Health risk appraisals as a risk management tool The following article was written by Kathleen M. Lux, R. N., M.S., graduate teaching associate, Department of Health Education, Ohio State University, Columbus.

Introduction

Diagnostic tests run on an Indian- apolis race car disclose possible problems with its futun: performance on the track. Health promotion risk management (HPRM) adapts the same principle to the human body using health risk appraisals (HRAs) to identify health risks. Both methods can identify risks but not absolutely predict outcomes.

Risk management concentrates on identifying and controlling the areas or events that have a potential for causing unwanted change (ref. 1). Using that basic definition, risk man- agement is conceptualized as having five components-planning, risk assess- ment, risk analysis, risk handling, and risk program monitoring and evaluation (ref. 2) (see figure).

Proper risk management requires a systematic approach to the identifica- tion of problems- and risk identifi- cation is the first step in the risk- assessment process. Risks cannot be managed until they are identified and described in an understandable way.

Risk managers can use HRAs to help identify the level of health risks present in hospital employees and/or clients, and to reduce and/or prevent those risks. HRAs can be adminis- tered by health care providers in clinics or at health fairs in communi- ties by trained personnel. Companies that have provided HRAs to employees have shown a differential rate of decrease in hospital costs incurred under the company health benefit program (ref. 3).

This artide focuses on how to use HRAs as a tool to identlfy health risks for risk assessment purposes.

What constitutes a health risk?

Health risks are genetic, social, and environmental factors associated with an incFeased risk of contracting

specific diseases. Resealrch shows that a person’s genetic characteristics, life- style, nutritional habits, social support, environment, and health practices are contributing risk factoxs for many of the leading causes of plemature death and disability (refs. 4-8).

It is important to understand that the presence of risk factors does not guarantee that an individual has or will develop disease, but merely implies the probability of developing disease.

Furthermore, health risk factors have a synergistic effect-that is, the combined potential for harm is more than the sum of each faaor’s indi- vidual potential (ref. 9). Health risks imply that disease is multifactorial in genesis- that the disease cannot be attributed to any single factor. Thus, it is important not to use risk factor identification as a way to “blame” individuals or assign guilt over life- style decisions. Rather, the use of risk factors can help individuals acquire the knowledge they need to make informed decisions about whether or not they wish to change their life- styles to decrease health risks.

Risk factors are usually divided into two major categories- factors that can be modified and those that cannot. For example, cigalette smoking, hypertension, and blood cholesterol levels can be contmlled through life- style choices. In contrast, age, gender, and family history are risk factors for

Risk Management Steps

chronic diseases that cannot be con- trolled. Modifying controllable risk factors is the major goal or principle behind health promotion and the use of HRAs.

What is health promotion risk management?

In health promotion risk manage- ment, the concepts of risk management are applied to the management of health risks. HPRM works to shift health care from a posture that merely reacts to disease to one that aims to minimize the risks of injury and illness.

It concerns factor identification and quantification of relationships between risk factors and personal characteristics for the purposes of risk prevention. It also involves early identification of diseases for diagnosis and treatment to prevent further progression of disease or secondary intervention. The effectiveness of any chosen strategy rests on three factors: the means available for the extent of the search for risk factoxs in a popu- lation, the means available for control- ling various risk factors, and the extent of their proper application.

The HPRM process involves the following steps:

Needs assessment -Measure illness/injury prevalence

and incidence

Risk Analysis I

Risk Handling

Risk Program Monitoring

and Evaluation

2s Ftrspectiws in Healthcarc Risk Management Winter 1992

-Define problem measures -Determine priorities of

illness/injury targets rn Risk attribution

conditions

each factor/ behavior

-Determine risk factors for target

-Determine attributable risk for

rn Selection of interventions and implementation -Establish measurable goals

and objectives -Identify interventions for

modifymg each risk factor -Select interventions and

implement them -Evaluate interventions

-Establish baseline morbidity and mortality data through use of HRAs

-Determine baseline risk factor incidence and prevalence

-Collect post-intervention data -Evaluate intervention effectiveness

rn Monitoriq

One of the basic steps of HPRM is the identification of health risks; HRA is the technique most frequently used (ref. 10). Risk managers can use HRAs to identify and assess the level of health risks within a population. HRAs employ personal risk assessment as an educational and motivational tool to encourage adoption of healthier life-styles (ref. U).

What is a health risk assessment?

HRAs are screening tools that may be used to discover areas of potential health risk, the magnitude of the risk incurred, and any suitable options to the risk situation (ref. 12). The tool incorporates risk factors that alter total risk and are based primarily on epidemiological studies.

HRAs haw the following three primary purposes (ref. W):

rn Many organizations use HRAs to characterize the general health status of their client or employee populations and thus form policies with respect to facilities and benefit plans.

Because they focus attention on the life-style factors that influence risk, HRAs are also widely used to alert

individuals to their personal health risks, usually in conjunction with some life-style modification program. rn HRAs may be used to evaluate deliberate attempts to sustain improved health - for example, through environ- mental or social changes resulting from a health promotion program.

Risk managers would most likely be interested in using HRAs for the first purpose mentioned above.

