Estimating the cost of lost productivity in dyspepsia

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.

Risk Factors Linked to Psychological Distress, Productivity Losses, and Sick Leave in Low-Back-Pain Employees: A Three-Year Longitudinal Cohort Study

Background. Low back pain (LBP) is one of the most common health problems worldwide. Purpose. To investigate the link between baseline demographic and occupational, medical, and lifestyle data with following psychological and occupational outcomes in a large sample of employees with LBP over a 3-year period. Study Design. Three-year prospective cohort study. Methods. Italian-speaking employees (N = 4492) with a diagnosis of LBP were included. Screening at Time 1 was done in order to collect information about severity and classification of LBP, demographic, lifestyle, and occupational status data. Psychological distress (PGWBI) and occupational burden were assessed after 3 years. Results. After 3 years, employees with LBP not due to organic causes had an increased risk of psychological distress. Gender appears to be an important variable for following occupational burden. Indeed, being a white-collar man with a LBP without organic causes seems to be a protective factor for following work outcomes, while being a white-collar woman with a LBP not due to organic causes appears to be a risk factor for subsequent sick leave. Moreover, LBP severity affects psychological and occupational outcomes. Conclusion. Our findings have several implications that could be considered in preventive and supportive programs for LBP employees.

Illness related wage and productivity losses: Valuing 'presenteeism'

One source of productivity loss due to illness is the reduced "quantity" or "quality" of labor input while working, often referred to as presenteeism. Illness-related presenteeism has been found to be potentially more costly than absenteeism. To value presenteeism, existing methods use wages as a proxy for marginal productivity at the firm level. However, wage may not equal marginal productivity in some scenarios. One instance is when a job involves team production and perfect substitutes for workers are not readily available. Using a Canadian linked employer-employee survey (2001-2005), we test whether relative wage equals relative marginal productivity among team workers and non-team workers with different frequencies of presenteeism (reduction at work due to illness). For the pooled cross-sectional estimates (2001, 2003, 2005) we obtain 13,755 observations with 6842 unique workplaces. There are 6490 observations for the first differences estimates from the odd years and 5263 observations for the first differences estimates from 2001 to 2002 and 2003 to 2004. We find that in both small and large firms, team workers with frequent reductions at work are less productive but earn similarly compared with non-team workers without reductions. We also find that in small firms, workers with occasional work reductions are more productive than workers without reductions, but the reverse is true in large firms. The study findings partially support the literature stating that productivity loss resulting from employee presenteeism could exceed wages if team work is involved.

The iMTA Productivity Cost Questionnaire: A Standardized Instrument for Measuring and Valuing Health-Related Productivity Losses

BACKGROUND

Productivity losses often contribute significantly to the total costs in economic evaluations adopting a societal perspective. Currently, no consensus exists on the measurement and valuation of productivity losses.

OBJECTIVE

We aimed to develop a standardized instrument for measuring and valuing productivity losses.

METHODS

A group of researchers with extensive experience in measuring and valuing productivity losses designed an instrument suitable for self-completion, building on preknowledge and evidence on validity. The instrument was designed to cover all domains of productivity losses, thus allowing quantification and valuation of all productivity losses. A feasibility study was performed to check the questionnaire's consistency and intelligibility.

RESULTS

The iMTA Productivity Cost Questionnaire (iPCQ) includes three modules measuring productivity losses of paid work due to 1) absenteeism and 2) presenteeism and productivity losses related to 3) unpaid work. Questions for measuring absenteeism and presenteeism were derived from existing validated questionnaires. Because validated measures of losses of unpaid work are scarce, the questions of this module were newly developed. To enhance the instrument's feasibility, simple language was used. The feasibility study included 195 respondents (response rate 80%) older than 18 years. Seven percent (n = 13) identified problems while filling in the iPCQ, including problems with the questionnaire's instructions and routing (n = 6) and wording (n = 2). Five respondents experienced difficulties in estimating the time that would be needed for other people to make up for lost unpaid work.

CONCLUSIONS

Most modules of the iPCQ are based on validated questions derived from previously available instruments. The instrument is understandable for most of the general public.

Estimating productivity costs in health economic evaluations: a review of instruments and psychometric evidence

Health economic evaluations (i.e. cost-effectiveness appraisal of an intervention) are useful aids for decision makers responsible for the allocation of scarce healthcare resources. The relevance of including health-related productivity costs (or benefits) in these evaluations is increasingly recognized and, as such, reliable and valid instruments to quantify productivity costs are needed. Over the years, a number of work productivity instruments have emerged in the literature, along with a growing body of psychometric evidence. The overall aim of this paper is to provide a review of available instruments with potential for estimating health-related productivity costs. This included the Health and Labor Questionnaire, Health and Work Performance Questionnaire, Health-Related Productivity Questionnaire Diary, Productivity and Disease Questionnaire, Quantity and Quality method, Stanford Presenteeism Scale 13, Valuation of Lost Productivity, Work and Health Interview, Work Limitations Questionnaire, Work Productivity and Activity Impairment Questionnaire, and Work Productivity Short Inventory. Critical discussions on the instruments' overall strengths and limitations, applicability for health economic evaluations, as well as the methodological quality of existing psychometric evidence were provided. Lastly, a set of reflective questions were proposed for users to consider when selecting an instrument for health economic evaluations.

