The relationship between modifiable health risks and health care expenditures. An analysis of the multi-employer HERO health risk and cost database

Health risks from extreme heat in China: Evidence from health insurance

Global warming has accentuated the effects of extreme heat on health. Health insurance, functioning as a risk management tool, has the potential to alleviate these impacts. Consequently, this paper investigates the correlation between extreme heat events and the demand for health insurance in China. Using data from the China Health and Nutrition Survey, we have observed a substantial increase in the likelihood of residents purchasing health insurance during extreme heat events. To be specific, for every extra day of extreme heat events annually, there is a 0.3% increase in the probability of purchasing health insurance. This effect is not uniform across different demographic groups. It is particularly pronounced among middle-aged and elderly individuals, rural residents, those with lower educational levels, higher income brackets, and individuals residing in underprivileged areas with limited access to green spaces and healthcare facilities. Furthermore, our study indicates that the increased frequency of extreme heat events not only impacts individuals' physical health but also triggers negative emotions, which in turn drive risk-averse behavior related to health insurance purchases. These findings carry substantial policy implications for mitigating the economic consequences of climate change.

Estimating the true effectiveness of smoking cessation interventions under variable comparator conditions: A systematic review and meta-regression

BACKGROUND AND AIMS

Behavioural smoking cessation trials have used comparators that vary considerably between trials. Although some previous meta-analyses made attempts to account for variability in comparators, these relied on subsets of trials and incomplete data on comparators. This study aimed to estimate the relative effectiveness of (individual) smoking cessation interventions while accounting for variability in comparators using comprehensive data on experimental and comparator interventions.

METHODS

A systematic review and meta-regression was conducted including 172 randomised controlled trials with at least 6 months follow-up and biochemically verified smoking cessation. Authors were contacted to obtain unpublished information. This information was coded in terms of active content and attributes of the study population and methods. Meta-regression was used to create a model predicting smoking cessation outcomes. This model was used to re-estimate intervention effects, as if all interventions have been evaluated against the same comparators. Outcome measures included log odds of smoking cessation for the meta-regression models and smoking cessation differences and ratios to compare relative effectiveness.

RESULTS

The meta-regression model predicted smoking cessation rates well (pseudo R2  = 0.44). Standardising the comparator had substantial impact on conclusions regarding the (relative) effectiveness of trials and types of intervention. Compared with a 'no support comparator', self-help was 1.33 times (95% CI = 1.16-1.49), brief physician advice 1.61 times (95% CI = 1.31-1.90), nurse individual counselling 1.76 times (95% CI = 1.62-1.90), psychologist individual counselling 2.04 times (95% CI = 1.95-2.15) and group psychologist interventions 2.06 times (95% CI = 1.92-2.20) more effective. Notably, more elaborate experimental interventions (e.g. psychologist counselling) were typically compared with more elaborate comparators, masking their effectiveness.

CONCLUSIONS

Comparator variability and underreporting of comparators obscures the interpretation, comparison and generalisability of behavioural smoking cessation trials. Comparator variability should, therefore, be taken into account when interpreting and synthesising evidence from trials. Otherwise, policymakers, practitioners and researchers may draw incorrect conclusions about the (cost) effectiveness of smoking cessation interventions and their constituent components.

Prediction of Future Medical Costs by Modifiable Measures of Health

Introduction

Strategies to mitigate rising health-care costs are a priority for patients, employers, and health insurers. Yet gaps currently exist in whether health risk assessment can forecast medical claims costs. This study examined the ability of a health quotient (HQ) based on modifiable risk factors, age, sex, and chronic conditions to predict future medical claims spending.

Methods

The study included 18,695 employees and adult dependents who participated in health assessments and were enrolled in an employer-sponsored health plan. Linear mixed effect models stratified by chronic conditions and adjusted for age and sex were utilized to evaluate the relationship between the health quotient (score of 0-100) and future medical claims spending.

Results

Lower baseline health quotient was associated with higher medical claims cost over 2 years of follow up. For participants with chronic condition(s), costs were $3628 higher for those with a low health quotient (<73; N = 2673) compared to those with high health quotient (>85; N = 1045), after adjustment for age and sex (P value = 0.004). Each one-unit increase in health quotient was associated with a decrease of $154 (95% CI: 87.4, 220.3) in average yearly medical claims costs during follow up.

Discussion

This study used a large employee population with 2 years of follow-up data, which provides insights that are applicable to other large employers. Results of this analysis contribute to our ability to predict health-care costs using modifiable aspects of health, objective laboratory testing and chronic condition status.

The Twenty Five Most Important Studies in Workplace Health Promotion

In what direction has workplace wellness research been evolving over the past 20 years? What proportion of occupational health researchers have been focusing on how health impacts work compared to researchers who ask how work affects health? This editorial poses an audacious, albeit largely subjective, question. That is, what have been the most important research studies about workplace wellness? Readers are invited to respond with their opinions about seminal studies we missed. Readers are also challenged with a thought experiment and exercise designed to organize the past decades of workplace wellness studies into a table that identifies trends in this research domain. Based on trends, I posit that researchers are waning in their interest in how health affects work productivity and healthcare costs and waxing in their considerations of how work affects well-being.

Associations among Health Status, Occupation, and Occupational Injuries or Diseases: A Multi-Level Analysis

PURPOSE

The present study used a hierarchical generalized linear model to explore the effects of physical and mental health and occupational categories on occupational injuries and diseases.

METHODS

The data were obtained from the Registry for Beneficiaries of the 2002-2013 National Health Insurance Research Database. The benefit categories involved adults with occupational injuries and diseases. Six major occupational categories and 28 subcategories were used. The main analysis methods were binary logistic regression (BLR) and hierarchical generalized linear model (HGLM).

RESULTS

After adjustment for relevant factors, the three major occupation subcategories most likely to develop occupational injuries and diseases were Subcategory 12 "employees with fixed employers" of Category 1 "civil servants, employees in public or private schools, laborers, and self-employed workers"; Subcategory 2 "employees in private organizations" of Category 1; and "sangha and religionists" of Category 6 "other citizens." Conditions such as mental disorders and obesity increased the risk of occupational injuries and diseases.

CONCLUSION

A portion of the occupational categories had a higher risk of occupational injuries and diseases. Physical and mental health issues were significantly correlated with occupational injuries and diseases. To the authors' knowledge, this is the first study to use HGLM to analyze differences in occupational categories in Taiwan.

Screening of drug candidates against Endothelin-1 to treat hypertension using computational based approaches: Molecular docking and dynamics simulation

Hypertension (HTN) is a major risk factor for cardiovascular and renal diseases, cerebrovascular accidents (CVA) and a prime underlying cause of worldwide morbidity and mortality. Hypertension is a complex condition and a strong interplay of multiple genetic, epigenetic and environmental factors is involved in its etiology. Previous studies showed an association of overexpression of genes with hypertension. Satisfactory control of Blood Pressure (BP) levels is not achieved in a major portion of hypertensive patients who take antihypertensive drugs. Since existing antihypertensive drugs have many severe or irreversible side effects and give rise to further complications like frequent micturition and headaches, dizziness, dry irritating cough, hypoglycemia, GI hemorrhage, impaired left ventricular function, hyperkalemia, Anemia, angioedema and azotemia. There is a need to identify new antihypertensive agents that can inhibit the expression of these overexpressed genes contributing to hypertension. The study was designed to identify drug-able targets against overexpressed genes involved in hypertension to intervene the disease. The structure of the protein encoded by an overexpressed gene Endothelin-1 was retrieved from Protein Database (PDB). A library of five thousand phytochemicals was docked against Endothelin-1. The top four hits against Endothelin-1 protein were selected based on S score and Root Mean Square Deviation (RMSD). S score is a molecular docking score which is used to determine the preferred orientation, binding mode, site of the ligand and binding affinity. RMSD refines value for drug target identification. Absorption, distribution, metabolism, excretion, and toxicity profiling (ADMET) was done. The study provides novel insights into HTN etiology and improves our understanding of BP pathophysiology. These findings help to understand the impact of gene expression on BP regulation. This study might be helpful to develop an antihypertensive drug with a better therapeutic profile and least side effects.

