Productivity costs before and after absence from work: as important as common?

Production Losses due to Absenteeism and Presenteeism: The Influence of Compensation Mechanisms and Multiplier Effects

BACKGROUND

Productivity costs can form a large and influential component of total costs in an economic evaluation taking a societal perspective. In calculating productivity costs, estimating productivity losses is a central element. Compensation mechanisms and multiplier effects may influence these losses but remain understudied. Compensation mechanisms could reduce productivity losses while multiplier effects may increase them.

METHODS

Data on productivity losses were collected in 2015 using an online survey among a sample of persons aged 15-65 years in The Netherlands who worked at least 12 h per week and reported to have experienced absenteeism and/or presenteeism during the past 4 weeks. A total of 877 respondents completed the survey that contained questions on productivity losses, compensation mechanisms, and multiplier effects.

RESULTS

We found that 45.5% of the respondents reported absenteeism (average 6.5 days) during the past 4 weeks, losing on average 48.7 working hours, while presenteeism was experienced by 75.9% of respondents, with an average loss of 10.7 working hours. Compensation mechanisms were reported by 76.9% of respondents, compensating almost 80% of their lost production, while multiplier effects were reported by 23.6% of respondents, reducing the productivity of 4.2 colleagues by 27.8% on average, implying a multiplier of 2.1 in that subgroup.

CONCLUSIONS

This study highlights that compensation mechanisms and multiplier effects are common and may substantially affect production losses. Investigating these mechanisms and effects further, as well as their interactions, remains important. Translating these findings into productivity cost calculations in economic evaluations is not straightforward and requires attention, especially since compensation mechanisms may not be costless and, for multiplier effects, the value of hours of colleagues may not be similar to that of the person experiencing health problems.

Multiplier Effects and Compensation Mechanisms for Inclusion in Health Economic Evaluation: A Systematic Review

BACKGROUND

Compensation mechanisms and multiplier effects may affect productivity losses due to illness, disability, or premature death of individuals. Hence, they are important in estimating productivity losses and productivity costs in the context of economic evaluations of health interventions. This paper presents a systematic literature review of papers focusing on compensation mechanisms and multiplier effects, as well as whether and how they are included in health economic evaluations.

METHODS

The systematic literature search was performed covering EconLit and PubMed. A data-extraction form was developed focusing on compensation mechanisms and multiplier effects.

RESULTS

A total of 26 studies were included. Of these, 15 were empirical studies, three studies were methodological studies, two studies combined methodological research with empirical research, four were critical reviews, one study was a critical review combined with methodological research, and one study was a cost-benefit analysis. No uniform definition of compensation mechanisms and multiplier effects was identified. The terminology used to describe compensation mechanisms and multiplier effects varied as well. While the included studies suggest that both multipliers as well as compensation mechanisms substantially impact productivity cost estimates, the available evidence is scarce. Moreover, the generalizability as well as validity of assumptions underlying the calculations are unclear. Available measurement methods for compensation mechanisms and multiplier effects differ in approaches and are hardly validated.

CONCLUSION

While our review suggests that compensation mechanisms and multiplier effects may have a significant impact on productivity losses and costs, much remains unclear about their features, valid measurement, and correct valuation. This hampers their current inclusion in economic evaluation, and therefore, more research into both phenomena remains warranted.

Can a workplace dialogue impact the perceived influence of neck and/or backpain on everyday activities and performance at work? A secondary analysis from the randomized controlled trial WorkUp

Background

Neck- and back- pain are highly prevalent conditions in Sweden and world-wide. Such pain often has consequences on everyday activities, work- and personal life. One consequence is work absence and decreased productivity at work. Adding a workplace dialogue to structured physiotherapy was recently found to lead to increased workability, i.e., not being on sick leave during the 12^th month of follow up.

Aim

The aim of the study was to explore the effect of a workplace dialogue intervention on secondary outcomes: perceived impact of neck and/or back pain on everyday activities and on performance at work, and total days of sick leave during 12 month follow up. A further aim was to examine associations between perceived influence of pain, and sick leave.

Method

Patients with neck and/or back pain in primary care in the south of Sweden were randomized into structured physiotherapy alone (n = 206) or with the addition of a workplace dialogue (n = 146). Data regarding the pain’s influence on everyday activities and on performance at work were collected using weekly text messages for 52 weeks. The pattern of change in perceived influence of neck and/or back pain on everyday activities and performance at work was compared between the groups with linear mixed models. Cross sectional correlations between perceived influence of neck and/or back pain on everyday activities and performance at work, and days of sick leave, during the preceding four weeks at months 3, 6, 9 and 12 were examined.

Result

We found no differences in change of perceived influence of neck and/or back pain on daily activities or perceived performance at work, or total days of sick leave during the 12 months of follow up between the groups with structured physiotherapy with or without a workplace dialogue. There was a weak to moderate positive correlation between days of sick leave and perceived influence of neck and/or back pain on everyday activities and performance at work (rho 0.28–0.47).

Conclusion

A workplace dialogue was not found to affect the perceived impact of neck and/or back pain on everyday activities and performance at work.

Trial registration

ClinicalTrials.gov ID: NCT02609750.

Measurement Instruments of Productivity Loss of Paid and Unpaid Work: A Systematic Review and Assessment of Suitability for Health Economic Evaluations From a Societal Perspective

OBJECTIVES

This study aimed (1) to perform a systematic literature review of instruments for measuring productivity loss of paid and unpaid work and (2) to assess the suitability (in terms of identification, measurement, and valuation) of these instruments for use in health economic evaluations from a societal perspective.

METHODS

Articles published from 2018 were sourced from PubMed/Medline, PsycInfo, Embase, and Econlit. Using 2 separate search strategies, eligible economic evaluations and validation studies were selected and unique measurement instruments identified. A data-extraction form was developed by studying previous literature and consulting an international panel of experts in the field of productivity costs. This data-extraction form was applied to assess the suitability of instruments for use in economic evaluations.

RESULTS

A total of 5982 articles were retrieved from the databases, of which 99 economic evaluations and 9 validation studies were included in the review. A total of 42 unique measurement instruments were identified. Nine instruments provided quantified measures of absenteeism, presenteeism, and unpaid work. Five instruments supplied the necessary information to enable the use of at least 1 common valuation method. The Health and Labour Questionnaire-Short Form, Health and Labour Questionnaire, and Institute for Medical Technology Assessment Productivity Cost Questionnaire met both criteria. Nevertheless, the developers replaced the Health and Labour Questionnaire-Short Form and Health and Labour Questionnaire by the more recently developed Institute for Medical Technology Assessment Productivity Cost Questionnaire.

CONCLUSIONS

Although many instruments for measuring productivity loss were identified, most were not suitable for capturing productivity changes for economic evaluations from a societal perspective. Future research can benefit from this study by making an informed instrument choice for the measurement of productivity loss of paid and unpaid work.

Work productivity loss in breast cancer survivors and its effects on quality of life

BACKGROUND

Return to work is an important process for many breast cancer survivors (BCSs) that acts as a positive step towards their reintegration into society.

OBJECTIVES

This study examined whether work productivity loss due to presenteeism could predict the quality of life (QOL) of employed BCSs.

