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2/23/2015
1
Growing Pains for Developing a CVD
Prevention Programs in Corporate Settings
Is it Worth the Effort?
Khurram Nasir MD MPH
Baptist Health South Florida
Background
• 130 million Americans are employed across the United States
• A huge proportion of health care cost is covered by the employer.
• Health care costs in the United States doubled from 2001-2012
• 60 percent of employers’ after-tax profits are spent on corporate health benefits – 3 decades ago, 7 percent of corporate profits paid for
health costs
• Significant attention is being paid in health maintenance
• 27 studies
• 6 RCT
• Small sample sizes
• Outcomes: Changes in risk factors and behaviors
• Follow-up: Limited in majority of studies
Evidence of Employee Health Related
Issues is Limited.
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2
Return on Investment: Projected risk modeling between
changes in risk factors and the subsequent impact on ROI.
Challenges in Implementing Best
Practices/Program within Employee
Population
• Lack of concrete comparative effectiveness research
– Temporal trends patterns of burden of disease
– Impact of interventions
– Concrete outcomes for prevention strategies
• Intermediate (surrogate) outcomes
• Health care costs
• Hard outcomes
• Effective and rigorously tested evidence is needed
Employee Health Outcomes
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3
Where Do We Stand with CVD
Employee Prevention Programs
at Baptist Health South Florida?
Assessment of American Heart Association’s Ideal Cardiovascular Health Metrics Among
Employees of a Large Health Care Organization: The Baptist Health South Florida
Employee Study
Oluseye Ogunmoroti1, Adnan Younus1, Erica S Spatz MD, Maribeth Rouseff2, Ehimen Aneni1,
Sankalp Das2, Don Parris2, Leah Holzwarth2, Henry Guzman2, Thinh Tran 2, Chukwuemeka
Osondu1, Omar Jamal1, Shozab S. Ali1, Janisse Post1, Arthur Agatston 3, Theodore Feldman4,
Michael Ozner4, Emir Veledar2, Khurram Nasir 1, 5, 6, 7 *
The Baptist Health South Florida
Employee Study
Design and Setting� Cross sectional study conducted among
employees of BHSF, a large not-for-profit Health care organization
� Incentive driven Health Risk Assessment (HRA) is offered annually to employees
� Employee participation is voluntary
� Total employee population is approximately 15,000
� 9364 employees participated in 2014 HRA
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4
The Baptist Health South Florida
Employee Study
Data Collection� Self-administered online questionnaire
�Age, gender, diet, smoking status, physical
activity levels etc
� Biometric measures taken by trained health
care professionals
� Height, weight, BMI, blood pressure, blood
glucose and total cholesterol etc
The Baptist Health South Florida
Employee StudyDefinition of Cardiovascular Health Metrics� Ideal cardiovascular health defined by the AHA as
the absence of disease and presence of 7 health factors and behaviors
� Blood pressure, cholesterol & fasting plasma glucose
�Smoking, physical activity, diet & body mass index
� To measure and assess progress towards AHA 2020 goal the CV health metrics are categorized as Ideal, Intermediate and Poor
Baptist Health Employees Vs National Estimates
85 4 5
51
2
3326
58
5
20
46
1
36
66 37 91 78 3 97 31
0%
20%
40%
60%
80%
100%
Total
Cholesterol
Blood
Pressure
Plasma
Glucose
Physical
Activity
Health Diet
Score
Smoking BMI
Poor Intermediate Ideal
13 148
48
79
20
35
4042
34
11
20
3
33
47 44 57 41 1 77 31
0%
20%
40%
60%
80%
100%
Total
Cholesterol
Blood
Pressure
Plasma
Glucose
Physical
Activity
Health Diet
Score
Smoking BMI
Poor Intermediate Ideal
NHANES
BHSF
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Trends of the prevalence of ideal status for each cardiovascular health metric from 2011 to 2013
Metabolic Syndrome: The Impact on CVD
Risk Is Real & Growing
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Impact of Metabolic Syndrome:
Three Year Projection for 10,000 Employees
Incremental Cost Due to Metabolic
Syndrome
people with metabolic syndrome cost $259 PMPM more than people with the
same age-sex mix but without metabolic syndrome
$46 PMPM of the excess is due to events.
A larger portion of the excess—about $213 PMPM—is due to the non-event costs.
