Can a collective-impact initiative improve well-being in three US communities? Findings from a prospective repeated cross-sectional study.

INTRODUCTION: Communities are seeking to learn if and how they can improve the well-being of their residents. We therefore examined the impact of a community-led, collective-impact initiative, deployed through Blue Zones Project by Sharecare, aimed at improving health and well-being in one set of US communities. METHODS: We used data from cross-sectional surveys of the Well-Being Index (2010-2017) to assess how the Life Evaluation Index (LEI) in Hermosa Beach, Manhattan Beach and Redondo Beach in California (Beach Cities) changed over time and how this change compares with change for similar cities (Beach Cities-like) and for the USA as a whole. We examined types of interventions, perceived impacts, and relationships between intervention type and change in LEI. RESULTS: The Beach Cities experienced greater increases in LEI than Beach Cities-like communities and the nation. The entire portfolio of interventions was positively associated with change in LEI in the Beach Cities (+1.12, p=0.012), with process-oriented interventions most closely associated with improvement. CONCLUSIONS: Community-led collective action that leverages community engagement and activation, strategic use of programming and large-scale built-environment and policy change can improve health and well-being at scale.

Trends and geographical variation in population thriving, struggling and suffering across the USA, 2008-2017: a retrospective repeated cross-sectional study.

OBJECTIVES: Well-being is a holistic, positively framed conception of health, integrating physical, emotional, social, financial, community and spiritual aspects of life. High well-being is an intrinsically worthy goal for individuals, communities and nations. Multiple measures of well-being exist, yet we lack information to identify benchmarks, geographical disparities and targets for intervention to improve population life evaluation in the USA. DESIGN: Using data from the Gallup National Health and Well-Being Index, we conducted retrospective analyses of a series of cross-sectional samples. SETTING/PARTICIPANTS: We summarised select well-being outcomes nationally for each year, and by county (n=599) over two time periods, 2008-2012 and 2013-2017. MAIN OUTCOME MEASURES: We report percentages of people thriving, struggling and suffering using the Cantril Self-Anchoring Scale, percentages reporting high or low current life satisfaction, percentages reporting high or low future life optimism, and changes in these percentages over time. RESULTS: Nationally, the percentage of people that report thriving increased from 48.9% in 2008 to 56.3% in 2017 (p<0.05). The percentage suffering was not significantly different over time, ranging from 4.4% to 3.2%. In 2013-2017, counties with the highest life evaluation had a mean 63.6% thriving and 2.3% suffering while counties with the lowest life evaluation had a mean 49.5% thriving and 6.5% suffering, with counties experiencing up to 10% suffering, threefold the national average. Changes in county-level life evaluation also varied. While counties with the greatest improvements experienced 10%-15% increase in the absolute percentage thriving or 3%-5% decrease in absolute percentage suffering, most counties experienced no change and some experienced declines in life evaluation. CONCLUSIONS: The percentage of the US population thriving increased from 2008 to 2017 while the percentage suffering remained unchanged. Marked geographical variation exists indicating priority areas for intervention.

Associations between community well-being and hospitalisation rates: results from a cross-sectional study within six US states.

OBJECTIVE: To evaluate the association between community well-being, a positively framed, multidimensional assessment of the health and quality of life of a geographic community, and hospitalisation rates. DESIGN: Cross-sectional study SETTING: Zip codes within six US states (Florida, Iowa, Nebraska, New York, Pennsylvania and Utah) MAIN OUTCOME MEASURES: Our primary outcome was age-adjusted, all-cause hospitalisation rates in 2010; secondary outcomes included potentially preventable disease-specific hospitalisation rates, including cardiovascular-related, respiratory-related and cancer-related admissions. Our main independent variable was the Gallup-Sharecare Well-Being Index (WBI) and its domains (life evaluation, emotional health, work environment, physical health, healthy behaviours and basic access). RESULTS: Zip codes with the highest quintile of well-being had 223 fewer hospitalisations per 100 000 (100k) residents than zip codes with the lowest well-being. In our final model, adjusted for WBI respondent age, sex, race/ethnicity and income, and zip code number of hospital beds, primary care physician density, hospital density and admission rates for two low-variation conditions, a 1 SD increase in WBI was associated with 5 fewer admissions/100k (95% CI 4.0 to 5.8; p<0.001). Results were similar for cardiovascular-related and respiratory-related admissions, but no association remained for cancer-related hospitalisation after adjustment. Patterns were similar for each of the WBI domains and all-cause hospitalisations. CONCLUSION AND RELEVANCE: Community well-being is inversely associated with local hospitalisation rates. In addition to health and quality-of-life benefits, higher community well-being may also result in fewer unnecessary hospitalisations.

