Probing immune infiltration dynamics in cancer by in vivo imaging.

Cancer immunotherapies typically aim to stimulate the accumulation and activity of cytotoxic T-cells or pro-inflammatory antigen-presenting cells, reduce immunosuppressive myeloid cells or regulatory T-cells, or elicit some combination of effects thereof. Notwithstanding the encouraging results, immunotherapies such as PD-1/PD-L1-targeted immune checkpoint blockade act heterogeneously across individual patients. It remains challenging to predict and monitor individual responses, especially across multiple sites of metastasis or sites of potential toxicity. To address this need, in vivo imaging of both adaptive and innate immune cell populations has emerged as a tool to quantify spatial leukocyte accumulation in tumors non-invasively. Here we review recent progress in the translational development of probes for in vivo leukocyte imaging, focusing on complementary perspectives provided by imaging of T-cells, phagocytic macrophages, and their responses to therapy.

Value-Driven Population Health: An Emerging Focus for Improving Stakeholder Role Performance.

Health and health care in the United States are being jeopardized by top-end spending whose share of the gross domestic product continues to increase even as aggregate health outcomes remain mediocre. This paper focuses on a new approach for improving stakeholder role performance in the marketplace, value-driven population health (VDPHSM). Devoted to maximizing the value of every dollar spent on population health, VDPH holds much promise for ameliorating this dilemma and exerting a constructive influence on the reshaping of the Affordable Care Act. This paper introduces VDPH and differentiates the science underlying it from the management that serves to make good on its potential. To highlight what VDPH brings to the table, comparisons are made with 3 like-minded approaches to health reform. Next, 2 areas are highlighted, workplace wellness and the quality and cost of health care, where without necessarily being recognized as such, VDPH has gained real traction among 2 groups: leading employers and, more recently, leading providers. Key findings with respect to workplace wellness are assessed in terms of psychometric performance to evaluate workplace wellness and to point out how VDPH can help direct future employer initiatives toward firmer scientific footing. Then, insights gleaned from the employer experience are applied to illustrate how VDPH can help guide future provider efforts to build on the model developed. This paper concludes with a framework for the use of VDPH by each of 5 stakeholder groups. The discussion centers on how VDPH transcends and differentiates these groups. Implications for health reform in the recently altered political landscape are explored.

Tracking low back problems in a major self-insured workforce: toward improvement in the patient's journey.

OBJECTIVE: To assess the cost outcomes of treatment approaches to care for back problems in a major self-insured workforce, using published guidelines to focus on low back pain. METHODS: Longitudinally tracked episodes of three types of International Classification of Diseases, Ninth Revision diagnosis code-identified back problems (n=14,787) during 2001 to 2009. Identified five patterns of care on the basis of the first 6 weeks of claims and compared their total costs per episode with tests that included splits by episode type and duration, use of guidelines, and propensity-derived adjustments. RESULTS: Care congruent with 10 of 11 guidelines was linked to lower total costs. Of the five patterns, complex medical management and chiropractic reported the highest and lowest rates, respectively, of guideline-incongruent use of imaging, surgeries, and medications, and the highest and lowest total costs. CONCLUSIONS: Approaches marked by higher resource utilization and lower guideline congruence are linked to greater low back pain total costs. Total cost is a needed input for guideline development.

Reducing total health burden from 2001 to 2009: an employer counter-trend success story and its implications for health care reform.

OBJECTIVES: To examine total health burden for an employer whose health-related focus is direct and indirect costs. To explore implications for the Final Rule for Accountable Care Organizations recently issued by the Centers for Medicare and Medicaid Services, whose focus includes direct but not indirect costs. METHODS: Used 42 claims and survey-based measures to track this employer's continental US workforce burden in the aggregate and by healthy and selected disease designations from 2001-2002 to 2008-2009. RESULTS: Starting from equivalent baselines, this employer's aggregate total direct costs decreased 16% (8.5% adjusted) whereas comparable US per capita expenditures rose 22.1%. Even larger decreases were recorded in total indirect costs. The healthy and disease designations replicated this pattern. Minimal employee cost shifting occurred. CONCLUSIONS: Attention to direct and indirect costs helped put this employer's health care investment on a markedly more sustainable path than comparable national cost trends. Fully tapping the applicable lessons this and other purchasers have learned will be facilitated by amending the Final Rule to include measures of indirect costs.

The self-reported health and productivity burden of autoimmune disorders at a major self-insured employer.

