Definition

No consensus definition exists for HRAs. An HRA may be a simple questionnaire eliciting self-reported information on risk factors, behaviors, or diagnoses. Questionnaires may be supplemented with clinical examinations to obtain data on variables such as height, weight, body mass index (BMI), heart rate, or blood pressure. Some HRAs may include performance tests such as grip strength, timed-up-and-go, chair rise, or four-meter walk test.

In health promotion, most observers agree that HRAs involve more than the collection of health information. HRAs are techniques or processes of gathering information to develop health profiles, using the profiles to estimate future risks of adverse health outcomes, and providing persons with feedback on means of reducing their health risks.^128–131

For the purpose of this technology assessment, our definition of an HRA contained three components: (1) participants provided self-reported information to identify individual risk factors for disease; (2) participants received individualized health-related feedback based on the information they provided; and (3) the information was used to give participants at least one recommendation or intervention to promote health, sustain function, or prevent disease.¹ Any HRA, regardless of the delivery mechanism that fulfilled these three criteria (e.g., single or multiple questionnaire administration, use of written feedback material, counseling, resource referral, etc.), was included in the review. This definition is consistent with the Centres for Disease Control and Prevention (CDC) definition, which states that an HRA is a tool used to assess individual health. The tool, which may consist of a health survey or questionnaire, physical examination, or laboratory tests, is utilized to develop an individual health risk profile. The profile is often followed by advice or strategies to reduce any observed risks.¹³²

History

HRAs began in the late 1940s with prevention strategies against cervical cancer and heart disease. HRA users believed that treatment and prevention strategies would produce better health outcomes than treatment alone. Early HRAs were little more than simple charts allowing physicians to document risks and discuss prevention strategies with patients. Over time, HRAs evolved into multifaceted processes involving risk assessment, feedback, and advice.^1,133

HRAs have been used at the community level and in universities, health maintenance organizations, and worksites. HRAs may target specific diseases (e.g., cardiovascular disease [CVD]) or general health. HRAs targeting general health collect data on an assortment of risk factors without a specific interest in any one disease (e.g., CVD) or behavioral area (e.g., smoking cessation, physical activity).

HRAs are most popular in workplace settings. A national survey reported that 56 percent of large employers offered HRAs to employees and 21 percent gave employees financial inducements to undergo HRAs.¹³⁴ The perception is that HRA program costs will be offset by lower downstream costs from sick leave, absenteeism, and lost worker productivity. However, evidence supporting corporate financial savings from HRAs is equivocal and many HRAs may not reach high-risk individuals.^1,135 HRA participation is voluntary and healthier persons, or people who are motivated to improve their health, may be more likely to volunteer. Persons who design or evaluate HRAs must factor potential volunteer bias into planning and research efforts.¹³⁵

Despite questions about the financial and health benefits of HRAs,^136,137 these programs remain popular because they are seen as rooted in science, easy to implement, applicable to many risk factors and health conditions, and amendable for presentation to multiple stakeholders, including health consumers who wish to receive personalized information to improve their health.^1,138

Health Risk Appraisals and the Elderly

The population of persons aged 65 years or over in the United States will increase more than twofold between 2002 and 2030, from 35.6 million to 71.5 million. In 2030, approximately 20 percent of Americans will be 65 years or older.¹³⁹

In the 20th century, the United States experienced an ‘epidemiologic transition’ whereby chronic and degenerative illnesses replaced infectious diseases and acute illnesses as the leading causes of death. Chronic diseases, whose deleterious health effects increase with age, disproportionately affect the elderly population. Roughly, 80 percent of American seniors have one or more chronic diseases, and 50 percent have two or more. These diseases can produce severe disability, increased caregiver burden, and concomitant increases in healthcare costs. Per capita health costs for American seniors are five times greater than the costs for persons under age 65.¹³⁹

The impact of chronic disease among American seniors raises the issue of whether HRAs have a role in health promotion and risk factor mitigation in this population. In fact, the Affordable Care Act authorizes Medicare to cover an annual HRA, with coverage guidelines due by March 23, 2011 and a program model due by September 23, 2011.¹⁴⁰ To prepare for this new regulatory environment, the Centers for Medicare and Medicaid Services (CMS) has requested a technology assessment to serve as background for meeting the Act’s requirements.

Earlier Literature Reviews

Anderson and Staufacker¹³⁰ reviewed 11 articles to assess the impact of workplace HRAs on health-related outcomes. HRAs positively affected seat-belt use and physical activity, although most evidence of associations between HRAs and health outcomes was weak. Some evidence suggested HRAs might be effective when included as part of comprehensive workplace health promotion programs.

Heaney and Goetzel¹⁴¹ reviewed 47 articles pertaining to 35 workplace health promotion programs. While program characteristics varied in terms of comprehensiveness and duration, all programs provided employees with health education and skills development. Results suggested personalized counseling on risk reduction for high risk employees might be the most important element of workplace programs. Conversely, short term ‘health awareness’ programs directed at workforces in general may not be sufficient to modify health risks or reduce absenteeism.

RAND Corporation,¹ defining HRA to include collecting information on individuals’ risk factors, providing individualized feedback to individuals, and linking individuals to at least one health-related intervention, reviewed 80 articles and found HRAs had health benefits on behavior (e.g., exercise), physiological or anthropometric variables (e.g., diastolic blood pressure, weight), and general health status. For these benefits to occur, RAND concluded that risk factor assessment questionnaires must be used in conjunction with feedback and interventions. Evidence showed HRA questionnaires and one time feedback alone were ineffective at health promotion. RAND found limited evidence regarding the effectiveness of HRAs in older adults.

Soler et al.,¹²⁸ reviewed 108 articles pertaining to what they called ‘Assessment of Health Risks with Feedback’ (AHRF). AHRF involved the collection of information on at least two individual health behaviors, transformation of this information into an individual risk score or description of health status, and transmission of this information back to the individuals from whom the data were collected. AHRF Plus involved the aforementioned three components, plus additional interventions such as health education lasting greater than one hour or occurring over multiple sessions, enhanced access to physical activity, healthy food, or medical care, or policies such as smoking bans. The authors were unable to make firm conclusions regarding the evidence for the effectiveness of AHRF. This was due to many small or moderate effect size estimates in the reviewed articles, inconsistent results for some outcomes, and potential biases in study design and execution. For AHRF Plus, the authors found evidence suggesting that supplementing risk assessment and feedback with health education positively effects outcomes such as tobacco and alcohol use, seatbelt use, dietary fat intake, blood pressure cholesterol, health risk scores, employee absenteeism, and healthcare resource utilization.

Key Questions

CMS, in consultation with the McMaster University Evidence-based Practice Center and the Agency for Healthcare Research and Quality (AHRQ), drafted the following key questions (KQ) to guide the technology assessment.

KQ1.

Describe the characteristics of the provision of HRAs, including the following:

1. Which specific HRAs were studied in the literature?
2. What were the methods of HRA administration, e.g., telephone, Web-based, in the doctor’s office, community based, workplace based, or other?
3. What was the training of personnel who administered HRAs?
4. What were the methods and frequencies of followup?
5. What were the characteristics of the patient populations who received HRAs?

KQ2.

What characteristics of HRAs (KQ1 a to e above) are associated with better health outcomes?

KQ3.

What is the generalizability of the data in KQ1 and 2 to the Medicare population or subpopulations?