Clinical and Economic Impact of a
                Hypertension Education and
                Awareness Program among
     ...
Learning Objectives
  Understand the impact of the change in DOT
  (Department of Transportation) Hypertension
  Guideline...
FACT!
                     Hypertension is a highly prevalent,
                     modifiable disease affecting approxima...
Introduction - The Employer
  In 2004, Georgia Power Company implemented a
  disease management and health promotion progr...
Introduction - The CDL Employees

  A CDL is a commercial
  drivers license issued
  by the state’s DOT


  A CDL is neede...
Introduction - DOT Hypertension Guidelines
            The medical exam includes blood pressure reading
            BP may...
Impact of DOT hypertension
guidelines




                             7
BP Category Change

       With this guideline change, the Normal range for
       blood pressure became more stringent
  ...
BP Category Change
The bottom line:
  If BPs do not return to a Normal category, driver will
  be disqualified
  What qual...
Impact on the CDL Employees
            As a result of the DOT classification change, the percentage
            of CDL em...
Impact on the CDL Employees
 Based on these findings, among the 2,038 CDL holders,
 significantly more would be at risk fo...
Impact on the CDL Employees

The bottom line:
Under the current DOT guidelines…
  More medical exams for periodic assessme...
The BP Downshift Program
 The BP DownShift Program is a resource for
 professional drivers focusing on CDL health
 require...
The BP Downshift Program
             The BP DownShift Program provides
             resources and information about impro...
The BP Downshift Program


                               The BP DownShift Program
                               explains...
Clinical Impact of a
Hypertension Education
and Awareness Program



                            16
Program Implementation
        The BP DownShift Program was implemented* at the utility company in
        2004
        BP...
Sample Characteristics -
 Age & BMI
      Most CDL employees                                     Based on Body Mass Index
...
Sample Characteristics -
Other Risk Factors
 Based on CDL employee self-report, over one-quarter already
 had a diagnosis ...
Baseline DOT BP Categories
              According to the Current DOT BP Categories, 26.1%
              of CDL Employees ...
The CDL Employees Before the Program

The bottom line:
  Over 25% of this population of CDL employees were
  at risk…
    ...
Clinical Impact of BP Downshift -
      DOT Categories
                After the program, the percentage of employees in t...
Clinical Impact of BP Downshift -
         Among those with a HTN Diagnosis
                Blood pressure levels after BP...
Clinical Impact of BP Downshift -
     Education and Awareness
                Increases in the self-report of hypertensio...
Clinical Impact of BP Downshift

The bottom line:
  The clinical impact of BP Downshift was significant
      More employe...
Economic Impact of a
   Hypertension Education
and Awareness program on
          a CDL employer


                       ...
Introduction - Economic Model Assessment
            Rising healthcare costs to large, self-
            insured employers...
The Economic Model Assessment
               An economic model was constructed to evaluate the two-
               year im...
Economic Model Inputs
  Clinical data were gathered from 499 employee
  DOT Medical Exam Reports as inputs to the model
  ...
Economic Model Outputs
   Model simulations generated the following direct
   and indirect cost estimates
       Hypertens...
Economic Model Outcomes -
    Total Costs
               Employer costs before BP Downshift were $3,312,220. After
       ...
Economic Model Outcomes -
Relative Total Costs
   A large proportion of the total Pre-Program costs was
   attributable to...
Economic Model Outcomes -
Itemized Total Costs and Savings
     The reduction in productivity loss alone equated to a cost...
Economic Model Outcomes -
 Total Costs and Savings per CDL Employee
       Cost savings per CDL employee was $1,084

     ...
Economic Impact of the BP Downshift
Program

The bottom line:
  The BP Downshift Program was associated with a
  significa...
Summary
and Conclusions




                  36
Summary and Conclusions
1. Learning Objective
  Understand the impact of the change in DOT
  Hypertension Guidelines on em...
Summary and Conclusions
2. Learning Objective
  Understand the clinical impact of a hypertension
  education and awareness...
Summary and Conclusions
3. Learning Objective
  Understand the economic saving of a hypertension
  education and awareness...
Can a Hypertension Education
                & Awareness Program Improve
                Employee Health and
             ...
The END


          41
APPENDIX -
     Old and Current DOT Hypertension Guidelines
            Each category of the DOT classification correspond...
APPENDIX -
    DOT Medical Examination Report (Page 1)




                                                               ...
APPENDIX -
DOT Medical Examination Report (Page 2)




                                          44
APPENDIX -
      Clinical Impact of BP Downshift, JNC 7

                Similar changes occur when CDL employees are
    ...
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Clinical and Economic Impact of a Hypertension Education and ...

