Lost Time, Absence Costs, and Reduced Productivity Output for Employees With Bipolar Disorder

Demographic and clinical associations to employment status in older-age bipolar disorder: Analysis from the GAGE-BD database project

OBJECTIVE

The current literature on employment in older adults with bipolar disorder (OABD) is limited. Using the Global Aging and Geriatric Experiments in Bipolar Disorder Database (GAGE-BD), we examined the relationship of occupational status in OABD to other demographic and clinical characteristics.

METHODS

Seven hundred and thirty-eight participants from 11 international samples with data on educational level and occupational status were included. Employment status was dichotomized as employed versus unemployed. Generalized linear mixed models with random intercepts for the study cohort were used to examine the relationship between baseline characteristics and employment. Predictors in the models included baseline demographics, education, psychiatric symptom severity, psychiatric comorbidity, somatic comorbidity, and prior psychiatric hospitalizations.

RESULTS

In the sample, 23.6% (n = 174) were employed, while 76.4% were unemployed (n = 564). In multivariable logistic regression models, less education, older age, a history of both anxiety and substance/alcohol use disorders, more prior psychiatric hospitalizations, and higher levels of BD depression severity were associated with greater odds of unemployment. In the subsample of individuals less than 65 years of age, findings were similar. No significant association between manic symptoms, gender, age of onset, or employment status was observed.

CONCLUSION

Results suggest an association between educational level, age, psychiatric severity and comorbidity in relation to employment in OABD. Implications include the need for management of psychiatric symptoms and comorbidity across the lifespan, as well as improving educational access for people with BD and skills training or other support for those with work-life breaks to re-enter employment and optimize the overall outcome.

Long-Term Healthcare Utilization and the Cost of Bipolar Disorder Among Participants in a Large Employer's Health Benefit Plan

OBJECTIVE

Bipolar disorder (BD) is a chronic illness with recurrent exacerbations. The objective was to evaluate longitudinal costs related to BD in an employer-sponsored medical plan.

METHODS

This analysis utilized 5 years of administrative claims data. Claimants with a diagnosis of BD were matched to plan members (1:5) based on age, sex, and years of follow-up.

RESULTS

Medical costs for hospitalized BD members were 3.5 times more expensive than the general population (BDhosp = $92.2K vs General population = $26.8K). Average 5-year paid costs among hospitalized members with BD was $107K, $105.4K with cancer, and $103.3K with myocardial infarction (MI).

CONCLUSIONS

Hospitalized BD plan members consumed more than 3.5 times the medical resources and were similar in longitudinal costs when compared with members with other costly conditions. These findings highlight the need for novel employer-sponsored programs to help manage BD.

The impact of lurasidone on functioning and indirect costs in adults with bipolar depression: a post-hoc analysis

OBJECTIVE

The aim of this post-hoc analysis was to assess the impact of lurasidone monotherapy on functional impairment, productivity, and associated indirect costs in patients with bipolar depression.

METHODS

Data were analyzed from a 6-week randomized, double-blind (DB; NCT00868699), placebo-controlled trial of lurasidone monotherapy and a 6-month open label extension (OLE; NCT00868959) study. Patients with bipolar depression who completed the 6-week DB trial were subsequently enrolled in the OLE. Analysis of the OLE was limited to patients who either continued lurasidone (LUR-LUR) or switched from placebo to lurasidone monotherapy (PBO-LUR). The Sheehan Disability Scale (SDS), which measures functional impairment and productivity, was collected at DB baseline, DB week 6/OLE baseline, OLE month 3, and OLE month 6. Annual indirect costs were calculated based on days lost or unproductive from work/school due to symptoms. Effect sizes (ES) in functioning and days lost/unproductive were reported for the DB trial and mean changes for the OLE.

RESULTS

A total of 485 patients were enrolled in the DB trial (lurasidone: n = 323; placebo: n = 162) and 316 were in the lurasidone monotherapy group during the OLE (LUR-LUR: n = 210; PBO-LUR: n = 106). In the DB trial, improvements in functioning (work: ES = 0.36, p = .0071; social: ES = 0.55, p < .0001; family: ES = 0.50, p < .0001) were significantly greater for lurasidone compared to placebo. Reductions in days lost (ES = 0.33, p = .0050) and unproductive (ES = 0.45, p = .0001) were significantly higher for lurasidone vs. placebo. This resulted in a greater reduction in indirect costs for lurasidone vs. placebo (least squares mean (standard error) = -$32,322 ($2,100) vs. -$20,091 ($2,838)). Improvements in functioning and productivity were sustained during the 6-month OLE for both LUR-LUR and PBO-LUR.

CONCLUSIONS

Lurasidone monotherapy for the treatment of bipolar depression significantly improved functioning and reduced indirect costs vs. placebo at week 6. Significant improvements in functioning and productivity were sustained for 6 months for both LUR-LUR and PBO-LUR.

Understanding the Barriers and Facilitators to Employment for People with Bipolar Disorder

People with Bipolar Disorder (BD) consistently report a desire for employment; however, this is not reflected in employment figures. Individuals' perceptions of barriers to employment, along with endorsement of facilitators to employment remain under-investigated. We aimed to address this limitation by: (i) first examining differences in employed versus unemployed individuals (demographic, clinical, functioning); then (ii) identifying barriers and/or facilitators to employment, perception of same, and subsequent impact on employment. We assessed demographics, functioning, and illness-related characteristics in 35 participants with BD (19 employed, 16 unemployed). Participants were asked to indicate perception of common barriers and facilitators to employment. Groups did not differ regarding demographic or clinical variables. High levels of absenteeism, termination of last role and commonly perceived barriers were attributed to mental ill-health. 93.3% of unemployed participants reportedly desired employment, and more perceived barriers were observed in the unemployed group. Identified facilitators included increased support and flexible work strategies. A comprehensive understanding of perceptions of limiting and helpful factors related to employment for people with BD was obtained. These findings have implications for service provision, encouraging targeted discussion, and tailored treatment approaches to individual's unique perceptions of factors related to employment.

