PREVENTIVE
MEDICINE
Progress
4, 282-295
(1975)
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 Sciences 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 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
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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. Functional 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
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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., hysteria, hypomania, or schizophrenia). A fifth feature of one’s health is one’s sense of well-being, a subjective counterpart of emotional and mental health. Deficiencies in this characteristic are manifest through psychophysiologic states, personality disorders, overt neuroses, 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 November 30, 1973, over 12,000 additional profiles were obtained and computerprocessed. 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-
ASSESSMENT
OF HEALTH
STATUS
285
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 detect early chronic disease by finding deviations from expected chemical, physiologic, 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 accomplished 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 statistically. 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 “Hemoglobin”); “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 recognize 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
WEALTH
MEOICINE
PROFILE
P-O
CENTER
DATE
W/OB/73
-----------------_-----------------------------------------------------UNIT NUMBER 400259 VISIT DATE 05120173 -------------------------------------------------------------------------TEST RESULTS +FLAG
.
CONSltlU7tONAL ,,E ,G”,-----------yc ‘G”,-----------
68.5 145
EVE AN0 EAR AUOtOME?RV--------
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RESPIRATORY SPtRORElRV-------CHEST X-RAV-------
OEFERREO OEFERPEO
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CHOLESTEROL------GENITOURINARV URINE BLOOO--------BtLtRUBtN--------GLUCOSE--------.pR‘,~E,N-----------
l
13.4 GK DEFERRED DEFERRED
CHEKISTRIES GLUCOSE-----meWltt ACtO--------
063 08.0
---
II 0
E
FAIL
1
C
ENR
2
:
KC
E
013 WG/lOO ML
UREA--------
COOES
CrOES
SEX/RACE
NEGATIVE NEGATIVE NEGATIVE NEGATIVE 6
WEKAlOLOGV HEKOGLOBtN-------GIPO SCREEN------SICKLE CELL------
N07E
FIG.
EARS
DEFERRED
ACTICN
62
PROBLER/URGENCV/ACltON
INCHES POUNDS
RH FAClOR---------
IJRGENCV
AGE
1501094 SITTING 150/100 RESTING DEFERRED 216 WC/l00 ML
l
SERUM
1417303
-
-
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0
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A = EWERGENCV, B = URGENT, C = REWIRES DEFERRED, E = YITHIN EXPECTED RANGE
3
SCL
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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
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.
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,
ASSESSMENT OF HEALTH
STATUS
287
TABLE 1 INSTRUCTIONSPROGRAMMEDINTO COMPUTERFOR 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 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)
Follow-up required (C)
Deferred (D) Follow-up required (C)
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 insidious 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 scription, and problem listing. (PMC, Univ. of Tennessee Center for the Health Sciences.)
288
de-
ASSESSMENT OF HEALTH
STATUS
289
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 function.” 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 disputes, physicians will be aided by appropriate specialists, particularly the physiatrist. 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 concentrated. The time required for detailed questioning can usually be greatly shortened. 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
MEDICAL
CENTER
PREVENTION
CLINIC
NULTIPHASIC PRINT-OUT DATE 06/18/73 ----_--------_---------------------------------------------------UNIT NUMBER 347305 TEST
.
FLAG
HEALTH DATE
06/11/73
AGE
49
TENNESSEE
HEALTH
EVALUATION
HISTORY RACE
B
PAGE SEX
01
F
PROOLEM/URGLNCY NUM8ER
HISTORY/OUESTION
CLIENTANSWERED “YES” TO THE FOLLOWING QU~TIONS: GENERAL HAVE YOU SEEN A OOCTOR WITHIN THE LAST TWO (2)
OR GEEN NONTHS.
00 YOU HAVE AN APPOINTMENT OR GO TO A CLINIC IN THE
TO NEAR
ARE
NEOICAL
YOU
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ACTIVE
ARE YOU NON IiY A DOCTOR.
TAKING
ANY
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TO THE APPOINTMENT
AN
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A CLINIC
SEE YOUR FUTURE.
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OF
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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 psychiatrists. 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 perfectly happy with your personality and your relationship to other people, this
ASSESSMENT OF HEALTH
lJNIVERS17V NLOICAL
HEALTH
UNIT
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CENTER
PREVENTIVE
MINTOUT
291
STATUS
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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 existence 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? Poor health? -,” tended to sort out those Fair health? 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 understandably 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 wellbeing 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 wellbeing 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 scientifically 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 selection 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.
ASSESSMENT OF HEALTH
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MEDICINE
Progress
4, 282-295
(1975)
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 Sciences 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 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
RM-00051-17)
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. Functional 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., hysteria, hypomania, or schizophrenia). A fifth feature of one’s health is one’s sense of well-being, a subjective counterpart of emotional and mental health. Deficiencies in this characteristic are manifest through psychophysiologic states, personality disorders, overt neuroses, 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 November 30, 1973, over 12,000 additional profiles were obtained and computerprocessed. 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-
ASSESSMENT
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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 detect early chronic disease by finding deviations from expected chemical, physiologic, 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 accomplished 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 statistically. 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 “Hemoglobin”); “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 recognize 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
WEALTH
MEOICINE
PROFILE
P-O
CENTER
DATE
W/OB/73
-----------------_-----------------------------------------------------UNIT NUMBER 400259 VISIT DATE 05120173 -------------------------------------------------------------------------TEST RESULTS +FLAG
.
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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.
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,
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TABLE 1 INSTRUCTIONSPROGRAMMEDINTO COMPUTERFOR 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 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)
Follow-up required (C)
Deferred (D) Follow-up required (C)
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 insidious 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..-
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FIG. 2. Physical assessment form, which provides for urgency coding, keypunching, narrative scription, and problem listing. (PMC, Univ. of Tennessee Center for the Health Sciences.)
288
de-
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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 function.” 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 disputes, physicians will be aided by appropriate specialists, particularly the physiatrist. 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 concentrated. The time required for detailed questioning can usually be greatly shortened. 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.
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DEAN F. DAVIES UNIVERSITY
OF
MEDICAL
CENTER
PREVENTION
CLINIC
NULTIPHASIC PRINT-OUT DATE 06/18/73 ----_--------_---------------------------------------------------UNIT NUMBER 347305 TEST
.
FLAG
HEALTH DATE
06/11/73
AGE
49
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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 psychiatrists. 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 perfectly happy with your personality and your relationship to other people, this
ASSESSMENT OF HEALTH
lJNIVERS17V NLOICAL
HEALTH
UNIT
OATE
NUNKER
MO259
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FAKE
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05/24/73
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PREVENTIVE
MINTOUT
291
STATUS
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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 existence 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? Poor health? -,” tended to sort out those Fair health? 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 understandably 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 wellbeing 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 wellbeing 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 scientifically 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 selection 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.
ASSESSMENT OF HEALTH
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