Integrating quantitative and qualitative approaches to assess wintertime illness-related absenteeism and its direct and indirect costs among the private sector in Ulaanbaatar

Causes for employee absenteeism vary. The commonest cause of work absenteeism is “illness-related.” Mongolia’s capital city, Ulaanbaatar, experiences high employee absenteeism during the winter than during other seasons due to the combination of extreme cold and extreme air pollution. We identified direct and indirect costs of absenteeism attributed to air pollution among private-sector employees in Ulaanbaatar. Using a purposive sampling design, we obtained questionnaire data for 1,330 employees working for private-sector companies spanning six economic sectors. We conducted 26 employee focus groups and 20 individual employer in-depth interviews. We used both quantitative and qualitative instruments to characterize the direct and indirect costs of absence due to illnesses attributed to severe air pollution during wintertime. Female employees and employees with a young child at home were more likely to be absent. Respiratory diseases accounted for the majority of reported air pollution-related illnesses. All participants perceived that air pollution adversely affected their health. Individual employee direct costs related to absence totaled 875,000 MNT ($307.10) for an average of three instances of three-day illness-related absences during the winter. This sum included diagnostic and doctor visit-related, medication costs and hospitalization costs. Non-healthcare-related direct cost (transportation) per absence was 50,000₮ ($17.60). Individual indirect costs included the value of lost wages for the typical 3-day absence, amounting to 120,000₮ ($42.10). These total costs to employees, therefore, may amount to as much as 10% of annual income. The majority of sick absences were unpaid. Overall, the cost of wintertime absences is substantial and fell disproportionately on female employees with young children.

The Impact of the COVID-19 Pandemic on Occupational Stress in Restaurant Work: A Qualitative Study

The economic downturn due to the COVID-19 pandemic disproportionately impacted the food service industry-one of the largest workforce sectors in the United States. The purpose of this qualitative study was to explore the occupational stressors experienced by restaurant and food service workers during the COVID-19 pandemic through a detailed assessment of their lived experiences. Thematic analysis was used to identify patterns within data from sixteen semi-structured interviews with people employed or recently employed in the restaurant industry during July of 2020. Five themes were highlighted including fear of being exposed to the COVID-19 virus while working under inadequate safety policies, job insecurity, inconsistent pay and hours and a lack of health benefits and paid time off, all of which increased occupational stress and led to uncertainty if respondents would return to the restaurant industry. Hardships associated with the pandemic were mitigated by the support and connections fostered by the communities built within the restaurants. Results led to several recommendations to address the social and economic contributors to occupational stress at the structural and population levels which can be used in the current and post-pandemic workplace.

Companies That Promote a Culture of Health, Safety, and Wellbeing Outperform in the Marketplace

OBJECTIVE

The objective of this research is to test the hypothesis that companies distinguished by their commitment to their workforce's health, safety, and well-being outperform in the marketplace.

METHODS

To test this, we analyzed the real-world stock market performance of an investment fund of publicly traded companies selected on evidence demonstrating their pursuit of a culture of health, safety, and well-being.

RESULTS

This fund outperformed the market by 2% per year, with a weighted return on equity of 264% compared with the S&P 500 return of 243% over a 10-year period.

CONCLUSIONS

Employers, fund managers, and fund investors would be well served by including strategies that assess a company's commitment to the health, safety, and well-being of their workforce when evaluating investments in their enterprise and portfolios.

Encountering Covid-19 and perceived stress and the role of a health climate among medical workers

Due to the outbreak of Covid-19 epidemic, work stress among health sector employees has risen too high. The study aims at determining the effect of the current coronavirus epidemic in the form of stress perceived among the medical workers in Pakistan and to discover the moderating role played by a healthy climate in offsetting it. The data was collected from 255 medical workers through a self-administered online questionnaire. Multiple Hierarchical Regression was used as a tool to test the hypotheses of the study. The results obtained indicate a correlation between the pandemic and the stress caused by it among the health workers, whereas, the role of a wholesome climate in the reduction of stress among them was found lacking. Sub-hypotheses indicate that the healthy environment provided by supervisors is effective in reducing the impact of workers' handling of the Covid-19 epidemic and perceived stress, while the healthy environment provided by hospitals in general or by workgroups fails to cause such positive change. This revelation necessitates the adoption of compulsory precautionary measures on the part of relevant authorities, because increase in stress caused by the pandemic can prove more lethal than the pandemic itself. The threat of the coronavirus pandemic has emerged as a massive socio-economic challenge for the global community, especially for the developing countries like Pakistan which faces serious socio-economic challenges in the current scenario. On account of the similarity of situations, the results obtained through this study can be safely generalized to other developing countries, particularly from the South Asian region.

Eight-Year Health Risks Trend Analysis of a Comprehensive Workplace Health Promotion Program

Research has shown that workplace health promotion (WHP) efforts can positively affect employees' health risk accumulation. However, earlier literature has provided insights of health risk changes in the short-term. This prospective longitudinal quasi-experimental study investigated trends in health risks of a comprehensive, eight-year WHP program (n = 523-651). Health risk data were collected from health risk assessments in 2010-2011, 2013-2014, and 2016-2017, applying both a questionnaire and biometric screenings. Health risk changes were investigated for three different time-periods, 2010-2013, 2014-2017, and 2010-2017, using descriptive analyses, t-tests, and the Wilcoxon Signed Rank and McNemar's test, where appropriate. Overall health risk transitions were assessed according to low-, moderate-, and high-risk categories. Trend analyses observed 50-60% prevalence for low-, 30-35% for moderate-, and 9-11% high-risk levels across the eight years. In the overall health risk transitions of the three time-periods, 66-73% of participants stayed at the same risk level, 13-15% of participants improved, and 12-21% had deteriorated risk level across the three intervention periods. Our findings appear to indicate that the multiyear WHP program was effective in maintaining low and moderate risk levels, but fell short of reducing the total number of health risks at the population level.

Going beyond the mean in examining relationships of adolescent non-cognitive skills with health-related quality of life and biomarkers in later-life

Several studies have established associations between early-life non-cognitive skills and later-life health and health behaviours. However, no study addresses the more important policy concern about how this relationship varies along the health distribution. We use unconditional quantile regression to analyse the effects of adolescent non-cognitive skills across the distributions of the health-related quality of life at age 50 and biomarkers at age 45 years. We examine the effects of measures of conscientiousness, agreeableness and neuroticism recorded at age 16 for 3585 individuals from the National Child Development Study. Adolescent conscientiousness is positively associated with ability to cope with stress and negatively associated with risk of cardiovascular disease in middle-age. Adolescent agreeableness is associated with higher health-related quality of life and lower physiological 'wear and tear', but negatively associated with ability to cope with stress in middle-age. Adolescent neuroticism is associated with lower health-related quality of life, higher physiological 'wear and tear', and a higher risk of cardiovascular disease in middle-age. All of these associations are stronger at the lower end of the health distribution except for the cardiovascular risk biomarkers. These associations are robust to correcting for attrition using inverse probability weighting and consistent with causal bounds assuming proportional selection on observables and unobservables. They suggest policies that improve non-cognitive skills in adolescence could offer most long-term health benefit to those with the poorest health.

