Implementation costs of the appraise alcohol brief intervention (ABI) for male remand prisoners: A micro-costing protocol and preliminary findings.

OBJECTIVE: This paper documents the methods used to assess the implementation costs of the APPRAISE alcohol brief intervention (ABI) delivered to male remand prisoners across two study sites in Scotland and North East England. METHOD: We first developed a comprehensive taxonomy of the activities constituting the APPRIASE ABI. Next, data were collected for each activity about the study staff and the subject time spent, in addition to the other resources used and unit costs. RESULTS: From the pilot data collection it was possible to construct a narrative, for both study sites, for how the intervention was delivered and the time required for each activity. The ABI was delivered by Change Grow Live and Humankind intervention staff and staff salaries were obtained from both organizations to calculate the staff delivery costs for each site. Other costs, such as the printing of materials, were estimated based on APPRAISE study records. Due to the ongoing Covid-19 restrictions and limited access to prison resources and staff, there were significant deviations from the initial study protocols. As a result, we document the costs of implementing the ABI as delivered rather than as planned. CONCLUSIONS: This paper provides the first estimates of the implementation costs of an ABI delivered in criminal justice setting in the UK. Although these costs are from a pilot implementation that was heavily impacted by the Covid-19 pandemic, this paper nonetheless provides useful, policy-relevant information on the potential costs of providing ABI to remand prisoners. It also serves as a methodological template, guidance, and proof of concept for future micro-costing studies of ABIs in criminal justice settings.

Estimating Joint Health State Utility Algorithms Under Partial Information.

OBJECTIVES: We explored the performance of existing joint health state utility estimators when data are not available on utilities that isolate single-condition health states excluding any co-occurring condition. METHODS: Using data from the National Epidemiologic Survey on Alcohol and Related Conditions-III, we defined 2 information sets: (1) a full-information set that includes the narrowly defined health state utilities used in most studies that test the performance of joint health state utility estimators, and (2) a limited information set that includes only the more broadly defined health state utilities more commonly available to researchers. We used an example of alcohol use disorder co-occurring with cirrhosis of the liver, depressive disorder, or nicotine use disorder to illustrate our analysis. RESULTS: We found that the performance of joint health state utility estimators is appreciably different under limited information than under full information. Full-information estimators typically overestimate the joint state utility, whereas limited-information estimators underestimate the joint state utility, except for the minimum estimator, which is overestimated in all cases. CONCLUSIONS: Researchers using joint health state utility estimators should understand the information set available to them and use methodological guidance appropriate for that information set. We recommend the minimum estimator under limited information based on its ease of use, consistency (and therefore a predictable direction of bias), and lower root mean squared error.

Alcohol consumption and health-related quality of life in the US during the COVID-19 pandemic: a US national survey.

BACKGROUND: Alcohol consumption has changed during the COVID-19 pandemic yet the impacts on alcohol-related outcomes, and specifically health-related quality of life, are not completely known. Our objective was to assess the association between alcohol consumption and health-related quality of life (HRQOL) during the COVID-19 pandemic. METHOD: We conducted an on-line/telephone survey of three cross-sectional samples of US adults during a nine-month stretch of the pandemic, from August 2020 through April 2021, collecting data on drinking-current quantity/frequency and change since prior to pandemic, HRQOL (using the SF-6D), and perceived impact of the pandemic on respondents' lives-overall impact and disruptions across various dimensions (job loss, school closures, social isolation, loss of income). We pooled the data from the three administrations and applied survey weights to reflect the US population. We described drinking behavior and pandemic impact, and regressed HRQOL on alcohol consumption risk level (per World Health Organization categories), change in drinking since pre-pandemic, and pandemic impact using weighted least squares, controlling for respondents' demographic characteristics. We tested the significance of categorical variables using Wald tests at a p-value of 0.05. RESULTS: Among 3,125 respondents, weighted to reflect the US population, 68% reported drinking during the pandemic and 40% reported a change in drinking from pre-pandemic level (either increased or decreased). Mean HRQOL among our sample was 0.721 (SD 0.003). Any change in drinking from pre-pandemic level was independently associated with significantly lower HRQOL compared to never drinking (pre or during pandemic), from - 0.0251 points for decreased/stopped drinking to -0.0406 points for increased drinking (combined levels' Wald test F = 10.62, p < 0.0000). COVID-19 pandemic related impacts/disruptions were associated with HRQOL decrements ranging from - 0.0834 to -0.1340 (Wald test F = 64.34, p < 0.0000). CONCLUSION: The US population HRQOL was substantially lower during the pandemic than reported a decade earlier (mean = 0.79 in 2012-13). While pandemic-related impacts and disruptions may explain a large part of this decrement, changes in drinking-and the associated implications of such changes-might also play a role. Both individuals who reduced their drinking during the pandemic and those who increased consumption may be at risk of poor HRQOL.

