The sudden death of Ryan Shay at the 2007 Olympic Marathon Trials – and – Alberto Salazar’s own bout with heart disease have prompted the publication of this article in Podium Sports Journal. Podium is focused on optimum health and peak performance – and this article provides a clear focus for the best practices in the prevention of heart attack and stroke. Every single reader has known at least one person who has succumbed to this disease. For every woman who is lost to breast cancer – seven will die from a heart attack. It is the world’s most deadly disease. It is also one of the most expensive to treat.
The Business Problem and the Cost of Heart Disease.
Business, municipal and non-profit organizations all experience costs associated with turnover. Every position within an organization is expensive to replace, but the cost can be significant when considering a highly skilled technical employee, or astronomical should the loss come at the executive level. The greater the investment an organization has in the training and productive work of an individual, the more costly to replace him or her. Whether an individual is terminated for poor performance or lost through a health challenge or death…..costs are incurred. Succession planning, cross training, and health screenings can be instrumental in reducing the damage done by such a loss, but many organizations fail to consider such things when planning strategically for their future.
Health challenges contribute additional costs which may include medical expenses, short or long term disability costs, and perhaps funeral costs should death take a key employee. Loss attributable to heart attack and stroke is a common occurrence these days. It is also one of the easiest to predict. Heart disease will ultimately be the cause of death for half of us, and for those planning on retiring…it’s sobering to realize that a full 30% of us will never reach the age of sixty five. Heart disease can be managed effectively if caught in time. Unfortunately the first cardiac symptom experienced by 71% of the population will be a heart attack, and, one out of every three of those will not survive.1 Because the bottom line drives business, it might be worth considering how much it might cost your organization if you or some other vital employee were lost to a heart attack or stroke?
Assessing the Costs.
A loss will definitely trigger a ripple effect throughout the business. A few of the measurable outcomes can help determine the financial impact on your organization. Some person or position-specific factors will require a closer look, depending on the individual’s role in the organization. Whether technical, administrative or sales oriented every position will have administrative costs, the search for a suitable replacement, recruitment, education, training, and lost productivity. It is also true that health insurance premiums may be impacted for the coming year since companies are rated based on the collective health history of their employees. Perhaps the greatest loss is not even measurable. Nobody can replace an individual whose personality or leadership boosted morale, touched the lives of many, and provided cohesion for the whole.
The Current Approach.
As of this writing, prevention is largely an afterthought for businesses and insurance carriers. They tend to employ a ‘one size fits all’ approach emphasizing diet and exercise. Some companies provide optional stress management classes for their employees. Kaiser-Permanente encourages quarterly lipid profiles. These efforts may be successful to a limited degree, but are rather conventional and not precise enough to consider the loss of a key person, or the cost of turnover. Basically screening programs and prospective measures neither identify who is at greatest risk nor do they equip them with the tools to help them remedy the problem.
Stress Management programs provide an excellent example. Stress, has long been known as a contributing factor in heart disease, but programs addressing this concern tend to be optional and limited to 1-2 hours once a year for those who self-select to attend. Ironically, the most stressed employees often ‘trivialize’ the benefits of a stress management program, or feel that they are too busy doing productive work to attend. Others may be in denial of the stress they are under and fail to understand their personal risk factors. They view ‘cranky’ behavior as a fact of life and unavoidable. Some pride themselves in giving ulcers not getting them. The lack of consideration for their personal health aside, ‘team’ chemistry is impacted by such attitudes.
It is precisely this individual that needs a process for screening, and a personalized assessment of their risk factors….because they are least likely to do it for themselves. As a business owner, your chief executive officers, highly trained experts and employees whose loss could severely interfere with the operations of your organization are of greatest concern. Are lipid profiles, stress treadmills, and other examples of the ‘one size fits all’ approach for risk assessment enough? Not likely.