Work productivity loss from depression: evidence from an employer survey

BACKGROUND

National working groups identify the need for return on investment research conducted from the purchaser perspective; however, the field has not developed standardized methods for measuring the basic components of return on investment, including costing out the value of work productivity loss due to illness. Recent literature is divided on whether the most commonly used method underestimates or overestimates this loss. The goal of this manuscript is to characterize between and within variation in the cost of work productivity loss from illness estimated by the most commonly used method and its two refinements.

METHODS

One senior health benefit specialist from each of 325 companies employing 100+ workers completed a cross-sectional survey describing their company size, industry and policies/practices regarding work loss which allowed the research team to derive the variables needed to estimate work productivity loss from illness using three methods. Compensation estimates were derived by multiplying lost work hours from presenteeism and absenteeism by wage/fringe. Disruption correction adjusted this estimate to account for co-worker disruption, while friction correction accounted for labor substitution. The analysis compared bootstrapped means and medians between and within these three methods.

RESULTS

The average company realized an annual $617 (SD = $75) per capita loss from depression by compensation methods and a $649 (SD = $78) loss by disruption correction, compared to a $316 (SD = $58) loss by friction correction (p < .0001). Agreement across estimates was 0.92 (95% CI 0.90, 0.93).

CONCLUSION

Although the methods identify similar companies with high costs from lost productivity, friction correction reduces the size of compensation estimates of productivity loss by one half. In analyzing the potential consequences of method selection for the dissemination of interventions to employers, intervention developers are encouraged to include friction methods in their estimate of the economic value of interventions designed to improve absenteeism and presenteeism. Business leaders in industries where labor substitution is common are encouraged to seek friction corrected estimates of return on investment. Health policy analysts are encouraged to target the dissemination of productivity enhancing interventions to employers with high losses rather than all employers.

TRIAL REGISTRATION

CLINICAL TRIALS REGISTRATION NUMBER

NCT01013220.

How to estimate productivity costs in economic evaluations

Productivity costs are frequently omitted from economic evaluations, despite their often strong impact on cost-effectiveness outcomes. This neglect may be partly explained by the lack of standardization regarding the methodology of estimating productivity costs. This paper aims to contribute to standardization of productivity cost methodology by offering practical guidance on how to estimate productivity costs in economic evaluations. The paper discusses the identification, measurement and valuation of productivity losses. It is recommended to include not only productivity losses related to absenteeism from and reduced productivity at paid work, but also those related to unpaid work. Hence, it is recommended to use a measurement instrument including questions about both paid and unpaid productivity, such as the iMTA Productivity Cost Questionnaire (iPCQ) or the Valuation of Lost Productivity (VOLP). We indicate how to apply the friction cost and the human capital approach and give practical guidance on deriving final cost estimates.

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.

Compensation mechanisms for lost productivity: a comparison between four European countries

OBJECTIVE

Productivity costs are usually estimated by multiplying the wage with the period absent. This can lead to an overestimation if compensation mechanisms occur. Until now only Dutch data are available on the influence of compensation mechanisms on lost productivity, but between-country differences in frequency and type of compensation mechanisms can be expected. The objective of this study was to understand whether compensation mechanisms for days absent from paid work differ in type and frequency across countries and to explore whether this would result in between-country differences in relevant lost productivity.

METHODS

Data from a cross-sectional survey among respondents with rheumatic disorders from four countries were the basis for this study. Analyses focused on respondents with paid employment who reported absence in the last 3 months. The different compensation mechanisms are described and the resulting lost productivity in terms of days absent was calculated with and without taking compensation mechanisms into account. Logistic regression analyses were performed to examine which variables influence compensation mechanisms leading to relevant lost productivity.

RESULTS

The results indicate that compensation mechanisms occur and are relevant in all four countries. Between-country differences in the type and frequency of compensation mechanisms and relevant lost productivity were observed. The logistic regression analyses indicate that, correcting for other variables, this is also the case for the use of compensation mechanisms leading to relevant lost productivity.

CONCLUSIONS

Between-country differences in compensation mechanisms in case of absenteeism exist and could vary to such an extent that foreign relevant lost productivity data should be used with caution.

Functional dyspepsia: the economic impact to patients

BACKGROUND

Although highly prevalent, little is known about the economic impact of functional dyspepsia (FD).

AIMS

To quantify FD patients' health care utilisation patterns and to estimate direct and indirect costs of FD to patients.