METHODS

This study used a cross-sectional design. Seventy-five BCSs and seventy-five participants in the Non-Cancer Comparison (NCC) group were surveyed. The main outcome measures were productivity loss (as measured by the Work Limitations questionnaire) and quality of life (as measure by the European Organization for Research and Treatment Quality of Life questionnaire C30). Other measures included psychological distress (as measured by the Hospital Anxiety and Depression Scale) and cognitive limitation at work (as measured by the Cognitive Symptom Checklist).

RESULTS

The BCS group had a lower summary score, a lower global health related score and greater work limitation in all domains than the NCC group. The productivity loss due to presenteeism of the BCS group was 8%. The multiple regression model shows that work productivity loss and level of job stress were the significant predictors of quality of life in the BCS group.

CONCLUSION

These findings raise questions about the effects of level of job stress and work productivity loss on the QOL of BCSs. Longitudinal studies are needed to map these relationships.

Does food insecurity affect musculoskeletal symptoms, fatigue, and productivity of municipality cleaners? A cross-sectional study

BACKGROUND

Municipality cleaners are exposed to food insecurity, Musculoskeletal Symptoms (MSs), and fatigue.

OBJECTIVE

This study aimed to investigate the effect of food insecurity on MSs, fatigue, and productivity among municipality cleaners.

METHODS

This study was conducted on 399 Iranian male municipality cleaners with at least one year of working experience. The data were gathered via a demographic/occupational questionnaire, the Persian version of the Household Food Insecurity Access Scale (P-HFIAS), the Persian version of Nordic Musculoskeletal Questionnaire (P-NMQ), the Persian version of the Multidimensional Assessment of Fatigue scale (P-MAF), and the Persian version of Health and Work Questionnaire (P-HWQ). Data were analyzed using descriptive statistics, multiple logistic regression (Forward Wald), and multiple linear regression (Stepwise).

RESULTS

The findings revealed that 42.6%of the municipality cleaners were in the 'severely food insecure' category. The highest prevalence of MSs in the past week were related to knees (35.8%), lower back (35.1%), and ankles/feet (28.8%). Based on the results, the chance of MSs in the shoulders (OR = 1.66) and ankles/feet (1.60) regions, and MSs at least in one body region (OR = 1.47) was higher in the individuals with severe food insecurity than the others. Considering the P-MAF, food insecurity was associated with the 'degree and severity', 'distress that it causes', and 'timing of fatigue' subscales and 'total fatigue'. Considering the P-HWQ, food insecurity was associated with 'productivity', 'other's assessment', 'concentration/focus', 'supervisor relations', 'non-work satisfaction', and 'impatience/irritability' subscales.

CONCLUSION

The study revealed an association between food insecurity and MSs in some body regions and fatigue and productivity subscales among the municipality cleaners. Nutritional and ergonomic programs are recommended to reduce municipality cleaners' food insecurity, MSs, and fatigue and enhance their productivity.

Supervisor ratings of productivity loss associated with presenteeism and sick leave due to musculoskeletal disorders and common mental disorders in Sweden

BACKGROUND

Health problems due to musculoskeletal disorders (MSD) and common mental disorders (CMD) result in costs due to lost productivity.

OBJECTIVE

This study aimed to increase knowledge of employers' productivity loss due to employees' presenteeism and sickness absence.

METHODS

A web questionnaire was sent to employers of workers who were sick-listed for more than 30 days due to MSD or CMD, response rate: 50%, n = 198. Presenteeism and the impact on productivity before and after sick leave, and the performance of work tasks by replacement workers during sick leave, were measured using supervisors' ratings.

RESULTS

The average loss of productivity per sick-leave case amounted to almost 10 weeks, 53%of productivity loss was attributable to presenteeism and 47%to lower productivity by replacement workers. Employees with a CMD diagnosis had significantly higher presenteeism-related productivity loss than those with MSD.

CONCLUSIONS

Employers experienced substantial productivity loss associated with employees' presenteeism and sick leave. Whether the supervisory rating of presenteeism is preferable to employee self-rating needs to be studied further. The long duration of presenteeism is counter-productive to resource-efficient organisations and indicates the need for improved supervisory skills to identify workers with poor health, both before and after sick leave.

Evaluating costs and health consequences of sick leave strategies against pandemic and seasonal influenza in Norway using a dynamic model

OBJECTIVES

To quantify population-level health and economic consequences of sick leave among workers with influenza symptoms.

INTERVENTIONS

Compared with current sick leave practice (baseline), we evaluated the health and cost consequences of: (1) increasing the proportion of workers on sick leave from 65% (baseline) to 80% or 90%; (2) shortening the maximum duration from symptom onset to sick leave from 4 days (baseline) to 2 days, 1.5 days, 1 day and 0.5 days; and (3) combinations of 1 and 2.

METHODS

A dynamic compartmental influenza model was developed using Norwegian population data and survey data on employee sick leave practices. The sick leave interventions were simulated under 12 different seasonal epidemic and 36 different pandemic influenza scenarios. These scenarios varied in terms of transmissibility, the proportion of symptomatic cases and illness severity (risk of primary care consultations, hospitalisations and deaths). Using probabilistic sensitivity analyses, a net health benefit approach was adopted to assess the cost-effectiveness of the interventions from a societal perspective.

RESULTS

Compared with current sick leave practice, sick leave interventions were cost-effective for 31 (65%) of the pandemic scenarios, and 11 (92%) of the seasonal scenarios. Economic benefits from sick leave interventions were greatest for scenarios with low transmissibility, high symptomatic proportions and high illness severity. Overall, the health and economic benefits were greatest for the intervention involving 90% of sick workers taking sick leave within one-half day of symptoms. Depending on the influenza scenario, this intervention resulted in a 44.4%-99.7% reduction in the attack rate. Interventions involving sick leave onset beginning 2 days or later, after the onset of symptoms, resulted in economic losses.

CONCLUSIONS

Prompt sick leave onset and a high proportion of sick leave among workers with influenza symptoms may be cost-effective, particularly during influenza epidemics and pandemics with low transmissibility or high morbidity.

Associations between perceived leadership and presenteeism in an industrial population

Background

Presenteeism has received increasing attention in occupational health research but the evidence for its association with perceived leadership is scant.

Aims

To assess the association of perceived leadership and presenteeism among industrial workers.

Methods

Survey responses from employees on perceived leadership were linked to the personnel register of a food industry company. The Presenteeism Scale method was used to determine the presenteeism percentage. Perceived leadership was measured as a composite variable of six individual items on motivating and participating leadership. Generalized linear models were used to determine the association of perceived leadership with presenteeism.

Results

There were 847 participants. The majority of office workers of both genders reported better perceived leadership than factory workers. We found that perceived poor leadership was associated with a higher likelihood of presenteeism (rate ratio (RR) 1.64, 95% confidence intervals (CIs) 1.51-1.78). However, there was variation amongst and within occupational groups and genders, with a higher risk of presenteeism amongst male factory workers (RR 2.28, 95% CI 2.02-2.52) than female office workers.

Conclusions

Leadership was found to be significantly associated with presenteeism, with a greater risk of presenteeism in those reporting poor perceived leadership. The association between levels of perceived leadership and presenteeism was stronger in men than women. Organizations should focus on motivating leadership practices to reduce the risk of presenteeism, especially among men.

