Clinical and Economic Impact of a Hypertension Education and ...

Presenters:Joseph Doyle, RPH, MBAGerald T. Richerson, AET, BSERobert S. Harshman, MD

Clinical and Economic Impact of a Hypertension Education and Awareness Program among Commercial Driver License

Employees

http://www.drivershealth.com/index.jsp

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Learning ObjectivesUnderstand 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

FACT!

Hypertension is a highly prevalent, modifiable disease affecting approximately one in three U.S. adults (~73 million persons)

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

The relationship between high blood pressure (BP) and risk of cardiovascular disease (CVD), cerebrovascular disease and peripheral vascular disease is well established

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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

Introduction - The Employer

Georgia Power is the largest subsidiary of Southern CompanyWith nearly 9,000 employees of which over 2,000 hold CDLsServes 2.25 million customers in 155 of Georgia’s 159 counties

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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

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Introduction - DOT Hypertension Guidelines

BP Category Certification* Re-Certification

The medical exam includes blood pressure readingBP may limit the length of time the CDL is validThe DOT change BP standards in September, 2004

If BPs do not return to a Normal category, disqualification will occur!

*See additional detail on expiration and certification guidelines in the Appendix

<140/90 2 years 2 years

140-159/90-99 1 year1 year if <140/90

3 months if 141-159/91-99169-179/100-109 3 months (1 time only) 1 year if <140/90

>180/110 6 months if <140/90 6 months if <140/90

1 United 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

http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/fmcsrruletext.asp?rule_toc=760&section=391.41&section_toc=1781

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Impact of DOT hypertension guidelines

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Stage 2Stage 1

Normal

Old DOT

> 179160 – 179140 – 159130 – 139120 – 129< 120

Systolic

BP Category Change

With this guideline change, the Normal range for blood pressure became more stringent

Stage 2

Stage 1

Normal

Old DOT

105 – 109> 109

100 – 104

90 – 9985 – 8980 - 84< 80Diastolic

Stage 3Stage 2Stage 1

Normal

Current DOT

Stage 3

Stage 2

Stage 1

Normal

Current DOT

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

If a blood pressure score corresponds to two different categories based on the systolic and diastolic measures, then it would be classified as the riskier category.

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BP Category Change The bottom line:

If BPs do not return to a Normal category, driver will be disqualifiedWhat qualified as a “Normal” blood pressure was lowered, so criteria became more strictHypertensive categories broadened with the addition of Stage 3

Blood pressure needs to be

below 140/90

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DOT Classification Category Comparison

Impact on the CDL EmployeesAs a result of the DOT classification change, the percentage of CDL employees within a Normal BP was reduced

Based on an Employer Sample of 501 CDL Employees Prior to September 2004

0%

100%

Old DOT Current DOT

80%

The percentage of CDL employees classified in a hypertensive category increased

2.8%Uncontrolled*

26.1%Uncontrolled*

*Uncontrolled refers to Stages 1 to 3See Appendix for JNC-7 Classification

97.2%Normal

60%

40%

20%

73.9%Normal

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CDL Employees at Risk for CDL Disqualification

Impact on the CDL EmployeesBased on these findings, among the 2,038 CDL holders, significantly more would be at risk for restriction or disqualification

Old DOT2,038 CDL holders

Current DOT2,038 CDL holders

1,981CDL Employees

With “normal” BPs

1,506CDL Employees

With “normal” BPs

57 CDL EmployeesAt Risk for

CDL RestrictionOr Disqualification

532 CDL EmployeesAt Risk for

CDL Restriction Or Disqualification

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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

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The BP Downshift ProgramThe BP DownShift Program is a resource for professional drivers focusing on CDL health requirements and overall health and wellness


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The BP Downshift Program

The program also advises on healthier habits that will work with the drivers’lifestyle—on and off the road

The BP DownShift Program provides resources and information about improving CDL holders’ health

Antihypertensive treatment informationBlood pressure diaries with tipsA tool to track blood pressure readingsOn-site Safety & Health presentationsOn-site BP monitoringMedical chart stickersAn audio CD that explains high blood pressure

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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

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Clinical Impact of a Hypertension Education and Awareness Program

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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

Program Implementation

^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.

