Ten years ago, I found I was growing weary of annual physicals. So often my patients left with too little information for all the time, energy and expense that went into their exams. Test results simply accumulated in their charts, and I had no objective way to measure changes in patients' health status from year to year. I always gave lip service to prevention, but my attempts to actualize the concept were very frustrating.
About that time, I heard about prospective medicine and health risk assessments (HRAs), and what I learned changed the way I practice medicine. In the traditional medical model, a patient presents with a symptom, a physician diagnoses and treats it, and success is measured by the patient's recovery. In the model of prospective medicine, the patient presents with risks for disease and disability. An HRA — which asks patients about their lifestyles, behaviors and health histories — quantifies the patient's mortality risk and serves as a tool for teaching the patient how to modify his or her risk factors.
Using the techniques of prospective medicine, the author turned his annual physicals into an organized wellness program.
Patients receive customized reports of their health status and risk levels.
Patients also receive wellness plans including exercise prescriptions, caloric requirement analyses and other detailed instructions.
The key to making wellness medicine work is to start small, beginning with patient education and working up to using health risk assessments and databases.
I decided to use these techniques to make my annual physicals more productive. The wellness program I developed, which I call HealthTrends, incorporates an HRA and computer-generated patient education materials with the results of the medical history, physical exam and laboratory tests. This program helps keep most of my patients well and out of the hospital. It has rewarded me financially (by increasing the demand for annual physicals) and professionally, and it has freed up a great deal of time that I once spent rounding.
How it works
I invite all my new patients to participate in HealthTrends, but it's not an easy sell. Many haven't had a physical for years, and none has participated in a program like this. I explain that although the physical is labor-intensive and will require the patient to complete lengthy questionnaires, the process will give back much more in return. I also emphasize that real health insurance isn't about paying premiums; it's knowing your risk factors and acting to change them. Most patients decide to enter the program. We then give each participant an explanatory brochure, a 102-item HRA questionnaire, a life stress-event test and a food log to complete at home before returning for the physical.
The HRA is the backbone of the program. Based on the patient's responses, the HRA quantifies his or her 10-year mortality risk by age, race and sex. But it also takes the data one step further: It breaks down the patient's aggregate risk into its component parts — risk of specific diseases and injuries — and indicates whether the patient's risk is greater than average compared with the patient's cohort. For example, an average 40-year-old white man might have a 5 percent mortality risk over the next 10 years, but an HRA would show what makes up that risk, (e.g., heart disease, accidents, suicide, cirrhosis, homicide) and the patients' mortality risk related to each condition.
The HealthTrends physical consists of a traditional medical history and exam, and I also inquire about the patient's health concerns, diet, exercise habits and life stressors. All patients receive a battery of 26 blood tests (Lyme disease, HIV, PSA and thyroid testing are not included), and those older than 40 receive a urinalysis and stool guaiac study. We schedule a follow-up visit for two weeks later, which gives us time to produce an analysis of the results.
At the follow-up visit, I use the results of the HRA, the physical exam and other resources to produce a personalized HealthTrends report. The first page details, in two columns, the patient's 10-year mortality risk, based on his or her age, race and sex, as well as the mortality risk for the patient's peer group in the population at large. Thus, at a glance, patients can see how they stack up against their peers, in the aggregate and in particular disease categories. (See below for a portion of a sample report.) Using software designed to provide patient education on diabetes and hypertension, I also give patients information on their diet and exercise habits and ideal body weights, quantify their stress levels, and produce exercise prescriptions and caloric requirement analyses to help patients lose weight. The exercise prescriptions include detailed instructions about walking, jogging, swimming or bicycling, and patients appreciate the details! As part of the HealthTrends report, patients also receive their lab data.
Based on the report, I educate the patient about the diseases for which he or she has greater-than-average mortality risk, as well as the associated risk factors and risk-reduction procedures. For example, a patient's miles driven per year, seat belt use, drinking habits and medication use might indicate a greater-than-average risk of dying in a motor vehicle accident. The patient could be counseled to wear a seat belt all the time, make sure his or her next car has air bags, reduce mileage whenever possible, not drink and drive, and avoid sedating antihistamines.
I encourage patients to read their reports thoroughly at home, call me if they have questions and keep the reports in a safe place so they can bring them back to be updated next year. When the next year comes, we send patients a postcard a month before their HealthTrends physicals are due, reminding them to make an appointment. Patients whose physicals are one month overdue receive a second reminder emphasizing the importance of preventive care. We find that most patients respond to the reminders or, if they skip their physicals, come back the next year. Over time, many have become converts and even proselytizers for the program.
A sample HealthTrends report
Here's part of the report for a hypothetical patient in the HealthTrends program. The report also includes information on how unfavorable health factors increase mortality risk, the patient's favorable and unfavorable health practices, how the patient's health factors may affect longevity, and suggestions for limiting risk factors and improving health.
HealthTrends Personal Health Risk Analysis
This details the most frequent causes of death in your current 10-year age group and how your personal health factors affect your chances of dying from each of these conditions during the next 10 years.
