Progress toward the assessment of health status

PREVENTIVE MEDICINE 4, 282-295 (1975)

Progress Toward the Assessment of Health Status1

DEAN F. DAVIES

Division of Health Care Services, University of Tennessee,

Memphis, Tennessee 38103

The distinction between medical care and health care is sharpened by a description of five features of current health status. In addition to current status, prognostic assessment based on known risk factors provides a second dimension of health. Together these features make up a health status profile.

The Preventive Medicine Center of the University of Tennessee Center for Health Sci- ences has been evolving computer-assisted health status profiles that are problem-oriented, urgency-oriented, disease-clustered, and interpretation-programmed.

It is the purpose of this paper to sharpen the distinction between health care and one of its subsets, medical care, and to do so by arriving at a definition of health and reviewing the current status and progress toward measuring the components of health.

Despite the popularity of the term “health,” as manifest in health science centers, health maintenance organizations, and national health insurance, only a little effort has been made to define the term “health.” Usually it is a shorthand way of combining medical, dental, nursing, and related activities into one word. “Medical care” in the literature is frequently used interchangeably with “health care.”

The health care delivery system is in the midst of an era of rapid flux evolving as it is from medical care delivery systems. The shift from medical orientation to health orientation is only beginning; it is largely because of tradition that the medical profession is primarily concerned with sick care rather than health care. As a result, medical care is too often initiated long after the opportunity for health maintenance has been lost.

Increasing attention is being paid to health education in the belief that the public should learn to protect and maintain its own health. Results have been disappointing because health maintenance usually entails changes in life style. The public has not responded well to seemingly controversial issues about diet, smoking, exercise, and other patterns of behavior. Techniques leading to greater incentive for changing behavior patterns are developing, however, and will be discussed under prognostic assessment below.

DEFINITION OF HEALTH

Health is the quality of wholeness of a biologic system as manifested in the level of harmony at which it functions. The term can apply to single biologic organisms or to social systems. The health of an organism is called individual

’ This study was supported in part under a grant (#243375 1765RO4 USPHSCR RM-00051-17) through the Memphis Regional Medical Program from RMPS, HEW.

Copyright 0 1975 by Academic Press, Inc. All rights of reproduction in any form reserved.

282

ASSESSMENT OF HEALTH STATUS 283

health. Unless otherwise specified, health refers to human individual health. The term “health” is value-free and is not here equated with being “healthy”

as in the World Health Organization definition, “state of complete physical, mental and social well-being.” There is good health and there is poor health. Until greater precision can be introduced into assessing those features that are encompassed, the term “health” will remain an abstraction meaning different things to different people.

Current Health Status

Currently five features of health can be identified. Each needs to be assessed separately. They are freedom from symptoms, physical health, functional capacity, mental and emotional health, and well-being. Each feature is qualitatively distinct and made up of qualitatively differing facets. These features and their facets do not have common denominators; therefore they cannot be added or otherwise combined into a so-called health index. There is no simple quantitative scale by which the health of one person or one population can be compared with another. However, specific indices of health such as frequency of a disease or mortality rates can be compared. In this paper I take the position that a middle ground between “health” as an abstraction and as a point on a linear scale will be most meaningful. The middle ground will be called a health status profile.

As stated above, medical care is a subset of health care. One feature of medical assessment is a measure of frequency and severity of symptoms. Presence or absence of symptoms, therefore, is one of the features of health. Each symptom is a feature that, though qualitatively different from each other symptom, can be scaled according to its nuisance value into three qualitatively dissimilar forms. At the lowest level are observed symptoms such as a growing mole on the skin or a yellowing of the sclera. At a second level are symptoms that are bothersome such as swelling of the ankles that makes the shoes fit tightly or weakness in an arm without pain. At a third level are sensate symptoms, including all forms of aches, pains, and other irritating sensations such as chills, fevers, and hot flashes. Although this classification is somewhat arbitrary and of little practical use in the diagnosis of disease, it can be used in studying the motivating factors that lead persons to seek medical help and the prevalence of significant symptoms that do not so motivate people and therefore are not diagnosed or treated until the symptoms become severe enough to become motivating.

