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

Exploring gender disparities in the disease and economic tobacco-attributable burden in Latin America

Introduction

Tobacco use has significant health consequences in Latin America, and while studies have examined the overall impact, the gender-specific effects have not been thoroughly researched. Understanding these differences is crucial for effective tobacco control policies. The objective of this study was to explore the differences in tobacco-attributable disease and economic burden between men and women in Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Mexico, and Peru.

Methods

We used a previously validated economic model to quantify the impact of tobacco-related illnesses, including morbidity, mortality, healthcare costs, productivity losses, informal care expenses, and DALYs, by gender and age. We utilized data from national surveys, records, studies, and expert opinions to populate the model.

Results

In 2020, there were 351,000 smoking-attributable deaths. Men accounted for 69% and women 31%. Ecuador and Mexico had the highest male-to-female death ratio, while Peru and Chile had the smallest disparities. 2.3 million tobacco-related disease events occurred, with 65% in men and 35% in women. Ecuador and Mexico had higher disease rates among men, while Peru had a more balanced ratio. Regarding DALYs, men lost 6.3 million due to tobacco, while women lost 3.3 million, primarily from COPD, cardiovascular disease, and cancer. Brazil and Mexico had the highest DALY losses for both genders. Costa Rica had a lower male-to-female tobacco use prevalence ratio but ranked second in deaths, disease events, and DALYs attributed to tobacco. Colombia had a unique pattern with a male-to-female death ratio of 2.08 but a higher ratio for disease events. The health systems spent $22.8 billion to treat tobacco-attributable diseases, with a male-to-female cost ratio 2.15. Ecuador showed the greatest gender cost difference, while Peru had the lowest. Productivity loss due to tobacco was $16.2 billion, with Ecuador and Mexico exhibiting the highest gender disparities and Peru the lowest. Informal care costs amounted to $10.8 billion, with men incurring higher costs in Ecuador, Costa Rica, and Mexico.

Discussion

Tobacco causes significant health and economic burdens in Latin America, with gender-based differences. There is a need for gender-disaggregated data to improve tobacco control policies.

Measuring the Indirect Cost of Illness Using EQ-5D-5L While Accounting for Job Characteristics

BACKGROUND

The EQ-5D-5L questionnaire is used to measure treatment effects on the quality of life. For cost-utility analyses, EQ-5D-5L profiles are assigned numbers representing societal preferences (index weights). On the cost side, the indirect costs are frequently included: the value of product lost due to illness-related absences (absenteeism) or diminished productivity (presenteeism). The possibility to use EQ-5D data to estimate absenteeism and presenteeism (A&P) would be useful, if real-world data on A&P are lacking. However, beyond-health factors may also matter for A&P.

OBJECTIVE

We aimed to assess how A&P depend on the EQ-5D-5L profile, while accounting for job characteristics (e.g. remote or in-office).

METHODS

We surveyed 756 employed Poles. Respondents reported their job characteristics and evaluated the impact of eight hypothetical EQ-5D-5L profiles on A&P (two blocks of states used). Econometric modelling was used to establish the determinants of A&P.

RESULTS

Both A&P increase with health problems as indicated across EQ-5D-5L dimensions (especially mobility and self-care), and this impact differs from the impact on index weight (e.g. pain/discomfort barely impact the A&P). The job characteristics mattered: absenteeism decreases in sedentary occupations and increases in those occupations performed remotely or requiring cooperation, while presenteeism increases in jobs performed remotely and decreases for those requiring creative thinking.

CONCLUSIONS

The entire EQ-5D-5L profile, not just index weights, should be used to estimate A&P. That job characteristics matter may be relevant in applications, as some diseases concentrate in specific subgroups.

Health, economic and social burden of tobacco in Latin America and the expected gains of fully implementing taxes, plain packaging, advertising bans and smoke-free environments control measures: a modelling study

OBJECTIVE

To investigate the tobacco-attributable burden on disease, medical costs, productivity losses and informal caregiving; and to estimate the health and economic gains that can be achieved if the main tobacco control measures (raising taxes on tobacco, plain packaging, advertising bans and smoke-free environments) are fully implemented in eight countries that encompass 80% of the Latin American population.

DESIGN

Markov probabilistic microsimulation economic model of the natural history, costs and quality of life associated with the main tobacco-related diseases. Model inputs and data on labour productivity, informal caregivers' burden and interventions' effectiveness were obtained through literature review, surveys, civil registrations, vital statistics and hospital databases. Epidemiological and economic data from January to October 2020 were used to populate the model.

FINDINGS

In these eight countries, smoking is responsible each year for 351 000 deaths, 2.25 million disease events, 12.2 million healthy years of life lost, US$22.8 billion in direct medical costs, US$16.2 billion in lost productivity and US$10.8 billion in caregiver costs. These economic losses represent 1.4% of countries' aggregated gross domestic products. The full implementation and enforcement of the four strategies: taxes, plain packaging, advertising bans and smoke-free environments would avert 271 000, 78 000, 71 000 and 39 000 deaths, respectively, in the next 10 years, and result in US$63.8, US$12.3, US$11.4 and US$5.7 billions in economic gains, respectively, on top of the benefits being achieved today by the current level of implementation of these measures.

CONCLUSIONS

Smoking represents a substantial burden in Latin America. The full implementation of tobacco control measures could successfully avert deaths and disability, reduce healthcare spending and caregiver and productivity losses, likely resulting in large net economic benefits.

The clinical and cost-effectiveness of a self-management intervention for patients with persistent depressive disorder and their partners/caregivers: study protocol of a multicenter pragmatic randomized controlled trial

BACKGROUND

After regular treatment, patients with persistent depressive disorder (PDD) may remain in specialized psychiatric outpatient care without achieving remission. Lacking other options, these patients often receive long-term, non-protocolized care as usual (CAU) that does not involve the partner/caregiver of the patient. Although the revised depression treatment guidelines suggest focusing on psychiatric rehabilitation and self-management as the next treatment step for PDD, an evidence-based cost-effective self-management protocol for PDD is lacking. This study investigates the "Patient and Partner Education Program for All Chronic Illnesses" (PPEP4All) as a brief self-management protocol that could lead to lower costs, higher quality of life, and less disease burden in PDD patients and their partners/caregivers.

METHODS

Presented is the rationale and methods of a multicenter pragmatic randomized controlled trial to evaluate the clinical efficacy and cost-effectiveness of PPEP4All for patients with PDD and their partners/caregivers. In accordance with current recommendations, a mixed methods research approach is used with both quantitative and qualitative data. A total of 178 eligible outpatients with PDD and their partners/caregivers are recruited and randomized to either PPEP4All or CAU. Those assigned to PPEP4All receive nine weekly self-management sessions with a trained PPEP4All therapist. Primary and secondary outcome measurements are at 0, 3, 6, and 12 months.

