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1.) Is this research study scholarly or non-scholarly? How would…
1.) Is this research study scholarly or non-scholarly? How would you support your evidence?
2.) Is this research study empirical or non-empirical? How would you support your evidence?
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Cardiac rehabilitation and exercise training (CRET) provides health risk intervention in cardiac patients over a relatively short time. Worksite health programs offer a unique opportunity for health intervention, but these programs remain underused due to concerns over recouping the costs. We evaluated the clinical efficacy and cost-effectiveness of a 6-month worksite health intervention using staff from CRET. Employees (n = 308) and spouses (n = 31) of a single employer were randomized to active intervention (n = 185) consisting of worksite health education, nutritional counseling, smoking cessation counseling, physical activity promotion, selected physician referral, and other health counseling versus usual care (n = 154). Health risk status was assessed at baseline and after the 6-month intervention program, and total medical claim costs were obtained for all participants before and the year after the intervention. Significant improvements were demonstrated in quality-of-life scores (+10%, p = 0.001), behavioral symptoms (depression -33%, anxiety -32%, somatization -33%, and hostility -47%, all p values <0.001), body fat (-9%, p = 0.001), high-density lipoprotein cholesterol (+13%, p = 0.0001), diastolic blood pressure (-2%, p = 0.01), health habits (-60%, p = 0.0001), and total health risk (-25%, p = 0.0001). Of employees categorized as high risk at baseline, 57% were converted to low-risk status. Average employee annual claim costs decreased 48% (p = 0.002) for the 12 months after the intervention, whereas control employees' costs remained unchanged (-16%, p = NS), thus creating a sixfold return on investment. In conclusion, worksite health intervention using CRET staff decreased total health risk and markedly reduced medical claim costs within 12 months. The cost of health care in the United States continues to increase, with chronic disease comprising the majority of health care expenditures, accounting for 75% of the nation's annual health care costs and affecting >1/3 of working-age Americans.1, 2 The increasing cost of health care has had a significant impact on employers, with nearly 60% of after-tax profit being spent on corporate health benefits.3, 4 Moreover, as much as 80% of this cost is currently being spent on only 10% of employees.3, 5Employers also have collateral consequences of poor health, including higher rates of absenteeism, presenteeism, disability, and injury leading to decreased productivity,6 producing a clear incentive for employers to partner with health care providers in implementing worksite health promotion activities that may decrease subsequent diseases and their costs. Cardiac rehabilitation and exercise training (CRET) are typically hospital-based programs structured to provide a broad range of risk-modification therapies within a concentrated period, most often over a 3-month intervention7; these programs employ health educators, dietitians, nurses, and exercise physiologists who are skilled in health education and behavior modification but are rarely used in the primary prevention setting. This investigation aimed to evaluate the impact of a comprehensive worksite intervention program, using predominantly staff and program components from CRET, on health risk factors and 1-year cost of care.
Methods
We recruited participants from a single employer with two geographically disparate work locations, one serving as the site of active intervention and the other serving as the control. The physical plant at each site was significantly different; however, the two locations offered the opportunity to exercise during lunch. Participants included employees and spouses who maintained health insurance through a single employer-sponsored health insurance provider. Risk evaluation was obtained at baseline in all participants by health educators and nurses and after six months of intervention in the active intervention group. Three subjects dropped out of the intervention group shortly after the program’s initiation; no dropouts were from the control group. Data obtained included weight, height, percent body fat, blood pressure, lipids, glucose, smoking status, physical activity level, general health and safety practices, behavioral assessment, addictive potential, quality of life, and evaluation of other known existing diseases.