Physical health is a second feature of current health status. It is measured by objective means and may not be associated with symptoms. Since limitations in physical health might not be perceived subjectively by the individual (e.g., elevated blood pressure, positive cervical cytology smear), the term “well-being” is inappropriate for this feature of health. It is more correct to say biologic disharmony is suggested by deviant chemical, physiological, or anatomic findings.

A third feature of health is the functional capacity of the individual. Func- tional capacity, or the ability to perform, is made up of both medical and nonmedical components. The medical component is called impairment. For example, amputees, paraplegics, and cardiacs have some degree of medical impairment that can be expressed in quantitative terms. Their capacity to support

284 DEAN F. DAVIES

themselves, however, is influenced not only by physical or mental impairment but by their skills, intelligence, and motivation as well.

A fourth feature of health is emotional and mental status. Disturbance in this area is measureable objectively and can be categorized by diagnosis (e.g., hyste- ria, hypomania, or schizophrenia).

A fifth feature of one’s health is one’s sense of well-being, a subjective coun- terpart of emotional and mental health. Deficiencies in this characteristic are manifest through psychophysiologic states, personality disorders, overt neu- roses, mild hypochondria&, situational stresses, or other nonorganic disease

.conditions. This feature, while varying qualitatively in its manifestations, falls largely into two primary facets anxieties and depressions.

These five, then, are the primary characteristics of current health status.

Prognostic Assessment.

Prognostic estimates of health have been under development for many years and have been based on risk factors that are identified with an individual and either increase or decrease risk as compared with that of an average person of the same age, sex, and race. Two tracks have been followed:

1. Estimation of the chances of a morbid event such as (1) coronary artery disease or (2) stroke occurring within a specified interval of time. This has been developed for cardiovascular disease and is based on Framingham data.

2. Estimation of risk of dying from any of the major causes within 10 years (7,9). The latter is called health hazard appraisal.

How are these six assessments to be made and recorded? In this early stage of development there are certain to be different opinions on how extensive the laboratory, psychologic, and physical examinations should be. A proposal to standardize what is considered a thorough work-up to assess health status would be premature at this time. It is not the intention here to recommend the optimum data set for each subgroup by age, sex, race, and occupation. However, it is possible to identify some of the measurements and tests that have been used as the data base for routine health assessments at this center.

METHODS

During the period of July 1, 1970, to August 3 1, 197 1, over 12,000 multitest profiles were obtained from clients attending the Preventive Medicine Center (PMC) at the University of Tennessee Center for the Health Sciences. These were recorded and tabulated manually. Between September 1, 197 1, and No- vember 30, 1973, over 12,000 additional profiles were obtained and computer- processed. For a smaller number of persons, health histories, mental health histories, and health hazard appraisals were carried out.

The balance of this discussion will be concerned with the methods used for simplifying the work of the physician and allied health professionals in obtaining an estimate of health status. In processing the data we have programmed the computer to be problem-, urgency-, action-, and organ-system-oriented (Figs. 1, 3,4). The computer also has been programmed to carry out complex mathemati-


cal procedures (Figs. 4, 5) and to have a sophisticated logic sequence for referrals (Fig. 1). These will be discussed below.

Health Status Appraisal

Health status standards for a data base are still being evolved. The state of progress toward this end, however, can be demonstrated. Four instruments were used in obtaining estimates of the status of the five identified characteristics of current health and a prognostic estimate of health status. These were a test profile, a health history, a mental health history, and a health hazard appraisal. The characteristics of health discussed above correspond generally with the instruments used. For the purposes of this paper the methods used will be discussed in terms of the characteristics of health rather than in terms of the instruments. Where concepts have progressed beyond implementation, these differences will be noted.

Physical Health

The major thrust of the effort of the Preventive Medicine Center was to de- tect early chronic disease by finding deviations from expected chemical, physio- logic, and anatomic states in an adult population. It became evident, however, that there was a potential value in identifying nondiagnosable or borderline deviations as well as in determining the level of a biologic measure within the normal or expected range. The set of data provides a baseline or test profile that is distinct for each individual and valuable for comparative purposes in the event of later manifestations of disease.