Economic evaluation of an experience sampling method intervention in depression compared with treatment as usual using data from a randomized controlled trial

BACKGROUND

Experience sampling, a method for real-time self-monitoring of affective experiences, holds opportunities for person-tailored treatment. By focussing on dynamic patterns of positive affect, experience sampling method interventions (ESM-I) accommodate strategies to enhance personalized treatment of depression-at potentially low-costs. This study aimed to investigate the cost-effectiveness of an experience sampling method intervention in patients with depression, from a societal perspective.

METHODS

Participants were recruited between January 2010 and February 2012 from out-patient mental health care facilities in or near the Dutch cities of Eindhoven and Maastricht, and through local advertisements. Out-patients diagnosed with major depression (n = 101) receiving pharmacotherapy were randomized into: (i) ESM-I consisting of six weeks of ESM combined with weekly feedback regarding the individual's positive affective experiences, (ii) six weeks of ESM without feedback, or (iii) treatment as usual only. Alongside this randomised controlled trial, an economic evaluation was conducted consisting of a cost-effectiveness and a cost-utility analysis, using Hamilton Depression Rating Scale (HDRS) and quality adjusted life years (QALYs) as outcome, with willingness-to-pay threshold for a QALY set at €50,000 (based on Dutch guidelines for moderate severe to severe illnesses).

RESULTS

The economic evaluation showed that ESM-I is an optimal strategy only when willingness to pay is around €3000 per unit HDRS and around €40,500 per QALY. ESM-I was the least favourable treatment when willingness to pay was lower than €30,000 per QALY. However, at the €50,000 willingness-to-pay threshold, ESM-I was, with a 46% probability, the most favourable treatment (base-case analysis). Sensitivity analyses confirmed the robustness of these results.

CONCLUSIONS

We may tentatively conclude that ESM-I is a cost-effective add-on intervention to pharmacotherapy in outpatients with major depression.

TRIAL REGISTRATION

Netherlands Trial register, NTR1974 .

Sickness Experiences of Korean Registered Nurses at Work: A Qualitative Study on Presenteeism

PURPOSE

Presenteeism is a relatively new concept in nursing describing the condition within which registered nurses (RNs) come to work while they are sick. The purpose of this study was to explore and describe presenteeism experiences among RNs in South Korea.

METHODS

In this constructivist grounded theory study, a focus group interview (FGI) technique was utilized for data collection. A total of 20 RNs at one hospital in Chuncheon city joined in three different FGIs. Semistructured questions were asked in reference to their sickness experience in the workplace. Data analysis was conducted according to the constructivist grounded theory methodology.

RESULTS

All participants had experiences of presenteeism. The overriding theme was "having no caring for nurses leads to losing one's nursing mind". The participants reported that due to either their personal preference or peer pressure they showed up to work, but they felt sad and their pride was hurt by the fact that there was no caring for them from other nurses. This emotional exhaustion often led to the loss of compassion and the resignation of nursing staff.

CONCLUSIONS

Care for nurses in the workplace is necessary for RNs to make their presenteeism experience positive and even effective.

Working with Musculoskeletal Pain

Pain has a significant impact on work in terms of presenteeism, sickness absence, and long-term incapacity for workA bio-psychosocial approach is required in understanding pain-related disability and incapacity for workLong-term absence from work is associated with a number of negative outcomes including; poverty, social exclusion and poorer physical and psychosocial well-beingReturn to work can improve recovery for people with musculoskeletal complaints and painInterventions to reduce the impact of pain on work can operate at clinical, worker, workplace, and wider systems levelsA broader whole systems approach to pain management needs to be adopted, with a greater focus on work retention as well as rehabilitation.

Estimating the Impact of Workplace Bullying: Humanistic and Economic Burden among Workers with Chronic Medical Conditions

Background. Although the prevalence of work-limiting diseases is increasing, the interplay between occupational exposures and chronic medical conditions remains largely uncharacterized. Research has shown the detrimental effects of workplace bullying but very little is known about the humanistic and productivity cost in victims with chronic illnesses. We sought to assess work productivity losses and health disutility associated with bullying among subjects with chronic medical conditions. Methods. Participants (N = 1717) with chronic diseases answered a self-administered survey including sociodemographic and clinical data, workplace bullying experience, the SF-12 questionnaire, and the Work Productivity Activity Impairment questionnaire. Results. The prevalence of significant impairment was higher among victims of workplace bullying as compared to nonvictims (SF-12 PCS: 55.5% versus 67.9%, p < 0.01; SF-12 MCS: 59.4% versus 74.3%, p < 0.01). The adjusted marginal overall productivity cost of workplace bullying ranged from 13.9% to 17.4%, corresponding to Italian Purchase Power Parity (PPP) 2010 US$ 4182–5236 yearly. Association estimates were independent and not moderated by concurrent medical conditions. Conclusions. Our findings demonstrate that the burden on workers' quality of life and productivity associated with workplace bullying is substantial. This study provides key data to inform policy-making and prioritize occupational health interventions.

Effectiveness of a problem-solving based intervention to prolong the working life of ageing workers

BACKGROUND

An ageing workforce combined with increasing health problems in ageing workers implies the importance of evidence-based interventions to enhance sustainable employability. The aim of this study is to evaluate the effectiveness of the 'Staying healthy at work' problem-solving based intervention compared to business as usual.

METHODS

This study was designed as a quasi-experimental trial with a one-year follow-up. Measurements were performed at baseline, three and twelve months. The problem-solving based intervention provides a strategy for increasing the awareness of ageing workers of their role and responsibility in living sustainable, healthy working lives. The primary outcomes were work ability, vitality and productivity. Secondary outcomes were perceived fatigue, psychosocial work characteristics, work attitude, self-efficacy and work engagement.

RESULTS

Analyses were performed on the 64 workers in the intervention and 61 workers from the business as usual group. No effects on productivity (OR = 0.83, 95% CI 0.23-3.00) and adverse effects on work ability (B = -1.33, 95% CI -2.45 to -0.20) and vitality (OR = 0.10, 95% CI 0.02-0.46) were found. Positive results were found for the work attitude secondary outcome (B = 5.29, 95% CI -9.59 to -0.99), the self-efficacy persistence subscale (B = 1.45, 95% CI 0.43-2.48) and the skill discretion subscale of the Job Content Questionnaire (B = 1.78, 95% CI 0.74-2.83).

CONCLUSION

The results of the problem-solving intervention showed no positive effects on the three outcome measures compared to business as usual. However, effectiveness was shown on three of the secondary outcome measures, i.e. work attitude, self-efficacy and skill discretion. We presume that the lack of positive effects on primary outcomes is due to programme failure and not to theory failure.

TRIAL REGISTRATION

The trial is registered with the Dutch Trial Register under number NTR2270 .

The prevalence of musculoskeletal disorder and association with productivity loss: a preliminary study among labour intensive manual harvesting activities in oil palm plantation

Production agriculture such as harvesting in oil palm plantation has been frequently associated with MSD and significant loss of productivities. This study tends to evaluate from the viewpoint of health, the association between self-reported prevalence of musculoskeletal disorders and productivities; the impact of musculoskeletal disorders on productivity. A cross-sectional study was conducted among 143 harvesters in oil palm plantation. A general questionnaire was used to collect socio-demographic background data while Nordic Musculoskeletal Questionnaire was used to determine the prevalence of MSD. Expressed in 4 different indicators; daily harvesting quantity, efficiency score, sick leave and presenteeism, the productivity data were analysed for association. There is significant association between reported acute prevalence of MSD (within 7 d) and productivity loss in terms of presenteeism (χ(2)=5.088; p<0.05) as well as quantity of daily harvest (χ(2)=7.406; p<0.01). Logistic regression adjusted for age, BMI and smoking indicate that harvesters with MSD (past seven days) were more likely to be engaged in presenteeism (OR=2.87 95% CI=1.34, 6.14) and had lower daily productivity (OR=2.09 95% CI=1.02, 4.29) compared to harvesters without MSD (past 7 d). This study reveals that oil palm harvesters suffering acute MSD (for the past week) were likely to be still present to work and produce half lesser than their healthy counterparts. Thus, further study with comprehensive surveillance strategy is essential in order to determine the urgency or need of appropriate intervention.

