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Blood Pressure Screening and Control

Doctor taking blood pressureOnce a company has conducted assessment and planning for blood pressure screening and control programs, and developed the specific tasks of implementation for these programs, it is time to develop the evaluation plan. This evaluation plan should be in place before any program implementation has begun.  

Metrics for worker productivity, health care costs, heath outcomes, and organizational change allow measurement of the beginning (baseline), middle (process), and results (outcome) of workplace health programs. It is not necessary to use all these metrics for evaluating programs. Some information may be difficult or costly to collect, or may not fit the operational structure of a company. These lists are only suggested approaches that may be useful in designing an evaluation plan. For blood pressure screening and control programs, key areas of evaluation include measures to track improvements in blood pressure screening and control outcomes and organizational changes to support blood pressure screening and control such as:

  • Have the number of employees screened for high blood pressure increased over the past year
  • Have the number of employees with high blood pressure who made changes to their lifestyle (e.g., lost weight , quit smoking) following screening and counseling increased over the past year
  • Does the worksite offer on-site screening programs and referrals including lifestyle counseling for those employees with high blood pressure
  • Does the worksite have policies and environmental strategies regarding blood pressure screening and control

These measures are designed for employee group assessment. They are not intended for examining an individual’s progress over time, which would raise concerns of employee confidentiality. For employer purposes, individual-level measures should be collected anonymously and only reported (typically by a third party administrator) in the aggregate, because the company’s major concerns are overall changes in productivity, health care costs, and employee satisfaction.

In general, data from the previous 12 months will provide sufficient baseline information and can be used in establishing the program goals and objectives in the planning phase, and in assessing progress toward goals in the evaluation phase. Ongoing measurements every 6 to 12 months after programs begin are usually appropriate measurement intervals, but measurement timing should be adapted to the expectations of the specific program. 

Hypertension is one of the 10 most expensive health conditions for U.S. employers.1

  • One in three Americans have high blood pressure and it is more common in African Americans and older adults2
  • Hypertension (i.e., high blood pressure) is the most common primary diagnosis in the United States and is responsible for 35 million office visits each year3
  • The estimated direct and indirect cost of High Blood Pressure for 2010 is $76.6 billion2

Chronic high blood pressure can cause heart disease, stroke, kidney disease, and blindness. The purpose of blood pressure screening is to identify people with high blood pressure levels and refer them for clinical evaluation and treatment.

In 2010, the economic costs of cardiovascular diseases and stroke were estimated at $444.2 billion, including $272.5 billion in direct medical expenses and $171.7 billion in indirect costs16

The United States Preventive Services Task Force recommends:

  • Clinicians screen adults aged 18 and older for high blood pressure

High blood pressure is treated by a combination of medication and lifestyle changes. Worksite programs related to physical activity, nutrition, alcohol use, stress, type 2 diabetes, and obesity can aid employees in reducing high blood pressure. Controlling blood pressure with medications is one of the most cost-effective methods of reducing premature cardiovascular morbidity and mortality.

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Worker productivity measures for blood pressure screening and control1,4-12,15

Healthier employees are less likely to call in sick. Employees with multiple heart disease and stroke risk factors such as high blood pressure and high cholesterol cost employers more in terms of medical care, absenteeism, and lost productivity than employees with one or none of these risk factors. Companies can sometimes assess sick day use to determine whether health programs are increasing worker productivity.

Baseline

  • Individuals with high blood pressure may be absent more often than individuals with normal blood pressure or those who have their blood pressure under control (e.g., with medication). Measure the average number of sick days for individuals with high blood pressure, over the previous 12 months
  • Chronic high blood pressure can cause heart disease, stroke, kidney disease, and blindness. Companies can measure the average number of sick days related to these complications of high blood pressure, per employee, over the previous 12 months. For example:
    • What are the average number of sick days due to diagnosed heart attack (total number of sick days due to heart attack divided by total number of employees)
    • What are the average number of sick days due to rehabilitation after stroke
    • This measure may be less useful if there has been a large increase or decrease in numbers of employees over the past 12 months
  • Determine costs for worker absenteeism related to high blood pressure and its complications such as heart disease, including costs of replacement workers, costs in training replacement workers, and lost and delay in productivity
  • Determine the time employees spend during working hours participating in blood pressure screening worksite programs or lifestyle programs that can control high blood pressure such as physical activity, nutrition, alcohol use, stress, type 2 diabetes, and obesity
  • Additional validated surveys have been developed to provide employers with information about the indirect costs of untreated or undertreated employee health issues such as high blood pressure. Employers who use these health and productivity surveys on an ongoing basis can begin to evaluate the return on investment (ROI) of offering blood pressure screening and control programs on employee absence or productivity. These surveys may be proprietary and may require a modest fee to use. Two examples are provided below:

Process

  • Re-assess the average number of sick days for high blood pressure and its complications per employee at the first follow-up evaluation
    • If employee education programs are successful, these measures may increase in the short term as screening and detection rates increase
  • Periodic repeats of other baseline measures
     

Outcome

  • Assess changes in the average number of sick days for high blood pressure and its complications per employee in repeated follow-up evaluations
  • Assess changes in time employees spend during working hours participating in blood pressure screening worksite programs or lifestyle programs that can control high blood pressure
  • Assess changes in costs from baseline

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Health care costs measures for blood pressure screening and control1,4, 5,13-15

In contrast with the worker productivity costs described above, health care costs are measures of the direct medical expenses of providing employee health care and preventive health programs.