A proper screening for occupational stress would assess the degree to which chronic stress, anger, hostility, anxiety, depression, negative emotions and social isolation play into each individual’s risk profile. Research in this area has revealed a clear understanding as to how toxic emotions alter a person’s blood chemistry contributing to heart disease.2 Cardiac psychology and effective stress assessments are only part of the solution. The key lies in the use of ‘stratified risk assessments’ and ‘targeted interventions’ which have grown out of the developing specialization of preventive cardiology. Dr. Harvey Hecht, Director of Preventive Cardiology at NY’s Beth Israel Hospital, asserted, “There is no doubt that President Clinton would have been identified as high risk 10 years ago — if he had undergone calcium scanning—and the odds are great that bypass surgery could have been avoided.”3
‘The Best Medicine.’
An emerging group of cardiologists displeased with traditional positions on prevention established by the American College of Cardiology has formed the Society for Heart Attack Prevention and Eradication (SHAPE) is one of the strongest proponents for risk stratification. A model research effort launched in the local Denver area used this protocol to identify who is really vulnerable within a commonly perceived high risk population; that of former NFL professional football players. Although there is agreement that these athletes have a significantly reduced life expectancy, the exact age is somewhat in dispute (estimations ranging from 52 to early 60’s depending on the data source).4 Comparison research conducted on this population provides conflicting data on mortality rates attributable to heart attack as compared to normal population of men aged 23-35 years in the CARDIA study.
This model intervention has been termed ‘The Best Medicine.’ Research supporting this kind of stratified risk assessment and targeted treatment regimen has been accruing over the past several years.5,6 This sample included 100 members of The Denver Bronco Football Club Alumni ranging in age from 35 to 61 years who were provided an opportunity and self-selected to participate in the study. With the support of several doctors lead by preventive cardiologist, Dr. Jeffrey Boone and program coordinator, Toni Standley, researchers, sponsoring agencies, venders and pharmaceutical manufacturers….the Bronco Alumni were provided a state-of-the-art intervention, have been treated proactively and continuously monitored since, utilizing the stratified risk assessment and a targeted intervention for each participant addressing every known indicator for heart disease in that patient. The protocols used in this research included both traditional and more progressive techniques for evaluating and treating heart disease (CAD). The research effort is ongoing.
Traditional patient intake information included age, family history, medical history, lifestyle risk factors, Framingham risk assessment, cardiac symptoms, history of medical procedures, situation specific blood pressure response, medication reviews, exercise patterns, health risk behaviors, smoking and obesity screening. Additional diagnostic testing included:
- Electron Beam CT Scan
- Treadmill Stress Test
- Stress Echocardiogram or Cardiac Ultrasound
- NMR, PLAQ test – LpPLa (2) screening
- Carotid IMT
- Aspirin Resistence Test
- Life Stress Assessments
These variables and others were utilized while tracking specific indicators of disease after a baseline heart health status was determined. For those in good health, very few treatment measures were recommended beyond daily aspirin, exercise regimens, dietary adjustments, nutritional supplements, stress management and additional testing as needed. Alumni presenting with data suggestive of progressive CAD were treated aggressively with medication management using statins, ace inhibitors, anti-inflammatory agents, platelet coagulation inhibitors and selective nutritional supplements in addition to recommended lifestyle changes. No extensive procedures such as bypass grafting, angiography, or nuclear perfusion studies were deemed necessary amongst the treatment sample.
Results of this approach using a stratified risk assessment and targeted treatment regimen have been documented and monitored quarterly. Thus far, at the end of two calendar years, the overall intervention has been significantly effective at reducing symptom indicators of CAD.7 Publication of this research is still pending. These interim results demonstrate how risk stratification is cost effective as a screening method. Even more importantly, the targeted intervention for specific risk factors demonstrated unequivocally that the progression of heart disease can actually be reversed when patient specific treatment guidelines are proactively implemented.
Benefits of Early Detection and Treatment of CAD.
