The term “high risk” in a health context is not a single, universal metric but rather a classification based on a variety of specific criteria and assessment models. What might be deemed high risk for a surgical procedure is different from the criteria used by an insurance company or a population health manager. Understanding these various classifications is crucial for both patients and providers to manage health proactively.
High-Risk Ratings in Population Health Management
In the context of managing large populations, healthcare systems use risk stratification to identify patients who may need more intensive care management. This helps in deploying resources where they are most needed to improve health outcomes and reduce costs. A common method is to analyze a patient's conditions and demographics.
Chronic Condition Counts
One straightforward approach to identifying high-risk individuals is to tally the number of chronic conditions. The National Association of Community Health Centers (NACHC) outlines a method for segmenting patients into risk groups:
- Low Risk: 0–1 chronic conditions.
- Rising Risk: 2–3 chronic conditions.
- High Risk: 4–5 chronic conditions.
- Highly Complex: 6 or more chronic conditions.
Risk Prediction Algorithms
More advanced systems use sophisticated algorithms, like the Care Assessment Need (CAN) model, which incorporates demographics, service utilization, and comorbidities to predict the likelihood of an adverse event, such as hospitalization. For instance, a probability of 90-day hospitalization of 10% or greater was defined as “high-risk” in one study. Key predictors for being persistently high-risk can include age, multiple chronic comorbidities, and factors related to social instability.
High-Risk Ratings for Surgical Procedures
Anesthesiologists and surgical teams use risk stratification to evaluate a patient's pre-operative health and determine if interventions are needed to optimize their condition before surgery. The assessment considers both patient characteristics and the complexity of the operation.
UCLA Health's Surgical Risk Stratification
- High Risk Factors: Include conditions like coronary artery disease (CAD), chronic congestive heart failure (CHF), insulin-dependent diabetes mellitus, morbid obesity (BMI > 40), and a history of stroke or transient ischemic attack (TIA).
- Risk Scores: Procedures are also assigned a risk score from 1 (very low) to 5 (very high), depending on factors like potential for blood loss. For example, a patient with a combination of high-risk medical conditions and a high-risk surgical procedure would receive a high overall rating.
High-Risk Ratings for Health and Life Insurance
Insurance companies assess risk to determine premium costs for life insurance policies. The rating is based on an individual’s estimated life expectancy, and a high-risk rating often leads to significantly higher premiums.
Factors Influencing Insurance Ratings
- Medical History: A history of cancer, heart attack, or other serious health conditions can place an applicant in the high-risk category. Well-managed chronic conditions may result in a more favorable rating.
- Lifestyle Habits: Smoking, heavy alcohol use, and a history of drug use are major risk factors.
- Dangerous Hobbies or Occupations: Engaging in risky activities (e.g., skydiving) or having a dangerous job can increase risk.
- Weight: Significant obesity (e.g., BMI above 30) is typically a factor considered in underwriting.
Comparing Different High-Risk Rating Contexts
| Assessment Context | Criteria for High Risk | Primary Purpose | Example Rating | Relevant Source |
|---|---|---|---|---|
| Population Health Management | Number of chronic conditions (e.g., 4-5) or high probability of hospitalization (e.g., >10%) | Proactive care management and resource allocation | High or Highly Complex | NACHC, AJMC |
| Surgical Risk | Co-morbidities (e.g., morbid obesity, CHF, stroke) and complexity of the procedure | Pre-operative optimization and planning | High or Very High (based on UCLA scale) | UCLA Health |
| Life Insurance | Health history (cancer, heart disease), lifestyle (smoking), and dangerous hobbies | Determine premium costs based on estimated life expectancy | Substandard, Table-rated, or Standard Tobacco | Bankrate, U.S. News, Aflac |
| Cardiac Risk | >20% risk of developing heart disease in the next 10 years (based on calculators) | Guide preventative treatment and patient lifestyle changes | High Risk | Cleveland Clinic |
Managing a High-Risk Rating
Receiving a high-risk rating is not a final verdict but an indication that proactive health management is necessary. By identifying and addressing specific risk factors, individuals and healthcare providers can work together to mitigate potential negative outcomes. For instance, managing chronic conditions diligently, adhering to a healthy lifestyle, and engaging in supportive care programs can lead to improved health and even a re-classification to a lower risk category over time.
For more information on the principles behind risk stratification, the National Institutes of Health provides insights into how risk scores are developed and applied. Ultimately, a high-risk rating is a tool for focused intervention, enabling patients to take a more informed and active role in their health journey.
Conclusion
In summary, the specific classification for what rating is considered as high risk? depends entirely on the framework being used, whether it is for population health, surgical preparation, or insurance underwriting. The common thread is the assessment of multiple factors—clinical, lifestyle, and social—to identify individuals most susceptible to adverse health events. A high-risk designation serves as a trigger for more intensive, personalized, and proactive management strategies to improve health outcomes and quality of life.
High-Risk Categories and Assessment Methods
- Diverse Classifications: A 'high-risk' rating is not universal but varies across contexts like insurance, surgical planning, and population health management.
- Chronic Condition Count: In population health, having 4–5 chronic conditions is often considered high risk, while 6 or more may be deemed 'highly complex'.
- Algorithmic Predictions: Some models, like the CAN algorithm, use demographics, comorbidities, and utilization data to predict risks, with high risk sometimes defined as a greater than 10% chance of hospitalization.
- Surgical Risk Factors: High risk before surgery is determined by pre-existing conditions like chronic congestive heart failure, morbid obesity, and a recent stroke.
- Insurance Underwriting: Life insurance companies classify high-risk applicants based on medical history, dangerous lifestyle habits (e.g., smoking), and hazardous jobs or hobbies.
- Cardiac Risk: A cardiac risk calculator may rate a person as high risk if they have a greater than 20% chance of developing heart disease within the next decade.
- Proactive Management: Regardless of the rating, a high-risk classification should prompt proactive management of health and lifestyle factors to mitigate future health complications.
