Improved Health and Well-being: Creating Value in Health Care

Value in health care can be calculated by measuring outcomes divided by cost. In the United States, where health care costs are high, patients’ choices are important components of both increasing value and reducing costs. Diet, exercise, and stress reduction—in addition to therapeutic interventions—help improve the physical, mental, and social components of health and well-being.

Contemporary definitions of health and well-being have long recognized that health moves beyond the clinical practice of medicine. In 1946, the Constitution of the World Health Organization (WHO) defined health as more than the absence of disease and referred to a state of “physical, mental and social well-being.” Recently, Witt et al¹ proposed that health

… is affected by: (1) individual biological factors and behaviors, social values, and public policy, (2) the physical, social, and economic environments, and (3) an integrative health care system that involves the active participation of the individual and the health care team in applying a broad spectrum of preventive and therapeutic approaches.

Improving health and well-being requires an awareness of social determinants of health and individual choice in health care decisions. The link between social determinants of health and well-being such as education, nutrition, and community health have long been studied in research epidemiology, health services, and the social sciences. For example, in 2007 Kaplan found that low income and low levels of physical activity were associated with an increase in mortality.²

Although improved health and well-being is important to most people, it is essential for caregivers who are responsible for the care of dependents. Approximately 43.5 million informal caregivers have provided unpaid care to an adult or child in the last 12 months.^3,4 The value of services provided by informal caregivers has steadily increased during the last decade, with an estimated economic value of $470 billion in 2013, up from $450 billion in 2009 and $375 billion in 2007.⁴ Managing multiple priorities often generates constant levels of stress for caregivers, which may result in negative health effects due in part to immune and autonomic dysregulation. It is well documented that the immune system is a prime example of a physiological system that is affected by stressful experiences, with acute and chronic stress often producing disruptive immunological outcomes.

A practical example of the interplay between stress and immunity can be highlighted by something as simple as a common cold. The cold, diagnosed as an upper-respiratory tract infection, is the most common syndrome of infection in human beings, occurs more frequently during the winter months, and is increased by environmental factors such as overcrowding and stress. Common colds are usually community acquired with self-limiting symptoms (nasal discharge, congestion, sneezing, sore throat, and cough); however, the cost in medical visits and lost productivity is estimated to be $40 billion annually.⁵

Lifestyle choices and over-the-counter medications may help prevent and treat the common cold, thereby reducing the occurrence, severity, and duration of symptoms. In 2014, investigators assessed the immune responsiveness in adults using intake obtained with a 3-day dietary recall recording as well as recall recording of physical activity level and peripheral blood mononuclear cells. Expression of activation markers on unstimulated immune subsets was assessed by flow cytometry: “The relationship between activation marker expression on T cells and T-cell effector functions; and in vitro cytokine secretion and URTI was determined by linear or logistic regression. CD69 and CD25 expression on unstimulated T cells was significantly associated with T-cell proliferation and interleukin-2 secretion.”⁶ Data suggested that the incidence and severity of cold or flu symptoms captured via the URTI questionnaire were accompanied by important immunological changes. Recognition of the importance of dietary factors was found to be important in understanding the immune responses among subjects, and their response to interventions.

Meditation and exercise were studied in 2009 for their effects on the cost of treating upper-respiratory tract infections. A total of 154 subjects were randomized to meditation, exercise, or wait-list control and costs associated with self-reported medication use, medical visits, and days lost from work were tracked: “The total cost per subject for the control group was $214 (95% CI: $105–$358), exercise $136 (95% CI: $64–$232) and meditation $65 (95% CI: $34–$104). The majority of cost savings was through a reduction in missed days of work.”⁷ Meditation and exercise both added value to the cost associated with upper-respiratory tract infections with meditation being superior to exercise.

Nonprescription over-the counter medications also have evidence supporting their use in potentially preventing and treating the common cold. In 1984, Eby⁸ reported on the treatment of an immune-comprised child undergoing chemotherapy for leukemia who had the rapid resolution of her cold symptoms after treatment with 50 mg of zinc. Other patients reported a similar response. Zinc inhibits rhinovirus replication by competitively binding with cell surface glycoproteins (ICAM-1) and has been tested in multiple trials for treatment of the common cold, most commonly as zinc acetate or gluconate.⁹ A Cochrane review identified 15 randomized controlled trials that enrolled 1360 participants of all age groups and compared zinc with a control, and it found that zinc was beneficial in reducing the duration and severity of the common cold in healthy people particularly when taken soon after the onset of symptoms.¹⁰ Chronic supplementation with zinc for at least 5 months reduced the incidence of cold, the need for other treatments, and school absences in school-age children. A separate meta-analysis of zinc lozenges¹¹ noted that patients given zinc lozenges recovered at a faster rate than those receiving placebo. The effect was not modified by age, sex, race, allergy, smoking, or baseline common cold severity. On the fifth day, 70% of the zinc patients had recovered compared with 27% of the placebo patients. None of the studies observed serious adverse effects of zinc.

In July 2007, a study found that vitamin C, taken daily, shortened the duration of a cold in children and adults and, in 2017, a study evaluated the safety and efficacy of Echinacea purpurea for prevention of the common cold with a standardized Echinacea purpurea extract in the course of 4 months.¹² They found a reduction in the total number of cold episodes, a reduction in the number of days with colds, and a reduction in cold episodes requiring additional medication.

Staying healthy is important, particularly for populations at risk such as school-age children, child care workers, immune-compromised individuals, and caregivers who are responsible for the well-being of those who depend on them. The use of multiple self-care strategies to potentially prevent as well as treat the common cold is an example of how to create value in health care.