Disability and workers' compensation trends for employees with mental disorders and SUDs in the United States

Introduction

US employee absence benefits may include workers' compensation (WC) for work-related injuries/illnesses, short- and long-term disability (STD and LTD, respectively) for non–work-related injuries/illnesses, and discretionary sick leave (SL). Absences can significantly impact business performance, and employers are intensifying efforts to manage benefits and connections with employee health. This research compares all-cause STD/LTD/WC/SL use and variation from baseline (2002) for eligible employees (EMPs) with mental disorders (MDs) and SUDs to determine if use/payments varied over time.

Methods

Employees incurring medical claims with Agency for Healthcare Research and Quality MD and SUD ICD-9/10 codes were identified in the WorkPartners database (January 1, 2002 to December 31, 2019). Retrospective analysis was performed on annual prevalence, benefit use, mean days of leave, and median payments as a percent of salary (including lump-sum distributions and potentially extending beyond initiation year). WC claims without work absences were excluded. For each benefit, annual outcomes were calculated as a percent of baseline to show variability.

Results

Use was 48.1% to 202.2% (median, 102.8%) of baseline rates for SL (SUD-EMPs), and 87.3% to 108.4% (median, 97.3%) for STD (MD-EMPs). Days of LTD leaves were 21.5% to 657.8% (median, 359.2%) of baseline days (MD-EMPs), and 122.7% to 1042.2% (median, 460.0%) of baseline days for (SUD-EMPs). Median payments for WC were 78.6% to 253.6% (median, 114.6%) of baseline (MD-EMPs) and 97.9% to 481.6% (median, 104.0%) for SUD-EMPs.

Discussion

Employees with MD/SUD used absence benefits at differing rates over time with varying days of leave and payments as a percent of salary. Using a constant cost or salary replacement factor over time for all benefits is not accurate or appropriate.

Second-Generation Antipsychotics in Management of Acute Pediatric Bipolar Depression: A Systematic Review and Meta-analysis

Objectives: To evaluate the efficacy in reduction of depressive symptoms, and safety and tolerability of second-generation antipsychotics (SGAs) to manage pediatric bipolar depression (PBD). Methods: We conducted a systematic review for randomized clinical trials (RCTs) for PBD in MEDLINE, Scopus, and EMBASE. Four (quetiapine: 2, lurasidone: 1, olanzapine-fluoxetine combination [OFC]: 1) out of 569 studies met the criteria for inclusion in meta-analysis. RevMan was used for statistical analysis, and the mean difference (MD) between mean children's depression rating scale-revised (CDRS-R) score was used to measure treatment difference between SGA and placebo. Results: Lurasidone displayed a significant reduction in depressive symptoms (MD -5.70, 95% confidence interval [CI] -8.67 to -2.73) in PBD, followed by OFC (MD -5.00, 95% CI -8.64 to -1.36) and quetiapine (MD -2.30, 95% CI -6.80 to 2.20; MD 1.00, 95% CI -9.88 to 11.88). The response was significantly higher for lurasidone (59.5% vs. 36.5%; p < 0.001) and OFC (78.2% vs. 59.2%, p = 0.003) compared with placebo. There was no statistically significant MD in treatment and response rates between quetiapine and placebo in all RCTs. The weighted mean CDRS-R total score difference was -4.58 (95% CI -6.59 to -2.56) and overall effect was significant (p < 0.00001). Importantly, the p value for heterogeneity was 0.46, which indicated that there was no heterogeneity between outcomes of the studies. The number needed to treat (NNT) for lurasidone was 4.3, followed by OFC (NNT = 5.3) and quetiapine (NNT = 12.5; NNT = 25). Conclusion: Our findings showed lurasidone and OFC were more efficacious than placebo for acute depressive episodes in PBD. RCTs of treatments for PBD remain scarce pressing the need for more research.

Prospective Cohort Study of Work Functioning Impairment and Subsequent Absenteeism Among Japanese Workers

OBJECTIVE

This study examined the association of work functioning impairment as measured by work functioning impairment scale (WFun) and subsequent sick leave.

METHODS

A prospective cohort study was conducted at a manufacturer in Japan, and 1263 employees participated. Information on sick leave was gathered during an 18-month follow-up period.

RESULTS

The hazard ratios (HRs) of long-term sick leave were substantially increased for those with a WFun score greater than 25 (HR = 3.99, P = 0.003). The incidence rate ratios (IRRs) of days of short-term absence gradually increased as scores of WFun increased (IRR = 1.18, P < 0.001 in the subjects with WFun of over 25 comparing with those with WFun of 14 or less).

CONCLUSIONS

Assessing work functioning impairment is a useful way of classifying risk for future sick leave among employees.

The economic burden of bipolar I disorder in the United States in 2015

BACKGROUND

The current societal costs of bipolar I disorder (BDI) have not been comprehensively characterized in the United States, as previous studies are based on data from two decades ago.

METHODS

The costs of BDI were estimated for 2015 and comprised direct healthcare costs, non-healthcare costs, and indirect costs, calculated based on a BDI prevalence of 1%. The excess costs of BDI were estimated as the difference between the costs incurred by individuals with BDI and those incurred by individuals without BD or individuals from the general population. Direct healthcare costs were assessed using three large US claims databases for insured individuals and the literature for uninsured individuals. Direct non-healthcare and indirect costs were based on the literature and governmental publications.

