Worksite: Assessment of Health Risks with Feedback to Change Employees’ Health – AHRF Used Alone

The CPSTF finding is based on evidence from a systematic review of 32 studies (search period through June 2005). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to worksite health promotion.

Thirty-two studies qualified for the review.

• Results were considered inconsistent, with some in favor and some not in favor of the intervention.
• The magnitude of effect for the eleven outcomes considered in this review was small.

An economic review of this intervention was not conducted because CPSTF did not have enough information to determine if the intervention works.

Applicability of this intervention across different settings and populations was not assessed because CPSTF did not have enough information to determine if the intervention works.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

The following outlines evidence gaps for assessment of health risks with feedback when used alone, and when combined with health education programs, with or without additional interventions.

This review of the use of assessments of health risks with feedback in worksite settings addressed important questions that earlier reviews were unable to address, such as:

• Does AHRF, when used alone, lead to behavior change or change in health outcomes among employees?
• Does this type of assessment, when used with other worksite-based intervention components result in change?
• And finally, what types of behaviors or health outcomes are affected by these interventions?

The structure of this review, however, leaves two additional questions about worksite health promotion programs unanswered:

• Are worksite health promotion programs with a health education component effective in the absence of AHRF and
• Does AHRF add value to worksite health promotion programs with regards to behavior change and improvement in health outcomes?

The field will also likely be interested in addressing questions related to implementation of the intervention: what components are necessary and for whom are they most effective? How many times must AHRF occur and for how long must employees be exposed to additional intervention components? What qualifications of staff or health educators are needed? How long do the effects last? With regards to the assessment: Are there key assessment questions or aspects of the assessment (like biometric screening) that provide information resulting in a more effective intervention? Does the format of the questionnaire or the feedback make a difference? Is employee participation in creation of the program important and what role does organizational support play in participation rates and overall effectiveness?

Finally, questions regarding economic efficiency will be of interest to most in the field and should be addressed more systematically. A first step would be to clearly delineate the aspects of program costs and benefits that should be assessed in program evaluation. How many employees need to be reached for a positive ROI? What should the GRP (gross rating product) be for the ROI? Is there a “break even point” or a certain amount of time for which costs will outweigh benefits before there are actual savings from program implementation? Although the questions above stem from this review of assessments of health risk with feedback, many of them pertain to the broader field of worksite health promotion and can be used to inform future evaluation of these programs.

• Of the 32 studies included in the AHRF review:
  • Eight studies included an untreated or lesser treated comparison group.
  • One study was a time series study.
  • Twenty-three studies were included as before-after study designs.
• Evaluated programs were conducted in small (2 studies), medium (6 studies), and large (24 studies) companies.

Soler E, Leeks KD, Razi S, et al. A systematic review of selected interventions for worksite health promotion: the assessment of health risks with feedback. American Journal of Preventive Medicine. 2010;38(2S):237-262.

Task Force on Community Services. Recommendations for worksite-based interventions to improve workers’ health. American Journal of Preventive Medicine. 2010;38(2S):232-236.

Fielding JE, Hopkins DP, Pronk NP. An introduction to evidence on worksite health promotion. In: ACSM’s Worksite Health Handbook: A Guide to Building Healthy and Productive Companies. 2nd ed. Champaign (IL): Human Kinetics; 2009:75-81. Available at: http://www.humankinetics.com/products/all-products/acsms-worksite-health-handbook-2nd-edition.

Soler RE, Griffith M, Hopkins DP, Leeks KD, Pronk NP. The assessment of health risks with feedback: results of a systematic review. In: ACSM’s Worksite Health Handbook: A Guide to Building Healthy and Productive Companies. 2nd ed. Champaign (IL): Human Kinetics; 2009:82-91. Available at: http://www.humankinetics.com/products/all-products/acsms-worksite-health-handbook-2nd-edition.

Effectiveness Review

Analytic Framework see Figure 1 on page S241

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Abrams DB, Boutwell WB, Grizzle J, Heimendinger J, Sorensen G, Varnes J. Cancer control at the workplace: the working well trial. Preventive Medicine 1994;23:15-27.

Anderson J, Dusenbury L. Worksite cholesterol and nutrition: an intervention project in Colorado. American Association of Occupational Health Nurses Journal 1999;47: 99-106.