METHODS

ICD-9 codes identified adult patients with dyspepsia. A validated questionnaire was mailed to patients who met Rome III criteria for FD.

RESULTS

Three hundred and fifty-five patients met all inclusion criteria. The response rate was 63%. The respondents' mean age was 50 (14) years; 75% were women; 52% of respondents rated their FD as moderate. Patients reported 3 visits (mean) to their PCP over 12 months; 75% reported having blood work, 92% an EGD, 59% an ultrasound and 40% a CT scan. The direct cost of testing using Medicare reimbursement rates per patient was $582. To treat FD symptoms, 89% tried dietary changes, 89% over-the-counter medications, 87% prescription medications and 25% alternative therapies. Mean patient expenditure over the last year was $246 for OTC medications (range $0-12,000), $290 for co-payments (range $0-9,000) and $110 for alternative treatments (range $0-3,741). Total mean direct cost yearly to patients was $699. In the 7 days prior to completing the questionnaire, respondents reported a mean of 1.4 h absence from work. Extrapolating the results to the US population, we conservatively calculate the costs of FD were $18.4 billion in 2009.

CONCLUSIONS

Functional dyspepsia patients incur significant direct and indirect costs and work productivity is impaired by dyspeptic symptoms.

Lost productivity in four European countries among patients with rheumatic disorders: are absenteeism and presenteeism transferable?

BACKGROUND

When national pharmacoeconomic guidelines are compared, different recommendations are identified on how to identify, measure and value lost productivity, leading to difficulties when comparing lost productivity estimates across countries. From a transferability point of view, the question arises of whether differences between countries regarding lost productivity are the result of using different calculation methods (methodological differences) or of other between-country differences. When lost productivity data differ significantly across countries, the transferability of lost productivity data across countries is hindered.

OBJECTIVE

The objective of this study was to investigate whether country of residence has a significant influence on the quantity of lost productivity among patients with rheumatic disorders. Confounding factors that might differ between countries were corrected for, while the methodology used to identify and measure lost productivity was kept the same.

METHODS

This question was investigated by means of an online questionnaire filled out by 200 respondents with a rheumatic disorder per country in four European countries, namely the Netherlands, the UK, Germany and France. In addition to those regarding lost productivity, the questionnaire contained questions about patient characteristics, disability insurance, disease characteristics, quality of life and job characteristics as these variables are expected to influence lost productivity in terms of absenteeism and presenteeism. The data were analysed by regression analyses, in which different components - being absent in last 3 months, number of days absent and presenteeism - of lost productivity were the main outcome measures and other variables, such as gender, impact of disease, shift work, job control, partial disability and overall general health, were corrected for.

RESULTS

The results showed that country sometimes has a significant influence on lost productivity and that other variables such as, for example, age, disease severity, number of contract hours, decision latitude, experienced health (as reported on the visual analogue scale) and partial disability, also influence lost productivity. A significant influence of country of residence was found on the variables 'being absent in the last three months', 'number of days absent' and 'quality of work on the last working day'. However, country did not influence 'quantity of work on the last working day' and 'overall presenteeism on the last working day'.

CONCLUSION

It can be concluded that country has a significant influence on lost productivity among patients with rheumatic disorders, when corrected for other variables that have an influence on absenteeism and presenteeism. Transferring lost productivity data across countries without adaptation is hindered by the significant differences between countries in this patient group. As a result, transferring lost productivity data, being either monetary values or volumes of productivity losses, between countries can give wrong estimations of the cost effectiveness of treatments.

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.

Economic impact of dyspepsia in rural and urban malaysia: a population-based study

BACKGROUND/AIMS

The economic impact of dyspepsia in regions with a diverse healthcare system remains uncertain. This study aimed to estimate the costs of dyspepsia in a rural and urban population in Malaysia.

METHODS

Economic evaluation was performed based on the cost-of-illness method. Resource utilization and quality of life data over a specific time frame, were collected to determine direct, indirect and intangible costs related to dyspepsia.

RESULTS

The prevalences of dyspepsia in the rural (n = 2,000) and urban (n = 2,039) populations were 14.6% and 24.3% respectively. Differences in socioeconomic status and healthcare utilisation between both populations were considerable. The cost of dyspepsia per 1,000 population per year was estimated at USD14,816.10 and USD59,282.20 in the rural and urban populations respectively. The cost per quality adjusted life year for dyspepsia in rural and urban adults was USD16.30 and USD69.75, respectively.

CONCLUSIONS

The economic impact of dyspepsia is greater in an urban compared to a rural setting. Differences in socioeconomic status and healthcare utilisation between populations are thought to contribute to this difference.

Influence of organic and functional dyspepsia on work productivity: the HEROES-DIP study

OBJECTIVES

Dyspepsia is defined as persistent or recurrent abdominal pain or discomfort centered in the upper abdomen. Dyspepsia represents up to 8.3% of all primary care physician visits and causes huge economic costs to patients and to the economy as a whole. The aim of this study was to measure the influence of dyspepsia on work productivity of people within the Brazilian workforce.

