Research ArticleOriginal ResearchA

Frequency and Prioritization of Patient Health Risks from a Structured Health Risk Assessment

Siobhan M. Phillips, Russell E. Glasgow, Ghalib Bello, Marcia G. Ory, Beth A. Glenn, Sherri N. Sheinfeld-Gorin, Roy T. Sabo, Suzanne Heurtin-Roberts, Sallie Beth Johnson and Alex H. Krist
The Annals of Family Medicine November 2014, 12 (6) 505-513; DOI: https://doi.org/10.1370/afm.1717

Article Figures & Data

Tables

  • Table 1

    MOHR Tool Health Risk Factor Assessment Questions and Risk Classifications

    Health Risk FactorQuestion(s)3,7Level of Concern/Risk
    None
    “Healthy”    		Some
    “At risk”    		High
    “At risk”
    BMI22Indicate height and weight20–2525 to <30≥30
    Fast food intakeNumber of fast food meals or snacks over past 7 days<11 to 3≥4
    Fruit and vegetable intakeServings of fruits/vegetables eaten per day over past 7 days≥53 to 4≤2
    Sugary beverage intakeNumber of soda and sugar sweetened drink per day over past 7 days<11 to 2≥3
    Physical activity23Number of days of exercise in past 7 days and average number of minutes of exercise per session≥150<150<150
    StressHow much stress experienced in past 7 days (0 to 10)0–4≥5≥5
    Anxiety or worry20Over past 2 weeks summed frequency of: (1) feeling nervous, anxious or on edge (0 to 3) and (2) not being able to stop or control worrying (0 to 3)Score <4Score ≥4aScore ≥4a
    Depression18,19Over past 2 weeks summed frequency of: (1) feeling down, depressed or hopeless (0 to 3) and (2) little interest or pleasure in doing things (0 to 3)Score <4Score ≥4aScore ≥4a
    SleepDaytime sleepiness in past 7 daysRarely/neverOftenAlways
    Tobacco use24Used tobacco (smoking or smokeless) in last 30 daysNo useUsedUsed
    Alcohol intake25Number of times in past year have had 4–5 or more drinks in a daybNever1 to 3×/yeara≥4×/yeara
    Illegal drug use and prescription drug abuseNumber of times in past year have used illegal drug or prescription medication for non-medical reasonsNoneUsed/misusedaUsed/misuseda
    General health ratingGeneral rating of overall healthGood, VeryGood, ExcellentFairPoor

    • ↵a Follow-up questions were asked, including the Generalized Anxiety Disorder 7-Item Scale20 (GAD-7; for anxiety or worry), Patient Health Questionnaire-918,19 (PHQ-9; for depression), the Alcohol Use Disorders Identification Test21 (AUDIT-C; for alcohol intake); Drug Abuse Screening Test17 (DAST-10; for drug use/misuse).

    • ↵b Recommendation varies by gender: 4 applies to women and 5 applies to men.

  • Table 2

    Total Number of Health Risk Factors by Patient Characteristics

    Patient CharacteristicNo. (%)Total Risk Factors P ValueaAdjusted P Valuea,b
    MeanMedianSDMinMax
    Sex.81.82
     Male568 (33.27)5.862.23013
     Female1,138 (66.67)5.862.07012
     Missing1 (0.06)–––––
    Age<.001<.001
     <30c212 (12.4)5.962.09112
     30 to <50582 (34.1)6.162.12013
     50 to 70787 (46.1)5.762.08012
     ≥70126 (7.4)4.752.0409
    Race.02.72
     Whitec1,219 (71.4)5.762.15013
     Black or African American380 (22.3)6.161.93111
     Asian or Pacific Islander24 (1.4)5.852.35212
     Other42 (2.5)6.36.52.22111
     Missing42 (2.5)4.64.52.27110
    Ethnicity.01<.001
     Non-Hispanicc1,150 (67.4)5.962.14013
     Hispanic487 (28.5)5.652.02012
     Missing70 (4.1)5.552.35111
    Marital status<.001.002
     Single, never been marriedc337 (19.7)6.062.10112
     Married/living as married892 (52.3)5.552.11012
     Divorced/separated/widowed452 (26.5)6.262.02113
     Missing26 (1.5)6.062.91110
    Education<.001<.001
     <High schoolc453 (26.5)6.262.00112
     High school or equivalent508 (29.8)6.262.06012
     Some college, associate, or technical training413 (24.2)5.962.07013
     ≥College degree306 (17.9)4.641.99011
     Missing27 (1.6)5.762.71110
    Employment status<.001<.001
     Unemployedc226 (13.2)6.562.20113
     Disabled265 (15.5)6.771.95111
     Employed part-time211 (12.4)5.862.06012
     Employed full-time518 (30.4)5.652.03012
     Homemaker181 (10.6)5.462.00011
     Other/student79 (4.6)5.252.07110
     Retired199 (11.7)4.851.8909
     Missing28 (1.6)6.36.52.81111
    How well the patient speaks English.05.26
     Wellc95 (5.6)6.362.24112
     Very well1,142 (66.9)5.962.13013
     Not well/Not well at all241 (14.1)5.661.81011
     Missing229 (13.4)5.552.28011

    • Note: Bold face indicates that the value is significantly different from that of the reference group (P <.05).

