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Seven-Year Trends in Employee Health Habits From a Comprehensive Workplace Health Promotion Program at Vanderbilt University Daniel W. Byrne, MS, Ron Z. Goetzel, PhD, Paula W. McGown, MSN, MAcc, RN, FNP-BC, CPA, Marilyn C. Holmes, MS, RD, LDN, Meghan Short Beckowski, MPH, Maryam J. Tabrizi, MS, Niranjana Kowlessar, PhD, and Mary I. Yarbrough, MD, MPH, FACOEM, FACPM

Objective: To assess long-term changes in health risks for employees participating in Vanderbilt University’s incentive-based worksite wellness program. Methods: Descriptive longitudinal trends were examined for employees’ health risk profiles for the period of 2003 to 2009. Results: The majority of risk factors improved over time with the most consistent change occurring in physical activity. The proportion of employees exercising one or more days per week increased from 72.7% in 2003 to 83.4% in 2009. Positive annual, monotonic changes were also observed in percentage for nonsmokers and seat belt usage. Although the largest improvements occurred between the first two years, improvements continued without significant regression toward baseline. Conclusions: This 7-year evaluation, with high participation and large sample size, provides robust estimates of health improvements that can be achieved through a voluntary incentive-based wellness program.

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n the past three decades, US employers sought ways to stem the growth in health care costs, which were often at double-digit annual inflationary rates and incompatible with viable long-term business models.1 This steep rise in health care spending changed the role of the employer from passively purchasing services for the treatment of disease to actively engaging in programs and benefit plan designs in attempts to control unnecessary utilization.1 More specifically, employers have redirected their efforts at population health management and incorporating health promotion and disease prevention programs alongside more traditional case and disease management. Tools used by employers for population health management typically include extensive awareness building through health education, health risk assessments (HRAs), in-person risk reduction interventions, telephonic health coaching, Web-enabled communications, social networking, and establishment of data warehouses.2–4 From Health & Wellness, Division of Administration (Mr Byrne, Ms McGown and Holmes, and Dr Yarbrough), the Division of General Internal Medicine and Public Health, Department of Medicine (Mr Byrne and Dr Yarbrough), the Department of Biostatistics (Mr Byrne), Vanderbilt University, Nashville, Tenn; the Institute for Health and Productivity Studies (Dr Goetzel), Emory University, Atlanta, Ga; and Thomson Reuters (Drs Goetzel and Kowlessar and Ms Beckowski and Tabrizi), Washington, DC. Authors Byrne, Yarbrough, McGown, Holmes, Short Beckowski, Tabrizi, Kowlessar, and Goetzel have no financial interest related to this study. Funding for this study was provided in part by Vanderbilt University Clinical and Translational Science Award grant UL1 RR024975 from NCRR/NIH. The contents are the sole responsibility of the authors and do not necessarily represent the official views of Vanderbilt University, Emory University, or Thomson Reuters. The JOEM Editorial Board and planners have no financial interest related to this research. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.joem.org). Address correspondence to: Mary I. Yarbrough, MD, MPH, FACOEM, FACPM, Health & Wellness, Department of Administration, Vanderbilt University, 1211 21st Avenue South, Suite 640, Medical Arts Building, Nashville, TN 37212 ([email protected]). C 2011 by American College of Occupational and Environmental Copyright  Medicine DOI: 10.1097/JOM.0b013e318237a19c

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Learning Objectives r Discuss the characteristics of Vanderbilt University’s workplace health promotion program, “Go For The Gold” (GFTG). r Identify long-term effects on health risk factors such as physical activity, smoking, and seat belt use. r Discuss factors leading to the overall health improvement and risk reduction among GFTG participants.