METHODS

Adult patients were enrolled if they met the Roma III criteria for uninvestigated dyspepsia. All patients answered a demographic questionnaire. Productivity impairment was measured by the Work Productivity and Activity Impairment questionnaire. Subjects underwent upper gastrointestinal endoscopy and were classified as having functional or organic dyspepsia. The study protocol was approved by the Ethics Committee of Hospital de Clínicas de Porto Alegre, Brazil.

RESULTS

Eight hundred fifty patients with dyspepsia were evaluated: 628 were women (73.9%); mean age was 46.4 ± 12.9 years; 387 (45.5%) were active workers. Among active workers, 32.2% mentioned that dyspepsia had caused absenteeism from work during the preceding week and 78% reported a reduction of the work productivity (presenteeism). The lost work productivity score was 35.7% among all employed patients. The affect on work productivity was similar between patients with functional or organic dyspepsia.

CONCLUSIONS

Our study showed an important influence of dyspepsia on work productivity. We did not find any statistically significant difference on the influence on work between patients with organic dyspepsia and functional dyspepsia. The social impact of these findings is underscored by taking into account the prevalence (up to 40%) of this condition in Brazil.

Specialized Rheumatology Nurse Substitutes for Rheumatologists in the Diagnostic Process of Fibromyalgia: A Cost-Consequence Analysis and a Randomized Controlled Trial

Objective.

To perform a cost-consequence analysis of the substitution of specialized rheumatology nurses (SRN) for rheumatologists (RMT) in the diagnostic process of fibromyalgia (FM), using both a healthcare and societal perspective and a 9-month period.

Methods.

Alongside a randomized controlled trial, we measured costs and consequences of a nurse-led diagnostic consult (SRN group, n = 97) versus a rheumatologist-led diagnostic consult [usual care (UC) group, n = 96]. Patients were followed for 9 months. Every second month a questionnaire on medical consumption and social participation was filled out. Satisfaction was measured 1 week after the first consultation. During followup, health status was measured by health-related quality of life (EQ-5D), functional status (Fibromyalgia Impact Questionnaire), fatigue (Checklist Individual Strength), and self-efficacy (Generalized Self-Efficacy Scale).

Results.

Patients in the SRN group were significantly more satisfied. Improvements in health status were similar in both groups after 9 months of followup. Total costs for healthcare consumption and patient and family costs were significantly lower in the SRN group (€1298 vs €1644; difference €346; 95% CI –€746 to –€2). Total societal costs were €3853 per patient for the SRN group and €5293 for the UC group after 9 months of followup (difference €1440; 95% CI –€3721 to €577).

Conclusion.

From both a healthcare and societal perspective, the nurse-led diagnostic process can be recommended. Patients in the SRN group were significantly more satisfied, improvements in health status were similar in both groups, and total societal costs were lower for the SRN group compared to the RMT group after 9 months’ followup. Registered with Current Controlled Trials, no.ISRCTN77212411.

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.

PRODISQ: a modular questionnaire on productivity and disease for economic evaluation studies

Productivity costs are often an important cost component in economic evaluations of healthcare programs. However, there still remains a low degree of consensus on the exact measurement and valuation of these productivity costs. The development and testing of valid measurement instruments in patient and worker populations may give researchers better tools to perform economic evaluations. This review briefly reports on the development, testing and validity of the modular PROductivity and DISease Questionnaire (PRODISQ) for the measurement (and valuation) of productivity costs. It was tested in several Dutch samples of patients and workers. The modular questionnaire covers all relevant aspects of the relationship between health and productivity including absence from work, compensation mechanisms that may reduce productivity loss, reduced productivity at work (efficiency losses) and productivity costs at the level of organizations. Using this questionnaire may facilitate the validity of estimates of productivity costs in economic evaluations of healthcare programs.

Cost effectiveness of home ultraviolet B phototherapy for psoriasis: economic evaluation of a randomised controlled trial (PLUTO study)

OBJECTIVE

To assess the costs and cost effectiveness of phototherapy with ultraviolet B light provided at home compared with outpatient ultraviolet B phototherapy for psoriasis.

DESIGN

Cost utility, cost effectiveness, and cost minimisation analyses performed alongside a pragmatic randomised clinical trial (the PLUTO study) at the end of phototherapy (mean 17.6 weeks) and at one year after the end of phototherapy (mean 68.4 weeks).

SETTING

Secondary care, provided by a dermatologist in the Netherlands.

PARTICIPANTS

196 adults with psoriasis who were clinically eligible for narrowband (TL-01) ultraviolet B phototherapy were recruited from the dermatology departments of 14 hospitals and were followed until the end of phototherapy. From the end of phototherapy onwards, follow-up was continued for an unselected, consecutive group of 105 patients for one year after end of phototherapy.