Health Risk Calculator: An Online, Interactive Tool to Estimate how Health Impacts Workers' Compensation Claim Incidence and Cost

OBJECTIVE

The purpose of this paper is to describe and evaluate a web-based, educational Health Risk Calculator that communicates the value of investing in employee health and well-being for the prevention of work-related injuries, illnesses, and fatalities.

METHODS

We developed and evaluated the calculator following the RE-AIM framework. We assessed effectiveness via focus groups (n = 15) and a post-use survey (n = 33) and reach via website analytics.

RESULTS

We observed evidence for the calculator's usability, educational benefit, and encouragement of action to improve worker health and safety. Website analytics data demonstrated that we reached over 300 users equally in urban and rural areas within 3 months after launch.

CONCLUSION

We urge researchers to consider the ways in which they can communicate their empirical research findings to their key stakeholders and to evaluate their communication efforts.

Variability and effectiveness of comparator group interventions in smoking cessation trials: a systematic review and meta-analysis

AIMS

To examine variability and effectiveness of interventions provided to comparator (control) groups in smoking cessation trials.

METHODS

Systematic review with meta-analysis of randomized controlled trials (RCTs) of behavioral interventions for smoking cessation, with or without stop-smoking medication. We searched the Cochrane Tobacco Addiction Group Specialized Register for RCTs with objective outcomes measured at ≥ 6 months. Study authors were contacted to obtain comprehensive descriptions of their comparator interventions. Meta-regression analyses examined the relationships of smoking cessation rates with stop-smoking medication and behavior change techniques.

RESULTS

One hundred and four of 142 eligible comparator groups (n = 23 706) had complete data and were included in analyses. There was considerable variability in the number of behavior change techniques delivered [mean = 15.97, standard deviation (SD) = 13.54, range = 0-45] and the provision of smoking cessation medication (43% of groups received medication) throughout and within categories of comparator groups (e.g. usual care, brief advice). Higher smoking cessation rates were predicted by provision of medication [B = 0.334, 95% confidence interval (CI) = 0.030-0.638, P = 0.031] and number of behavior change techniques included (B = 0.020, 95% CI = 0.008-0.032, P < 0.001). Modelled cessation rates in comparator groups that received the most intensive support were 15 percentage points higher than those that received the least (23 versus 8%).

CONCLUSIONS

Interventions delivered to comparator groups in smoking cessation randomized controlled trials vary considerably in content, and cessation rates are strongly predicted by stop-smoking medication and number of behavior change techniques delivered.

Ten Modifiable Health Risk Factors and Employees' Medical Costs-An Update

PURPOSE

To estimate the relationship between employees' health risks and health-care costs to inform health promotion program design.

DESIGN

An observational study of person-level health-care claims and health risk assessment (HRA) data that used regression models to estimate the relationship between 10 modifiable risk factors and subsequent year 1 health-care costs.

SETTING

United States.

PARTICIPANTS

The sample included active, full-time, adult employees continuously enrolled in employer-sponsored health insurance plans contributing to IBM MarketScan Research Databases who completed an HRA. Study criteria were met by 135 219 employees from 11 employers.

MEASURES

Ten modifiable risk factors and individual sociodemographic and health characteristics were included in the models as independent variables. Five settings of health-care costs were outcomes in addition to total expenditures.

ANALYSIS

After building the analytic file, we estimated generalized linear models and conducted postestimation bootstrapping.

RESULTS

Health-care costs were significantly higher for employees at higher risk for blood glucose, obesity, stress, depression, and physical inactivity (all at P < .0001) than for those at lower risk. Similar cost differentials were found when specific health-care services were examined.

CONCLUSION

Employers may achieve cost savings in the short run by implementing comprehensive health promotion programs that focus on decreasing multiple health risks.

Caracterização da síndrome de burnout em enfermeiros em municípios do interior do Estado da Paraíba – Brasil

Objetivos: Caracterizar a síndrome de burnout (SB) em enfermeiros em cinco municípios do alto sertão do Estado da Paraíba, Brasil. Métodos: Estudo descritivo, transversal, de caráter prospectivo, realizado em enfermeiros nos municípios de Uiraúna, Poço de José de Moura, Poço Dantas, Joca Claudino e Bernardino Batista, entre abril e dezembro de 2018, baseado na aplicação de um questionário com informações sócio-organizacionais (Copenhagen Burnout Inventory), do qual foram obtidas as frequências relativa e absoluta, média, mediana, desvio padrão, desvio padrão relativo e associações entre as variáveis. Resultados: As dimensões burnout pessoal (51,4%) e burnout relacionado ao paciente (60,0%) apresentaram um nível moderado e burnout relacionado ao trabalho (48,6%) um nível baixo. As variáveis idade, tempo de trabalho e vínculo empregatício apresentaram associação com burnout pessoal, relacionadas ao paciente e ao trabalho respectivamente. Conclusão: Os níveis de burnout moderados encontrados (nos domínios pessoal e relacionado ao paciente) devem gerar um alerta por parte dos gestores das instituições para fins de prevenção de agravos na saúde desses trabalhadores. A associação do burnout entre as variáveis idade, tempo de trabalho e vínculo empregatício indicam que essas variáveis estão envolvidas no desenvolvimento da SB em enfermeiros.

Impact of Physician Referral to Health Coaching on Patient Engagement and Health Risks: An Observational Study of UPMC's Prescription for Wellness

PURPOSE

Evaluate impact of physician referral to health coaching on patient engagement and health risk reduction.

DESIGN

Four-year retrospective, observational cohort study with propensity-matched pair comparisons.

SETTING

Integrated delivery and finance system in Pittsburgh, Pennsylvania.

SAMPLE

10 457 adult insured members referred to health coaching by their physician; 37 864 other members identified for health coaching through insurer-initiated outreach.

INTERVENTION

Practice-based, technology-supported workflow and process for physician prescribing of health coaching during regular office visit, with follow-up on patient's progress and implementation supports.

MEASURES

Patient engagement based on completion of pre-enrollment assessment, formal enrollment in health coaching, completion of required sessions, health risk levels, and number of health risks pre- and post-health coaching referral.

ANALYSIS

Difference-in-difference analysis to assess change in health risk levels and number of health risks pre- and post-health coaching and probability weighting to control for potential confounding between groups.

RESULTS

Members referred by a physician were significantly more likely to enroll in a health coaching program (21.0% vs 6.0%, P < .001) and complete the program requirements (8.5% vs 2.7%, P < .001) than when referred by insurer-initiated outreach; significant within group improvement in health risk levels from baseline (P < .001) was observed for both the groups.

CONCLUSIONS

Patients are significantly more likely to engage in health coaching when a referral is made by a physician; engagement in health coaching significantly improves health risk levels.

Effects of adults' health behaviors and combinations thereof on health outcomes: an analysis using National Health Insurance Service of Korea cohort data

OBJECTIVES

The purpose of this study was to estimate the effects of health-risk behaviors, alone and in combination, on health outcomes.

METHODS

This study used sample cohort data provided by the National Health Insurance Service focusing on the use of hospital services, direct medical expenses, length of stay, and re-entry rate according to health-risk behaviors. A frequency analysis and the chi-square test were used to investigate associations between the demographic characteristics of study subjects and their health-risk behaviors. The strength of the association of each factor was calculated as the odds ratio in a crossover analysis.

RESULTS

Obesity had the largest effect, especially in combination with smoking and drinking. In particular, significant associations were shown with the duration of hospitalization and direct medical expenses. After adjustment for sex, age, economic status, and pre-existing medical conditions, the duration of hospitalization was 7.37 times longer and that of medical expenses was 5.18 times higher in the obese group relative to the non-obese group. Drinking showed a statistically significant association with the number of days of hospitalization. After adjusting for the control variables, the number of hospital days was 1.24 longer in the drinking group than in the non-drinking group.