  1. 1. Clinical and Economic Impact of a Hypertension Education and Awareness Program among Commercial Driver License Employees Presenters: Joseph Doyle, RPH, MBA Gerald T. Richerson, AET, BSE Robert S. Harshman, MD
  2. 2. Learning Objectives Understand the impact of the change in DOT (Department of Transportation) Hypertension Guidelines on employers with CDL (Commercial Drivers License) employees Understand the clinical impact of a hypertension education and awareness program among CDL employees Understand the economic saving of a hypertension education and awareness program on a CDL employer 2
  3. 3. FACT! Hypertension is a highly prevalent, modifiable disease affecting approximately one in three U.S. adults (~73 million persons) The relationship between high blood pressure (BP) and risk of cardiovascular disease (CVD), cerebrovascular disease and peripheral vascular disease is well established The total direct and indirect cost of hypertension treatment in the United States was estimated to be $69.4 billion in 2008 This estimate increases to more than $100 billion when the cost of subsequent complications of cardiovascular disease is included
  4. 4. Introduction - The Employer In 2004, Georgia Power Company implemented a disease management and health promotion program to help CDL employees maintain or restore a healthy blood pressure to meet DOT hypertension guidelines Georgia Power is the largest subsidiary of Southern Company With nearly 9,000 employees of which over 2,000 hold CDLs Serves 2.25 million customers in 155 of Georgia’s 159 counties 4
  5. 5. Introduction - The CDL Employees A CDL is a commercial drivers license issued by the state’s DOT A CDL is needed to drive and operate most utility vehicles All CDL holders have to pass a DOT medical exam to obtain and maintain their CDL 5
  6. 6. Introduction - DOT Hypertension Guidelines The medical exam includes blood pressure reading BP may limit the length of time the CDL is valid The DOT change BP standards in September, 2004 BP Category Certification* Re-Certification <140/90 2 years 2 years 1 year if <140/90 140-159/90-99 1 year 3 months if 141-159/91-99 169-179/100-109 3 months (1 time only) 1 year if <140/90 >180/110 6 months if <140/90 6 months if <140/90 If BPs do not return to a Normal category, disqualification will occur! 1United States Department of Transportation, Federal Motor Carrier Safety Administration, Federal Regulation 391.41, Physical Qualifications for Drivers. Accessed November 28, 2006. Available at: http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/fmcsrruletext.asp?rule_toc=760&section=391.41&section_toc=1781 6 *See additional detail on expiration and certification guidelines in the Appendix
  7. 7. Impact of DOT hypertension guidelines 7
  8. 8. BP Category Change With this guideline change, the Normal range for blood pressure became more stringent What used to be a “normal” systolic pressure would be considered “Stage 1” Hypertension under the new guidelines. Stages 1 and 2 became more strict with the addition of Stage 3 Systolic Old DOT Diastolic Old DOT Current DOT < 120 < 80 120 – 129 80 - 84 Normal Normal Normal 130 – 139 85 – 89 Current DOT 140 – 159 90 – 99 Stage 1 Stage 1 160 – 179 Stage 1 100 – 104 Stage 2 Normal > 179 Stage 2 105 – 109 Stage 3 Stage 2 > 109 Stage 1 Stage 2 If a blood pressure score corresponds to two different categories based on the systolic and Stage 3 diastolic measures, then it would be classified as the riskier category. 8
  9. 9. BP Category Change The bottom line: If BPs do not return to a Normal category, driver will be disqualified What qualified as a “Normal” blood pressure was lowered, so criteria became more strict Hypertensive categories broadened with the addition of Stage 3 Blood pressure needs to be below 140/90 9