When Time is Not on Your Side: Patient Experiences with Waiting for Home Care and Admission to a Nursing or Residential Home

BACKGROUND

Waiting for care is common in many countries as a result of supply-side rationing. The effects that waiting has on patients and their environment have not received much attention thus far. We discuss the literature and present the results of a study on patient experiences with waiting for home care or admission to a nursing or residential home.Health status, well-being (or happiness), and different measures of the burden of waiting were assessed using a visual analog scale (VAS). Finally, respondents were asked to evaluate five statements regarding changes in health status and feelings of uncertainty, dependence, stress, and autonomy as a result of waiting for care, using a Likert-type scale (four categories ranging from 'totally agree' to 'totally disagree').Data were analyzed using SPSS (version 12.0.1). Differences in means between people waiting for home care and admission were tested using one-way ANOVA; differences in proportions were tested using the Chi-squared test. Multivariate analysis was conducted to explore associations of the burden of waiting with background variables and characteristics of intermittent care received, using a forward conditional regression model.

METHODS

Late in 2003 we recruited people on a waiting list in the Waardenland and Midden-Holland regions in the Netherlands to participate in a survey. People were randomly selected from waiting lists for home care or admission to a nursing or residential home. A structured questionnaire was administered to either the patient or their proxy. Respondents answered questions about socioeconomic status, health, well-being, intermittent care use, care providers, and additional costs associated with waiting. Furthermore, the survey included questions addressing waiting (time) perceptionsHealth status, well-being (or happiness), and different measures of the burden of waiting were assessed using a visual analog scale (VAS). Finally, respondents were asked to evaluate five statements regarding changes in health status and feelings of uncertainty, dependence, stress, and autonomy as a result of waiting for care, using a Likert-type scale (four categories ranging from 'totally agree' to 'totally disagree').Data were analyzed using SPSS (version 12.0.1). Differences in means between people waiting for home care and admission were tested using one-way ANOVA; differences in proportions were tested using the Chi-squared test. Multivariate analysis was conducted to explore associations of the burden of waiting with background variables and characteristics of intermittent care received, using a forward conditional regression model.

RESULTS

We found that waiting for care may have far-reaching consequences for patients and their families, and that approximately half of the patients waiting for care considered their current waiting time to be unacceptable. However, the mean burden of waiting is moderate and associated with the extent to which shortages in care are supplemented by support from informal caregivers, volunteers, or a domestic help.

CONCLUSIONS

Differences in how waiting time is perceived between individuals and care sectors are helpful building blocks for the development of more tailor-made policies aimed at reducing the burden of waiting time. These policies include additional support or quicker access to support at home for those most in need, and setting waiting time guarantees in order to reduce uncertainty.

Productivity costs in economic evaluations: past, present, future

Productivity costs occur when the productivity of individuals is affected by illness, treatment, disability or premature death. The objective of this paper was to review past and current developments related to the inclusion, identification, measurement and valuation of productivity costs in economic evaluations. The main debates in the theory and practice of economic evaluations of health technologies described in this review have centred on the questions of whether and how to include productivity costs, especially productivity costs related to paid work. The past few decades have seen important progress in this area. There are important sources of productivity costs other than absenteeism (e.g. presenteeism and multiplier effects in co-workers), but their exact influence on costs remains unclear. Different measurement instruments have been developed over the years, but which instrument provides the most accurate estimates has not been established. Several valuation approaches have been proposed. While empirical research suggests that productivity costs are best included in the cost side of the cost-effectiveness ratio, the jury is still out regarding whether the human capital approach or the friction cost approach is the most appropriate valuation method to do so. Despite the progress and the substantial amount of scientific research, a consensus has not been reached on either the inclusion of productivity costs in economic evaluations or the methods used to produce productivity cost estimates. Such a lack of consensus has likely contributed to ignoring productivity costs in actual economic evaluations and is reflected in variations in national health economic guidelines. Further research is needed to lessen the controversy regarding the estimation of health-related productivity costs. More standardization would increase the comparability and credibility of economic evaluations taking a societal perspective.

The influence of perceived stress and musculoskeletal pain on work performance and work ability in Swedish health care workers

OBJECTIVES

To evaluate the influence of perceived stress and musculoskeletal ache/pain, separately and in combination, at baseline, on self-rated work ability and work performance at two-year follow-up.

METHODS

Survey data were collected with a 2-year interval. Health care workers participating at both waves were included. Inclusion criteria were good self-reported work ability and unchanged self-rated work performance at baseline, resulting in 770 participants; 617 women and 153 men. Musculoskeletal pain was assessed using the question "How often do you experience pain in joints and muscles, including the neck and low back?", perceived stress with a modified version of a single item from the QPS-Nordic questionnaire, work performance by the question "Have your work performance changed during the preceding 12 months?" and work ability by a single item from the work ability index. Associations between baseline data and the two outcomes at follow-up were analysed by means of the log binomial model and expressed as risk ratios (RR) with 95% confidence intervals (CI).

RESULTS

A combination of frequent musculoskeletal pain and perceived stress constituted the highest risk for reporting decreased work performance (RR 1.7; CI 1.28-2.32) and reduced work ability (RR 1.7; CI 1.27-2.30) at follow-up. Separately, frequent pain, but not stress, was clearly associated with both outcomes.

CONCLUSION

The results imply that proactive workplace interventions in order to maintain high work performance and good work ability should include measures to promote musculoskeletal well-being for the employees and measures, both individual and organizational, to minimize the risk of persistent stress reactions.

Development of a composite questionnaire, the valuation of lost productivity, to value productivity losses: application in rheumatoid arthritis

OBJECTIVE

Existing productivity questionnaires do not capture sufficient information to enable the proper valuation of an individual's productivity loss to a society. The purpose of this article is to develop a questionnaire that captures the time lost from work due to a health problem and job and workplace characteristics so that the value of productivity loss to society can be calculated.

METHODS

First, a questionnaire battery was developed by selecting items from existing productivity questionnaires. Next, items with similar content were identified and duplications were eliminated. Third, the draft questionnaire's feasibility was pretested in a focus group (n = 15). Finally, after appropriate refinements, its applicability was tested in 140 employed patients with rheumatoid arthritis recruited from a cohort in the United Kingdom. Multipliers relating the wage to marginal productivity were also derived using the questionnaire.

RESULTS

The final questionnaire includes items on employment status; absenteeism; presenteeism; unpaid work; and job characteristics, which includes questions on team dynamics, availability of substitutes and their substitutability, time sensitivity, and compensation mechanisms. The importance of incorporating these questions demonstrated that when one employee was absent, or present at work but unable to work at full capacity, the consequent output loss could exceed the output of the employee alone. Multipliers were shown to be greater than one and represented the excess output loss.