DISCUSSION

This project will result in the implementation of a self-management intervention for patients with PDD, meeting an urgent need in mental healthcare. Using PPEP4All can optimize the quality and efficiency of care for both patients with PDD and their partners/caregivers.

TRIAL REGISTRATION

Netherlands Trial Register Identifier NTR5973 . Registered on 20 July 2016.

Work Productivity and Economic Burden of Systemic Sclerosis in a Multi-Ethnic Asian Population

OBJECTIVE

To assess work productivity, identify associated factors and evaluate the economic burden of systemic sclerosis (SSc) in a multi-ethnic Asian population.

METHODS

Data on employment status and work productivity loss were collected. Associations between demographic and disease characteristics and unemployment status, work productivity loss and activity impairment were examined using logistic and linear regression analyses, as appropriate. Costs of unemployment and work productivity loss were estimated using the human capital approach.

RESULTS

Of 111 patients with a mean disease duration of 9.1 years, 33 (29.7%) were unemployed. Their mean age at unemployment was 44.2 years, equating to 22.8 years of lost employment. No demographic and disease characteristics were significantly associated with unemployment status in multivariable analysis. Of 73 employed patients, 39 (53.4%) reported work productivity loss, accounting for 45.9% of the working week. Presence of hyperlipidemia (coefficient= -19.01, p=0.03) was associated with work productivity loss in multivariable analysis. Of 78 employed and 33 unemployed patients, 37 (47.4%) and 19 (57.6%) reported activity impairment, accounting for 42.2% and 50.0% of the preceding week, respectively. Presence of hyperlipidemia (coefficient= -18.56, p<0.01) was associated with activity impairment in multivariable analysis. Annual cost of unemployment and work productivity loss were estimated to be SGD$53,244 and SGD$13,045 per patient, respectively.

CONCLUSION

SSc imposes significant unemployment and work productivity loss and causes substantial economic burden to both affected individuals and society. Modifying the identified factors associated with unemployment and work productivity loss may reduce the burden of SSc.

Impacts of physical late effects on presenteeism in childhood cancer survivors

BACKGROUND

Many childhood cancer survivors (CCSs) experience physical late effects related to their cancer types and treatment modalities. Physical late effects are an important factor in various occupational outcomes among CCSs. However, the relationship between physical late effects and presenteeism has remained unclear. This study aimed to estimate the impacts of physical late effects on presenteeism among employed CCSs.

METHODS

Childhood cancer survivors replied to a questionnaire regarding presenteeism, and their attending physicians assessed their physical late effects between September 2014 and December 2015. The Work Limitations Questionnaire was used to measure presenteeism. Propensity score analysis and a generalized linear model were used to adjust covariates related to physical late effects and / or presenteeism.

RESULTS

Of the 125 questionnaires distributed, 114 were returned. The data from 61 employed CCSs were analyzed. After controlling for covariates by propensity score analysis and generalized linear model, there were no significant differences in presenteeism between employed CCSs with either no or single physical late effects. However, employed CCSs with multiple physical late effects reported higher scores in Output (Estimate = 9.3, P = 0.041), Physical Demands (Estimate = 12.2, P = 0.020), and Productivity Loss scores (Estimate = 2.4, P = 0.045) on the Work Limitations Questionnaire than employed CCSs with no physical late effects.

CONCLUSIONS

Employed CCSs with multiple physical late effects were at an increased risk for presenteeism. Healthcare and social welfare systems should be established to provide vocational assistance for CCSs after being employed to alleviate presenteeism.

How Different Stressors Affect Quality of Life: An Application of Multilevel Latent Class Analysis on a Large Sample of Industrial Employees

Background

Quality of life (QoL) indicates individual’s perception of the physical, psychological and social aspects of health. The association between QoL and all stressful life events‘ dimensions has not been investigated among industrial employees.

Purpose

The present study aimed to investigate the association between stressful life events and QoL in a large sample of Iranian industrial employees.

Material and Methods

In a cross-sectional study, 3063 manufacturing employees in Isfahan, Iran, were recruited. QoL was measured with the Euro-QoL five dimension questionnaire (EQ-5D). Stressful life events were assessed by an Iranian validated stressful life event questionnaire (SLE). Multilevel latent class regression was employed for classifying participants based on QoL and for determining its association with stressful life events.

Results

Two classes of employees, ie, low (comprised 20% of participants) and high QoL (80%), were identified. From 11 dimensions of stressful life events two major domains, socioeconomic and personal stressor profiles, were identified. Multilevel latent class regression results showed that the higher scores of social (OR: 1.14, 95%CI: 1.12–1.16) and personal (OR: 2.36, 95%CI: 1.87– 2.98) stressor domains were significantly associated with increased risk of being in the poor QoL class. Among personal and socioeconomic stressors, health concerns and daily life dimensions had higher significant association with poor QoL.

Conclusion

Results of our study indicated that life stressors have negative impacts on QoL of employees. Personal stressors showed higher negative impact than socioeconomic on QoL. Managing the stressors can play an effective role in improving the QoL of employees, their physical and mental health, and indirectly enhances the organizational performance and job productivity.

Using qualitative methods for a conceptual analysis of measures of health status and presenteeism prior to a mapping study

OBJECTIVES

The inclusion of productivity in economic evaluations is a contentious issue. Methods are currently being developed to assess how it may feasibly be included for specific interventions, such as workplace interventions (WPIs), where productivity is a key outcome. Mapping (also called cross-walking or prediction modelling) may offer a solution. Prior to producing a mapping algorithm, it is recommended that the conceptual validity between 'source' and 'target' measures be understood first. This study aimed to understand the conceptual validity of two existing measures of health status (EQ-5D; SF-6D) and presenteeism to inform the potential for a subsequent mapping algorithm.

METHODS

A purposive sample of individuals who were currently working and had either rheumatoid arthritis (RA), ankylosing spondylitis (AS) or psoriatic arthritis (PsA). Individuals were recruited through support groups. Semi-structured telephone interviews were conducted until data saturation (no new emerging themes) was reached. Deductive and inductive framework analysis methods were used to identify key aspects of the conditions (themes) that impact on presenteeism (working at reduced levels of health).

RESULTS

Twenty-two (RA = 10; AS = 9; PsA = 3) employed individuals were interviewed. Deductive analysis identified evidence which confirmed the domains included in the EQ-5D and SF-6D capture those key aspects of RA, AS and PsA that increase presenteeism. Inductive analysis identified an additional theme; mental clarity, not captured by the EQ-5D or SF-6D, was also found to have a direct impact on presenteeism.

CONCLUSIONS

The results of the study indicate conceptual validity of both health status measures to predict presenteeism. The next step is to develop a mapping algorithm for presenteeism.

Work disability in rheumatic diseases: Baseline results from an inception cohort

AIM

We aimed to characterize work disability in patients with newly diagnosed rheumatic diseases and compare work characteristics between patients with rheumatic diseases and controls without rheumatic diseases at diagnosis.

