Effect of Reliable Recovery on Health Care Costs and Productivity Losses in Emotional Disorders

Despite the high economic costs associated with emotional disorders, relatively few studies have examined the variation in costs according to whether the patient has achieved a reliable recovery. The aim of this study was to explore differences in health care costs and productivity losses between primary care patients from a previous randomized controlled trial (RCT)-PsicAP-with emotional symptoms who achieved a reliable recovery and those who did not after transdiagnostic cognitive-behavioral therapy (TD-CBT) plus treatment as usual (TAU) or TAU alone. Sociodemographic and cost data were obtained for 134 participants treated at five primary care centers in Madrid for the 12-month posttreatment period. Reliable recovery rates were higher in the patients who received TD-CBT + TAU versus TAU alone (66% vs. 34%, respectively; chi-square = 13.78, df = 1, p < .001). Patients who did not achieve reliable recovery incurred more costs, especially associated with general practitioner consultations (t = 3.01, df = 132, p = .003), use of emergency departments (t = 2.20, df = 132, p = .030), total health care costs (t = 2.01, df = 132, p = .040), and sick leaves (t = 1.97, df = 132, p = .048). These findings underscore the societal importance of achieving a reliable recovery in patients with emotional disorders, and further support the value of adding TD-CBT to TAU in the primary care setting.

Cancer Screening after the Adoption of Paid-Sick-Leave Mandates

BACKGROUND

By the end of 2022, nearly 20 million workers in the United States have gained paid-sick-leave coverage from mandates that require employers to provide benefits to qualified workers, including paid time off for the use of preventive services. Although the lack of paid-sick-leave coverage may hinder access to preventive care, current evidence is insufficient to draw meaningful conclusions about its relationship to cancer screening.

METHODS

We examined the association between paid-sick-leave mandates and screening for breast and colorectal cancers by comparing changes in 12- and 24-month rates of colorectal-cancer screening and mammography between workers residing in metropolitan statistical areas (MSAs) that have been affected by paid-sick-leave mandates (exposed MSAs) and workers residing in unexposed MSAs. The comparisons were conducted with the use of administrative medical-claims data for approximately 2 million private-sector employees from 2012 through 2019.

RESULTS

Paid-sick-leave mandates were present in 61 MSAs in our sample. Screening rates were similar in the exposed and unexposed MSAs before mandate adoption. In the adjusted analysis, cancer-screening rates were higher among workers residing in exposed MSAs than among those in unexposed MSAs by 1.31 percentage points (95% confidence interval [CI], 0.28 to 2.34) for 12-month colorectal cancer screening, 1.56 percentage points (95% CI, 0.33 to 2.79) for 24-month colorectal cancer screening, 1.22 percentage points (95% CI, -0.20 to 2.64) for 12-month mammography, and 2.07 percentage points (95% CI, 0.15 to 3.99) for 24-month mammography.

CONCLUSIONS

In a sample of private-sector workers in the United States, cancer-screening rates were higher among those residing in MSAs exposed to paid-sick-leave mandates than among those residing in unexposed MSAs. Our results suggest that a lack of paid-sick-leave coverage presents a barrier to cancer screening. (Funded by the National Cancer Institute.).

Integrating quantitative and qualitative approaches to assess wintertime illness-related absenteeism and its direct and indirect costs among the private sector in Ulaanbaatar

