CC BY
13
UDC 616.1-084-055.1:625.1
CLINICAL AND ECONOMIC ANALYSIS OF THE IMPLEMENTATION OF PRIMARY PREVENTION OF CARDIOVASCULAR DISEASES IN THE ORGANIZED GROUP
1 Altai State Medical University, Barnaul
2 National Medical Research Center for Preventive Medicine, Moscow N.V. Pyrikova1, A.V. Kontsevaya2, I.V. Osipova1
In 2012, against the background of preventive measures in the 1st group, compared with the 2nd, the total employer costs for two years were less by 10,243.3 rubles; a decrease in temporary disability due to cardiovascular diseases for 32 days (per 100 employees per year) was revealed; the additional gross regional product produced by reducing the days of temporary disability amounted to 47,622.4 rubles. Conclusions. The implementation of the organizational model of primary prevention in the team of railway workers for three years reduces the main risk factors and temporary disability for cardiovascular diseases by 34.6%. The economic feasibility of the organizational model of primary prevention from the position of the employer is confirmed by the return on investment of 4.65 rubles for 1 ruble spent for three years.
Key words: primary prevention; organizational model; return on investment; clinical and economic efficacy; railway workers.
Objective: to assess, from the position of the employer, the feasibility of implementing an organizational model of primary prevention in the team of men of railway transport. Materials and methods: machinists and machinist assistants of 20-55 years at the Barnaul Station. In the 1st group, an organizational model of primary prevention of cardiovascular diseases was implemented, the 2nd group was under regular medical supervision. An assessment was made of the dynamics of risk factors, temporary disability for cardiovascular diseases, the calculation of the return of employer's investments against the background of the implementation of an organizational model of primary prevention for three years from 2010 to 2012. Results: In 2012, in the 1st group, compared with the 2nd, smoking was 1.5 times less common, overweight and abdominal obesity - 1.2 times, hypercholesterolemia - 2 times, hypodynamia - 2,4 times, excessive alcohol consumption - 1.6 times, insufficient consumption of fruits and vegetables -14.8 times.
Premature mortality from noncommunicable diseases (NCDs) at working age is one of the main factors determining the significant socio-economic damage in the Russian Federation (RF), and the loss of labor potential is a threat to the economic security of the country as a whole [1]. The most active part of the working-age population is predominantly engaged in railway transport; its health level is "supermortality", high incidence rates and disability, especially in connection with cardiovascular diseases (CVD), are a constant subject of research by public health organizers. The sudden cardiac death of locomotive drivers and their assistants constituted 34.2% and 19.1%, respectively, of the total number of deaths "on the
enterprise, on the way to and from work," acute heart failure occurred in 16.3% and 9.3% of drivers and their assistants [2]. In 2015, the Declaration adopted by the High-level Meeting of the United Nations General Assembly (UN) called on countries to join efforts of all sectors of society, economic sectors and accelerate the implementation of effective measures to prevent and combat CVDs and other NCDs, which should lead to a reduction in premature mortality from NCDs by 30% by 2030 [3].
One of the problems of primary prevention of CVD is the difficulty of reaching preventive measures for people of working age who are busy with work and family and often do not attend primary health care facilities, especially for preventive purposes. Consequently, the workplace can be the optimal organizational form for the implementation of individual and group measures of CVD prevention [4]. At the same time, the implementation of a CVD prevention program in the workplace is an economically viable measure, both from the point of view of the state and from the point of view of an employer investing in the health of workers [4, 5].
Objective: to evaluate the effectiveness of the organizational model of primary prevention in the group of men of railway transport in relation to the reduction of cardiovascular risk and the feasibility of its implementation from the perspective of the employer.
Materials and methods
Inclusion criteria: male gender; age of 20-55 years; profession of railway worker (driver and assistant driver); consent to participate in the study. Exclusion criteria: symptomatic arterial
hypertension (AH); 3 degree of hypertension; presence of ischemic heart disease (IHD) and other associated clinical conditions; diabetes mellitus (DM); disturbances of high gradation rhythm; chronic diseases with functional insufficiency of organs and systems; acute diseases.
