Cost Effective Health Promotion for Older WorkersSusan L. Hughes, DSW, Rachel Seymour, PhD, Rosemary Sokas, MD, MOH, Richard Campbell, PhD, Camille Fabiyi, MPH, Chiquia Coppage, MPH, Karumah Cosey, BS

Center for Research on Health and Aging, University of Illinois-Chicago

Acknowledgements

NIA Roybal Center Pilot Grant (P30 2003-0780) Funded under the Health Protection Research Initiative, Centers for Disease Control and Prevention (R01 DP000094-01)

Significance

Number of workers aged 55+ has grown steadily since ’85

Older workers bring beneficial traits to the workplace, but are at greater risk for healthcare use & cost

Risk of days lost from work high in this group

Improving health behaviors prior to retirement may reduce health care costs for employers and post-retirement Medicare costs

Study Hypotheses

Abstract Body Mass Index & Waist Circumference ( N= 214)

Planned Cost Effectiveness Analyses

Little is known about the effectiveness of worksite wellness programs for older workers. We have been funded by CDC’s national Health Protection Research Initiative to test the cost-effectiveness of two worksite health promotion interventions with support staff aged 50-59 at our University. We are using a randomized trial with two treatment groups and a control group. The first intervention (COACH) combines web-based risk assessments with personalized follow up and a negotiated action plan. The second intervention, RealAge, is similar but totally web-based. Prior to the trial we conducted focus groups to examine staff perceptions, use, and needs regarding health promotion. Staff reported needing help with physical activity, diet, smoking cessation, and depression or stress reduction. Seventy-three staff enrolled in a randomized three-month pilot of the main study. Approximately 84% were female, 79% were minority, and 49% reported at least one chronic condition. At three months positive movement on physical activity was seen in all three groups, with the strongest positive trend in the COACH group (55% active at baseline vs. 74% at 3 months, compared to 56% vs. 60% and 35% vs. 50% in the RealAge and control groups, respectively). Self-efficacy for chronic disease management, exercise, fat-related diet behavior, and weight loss stayed approximately constant. We are now recruiting 450 participants (150 per study group) for the full study to assess behaviors, and use and cost of health services at baseline, 6 and 12 months. Focus group, pilot, and baseline data on study participants and study methods will be presented.

Specific Aims

Assess staff preferences for type and format of behavior change interventions; Modify Health Enhancement Program (HEP) for worksite application; (COACH) Develop and test recruitment procedures; Conduct pilot RCT with COACH, RealAge, and a no treatment control group; Test data collection procedures and outcome measures at baseline and three months, analyze pilot data; Revise all procedures and instruments as necessary; Recruit 450 support staff, randomly assign each to one of the same three groups (150 per group) and obtain costs and outcomes at baseline, six and 12 months and Analyze process and outcome data, conduct cost-effectiveness analyses and prepare final reports and project papers.

Conceptual Model

Interest in learning more about adopting and maintaining healthy behaviors.

Aware of need to engage in healthy behaviors, particularly diet, exercise, and stress reduction.

All have made attempts to engage in healthy behaviors.

Primary Health Concerns:Heart disease Breast Cancer StressHypertension Arthritis DepressionDiabetes Fatigue Healthcare CostsHigh Cholesterol Overweight Menopausal Symptoms

Conclusions: Considerable amount of unmet need for help changing behaviors Focus group participants report being stressed- stress management added as a behavior of interest Many respondents had caregiving responsibilities in addition to job (i.e., spouse, parent, disabled child) Many find help in religion as buffer

Interventions: Coach and RealAge

Intervention Flow Diagram

Goal: To estimate the cost-effectiveness of COACH relative to the Real Age program

Hypothesis: The COACH program will be more costly to administer, but will be cost-effective relative to RealAge, due to improved health outcomes, and lower downstream health costs.

Decision Model:1 year model – conducted based upon data observed over the study period Simulations

Intermediate model – outcomes extrapolated to employee retirement Continued participation in program Probabilities of cardiovascular and other disease Expected costs and utility for related health states

Long-term model – outcomes extrapolated to employee death

Presence of Chronic Conditions (N=214)

Primary Study Hypotheses: COACH participants will experience significantly greater reductions in absenteeism, disability days, and healthcare use and cost at 6 and 12 months than RealAge participants.

Participants in both treatment groups will experience significantly greater reductions in absenteeism, disability days, and healthcare use and cost than controls at 6 and 12 months.

Secondary Study Hypotheses: COACH participants will experience significantly greater levels of adherence to health promotion Action Plans and greater reduction in weight, BMI, and depression and greater increase in vitality and quality of life than RealAge participants at 6 and 12 months.

Participants in both treatment groups will experience significantly better outcomes on these measures at 6 and 12 months than controls.