When implemented appropriately, these tools are effective in three areas: risk identification; behavioral change facilitation; and creation of knowledgeable health care consumers. While some employers have adopted these programs with enthusiasm, others are looking critically at the evidence that expanded primary prevention can improve outcomes. For individual employers, assessing this evidence can be challenging because of the difficulty in establishing a stable, unbiased cohort within the workforce that has experienced consistent programming from which outcomes can be determined. Although the general consensus is that workplace wellness programs can help individuals improve modifiable risk factors,5 the current literature is often limited to data collected at two time periods (before and after a health promotion program intervention), with the second period suffering from high attrition and low participation levels, many of which are less than 50%,6 making it difficult to assess the true long-term trends in risk factors. The analysis described here attempts to overcome some of these limitations by tracking the experience of Vanderbilt University employees participating in an incentive-based wellness program called “Go for the Gold” (GFTG) over a 7-year period. The GFTG Program, initiated in 2003, aimed to engage faculty and staff at the university in identifying their lifestyle risks and maintaining or improving those risks through dynamic programming. The program, now in its eighth year of existence, has continued with stable management and consistent data collection. The longitudinal trends in lifestyle risks of faculty and staff who participated in this incentive-based program during the 7 years since its inception have been tracked and benchmarked against national and state results. The high annual participation rate in GFTG (averaging 75.5%) provides a valuable database to investigate changes in risk factors and healthy lifestyle characteristics over time and to compare the results to benchmark norms.

METHODS Setting and Population This is a longitudinal descriptive analysis of Vanderbilt University employees’ health risk data for an aggregate and cohort population during the period of 2003 to 2009. Located on a 330-acre JOEM r Volume 53, Number 12, December 2011

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JOEM r Volume 53, Number 12, December 2011

campus in Nashville, Tennessee, Vanderbilt is a private research university and medical center containing 129 undergraduate, graduate, and professional degree programs in ten different schools. A total of 22,505 individuals (18,772 staff and 3733 faculty) were employed at the end of the fiscal year 2010. Of these, 95% were eligible for the GFTG Program (active, full-time, regular faculty and staff enrolled in the Vanderbilt Health Plan). Between 2003 and 2009, the number of eligible participants increased from 15,070 to 21,701, and the percent participating increased from 68% to 80%. The overall university population demographics, including the male to female ratio (34%:66%), faculty to staff ratio (15%:85%), and medical center to university employees ratio (76%:24%), remained relatively stable over the 7 years, as did the average age of employees (41 to 42 years).

Intervention and Structure of the Wellness Program Health Plus Program Health Plus is one of the four Health and Wellness programs offered by Vanderbilt to support the health and productivity of faculty and staff; the other three programs are Occupational Health, Work/Life Connections-Employee Assistance Program, and the Child and Family Center. Health Plus provides awareness, health promotion, primary prevention, and environmental support for employee health, wellness, and productivity. Health Plus has a 17,000-square foot fitness facility; provides behavior change counseling, including health coaching; offers biometric testing; and makes available a variety of educational programs, including newsletters, Web tools, video and podcasting, lectures, workshops, and individual consultations. The cornerstone of Health Plus is the GFTG Program, a multiplatform, Web-based incentive program developed in 2003 by the Vanderbilt Health & Wellness team with input from a design team and outside consultants. The program is voluntary and multitiered. Tiers consist of (1) completing an HRA with the goal of identifying health risks, (2) completing a self-directed lifestyle management tool for setting goals to maintain health or improve health risks, and (3) viewing an annual educational video featuring local experts who discuss both the importance of reducing a particular health risk and ways to take charge of improving that risk. The “Personal Wellness Profile Concise Plus Questionnaire” version of the Wellsource HRA7 was used consistently throughout the program. As an incentive for participation, up to $20 per month was added to an employee’s paycheck during the following calendar year for completing all three tiers of the program. Other components, such as coaching and targeted risk-reduction programs, provide more personalized support. Employees with specific risks, based on their responses to the HRA, are notified of additional risk-reduction programming opportunities. Those with low scores on the HRA are also contacted and offered health coaching. The GFTG had three primary goals—high participation (≥80%), increasing the percentage of participants who were low risk (≥80%), and increasing the overall HRA wellness score. During the course of the program, interventions and goals were refined based on the evaluation of participation data and health improvements observed.

Vanderbilt University Workplace Health Promotion Trends

“Go for the Gold” Program Components The HRA used in GFTG has 39 questions focused on behavioral health risks, plus items asking for biometric and demographic information. The Wellsource wellness scores range from 0 to 100, with higher scores indicating better health behaviors. Scores are based on an algorithm that subtracts points for unhealthy behaviors, with adjustments for age. One-on-one feedback and coaching, as well as group sessions, are available to individuals at greatest risk. Employees, who only complete the HRA, without engaging in the other two program components, achieve bronze participation level. The “Wellness Actions Log” (WAL) is an on-line form that participants use to document healthy actions taken to maintain or improve health. Participants are awarded credit for completing a designated number of actions. The number of required actions increased from 5 of the 9 in 2003 to 7 of the 10 in 2009 to make the WAL broader in scope and more challenging. Employees who both complete the HRA and participate in the WAL achieve silver participation level. The “Game Plan for Your Health” videos feature interviews with Vanderbilt faculty and staff that provide practical advice on ways to take charge of one’s health. Participants are awarded credits for completing a pretest, watching the video, and then completing a posttest. Employees who complete the HRA, participate in the WAL, and complete Game Plan requirements achieve gold level of participation.