For purposes of maximum utility, certain specific requirements evolved regarding how the data should be portrayed. First, abnormal values needed to be flagged. Second, the number of abnormal values requiring follow-up should be seen at a glance. Third, a priority system according to urgency of follow-up was needed. Fourth, the direction and nature of the follow-up should be indicated. Fifth, the information should be arranged in a logical rather than a random or source-oriented fashion. These five requirements were considered to be important for saving the physician time. Although all these objectives could be ac- complished manually, it was thought to be more economical if routine protocols could be programmed for computer handling. An equally important reason for utilizing the computer (IBM 360 Model 40) was the need to analyze the data sta- tistically.

The following can be seen from the test profile printout (Fig. 1): tests are grouped largely by organ system (e.g., blood pressure, ECG, and cholesterol under “Cardiovascular”); tests requiring follow-up are flagged by an asterisk (two for urgent); borderline values are identified but deferred (e.g., see “Hemo- globin”); “problems” for follow-up are numbered sequentially; and indicators are provided for the type of follow-up needed unless the client has identified a personal physician. In that case the action code is “LMD.”

A single example of the way in which the computer was programmed to rec- ognize significant patterns of small, multiple deviations from the expected range and to identify the level of urgency of follow-up will suffice. The instruc-

286 DEAN F. DAVIES

Ul PREVENTIVE MEOICINE CENTER

WEALTH PROFILE P-O DATE W/OB/73

-----------------_------------------------------------------------------ UNIT NUMBER 400259 VISIT DATE 05120173 1417303 AGE 62 SEX/RACE II 0 --------------------------------------------------------------------------

+FLAG

CONSltlU7tONAL ,,E ,G”,------------ yc ‘G”,-- ----------

EVE AN0 EAR . AUOtOME?RV--------

RESPIRATORY SPtRORElRV-------- CHEST X-RAV-------

CAROIOVASCULAR B.p.------------

l

EC,+-------------

CHOLESTEROL-------

GENITOURINARV URINE

BLOOO--------- BtLtRUBtN--------- GLUCOSE--------.- pR‘,~E,N-----------

SERUM UREA--------

RH FAClOR---------

WEKAlOLOGV HEKOGLOBtN-------- GIPO SCREEN------- SICKLE CELL------

CHEKISTRIES GLUCOSE-----me-

l Wltt ACtO--------

TEST RESULTS

68.5 INCHES 145 POUNDS

BOTH EARS FAIL

OEFERREO OEFERPEO

1501094 SITTING 150/100 RESTING DEFERRED 216 WC/l00 ML

NEGATIVE NEGATIVE NEGATIVE NEGATIVE 6

013 WG/lOO ML

DEFERRED

13.4 GK DEFERRED DEFERRED

063 MG/tOO ML 08.0 HG/lOO KL

PROBLER/URGENCV/ACltON

E

1 C ENR

2 : KC

E

0

3 z SCL

IJRGENCV COOES - A = EWERGENCV, B = URGENT, C = REWIRES FOLLOW UP. 0 = DEFERRED, E = YITHIN EXPECTED RANGE

ACTICN CrOES - APT = REPEAT TESl,ENR = ENRICH DATA BASE YtlH SECONOARV TESTtSl. E+C = HEALTH EOU;AltON AND COUISELLINS, ItCC = HEALIH CARE CLINIC. SCL - REFER TO SPEClAilV CLINIC, LND = REFER 10 PRIVATE PHVSICIAN

N07E --- SINCE RANV TESTS ARE ACE AN0 SEX OEPENOENT~ SO-CALLED NORFAL NANGES ARE NOT LISTEO NI7M EACH REPORT. TABLES OF NORNS USEC NILL BE OtSfRtBUTEO TO USERS.

FIG. 1. Typical test profile. (PMC, Univ. of Tennessee Center for the Health Sciences.)

tions shown in Table 1 were programmed into the computer for serum uric acid levels.