The cumulative research in this field is now able to identify with greater clarity how the disease progresses. The crucial role is played by each person’s blood chemistry. Not only is blood chemistry highly variable, it is influenced by diet, emotional reactions to stress, exercise (or lack of), dental health and a number of genetic and environmental factors. Because the blood serves to transport hormonal messages, nutrients and waste products to and from specific organs in the body, it is also the carrier of other by-products that can be harmful to the cardiovascular system itself. Often referred to as metabolic syndrome, a process is engaged that progressively damages the lining of the blood vessels themselves (endothelial dysfunction). Once compromised, inflammation sets in, frequently contributing to the coagulation of platelets sometimes causing clots to form. Any or all of these steps can create unstable plaque and trigger a thrombosis….resulting in a heart attack or stroke.8
In July 2006 the American Heart Association published guidelines for the early detection and treatment of the physical markers of heart disease through its own SHAPE initiative.9 SHAPE stands for ‘screening for heart attack prevention and education’ which summarizes the body of research and provides guidelines which recommend stratified risk assessments and targeted interventions. The AHA’s initiative established a precedent from which the Society for Heart Attack Prevention Eradication was formed. Many of these tests and procedures are not covered by traditional insurance reimbursement formularies. This reality places even more responsibility on our corporate citizens to take care of their own bottom line.
Unfortunately, our health care system tends to respond best to heart disease once a patient has had a heart attack, even though the patient’s quality of life and survivability may be compromised significantly after the fact. Once afflicted, these patients subsequently utilize a larger percentage of the total healthcare resources available. Estimates in 2004 by the Center of Disease Control indicate the financial costs of heart disease at 396 billion dollars.10 ‘The Best Medicine’ is one of a number of leading programs designed to lower the costs of heart disease by employing a stratified risk assessment and proactively addressing those causative factors. At the very minimum, this approach saves lives by preventing the incidence of heart attack and stroke.
Risk Stratification as a Business Solution – The ROI.
The CFO of an organization considering this type of screening would likely determine the variables assessing the potential return on investment of a stratified risk assessment such as this. Because no two businesses or municipal organizations are exactly alike this return must be determined on a case-by-case basis. Models for assessing the cost of turnover have rarely been modified for such a purpose. Even less frequently are they weighed against the direct costs of a prevention initiative. Models exist for evaluating the cost benefit of sales training programs, or the effectiveness of an advertising campaign, but the process for assessing the ROI of a strategically designed health and wellness intervention requires a more specialized formula.
What to Measure?
One model for measuring costs of turnover was developed by Dr. Michael Mercer, consultant with The Mercer Group, in his book, Turning Human Resource Departments into a Profit Center.11 It is designed for the expressed purpose of evaluating the costs of turnover within an organization. His model provides a good baseline. We have modified it to include both the direct costs of a heart attack or stroke, in addition to some variable costs including:
- Separation Costs
- Replacement Costs
- Training Costs
- Lost Productivity Costs
- Lost Business Costs
- Disability Costs
- Costs from Death of an Employee
In situations where key employees have died, been taken ill, or injured on the job there are likely to be additional costs to the organization. Companies that experience the loss of a highly trained employee are not only responsible for the replacement costs for that employee, they may also have to deal with some additional medical expenses and incidental costs. Some organizations, such as fire and police departments, have extraordinary costs associated with the burial, ceremonies, and replacement officer uniform costs. In recent years, higher deductibles and stop loss expense caps allow for the estimation of some of these additional cost factors, but they do little to address them. More responsibility is continuously being placed on the corporations themselves and each employee through ‘consumer driven health care plans’.12 Companies that self-insure have the most incentive to employ stratified risk assessments and targeted treatment regimens.
A Case Study.
In January of 2006 a 55 year old Fire Chief completed his annual physical. The physical was normal except for an abnormal EKG, which was considered not diagnostically significant. The Chief reported that he felt fine, had no experience of chest pain or any other symptoms of heart disease, and indicated he was unconcerned with the abnormal EKG. A few days later he was seen by a cardiologist who conducted a stress treadmill which also appeared abnormal. It was followed by a perfusion study. Circulatory impairments clearly existed. The Chief stopped work
immediately and was placed on short-term disability. Subsequent angiography determined that the Chief’s problems were systemic and surgery was required immediately. He then received four coronary arterial bypass grafts, was hospitalized for 5 days and his duties were absorbed in-house by the Deputy Chief of Administration and the Assistant Chief of Operations for the department.