Cost of Program During the first year, an incentive was awarded to GFTG Program participants; the average annual cost to deliver the program, including incentives and operational costs for the program, was $157 per participant. The average annual cost per participant increased to $234 in 2009. Over the course of 7 years, the average cost per participant was $212. This cost excludes costs attributable to the fitness facility. Most costs were recovered in the design of the health plan.

Definitions Participation in the program was defined as the proportion of benefits-eligible employees on the last day of the GFTG Program year who completed an HRA7 during the previous 12 months. Biometric screening was not a mandatory element of the wellness program but offered throughout the year at various health promotion events. Participants could voluntarily take part in the biometric screenings and self-report their results into the HRA. Stratification of health risks were based on the work of Edington.12 Those with zero to two risks were defined as low risk, three to four as medium risk, and five or more as high risk. The definition of high risk for each factor is listed in Appendix A (see Supplemental Digital Content 1, http://links.lww.com/JOM/A76). To compare our results with national and state figures and goals, we contrasted our data with those of the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System,13 the National Highway Traffic Safety Administration’s National Occupant Protection Use Survey,14 and Healthy People 2010 goals11 (Figs. 1 to 4).

Statistical Analysis Primary Intervention Focus In 2003, GFTG staff identified specific modifiable lifestyle behaviors to target based on the evidence from medical literature,8–10 the Healthy People 2010 Report,11 university population demographics, and a health plan analysis. Lifestyle characteristics of primary, but not exclusive, focus were inadequate physical activity, overweight and obesity, smoking, too few fruits and vegetables consumed, and poor coping with stress.

Approval for this project was obtained from Vanderbilt University’s Institutional Review Board and university leadership. This was a single-center, observational, prospective cohort study. No sample size or power calculations were performed at inception since the goal was to include as many employees as possible. Descriptive statistics were used to present the results of the trends for both aggregate and paired analysis, based on a cohort of employees who completed an HRA in any given calendar year, and a cohort of employees who completed the HRA all 7 years. The aggregate group

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JOEM r Volume 53, Number 12, December 2011

Byrne et al

FIGURE 1. Physical activity trends for the aggregate and cohort groups of Vanderbilt’s GFTG Program and comparison to national and Tennessee norms from Behavioral Risk Factor Surveillance System. For the Vanderbilt data, the HRA question was “How many days per week do you engage in aerobic exercise of at least 20 to 30 minutes duration (fitness walking, cycling, jogging, swimming, aerobic dance, or active sports)?”

FIGURE 3. Seat belt use trends for the aggregate and cohort groups of Vanderbilt’s GFTG Program and comparison to national and Tennessee norms from National Occupant Protection use Survey. The HRA question was “When driving or riding in a vehicle, how often do you wear a seat belt?”

FIGURE 2. Tobacco use trends for the aggregate and cohort groups of Vanderbilt’s GFTG Program and comparison to national and Tennessee norms from Behavioral Risk Factor Surveillance System. The HRA question identified those who currently smoke cigarettes daily. Former smokers, pipe, cigar, and chewing tobacco were not included.

FIGURE 4. Obesity trends for the aggregate and cohort groups of Vanderbilt’s GFTG Program and comparison to national and Tennessee norms from Behavioral Risk Factor Surveillance System. Obesity was defined as a BMI ≥ 30.

of employees ranged from 10,248 individuals in 2003 to 17,335 in 2009; the cohort was composed of 3745 employees participating every year from 2003 to 2009. For comparison of participants versus nonparticipants, a chisquare test for categorical variables and the Mann-Whitney U test for continuous and ordinal variables were used on demographic data from the employee record, such as age, gender, race, job category, and length of employment. Attrition was assessed by using Cox proportional-hazard analysis. Health risks were compared descriptively, including annual differences and the average annual difference across all years. Several of the ordinal and continuous variables were dichotomized to allow for comparisons with state and national figures and previously published reports. McNemar’s test was used for comparing the changes in the risk factors in the cohort between year 1 and year 7. A paired t-test was used for comparing the wellness score and body mass index (BMI) between these time points.