OBJECTIVES: Examine the self-reported health and productivity burden of three autoimmune disorders: rheumatoid arthritis, psoriasis, and inflammatory bowel disease. METHODS: A 2009 representative survey of a major employer's US workforce, with two approaches for disease identification: (1) self-report and (2) self-report replicated by claims-based International Classification of Diseases, 9th Revision (ICD-9), codes. RESULTS: Self-reported prevalence: rheumatoid arthritis, 4.2%; psoriasis, 3.0%; inflammatory bowel disease, 1.2%. Psoriasis and inflammatory bowel disease replicated rheumatoid arthritis' pattern of health and productivity effects though not as strongly. The three autoimmune disorders combined significantly affected health at all severity levels. They also significantly affected productivity at higher severity but not at no symptom/lower severity levels. CONCLUSIONS: When employees with autoimmune disorders with lower severity/no symptoms do not progress to higher severity, their work performance remains on par with healthy employees. Autoimmune disorders' high impact/low prevalence offers much promise for lowering costs through benefit design.

Managing the burden of chronic obstructive pulmonary disease on workforce health and productivity: upping a leading employer's game.

OBJECTIVE: To develop new evidence for advancing a leading employer's capacity to manage the burden of chronic obstructive pulmonary disease (COPD). METHODS: Retrospective analyses of an integrated database tracking active employees (n = 19,989) from 2001-2009. Tests on 29 measures of direct/indirect costs and drivers examined unique disease burden and impact over time. RESULTS: The costs of COPD exceeded workforce-wide costs by wide margins in 2001-2002. Direct costs linked to the disease rose in 2008-2009; whereas, its indirect costs dropped sharply. Differences between yet-to-be-diagnosed versus diagnosed and newly diagnosed versus established diagnosed groups were directionally consistent on driver and cost measures in 2001-2002. In 2008-2009, these comparisons were similarly consistent on indirect measures but not direct measures. Medication use helped to explain the inconsistencies. DISCUSSION: New action on COPD-oriented unit price escalation, prevention, and medical management concerns raised by these results could strengthen an already exemplary health and productivity program.

Optimizing health care delivery by integrating workplaces, homes, and communities: how occupational and environmental medicine can serve as a vital connecting link between accountable care organizations and the patient-centered medical home.

In recent years, the health care reform discussion in the United States has focused increasingly on the dual goals of cost-effective delivery and better patient outcomes. A number of new conceptual models for health care have been advanced to achieve these goals, including two that are well along in terms of practical development and implementation-the patient-centered medical home (PCMH) and accountable care organizations (ACOs). At the core of these two emerging concepts is a new emphasis on encouraging physicians, hospitals, and other health care stakeholders to work more closely together to better coordinate patient care through integrated goals and data sharing and to create team-based approaches that give a greater role to patients in health care decision-making. This approach aims to achieve better health outcomes at lower cost. The PCMH model emphasizes the central role of primary care and facilitation of partnerships between patient, physician, family, and other caregivers, and integrates this care along a spectrum that includes hospitals, specialty care, and nursing homes. Accountable care organizations make physicians and hospitals more accountable in the care system, emphasizing organizational integration and efficiencies coupled with outcome-oriented, performance-based medical strategies to improve the health of populations. The ACO model is meant to improve the value of health care services, controlling costs while improving quality as defined by outcomes, safety, and patient experience. This document urges adoption of the PCMH model and ACOs, but argues that in order for these new paradigms to succeed in the long term, all sectors with a stake in health care will need to become better aligned with them-including the employer community, which remains heavily invested in the health outcomes of millions of Americans. At present, ACOs are largely being developed as a part of the Medicare and Medicaid systems, and the PCMH model is still gathering momentum and evolving among physicians. But, the potential exists for implementation of both of these concepts across a much broader community of patients. By extending the well-conceived integrative concepts of the PCMH model and ACOs into the workforce via occupational and environmental medicine (OEM) physicians, the power of these concepts would be significantly enhanced. Occupational and environmental medicine provides a well-established infrastructure and parallel strategies that could serve as a force multiplier in achieving the fundamental goals of the PCMH model and ACOs. In this paradigm, the workplace-where millions of Americans spend a major portion of their daily lives-becomes an essential element, next to communities and homes, in an integrated system of health anchored by the PCMH and ACO concepts. To be successful, OEM physicians will need to think and work innovatively about how they can provide today's employer health services-ranging from primary care and preventive care to workers' compensation and disability management-within tomorrow's PCMH and ACO models.

How to align evidence-based benefit design with the employer bottom-line: a case study.

OBJECTIVE: To illustrate how to use evidence-based benefit design (EBD) by presenting the case study of a major manufacturer. METHOD: Key components of the company's measurement and management approach to EBD are introduced. Descriptive results on the direct and indirect cost and utilization trends of the company's US active workforce during 2002 to 2008 are presented. RESULTS: From 1999 to 2002 aggregated to 2008, health care costs dropped sharply, with 2006, 2008, and projected 2009 reporting decreases even as annualized increases in national expenditures approximated 10%. Annualized rates for hospitalizations, office visits, and prescriptions showed corresponding decreases from 2004 to 2008. From 2002 to 2008, workers' compensation/disability and absenteeism costs decreased 38% and 46%, respectively. CONCLUSIONS: These results support the company's direction in health benefit design although further confirmation is needed. Ongoing quality improvement processes are discussed, as are implications for implementing EBD.

