An Evaluation of the Economics of Hypertension:
How Can We Control the Problem and Its Costs?
An Honors Thesis (ID 499)
by
Gretchen A. Melichar
Dr. Ray Montagno
Ball State University
Muncie, Indiana
May 1988
Spring 1988
My senior
honors project
has consisted
a research paper and practical experience
and communication
with wellness
of two components:
by way
experts.
of observation
The library work that
ultimately went into the research paper has been done to increase
my
knowledge
about
a
topic
in the health-related field.
The
practical experience has come about from observing presentations,
lectures,
and
the
actual
functioning
of a company's wellness
resource center.
I chose to focus my area of research on hypertension and the
implications it
can have
on businesses.
has increased my understanding of a
My study of this topic
health-related concern which
I knew very little about.
I
spent
time
at
Blue Cross Blue Shield, Indianapolis, in
the Wellness Resource Center.
I
had
the
opportunity
learn more about what
wellness
in
the
While
to
Cross Blue Shield,
talk with several staff members and
various
companies
are
doing
to promote
This experience has given me new
workplace.
insight into how wellness
at Blue
,is
a
relevant
area
of
concern for
businesses today.
Therefore,
the
separate sections.
hypertension,
activities with
and
following
The
the
work
first section
second
Blue Cross
is
divided
is the
section
Blue Shield.
is
The
into
two (2)
research paper on
a
summary
of
my
two sections are
separate from each other in content, but both components are part
of my senior honors project.
An Evaluation of the Economics of Hypertension:
How Can We Control the Problem and Its Costs?
Part A
TABLE OF CONTENTS
Page ::
I.
Introduction
A.
B.
C.
D.
E.
II.
E.
F.
G.
.5 - 8
8
.8 - 9
Health promotion in the workplace .
Aggregate cost figures.
..... .
Cost-effectiveness analysis • .
. ..
Studies evaluating cost-effectiveness
Additional considerations for managers . .
Educational Intervention.
Yield from risk reduction
.9 -10
.10-11
.11-12
.12-16
.17-18
.18-20
.20-22
Compliance
A.
B.
IV.
.1 - 3
.3 - 5
Economics of Hypertension
A.
B.
C.
D.
III.
Facts/concerns about hypertension . • •
Definition of terms • .
••....
Factors that influence blood pressure
Physiologirial cause of high blood pressure.
Treatments. • • . . . . •
• ....
Problem of low compliance .
Dealing with low compliance .
.22-23
.23-24
Conclusion
A.
B.
Goals of control programs .
Future considerations .
i
.24-25
25
INTRODUCTION
Facts and Concerns
Hypertension,
arteries
and
an
increase
arterioles,
cardiovascular diseases.
feel ill and rarely
high
blood
is
blood
in
most
the
prevalent
are
not
many people
even
aware
outside the normal blood pressure range.
only 51%
of persons
condition.
they
had
with hypertension
The statistics
increased, and
in 1984
high
blood
aggressive treatment
a 1972 survey
were aware of their
as awareness has
85% of all hypertensives were aware
However,
pressure.
programs for
way to
who have
that they fall
In
have improved
education and
hypertension are still a
necessity (Charles Lenfant, 1987,
only reliable
of all
Because it does not make a person
causeS symptoms,
pressure
pressure within
p. 2709).
Basically the
diagnose hypertension is to have your
doctor take your blood pressure using an instrument called a
sphygmomanometer.
pressure when
The fact
People often learn they have raised blood
they visit
that many
Information
a
physicians,
and
interchangeably
about something else.
people do not know they are at risk for
high blood pressure is
educators,
the doctor
cause
employers,
education
with
emphasized so people will
for
high
concern
among health
and society in general.
about
hypertension
blood
pressure) ,
become more
aware of
(used
must
be
the risks,
and what they can do on an individual basis to control these
risks.
The
States
United
hypertension
as
a
condition
consistently exerts too much
the
blood
,~hich
in
Service
a
period
pressure can damage the heart and
defines
the flow of blood
pressure against
Over
vessels.
Health
Public
the walls of
of years, excessive
blood vessels
and result
in premature aging of the arteries (Sharon Johnson, 1985, p.
168).
High blood pressure
heart failure,
increases
determined
that
failure.
30.8
afflicted with the disease,
indirectly
Heart
to
about
Association,
Association (AHA)
of stroke,
1
million
which
million
1986,
Only recently
p.
of three
number of elderly
directly or
deaths per year (American
The
41) •
now estimates
American
Heart
that one out of every five
hypertension, and that
aged 65 or over have the disease.
persons
it has
American workers were
contributes
individuals in the United States has
two out
risk
sudden death, heart attack, peripheral blood
vessel disease, and kidney
been
the
increases,
high
As the
blood pressure
will become a mOFe significant public health problem.
In 1980 three principal areas of concern were expressed
by
the
National
Institute
hypertension control.
of
These
Health
include:
(NIH)
1.)
public's knowledge of high blood pressure,
the adoption
of behaviors
control, and 3.)
regarding
increasing the
2.)
encouraging
conducive to high blood pressure
implementing systems
2
designed to improve
control
The Institute has
2709).
p.
(Lenfant,
methods
conducted various surveys since 1980, and
there is evidence
of progress
in meeting the goals that relate to these areas
of concern.
~ore
respondents than
ever seem
to understand
the consequences of high blood pressure and are taking steps
to
reduce
objectives
potential
risks.
can
be
only
organizations continue to
The
met
if
educate
nation's
both
hypertension
public and private
about
hypertension, and
if individuals make an effort to control the disease.
Definitions
Before
define
discussing
several
further
terms
that
issues,
will
be
it is necessary to
used
throughout the
following pages.
Systolic pressure.
The
pressure on the blood vessels
when the heart muscle contracts (pumping measure);
the level
to which the arterial pressure rises with each contraction.
Diastolic pressure.
when the heart muscle
The pressure in the blood vessels
relaxes (resting
measure); the level
of arterial pressure in the relaxation phase.
Arterial blood pressure.
The force which is exerted by
the blood against the inner walls of the arteries; expressed
in centimeters or millimeters of mercury (em or mm Hg).
Normotensive.