The COVID-19 pandemic has precipitated changes in drinking that may be positive or negative depending on who is affected and how. We conducted a survey of over 3,000 adults in the US during the middle of the pandemic to understand drinking and quality of life. We found that US adults' quality of life was worse during the pandemic than in prior years, and people who either increased or decreased the amount that they drank were particularly worse-off. People who reported being severely impacted by the pandemic, however, were also much worse-off in terms of quality of life, and actually more so than people whose drinking habits changed. We need to pay attention to how drinking is connected to stressful events such as the pandemic, and make sure to attend to people who change their drinking in either direction as this may indicate underlying problems.

Health Utility of Drinkers' Family Members: A Secondary Analysis of a US Population Data Set.

Background. Problematic alcohol use is known to harm individuals surrounding the drinker. This study described the health utility of people who reported having a family member(s) whom they perceived as a "problem drinker."Methods. We conducted a secondary analysis of the US National Epidemiologic Survey of Alcohol and Related Conditions Wave 3 (NESARC-III, 2012-13) data to estimate the independent associations of a family member's problem drinking on the respondent's health utility, also known as health-related quality of life, assessed via the SF-6D. Participants included 29,159 noninstitutionalized adults, of whom 21,808 reported perceiving a family member or members as having a drinking problem at any point in that person's life. Respondent drinking was assessed via self-report and diagnostic interview. We used population-weighted multivariate regression to estimate disutility. Results. After adjusting for the respondent's own alcohol consumption, alcohol use disorder (AUD), family structure, and sociodemographic characteristics, the mean decrement in SF-6D score associated with perceiving a family member as a problem drinker ranged from 0.033 (P < 0.001) for a spouse/partner to 0.023 (P < 0.001) for a grandparent, sibling, aunt, or uncle. The mean decrement in SF-6D score from having AUD oneself was 0.039 (P < 0.001). Conclusions. Perceived problem drinking within one's family is associated with statistically significant losses in health utility, the magnitude of which is dependent on relationship type. The adverse consequences associated with problem drinking in the family may rival having AUD oneself. Implications. Family-oriented approaches to AUD interventions may confer outsize benefits, especially if focused on the spouse or partner. Economic evaluation of alcohol misuse could be made more accurate through the inclusion of family spillover effects. Highlights: Spillover effects from problem drinking in the family vary by relationship type.One's perception of their spouse or child as having a drinking problem is associated with a utility decrement of equal magnitude to having alcohol use disorder oneself.Medical decision makers should consider the outsize effects of family spillovers in treatment decisions in the context of alcohol consumption, particularly among spouses and children of problem drinkers.Economic evaluation should consider how to incorporate family spillover effects from problem drinking in alcohol-related models.

Association of opioid utilization management with prescribing and overdose.

OBJECTIVES: Deaths from prescription opioids have reached epidemic levels in the United States, yet little is known about how insurers' coverage policies may affect rates of fatal and nonfatal overdose among individuals filling an opioid prescription. STUDY DESIGN: Retrospective cohort study using 2010-2016 Medicare claims data for beneficiaries with 1 or more filled prescriptions for a Schedule II opioid. METHODS: Outcomes were opioid volume dispensed in morphine milligram equivalents (MME), number of days supplied, and number of pills dispensed on each prescription and emergency department or inpatient stay associated with an opioid overdose during a prescription or within 7 days of the end of the prescription. RESULTS: A total of 7.03 million prescriptions for Schedule II opioids were dispensed over 1.87 million Part D beneficiary-years. The 7.03 million opioid prescriptions were associated with 8.5 opioid overdoses per 10,000 prescriptions. Prior authorization was associated with larger opioid volumes per prescription (103.6 MME; 95% CI, 36.2-171.0). Step therapy was associated with a greater number of days supplied (0.62 days; 95% CI, 0.10-1.13) and more pills dispensed (6.12 pills; 95% CI, 2.17-10.1). Quantity limits were associated with smaller opioid volumes (24.3 MME; 95% CI, 12.3-36.3) and fewer pills dispensed (2.35 pills; 95% CI, 1.77-2.93). In adjusted models, beneficiaries filling an opioid requiring prior authorization experienced 3.3 fewer overdoses per 10,000 prescriptions (95% CI, 0.41-6.2). CONCLUSIONS: Opioid utilization management among these beneficiaries was associated with mixed effects on opioid prescribing, and prior authorization was associated with a decreased likelihood of subsequent overdose. Further work exploring the impact of utilization management and insurer policies is needed.

