June 2001\u00a0<\/span><\/strong><\/span><\/p>\n Behavior change can improve health status for many adults.<\/span> Further, for adults with chronic illness and permanent injuries, a growing body of literature identifies health promotion as both effective in improving health and cost-effective compared to treatment alternatives. Yet third-party payers (Medicaid, Medicare, and private insurance) typically do not reimburse health promotion interventions. This is a problem for many individuals with disabilities who have significant health care costs and cannot pay for health promotion programs.<\/span><\/p>\n For more than a decade, the Office on Disability and Health at the Centers for Disease Control and Prevention has supported research culminating in the Living Well with a Disability<\/a><\/em> health promotion program for people with disabilities. This research has progressed from an initial focus on behavioral epidemiology and the risk factors for secondary conditions experienced by people with physical impairments to development, implementation and evaluation of the Living Well<\/em> intervention.<\/span><\/p>\n The Living Well <\/em>workshop differs from many medically-based health promotion interventions because improved health is an objective to a goal, rather than the goal itself. Living Well<\/em> links health with function; and participants’ goal-setting and problem-solving activities drive their health behavior <\/span>changes.<\/p>\n Research Process<\/span><\/strong><\/p>\n A pair of lay facilitators presented eight weekly, two-hour Living Well <\/em>sessions which covered goal-setting, problem-solving, attribution training, depression, healthy communication, information-seeking, physical activity, nutrition, advocacy, and health maintenance. For this study, a total of nine Centers for Independent Living (CILs) in eight states recruited a total of 246 participants into 34 Living Well<\/em> workshops.<\/span><\/p>\n Participants completed self-report surveys at five intervals (immediately pre-intervention, immediately post-intervention, and at two-, four- and twelve-month post-intervention intervals). An additional wave of data was collected at two months pre-intervention for approximately half of the participants who were randomly assigned to wait two months before receiving the Living Well<\/em> intervention, serving as an extended baseline control group. Because this study focused on longitudinal changes for people who completed the Living Well<\/em> workshop, the study sample was confined to 188 participants who completed both an immediate pre- and immediate post-intervention survey instrument.<\/span><\/p>\n Health outcomes were measured using the sum of participant ratings for the limitation they experience due to secondary conditions. Health behavior frequency and intensity were measured using the Health Promoting Lifestyle Inventory II.<\/em> Finally, using a 2-month retrospective recall, health care utilization rates were determined from participants’ reports of their physician and emergency room visits, outpatient surgeries and hospital days. <\/span><\/p>\n The extended baseline group was similar to the larger study group in terms of demographics, health outcomes, and medical care utilization rates. As a result, significant changes in health outcomes and costs after participation in the program can be more confidently attributed to the Living Well<\/em> intervention. Reported results include this extended baseline group.<\/span><\/p>\n Cost Analysis<\/span><\/strong><\/p>\n The cost analyses were approached from two perspectives. From an economic perspective, costs were totaled for all participants who reported data at each wave regardless of whether respondents had completed either previous or subsequent waves of data. These estimates provide the best estimates of healthcare expenditure at each point in time. Because the composition of the sample changes across time, however, the estimates are not applicable to assessing the efficacy of the intervention on healthcare costs. As interventionists, we also computed cost estimates using a repeated measures analysis for the consistent sample of individuals who returned outcome data at each wave of data collection.<\/span><\/p>\n Health care cost estimates were skewed by a small number of extremely high medical care users. Specifically, cost estimates associated with hospital stays showed that 3.6% of the sample accounted for 80% of hospitalization expenditures. To mitigate this effect, results are presented for the entire cohort and a trimmed data set which excludes hospital stays longer than 7 days for any 2 month retrospective. The rationale for presenting a trimmed data set comes from the assertion that individuals requiring hospitalization for more than a week are experiencing medical conditions that would not be prevented by health promotion efforts examined within a six-month time frame.<\/span><\/p>\n Preliminary Results<\/span><\/strong><\/p>\n The average participant in this study was 45 years old and had experienced disability for 17 years. The sample was predominately female (64.2%), unmarried (63.4%), and unemployed (83.8%). Additionally, 80.3% of our study sample participants were Medicaid or Medicare beneficiaries and 58.2% depended on Medicaid and\/or Medicare coverage exclusively.<\/span><\/p>\n First, results are reported from an economic perspective on costs incurred by the total cohort at each wave. Next, costs are presented using the intervention evaluation perspective using a repeated measures analysis of variance.<\/span><\/p>\n Economic Perspective<\/span><\/strong><\/p>\n From an economic perspective, we can project savings due to declines in medical service utilization pre- to post-intervention. A financial cost-benefit analysis from the perspective of a third party payer measures the program’s net benefits (program outcomes minus programmatic costs) and shows a six-month return on investment.<\/span><\/p>\n Programmatic costs <\/strong><\/span><\/strong><\/span>include costs for contracted services to implement the Living Well<\/em> workshop, instructor training, and variable costs for participant workshop materials. Based on 188 participants, programmatic costs are $596 per participant.<\/span><\/p>\n Program outcomes <\/strong><\/span><\/strong><\/span>(PO) are measured as changes in medical care utilization costs. In each survey round, participant medical utilization rates were multiplied by unit Medicare cost estimates to generate total medical expenses at each survey point. Program outcomes (PO) measure the change between pre-intervention medical costs (COST_B) and three post-intervention medical cost measures (COST_C, COST_D, and COST_E) to generate a six- month change in medical costs. Specifically: <\/span><\/p>\n PO = (COST_B – COST_C) + (COST_B – COST_D) + (COST_B – COST_E)<\/span><\/strong><\/p>\n Table 1 shows the mean cost estimates for each survey point and the projected program outcome and net benefit measures. Data are presented for both the entire cohort and the trimmed data set.<\/span><\/p>\n <\/a>Table 1: Mean Cost Estimates<\/strong><\/span><\/strong><\/span>
\n Description of Table 1.<\/a> <\/strong><\/strong><\/p>\n
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