 1969 for
management programs as a way of learning in groups without formal instruction.
Participants use the materials to develop answer to all the problems and question
arising from the learning experience.
3.2
The materials include:
a. Program Manual – Which is used and retained by participants and includes:
discussion notes, simplified glossary, HHA forms, articles and references for
future study
b. Text Book – which is used and retained by participants and includes: GellnerGesner Tables, by age, sex and race, risk factors, definitions, weight analysis data
and health age, etc.
c. Work Pack – which is used but NOT retained by participants and includes: case
studies, questions to aid the analysis of the cases, exercises, quizzes, case
solutions, learning patterns, etc.
3.3
The work will be done: IND – individually; PAIR – in pairs; SG – small group; CSG –
combined small groups; MG – main group
Groupings will be changed so as to give participants the opportunity to work with
different course members.
3.4
The Group Organizer is provided to assist the groups in solving the problems and to
answer
Questions, and thus achieve rapid individual learning in the limited time available.
3.5
Separate notes are provided to who how the AGL method is applied to the ues of
Discussion Notes and Case Studies.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
4.
Acknowledgements
We are extremely grateful to Charlie Althafer, Richard Lasco of CDC for all the help
and encouragement they have given us.
Lynn Hawkins and Paul Melia from Health and Welfare, Canada, has provided us
with all and information that was available of the work being done in Canada. Robert
Spasoff and Ian McDowell spent time with us discussing their studies. To all these people
and others in the
“ Prospective Medicine”.
Community, too numerous to mention, we offer our sincerest thanks. Any errors or
omissions, however, we must take full responsibility. We would like to hear from you as to
how to improve this presentation.
Robert Boland
Adam Lisiewicz
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
5.0
SYLLABUS OF THE INSTITUTE
GOALS
The major emphasis of the Institute is to improve the competence of health
professionals to use the HHA instrument.
The specific goals would be to:
-
teach the participants the mechanics of the Robbins & Hall method for HHA.
-
help them understand the scientific basis of risk estimation.
-
make them aware of the controversies surrounding the way HHA risks have
been
assessed .
-
Introduce them to the latest methodological advancement in appraising risk.
-
Re-orient those people using the HHA instrument towards research on the
effectiveness of the instrument in motivating people to change their life styles.
OBJECTIVES
A.
Cognitive objectives
At the end of the Institute, the participant will be able to:
-
use frequency tables to answer to answer questions about probabilities.
apply Bayes’ Rule to the solution of simple diagnostic problems.
define the odds ratio.
know the difference between prospective and retrospective studies.
critically appraise the odds ratio concept.
understand the importance of independence for estimating risk.
describe the American Cancer Society and Framingham Studies.
use the formulas that quantify a single risk variable.
combine the quantitative effects of multiple risk factors for a single cause into a
composite risk factor.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
B.
manipulate given information to calculate the probability of dying from a given
cause in a specified cohort.
Covert probabilities to represent death per 100,00.
Affective Objectives
At the end of the Institute, the participant will be:
-
C.
more critical in examining HHA instruments.
Appreciative of the subtle controversies regarding risk assessment.
More oriented towards research of the effectiveness of the HHA instrument as
motivators of life style change.
More selective in the utilization of an HHA instrument.
Psychomotor Objectives
At the end of the Institute, the participants will be able to:
- use the HHA tables found in the “ Prospective Medicine” textbook.
- calculate the estimated risk from given information.
- utilize the Geller-Gesner risk from given information.
- estimate health appraisal age using standard or current methodologies.
CONTENT OF THE COURSE
1. The evolution of the HHA concept is historically linked with the Robbins and Hall
work in Prospective Medicine.
2. The Mechanics of calculating HHA’s based on laws of probability, odds ratio concept
risk assessment extrapolation is practiced used the case study and AGL methodology.
3. Issues in methodology and organization is described
4. Cardiovascular Update and its application to the HHA is presented.
5. New methodologies for measurement of HHA are described.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
FACULTY ON THE COURSE:
R. E. Boland, M.D, M.P.H.
D. Caralis, M.D ., M.P.H.
A. Lisiewicz,M.Sc., Ph.D.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
6.
