Between A Rock And A Hard Place: Understanding The Employer Mind-Set

A Worker-Centered Personal Health Record App for Workplace Health Promotion Using National Health Care Data Sets: Design and Development Study

Background

Personal health record (PHR) technology can be used to support workplace health promotion, and prevent social and economic losses related to workers’ health management. PHR services can not only ensure interoperability, security, privacy, and data quality, but also consider the user’s perspective in their design.

Objective

Using Fast Healthcare Interoperability Resources (FHIR) and national health care data sets, this study aimed to design and develop an app for providing worker-centered, interconnected PHR services.

Methods

This study considered the user’s perspective, using the human-centered design (HCD) methodology, to develop a PHR app suitable for occupational health. We developed a prototype after analyzing quantitative and qualitative data collected from workers and a health care professional group, after which we performed a usability evaluation. We structured workers’ PHR items based on the analyzed data, and ensured structural and semantic interoperability using FHIR, Systematized Nomenclature of Medicine–Clinical Terms (SNOMED-CT), and Logical Observation Identifiers Names and Codes (LOINC). This study integrated workers’ health information scattered across different Korean institutions through an interface method, and workers’ PHRs were managed through a cloud server, using Azure API for FHIR.

Results

In total, 562 workers from industrial parks participated in the quantitative study. The preferred data items for PHR were medication, number of steps walked, diet, blood pressure, weight, and blood glucose. The preferred features were ability to access medical checkup results, health information content provision, consultation record inquiry, and teleconsultation. The worker-centered PHR app collected data on, among others, life logs, vital signs, and medical checkup results; offered health care services such as reservation and teleconsultation; and provided occupational safety and health information through material safety data sheet search and health questionnaires. The app reflected improvements in user convenience and app usability proposed by 19 participants (7 health care professionals and 12 end users) in the usability evaluation. The After-Scenario Questionnaire (ASQ) was evaluated with a mean score of 5.90 (SD 0.34) out of 7, and the System Usability Scale (SUS) was evaluated a mean score of 88.7 (SD 4.83) out of 100.

Conclusions

The worker-centered PHR app integrates workers’ health information from different institutions and provides a variety of health care services from linked institutions through workers’ shared PHR. This app is expected to increase workers’ autonomy over their health information and support medical personnel’s decision making regarding workers’ health in the workplace. Particularly, the app will provide solutions for current major PHR challenges, and its design, which considers the user’s perspective, satisfies the prerequisites for its utilization in occupational health.

Effect of Physical Therapy Visits on Clinical Outcomes Following Anterior Cruciate Ligament Reconstruction With and Without Concurrent Meniscal Repair

BACKGROUND

Health care payment reform has increased employers and health insurance companies' incentive to take measures to control the rising costs of medical care in the United States. To date, limited research has investigated the influence outpatient physical therapy (PT) visits have on clinical outcomes following anterior cruciate ligament reconstruction (ACLR) with and without a concurrent meniscal repair.

OBJECTIVE

To examine the relationship between the number of PT visits and patient-reported outcome scores following ACLR outpatient rehabilitation.

STUDY DESIGN

Retrospective cohort.

LEVEL OF EVIDENCE

2b.

METHODS

Patients following ACLR with (n = 62) and without (n = 328) meniscal repair were identified through an electronic medical record database.

RESULTS

Patients with more PT visits had higher knee outcome survey-activities of daily living (KOS-ADL) change scores (P = .01) following ACLR without meniscal repair. Younger patients yielded significantly higher KOS-ADL change scores (P = .05) in the same cohort. Patients in the semisupervised PT visit strata recorded an 11.1 higher KOS-ADL change score compared with patients within the unsupervised PT visit stratum (P = .02). Younger patients also yielded significantly larger reductions in numeric pain (P = .01) following ACLR without meniscal repair. No significant differences were found between PT visits and either patient-reported outcome following ACLR with meniscal repair.

CONCLUSIONS

Our findings suggest that younger patients and those in a semisupervised PT visit model have superior patient-reported outcomes following ACLR without meniscal repair. Preliminary findings indicate no relationship with PT visits and patient-reported outcomes in patients after ACLR with meniscal repair surgery.

CLINICAL RELEVANCE

These findings promote an alternative model to outpatient PT following ACLR without meniscal repair that may be more clinically effective and value based. There appears to be a need for patients to undergo a balanced regimen of supervised PT and effective interventions that can be conducted independently.

Comparison of effects of supervised physiotherapy and a standardized home program on functional status in patients with total knee arthroplasty: a prospective study

[Purpose] The aim of this study was to determine the functional differences between total knee arthroplasty (TKA) patients who were treated with supervised physiotherapy or a standardized home program and perform a cost analysis. [Subjects and Methods] Patients who received total knee arthroplasty between January 2009 and June 2011 were enrolled in this study; those with mean ages of 64.25±3.86 (60-68) years (n=18) and 68.08±6.25 (61-79) years (n=16) were placed in the supervised physiotherapy and standardized home program groups, respectively. All patients were evaluated by the same researcher before and after surgery, and the therapy programs were applied by another physiotherapist. All patients were evaluated for joint range of motion (ROM), pain, functional status (WOMAC), overall quality of life (SF-36), and depressive symptoms (BECK Depression Scale). [Results] A significant clinical improvement was observed in postoperative assessments. A statistically significant difference could not be found between ROM and functional levels of the patients in both groups. [Conclusion] No difference was found between the patients performing supervised or standardized home program with respect to the effects on functional status. A home exercise program can be used in the rehabilitation of patients with TKA, and implementation of home exercise programs can also reduce health-care spending.