METHODS

Patients with inflammatory arthritis (IA) and osteoarthritis (OA), surrogates for autoimmune and non-autoimmune rheumatic diseases, respectively, and controls of working age were surveyed at diagnosis. Patients with rheumatic diseases who were employed before symptom onset were characterized as having work disability if they reported reduced work ability and productivity while remaining in the same job as before symptom onset, changed to a less demanding job or stopped working/retired. Work characteristics at diagnosis were compared between rheumatic diseases patients and controls.

RESULTS

The unemployment rate before symptom onset was lower in patients with IA (20%) compared to patients with OA (32%). Among patients with IA and OA who were employed before symptom onset, 59% and 43% reported work disability, respectively (P = .04). The unemployment rate at diagnosis was comparable in patients with IA (26%) and higher in patients with OA (38%) compared to controls (29%). Employed patients with IA and OA, when compared with controls, reported poorer work ability (score: 37 vs 39 vs 41, P < .01; proportion with poor/moderate work ability: 48% vs 33% vs 21%, P < .01) and greater work productivity loss (score: 32 vs 29 vs 17, P < .01) at diagnosis.

CONCLUSION

Rheumatic diseases impose significant work disability at diagnosis, highlighting the need for identification and interventions targeting work disability early in the course of disease.

Dance Fitness Classes Improve the Health-Related Quality of Life in Sedentary Women

Introduction: This study aims to analyze the effect of two dance-focused and choreographic fitness classes on Health-Related Quality of Life (HRQoL) in sedentary worker women. Methods: 65 sedentary middle-aged worker women (38 ± 7.3 years old) completed a 16-week intervention randomly assigned to: (1) dance fitness group based on Zumba Fitness classes (DF group, n = 25)], (2) dance fitness + functional strength training group (DFFT group, n = 20), and (3) control group (n = 20). HRQoL was assessed by the 36-Item Short-Form Health-Survey (SF-36), which evaluates 8 dimensions of health [General Health (GH), Physical Functioning (PF), Social Functioning (SF), Physical Role (PR), Emotional Role (ER), Bodily Pain (BP), Vitality (V), and Mental Health (MH)] scored from 0 (worst) to 100 (best health status). Results: The control group statistically differed from both exercise groups in PF and PR, and from the DF group in SF and MH showing a lower score. No statistical differences were observed between exercise groups post-intervention, except in V. DF group showed increases in GH, PF, SF, V, PR, and MH post-intervention. Conclusions: A 16-week dance fitness intervention based on Zumba Fitness classes generates notable improvements in a wide range of HRQoL dimensions in sedentary middle-aged worker women, especially in V, PR and MH dimensions.

The Effect of Intelligent Physical Exercise Training on Sickness Presenteeism and Absenteeism Among Office Workers

OBJECTIVE

The aim of this study was to investigate the effect of individually tailored intelligent physical exercise training (IPET) on presenteeism and absenteeism among office workers.

METHODS

In a 1-year randomized controlled trial (RCT), employees were allocated to a training group TG (N = 193) or control group CG (N = 194). TG received 1-hour high-intensity IPET once a week within working hours, and was recommended to perform 30 minutes of moderate-intensity physical activity (PA) 6 days a week during leisure-time.

RESULTS

An intention-to-treat analysis showed no effect on absenteeism, but a significant 4% increase in workability and 9% increase in general health in TG compared with CG. A per-protocol analysis [adherence of ≥70% (N = 89)] in addition showed a significant 6% increase in productivity and a 29% reduction in absenteeism compared with CG.

CONCLUSION

IPET combined with recommendations of leisure-time PA significantly improved presenteeism and decreased absenteeism if following the protocol.

Predicting Productivity Losses from Health-Related Quality of Life Using Patient Data

OBJECTIVE

This paper estimates productivity loss using the health of the patient in order to allow indirect estimation of these costs for inclusion in economic evaluation.

METHODS

Data from two surveys of inpatients [Health outcomes data repository (HODaR) sample (n = 42,442) and health improvement and patient outcomes (HIPO) sample (n = 6046)] were used. The number of days off paid employment or normal activities (excluding paid employment) was modelled using the health of the patients measured by the EQ-5D, international classification of diseases (ICD) chapters, and other health and sociodemographic data. Two-part models (TPMs) and zero-inflated negative binomial (ZINB) models were identified as the most appropriate specifications, given large spikes at the minimum and maximum days for the dependent variable. Analysis was undertaken separately for the two datasets to account for differences in recall period and identification of those who were employed.

RESULTS

Models were able to reflect the large spike at the minimum (zero days) but not the maximum, with TPMs doing slightly better than the ZINB model. The EQ-5D was negatively associated with days off employment and normal activities in both datasets, but ICD chapters only had statistically significant coefficients for some chapters in the HODaR.

CONCLUSIONS

TPMs can be used to predict productivity loss associated with the health of the patient to inform economic evaluation. Limitations include recall and response bias and identification of who is employed in the HODaR, while the HIPO suffers from a small sample size. Both samples exclude some patient groups.

Assessment of physical function and participation in chronic pain clinical trials: IMMPACT/OMERACT recommendations

Although pain reduction is commonly the primary outcome in chronic pain clinical trials, physical functioning is also important. A challenge in designing chronic pain trials to determine efficacy and effectiveness of therapies is obtaining appropriate information about the impact of an intervention on physical function. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) and Outcome Measures in Rheumatology (OMERACT) convened a meeting to consider assessment of physical functioning and participation in research on chronic pain. The primary purpose of this article is to synthesize evidence on the scope of physical functioning to inform work on refining physical function outcome measurement. We address issues in assessing this broad construct and provide examples of frequently used measures of relevant concepts. Investigators can assess physical functioning using patient-reported outcome (PRO), performance-based, and objective measures of activity. This article aims to provide support for the use of these measures, covering broad aspects of functioning, including work participation, social participation, and caregiver burden, which researchers should consider when designing chronic pain clinical trials. Investigators should consider the inclusion of both PROs and performance-based measures as they provide different but also important complementary information. The development and use of reliable and valid PROs and performance-based measures of physical functioning may expedite development of treatments, and standardization of these measures has the potential to facilitate comparison across studies. We provide recommendations regarding important domains to stimulate research to develop tools that are more robust, address consistency and standardization, and engage patients early in tool development.

Effectiveness and cost-effectiveness of a physical activity loyalty scheme for behaviour change maintenance: a cluster randomised controlled trial

BACKGROUND

Increasing physical activity in the workplace can provide employee physical and mental health benefits, and employer economic benefits through reduced absenteeism and increased productivity. The workplace is an opportune setting to encourage habitual activity. However, there is limited evidence on effective behaviour change interventions that lead to maintained physical activity. This study aims to address this gap and help build the necessary evidence base for effective, and cost-effective, workplace interventions.

