The Association Between Incentive Designs and Health Assessment or Biometric Screening Completion.

OBJECTIVES: To identify statistically significant predictors for completing a Personal Health Assessment (PHA) or biometric screening from attributes of incentive designs. METHODS: A cross-sectional study was conducted that included 426,694 members from 56 employer groups who required a PHA or screening as part of their incentive during 2016. RESULTS: Incentive designs that combine high-value with immediate disbursement can relatively increase employee PHA participation by as much as 66% over plans with low-value and delayed disbursement (56.7% vs 34.1%, P < 0.001). Surcharge component was a significant predictor of PHA completion (P < 0.001); similar predictors were found for screening completion. CONCLUSIONS: This study identified several significant predictors of PHA or screening completion, including: monetary value, time to disbursement, disbursement method, and frequency. Our findings are consistent with prior research in human behavior responses to positive reinforcement.

Employee Use of a Wireless Physical Activity Tracker Within Two Incentive Designs at One Company.

Physical activity provides numerous health benefits, including reducing risk factors that contribute to the leading causes of morbidity and mortality. Many employers offer incentives to employees to motivate engagement in wellness program activities. Two incentive designs to reward employees for achieving step goals were evaluated. This study used a retrospective design and the study population consisted of benefit-eligible employees at American Specialty Health ages 18 to 65 years who completed a health assessment and biometric screening during 2011 (N=396) or 2012 (N=500). A total of 320 employees participated in both years. During 2011, the incentive goal was 500,000 steps per quarter. By comparison, a 3-tier step goal plan was implemented in 2012 (ie, 400,000; 650,000; or 900,000 steps/quarter). The prevalence of participants in the step program was 64.7% in 2011 and 72.8% in 2012. The percentage of employees who reached at least 1 quarterly incentive increased from 36.3% in 2011 to 51.4% in 2012. Average steps/day was higher in 2012 (mean [M]=3573, standard deviation [SD]=3010) compared to the same employees in 2011 (M=2817, SD=2654) (P<.001). The findings suggest that a tiered incentive design may be an effective population approach to engage employees in physical activity. A multitier incentive design offers participants choices for goal setting and may help shape behavior toward what may be perceived as a difficult goal to achieve. (Population Health Management 2016;19:88-94).

Examining incentive design strategies for worksite wellness program engagement.

The objective was to examine employee engagement in worksite wellness activities at 2 large US companies that differed in engagement strategy and incentive plan. Inclusion criteria were US employees aged 18 to 65 who were eligible to receive wellness benefits throughout 2012. Company B's incentive was twice the dollar value of Company A's and produced higher engagement rates for the health assessment (HA; 26.1% vs. 24.4%, P<.001), and biometric screening (32.8% vs. 25.4%, P<.001). Among the subgroup of employees who completed the HA and the biometric screening, 44.6% (N=2,309) at Company A engaged in at least 1 coaching session compared to 8.9% (N=594) at Company B. Fewer employees at Company A with high-risk cholesterol engaged in coaching compared to Company B (44.6% vs. 54.9%, P=.009). However, more Company A employees with high-risk blood pressure engaged in coaching compared to Company B (41.3% vs. 34.8%, P=.053). Company A engaged more obese employees compared to Company B (43.7% vs. 13.9%, P<.001), although obesity was not directly targeted at either company. Predictors of enrolling in coaching included being female, older age, higher education, and those not at high risk for stress, diet, and tobacco for Company A, and older age, and high risk for blood pressure, cholesterol, and obesity for Company B. A population approach to incentive design for program engagement engaged high-risk employees in coaching, and engaged a high proportion of employees not at high risk, but who can still be at risk for chronic diseases.

Dwell time and psychological screening outcomes among military service members with multiple combat deployments.

Recent studies have found that longer dwell times, or the period of time between deployments, may be protective against combat-related psychological outcomes. The purpose of this study was to examine the association between dwell time and psychological morbidity, while accounting for combat exposure. U.S. Marines with two combat deployments between 2005 and 2008 were identified from electronic deployment records. Those who screened positive for post-traumatic stress disorder and depression, and who were referred for mental health services were identified from the Post-Deployment Health Assessment. For the final study sample of 3,512 Marines, dwell time was calculated as time between deployments, and was analyzed as a ratio over length of first deployment. After adjustment for all covariates, there was an interaction (p = 0.01) between dwell time and combat exposure on mental health referral outcome. For personnel with maximum reported combat exposure, longer dwell times were associated with a 49% to 92% reduced odds of mental health referral. Longer dwell times may be protective against combat-related psychological outcomes. Because multiple deployments are likely to be the norm in future military operations, regulating dwell time, particularly for those with greater risk of combat exposure, should continue to be explored.

