Cost-effectiveness of workplace wellness to prevent cardiovascular events among U.S. firefighters

Cost-effectiveness analysis of implementing polygenic risk score in a workplace cardiovascular disease prevention program

Background

Polygenic risk score for coronary artery disease (CAD-PRS) improves precision in assessing the risk of cardiovascular diseases and is cost-effective in preventing cardiovascular diseases in a health system and may be cost-effective in other settings and prevention programs such as workplace cardiovascular prevention programs. Workplaces provide a conducitve environment for cardiovascular prevention interventions, but the cost-effectiveness of CAD-PRS in a workplace setting remains unknown. This study examined the cost-effectiveness of integrating CAD-PRS in a workplace cardiovascular disease prevention program compared to the standard cardiovascular workplace program without CAD-PRS and no-workplace prevention program.

Methods

We developed a cohort simulation model to project health benefits (quality-adjusted life years gained) and costs over a period of 5 years in a cohort of employees with a mean age of 50 years. The model health states reflected the risk of disease (coronary artery disease and ischemic stroke) and statin prevention therapy side effects (diabetes, hemorrhagic stroke, and myopathy). We considered medical and lost productivity costs. Data were obtained from the literature, and the analysis was performed from a self-insured employer perspective with future costs and quality-adjusted life years discounted at 3% annually. Uncertainty in model parameter inputs was assessed using deterministic and probabilistic sensitivity analyses. Three programs were compared: (1) a workplace cardiovascular program that integrated CAD-PRS with the pooled cohort equation-a standard of care for assessing the risk of cardiovascular diseases (CardioriskSCORE); (2) a workplace cardiovascular prevention program without CAD-PRS (Standard-WHP); and (3) no-workplace health program (No-WHP). The main outcomes were total costs (US $2019), incremental costs, incremental quality-adjusted life years, and incremental cost-effectiveness ratio.

Results

CardioriskSCORE lowered employer costs ($53 and $575) and improved employee quality-adjusted life years (0.001 and 0.005) per employee screened compared to Standard-WHP and No-WHP, respectively. The effectiveness of statin prevention therapy, employees' baseline cardiovascular risk, the proportion of employees that enrolled in the program, and statin adherence had the largest effect size on the incremental net monetary benefit. However, despite the variation in parameter input values, base case results remained robust.

Conclusion

Polygenic testing in a workplace cardiovascular prevention program improves employees' quality of life and simultaneously lowers health costs and productivity monetary loss for employers.

High Intensity Functional Training (HIFT) Improves Fitness in Recruit Firefighters

BACKGROUND

Firefighting is a strenuous profession requiring adequate levels of fitness for effective job performance. Providing firefighters with a safe and effective fitness program is essential for optimal performance. The purpose of this project was to examine changes in various parameters of physical fitness and firefighter ability following a 7-week high intensity functional training (HIFT) program.

METHODS

Participants were male firefighter recruits (N = 89; age = 27.1 ± 4.2 years, height = 1.78 ± 0.1 m, BMI = 28.1 ± 4.2) enrolled in a Basic Operations Firefighter Academy. Fitness and firefighting ability (via the Academy Firefighter Challenge) were assessed at Weeks 1 and 7 of the Academy.

RESULTS

Significant improvements in both fitness and firefighter ability were seen following the HIFT program. Specifically, fitness (BMI, cardiovascular fitness, muscular endurance) improved significantly [Hotelling's T² = 8.98, F(5, 84) = 150.92, p < 0.001, η²_p = 0.90]. Firefighter ability also improved significantly [Hotelling's T² = 3.95, F(7, 88) = 46.26, p < 0.001, η²_p = 0.80].

CONCLUSIONS

Following a 7-week Basic Operations Firefighter Academy that included daily HIFT, significant increases in fitness and firefighting ability were observed. These findings suggest that HIFT appears to be an effective means of improving fitness and firefighting ability in recruit firefighters.