RESULTS

The total costs of BDI were estimated at $202.1 billion in 2015, corresponding to an average of $81,559 per individual, while the excess costs of BDI were estimated at $119.8 billion, corresponding to an average of $48,333 per individual. The largest contributors to excess costs were caregiving (36%), direct healthcare costs (21%), and unemployment (20%). In sensitivity analyses, excess costs ranged from $101.2 to $124.3 billion.

LIMITATIONS

Direct healthcare costs were calculated based on a BDI diagnosis, thus excluding undiagnosed patients. Direct non-healthcare and indirect costs were based on combined estimates from the literature.

CONCLUSIONS

Besides direct healthcare costs, BDI was associated with substantial direct non-healthcare and indirect costs. More effective treatments and practices are needed to optimize therapeutic strategies and contain direct and indirect costs.

Quality of life in children and adolescents with bipolar I depression treated with olanzapine/fluoxetine combination

BACKGROUND

We examined the efficacy of olanzapine/fluoxetine combination (OFC) in improving health-related quality of life (QoL) in the treatment of bipolar depression in children and adolescents.

METHODS

Patients aged 10-17 years with bipolar I disorder, depressed episode, baseline children's depression rating scale-revised (CDRS-R) total score ≥40, Young Mania Rating Scale (YMRS) total score ≤15, and YMRS-item 1 ≤ 2 were randomized to OFC (6/25-12/50 mg/day olanzapine/fluoxetine; n = 170) or placebo (n = 85) for up to 8 weeks of double-blind treatment. Patients and parents completed the revised KINDL questionnaire for measuring health-related QoL in children and adolescents (KINDL-R) at baseline and endpoint. The mean change in CDRS-R total and item scores were used to compare improvement in symptomatology in patients taking OFC and placebo. Tests were 2-sided using a Type I error cutoff of 0.05, and no adjustments for multiple comparisons were made.

RESULTS

Baseline QoL as measured by the KINDL-R was substantially impaired relative to published norms for a healthy school-based sample. OFC-treated patients demonstrated an improvement over placebo at endpoint with respect to mean change from baseline in the patient-rated KINDL-R Self-esteem subscale score (p = 0.028), and in the parent KINDL-R ratings of emotional well-being (p = 0.020), Self-esteem (p = 0.030), and Family (p = 0.006). At endpoint, OFC-treated patients still had a lower QoL compared to the normative population. OFC showed significant improvement (p ≤ 0.05) versus placebo on the CDRS-R total score and on 7 of the 17 CDRS-R items.

CONCLUSIONS

Patients aged 10-17 years with an acute episode of bipolar depression and their parents reported greater improvements (parents noticed improvements in more areas than did their offspring) on some aspects of QoL when treated with OFC compared with placebo. However, after 8 weeks of treatment, KINDL-R endpoint scores remained lower than those of the, presumably healthy, control population. Clinical trial registration information A Study for Assessing Treatment of Patients Ages 10-17 with Bipolar Depression; http://www.clinicaltrials.gov; NCT00844857.

The prevalence and burden of bipolar depression

BACKGROUND

Bipolar disorder is characterized by debilitating episodes of depression and mood elevation (mania or hypomania). For most patients, depressive symptoms are more pervasive than mood elevation or mixed symptoms, and thus have been reported in individual studies to impose a greater burden on affected individuals, caregivers, and society. This article reviews and compiles the literature on the prevalence and burden of syndromal as well as subsyndromal presentations of depression in bipolar disorder patients.

METHODS

The PubMed database was searched for English-language articles using the search terms "bipolar disorder," "bipolar depression," "burden," "caregiver burden," "cost," "costs," "economic," "epidemiology," "prevalence," "quality of life," and "suicide." Search results were manually reviewed, and relevant studies were selected for inclusion as appropriate. Additional references were obtained manually from reviewing the reference lists of selected articles found by computerized search.

RESULTS

In aggregate, the findings support the predominance of depressive symptoms compared with mood elevation/mixed symptoms in the course of bipolar illness, and thus an overall greater burden in terms of economic costs, functioning, caregiver burden, and suicide.

LIMITATIONS

This review, although comprehensive, provides a study-wise aggregate (rather than a patient-wise meta-analytic) summary of the relevant literature on this topic.

CONCLUSION

In light of its pervasiveness and prevalence, more effective and aggressive treatments for bipolar depression are warranted to mitigate its profound impact upon individuals and society. Such studies could benefit by including metrics not only for mood outcomes, but also for illness burden.

Sex differences in rates of obesity in bipolar disorder: postulated mechanisms

OBJECTIVE

The increased standardized mortality ratio (SMR) from cardiovascular disease (CVD) in women with bipolar disorder (BD), relative to men with BD and individuals of both sexes in the general population, provides the impetus to identify factors that contribute to the differential association of obesity with BD in women.

METHODS

We conducted a selective PubMed search of English-language articles published from September 1990 to June 2012. The key search terms were bipolar disorder and metabolic syndrome cross-referenced with gender, sex, obesity, diabetes mellitus, hypertension, and dyslipidemia. The search was supplemented with a manual review of relevant article reference lists. Articles selected for review were based on author consensus, the use of a standardized experimental procedure, validated assessment measures, and overall manuscript quality.

RESULTS

It is amply documented that adults with BD are affected by the metabolic syndrome at a rate higher than the general population. Women with BD, when compared to men with BD and individuals of both sexes in the general population, have higher rates of abdominal obesity. The course and clinical presentation of BD manifest differently in men and women, wherein women exhibit a higher frequency of depression predominant illness, a later onset of BD, more seasonal variations in mood disturbance, and increased susceptibility to relapse. Phenomenological factors can be expanded to include differences in patterns of comorbidity between the sexes among patients with BD. Other factors that contribute to the increased risk for abdominal obesity in female individuals with BD include reproductive life events, anamnestic (e.g., sexual and/or physical abuse), lifestyle, and iatrogenic.