Use of Well-Being in Identification of Members With Future Health Risk Factors and Future Diagnosed Chronic Disease.

OBJECTIVE: To evaluate if well-being is associated with the development of future health risks or incidence of new chronic disease. METHODS: A retrospective cohort study was employed using longitudinal well-being assessment survey data from participants of a Fortune 500 US company wellness program, claims based International Classification of Diseases, Ninth Revision diagnoses, and Cox proportional hazards models to assess associations between well-being and well-being change with future health risk and chronic disease incidence. RESULTS: Individuals who maintained high well-being and those who increased their level of well-being displayed a significantly decreased hazard of accruing new health risk and new chronic disease incidence; those whose well-being worsened over time showed significant increases in health risk and hazard of new chronic disease incidence. CONCLUSIONS: Well-being levels and change over time are significantly associated with future development of health risk and disease incidence.

Impact of a scalable care transitions program for readmission avoidance.

OBJECTIVES: To evaluate the Care Transition Solution (CTS) as a means to improve quality through reduction of preventable hospital readmissions among patients with readmission-sensitive conditions subject to penalties imposed by the Affordable Care Act. STUDY DESIGN: A retrospective quasi-experimental evaluation of the impact of the CTS among admitted patients diagnosed with heart failure, acute myocardial infarction, chronic obstructive pulmonary disease, and/or pneumonia (CMS readmission-penalty diagnoses) in 14 acute care hospitals in Texas. The program, designed for scalable delivery, incorporated identification of high readmission-risk patients, assessment of individual needs, medication reconciliation, discharge planning, care coordination, and telephonic postdischarge follow-up. METHODS: The treatment group of program enrollees (N = 560) and the comparison group with no program contact (N = 3340) were matched on 8 coarsened demographic, diagnosis, and severity variables associated with readmission risk. Assessed outcomes included relative risk and odds of readmission within 30 days postdischarge and overall within the 6-month evaluation period. Zero-inflated Poisson multivariate models were used to estimate intervention effects controlling for matching-generated weights, age, disease status, and period of evaluation. RESULTS: Treatment group risk of readmission was 22% lower overall (incidence rate ratio [IRR], 0.78; P < .01) and 30-day readmission risk was 25% lower (IRR, 0.75; P = .01) relative to the comparison group. Odds of any or 30-day readmission were 0.47 (95% CI, 0.35-0.65) and 0.56 (95% CI, 0.41-0.77), respectively, for treatment relative to comparison. CONCLUSIONS: Participation in the CTS resulted in significantly lower rates of readmissions among patients with readmission-sensitive conditions, offering a scalable and sustainable approach to reduce the number of preventable hospital readmissions.

Well-being improvement in a midsize employer: changes in well-being, productivity, health risk, and perceived employer support after implementation of a well-being improvement strategy.

OBJECTIVE: To evaluate employee well-being change and associated change in productivity, health risk including biometrics, and workplace support over 2 years after implementation of a well-being improvement strategy. METHODS: This was an employer case study evaluation of well-being, productivity (presenteeism, absenteeism, and job performance), health risk, and employer support across three employee assessment spanning 2 years. Employee well-being was compared with an independent sample of workers in the community. RESULTS: Well-being and job performance increased and presenteeism and health risk decreased significantly over the 2 years. Employee well-being started lower and increased to exceed community worker averages, approaching significance. Well-being improvement was associated with higher productivity across all measures. Increases in employer support for well-being were associated with improved well-being and productivity. CONCLUSIONS: This employer's well-being strategy, including a culture supporting well-being, was associated with improved health and productivity.

Impact of a senior fitness program on measures of physical and emotional health and functioning.

The SilverSneakers fitness program is a health plan benefit for Medicare beneficiaries that provides older adults with fitness center membership, customized group exercise classes, and a supportive social environment that promotes socialization among participants. This study evaluated the impact of the SilverSneakers program on physical and emotional health and activities of daily living (ADLs). A quasi-experimental retrospective analysis compared annual survey responses from SilverSneakers members (treatment N=5586) to a matched national random sample of Medicare Advantage organization beneficiaries (comparison N=22,344) in Cohort 10 of the Medicare Health Outcomes Survey. Matching was performed based on 6 demographic and 6 disease status variables. Survey responses from 2007 and 2009 were evaluated using categorical and logistic regression analysis. The treatment group showed significantly better physical and emotional health and lower impairment in both 2007 and 2009, less impairment for 4 of 6 ADLs in 2007, and all 6 in 2009, and a higher average number of days of good health within the prior month for both years. Three-year longitudinal analyses indicated a significantly more favorable survey response trend for the treatment group for nearly all measures of health and ADLs. Members who exercised less frequently had poorer health and functioning. Overall, participation in the SilverSneakers program was associated with more favorable overall physical and social/emotional health status and fewer activity impairments, suggesting that the provision of senior-oriented group fitness programs may be a valuable approach to improve quality of life and reduce the burden associated with declining health and functioning as older adults age.

