GE Energy Pre Diabetes Intervention A Collaboration with Centers for Disease Control

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GE Energy Pre Diabetes InterventionA
Collaboration withCenters for Disease Control
Prevention and the National Business Group on
Health

• March 16, 2005
• Business Health Agenda
• National Business Group on Health

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Welcome

• Ron Finch, EdD
• Director, Center for Prevention and Health
  Services
• National Business Group on Health
• David Pratt, MD
• Medical Director, GE Energy

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CDCs New Goal Bridging Public Health and the
Business Community
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Business Values vs Community Health Values
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Business vs Community Health

• ROI
• Stay in business
• Productivity
• Profit and loss
• Overhead
• Employees as a capital investment

• Public good
• Healthy people
• Public and private partnerships
• Non-profits
• Advocacy

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Know the Language

• CoCHis
• DDT, CVD
• DNPA, Asthma
• OSH, DRH
• ROI
• Presenteeism
• NBGH

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Community and Public Health

• Community health primary domain of the public
  health entities.
• Models, based on epidemiological evidence, target
  populations with identified health risk factors
  or conditions.
• Engaging business in such activities is
  challenging, and many community health
  development efforts lack effective partnership
  with local businesses.

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Opportunity knocks to open the doors between
business and community health
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CDC Reinvention

• Two Overarching Health Protection Goals
• Health promotion and prevention of disease,
  injury, and disability
• Preparedness

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CDC Reinvention Six Strategic Imperatives

• Health Impact.
• CDC will be a customer-centric organization.
• Public Health Research.
• Leadership for the nations health system. Global
  Health.
• Effectiveness and Accountability.

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CDC New Initiatives

• Cooperative agreements
• Multiple divisions working together, sharing
  expertise and resources
• DDT, CVD, DNPA
• Asthma
• Center for Public and Private Partnerships

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We Have an Epidemic of Diabetes !
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Why pick diabetes for a health promotion
intervention?

• Costs over 100 billion/year in health care
  expenditures
• Effective interventions promote multiple good
  outcomes
• Leading cause of heart disease and stroke
• Leading cause of blindness in adults
• Leading cause of end stage renal disease
  requiring dialysis

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Consequences of uncontrolled diabetes

• Loss of productivity
• Increased direct and indirect health care
  expenditures
• Poorer quality of life for employees
• Possible permanent disability

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Why Control Diabetes?

• Better control translates into fewer
  complications
• Fewer complications translate into fewer days
  lost to absenteeism and disability, and future
  savings on health care expenditures

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Why the workplace as a site of disease education?

• Unique opportunity for education
• Less time away from work
• Improves employer-employee relations and shows
  employer cares about employees

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Do Any of These Things Work?

• Bottom Line Does better glucose control
  translate to better outcomes or better health in
  the individual?
• Does better glucose control translate into
  improved productivity in the workplace?

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Economic Benefits of Improved Glycemic Control

• Testa et al, JAMA, Nov 1, 1998
• Workers with better Hba1c had fewer days lost to
  absenteeism
• Fewer days of restricted activity

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Strategies for Better Outcomes Examples of
Worksite Programs

• Canadaworksite physical activity classessavings
  of 679/person
• Coca Cola companyworksite wellness gt500
  /year/person x 2500 people
• First ChicagoWorksite diabetes education
  program-improvement of HbA1c 9.0 to 8.3

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National Diabetes Education Program (NDEP) Goals

• CDC and NIH program formed after evidence showed
  that better glucose control translated into fewer
  complications
• Public and private partnerships to improve
  diabetes treatment and outcomes
• Increased public awareness of the seriousness of
  diabetes, its risk factors, and strategies for
  preventing diabetic complications

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NDEP Workgroups

• African American Workgroup
• Latino Hispanic Workgroup
• American Indian Alaska Native
• Diabetes in youth
• Older adults
• PPOD
• Business and Managed Care Workgroup

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NDEP Business and Managed Care workgroup
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Business and Managed Care Work Group (BMC)

• To increase awareness of the benefits of quality
  diabetes care among employers, benefits managers
  and managed care decision makers
• To provide employers, health plans and employees
  with tools and information for incorporating
  diabetes education programs into the workplace
• To promote the value of investing in prevention

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NDEP Business/Managed Care Workgroup Who are we?