Beyond interests and institutions: US health policy reform and the surprising silence of big business

Interest-based arguments do not provide satisfying explanations for the surprising reticence of major US employers to take a more active role in the debate surrounding the 2010 Patient Protection and Affordable Care Act (ACA). Through focused comparison with the Bismarckian systems of France and Germany, on the one hand, and with the 1950s and 1960s in the United States, on the other, this article concludes that while institutional elements do account for some of the observed behavior of big business, a necessary complement to this is a fuller understanding of the historically determined legitimating ideology of US firms. From the era of the "corporate commonwealth," US business inherited the principles of private welfare provision and of resistance to any expansion of government control. Once complementary, these principles are now mutually exclusive: employer-provided health insurance increasingly is possible only at the cost of ever-increasing government subsidy and regulation. Paralyzed by the uncertainty that followed from this clash of legitimate ideas, major employers found themselves unable to take a coherent and unified stand for or against the law. As a consequence, they failed either to oppose it successfully or to secure modifications to it that would have been useful to them.

The multi-stakeholder movement for primary care renewal and reform

A multi-stakeholder movement for primary care renewal and reform has emerged in the United States, out of recognition that the achievement of an efficient, effective, and sustainable health system requires a vibrant primary care sector. We describe the case for reform from the perspective of private purchasers, government, consumers, and clinicians; the principles around which these stakeholders have coalesced; the groundswell of primary care reform initiatives taking place across the country; and the prospects for this coalition to reshape the character of U.S. health care on a stronger foundation of primary care.

Impacts of rising health care costs on families with employment-based private insurance: a national analysis with state fixed effects

BACKGROUND

Given the rapid growth of health care costs, some experts were concerned with erosion of employment-based private insurance (EBPI). This empirical analysis aims to quantify the concern.

METHODS

Using the National Health Account, we generated a cost index to represent state-level annual cost growth. We merged it with the 1996-2003 Medical Expenditure Panel Survey. The unit of analysis is the family. We conducted both bivariate and multivariate logistic analyses.

RESULTS

The bivariate analysis found a significant inverse association between the cost index and the proportion of families receiving an offer of EBPI. The multivariate analysis showed that the cost index was significantly negatively associated with the likelihood of receiving an EBPI offer for the entire sample and for families in the first, second, and third quartiles of income distribution. The cost index was also significantly negatively associated with the proportion of families with EBPI for the entire year for each family member (EBPI-EYEM). The multivariate analysis confirmed significance of the relationship for the entire sample, and for families in the second and third quartiles of income distribution. Among the families with EBPI-EYEM, there was a positive relationship between the cost index and this group's likelihood of having out-of-pocket expenditures exceeding 10 percent of family income. The multivariate analysis confirmed significance of the relationship for the entire group and for families in the second and third quartiles of income distribution.

CONCLUSIONS

Rising health costs reduce EBPI availability and enrollment, and the financial protection provided by it, especially for middle-class families.

Improving low-wage, midsized employers' health promotion practices: a randomized controlled trial

BACKGROUND

The Guide to Community Preventive Services (Community Guide) offers evidence-based intervention strategies to prevent chronic disease. The American Cancer Society (ACS) and the University of Washington Health Promotion Research Center co-developed ACS Workplace Solutions (WPS) to improve workplaces' implementation of Community Guide strategies.

PURPOSE

To test the effectiveness of WPS for midsized employers in low-wage industries.

DESIGN

Two-arm RCT; workplaces were randomized to receive WPS during the study (intervention group) or at the end of the study (delayed control group).

SETTING/PARTICIPANTS

Forty-eight midsized employers (100-999 workers) in King County WA.

INTERVENTION

WPS provides employers one-on-one consulting with an ACS interventionist via three meetings at the workplace. The interventionist recommends best practices to adopt based on the workplace's current practices, provides implementation toolkits for the best practices the employer chooses to adopt, conducts a follow-up visit at 6 months, and provides technical assistance.

MAIN OUTCOME MEASURES

Employers' implementation of 16 best practices (in the categories of insurance benefits, health-related policies, programs, tracking, and health communications) at baseline (June 2007-June 2008) and 15-month follow-up (October 2008-December 2009). Data were analyzed in 2010-2011.

RESULTS

Intervention employers demonstrated greater improvement from baseline than control employers in two of the five best-practice categories; implementing policies (baseline scores: 39% program, 43% control; follow-up scores: 49% program, 45% control; p=0.013) and communications (baseline scores: 42% program, 44% control; follow-up scores: 76% program, 55% control; p=0.007). Total best-practice implementation improvement did not differ between study groups (baseline scores: 32% intervention, 37% control; follow-up scores: 39% intervention, 42% control; p=0.328).