Barrere CCP. Hospital employee cholesterol screening: modification of dietary behavior.Amercian Association of Occupational Health Nurses Journal 1994;42:261-9.

Blair SN, Piserchia PV, Wilbur CS, Crowder JH. A public health intervention model for work-site health promotion. Impact on exercise and physical fitness in a health promotion plan after 24 months. Journal of the American Medical Association 1986; 255:921-6.

Burton WN, McCalister KT, Chen CY, Edington DW. The association of health status, worksite fitness center participation, and two measures of productivity. Journal of Occupational & Environmental Medicine 2005;47:343-51.

Burton WN, Chen CY, Conti DJ, Schultz AB, Edington DW. The association between health risk change and presenteeism change. Journal of Occupational & Environmental Medicine 2006;48:252-63.

Dunton S, Perkins DD, Zopf KJ. The impact of worksite-based health risk appraisal programs on observed safety belt use. Health Education Research 1990;5:207-16.

Edye BV, Mandryk JA, Frommer MS, Healey S, Ferguson DA. Evaluation of a worksite programme for the modification of cardiovascular risk factors. Medical Journal of Australia 1989;150:574-81.

Fitzgerald ST, Gibbens S, Agnew J. Evaluation of referral completion after a workplace cholesterol screening program. American Journal of Preventive Medicine 1991;7:335-40.

Fries JF, Fries ST, Parcell CL, Harrington H. Health risk changes with a low-cost individualized health promotion program: effects at up to 30 months. American Journal of Health Promotion 1992;6:364-71.

Fries JF, Harrington H, Edwards R, Kent LA, Richardson N. Randomized controlled trial of cost reductions from a health education program: the California Public Employees’ Retirement System (PERS) study. American Journal of Health Promotion 1994;8:216-56.

Frommer MS, Mandryk JA, Edye BV, Healey S, Berry G, Ferguson DA. A randomised controlled trial of counseling in a workplace setting for coronary heart disease risk factor modification: effects on blood pressure. Asia Pacific Journal of Public Health 1990;4:25-33.

Gemson DH, Sloan RP. Efficacy of computerized health risk appraisal as part of a periodic health examination at the worksite. American Journal of Health Promotion 1995;9:462-6.

Gomel M, Oldenburg B, Simpson JM. Work-site cardiovascular risk reduction: a randomized trial of health risk assessment, education, counseling, and incentives. American Journal of Public Health 1993;83:1231-8.

Gomel MK, Oldenburg B, Simpson JM, Chilvers M, Owen N. Composite cardiovascular risk outcomes of a work-site intervention trial. American Journal of Public Health 1997;87:673-6.

Hagihara A, Kusaka Y, Morimoto K, Tamura T, Matsuura Y. Health risk appraisal (HRA) and its educational effect on bank employees. Industrial Health 1992;30:61-4.

Hanlon P, Carey L, Tannahill C, Kelly M, Gilmour H, Tannahill A, McEwen J. Behaviour change following a workplace health check: how much change occurs and who changes? Health Promotion International 1998;13:131-9.

Hanlon P, McEwen J, Carey L, Gilmour H, Tannahill C, Tannahill A, Kelly M. Health checks and coronary risk: further evidence from a randomised controlled trial. British Medical Journal 1995;311:1609-13.

Hartman TJ, Himes JH, McCarthy PR, Kushi LH. Effects of a low-fat, worksite intervention on blood lipids and lipoproteins. Journal of Occupational & Environmental Medicine 1995;37:690-6.

Hartman TJ, McCarthy PR, Himes JH. Use of eating-pattern messages to evaluate changes in eating behaviors in a worksite cholesterol education program. Journal of the American Dietetic Association 1993;93:1119-23.

Heimendinger J, Feng Z, Emmons K, Stoddard A, Kinne S, Biener L et al. The Working Well trial: baseline dietary and smoking behaviors of employees and related worksite characteristics. Preventive Medicine 1995;24:180-93.

Hyner GC, Petri CJ, Melby CL, Duda JL, Huddy DC. The effects of different health risk appraisal feedback on health-related behaviors in a worksite population. Health Education Research 1987;2:161-4.

