Risk Assessment Tool Has Value, but Is Cumbersome for PCPs

Diana Phillips

November 11, 2014

The integration of a comprehensive, patient-centered health risk assessment (HRA) into routine primary care is feasible and can identify a high number of behavioral and psychosocial health risks across diverse patient populations, according to a new study. However, primary care practices would need additional resources to implement the program outside of a study, a related report shows.

My Own Health Report (MOHR) is a 20-item electronic- or paper-based risk assessment and feedback tool that is designed for use in routine primary care settings and includes patient counseling and goal setting.

To understand how primary care practices would implement MOHR, investigators designed a cluster-randomized pragmatic trial. They observed participating practices' willingness to adopt the MOHR tool, how they implemented it, the number and characteristics of patients completing the assessment based on implementation strategy, and whether practices maintained use of the tool after the study period. In a related study, they evaluated the frequency and patient-reported readiness to change, desire to discuss, and perceived importance of 13 health risk factors across nine pairs of diverse primary care practices participating in the trial.

In the implementation study, 18 of 30 practices approached agreed to participate. Of the 3591 patients offered MOHR, 1782 completed the assessment, for an overall reach of nearly 50%, Alex H. Krist, MD, MPH, from the Department of Family Medicine and Population Health of Virginia Commonwealth University in Richmond, and colleagues report in the November/December issue of the Annals of Family Medicine.

Dr Krist and colleagues saw significant variation in patient-level reach with different implementation approaches. Specifically, the response to mailed invitations ranged from 2.6% to 45.6%, telephone calls yielded a 64.2% response rate, in-office responses by patients via paper assessments was 43.9%, and the completion rate for Web-based assessment with staff assistance ranged from 56.8% to 94.4%.

The trend toward higher completion rates for assessments completed by practice or research staff vs patients was exemplified by the "dramatic increase in reach" observed when one of the practices converted from mailed to telephone completion.

All but one of the participating practices required additional support to field MOHR, including querying appointment records, mailing invitations, and administering the tool, the researchers report. In addition, MOHR use increased the average office visit by 28 minutes, including the time required for clinicians to counsel patients regarding their MOHR responses.

None of the participating practices continued to use MOHR after study completion. However, "[s]ix practices have embedded elements of MOHR into their patient portal or pre-visit patient paperwork as part of a standardized HRA process," the authors write.

Despite the willingness of practices to do the MOHR assessment, as exemplified by the high study adoption rate (60%), "most practices lacked capacity and infrastructure to field MOHR independently and required external assistance," the authors observe. Most sites integrated elements of MOHR into their workflow, but the authors note that "more substantial practice transformation will be necessary to integrate MOHR-like assessments routinely into primary care, and current incentives, such as the mandate to include HRAs as part of wellness care, are insufficient to facilitate this practice change."

Patients Reported Nearly Six Risk Factors, On Average

In the second, related study, the researchers evaluated responses across nine practices and included a general sample of 1707 primary care patients who completed all of the MOHR health risk items. The MOHR questionnaire asks about eight sociodemographic elements and 13 specific health risk factors grouped into three categories (general health, health behaviors, and psychosocial factors).

On average, patients had 5.8 of 13 risk factors, report Siobhan M. Phillips, PhD, from the Department of Preventive Medicine at Feinberg School of Medicine at Northwestern University, Chicago, Illinois, and colleagues. Less than 1% of patients had no risk factors and 54.6% had six or more risk factors.

The vast majority of patients (93%) reported one or more risk factor associated with poor diet, including low fruit and vegetable consumption, fast food, or sugary beverages. The next most commonly reported issues were inactivity (70.8%) and sleep problems (63.9%).

Of patients who reported being ready to change at least one risk factor, 66.3% identified overall health status as the most important health risk to them, followed by body mass index (57.6%) and anxiety or worry (35.9%). In contrast, much smaller proportions of patients were ready and willing to address alcohol intake (7.0%), sugary beverage consumption (8.3%), and fast food consumption (9%).

"The magnitude of differences in number of risks by patient characteristics was small to moderate, although statistically significant, and should be interpreted with caution," the authors warn. They note that even the "most advantaged" groups reported an average of 4.6 risks that "cut across traditional categories of physical, psychological, and behavioral health."

The number of health risks and their prioritization by patients "has several policy implications," the authors write. "First, if such risks are not systematically assessed, the likelihood they will be routinely identified is limited," they write. "More routine use of HRAs and patient-reported measures would align with public health goals and has the potential to increase patient-centered care and provide important information regarding patients' unmet needs."

Funding for the MOHR project was provided by the National Cancer Institute, Agency for Healthcare Research and Quality, Office of Behavioral and Social Sciences Research, and National Center for Advancing Translational Sciences, National Institutes of Health. The authors have disclosed no relevant financial relationships.

Ann Fam Med. 2014;12:505-513, 525-533. Krist full text, Phillips full text


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