CONCLUSIONS

A confluence of factors broadly categorized as broad- and sex-based subserve the increased rate of obesity in women with BD. It remains a testable hypothesis that the increased abdominal obesity in women with BD mediates the increased SMR from CVD. A clinical recommendation that emerges from this review is amplified attention to the appearance, or history, of factors that conspire to increase obesity in female patients with BD.

Stigma experiences in bipolar patients: the impact upon functioning

The aim of this study was to investigate the impact of self-rated stigma and functioning in patients with bipolar disorder in South Brazil. This is a cross-sectional study. Sixty participants with bipolar disorder were recruited from an outpatient Bipolar Disorder Program. Experiences with and impact of perceived stigma were evaluated using the Inventory of Stigmatizing Experiences. Functional impairment was assessed with the Functioning Assessment Short Test (FAST). Higher scores of self-perceived stigma were correlated with higher FAST scores, indicating more disability. After linear correlation analysis, current depressive symptoms, age at onset of treatment, age at diagnosis and functioning were correlated with self-perceived stigma. The study demonstrated a correlation between stigma and poor functioning in bipolar disorder. Perceived stigma is really important to individuals with bipolar disorder, both to how they experience their illness and to its results on functioning. Potential consequences of such results for mental health care professionals are discussed. Differential clinical features, sociocultural factors and the sample size limit the generalization of the present findings.

Treating bipolar disorder in the primary care setting: the role of aripiprazole

OBJECTIVE

The objective of this article is to present practical strategies for detecting and diagnosing bipolar disorder in the primary care setting and to review the evidence for the efficacy and safety of aripiprazole treatment for bipolar disorder.

DATA SOURCES

A review of the literature from 1980 to 2007 was conducted from November 2006 through February 2007 using a MEDLINE search and the key words bipolar disorder, primary care, detection, diagnosis, and aripiprazole.

STUDY SELECTION

A total of 100 articles that focused on the accurate detection and diagnosis of bipolar disorder and the evidence of the efficacy and safety of aripiprazole in the treatment of bipolar disorder were selected.

DATA SYNTHESIS

Patients with bipolar disorder often present to primary care physicians with depressive or mixed symptoms as opposed to purely hypomanic or manic symptoms. Accurate diagnosis of bipolar disorder is essential in order to provide timely and appropriate treatment. One treatment option available is aripiprazole, a partial agonist of dopamine (D)₂ and D₃ and serotonin (5-HT)(₁A) receptors and an antagonist of the 5-HT(₂A) receptor. Clinical trial data have shown aripiprazole to be effective in treating manic and mixed episodes associated with bipolar I disorder, both in the acute phase and over an extended period of treatment lasting from 6 months to 2 years.

CONCLUSIONS

Accurate diagnosis and treatment of bipolar disorder are challenges increasingly faced by primary care physicians. Strategies geared toward detection, diagnosis, and management of bipolar I disorder and other bipolar spectrum disorders may improve the treatment outcome for patients. Aripiprazole may be considered as another first-line choice for the treatment of bipolar I disorder; however, its utility in patients with bipolar spectrum disorders is yet to be determined.

The 'magic button question' for those with a mood disorder--would they wish to re-live their condition?

BACKGROUND

To determine any positive aspects of living with a clinical mood disorder, and indirectly address the question--"If you could live your life again, would you press the 'magic button' to experience life without a mood disorder?"

METHOD

Patients referred to a tertiary mood disorder facility were asked to complete a series of questionnaires pursuing detailed historical information about their mood disorder, including its 'best' and 'worst' aspects.

RESULTS

Of the 884 patients surveyed, 335 (38%) returned data on their mood disorder's advantages and/or disadvantages. Of these, 62.2% of the bipolar and 22.4% of the unipolar patients stated that having their condition had advantages, with the most commonly nominated consequences being increased empathy and self-awareness, enhanced relationships, a heightened appreciation of life and increased creativity.

LIMITATIONS

The qualitative design disallows any inferences as to the exact cause of benefits described in this study, so that we cannot conclude that the patients perceived these benefits as attributable to depression or bipolar disorder alone.

CONCLUSIONS

While some respondents may well have focussed on transient benefits associated with bipolar 'highs', analyses indicated that a distinct sub-set of both unipolar and bipolar patients experienced some benefits, arguing for introducing the principles of positive psychology into management of wellbeing plans. In essence, while mood disorders are--by definition--disabling, they may also have enabling consequences.

Excess comorbidity prevalence and cost associated with functional dyspepsia in an employed population

BACKGROUND

Limited published data exist on the associated comorbid conditions with functional dyspepsia (FD).

AIMS

This study aimed to assess the prevalence, services, and costs related to comorbid conditions associated with FD and the risk of having FD for each comorbid condition.

METHODS

A retrospective database analysis was undertaken using payroll data and adjudicated claims from January 1, 2001, through December 31, 2004 among >300,000 employees. Employees with FD were compared to propensity-score-matched employees without FD (controls). Outcome measures included the prevalence, costs, and utilization of health services for comorbid conditions as defined by the Agency for Healthcare Research and Quality (AHRQ) and the odds ratios of having FD from a multivariate model.

RESULTS

FD employees (N = 1,669) and a 50:1 matched control cohort (N = 83,450) were compared. Compared to matched controls, FD employees were more likely to have all major diagnostic categories. Moreover, 199/261 of the AHRQ's specific categories were more common in the FD cohort. Annual medical costs for the FD cohort were greater than for controls in 155/261 (59%) specific categories and significantly greater (P ≤ 0.05) in 76 categories (29%). Similarly, services were greater for 179/261 (69%) specific categories and significantly greater (P ≤ 0.05) in 110 categories (42%). In a multivariate model, esophageal disorders, gastritis and duodenitis, and abdominal pain were the most associated with having FD (odds ratios 3.8, 3.7, and 3.6, respectively). Only hypertension complications and disorders of the teeth and jaw were significantly negatively associated with FD.