INTERVENTIONS

Ultraviolet B phototherapy provided at home (intervention) and conventional outpatient ultraviolet B phototherapy (control) in a setting reflecting routine practice in the Netherlands. Both treatments used narrowband ultraviolet B lamps (TL-01).

MAIN OUTCOME MEASURES

Total costs to society, quality adjusted life years (QALYs) as calculated using utilities measured by the EQ-5D questionnaire, and the number of days with a relevant treatment effect (>/=50% improvement of the baseline self administered psoriasis area and severity index (SAPASI)).

RESULTS

Home phototherapy is at least as effective and safe as outpatient phototherapy, therefore allowing cost minimisation analyses (simply comparing costs). The average total costs by the end of phototherapy were euro800 for home treatment and euro752 for outpatient treatment, showing an incremental cost per patient of euro48 (95% CI euro-77 to euro174). The average total costs by one year after the end of phototherapy were euro1272 and euro1148 respectively (difference euro124, 95% CI euro-155 to euro403). Cost utility analyses revealed that patients experienced equal health benefits-that is, a gain of 0.296 versus 0.291 QALY (home v outpatient) by the end of phototherapy (difference 0.0052, -0.0244 to 0.0348) and 1.153 versus 1.126 QALY by one year after the end of phototherapy (difference 0.0267, -0.024 to 0.078). Incremental costs per QALY gained were euro9276 and euro4646 respectively, both amounts well below the normally accepted standard of euro20 000 per QALY. Cost effectiveness analyses indicated that the mean number of days with a relevant treatment effect was 42.4 versus 55.3 by the end of phototherapy (difference -12.9, -23.4 to -2.4). By one year after the end of phototherapy the number of days with a relevant treatment effect were 216.5 and 210.4 respectively (6.1, -41.1 to 53.2), yielding an incremental cost of euro20 per additional day with a relevant treatment effect.

CONCLUSIONS

Home ultraviolet B phototherapy for psoriasis is not more expensive than phototherapy in an outpatient setting and proved to be cost effective. As both treatments are at least equally effective and patients express a preference for home treatment, the authors conclude that home phototherapy should be the primary treatment option for patients who are eligible for phototherapy with ultraviolet B light.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN83025173 and Clinicaltrials.gov NCT00150930.

Economic consequences of near-patient test results: the case of tests for the Helicobacter Pylori bacterium in dyspepsia

We have developed a model for economic evaluation related to the diagnostic accuracy (sensitivity and specificity) of near patient tests used in office laboratories, as opposed to using hospital-based tests. Blood-sample based tests to detect the bacterium Helicobacter Pylori (HP) are useful in diagnosing peptic ulcer, and suitable to illustrate the model. First, general practitioners' initial management plans for a dyspeptic patient are elucidated using a paper vignette survey. Based on survey results, and medical literature, a decision tree is constructed to visualize expected costs and outcomes resulting from using three different HP tests. Tests included are two rapid tests for use in general practice, and one hospital laboratory test for comparison. The tests had different sensitivities and specificities. Then a cost-effectiveness analysis is undertaken from a societal perspective. Finally we use sensitivity analyses to model the decision uncertainty. Estimating for a follow-up period of 120 days, the rapid test with lower sensitivity and specificity than the hospital HP test is cost-effective because the test result is available immediately. Further, in general practice, the rapid test with the highest sensitivity is significantly cost effective compared to the test with the highest specificity when the willingness to pay for each dyspepsia-free day exceeds 42.6 euros. When deciding whether a laboratory analysis should be analyzed in the office laboratory or not, it is important to consider both the diagnostic accuracy of the tests and waiting time for the alternative hospital laboratory result.

Cost-effectiveness analysis of two management strategies for dyspepsia

OBJECTIVES

To compare the cost-effectiveness of endoscopy and empirical proton pump inhibition (PPI) therapy for management of dyspepsia in primary care.

METHODS

A randomized controlled trial, including prospective collection of economic resource data, was conducted in general practice from June 2000 to August 2002, Aarhus County, Denmark. We randomly assigned 368 dyspeptic patients from thirty-two general practices to treatment with omeprazol 40 mg for 2 weeks (n=184) or endoscopy (n=184). The study adopted a societal perspective, and the year of costing was 2006.

OUTCOME MEASURES

days free of dyspeptic symptoms and proportion of patients with dyspepsia after 1 year based on patients' and general practitioners' (GPs) assessment. Costs were estimated from patient and GP questionnaires and from medical records.

RESULTS

The incremental cost-effectiveness (CE) ratio for 1 day free of dyspeptic symptoms using the endoscopy strategy was euro/day 154 compared with the PPI strategy. The incremental CE ratio for one person free of dyspeptic symptoms after 1 year using the endoscopy strategy was euro13,905 based on the patients' evaluation, and the incremental CE ratio for one person free of predominant symptoms after 1 year was euro5,990 according to the GPs' evaluation. The PPI strategy was both cheaper and more effective than the endoscopy strategy when reflux was the predominant symptom.