SBIRT administered by mental health counselors for hospitalized adults with substance misuse or disordered use: Evaluating hospital utilization and costs.

OBJECTIVE: We analyzed the association of Screening, Brief Intervention, and Referral to Treatment (SBIRT) with hospitalizations, emergency department (ED) visits, and related costs, when administered to inpatients with substance misuse or disordered use by professional mental health counselors. METHODS: Our study used retrospective program and health records data and a difference-in-differences design with propensity score covariates. The study population consisted of hospital inpatients admitted to integrated care services staffed by physicians, nurses, and mental health counselors. The intervention group consisted of patients selected for intervention based on substance use history and receiving SBIRT (n = 1577). Patients selected for intervention but discharged before SBIRT administration (n = 618) formed the comparison group. The outcome variables were hospitalization and ED visits costs and counts. Costs of hospitalizations and ED visits were combined to allow sufficient data for analysis, with counts treated similarly. Patient-level variables were substance use type and substance use severity. A cluster variable was inpatient clinical service. Zero-censored and two-part logistic and generalized linear models with robust standard errors tested the association of SBIRT interventions with the outcomes. RESULTS: For the full study population of patients using alcohol, illicit drugs, or both, SBIRT administered by mental health counselors was not associated with changes in hospitalizations and ED visits. For patients with alcohol misuse or disordered use, SBIRT by mental health counselors was associated an odds ratio of 0.32 (p < .001) of having subsequent hospitalizations or ED visits. For patients with alcohol use who did return as hospital inpatients or to the ED, SBIRT by counselors was associated with a reduction in costs of $2547 per patient (p < .001) and with an incidence rate ratio of 0.57 for counts (p = .003). CONCLUSION: Our results suggest that professional mental health counselors on inpatient integrated care teams may provide SBIRT effectively for patients with misuse and disordered use of alcohol, reducing the likelihood of future healthcare utilization and costs.

The "Outcome Reporting in Brief Intervention Trials: Alcohol" (ORBITAL) Core Outcome Set: International Consensus on Outcomes to Measure in Efficacy and Effectiveness Trials of Alcohol Brief Interventions.

OBJECTIVE: The purpose of this study was to report the "Outcome Reporting in Brief Intervention Trials: Alcohol" (ORBITAL) recommended core outcome set (COS) to improve efficacy and effectiveness trials/evaluations for alcohol brief interventions (ABIs). METHOD: A systematic review identified 2,641 outcomes in 401 ABI articles measured by 1,560 different approaches. These outcomes were classified into outcome categories, and 150 participants from 19 countries participated in a two-round e-Delphi outcome prioritization exercise. This process prioritized 15 of 93 outcome categories for discussion at a consensus meeting of key stakeholders to decide the COS. A psychometric evaluation determined how to measure the outcomes. RESULTS: Ten outcomes were voted into the COS at the consensus meeting: (a) typical frequency, (b) typical quantity, (c) frequency of heavy episodic drinking, (d) combined consumption measure summarizing alcohol use, (e) hazardous or harmful drinking (average consumption), (f) standard drinks consumed in the past week (recent, current consumption), (g) alcohol-related consequences, (h) alcohol-related injury, (i) use of emergency health care services (impact of alcohol use), and (j) quality of life. CONCLUSIONS: The ORBITAL COS is an international consensus standard for future ABI trials and evaluations. It can improve the synthesis of new findings, reduce redundant/selective reporting (i.e., reporting only some, usually significant outcomes), improve between-study comparisons, and enhance the relevance of trial and evaluation findings to decision makers. The COS is the recommended minimum and does not exclude other, additional outcomes.

Health-related quality of life of alcohol use disorder with co-occurring conditions in the US population.

