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Impact of a 12-week, pharmacist-directed walking program in an established employee preventive care clinic Amy M. Fanous, Karen L. Kier, Michael J. Rush, and Sara Terrell

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ccording to the Sporting Goods Manufacturers Association’s 2012 Sports, Fitness and Leisure Activities report, nearly 70 million Americans, or approximately 22% of the population, are considered to be inactive. This rate of inactivity has increased by 8% over the past three years.1 There is strong evidence to show that physical inactivity increases the risk of many adverse health conditions, including coronary heart disease and type 2 diabetes mellitus, and shortens life expectancy.2 The link between lack of physical activity and adverse health conditions presents a major public health issue. Adopting a healthier lifestyle could substantially improve health by decreasing the number of chronic health conditions. Ohio Northern University (ONU) is a small, rural, private university with approximately 3500 students and 675 faculty and staff. The university is a self-insured employer, with over 900 covered lives, including retirees and employees of the university, as well as their dependents. In an attempt to reduce health care costs by improving health and wellness of in-

Purpose. The impact on physical activity and health of a 12-week, pharmacistdirected walking program incorporated into an employee health and wellness clinic was evaluated. Methods. Clinic participants were eligible for study inclusion if they or their spouse was a current or retired employee of Ohio Northern University. Participants received a pedometer, a calendar with specific daily walking goals for the 12-week period, and maps with walking routes. Participants also met with a pharmacist and a student pharmacist for point-of-care tests measuring lipid and fasting glucose concentrations and blood pressure. Participants reported to weekly pedometer checks where steps were recorded and medications were reassessed by the pharmacist or student pharmacist. As an incentive to meet the walking goals, the participants received a raffle ticket each week their goal had been achieved. After 12 weeks, participants reported for a final appointment when all

dividuals covered by the university’s insurance plan, a disease and medication therapy management (MTM) clinic, ONU HealthWise, was implemented in 2010.

Amy M. Fanous, Pharm.D., is Postgraduate Year 1 Pharmacy Resident, ONU HealthWise; Karen L. Kier, Ph.D., B.S.Pharm., BCPS, BCACP, is Professor of Clinical Pharmacy and Director of Assessment; Michael J. Rush, Pharm.D., CDE, BCACP, is Program Director, ONU HealthWise; and Sara Terrell, M.S., CSCS, FMS, is Assistant Professor of Exercise Physiology and Adult Fitness Coordinator, Ohio Northern University, Ada. Address correspondence to Dr. Fanous ([email protected]).

baseline variables were reassessed by a team of health care professionals. Results. A total of 144 participants were screened at baseline and included in the study, 65 of whom completed the program. At baseline, there were 240 abnormal laboratory test values found in participants with no prior history of dyslipidemia, hyperglycemia, or hypertension. After 12 weeks, significant changes in high-densitylipoprotein (HDL) cholesterol concentrations (p = 0.0012), fasting blood glucose concentrations (p = 0.0017), and blood pressure (p = 0.021) were noted. Conclusion. A pharmacist-directed walking program that included clinical assessments, walking goals, and weekly pedometer checks was an effective approach to increase employee activity levels, identify previously unknown health conditions, lower blood glucose concentrations and blood pressure values, and increase HDL cholesterol concentrations. Am J Health-Syst Pharm. 2014; 71:1219-25

The university-funded ONU HealthWise clinic consists of an interprofessional team of 4 pharmacists, 1 nurse, 2 exercise physiologists, and a nutrition coach. Historically,

Funded in part by an ASHP Foundation Pharmacy Resident Practice-Based Research Grant. The authors have declared no potential conflicts of interest. Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/0702-1219$06.00. DOI 10.2146/ajhp130484

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Table 1.

Walking Program Goals Week No.