CONCLUSIONS

A strategy using empirical antisecretory PPI therapy should be recommended if the alternative is an endoscopy strategy for managing dyspeptic patients in general practice, especially if reflux was the predominant symptom.

An economic model of long-term use of celecoxib in patients with osteoarthritis

Background

Previous evaluations of the cost-effectiveness of the cyclooxygenase-2 selective inhibitor celecoxib (Celebrex, Pfizer Inc, USA) have produced conflicting results. The recent controversy over the cardiovascular (CV) risks of rofecoxib and other coxibs has renewed interest in the economic profile of celecoxib, the only coxib now available in the United States. The objective of our study was to evaluate the long-term cost-effectiveness of celecoxib compared with nonselective nonsteroidal anti-inflammatory drugs (nsNSAIDs) in a population of 60-year-old osteoarthritis (OA) patients with average risks of upper gastrointestinal (UGI) complications who require chronic daily NSAID therapy.

Methods

We used decision analysis based on data from the literature to evaluate cost-effectiveness from a modified societal perspective over patients' lifetimes, with outcomes expressed as incremental costs per quality-adjusted life-year (QALY) gained. Sensitivity tests were performed to evaluate the impacts of advancing age, CV thromboembolic event risk, different analytic horizons and alternate treatment strategies after UGI adverse events.

Results

Our main findings were: 1) the base model incremental cost-effectiveness ratio (ICER) for celecoxib versus nsNSAIDs was $31,097 per QALY; 2) the ICER per QALY was $19,309 for a model in which UGI ulcer and ulcer complication event risks increased with advancing age; 3) the ICER per QALY was $17,120 in sensitivity analyses combining serious CV thromboembolic event (myocardial infarction, stroke, CV death) risks with base model assumptions.

Conclusion

Our model suggests that chronic celecoxib is cost-effective versus nsNSAIDs in a population of 60-year-old OA patients with average risks of UGI events.

Economic evaluation of empirical antisecretory therapy versus Helicobacter pylori test for management of dyspepsia: a randomized trial in primary care

OBJECTIVES

An economic evaluation was performed of empirical antisecretory therapy versus test for Helicobacter pylori in the management of dyspepsia patients presenting in primary care.

METHODS

A randomized trial in 106 general practices in the County of Funen, Denmark, was designed to include prospective collection of clinical outcome measures and resource utilization data. Dyspepsia patients (n = 722) presenting in general practice with more than 2 weeks of epigastric pain or discomfort were managed according to one of three initial management strategies: (i) empirical antisecretory therapy, (ii) testing for Helicobacter pylori, or (iii) empirical antisecretory therapy, followed by Helicobacter pylori testing if symptoms improved. Cost-effectiveness and incremental cost-effectiveness ratios of the strategies were determined.

RESULTS

The mean proportion of days without dyspeptic symptoms during the 1-year follow-up was 0.59 in the group treated with empirical antisecretory therapy, 0.57 in the H. pylori test-and-eradicate group, and 0.53 in the combination group. After 1 year, 23 percent, 26 percent, and 22 percent, respectively, were symptom-free. Applying the proportion of days without dyspeptic symptoms, the cost-effectiveness for empirical treatment, H. pylori test and the combination were 12,131 Danish kroner (DKK), 9,576 DKK, and 7,301 DKK, respectively. The incremental cost-effectiveness going from the combination strategy to empirical antisecretory treatment or H. pylori test alone was 54,783 DKK and 39,700 DKK per additional proportion of days without dyspeptic symptoms.

CONCLUSIONS

Empirical antisecretory therapy confers a small insignificant benefit but costs more than strategies based on test for H. pylori and is probably not a cost-effective strategy for the management of dyspepsia in primary care.

Cost-effectiveness of a 'score and scope' strategy for the management of dyspepsia

OBJECTIVE

It is important to identify the best initial work-up in patients with uninvestigated dyspepsia because of its epidemiological and economical relevance. The objective of the study was to assess systematically the effectiveness and cost-effectiveness of invasive and non-invasive strategies for the management of dyspepsia.

METHODS

A decision analysis was performed to compare prompt endoscopy, score and scope, test and scope, test and treat, and empirical antisecretory treatment. Published and local data on the prevalence of different diagnoses, rates of Helicobacter pylori infection, accuracy values of diagnostic tests, and effectiveness of drug treatments were used. The perspective of analysis was that of the public healthcare payer, and only direct costs were included, with a one-year post-therapy time horizon. The main outcome measure was cost per asymptomatic patient, valued in 2003 Euros.

