Worksite Wellness in the 21st Century: The Baptist Health South Florida Experience

Theodore Feldman MD FACC FACPMedical Director, Center for Prevention and

Wellness, Baptist Health South FloridaClinical Associate Professor of Medicine

FIU Wertheim College of Medicine

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.

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

Where Do We Stand with CVD Employee Prevention Programs at Baptist Health South Florida?

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

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 Study

Definition 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

Total Cholesterol

Blood Pressure

Plasma Glucose

Physical Activity

Health Diet Score

Smoking BMI0%

10%20%30%40%50%60%70%80%90%

100%

8 5 4 5

51

2

3326

58

5

20

46

1

36

66 37 91 78 3 97 31

Poor Intermediate Ideal

Total Cholesterol

Blood Pressure

Plasma Glucose

Physical Activity

Health Diet Score

Smoking BMI0%

10%20%30%40%50%60%70%80%90%

100%

13 148

48

79

20

35

40 42

34

11

20

3

33

47 44 57 41 1 77 31

Poor Intermediate IdealNHANES

BHSF

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

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 thesame 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.

Distribution and Potential Impact of Obesity in BHSF Employees

Normal weight Overweight Grade i Obesity Grade II Obesity Grade III Obesity0

5

10

15

20

25

30

35

40

45

50

36

32

17

86

18

46

24

8

4

Females Males

• 7% (n=748) individuals met criteria for bariatric surgery • Total annual estimated cost attributable to high BMI (>25) were $8.05 million

• 74% medical and 26% work lost• 41% were contributed by 14% employees with BMI>35. • The average attributable cost per high BMI employee ranged from $598 among those

with BMI 25-29.9 to $2695 with BMI>=40.

My Unlimited PotentialWorkplace Cardio-Metabolic Risk Reduction Program

among High-Risk Employees Lifestyle intervention that combines nutritional counseling with fitness training and

close clinical observation over a duration of 12 months

Inclusion Criteria

Current BHSF Employees

High Cardio-Metabolic Risk defined as 2 or more of the following

Interventions

Three Major components – Diet/Nutrition, Physical Fitness, Wellness Check-up

Multidisciplinary team consisting of Registered Nurses, Registered Dietitians, Fitness

trainer/Exercise Physiologist

10 weeks of Supervision, 2 weeks (5 and 10) unsupervised.

Follow-up

12 weeks, 6 months, 12 months

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)

20

30

40

50

60

70

80

51

43

39

27

33

50

59

73

37

34

40

25

29

45

54 55

MyUP: Baseline and 12 month compar-isons of Select Outcomes

Baseline 1 year

Prev

alen

ce (i

n %

)

Impact of MyUP on Weight Loss: 12 Months FU

BMI

Category at

Baselin

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-Weight 7 (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

Cost Saving of MyUP on Employees Considered for Bariatric Surgery

1 year6 months

3 months

Baseline

Qualify: n=46

Qualify: n=22

Qualify=21Qualify=19

Do Not Qualify=2

Do Not Qualify=1

Do Not Qualify=1

Do Not Qualify=24

Qualify=5Qualify=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= $1.4 M

Conservative Cost Saving= $0.7 M

Average Cost of 748 Bar. Sx= $18.7 M

Conservative Cost Saving= $8.3 M

Average Cost of 100 Bar. Sx= $4.1 M

Conservative Cost Saving= $1 M

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 and work 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 days 7,744 days

Estimated medical and work loss costs attributable to overweight and obesity

MethodsInclusion 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)

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 0.008

Median 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 available 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 )

3 months 6 months 12 months0

10

20

30

40

50

60

43

51

31

1

15

9

5% weight reduction 10% weight reduction

Fre

qu

ency

(%

)

• At the end of 12 weeks, 43% had lost 5% of their weight; only 1% lost10%.

•Weight loss continued to improve with 51% and 15% losing 5 and 10% weight at 6 months

•There was sustained weight loss at 1 year though not as large as 6 months.

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)

20

30

40

50

60

70

80

51

43

39

27

33

50

59

73

3734

40

25

29

45

54 55

Baseline 1 year

Pre

vale

nce

(in

%)

•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 and hsCRP.

Impact of MyUP on Weight Loss: 12 Months FU

BMI

Category at

Baselin

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-Weight 7 (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 year6 months

3 months

Baseline

Qualify: n=46

Qualify: n=22

Qualify=21Qualify=19

Do Not Qualify=2

Do Not Qualify=1

Do Not Qualify=1

Do Not Qualify=24

Qualify=5Qualify=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

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 reducti

on

0.66% HbA1c

net reductio

n

Lipid Markers

23/ 34 studies –

improvement in ≥ 1

Lipid Paramete

r

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

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 Risk43%

CVD High Risk57% 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

Summary

• Worksite becomes critical place to educate, encourage, and monitor personal health activities

• Self insured employers now able to offer financial based incentives to encourage heart healthy and successful preventive strategies

• Aggressive on site and internet/smartphone based programs that focus on weight loss and nutritional guidance, increased physical activity (AHA 10K steps goal), BP and glucose monitoring will be necessary to improve intermediate metrics and long term health care outcomes