Exploring robust methods for evaluating treatment and comparison groups in chronic care management programs.

Evaluation of chronic care management (CCM) programs is necessary to determine the behavioral, clinical, and financial value of the programs. Financial outcomes of members who are exposed to interventions (treatment group) typically are compared to those not exposed (comparison group) in a quasi-experimental study design. However, because member assignment is not randomized, outcomes reported from these designs may be biased or inefficient if study groups are not comparable or balanced prior to analysis. Two matching techniques used to achieve balanced groups are Propensity Score Matching (PSM) and Coarsened Exact Matching (CEM). Unlike PSM, CEM has been shown to yield estimates of causal (program) effects that are lowest in variance and bias for any given sample size. The objective of this case study was to provide a comprehensive comparison of these 2 matching methods within an evaluation of a CCM program administered to a large health plan during a 2-year time period. Descriptive and statistical methods were used to assess the level of balance between comparison and treatment members pre matching. Compared with PSM, CEM retained more members, achieved better balance between matched members, and resulted in a statistically insignificant Wald test statistic for group aggregation. In terms of program performance, the results showed an overall higher medical cost savings among treatment members matched using CEM compared with those matched using PSM (-$25.57 versus -$19.78, respectively). Collectively, the results suggest CEM is a viable alternative, if not the most appropriate matching method, to apply when evaluating CCM program performance.

The impact of proactive chronic care management on hospital admissions in a German senior population.

An increase in chronic disease prevalence is contributing to health care cost growth and decreased quality of life in industrialized nations worldwide. Inadequate management of chronic diseases is a leading cause of hospitalizations and, thus, avoidable expenditures. In this study, we evaluated the impact of nurse-delivered care calls, the primary intervention of a proactive chronic care management (CCM) program, in a population aged 65 and older in Germany. In this analysis, hospital admission rates were evaluated among program enrollees who were diagnosed with diabetes, heart failure, coronary heart disease, or chronic obstructive pulmonary disease. The Intervention group comprised those members who participated in care calls (n=13,486), whereas the Comparison group included enrollees who did not participate in these calls (n=4,582). Changes in admission rates were calculated between the year prior to and year after program commencement. Comparative analyses were adjusted for age, sex, region of residence, and disease severity (stratification of 3 [least severe] to 1 [most severe]). Overall, a 6.0% decrease in admissions was observed among Intervention group members compared with an 18.9% increase among Comparison group members (P ≤ 0.0001). This decrease in admissions was driven by participants with the highest levels of risk. In addition, a dose-response relationship was observed in which admissions decreased with an increased number of care calls (P=0.0001). These results indicate that proactive CCM interventions are effective in reducing hospital admission rates in a senior population with chronic disease.

The impact of a proactive chronic care management program on hospital admission rates in a German health insurance society.

Hospital admissions are the source of significant health care expenses, although a large proportion of these admissions can be avoided through proper management of chronic disease. In the present study, we evaluate the impact of a proactive chronic care management program for members of a German insurance society who suffer from chronic disease. Specifically, we tested the impact of nurse-delivered care calls on hospital admission rates. Study participants were insured individuals with coronary artery disease, heart failure, diabetes, or chronic obstructive pulmonary disease who consented to participate in the chronic care management program. Intervention (n = 17,319) and Comparison (n = 5668) groups were defined based on records of participating (or not participating) in telephonic interactions. Changes in admission rates were calculated from the year prior to (Base) and year after program commencement. Comparative analyses were adjusted for age, sex, region of residence, and disease severity (stratification of 3 [least severe] to 1 [most severe]). Overall, the admission rate in the Intervention group decreased by 6.2% compared with a 14.9% increase in the Comparison group (P < 0.001). The overall decrease in admissions for the Intervention group was driven by risk stratification levels 2 and 1, for which admissions decreased by 8.2% and 14.2% compared to Comparison group increases of 12.1% and 7.9%, respectively. Additionally, Intervention group admissions decreased as the number of calls increased (P = 0.004), indicating a dose-response relationship. These findings indicate that proactive chronic care management care calls can help reduce hospital admissions among German health insurance members with chronic disease.