Causes for employee absenteeism vary. The commonest cause of work absenteeism is “illness-related.” Mongolia’s capital city, Ulaanbaatar, experiences high employee absenteeism during the winter than during other seasons due to the combination of extreme cold and extreme air pollution. We identified direct and indirect costs of absenteeism attributed to air pollution among private-sector employees in Ulaanbaatar. Using a purposive sampling design, we obtained questionnaire data for 1,330 employees working for private-sector companies spanning six economic sectors. We conducted 26 employee focus groups and 20 individual employer in-depth interviews. We used both quantitative and qualitative instruments to characterize the direct and indirect costs of absence due to illnesses attributed to severe air pollution during wintertime. Female employees and employees with a young child at home were more likely to be absent. Respiratory diseases accounted for the majority of reported air pollution-related illnesses. All participants perceived that air pollution adversely affected their health. Individual employee direct costs related to absence totaled 875,000 MNT ($307.10) for an average of three instances of three-day illness-related absences during the winter. This sum included diagnostic and doctor visit-related, medication costs and hospitalization costs. Non-healthcare-related direct cost (transportation) per absence was 50,000₮ ($17.60). Individual indirect costs included the value of lost wages for the typical 3-day absence, amounting to 120,000₮ ($42.10). These total costs to employees, therefore, may amount to as much as 10% of annual income. The majority of sick absences were unpaid. Overall, the cost of wintertime absences is substantial and fell disproportionately on female employees with young children.

Friction Costs and the Chain of Vacancies Problem: A Novel Vacancy Multiplier Solution

OBJECTIVES

A key criticism of applying the friction cost approach (FCA) to productivity cost estimation is its focus on a single friction period. A more accurate estimate of the friction cost of worker absence requires consideration of the chain of secondary vacancies arising from the opening of a new primary vacancy. Currently, empirical evidence on this is almost absent. We suggest an original approach to empirically estimate productivity costs that include a chain of secondary vacancies.

METHODS

The vacancy multiplier is based on labor market flows and transition probabilities between states of employment, unemployment, and economic inactivity. It is a summed infinite geometric series using a common ratio e_t - the probability of an employed person filling a new job vacancy in a given year. We report vacancy multipliers for 30 European countries for 2011-2019.

RESULTS

The average multiplier across Europe is 2.21 (standard deviation [SD] = 0.40) in 2019, meaning that every new primary vacancy created a chain of secondary vacancies that increased the primary friction cost by a factor of 2.21. The equivalent multiplier is 1.99 (SD = 0.37) between 2011 and 2019. Romania had the lowest country-specific multiplier (1.11 in 2011), and Greece the highest (4.51 in 2011).

CONCLUSIONS

Our results highlight the extent of underestimation of current FCA costs, comprise a resource for future researchers, and provide an implementable formula to compute the multiplier for other countries.

Paid Leave and Access to Telework as Work Attendance Determinants during Acute Respiratory Illness, United States, 2017-2018

We assessed determinants of work attendance during the first 3 days after onset of acute respiratory illness (ARI) among workers 19-64 years of age who had medically attended ARI or influenza during the 2017-2018 influenza season. The total number of days worked included days worked at the usual workplace and days teleworked. Access to paid leave was associated with fewer days worked overall and at the usual workplace during illness. Participants who indicated that employees were discouraged from coming to work with influenza-like symptoms were less likely to attend their usual workplace. Compared with workers without a telework option, those with telework access worked more days during illness overall, but there was no difference in days worked at the usual workplace. Both paid leave benefits and business practices that actively encourage employees to stay home while sick are necessary to reduce the transmission of ARI and influenza in workplaces.

Costs of Health Service Use among Unemployed and Underemployed People with Mental Health Problems

BACKGROUND

Unemployment is associated with a high risk of experiencing mental illness. This can lead to stigmatisation, reduced quality of life, and long-term costs like increased healthcare expenditure and productivity losses for society as a whole. Previous research indicates evidence for an association between unemployment and higher mental health service costs, but there is insufficient information available for the German healthcare system.

AIM OF THE STUDY

This study aims to identify costs and cost drivers for health and social service use among unemployed people with mental health problems in Germany.

METHODS

A sample of 270 persons participated at baseline and six-month-follow-up. Healthcare and social service use was assessed using the Client Socio-Demographic and Service Receipt Inventory. Descriptive cost analysis was performed. Associations between costs and potential cost drivers were tested using structural equation modelling.