The normal
blood pressure is 90 -
140 mm Hg
accepted range for arterial
for the
systolic pressure
and 60 - 90 mm Hg for the diastolic pressure.
3
Borderline
The
hypertensive.
pressure lies between 140
pressure between
90 and
and 160
range
mm Hg
95 mm Hg.
where systolic
and the diastolic
This corresponds to the
upper limits of the normal statistical range.
Arterial blood
Hypertensive.
systolic pressure
is above
pressure readings where
160 mm Hg and/or when diastolic
pressure is above 95 mm Hg.
A.
process where
essential (primary) hypertension.
no precise
The disease
cause can be detected; 95% of all
cases.
B.
secondary hypertension.
The
disease process
where precise causes can be identified; 5% of all cases.
Aggregate
cost
figures.
indirect) to society.
down into
It is
Total
costs
difficult to
various groupings;
(direct
and
break the total
therefore, these figures must
be estimated.
Cost-effectiveness (of a health
care
practice).
net cost in dollars per unit of health benefits gained.
lower the ratio of
costs to
effectiveness, the
The
The
more cost-
effective a givep health program is.
Opportunity costs.
The
value of the best alternative
use of resources.
Yield (in terms of health).
in the
entire workforce
The extent
is lowered.
available reports of intervention.
4
It
to which risk
is assessed from
Compliance.
(keeping
The extent
appointments,
to which
taking
a person's behavior
medication, executing life-
style changes) coincides with medical advice.
A
Testing procedure.
around
the
arm
just
fabric covered
above
cuff is wrapped
the elbow, and inflated until
blood stops flowing through the artery in the
arm.
Air is
then gradually released to reach the relaxation rate.
To be
really
blood
accurate,
the
physician
should
take
the
pressure reading twice in one visit.
Factors
The previously
definitions.
mentioned definitions are not "perfect"
With regard
to hypertension
there are other
factors that must be taken into consideration before one can
classify a person
as
hypertensive
or
otherwise.
genetic and social factors need to be examined.
part because
arterial
life.
people
As
pressure
age
is
blood
not
be considered
pressure
Because of this "natural
discuss
his/her
normally
with
tends
have
a
the
Gender
normality
lower
a 65
to
rise
year old
for a younger person.
each
to control
p. 96).
account when judging
Women
tendency,
situation
actions should be taken
O'Donnell, 1986,
too high
Age plays a
stable throughout
progressively; therefore, what is normal for
person might
First,
individual should
doctor
to decide what
blood pressure (Michael
must also
of
be taken into
arterial pressure.
arterial pressures than men of
similar age; therefore, with all other things being
5
equal a
woman
has
less
a
chance of falling into the hypertensive
range.
Hypertension
specifically
it
is
a
disease
is
related
unique
to
humans;
to
industrial
more
development.
Primitive populations living apart from the industrial world
are not
11).
affected by
It
seems
protected from
primitive
hypertension (Philippe Meyer, 1980, p.
that
people
in
hypertension as
way
of
populations remain
long as they maintain their
life.
industrialized regions
these
they
If
or adopt
migrate
toward
a style of life similar to
ours, then blood pressure increases become a concern.
Also,
along the lines of social factors, blacks are about twice as
likely as Caucasians to develop high
Wilson, 1986, p. 280).
blood pressure (Thomas
This fact may reflect an interaction
between a modern high-salt diet and genes that
historical scarcity
of salt.
Those persons with ancestors
who consumed little salt are at
genes
tend
to
make
them
adapted to a
greater risk
less
because their
tolerant of the salt in a
modern diet.
Additionally,
family member
wjth hypertension is at a greater risk, which
means
that
component.
hypertension
It
is
anyone
does
difficult
who
indeed
to
has
have
an immediate
a
genetic
demonstrate exactly how
genetic factors intervene, but hypertension is more frequent
in
persons
from
families
with
pressure.
6
a history of raised blood
Along
with
social
and
genetic
there
factors
are
behavioral factors that contribute to raised blood pressure.
A study conducted by Seppo
correlations
between
The
levels.
Aro
various
1984
habits
health-related
smoking, drinking,
in
habits
set
and
he
out
blood
to show
pressure
studied included:
leisure-time physical activity, relative
weight (fat-free weight), and change in weight over the time
of the
study (p.
334).
drawn from employees of
initial
sample
The study
three metal
group
was
strong and
with
both
blood
The study concluded that there
pressure
smoking
Cigarette
pressure.
The
for five (5) years to
consistent association
systolic
on a sample
industry plants.
followed
ensure stability of results.
is a
was based
of relative weight
and
and
diastolic
frequency
blood
of
mild
intoxication were also associated particularly with systolic
Weight
blood pressure.
change was the strongest predictor
of diastolic blood pressure
changes
and
behavior
these factors
which
hypertensive.
A
regarding diet,
modification
can
increase
physician
exercise,
1) .
(Table
change
be used to combat
can
your
can
smoking
Lifestyle
risk
make
of becoming
recommendations
cessation,
and reduced
alcohol consumption.
Finally,
psychological
blood pressure levels.
Israel
Hospital's
factors
Herbert
Division
of
or
Benson,
director
Behavioral
Hypertension Section in Boston, has done
7
stress can effect
of Beth
Medicine
and
research which has
shown
that
when
people
are
under
their
stress,
pressure increases, their muscles tighten, their
blood
heart rate
goes up, and their breathing quickens (Johnson, p. 170).
some circumstances
response
prolonged
is
stress
this
is
but if
appropriate,
damage
can
it
body
the
In
by
overstimulating it, resulting in hypertension.
In
the
study
psychological
done
by
stressors
it
Aro,
can
was
an
have
concluded that
effect
on
blood
pressure; however, it has been difficult
to specify exactly
how
elevation of blood
stress
pressure.
works
to
force
sustained
Stress itself does not
give a
person high blood
pressure, but the person's response to it can.
Physiological cause.
So,
what
pressure?
is
the
Dr. John
and director
H. Laragh,
of the
control
reaction which
turn
causes
M. D.,
has found
mechanism
body
to
off
vessels to
retain
the effect
of either
malfunction in the
a
chemical
chain
constrict. This in
more sodium, as well as
increasing total body fluid (Johnson, p.
believes that
of high blood
Chief of cardiology
that a
sets
causes blood
th~
cause
hypertension and cardiovascular center
at New York Hospital,
kidney's
physiological
168).