CONCLUSION

There is unexplained excess comorbidity associated with FD which may be a major determining factor for excess healthcare services and costs.

The impact of hepatitis C virus infection on work absence, productivity, and healthcare benefit costs

Chronic hepatitis C virus (HCV) infection is generally considered an asymptomatic disease. However, studies have shown that HCV has a substantial negative impact on patients' quality of life and functioning. This study was designed to compare absenteeism, productivity, and health cost between employees with and without HCV infection in the United States. Employee records from multiple large employers in the United States were obtained from the Human Capital Management Services Research Reference Database and were assessed for demographics, salary, healthcare use, work loss, and workers' compensation. HCV-infected subjects were identified by International Classification of Diseases 9th revision Clinical Modification codes. Controls were randomly selected from employees not diagnosed with HCV. T-tests and chi-square tests were used to determine if there were differences in demographic characteristics. Regression modeling compared days absent (among benefit-eligible employees) and productivity (among employees with data on task-oriented activities), while controlling for the impact of confounding factors. A total of 339,456 subjects were evaluated. Employees with HCV (n = 1664) had significantly more lost work days per employee than the control cohort (n = 337,792), including sick leave, short-term disability, and long-term disability. HCV-infected workers had 4.15 more days of absence per employee than the control cohort. Productivity was measured by units of work processed per hour; employees with HCV processed 7.5% fewer units per hour than employees without HCV (P > 0.05). All healthcare benefit costs among HCV employees were significantly higher than the same costs among employees without HCV. Overall, the total incremental difference was $8352 per year.

CONCLUSION

This real world study provides evidence that there is a substantial indirect burden of illness and describes a relationship between HCV infection, productivity, increased absenteeism, and higher healthcare benefit costs.

Functional dyspepsia impacts absenteeism and direct and indirect costs

BACKGROUND & AIMS

Functional dyspepsia (FD) is a common morbid condition but data are limited on the direct and indirect costs for employees with FD or on its impact on productivity. Few data on absenteeism and no objective information are available. This study aimed to assess the impact of FD on costs and effects on absenteeism and work output (productivity).

METHODS

We performed a retrospective analysis of payroll data and adjudicated health insurance medical and prescription claims collected over a 4-year study period (January 1, 2001 to December 31, 2004) from more than 300,000 employees. Data from employees with and without (controls) FD were compared using 2-part regression techniques. Outcome measures included medical (total and by place of service) and prescription costs, absenteeism, and objectively measured productivity output.

RESULTS

Employees with FD (N = 1669) had greater average annual medical and prescription drug costs and indirect costs (owing to sick leave and short- and long-term disability absences) than controls (N = 274,206). Compared with controls, the FD employees incurred costs that were $5138 greater and had greater costs for each place of service (all P < .0001). The employees with FD had an additional 0.83 absence days per year and produced 12% fewer units per hour than controls (both P < .05).

CONCLUSIONS

Employees with FD have greater costs at all places of service and lower productivity than employees without FD.

Burden of fibromyalgia and comparisons with osteoarthritis in the workforce

OBJECTIVES

To calculate the fibromyalgia (FM) burden of illness (BOI) from the employer perspective and to compare annual prevalence, work output, absence, and health benefit costs of employees with FM versus osteoarthritis (OA).

METHODS

Retrospective regression model analysis comparing objective work output, total health benefit (health care, prescription drug, sick leave, disability, workers' compensation) costs, and absence days for FM, versus OA and NoFM cohorts, while controlling for differences in patient characteristics.

RESULTS

FM prevalence was 0.73%; OA 0.90%. Total health benefit costs for FM were $8452 versus $11,253 (P < 0.0001) for OA and $4013 (P < 0.0001) for NoFM, with BOI = $4439. Total absence days were 16.8 versus 19.8 (P < 0.0001) and 6.4 (P < 0.0001), respectively. FM had significantly lower annual work output than NoFM (19.5%, P = 0.003) but comparable with OA.

CONCLUSION

FM places a significant cost, absence, and productivity burden on employers.

Workplace productivity, employment issues, and resource utilization in patients with bipolar I disorder

OBJECTIVE

To collect workplace productivity and healthcare utilization data from subjects with bipolar I disorder and compare the results with those from normative subjects.

METHODS

A cross sectional survey was administered to patients and recruiting physicians. Data collected included employment status, Endicott Workplace Productivity Scale (EWPS) results, healthcare resource utilization, and quality-of-life.

RESULTS

In comparison with normative subjects, bipolar I subjects reported lower levels of work productivity (measured by the EWPS). Bipolar I subjects also reported more frequent outpatient visits and more prescribed pharmaceuticals. Bipolar I subjects were more likely to miss work, have worked reduced hours due to medical or mental health issues, receive disability payments, been involved in a crime, be uninsured or covered by Medicare, or have been fired or laid off. The study groups were age- and gender-matched to reduce the impact of selection bias associated with a non-randomized study design. Other potential limitations affecting the results of the study include recall bias and possibly an impact of different data collection methods (e.g. Internet versus telephone).

CONCLUSIONS

Bipolar I disorder is associated with a negative effect on work productivity and resource utilization and is an appropriate disease management target for employers and healthcare decision makers.

An employer perspective on annual employee and dependent costs for pediatric asthma

BACKGROUND

The burden of pediatric asthma on parents' health care costs is not well described.

OBJECTIVE

To evaluate direct and indirect health care costs of employees with children with asthma (asthma cohort) compared with employees with children without asthma (control cohort).