RESULTS

Direct mean costs for 12 months range from EUR 1265.13 (somatic costs) to EUR 2206.38 (psychiatric costs) to EUR 3020.70 (total costs) per person. Path coefficients indicate direct positive effects from the latent variable mental health burden (MHB) on stigma stress, somatic symptoms, and sick leave.

DISCUSSION

The hypothesis that unemployed people with mental health problems seek help for somatic symptoms rather than psychiatric symptoms was not supported. Associations between MHB and costs strongly mediated by sick leave indicate a central function of healthcare provision as being confirmation of the inability to work.

IMPLICATIONS FOR HEALTH POLICIES

Targeted interventions to ensure early help-seeking and reduce stigma remain of key importance in reducing long-term societal costs.

IMPLICATIONS FOR FURTHER RESEARCH

Future research should explore attitudes regarding effective treatment for the target group.

Sickness absence, disability pension and economic situation after a spontaneous subarachnoid haemorrhage among people of working age: a Swedish longitudinal nationwide cohort study

OBJECTIVES

The aim was to describe the course of sickness absence (SA), disability pension (DP) and work-related economic situation defined as earnings (EA) and disposable income (DI), after spontaneous subarachnoid haemorrhage (SAH). Associations of SA, DP, EA and DI with demographic factors were also studied.

DESIGN

A longitudinal cohort study of all 1932 people in Sweden who in January 2005 to December 2010 had a first time SAH when aged 17 to 64 years and survived during the 3-year follow-up. Microdata from four nationwide administrative registers were used.

MAIN OUTCOME MEASURES

Primary outcome was the presence of SA and DP and how this changed during the study period of 5 years (the year before, the year of SAH and the following 3 years). The secondary outcome was the development of the income variables EA and DI. Demographic factors analysed were sex, age, source of bleeding, country of birth, family situation, educational level and type of living area.

RESULTS

The year before the SAH, 7.9% of women and 4.6% of men had some SA registered (p<0.004). A model consisting of female sex, higher education and living single predicted having SA that year. At the end of the follow-up, 39.2% of women and 28.3% of men had SA and/or DP (p<0.0001). A model consisting of female sex, living in a village/ rural area and having a defined bleeding source for the SAH was predicting having SA and/or DP at end of follow-up. The levels of EA decreased, while DI increased during follow-up and were at the end of follow-up associated with age, sex, type of living area, country of birth, educational level and family situation. The women's EA was lower than the men's during all years.

CONCLUSIONS

SAH influenced future SA, DP, as well as EA. Both SA, DP and the economic variables studied were predicted by models including sex.

Moving to productivity: The benefits of healthy buildings

Health is a critical factor for the generation of value by workers. Companies bear substantial costs associated with absenteeism and presenteeism among their employees. This study investigates the impact of the environmental conditions in the workplace on the health and job satisfaction of employees, as core factors of productivity. We provide evidence based on a natural experiment, in which 70% of the workforce of a municipality in the Netherlands was relocated to a building with a design focused on sustainability and health and well-being. We construct a longitudinal dataset based on individual surveys of the entire municipality workforce and include measures before and after the move. The estimation results show a significant improvement in the perceived environmental conditions, as well as in the health and well-being of the relocated workers, measured by the drop in incidence of sick building syndrome symptoms. Results are heterogeneous based on age: older groups of employees enjoy larger health impacts. The relocation effects remain persistent in the medium term (two years after the moving date). Importantly, a mediation analysis suggests that the achieved improvements in health and well-being lead to significantly enhanced job satisfaction and a 2% reduction in the prevalence of sick leave.