Dr. Laragh
narrowed blood vessels
or increased liquid is what creates hypertension.
Treatments
High
controlled.
blood
pressure
has
no
cure,
but
it
can
be
As mentioned previously, behavior changes such
8
as maintaining a desirable weight, reducing
consumption, and smoking cessation
blood pressure
practiced.
blood
control.
Drugs
are
ways
to
assist in
Also, relaxation techniques can be
However, medication is often needed to keep high
pressure
groups of
alcohol
moderating
exercise,
vigorous
increasing
dietary sodium,
under
control.
antihypertensive
acting
on
the
There are three principal
drugs:
nervous
1.)
Diuretics, 2.)
system, and 3.)
Peripheral
vasodilators (Meyer, p. 153).
Diuretics wash
reducing the
walls.
out
salt
amount of
from
water retained
They also reduce the
the brain
(sodium)
and decrease
body by
in the blood vessel
number of
adrenaline.
the
nerve impulses from
This group of drugs is
the most commonly used group to control hypertension.
Drugs
acting
on
adrenergic-inhibiting
tension of the blood
nervous
the
agents.
vessels
system
These
by
are
drugs
blocking
called
reduce
the
the
nervous or
chemical stimuli that cause blood vessels to constrict.
Finally,
peripheral
that
blood
vasodilators
flows
through
relax
the
the
blood
vessels
so
arteries more
easily.
Again, the type and amount of medication taken will
be determined after consultation with a physician.
ECONOMICS OF HYPERTENSION
Health promotion
Hypertension is
American
medicine
one
simply
of
the
because
9
major
challenges facing
it affects a very large
number of people.
The economics
of health
specifically hypertension,
need to
the cost
the benefits
implications and
care, and more
be studied
in terms of
that treatment can
Employers are aware of the financial impact of
bring about.
rising health care costs
because
many
of
them
have been
faced with 20% to 80% increases in these costs over the past
1984, p.
several years (Roger Reed,
these dramatic
Health promotion
assists
the
costs by
their
them
Can
health
risk
elimination/reduction
in
maintaining
question then becomes:
it?
utilizing health promotion.
educates people about health risk factors,
helps people identify
in
result of
dollar increases many companies have decided
to attack health care
them
As a
41) •
corporate
of
factors, assists
these
healthier
risks,
lifestyles.
and
The
Is the health promotion effort worth
health
programs
promotion
have
a
significant impact in reducing risk factors and illnesses?
Aggregate cost figures
There are
two basic
ways in
which information on the
costs of illness and the costs of medical
.
to influence health care decisions.
aggregate
importance
cost
of
figures
a
The second
can
in
health
between
treatment or uses of health care
p.
the
care
is cost-effectiveness
selecting
250).
10
be used
The first is to use the
describe
particular
solution.
help
to
care can
magnitude
problem
or
and/or
analysis which
alternative approaches to
(William B.
Stason, 1983,
The economic costs of an illness are the costs that are
most often brought out
the
economic
estimates are
costs
in the
of
hard to
These costs include
media.
hypertension to society.
come by
because it
Accurate
is difficult to
separate high blood pressure from other risk factors, and it
is difficult to decide how to
value human
life or economic
productivity (Stason, p. 252).
Cost-effectiveness analysis
analysis
Cost-effectiveness
1.)
assumptions:
is
why
costs
effectiveness
managers.
Health care
must
may
be
he
medical
specified
care
physician visits,
of
were
1).
direct
treating
Both costs and
to
different
To
and
develop this
indirect.
Direct
hypertension
include
laboratory examinations, and medications.
Indirect costs include savings
that
limited which
meanings
(Figure
costs;
costs
two
developed a multistage model for the
management of hypertension
model
resources are
different
by
backed
contained, and 2.)
have
Stason has
is
prevented,
costs
in death
of
from strokes, etc.
treating
medication side
effects, and costs of health care in added years of life.
Measures
of
effectiveness
include increased
from
morbidity
treatment
on
considered
in
the
model
life expectancy, improved quality of life
prevented,
the
quality
and
the
of
life.
results are shown in terms of the net
adverse
effects
Cost-effectiveness
dollar cost
per year
of increased quaiity adjusted life expectancy gained.
11
of
that
believes
Stason
hypertensive care are
health care costs.
of the cost
of
extremely
expenditures
unlikely
to
for
reduce total
He estimates that only slightly over 20%
treating
blood pressure
additional
of 105
(initial diastolic
hypertensives
mm Hg
+) will
savings from reduced hospitalization
be recovered through
for strokes
and heart
attacks (p. 258).
How can the results from cost-effectiveness analysis be
used
by
managers?
Results
can
be
used
to
influence
decisions in the allocation of health care resources; within
hypertension
and
areas.
Also,
incentive
to
positive
benefits
implement
should
programs
effects
The
impact,
hypertension
cost-effectiveness
indirect
health care.
limited
between
results by
but
can
showing
be
awareness
lot
a
in
can
provide
evidence of
realized through
themselves will
increased
achieve
other medical
results
by
that
and
have only a
of costs versus
the
direction
of
controlling health care costs.
Studies evaluating cost-effectiveness
The
overview
prece~ing
hypertension" should provide
the
following
studies
effectiveness measures.
on
his
controlled
cost-effectiveness of
which all
of
for
that
have
the
clearer
"Economics
of
understanding of
evaluated various cost-
In 1981 Alexander G. Logan reported
study
that was conducted to assess the
a work-based
care was provided onsite
12
hypertension program in
(p. 211).
Participants
(those with
high blood
for
treatment
either
community
care, Re).
a
from
pressure) were
at
the
physicians
divided into groups
(WS),
worksite
in
private
or
in the
(regular
practice
Those in the WS group were evaluated at entry by
physician,
who
helped
them
a
establish
goal
blood
Hypertensive therapy was initiated and long-term
pressure.
follow-up was
group were
provided on
Those
company time.
also evaluated
in the RC
at entry by a physician and then
given an appointment with their own doctor.