The techniques of physical examination are well-established and should be part of a thorough health assessment. In the Preventive Medicine Center it was the policy to leave the physical examination to the physician responsible for diagnosis and therapy. This decision was based on two convictions: (a) routine physical examination by physicians of persons without motivating symptoms is not cost-effective; (b) even if the yield of unsuspected and manageable lesions were substantial, there are not enough physicians in the community to carry out such examinations without seriously affecting the care of the sick. Nevertheless,


TABLE 1 INSTRUCTIONS PROGRAMMED INTO COMPUTER FOR SERUM URIC ACID LEVELS

Uric acid (m4dl) Urgency code

Males 57.5

7.5-9.0 plus HCT < 35% or

BUN > 20 mg/dl or

Syst. BP > 120 or

Diast. BP > 90 7.5-9.0 plus none of above >9.0

Expected (E)

Follow-up required (C)

Deferred (D) Follow-up required (C)

Females 17.0 7.0-8.5 plus HCT < 30%

or BUN > 20 mg/dl

or Syst. BP > 120

or Diast. BP > 90

7.0-8.5 plus none of above >8.5

Expected (E)

L Follow-up required (C)

Deferred (D) Follow-up required (C)

a thorough health assessment should include a physical examination. Methods by which this goal can be achieved will be discussed in a later paragraph. Although many forms are available for recording physical findings, Fig. 2 is presented as “Physical Examination Form” because it calls for a decision as to urgency of an abnormality, tends to standardize the examinations to be carried out, is readily keypunched for statistical analysis, allows space for detailed description of specific characteristics, and provides for a provisional problem list.

Functional Capacity

The Preventive Medicine Center’s primary focus was on the presence of insid- ious disease in apparently well persons. However, at the request of an employer the center participated in an assessment of functional capacity. For example, men being examined for employment as city fireman were screened with particular care for visual acuity and for hearing. If they did not pass the audiometric test they were referred to the Memphis Speech and Hearing Center for further evaluation. These tests were for the medical impairment component of functional capacity. Physical strength, agility, and endurance were subsequently determined by the city’s personnel department. Limitations of functional capacity were isolated from the other assessments.

In a major effort extending from 1958 to 1970 a Committee on Medical Rating

. .

“: s..-

:: “.D

FIG. 2. Physical assessment form, which provides for urgency coding, keypunching, narrative description, and problem listing. (PMC, Univ. of Tennessee Center for the Health Sciences.)

288


of Mental and Physical Impairment of the American Medical Association, assisted by panels of specialists, developed thirteen “Guides to the Evaluation of Permanent Impairment.” They were published individually in the Journal of the American Medical Association between 1958 and 1970 and in bound form in 1971 (3). In order that evaluation could be accurate, equitable, and uniform, the estimates are converted into numerical terms. Each organ system is assessed separately. The preface to the volume states that the evaluation of permanent disability is an “administrative and not solely a medical responsibility and func- tion.” For purposes of determining ability to engage in gainful activity, it is true that one’s functional capacity is affected “by such diverse factors as age, sex, education, economic and social environment” as well as that elusive quality, motivation. The quantification of medical impairment has provided a major step toward assessment of functional capacity. In the long run the primary physician is concerned not just with medical impairments but with his patient’s ability to cope. In this his assessment will be aided by the health history and personality inventory, by measures of physical health, and by a knowledge of his patient’s vocational skills. For example, the impairment resulting from the loss of the fifth finger of the left hand would be the same for a pianist and a writer, but the disability would be much greater for the pianist.

In cases of disability claims, workmen’s compensation, and medicolegal dis- putes, physicians will be aided by appropriate specialists, particularly the physia- trist. Other methods of evaluating disability may be useful (56).

Symptoms

In contrast to the objectivity of physical health and medical impairment, symptom assessment appears to be nonquantifiable. However, there are several facts about symptoms that make an evaluation possible.

In Fig. 3 is shown the first page only of a four-page printout of significant information derived from a self-administered health history form.2 The format resembles that of the test profile: significant symptoms and items of medical history are flagged, numbered, and coded for urgency. They are also rearranged by organ system so that family history, past history, and current symptoms that are related can be seen at a glance. In this way a symptom profile within a health profile tells the physician whether the symptoms are numerous, diffuse, or con- centrated. The time required for detailed questioning can usually be greatly short- ened.