A central goal of GFTG was to achieve high annual participation rates. Before GFTG was introduced, the annual HRA completion rate was less than 24%. This increased to 68% in the first year after introduction of the incentive program and continued to increase to 80% and more in years 4 to 7 (Table 1). Also during this time, a greater proportion of participants enrolled in the highest level, the gold level, compared with the silver and bronze levels. Of the 17,335 GFTG Program participants in 2009, 71% achieved gold (HRA, WAL, and Game Plan), 6% silver (HRA and WAL), and 23% bronze levels (HRA only) (Appendix B [see Supplemental Digital Content 2, http://links.lww.com/JOM/A77]).

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RESULTS Participation in the “Go for the Gold” Program

Characteristics of Participants Participation in the GFTG Program was broad and fairly representative of the underlying employee population; however, the nonparticipants differed in several ways (Table 2). Nonparticipants were

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JOEM r Volume 53, Number 12, December 2011

Vanderbilt University Workplace Health Promotion Trends

TABLE 1. Characteristics of the Participants—Aggregate and Cohort Data for 7 Years Year Benefits-eligible employees* Aggregate participants Participation rate Age (yrs)† Gender Male Female

1 (2003)

2 (2004)

3 (2005)

4 (2006)

5 (2007)

6 (2008)

7 (2009)

15,070

16,097

17,247

18,701

19,810

20,494

21,701

(n = 10,248)

(n = 10,463)

(n = 12,444)

(n = 14,698)

(n = 15,811)

(n = 16,764)

(n = 17,335)

68% 40.4 ± 10.9 (18–83)

65% 40.6 ± 11.0 (18–79)

72% 41.4 ± 11.1 (18–80)

79% 40.7 ± 11.3 (18–81)

80% 40.8 ± 11.5 (18–82)

82% 40.9 ± 11.7 (18–82)

80% 41.2 ± 11.7 (18–83)

3,275 (32.0%) 6,973 (68.0%)

3,260 (31.2%) 7,203 (68.8%)

3,899 (31.3%) 8,545 (68.7%)

4,611 (31.4%) 10,087 (68.6%)

4,880 (30.9%) 10,931 (69.1%)

5,153 (30.7%) 11,611 (69.3%)

5,327 (30.7%) 12,008 (69.3%)

Cohort participants (N = 3745), participation rate 48% (7,802 benefits eligible employees all 7 yrs) Age (yrs)† Gender Male Female

43 ± 9.4 (19–77) 44 ± 9.4 (20–78) 45 ± 9.4 (21–79) 46 ± 9.4 (22–80) 47 ± 9.4 (23–81) 48 ± 9.4 (24–82) 49 ± 9.4 (25–83) 1,098 (29.3%) 2,647 (70.7%)

1,098 (29.3%) 2,647 (70.7%)

1,098 (29.3%) 2,647 (70.7%)

1,098 (29.3%) 2,647 (70.7%)

1,098 (29.3%) 2,647 (70.7%)

1,098 (29.3%) 2,647 (70.7%)

1,098 (29.3%) 2,647 (70.7%)

*Total number of benefits-eligible employees defined as those eligible for health care coverage, as determined by Human Resources Benefits on the last day of the GFTG Program year (November 30, all active, full-time, regular faculty and staff). Participation in GFTG Program was defined as completing the HRA in that calendar year. †Age is mean ± SD (range).

TABLE 2. Comparison of “Go for the Gold” Participants and Nonparticipants, Year 1 (2003) and Year 7 (2009) Year 1 (2003)

Nonparticipants Participants Age (yrs)b Gender Female Male Job classification House staff Research Associate Staff Faculty Medical group Location Medical center University Race Asian White Hispanic African American American Indian Other

Year 7 (2009)

Participation Ratea (%)

44.0 ± 11.6

41.2 ± 10.8

3,153 2,350

6,973 3,275

68.9 58.2

320 37 4,055 691 400

725 99 8,102 952 370

69.4 72.8 66.6 57.9 48.1

4,017 1,486

7,651 2,597

65.6 63.6

233 3,856 80 1,290 12 32

690 8,012 158 1,324 21 42

74.8 67.5 66.4 50.7 63.6 56.8

P