Co-occurring mental health and alcohol misuse: dual disorder symptoms in combat injured veterans.

OBJECTIVE: Service members face difficulties during military deployment potentially resulting in morbidities such as posttraumatic stress disorder (PTSD), depression, and alcohol misuse. The co-occurrence of alcohol misuse and mental health disorders is termed dual disorder and has been associated with adverse outcomes. METHODS: The study included 812 high-risk (i.e., endorsing combat exposure with documented combat injury) male U.S. veterans of Operation Iraqi Freedom, injured between October 2004 and November 2007, identified from the Expeditionary Medical Encounter Database. RESULTS: PTSD and depression symptoms were significant correlates of alcohol misuse. Veterans with dual disorder symptoms reported a significantly higher mean number of health complaints on the Post-Deployment Health Reassessment compared with those endorsing only mental health symptoms. CONCLUSIONS: These results highlight how mental health disorders among injured service members increases the odds of problem drinking and those with dual disorder have elevated health complaints.

Blast-related ear injuries among U.S. military personnel.

Blast-related ear injuries are a concern during deployment because they can compromise a servicemember's situational awareness and adversely affect operational readiness. The objectives of this study were to describe blast-related ear injuries during Operation Iraqi Freedom, identify the effect of hearing protection worn at the point of injury, and explore hearing loss and tinnitus outcomes within one year after injury. The Expeditionary Medical Encounter Database was used to identify military personnel who survived blast-related injury, and it was linked with outpatient medical databases to obtain diagnoses of hearing loss and tinnitus. The prevalence of ear injuries was 30.7% (1,223 of 3,981). The most common ear injury diagnoses were "inner or middle ear injury involving tinnitus" and tympanic membrane (TM) rupture. Hearing protection reduced the odds of ear injury involving tinnitus. Personnel with TM rupture had higher odds of hearing loss (odds ratio [OR] = 6.65, 95% confidence interval [CI] = 5.04-8.78) and tinnitus outcomes (OR = 4.34, 95% CI = 3.12-6.04) than those without TM rupture. Ear injuries and hearing impairment are frequent consequences of blast exposure during combat deployment. Hearing protection is warranted for all servicemembers at risk of blast exposure.

Blast-related mild traumatic brain injury is associated with a decline in self-rated health amongst US military personnel.

INTRODUCTION: Mild traumatic brain injury (MTBI) has emerged as the preeminent injury of combat from the recent conflicts in Iraq and Afghanistan. Very little is known about short- and long-term outcomes after combat-related MTBI. As a measure of outcome after injury, self-rated health is a reliable, widely used measure that assesses perceived health. The primary aim of this study was to determine the effect of combat-related MTBI on self-reported health status after return from deployment. The secondary objective was to examine predictors of a decline in self-reported health status amongst US service members with MTBI, as compared to those service members with other minor non-TBI injuries. PATIENTS AND METHODS: MTBI cases and an injured comparison group were identified from the Expeditionary Medical Encounter Database records of 1129 male, US service members who experienced blast-related injuries in Iraq from March 2004 to March 2008. Self-rated health was assessed from the routinely administered pre- and post-deployment health assessment questionnaires by the following question, "Overall, how would you rate your health during the past month?" Possible responses were "poor", "fair", "good", "very good", or "excellent." A distinction was made between minor and major negative changes in health (i.e., very good to fair) based on these self-rated health outcomes captured post-injury. RESULTS: For all personnel, post-injury levels of self-rated health were statistically significantly worse than pre-injury health rating. At 6months post-injury, service members with MTBI were 5 times more likely to report a major negative change in health as compared to members with other mild injuries. This association was independent of age, rank, branch of service, Injury Severity Score, mental health diagnosis prior to injury, and having been referred to a health care professional. DISCUSSION: Blast-related injuries, specifically MTBI, during deployment have negative consequences on service members' perception of health. Future research is needed to improve our understanding of the overall effects of MTBI on health and quality of life.