• CDC and NIH
• Large and small businesses
• Unions
• Occupational health professionals
• Public health agencies
• Managed care groups
• Non-profit organizations

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BMC Work Group

• NBGH
• GE Power
• GM
• American Association of Health Plans
• United Automobile Workers Union

• Wisconsin Diabetes Control
• Program
• Novo-Nordisk
• Harrington and Chappell
• National Fed of Ind
• Businesses

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NDEP TARGET GROUPS

• Occupational health professionals
• Wellness coordinators
• Benefits personnel and HR managers
• Large and small businesses
• Unions
• Regional and national business groups
• Managed care organizations

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BMC Workgroup Projects

• Diabetes White Paper Call to action!
• Diabetes Needs Assessment Tool
• Diabetes Worksite Intervention Kit
• Regional partner conferences General
  Motors, DFWBGH, Federal Reserve, Lands End

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Needs Assessment

• What is it and why does my company need to
  address diabetes?
• Helps to see the potential prevalence of diabetes
  in the company based on NHIS data. Each company
  has a unique workforce, based on age, ethnicity
• Is diabetes relevant at this time?

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Diabetesatwork.org Content

• Planning Guide
• Assessment Tool
• Choosing a Health Plan
• Lesson Plans
• Fact Sheets
• Resources
• Frequently Asked Questions (FAQ's)

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Diabetesatwork Content

• General Diabetes Education
• Managing Diabetes Complications
• Cardiovascular Disease
• Emotional Well-Being
• Nutrition, Weight Control, and Physical Activity
• Dealing With Type 1 Diabetes

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Lesson Plans, Lunch Learns

• High and Low Blood Glucose Symptoms and Causes
• Making Your Doctor Visit Count
• Cardiovascular risk factors
• Feet

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Other Topics

• Guide to choosing a health plan, developed with
  AAHP
• Supervisors guide
• Shift work
• Links to other NDEP sites

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What Can My Company Do?

• Develop a Supportive Work Environment
• Seize the moment for education
• Educate other employees about diabetes
• Create a wellness committee
• Sponsor health screenings
• Coordinate All Health Efforts

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Resources

• National Business Group on Health www.wbgh.com
• WK Kellogg Foundation, The Business Interest in a
  Communitys Health, pdf on NBGH web site,
• National Business Coalition on Health
  www.nbch.org
• American College of Occupational and
  Environmental Medicine www.acoem.org
• American Occupational Health Nurses www.aaohn.org

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Resources American College of Occupational and
Environmental Health

• www.acoem.org
• Consensus Statement on Health and Productivity
• The Business Case for Managing Health and
  Productivity
• Health and Wellness in the Workplace
• Business and Managed Care Diabetes and Health
  Resource Kit

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Remember

• New evidence DPT Diabetes Prevention Trial
  lifestyle and/or meds can PREVENT type 2 diabetes
• The lifestyle changes and medical care
  recommended for diabetes control helps prevent
  and control MANY chronic diseases.

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Diabetes Prevention_at_ GE Energy

• Donna Tomlinson, MD MSc
• Health Promotions Manager, GE Energy
• Tiana Howland, RN
• Cardiovascular Disease Prevention Specialist
  Health Coach, Community Care Physicians

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GE Energy Risk ManagementOverview

• Cardiovascular Risk Assessment
• CRA input
• CRA output
• Cardiovascular Risk Management
• Energy Health Coach
• Diabetes Prevention _at_ GE Energy
• Sample of program
• Implementation Planning
• Results

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Diabetes Prevention_at_ GE Energy

• Cardiovascular Risk Assessment Input
• 11 questions
• Height, weight, girth
• Blood pressure
• Lipids glucose