The study was carried out in two groups of workers of the railway transport of Barnaul, divided geographically, from 2010 to 2012. In the 1st group (224 employees), an organizational model of primary prevention of CVD was implemented (Figure 1). Since 2006, the "School of Health in the Workplace" has been held in the locomotive depot of the Barnaul station, once a week, for up to 15
2006
2010
minutes, before the beginning of the working shift of workers. Against the background of the "School of Health in the Workplace", earlier results were obtained in reducing the frequency of CVD risk factors in employees of locomotive brigades [6].
Since 2010, individual preventive counseling has been carried out in a complex with the "School of Health in the Workplace" in the Department of Prevention of Polyclinic No. 1 and the Health and Fitness Center of the Locomotive Depot, and in addition to the conditions of the Health and Fitness Center of the Locomotive Depot, measures are taken to increase physical activity and to correct psycho-emotional state of workers.
Polyclinic No. 1 Department of Prevention
Individual preventive counseling
Locomotive depot Barnaul Station
School of Health in the workplace
Health and Fitness Center of the Locomotive Depot
Individual preventive counseling Increase of physical activity
2010
Figure 1 - Organizational model of primary prevention of CVD in the group of railway workers.
The second group of railway workers (128 people) was under regular medical supervision (pre-driving examinations, clinical examination and medical commission).
To assess the clinical and economic effectiveness of the organizational model of primary prevention, including from the position of the employer, this work presents the results obtained against the background of the implementation of preventive measures for three years (2010 to 2012) in the 1st group, compared to 2nd control group.
Conducted research methods:
1. Assessment of risk factors for CVD [7].
2. Analysis of temporary disability (TD) for CVD per 100 employees per year (number of cases, number of days) based on reports from the section therapist and reporting form No. 16-BH.
3. Calculation of the return on investment of the employer against the background of the implementation of the organizational model of primary prevention of CVD during three years from 2010 to 2012. The employer's costs [8] consisted of the costs of examining and treating
workers with TD for CVD, the costs of preventive examinations and the costs of implementing an organizational model of primary prevention of CVD. To calculate the costs of examination and treatment of employees with TD for CVDs, tariffs for medical services were used according to the "NHI DCH at the Barnaul station" of OAO Russian Railways registry for 2010 and 2012. The cost of preventive examination consisted of the cost of the medical personnel work to identify risk factors and conduct the necessary laboratory tests: total cholesterol, blood glucose. The costs of implementing the organizational model of primary prevention of CVD included the costs of the work of medical prevention specialists (conducting the "School of Health in the Workplace" and individual preventive counseling), the cost of printed products (booklets, a self-monitoring diary for workers, handouts). To compare all costs, the total amount in each group was recalculated for 100 employees. Indicators of gross regional product (GRP) were taken on the official website of the Federal State Statistics Service (http://www.gks.ru).
4. Statistical processing of the material was performed using Microsoft Office 2007 Excel and STATISTICA 6.0 by StatSoft Inc. Differences between groups were considered statistically significant at a significance level of p <0.05.
Results and discussion
In recent years, conditions have emerged that allow one to pay attention to the solution of the actual problem of optimizing the system of medical care for industrial enterprises with an emphasis on ensuring economic efficiency and medical and social performance of this activity [9]. Experience shows that the effect of the implementation of preventive programs can be significantly higher in organized populations, since the workplace (organized group) is the optimal model for implementing preventive programs, and it provides access to a large number of people of working age who constitute a fairly stable population [10].
It is known that the development of CVD is closely related to the lifestyle of people and behavioral RF [7]; adherence to the principles of a
healthy lifestyle and a decrease in the level of major risk factors at the population level can prevent up to 80% of premature deaths from CVD [11]. It is necessary to note the experience of recent years, when large corporations, small and medium-sized businesses actively incorporate into corporate practice issues of counteracting socially significant diseases and epidemics, which remain in the focus of attention of the state and the International Labor Organization (ILO). For example, in FC URALSIB, according to regular health monitoring against the background of preventive measures held in April 2010, 38% became physically more active during the year, 40% began to consume more fruits and vegetables, 22% reduced salt intake, 35% reduced fat and sugar intake, 9% stopped smoking. Nearly 95% of employees thought that conducting a healthy lifestyle program in a corporation was necessary [12]. In our study, against the background of the implementation of the organizational model of primary prevention of CVD in the team of railway workers from 2010 to 2012, positive dynamics of CVD risk factors was obtained (Figure 2).
lack of fruits and vegetables
64,7 L
-1-
alcohol abuse
hypodynamia
I
43,8 L
1i,1 L
hypercholesterolemia
32,1 L
excess BW and obesity
_I
smoking 27,31
I ^T
AO 131-
8 C
0 0,8
10,9
ID 1,5
□ 1st group II 2nd group
113,1
111,5
Note: * p = 0.0000; ** p = 0.0001 - reliability of differences between the 1st and 2nd groups in 2012. AO - abdominal obesity, BW -body weight.