20042003 2006

Follow-up DataJan ‘05 to Dec ’05

(N=501)

2005

BP DownShift Implementation

Apr ‘04 to Sept ‘04

Baseline DataJan ‘03 to Dec ’03*

(N=501)

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Most CDL employees (64.6%) were 40 to 59 years old

Mean age was 42.5 years

Sample Characteristics - Age & BMI

Age At Baseline

26.1%

38.5%

22.2%

12.2%

Mean = 42.5Median = 43.0Range = 19 to 62

(N=501)

30-39 Years

Under 30

40-49 Years

50-59 Years

Age At Baseline

26.1%

38.5%

22.2%

12.2%

Mean = 42.5Median = 43.0Range = 19 to 62

(N=501)

30-39 Years

Under 30

40-49 Years

50-59 Years

10.0%

44.0%

46.0%

0%

20%

40%

60%

80%

100%

Baseline, N=501

% o

f CD

L Em

ploy

ees

Obese

Overweight

BMI At Baseline

Normal

Mean = 29.8Median = 29.3Range = 19.7 to 65.3

BMI CategoriesObese (30.0+)Overweight (25.0-29.9)Normal (< 24.9)

Based on Body Mass Index (BMI), most CDL employees were either overweight or obese

44% were Obese

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Based on CDL employee self-report, over one-quarter already had a diagnosis of hypertension and was currently taking anti-hypertensive medication

Sample Characteristics - Other Risk Factors

Risk Factors Baseline(n=501)

Hypertension Diagnosis 25.5%

Personal History of CVD 3.0%

Diabetes 6.2%

Anti-Hypertension Medication Use 25.3%

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According to the Current DOT BP Categories, 26.1% of CDL Employees had uncontrolled BP levels

Baseline DOT BP Categories

DOT Classification At Baseline

Baseline (n=501)

26.1%

73.9%

0%

20%

40%

60%

80%

100%

% o

f CD

L Em

ploy

ees

Normal

Uncontrolled*

*Uncontrolled refers to Stages 1 to 3

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The CDL Employees Before the Program

The bottom line:Over 25% of this population of CDL employees were at risk…

At risk for CDL disqualificationAt risk for cardiovascular disease

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After the program, the percentage of employees in the DOT normal category significantly increased

Clinical Impact of BP Downshift - DOT Categories

/ Significantly higher/lower than Baseline at 99% confidence interval.^One Follow-up examination was missing data for systolic and diastolic measurements.

DOT Classification At Baseline and Follow-up

Baseline (n=501)

Follow-up (n=500^)

% o

f CD

L Em

ploy

ees

82.8%73.9%

0%

20%

40%

60%

80%

100%

NormalNormal

And the percentage in the hypertension categories significantly decreased

17.2%Uncontrolled*

26.1%Uncontrolled*

Note: Results were adjusted 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. 2008 Mar;50(3):359-65.


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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

58%Normal

75%Normal

Baseline (n=128)

Follow-up (n=128)

25%Uncontrolled*

42%Uncontrolled*




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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

CVD Risk Factors Baseline (N=501)

Follow-up (N=500)

HTN Diagnosis 25.5% 30.2%

Personal History of CVD 3.0% 4.2%

Diabetes 6.2% 7.4%

AHY Medication Use 25.3% 30.2%

Clinical Impact of BP Downshift - Education and Awareness



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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 medicationFewer CDL employees were at risk for CDL disqualificationEducation and awareness was increased as suggested by more employees reporting a diagnosis of hypertension and the increased use of anti-hypertensive medications

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Economic Impact of a Hypertension Education

and Awareness program on a CDL employer

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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.

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The Economic Model AssessmentAn 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 HTNThis 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 Commercial Driver License Employees. J Occup Environ Med. 2009, in press.

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Economic Model InputsClinical data were gathered from 499 employee DOT Medical Exam Reports as inputs to the model

Gender, age, body mass index, and DOT HTN classification categoryPatient-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

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Economic Model OutputsModel simulations generated the following direct and indirect cost estimates

Hypertension TreatmentCHD TreatmentStroke TreatmentDiabetes CareCDL ExaminationsLost Productivity

Model Outputs were compared before and after the BP Downshift Program

Pre-Program Post-Program

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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

16.3% Reduction$3,312,220

$2,771,094

$0

$1,000,000

$2,000,000

$3,000,000

$4,000,000

Pre-Program Post-ProgramGreene 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 Med. 2009, in press.