BACKGROUND: Alcohol use disorder (AUD) commonly co-occurs with other health conditions or other substance use, complicating our understanding of the health-related quality of life (HRQoL) of AUD. We described the HRQoL of alcohol use disorder in the presence of co-occurring conditions and identified the contribution of each. METHODS: Secondary analysis of National Epidemiologic Survey on Alcohol and Related Conditions III data, consisting of 36,309 non-institutionalized US adults; descriptive and regression analysis. HRQoL measured via the SF-6D; AUD via the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS-5); physical, mental health, and substance use disorders/conditions as reported or assessed via AUDADIS-5. RESULTS: AUD was independently associated with lower HRQoL for individuals experiencing co-occurring conditions. Compared to no AUD, past year AUD reduced SF-6D score by 0.0304 (SE = 0.0027) and prior-to-past-year AUD reduced SF-6D by 0.0163 (SE = 0.0023). AUD's co-occurring conditions were independently associated with lower HRQoL, beyond the reduction from AUD: any co-occurring physical health condition was associated with a 0.062 point reduction in SF-6D score (SE = 0.0023), any mental health condition with a 0.084 point reduction (SE = 0.0025), and any substance use disorder with a 0.038 point reduction (SE = 0.0023). CONCLUSIONS: AUD's association with diminished HRQoL may be explained in large part by the presence of co-occurring conditions among individuals reporting AUD, as these co-occurring conditions are associated with substantial decrements in HRQoL-often eclipsing the magnitude of the decrements associated with AUD alone. Alcohol use interventions endeavoring to improve HRQoL should consider the entirety of an individual to design patient-centered care.

SF-6D utility scores for alcohol use disorder status and alcohol consumption risk levels in the US population.

AIMS: To estimate US population health utilities for subgroups defined by alcohol use disorder (AUD) status and consumption level. DESIGN: Cross-sectional survey. SETTING: Community settings in the United States (i.e. excluding institutional settings). PARTICIPANTS: A total of 36,042 adults (age 18+) in non-institutional settings in the United States. MEASUREMENTS: We used 12-item Short Form Survey (SF-12) data from the National Epidemiologic Survey on Alcohol and Related Conditions-III to calculate mean Short Form-6 dimension (SF-6D) utility scores across World Health Organization alcohol consumption risk levels-very high risk, high risk, medium risk, low risk and an additional abstinent level-for three groups: (1) the general population (n = 36,042), (2) individuals with life-time AUD (n = 9925) and (3) individuals with current AUD (n = 5083), and assessed minimally important differences (MIDs) between consumption levels. Each group is a subset of the previous group. FINDINGS: The general population's mean SF-6D utility was higher than that of individuals with life-time or current AUD across all consumption risk levels (0.79 versus 0.76 for both AUD groups). For all groups, SF-6D utilities increased as consumption risk level decreased to non-abstinent levels, and reducing consumption from very high risk to any lower level was associated with a statistically significant and meaningful improvement in utility. For individuals with life-time or current AUD, becoming abstinent from high-, medium- and low-risk levels was associated with significantly and meaningfully worse utilities. CONCLUSIONS: Higher alcohol consumption risk levels appear to be associated with lower health index scores for the general population and individuals with a history of alcohol use disorder, meaning that higher alcohol consumption is associated with worse health-related quality of life.

Return on Investment of Workplace Wellness: Evidence From a Long-Term Care Company.

BACKGROUND: Workplace wellness programs (WWPs) are increasingly promoted by businesses and governments as an important strategy to improve workers' overall health and well-being and to reduce health care and other organizational costs. Few studies have evaluated WWPs in small businesses to provide evidence on the potential return-on-investment (ROI) that WWPs might yield. This study aimed to fill this gap by presenting a quasi-experimental, ROI analysis of a WWP in a small company. METHODS: This observational quasi-experimental study evaluated economic outcomes of a multicomponent WWP implemented by a small long-term care company. The company provided approximately 2 years of de-identified, individualized data on its employees for 2013-2015. There were 116 WWP participants and 323 nonparticipants. Difference-in-differences models were used to evaluate the program using organizational costs and ROI estimates. FINDINGS: The estimated program cost was $132.692 (95% confidence interval [CI]: [$112.957, $156.101]) per participant and the estimated organizational costs savings were $210.342 (95% CI: [-4354.095, 2002.890]). The WWP achieved an ROI of $0.585 (95% CI: [-$35.095, $14.103]) per participant. Although not statistically significant, the results suggest that the WWP saved $1.585 for every $1 invested. CONCLUSIONS/APPLICATION TO PRACTICE: These results suggest that the evaluated WWP yielded a positive, although nonsignificant, ROI estimate. While ROI is still one of the most common evaluation metrics used in workplace wellness, few studies present ROI estimates of WWPs in small companies. Given policy efforts to promote WWPs in small businesses, there is a need to conduct high-quality ROI analyses for WWPs in smaller companies.