The Kellner Symptom Questionnaire measured behavioral assessment, a 92-question survey validated to assess behavioral characteristics, including symptoms of depression, anxiety, somatization, and hostility, with a lower score being more favorable for each behavioral sign.The CAGE obtained 8 Addictive potentials (Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers) questionnaire. 9 The Medical Outcomes Short-Form 36 survey was used to assess the quality of life, with a high score indicating a more favorable quality of life trait. 10 Scores were generated for each health risk category. A total health risk score was created that summed scores relating to behavioral characteristics, health habits, cardiac risk factors, and physical activity, with a lower score indicating a more favorable health risk status. Based on the total health risk score, participants were divided into high-risk (total health score =10) and low-risk (total health score <10) groups. Over six months, the Risk Assessment and Modification Program (RAMP) through Ochsner Health System (New Orleans, Louisiana) provided health intervention. The RAMP program used nurses, dietitians, health educators, exercise physiologists and psychologists from CRET to create a worksite-based program consisting of onsite health education, referrals to group smoking cessation programs, stress management, lipid clinic, physician referral for hypertension and diabetes management, treatment for drug and alcohol addiction, and membership in a consortium of health and fitness centers located throughout the greater New Orleans area. Onsite classes were given weekly, including nutritional education, fitness counseling, weight control, worksite, home safety, and general health measures. One month before the intervention, newsletters went to all employees describing the program, and focus groups and team leaders were selected. Monthly newsletters were generated for all employees, and monthly themes were created stressing the importance of a unique health risk behavior. Awards were made for milestones in behavior change. Group competition was held with prizes for the best outcomes (including vacation days and other job-related perks). Free health-related premiums were dispensed at worksite lunch-and-learn programs to encourage attendance. Healthcare costs were obtained from the health insurer the year before intervention in each participant and the 12 months after the intervention. Results Family units randomized three hundred thirty-nine participants (308 employees and 31 spouses) into active intervention (n = 185) and usual care (n = 154). The active intervention group comprised 96 men (52%) at a mean age of 40 ± 8 years (range 23 to 65). Twenty-seven percent of participants were identified as hypertensive (19% stage 1, 7% stage 2, and 1% stage 3). These subjects (active and control groups) were referred to their primary care physicians or a dedicated hypertension clinic. There were no significant baseline differences between the functional and usual-care groups (Table 1). Table 1. Baseline characteristics in intervention and control subjects Variable Intervention Control Empty Cell (n = 185) (n = 154) Age (years) 40 ± 8 43 ± 10 Body mass index (kg/m2) 28.6 ± 5.7 28.2 ± 6.1 Fat (%) 27.0 ± 7.5 26.7 ± 7.2 Men (%) 52% 53% Smokers (%) 18% 20% CAGE (U) 0.17 ± 1.1 0.19 ± 1.3 Sedentary (%) 79% 78% Anxiety (U) 3.7 ± 4.2 3.4 ± 4.0 Depression (U) 2.4 ± 3.7 2.5 ± 4.0 Somatization (U) 5.2 ± 4.1 5.9 ± 4.4 Hostility (U) 3.6 ± 4.0 3.5 ± 3.9 Quality of life (U) 117 ± 12 119 ± 12 Systolic blood pressure (mm Hg) 124 ± 14 126 ± 16 Diastolic blood pressure (mm Hg) 81 ± 10 82 ± 10 Total cholesterol (mg/dl) 190 ± 27 196 ± 30 HDL cholesterol (mg/dl) 47 ± 10 44 ± 10 TC/HDL (U) 4.2 4.4 Health habits (U) 2.8 ± 1.7 2.6 ± 1.7 Total health risk score (U) 7.2 ± 5.1 7.0 ± 5.0 CAGE = Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers; TC = total cholesterol. After the intervention, there were significant improvements in scores of quality of life, depression, anxiety, hostility, and somatization (all p values <0.001; Table 2). Significant improvements were demonstrated in body fat, diastolic blood pressure, and general health habits. There was a significant improvement in HDL cholesterol (+13%, p = 0.0001), total cholesterol/HDL cholesterol ratio (-14%, p = 0.0001), and total health score (-25%, p = 0.0001). Twenty-six percent (n = 48) of the active arm was classified as high risk at baseline. After the intervention, 42% of this group (n = 20) remained at high risk, whereas 58% converted to the low-risk category (Figure 1). Of the 74% (n = 137) who were low risk at baseline, 99% (n = 136) remained at low risk after the intervention. Table 2. Change in health parameters in active participants after worksite health intervention (n = 185) Variable Baseline After Intervention Change p Value Anxiety (U) 3.7 ± 4.2 2.5 ± 3.6 -32% 0.0001 Depression (U) 2.4 ± 3.7 1.6 ± 3.1 -33% 0.0002 Somatization (U) 5.2 ± 4.1 3.5 ± 3.3 -33% 0.0001 Hostility (U) 3.6 ± 4.0 1.9 ± 2.8 -47% 0.0001 Quality of life (U) 117 ± 12 128 ± 14 10% 0.001 CAGE (U) 0.17 ± 1.1 0.09 ± 0.08 -47% NS Body mass index (kg/m2) 28.5 ± 5.7 28.3 -1% 0.08 Fat (%) 26.7 24.4 -9% 0.001 Smoker (%) 17% 15% -12% NS Sedentary (%) 79% 72% -9% 0.14 Total cholesterol (mg/dl) 190 184 -3% NS HDL cholesterol (mg/dl) 47 53 13% 0.0001 TC/HDL (U) 4.2 3.6 -14% 0.0001 Systolic blood pressure (mm Hg) 124 122 -2% 0.08 Diastolic blood pressure (mm Hg) 81 79 -2% 0.01 Health habits (U) 2.0 0.8 -60% 0.0001 Total health risk score (U) 7.2 ± 5.1 5.4 ± 4.0 -25% 0.0001 Abbreviations as in Table 1. Figure 1. Categorical change in health risk status after worksite health intervention. Total medical claim costs for the entire cohort averaged $2,981 per subject for the 12 months before intervention and were not significantly different between the active and control arms ($2,960 vs. $3,002, respectively). For the 12 months after the intervention, medical claim costs decreased to an average of $1,539 per subject in the active group (p = 0.002) and $2,522 per subject in the control group (p = NS). The difference in annual cost change (Figure 2) was statistically significant between groups (p = 0.01). For every dollar invested in worksite intervention, $6 was realized in healthcare savings. Figure 2. One-year change in total medical costs in active participants versus control subjects after worksite health intervention (*p = 0.002). Discussion There are several implications from this study. First, worksite health intervention, using staffing from existing CRET services, leads to significant improvements in multiple aspects of general health. Second, >1/2 of subjects categorized as having a high-risk health status can be converted to a low-risk health status in a relatively short period. Third, the financial benefits of a comprehensive worksite health intervention can be realized within one year of intervention, generating a sixfold return on investment.