  10. 10. Impact on the CDL Employees As a result of the DOT classification change, the percentage of CDL employees within a Normal BP was reduced The percentage of CDL employees classified in a hypertensive category increased DOT Classification Category Comparison 2.8% 26.1% 100% Uncontrolled* Uncontrolled* 80% 60% 97.2% 73.9% 40% Normal Normal 20% 0% Old DOT Current DOT *Uncontrolled refers to Stages 1 to 3 Based on an Employer Sample of 501 CDL Employees Prior to September 2004 10 See Appendix for JNC-7 Classification
  11. 11. Impact on the CDL Employees Based on these findings, among the 2,038 CDL holders, significantly more would be at risk for restriction or disqualification CDL Employees at Risk for CDL Disqualification 57 CDL Employees 532 CDL Employees At Risk for At Risk for CDL Restriction CDL Restriction Or Disqualification Or Disqualification 1,981 1,506 CDL Employees CDL Employees With “normal” BPs With “normal” BPs Old DOT Current DOT 2,038 CDL holders 2,038 CDL holders 11
  12. 12. Impact on the CDL Employees The bottom line: Under the current DOT guidelines… More medical exams for periodic assessment will be required (~ 30% more) More than 9X as many CDL employees are at risk for CDL disqualification 12
  13. 13. The BP Downshift Program The BP DownShift Program is a resource for professional drivers focusing on CDL health requirements and overall health and wellness 13
  14. 14. The BP Downshift Program The BP DownShift Program provides resources and information about improving CDL holders’ health Antihypertensive treatment information Blood pressure diaries with tips A tool to track blood pressure readings On-site Safety & Health presentations On-site BP monitoring Medical chart stickers An audio CD that explains high blood pressure The program also advises on healthier habits that will work with the drivers’ lifestyle—on and off the road 14
  15. 15. The BP Downshift Program The BP DownShift Program explains the special health guidelines required to maintain a CDL Assists the CDL holder when talking with their doctor, so they can develop a plan that meets their special needs as a driver BP Downshift materials were disseminated to all CDL employees on a monthly basis 15
  16. 16. Clinical Impact of a Hypertension Education and Awareness Program 16
  17. 17. Program Implementation The BP DownShift Program was implemented* at the utility company in 2004 BP levels and other health information from the Medical Examination Report^ were obtained from a random sample of 501 CDL employees— both before and after program implementation All CDL employees were male Baseline Data BP DownShift Follow-up Data Jan ‘03 to Dec ’03* Implementation Jan ‘05 to Dec ’05 (N=501) Apr ‘04 to Sept ‘04 (N=501) 2003 2004 2005 2006 ^See APPENDIX – DOT Medical Examination Report *All CDL employees were continuously provided educational materials on a monthly basis explaining the importance of BP control in lowering their cardiovascular risk and maintaining their CDL certification. Employees also received resources to help them understand and manage hypertension, such as treatment information, suggested questions for their physician, and record-keeping tools. The program also supplied tools to the employer, and the physicians caring for CDL employees, to help promote hypertension awareness and participation in the program. 17
  18. 18. Sample Characteristics - Age & BMI Most CDL employees Based on Body Mass Index (64.6%) were 40 to 59 years (BMI), most CDL employees were old either overweight or obese Mean age was 42.5 years 44% were Obese Age At Baseline BMI At Baseline 100% Under 30 % of CDL Employees 50-59 Years 80% Obese 12.2% 44.0% 26.1% 60% 22.2% 30-39 Years 40% 38.5% 46.0% Overweight 20% Mean = 42.5 40-49 Years Median = 43.0 10.0% Normal Range = 19 to 62 0% (N=501) Baseline, N=501 Mean = 29.8 BMI Categories Obese (30.0+) Median = 29.3 Overweight (25.0-29.9) Range = 19.7 to 65.3 Normal (< 24.9) 18
  19. 19. Sample Characteristics - Other Risk Factors Based on CDL employee self-report, over one-quarter already had a diagnosis of hypertension and was currently taking anti- hypertensive medication Baseline Risk Factors (n=501) Hypertension Diagnosis 25.5% Personal History of CVD 3.0% Diabetes 6.2% Anti-Hypertension Medication Use 25.3% 19