Implementation science on the margins: How do we demonstrate the value of implementation strategies?

Implementation science (IS) has developed as a field to assess effective ways to implement and disseminate evidence-based practices. Although the size and rigor of the field has improved, the economic evaluation of implementation strategies has lagged behind other areas of IS (Roberts, Healey, & Sevdalis, 2019). Beyond demonstrating the effectiveness of implementation strategies, there needs to be evidence that investments in these strategies are efficient or financially sustainable. In this editorial, we lay out conceptual challenges in applying economic evaluation to IS and the implications for conducting economic analyses in integrated primary care research. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Variability of Outcomes Used in Efficacy and Effectiveness Trials of Alcohol Brief Interventions: A Systematic Review.

OBJECTIVE: The purpose of this study was to characterize recent alcohol brief intervention (ABI) efficacy and effectiveness trials, summarize outcomes, and show how variability in outcomes and reporting compromises the evidence base. METHOD: A systematic review and narrative synthesis of articles from 10 databases were undertaken (January 2000-November 2017); study selection represented recent, readily available publications. The National Institute of Care Excellence (NICE) Public Health Guideline 24 (Alcohol use disorders: prevention) informed ABI definitions. The review was conducted using Centre for Reviews and Dissemination (CRD) guidance and pre-registered on PROSPERO (CRD42016047185). Seven a priori specified domains were used to classify outcomes: biomarkers, alcohol-related outcomes, economic factors/resource use, health measures, life impact, intervention factors, and psychological/behavioral factors. RESULTS: The search identified 405 trials from 401 eligible papers. In 405 trials, 2,641 separate outcomes were measured in approximately 1,560 different ways. The most common outcomes used were the number of drinks consumed in a week and frequency of heavy episodic drinking. Biomarkers were least frequently used. The most common primary outcome was weekly drinks. By trial type, the most frequent outcome in efficacy and effectiveness trials was frequency of heavy drinking. CONCLUSIONS: Consumption outcomes predominated; however, no single outcome was found in all trials. This comprehensive outcome map and methodological detail on ABI effectiveness and efficacy trials can aid decision making in future trials. There was a diversity of instruments, time points, and outcome descriptions in methods and results sections. Compliance with reporting guidance would support data synthesis and improve trial quality. This review establishes the need for a core outcome set (COS)/minimum data standard and supports the Outcome Reporting in Brief Interventions: Alcohol initiative (ORBITAL) to improve standards in the ABI field through a COS for effectiveness and efficacy randomized trials.

Prioritization of Outcomes in Efficacy and Effectiveness of Alcohol Brief Intervention Trials: International Multi-Stakeholder e-Delphi Consensus Study to Inform a Core Outcome Set.

OBJECTIVE: Outcomes used in alcohol brief intervention trials vary considerably. Achieving consensus about key outcomes can enhance evidence synthesis and improve healthcare guidelines. This international, e-Delphi study sought to prioritize outcomes for alcohol brief intervention trials as part of a larger program of work develop an alcohol brief intervention core outcome set. METHOD: In total, 150 registrants from 19 countries, representing researchers, policymakers, and patients, participated in a two-round e-Delphi study. In Round 1, participants (n = 137) rated 86 outcomes, derived from a review of the literature and a patient and public involvement panel, by importance. In Round 2, participants (n = 114) received feedback on importance ratings for each outcome, and a reminder of their personal rating, before rating the outcomes for importance a second time. Seven additional outcomes suggested in Round 1 were added to the Round 2 questionnaire. We defined consensus a priori as 70% agreement across all stakeholder groups. RESULTS: Seven consumption outcomes met inclusion criteria: typical frequency, typical quantity, frequency of heavy drinking, alcohol-related problems, weekly drinks, at-risk drinking, and combined consumption measures. Others meeting the threshold were alcohol-related injury, quality of life, readiness to change, and intervention fidelity. CONCLUSIONS: This is the first international e-Delphi study to identify and prioritize outcomes for use in alcohol brief intervention trials. The use and reporting of outcomes in future alcohol brief intervention trials should improve evidence synthesis in systematic reviews and meta-analyses. Further work is required to refine these outcomes into a core outcome set that includes guidance for measurement of outcomes.