Kellerman ST, Felts WM, Chenier TC. The impact on factory workers of health risk appraisal and counseling in health promotion. American Journal of Preventive Medicine 1992;8:37-42.

Maes S, Verhoeven C, Kittel F, Scholten H. Effects of a Dutch work-site wellness-health program: the Brabantia Project. American Journal of Public Health 1998;88: 1037-41.

McCarthy P. Content of an effective worksite cholesterol education program. Nutrition Update 1991;1:1-3.

Nilsson PM, Klasson EB, Nyberg P. Life-style intervention at the worksite – reduction of cardiovascular risk factors in a randomized study. Scandinavian Journal of Work, Environment & Health 2001;27:57-62.

Oldenburg B, Owen N, Parle M, Gomel M. An economic evaluation of four work site based cardiovascular risk factor interventions. Health Education Quarterly 1995;22:9-19.

Purath J, Miller AM, McCabe G, Wilbur J. A brief intervention to increase physical activity in sedentary working women. Canadian Journal of Nursing Research 2004;36:76-91.

Puska P, Niemensivu H, Puhakka P, Alhainen L, Koskela K, Moisio S et al. Results of a one-year worksite and mass media based intervention on health behaviour and chronic disease risk factors. Scandinavian Journal of Work, Environment & Health 1988;16:241-50.

Richmond R, Kehoe L, Heather N, Wodak A. Evaluation of a workplace brief intervention for excessive alcohol consumption: the workscreen project. Preventive Medicine 2000;30:51-63.

Richmond RL, Kehoe L, Hailstone S, Wodak A, Uebel-Yan M. Quantitative and qualitative evaluations of brief interventions to change excessive drinking, smoking and stress in the police force. Addiction 1999;94:1509-21.

Rodnick JE. Health behavior changes associated with health hazard appraisal counseling in an occupational setting. Preventive Medicine 1982;11:583-94.

Serxner SA, Gold DB, Bultman KK. The impact of behavioral health risks on worker absenteeism. Journal of Occupational & Environmental Medicine 2001;43:347-54.

Shi L. Impact of increasing intensity of health promotion intervention on risk reduction. Evaluation & the Health Professions 1992;15:3-25.

Shi L. Health promotion, medical care use, and costs in a sample of worksite employees.Evaluation Review 1993;17:475-87.

Shipley RH, Orleans T, Wilbur CS, Piserchia PV, McFadden DW. Effect of the Hohnson & Johnson Live for Life Program on employee smoking. Preventive Medicine 1988;12:25-34.

Sorensen G, Stoddard AM, LaMontagne AD, Emmons K, Hunt MK, Youngstrom R, et al. A comprehensive worksite cancer prevention intervention: behavior change results from a randomized controlled trial (United States). Cancer Causes Control 2002;13:493-502.

Stonecipher LJ, Hyner GC. Health practices before and after a work-site health screening: differences among subpopulations of employees. Journal of Occupational Medicine 1993;35:297-306.

Stonecipher LJ, Hyner GC. The effects of a comprehensive health risk appraisal, basic screening, and interpretation session on employee health practices: differences between participants and nonparticipants. American Journal of Health Promotion 1993;7:167-9.

Szymanski L, Pate RR, Dowda M, Blair SN, Howe HG, Jr., Parker G, et al. A comparison of questionnaire and physiological data in predicting future chronic disease risk factor status in an employee population. American Journal of Health Promotion 1991;5:298-304.

Tilley BC, Glanz K, Kristal AR, Hirst K, Li S, Vernon SW, et al. Nutrition intervention for high-risk auto workers: results of the Next Step Trial. Preventive Medicine 1999;28:284-92.

Tilley BC, Vernon SW, Glanz K, Myers R, Sanders K, Lu M, et al. Worksite cancer screening and nutrition intervention for high-risk auto workers: design and baseline findings of the Next Step Trial. Preventive Medicine 1997;26:227-35.

Tilley BC, Vernon SW, Myers R, Glanz K, Lu M, Hirst K, et al. The Next Step Trial: impact of a worksite colorectal cancer screening promotion program. Preventive Medicine 1999;27:276-83.

Williams A, Mason A, Wold J. Cultural sensitivity and day care workers: examination of a worksite based cardiovascular disease prevention project. Amercian Association of Occupational Health Nurses Journal 2001;49:35-43.