CONCLUSIONS

An analysis of combinations of health risk factors showed obesity had the largest effect.

Mental Health in the Workplace: A Call to Action Proceedings From the Mental Health in the Workplace-Public Health Summit

OBJECTIVE

The aim of the study was to declare a call to action to improve mental health in the workplace.

METHODS

We convened a public health summit and assembled an Advisory Council consisting of experts in the field of occupational health and safety, workplace wellness, and public policy to offer recommendations for action steps to improve health and well-being of workers.

RESULTS

The Advisory Council narrowed the list of ideas to four priority projects.

CONCLUSIONS

The recommendations for action include developing a mental health in the workplace (1) "how to" guide, (2) scorecard, (3) recognition program, and (4) executive training.

The Predicted Impact of Adopting Health-Promoting Behaviors on Disease Burden in a Commercially Insured Population

OBJECTIVE

The aim of this study was to better understand, in a commercially insured population, the potential impact of adopting six health-promoting behaviors relative to treating diseases and conditions.

METHODS

We combined survey and insurance claims data to compare the potential benefit from adopting behaviors relative with the burden from 27 groups of diseases and conditions.

RESULTS

If every member adopted all six behaviors, an 11.6% reduction in disability-adjusted life years (DALYs) might be expected, and a 7.6% reduction in DALYs might be expected if they adopted the one most impactful behavior that they did not currently practice. These amounts are, respectively, greater than the DALYs attributed to all but the two and five most burdensome groups of diseases and conditions in this population.

CONCLUSIONS

The potential impact of adopting health-promoting behaviors is large relative to the burden from most medical conditions.

Participant Engagement in and Perspectives on a Web-Based Mindfulness Intervention for 9-1-1 Telecommunicators: Multimethod Study

Background

Demanding working conditions and secondary exposure to trauma may contribute to a high burden of stress among 9-1-1 telecommunicators, decreasing their ability to work effectively and efficiently. Web-based mindfulness-based interventions (MBIs) can be effective in reducing stress in similar populations. However, low engagement may limit the effectiveness of the intervention.

Objective

The aim of this study was to assess participant engagement in a Web-based MBI designed for 9-1-1 telecommunicators. Specifically, we sought to describe the following: (1) participant characteristics associated with intervention engagement, (2) participant perspectives on engaging with the intervention, and (3) perceived challenges and facilitators to engaging.

Methods

We used qualitative and quantitative data from participant surveys (n=149) that were collected to assess the efficacy of the intervention. We conducted descriptive and bivariate analyses to identify associations between demographic, psychosocial, and workplace characteristics and engagement. We conducted a thematic analysis of qualitative survey responses to describe participant experiences with the MBI.

Results

We found that no individual participant characteristics were associated with the level of engagement (low vs high number of lessons completed). Participant engagement did vary by the call center (P<.001). We identified the following overarching qualitative themes: (1) the participants perceived benefits of mindfulness practice, (2) the participants perceived challenges to engage with mindfulness and the intervention, and (3) intervention components that facilitated engagement. The participants expressed positive beliefs in the perceived benefits of practicing mindfulness, including increased self-efficacy in coping with stressors and increased empathy with callers. The most commonly cited barriers were work-related, particularly not having time to participate in the intervention at work. Facilitators included shorter meditation practices and the availability of multiple formats and types of intervention content.

Conclusions

The findings of this study suggest that efforts to improve intervention engagement should focus on organizational-level factors rather than individual participant characteristics. Future research should explore the effect of mindfulness practice on the efficiency and effectiveness of 9-1-1 telecommunicators at work.

Trial Registration

ClinicalTrials.gov NCT02961621; https://clinicaltrials.gov/ct2/show/NCT02961621

Enhancing Behavior Change Technique Coding Methods: Identifying Behavioral Targets and Delivery Styles in Smoking Cessation Trials

BACKGROUND

The behavior change technique (BCT) taxonomy v1 is often used in systematic reviews for identifying active components of interventions. Its utility could be enhanced by linking BCTs to specific target behaviors and qualifying BCT delivery style.

PURPOSE

To determine whether behavioral targets and delivery styles of BCTs can be coded reliably and to determine the utility of coding these characteristics.

METHODS

As part of a large systematic review of 142 smoking cessation trials, two researchers independently coded publicly and privately held intervention and comparator group materials, specifying the behavioral target (quitting, abstinence, medication adherence, or treatment engagement) and delivery style (tailored vs. not tailored; active participation vs. passive receipt) of each BCT.

RESULTS

Researchers coded 3,843 BCTs, which were reliably attributed to behavioral targets (AC1 = 0.92, PABAK = 0.91). Tailoring (AC1 = 0.80, PABAK = 0.74) and participation (AC1 = 0.71, PABAK = 0.64) were also coded reliably. There was considerable variability between groups in quitting and abstinence BCTs (ranges: 0-41; 0-18) and in tailoring and participation (ranges: 0-20; 0-32), but less variability for medication adherence and treatment engagement (ranges: 0-6; 0-7).

CONCLUSIONS

Behavioral targets and delivery styles of BCTs can be reliably identified and occur with sufficient frequency in smoking cessation trials for inclusion in quantitative syntheses (e.g., meta-regression analyses). Systematic reviewers could consider adopting these methods to evaluate the impact of intervention components targeting different behaviors, as well as the benefits of different BCT delivery styles.

Measuring Participation in Employer-Sponsored Health and Well-Being Programs: A Participation Index and Its Association With Health Risk Change

PURPOSE

To develop an index of participation in workplace health and well-being programs and assess its relationship with health risk status.

DESIGN

Study design comprised a retrospective longitudinal analysis of employee health risk assessment (HRA) and program participation data.

SETTING

Data from 6 companies that implemented health and well-being programs from 2014 to 2016.

PARTICIPANTS

Employee participants (n = 95 318) from 6 companies who completed an HRA in 2014 to 2016. After matching those who completed the HRA in all 3 years, the longitudinal file included 38 789 respondents.

MEASURES

Participation indicators were created for 9 different program components. The sum of these 9 components established the total participation index.

ANALYSIS

Descriptive and correlation analyses were conducted on all participation measures. Repeated-measures analysis of variance was used to assess the impact of participation level on health risk over time.

RESULTS

Higher levels of participation were associated with a greater reduction in risks, with each participation dose yielding a reduction of 0.038 risks (P < .001).

CONCLUSION

Results suggest that employees who participate more in workplace health and well-being programs experience more health risk improvement. The study also supports a more granular definition of participation based on the number of interactions and type of program.

A Cross-Sectional Study of Perceived Stress, Mindfulness, Emotional Self-Regulation, and Self-Care Habits in Registered Nurses at a Tertiary Care Medical Center

Introduction

Workplace stress and burnout may influence nurses’ physical and emotional well-being, which can impact the quality of care patients receive and their overall satisfaction with their hospitalization.

Objectives

The objectives of the study were to evaluate whether there are significant statistical relationships between nurses’ perceived stress, frequency of stressors, mindfulness, emotional self-regulation, self-care habits, and patient satisfaction scores.

Methods

The study took place over the course of 4 weeks. In this study, 340 nurse participants were surveyed using cross-sectional voluntary sampling design. The survey included previously developed and validated instruments. SAS v. 9.4 was used for statistical analysis.

Results

Significant differences were noted in average patient satisfaction scores by perceived stress; major nursing units in the Death and Dying, Conflict with Physicians, Lack of Support, and Work Load subscales of the Nursing Stress Scale; and major nursing units and dispositional mindfulness.

Conclusions

Hospital administrators can use this information in their organizations and set priorities and tailor mindfulness-based stress-reduction interventions for nursing professionals.

