Introduction

Health risk assessments (HRAs) have been used for many years as a means to evaluate disease risks linked to lifestyle. With the de novo interest in preventive medicine in the U.S. an update on their use, value and perspectives seems timely.

Background

The first mention of the interaction between lifestyle and disease prevention goes back to the Greek civilization. Hippocrates, the great physician of the 5th century B.C., classified causes of disease and identified behavior- related and therefore actionable factors such as irregular food intake, exercise and habits.

Much more recently, in 1978 the Alma –Ata declaration1, emphasized the importance of prevention to improve global health. Over the past forty years, there has been a growing awareness of the link between lifestyle and many major diseases, particularly in developed countries. Concomitantly, the exponential growth in costs associated with medical care has revived the interest in health risk appraisals in the United States.

HRAs were developed by Dr. Lewis Robbins2 and first used in conjunction with the Framingham study. Their original purpose was to assess mortality risk. Then, this instrument evolved and led to the Geller Tables3 which were designed for primary care physicians with the same intent. The LaLonde report4 issued by the Canadian government in 1974 gave impetus to the perceived value of prospective medicine and stimulated interest by the Centers for Diseases Control, which developed its own HRA5. It included information on demographics, medical history and lifestyle behavior. Some other HRAs also incorporated clinical and biological data such as BMI, cholesterol and blood pressure to compute a health score. In the past thirty years HRSs had been in limbo. However, in the past three years approximately, a new focus has been found in HRAs' potential as a tool for education and behavior change.

In 2006, 19% of employers with 500 or more employees offered incentives for HRAs compared to 7% in 20046. In 2007, 91% of employers believed they could reduce health costs by influencing healthier lifestyles7. In the same year, 66% of insurers said they were somewhat or very likely to provide incentives for health-enhancing behaviors6. Nevertheless, the vast majority of the economic literature concludes that preventive medicine is not cost-effective8. This evidence was drawn from macro-economic analyses showing that the cost of healthcare is driven essentially by technology. As a mater of fact, many employers still consider wellness programs as benefits. Hence the value of preventive medicine which directly results in the reduction of use of all diagnostic devices.

This rekindled interest in HRAs and wellness programs is understandable since lifestyle accounts for about 50% of mortality overall in the U.S. Furthermore, according to the MacArthur Foundation Select Panel on Healthy Aging, 80% of health is determined by lifestyle in adults.

Discussion

In 2008, HRAs are used in isolation or followed up with different interventions: Health risk and reduction sessions, group coaching, one on one coaching, wellness programs, health education plans, preventive medicine actions (e.g., immunization, screening, etc). These take place in a worksite, through a health plan, in a community clinic or in a general community-based program. HRAs are given with or without incentives. It is important to note that the failure of many wellness programs is due to the lack of a crucial step, which is the participant's motivation assessment. As an example, the Stanford science-based six-step method for behavior change9 has been proven effective. It includes the following, with a variety of assessments and steps:

* Identifying the problem and assessing your current behaviors (healthy lifestyle behaviors vs. risks)

* Building confidence and commitment, assessing readiness for change and motivational assets (motivational assets available vs. those which need to be strengthened) and building a support network (who can help/what type of support they can provide /what is not needed from them)

* Increasing awareness of the behavior and keeping track of the behavior change progress

Developing and implementing an action plan, setting a long term goal (which must be sustainable and realistic), anticipating barriers and designing strategies to overcome them, maintaining motivation (through benefits from the wellness plan and extrinsic rewards) and setting the first short-term goal (it has to be specific in time and part of a gradual progress)

* Evaluating the action plan and assessing motivation on a scale from 1 to 5 (if the score is less than 4, the goal must be re-visited)

Maintaining the behavior change and preventing relapse by becoming an opinion leader and/or mentor, for example

High participation to HRAs and health promotion programs is essential to yield a good return on investment. The conditions for high participation include: Good program (capturing interests, educating, encouraging behavior change), good communication plan starting from the top (e.g., CEO blast e-mails), easy navigation and understandability, easy accessibility (intranet, website), easy and fast completion (less than 15 minutes), adequate financial incentives and prizes, privacy, quality of output (in particular, quality of the aggregate report), quality of customer service (reputable and trusted provider).

Participation has been proven much lower without financial incentives. On average, with a $100 incentive a 66% participation can be achieved. Other material incentives include, for example: gift cards, merchandise, health club membership, health account contribution10, sport items (bicycles, tennis rackets, running shoes), etc.

The main issues of concern to potential participants in HRAs encompass legal matters11 (in particular, privacy and Health Insurance Portability and Accountability Act or HIPAA).

In summary:

HRAS are more commonly used than ever in 2008

Their quality varies greatly. Good ones are science-based

Participation is much higher with financial incentives10

Best results are achieved when HRAs are followed by health promotion/wellness
programs7

Good return on investment is achieved with the right program design and implementation

There is (a) Cumulative effect and (b) Dose response12,13,14

The cumulative effect means that the result produced by two different health promotion interventions is greater than the sum of them considered separately. This is due in part to the fact that health awareness in these two domains reverberates onto other healthy behaviors by osmosis. The dose response implies that the higher the number of participants the better the results15,16. Several studies have demonstrated significant return on investment (on average $5.75 for $1.00) after using HRAs as the basis for health promotion interventions, such as:

Figure 1

Another 5-year study conducted among employees of Chrysler Daimler Benz in 14 sites in Michigan showed an average $212.00 return on each $1.00 invested24. In his review, Pelletier found that from 2000 to 2004, the vast majority of more than 122 research studies to date indicated positive clinical and cost outcomes25. Moreover, often this return on investment happens within the first year of intervention26.

Future Trends of HRAs

In the near future, HRAs have a great potential in advancing the agenda of preventive medicine. For example:

a- Medical conditions

Currently, health promotion interventions are focusing on lifestyle modification to stop smoking, decrease weight, exercise sufficiently, reduce stress, eat in a healthy way, screen for cancer or update immunizations. However, going forward new fields may be included such as early detection of medical conditions and preventive therapy such as, for example:

- Aortic Abdominal Aneurism

- Aspirin Therapy

Conclusion

HRAs have been around for a long time and have evolved progressively. Recently, there has been a surge in their interest. This phenomenon is interesting for preventive medicine as a whole because when they are used adequately as the port of entry to health promotion programs they produce good return on investment and contribute significantly to health improvement. Furthermore, HRAs can be efficient tools for physicians and patients for improving the quality of medical services.