Caring for the elderly at work and home: Can a randomized organizational intervention improve psychological health?

Although job stress models suggest that changing the work social environment to increase job resources improves psychological health, many intervention studies have weak designs and overlook influences of family caregiving demands. We tested the effects of an organizational intervention designed to increase supervisor social support for work and nonwork roles, and job control in a results-oriented work environment on the stress and psychological distress of health care employees who care for the elderly, while simultaneously considering their own family caregiving responsibilities. Using a group-randomized organizational field trial with an intent-to-treat design, 420 caregivers in 15 intervention extended-care nursing facilities were compared with 511 caregivers in 15 control facilities at 4 measurement times: preintervention and 6, 12, and 18 months. There were no main intervention effects showing improvements in stress and psychological distress when comparing intervention with control sites. Moderation analyses indicate that the intervention was more effective in reducing stress and psychological distress for caregivers who were also caring for other family members off the job (those with elders and those "sandwiched" with both child and elder caregiving responsibilities) compared with employees without caregiving demands. These findings extend previous studies by showing that the effect of organizational interventions designed to increase job resources to improve psychological health varies according to differences in nonwork caregiving demands. This research suggests that caregivers, especially those with "double-duty" elder caregiving at home and work and "triple-duty" responsibilities, including child care, may benefit from interventions designed to increase work-nonwork social support and job control. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Health Behavior Among Men With Multiple Family Roles: The Moderating Effects of Perceived Partner Relationship Quality.

Men in the United States are increasingly involved in their children's lives and currently represent 40% of informal caregivers to dependent relatives or friends aged 18 years and older. Yet much more is known about the health effects of varying family role occupancies for women relative to men. The present research sought to fill this empirical gap by first comparing the health behavior (sleep duration, cigarette smoking, alcohol consumption, exercise, fast food consumption) of men who only occupy partner roles and partnered men who also fill father, informal caregiver, or both father and informal caregiver (i.e., sandwiched) roles. The moderating effects of perceived partner relationship quality, conceptualized here as partner support and strain, on direct family role-health behavior linkages were also examined. A secondary analysis of survey data from 366 cohabiting and married men in the Work, Family and Health Study indicated that men's multiple family role occupancies were generally not associated with health behavior. With men continuing to take on more family responsibilities, as well as the serious health consequences of unhealthy behavior, the implications of these null effects are encouraging - additional family roles can be integrated into cohabiting and married men's role repertoires with minimal health behavior risks. Moderation analysis revealed, however, that men's perceived partner relationship quality constituted a significant factor in determining whether multiple family role occupancies had positive or negative consequences for sleep duration, alcohol consumption, and fast food consumption. These findings are discussed in terms of their empirical and practical implications for partnered men and their families.

Effects of a Flexibility/Support Intervention on Work Performance: Evidence From the Work, Family, and Health Network.

PURPOSE: To estimate the effects of a workplace initiative to reduce work-family conflict on employee performance. DESIGN: A group-randomized multisite controlled experimental study with longitudinal follow-up. SETTING: An information technology firm. PARTICIPANTS: Employees randomized to the intervention (n = 348) and control condition (n = 345). INTERVENTION: An intervention, "Start. Transform. Achieve. Results." to enhance employees' control over their work time, to increase supervisors' support for this change, and to increase employees' and supervisors' focus on results. METHODS: We estimated the effect of the intervention on 9 self-reported employee performance measures using a difference-in-differences approach with generalized linear mixed models. Performance measures included actual and expected hours worked, absenteeism, and presenteeism. RESULTS: This study found little evidence that an intervention targeting work-family conflict affected employee performance. The only significant effect of the intervention was an approximately 1-hour reduction in expected work hours. After Bonferroni correction, the intervention effect is marginally insignificant at 6 months and marginally significant at 12 and 18 months. CONCLUSION: The intervention reduced expected working time by 1 hour per week; effects on most other employee self-reported performance measures were statistically insignificant. When coupled with the other positive wellness and firm outcomes, this intervention may be useful for improving employee perceptions of increased access to personal time or personal wellness without sacrificing performance. The null effects on performance provide countervailing evidence to recent negative press on work-family and flex work initiatives.