Screening data
respective doctors.
Reassessment at
was sent
to patients'
work was done 6-12 months after program entry.
Costs were assessed for each group and were reported as
the
average
cost
per
patient.
included medical care costs
patient,
screening
for
costs,
and
Costs taken into account
the
organization
treatment
costs.
and the
The
effectiveness measure was the average reduction in diastolic
blood pressure over one year.
Therefore, cost-effectiveness
was calculated as the ratio of the average
to the
average reduction
one year.
by
$31.52
in diastolic
Logan. found that the WS
per
patient
per
blood pressure over
program was
mm Hg.
more costly
year, but that it was able to
achieve an additional reduction in diastolic
of 5.6
cost per patient
blood pressure
This study showed that treatment of employed
hypertensives at their work-place is both more effective and
more
216).
cost-effective
The major cost
than
usual
saving
13
of
care in the community (p.
the
WS
program
was the
reduction
in
patient
The work setting facilitates
cost.
access to care, targets a population
of
are
hypertension
follow-up.
concluded
Logan
have
programs
control
productivity
and
large,
encourages
that
great
longer-term
effective hypertension
potential
reducing
and/or
where the consequences
costs
for
improving
associated
with
absenteeism or premature death.
In
1983
Logan
conducted
another study to assess the
clinical effectiveness and cost-effectiveness
of monitoring
blood
In this study
pressure
of
hypertensives
at
work.
there were again two groups
a
where hypertensives
family doctors
saw their
occupational health nurse (OHN)
regular
care
group where
(RC) group
only, and an
employees were
treated by their family doctor plus the nurse (p. 829).
cost-effectiveness
calculated as
of
the
the ratio
the average reduction in
year.
The
employees
saw
their
programs
was
again
of the average cost per patient to
diastolic blood
occupational
scheduled regular
measure blood
treatment
The
health
family
pressure over one
nurse
physician.
made
The
sure
that
nurse also
visits with employees in the OHN group to
pressures,
to
question
compliance,
and to
communicate results to the family physician.
The results of this study indicate that "monitoring the
blood pressure of hypertensive employees at
work is neither
clinically
(p.
effective
increased cost of
nor
cost-effective"
treatment
brought
14
about
by
835) •
The
hiring and
utilizing the OHN were greater than the improvement of blood
pressure reduction.
treatment dropout
However,
was
determined
that the
rate in the OHN group was 5.5% lower than
This suggests
the RC group.
it
that monitoring
does at least
influence hypertensives, despite the fact that the increased
cost of treatment made this method less attractive.
Logan's two studies have shown that analyzing the costs
and benefits
of various
very complex process.
variables
in
hypertension control programs is a
Managers have to carefully assess the
decisions about any type
appear
that
corporate situation before making
own
their
worksite
of health
care program.
It does
hypertension control programs
~
be
cost-effective; however, excess intervention can be costly.
In 1984, John C.
cost-effectiveness
Erfurt and
study
of
follow-up.
at the four sites.
except
for
a
At
was
initiated,
with
Each plant had a different
Screening procedures were the same
site #1
courtesy
physicians (control
conducted a
hypertension programs in four
automobile manufacturing plants.
approach to
Andrea Foote
letter
site).
no follow-up
sent
At site
to
was conducted
the
employee's
#2 modified follow-up
a blood pressure counselor contacting
each hypertensive employee every 6 months.
At
site #3 full
follow-up was initiated, with contact every 6 months as well
as routine contact with employees' attending physicians.
site #4
an on-site
treatment program
15
At
was implemented with
educational
efforts
put
into
To
place.
assess costs,
detailed daily time records were kept by all project staff.
The
largest
activities,
with
the adequacy
It
was
for
administrative
of blood
follow-up/monitoring
costs
was
pressure control
found
that
lowest at site #2, at $26.26
year, and
the
also
an important
The measure of effectiveness was defined as
consideration.
study.
cost
highest at
at the
end of the
the cost of intervention was
per hypertensive
site #4,
employee per
Site #1 did not
at $96.19.
have any intervention costs since there was no intervention.
It was
the
used only
as a
effectiveness
significant
In computing
basis for comparison.
the
data
improvements
show
in
there
the
were
large
and
number of people who had
their blood pressure under control at the end
of the study,
I
with the
largest improvement
follow-up interventions, each dollar
per client
Across the three
at site #4.
spent
on
resulted in an additional 1% of the hypertensive
This is the
group being maintained under control (p. 897).
reverse of
the cost-effectiveness
annual dollar co~t per
Foote
control
the program
were
able
to
programs
effectiveness
can
additional costs
a
unit of
show
ratio which produces the
that
work-site
blood pressure
be
vary
considerably,
might
incur
adopting a hypertension control program.
16
depending
as
that
but
cost-effective,
can
company
Erfurt and
effectiveness.
a
on
the
result of
Additional considerations
Any
analysis
will
vary
since every
cost to
organizations
program
how costs are
for
employees
their
such
as
costs to whom,
one party can be a benefit to another.
In the previous studies
the
on
Costs must always be specified as
measured.
by
depending
mentioned, the
who
adopted
costs were incurred
a hypertension control
Treatment
employees.
costs
to
the
physician visits, laboratory tests, and
medications were not computed.
Before
making
the
decision
to
implement
a
blood
pressure control program a company must look at many factors
rather than just the cost-effectiveness ratio.
If it can be
demonstrated that savings in employee retirement/replacement
costs, short- and long- term disability payments, and health
care
coverage
premiums
can
be realized, then a work-site
program would probably be feasible.
On the other hand,
might
already
hypertension
etc).
In
a
provide
coverage
intervention
this
firm's
case
current
for
benefit package
various
(off-site
care,
aspects
of
prescriptions,
a manager must evaluate the current
policies and/or programs to determine if it would be wise to
implement
an
on-site
economic factors as
program.
well
as
the
Further consideration of
feasibility
of specific
programs should be well thought out before action is taken.
The selection of a hypertension control program depends
on
cost
considerations;
however,
17
a
minimal
level
of
effectiveness
is
usually
If
expected.
an intervention
program does not produce an adequate level of effectiveness,
then
a
company
might
decide
that
the
necessary to achieve a particular level
worth
it
such as
(to
the
organization).
increased employee
productivity, and
the
program.