METHODS

Retrospective analysis of 2001-2007 employer data including employee medical and pharmacy claims, payroll, work absence, demographics, and dependent medical and pharmacy claims. Asthma diagnosis or pharmacy claims for asthma controller medications were used to identify employees with dependents younger than 12 years for the asthma cohort. Controls were identified based on dependent age and lack of an asthma diagnosis or pharmacy claim for a controller medication. All costs were calculated using 2-part regression models that controlled for demographics, job information, Charlson Comorbidity Index, and region. Costs were calculated for employee health care, prescriptions, sick leave, short- and long-term disability, and workers' compensation and dependent health care and prescriptions. Costs were compared for employees with children aged 0 through 3 years, 4 through 7 years, 8 through 11 years, and younger than 12 years.

RESULTS

Data were available for 11,794 asthma cohort employees and 64,812 controls. Statistically significant annual cost differences were identified for employee health care ($154, P < .001), prescriptions ($95, P < .001), sick leave (-$41, P < .001), short-term disability (-$41, P = .008), dependent health care ($862, P < .001), and prescriptions ($534, P < .001).

CONCLUSIONS

Pediatric asthma is associated with significant additional health care and prescription costs for both employees and dependents.

The impact of morbid obesity and bariatric surgery on comorbid conditions: a comprehensive examination of comorbidities in an employed population

OBJECTIVE

Find conditions with significantly different prevalence among employees diagnosed with morbid obesity (DMO). Examine the effect of bariatric surgery on the prevalence of all categories of comorbid conditions after surgery.

METHODS

This large employer retrospective database analysis used matching to create two cohorts: Those with a DMO and those without.

RESULTS

The DMO cohort had higher diagnosis rates in every Agency for Healthcare Research and Quality major diagnostic category except pregnancy, and it had significantly higher prevalence in 147 of 261 Agency for Health care Research and Quality specific categories. Those electing to undergo bariatric surgery experienced significant prevalence decreases in 26 of 261 specific categories.

CONCLUSION

Employees DMO are at higher risk for many serious diseases. Bariatric surgery has been effective in promoting weight loss and decreasing the rates of many serious comorbidities.

Absenteeism and health-benefit costs among employees with MS

OBJECTIVE

The purpose of this analysis was to assess the differences in lost time and health-benefit costs (HBCs) among employees treated with disease modifying treatments (DMTs) for multiple sclerosis (MS).

STUDY DESIGN

Employees with an MS diagnostic code (ICD-9 340.xx) and a DMT prescription claim (1/1/2001-6/30/2007) were identified from the HCMS Research Reference Database and assigned to DMT cohorts. The first prescription for the DMT was used as each person's index date. One-year outcomes included HBCs and absenteeism (lost time, comprising sick leave [SL], short- and long-term disability [STD/LTD], and workers' compensation).

METHODS

Demographics were compared using t-tests for continuous variables and chi-square tests for discrete variables. Two-part multivariate regression modeling (logistic regression combined with generalized linear regression) was used to determine annual HBCs and absenteeism for each cohort controlling for age, gender, job-related variables, and Charlson Comorbidity Score. All cost variables were inflated to US$2007.

RESULTS

Annual ranges among the DMTs were: HBCs $17,953-26,970 and absenteeism 7.33-20.67 days. Compared with glatiramer acetate ('C'), IFN-beta1a IM ('A') users had lower SL ($445, p = 0.0469) and STD ($969, p = 0.0164) costs; and IFN-beta1b ('B') users had lower medical costs ($2143, p = 0.0091). In addition, those treated with 'A' had 4.2 fewer SL days (p = 0.0101) compared with those treated with 'C'.

CONCLUSIONS

Patients treated with 'A' reported significantly lower SL costs, SL days, and STD costs than patients treated with 'C', suggestive of greater real world benefits with 'A'. Despite small sample sizes and the retrospective nature, the study provides interesting insights into the use of DMTs in MS. The study also revealed important areas of future research, specifically the need for development of methods to determine which MS patient groups respond best to which DMT treatments.

Risk of rehospitalization among bipolar disorder patients who are nonadherent to antipsychotic therapy after hospital discharge

PURPOSE

The relationship between nonadherence to antipsychotic medication after hospital discharge and risk of rehospitalization in patients who were previously hospitalized for treatment of bipolar disorder was studied.

METHODS

Administrative claims data from 2000 through 2006 were obtained from commercial insurance plans. Patients age 18-64 years who were discharged from a hospital with a diagnosis of bipolar disorder and given a prescription for an antipsychotic 0-14 days after discharge comprised the study sample. Adherence to antipsychotic medication was determined by measuring the number of unique days during which medication was supplied during the treatment period, a calculation known as the medication possession ratio (MPR). Rehospitalization was considered to be an indicator of relapse. A multivariate, stepwise logistic regression, which controlled for patient characteristics, type of bipolar disorder, general health status, and comorbid conditions, was used to assess the relationship between medication non-adherence and rehospitalization.

RESULTS

A total of 1973 individuals were included in the analyses. The mean +/- S.D. MPR for this patient population was 0.46 +/- 0.32. Patients whose MPR was 0.75 or greater had a lower risk of all-cause rehospitalization (odds ratio [OR], 0.730; 95% confidence interval [CI], 0.580-0.919) and a lower risk of a mental-health-related rehospitalization (OR, 0.759; 95% CI, 0.603-0.955). As medication adherence increased above the MPR of 0.75, the risk of rehospitalization significantly decreased.

CONCLUSION

Among patients who were previously hospitalized for treatment of bipolar disorder, those who were adherent to their antipsychotic medication at least 75% of the time had lower risks of all-cause rehospitalization and mental-health-related rehospitalization.

Quetiapine monotherapy in the treatment of depressive episodes of bipolar I and II disorder: Improvements in quality of life and quality of sleep

INTRODUCTION

The depressive symptoms of bipolar disorder impact health-related quality of life, quality of sleep and functioning. The BOLDER I and II trials demonstrated that quetiapine significantly improves depressive symptoms in patients with acute bipolar depression. Post-hoc analysis of the BOLDER I and II data permits a detailed investigation of the effects of quetiapine on these other measures in this patient population.