CONCLUSIONS

The new questionnaire enabled the job and workplace characteristics to be captured so that the actual productivity loss at the societal level attributable to absenteeism and presenteeism could be valued.

Cost of low back pain in Switzerland in 2005

Low back pain (LBP) is the most prevalent health problem in Switzerland and a leading cause of reduced work performance and disability. This study estimated the total cost of LBP in Switzerland in 2005 from a societal perspective using a bottom-up prevalence-based cost-of-illness approach. The study considers more cost categories than are typically investigated and includes the costs associated with a multitude of LBP sufferers who are not under medical care. The findings are based on a questionnaire completed by a sample of 2,507 German-speaking respondents, of whom 1,253 suffered from LBP in the last 4 weeks; 346 of them were receiving medical treatment for their LBP. Direct costs of LBP were estimated at <euro>2.6 billion and direct medical costs at 6.1% of the total healthcare expenditure in Switzerland. Productivity losses were estimated at <euro>4.1 billion with the human capital approach and <euro>2.2 billion with the friction cost approach. Presenteeism was the single most prominent cost category. The total economic burden of LBP to Swiss society was between 1.6 and 2.3% of GDP.

Measuring the Impact of Arthritis on Worker Productivity: Perspectives, Methodologic Issues, and Contextual Factors

Leading up to the Outcome Measures in Rheumatology (OMERACT) 10 meeting, the goal of the Worker Productivity Special Interest Group (WP-SIG) was to make progress on 3 key issues that relate to the application and interpretation of worker productivity outcomes in arthritis: (1) to review existing conceptual frameworks to help consolidate our intended target and scope of measurement; (2) to examine the methodologic issues associated with our goal of combining multiple indicators of worker productivity loss (e.g., absenteeism <—> presenteeism) into a single comprehensive outcome; and (3) to examine the relevant contextual factors of work and potential implications for the interpretation of scores derived from existing outcome measures. Progress was made on all 3 issues at OMERACT 10. We identified 3 theoretical frameworks that offered unique but converging perspectives on worker productivity loss and/or work disability to provide guidance with classification, selection, and future recommendation of outcomes. Several measurement and analytic approaches to combine absenteeism and presenteeism outcomes were proposed, and the need for further validation of such approaches was also recognized. Finally, participants at the WP-SIG were engaged to brainstorm and provide preliminary endorsements to support key contextual factors of worker productivity through an anonymous “dot voting” exercise. A total of 24 specific factors were identified, with 16 receiving ≥ 1 vote among members, reflecting highly diverse views on specific factors that were considered most important. Moving forward, further progress on these issues remains a priority to help inform the best application of worker productivity outcomes in arthritis research.

Economic evaluations of occupational health interventions from a company's perspective: a systematic review of methods to estimate the cost of health-related productivity loss

OBJECTIVES

To investigate the methods used to estimate the indirect costs of health-related productivity in economic evaluations from a company's perspective.

METHODS

The primary literature search was conducted in Medline and Embase. Supplemental searches were conducted in the Cochrane NHS Economic Evaluation Database, the National Institute for Occupational Safety and Health database, the Ryerson International Labour, Occupational Safety and Health Index database, scans of reference lists and researcher's own literature database. Article selection was conducted independently by two researchers based on title, keywords, and abstract, and if needed, full text. Differences were resolved by a consensus procedure. Articles were selected based on seven criteria addressing study population, type of intervention, comparative intervention, outcome, costs, language and perspective, respectively. Characteristics of the measurement and valuation of health-related productivity were extracted and analyzed descriptively.

RESULTS

A total of 34 studies were included. Costs of health-related productivity were estimated using (a combination of) data related to sick leave, compensated sick leave, light or modified duty or work presenteeism. Data were collected from different sources (e.g. administrative databases, worker self-report, supervisors) and by different methods (e.g. questionnaires, interviews). Valuation varied in terms of reported time units, composition and source of the corresponding price weights, and whether additional elements, such as replacement costs, were included.

CONCLUSIONS

Methods for measuring and valuing health-related productivity vary widely, hindering comparability of results and decision-making. We provide suggestions for improvement.

Cost-utility analysis of a one-time supervisor telephone contact at 6-weeks post-partum to prevent extended sick leave following maternity leave in The Netherlands: results of an economic evaluation alongside a randomized controlled trial

Background

Working women of childbearing age are a vital part of the population. Following childbirth, this group of women can experience a myriad of physical and mental health problems that can interfere with their ability to work. Currently, there is little known about cost-effective post-partum interventions to prevent work disability. The purpose of the study was to evaluate whether supervisor telephone contact (STC) during maternity leave is cost-effective from a societal perspective in reducing sick leave and improving quality-adjusted life years (QALYs) compared to common practice (CP).

Methods

We conducted an economic evaluation alongside a randomized controlled trial. QALYs were measured by the EuroQol 5-D, and sick leave and presenteeism by the Health and work Performance Questionnaire. Resource use was collected by questionnaires. Data were analysed according to intention-to-treat. Missing data were imputed via multiple imputation. Uncertainty was estimated by 95% confidence intervals, cost-utility planes and curves, and sensitivity analyses.

Results

541 working women from 15 companies participated. Response rates were above 85% at each measurement moment. At the end of the follow-up, no statistically significant between-group differences in QALYs, mean hours of sick leave or presenteeism or costs were observed. STC was found to be less effective and more costly. For willingness-to-pay levels from €0 through €50,000, the probability that STC was cost-effective compared to CP was 0.2. Overall resource use was low. Mean total costs were €3678 (95% CI: 3386; 3951). Productivity loss costs represented 37% of the total costs and of these costs, 48% was attributable to sick leave and 52% to work presenteeism. The cost analysis from a company's perspective indicated that there was a net cost associated with the STC intervention.

Conclusions

STC was not cost-effective compared to common practice for a healthy population of working mothers; therefore, implementation is not indicated. The cost-utility of STC for working mothers with more severe post-partum health problems, however, needs to be investigated. Work presenteeism accounted for half of the total productivity loss and warrants attention in future studies.

Trial registration number

ISRCTN: ISRCTN73119486

Measuring and valuing productivity loss due to poor health: A critical review

The objective of this study is to review current measurement issues and valuation methods such as "human capital" and "friction cost" for estimating productivity loss due to illness. Since observed wages diverge from marginal productivity when allowances are made for sick days and workers are risk averse, or when a job type involves team production, unavailability of perfect substitutes, and/or time-sensitivity of output, productivity loss is likely to be underestimated. A multiplier adjusting wage to marginal productivity needs to be developed for practical use. We further consider the ramifications of measuring labour input loss due to illness in both paid and unpaid work as well as the inclusion of presenteeism to the more traditional approach of measuring only absenteeism. Although a number of instruments have been developed to measure presenteeism, they generate widely varying estimates of productivity loss. Further investigation is required to identify which instrument provides a better estimate. Finally, we provide recommendations on measurement methods such as using subjective measures due to the unavailability of objective measures and the appropriate recall periods. We conclude by proposing a generic measure instead of a disease-specific measure and discuss important perspective related issues.

The transferability of valuing lost productivity across jurisdictions. differences between national pharmacoeconomic guidelines

For at least two decades, there has been an intense debate on whether and how to include the value of lost productivity in economic evaluations. This debate is often reflected in pharmacoeconomic guidelines, which have been developed to indicate the methods and requirements for the design, execution, and reporting of economic evaluations in a particular country.

