CH AP TER 16 Principles and Practice of Secondary Prevention 203 During the 1970s, investigators began moving toward the The HRAs usually provide a printed report about th idea of modifying the periodic examination to focus or assessed person's relative risk of dying or risk age, combined the conditions and diseases that would be most likely to be with some sort of educational message regarding the types found in a person of a given age, gender, and family history of interventions that would have the most positive effect or This approach was termed lifetime health monitoring, the person's life expectancy, if instituted. The printed HRA he greatest support for a new approach came in 1979, when reports have become more sophisticated in recent years and the Canadian Task Force on the Periodic Physical Examin are sometimes supplemented with individualized educa- tion recommended that the traditional form of periodic tional messages. checkup be replaced by the use of health protection pack Studies have extensively evaluated HRAs, with mixed ages that included gender-appropriate and age-appropriate results. - Criticisms focus on errors or lack of information immunizations, screening, and counseling of patients on a by the persons entering the data, difficulties in validating the periodic basis. Specifically, the Task Force recommended predictions, uncertainties about the correct reference popu that"with certain exceptions, the procedures be carried out lation for baseline risks, and limitations related to the instru- case finding rather than screening techniques; that is, they ments focusing mainly or exclusively on mortality and not hould be performed when the patient is attending for unre- on morbidity or the quality of life. The greatest strength of lated symptoms rather than for a specific preventive purpose. HRAs may be the ability to estimate disease levels at the Among the certain exceptions noted by the task force were population level, clarify how nutritional and lifestyle factors pregnant women, the very young, and the very old, for whom affect an assessed persons risk of death, and motivate the they recommended regular visits specifically for preventive person to make changes in a positive direction. HRAs prin purposes cipally serve to raise awareness, which is just one of several do and generally not the most important, related te B. Health Risk Assessments Health risk assessments(HRAs)use questionnaires or com puter programs to elicit and evaluate information concern I. SCREENING GUIDELINES AND Each assessed person receives information concerning his or RECOMMENDATIONS her estimated life expectancy and the types of interventions that are likely to have a positive impact on health and The many organizations that issue screening guidelines and longevity recommendations include the following For many years, the idea of HRAs has been promoted by clinicians enthusiastic about detecting disease and risk Specialty organizations (e.g, American Ure Actors in individuals. Based on the founders original work, the Society for Prospective Medicine was formed,to a Organizations representing primary care specialties(e.g. improve the construction and use of HRAs and the practice American College of Physicians, American Academy of of preventive(prospective)medicine in a clinical or industrial medical practice. Toward this end, the Society promotes the Foundations for the treatment and prevention of particu- use of HRAs for the following lar diseases(e.g, American Cancer Society) Organizations dedicated to evaluating screening recom Assessing the needs of individual patients as they enter a mendations (e.g, U.S. Preventive Services Task Force medical care system or of employees in an industrial SPSTFI, American College of Preventive Medicine [ACPMI, Canadian Task Force on the Periodic Health Developing health education information tailored to the needs of the individuals who complete the assessment a Developing cost-containment strategies based on better In many cases, these organizations agree on their screen- acquisition of health risk information from individuals ing recommendations. However, certain diseases and screen- ng methods have led to major controversy, such as breast Most HRAs use questionnaires or interactive computer cancer screening and prostate cancer screening. In general, programs to gather data concerning each person being the specialty organizations tend toward recommending ssessed. In addition to data such as height, weight, blood screening methods related to their field, unless there is evi pressure, cholesterol level, and previous and present diseases, dence of harm. In contrast, the ACPM and USPSTF tend to the information usually includes details concerning the per- only recommend screening programs for which there is son's lifestyle and family history. Using an algorithm, a com- unequivocal evidence of benefits puter calculates the person's "risk age" on the basis of the Box 16-2 and Chapter 18.) data. Most HRAs use an algorithm based on findings of the In an effort to clarify many of the issues concerning Imingham Heart Study. The risk age is defined as the age screening and case finding and to make evidence-based rec at which the average individual would have the same risk of ommendations, the U.S. Department of Health and Human dying as the person being assessed. If the assessed persons Services created the U.S. Preventive Services Task Force. It risk age is older than his or her chronologic age, that means its investigations, USPSTF reviews data concerning the effi he or she has a higher risk of dying than the average indi cacy of three broad categories of interventions vidual of the same chronologic age. Likewise, if the assessed person's risk age is younger than the chronologic age, the Screening for disease in asymptomatic clinical popu erson has a lower risk of dying than the average individual lations and in certain high-risk groups (secondary of the same chronologic age prevention)