Figure 2 - Dynamics of risk factors in 2010 and 2012 against the background of the implementation of the organizational model of primary prevention of CVD in the group of railway workers.
In the 1st group, smoking decreased by 27.3% (X2 = 33.3; p = 0.0000), excess BW and obesity - by 13% (x2 = 7.4; p = 0.007), hypercholesterolemia - by 32.1% ( x2 = 46.2; p = 0.0000), hypodynamia - by 43.8% (x2 = 84.6; p = 0.0000), excessive alcohol consumption - by 16.1% (x2 = 11.0; p = 0.0009), insufficient consumption of vegetables and fruits - by 64.7% (x2 = 198.0; p = 0.0000). In the control group, during three-year follow-up, smoking decreased by 1.6% and hypercholesterolemia by 3.1%, the incidence of overweight and obesity, hypodynamia increased by 1.5%, abdominal obesity by 3.1%, ex-
cessive alcohol consumption by 10,9%, insufficient consumption of vegetables and fruits by 0.8%. Thus, in 2012, in the 1st group, compared with the 2nd group, smoking was 1.5 times less common (x2 = 19.2; p = 0.0000), overweight and abdominal obesity - 1.2 times (x2 = 3.9; p = 0.05), hypercholesterolemia - 2 times (x2 = 19.9; p = 0.0000), hypodynamia 2.4 times (x2 = 67.1; p = 0.0000), alcohol abuse - 1.6 times (x2 = 25.4; p = 0.0000), insufficient consumption of fruits and vegetables - 14.8 times (x2 = 135.7; p = 0.0000 ).
Table 1
Risk factors for cardiovascular diseases in the studied groups of railway workers before the implementation of the organizational model of primary prevention, 2010
Occupational and risk factors 1st group (n=224) 2nd group (n=128)
Age, years 42,1±7,3 43,2±6,7
Profession: - driver - assistant driver,% 69,6 30,4 67,9 32,1
Work experience, years 18,9±10,3 19,3±9,6
Smoking, % 72,8 71,9
Overweight and obesity, % 75,9 76,6
Abdominal obesity (waist circumference> 94cm), % 67,9 63,3
Hypercholesterolemia (total cholesterol> 5 mmol / l),% 58 53,1
Low physical activity,% 75,9 76,6
Alcohol use above the recommended dose per day,% 61,2 59,4
The implementation of preventive measures in the workplace, as a rule, is associated with the costs of the employer, due to the costs of technology expansion. Consequently, the employer must represent what positive effect is associated with such interventions, not only for the health of the worker himself, but also for the production process as a whole [4]. A number of American studies have demonstrated that prevention programs in the workplace are feasible, since they provide a return of between $1.5 and $3 for each ruble invested [5,
In 2012, against the background of preventive measures in the 1st group, employer costs amounted to 1,06082.0 rubles and were less than in the 2nd group (165,627.3 rubles). Thus, the total costs for two years in the 1st group amounted to 312,026.9 rubles, in the 2nd group - 301,783.6 rubles, the cost difference - 10,243.3 rubles.
Taking into account the peculiarities of the professional activities of railway workers (prolonged psycho-emotional stress combined with frequent acute stressful situations, high frequency
13]. The employer's expenses for examination and treatment of workers with TD for CVD, preventive examinations in both groups, implementation of the organizational model of primary prevention of CVD in the 1st group are presented in Table 2. In 2010, costs in the 1st group (205944.9 rubles) were higher than in the 2nd group (13,6156.3 rubles), mainly due to the costs of implementing the organizational model of primary prevention of CVD (58,236 rubles).