Fitness Fights Fires: Exploring the Relationship between Physical Fitness and Firefighter Ability

Background: Regular exercise in firefighters may be effective in preventing or attenuating ill health (e.g., hypertension, diabetes, and obesity), as well as improving their firefighting ability. The purpose of this study was to investigate the relationship between physical fitness and firefighting ability. Methods: Male firefighter recruits' (n = 89; age = 27.1 ± 4.2 yrs) physical fitness and firefighting ability were assessed at Week 1 and Week 7 during a basic firefighting training academy. Physical fitness was assessed via 1.5 mile run time, sit-up and push-up repetitions, the Young Men's Christian Association (YMCA) bench press test, vertical jump height, and sit-and-reach flexibility, while firefighting ability was assessed via completion time on a firefighting skills test. Results: Fitness predicted significant variance in firefighting ability at Week 1 (R²= 0.46; p < 0.01) and Week 7 (R² = 0.46; p < 0.01), after accounting for age and body mass index. Cardiovascular endurance accounted for 22.4% (FΔ (1, 85) = 25.75) and 39.3% (FΔ (1, 85) = 55.53) while muscular endurance accounted for an additional 19.0% (FΔ (3, 82) = 10.34) and 6.3% (FΔ (3, 82) = 3.2) unique variance in firefighting ability at Week 1 and Week 7, respectively. Conclusions: Given the strong association between fitness and firefighting performance, municipal departments may want to focus on increasing fitness levels among firefighters.

Cost and consequence analysis of the Healthy Choices at Work programme to prevent non-communicable diseases in a commercial power plant, South Africa

BACKGROUND

The workplace is an ideal setting for the implementation of a health promotion programmes to prevent non-communicable diseases (NCD). There are limited resources assigned to workplace health promotion programmes in low-and middle-income countries (LMIC).

AIM

This study aimed to conduct a cost and consequence analysis of the Healthy Choices at Work programme.

SETTING

This study was conducted at a commercial power plant in South Africa.

METHODS

Incremental costs were obtained for the activities of the Healthy Choices at Work programme over a two-year period. A total of 156 employees were evaluated in the intervention, although the effect was experienced by all employees. An annual health risk factor assessment at baseline and follow up evaluated the consequences of the programme.

RESULTS

The total incremental costs over the two-year period accumulated to $4015 for 1743 employees. The cost per employee on an annual basis was $1.15 and was associated with a -10.2mmHg decrease in systolic blood pressure, -3.87mmHg in diastolic blood pressure, -0.45mmol/l in total cholesterol and significant improvement in harmful alcohol use, fruit and vegetable intake and physical inactivity (p 0.001). There was no correlation between sickness absenteeism and risk factors for NCDs.

CONCLUSION

The cost to implement the multicomponent HCW programme was low with significant beneficial consequences in transforming the workplace environment and reducing risks factors for NCDs. Findings of this study will be useful for small, medium and large organisations, the national department of health, and similar settings in LMICs.

Strategies to improve the implementation of workplace-based policies or practices targeting tobacco, alcohol, diet, physical activity and obesity

BACKGROUND

Given the substantial period of time adults spend in their workplaces each day, these provide an opportune setting for interventions addressing modifiable behavioural risk factors for chronic disease. Previous reviews of trials of workplace-based interventions suggest they can be effective in modifying a range of risk factors including diet, physical activity, obesity, risky alcohol use and tobacco use. However, such interventions are often poorly implemented in workplaces, limiting their impact on employee health. Identifying strategies that are effective in improving the implementation of workplace-based interventions has the potential to improve their effects on health outcomes.

OBJECTIVES

To assess the effects of strategies for improving the implementation of workplace-based policies or practices targeting diet, physical activity, obesity, tobacco use and alcohol use.Secondary objectives were to assess the impact of such strategies on employee health behaviours, including dietary intake, physical activity, weight status, and alcohol and tobacco use; evaluate their cost-effectiveness; and identify any unintended adverse effects of implementation strategies on workplaces or workplace staff.

