Bethuel Best

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Impact of Worksite Wellness Intervention on Cardiac Risk Factors and One-Year Health Care Costs

Richard V. Milani, MD*, and Carl J. Lavie, MD

Cardiac rehabilitation and exercise training (CRET) provides health risk intervention in cardiac patients over a relatively short time frame. 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 coun- seling, 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 in all partic- ipants during the year before and the year after intervention. Significant improvements were demonstrated in quality-of-life scores (�10%, p � 0.001), behavioral symptoms (depres- sion �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 decreased medical claim costs within 12 months. © 2009 Elsevier Inc. All rights reserved. (Am J

Cardiol 2009;104:1389–1392)

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The cost of health care in the United States continues to ncrease, with chronic disease comprising the majority of ealth care expenditures, accounting for 75% of the nation’s nnual health care costs and affecting �1/3 of working-age mericans.1,2 The increasing cost of health care has had a ajor impact on employers, with nearly 60% of after-tax

rofit being spent on corporate health benefits.3,4 Moreover, s much as 80% of this cost is currently being spent on only 0% of employees.3,5 Employers also have collateral con- equences of poor health including higher rates of absen- eeism, presenteeism, disability, and injury leading to ecreased productivity,6 producing a clear incentive for mployers to partner with health care providers in imple- enting worksite health promotion activities that may

ecrease subsequent diseases and their costs. Cardiac re- abilitation and exercise training (CRET) are typically hos- ital-based programs structured to provide a broad range of isk-modification therapies within a concentrated period, ost often over a 3-month intervention7; these programs

mploy health educators, dietitians, nurses, and exercise hysiologists who are skilled in health education and be- avior modification, but are rarely used in the primary revention setting. The purpose of this investigation was to

Department of Cardiovascular Disease, Ochsner Health System, New rleans, Louisiana. Manuscript received June 2, 2009; revised manuscript

eceived and accepted July 2, 2009. *Corresponding author: Tel: 504-842-5874; fax: 504-842-5875.

sE-mail address: [email protected] (R.V. Milani).

002-9149/09/$ – see front matter © 2009 Elsevier Inc. All rights reserved. oi:10.1016/j.amjcard.2009.07.007

valuate the impact of a comprehensive worksite interven- ion program, using predominantly staff and program com- onents from CRET, on health risk factors and 1-year cost f care.

ethods

We recruited participants from a single employer with 2 eographically disparate work locations, 1 serving as the ite of active intervention, the other site serving as the ontrol. The physical plant at each site was significantly ifferent; however, the 2 sites offered the opportunity to xercise during lunch. Participants included employees and pouses who maintained health insurance through a single mployer-sponsored health insurance provider. Risk evalu- tion was obtained at baseline in all participants by health ducators and nurses and after 6 months of intervention in he active intervention group. Three subjects dropped out of he intervention group shortly after initiation of the pro- ram; there were no dropouts from the control group. Data btained included weight, height, percent body fat, blood ressure, lipids, glucose, smoking status, physical activity evel, general health and safety practices, behavioral assess- ent, addictive potential, quality of life, and evaluation of

ther known existing disease. Behavioral assessment was measured by the Kellner

ymptom Questionnaire, a 92-question survey validated to ssess behavioral characteristics including symptoms of de- ression, anxiety, somatization, and hostility, with a lower

core being more favorable for each behavioral symptom.8

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ddictive potential was obtained by the CAGE (Cutting own, Annoyance by criticism, Guilty feeling, and Eye- peners) questionnaire.9 The Medical Outcomes Short- orm 36 survey was used to assess quality of life, with a igh score indicating a more favorable quality of life trait.10

cores were generated for each category of health risk and total health risk score was created that summed scores

elating to behavioral traits, health habits, cardiac risk fac- ors, and physical activity, with a lower score indicating a ore favorable health risk status. Based on total health risk

core, participants were divided into high-risk (total health core �10) and low-risk (total health score �10) groups.