    • ↵a P values are calculated using statistical analysis that excludes the Missing category of each demographic variable.

    • ↵b P value adjusted to control for all other demographic factors.

    • ↵c Reference value.

  • Table 3

    Risk Factors per Patient and Frequency of Health Risk Factors by Practice Site

    US Prevalence, %All SitesSite 1Site 2Site 3Site 4Site 5Site 6Site 7Site 8Site 9P ValueAdjusted P Valuea
    Respondents, No.1,707114130291141113271214246187
    Risk factors per patient, Mean (SD)5.8 (2.1)4.3 (2.0)6.9 (1.9)6.6 (2.0)5.3 (2.3)4.2 (1.9)6.1 (1.8)5.9 (2.0)6.0 (2.0)5.4 (2.1)<.001
    Patients “at risk” for given risk factors, No. (%)
    Health behavior risk factors
     Fast food–975 (57.1)49 (43.0)112 (86.2)175 (60.1)63 (44.7)45 (39.8)191 (70.5)122 (57.0)141 (57.3)77 (41.2)<.001<.001
     Fruits and vegetables76.5261,443 (84.5)88 (77.2)120 (92.3)241 (82.8)117 (83.0)88 (77.9)250 (92.3)180 (84.1)199 (80.9)160 (85.6)<.001.003
     Sugary beverages23.927763 (44.7)17 (14.9)110 (84.6)164 (56.4)30 (21.3)14 (12.4)148 (54.6)96 (44.9)131 (53.3)53 (28.3)<.001<.001
     Physical activity48.8281,209 (70.8)73 (64.0)89 (68.5)215 (73.4)101 (71.6)71 (62.8)206 (76.0)144 (67.3)179 (72.8)131 (70.1).11.34
     Sleep–1,091 (63.9)62 (54.4)90 (69.2)199 (68.4)96 (68.1)72 (63.7)190 (70.1)131 (61.2)159 (64.6)92 (49.2)<.0010.01
     Alcohol intake16.929407 (23.8)36 (31.6)45 (34.6)52 (17.9)30 (21.3)22 (19.5)62 (22.3)62 (29.0)63 (25.6)35 (18.7).001.008
     Tobacco use18.129407 (23.8)9 (7.9)45 (34.6)126 (43.3)22 (15.6)7 (6.2)68 (25.1)27 (12.6)70 (28.5)33 (17.7)<.001.002
     Illegal drug use or prescription drug abuse9.23055 (3.2)2 (1.8)8 (6.2)18 (6.2)5 (3.4)1 (0.9)2 (0.7)6 (2.8)7 (2.9)6 (3.2).03.25
    Psychosocial risk factors
     Anxiety or worry18.131265 (15.5)13 (11.4)31 (23.9)79 (27.2)24 (17.0)9 (8.0)20 (7.4)29 (13.6)26 (10.6)34 (18.2)<.001<.001
     Depression9.132146 (8.9)4 (3.5)21 (16.2)46 (15.8)13 (9.2)3 (2.7)4 (1.5)20 (9.4)16 (6.5)19 (10.2)<.001<.001
     Stress–1,017 (59.6)58 (50.9)85 (65.4)197 (67.7)76 (53.9)47 (41.6)165 (60.9)137 (64.0)133 (54.1)119 (63.6)<.001.080
    General health risk factors
     Body mass index63.9291,358 (79.6)64 (56.1)97 (74.6)231 (79.4)107 (75.9)80 (70.8)242 (89.3)176 (82.2)216 (87.8)145 (77.5)<.001<.001
     Overall health status17.129767 (44.9)19 (16.7)42 (32.3)162 (55.7)56 (39.7)13 (11.5)94 (34.7)136 (63.6)147 (59.8)98 (52.4)<.001<.001

    • Note: All frequency values reported are the raw, unadjusted values.

    • ↵a P value adjusted for age, sex, ethnicity, marital status, education, and employment status.