Discussion I – Theory and Practice of HHA
Preliminary notes on AGL method of using the materials:
6.1 (SG Individually (IND) – briefly scan the discussion notes
6.2 In small groups (SG) (A, B, C, D)
- A
- B
- C
reads the first section to the SG
summarized briefly what A has said and then reads the seconds section to
the SG
summarized what B has said and reads the next section to the SG, etc.
6.3 Individually – re-read the discussion material
6.4 Small group – discuss questions arising using the flip chart to improve
communication
Note:
a.
Work quickly to cover all the material in the short time allowed. The data will be
repeated again and again during the program so that points not fully understood
initially will become clear in subsequent discussions
b.
Use your notebook to record key points and questions for which the small group
cannot develop satisfactory answer. Raise the questions later in the program.
c.
Use the glossary for new technical words.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
HEALTH RISK APPRAISAL – ONE DAY PROGRAM
1.
OBJECTIVES OF THE PROGRAM
a.
To use the language and concepts of HRA starting with the Robbins
technique and progressing to more advanced models using computers.
b.
To develop skills in making HRA computations using Personal Data sheets,
Geller-Gesner Tables and Computation Charts.
c.
To determine relevant lifestyle interventions and compute new risk Score and
Health Compliance Age.
d.
To evaluate the existing and future HRA methodologies and their
appropriateness to individuals, groups and organization.
e.
To motivate further study in the future.
2.
TIME & LOCATION – date one day 8:30 am to 5:00 pm
3.
PARTICIPANTS
The program is designed for both Health Professionals (physicians, nurses, health
educators, etc) and for non-health professionals (personnel officers, managers,
administrative staff, etc.).
4.
CONTENT
The syllabus covers the following topic: definitions of HRA, historical review of
HRA, data base problems and research, risk factors, HRA systems, personal data
sheet, computations charts, relevant disease/injuries, prognostic characteristics, risk
score computation, health appraisal age computation, intervention and compliance
strategies, choice of prognostic characteristics, quantification of risk, risk and the
healthy participant, risk and the young male, HRA effectiveness, HRA trends for
the 1980’s, debit/credit methods, log linear methods, logistic methods, traveling
methods, ethical issues, formatting, motivation and overall methodology for HRA
implementation.
5.
METHOD
The program will use the AGL (Autonomous Group Learning) method which was
developed in 1969 for international management training program. It is a way of
learning I groups without formal instruction. Participants use the materials and
group resources to develop answers to all cases and question arising from the
learning experience.
6.
MATERIALS
The materials include: participants manual (lectures, question, exercises, cases,
glossary, references, and articles for future study), text book and a learning recall
tape (LRT). The tape is used for one hour weekly for three weeks following the
program to improve the quality of learning and to convert short term learning to
long term learning.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
Johnson & Johnson employees and member companies.
The institute personal were
confident that if such a program was judged to be effective it could be made cost-effective
through automation and the involvement of large numbers of people. Program personnel
stated that one can screen people cheaply and although they don’t know the exact costs
they are certain that such a program might be done for less than $140.00 per employee per
year for a three year program in a fairly large company.
V. Data and Data Processing
In-house computer processing was considered but a bid from CISI group was
considered more cost-effective. The CISI group provides computer services for those
phases of the program which involve a production mode. Research Triangle Institute in
North Carolina did the original programming for the health profile. There is also an
employee participation system data set which is collected in-house and then is sent to RTI
for analysis. There is also an employee cost system which is attempting to obtain and
analyze data on health care costs. Since Johnson & Johnson is a self-insured Corporation
they are able to collect information on numbers of dollars spent, numbers of claims, and
numbers of dollars per claim.
VI. General Assessment
The representatives of Johnson & Johnson feel that the philosophy of the Live for
Life Institute and the model which they have chosen to follow is consistent with the
current state of the art in risk estimation and risk reduction. They are convinced that the
“classical” HHA/HRA method because of its rather heavy-handed approach to motivation
and its failure to focus on positive aspects of health behavior is inferior to the Live for the
Life Institute model, at least for Johnson& Johnson employees.