  20. 20. Baseline DOT BP Categories According to the Current DOT BP Categories, 26.1% of CDL Employees had uncontrolled BP levels DOT Classification At Baseline 100% 26.1% 80% Uncontrolled* % of CDL Employees 60% 40% 73.9% Normal 20% 0% Baseline (n=501) 20 *Uncontrolled refers to Stages 1 to 3
  21. 21. The CDL Employees Before the Program The bottom line: Over 25% of this population of CDL employees were at risk… At risk for CDL disqualification At risk for cardiovascular disease 21
  22. 22. Clinical Impact of BP Downshift - DOT Categories After the program, the percentage of employees in the DOT normal category significantly increased And the percentage in the hypertension categories significantly decreased DOT Classification At Baseline and Follow-up 100% 26.1% 17.2% Uncontrolled* Uncontrolled* % of CDL Employees 80% 60% 73.9% 82.8% 40% Normal Normal Harshman RS, Richerson GT, 20% Note: Results Hadker N, Greene BL, Brown TM, were adjusted Foster TS, Turner BH, Skrepnek SH, Doyle JJ. Impact of a for age and BMI hypertension management/health promotion program on 0% commercial driver's license employees of a self-insured utility company. J Occup Environ Med. Baseline Follow-up 2008 Mar;50(3):359-65. (n=501) (n=500^) *Uncontrolled refers to Stages 1 to 3 / Significantly higher/lower than Baseline at 99% confidence interval. 22 ^One Follow-up examination was missing data for systolic and diastolic measurements.
  23. 23. Clinical Impact of BP Downshift - Among those with a HTN Diagnosis Blood pressure levels after BP Downshift, according to the Current DOT guidelines, also improved among employees diagnosed with hypertension 42% were categorized as hypertensive before the program vs. 25% after the program Similar results were observed among those taking anti-hypertensive medication 42% 25% Uncontrolled* Uncontrolled* 58% 75% Normal Normal Harshman RS, Richerson GT, Hadker N, Greene BL, Brown TM, Foster TS, Turner BH, Skrepnek Note: Results SH, Doyle JJ. Impact of a were adjusted hypertension management/health for age and BMI promotion program on commercial driver's license employees of a self-insured utility Baseline Follow-up company. J Occup Environ Med. (n=128) (n=128) 2008 Mar;50(3):359-65. 23 *Uncontrolled refers to Stages 1 to 3
  24. 24. Clinical Impact of BP Downshift - Education and Awareness Increases in the self-report of hypertension, medication use, and other hypertension risk factors support the education and awareness value of the BP Downshift Program Baseline Follow-up CVD Risk Factors (N=501) (N=500) HTN Diagnosis 25.5% 30.2% Personal History of CVD 3.0% 4.2% Diabetes 6.2% 7.4% Note: Results were adjusted AHY Medication Use 25.3% 30.2% for age and BMI Harshman RS, Richerson GT, Hadker N, Greene BL, Brown TM, Foster TS, Turner BH, Skrepnek SH, Doyle JJ. Impact of a hypertension management/health promotion program on commercial driver's license employees of a self-insured utility company. J Occup Environ Med. 24 2008 Mar;50(3):359-65.
  25. 25. Clinical Impact of BP Downshift The bottom line: The clinical impact of BP Downshift was significant More employees had controlled blood pressures - especially among those with a diagnosis and/or taking anti- hypertensive medication Fewer CDL employees were at risk for CDL disqualification Education and awareness was increased as suggested by more employees reporting a diagnosis of hypertension and the increased use of anti-hypertensive medications 25
  26. 26. Economic Impact of a Hypertension Education and Awareness program on a CDL employer 26
  27. 27. Introduction - Economic Model Assessment Rising healthcare costs to large, self- insured employers have prompted interest in programs to manage and prevent chronic conditions such as cardiovascular disease (CVD). The BP DownShift Program was designed to improve BP outcomes among CDL employees based on the DOT’s Hypertension Guidelines for CDL certification. 27