METHODS

Secondary analysis was performed on data from BOLDER I and II, which were two 8-week, double-blind, randomized, placebo-controlled studies of quetiapine at fixed doses (300 or 600 mg/day) in a total of 1051 patients with acute depressive episodes of bipolar I or II disorder. Measures included the Short-Form Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q SF) in BOLDER I and II, the Pittsburgh Sleep Quality Index (PSQI) in BOLDER I, and the Sheehan Disability Scale (SDS) in BOLDER II. Analyses of Q-LES-Q SF score changes were based on data from the combined BOLDER I and II populations, and analyses of PSQI and SDS score changes were based on BOLDER I and BOLDER II populations, respectively.

RESULTS

Assessments at day 57 by mixed-model repeated measures analysis demonstrated that quetiapine relative to placebo provided significant or numerical improvements in rating scale score on the Q-LES-Q SF (10.89 with 300 mg/day and 12.14 with 600 mg/day vs. 7.79 with placebo; p<0.001 for each quetiapine dose), PSQI (-5.34 and -6.00 vs. -3.35; p<0.001, each dose), and SDS (-7.78 and -8.25 vs. -6.49; p=0.156 and 0.054, respectively). Effect sizes at day 57 with quetiapine 300 and 600 mg/day, respectively, were 0.34 and 0.46 for Q-LES-Q SF, 0.59 and 0.79 for PSQI, and 0.17 and 0.23 for SDS. Improvements were evident at first post-baseline assessment on day 29 and were consistent over the majority of rating scale domains. Quetiapine was generally well tolerated and most adverse events were of mild to moderate intensity.

CONCLUSIONS

Quetiapine monotherapy is effective in improving impairment in important aspects of life that accompany improvements in depressive symptoms in patients with acute bipolar depression.

Bipolar depression: trial-based insights to guide patient care

For the majority of patients with bipolar disorder, major depressive episodes represent the most debilitating and difficult-to-treat illness dimension. Patients spend significantly more time depressed than manic or hypomanic, and attempt suicide more frequently during this illness phase, yet the availability of treatments remains limited. The discovery of more effective therapeutics for managing depressive episodes is arguably the greatest unmet need in bipolar disorder. This article provides an evidence-based summary of pharmacological treatments for the acute and longitudinal management of bipolar depression. Clinical trial results are reviewed for a diverse array of compounds, inclusive of traditional mood stabilizers (eg, lithium and divalproex), atypical antipsychotics, unimodal antidepressants, and modafinil. Where applicable, differences in efficacy across compounds are examined through discussion of number needed to treat and effect size determinations. A pragmatic clinical approach is presented for management of the depressed phase of bipolar disorder.

Objective measurement of work absence and on-the-job productivity: a case-control study of US employees with and without gastroesophageal reflux disease

OBJECTIVE

To establish an association between gastroesophageal reflux disease (GERD) and increased work absence, as well as reduced productivity while at work, by using objective productivity measurements.

METHODS

Retrospective case-control analysis of a database containing US employees' administrative health care and payroll data for employees (N = 11,653 with GERD; N = 255,616 without GERD) who were enrolled for at least one year in an employer-sponsored health insurance plan.

RESULTS

Employees with GERD had 41% more sick leave days (P < 0.0001), 59% more short-term disability days (P < 0.0001), 39% more long-term disability days (P = 0.1910), 48% more workers' compensation days (P < 0.0001), 4.4% lower objective productivity per hour worked (P = 0.0481), and 6.0% lower annual objective productivity (P = 0.0391) than the employees without GERD.

CONCLUSIONS

GERD is associated with a significant impact on employees' work absence and productivity while at work as measured using objective data.

Cost of gastro-oesophageal reflux disease to the employer: a perspective from the United States

BACKGROUND

Employers pay more than just salary for their employees. Previous studies have largely focused on direct medical and prescription drug costs of gastro-oesophageal reflux disease (GERD), and few have reported on total absenteeism costs.

AIMS

To examine the annual cost of illness of GERD in an employed US population by benefit category and by place of service for direct medical costs.

METHODS

Retrospective data analysis from 2001 to 2004. International Classification of Diseases (ICD)-9 codes (530.1, 530.10, 530.11, 530.12, 530.19, 530.81, 787.1x, 787.2x or 251.5x) were used to identify employees with and without GERD (the control group). Measures included medical and prescription drug claims, plus indirect costs for sick leave, short- and long-term disability, and workers' compensation. For a subset of the population, the direct medical claims were analysed by place of service.

RESULTS

Data were available for 267,269 eligible employees of which 11,653 had gastro-oesophageal reflux disease. GERD was associated with a mean incremental cost of US $3,355 per employee of which direct medical costs accounted for 65%, prescription drug costs 17%, and indirect costs 19%. The place of service 'out-patient hospital or clinic' accounted for the largest part (47%) of the difference in medical costs.

CONCLUSIONS

GERD is associated with substantial direct and indirect costs, which highlight the importance of managing the disease effectively.

Employee health and presenteeism: a systematic review

INTRODUCTION

Many employers focus on their large and easily measured cost of health care, yet until recently they have ignored the impact of health on productivity. Studies of some chronic conditions and some health risk factors suggest that costs of lost productivity exceed costs of medical care. This review will examine the literature to explore the link between employee health and on-the-job productivity, also known as presenteeism.

METHODS

Searches of Medline, CINAHL and PubMed were conducted in October 2006, with no starting date limitation with "presenteeism" or "work limitations" as keywords. A total of 113 studies were found using this method. Each study was evaluated based on the strength of the study design, statistical analyses, outcome measurement, and controlling of confounding variables.