For example, if rewards
extensive
expenditure
However, one
is budget.
of effectiveness is
decreased absenteeism can be seen through
extra
constraint on
cost
satisfaction, improved employee
the implementation of a more
worth
additional
to
program
implement
must remember
it
a
that the
may be
work-site
most common
health intervention and/or education programs
If
the
money
is
not
available
then other
alternatives must be considered.
Educational intervention
Up to
this point
discussed in detail.
pressure
control
actual work-site
Another strategy in dealing with blood
involves
educational intervention.
study conducted by Joel C. Cantor
educational
determine
interventions
to
10-
minute
following
the
questions, 2.)
in 1985,
were
three
to
medical
with
visit
the
(again)
phases
used in this study included:
interview
In a
combinations of
evaluated
The
cost-~ffectiveness.
educational program
programs have been
patient
1.)
of the
a 5-
immediately
to clarify problems or other
an educational session
in the
home with an
adult with whom the patient has the most contact, and 3.)
series
of
three,
1-hour
group
18
discussions
centered
a
on
hypertension management
this study measured program
Measures
patient.
risk factors,
ie.
one
two or
efforts
easily integrated
were
that some
three phases.
interventions
effectiveness on most outcomes,
educational
divided so
phase of education while others
multiple
the
that
behavior, appointment-
Study groups were
getting
to the
loss, as well as actual blood
were getting combinations of
found
social costs
effectiveness evaluated behavioral
and weight
pressure readings.
were
costs and
medication-taking
keeping behavior,
persons
of
Costs in
(p. 783).
and compliance
but were
more
showed
costly.
cost-effective,
into currently
Cantor
high
Modified
and
more
existing health programs.
Single interventions, especially the home visit, can be very
effective in improving blood pressure control.
The amount
what a
of
educational
particular company
budgets may be limited,
may vary,
intervention
depends upon
is trying to accomplish.
blood
pressure
Again,
control objectives
and organizational needs may change over time.
manager must remember that
follow-up is
A
the most expensive
component of a tptal intervention/educational program; about
5/6 of the program
screening
involves follow-up
expenses
(Erfurt
and
expenses rather than
Foote,
1977,
p.
340).
However, during subsequent years of follow-up, patients will
require less
time and expense on the part of a company.
is up to various
company
organization stands
managers
to
assess
It
where their
in terms of blood pressure control, and
19
what they
want to
achieve in
can
decision-makers
company
established,
When goals are
the future.
proceed
to
implement programs and changes.
Yield from risk reduction
Another
way
of
approaching
programs from a busineess
~yield~
of
such a
blood
standpoint is
program.
pressure
control
by looking
at the
In terms of health, the yield
from such efforts is the "extent to which risk in the entire
work
force
is
(Laura C. Leviton, 1987, p. 931).
lowered"
Other benefits such as
increased
morale,
image, and
increased productivity
yield
health
for
is
an
company-wide intervention.
well controlled.
entire
range
enhanced company
can be realized, but the
important
justification
a
Only a few workplace studies are
These studies do not always
of
for
represent the
work settings, populations, and outcomes;
therefore, in the study
involving the
yield from workplace
interventions all available reports are presented.
Leviton
being
participation,
reduction.
known
defines
of
group
an
outcomes in workplace studies as
retention,
Participation
at-risk
beginning
the
that
rate
is
intervention
and
is
indicators
involved
An
retained participants
variables can
then be
indicator of
brought
under
multiplied (P
20
at
the
Retention rate is the
proportion of participants still involved at
intervention (R).
risk
the proportion of the
actively
(P) •
of
the end
of an
risk is the portion of
control
( I) .
These
x R x I) to calculate
the
yield
from
proportion of
a
the
considering what
workplace
work
program.
force
would have
who
reduced
risk, without
happened with no intervention.
This figure is important
when a
raw data
a study.
collected from
Gross yield is the
manager is
looking at the
The gross yield can show
the need for intervention when it is evident that there is a
high number
of at-risk
would occurred in the absence
words, the
Net yield reflects what
employees.
of
In other
intervention.
net yield is the gross yield in the intervention
group, minus gross yield in the control group (p. 932).
It seems
hypertension
activity,
that
control
participation
are
including
screening, etc.
the
and
hig~est
smoking
(Table 2).
retention
of
any
cessation,
workplace
cholesterol
With all the attention given to
hypertension over the past decade, one would think
United
control.
States
population
However, as
Health Service
of
has found
are hypertensive have
(Carla L. Barnes 4
rates in
had
gotten
1988,
the
the
that the
problem
United
under
States Public
that only 11% to 24% of those who
their
blood
1988, p. 113).
pressure
under control
This figure conflicts with
the 41.2% figure that Leviton reported in 1987.
Despite the
fact that public awareness about hypertension is high, there
are still thousands of people who
unsuccessfully.
are untreated
At each step of the process, from detection
through long-term follow-up, large numbers of
out of
care.
or treated
patients fall
According to R. Brian Haynes, up to 50% fail
21
to follow through with
who begin
treatment drop
two-thirds of those who
their
of those
out within 1 year, and only about
stay under
medication
prescribed
over 50%
referral advice,
to
care consume
achieve
enough of
adequate
blood
pressure reduction (1982, p. 415).
COMPLIANCE
Problem
Low compliance has been
facing
individuals
with
and still
high
blood
employers and society in general.
to which
major problem
pressure
as well as
Compliance is
the extent
a person's behavior coincides with medical advice.
The "health
model
is a
belief model"
is the
It
compliance.
of
cooperation with
which that
the disease,
says
health advice
person perceives
most common motivational
that
an
depends upon
that he/she
individual's
the extent to
is susceptible to
that the disease is serious, that
treatment is
beneficial, and that the barriers to compliance are possible
to overcome (Haynes, p. 416).
After a person has come to the conclusion that barriers
.
are possible
importance
it becomes easier to enforce the
to overcome,
of
manage patient
sticking
with
treatment.
compliance, accurate
To efficiently
methods of measurement
must be administered.