of behavioral risk factors), CVD makes a significant contribution to the morbidity structure of drivers and their assistants [14]. According to the results of our study in 2010, the groups had the following structure of TD for CVD (Table 3): the number of cases in the 1st group was 6.7, in the 2nd - 6.3 per 100 employees, the number of days in the 1st group - 129.1, in the 2nd group - 106.3 per 100 employees. Against the background of the implementation of the organizational model of primary prevention of CVD, the number of cases of TD decreased by
Table 2
Employer costs before and after the implementation of the organizational model of primary prevention of cardiovascular diseases in the group of railway workers (per 100 employees)
Indicator 1st group (n=224) 2nd group (n=128)
2010 2012 2010 2012
Costs of examination and treatment of
workers with temporary disability due to 109583,9 63959 98031,3 123504,3
cardiovascular diseases, rub.
Costs of preventive examination, rub. 38125 42123 38125 42123
Costs of preventive intervention, rub. 58236
Total employer costs, rub. 205944,9 106082,0 136156,3 165627,3
Total costs for 2 years, rub. 312026,9 301783,6
Cost difference, rub. 10243,3
32.8% and the number of days by 34.6% in the 1st group for three years. During the three years of follow-up in the 2nd group, the number of cases
Thus, in 2012, in the 1st group, a decrease in TD was detected, compared to the 2nd group, by 32 days, the additional gross regional product (GRP), produced by reducing the TD days, amounted to 47,622.4 rubles. When analyzing the economic feasibility of the organizational model of primary prevention of CVD from the position of the employer, it was established that for every ruble spent in 2010, the return on investment by the employer constituted 4.65 rubles for three years.
As national and foreign experience shows, the benefits from the implementation of preventive programs in the workplace for an employer can be both economic (return on investment in the program by reducing TD and treatment costs, reducing employee turnover), and image-building (increasing trust in the company in the market, the image of a socially responsible employer) [5]. In modern conditions, the conduct of clinical and economic analysis in the implementation of preventive technologies in an organized group is necessary to justify the economic feasibility of these technologies from the point of view of the employer and the management decision making. Clinical and economic aspects of the implementation of preventive programs, for example, training programs for patients with hypertension in the school of health for 12 months, have led to a decrease in the number of hospitalizations, outpatient visits, emergency calls, and cases of TD. The analysis of "cost minimization" showed a decrease in expenditures on HD by an average of 56.02%, a cost-effectiveness analysis revealed that the use
of TD increased by 19.2%, the number of days increased by 8.7%.
of training programs in the treatment of patients with hypertension is characterized by lower costs per unit of efficiency [15]. Differentiated treatment and rehabilitation programs for hypertension introduced into the activities of the National Medical Research Center for Preventive Medicine of the Railroad Clinical Hospital demonstrated high medical and social efficacy: the maximum possible savings from the implementation of the proposed treatment and prevention programs reached 25,296.04 thousand rubles per year [14].
Railway transport as an industry, being the core of the economy of any country, occupies one of the leading places in terms of the number of workers in difficult and unfavorable working conditions, with high labor intensity, which requires the active introduction of preventive technologies [16]. The implementation of the organizational model of primary prevention in the group of railway workers, on the one hand, allows to preserve the health of employees and prolong their professional longevity, on the other hand - to reduce employer losses associated with TD.
Conclusion
The implementation of an organizational model of primary prevention in a team of railway workers for three years leads to a significant decrease in behavioral and associated biological risk factors: smoking - by 27.3%, abdominal obesity - by 13%, hypercholesterolemia - by 32.1%, hypodynamia - by 43,8%, excessive alcohol consumption - by 16.1%, insufficient consumption of vegetables and
Table 3
Economic feasibility of the organizational model of primary prevention of cardiovascular diseases in the group of railway workers from the perspective of an employer (per 100 employees)
Indicator 1st group (n=224) 2nd group (n=128)
2010 2012 2010 2012
Cases of temporary disability for cardiovascular diseases 6,7 4,5 6,3 7,8
Days of temporary disability for cardiovascular diseases 129,1 84,4 106,3 116,4
Difference of days of temporary disability in 2012 32 days
Gross regional product for 1 day in 2012, rub. 1488,2 1488,2
Additional gross regional product produced by reducing the number of days of temporary disability in the 1st group, compared with the 2nd group 47622,4
Return on investment, rub. 47622,4/10243,3=4,65
fruits - by 64.7%; and reduce the number of cases of temporary disability for CVD by 32.8% and the number of days by 34.6%. The economic feasibility of the organizational model of primary prevention of CVD from the position of the employer is confirmed by the return on investment of 4.65 rubles per 1 ruble spent for three years. This model can be translated in any organized group.
