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.

2/23/2015

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

2/23/2015

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

2/23/2015

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

2/23/2015

5

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

2/23/2015

6

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*

2/23/2015

7

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

2/23/2015

8

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)

2/23/2015

9

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

11

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

12

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