METHODS/DESIGN

This cluster randomised control trial will recruit 776 office-based employees from public sector organisations in Belfast and Lisburn city centres, Northern Ireland. Participants will be randomly allocated by cluster to either the Intervention Group or Control Group (waiting list control). The 6-month intervention consists of rewards (retail vouchers, based on similar principles to high street loyalty cards), feedback and other evidence-based behaviour change techniques. Sensors situated in the vicinity of participating workplaces will promote and monitor minutes of physical activity undertaken by participants. Both groups will complete all outcome measures. The primary outcome is steps per day recorded using a pedometer (Yamax Digiwalker CW-701) for 7 consecutive days at baseline, 6, 12 and 18 months. Secondary outcomes include health, mental wellbeing, quality of life, work absenteeism and presenteeism, and use of healthcare resources. Process measures will assess intervention "dose", website usage, and intervention fidelity. An economic evaluation will be conducted from the National Health Service, employer and retailer perspective using both a cost-utility and cost-effectiveness framework. The inclusion of a discrete choice experiment will further generate values for a cost-benefit analysis. Participant focus groups will explore who the intervention worked for and why, and interviews with retailers will elucidate their views on the sustainability of a public health focused loyalty card scheme.

DISCUSSION

The study is designed to maximise the potential for roll-out in similar settings, by engaging the public sector and business community in designing and delivering the intervention. We have developed a sustainable business model using a 'points' based loyalty platform, whereby local businesses 'sponsor' the incentive (retail vouchers) in return for increased footfall to their business.

TRIAL REGISTRATION

ISRCTN17975376 (Registered 19/09/2014).

Influence of work-related psychosocial factors on the prevalence of chronic pain and quality of life in patients with chronic pain

OBJECTIVES

Working is a common cause of chronic pain for workers. However, most of them need to continue working despite the pain in order to make a living unless they get a sick leave or retirement. We hypothesised that the therapeutic effect of vocational rehabilitation may depend on psychosocial factors related to the workplace. To test this hypothesis, we examined the association of work-related psychosocial factors with the prevalence of chronic pain or health-related quality of life (HRQoL) among workers with chronic pain.

METHODS

We examined 1764 workers aged 20-59 years in the pain-associated cross-sectional epidemiological survey in Japan. The outcomes were (1) chronic pain prevalence among all workers and (2) low Euro QoL (EQ-5D <0.76; mean value of the current study) prevalence among workers with chronic pain according to the degree of workplace social support and job satisfaction. Workplace social support and job satisfaction were measured using the Brief Job Stress Questionnaire. Multivariable-adjusted ORs were calculated using a logistic regression model including age, sex, smoking, exercise, sleep time, work hours, body mass index, personal consumption expenditure, intensity of pain and the presence of severe depressive symptoms.

RESULTS

Chronic pain prevalence was higher among males reporting job dissatisfaction compared with those reporting job satisfaction. No difference was observed among women. Chronic pain prevalence did not differ between workers of either sex reporting poor workplace social support compared with those reporting sufficient support. Among workers with chronic pain, low HRQoL was more frequent in those reporting job dissatisfaction. Similarly, low HRQoL was more frequent in patients with chronic pain reporting poor social support from supervisors or co-workers compared with patients reporting sufficient support.

CONCLUSIONS

Work-related psychosocial factors are critical for HRQoL in patients with chronic pain.

Comprehensive disease control (CDC): what does achieving CDC mean for patients with rheumatoid arthritis?

BACKGROUND

This study assessed the impact of simultaneous achievement of clinical, functional and structural efficacy, herein referred to as comprehensive disease control (CDC), on short-term and long-term work-related outcomes, health-related quality of life (HRQoL), pain and fatigue.

METHODS

Data were pooled from three randomised trials of adalimumab plus methotrexate for treatment of early-stage or late-stage rheumatoid arthritis (RA). CDC was defined as 28-joint Disease Activity Score using C reactive protein <2.6, Health Assessment Questionnaire <0.5 and change from baseline in modified Total Sharp Score ≤0.5. Changes in scores at weeks 26 and 52 for work-related outcomes, Short Form 36 (SF-36) physical (PCS) and mental component scores (MCS), a Visual Analogue Scale measuring pain (VAS-Pain) and Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) were compared between patient groups defined by achievement of CDC at week 26 using linear regression with adjustment for baseline scores.

RESULTS

Patients with RA who achieved CDC at week 26 (n=200) had significantly greater improvements in VAS-Pain (46.9 vs 26.9; p<0.0001), FACIT-F (13.3 vs 7.5; p<0.0001), SF-36 PCS (19.7 vs 8.9; p<0.0001) and SF-36 MCS (8.1 vs 5.0; p=0.0004) than those who did not (n=1267). Results were consistent at week 52 and among methotrexate-naive patients with early RA, methotrexate-experienced patients with late-stage RA and patients with inadequate response to methotrexate.

CONCLUSIONS

Patients with RA who achieved CDC at week 26 had improved short-term and long-term HRQoL, pain, fatigue and work-related outcomes compared with patients who do not. These results demonstrate that the joint achievement of all CDC components provides meaningful benefits to patients.

TRIAL REGISTRATION NUMBERS

DE019: NCT00195702, PREMIER: NCT00195702, OPTIMA: NCT00195702.

Effect of short-term oral immunotherapy with Cry j1-galactomannan conjugate on quality of life in Japanese cedar pollinosis patients: A prospective, randomized, open-label study

OBJECTIVE

We have recently reported that a new regimen of short-term oral immunotherapy (OIT) with the Cry j1-galactomannan conjugate for Japanese cedar pollinosis (JCP) is effective to the improvement in the symptoms and medication use during the pollen season and relatively safe. The effect of OIT on quality of life (QOL) of JCP patients has not been assessed. Therefore, we evaluated for the first time the effect of OIT on QOL during the Japanese cedar/cypress pollen season.

METHODS

A prospective, randomized, open-label trial was conducted over a period of 4 months. Participants were randomly divided into two groups. The OIT and control groups comprised 23 and 24 subjects, respectively. The build-up phase was initiated 1 month before the expected pollen season. The maintenance phase was continued for 51 days during the peak of the cedar pollen season. The QOL score in the Japan Rhinoconjunctivitis Quality of Life Questionnaire (JRQLQ) No. 1 and visual analog scale (VAS) throughout the pollen season were evaluated.

RESULTS

Participants receiving OIT showed significant improvements in the total QOL score and VAS throughout the pollen season compared with the control group. In addition, the mean total QOL score and VAS correlated in both groups during the pollen season.

CONCLUSION

The new regimen of short-term OIT using the Cry j1-galactomannan conjugate results in meaningful improvements in QOL of JCP patients. Our findings suggest that short-term OIT using allergen-galactomannan conjugates, as well as sublingual and subcutaneous immunotherapy, improves QOL of patients with pollinosis. The study was registered in UMIN-CTR (UMIN000013408) as the name of "a prospective, randomized, open study of oral Cry j1-galactomannan conjugate immunotherapy for Japanese cedar pollen allergy".

