David A. Alter, M.D., Ph.D., F.R.C.P.C

1. Employee health and wellness metrics, measurements, and evaluation - - the building blocks for ROI David A. Alter, M.D., Ph.D., F.R.C.P.C Senior Scientist, Institute for Clinical Evaluative Sciences Division of Cardiology, The Li Ka Shing Knowledge institute of St. Michael’s Hospital Division of Cardiology, Cardiac and secondary prevention program, The Toronto Rehabilitation Institute Associated Professor of Medicine, University of Toronto

2. Disclosures • Chief Scientific Officer, INTERxVENT Canada

3. Microvascular Disease Macrovascular Disease “Ticking Clock” Hypothesis Deferred Gratification NGT IGT Hyperglycemia Haffner SM et al. JAMA. 1990;263:2893-2898.

4. Microvascular Disease Macrovascular Disease “Ticking Clock” Hypothesis Deferred Gratification NGT IGT Hyperglycemia Haffner SM et al. JAMA. 1990;263:2893-2898.

5. Microvascular Disease Macrovascular Disease “Ticking Clock” Hypothesis Deferred Gratification NGT IGT Hyperglycemia Haffner SM et al. JAMA. 1990;263:2893-2898.

6. Microvascular Disease Macrovascular Disease “Ticking Clock” Hypothesis Deferred Gratification NGT IGT Hyperglycemia Haffner SM et al. JAMA. 1990;263:2893-2898.

7. How much?How long? At what costs? Metrics, measurement, and evaluation

8. Building blocks for ROI evaluation • Choosing the appropriate question • Selecting the appropriate population • Designing the appropriate intervention • Appropriate knowledge translation • Determining the appropriate context

9. Asking the appropriate question

10. Benefits & payers Government Health Service Consumption Employers Pharmacy/Pharma • Avoidable Hospitalizations • Emergency Room Visits • Physician Visits Productivity Pharmaceuticals • Absenteeism • Disability • Impairment • Engagement • Appropriate use of meds • Efficient use of meds Building blocks • Metrics • Measurement • Evaluation

11. The evidence Chapman et al; The American Journal of Health Promotion 2003

12. Test case example

13. Healthcare payer % Change in Average Health Care Claims Per Employee (Oklahoma Employer): 2002 vs. 2003 Non-INTERxVENT Participants INTERxVENT Participants Notes: INTERxVENT Program was implemented in January 2003. Participants enrolled in the INTERxVENT Program in 2003 and completed a full year of service and evaluations. Analysis performed by Milliman Consultants and Actuaries.

14. Selecting the appropriate population

15. Early dividends • Absolute risk reduction; population impact driven by baseline risk Impact of interventions (ARR) Baseline risk

16. Number of Health Risks and Productivity Loss The average employee has 2.2 health risks, resulting in productivity losses of about $2,000/year. Excess Productivity Loss Productivity Loss (%) BaseCost Number of Health Risks n = 28,375 Journal of Occupational and Environmental Medicine 2005;47:769-77

17. Adjusted for age, gender, medical conditions, other baseline risks, and each individual’s productivity loss at baseline. Burton et al, J Occup Environ Med, 2006; 48:252-63

18. Designing the appropriate intervention

19. Organizational Intervention Global Health Risk Assessment: Action Plan & Reports Average or Low-risk High-risk(e.g. Multiple risk factors, heart disease, depression, behaviors) Self-Help Program Exercise, diet, weight management, stress management, tobacco, smoking cessation, cardiovascular risk reduction Mentored Program Step-by-step guidance on exercise, diet, weight management, stress management, tobacco, smoking cessation, cardiovascular risk reduction, drug safety & compliance. Personalized

20. Organizational Intervention Global Health Risk Assessment: Goal: reducing the prevalence of high-risk populations Action Plan & Reports Average or Low-risk High-risk(e.g. Multiple risk factors, heart disease, depression, behaviors) Self-Help Program Exercise, diet, weight management, stress management, tobacco, smoking cessation, cardiovascular risk reduction Mentored Program Step-by-step guidance on exercise, diet, weight management, stress management, tobacco, smoking cessation, cardiovascular risk reduction, drug safety & compliance. Personalized

21. Organizational Intervention Global Health Risk Assessment: Goal: reducing the prevalence of high-risk populations Variations in stratification algorithms Action Plan & Reports Average or Low-risk High-risk(e.g. Multiple risk factors, heart disease, depression, behaviors) Self-Help Program Exercise, diet, weight management, stress management, tobacco, smoking cessation, cardiovascular risk reduction Mentored Program Step-by-step guidance on exercise, diet, weight management, stress management, tobacco, smoking cessation, cardiovascular risk reduction, drug safety & compliance. Personalized Controls Culture

22. Attributing productivity-impairment to costs = Knowledge-Translation

23. Positioning Health & Wellness/Disease-management programs into their appropriate context

24. http://www.scotland.gov.uk/Publications/2007/

25. http://www.scotland.gov.uk/Publications/2007/

26. To what extent is employee-engagement impacted by health and wellness interventions? http://www.scotland.gov.uk/Publications/2007/

27. Test case example

28. Presenteeism – health metrics of employee engagement

29. Presenteeism – health metrics of employee engagement

30. Summary • Building blocks for ROI • Appropriate questions • Appropriate population • Appropriate intervention • Appropriate knowledge translation • Appropriate context – employee-engagement • Measurement, metrics, and evaluation • Quantification of both deferred gratification and earlier dividends

31. Selecting appropriate programs

32. Building blocks of the program Population screening Information & monitoring system Personalized interventions Therapeutic life-style and disease-management Reporting & feedback-loops Self-management & Education Behavioral learning theories Evidence-based care

33. Selecting a program INTERxVENT’s Health Lifestyle Health Coaching Program Versus Program Offered By a Leading Academic Institution/Healthcare System (Comparison Program): 10% 4.3% 5% Percent Change in 10-Year Framingham CHD Risk Score in Higher-Risk Employees (1-Yr Follow-Up; p<0.05 for NBH vs Comparison Program ) 0% % of Change -5% -10% -15% -20% -22.6% -25% Comparison program INTERxVENT Source: Abstract #62 May 2005 – AHA, CVD Epidemiology & Prevention Conference – Washington DC, Maron, David P, et al 33

34. Selecting a program Metrics, measurement, and evaluation 34