  • Table 4

    Readiness to Change, Desire to Discuss with Provider, and Importance Rating for Each Risk Factor

    Health Risk FactorsRespondents at Risk, No.Ready to Change, No. (%)aDesire to Discuss With Provider, No. (%)aRated Most Important of Factors Ready to Change, No. (%)b
    Health behavior risk factors
     Any dietary factor1,456405 (27.8)161 (11.1)100/405 (24.7)
     Fast food862190 (22.0)73 (8.5)17/90 (9.0)
     Fruits and vegetables1321361 (27.3)139 (10.5)73/361 (20.2)
     Sugary beverages652120 (18.4)48 (7.4)10/120 (8.3)
     Physical activity1,118300 (26.8)145 (13.0)86/300 (28.7)
     Sleep69986 (8.6)96 (9.6)14/86 (16.3)
     Alcohol intake36271 (19.6)37 (10.2)5/71 (7.0)
     Tobacco use36168 (18.8)49 (13.4)21/68 (30.9)
     Illegal drug use or prescription drug abuse4510 (22.2)9 (20)2/10 (20.0)
    Psychosocial risk factors
     Anxiety or worry23253 (22.8)82 (35.3)19/53 (35.9)
     Depression12438 (30.7)52 (41.9)10/38 (26.3)
     Stress930209 (22.5)210 (22.6)65/209 (31.1)
    General health risk factors
     Body mass index1,260420 (33.3)295 (23.4)242/420 (57.6)
     Overall health status723172 (23.8)125 (17.3)114/172 (66.3)

    • ↵a The denominator for each health factor is the individuals classified as “at risk” for the factor who responded to the Ready to Change or Desire to Discuss with Provider questions (n=1,575).

    • ↵b The denominator for each health factor is the individuals classified as “at risk” for the factor who were said they were ready to change their risk for the factor; ie, the number given in the Ready to Change column.

Additional Files

  • In Brief

    Frequency and Prioritization of Patient Health Risks from a Structured Health Risk Assessment

    Siobhan M. Phillips , and colleagues

    Background Because behavioral factors help determine health, it is important to assess patient-reported health behaviors and psychosocial well-being. The My Own Health Report (MOHR) is a new electronic or paper-based health behavior and mental health risk assessment and feedback system. In preparation for integrating the MOHR into practice, this study examined the frequency of patient risk factors, the average number of risk factors per patient, and patients' perceptions of importance, readiness to change and desire to discuss identified risks with clinicians.

    What This Study Found Patients reported a consistently high number of health risks, with more than one-half of patients reporting six or more risk factors. Despite the high number of health risks, most patients were not ready to change any risk factors and few wanted to discuss risk factors with their clinicians. The most common risk was poor diet (low fruit and vegetable consumption, frequent fast food consumption or frequent sugary beverage consumption), followed by overweight/obesity. Patients were most ready to change body mass index and depression and most wanted to discuss depression and anxiety or worry.

    Implications

    • These findings present a challenge, given the small amount of time available for prevention in primary care, and support the need for more integrated care.
    • The authors suggest the need for routine administration of health risk assessments in primary care, the importance of real world approaches for implementing their findings and connecting patients and practices to appropriate resources, and the potential added value of including patients' perspective in the allocation of these resources.

  • Annals Journal Club

    Nov/Dec: Frequency and Prioritization of Patient Health Risks from a Structured Health Risk Assessment


    The Annals of Family Medicine encourages readers to develop a learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care and then acting on those discussions.1

    HOW IT WORKS

    In each issue, the Annals selects an article or articles and provides discussion tips and questions. We encourage you to take a RADICAL approach to these materials and to post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Discussion: Submit a comment.") You can find discussion questions and more information online at: http://www.AnnFamMed.org/site/AJC/.

    CURRENT SELECTION

    Article for Discussion

    • Phillips SM, Glasgow RE, Bello G, et al. Frequency and prioritization of patient health risks from a structured health risk assessment. Ann Fam Med. 2014;12(6):505-513.

    Discussion Tips

    This paper presents useful information on (a) patient priorities in addressing their health behaviors and (b) the frequency of health risks in primary care. Do the data make a compelling case in support of an integrated care approach?

    Discussion Questions

    • What question is asked by this study and why does it matter?
    • How does this study advance beyond previous research and clinical practice on this topic?
    • How strong is the study design for answering the question?
    • To what degree can the findings be accounted for by:
      1. How patients were selected or how many chose to participate?
      2. How the main variables were measured?
      3. Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?
      4. Chance?
      5. How the findings were interpreted?
    • What are the main study findings?
    • How comparable is the study sample to similar patients in your practice? What is your judgment about the transportability of the findings?
    • What contextual factors are important for interpreting the findings?
    • How might this study change your practice? In particular, will the study inform your approach to helping patients identify and address specific health risks?
    • How might this study change policy? Education? Research?
    • Who the constituencies are for the findings, and how might they be engaged in interpreting or using the findings?
    • What researchable questions remain?

    References

    1. Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197 http://annfammed.org/content/4/3/196.full.

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