References
1. Oganov R.G., Kontsevaya A.V., Kalinina A.M. Economic damage from cardiovascular diseases in the Russian Federation. Cardiovascular therapy and prevention. 2011; 10(4): 4-9.
2. Kraevoy S.A. Standardization in assessing medical losses in rail transport and the need to create a system of prevention. Problems of standardization in health care. 2012; 7(8): 42-44.
3. Hughes BB, Kuhn R, Peterson CM [et al.]. Projections of global health outcomes from 2005 to 2060 using the International Futures integrated forecasting model. Bull WHO. 2011; (89): 478-486.
4. Kontsevaya A.V., Kalinina A.M., Belonoso-va S.V., Pozdnyakov Yu.M., Khudyakov M.B. The cost-effectiveness of the implementation of the program of multifactorial prevention of cardiovascular diseases in an organized team of employees of a technical research institute. Rational pharmacotherapy in cardiology. 2010; 6(4): 469-473.
5. Carnethon M, Whitsel LP, Franklin BA [et al.]. Worksite Wellness Programs for Cardiovascular Disease Prevention. Circulation. 2009; (120): 1725-1741.
6. Osipova I.V., Pyrikova N.V., Antropova O.N., Komissarova I.N., Borodina L.M. The efficiency of onsite health school and individual counseling in locomotive crew members. Profilakticheskaya meditsina. 2013;16(1):13-17.
7. Recommendations for cardiovascular prevention. M., 2017: 289.
8. Clinical and economic research. General provisions. Industry standard. M., 2002.
9. Novokreshchenova I.G., Novokreshchen-ov I.V., Bulanov V.E..Organization of medical aid for workers of industrial enterprises in contemporary conditions. Saratov Journal of Medical Scientific Research, 2010, 6(2): 282-287.
10. Oganov R.G., Maslennikova G.Ya. The epidemic of cardiovascular diseases can be stopped by increasing prevention. Profilakticheskaya meditsina. 2009; 12(6): 3-7.
11. Jousilahti P, Laatikainen T, Peltonen M [et al.]. Primary prevention and risk factor reduction in coronary heart disease mortality among working aged men and women in eastern Finland over 40 years: population based observational study. BMJ. 2016; 352: i721.
12. Health in the workplace. Collection of corporate practices. M: RSPP, 2011.
13. Naydeck BL, Pearson JA, Ozminkowski RJ, Day BT, Goeteel RZ. The impact of the highmark employee wellness programs on 4-year healthcare costs. J Occup Environ Med. 2008; 50: 146-156.
14. Molodtsov R.N., Shemetova G.N. Diseases of the circulatory system in railway workers: trends in morbidity, medical and social importance, approaches to prevention. Problems of social hygiene, health and medical history. 2013; 2: 8-11.
15. Magalyas E.V. Evaluation of the clinical and socio-economic effectiveness of teaching patients with arterial hypertension in school health. Abstract of thesis ... candidate of medical sciences. Blagoveshchensk, 2010.
16. Atkov O. Yu. A strategy for improving the health of employees of Russian Railways until 2020. Railway transport. 2010; 12: 8-13.
Contacts
Corresponding author: Pyrikova Natalia Viktorov-na, Doctor of Medical Sciences, Associate Professor, Department of Faculty Therapy and Occupational Diseases, Altai State Medical University, Barnaul. 656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201279. Email: allinatali@mail.ru
Author information
Kontsevaya Anna Vasilyevna, Doctor of Medical Sciences, Corresponding Member of the Russian Academy of Sciences, Deputy Director for Scientific and Analytical Work of the National Medical Research Center for Preventive Medicine, Moscow. 101990, Moscow, per. Petroverigsky, 10/3. Tel.: (495) 7907172. Email: zdorov@gnicpm.ru
Osipova Irina Viktorovna, Doctor of Medical Sciences, Professor, Head of the Department of Faculty Therapy and Occupational Diseases, Altai State Medical University, Barnaul. 656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201279. Email: i.v.osipova@gmail.com