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Data QualityMisclassification Bias
Digit bias resulted in 362 false positive
diagnoses of hypertension with an unnecessary
physician referral. Cost of unnecessary
referrals 350 70 24,500
Frequency
Systolic BP Ones Digit
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AssessmentTime

• Production time focus
• Customer oriented
• Efficiently

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Cardiovascular Risk Assessment
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Cardiovascular Risk Assessment Output

• 10 year risk of cardiac event
• 10 year risk of stroke
• Existing CAD, PAD, CVA
• Blood pressure
• Including medication use
• Tobacco users
• LDL-cholesterol
• Including medication use
• Overweight/obese

• Hypertriglyceridemia
• Metabolic Syndrome
• Diabetes

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GE Energy Profile
78 male mean age 42.7 2 CVD 17 metabolic
syndrome
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Percent of Population withMetabolic Syndrome
Risk Factors
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Mean Change Between CRA 1 CRA 2

• Age (yrs.) 1.2, p 0.000
• Total Cholesterol (mg/dl) -3.1, p 0.000
• HDL Cholesterol (mg/dl) 1.6, p 0.000
• LDL Cholesterol (mg/dl) -4.0, p 0.000
• Imputed serum triglycerides -7.7, p 0.039
• Serum glucose (mg/dl) -5.4, p 0.000
• Systolic blood pressure (mmHg) -2.5, p 0.000
• Diastolic blood pressure -0.7, p 0.012
• BMI (kg/m2) -0.0, p 0.507
• Waist Circumference (cm) -0.1, p 0.412

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Change Between CRA 1 CRA 2
CRA 1 CRA 1 CRA 1 CRA 1
CRA 2 Diabetes ? Diabetes ? Diabetes
CRA 2 ? Diabetes 1,134 5 1,139
CRA 2 ? Diabetes 12 22 34
CRA 2 1,146 27 1,173
Incident diabetes 1.0 Prevalent diabetes
3.0 Cured diabetes ?
CRA 1 CRA 1 CRA 1 CRA 1
CRA 2 Tobacco ? Tobacco ? Tobacco
CRA 2 ? Tobacco 1,047 33 1,080
CRA 2 ? Tobacco 15 78 93
CRA 2 1,062 111 1,173
Net tobacco quit rate at 1.2 years 28.3
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Net Effect of CRA As an Intervention

• Change in Predicted Risk of Primary Cardiac Event
• (Cardiac Event fatal non-fatal MI, sudden death
  or surgical intervention)
• Mean change in Real 5 yr. CHD risk -0.002, p
  0.001
• Mean change in Real 10 yr. CHD risk -0.003, p
  0.003
• Mean change in 5 yr. CHD risk (age held
  constant) -0.004, p 0.000
• Mean change in 10 yr. CHD risk (age held
  constant) -0.008, p 0.000

• Per 1000 employees screened, 4 events (in 5
  years) are averted
• 24.8 events averted in our screened population
• At 40,000 per event 992,000

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CRA Intensive Follow UpEnergy Health Coach
Current Baseline Risk Old Recruitment Method

• Our focus is on those with highest modifiable
  risk
• NNT to prevent one event (10 year risk) is 20

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CRA Follow UpLess Intensive Intervention

• Criteria for Intensive
• Risk gt 10, modifiable
• Risk gt 7.5, LDL med level
• Trigs gt 1000 mg/dL
• Stage 2 Hypertension
• New or poorly controlled diabetes

• Criteria considered for less intensive follow-up
• Prehypertensives
• Stage 1 hypertensives
• LDL-cholesterol at lifestyle levels
• Overweight or obese
• Metabolic syndrome
• Other pre-diabetic

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• They built it.

• We came.

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Complications of Diabetes

• 1 Cause of Blindness
• 90 Preventable

• 1 Cause of Kidney Failure
• Most is Preventable

• 1 Cause of NT Amputation
• 40 to 50 Preventable

• 60 to 70 of Diabetes
• Deaths are Cardiovascular
• Stroke
• Heart Failure
• Coronary Heart Disease

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Six Sigma Care?