The joint contribution of physical activity, insomnia symptoms, and smoking to the cost of short-term sickness absence

Physical inactivity has been associated with both insomnia symptoms and smoking. Further, they are all independently associated with increased sickness absence (SA) from work. However, joint contribution of either physical activity (PA) with insomnia symptoms or with smoking to SA and, especially, their direct cost for the employer is poorly understood. Therefore, we aimed to examine these joint associations with short-term (<15 days) SA cost. The Helsinki Health Study is a cohort of midlife employees of the City of Helsinki, Finland (baseline n = 8960, response rate 67%). During 2000-2002, the participants were mailed a survey questionnaire that gathered information on health behavior and sociodemographic characteristics. SA, salary, and time of employment were followed up through the employer's personnel register between 2002 and 2016 for those with a written consent to the use of their register data (78% of the participants). Individual salary data were used to calculate the direct cost of short-term SA. Data were analyzed with a two-part model. Inactive participants with frequent insomnia symptoms had 2526€ (95% CI 1736€-3915€) higher cost of short-term SA than vigorously active participants without insomnia symptoms. Furthermore, inactive smokers had 4166€ (95% CI 2737€-5595€) higher cost for the employer over the follow-up than vigorously active non-smokers. In conclusion, this study showed that PA and insomnia symptoms as well as PA and smoking are jointly associated with short-term SA cost. The results emphasize encouraging employers to improve work environments so that they promote active lifestyle, good sleep, and non-smoking in order to reduce the cost of SA.

Accounting for employee health: The productivity cost of leading health risks

BACKGROUND

"Workplace health promotion and protection" broadly refers to an integrated approach to workplace health and safety initiatives. There are substantial benefits to adopting such an approach, including the potential for: improvements to individual employees' health and well-being; increased productivity; and reduced safety risks and expenses. Yet many employers remain reluctant to shift from traditional safety initiatives and spending. This paper aims to demonstrate the value of investing in an integrated health promotion and protection approach by calculating the productivity costs associated with 11 modifiable health risks and 14 chronic conditions in an Australian mining company.

METHOD

Eight hundred and ninety-seven employees participated in a self-report health survey aimed at investigating employee health behaviours, health conditions and productivity.

RESULTS

Overall, modifiable health risks and chronic health conditions were calculated to contribute to an estimated $22.15 million (AUD) and $7.95 million (AUD) in lost productivity per 1000 employees per annum, respectively. Although employee stress was identified as the third highest prevalence health risk across the employee sample (at 42%), it accounted for the highest financial burden.

CONCLUSION

Employee health plays a vital role in the profitability, productivity, and safety outcomes of an organisation. For modifiable health risks and chronic conditions, ailments that affected cognition resulted in the highest financial burden (ie, stress and migraine headaches). SO WHAT?: These findings make a strong financial and business case for the integration of preventative health and safety initiatives, with particular emphasis on modifiable health risk behaviours.

Ferrari Corporate Wellness Program: Results of a Pilot Analysis and the "Drag" Impact in the Workplace

INTRODUCTION

Preventive strategies based on advice and interventions on lifestyle habits represent the most powerful resource available to reduce the burden of cardiovascular (CV) diseases. Workplace represents an unmissable context for lifestyle changes at population level.

AIM

To evaluate the mid-term efficacy of a corporate wellness program in a cohort of healthy and physically active employees of the Ferrari car manufacturer.

METHODS

A corporate wellness program, named "Ferrari Formula Benessere", was proposed to adult individuals working in a Ferrari car company at Maranello, Modena (Italy). Employees who voluntarily agreed to the program received healthy nutritional advice and were trained three times a week (60 min per session), and periodically re-evaluated during a 4-year follow-up period.

RESULTS

Among the 719 Ferrari employees that joined the program, 168 (23%) subjects (88.5% males, age 30.8 ± 5.9 years) were considered the most active participants, based on a self-administered standardized questionnaire, and included in the study. A relevant improvement of several CV risk factors (body mass index, total and LDL cholesterol, triglycerides, blood pressure) and cardio-respiratory fitness parameters (estimated VO_2max, Watt_peak, METs) was observed compared to baseline values. Furthermore, it was recorded a clear "drag effect" towards non-participating and sedentary peers, resulting in a 90% adherence increase over the years.

CONCLUSIONS

The "Ferrari Formula Benessere" corporate wellness project proved to be effective in improving CV risk profile and cardio-respiratory fitness in a population of already physically active employees.

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of risk factor exposure and attributable burden of disease. By providing estimates over a long time series, this study can monitor risk exposure trends critical to health surveillance and inform policy debates on the importance of addressing risks in context.

METHODS

We used the comparative risk assessment framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2016. This study included 481 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk (RR) and exposure estimates from 22 717 randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources, according to the GBD 2016 source counting methods. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. Finally, we explored four drivers of trends in attributable burden: population growth, population ageing, trends in risk exposure, and all other factors combined.

FINDINGS

Since 1990, exposure increased significantly for 30 risks, did not change significantly for four risks, and decreased significantly for 31 risks. Among risks that are leading causes of burden of disease, child growth failure and household air pollution showed the most significant declines, while metabolic risks, such as body-mass index and high fasting plasma glucose, showed significant increases. In 2016, at Level 3 of the hierarchy, the three leading risk factors in terms of attributable DALYs at the global level for men were smoking (124·1 million DALYs [95% UI 111·2 million to 137·0 million]), high systolic blood pressure (122·2 million DALYs [110·3 million to 133·3 million], and low birthweight and short gestation (83·0 million DALYs [78·3 million to 87·7 million]), and for women, were high systolic blood pressure (89·9 million DALYs [80·9 million to 98·2 million]), high body-mass index (64·8 million DALYs [44·4 million to 87·6 million]), and high fasting plasma glucose (63·8 million DALYs [53·2 million to 76·3 million]). In 2016 in 113 countries, the leading risk factor in terms of attributable DALYs was a metabolic risk factor. Smoking remained among the leading five risk factors for DALYs for 109 countries, while low birthweight and short gestation was the leading risk factor for DALYs in 38 countries, particularly in sub-Saharan Africa and South Asia. In terms of important drivers of change in trends of burden attributable to risk factors, between 2006 and 2016 exposure to risks explains an 9·3% (6·9-11·6) decline in deaths and a 10·8% (8·3-13·1) decrease in DALYs at the global level, while population ageing accounts for 14·9% (12·7-17·5) of deaths and 6·2% (3·9-8·7) of DALYs, and population growth for 12·4% (10·1-14·9) of deaths and 12·4% (10·1-14·9) of DALYs. The largest contribution of trends in risk exposure to disease burden is seen between ages 1 year and 4 years, where a decline of 27·3% (24·9-29·7) of the change in DALYs between 2006 and 2016 can be attributed to declines in exposure to risks.

INTERPRETATION

Increasingly detailed understanding of the trends in risk exposure and the RRs for each risk-outcome pair provide insights into both the magnitude of health loss attributable to risks and how modification of risk exposure has contributed to health trends. Metabolic risks warrant particular policy attention, due to their large contribution to global disease burden, increasing trends, and variable patterns across countries at the same level of development. GBD 2016 findings show that, while it has huge potential to improve health, risk modification has played a relatively small part in the past decade.

FUNDING

The Bill & Melinda Gates Foundation, Bloomberg Philanthropies.

Effectiveness of a Web-Based Intervention in Reducing Depression and Sickness Absence: Randomized Controlled Trial

Background

Depression is highly prevalent in the working population and is associated with significant loss of workdays; however, access to evidence-based treatment is limited.

Objective

This study evaluated the effectiveness of a Web-based intervention in reducing mild to moderate depression and sickness absence.