Goal No. Steps/Day

1  2  3  4  5  6  7  8  9 10 11 12

5,000 5,500 6,000 6,500 7,000 7,500 8,000 8,500 9,000 9,500 10,000 10,000

the clinic has provided pharmacistled disease management and MTM services for employees and retirees who are members of the university’s health insurance plan. Disease management services for patients with hypertension, diabetes mellitus, and hyperlipidemia have been established, which include the monitoring of clinical outcomes, patient education, and the provision of therapeutic recommendations to the patient’s primary provider. MTM services for patients with multiple medications are offered during disease management appointments and are provided on request for employees or retirees not participating in the services. In addition, exercise and nutrition coaching are provided to these patients by other health care professionals on the team to help achieve disease control. Participation in the ONU HealthWise clinic is voluntary and free of charge to employees, and patients are recruited via advertisements highlighting the various services offered. Although the traditional ONU HealthWise clinic did experience great success in assisting patients with the management of chronic diseases, only a select portion of the University population—those with hypertension, diabetes mellitus, or hyperlipidemia—could benefit from 1220

the services offered. In order to expand the patient population served by the ONU HealthWise clinic, the decision was made to incorporate a preventive care program into the clinic. Focusing on optimizing treatment of members with chronic conditions, as well as preventing these conditions in healthier individuals, has produced further improvements in employee health status and additional cost savings for the university.3-6 The focus of the ONU HealthWise program over the past three years has shifted to expanding work-site programs that involve wellness initiatives, preventive medicine, and behavior modification. One such example is the addition of a worksite walking program. This program provided an opportunity to expand the role of the pharmacist into preventive medicine services through consistent patient education regarding the role of physical activity on health outcomes. This program offered the participants a means to increase their physical activity and improve their health with a lifestyle modification program that offered complete follow-through for 12 weeks. This service was designed to be self-sustainable based on baseline and final physical assessments and MTM appointments structured into the walking program. A pharmacist is well suited to run this type of program because the pharmacist serves as an accessible health care professional who can provide comprehensive MTM and preventive care education services. Subsequently, this walking program incorporated the necessary professional spectrum required of pharmacists today. For example, the program was designed to ensure that a pharmacist was available to interpret and discuss the patient’s laboratory test results at baseline and after 12 weeks as well as to encourage weekly step-count goals specific to each patient’s needs and abilities. This type of program approach ensured that patients were re-

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ceiving weekly feedback and optimal medical therapy for their condition if needed. Since a pharmacist has the ability to interpret and discuss the patient’s laboratory test results, this was a novel approach to discover a patient’s previously unknown health conditions. T h e p u r p o s e of t h i s s tu dy was to determine if incorporating a pharmacist-directed walking program into an existing preventive care clinic motivates employees to increase their physical activity and provides a means for participants to improve health. Methods A 12-week walking program was implemented into ONU HealthWise preventive care employee health and wellness clinic. Clinic participants were eligible for study inclusion if they or their spouse was a current or retired employee of the university. Participants were excluded if they were unable to complete the 12-week program or if they had a newly diagnosed disease that required a change in or start of medication that could modify the results of laboratory tests. Patients with a preexisting diagnosis of diabetes mellitus, hyperlipidemia, or hypertension were included in the study as long as no changes were made to their therapy during the 12-week study period. No other preexisting diseases or conditions were excluded. In addition, any program participant who participated in the baseline assessment but did not follow up with at least one pedometer check was excluded from the study. At the baseline appointment, participants received a pedometer, a calendar with specific daily walking goals for the 12-week period (Table 1), and maps with walking routes Participants also met with a pharmacist and a student pharmacist for point-of-care tests measuring lipid and fasting glucose concentrations and blood pressure. The pharmacist and student pharmacist educated

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participants on the goal values for each test and the risks associated with having clinical laboratory values that were not in the target range and counseled them on how to improve any abnormal laboratory test values and their general health. Laboratory test values that were reported to the participant’s primary care provider included a fasting blood glucose concentration of ≥126 mg/dL, a triglyceride concentration of ≥200 mg/ dL, a systolic blood pressure value of ≥140 mm Hg, a diastolic blood pressure value of ≥90 mm Hg, and a low-density-lipoprotein (LDL) cholesterol concentration exceeding 30 mg/dL over the goal value, which was individualized to the specific patient. After the appointment with the pharmacist and the student pharmacist, each participant met with an exercise physiologist and an exercise physiology student. The exercise physiologist and the exercise physiology student measured participants’ weight, body mass index (BMI), waist:hip ratio, and body composition (a measure of percent body fat) at baseline. Participants were encouraged (but not required) to walk as a team (groups of 2–10 people) for increased accountability. Finally, each participant completed an initial questionnaire, which assessed how many days per week he or she exercised, how long the exercise sessions lasted, and the intensity of the activity. The questionnaire also asked participants to rate their overall health on a scale of 1–10 and rank the factors that affected their decision to begin and complete the walking program on a scale of 1–10. After the baseline appointment, each participant reported for a pedometer check once a week during the 12-week study. At each pedometer check, a pharmacist and a student pharmacist assessed the participant’s pedometer to ensure he or she had met the walking goal for that week, assessed the participant’s medications, and addressed

Table 2.