Health-related quality of life and productivity losses in patients with depression and anxiety disorders

OBJECTIVES

To assess the explanatory power of disease severity and health-related quality of life (HRQOL) on absenteeism and presenteeism in a working population suffering from depression and/or anxiety disorders.

METHODS

We used data of a large, multicenter, randomized trial (n = 644). Pearson chi-squared tests, analysis of variance, and multinomial logistic regression analyses were performed to explore associations of the type of the disorder and HRQOL with different types of productivity losses. Multivariate regression analyses were performed to assess associations with the duration of absenteeism.

RESULTS

The type of the disorder, disease severity, and HRQOL were associated with different types of productivity losses. Health-related quality of life and age were significantly associated with the duration of absenteeism.

CONCLUSIONS

Our findings indicate that HRQOL may significantly explain the type of productivity loss as well as the duration of absenteeism.

Do the Washington Panel recommendations hold for Europe: investigating the relation between quality of life versus work-status, absenteeism and presenteeism

BACKGROUND

The question of how to value lost productivity in economic evaluations has been subject of debate in the past twenty years. According to the Washington panel, lost productivity influences health-related quality of life and should thus be considered a health effect instead of a cost to avoid double counting. Current empirical evidence on the inclusion of income loss when valuing health states is not decisive. We examined the relationship between three aspects of lost productivity (work-status, absenteeism and presenteeism) and patient or social valuation of health-related quality of life (HRQoL).

METHODS

Cross-sectional survey data were collected from a total of 830 respondents with a rheumatic disorder from four West-European countries. Health-related quality of life was expressed in either the European societal utility using EQ-5D-3L or the patient valuation using EQ-VAS. The impact of work-status (four categories), absenteeism (absent from paid work during the past three months), and presenteeism (QQ method) on EQ-5D utilities and VAS scores was examined in linear regression analyses taking into account demographic characteristics and disease severity (duration, pain and restriction).

RESULTS

The relationship between work-status, absenteeism or presenteeism and HRQoL was stronger for patient valuation than societal valuation. Compared to work-status and presenteeism the relationship between absenteeism and HRQoL was even less explicit. However, results for all measures of lost productivity are only marginally significant and negligible compared to the influence of disease-related restrictions.

CONCLUSIONS

This survey study in patients with a rheumatic disorder in four European countries, does not fully support the Washington panel's claim that lost productivity is a significantly related with HRQoL, and this is even more apparent for absenteeism than for work-status and presenteeism. For West-European countries, there is no reason, to include absenteeism in the QALY. Findings need to be confirmed in other disease areas.

The economic impact of Marfan syndrome: a non-experimental, retrospective, population-based matched cohort study

Background

Marfan syndrome is a rare disease of the connective tissues, affecting multiple organ systems. Elevated morbidity and mortality in these patients raises the issue of costs for sickness funds and society. To date, there has been no study analysing the costs of Marfan syndrome from a sickness fund and societal perspective.

Objective

To estimate excess health resource utilisation, direct (non-)medical and indirect costs attributable to Marfan syndrome from a healthcare payer and a societal perspective in Germany in 2008.

Methods

A retrospective matched cohort study design is applied, using claims data. For isolating the causal effect of Marfan syndrome on excess costs, a genetic matching algorithm was used to reduce differences in observable characteristics between Marfan syndrome patients and the control group. 892 patients diagnosed with Marfan syndrome (ICD-10 Q87.4) were matched from a pool of 26,645 control individuals. After matching, we compared health resource utilisation and costs.

Results

From the sickness fund perspective, an average Marfan syndrome patient generates excess annual costs of €2496 compared with a control individual. From the societal perspective, excess annual costs amount to €15,728. For the sickness fund, the strongest cost drivers are inpatient treatment and care by non-physicians. From the sickness fund perspective, the third (25–41 years) and first (0–16 years) age quartiles reveal the greatest surplus in total costs. Marfan syndrome patients have 39% more physician contacts, a 153% longer average length of hospital stay, 119% more inpatient stays, 33% more prescriptions, 236% more medical imaging and 20% higher average prescription costs than control individuals. Depending on the prevalence, the economic impact from the sickness fund perspective ranges between €24.0 million and €61.4 million, whereas the societal economic impact extends from €151.3 million to €386.9 million.

Conclusions

Relative to its low frequency, Marfan syndrome requires high healthcare expenditure. Not only the high costs of Marfan syndrome but also its burden on patients’ lives call for more awareness from policy-makers, physicians and clinical researchers. Consequently, the diagnosis and treatment of Marfan syndrome should begin as soon as possible in order to prevent disease complications, early mortality and substantial healthcare expenditure.

Predicting productivity based on EQ-5D: an explorative study

BACKGROUND

Productivity costs are often ignored in economic evaluations. In order to facilitate productivity cost inclusion, it has been suggested to estimate productivity costs indirectly using quality of life data.

OBJECTIVE

This study aimed to derive and validate an algorithm for predicting productivity losses on the basis of quality-of-life data using the EQ-5D-3L.

METHODS

A large representative sample of the Dutch general public (n = 1,100) was asked in a web-based questionnaire to state their expected level of productivity in terms of absenteeism and presenteeism for multiple EQ-5D health states. Based on these data, two generalized estimating equations (GEE) models were constructed: (1) a model predicting levels of absenteeism and (2) a model predicting presenteeism. The models were validated by comparing model predictions with conventionally measured productivity within a group of low back pain patients.

RESULTS

Predicted absenteeism levels based on EQ-5D health state closely resembled conventionally measured absenteeism levels. Productivity losses related to presenteeism seemed somewhat overestimated by our prediction model. Measured and predicted productivity were moderately but highly significantly correlated.

CONCLUSIONS

Overall, it appears possible to make reasonable productivity predictions based on EQ-5D data. Further exploration and validation of prediction algorithms remains necessary, however, especially for presenteeism.

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.

An education programme to increase general practitioners' awareness of their patients' employment: design of a cluster randomised controlled trial

BACKGROUND

Work and being able to work are important prerequisites for health and well being. Health problems can have a negative influence on the ability to work and not being able to work can be detrimental for patients' psychosocial well being. Although GPs are aware of this importance they do not always structurally pay attention to patients' work during their daily practice.

METHODS/DESIGN

To investigate whether GPs can be trained to increase their awareness of work and improve their skills when dealing with work related problems we designed a cluster randomised controlled trial. The intervention in this trial is a tailored training based on the findings of qualitative research with focus groups of GPs. Gender aspects received specific attention in these focus groups. Primary outcome measures are self efficacy of patients concerning return to work, and GPs' use of ICPC code Z05 (work problems) and registration of patients' occupation. Secondary outcome measures are work awareness of GPs as perceived by patients, quality of life, health, use of care and illness related costs. A process evaluation will be part of our study.