Progress to Date

Conducted 4 focus groups with UIC staff Negotiated contracts with SSSKC and RealAge Enrolled 73 participants in pilot Conducted 3-month posttest interviews with 70 pilot participants Conducted preliminary analyses of baseline to 3 month pilot findings Enrolled 214/450 participants to date in main cost-effectiveness study

Focus Groups Findings

Four focus groups conducted with UIC support staff (N = 26) 88% female 65% minority Majority from health sciences campus

Coach: Evidence-based motivational intervention: Computerized risk assessment (modified HEP)

Negotiated action plan Reinforcement from Coach as neededWellWare: Web-based participant management program; tracking; modifications for UIC- different conditions of interest for working age population

RealAge: Totally high-tech Computerized risk assessment and risk profile Individualized web-based action plan (“age reduction steps”) Daily generic email health tips Tracking

Coach

(N=77)

RealAge

(N=68)

Control

(N=69)

Age (mean) 52.6 52.8 53.4

Gender

% Female 79.2 73.5 82.6

Education

% High School

% 1-3 years of college

% College grad

6.5

31.2

62.3

5.9

41.2

52.9

11.6

33.3

55.1

Ethnicity

% Hispanic/Latino 9.1 11.8 5.8

Race

% Caucasian

% African American

% Other

47.4

43.4

9.2

45.6

39.7

14.7

52.2

44.9

2.8

Sample Characteristics to Date (N=214)

Adherence to Action

Plan

Contacts with Coach

Baseline

(Repeated Measures – baseline, 6 & 12 months)

Demographics

DiseaseCharacteristics

Efficacy for Chronic

Disease Self-Management

Adherence Efficacy for

Behavior Change

Barriers Efficacy

Enhanced Self-Efficacy

(posttest)

Increased Health-Related Quality of Life

Increased vitality (posttest)

Decreased depression (posttest)

Decreased Weight

MD visits

ER visits

Hospital stays

Hospital days

Disability days

Absenteeism

Cost effectiveness

HEPIndividualized health risk assessment with health educator (Coach) Tailored action planTelephone reinforcement

RealAgeComputerized health risk assessment and action planOngoing access to RealAge resources and informationGeneric daily health tip

Health Education ControlMinimal health education materials and resource guide

Adherence to Action

Plan

RealAge usage

Antecedent Conditions

Mediating Conditions

InterventionsProcess Outcomes

SecondaryOutcomes

Primary Outcomes

ConsentBaseline

RandomizationReal Age

Initial Health Assessment

(in-person; with Health Educator)

- Phone call/email reinforcement(as needed)

- Additional one-on-one meetings(as needed)

- Monthly “support group”

Emailed daily health tips

Real Age test (web-based)

“High touch”&

high tech

Health Risk Profiles

Personalized Heath Action Plan

Recruitment

Risk profile update at 3

months

Control(generic written materials only)

Coach

High techvs.

Healthcare Utilization, Past 6 months (N = 214)

Coach

N=77

Mean (Range)*

RealAge

N=68

Mean (Range)*

Control

N=69

Mean (Range)*

Physician Visits 2.98 (1-12) 3.02 (1-24) 2.80 (1-12)

Psychiatrist Visits 2.00 (2) 4.80 (1-10) 3.25 (1-6)

NP or PA Visits 1.50 (1-3) 2.90 (1-10) 1.29 (1-3)

Alternative Medicine Visits

5.08 (1-24) 5.83 (1-26) 4.64 (1-12)

ER Visits 1.00 (1) 1.50 (1-3) 1.25 (1.25)

# Hospital Stays 1.00 (1) 1.50 (1-2) 1.00 (1)

# Total Nights in Hospital

3.00 (1-7) 4.50 (4-5) 5.00 (5)

Outpatient surgery 1.00 (1) 1.20 (1-2) 1.67 (1-3)

Coach Baseline

(n=77)

%

RealAge

Baseline

(n=68)

%

Control

Baseline

(n=69)

%

Underweight 0 1.6 1.4

Normal 28.0 18.8 15.9

Overweight 28.0 31.3 37.7

Obese 44.0 48.4 44.0

Waist Circumference 36.9

(25.5-53.0)

37.2

(22.0-53.0)

38.1

(24.5-55.0)

Coach Baseline

(n=77)

%

RealAge

Baseline

(n=68)

%

Control

Baseline

(n=69)

%

Arthritis 29.7 31.3 26.9

Diabetes 9.2 10.4 16.2

Hypertension 35.1 37.3 38.8

Chronic Back Pain 27.0 31.3 29.9

High Cholesterol 29.3 27.3 42.6

Respiratory Conditions 19.5 16.2 15.9

Mental Health Conditions 27.3 29.4 18.8

* If reported at least once.