Methods

In an open-label randomized controlled trial, participants were recruited from a large-scale statutory health insurance and were assigned to two groups. The intervention group had access to a 12 week Web-based program consisting of structured interactive sessions and therapist support upon request. The wait-list control group had access to unguided Web-based psycho-education. Depressive symptoms were self-assessed at baseline, post-treatment, and follow-up (12 weeks after treatment) using the Patient Health Questionnaire (PHQ-9) and Beck Depression Inventory (BDI-II) as primary outcome measures. Data on sickness absence was retrieved from health insurance records. Intention-to-treat (ITT) analysis and per-protocol (PP) analysis were performed.

Results

Of the 180 participants who were randomized, 88 completed the post-assessment (retention rate: 48.8%, 88/180). ITT analysis showed a significant between-group difference in depressive symptoms during post-treatment in favor of the intervention group, corresponding to a moderate effect size (PHQ-9: d=0.55, 95% CI 0.25-0.85, P<.001, and BDI-II: d=0.41, CI 0.11-0.70, P=.004). PP analysis partially supported this result, but showed a non-significant effect on one primary outcome (PHQ-9: d=0.61, 95% CI 0.15-1.07, P=.04, and BDI-II: d=0.25 95% CI −0.18 to 0.65, P=.37). Analysis of clinical significance using reliable change index revealed that significantly more participants who used the Web-based intervention (63%, 63/100) responded to the treatment versus the control group (33%, 27/80; P<.001). The number needed to treat (NNT) was 4.08. Within both groups, there was a reduction in work absence frequency (IG: −67.23%, P<.001, CG: −82.61%, P<.001), but no statistical difference in sickness absence between groups was found (P=.07).

Conclusions

The Web-based intervention was effective in reducing depressive symptoms among adults with sickness absence. As this trial achieved a lower power than calculated, its results should be replicated in a larger sample. Further validation of health insurance records as an outcome measure for eHealth trials is needed.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 02446836; http://www.isrctn.com/ISRCTN02446836 (Archived by WebCite at http://www.webcitation.org/6jx4SObnw)

Cardiovascular Health and Healthcare Utilization and Expenditures Among Medicare Beneficiaries: The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

Background

Better cardiovascular health is associated with lower cardiovascular disease risk.

Methods and Results

We determined the association between cardiovascular health and healthcare utilization and expenditures in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. We included 6262 participants ≥65 years with Medicare fee‐for‐service coverage for the year after their baseline study visit in 2003‐2007. Cardiovascular health at baseline was assessed using the American Heart Association's Life's Simple 7 (LS7) metric, which includes 7 factors: cigarette smoking, physical activity, diet, body mass index, blood pressure, cholesterol, and glucose. Healthcare utilization and expenditures were ascertained using Medicare claims in the year following baseline. Overall, 17.2%, 31.1%, 29.0%, 16.4% and 6.4% of participants had 0 to 1, 2, 3, 4, and 5 to 7 ideal LS7 factors, respectively. The multivariable‐adjusted relative risk (95% confidence interval [CI]) for having any inpatient and outpatient encounters comparing participants with 5 to 7 versus 0 to 1 ideal LS7 factors were 0.55 (0.39, 0.76) and 1.00 (0.98, 1.02), respectively. Among participants with 0 to 1 and 5 to 7 ideal LS7 factors, mean inpatient expenditures were $3995 and $1250, respectively, mean outpatient expenditures were $5166 and $2853, respectively, and mean total expenditures were $9147 and $4111, respectively. After multivariable adjustment, the mean (95% CI) cost difference comparing participants with 5 to 7 versus 0 to 1 ideal LS7 factors was −$2551 (−$3667, −$1435) for inpatient, −$2410 (−$3089, −$1731) for outpatient, and −$5016 (−$6577, −$3454) for total expenditures.

Conclusions

Better cardiovascular health is associated with lower risk for inpatient encounters and lower inpatient and outpatient healthcare expenditures.

Improving physical and mental health in frontline mental health care providers: Yoga-based stress management versus cognitive behavioral stress management

The need for brief, low-cost, easily disseminable and effective interventions to promote healthy lifestyles is high. This is especially true for mental health providers. We developed two studies to compare the impacts of Cognitive Behavioral Stress Management (CBSM) and Yoga Based Stress Management (YBSM) interventions for healthcare professionals. Study 1 offered an 8-week YBSM intervention to 37 mental healthcare participants and collected health data pre and post. Study 2 offered YBSM and CBSM classes to 40 randomly assigned mental healthcare providers and collected mental and physical health data at four time points. In Study 1, using t-tests, the YBSM intervention affected a number of mental and physical wellbeing indices pre to post. In Study 2, using linear mixed modeling, both YBSM and CBSM groups improved significantly (p <.05) in fruit and vegetable intake, heart rate, alcohol consumption, relaxation and awareness, professional quality of life, compassion satisfaction, burnout, depression, and stress levels. There was a group by time effect for coping confidence (CBSM increased more, p<.05, F = 4.34), physical activity (YBSM increased more, p<.05, F = 3.47), overall mental health (YBSM increased more, p<.10, F =5.32), and secondary traumatic stress (YBSM decreased more, p<.10, F = 4.89). YBSM and CBSM appear to be useful for healthcare professionals' mental and physical health. YBSM demonstrates some benefit above and beyond the extremely well-studied and empirically supported CBSM, including increased physical activity, overall mental health, and decreased secondary traumatic stress benefits.

Modifiable Healthy Lifestyle Behaviors: 10-Year Health Outcomes From a Health Promotion Program

INTRODUCTION

Previous studies have examined the impact of healthy lifestyle choices on health-related outcomes; however, given their fragmented, often cross-sectional nature, assessing the relative impact of daily modifiable behaviors on overall long-term outcomes, particularly for a diverse working adult population, remains challenging.

METHODS

Relationships between ten self-reported healthy lifestyle behaviors and health outcomes during the subsequent 9 years in a cohort of 10,248 participants enrolled during 2003 in a voluntary workplace wellness program were assessed. Cox proportional-hazards models computed hazard ratios (HRs) for lifestyle characteristics associated with time to one of seven self-reported chronic diseases or death. Data were collected between 2003 and 2012 and analyzed between 2014 and 2016.

RESULTS

Behaviors that most significantly affected future outcomes were low-fat diet, aerobic exercise, nonsmoking, and adequate sleep. A dose-response effect was seen between dietary fat intake and hypertension, obesity, diabetes, heart disease, and hypercholesterolemia. After dietary fat intake, aerobic exercise was the next most significant behavior associated with development of outcomes. Compared with sedentary participants, those who exercised 4 days per week were less likely to develop new-onset diabetes (HR=0.31, 95% CI=0.20, 0.48); heart disease (HR=0.46, 95% CI=0.27, 0.80); and hypercholesterolemia (HR=0.61, 95% CI=0.50, 0.74). Low-fat diet and adequate sleep were more significant than commonly promoted healthy behaviors, such as eating a daily breakfast.

CONCLUSIONS

Modifiable lifestyle behaviors targeted in health promotion programs should be prioritized in an evidence-based manner. Top priorities for workplace health promotion should include low-fat diet, aerobic exercise, nonsmoking, and adequate sleep.

Health at Every Size

The underlying goal of traditional approaches to weight and health is for individuals to be smaller (i.e., lose weight). Little evidence exists supporting the efficacy of such approaches and concern is mounting that they may be causing harm. An effective, compassionate approach to issues of weight and health--Health At Every Size (HAES)--acknowledges the naturally existing diversity in body shapes and sizes, the ineffectiveness and dangers of dieting for weight loss, the importance of relaxed eating in response to internal body clues, and the critical contribution of social, emotional, spiritual, and physical factors to health and happiness. Occupational health nurses can use the HAES approach at the worksite to assist employees with effectively addressing their weight-related concerns.