• You have got to take an active role in monitoring
  measuring your health.
• Waiting for the system to help you just wont
  work.

• In one California HMO
• 26 had a documented eye exam
• 48 had their blood or urine examined for signs
  of kidney failure
• 56 had total cholesterol 31 had LDL
  cholesterol checked
• 8 had a foot exam at every visit

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Counting Saturated Fats
(Sat fat per serving) (Servings) Grams of Sat
Fat
3 g x 2 Servings 6 g Sat Fat 7 g x 2
tablespoons of butter 14 g Sat Fat 20 g Sat Fat
Some examples of saturated fat content 8 oz
glass of whole milk 5 g Sat Fat One tablespoon
heavy cream 3 g Sat Fat 1 ounce slice cheese
5 g Sat Fat 3 oz serving skinless white chicken
1 g Sat Fat 3 oz serving dark meat chicken 2
g Sat Fat 3 oz lean pork 4 g Sat Fat 3 oz
marbled steak or roast 4 to 11 g Sat Fat Hot
dog 5 to 11 g Sat Fat Double quarter pound
cheeseburger 20g Sat Fat
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Script forInstructor
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Counting Grams of Saturated Fat

• Breakfast sausage egg and cheese on a biscuit, 2
  hash browns and large coffee with cream
• Lunch big bacon classic burger, biggie fries,
  and a medium frosty
• Dinner 10 oz steak with mashed potatoes with
  butter and salad with hidden valley original with
  bacon
• Dessert 1 pint of Haagen-Dazs ice cream

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Counting Grams of Saturated Fat
Sausage egg with cheese
2 Hash Browns
Large Coffee w/6 tablespoons cream
Big bacon classic
Biggie Fries (5.6 ounce)
Frosty medium
10 ounce steak
Mashed potatoes
Butter 3 tablespoons
Lettuce
Hidden Valley Dressing 4 tablespoons
1 pint 2 cups Haagen-Dazs
8 g
3 g
13.2 g
12 g
3.5 g
7 g
18 g
0 g
140.3g
21.6 g
0 g
10 g
44 g
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Diabetes and High Blood PressureAre Like Twins
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Create a Blood Pressure Action Plan

• Johns average blood pressure is 132/85
• He should reduce his systolic blood pressure down
  below 120
• 132 -120 12 points

Obese Does not exercise Eats fast food daily Does
not drink alcohol
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Create a Blood Pressure Action Plan

• Harrys average blood pressure is 124/81
• He should reduce his systolic blood pressure down
  below 120
• 124 -120 4 points

Healthy weight, but gained 5 pounds last
year Moderately active Eats typical American
diet Has 1 or 2 drinks on the weekend
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You will learn that our nutrition message is more
than just 5 A Day . . .
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Top 10 Daily HasslesA Survey of Middle-aged
Adults

1. Concerns about weight
2. Health of a family member
3. Rising prices
4. Home maintenance
5. Too many things to do
6. Misplacing or losing things
7. Yard work or outside home maintenance
8. Property, investments, or taxes
9. Crime
10. Physical appearance

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Diabetes Prevention _at_ GE EnergyProgram Sites

• Houston
• Pilot program complete (24 employees)
• Schenectady
• Program in progress (11 employees)
• Minden
• Program in progress (25 employees)
• Bangor
• CRA first week in June program to begin same
  week