The Live for Life
Institute is investing considerable resources in order to demonstrate that the Live for Life
model is proper, cost-effective, and beneficial. However, even given this the data may not
support their hypotheses. If such is the case a decision will be made as to whether the
subsequent step will involve further program development and refinement or cessation of
the program. The Live for Life Institute is a part of a profit-making concern and therefore,
the representatives of the program were cautions in sharing their information and data with
us. We understand and support this reluctance. It should be noted that the reluctance did
not affect their willingness to talk frankly about the program.
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
Summary Resume – Dr. R.G.A. Boland
1.
Personal
Address- c/o Bridgeport Hospital, Conn.06602 (203-384-3000 or 3644)
Nationality – English with U.S residence visa
Languages – English, Spanish, French
2.
General Education
Nottingham University (B.A. hons 1957)
Harvard University (I.T.P. 1962)
Stellenbosch University (PhD psychology 1973)
3.
Medical Education
Phd-MD program of Juarez Medical School – MD due in June 1978
4.
Medical Experience
Director of Cape Regional Hospital Management Training Program (1966/70)
Juarez General Hospital and Juarez Social Security Hospital – clinical
experience (1976/77)
Fair field Hills Hospital (Conn) – external (psychiatric) (1977)
Bridgeport Hospital (Conn) – extern (OBGY, surgery, pediatrics) (1977/78)
St. Mary’s Hospital (Conn) – extern (medicine) (1978)
5.
Other Professional Experience
Tenured full professor (University of Cape Town) (1965/76)
Professor of educational technology (INSEAD, Paris) (1965/76)
Consultant in training and management to various organizations in U.S.A.,
Europe and Africa (chitin Accountant (u.k). C.P.J (U.S.A)
About forty publications in learning systems used in thirty countries and seven
languages.
6.
References
Professor Dean Berry, yale University, New Have, Conn.
Dr. Douglas Thomas (DME) Fairfield Hills Hospital, Conn.
Dr. Norman Canter, Bridgeport Hospital, Conn.
Dr. Mariano C.Allen (former Director of PhD-KD Program), Hotel Dieu
Hospital, El Paso, Texas
Various international references in educational technology field used to obtain
3rd preference visa for U.S. residence
AGL 22 - BASICS OF HEALTH RISK APPRAISAL FOR HEALTH PROFESSIONALS
SKILLS BUILDING SESSION
POSITIVE SELF-STATEMENTS:
Our thoughts and beliefs can make even the most nonthreatening situation stressful. Selfdefeating beliefs can be changes.
MEDITATION:
Meditation is the ancient method of relaxation that ha been practiced the world over,
especially in the EAST, that Western science has now discovered as very helpful in
relieving stress. The ancient philosophy behind it is complex , but unnecessary to the
modern user of the method. Once the method has been learned, it takes no more than about
20 minutes a day to receive full benefit. This skill session will talk about its benefits: way
to use it in a busy schedule, and a twenty minute practice will be utilized.
JACOBSON’S METHOD O FPROGRESSIVE MUSCLE RELAXATION:
This is the mos popular and one of the most effective methods of whole body muscle
relaxation. Participants will be given some theoretical background and instruction in the
method. Participants will also experience the complete method in the session so that they
can begin to develop the skills involved.
COMMUNICATION TECHNIQUES:
Interested in brushing up on skills in listening and giving feedback? In this elective,
concepts of active listening and communicating with empathy wil be introduced, and you
will have an opportunity to try out and practice these communication skills. (P.S. This may
be a little elementary for those who have taken the Westinghouse Communications
Workshop).
FLEXIBILITY EXERCISE AND PULSE MONITORING:
Participants will be introduced to and briefly engage in a simple routine of bending,
stretching, twisting exercises. Use of this routine for 3-5 minutes per day can improve and
maintain flexibility. Also, for those interested in a program of vigorous exercise or
aerobics opportunity will be provided to learn to check one’s own pulse and to determine
the pulse range which is both sufficient and safe. This technique can be used to monitor an
exercise program to assure that one does enough but not too much of any strenuous
exercise.