Most frequent causes of death for a white male age 31:
|Disease||Average Person's Chance of Death in Next 10 Years||Your Chance of Death in Next 10 Years||Risk|
|Arteriosclerotic heart disease||0.06%||0.02%||Decreased|
|Cirrhosis of the liver||0.03%||0.00%||Decreased|
|Motor vehicle accidents||0.44%||0.36%||Decreased|
Favorable and unfavorable health factors in your life:
|Favorable health factors||Unfavorable health factors|
|Normal blood pressure||Overweight|
|Frequent use of seat belts||High driving mileage|
|Low alcohol use||Carrying a weapon|
|History of pneumonia|
Costs and benefits
From the perspective of evidence-based medicine, it's hard to justify the kinds of annual blood tests I perform, including a CBC and chemistry screen. Guidelines from the U.S. Preventive Services Task Force point to the risk of false-positives that occasion unnecessary work-ups as well as possible iatrogenic injury. That said, I believe there's a difference between annual test results that accumulate haphazardly in a patient's chart and those that go into a database that's used to customize wellness plans.
My database now has 1,000 rows, one for each patient who has participated in the program, and 152 columns of data for each participant. With a few keystrokes, I can graph a patient's weight, blood pressure, daily salt and caloric intake, weekly alcohol consumption, liver or renal function test results, or annual stress scores over time. These graphs have proven to be powerful tools. For example, one patient's blood glucose level shot up to 150 mg/dL after being in the normal range for eight years, and he had gained 25 pounds. When he saw these trends depicted graphically, he immediately began following his exercise prescription and within three months had lost weight and normalized his serum glucose.
The database also enables me to identify patients with particular risk factors, such as those with cholesterol levels higher than 300, those who haven't received indicated annual mammograms, those who smoke more than two packs per day or those who have more than 24 drinks per week. I can also identify patients with diseases as common as diabetes and hypertension or as rare as Hashimoto's thyroiditis or Peutz-Jeghers syndrome. Being able to identify patients according to their risk factors and conditions helps me ensure that I'm not neglecting possible interventions for any patient who might benefit from them.
When I started the HealthTrends program 11 years ago, I performed 80 of these physicals. Now I perform more than 250 annually, and the HealthTrends physical is the only kind I will perform (unless the patient is clearly noncompliant or has language barriers that prevent him or her from completing the questionnaires and reading the results). Getting paid for these exams hasn't presented a great problem for us, since many of our patients' insurance plans cover an annual physical. I absorb the costs of data entry and chart production because I feel the benefits to the patient are well worth the extra effort and expense.
How can you make wellness medicine work in your practice? Start small. As a first step, buy a computer and a color printer for your consultation room and dedicate it to patient education. (For recommended patient education CD-ROMs and web sites, see “Sources of computerized patient education.”) Patients appreciate having handouts that explain their medical problems in a way they can understand. The handouts often list support groups and additional resources as well. You also may want to share professional resources with better-educated patients or those with some knowledge of medicine; for example, you can search American Family Physician online or on a CD-ROM to find information specific to a patient's concerns. If you're too busy to search for and print the article, have a member of your office staff do it for you.
HRAs are excellent tools for motivating patients to make lifestyle changes. More than 100 HRAs are now on the market. The Society of Prospective Medicine produces the Handbook of Health Risk Appraisals, which describes many in detail and provides particulars about their producers and the computer hardware required to use them. (For more information about the handbook, visit http://www.spm.org/desc.html or call 412-647-1087.) Many HRAs are self-scoring and can be completed in the waiting room. Some can be completed by the patient on a computer while waiting for an appointment or completed on paper and then scanned into a computer so that the results can be printed and given to the patient when he or she leaves. Others can be sent out for scoring and mailed back to you and the patient at a nominal cost.
As I shopped for an HRA in 1987, my major requirement was that the answers to the questions be transferable to a spreadsheet; it was crucial that I have a way to store the data and manipulate it. As HealthTrends has evolved, I've added columns of data to my spreadsheet and now use a relational database (Corel's Paradox) to manage the data and produce graphs of changing health patterns for my patients. You don't have to be a computer programmer to manipulate the data this way, but you do have to write scripts in the database.
Sources of computerized patient education
You can find a number of CD-ROMs offering excellent patient education materials. Here are four that I've found especially helpful:
The AAFP Patient Education Handouts on CD-ROM. Portland, Ore: CMC ReSearch; 1998.
The Family Doctor: The Only Medical Reference You Will Ever Need. 4th ed. A.H. Bruckheim. Portland, Ore: Creative Multimedia; 1996.
The Merck Manual Illustrated. 16th ed. CMC Medical Division, ed. Portland, Ore: CMC ReSearch; 1995.
The NORD Manual: A Comprehensive Resource for Uncommon and Rare Disorders. New Fairfield, Conn: National Organization for Rare Disorders; 1998.
If you have a web browser on your patient-education computer, you can access the Academy's web site for health information for patients, familydoctor.org (https://familydoctor.org), which contains more than 240 patient handouts. Similarly valuable sites include drkoop.com (http://www.drkoop.com) and HealthWorld Online (http://www.healthy.net). [For more information on these sites, see “Three Sites for Patient Health Information.”]
A prescription for wellness
I've heard it said that the Chinese pay their doctors when they're well but pay nothing once they get sick. I don't know whether that's true, but the concept behind it — that if patients follow their doctors' recommendations but get sick, then it's the doctors' fault — has some appeal.
We all practice wellness medicine to the extent that we ensure that our patients receive regular Pap smears and mammograms, tetanus boosters and other immunizations, and PSA and occult blood tests. We exhort smokers to quit, couch potatoes to exercise and heavy drinkers to desist. That's a start, but a more systematic approach to promoting health and preventing disease is within our reach, even for a solo practice (like mine) or small group. In pursuing it — in fostering healthy patient populations — we are limited only by our imaginations.