DISCUSSION

We investigate a training to increase work awareness among GPs, improve their skills in managing work related problems and structurally register work related data in the EMR. We think this study will make a contribution to better health care for workers by motivating GPs to appreciate their specific needs. It will also add to our knowledge of the complex relationship between gender, work and health.

Challenges in measuring and valuing productivity costs, and their relevance in mood disorders

Lost productivity is often excluded from economic evaluations, which may lead to an underestimation of the societal benefits of treatment. However, there are multiple challenges in reliably estimating and reporting productivity losses. This article explores the main challenges, ie, selecting an appropriate valuation method (ie, human capital, friction cost, or multiplier), avoiding double counting, and accounting for equity. It also discusses the use of presenteeism instruments and their application in clinical trials, with a specific focus on their relevance in individuals with mood disorders. Further research and discussion is required on the development of reliable techniques for measuring and valuing productivity changes due to presenteeism.

Worker Productivity Outcome Measures: OMERACT Filter Evidence and Agenda for Future Research

The objective of the Outcome Measures in Rheumatology (OMERACT) Worker Productivity working group is to identify worker productivity outcome measures that meet the requirements of the OMERACT filter. At the OMERACT 11 Workshop, we focused on the at-work limitations/productivity component of worker productivity (i.e., presenteeism) — an area with diverse conceptualization and instrumentation approaches. Various approaches to quantify at-work limitations/productivity (e.g., single-item global and multi-item measures) were examined, and available evidence pertaining to OMERACT truth, discrimination, and feasibility were presented to conference participants. Four candidate global measures of presenteeism were put forth for a plenary vote to determine whether current evidence meets the OMERACT filter requirements. Presenteeism globals from the Work Productivity and Activity Impairment Questionnaire (72% support) and Rheumatoid Arthritis-specific Work Productivity Survey (71% support) were endorsed by conference participants; however, neither the presenteeism global item from the Health and Work Performance Questionnaire nor the Quantity and Quality method achieved the level of support required for endorsement at the present time. The plenary was also asked whether the central item from the Work Ability Index should also be considered as a candidate measure for potential endorsement in the future. Of participants at the plenary, 70% supported this presenteeism global measure. Progress was also made in other areas through discussions at individual breakout sessions. Topics examined include the merits of various multi-item measures of at-work limitations/productivity, methodological issues related to interpretability of outcome scores, and approaches to appraise and classify contextual factors of worker productivity. Feedback gathered from conference participants will inform the future research agenda of the working group.

A lesson in business: cost-effectiveness analysis of a novel financial incentive intervention for increasing physical activity in the workplace

BACKGROUND

Recently both the UK and US governments have advocated the use of financial incentives to encourage healthier lifestyle choices but evidence for the cost-effectiveness of such interventions is lacking. Our aim was to perform a cost-effectiveness analysis (CEA) of a quasi-experimental trial, exploring the use of financial incentives to increase employee physical activity levels, from a healthcare and employer's perspective.

METHODS

Employees used a 'loyalty card' to objectively monitor their physical activity at work over 12 weeks. The Incentive Group (n=199) collected points and received rewards for minutes of physical activity completed. The No Incentive Group (n=207) self-monitored their physical activity only. Quality of life (QOL) and absenteeism were assessed at baseline and 6 months follow-up. QOL scores were also converted into productivity estimates using a validated algorithm. The additional costs of the Incentive Group were divided by the additional quality adjusted life years (QALYs) or productivity gained to calculate incremental cost effectiveness ratios (ICERs). Cost-effectiveness acceptability curves (CEACs) and population expected value of perfect information (EVPI) was used to characterize and value the uncertainty in our estimates.

RESULTS

The Incentive Group performed more physical activity over 12 weeks and by 6 months had achieved greater gains in QOL and productivity, although these mean differences were not statistically significant. The ICERs were £2,900/QALY and £2,700 per percentage increase in overall employee productivity. Whilst the confidence intervals surrounding these ICERs were wide, CEACs showed a high chance of the intervention being cost-effective at low willingness-to-pay (WTP) thresholds.

CONCLUSIONS

The Physical Activity Loyalty card (PAL) scheme is potentially cost-effective from both a healthcare and employer's perspective but further research is warranted to reduce uncertainty in our results. It is based on a sustainable "business model" which should become more cost-effective as it is delivered to more participants and can be adapted to suit other health behaviors and settings. This comes at a time when both UK and US governments are encouraging business involvement in tackling public health challenges.

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.

Self-reported work ability and work performance in workers with chronic nonspecific musculoskeletal pain

PURPOSE

To assess self-reported work ability and work performance of workers who stay at work despite chronic nonspecific musculoskeletal pain (CMP), and to explore which variables were associated with these outcomes.

METHODS

In a cross-sectional study we assessed work ability (Work Ability Index, single item scale 0-10) and work performance (Health and Work Performance Questionnaire, scale 0-10) among 119 workers who continued work while having CMP. Scores of work ability and work performance were categorized into excellent (10), good (9), moderate (8) and poor (0-7). Hierarchical multiple regression and logistic regression analysis was used to analyze the relation of socio-demographic, pain-related, personal- and work-related variables with work ability and work performance.

RESULTS

Mean work ability and work performance were 7.1 and 7.7 (poor to moderate). Hierarchical multiple regression analysis revealed that higher work ability scores were associated with lower age, better general health perception, and higher pain self-efficacy beliefs (R(2) = 42 %). Higher work performance was associated with lower age, higher pain self-efficacy beliefs, lower physical work demand category and part-time work (R(2) = 37 %). Logistic regression analysis revealed that work ability ≥8 was significantly explained by age (OR = 0.90), general health perception (OR = 1.04) and pain self-efficacy (OR = 1.15). Work performance ≥8 was explained by pain self-efficacy (OR = 1.11).

CONCLUSIONS

Many workers with CMP who stay at work report poor to moderate work ability and work performance. Our findings suggest that a subgroup of workers with CMP can stay at work with high work ability and performance, especially when they have high beliefs of pain self-efficacy. Our results further show that not the pain itself, but personal and work-related factors relate to work ability and work performance.

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.

An urban neo-poverty population-based quality of life and related social characteristics investigation from northeast China

Objective

To investigate quality of life (QOL) and related characteristics among an urban neo-poverty population in northeast China, and to compare this population with a traditional poverty cohort.

Design

The research was a cross-sectional survey executed from June 2005 to October 2007, with a sample of 2940 individuals ages 36 to 55 in three different industrial cities of northeast China. Data were collected on QOL status and sociodemographic characteristics. QOL was assessed using the 36-item Short Form Health Survey (Chinese version). Multiple regression analysis was employed to analyze association between sociodemographic variables and QOL.