Prevalence and Cost Estimates of Obesity in a large employee population: The
Baptist Health South Florida Employee Study
Chukwuemeka U. Osondu1, Ehimen C. Aneni1, Oluseye Ogunmoroti1, Maribeth Rouseff2,
Sankalp Das2, Henry Guzman2, Thinh Tran 2, Don Parris2, Janisse Post1, Lara Roberson1,
Theodore Feldman1,3,6, Arthur S. Agatston1,2,4,6, Emir Veledar1,2, Khurram Nasir 1,5,6,7*
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Distribution and Potential Impact of Obesity in BHSF
Employees
36
32
17
86
18
46
24
84
0
5
10
15
20
25
30
35
40
45
50
Normal weight Overweight Grade I Obesity Grade II Obesity Grade III Obesity
Females Males
• 7% (n=748) individuals met criteria for bariatric surgery
BMI25.0 - 29.9
BMI30.0 - 34.9
BMI35.0 - 39.9
BMI40.0 +
Total
Number of employees with overweight and obesity3,565(52%)
1,851(27%)
831(12%)
581(9%)
6,828
Medical andwork loss costs attributable to overweight and obesity
Annual medical costs $1,434,700 $1,658,000 $1,239,500 $1,033,400$5,365,600
Annual work loss costs $518,100 $687,800 $397,200 $401,500 $2,004,700
Total annual cost$1,952,800
(26%)$2,345,800
(32%)$1,636,700
(22%)$1,434,900
(19%)$7,370,300
(100%)
Average attributable cost per high BMI employee
Medical Cost $402 $896 $1,492 $1,779 $786
Work loss Cost $145 $372 $478 $691 $294
Total average cost $548 $1,267 $1,970 $2,470 $1,079
Annual work days lost 2,015 days 2,598 days 1,550 days 1,581 days7,744 days
Estimated medical and work loss costs attributable to overweight and obesity
Six and Twelve-Month Outcomes of a 12-Week Intense Workplace Cardio-Metabolic Risk
Reduction Program among High-Risk Employees: The My Unlimited Potential
Maribeth Rouseff MBA*1 , Ehimen C Aneni MD, MPH*2, Henry Guzman RN1, Sankalp Das BDS MPH1,
Chukwuemeka U Osondu MD MPH2, Erica Spatz MD MHS3 Oluseye Ogunmoroti MD MPH2, Doris
Brown FNP, MSN1, Joann Santiago-Charles BS1, Teresa Ochoa RD MS1, Joseph Mora PhD1, Cynthia
Gilliam RN MSN1, Virginia Lehn RN, BSN1, Shoshana Sherriff RN 1, Thinh H Tran MD1, Janisse Post
RN, MSHA2, Emir Veledar PhD2, Theodore Feldman MD2,4, Arthur S Agatston MD2, Khurram Nasir
MD MPH2,4,5,6†
*Co-First Authors. Both authors contributed equally to the preparation of this manuscript
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Methods� Inclusion Criteria
� Current BHSF Employees
� High Cardio-Metabolic Risk defined as 2 or more of the following
• Total cholesterol ≥ 200 mg/dl
• Systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg,
• Hemoglobin A1C ≥ 6.5%
• Body mass index (BMI) ≥ 30
� Clearance from their physician
� Interventions (weeks 0 – 12)
� Three Major components – Diet/Nutrition, Physical Fitness, Wellness Check-up
� Multidisciplinary team consisting of Registered Nurses, Registered Dietitians,
Fitness trainer/Exercise Physiologist
� Had exercise stress testing at baseline and 12 weeks
� 10 weeks of Supervision, 2 weeks (5 and 10) unsupervised.
Screening
Baseline
12 Weeks
6 Months
12 Months
205 presented for follow-up; 205 completed blood work
230 persons in 7 groups
185 present for follow-up; 156 completed blood work
152 present for follow-up; 149 completed blood work
25 were withdrawn / dropped out from study
15 participants did not come for 6 month follow-up
27 participants did not come for 6 month follow-up
Yearly Screening Health Fair; > 15,000 participants
Exclusion Criteria (any of below)� < 2 metabolic risk factors�Unwilling to commit to
intervention �not interested
�unable to obtain clearance from healthcare provider
�not willing to sign consent