The Effects of Two Workplace Weight Management Programs and Weight Loss on Health Care Utilization and Costs

OBJECTIVES

The aim of this study was to compare the impact of two worksite weight management (WM [education] and WM+ [education plus counseling]) programs, on health care utilization and costs. Secondarily, compare the intervention groups to an observational control group of obese workers. Finally, evaluate the impact of actual weight loss on these outcomes.

METHODS

Estimate the change in the WM and WM+ intervention groups. Using propensity score adjustment compare the two intervention groups with the observational control group; and compare those who lost weight with those who did not.

RESULTS

No significant differences between the two intervention groups, or between these intervention groups and the observational control group. Those who lost weight reduced their overall health care costs.

CONCLUSIONS

To achieve weight loss and associated morbidity reductions, more extensive and intensive interventions, with more attention to motivation and compliance, are required.

The Portion of Health Care Costs Associated With Lifestyle-Related Modifiable Health Risks Based on a Sample of 223,461 Employees in Seven Industries: The UM-HMRC Study

OBJECTIVE

This study estimates the percent of health care costs associated with employees' modifiable health risks.

METHODS

Cross-sectional multivariate analysis of 223,461 employees from seven industries who completed a health risk assessment during 2007 to 2012.

RESULTS

Modifiable health risks were associated with 26.0% of health care costs ($761/person) among employees with no self-reported medical conditions and 25.4% among employees with a medical condition ($2598/person). The prevalence and relative costs of each of the 10 risks were different for those without and with medical conditions, but high body mass index was the most prevalent risk for both groups (41.0% and 63.9%) and also contributed the largest percentage of excess costs (7.2% and 7.3%).

CONCLUSIONS

This study, coupled with past work, gives an employer a sense of the magnitude that might be saved if modifiable health risks could be eliminated.

Beyond Bootstraps: A Rural, Midwestern Health Care Organization’s Response to Employee Depression

Depression is one of the most prevalent and costly employee health issues in American business and industry. Despite the high costs—both human and economic—associated with depression and the availability of prompt and efficacious treatment options, most employers remain unresponsive due to either a lack of concern or awareness regarding the significant impact of depression on the workplace.

Changes in Depressed Mood Associated with 10 Weeks of Moderate Cardiovascular Exercise in Formerly Sedentary Adults

Two groups of adults classified with depressed mood (10% highest scores on the Profile of Mood States-Short Form Depression scale) were contrasted on changes in POMS Depression scores over 10 weeks. The exercise group ( n = 26) was given a moderate cardiovascular exercise program of 3x/week for 20 to 30 min. per session. The control group ( n = 24) did not participate in exercise. Significant reductions in POMS Depression scores over 10 weeks were noted for the exercise group in between-group ( d = –.88) and within-group ( d = −1.32) analyses. Significantly more participants in the exercise group scored in the normal range at Week 10 (62%) than in the control group (29%). Neither changes in cardiorespiratory function (VO2 max) nor initial POMS Depression scores were significantly correlated with changes in POMS Depression scores after 10 weeks. Methodological improvements, limitations, and practical application of findings after replication were discussed.

Association of Additional Health Risks on Medical Charges and Prevalence of Diabetes within Body Mass Index Categories

Purpose.

The prevalence of obesity and diabetes continues to increase among employee populations. Although medical costs and the prevalence of diabetes have been studied across increasing body mass index (BMI) categories, little attention has been given to the association of additional health risks within those categories. The purpose of this study was to examine the association of health risk levels on medical charges and prevalence of diabetes across BMI categories within an employee population.

Methods.

A cross-sectional study design utilized health risk appraisal data (30% response rate) to measure BMI levels, self-reported diabetes status, and selected additional health risks among 38,841 active employees under age 65 of the General Motors Corporation. Associated average annual medical charges from 1996 to 2000 were calculated for defined health risk levels across five BMI categories (<18.5; 18.5–24.9, 25–29.9, 30–34.9, and ≥35).

Results.

Higher medical charges were significantly associated with additional health risks (zero risks to four or more risks) across each of the BMI categories: $2689 to $7576 (<18.5); $2655 to $6555 (18.5–24.9); $3239 to $7118 (25–29.9); $3579 to $7758 (30–34.9); and $4151 to $8075 (≥35). Likewise, higher prevalence of diabetes was significantly associated with additional health risks (zero risks to four or more risks) across the BMI categories: 2.6% to 7.0% (<18.5); 1.3% to 2.7% (18.5–24.9); 2.4% to 5.3% (25–29.9); 5.5% to 8.3% (30–34.9); and 7.7% to 15.8% (≥35).

Discussion.

Medical costs and the prevalence of diabetes were lower when the numbers of additional health risks were lower, regardless of the BMI category. Programs to promote weight management have largely been unsuccessful in maintaining long-term weight control. The current results suggest that a strategy focused on reducing health risks within any weight category could provide an alternative strategy to achieve medical cost savings and a lower prevalence of diabetes. The implied benefits of risk reduction within BMI categories would need to be confirmed with a longitudinal study.

Understanding the Relationship between Health Risks and Health-Related Costs

Dr. Anderson reflects on the lack of consistency in studies on the relationship between health risks and medical costs. Part of the inconsistency is caused by differences in risk assessment instruments, but a more important concern is lack of clear conceptualization and statement of research goals. One reason for exploring this relationship is to be able to predict health care costs accurately: a very different reason is to identify causal variables, the modification of which will have an impact on costs.

Estimating Risk Reduction Required to Break Even in a Health Promotion Program

Purpose.

To illustrate a formula to estimate the amount of risk reduction required to break even on a corporate health promotion program.

Design.

A case study design was implemented. Base year (2001) health risk and medical expenditure data from the company, along with published information on the relationships between employee demographics, health risks, and medical expenditures, were used to forecast demographics, risks, and expenditures for 2002 through 2011 and estimate the required amount of risk reduction.

Setting.

Motorola.

Subjects.

52,124 domestic employees.

Measures.

Demographics included age, gender, race, and job type. Health risks for 2001 were measured via health risk appraisal. Risks were noted as either high or low and related to exercise/eating habits, body weight, blood pressure, blood sugar levels, cholesterol levels, depression, stress, smoking/drinking habits, and seat belt use. Medical claims for 2001 were used to calculate medical expenditures per employee.

Results.

Assuming a $282 per employee program cost, Motorola employees would need to reduce their lifestyle-related health risks by 1.08% to 1.42% per year to break even on health promotion programming, depending upon the discount rate. Higher or lower program investments would change the risk reduction percentages.

Conclusion.

Employers can use information from published studies, along with their own data, to estimate the amount of risk reduction required to break even on their health promotion programs.

The Association between Health Risks and Medical Expenditures in a Japanese Corporation

Purpose.

To examine the relationship between health risks and medical care expenditures in an employer setting in Japan.

Design.

A cross-sectional, correlational study.

Setting.

A large Japanese corporation.

Subjects.

A total of 6543 employees of a large Japanese electronics company, for whom medical expenditures, lifestyle risks and biometric data were available, were included in the analysis. Seventy-six percent were male, and subjects were primarily white-collar workers.

Measures.

Medical expenditure data were available for fiscal year 2000, including inpatient, outpatient, and total expenditures, measured in Japanese yen. Binary expenditure indicators for those having no claims and those having high claims (90th percentile) were also created. Risk measures included biometric assessment of high blood pressure and high body mass index (BMI, body weight and height) and self-reported stress, lack of exercise, excess alcohol consumption, poor nutrition, current smoking, and recent quitting. High cholesterol and high blood glucose measures were also available for some subjects from company physicals.