Monitoring
because
this
awareness about
attendance
is
one
of
at
the
hypertension.
22
appointments
first
Along
is
critical
steps
in developing
with
this, patient
self-reports
directly
are
from
his/her
a
valuable
the
pattern
way of obtaining information
patient.
of
The
patient
medication consumption from monitoring
Pill counts can also provide an
himself.
can determine
accurate estimate
of compliance over time.
Dealing with low compliance
In
order
to
maximize
an employee's compliance it is
essential that his/her blood pressure be
that
oral
and
written
feedback
pressure levels, that the
and that
114).
questions be
Once the
be
checked regularly,
provided about blood
prescribed regimen
encouraged and
patient
is
under
be discussed,
answered (Barnes, p.
care
for hypertension,
additional efforts are usually required to maintain control.
The most
are
successful interventions
characterized
supervision
of
and
Options
factor.
for
for
improved
forgetting
support, encouraging
discussion,
to the
and
between
to
ongoing
interaction
include
compliance
and/or
medications
and
to
self-help
negotiating
Of course,
medication must
the level of
care
is
a
key
rewarding the
lowered
daily
blood
schedules to
inconvenience, encouraging family
through
group
support and
a brief written contract with
the patient for improvements in health
419) .
providers and
conclusion that
attention
pressure, tailoring of
decrease
interactions
This leads
patients.
patient
by
for improving compliance
behavior (Haynes, p.
screening programs must be supported and
be taken
as prescribed
23
to achieve optimal
In
control.
regularly
previous
addition,
scheduled
studies have shown that
essential
also
is
follow-up
for
hypertension control.
Once a
term
person is
control,
the
thinking along
easier
it
otherwise)
is
paper, ie.
conduct
program
control
A
successful.
regular
be
to
stick
with a
Compliance is the sole factor
prescribed treatment program.
in determining if a
will
the lines of longer-
(work
site
based or
program might look good on
screenings,
offer educational
intervention, and even follow-up programs, but if compliance
remains low then the overall problem has not been solved.
CONCLUSION
Goals
The advancements made over
awareness
impressive.
of the
education
and
the
past
decade regarding
hypertension
about
have
In a 1985 national public awareness survey, 92%
adult population were aware that high blood pressure
increases one's chances of having heart disease, and
the population
had had
Public Health
73% of
their blood pressure checked within
the past year (Barnes, p. 113).
under
been
However,
the United States
Service goal of getting 60% of the population
successful
long-term
blood
pressure
control,
is
unlikely to be met.
The fact
that so
many people
still do not have their
blood pressure under control is cause for concern for health
educators,
employers,
and
society in general.
24
Businesses
have found that cost savings can
be realized
if their work
force is healthy and keeps risk factors under control.
is a primary reason for the
concern of
This
managers over their
employee's lifestyles.
Future considerations
For
the
future
it
will be necessary for managers to
emphasize the importance of the benefits
Businesses will
benefit by
gaining a more competitive work
force, and individuals will
that
will
be
seen
in
of healthy living.
benefit
from
themselves.
the improvements
However, for the near
future, most workplace efforts will be fairly low budget and
will
not
have
access
expertise
that
the
to
either
"model"
the
facilities
programs
take
or the
advantage
of
(Leviton, p. 931).
Because
hypertension
is
the
most
prevalent
of all
the
attention
of all
cardiovascular diseases, it deserves
individuals.
programs,
Through
progress
continued
toward
education
obtaining
rates should be realized.
25
and follow-up
improved
compliance
STRESS. BEHAVIOR. AND BLOOD PRESSURE
TABLE 1
AGE-ADJUSTED PAmAL COIII1.AT10N' (r) I!TWEEN PREDICTOI VAIIAIILES AMD BLOOD PRESSulE
tBP) V","UIS AT THI BEGINNING 0' THE FOLLOw·UP " .. 0 a~EM PREDICTOR VAIIAILES AND BP
CHANGE (II • 3881
Yariabfe
S8P
in 197]
(ia (913)
("
Predictor
DBP
in 191]
("
. .lad.. weicbt
0.16
O.ll
Weicht cJIance
lacoxicaIioa
Cipretta per day
PIIysicaI actmly
0.11
0.1"
0.10
0.09
0.01
0.04
_us
• IP in 1971
8' ia 1973.
r a 0.10. P < O.M.
, a 0.13. P < 0.01.
26
S8P chan...
t"
-0.02
0.11
0.04
0.01
0.00
DBPchan __
."
0.'"
0.26
0.1"
0.10
0.0'
,-It.
5.
T.Jfge'
~-
t - ..
.
5,;
SusMc*I
...,..n--
,
S.;
-...
t _-,
Frprr I. Multistage model (or the management ofhypenc:nsion
27
Sp·
T....-.
conttnu.o
tip
S•
ContnMIeG
TABLE 2
VieICI '""" INcrtt
Site FIIISIC
11' ........ -
auPartJQOaQOn
Rate"
c....-
studieS.
MecMn I*'I*'t (al
IV 'al
~ pen:ent (pUCIisMd)§
S1UOeS'
N (puc!iSheG'
Range I*'I*'t (al ssum-J't
A.-lDan,..
MecMn I*'I*'t (II . . . . .
N( ........
~ ~t
FII.auc:nan ~
(pubIisneG)
N (puCIIiSned)
R.-.gel*'l*'t (II ssum-.
ImOI O¥eI!'*It iI iCIiC:atOr:
Mecan pen:81t tal
studIIIS,
s-trII)
o.-_
~.7
~
20
22
66.5
12
1-.
4
50
3
93
15
93
15
77-100
91
15
94.5
12.2
68
32
9.5
25
10
7.8
8
75.4
19
37-91
10
17-100
23
s.a
" . . " cerc:ent (guI)IiSI'IeC)
68
22
23
Range percent (all
studIeS,
,,~
75.2
N(aI~'
N(~)
OlDt . . . .
9-100
23-a9
22.8-G
2
12.2
2
79.3-85
0-16.2
Gress yIIIId
Median pen:ent (all studieS,
N tal StuaMlS'
Mecan percent (puCIiSnea)
N (pucllisneal
Range percent (all studieS)
16.1
41.2
11
12
18.2
41.2
9
12
20.1-01.4 1.4-26.6
*Participation rate in the
hypertension control group
is 75.2%, implying that programs
for high blood pressure are
widely taken advantage of.