RESULTS

Endoscopy was found to be the most effective strategy for the management of dyspepsia (38.4% asymptomatic patients), followed by test and scope (35.5%), test and treat (35.3%), score and scope (34.7%), and empirical treatment (28.5%). Incremental cost-effectiveness ratios showed that score and scope was the most cost-effective alternative (483.17 Euros per asymptomatic patient), followed by prompt endoscopy (1396.85 Euros). Sensitivity analyses showed variations when varying the values of prevalence of duodenal ulcer, and the values of healing of functional dyspepsia with antisecretory and eradication drugs. There were no changes when varying the prevalence of H. pylori in dyspepsia.

CONCLUSIONS

We would recommend stratifying patients by a score system, referring first to endoscopy those patients at higher risk of organic dyspepsia.

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.

Dyspepsia management in primary care: a management trial

The aim was to evaluate the outcomes associated with four initial management strategies in new patients presenting to primary care physicians with dyspepsia. Patients with new symptoms (no alarm features) were randomised to empirical therapy (n = 11), Helicobacter pylori (HP) serology (n = 8), HP breath testing (n = 11) or oesophagogastroduodenoscopy (n = 13). Dyspepsia and health-related quality of life were assessed using standardised questionnaires at entry, 6 and 24 weeks post-trial enrollment. Outcomes were assessed by structured telephone interview every 6 weeks. In the initial HP testing arms, 21% were positive; 27% in the oesophagogastroduodenoscopy arm had inflammatory changes without ulcers at baseline. The majority (67%) received over the counter medication after initial management. Symptom-free status was similarly common in all groups (p = 0.49); only 20% pursued further evaluation. Total billed charges were higher in the oesophagogastroduodenoscopy group (US 2077 dollars) vs. empirical therapy (US 512 dollars), despite excluding the charge for initial oesophagogastroduodenoscopy, but overall, no effects on total medical charges were detected (p = 0.10). Regardless of initial management, most patients remained symptomatic, yet did not return for health care visits or undergo endoscopies. The cost of upfront endoscopy may not be the best choice for patients presenting with new dyspepsia.

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.

Validation of the Health-Related Productivity Questionnaire Diary (HRPQ-D) on a sample of patients with infectious mononucleosis: results from a phase 1 multicenter clinical trial

The objective of this work was to assess the performance of the newly developed Health-Related Productivity Questionniare-Diary (HRPQ-D). Patients completed the HRPQ-D daily for 1-week periods during weeks 1, 2, 4, and 8 of a clinical trial for infectious mononucleosis. Productivity data were collected on a daily basis in terms of absenteeism, presenteeism, and combined lost productivity for three work venues (work outside home, housework, and classes/homework). These were then correlated with patient symptom scores. Symptom scores were positively correlated with lost work hours because of absenteeism and combined lost productivity scores. However, negative correlations were observed between symptom scores and the lost work hours due to presenteeism. The HRPQ-D demonstrated good construct validity, making it a useful tool for determining productivity levels across different work venues within clinical trial or survey research applications.

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

Traditionally, production losses are estimated using the human capital or friction cost method. These methods base estimations of productivity costs on data on absence from work. For some diseases, like migraine, productivity losses without absence are occasionally calculated by estimating the production losses from reduced productivity at work. However, diseases typically only associated with absence may also be expected to cause reduced productivity before and after absence. In a previous study, Brouwer et al. concluded that productivity losses without absence are also very relevant in common diseases, like influenza, common cold or neck-problems. Studying a new sample of employees of a Dutch trade-firm (n = 51), who completed the questionnaire 'Ill and Recovered' upon return to work after absence due to illness, it was revealed that about 25% of the respondents experienced production losses before absence and about 20% of the respondents experience production losses after absence. This leads to an increase in estimated production losses of about 16% compared with only considering absence data. Current productivity costs estimates based solely on absence data may, therefore, underestimate real productivity costs. Compensation mechanisms in firms may reduce the underestimation.

Validity of a Work Productivity and Activity Impairment questionnaire for patients with symptoms of gastro-esophageal reflux disease (WPAI-GERD)--results from a cross-sectional study

OBJECTIVES

To validate a Work Productivity and Activity Impairment questionnaire (WPAI-GERD) developed to measure lost productivity due to symptoms of gastro-esophageal reflux disease (GERD).

METHODS AND DATA

The WPAI-GERD was administered along with two quality-of-life questionnaires, Quality of Life in Reflux and Dyspepsia (QOLRAD) and Short Form 36 (SF-36), to a Swedish working population (N = 136) visiting a general practitioner for symptoms attributed to GERD. Correlation coefficients were calculated between each productivity variable derived from the WPAI-GERD and symptom severity, symptom frequency, quality of life dimensions, age, and gender. Statistical tests were carried out to determine the relationship between each productivity variable and the severity of heartburn.