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Economic Model Outcomes - Relative Total Costs

TOTAL COST = $3,312,220

A large proportion of the total Pre-Program costs was attributable to Lost Productivity

8%

5%

2%

1%

1%

83% Lost Productivity

HTN TreatmentCHD Treatment

Diabetes Care

CDL Examinations

Stroke Treatment

Pre-Program

TOTAL COST = $2,771,094

10%3%

1%

1%

6%

79% Lost Productivity

HTN TreatmentCHD Treatment

Diabetes CareCDL Examinations

Stroke Treatment

Post-Program

The 83% due to Lost Productivity was reduced to 79%

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 Med. 2009, in press.

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Economic Model Outcomes - Itemized Total Costs and Savings

The reduction in productivity loss alone equated to a cost savings of ($552,103)

There were cost increases for treatment of HTN and chronic

disease, ($19,387)

Difference $18,740$541$106-($8,410)($552,103)

$270,754$81,225$39,137$32,089$154,319$2,193,570

$252,014$80,684$39,031$32,089$162,730$2,745,673

HTN Treatment

CHD Treatment

Stroke Treatment

Diabetes CareCDL ExamLost

Productivity

Pre-Program

Post-Program

Fewer CDL examinations saved ($8,410)

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Economic Model Outcomes - Total Costs and Savings per CDL Employee

Cost savings per CDL employee was $1,084

Employer Costs Per Employee

Pre-Program Post-Program

$1,084Saved

$5,553$6,638

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.

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Economic Impact of the BP Downshift Program

The bottom line:The BP Downshift Program was associated with a significant reduction in CDL employer costsCosts were reduced due to fewer CDL employees with uncontrolled BP

2-Year employer costs were reduced from $3,312,220 to $2,771,094Employer costs decreased by 16.3% over 2 years—over one-half million in savings ($541,126)A savings of $1,084 per each CDL employeeMajority of cost-savings were attributable to decreases in lost productivity costs

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Summary and Conclusions

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Summary and Conclusions1. 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 stringentThis change in classification caused nearly 4X as many CDL employees to be classified in a “hypertensive” categoryThe frequency of routine medical exams increases for any CDL holder in a “hypertensive” category

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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 riskAs a result of the program, fewer CDL employees are at risk for CDL disqualificationEducation and awareness related to hypertension and its risks was increased

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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 ProgramCosts were reduced due to fewer CDL employees with uncontrolled BPMajority of cost-savings were attributable to decreases in lost productivity costs and fewer CDL medical examsBP DownShift raises awareness, educates and mobilizes moderate to high risk CDL employees

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Can a Hypertension Education & Awareness Program Improve Employee Health and Productivity? And Reduce Employer Costs?

More CDL employees had controlled BP levels

CDL employee productivity increased

Heart health awareness and knowledge increased

Employer costs were reduced

Yes!

Yes!

Yes!

Yes!

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The END


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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*

Stage 1140-159

90-991 year; rarely disqualifying

alone

1 year if <140/90

One-time certificate for 3 months if 140-159/90-99

Annually

Stage 2160-179

100-109One-time certificate for 3

months1 year from date of initial

exam if <140/90 Annually

Stage 3 >179, >109 Disqualified; 6 month certificate if <140/90 at recheck

6 month certificate from date of initial exam if <140/90 Bi-annually

Old DOT Range Certification Re-certification Frequency

Normal <160, <90 2 years 2 years if <160/90 Every 2 years*

Stage 1 160-179, 90- 104 3 months 1 year if <160/90 Annually

Stage 2 >179, >104 Disqualified; 3 month certificate if <180/90 at recheck 6 months if <160/90 Bi-annually

*May be certified every 2 years, provided the driver is not using medication to control blood pressure and there is no medical condition for which a shorter certification would be appropriate.

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APPENDIX - DOT Medical Examination Report (Page 1)

http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf

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APPENDIX - DOT Medical Examination Report (Page 2)

45/ Significantly higher/lower than Baseline at 99% confidence interval./ Significantly higher/lower than Baseline at 95% confidence interval.

^One Follow-up examination was missing data for systolic and diastolic measurements.

APPENDIX - Clinical Impact of BP Downshift, JNC 7

Similar changes occur when CDL employees are classified according to the JNC-7 categories.

Baseline (n=501)

Follow-up (n=500^)

% o

f CD

L Em

ploy

ees

15%Normal

67%Pre-hypertension

55%Pre-hypertension

25%Stage 1 and 2

18%Stage 1 and 2

0%

20%

40%

60%

80%

100%

20%Normal



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