Abnormal Laboratory Test Values at Baseline in Participants Without History of Dyslipidemia, Hyperglycemia, or Hypertension7-9,a No. Participants

Abnormal Test Result HDL cholesterol conc. of 100 mg/dL Blood pressure of >120/80 mm Hg

49 7 36 78 70

HDL = high-density lipoprotein, LDL = low-density lipoprotein. Abnormal result based on risk per National Cholesterol Education Program.

a

b

Table 3.

Comparison of Participants’ Baseline Valuesa All Participants Screened (n = 144)

Participants Who Completed Program (n = 65)



73 (50.7)

32 (49.2)



13 (9.0)

6 (9.2)



49 (34.0) 91 (63.2)

21 (32.3) 39 (60.0)

Variable No. (%) pts with low HDL cholesterol conc. No. (%) pts with LDL cholesterol conc. above normal range No. (%) pts with triglyceride conc. above normal range No. (%) pts with hyperglycemia No. (%) pts with blood pressure value above normal range Mean ± S.D. weight, lb Mean ± S.D. body mass index Mean ± S.D. waist:hip ratio Mean ± S.D. body composition, %

94 (65.3) 42 (64.6) 178.3 ± 37.4 175.2 ± 35.4 28.9 ± 6.2 28.3 ± 4.8 0.91 ± 0.05 (men), 0.91 ± 0.06 (men),  0.84 ± 0.08 (women)    0.83 ± 0.07 (women) 34.3 ± 7.8 32.4 ± 8.2

Statistical data analyzed using a paired t test; no significant differences in variables were detected between participants screened and those completing the program. HDL = high-density lipoprotein, LDL = low-density lipoprotein. a

any questions or concerns regarding medications or the program. Each week, the top three teams and the top three individual walkers were recognized online on an employee website as a means to increase competition among study participants. Participants who met their walking goal received a raffle ticket, as an incentive, for a chance to win a prize at the end of the program. Other prizes were given throughout the program as incentives to encourage continued participation.

After 12 weeks, participants reported for a final appointment when all baseline variables (i.e., lipid panel, fasting glucose concentration, blood pressure, weight, BMI, waist:hip ratio, and body composition) were reassessed by the interprofessional team of health care professionals. The targeted wellness goals were as follows: LDL concentration, patient-specific goal; high-densitylipoprotein (HDL) cholesterol concentration, ≥40 mg/dL for men and ≥50 mg/dL for women; triglyceride

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Table 4.

Assessment Results During Study Period for All Participantsa Variable No. (%) pts with low HDL cholesterol conc. No. (%) pts with above normal LDL cholesterol conc. No. (%) pts with high triglyceride conc. No. (%) pts with hyperglycemia Mean ± S.D. body mass index Mean ± S.D. waist:hip ratio No. (%) pts with high blood pressure Mean ± S.D. weight, lb



Baseline (n = 144)

Week 4 (n = 120)

Week 9 (n = 86)

Week 12 (n = 65)

p

73 (50.7)

...

. . .

18 (27.7)

0.0012c

b

13 (9.0) . . . . . . 49 (34.0) . . . . . . 91 (63.2) . . . . . . 28.9 ± 6.2 . . . . . . 0.91 ± 0.05 (men), . . . . . . 0.84 ± 0.08 (women)   94 (65.3) 68 (65.4) 43 (71.7) 178.3 ± 37.4 173.1 ± 35.9 166.5 ± 33.1

7 (10.8) NSc 22 (33.8) NSc 23 (35.4) 0.0017c 27.6 ± 4.5 NSc 0.90 ± 0.06 (men), NSc 0.81 ± 0.07 (women) 36 (55.4) 0.021d 173.3 ± 34.9 NSd

HDL = high-density lipoprotein, LDL = low-density lipoprotein, NS = not significant. Not measured. Paired t test. d Analysis of variance. a

b c

concentration,

Impact of a 12-week, pharmacist-directed walking program in an established employee preventive care clinic.

The impact on physical activity and health of a 12-week, pharmacist-directed walking program incorporated into an employee health and wellness clinic ...
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