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Implementation Planning
Role CRA Diabetes Prevention
Top Management Culture of confidence in Medical director Digitization drive in 2001 Access prototype Largely unnoticed as a separate program
HQ Medical Team Expertise available Software Public Health/CVD Prevention design Implementation Public Health/CVD Prevention Health Coach Experience
Site Nurse Short term intense commitment Commitment of minimum of 10 hours
Site Leaders Most familiar with our product Nurses present case, has not been an obstacle
Major investment from business Most costs are from site nurse and production time
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Planning Upfront, Direct, Simple
Eligible Costs to Business Planning Steps
Group high risk for diabetes. 3 or more metabolic syndrome risk factors No direct expenditure for site Recommend hourly workers participate in the program on the clock for ½ of the program Giveaways provided by GEE Health services without charge Nurse or health educator time to present materials required. Minimal preparation time. View program materials Identify program lead       Obtain site approval Approved by      On clock/off clock    Order sample materials and printed script from Joan. Schedule classes (begin within 30 days of CRA) 1-1     1-2   1-3   1-4  2-1     2-2  3-1   3-2   4-1  4-2  6-1   Prepare invitation (with schedule above) to be distributed at CRA event Identify invite participants to prevention program at the time of the event. Give pre-program survey to all who are eligible for the program.
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Pilot Study Results
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Business and Public Health Bridging the Gap in
Health Improvement

• Impetus for the project
• CEO concerned about health status of employees
• Top management wants productive workforce
• Management understood link between health status
  and productivity
• GE, CDC and NBGH
• Cooperative Agreement
• Objectives of the collaboration
• Science-to-Service
• Link CDC scientist with business

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ROI The Business Case

• Healthcare costs increasing 10 annually
• 95 of healthcare costs goes to direct medical
  services
• 5 is allocated to preventing disease
• 50 to 70 of all diseases are associated with
  modifiable health risks
• CFO want costs justification

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Developing the ROI

• Identify the populations
• Participants
• Control Group
• Monitor healthcare costs and utilization during
  periods of
• Pre-intervention
• Intervention
• Post Intervention

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Costs and Utilization Metrics

• Costs
• Health Plan Claims Data
• Prescription Medication Costs
• Disability Costs Data
• Utilization Data
• Admissions
• ER visits
• Scripts
• Disability Days/Events

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Discussion of Pre-Intervention Data

• Data collected
• 6, 12, 18 month intervals
• Review of Data
• Range 139,000 to 00 over 18 month period
• Breakdown by range and categories
• Included in ROI calculation is costs of
• Spouse
• Children

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Intervention Participation Rate

• Dose Response
• Percent of Activities Attended
• Participant Survey
• Lifestyle changes
• Exercise
• Healthy Diet
• Adherence to Medications

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Program Costs
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ROI (Cont)

• First Employee only
• Second Employee and family
• Third Participants compared to control group

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Current Status

• Houston, TX pilot
• Continuing to monitor claims data
• Will offer reassessment at 1 year
• Schenectady, NY began 2/15/05
• Minden, NV began 2/28/05
• Greenville, SC on hold for now
• Bangor, ME to begin week of CRA event in June

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Integrating Health Promo Programs With Health Plan

• Lynn Kohrs
• Healthcare Manager,
• GE Energy

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Group Health Plan Benefit Design
Diabetes care Insulin and supplies, free or very
low cost? Ease of lab services, free or very low
cost? Diabetic education? Covered? Partnering
with Health Promotions Team Patient advocacy,
benefit clarity, delivery, referrals to
healthcare resources, COEs Employer
Involvement Bridges to Excellence, Leapfrog,
both important to quality of care in our
communities
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Group Health Plan Benefit Design
Diabetes care Insulin and supplies, free or very
low cost? Ease of lab services, free or very low
cost? Diabetic education? Covered? Partnering
with Health Promotions Team Patient advocacy,
benefit clarity, delivery, referrals to
healthcare resources, COEs Employer
Involvement Bridges to Excellence, Leapfrog,
both important to quality of care in our
communities
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Health Costs (U.S.)
2,321
(MM)
2,093
2,033
Retiree (Accrual)
1,792
1,552
1,366
Post 65 (Cash)
1,123
1,026
983
982
958
Disability (Cash)
Pre 65 (Cash)
V/Active EE (3) (1) 3 4 4 12 7 12 8 7 1
1 /Active EE 6,850 13,000
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Next Steps

• Continue to implement and evaluate program
• Use data for additional six sigma projects

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Summary

• Goals/Objective
• Public Private Partnerships
• Lessons Learned Strength/Weaknesses

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Open ForumQA

•