  28. 28. The Economic Model Assessment An economic model was constructed to evaluate the two- year impact of the BP DownShift Program on direct and indirect employer costs associated with changes in HTN This simulation model can be utilized to estimate 2,5, and 10 year cost- savings Greene BL, Miller JD, Brown TM, Harshman RS, Richerson GT, Doyle JJ. Economic Impact of the BP DownShift Program on Blood Pressure Control among 28 Commercial Driver License Employees. J Occup Environ Med. 2009, in press.
  29. 29. Economic Model Inputs Clinical data were gathered from 499 employee DOT Medical Exam Reports as inputs to the model Gender, age, body mass index, and DOT HTN classification category Patient-reported medical histories Framingham Heart Study risk equations were used to estimate cardiovascular risk To utilize the Framingham equations, sample employees were matched to NHANES data (by age, gender, and BMI) to obtain triglycerides and cholesterol estimates. Cost parameters (2007 U.S. dollars) were obtained from employer records and published literature 29
  30. 30. Economic Model Outputs Model simulations generated the following direct and indirect cost estimates Hypertension Treatment CHD Treatment Stroke Treatment Diabetes Care CDL Examinations Lost Productivity Model Outputs were compared before and after the BP Downshift Program Pre-Program Post-Program 30
  31. 31. Economic Model Outcomes - Total Costs Employer costs before BP Downshift were $3,312,220. After BP Downshift, employer costs were $2,771,094 Employer costs decreased by 16.3% ($541,126) over 2 years $4,000,000 16.3% $3,312,220 Reduction $3,000,000 $2,771,094 $2,000,000 $1,000,000 $0 Greene BL, Miller JD, Brown TM, Harshman RS, Richerson Pre-Program Post-Program GT, Doyle JJ. Economic Impact of the BP DownShift Program on Blood Pressure Control among Commercial Driver License 31 Employees. J Occup Environ Med. 2009, in press.
  32. 32. Economic Model Outcomes - Relative Total Costs A large proportion of the total Pre-Program costs was attributable to Lost Productivity The 83% due to Lost Productivity was reduced to 79% Pre-Program Post-Program HTN Treatment HTN Treatment 8% CHD Treatment 10% CHD Treatment 2% 3% Stroke Treatment 1% 1% Stroke Treatment Diabetes Care 1% Diabetes Care 1% 6% CDL Examinations CDL Examinations 5% 83% 79% Lost Productivity Lost Productivity Greene BL, Miller JD, Brown TM, Harshman RS, Richerson GT, Doyle JJ. Economic Impact of the BP DownShift Program on Blood Pressure Control among Commercial Driver License Employees. J Occup Environ 32 TOTAL COST = $3,312,220 TOTAL COST = $2,771,094 Med. 2009, in press.
  33. 33. Economic Model Outcomes - Itemized Total Costs and Savings The reduction in productivity loss alone equated to a cost savings of ($552,103) Fewer CDL examinations saved ($8,410) Lost Diabetes Stroke CHD HTN CDL Exam Productivity Care Treatment Treatment Treatment Pre-Program $2,745,673 $162,730 $32,089 $39,031 $80,684 $252,014 Post-Program $2,193,570 $154,319 $32,089 $39,137 $81,225 $270,754 Difference ($552,103) ($8,410) - $106 $541 $18,740 There were cost increases for treatment of HTN and chronic disease, ($19,387) 33
  34. 34. Economic Model Outcomes - Total Costs and Savings per CDL Employee Cost savings per CDL employee was $1,084 Pre-Program Post-Program $1,084 Saved Employer Costs Per $6,638 $5,553 Employee Hypothetically, based on model findings among the CDL employee sample, the utility company with 2,038 CDL employees would incur a cost savings of more than $2.2 million over 2 years. 34
  35. 35. Economic Impact of the BP Downshift Program The bottom line: The BP Downshift Program was associated with a significant reduction in CDL employer costs Costs were reduced due to fewer CDL employees with uncontrolled BP 2-Year employer costs were reduced from $3,312,220 to $2,771,094 Employer costs decreased by 16.3% over 2 years— over one-half million in savings ($541,126) A savings of $1,084 per each CDL employee Majority of cost-savings were attributable to decreases in lost productivity costs 35
  36. 36. Summary and Conclusions 36