Baseline

  • Determine costs and use for health care such as screening, treatment (e.g., medications), and hospitalizations for employees with high blood pressure who have complications of heart disease, stroke, kidney disease, and blindness
  • Determine the health care use and costs of employee participants before and after a blood pressure screening and control intervention such as counseling or referral for treatment and follow-up to control blood pressure

Process

  • Periodic repeats of baseline measures

Outcome

  • Assess changes in health care use and costs from baseline
  • Compare health care use and costs of employee participants before and after a blood pressure screening and control intervention such as counseling or referral for treatment and follow-up to control blood pressure

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Health outcomes measures for blood pressure screening and control1,4, 5,13-15

The effectiveness of blood pressure screening and control programs depends on the intensity of program effort and the use of multiple interventions. A rule of thumb is that the more programs implemented together as a package or campaign, the more successful the interventions will be.

Baseline

Process

  • Periodic repeats of baseline measures

Outcome

  • Assess changes in the numbers of employees receiving blood pressure screening
  • Assess changes in the percentage of employees who report high blood pressure levels
  • Assess aggregated changes in the percentage of employees with health behaviors or conditions where individuals have a higher risk associated with high blood pressure such as overweight, type 2 diabetes, nutrition (a high sodium intake increases blood pressure in some people), heavy and regular use of alcohol, or being physically inactive
    • The percent of employees identified through medical claims data as having high blood pressure will remain the same or increase, since a person who has been diagnosed with high blood pressure keeps that diagnosis permanently. However, over time medical claims data should show a decrease in the complications of high blood pressure (e.g., heart disease, stroke, kidney disease, and blindness)
  • Determine change in levels of diagnostic and treatment procedures from health care and pharmaceutical data
  • Assess changes in employee knowledge, attitudes, and beliefs about blood pressure screening and control
    • Evaluate changes in employee knowledge of the health benefits of screening and control for high blood pressure
    • Measure changes in employee’s knowledge of their risks for high blood pressure
    • Assess changes in employee awareness of existing workplace blood pressure screening and control programs, policies and benefits
    • Assess changes in employee awareness of behaviors that may reduce high blood pressure risk
       

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Organizational change measures for blood pressure screening and control1,4, 5,13-15

Regular blood pressure screening for employees, along with other health behaviors, requires ongoing support from employers. New programs can be added over time and evaluated periodically for their effectiveness. For best results, recognition of the benefits of blood pressure screening should become an inherent part of organizational change and corporate culture.

Measuring organization change is an assessment of company-initiated programs and policies that affect most employees regardless of their health status (e.g., changes of food options in the cafeteria, establishing walking trails on the company campus). These efforts need to be integrated for greatest effectiveness and will require time for full implementation. Regular measures of employee attitudes and program development are key in determining whether new programs are effective or require further adaptation to prevent continuing investment in ineffective efforts.

Baseline

  • Determine workplace barriers to regular employee blood pressure screening and control programs
  • Assess current workplace supported blood pressure screening and control programs (during the past 12 months)
    • List current blood pressure screening and control options for employees through worksite and identify number of employees (i.e., participation) using each option. Examples:
      • Number of blood pressure screening and control programs (e.g., on-site screening programs, education seminars, workshops or classes, individual counseling) and participation in these programs
      • A clinical referral and follow-up program including lifestyle counseling for screened employees with high blood pressure
      • Availability of educational materials (e.g., brochures, videos, newsletters) on blood pressure screening and control and health risks associated with high blood pressure
      • Number of communications/media campaigns regarding blood pressure screening and control
      • Number of health-related policies that enhance worksite lifestyle programs to help employees control their blood pressure (e.g., physical activity and nutrition)
      • Number of environmental strategies to support activities for lifestyle change can be used to reduce high blood pressure among employees (e.g., physical activity and nutrition)
      • Number of worksite blood pressure monitoring devices available for employees to perform self-assessments as well as information or training on these devices
      • Number of partnerships with community resources for blood pressure screening and control such as the American Heart Association, local health department, local hospital, etc
    • Determine costs of current company blood pressure screening and control programs such as:
      • Staffing, equipment, and space
      • Employee time to participate in blood pressure screening programs during work hours (e.g., education, lifestyle counseling)
      • Incentives tied to blood pressure screening programs
      • Costs of current company programs on physical activity, nutrition, alcohol use, stress, type 2 diabetes, and obesity, which are the key worksite-based programs that can affect high blood pressure
    • Conduct survey of employee satisfaction with current workplace supported blood pressure screening and control programs