SEARCH METHODS

We searched the following electronic databases on 31 August 2017: CENTRAL; MEDLINE; MEDLINE In Process; the Campbell Library; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Scopus. We also handsearched all publications between August 2012 and September 2017 in two speciality journals: Implementation Science and Journal of Translational Behavioral Medicine. We conducted searches up to September 2017 in Dissertations and Theses, the WHO International Clinical Trials Registry Platform, and the US National Institutes of Health Registry. We screened the reference lists of included trials and contacted authors to identify other potentially relevant trials. We also consulted experts in the field to identify other relevant research.

SELECTION CRITERIA

Implementation strategies were defined as strategies specifically employed to improve the implementation of health interventions into routine practice within specific settings. We included any trial with a parallel control group (randomised or non-randomised) and conducted at any scale that compared strategies to support implementation of workplace policies or practices targeting diet, physical activity, obesity, risky alcohol use or tobacco use versus no intervention (i.e. wait-list, usual practice or minimal support control) or another implementation strategy. Implementation strategies could include those identified by the Effective Practice and Organisation of Care (EPOC) taxonomy such as quality improvement initiatives and education and training, as well as other strategies. Implementation interventions could target policies or practices directly instituted in the workplace environment, as well as workplace-instituted efforts encouraging the use of external health promotion services (e.g. gym membership subsidies).

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently performed citation screening, data extraction and 'Risk of bias' assessment, resolving disagreements via consensus or a third reviewer. We narratively synthesised findings for all included trials by first describing trial characteristics, participants, interventions and outcomes. We then described the effect size of the outcome measure for policy or practice implementation. We performed meta-analysis of implementation outcomes for trials of comparable design and outcome.

MAIN RESULTS

We included six trials, four of which took place in the USA. Four trials employed randomised controlled trial (RCT) designs. Trials were conducted in workplaces from the manufacturing, industrial and services-based sectors. The sample sizes of workplaces ranged from 12 to 114. Workplace policies and practices targeted included: healthy catering policies; point-of-purchase nutrition labelling; environmental supports for healthy eating and physical activity; tobacco control policies; weight management programmes; and adherence to guidelines for staff health promotion. All implementation interventions utilised multiple implementation strategies, the most common of which were educational meetings, tailored interventions and local consensus processes. Four trials compared an implementation strategy intervention with a no intervention control, one trial compared different implementation interventions, and one three-arm trial compared two implementation strategies with each other and a control. Four trials reported a single implementation outcome, whilst the other two reported multiple outcomes. Investigators assessed outcomes using surveys, audits and environmental observations. We judged most trials to be at high risk of performance and detection bias and at unclear risk of reporting and attrition bias.Of the five trials comparing implementation strategies with a no intervention control, pooled analysis was possible for three RCTs reporting continuous score-based measures of implementation outcomes. The meta-analysis found no difference in standardised effects (standardised mean difference (SMD) -0.01, 95% CI -0.32 to 0.30; 164 participants; 3 studies; low certainty evidence), suggesting no benefit of implementation support in improving policy or practice implementation, relative to control. Findings for other continuous or dichotomous implementation outcomes reported across these five trials were mixed. For the two non-randomised trials examining comparative effectiveness, both reported improvements in implementation, favouring the more intensive implementation group (very low certainty evidence). Three trials examined the impact of implementation strategies on employee health behaviours, reporting mixed effects for diet and weight status (very low certainty evidence) and no effect for physical activity (very low certainty evidence) or tobacco use (low certainty evidence). One trial reported an increase in absolute workplace costs for health promotion in the implementation group (low certainty evidence). None of the included trials assessed adverse consequences. Limitations of the review included the small number of trials identified and the lack of consistent terminology applied in the implementation science field, which may have resulted in us overlooking potentially relevant trials in the search.

AUTHORS' CONCLUSIONS

Available evidence regarding the effectiveness of implementation strategies for improving implementation of health-promoting policies and practices in the workplace setting is sparse and inconsistent. Low certainty evidence suggests that such strategies may make little or no difference on measures of implementation fidelity or different employee health behaviour outcomes. It is also unclear if such strategies are cost-effective or have potential unintended adverse consequences. The limited number of trials identified suggests implementation research in the workplace setting is in its infancy, warranting further research to guide evidence translation in this setting.