OBJECTIVE

To examine what various national pharmacoeconomic guidelines recommend regarding the identification, measurement, and valuation of lost productivity.

METHODS

First, the theoretical framework on how lost productivity can be identified, measured, and valued is described. Second, a summary sheet has been used to identify various pharmacoeconomic guidelines recommendations regarding the value of lost productivity.

RESULTS

Twenty-two of the 30 guidelines identified recommend performing economic evaluations using the societal perspective. Nevertheless, even if the societal perspective is recommended, it is not always clear how the value of lost productivity should be taken into account. Most guidelines recommend including the costs of absenteeism from paid and/or unpaid work. In addition, although no agreement exists on how lost productivity should be valued, none of the guidelines recommended using the US panel approach for the valuation of lost productivity.

DISCUSSION

The different recommendations hinder international transferability of the value of lost productivity. This difficulty is mainly caused by different recommendations regarding identification and valuation. These differences result from the debate and lack of consensus on including the value of lost productivity losses in economic evaluations. It will become easier to transfer data across jurisdictions if all data are reported transparently.

Sickness presenteeism today, sickness absenteeism tomorrow? A prospective study on sickness presenteeism and future sickness absenteeism

OBJECTIVE

To prospectively investigate whether sickness presenteeism (SP), ie, going to work despite illness, has an impact on future sickness absenteeism.

METHODS

Two study populations were used, one female dominated from the public sector that included 3757 employees, and one male dominated from the private sector comprising 2485 employees.

RESULTS

SP on more than five occasions during the baseline year (2000) was a statistically significant risk factor for future sick leave (2002 and 2003) of more than 30 days among both populations even after adjusting for previous sick leave, health status, demographics, lifestyle, and work-related variables (2002, public sector, relative risk = 1.40; private sector, relative risk = 1.51).

CONCLUSIONS

SP may be an important phenomenon to consider when evaluating measures aimed at decreasing sickness absenteeism because more SP may lead to future sickness absence.

Hot flashes, fatigue, treatment exposures and work productivity in breast cancer survivors

INTRODUCTION

While fatigue has been associated with work limitations the combined influence of specific diagnosis and treatment exposures based on medical records on work limitations in breast cancer survivors is currently unknown. Since symptom burden and perceived health can interfere with work, the present study investigated the relationship among these variables and work outcomes.

METHODS

Medical chart abstraction, demographic measures, SF 36, the Work Limitations Questionnaire (WLQ) and measures of symptom burden, including hot flushes were obtained in 83 breast cancer survivors a mean of three years post treatment. OLS and poisson regression were used to determine the relationship of these factors to work productivity and work absences.

RESULTS

Breast cancer survivors reported a mean reduction in productivity of 3.1% below the healthy worker norm. This amounts to a loss of 2.48 hours of work over two weeks of full time employment. Stages 1 and 2 were related to work limitations. After controlling for stage, fatigue and hot flashes were each associated with work performance losses of 1.6% (p = 0.05) and 2.2% (p < 0.001), respectively. Protective factors included marriage and greater personal earned income.

CONCLUSIONS

Fatigue and hot flashes are important factors related to work productivity in breast cancer survivors even at three years post treatment. IMPLICATIONS FOR SURVIVORS: Therapy for hot flashes should be given serious consideration in breast cancer survivors who are experiencing work limitations.

Cost-effectiveness of a workplace intervention for sick-listed employees with common mental disorders: design of a randomized controlled trial

Background

Considering the high costs of sick leave and the consequences of sick leave for employees, an early return-to-work of employees with mental disorders is very important. Therefore, a workplace intervention is developed based on a successful return-to-work intervention for employees with low back pain. The objective of this paper is to present the design of a randomized controlled trial evaluating the cost-effectiveness of the workplace intervention compared with usual care for sick-listed employees with common mental disorders.

Methods

The study is designed as a randomized controlled trial with a follow-up of one year. Employees eligible for this study are on sick leave for 2 to 8 weeks with common mental disorders. The workplace intervention will be compared with usual care. The workplace intervention is a stepwise approach that aims to reach consensus about a return-to-work plan by active participation and strong commitment of both the sick-listed employee and the supervisor. Outcomes will be assessed at baseline, 3, 6, 9 and 12 months. The primary outcome of this study is lasting return-to-work, which will be acquired from continuous registration systems of the companies after the follow-up. Secondary outcomes are total number of days of sick leave during the follow-up, severity of common mental disorders, coping style, job content, and attitude, social influence, and self-efficacy determinants. Cost-effectiveness will be evaluated from the societal perspective. A process evaluation will also be conducted.

Discussion

Return-to-work is difficult to discuss in the workplace for sick-listed employees with mental disorders and their supervisors. Therefore, this intervention offers a unique opportunity for the sick-listed employee and the supervisor to discuss barriers for return-to-work. Results of this study will possibly contribute to improvement of disability management for sick-listed employees with common mental disorders. Results will become available in 2009.

Trial registration

ISRCTN92307123

Unrelated medical costs in life-years gained: should they be included in economic evaluations of healthcare interventions?

Which costs and benefits to consider in economic evaluations of healthcare interventions remains an area of much controversy. Unrelated medical costs in life-years gained is an important cost category that is normally ignored in economic evaluations, irrespective of the perspective chosen for the analysis. National guidelines for pharmacoeconomic research largely endorse this practice, either by explicitly requiring researchers to exclude these costs from the analysis or by leaving inclusion or exclusion up to the discretion of the analyst. However, the inclusion of unrelated medical costs in life-years gained appears to be gaining support in the literature.This article provides an overview of the discussions to date. The inclusion of unrelated medical costs in life-years gained seems warranted, in terms of both optimality and internal and external consistency. We use an example of a smoking-cessation intervention to highlight the consequences of different practices of accounting for costs and effects in economic evaluations. Only inclusion of all costs and effects of unrelated medical care in life-years gained can be considered both internally and externally consistent. Including or excluding unrelated future medical costs may have important distributional consequences, especially for interventions that substantially increase length of life. Regarding practical objections against inclusion of future costs, it is important to note that it is becoming increasingly possible to accurately estimate unrelated medical costs in life-years gained. We therefore conclude that the inclusion of unrelated medical costs should become the new standard.

Design of a randomized controlled trial on the effects of counseling of mental health problems by occupational physicians on return to work: the CO-OP-study

Background

Mental health problems often lead to prolonged sick leave. In primary care, the usual approach towards these patients was the advice to take rest and not return to work before all complaints had disappeared. When complaints persist, these patients are often referred to psychologists from primary and specialized secondary care. As an alternative, ways have been sought to activate the Dutch occupational physician (OP) in primary care. Early 2000, the Dutch Association of Occupational Physicians (NVAB) published a guideline concerning the management by OPs of employees with mental health problems. The guideline received positive reactions from employees, employers and Dutch OPs. This manuscript describes the design of a study, which aims to assess the effects of the guideline, compared with usual care.

Methods/Design

In a randomized controlled trial (RCT), subjects in the intervention group were treated according to the guideline. The control group received usual care, with minimal involvement of the OP and easy access to a psychologist. Subjects were recruited from two Dutch police departments. The primary outcomes of the study are return to work and treatment satisfaction by the employee, employer, and OP. A secondary outcome is cost-effectiveness of the intervention, compared with usual care. Furthermore, prognostic measures are taken into account as potential confounders. A process evaluation will be done by means of performance indicators, based on the guideline.