Mental and Emotional Health

In the context of the definition of health being advanced, mental and emotional health are objectively assessed and can usually be classified by type. Figure 4 shows the results of a screening assessment of eight clinical scales derived from the Minnesota Multiphasic Personality Inventory (MMPI). Because the mental health history form is a “midi-mult” of 86 questions out of 576 in the MMPI, it

* Health history and mental health history forms are available on request.

290 DEAN F. DAVIES

UNIVERSITY OF TENNESSEE

MEDICAL CENTER

PREVENTION CLINIC

NULTIPHASIC HEALTH EVALUATION

PRINT-OUT DATE 06/18/73 HEALTH HISTORY PAGE 01 ----_--------_----------------------------------------------------

UNIT NUMBER 347305 TEST DATE 06/11/73 AGE 49 RACE B SEX F

. FLAG HISTORY/OUESTION

CLIENT ANSWERED “YES” TO THE FOLLOWING QU~TIONS: PROOLEM/URGLNCY NUM8ER

GENERAL

HAVE YOU SEEN A OOCTOR OR GEEN TO A CLINIC WITHIN THE LAST TWO (2) NONTHS.

00 YOU HAVE AN APPOINTMENT TO SEE YOUR DOCTOR OR GO TO A CLINIC IN THE NEAR FUTURE.

ARE YOU NOY UNOER ACTIVE NEOICAL CARE.

l

ARE YOU NON TAKING ANY NEDICINE PRESCRIEEO IiY A DOCTOR.

NHV 010 vau care TO THE PREVENTION CLINIC. I RECEIVE0 AN APPOINTMENT WITH MY WELFARE CHECK

ARE YOU NOII BEING TREATECI ACTIVELY FOR SONE ILLNESS OR CONDITION.

IS YOUR HEALTH NORSE THAN IT WAS ONE YEAR AGO.

IN GENERAL 00 YOU FEEL THAT YOU ARE IN FAIR HEALTH.

PERSONALIlY

t HAS A DOCTOR EVER TOLD YOU THAT YOU HAG A NERVOUS BREAKOONN.

NUSCULOSKELETAL

I C

2 C

. HAVE you HAD BACK TROUBLE. 3 C

. 00 YOU HAVE ANY LINITATION OF NOTION OF YOUR 4 C BACK, ARMS. LEGS, HANDS. OR FEET.

FIG. 3. Health history. The figure is the first of a four-page printout containing positive and significant responses to the self-administered health history. Symptoms and statements indicating need for follow-up are given provisional problem numbers. See text. (PMC, Univ. of Tennessee Center for the Health Sciences.)

serves well for screening purposes, and its results have been shown to correlate well with the MMPJ (4).

Nevertheless, the results are not diagnostic, and great care has been taken to prevent labeling a patient with results that on this screen fall outside the expected range. Printouts have been available only to psychologists and psychia- trists. Because the clients did not seek assistance for their mental or emotional state, they are offered help in a carefully worded letter that begins as follows. “Personalities differ. It would be a dull world if we were all alike. If you are per- fectly happy with your personality and your relationship to other people, this


MINTOUT OATE 05/24/73

lJNIVERS17V OF TENNESSEE

NLOICAL CENTER

PREVENTIVE NEDXCINE CENTER

HEALTH PROFILE

PERSONALITV INVENTORV

UNIT NUNKER MO259 9/R 05-21-73-003

FL16 INSIDE OR OUTSIDE PROBLEM UR6ENCV ACTION VALIDITV SCALES EXPECTED RAN6E

LIE (L) T=49 INSIDE E

FAKE #F) T-60 INSIDE E

K T-55 INSIOE E

CLINICAL SCALES

MVPOCHORORIASIS WSI T=SK INSIDE E

DEPRESSION ID) T-70 INSIOE E

HVSTERIA WV) 7161 INSIDE E

l PSVCHOPATMIC DEV. (PO1 T-01 OUTSIDE 1 C HC

PARANOIA (PA) 7139 INSIOE E

PSVCHASTl4ENIA 1PTB T-58 INSIDE E

SCHIZOPMRENIA (SC) T=67 INSIOE Ii

HYPONANIA INA) I-49 INSIDE E

FIG. 4. Typical printout from mental health history. Printout represents interpretive evidence from 86 “midi-mult” questions. See Fig. 1 for urgency and action codes. (PMC, Univ. of Tennessee Center for the Health Sciences.)

letter is not for you.” A return card offers the following types of choices: “Please make an appointment for me ----. I am making an appointment with ----. Please send the results to ----. I first want to have a talk with my family physician. I feel fine. I do not feel any need for follow-up ----.”