Is pharmacologic care of chronic obstructive pulmonary disease consistent with the guidelines?

Chronic obstructive pulmonary disease (COPD) is a common chronic illness that affects an estimated 210 million people worldwide, including 12 million people in the United States. National and international guidelines for treatment of COPD recommend use of certain medications, especially bronchodilators and corticosteroids, but the extent to which these are used appropriately is largely unknown. The objective of this study was to determine the extent to which pharmacotherapy for COPD is consistent with guidelines. Individuals with COPD (N = 2272), enrolled for at least 2 years in a large midwestern managed care organization, were identified from medical claims data. Medications dispensed in 2003 were examined using National Drug Codes from dispensation records. Quality indictors, developed from guidelines, focused on (1) use of bronchodilators, (2) use of inhaled corticosteroids (ICS) for patients with frequent exacerbations, and (3) use of systemic corticosteroids for acute exacerbation of COPD (AE-COPD). A total of 2272 subjects aged 45 years or older with a diagnosis of COPD were identified. Seventy-two percent of subjects with COPD received at least 1 bronchodilator; 64% of subjects with frequent prior exacerbations (> or =3 in the past year) received ICS; and only 51% of subjects with AE-COPD during the study year received systemic corticosteroids. Although most patients received 1 or more respiratory medications recommended by the guidelines, there were gaps in care including limited use of systemic corticosteroids for AE-COPD and ICS for patients with frequent exacerbations. Greater use of appropriate medications could lead to improved health for patients with COPD.

Impact of telephonic interventions on glycosylated hemoglobin and low-density lipoprotein cholesterol testing.

OBJECTIVES: To determine whether diabetes disease management (DM) programs are able to improve adherence to glycosylated hemoglobin (A1C) and low-density lipoprotein cholesterol (LDL-C) clinical testing in a nonadherent population and to quantify the efficacy of telephonic interventions in improving clinical testing rates. STUDY DESIGN: Retrospective, observational cohort study before and after DM program implementation. METHODS: A baseline cohort of members with diabetes (n = 5640) was identified from among large-scale diabetes DM programs administered for 13 geographically diverse health plans. Members were defined by nonadherence at baseline to A1C and/or LDL-C testing, grouped together based on how long they had participated in the program, divided retrospectively into telephonically contacted and uncontacted groups, and analyzed in the subsequent 12-month implementation period for testing rates. Subgroups defined by disease burden at baseline and frequency of telephonic interactions were analyzed to determine achievement of guideline-based A1C and LDL-C testing rates. RESULTS: Participation in diabetes DM programs was associated with improved A1C and LDL-C testing rates in previously nonadherent members. Calling nonadherent members improved A1C testing by 30.2% and LDL-C testing by 10.9% compared with testing rates for members who were not called. Members with high disease burden benefited even more from the diabetes intervention. Frequency of telephonic contacts with nonadherent individuals demonstrated a linear relationship with improved rates of adherence to A1C and LDL-C testing guidelines, and markedly improved testing rates compared with a not-called group. CONCLUSION: Telephonic interventions as part of comprehensive DM programs are associated with improved disease-monitoring testing.

Association between frequency of telephonic contact and clinical testing for a large, geographically diverse diabetes disease management population.

Diabetes disease management (DM) programs strive to promote healthy behaviors, including obtaining hemoglobin A1c (A1c) and low-density lipoprotein (LDL) tests as part of standards of care. The purpose of this study was to examine the relationship between frequency of telephonic contact and A1c and LDL testing rates. A total of 245,668 members continuously enrolled in diabetes DM programs were evaluated for performance of an A1c or LDL test during their first 12 months in the programs. The association between the number of calls a member received and clinical testing rates was examined. Members who received four calls demonstrated a 24.1% and 21.5% relative increase in A1c and LDL testing rates, respectively, compared to members who received DM mailings alone. Response to the telephonic intervention as part of the diabetes DM programs was influenced by member characteristics including gender, age, and disease burden. For example, females who received four calls achieved a 27.7% and 23.6% increase in A1c and LDL testing, respectively, compared to females who received mailings alone; by comparison, males who were called achieved 21.2% and 19.9% relative increase in A1c and LDL testing, respectively, compared to those who received mailings alone. This study demonstrates a positive association between frequency of telephonic contact and increased performance of an A1c or LDL test in a large, diverse diabetes population participating in DM programs. The impact of member characteristics on the responsiveness to these programs provides DM program designers with knowledge for developing strategies to promote healthy behaviors and improve diabetes outcomes.