Health intervention over a 6-month period was provided y the Risk Assessment and Modification Program (RAMP) hrough Ochsner Health System (New Orleans, Louisiana). he RAMP program used nurses, dietitians, health educa-

ors, and exercise physiologists and psychologists from RET to create a worksite-based program consisting of nsite health education, referrals to group smoking cessa- ion programs, stress management, lipid clinic, physician eferral for hypertension and diabetes management, treat- ent for drug and alcohol addiction, and membership in a

onsortium of health and fitness centers located throughout he greater New Orleans area. Onsite classes were given eekly and included nutritional education, fitness counsel-

ng, weight control, worksite and home safety, and general ealth measures. One month before intervention, newslet- ers went to all employees describing the program and focus roups and team leaders were selected. Awards were cre- ted for milestones in behavior change. Group competition as held with awards for best outcomes (including vacation ays and other job-related perks). Monthly newsletters were enerated to all employees, and monthly themes were cre- ted stressing the importance of a unique health risk behav-

able 1 aseline characteristics in intervention and control subjects

ariable Intervention Control (n � 185) (n � 154)

ge (years) 40 � 8 43 � 10 ody mass index (kg/m2) 28.6 � 5.7 28.2 � 6.1 at (%) 27.0 � 7.5 26.7 � 7.2 en (%) 52% 53%

mokers (%) 18% 20% AGE (U) 0.17 � 1.1 0.19 � 1.3 edentary (%) 79% 78% nxiety (U) 3.7 � 4.2 3.4 � 4.0 epression (U) 2.4 � 3.7 2.5 � 4.0 omatization (U) 5.2 � 4.1 5.9 � 4.4 ostility (U) 3.6 � 4.0 3.5 � 3.9 uality of life (U) 117 � 12 119 � 12 ystolic blood pressure (mm Hg) 124 � 14 126 � 16 iastolic blood pressure (mm Hg) 81 � 10 82 � 10 otal cholesterol (mg/dl) 190 � 27 196 � 30 DL cholesterol (mg/dl) 47 � 10 44 � 10 C/HDL (U) 4.2 4.4 ealth habits (U) 2.8 � 1.7 2.6 � 1.7 otal health risk score (U) 7.2 � 5.1 7.0 � 5.0

CAGE � Cutting down, Annoyance by criticism, Guilty feeling, and ye-openers; TC � total cholesterol.

or. Free health-related premiums were dispensed at work- S

ite lunch-and-learn programs to encourage attendance. ealth care costs were obtained from the health insurer the ear before intervention in each of the participants and the 2 months after the intervention.

esults

Three hundred thirty-nine participants (308 employees nd 31 spouses), were randomized by family units into ctive intervention (n � 185) and usual care (n � 154). The ctive intervention group consisted of 96 men (52%) at a ean age of 40 � 8 years (range 23 to 65). Twenty-seven

ercent of participants were identified as hypertensive (19% tage 1, 7% stage 2, and 1% stage 3). These subjects (active nd control groups) were referred to their primary care hysicians or to a dedicated hypertension clinic. There were o significant baseline differences between the active and sual-care groups (Table 1).

After the intervention, there were significant improve- ents in scores of quality of life, depression, anxiety, hos-

ility, and somatization (all p values �0.001; Table 2).

igure 1. Categorical change in health risk status after worksite health ntervention.

able 2 hange in health parameters in active participants after worksite health

ntervention (n � 185)

ariable Baseline After Intervention

Change p Value

nxiety (U) 3.7 � 4.2 2.5 � 3.6 �32% 0.0001 epression (U) 2.4 � 3.7 1.6 � 3.1 �33% 0.0002 omatization (U) 5.2 � 4.1 3.5 � 3.3 �33% 0.0001 ostility (U) 3.6 � 4.0 1.9 � 2.8 �47% 0.0001 uality of life (U) 117 � 12 128 � 14 10% 0.001 AGE (U) 0.17 � 1.1 0.09 � 0.08 �47% NS ody mass index (kg/m2) 28.5 � 5.7 28.3 �1% 0.08 at (%) 26.7 24.4 �9% 0.001 moker (%) 17% 15% �12% NS edentary (%) 79% 72% �9% 0.14 otal cholesterol (mg/dl) 190 184 �3% NS DL cholesterol (mg/dl) 47 53 13% 0.0001 C/HDL (U) 4.2 3.6 �14% 0.0001 ystolic blood pressure

(mm Hg) 124 122 �2% 0.08

iastolic blood pressure (mm Hg)

81 79 �2% 0.01

ealth habits (U) 2.0 0.8 �60% 0.0001 otal health risk score (U) 7.2 � 5.1 5.4 � 4.0 �25% 0.0001

Abbreviations as in Table 1.

ignificant improvements were demonstrated in body fat,

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1391Preventive Cardiology/Worksite Wellness and Health Costs

iastolic blood pressure, and general health habits. There as a significant improvement in HDL cholesterol (�13%, � 0.0001), total cholesterol/HDL cholesterol ratio (�14%, � 0.0001), and total health score (�25%, p � 0.0001).

wenty-six percent (n � 48) of the active arm was classified s high risk at baseline. After the intervention, 42% of this roup (n � 20) remained at high risk, whereas 58% con- erted to the low-risk category (Figure 1). Of the 74% (n � 37) who were low risk at baseline, 99% (n � 136) re- ained at low risk after the intervention. Total medical claim costs for the entire cohort averaged