Lifestyle behaviors, including physical activities, nutrition, smoking, and substance abuse, significantly impact long-term health, contributing to chronic diseases such as hypertension, obesity, heart disease, type 2 diabetes, stroke, and some forms of cancer. According to the Centers for Disease Control and Prevention,=300,000 patients die each year from obesity-related illness, 440,000 die from diseases attributed to cigarette smoking, and 40% of all deaths are caused by heart disease or stroke.11 In addition, behavioral disorders, including depression and hostility, are major health problems and have been shown to contribute significantly to the risk of heart disease, accounting for 33% of the population’s attributable risk for the development of myocardial infarction.12 That these and other risk factors are modifiable over the short term, and lead to long-term health benefits, has been demonstrated in numerous secondary prevention studies using CRET.13, 14, 15, 16, 17, 18, 19, 20
The worksite provides a unique opportunity for primary health intervention because most American adults spend considerable time at work. That amount of time has increased over the previous two decades.4, 21, 22 Costs of care for employees are distributed unevenly, with as much as 80% of expenses incurred in only 10% to 20% of employees.3, 5, 23, 24, 25 With health care costs increasing at a rate well ahead of inflation, and nearly 60% of after-tax profit being spent on corporate health benefits, employers are incented to partner with health care providers in creating successful worksite health intervention.3
Our program used health educators, dietitians, exercise physiologists, psychologists, and nurses from CRET services provided at our institution to create activities and educational events that targeted high-risk behaviors in employees at the worksite. Physicians were used in a minority of cases in which a significant chronic disease was diagnosed, thus creating an overall relatively low-cost intervention, such that each dollar invested realized a $6 savings in medical claims. The worksite intervention successfully decreased multiple individual aspects of health risk, leading to >1/2 of high-risk subjects being converted to a low-risk (and lower-cost) status. These changes led to a marked decrease in total claim costs for the year after the intervention, suggesting that this type of primary intervention can be cost-effective for employer groups.
Notably, although the positive effects on overall risk profiles and total medical claims were recognized after only a 1-year follow-up, it seems likely that the changes noted in this study would result in even more substantial long-term cardiovascular benefits. For example, our study demonstrated an average 13% increase in HDL cholesterol levels in the intervention group. Studies have shown that for every 1% increase in HDL cholesterol, decreases in overall cardiovascular risk of 3% to 5% occur over a 3- to 5-year follow-up period.26, 27 Likewise, although our CRET data have demonstrated that improvements in psychological factors, including depression and overall psychological stress, result in some decreases in cardiovascular risk during the first year of follow-up, progressive benefits have been noted during 3- to 5-year follow-up, periods.17Although the marked improvements in health habits may result in some decrease in risk even during the first year of follow-up, additional benefits would likely be noted during a more extended follow-up period.28
There are several limitations of this study worth describing. First, although this investigation was prospective and randomized, there was some spillover in the intervention because subjects diagnosed with a significant disease at a screening in the two groups were referred to their physicians for treatment. In addition, there were interactions between employees in the two groups, and behavior changes likely carried over to the control arm. Second, we chose an employer that was highly motivated and with a very stable workforce without significant employee turnover, and our results may not be exportable to other employee groups. Third, we did not measure health risk over time in our control group because the cost was our principal endpoint. Despite these limitations, however, we believe our conclusions to be noteworthy.