CONCLUSIONS

WPS improved employers' health-related policies and communications but did not improve insurance benefits design, programs, or tracking. Many employers were unable to modify insurance benefits and reported that the time and costs of implementing best practices were major barriers.

TRIAL REGISTRATION

This study is registered at clinicaltrials.gov NCT00452816.

Health Behaviors of Employed and Insured Adults in the United States, 2004-2005

Purpose.

To examine the prevalence of health behaviors, including clinical preventive services and lifestyle risk behaviors, among insured workers and to determine whether disparities in health behaviors based on demographic factors exist among this group.

Design.

Cross-sectional analysis of 2004–2005 Behavioral Risk Factor Surveillance System data.

Setting.

United States.

Subjects.

A representative sample of noninstitutionalized employed and insured adults aged 18 to 64 years (139,738 in 2004 and 159,755 in 2005).

Measures.

Self-reported clinical preventive services utilization and lifestyle-related behaviors, as well as multiple logistic regression analyses assessing the independent effects of demographic and access variables on health behaviors.

Results.

Among insured workers, rates of not using recommended clinical preventive services ranged from 8.5% (cervical cancer screening) to 73.9% (influenza vaccination). Rates for engaging in lifestyle-related risks ranged from 5.5% (heavy drinking) to 77.1% (inadequate fruit-vegetable consumption). In multivariate analyses, lower income, lower education, cost as a barrier to health care, and no health care provider were associated with significantly decreased clinical preventive services utilization (p < .01). Lower education and no health care provider were associated with lifestyle-related risks (p < .01).

Conclusions.

Working insured adults are not meeting recommendations for health behaviors. Significant disparities in health behaviors related to socioeconomic status exist among this group. Employers and insurers should consider these poor health behaviors and disparities when designing insurance benefits addressing clinical preventive services utilization and workplace health promotion programs addressing lifestyle-related behaviors.

Is physical therapy more beneficial than unsupervised home exercise in treatment of post surgical knee disorders? A systematic review

Physical therapy is common following a knee surgery. With rising healthcare costs there is debate as to the appropriateness of outpatient physical therapy following such interventions. Many of the existing controlled trials have concluded that there is no benefit to subjects that receive supervised physical therapy when compared to subjects that perform their exercises at home. The purpose of this systematic review was to consider the existing evidence regarding benefit following knee surgery and evaluate the quality, internal and external validity of such evidence. Ten studies, all randomized control trials, were found to be applicable to our review. Using the PEDro scale all studies were considered at least moderate in quality. Many of the studies had designs that biased the home exercise group, providing supervision similar to that provided by outpatient physical therapy. In select young and healthy population with few co morbidities supervised physical therapy is no more beneficial than a home exercise program following relatively simple knee surgical procedures (arthroscopic meniscetomy). However there is a lack of evidence regarding older populations with co morbidities or for more complicated knee surgical procedures (ACL reconstruction, Total Knee Arthroplasty) prohibiting a conclusion at this time for these populations and/or these procedures.

Does public insurance provide better financial protection against rising health care costs for families of children with special health care needs?

BACKGROUND

Health care costs grew rapidly since 2001, generating substantial economic pressures on families, especially those with children with special health care needs (CSHCN).

OBJECTIVE

To examine how the growth of health care costs affected financial burden for families of CSHCN between 2001 and 2004 and to determine the extent to which health insurance coverage protected families of CSHCN against financial burden.

RESEARCH DESIGN AND SUBJECTS

In 2001-2004, 5196 families of CSHCN were surveyed by the national Medical Expenditure Panel Survey (MEPS).

MEASURES

The main outcome was financial burden, defined as the proportion of family income spent on out-of-pocket (OOP) health care expenditures for all family members, including OOP costs and premiums. Family insurance coverage was classified as: (1) all members publicly insured, (2) all members privately insured, (3) all members uninsured, (4) partial coverage, and (5) a mix of public and private with no uninsured periods.

RESULTS

An upward trend in financial burden for families of CSHCN occurred and was associated with growth of economy-wide health care costs. A multivariate analysis indicated that, given the economy-wide increase in medical costs between 2001 and 2004, a family with CSHCN was at increased risk in 2004 for having financial burden exceeding 10% of family income [odds ratio (OR) = 1.39; P < 0.01]. Similar findings were noted for financial burden exceeding 20% of family income. Over 15% of families with public insurance had financial burden exceeding 10% of family income compared with 20% of families with private insurance (P < 0.05; chi2 test). After controlling for covariates, publicly-insured families of CSHCN had significantly lower likelihood of financial burden of >10% or 20% of family income than privately-insured families.

CONCLUSIONS

Rising health care costs increased financial burden on families of CSHCN in 2001-2004. Public insurance coverage provided better financial protection than private insurance against the rapidly rising health care costs for families of CSHCN.

Chiropractic and the Changing US Health Care Marketplace: Where We are Going and What Needs to be Done

This editorial reviews the current health care marketplace in the United States as it relates to chiropractic and the complementary and alternative medicine community. A 4-part strategy of research, education, alliance-building, and politics, is offered to address current obstacles.