  37. 37. Summary and Conclusions 1. Learning Objective Understand the impact of the change in DOT Hypertension Guidelines on employers with CDL employees The change in the DOT Guidelines made the “Normal” category more stringent This change in classification caused nearly 4X as many CDL employees to be classified in a “hypertensive” category The frequency of routine medical exams increases for any CDL holder in a “hypertensive” category 37
  38. 38. Summary and Conclusions 2. Learning Objective Understand the clinical impact of a hypertension education and awareness program among CDL employees Prior to the BP Downshift Program, more than one in four CDL holders was at risk for CDL disqualification After BP Downshift, there was a 34% reduction in the percentage of CDL holders with uncontrolled BP A 40% reduction among those at highest risk As a result of the program, fewer CDL employees are at risk for CDL disqualification Education and awareness related to hypertension and its risks was increased 38
  39. 39. Summary and Conclusions 3. Learning Objective Understand the economic saving of a hypertension education and awareness program on a CDL employer A 16% reduction in CDL employer costs was attributed to the BP Downshift Program Costs were reduced due to fewer CDL employees with uncontrolled BP Majority of cost-savings were attributable to decreases in lost productivity costs and fewer CDL medical exams BP DownShift raises awareness, educates and mobilizes moderate to high risk CDL employees 39
  40. 40. Can a Hypertension Education & Awareness Program Improve Employee Health and Productivity? And Reduce Employer Costs? Yes! More CDL employees had controlled BP levels Yes! CDL employee productivity increased Yes! Heart health awareness and knowledge increased Yes! Employer costs were reduced 40
  41. 41. The END 41
  42. 42. APPENDIX - Old and Current DOT Hypertension Guidelines Each category of the DOT classification corresponds to a set length of time the CDL is valid before returning for re-certification. Current DOT Range Certification Re-certification Frequency Normal <140, <90 2 years 2 years if <140/90 Every 2 years* 1 year if <140/90 140-159 1 year; rarely disqualifying Stage 1 One-time certificate for 3 Annually 90-99 alone months if 140-159/90-99 160-179 One-time certificate for 3 1 year from date of initial Stage 2 Annually 100-109 months exam if <140/90 Disqualified; 6 month certificate 6 month certificate from date Stage 3 >179, >109 Bi-annually if <140/90 at recheck of initial exam if <140/90 Old DOT Range Certification Re-certification Frequency Normal <160, <90 2 years 2 years if <160/90 Every 2 years* 160-179, 90- Stage 1 3 months 1 year if <160/90 Annually 104 Disqualified; 3 month certificate Stage 2 >179, >104 6 months if <160/90 Bi-annually if <180/90 at recheck *May be certified every 2 years, provided the driver is not using medication to control blood pressure and there 42 is no medical condition for which a shorter certification would be appropriate.
  43. 43. APPENDIX - DOT Medical Examination Report (Page 1) 43 http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf
  44. 44. APPENDIX - DOT Medical Examination Report (Page 2) 44
  45. 45. APPENDIX - Clinical Impact of BP Downshift, JNC 7 Similar changes occur when CDL employees are classified according to the JNC-7 categories. 100% 25% 18% Stage 1 and 2 Stage 1 and 2 80% % of CDL Employees 60% 55% 67% Pre-hypertension Pre-hypertension 40% 20% Harshman RS, Richerson GT, 20% 15% Note: Results Hadker N, Greene BL, Brown TM, Normal were adjusted Foster TS, Turner BH, Skrepnek Normal for age and BMI SH, Doyle JJ. Impact of a 0% hypertension management/health promotion program on commercial driver's license employees of a self-insured utility Baseline Follow-up company. J Occup Environ Med. 2008 Mar;50(3):359-65. (n=501) (n=500^) / Significantly higher/lower than Baseline at 99% confidence interval. / Significantly higher/lower than Baseline at 95% confidence interval. 45 ^One Follow-up examination was missing data for systolic and diastolic measurements.

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