Weight changes among male Navy personnel deployed to Iraq or Kuwait in 2005-2008.

The objective of this study was to identify changes in weight that occurred during deployment to Iraq or Kuwait between 2005 and 2008. Data on length and type of deployment among 16,365 male U.S. Navy personnel were combined with weight measurements before and after deployment from the Physical Readiness Information Management System. Weight measurements were available for 10,886 men who did not exceed Navy weight recommendations before deployment. In general, weight increased after deployment and, for those who did not exceed Navy recommendations before deployment, factors associated with weight gain included being enlisted and having a deployment longer than 228 days. Among 1,108 men with 2 deployments, a dwell time shorter than the combined deployed time was a risk factor for weight gain during the second deployment. Future studies should explore the combined effects of long deployments and short dwell times in maintaining the readiness of military personnel.

Inpatient hospitalizations of U.S. military personnel medically evacuated from Iraq and Afghanistan with combat-related traumatic brain injury.

Traumatic brain injury (TBI) has been called the signature wound of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). The aim of the present study was to describe and assess the incidence of inpatient hospitalizations of U.S. military personnel who were medically evacuated from OIF and OEF with combat-related TBI. Inpatient medical records from 2003 to 2008 were used to determine incident episodes of TBI requiring hospitalization in Landstuhl or CONUS Regional Medical Centers. Denominator data for calculating incidence rates were available from the Defense Manpower Data Center. During the study period, 1,213 U.S. military personnel from OIF and OEF were hospitalized with combat-related TBI. Of these, the largest proportion (40.9%) occurred in 2007. The rate of inpatient hospitalization with TBI was 10.4 per 10,000 troop strength (95% confidence interval: 9.9, 10.9). Future research should examine the incidence of TBI in-theater and include an analysis by injury severity.

Alcohol abuse disorders among U.S. service members with mild traumatic brain injury.

Traumatic brain injury (TBI) has emerged as a preeminent injury in Iraq and Afghanistan. The relationship between TBI and post-injury alcohol use in military personnel has not been clearly defined. The aim of this study was to examine the prevalence of alcohol abuse disorders among combat-injured service members with mild TBI (MTBI). Male U.S. service members with combat injuries were identified from the Expeditionary Medical Encounter Database (n = 3,123). Diagnoses of alcohol abuse disorders were collected from the standard inpatient and ambulatory data records. Overall, a slightly higher proportion of service members with MTBI were diagnosed with an alcohol abuse disorder compared to those with other injury (6.1% vs. 4.9%). In a multivariate analysis, however, it was found that MTBI was not associated with higher levels of alcohol abuse (odds ratio, 1.24; 95% confidence interval, 0.90, 1.70). To better define the consequences of MTBI, future research should include other alcohol dependency measures along with comorbid mental health disorders.

Visual dysfunction following blast-related traumatic brain injury from the battlefield.

PRIMARY OBJECTIVE: To assess the occurrence of ocular and visual disorders following blast-related traumatic brain injury (TBI) in Operation Iraqi Freedom. RESEARCH DESIGN: Retrospective cohort study. METHODS AND PROCEDURES: A total of 2254 US service members with blast-related combat injuries were identified for analysis from the Expeditionary Medical Encounter Database. Medical record information near the point of injury was used to assess factors associated with the diagnosis of ocular/visual disorder within 12 months after injury, including severity of TBI. MAIN OUTCOMES AND RESULTS: Of 2254 service members, 837 (37.1%) suffered a blast-related TBI and 1417 (62.9%) had other blast-related injuries. Two-hundred and one (8.9%) were diagnosed with an ocular or visual disorder within 12 months after blast injury. Compared with service members with other injuries, odds of ocular/visual disorder were significantly higher for service members with moderate TBI (odds ratio (OR) = 1.58, 95% confidence interval (CI) = 1.02-2.45) and serious to critical TBI (OR = 14.26, 95% CI = 7.00-29.07). CONCLUSIONS: Blast-related TBI is strongly associated with visual dysfunction within 1 year after injury and the odds of disorder appears to increase with severity of brain injury. Comprehensive vision examinations following TBI in theatre may be necessary.