*Retention rate in the hypertension
control group is 93%, implying
that most employees actively
participate in hypertension
control programs.
*Improvement was realized bv
68% of the emplovees in the
hypertension control group.
-,
• Ooes not conSlQef' saeen'"9 parncoaQOn (see text,.
t Ranges are vtrtuaIIy me same far pucIISned st1JdIe5 and far total
stuaJes.
: lmorovement InalC3tCB went defined as percent 'NI1t'i 0I00d cressure 140/90 or oetOW. percent QUItting smokll"9. >If mean percent
reduction .n d1OIeSterOI.
§ PuDIIsNa ouu:omes .ncIude orWy tnoIIe
stuCeS.ncauaecs grass
'See text.
Two
1ft ~-nMeWed
ana,. yieIC 0I'IIf.
jowna&L
.
**Twelve (12) studies supplied the above outcomes.
--The gross yield of known hypertensive persons in a
work force whose blood pressure is under control
is 41.2%.
This figure is derived by calculating
participation, retention, and indicator of risk.
--The hypertension control group has had better success than
smoking cessation or cholesterol reduction programs.
28
WORKS CITED
"The Hypertension Threat."
American Heart Association.
40-41.
Futurist.
20 (1986):
Aro, Seppo.
"Occupational
and Blood Pressure:
Medicine.
13 (1984):
Stress, Health-Related Behavior,
A 5-Year Follow-up." Preventive
333-348.
"Worksite Hypertension Control:
A Guide
Barnes, Carla L.
36.3 (1988):
113-116.
to Success." AAOHN Journal.
Cantor, Joel C. et al.
"Cost-effectiveness of Educational
Interventions to Improve Patient Outcomes in Blood
Pressure Control."
Preventive Medicine.
14 (1985):
782-800.
Erfurt,
John
C.
and
Foote,
Andrea.
"Controlling
Hypertension:
A Cost-effective Model." Preventive
Medicine.
6 (1977):
319-343.
Erfurt, John C. and Foote, Andrea.
"Cost-effectiveness of
Worksite Blood Pressure Control Programs." Journal of
Occupational Medicine.
26 (1984):
892-900.
Haynes, R. Brian.
Treatment of
415- 421.
"Management of Patient Compliance in the
Hypertension."
Hypertension.
4 (1982):
Johnson, Sharon.
"Facts on Hypertension."
168-171.
10 (1985):
Working Woman.
Lenfant, Charles.
"Advancements in Meeting the 1990
Hypertension Objectives."
Journal of the American
Medical Association. 257.20 (1987):
2709, 2718 .
•
Leviton, Laura L.
"The Yield from Worksite Cardiovascular
Risk Reduction."
Journal of Occupational Medicine.
29.12 (1987): 931-935.
Logan, Alexander G.
"Clinical Effectiveness and Costeffectiveness
of
Monitoring
Blood
Pressure
of
Hypertensive Employees at Work."
Hypertension.
5
(1983):
828-838.
Logan,
Alexander G.
"Cost-effectiveness of a Worksi te
Hypertension Treatment Program."
Hypertension.
3
(1981):
211-218.
29
Meyer, Philippe. Hypertension: Mechanisms and Clinical and
Therapeutic Aspects. Oxford:
Oxford University Press,
1980.
O'Donnell, Michael.
"Hypertension May Seem Trivial, But
It's Worth Worrying About."
International :vianagement.
41.4 (1986): 96.
"Is Education the Key to Lower Health
Reed, Roger W.
41-46.
63.1 (1984):
Personnel Journal.
Costs?"
Stason, William B.
Economics of Hypertension.
Martinus Nijhoff Publishers Group, 1983.
Wilson,
Thomas.
Science News.
Roots
"Historical
280.
129 (1986):
30
of
Boston:
Hypertension."
Activity Summary-Blue Cross Blue Shield
Spring 1988
Part B
I have
spent the quarter doing research on hypertension for
my thesis paper, as well as learning about
of Wellness
apolis.
various other aspects
while working with Blue Cross Blue Shield in Indian-
Cathy Nordholm,
Hypertension
Coordinator
in
the Blue
Cross Blue Shield Wellness Resource Center, has been my guide and
has provided me with several contacts
have had
the opportunity
have learned
a lot
in the
Wellness area.
I
to meet with a variety of people and I
about health
related issues
and the impli-
cations they have for business.
The
Wellness
Resource
Center
provides information and training
methods/programs.
Healthy
Best,
These
worksite
at
Cross Blue Shield
to businesses
include
based
Blue
Stay
high
Alive
blood
through several
and
Well, Your
pressure
control,
wellness payroll stuffers, and health booklets.
Stay Alive and Well is a cost-effective program that helps a
company manage health care costs.
personal
health
survey
followed
The
by
program
a
mini-exam
Results are then reviewed with the person and
analyzed.
Finally,
vention groups
to
employees
modify
their
are
begins
with a
(physical).
the information is
assigned to various inter-
behavior,
and
follow-up then
takes place.
Your Healthy Best is a self-help program where employees are
taught positive motivation techniques
goals for
change.
and
how
to
set personal
This program is flexible and uses any number
of mediums including a video, guide book, personal fitness diary,
31
self-help
files.
and
newsletter,
handbook,
lifestyle assessment pro-
An employee can do as much or as
little as
he/she would
like toward making positive changes in his/her lifestyle.
The worksite
set up to help
based high
employees of
pressure control.
The
blood pressure
a company
control program is
gain and
maintain blood
program includes informing all employees
about high blood pressure, screening employees to detect possible
causes of
blood
high blood pressure, referring all employees with high
pressure
readings
to
their
physicians,
and
long-term
monitoring of diagnosed hypertensives at the worksite.
Wellness
payroll
stuffers
are
used
about the use of health
care
inexpensive way
employer to provide positive health tips
for an
services.
to educate employees
The
stuffers
are an
and information on taking better care of one's self.