Results

The scores for QOL in the neo-poverty group were higher than those in the traditional poverty group, but lower than those in the general population. When the neo-poverty population was divided into two subgroups by age, 36–45 years and 46–55 years, the differences in QOL scores were not significant. However, there were significant differences in several dimensions between two subgroups according to unemployment time (<5 years and >5 years). Additionally, stepwise regression analysis indicated that disease burden, including disease and medical expenditures, was a common risk factor for declining QOL in the neo-poverty group.

Conclusions

Despite some limitations, this study provides initial evidence that the QOL of the urban neo-poverty population lies between that of the general population and traditional poverty. QOL of the neo-poverty group approached QOL of the traditional poverty group with increased unemployment years. In addition to decreased income, disease burden is the most important factor influencing QOL status in urban neo-poverty.

Design of a trial-based economic evaluation on the cost-effectiveness of employability interventions among work disabled employees or employees at risk of work disability: the CASE-study

BACKGROUND

In the Netherlands, absenteeism and reduced productivity due to work disability lead to high yearly costs reaching almost 5% of the gross national product. To reduce the economic burden of sick leave and reduced productivity, different employability interventions for work-disabled employees or employees at risk of work disability have been developed. Within this study, called 'CASE-study' (Cost-effectiveness Analysis of Sustainable Employability), five different employability interventions directed at work disabled employees with divergent health complaints will be analysed on their effectiveness and cost-effectiveness. This paper describes a consistent and transparent methodological design to do so.

METHODS/DESIGN

Per employability intervention 142 participants are needed whereof approximately 66 participants receiving the intervention will be compared with 66 participants receiving usual care. Based on the intervention-specific characteristics, a randomized control trial or a quasi-experiment with match-criteria will be conducted. Notwithstanding the study design, eligible participants will be employees aged 18 to 63, working at least 12 h per week, and at risk of work disability, or already work-disabled due to medical restrictions. The primary outcome will be the duration of sick leave. Secondary outcomes are health status and quality of life. Outcomes will be assessed at baseline and then 6, 12 and 18 months later. Economic costs will consist of healthcare costs and cost of lost production due to work disability, and will be evaluated from a societal perspective.

DISCUSSION

The CASE-study is the first to conduct economic evaluations of multiple different employability interventions based on a similar methodological framework. The cost-effectiveness results for every employability intervention will be published in 2014, but the methods, strengths and weaknesses of the study protocol are discussed in this paper. To contribute to treatment options in occupational health practice and enable the development of guidelines on how to conduct economic evaluation better suited to this field; this paper provides an important first step.

TRIAL REGISTRATION

Four trials involved in the CASE-study are registered with the Netherlands Trial Registry: Care for Work (NTR2886), Health and Motion (NTR3111), Guidance to Excel in Return to Work (NTR3151), Care for Companies/Second Care (NTR3136).

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.

Changes in Work Habits of Lifeguards in Relation to Florida Red Tide

The marine dinoflagellate, Karenia brevis, is responsible for Florida red tides. Brevetoxins, the neurotoxins produced by K. brevis blooms, can cause fish kills, contaminate shellfish, and lead to respiratory illness in humans. Although several studies have assessed different economic impacts from Florida red tide blooms, no studies to date have considered the impact on beach lifeguard work performance. Sarasota County experiences frequent Florida red tides and staffs lifeguards at its beaches 365 days a year. This study examined lifeguard attendance records during the time periods of March 1 to September 30 in 2004 (no bloom) and March 1 to September 30 in 2005 (bloom). The lifeguard attendance data demonstrated statistically significant absenteeism during a Florida red tide bloom. The potential economic costs resulting from red tide blooms were comprised of both lifeguard absenteeism and presenteeism. Our estimate of the costs of absenteeism due to the 2005 red tide in Sarasota County is about $3,000. On average, the capitalized costs of lifeguard absenteeism in Sarasota County may be on the order of $100,000 at Sarasota County beaches alone. When surveyed, lifeguards reported not only that they experienced adverse health effects of exposure to Florida red tide but also that their attentiveness and abilities to take preventative actions decrease when they worked during a bloom, implying presenteeism effects. The costs of presenteeism, which imply increased risks to beachgoers, arguably could exceed those of absenteeism by an order of magnitude. Due to the lack of data, however, we are unable to provide credible estimates of the costs of presenteeism or the potential increased risks to bathers.

In or out? Income losses in health state valuations: a review

BACKGROUND

In 1996 the Washington Panel controversially recommended valuing productivity costs (PC) in terms of quality-adjusted life years. The Panel's assumption that respondents in health state valuation (HSV) exercises take income losses into account could not be countered since there was no evidence regarding what people consider in HSV exercises. If they do consider income losses and if this changes HSVs, then all economic evaluations that have included PC in the numerator may have double-counted these costs. Alternatively, if respondents do not consider income losses then all past economic evaluations that have not included PC in the numerator have failed to account for sizeable societal costs.

OBJECTIVES

Through a review we aim to recapture the debate surrounding the appropriate method for including PC in health economic evaluations, to identify empirical evidence addressing the assumptions of the Panel, and recommend a future research agenda.

METHODS

Through a review we identify, outline, and critically appraise the existing empirical studies that attempt to address whether respondents include income effects in HSV exercises.

RESULTS AND CONCLUSION

Seven empirical studies were identified. Overall, it seems that not explicitly mentioning the inclusion of income will induce a minority of respondents to include these effects and this appears not to influence results. More empirical work is needed, using generic instruments, larger samples, and using the interview method of administration.

Measuring Worker Productivity: Frameworks and Measures

Worker productivity is a combination of time off work (absenteeism) due to an illness and time at work but with reduced levels of productivity while at work (also known as presenteeism). Both can be gathered with a focus on application as a cost indicator and/or as an outcome state for intervention studies. We review the OMERACT worker productivity groups’ progress in evaluating measures of worker productivity for use in arthritis using the OMERACT filter. Attendees at OMERACT 9 strongly endorsed the importance of work as an outcome in arthritis. Consensus was reached (94% endorsement) for fielding a broader array of indicators of absenteeism. Twenty-one measures of at-work productivity loss, ranging from single item indicators to multidimensional scales, were reviewed for measurement properties. No set of at-work productivity measures was endorsed because of variability in the concepts captured, and the need for a better framework for the measurement of worker productivity that also incorporates contextual issues such as job demands and other paid and unpaid life responsibilities. Progress has been made in this area, revealing an ambivalent set of results that directed us back to the need to further define and then contextualize the measurement of worker productivity.

Do individuals consider expected income when valuing health states?

Objectives:The purpose of this study was to empirically explore whether individuals take their expected income into consideration when directly valuing predefined health states. This was intended to help determine how to handle productivity costs due to morbidity in a cost-effectiveness analysis.