Table 1: Baseline frequency of demographic and medical history characteristicsVariable Total Frequency (%) or Mean ± SD
Mean age in years ± SD 230 48.4 ± 9.6
Male (%) 230 50 (21.8)
Race 230
Hispanic (%) 110 (47.8)
Non-Hispanic White (%) 48 (20.9)
Black/African American (%) 54 (23.5)
Asian (%) 12 (5.2)
Other (%) 6 (2.6)
Marital Status frequency 230
Married (%) 130 (57.3)
Single (%) 49 (21.6)
Divorced /Separated/Widowed (%) 48 (21.1)
Missing (%) 3 (0.01)
Existing diagnosis of Diabetes (%) 230 81 (35.2)
Existing diagnosis of Hypertension (%) 230 149 (64.8)
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Table 2: Baseline and 12-week follow-up comparison of metabolic variablesN at 12 weeks Mean baseline (SD) Mean
12 weeks (SD)p value
BMI 204 35.3 ± 6.5 33.7 ± 6.3 <0.001Weight (kg) 204 96.3 ± 20.3 92.3 ± 19.6 <0.001
Body Fat percentage 198 39.8 ± 7.5 38.6 ± 7.6 <0.001Systolic BP (mmHg) 204 127 ± 13 113 ± 11 <0.001Diastolic BP (mmHg) 204 81 ± 7 71 ± 6 <0.001Hemoglobin A1C (%) 205 6.4 ± 1.5 6.0 ± 1.0 <0.001
Hemoglobin A1C (%) among persons with diabetes
75 7.6 ± 1.8 6.7 ± 1.2 <0.001
Total Cholesterol (mg/dL) 205 186.3 ± 39.9 175.4 ± 35.4 <0.001Triglycerides (mg/dL) 205 133.5 ± 83.8 117.9 ± 63.4 <0.001
LDL-c (mg/dL) 205 111.4± 35.0 104.9 ± 34.0 <0.001HDL-c (mg/dL) 205 48.3 ± 12.3 47.1 ± 11.7 0.008Median HSCRP
(IQR, mg/dL)205 4.4 (1.8 – 8.4) 3.6 (1.6 – 8.6) 0.143
METS at Max Exercise (kcal·kg−1·h−1)
175 8.8 ± 2.7 11.1 ± 2.8 <0.001
Energy level 204 5.5 ± 2.3 8.0 ± 1.9 <0.001Stress level 204 5.0 ± 2.7 4.2 ± 2.6 <0.001
A p value for paired sample t-test, Abbreviations: BMI: body mass index, BP: blood pressure, Hemoglobin A1C: glycosylated hemoglobin, LDL-c: low density lipoprotein cholesterol, HDL-c: high density lipoprotein cholesterol, HSCRP: high-sensitivity C-reactive protein, METS: metabolic equivalent of task, HQ score: health quotient score by WebMD, PHQ-9: patient health questionnaire for screening of depression.
Change from baseline at 3, 6 and 12 months among persons avail able at 12 months follow-up
N Mean baseline (SD)
Mean change at 3 months (95% CI)
Mean change at 6 months (95% CI)
Mean change at 1 year (95%CI)
Body Mass Index 151 35.0 ± 6.6 -1.6 ( -1.4, -1.8) -1.9 (-1.6, -2.1) -1.2 (-0.9, -1.5)
Weight (kg) 151 95.8 ± 20.5 -4.4 (-3.9,-4.8) -5.1 (-4.4, -5.8) -3.3 (-2.5, -4.2)Body Fat percentage 131 39.3 ± 7.0 -1.2 (-1.0, -1.5) -1.5 (-1.1, -1.8) -0.7 (-0.4, -1.0)
Systolic BP (mmHg) 150 127 ± 13 -14 (-12, -16) -8 (-6, -10) -4 (-2, -6)
Diastolic BP (mmHg) 150 81 ± 7.0 -11 (-9, - 12) -6 (-4, -7) -3 ( -1, - 4)
Hemoglobin A1C (%) 150 6.3 ± 1.4 -0.4 (-0.3, – 0.5) -0.4 (-0.2, -0.5) -0.3 (-0.1, – 0.4)
Hemoglobin A1C (%) among persons with
Diabetes
51 7.5 ± 1.7 -0.9 (-0.6, – 1.2) -0.9 (-0.5, -1.3) -0.6 (-0.3, – 1.0)
Total Cholesterol (mg/dL) 150 188.8 ± 40.6 -13.3 (-8.8, – 17.7) -1.3 (3.8, – 6.3) -0.3 (- 4.9, 4.3)
Triglycerides (mg/dL) 150 136.8 ± 93.1 -21.8 (-11.1, -32.4) -13.8 (-1.7, -25.8) -10.6 (-21.6, 0.4)
LDL-c (mg/dL) 150 113.4 ± 34.5 -8.1 (-4.0, - 12.1) -0.4 (- 5.0, 4.2) 0.0 (-4.4, 4.5)
HDL-c (mg/dL) 150 48.2 ± 12.5 -0.9 (-1.9, 0.1) 2.1 (0.8,3.5) 2.8 (1.5, 4.0)HSCRP (mg/dL) 148 5.8 ± 5.6 -0.6 (- 1.2, 0.0) -1.2 (-0.7, -1.8) -1.0 (-0.3, -1.7)
Energy level 139 5.7 ± 2.2 2.5 (2.2, 2.8) 1.8 (1.4, 2.2) 1.7 (1.3, 2.1)
Stress level 140 4.8 ± 2.7 -0.9 (-0.4, -1.3) 0.0 (- 0.6, 0.5) -0.2 (-0.7, 0.4 )
43
51
31
1
15
9
0
10
20
30
40
50
60
3 months 6 months 12 months
Fre
quen
cy (%
)
5% weight reduction 10% weight reduction
• At the end of 12 weeks, 43% had lost 5% of their we ight; only 1% lost10%.