Evidence-based benefit design: toward a sustainable health care future for employers.

Health care costs for employers are rising much faster than inflation. The common approach to health benefit design of increasing cost sharing has failed to contain costs. Some employers, however, have been successful at mitigating the cost trend or actually reducing health care costs. These employers have in common a dedication to data analysis, a search for cost drivers, and a willingness to adjust their approach to health benefit design to address these cost drivers. This approach has much in common with the movement in clinical practice toward evidence-based medicine. We propose that employers adopt a similar approach toward health benefits termed evidence-based benefit design, which is based on a health and productivity framework focused on direct and indirect costs. Evidence-based benefit design incorporates the relevant literature and employer-specific data that are integrated and regularly analyzed.

Using self-reports of symptom severity to measure and manage workplace depression.

OBJECTIVES: To test the workplace impact of depression when it is stratified by severity and considered in broader context. METHODS: Structural equation models of health risk appraisal data (n = 39,097) involving 41 measures of contextual characteristics, depression severity, health, and job performance. RESULTS: Approximately 15.7% exhibited mild depression, whereas 6.9% recorded moderate to severe symptoms. Depression severity exerted large effects on general health and productivity loss, with the mild group posting the largest aggregate impact. Adverse personal life impact and financial concerns more significantly affected moderate to severe depression. In contrast, factors more directly amenable to employer health management efforts (eg, stressful job) better predicted mild depression. CONCLUSIONS: These results link depression to large health and productivity deficits. They call for public-private collaboration, parity in mental and physical health benefits, and resource allocation that is proportionate across the depression spectrum and facilitated by symptom severity screening.

Age, overtime, and employee health, safety and productivity outcomes: a case study.

OBJECTIVES: To expand a study of the impact of overtime on employee health, safety, and productivity outcomes, previously reported in this journal, with tests comparing older versus younger workers on these relationships. METHODS: Secondary analyses of a longitudinal panel (n = 2746) representing workers at US sites for a heavy manufacturer during 2001 to 2002. Structural equation techniques were used to assess two hypotheses in the context of multiple group models positing the prediction of a broad set of employee outcomes using a three-step causal sequence. One set of models compared overtime impact for three age groups (<45, 45 to 49, 50+) at the aggregate level. Two others compared overtime impact for the three age groups by compensation type (hourly vs salaried). RESULTS: Advancing age was linked to greater rates of adverse consequences as a function of overtime (hypothesis #1), but these increases were largely confined to hourly employees working extended overtime (averaging 60+ hours per week) and occurred on only four of the nine study outcomes. With respect to moderate overtime (48.01 to 59.99 hours) and to variables reflecting the possible impact of past overtime (eg, prior disability episodes), increases in age among hourly employees did not lead to stronger associations between overtime and adverse outcomes on most tests and in fact in many cases were linked to decrements in these associations (hypothesis #2). Salaried employees recorded no greater linkages between overtime and adverse outcomes with advancing age across all tests involving hypothesized overtime effects or "possibly a function of overtime" effects. CONCLUSIONS: The results support the proposition that, when employees work overtime, adverse outcomes--and indirect costs--do not increase with advancing age in any kind of wholesale fashion. Where rates of adverse outcomes do increase, they are confined to certain subgroups of employees doing certain types of work and occur on certain dimensions at certain levels of longer work hours. It is argued that carefully calibrated approaches vis-à-vis older workers are needed to maximize employer capacity to address the unique challenges posed by this increasingly important portion of the workforce.

Using routinely collected data to augment the management of health and productivity loss.

OBJECTIVES: To test models of productivity loss developed from data collected using a health risk appraisal (HRA) designed to examine health in the broader context of work, mental well-being, and the demands of organizational and family life. METHODS: Secondary analyses of a data extract provided by the HRA's developer. These analyses focused on 17,821 respondents whose version of the HRA included the Work Limitation Questionnaire. Structural equation techniques were used to estimate a series of models featuring 38 measures and a four-step hypothesized sequence. RESULTS: The tests confirmed the presence of two distinct but interrelated components driven by health issues--Presenteeism (impaired performance at work) and Absenteeism (time away from work)--posited to describe productivity loss. The tests also documented the predictive power of eight categories of measures in accounting for the phenomenon. Preeminent among these predictors was a heterogeneous set of measures encompassing current and future aspects of Health. But measures from seven other categories--Work-Life Balance, Personal Life Impact, Stress, Financial Concerns, and Job, Employee, and Company Characteristics--also made significant contributions. Combined, their unique contribution was five times that of Health alone. CONCLUSIONS: This case study illustrates how data routinely captured via an instrument that is an example of a class of self-reports surveys increasingly being used to address a variety of workforce issues can be tapped to describe and predict productivity loss. The results confirm the key role that Health plays in determining the phenomenon. They also affirm the advisability of incorporating into interventions undertaken to reduce productivity loss an orientation that is paralleled by the recent emergence of the use of quality of life measures in provider settings. This orientation is predicated on the need to take into better account other contextual factors that exert considerable influences through as well as above and beyond Health.