The form of the printout is similar to that of the test profile and health history with an asterisk to flag the clinical condition, the c value as calculated by the computerized program, a statement about whether the measure is inside or outside the expected range, problem numbering, an urgency code, and for the client in Fig. 4 an action code for “education and counselling.” In a subsequent report the relationship between results of the mental health history and the health history will be discussed.

Well-being

The most commonly deficient, least quantifiable, most subjective, and most frequently suppressed feature of health is well-being. Because the efforts of

292 DEAN F. DAVIES

PMC were focused on chronic organic disease, no effort was made to separate it from the health history and the mental health history. An indication of a client’s state of well-being was obtainable in part from the number of symptoms recorded on the health history. This relationship had less to do with the exis- tence of underlying organic disease than with the perception of symptoms by the individual. The question, “In general, do you feel you are in: Good health?

Fair health? Poor health? -,” tended to sort out those with anxieties and depression from those in a healthy state of well-being. More directly, however, among its 86 questions, the mental health history includes such true-or-false questions as “I work under a great deal of tension,” “I wish I could be as happy as others seem to be,” “I am happy most of the time,” “I frequently find myself worrying about something,” and “I have never felt better in my life than I do now.”

Clearly these questions by themselves do not reveal the underlying condition; the Napoleon in the psychiatric ward is happy, and the bereaved may be under- standably depressed. What the person perceives subjectively is a necessary part of his health status, but it should not be confused with his mental and emotional health. This feature of health deserves more effort that has been applied here, but my purpose has been served if it is recognized as separate from the other features described. For the present an individual can locate his state of well- being on a scale of 10 and be asked whether it is a problem he believes someone else might help him resolve. It is his own perception of whether his level of well- being is a “problem,” not the health professional’s recognition of a problem, that is important. A combination of the person’s own sense of urgency and the health professional’s interpretive judgment will determine whether such an effort should be deferred (D), is needed (C), or is urgent (B).

Prognostic Assessment

Another dimension of a health status profile is prognostication. Prognostic appraisal has always relied heavily on clinical judgment. It is becoming more sci- entifically based. One form being carried out with the help of the computer in our center is that of health hazard appraisal (7,9). The program makes the selec- tion of responses from the health history and test profile that constitute risks of mortality within 10 years, calculates the major risks of dying, and converts them to the age equivalent (health appraisal age) of persons of the same sex and race with a similar risk.3 Figure 5 shows the top portion only of such a printout. This particular man came through PMC for a routine examination. Chronologically he was 39 years old, but because of his several risk factors his health appraisal age was that of a man of 52. Although he had no symptoms and therefore no reason to seek medical assistance, he failed to pass the test of optimum health. The figure demonstrates his risk of death within 10 years per 100,000 compared with the average for black men of his age. It also lists the risk for each contributing

3 Health hazard appraisal can also be obtained from a short personal risk registry form available on request.


DlTIFNT NItlE: RU OLTCZ 01-11-13

0oc10R nrnr: OQ. DAVTES. DELN f. PITIENT Tn 000000519 N

8u=R~fiE RTTK OF DflTH PER lOO.OOO 41 TWTS PITTCNTS IF.? 9.7FO cn*~UT=o RTSK OF DFITW PER 100dl00 FOR TIIIS PaTTENT Ill. 532 CCHPUTEo RTSK Of OCATW PER 100.000 FOR THTS PLTIENT WC n.mb

CHQONnLOKTClL ABE’: 39 APPRITSAL &RF: 52 COWLILNCE &RF: al ---_----______----------------------------

cause: ~RYFRTOSCLEROTYC HEIR7 OISE~SF LVfRlGE RTSK 1.301 CUERENT RTSK R.5Rl 6.6 TIM5 AVR. COWLIINCE RISK 1.137 .9 TIMES IVR.