2,981 per subject for the 12 months before intervention and ere not significantly different between the active and con-

rol arms ($2,960 vs $3,002 respectively). For the 12 months fter the intervention, medical claim costs decreased to an verage of $1,539 per subject in the active group (p � .002) and $2,522 per subject in the control group (p � NS). he difference in annual cost change (Figure 2) was statis-

ically significant between groups (p � 0.01). For every ollar invested in worksite intervention, $6 was realized in ealth care savings.

iscussion

There are several implications from this study. First, orksite health intervention, using staffing from existing RET services, leads to significant improvements in mul-

iple aspects of general health. Second, �1/2 of subjects ategorized as having a high-risk health status can be con- erted to a low-risk health status in a relatively short period f time. Third, the financial benefits of a comprehensive orksite health intervention can be realized within 1 year of

ntervention, generating a sixfold return on investment. Lifestyle behaviors including physical activities, nutri-

ion, smoking, and substance abuse have a significant im- act on long-term health, including contributing to chronic iseases such as hypertension, obesity, heart disease, type 2 iabetes, stroke, and some forms of cancer. According to the

igure 2. One-year change in total medical costs in active participants ersus control subjects after worksite health intervention (*p � 0.002).

enters for Disease Control and Prevention, each year s

300,000 patients die from obesity-related illness, 440,000 ie from illness attributed to cigarette smoking, and 40% of ll deaths are caused by heart disease or stroke.11 In addi- ion, behavioral disorders, including depression and hostil- ty, are major health problems and have been shown to ontribute significantly to the risk of heart disease, account- ng for 33% of the population’s attributable risk for devel- pment of myocardial infarction.12 That these and other risk actors are modifiable over the short term, and lead to ong-term health benefits, has been demonstrated in numer- us secondary prevention studies using CRET.13–20

The worksite provides a unique opportunity for primary ealth intervention because most American adults spend onsiderable time at work, and that amount of time has ncreased over the previous 2 decades.4,21,22 Costs of care or employees are distributed unevenly, with as much as 0% of expenses incurred in only 10% to 20% of employ- es.3,5,23–25 With health care costs increasing at a rate well head of inflation, and nearly 60% of after-tax profit being pent on corporate health benefits, employers are incented to artner with health care providers in creating successful orksite health intervention.3

Our program used health educators, dietitians, exercise hysiologists, psychologists, and nurses from CRET ser- ices provided at our institution to create activities and ducational events that targeted high-risk behaviors in em- loyees at the worksite. Physicians were used in a minority f cases in which a significant chronic disease was diag- osed, thus creating an overall relatively low-cost interven- ion, such that each dollar invested realized a $6 savings in edical claims. The worksite intervention was successful in

ecreasing multiple individual aspects of health risk, and as result led to �1/2 of high-risk subjects being converted to low-risk (and lower-cost) status. These changes led to a arked decrease in total claim costs for the year after the

ntervention, suggesting that this type of primary interven- ion can be cost-effective for employer groups.

Importantly, however, although the positive effects on verall risk profiles and total medical claims were recog- ized after only a 1-year follow-up period, it seems likely hat the changes noted in this study would result in even ore substantial long-term cardiovascular benefits. For ex-

mple, our study demonstrated an average 13% increase in evels of HDL cholesterol in the intervention group. Studies ave demonstrated that for every 1% increase in HDL holesterol, decreases in overall cardiovascular risk of 3% o 5% occur over a 3- to 5-year follow-up period.26,27

ikewise, although our CRET data have demonstrated that mprovements in psychological factors, including depres- ion and overall psychological stress, result in some de- reases in cardiovascular risk during the first year of follow- p, progressive benefits have been noted during 3- to 5-year ollow-up periods.17 Although the marked improvements in ealth habits may result in some decrease in risk even uring the first year of follow-up, it is likely that additional enefits would be noted during a longer follow-up period.28

There are several limitations of this study worth describ- ng. First, although this investigation was prospective and andomized, there was some spillover in the intervention, ecause subjects diagnosed with significant disease at

creening in the 2 groups were referred to their physicians

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or treatment. In addition, there were interactions of em- loyees in the 2 groups and behavior changes likely carried ver to the control arm. Second, we choose an employer that as highly motivated and with a very stable workforce ithout significant employee turnover and our results may ot be exportable to other employee groups. Third, we did ot measure health risk over time in our control group, ecause cost was our principal end point. Despite these limi- ations, however, we believe our conclusions to be noteworthy.

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