RESULTS

High correlations (range: 0.30-0.75) were found between productivity and symptom severity as well as between productivity and quality-of-life dimensions related to work and daily activities. The results demonstrated the ability of the questionnaire to discriminate between different grades of heartburn severity. On average, patients with heartburn reported 2.5 hours absence from work, 23% reduced productivity while at work, and 30% reduced productivity while doing regular daily activities during the week preceding the consultation. The SF-36 scores implied that patients, especially those with moderate-to-severe heartburn, had a poor quality of life compared with a normal population.

CONCLUSION

The results indicate a high convergent and discriminant validity of the WPAI-GERD questionnaire and also show that patients consulting a physician because of symptoms attributed to GERD report substantial impairment in both productivity and health-related quality of life.

What is the optimal length of proton pump inhibitor-based triple therapies for H. pylori? A cost-effectiveness analysis

BACKGROUND

Triple therapy with a proton pump inhibitor, clarithromycin and amoxicillin is widely used for H. pylori infection. The appropriate length of treatment remains controversial.

AIM

To determine whether length of treatment has an impact on the cost-effectiveness of triple therapy.

METHODS

The study took the form of a cost-effectiveness analysis spanning 2 years. The perspective was societal and the setting, ambulatory care. Subjects were Helicobacter pylori-positive patients with a duodenal ulcer. The triple therapy trials spanned 7, 10 or 14 days and the main outcome measures were cost per patient and marginal cost for additional cured patient calculated for a low cost-of-care setting (Spain), for a high-cost setting (USA), and for two follow-up strategies: (i) systematic 13C-urea breath test after eradication; (ii) clinical follow-up, breath-test if symptoms recurred.

RESULTS

Base-case analysis showed that for both the 13C-UBT and the clinical follow-up branches, lowest costs were obtained with 7-day schedules both in Spain and the USA. Sensitivity analysis showed that in Spain, 10-day therapies would have to increase 7-day cure rates by 10-12% to become cost-effective. In contrast, in the USA only a 3-5% increase was needed. The corresponding figures for 14-day therapy were 25-35% and 8-11%, respectively.

CONCLUSIONS

Seven-day therapies seem the most cost-effective strategy. However, in high-cost areas the differences were less evident.

Different approaches to valuing the lost productivity of patients with migraine

OBJECTIVE

To calculate and compare the human capital approach (HCA) and friction cost approach (FCA) methods for estimating the cost of lost productivity of migraineurs after the initiation of sumatriptan from a US societal perspective.

DESIGN

Secondary, retrospective analysis to a prospective observational study.

SETTING

A mixed-model managed care organisation in western Pennsylvania, USA.

PATIENTS

Patients with migraine using sumatriptan therapy.

INTERVENTIONS

Patient-reported questionnaires collected at baseline, 3 and 6 months after initiation of sumatriptan therapy.

OUTCOME MEASURES

The cost of lost productivity estimated with the HCA and FCA methods.

RESULTS

Of the 178 patients who completed the study, 51% were full-time employees, 13% were part-time, 18% were not working and 17% changed work status. Twenty-four percent reported a clerical or administrative position. From the HCA, the estimated total cost of lost productivity for 6 months following the initiation of sumatriptan was $US117905 (1996 values). From the FCA, the six-month estimated total cost of lost productivity ranged from $US28329 to $US117905 (1996 values).

CONCLUSIONS

This was the first study to retrospectively estimate lost productivity of patients with migraine using the FCA methodology. Our results demonstrate that depending on the assumptions and illustrations employed, the FCA can yield lost productivity estimates that vary greatly as a percentage of the HCA estimate. Prospective investigations are needed to better determine the components and the nature of the lost productivity for chronic episodic diseases such as migraine headache.

Diagnosis of Helicobacter pylori after triple therapy in uncomplicated duodenal ulcers--a cost-effectiveness analysis

BACKGROUND

The cost-effectiveness of determining Helicobacter pylori status after treatment remains to be established.

AIM

To determine the benefit of post-treatment assessment of H. pylori eradication in patients with uncomplicated duodenal ulcer.

MATERIALS AND METHODS

A decision analysis was performed in patients with uncomplicated duodenal ulcer who were H. pylori-positive and had received eradication therapy. A decision tree was devised to compare the costs per patient of two different strategies: (a) systematic performance of post-treatment urea breath test and new treatment if positive; and (b) clinical follow-up, 13C-urea breath test if dyspeptic symptoms recurred and eradication treatment if the test was positive.

RESULTS

Post-eradication 13C-urea breath test was notably more expensive than clinical follow-up, both in a low-cost per care setting (197 vs. 132 Euros) and in a high-cost per care (614 vs. 340 US $) scenario. This conclusion remained stable for a wide range of variations of the variables included in the decision tree (e.g. cure rates of eradication treatment, cost of the urea breath test or sensitivity, and specificity of urea breath test to detect eradication).

CONCLUSION

In patients with uncomplicated duodenal ulcer, evaluation of eradication after H. pylori treatment markedly increases costs with no clear improvement in results and therefore should not be performed routinely.