CONTRIRUTING FACTnRS PPESENT RISK PREWRIQFO COKPLTANCE RIZK IFTFR COMPLTlNCE P.P. (CURI?) ---1991106 a.n 89. ltO/GO OR LESS 1.3 CH’X. (Cl199 1 ---23QKCt 1.2 CWOLFSTEROL 1GO OR LFSS .9 CXERCTZE:<EWNT lRV 2.5 EXERCISF IS DIRECTED ).G tKOKCR: I PaCWlolv 1.5 CT00 SNGKINfi .1 YEIGHT-49? OVFRYETGUT i.5 REOUEE Tn LVEPIGE 1.0

______--_---------------------------------

CAUSF: VlSCULAR LWTONT LFFfCTmG MS &VFD&SF RISK 521 CURRENT QISK 2.301 ‘I.9 TIKFS IVR. CnKPLTkNCE RISK l8Q 1.5 TIKFS aV6.

CONTRTRUTING FLCTORS PREqfNT RTCY PRESCRIRFO COKPLILNCE RISK ACT’R COWPLTANCF 9.P. lC!llQQ) ---lQq/lGG 2.0 A.P. 1201110 nR LFSS 1.3 CWOL ICURGt. ---23WCI 1.7 1.7 SMOKFQ’: 1 P&CKIOLY 1.2 STOP SWOKIWB 1 .c

____________------------------------------

CIUTF: NYDFRTENSIVE HPPRY OYSEl~E lYERlfiE RTSK 264 CUGRENT RTSK l.lRR 4.5 TIrFS 1VG. CO F’ LI4 NCF QIQ K 3#3 1.3 TIMFS aVfi.

CONTRTRUTINS FOCTORZ PRFSFNT RI<K PRESERTQEO COKPLIAN@f aFTfR CONPLTANCF

FIG. 5. Typical printout of health hazard appraisal. See text. (PMC, Univ. of Tennessee Center for the Health Sciences.)

factor by disease category and the achievable risk after compliance with correc- tive prescriptions.

DISCUSSION

Good health is that abstract ideal that liberals and conservatives, providers and consumers, and young and old can agree is desirable. A number of efforts are being made to define the term in a way that is measurable. At the present state of development of the science of health no definition has been at the same time sufficiently specific and practical. In particular, those efforts to combine all the features of health into an index like the GNP are doomed to failure.

It has been the thesis of this paper that efforts to define health in a measurable way are not only justifiable but also desirable. How can the health care system with its primary physician shortage carry out a thorough health assessment, including physical examination, on the general population? The question has two parts. The first is whether there should be exclusions by age or other characteristics and how frequently a person should have a health assessment. The second is concerned with the nature of the examination itself and whether nonphysician health professionals can be trained to carry it out. In recent years a number of

294 DEAN F. DAVIES

health professionals have assumed new roles, some of which include training in physical assessment. Physician’s assistants, pediatric nurse associates, nurse practitioners, and family nurse specialists fall into this category. Experience has shown that these professionals often can do a creditable job of identifying deviations from the expected patterns (8,lO). Thus the beginnings of a quantifiable health assessment, including prognostic assessment, are at hand. The state of the art does not yet allow a totally adequate definition, but five of its components have been described. Quantitative estimates of the status of each can be tabulated.

The health status profile proposed (Table 2) is a middle ground between the “lumpers” and the “splitters.” Some will be tempted to add the total number of problems to arrive at a single measure of a person’s health. Others will immedi- ately see descriptive detail necessary for diagnosing and treating the “patient.” The advantage of the profile is readily appreciated when one considers the vantage points from which one’s health must be viewed. The employer is primarily concerned with functional capacity of his employees. He is also concerned with their health prognoses and doesn’t want to lose highly skilled executives to premature disability or death. The behaviorist sees disharmony of interpersonal relationships as a result of deficiencies in mental or emotional health or well- being. The subject is concerned.with his symptoms and well-being now, but his enlightened self-interest can make him want to avoid risks that would endanger his future health or life expectancy. From still a different vantage point, the physician and those concerned with effectiveness and efficiency of health care delivery have needed a practical means of taking stock of the benefits of their services in relation to the cost of delivering them.