Unfortunately there were complications. Two of the grafts failed and an additional procedure resulted in the placement of stents repairing the grafts. After three days, the Chief was released from the hospital and again started phase I rehab. A month later, symptoms appeared requiring plural effusion studies and another hospitalization this time for an infection and mild pericarditis. Intravenous antibiotics controlled the infection and he has been steadily improving since, first in rehab and now on his own. Following his 56th birthday, the Chief decided he should retire and was placed on permanent disability.
The financial aspects of this case-study incorporate the current outcome and costs of the incident as it impacted the organization, the chief, the insurance carrier, the department’s obligations in providing insurance, short-term disability, long-term disability, the costs of separation, and replacement costs as of this writing. A search is currently underway for his replacement. The organization is using a headhunter to identify and recruit properly trained and experienced candidates.
In the eleven months since the ordeal began, the medical expenses realized by the Chief, the department, and the insurance carrier have reached $196,000. The cost of lost productivity to the department was estimated at $47,420. The organization anticipates replacement costs for recruitment and hiring of his successor to be between $40,000 and $45,000 depending on travel expenses, moving, and uniform costs. The total cost of this episode to the parties concerned has been conservatively estimated at $277,470 to date. The stress incurred by those assuming additional responsibilities is not considered measurable, nor is the stress incurred by their families who were required to adjust to these extraordinary demands placed upon them. The required yet unpaid overtime has not been calculated because those affected are salaried and exempt employees.
The costs of replacing that one employee could have funded a risk stratification screening for every employee and included a Life Stress Interview, EBCT heart Scan, blood lipid particle test (NMR), and a carotid IMT test for all 117 department employees…AND RETURNED $210,000 to the respective responsible parties. Just the direct costs incurred by the department in lost productivity and replacement costs would have funded the SHAPE guidelines for every career and volunteer employee. The peace of mind and the benefits experienced by every family, their children, and smooth operations of the organization….priceless.
1) American Heart Association: Heart Disease and Stroke Statistics – 2006 Update. Dallas, Texas, American Heart Association, 2006.
2) Rozanski, A, Blumenthal, J, Davidson K, Saab P, Kubzansky L, “The Epidemiology, Pathophysiology, and Management of Psychosocial Risk Factors in Cardiac Practice”, J Am Coll Cardiol 2005;45:5:637-651.
3) Hecht, Harvey, “Aggressive Testing for and Treatment of Heart Disease and Stroke”, Seminar Procedings, Denver, Colorado, Nov.19, 2005.
4) National Institute for Occupational Safety and Health Study in conjunction with the NFL Players Assn., Proceedings 1992.
5) Bard, R., Kalsi, H., Rubenfire, M., Wakefield, T., Fex, B., Rajagopalan, S., & Brook, R., Effect of Carotid Atherosclerosis Screening on Risk Stratification During Primary Cardiac Disease Prevention, Am.Journal of Cardiology, Vol 93; 8: April 2004, 1030-1032.
6) Yusuf S, Hawkin S, Ounpuu S, et al. “Effect of Potentially Modifiable Risk Factors Associated with Myocardial Infarction in 52 Countries (The INTERHEART Study): Case-control Study. Lancet 2004;364:937-52.
7) Boone, J. and Standley, T. Preliminary data – Denver Bronco Alumni Program to Eradicate Heart Disease and Stroke, September 2006.
8) Berger, G., Hartwell, D., Wagner, D., “P-Selectin and Platelet Clearance”, Blood, Vol. 92:11, December 1998: pp. 4446-4452.
9) Screening for Heart Attack Prevention and Education Taskforce – Guidelines published in the American Journal of Cardiology, July 2006.
10) Center for Disease Control and Prevention, Preventing Chronic Diseases: Investing Wisely in Health – 2005 (Center for Disease Control and Prevention).
11) Mercer, M., Turning Human Resource Departments Into a Profit Center., Castlegate Publishers, Inc., Barrington Il., 2005.
12) Herzlinger, R., Consumer Driven Healthcare: Implications for Providers, Payors, and Policy Makers., Harvard University Press, Boston, 2004.