Methods:Two hundred students each valued four hypothetical health states by using time trade-off (TTO) and a visual analogue scale (VAS). The students were randomly assigned to two groups. One group was simply asked, without mentioning income, to value the different health states (the non-income group). The other group was explicitly asked to consider their expected income in relation to the health states in their valuations (the income group).

Results:For health states that are usually assumed to have a large effect on income, the valuations made by the income group seemed to be lower than the valuations made by the non-income group. Among the students in the non-income group, 96 percent stated that they had not thought about their expected income when they valued the health states. In the income group, 40 percent believed that their expected income had affected their valuations of the health states.

Conclusion:The results show that, as long as income is not mentioned, most individuals do not seem to consider their expected income when they value health states. This indicates that productivity costs due to morbidity are not captured within individuals' health state valuations. These findings, therefore, suggest that productivity costs due to morbidity should be included as a cost in cost-effectiveness analyses.

[Concept analysis of presenteeism and its possible applications in Japanese occupational health]

The purposes of this systematic review were to define the concept of presenteeism in accordance with Rodgers' concept analysis methods and to examine the possibility of applying the concept to Japanese occupational health. Using presenteeism as a search term, articles were selected from the MEDLINE, PsycINFO and Japana Centra Revuo Medicina databases. The definitions, antecedents, and consequences of presenteeism were extracted from the selected articles and were examined in order to determine how presenteeism was used in the literature. A total of forty-four articles published from 1955 to 2005 were selected for analysis. Based on the extracted definitions, four attributes of presenteeism were identified, and presenteeism was defined as "a self-rated measurable loss of work performance due to health problems in the workplace." Antecedents of presenteeism were classified into occupational and personal factors. These factors affected the decisions of workers with health problems regarding whether or not to go to work. Consequences of presenteeism were the aggravation of quality of life and health status, increases in health-related costs, adverse effects on colleagues, increases in occupational accidents, and deterioration of the quality of products and services. Therefore, the reduction of presenteeism is considered to be an important challenge for occupational health professionals. Possible applications of the concept of presenteeism in Japanese occupational health are the following: 1) measurement of presenteeism and examination of its related factors, 2) identification of factors that discourage workers from taking adequate sickness absenteeism, and 3) design of occupational health activity plans and the evaluation of such activities. In order to measure presenteeism in Japan, it is necessary to introduce Euro-American instruments suitable for the purpose of measuring presenteeism and to develop new measures. Occupational health professionals can incorporate assessments of presenteeism in their occupational health activities by considering not only the individual state of presenteeism, but also the state of the entire organization and interaction among workers' health problems, occupational factors, and personal factors. Moreover, if the loss of work performance due to presenteeism is converted to financial loss, it is considered that the necessity and the validity of workplace-based health activities will be clarified.

The Work Productivity and Activity Impairment Questionnaire for Patients with Gastroesophageal Reflux Disease (WPAI-GERD): responsiveness to change and English language validation

BACKGROUND

A validated productivity questionnaire, the Work Productivity and Activity Impairment questionnaire for Gastroesophageal Reflux Disease (WPAI-GERD), exists for Swedish patients with GERD.

OBJECTIVE

To assess responsiveness to change of the WPAI-GERD and construct validity of the English language version.

METHODS

We used the WPAI-GERD in a before-after treatment clinical study of Canadian GERD patients with moderate or severe symptoms treated with esomeprazole 40 mg once daily for 4 weeks. We measured productivity variables including GERD-specific absence from work, reduced productivity while at work and reduced productivity while carrying out regular daily activities other than work during the preceding week.

RESULTS

The analysis included 217 patients, of whom 71% (n = 153) were employed. Before treatment, employed patients reported an average 0.9 hours of absence from work due to GERD and 14.0% reduced work productivity (5.8 hours equivalent) in the previous week, as well as 21.0% reduced productivity in daily activities (all patients). After treatment, the corresponding figures decreased to 0.3 hours, 3.0% (1.1 hours equivalent) and 4.9%, respectively. Thus, the improvement (difference from start of treatment) in productivity was 0.6 hours (p = 0.011) for absence from work and 11.0% units (p < 0.001) for reduced work productivity (4.7 hours equivalent, p < 0.001). This translated into an avoided loss of work productivity of 5.3 hours in total on a weekly basis per employed patient. In addition, a 16.1% unit (p < 0.001) improvement for reduced productivity in activities was observed. Cross-sectional correlation coefficients of WPAI variables with symptoms (range 0.04-0.63) and health-related quality of life (HR-QOL; range 0.02-0.65) supported cross-sectional construct validity. Corresponding change score correlations between WPAI variables and HR-QOL (range 0.05-0.56) supported longitudinal construct validity of the WPAI-GERD while low change score correlations between productivity variables and relevant symptoms (range 0.06-0.34) did not.

CONCLUSION

The English version of the WPAI-GERD showed good cross-sectional construct validity, and results indicated that the WPAI-GERD is responsive to change. Although the results also indicated that longitudinal construct validity may be poor, the overall findings suggest that further study of the instrument remains warranted.

Productivity costs in health-state valuations : does explicit instruction matter?

BACKGROUND

There has been considerable debate on whether productivity costs should be captured in the numerator or the denominator of the cost-effectiveness ratio. That debate cannot be resolved on the basis of theoretical arguments alone because the final choice also depends on what is incorporated in health-state valuations by respondents and how this influences outcomes. At the moment, little is known about whether the effects of ill health on income are included in health-state valuations, and how instructions on including or excluding the effects on income influence health-state valuations.

AIM

To conduct an empirical study of health-state valuations to test: (i) whether or not respondents spontaneously include the effect of ill health on income and leisure time; (ii) the impact on the valuation of inclusion (or exclusion) of such effects; and (iii) the influence of explicit instructions on this matter.

METHODS

Three questionnaires were developed and administered to the general public. Health-state valuations were conducted by visual analogue scale scoring of three health states of differing severity taken from the EQ-5D. Version 1 had no directions regarding inclusion/exclusion of effects of ill health on income. Those respondents who spontaneously included effects on income were subsequently asked to value the same three health states again, excluding these effects. Version 2 had explicit instructions to incorporate the effects on income. Version 3 stated that income was assumed to not change as a result of ill health. Respondents for versions 2 and 3 were also questioned about inclusion of effects on leisure time.

RESULTS

Giving explicit instructions on the incorporation or exclusion of effects of ill health on income did not lead to significant differences in subsequent health-state valuations. In the absence of instruction, 36% of respondents included and 64% excluded effects on income, but the health-state valuations of the two groups were not significantly different. Eighty-four percent of respondents included the effects of ill health on leisure activities, and again this had no significant impact on the resulting health-state valuations.

CONCLUSIONS

It appears that neither spontaneous differences in incorporation of effects on income, nor explicit instructions will yield significantly different health-state valuations. This may suggest that QALY measures are insensitive to concerns regarding effects on income even when these are (explicitly) incorporated, and these effects may therefore be best placed on the cost side of the cost-effectiveness ratio.