Results.

Average total expenditures were ¥48,017 (US$445). The 90th percentile of the expenditure distribution was approximately ¥111,750 (US$1037). The most commonly reported risk factors were lack of exercise (52.9%), current smoking (35%), stress (33%), and poor nutritional habits (23.6%). Least common were recently quitting smoking (2%), high blood pressure (4.1%), and high blood glucose (9.4%). The prevalence of overweight or obesity was 15.9%. High blood pressure and recent quitting were consistently related to high expenditures, after adjusting for the influence of other predictors. Adjusted expenditures were 76% higher for recent quitters and 22.6% higher for employees with high blood pressure. Males and younger employees had consistently lower expenditures. Current smoking, poor nutrition, and alcohol risk were also associated with lower expenditures. Those with multiple cardiovascular risk factors had adjusted medical expenditures that were 128% higher than those with no cardiovascular risks. Those who had multiple risk factors for stroke had expenditures that were 13% lower than those without stroke risk factors.

Conclusions.

This paper represents a first step in examining the association between health risks and medical expenditures in Japanese employees. The investigation uncovered some significant levels of risk for lack of exercise, smoking, and stress. Although results indicate some significant associations between health risks and medical expenditures, several unexpected associations were noted that require further study. Such information provides a solid foundation for health promotion efforts in Japan and direction for subsequent investigations of health risks and medical expenditures. Future studies should address important issues of health risk measurement, data collection, and research design.

Impact of a Health Promotion Program on Employee Health Risks and Work Productivity

Purpose.

Evaluate the impact of a multicomponent workplace health promotion program on employee health risks and work productivity.

Design.

Quasi-experimental 12-month before-after intervention-control study.

Setting.

A multinational corporation headquartered in the United Kingdom.

Subjects.

Of 618 employees offered the program, 266 (43%) completed questionnaires before and after the program. A total of 1242 of 2500 (49.7%) of a control population also completed questionnaires 12 months apart.

Intervention.

A multicomponent health promotion program incorporating a health risk appraisal questionnaire, access to a tailored health improvement web portal, wellness literature, and seminars and workshops focused upon identified wellness issues.

Measures.

Outcomes were (1) cumulative count of health risk factors and the World Health Organization health and work performance questionnaire measures of (2) workplace absenteeism and (3) work performance.

Results.

After adjusting for baseline differences, improvements in all three outcomes were significantly greater in the intervention group compared with the control group. Mean excess reductions of 0.45 health risk factors and 0.36 monthly absenteeism days and a mean increase of 0.79 on the work performance scale were observed in the intervention group compared with the control group. The intervention yielded a positive return on investment, even using conservative assumptions about effect size estimation.

Conclusion.

The results suggest that a well-implemented multicomponent workplace health promotion program can produce sizeable changes in health risks and productivity.

Association between Lifestyle-Disease Diagnosis or Risk Status and Medical Care Costs in a Japanese Corporation

Purpose.

This study examined the differences in medical care costs among (1) individuals who carried the diagnosis of selected lifestyle diseases (diabetes mellitus, hypertension, and hyperlipidemia), (2) individuals whose levels of risks (blood glucose, blood pressure, and total cholesterol) satisfied the diagnosis guidelines yet who did not carry the diagnoses, (3) individuals who had these risks but whose risk levels were not high enough to satisfy the diagnosis guidelines, and (4) individuals without the risks.

Design.

A one-time cross-sectional design was used. Health checkup data and medical-claims data obtained from the fiscal year 2000 were examined for correlations.

Sample.

A total of 3292 employees aged 34 years and older were selected from the entire employee population of 6543 in a Japanese corporation. Employees younger than 34 years old were excluded because their clinical risk data were not available.

Measures.

On the basis of their absence or presence of diagnoses (obtained from medical claims) and underlying risk levels (obtained from health checkups), employees were categorized into (1) the diagnosed group, (2) the extremely high-risk group, (3) the high-risk group, or (4) the no-risk group. Reimbursement points on medical care claims were summed for each individual during the study period and multiplied by 10 to calculate the total medical care costs, as each point in the reimbursement request form represents ¥10.

Analysis.

The high-cost case analysis was used. First, the high costs were determined as the costs at or above the 90th percentile. The diagnosis or risk status was examined in its relation to the newly created dichotomous variable (whether the medical costs were at or above the threshold or were lower than the threshold) by using a χ2 test. Furthermore, excluding the diagnosed group, a χ2 test was performed to examine the relationships between the levels of risk and the likelihood of incurring any medical care costs (use vs. nonuse).

Results.

Approximately 15% of employees were already diagnosed with at least one of the three diseases (the diagnosed group; n = 490). One-quarter of employees had at least one risk that was high enough to be diagnosed with the corresponding disease if they had sought medical care (the extremely high-risk group; n = 809). There were 1343 employees in the high-risk group and 650 employees in the no-risk group. The diagnosed group had much higher chances of incurring medical care costs at or above the 90th percentile than did any other risk or no-risk group. No difference among the three risk or no-risk groups was found in mean medical care costs or in the likelihood of any use of medical care services after controlling for the effect of diagnosis.

Conclusions.

In a Japanese employee population, the diagnosis status of diabetes mellitus, hyperlipidemia, and hypertension was found to be associated with higher medical care costs while risk levels for the diseases were not in a 1-year time period.

The Relationship between Modifiable Health Risks and Future Medical Care Expenditures: The Korea Medical Insurance Corporation (KMIC) Study

Context.

The relationship between lifestyle risk factors, morbidity, and mortality is well established, but the relationship between lifestyle risk factors and medical care costs is not as well defined.

Objectives.

To determine the ability of modifiable biometric and lifestyle risk factors to predict future medical care costs.

Design.

Prospective cohort study.

Setting and Participants.

Data on modifiable risk factors collected in 1992 and medical care costs collected in 1998 by the Korea Medical Insurance Corporation in South Korea. Data were examined for a final cohort 78 of 728 men and 50,414 women enrolled in the health insurance plan from 1990 through 1998.

Main Outcome Measures.

Outcome measures included likelihood of any inpatient, outpatient, and total medical care costs and outlier costs; amount of inpatient, outpatient, and total medical care costs; and portion of total medical costs attributable to each risk factor through unadjusted and adjusted multivariate analyses.

Results.

Baseline modifiable risk factors measured in 1992 (including lifestyle factors such as smoking high body mass index, exercise, and biometric measures such as cholesterol, blood sugar, blood pressure, and urinary sugar) were important predictors of the amount of medical care costs incurred 6 years later in 1998, even after controlling for age, perceived health status, and each of the other modifiable variables. These risk factors were generally better predictors than nonmodifiable demographic risk factors, including income level and type of job. For men, lifestyle risk factors were associated with total costs that were 2.4% (for high blood pressure) to 16.1 % (for former smokers) higher than among men without those risk factors. Biometric risk factors were associated with costs ranging from 9.2% (for cholesterol) to 38.2% (for positive urinary glucose) higher. For women, lifestyle risk factors were associated with total costs that were 2.5% (for exercise) to 6.4% (for current smokers) higher than among those without the risk factors. Biometric risk factors were associated with costs ranging from 10.2% (for cholesterol) to 60.4% (for positive urinary glucose) higher. For men, a cluster of six heart disease risk factors were associated with total costs 54.7% higher, and a cluster of three stroke risk factors were associated with total costs 22.2% higher than in men who had none of these risk factors. Modifiable risk factors accounted for 23.1% of medical costs for men and 8.7% for women.

Conclusions.

These results suggest that modifiable biometric and lifestyle risk factors can predict a moderate portion of future medical care costs. If these risk factors can be reduced, future medical care costs may be reduced.