RESULTS

Literature on presenteeism has investigated its link with a large number of health risks and health conditions ranging from exercise and weight to allergies and irritable bowel syndrome. As expected, the research on some topic areas is stronger than others.

CONCLUSIONS

Based on the research reviewed here, it can be said with confidence that health conditions such as allergies and arthritis are associated with presenteeism. Moreover, health risks traditionally measured by a health risk appraisal (HRA), especially physical activity and body weight, also show an association with presenteeism. The next step for researchers is to tease out the impact of individual health risks or combinations of risks and health conditions on this important outcome measure.

The impact of gout on work absence and productivity

OBJECTIVE

The goal of this analysis was to evaluate the impact of gout, a painful inflammatory arthritis condition, on an employed population's health-related work absence and objectively measured productivity output.

METHODS

Payroll, demographic, medical, pharmaceutical, sick leave, short- and long-term disability, and workers' compensation data were collected from multiple large employers with employees widely dispersed across the United States. Data were collected during the time period of 2001 to 2004 from approximately 300,000 employees. Objective productivity output data were also available for a subset of employees (captured electronically in the form of units of work processed per person). T-tests and chi-square tests were used to compare demographic data. Two-stage multivariate regression models were used to compare annual work absence and at-work productivity between employees with and without gout, while controlling for group differences in demographics, salary, other work-related variables, and comorbidities (using the Charlson Comorbidity Index).

RESULTS

The annual prevalence of gout was 4.7 per 1000 employees from 2001 to 2004. Employees with gout had 4.56 more annual absence days for all categories of health-related work absence than those without gout. Objective productivity (units of work processed) results were only available for a small subsample of employees (86 with gout and 27,472 without gout). Employees with gout processed 3.51% fewer units per hour worked and 2.38% fewer units per year than employees without gout (nonsignificant at P = 0.49 and P = 0.78, respectively).

CONCLUSION

This study suggests that gout has a substantial impact on work absence and may also negatively impact productivity.

Costs of physical and mental comorbidities among employees: a comparison of those with and without bipolar disorder

OBJECTIVE

To compare the cost and utilization of health care services for various comorbid conditions among employees with bipolar disorder (BPD) and two other population cohorts: employees without BPD and employees with other mental disorders (OMD).

METHODS

Retrospective database analysis on a 2-year study period, from January 1, 2001, through December 31, 2002 using adjudicated health insurance medical claims on more than 230 000 employees plus their eligible dependents. Study comparisons were performed among employees with BPD (cohort BPD), employees without BPD (cohort NBD), and employees with OMD (cohort OMD). Outcome measures included the cost and utilization of health services for various comorbid conditions as defined by the Agency for Healthcare Research and Quality (AHRQ); using 261 specific categories (SCs) and the 17 Major Diagnostic Categories (MDCs).

RESULTS

Employees in cohort BPD (n = 761) had greater average annual medical and prescription drug costs than the two other employee cohorts. Costs for cohort BPD were significantly greater (p <or= 0.05) than for cohort NBD (n = 229 145) for six of the 17 MDCs, including the categories of mental disorders (2036 dollars vs. 65 dollars), injury and poisoning (544 dollars vs. 162 dollars), musculoskeletal/connective tissue (607 dollars vs. 315 dollars), other conditions (274 dollars vs. 134 dollars), respiratory system (217 dollars vs. 104 dollars), and nervous system/sensory organs (225 dollars vs. 119 dollars). Similarly, comparisons across AHRQ's 261 SCs found the annual medical costs associated with BPD were greater in 137 (52%) of the 261 categories. Differences between cohort BPD and cohort OMD (n = 26 776) were significant (p <or= 0.05) in three MDCs, with BPD 3.4 times greater than OMD in the mental disorders category: 2036 dollars vs. 596 dollars, respectively.

CONCLUSION

Employees with BPD have greater cost and utilization of services due to various mental and physical comorbidities than either employees without BPD or employees with OMD. The findings are consistent with current literature concerning the comorbidities associated with BPD, and suggest that further longitudinal and observational investigation is necessary to attempt to improve diagnosis and treatment of not only BPD, but also associated targeted diseases commonly found in employees with BPD.

Incurring greater health care costs: risk stratification of employees with bipolar disorder

PURPOSE

To compare the costs of employees with bipolar disorder with other employee cohorts and to assess cost differences among employees with bipolar disorder of varying severity.

METHODS

Retrospective data analysis comparing employees with bipolar disorder (cohort 1) with employees without bipolar disorder (cohort 2), employees with other mental disorders (cohort 3), and employees with no mental disorders (cohort 4). Sick leave, short-term disability, long-term disability, and workers' compensation data were used to compare annual lost time and work-absence costs from January 1, 2001, through December 31, 2002. For bipolar disorder severity and risk stratification, quintiles were identified based on total medical and prescription drug costs and analyzed for many health benefits cost categories.

RESULTS

Cohort 1 was the most costly in nearly every health benefits cost category. All comparisons between cohort 1 and cohorts 2, 3, and 4 yielded significant (p ≤ .05) differences except for sick leave costs in cohorts 1 and 3. The aggregate health benefits costs for the highest-cost cohort 1 quintile were $70,616, or 21 times greater than the health benefits costs for the lowest-cost quintile ($3385). Medical comorbidity costs accounted for most of this difference ($51,495; p ≤ .05).

CONCLUSION

Employees with bipolar disorder are the most costly in nearly every health benefits category, with a small minority (2.4%) accounting for 20% of the costs. Employers need to identify and target high-risk ("high cost") employees with bipolar disorder and coexisting conditions that use resources more frequently for appropriate interventions that may include early screening and diagnosis, appropriate treatment, and/or behavioral strategies for improved adherence. These strategies have the potential to improve quality of patient care and reduce costs.