•Weight loss continued to improve with 51% and 15% l osing 5 and 10% weight at 6 months
•There was sustained weight loss at 1 year though n ot as large as 6 months.
2/23/2015
10
51
43
39
27
33
50
59
73
3734
40
25
29
45
54 55
20
30
40
50
60
70
80
Poorly Controlled BP
BMI >35 Total Cholesterol > 200
Triglycerides >150
LDL > 130 HDL < 40 (men) or < 50 (women)
HsCRP > 3mg/dl HbA1c >6.5 (among DM)
Pre
vale
nce
(in
%)
Baseline 1 year
•Most notable improvements were seen with BP control , reduction in BMI >35
and improvement in HbA1c.
•Little or no improvement was seen with the lipids a nd hsCRP.
Impact of MyUP on Weight Loss: 12
Months FU
BM
IC
ate
go
ry a
t B
ase
lin
e
BMI Category Change at 12-Months Follow-up
BMI Category at 12- Months
Normal Weight Over Weight Class I Obesity Class II Obesity Class III Obesity Total
Over-
Weight7 (24%) 18 (62%) 4 (14%) - - 29
Class I 2 (4%) 9 (19%) 33 (70%) 3 (6%) - 47
Class II - 1 (3%) 14 (45%) 13 (42%) 3 (10%) 31
Class III - - 1 (3%) 9 (26%) 24 (71%) 34
Total 9 28 52 25 27 141
Impact of MyUp on Employees
Considered for Bariatric Surgery
1 year1 year6
months6
months3
months3
monthsBaselineBaseline
Qualify: n=46
Qualify: n=22
Qualify=21
Qualify=19
Do Not Qualify=2
Do Not Qualify=1
Do Not Qualify=1
Do Not Qualify=24
Qualify=5
Qualify=4
Do Not Qualify=1
Do Not Qualify=19
Qualify=3
Do Not Qualify=16
20/46 (43%) no longer considered for
Bariatric Surgery after 1 year.
Average Cost of 46 Bar. Sx= $1.2 M
Conservative Cost Saving= $0.5 M
Average Cost of 748 Bar. Sx= $18.7 M
Conservative Cost Saving= $8 M
2/23/2015
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Targeting a larger segment of population:
Need for Innovation!• Newer Approaches
– Flexible/Accessible
– Repeated/Consistent Feedback
– Cost Effective
• Successful programs need to focus on offering “something for
everyone” through multichannel engagement strategies.
• Goal: optimizes personal action and, ultimately, commitment to
change.
Mobile Health: Future of Employee CVD Prevention Program
Websites, Social Media, Internet Applications, electronic mail, PDA
BP & Glucose Control
4.7/2.4mmHg BP reduction
0.66% HbA1c
net reduction
Lipid Markers
23/ 34 studies –
improvement in ≥ 1 Lipid Parameter
Physical Activity & Nutrition
• Net Increase in Physical Activity
• 0.2 more fruit servings• 1.5g more fiber• 1.4% less energy from
total fat
Smoking & Weight Loss
• 30% increase in prolonged Smoking Cessation
• Net Weight Loss of 0.7kg compared to control
2/23/2015
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Baptist Hospital Employee Heart Health Project
• Purpose: A) Identification of employees at high coronary heart disease (CHD)
risk associated with the metabolic syndrome and B) reduction of risk through a
web based lifestyle modification program.
• Program Design
– 180 employees with metabolic syndrome
– Assessment of risk via standard & advanced lipid testing.
– Assessment of baseline AHA indicators for health and specifically
metabolic syndrome
– Randomization: Modification of risk through lifestyle modification directed
through the 4MyHeart onsite educator vs. standard care
• Outcome: ∆ Metabolic risk factors, weight, exercise, diet, biomarker profle
subclinical CVD measures
CVD Low Risk
43%
CVD High Risk
57% P value
LDL Phenotype B 53% 68% 0.04
High Lp(a) 31% 36% 0.67
Insulin Resistance 63% 69% 0.37
Elevated Apolipoprotein B 37% 44% 0.43
Elevated C-Reactive Protein 67% 60% 0.34
Endothelial Dysfunction 25% 23% 0.81
Coronary Calcium Score
CAC Zero=70%
CAC 1-100=21%
CAC>100=9%
CAC Zero=35%
CAC 1-100=37%
CAC>100=28% <0.0001
Weight Loss Programs Can Further Benefit With Advanced Screening
Baptist Employee Healthy Heart Study: Randomized Trial on the
Efficacy of an Interactive Web-Based Lifestyle Intervention
Versus Usual Care in a High Risk Employee Population
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