Discussion

In this pragmatic trial, effectiveness instead of efficacy is studied. We will evaluate what is possible in real clinical practice, rather than under ideal circumstances. Many requirements for a high quality trial are being met. Results of this study will contribute to treatment options in occupational health practice for employees on sick leave due to mental health problems. Additionally, they may contribute to new and better-suited guidelines and stepped care. Results will become available during 2007.

Trial registration

Current Controlled Trials ISRCTN34887348

Economic evaluation of a multi-stage return to work program for workers on sick-leave due to low back pain

OBJECTIVE

To evaluate the cost-effectiveness and cost-utility of a return to work (RTW) program for workers on sick-leave due to low back pain (LBP), comparing a workplace intervention implemented between 2 to 8 weeks of sick-leave with usual care, and a clinical intervention after 8 weeks of sick-leave with usual care.

DESIGN

Economic evaluation alongside a randomised controlled trial (RCT).

STUDY POPULATION

Workers sick-listed for a period of 2 to 6 weeks due to LBP.

INTERVENTIONS

1. workplace assessment, work modifications and case management). 2. physiotherapy based on operant behavioural principles. 3. usual care: provided by an occupational physician.

OUTCOMES

The primary outcome was return to work (RTW). Other outcomes were pain intensity, functional status, quality of life and general health. The economic evaluation was conducted from a societal perspective. Outcomes were assessed at baseline (after 2-6 weeks on sick-leave), and 12 weeks, 26 weeks, and 52 weeks after the first day of sick-leave.

RESULTS

The workplace intervention group returned to work 30.0 days (95% CI=[3.1, 51.3]) earlier on average than the usual care group at slightly higher direct costs (ratio of 1 day: 19 euro). Workers in the clinical intervention group that had received usual care in the first 8 weeks returned to work 21.3 days (95% CI= [-74.1, 29.2]) later on average. The group that had received the workplace intervention in the first 8 weeks and the clinical intervention after 8 weeks returned to work 50.9 days (95% CI=[-89.4, -2.7]) later on average. A workplace intervention was more effective than usual care in RTW at slightly higher costs and was equally effective as usual care at equal costs on other outcomes. A clinical intervention was less effective than usual care and associated with higher costs.

CONCLUSION

The workplace intervention results in a safe and faster RTW than usual care at reasonable costs for workers on sick-leave for two to six weeks due to LBP.

The association of two productivity measures with health risks and medical conditions in an Australian employee population

PURPOSE

To investigate the impact of health on job performance using two measures of productivity loss: (1) a self-reported measure of health-related presenteeism and (2) an objective measure of absenteeism.

DESIGN

A cross-sectional survey using a Health Risk Appraisal (HRA) to evaluate self-reported presenteeism and the prevalence of 12 health risks and eight medical conditions.

SETTING AND SUBJECTS

Employees (n=224) of a private insurance provider in Australia.

MEASURES

A Health Risk Appraisal (HRA) questionnaire was used to evaluate self-reported presenteeism on different aspects of job demands and to assess the prevalence of 12 health risks and eight medical conditions. Illness absent hours were obtained from company administrative records.

RESULTS

Increased presenteeism was significantly associated with high stress, life dissatisfaction, and back pain, while increased illness absenteeism was significantly associated with overweight, poor perception of health, and diabetes. Excess presenteeism associated with excess health risks (productivity loss among those with medium- or high-risk status compared to those with low-risk status) was independently calculated at 19.0% for presenteeism and 12.8% for illness absenteeism.

CONCLUSIONS

This study demonstrates an association between health metrics and self-reported work impairment (presenteeism) and measured absenteeism. The study provides a first indication of the potential benefits of health promotion programming to Australian employees in improving health and to the corporation in minimizing health-related productivity loss.

How Much Does Quality Mental Health Care Profit Employers?

OBJECTIVE

Employers provide most American mental health benefits and are increasingly cost conscious. However, commonplace anxiety and depressive disorders have enormous economic and workplace performance costs.

METHODS

We performed multiple literature searches on several areas of pertinent research (and on key articles) covering the past 5 years.

RESULTS

Substantial research exists about anxiety and depression costs, such as performance and productivity, absenteeism, presenteeism, disability, physical disability exacerbation, mental health treatment, increased medical care costs, exacerbating of physical illness, and studies of mental health care limitations and cost-offset. Research addressing the potential value of higher quality mental health care is limited.

CONCLUSIONS

Commonplace anxiety and depressive disorders are costly in the workplace. Employers and researchers remain largely unaware of the value of quality care and psychiatric skills. Effective solutions involve the increased use of psychiatric skills and appropriate treatment.

Nasal cytokines as mediators of illness during the common cold

Identification of a pharmacologically targeted mediator of the common cold is a desirable, but, to date, elusive goal of current research. The roles of various mediators, such as histamine, leukotrienes, bradykinin, and, more recently, chemokines and cytokines, in the pathophysiology and development of complications of the common cold are the subject of previous and current investigations. Establishing causality of a mediator in the common cold has been difficult for a number of reasons, including the limitations of our research tools and protocols and the complexity of the inflammatory and immune pathways that participate during the common cold. The available evidence for mediation of the common cold is the subject of this manuscript.

The cost and benefit of Listeria monocytogenes food safety measures

The objectives of this study were to evaluate economic techniques used to determine the cost and benefit of Listeria monocytogenes control and to estimate the economic optimum of L. monocytogenes food safety measures. The level of food safety measures is optimal if marginal benefit and marginal cost equate. Estimates of benefit and cost of L. monocytogenes food safety measures, from available published literature, are derived from different methods of economic analysis (willingness to pay, cost of illness, cost function, and event study methods). The estimated annual benefit and cost of L. monocytogenes food safety measures range from $2.3 billion to $22 billion and from $.01 billion to $2.4 billion, respectively. The estimated marginal benefit exceeds the estimated marginal cost, which implies that more food safety measures are warranted before the optimal level of L. monocytogenes food safety can be reached. However, due to considerable lack of data, the optimal level of L. monocytogenes food safety measures could not be estimated. When better data become available, this study can serve as a template for estimating the optimal level of food safety. The understanding of the economic optimum of food safety level will contribute to designing a control program that is economical and acceptable for US society.

Correcting for compensating mechanisms related to productivity costs in economic evaluations of health care programmes

In the economic evaluation of health care programmes, productivity costs are often estimated using patients' wages for the period of absence. However, the use of such methods for short periods of absence is controversial. A previous study found that short-term absence is often compensated for during normal working hours and therefore does not lead to productivity losses. As such, the application of any approach almost certainly overestimates productivity costs. In this study, we examined the productivity costs for five different patient populations and one employee population, using the classical method and by identifying when extra effort was needed. In general, the results showed that productivity costs based on identifying extra effort were 25-30% of the classical estimates. For absences of just one day, productivity costs were relevant in only 17-19% of cases. For absences of two weeks or longer, productivity costs were relevant in 35-39% of cases. Measurement of the compensating mechanisms seemed to be valid, since there is considerable agreement between the opinion of supervisors and their employees about whether compensation covers productivity costs. There was much less agreement between supervisors and their employees on specific compensating mechanisms, however. The measurement of compensating mechanisms also seemed to be valid, because--as expected--different compensating mechanisms were reported for different occupations. In our study populations, compensating mechanisms appeared to differ with occupational characteristics, like part-time work, managerial work and shift work.