Williams A, Wold J. Nurses, cholesterol, and small work sites: innovative community intervention comparisons. Family & Community Health 2000;23:59-75.

The following outlines the search strategy used for reviews of assessment of health risks with feedback when used alone, and when combined with health education programs, with or without additional interventions.

The articles to be reviewed were obtained from systematic searches of multiple databases, reviews of bibliographic reference lists, and consultations with experts in the field. The following databases were searched: Medline, Employee Benefits, NTIS, Sports Information Resource Center, Cambridge Scientific Abstracts, Inc., Business Week, ABI Inform, Health Promotion and Education, Cumulative Index to Nursing & Allied Health Literature, Office of Smoking and Health, AIDSLine, PsycInfo, and Sociological Abstracts.

Database: Ovid MEDLINE(R) [1966 to June Week 4 2005]

1. exp health behavior/ or exp health education/ or health promotion/ or exp primary prevention/ (218287)
2. exp work/ or workplace/ or occupational health/ (22008)
3. risk assessment/ or risk factors/ or health status indicators/ or mass screening/ (357682)
4. (health risk assessment$ or health risk appraisal$ or health screening$ or health status assessment$ or health assessment$ or screening$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (189292)
5. (risk awareness or risk profile$ or lifestyle check$ or health quiz or health measur$ or health report$ or risk identification).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (5429)
6. 3 or 4 or 5 (490335)
7. (health maintenance organization$ or health clinic$ or insurance compan$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (18831)
8. 2 or 7 (40777)
9. 1 and 6 and 8 (607)
10. limit 9 to english language (559)

Database: Employee Benefits_1986-2005/Jun (c) 2005

Sets selected:

Set Items Description

1. 831 HEALTH()BEHAVIOR OR HEALTH()EDUCATION OR HEALTH()PROMOTION OR PRIMARY()PREVENTION
2. 1291 HEALTH()RISK()ASSESSMENT? OR HEALTH()RISK()APPRAISAL?
   OR HEALTH()SCREENING? OR HEALTH()STATUS()ASSESSMENT?
   OR HEALTH()ASSESSMENT? OR SCREENING?
3. 554 RISK()AWARENESS OR RISK()PROFILE?
   OR LIFESTYLE()CHECK? OR HEALTH()QUIZ
   OR HEALTH()MEASUR? OR HEALTH()REPORT?
   OR RISK()IDENTIFICATION
4. 1360 S2 OR S3
5. 310 S1 AND S4

Databases:BAMP_2005/Jul W2 (c) 2005 and PAIS Int._1976-2005/Jun (c) 2005

Sets selected:

Set Items Description

1. 2363 HEALTH()BEHAVIOR OR HEALTH()PROMOTION OR HEALTH()EDUCATION OR PRIMARY()PREVENTION
2. 7157 HEALTH()RISK()ASSESSMENT? OR HEALTH()RISK()APPRAISAL? OR HEALTH()SCREENING? OR HEALTH()STATUS()ASSESSMENT? OR HEALTH()ASSESSMENT? OR SCREENING?
3. 509 RISK()AWARENESS OR RISK()PROFILE? OR LIFESTYLE()CHECK? OR HEALTH()QUIZ? OR HEALTH()MEASUR? OR HEALTH()REPORT? OR RISK()IDENTIFICATION
4. 7632 S2 OR S3
5. 255 S1 AND S4
6. 174772 WORKSITE? OR WORKPLACE? OR EMPLOYER? OR EMPLOYEE? OR WORKER?
7. 196 S5 AND S6
8. 195 RD S7 (unique items)
9. 195 S8/ENG

Database: TGG Management Contents(R)_86-2005/Jul W2 (c) 2005 and Business Week_1985-2005/Jul 21 (c) 2005

Sets selected:

Set Items Description

1. 561 HEALTH()BEHAVIOR OR HEALTH()PROMOTION OR HEALTH()EDUCATION OR PRIMARY()PREVENTION
2. 2925 HEALTH()RISK()ASSESSMENT? OR HEALTH()RISK()APPRAISAL? OR HEALTH()SCREENING? OR HEALTH()STATUS()ASSESSMENT? OR HEALTH()ASSESSMENT? OR SCREENING?
3. 695 RISK()AWARENESS OR RISK()PROFILE? OR LIFESTYLE()CHECK? OR HEALTH()QUIZ? OR HEALTH()MEASUR? OR HEALTH()REPORT? OR RISK()IDENTIFICATION
4. 3582 S2 OR S3
5. 103 S1 AND S4
6. 82979 WORKSITE? OR WORKPLACE? OR EMPLOYER? OR EMPLOYEE? OR WORKER?
7. 78 S5 AND S6
8. 78 RD S7 (unique items)
9. 77 S7/ENG

Database: ABI Inform(R)_1971-2005/Jul 22 (c)

Sets selected:

Set Items Description

1. 6388 HEALTH()BEHAVIOR OR HEALTH()PROMOTION OR HEALTH()EDUCATION OR PRIMARY()PREVENTION
2. 6342 (HEALTH()RISK()ASSESSMENT? OR HEALTH()RISK()APPRAISAL? OR HEALTH()SCREENING? OR HEALTH()STATUS()ASSESSMENT? OR HEALTH()ASSESSMENT? OR SCREENING?)/TI,AB
3. 1039 (RISK()AWARENESS OR RISK()PROFILE? OR LIFESTYLE()CHECK? OR HEALTH()QUIZ? OR HEALTH()MEASUR? OR HEALTH()REPORT? OR RISK()IDENTIFICATION)/TI,AB
4. 7371 S2 OR S3
5. 252 S1 AND S4
6. 517172 WORKSITE? OR WORKPLACE? OR EMPLOYER? OR EMPLOYEE? OR WORKER?
7. 184 S5 AND S6
8. 184 S9/ENG

Database: CDP File (Health Promotion and Education Database)

Descriptors: “WORKSITE” and “HEALTH RISK APPRAISAL” and
Form: “JOURNAL ARTICLE” OR
Descriptors: “worksite” not “health risk appraisal” and
Textwords: HEALTH ADJ1 RISK ADJ1 ASSESSMENT* OR HEALTH ADJ1 SCREEN* OR RISK ADJ1 ASSESSMENT* OR HEALTH ADJ1 ASSESSMENT* OR *RISK ADJ1 (AWARENESS* OR PROFILE* OR IDENTIFICATION) OR HEALTH ADJ1 (MEASURING OR REPORT* OR QUIZ*) OR LIFESTYLE ADJ1 CHECK* and Form: “JOURNAL ARTICLE”
TOTAL = 212

Database: CINHAL

Descriptors: “WORKSITE” and “HEALTH RISK APPRAISAL” and
Form: “JOURNAL ARTICLE” OR
Descriptors: “worksite” not “health risk appraisal” and
Textwords: HEALTH ADJ1 RISK ADJ1 ASSESSMENT* OR HEALTH ADJ1 SCREEN* OR RISK ADJ1 ASSESSMENT* OR HEALTH ADJ1 ASSESSMENT* OR *RISK ADJ1 (AWARENESS* OR PROFILE* OR IDENTIFICATION) OR HEALTH ADJ1 (MEASURING OR REPORT* OR QUIZ*) OR LIFESTYLE ADJ1 CHECK* and Form: “JOURNAL ARTICLE”
TOTAL = 212

Database: NTIS, Intl Cpyrght All Rights Res

Sets selected:

Set Items Description

1. 9285 HEALTH()BEHAVIOR OR HEALTH()EDUCATION OR HEALTH()PROMOTION OR PRIMARY()PREVENTION
2. 4804 WORKSITE OR WORKPLACE OR WORK-SITE OR OCCUPATIONAL()HEALTH
3. 289 S1 AND S2
4. 17896 HEALTH()RISK()ASSESSMENT? OR HEALTH()RISK()APPRAISAL? OR HEALTH()SCREENING? OR HEALTH()STATUS()ASSESSMENT? OR HEALTH()ASSESSMENT? OR SCREENING?
5. 477 RISK()AWARENESS OR RISK()PROFILE? OR LIFESTYLE()CHECK? OR HEALTH()QUIZ OR HEALTH()MEASUR? OR HEALTH()REPORT? OR RISK()IDENTIFICATION
6. 18332 S4 OR S5
7. 47 S3 AND S6

Database: SportDiscuss

Sets selected:

Set Items Description

1. 9166 HEALTH()BEHAVIOR OR HEALTH()EDUCATION OR HEALTH()PROMOTION OR PRIMARY()PREVENTION
2. 1589 WORKSITE OR WORKPLACE OR WORK-SITE OR OCCUPATIONAL()HEALTH
3. 479 S1 AND S2
4. 2169 HEALTH()RISK()ASSESSMENT? OR HEALTH()RISK()APPRAISAL? OR HEALTH()SCREENING? OR HEALTH()STATUS()ASSESSMENT? OR HEALTH()ASSESSMENT? OR SCREENING?
5. 176 RISK()AWARENESS OR RISK()PROFILE? OR LIFESTYLE()CHECK? OR HEALTH()QUIZ OR HEALTH()MEASUR? OR HEALTH()REPORT? OR RISK()IDENTIFICATION
6. 2341 S4 OR S5
7. 22 S3 AND S6
8. 22 S7/ENG

Database: OSH (Office of Smoking and Health)

Descriptors: (“WORKERS” OR “WORKPLACE*” OR “WORKSITE CESSATION PROGRAMS”) AND (“HEALTH EDUCATION*” OR “HEALTH PROMOTION*” OR
“PREVENTION*” OR “INTERVENTION*”) and
Textwords: RISK* OR SCREEN* OR ASSESSMENT* OR LIFESTYLE ADJ1 CHECK OR HEALTH ADJ1 QUIZ* OR HEALTH ADJ1 MEASUR* OR HEALTH ADJ1 REPORT*
Total 20

Database: Sociological Abstracts [1963 to April 2005]

1. exp health behavior/ or exp health education/ or exp prevention/ or health promotion.mp. (8199)
2. (workplace or worksite or work-site or occupational).mp. (20332)
3. (health risk assessment$ or health risk appraisal$ or health screening$ or health status assessment$ or health assessment$ or screening$).mp. (1675)
4. (risk awareness or risk profile$ or lifestyle check$ or health quiz or health measur$ or health report$ or risk identification).mp. (376)
5. 1 and 2 (242)
6. 3 or 4 (2027)
7. 5 and 6 (19)
8. limit 7 to english language (19)
9. from 8 keep 1-19 (19)

Database: PsycINFO [1967 to June Week 4 2005]

1. exp health behavior/ or exp health education/ or health promotion/ or exp prevention/ (36831)
2. (workplace or worksite or work-site or occupational).mp. [mp=title, abstract, subject headings, table of contents, key concepts] (27805)
3. 1 and 2 (1130)
4. (health risk assessment$ or health risk appraisal$ or health screening$ or health status assessment$ or health assessment$ or screening$).mp. [mp=title, abstract, subject headings, table of contents, key concepts] (19187)
5. (risk awareness or risk profile$ or lifestyle check$ or health quiz or health measur$ or health report$ or risk identification).mp. (1259)
6. 4 or 5 (20366)
7. 3 and 6 (101)
8. limit 7 to english language (99)
9. from 8 keep 1-99 (99)

Database: AIDSLINE [1980 to December 2000] CLOSED FILE

1. exp health behavior/ or exp health education/ or health promotion/ or exp primary prevention/ (14069)
2. exp work/ or workplace/ or occupational health/ (347)
3. risk assessment/ or risk factors/ or health status indicators/ or mass screening/ (18933)
4. (health risk assessment$ or health risk appraisal$ or health screening$ or health status assessment$ or health assessment$ or screening$).mp. [mp=title, abstract, mesh subject heading] (6055)
5. (risk awareness or risk profile$ or lifestyle check$ or health quiz or health measur$ or health report$ or risk identification).mp. [mp=title, abstract, mesh subject heading] (239)
6. 3 or 4 or 5 (23204)
7. (health maintenance organization$ or health clinic$ or insurance compan$).mp. [mp=title, abstract, mesh subject heading] (488)
8. 2 or 7 (831)
9. 1 and 6 and 8 (36)
10. limit 9 to english language (36)
11. limit 10 to nonmedline (23)
12. from 11 keep 1-23 (23)

CPSTF did not have enough evidence to determine whether the intervention is or is not effective. This does not mean that the intervention does not work, but rather that additional research is needed to determine whether or not the intervention is effective.