Do long workhours impact health, safety, and productivity at a heavy manufacturer?

OBJECTIVES: To test the health, safety, and productivity effects of long workhours. METHODS: Secondary analyses of a longitudinal employee panel (n = 2746). Average hours worked during spring 2001 were assessed relative to health, safety, and productivity outcomes spanning summer 2001 through spring 2002. RESULTS: Employees working overtime were no more likely to incur adverse physical or mental health, presenteeism, or disability outcomes. Those working 60+ hours were more likely to report new injuries and diagnoses, but these effects were overwhelmed by prior health, demographics, and compensation type. CONCLUSIONS: Much previous work has suggested that long workhours generate a wide range of adverse outcomes across the employee continuum. This study found no evidence for pervasive workhour effects. Rather, long workhours--especially weekly schedules at the 60 hour or above mark--can lead to problems in certain areas of health and safety. More research is needed that tests group differences across segmented characteristics (eg, poor versus good health) but keeps workhour impact in perspective.

The burden of pain on employee health and productivity at a major provider of business services.

OBJECTIVE: The objective of this study was to examine the burden of pain on employee health and productivity at a Fortune 100 company headquartered in the northeastern United States to prioritize target areas for reducing this burden. METHODS: An electronic survey was conducted in late 2004, which produced a reasonably representative national sample of 1039 active employee respondents. RESULTS: A total of 28.6% of respondents met the study definition for pain. Pain was linked to: 1) drops of more than 45% and 23%, respectively, in Overall Physical and Mental Health; 2) a fivefold increase in health-induced limitations in work performance; and 3) nearly three and two thirds workdays lost to presenteeism and absenteeism over a 4-week period. Afflicted workers displayed considerable room for improvement in their capacity for pain control and management. CONCLUSIONS: The prevalence of pain and its impact on those with the condition combine to make it an area of much opportunity for improving workforce health and productivity. Musculoskeletal diseases offer a promising initial target for corporate intervention.

Validating self-reported measures of productivity at work: a case for their credibility in a heavy manufacturing setting.

The extent to which employee responses to productivity surveys assess what they are intended to assess has become a pivotal issue for employers and providers. Much work is now being devoted to the validity and reliability of these self-reports. Such issues will likely be resolved only over the long term. In the interim, the skepticism of business decision-makers who are unfamiliar with survey techniques needs to be addressed. This article taps the widespread acceptance that administrative adverse events have gained as indicators of productivity loss to address this issue. Joint analyses of adverse event measures and productivity self-reports on employees at International Truck and Engine Corporation are conducted to test 2 types of criterion validity: 1) concurrent validity; do prior/concurrent adverse events associate with self-reports as logic and common sense dictate? and 2) predictive validity; do self-reports distinguish the risk of subsequent adverse events? Self-reports are found to perform well in both sets of tests. The results are explored in light of: 1) concerns that users have with respect to how self-reports are now being applied, and 2) ways in which self-reports serve as a cornerstone for 3 articles that follow in this issue.

The burden of allergies--and the capacity of medications to reduce this burden-in a heavy manufacturing environment.

This article addresses the observational findings of the first systematic study undertaken by a manufacturer to address the impact of allergies and use of allergy medications on health, safety, and productivity. It provides background for 3 other papers from the same project, including an evaluation of an intervention to promote appropriate medication use among affected employees, which appear in this issue. The observational data are developed on 10,714 employees from: 1) 2 employee surveys; 2) administrative databases monitoring employee absenteeism, workers compensation, short-term disability, and group health. The results show that health, productivity, absenteeism, workplace injury, and workers compensation measures register consistent declines as allergy severity levels increase. This pattern is present but less pronounced for the short-term disability and group health measures. In addition, among the 16 measures registering a significant allergy burden, 6 posted significant advantages for the use of nonsedating antihistamines relative to other medication regimens that included sedative antihistamines. These results document the burden of allergies and the capacity of medications to reduce this burden. Effective intervention programs that target this condition can achieve improved health, productivity, and related outcomes.