The relationship between productivity and health-related quality of life: An empirical exploration in persons with low back pain

OBJECTIVE

In economic evaluation of health care programmes normally health-related quality of life is part of measurement of a programme's effectiveness and productivity part of its costs. In this paper the relationship between quality of life and productivity is highlighted and empirically assessed in persons suffering from low back pain.

METHODS

A secondary analysis was performed on data from a sample of 483 patients treated for low back pain. Periodically, both quality of life (EQ-5D) and productivity indicators for both paid and unpaid work were measured. Mean EQ-5D scores were compared for groups of patients classified by level of productivity. The relationship between quality of life and productivity was also assessed using Spearman rank correlation coefficients.

RESULTS

Mean EQ-5D scores for patients without productivity losses were a half to a full standard deviation higher than for patients with the lowest levels of productivity. The correlation between quality of life and productivity was moderate.

CONCLUSION

Lower levels of quality of life were associated with efficiency loss and absenteeism. However, due to the moderate strength of the relation the use of information on quality of life to model productivity costs in case of absence of productivity data was not recommended.

Measuring productivity changes in economic evaluation: setting the research agenda

Productivity costs related to illness may be relevant in assessing healthcare programmes for patients, as well as occupational interventions for workers. When performing an economic evaluation for both types of programmes, a sound methodology for measuring and valuing these productivity costs is essential. This article reviews research questions related to productivity and health, focusing on the costs of short-term absence from work, productivity costs without absence ('presenteeism') and possible compensation mechanisms and circumstances that may affect productivity costs. Furthermore, the important but under-explored relationship between productivity and QOL is analysed. Strategies for better answers on these research questions, such as developing more valid measurement instruments, are discussed. It is stressed that the analysis of productivity costs should not be restricted to the level of the individual patient and worker but extended to the level of teams of workers and firms. It may be advisable to explore several issues such as compensation mechanisms and efficiency losses in detail using employee questionnaires and consecutively applying the key elements in patient settings. It seems advisable to develop flexible, modular instruments for measuring and valuing absence from work, compensation mechanisms, efficiency loss and details of jobs and organisation in an integrative and consistent way. Further, it seems crucial to identify what determinants of jobs and organisations are the key factors in estimating productivity costs. This list of determinants could be mapped with a classification of jobs, to be used as a screener in patient questionnaires.

The relationship between productivity and health-related QOL: an exploration

In economic evaluation of healthcare programmes both QOL and productivity of patients are aspects to be studied. Normally, the former is part of the measurement of the effectiveness of the programme and the latter is part of the measurement of its costs. In this paper we highlight the relationship between QOL and productivity. Two aspects are discussed: (i) the relationship between perceived productivity and health-state valuations; and (ii) the observed relationship between productivity and QOL. The first aspect relates to the fact that in health-state valuations, respondents may consider income changes and ability to work. While this may have important methodological and practical implications, little empirical evidence exists in this area. The second aspect relates to the fact that the observed productivity of individuals is expected to be related to their health-related QOL. Worse health states are expected to be associated with lower productivity. Again, empirical investigation is lacking; however, this relationship may prove important, for instance in modelling productivity costs with use of information on QOL. This paper explores these relationships between productivity and QOL to stimulate debate and research in this area.

Reliability and Validity of the Stanford Presenteeism Scale

OBJECTIVE

This study reports the reliability and validity of the 13-item Stanford Presenteeism Scale (SPS). The SPS differs from similar scales by focusing on knowledge-based and production-based workers.

METHODS

Data were obtained from administrative and medical claims databases and from a survey that incorporated the SPS, SF-36, and the Work Limitations Questionnaire.

RESULTS

Sixty-three percent (7797) of employees responded. Cronbach's alpha (0.83) indicates adequate reliability. Factor analysis identified two underlying factors, "completing work" and "avoiding distraction." Knowledge-based workers load on "completing work" (alpha = 0.97), whereas production-based workers load on "avoiding distraction" (alpha = 0.98). There were significant and positive relationships between the SPS, SF-36, and Work Limitations Questionnaire.

CONCLUSIONS

The SPS demonstrates a high degree of reliability and validity and may be ideal for employers who seek a single scale to measure health-related productivity in a diverse employee population.

Burden and cost of illness in patients with juvenile idiopathic arthritis

OBJECTIVE

To estimate the cost of illness in an incidence based cohort of patients with juvenile idiopathic arthritis.

METHODS

Direct costs (healthcare and non-healthcare costs) and indirect costs (productivity loss due to sick leave and work disability) were measured in 215 JIA patients, assessed on an average of 17 years after disease onset. Assessment included a clinical evaluation, a structured interview, and two self completion questionnaires. Annual direct costs were estimated based on the reported use of healthcare services and resources, using average unit prices. Indirect costs were estimated from the number of work days missed-that is, using the human capital approach.

RESULTS

The mean total cost of late JIA was estimated to be 3500 per patient and year, of which the direct cost contributed more than half. Patients with still active disease (55%) incurred the major share (90%) of the cost. They had a mean total cost of 5700 per patient year, with those under rheumatological care incurring a cost of 9300. Having a certain JIA subgroup, functional disability, or receipt of specialised care independently contributed to the total cost in active JIA. Highest mean total costs were found in active seropositive polyarthritis (17 000) and extended oligoarthritis (11 000), while the lowest were found in active enthesitis related arthritis (1500) and persistent oligoarthritis (2700).

CONCLUSIONS

Estimated 12 month costs in late JIA are considerable, differing among the various JIA subgroups. Treatment strategies in JIA should be analysed for their cost effectiveness in the long term.

Cost effectiveness of a multi-stage return to work program for workers on sick leave due to low back pain, design of a population based controlled trial [ISRCTN60233560]

BACKGROUND

To describe the design of a population based randomized controlled trial (RCT), including a cost-effectiveness analysis, comparing participative ergonomics interventions between 2-8 weeks of sick leave and Graded Activity after 8 weeks of sick leave with usual care, in occupational back pain management.

METHODS

DESIGN

An RCT and cost-effectiveness evaluation in employees sick-listed for a period of 2 to 6 weeks due to low back pain. Interventions used are 1. Communication between general practitioner and occupational physician plus Participative Ergonomics protocol performed by an ergonomist. 2. Graded Activity based on cognitive behavioural principles by a physiotherapist. 3. Usual care, provided by an occupational physician according to the Dutch guidelines for the occupational health management of workers with low back pain. The primary outcome measure is return to work. Secondary outcome measures are pain intensity, functional status and general improvement. Intermediate variables are kinesiophobia and pain coping. The cost-effectiveness analysis includes the direct and indirect costs due to low back pain. The outcome measures are assessed before randomization (after 2-6 weeks on sick leave) and 12 weeks, 26 weeks and 52 weeks after first day of sick leave.

DISCUSSION

The combination of these interventions has been subject of earlier research in Canada. The results of the current RCT will: 1. crossvalidate the Canadian findings in an different sociocultural environment; 2. add to the cost-effectiveness on treatment options for workers in the sub acute phase of low back pain. Results might lead to alterations of existing (inter)national guidelines.