As indicated above, the five features of health described can each be assessed

TABLE 2 PROPOSED PROFILE FOR FIRST LEVEL ASSESSMENT” OF CURRENT AND

PROGNOSTIC FEATURES OF HEALTH STATUS

Initial visit Subsequent visit

Highest Highest No. of level of No. of level of

problems urgency problems urgency

Symptoms Tests ImpairmenP Mental and emotional Well-being

Prognostic: Health appraisal age Health appraisal age Compliance age Compliance age

a The problem list is the second level of assessment of health status. b Impairment is currently the only objectively determined component of functional capacity.


independently and do not necessarily influence any other features. Usually they do overlap in all combinations and have influence on each other. Lack of physical health and functional impairments influence mental-emotional health and well-being. On the other hand, the family and social environment can be incapac- itating and bring on disease. These cause-effect relationships vary from person to person and are not now predictable.

Both for health professionals and the public, progress in developing the art and science of health maintenance will be slow as long as health care remains a euphemism for medical care on the one hand or a vague abstraction on the other. Of particular interest to primary physicians and the public is the rapidly growing field of health hazard appraisal. There has long been widespread public interest in every facet of medical and dental concerns, but there is real fascination with the quantification of one’s own prognosis. Health hazard appraisal is going a long way toward bridging the gap between health education and health motivation. A person is taken from general population statistics to confronting his personal risks and an estimate of the consequences of removing or diminishing those risks.

The science of health is still very young, and the efforts expressed in this study are undergoing a rapid evolutionary process. There will be those who take issue with some of the concepts expressed. If they agree, however, that health is a broader concept than absence of sickness, our differences are already of minor significance and we should close ranks.

REFERENCES

1. American Medical Association “Coronary Risk Handbook: Estimating Risk of Coronary Heart Disease in Daily Practice,” p. 35. American Heart Association, New York, 1973.

2. American Medical Association “Stroke Risk Handbook: Estimating Risk of Stroke in Daily Practice,” p. 9. American Heart Association, New York, 1974.

3. American Medical Association “Guides to the Evaluation of Permanent Impairment,” p. 164. American Medical Association, Chicago, 197 1.

4. Gilroy, F. D. Personality testing in the health evaluation center, in “Automated Multiphasic Health Testing: A Health Services R & D Laboratory” (R. K. C. Hsieh, F. D. Gilroy, and M. Greberman, Eds.), p. 114. U. S. Department of Health, Education and Welfare, Health Ser- vices Research Branch, Baltimore, 197 1.

5. Jones, E. W. “Patient Classification for Long-term Care: User’s Manual,” p. 99. Department of Health, Education and Walfare Publication HRA 74-3107, Washington, DC, 1973.

6. Medical Advisory Committee to the Social Security Administration. “Disability Evaluation under Social Security: A Handbook for Physicians,” p. 71. Department of Health, Education and Welfare Social Security Administration, Washington, DC, 1970.

7. Robbins, L. C., and Hall, J. H. “How to Practice Prospective Medicine,” p. 100. Methodist Hospital of Indiana, Indianapolis, IN, 1970.

8. Spitzer, W. O., Sackett, D. L., Sibley, J. C., Roberts, R. S., Gent, M., Hackett, B. C., and Olynich, A. The Burlington randomized trial of the nurse practitioner. New Engl. J. Med. 290, 251-256 (1974).

9. Walsh, T. F. Prospective medicine: The case for doing health hazard appraisals. P&en? Care, 8, 106-140 (1974).

10. Yankauer, A., Tripp, S., Andrews, P., and Connelly, J. P. The outcomes and service impact of a pediatric nurse practitioner training program-nurse practitioner training outcomes. Amer. J. Public Health 62, 347-353 (1972).

Documents

Progress toward the assessment of health status