How does the HRA estimate risk?

Davies has outlined guidelines for translating data as reported in the literature into a coherent and internally consistent set of risk indicators and factors (ref. 14). Guidelines for esti- mating risk factors are listed in table 1.

Using HRAs to estimate risk is based on two underlying hypotheses (ref. 15): (1) Given a particular disease with a known incidence and for which there are identified risk indicators, a change in the prevalence of those risk indica- tors in the population will result in a change in the incidence of the disease, and (2) giving people information about their own risk will lead to actions per- ceived as, and directed at, reducing risk.

Neither hypothesis has been fully tested; however, community-based health promotion programs to decrease cardiovascular disease (CVD) mor- bidity and mortality through a decrease in risk factors related to heart disease in Finland and the United States have shown promising evidence (refs. 16-18).

What are the limitations of the HRA?

HRAs have several advantages and disadvantages, summarized in table 2. The HRA risk estimation procedure has been criticized for several sources of inaccuracy, such as geographical differences in mortality, errors in death certificates, racial differences, and age limitations (ref. 19). Because of those limitations, HRA predictions are best regarded as statements about charac- teristics and behaviors rather than as statements about individuals. The standard HRA attempts to reflect the distinction between the risk asso- ciated with a characteristic and the

reduction in risk that can be expected from modifymg that characteristic.

The preponderance of the research literature supports the use of HRAs to measure the prevalence of risk factors within communities and for health program planning. Risk man- agers can use HRAs to help identify the level of risk factors in their hospi- tal's employees or clientele. Used in this manner, HPRM becomes a sub- set of risk management.

Future of health promotion risk management

Health promotion is a relatively new field. Thus, it continues to be confronted by several issues that relate to the use of health risks for program planning and evaluation.

One is the plesent state of knowledge pertaining to different aspects of health improvement. In other words, is there empirical evidence to support the relationship between health risks and disease? Present research has docu- mented the risk factors associated with CVD and decreased mottality, but other health problems need further research to show similar documentation.

Two, there are problems in how, when, where, and by whom know- ledge about health risks and behavior should be applied.

Three, there are general social barriers to primary prevention. For example, some people firmly believe they have a right to smoke.

Four, what are the factors influ- encing behavior change? Research has as yet been unable to identify the vari- ables influencing behavior change.

Five, do health promotion specialists have a need or right to enforce beha- vior changes that improve or protect health?

Those issues will not be readily resolved; however, HRAs provide risk managers with a tool that can be used to identify health risks. It is hoped (and believed) that an awareness of risk factors that are difficult to change may prompt people to try to reduce risks more directly under their con- trol and thus decrease their overall risk of disease and injury.

26 Rapectiws in Healthcare Risk Management Winter 1992

Table 1. Guidelines for Estimating Risk Factors Prognostic characteristics

selected disease. 1. Search the literature for all evidence of prognostic characteristics for each

2. Identify those that have quantitative data on relative risks. 3. For those with relative risks, find an estimate of incidence in general

4. Select prognostic characteristics with adequate quantitative data. 5 . Eliminate duplicates or any that are secondary to a primary characteristic. 6. Sort into classes and mutually exclusive categories.

population by age, gender, and race.

Derivation of risk factors

1. Convert relative risk-to-risk ratio, with lowest being 1.0. 2. Convert risk ratio to risk factor. 3. Indicate where assumptions, interpolation, smoothing, averaging, or

extrapolation are used. 4. Identify published sources.

Combining independent risks

1. Search for evidence of interaction between independent prognostic classes. 2. If none of significance exist, follow probability theory.

Note: Adapted from Public Health Reports, 1980 (vol. 95, pp. 119- 126).

Table 2. Advantages a d Disadvantages of HRA Assessment Procedures Advantages

1. Covers all major causes of death and major known risk factors. 2. Aims to appeal to persons of all ages and all major race-gender groups. 3. Uses easily and inexpensively obtained client data. 4. Compares the dent with the national average for hidher age, race, and gender. 5 . Deals with the joint effects of multiple risk factors. 6. Provides quantitative estimates of health risk. 7. Summarizes client life-style into an appraisal or risk age. 8. Encourages clients to think about their present life-style and whether or

9. Helps clients understand that individual risks add up and may compound not it is healthy.

each other. 10. Personalizes health information-% can happen to me.”

Disadvantages

1. Risk factor data must often be extrapolated from age-gender-race groups other than that of the client. Clients who are not “typical” of their age- gender-race group may receive inappropriate appraisals.

2. Appraisals based on inaccurate or imputed client data can be misleading. 3. Relationship between appraisal age and risk age varies greatly with the age

of the client. Impact of behavior change on appraisal depends on the level of risk from other causes.

4. Clients may view HRAs as a diagnostic tool. 5 . Most are are oriented to chronic disease, middle age, and middle class.

6. Requires that national population distributions of risk factors match those Validity and reliability for other groups has not been tested.

on which risk factor values are placed.

Note: Adapted from ]oumal of Chronic Disease, 1983 (vol. 36, PP. 625-638).

27 Perspecti\cs in Healthcare Risk Management Winter 1992

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