Process

  • Reassess barriers to employee engagement in blood pressure screening and control programs
  • Document steps taken and progress toward implementing each intervention selected
    • List numeric goals (e.g., desired increases in employee screening rates) in each form of intervention within a designated time period (e.g., 12 months from startup):
      • Employee reach (e.g., number of educational pamphlets distributed)
      • Employee participation (e.g., number of desired participants in blood pressure screening)
    • Describe timeline for implementation of each planned intervention (e.g., length of time and timing of tasks to develop, initiate, and conduct a mass campaign)
    • Create a baseline budget for new interventions including classes, instructors, classroom space, materials, incentives, etc
    • Identify opportunities for new partnerships with community groups who provide blood pressure screening and control programs (e.g., The American Heart Association, local health department, local hospital, etc.)
  • Reassess employee satisfaction regarding workplace supported blood pressure screening and control programs

Outcome

  • Measure reductions in the number and type of employee barriers to blood pressure screening and control programs
  • Assess changes in workplace blood pressure screening and control programs including progress in achieving goals and in implementation of each intervention (e.g., length of time and timing of tasks to develop, initiate, and conduct a mass campaign)
    • Measure changes in the number of blood pressure screening and control options for employees through the worksite and changes in employee participation using each option before and after the blood pressure screening and control program or campaign. Examples:
      • Number of new programs developed and offered to employees including the number of employees screened and referred for clinical follow-up and lifestyle counseling if found to have elevated blood pressure levels
      • Number of new educational materials developed and made available to employees
      • Number of new workplace communications/media campaigns such as posters and brochures
      • Number of new workplace policies and environmental strategies regarding blood pressure screening and control (e.g., number of worksite blood pressure monitoring devices available for employees to perform self-assessments as well as information or training on these devices)
      • Number of new partnerships with community groups to enhance access and opportunity for employee blood pressure awareness and screening
    • Assess changes in program costs from baseline (so that a return-on-investment can be calculated)
      • Increases in staffing or equipment needs due to new program offerings
      • Changes in employee participation time during work hours (e.g., education, lifestyle counseling)
      • New incentives or benefits or changes in existing incentives or benefits based on employee participation
      • Changes in costs of current company programs on physical activity, nutrition, alcohol use, stress, type 2 diabetes, and obesity, which are the key worksite-based programs that can affect high blood pressure
    • Assess changes in survey responses for employee satisfaction following implementation of a workplace supported blood pressure screening and control program and compare with baseline

Depending on goal success, evaluate the need to adjust workplace programs.

 

Tools and Resources

Blood Pressure Screening and Control Baseline Measures

The assessment tools described in the assessment module include specific questions related to blood pressure screening and control.

  Health-related Programs

  • Q11; Q12; Q13; Q20,b,c,e,f,h; Q21d,f,g; Q22; Q23; Q24a,b,c,d,e,h,i,j; Q26, Q27; Optional Questions A, B, C, I, J, K, L, M, OO

  Health-related Policies

  • Q28a,b,c,e

  Health Benefits

  • Q29; Q30; Q31; Q32; Q33; Q34; Q36; Q37; Optional Questions T, U, V, W, Y, Z, AA

  Environmental Support

  • Q24g; Q39; Q40; Q41; Q43; Q45; Q46; Q47; Optional Questions CC, DD, EE, FF, GG, HH, JJ, LL, NN

Additional Tools

  • In addition to the following suggestions for measures of worker productivity, health care costs, health outcomes, and organization change in blood pressure screening and control programs, see measurement recommendations for obesity, physical activity, nutrition, alcohol misuse, stress, and type 2 diabetes
  • CDC Health Scorecard [PDF – 3.5MB] developed by the Centers for Disease Control and Prevention (CDC), the Health Scorecard is a tool designed to help employers assess the extent to which they have implemented evidence-based health promotion interventions or strategies in their worksites to prevent heart disease, stroke, and related conditions such as hypertension, diabetes, and obesity.
  • Health Risk Appraisals at the Worksite: Basics for HRA Decision Making [PDF - 2.3MB] is a guide developed by the National Business Coalition on Health in collaboration with the Centers for Disease Control and Prevention (CDC) in the selection and use of health risk appraisals in the workplace available for employers
  • The CDC Healthy Communities Program developed the Community Health Assessment and Group Evaluation (CHANGE) assessment tool to provide communities with a picture of the policy, systems, and environmental change strategies currently in place throughout the community, where gaps exists and facilitate action planning for making improvements. The CHANGE tool address five community sectors including worksites and health indicators related to physical activity, nutrition, tobacco use, chronic disease management, and leadership

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