Finally,
issues.
health
booklets
Books available
are
include:
available
on
vital health
Feel Better, Food & Fitness,
Stress, and the Self-Help Handbook of Symptoms and Treatments.
These programs offer
a
variety
of
methods
to
company's employees about the importance of wellness.
in the Resource Center are knowledgeable about the
and how
wellness relates
from
Wellness
employees and at the
The people
wellness area
to the "business aspects" of running a
company in terms of cost savings, etc.
realized
educate a
education
company level
cents.
32
at
There are
a
in the
benefits to be
personal
form of
level
for-
dollars and
The
following
information
spent
Center.
Tuesday
afternoons
and
I was able to meet with
their jobs
a
summary of my activities
I travelled to Indianapolis
throughout the quarter.
and
is
Wednesday
at
several people
this Spring
the Wellness
and learn about
as well as participate in other activities pertaining
to my areas of interest.
3/15-16
ist at
Met with Phyllis Mendenhall,
Blue Cross
Blue Shield.
job in personnel, and
what a
job in
Ms. Mendenhall talked about her
passed along
human resources
Senior Personnel Special-
some valuable
involves.
insight as to
She informed me about
how the personnel function at Blue Cross Blue Shield is organized
and how
the various other Blue Cross offices fit into the scheme
of things.
We talked about recruitment, compensation, training, and the
Blue Cross
Blue Shield
purpose of this contact
human resource
Human Resource
Information Center.
was for
learn more
manager actually
me to
exempt
vs.
non-exempt
job analysis by way ot
about what a
does on-the-job.
the various "personnel terms" that Ms.
The
I understood
Mendenhall used,
such as
employees, corporate salary surveys, and
the
point
method.
The
information I
gained was helpful and I was glad to have the opportunity to talk
with someone in this type of position.
3/15-16
Blue Cross
~et
with Jan Ranger of Key
Blue Shield).
with various companies
in
Health Plan
(subsidiary of
Jan is a Wellness Specialist and works
a
consulting
33
capacity.
She gives
presentations
in
the
areas
of
CPR, smoking cessation, stress
management, weight control, and high blood pressure education.
My meeting with Jan was very informative.
differences
between
the
ceeded to talk about
she does.
This
various
the types
She explained the
types of HMO's, and then pro-
of presentations
and other work
meeting provided me with a better understanding
of how a "manager" functions in the wellness area, and it left me
feeling optimistic that there are job opportunities in a business
setting for persons interested in wellness.
4/12-13
I
Scientific,
listened
give
analysis system.
a person's
a
Wayne
sales
Hedden,
President
presentation
on
of Valhalla
a body composition
This was basically a computer that hooks
body by
percent body fat,
to
way of
total body
up to
electrodes and then determines one's
water,
target
weight
range, etc.
The presentation was interesting because I had never seen a piece
of equipment such as the one he demonstrated.
observe an
actual sales
pitch which
I was also able to
made me take a look at the
technique, style, and approach that were used.
4/19-20
I attended a conference
Health Educators.
Indiana Association of
The Association held their spring meeting, as
well as having a
dinner and
with
and
networking
of the
health related fields.
I
speaker.
was
The
The evening
started out
able to meet several new people in
speaker,
Dr.
Roger
Indiana Heart Institute, had a varied background:
degree in Personnel Management,
his master's
34
Pinto
of the
his bachelor's
degree in Exercise
Physiology, and
"Helping Behavior Changes Stick:
He
Relapse".
focused
on
healthy habits.
sizing the gains to
be
The Prevention and Treatment of
correcting
smoking), and
(alcoholism, overweight,
the new,
Dr. Pinto spoke on
his doctorate in Psychology.
undesirable
then on
behaviors
how to maintain
He tied everything together by empharealized
by
the
individual
(and also
acquaintances and employers), if he/she took control and actively
pursued a healthy lifestyle.
given by
I attended a lecture
Nutrition expert
- New
benefits of
healthy
hazards
smoking,
of
positive effects of a
the
She
Health and
Brody spoke about the
Ms.
York Times.
living.
Jane Brody,
specifically
addressed the
importance of good nutrition, and the
regular
exercise
program.
The lecture
reinforced my commitment to healthy living and was inspirational.
My only concern was that people are often motivated after hearing
a
lecture
such
as
this
one,
implementing long-term changes.
but
do
not carry through with
It's easy
to talk
about these
health issues but permanent changes are often difficult to make.
~
I
attended
a
presentation
Wellness Consultant-Blue Cross Blue
Memorial Hospital.
Janet
program, which is one of the
are members
of the
by
Shield, at
Janet
ZeBell,
the Henry County
was promoting the Stay Alive and Well
benefits provided
Preferred Care
about the purpose of her visit;
interest in
given
network.
which was
She talked briefly
to inform
this particular wellness program.
35
to hospitals who
and elicit
There was a brief
slide presentation, and then Janet went
through the
contents of
the packets she had brought along.
In
this
presentation
there
was
no
pressure
put on the
hospital administrators since the program is available to them at
no charge.
The hospital only has to purchase the materials from
the Resource
charge.
Center, while
the training,
done free of
So what does Blue Cross Blue Shield get out of
this wellness program to members of the
from the
Stay
pcr
system?
~giving"
They benefit
networks that are created once a hospital gets involved
with the program.
the
etc. is
Alive
The hospitals are free
and
Well
material
to market
and promote
as it suits their needs or
particular situations.
I learned
very poised
credible.
a lot
from observing
and convincing,
this exchange.
and I felt she came across as being
I sensed that Blake and Elaine (of the
receptive toward
the program,
implemented.
wellness concept, but
evidence backing
r
realize
I
know
the. concept
hospital) were
but were being realistic in their
thinking that changes take a good amount of
fully
Janet was
the
that
are the
work.
36
time to
importance
seeing
actual
keys to
be successof
the whole
results and
making a program
Conclusion
These meetings and
expert views
on Wellness
earned a lot about
are many
activities
and Personnel
various positions,
career paths
that I
The practical experience I
valuable asset
have
when I
given
start my
decision-making role.
37
exposure to
I have
related issues.
and I
'could choose
have
me
gained
realize that there
with my background.
should
prove
to
be a
own career and find myself in a