The fiscal consequences of public health investments in disease-modifying therapies for the treatment of multiple sclerosis in Sweden

Background and aims: The economic consequences of multiple sclerosis (MS) are broader than those observed within the health system. The progressive nature suggests that people will not be able to live a normal productive life and will gradually require public benefits to maintain living standards. This study investigates the public economic impact of MS and how investments in disease-modifying therapies (DMTs) influence the lifetime costs to government attributed to changes in lifetime tax revenue and disability benefits based on improved health status linked to delayed disease progression.Methods: Disease progression rates from previous MS Markov cohort models were applied to interferon beta-1a, peginterferon beta-1a, dimethyl fumarate, and natalizumab using a public economic framework. The established relationship between expanded disability status scale and work-force participation, annual earnings, and disability rates for each DMT were applied. Subsequently, we assessed the effect of DMTs on discounted governmental costs consisting of health service costs, social insurance and disability costs, and changes in lifetime tax revenues.Results: Fiscal benefits attributed to informal care and community services savings for interferon beta-1a, peginterferon beta-1a, dimethyl fumarate, and natalizumab were SEK340,387, SEK486,837, SEK257,330, and SEK958,852 compared to placebo, respectively. Tax revenue gains linked to changes in lifetime productivity for interferon beta-1a, peginterferon beta-1a, dimethyl fumarate, and natalizumab were estimated to be SEK27,474, SEK39,659, SEK21,661, and SEK75,809, with combined fiscal benefits of cost savings and tax revenue increases of SEK410,039, SEK596,592, SEK326,939, and SEK1,208,023, respectively.Conclusion: The analysis described here illustrates the broader public economic benefits for government attributed to changes in disease status. The lifetime social insurance transfer costs were highest in non-treated patients, and lower social insurance costs were demonstrated with DMTs. These findings suggest that focusing cost-effectiveness analysis only on health costs will likely underestimate the value of DMTs.

Older Workers in the Time of COVID-19: The Senior Community Service Employment Program and Implications for Social Work

It has long been the goal of many gerontological social work scholars to increase the ability and opportunity for people to be engaged in paid and unpaid work throughout the life course. Yet the COVID-19 pandemic is revealing and exacerbating the financial insecurity of many older adults. In this paper, we review information related to older workers and how they might be affected by this pandemic and its aftermath, paying particular attention to the most socioeconomically and physically vulnerable older workers. We also offer first-hand experiences from our careers working with and conducting scholarship on older workers, paying particular attention to recent actions by many in the Senior Community Service Employment Program (SCSEP) network to provide paid sick leave to its low-income, older adult participants. We conclude with implications for social work scholarship and teaching, noting the uptick in technology use among older adults and the disparities that remain, as well as teaching that integrates discussions on the lifelong and cumulative effects of inequalities and marginalization and the need for additional researcher, student, and community collaborations.

How does the integration of collaborative care elements in a gatekeeping system affect the costs for mental health care in Germany?

Mental disorders are widespread, debilitating and associated with high costs. In Germany, usual care (UC) for mental disorders is afflicted by poor coordination between providers and long waiting times. Recently, the primary alternative to UC-the gatekeeping-based general practitioners (GP) program-was extended by the collaborative Psychiatry-Neurology-Psychotherapy (PNP) program, which is a selective contract designed to improve mental health care and the allocation of resources. Here, we assess the effects of the GP program and the PNP program on costs for mental health care. We analyzed claims data from 2014 to 2016 of 55,472 adults with a disorder addressed by PNP to compare costs and sick leave days between PNP, the GP program and UC. The individuals were grouped and balanced via entropy balancing to adjust for potentially confounding covariates. We employed a negative binomial model to compare sick leave days and two-part models to compare sick pay, outpatient, inpatient and medication costs over a 12-month period. The PNP program significantly reduced sick pay by 164€, compared to UC, and by 177€, compared to the GP program. Consistently, sick leave days were lower in PNP. We found lower inpatient costs in PNP than in UC (-194€) and in the GP program (-177€), but no reduction in those shares of inpatient costs that accrued in psychiatric or neurological departments. Our results suggest that integrating collaborative care elements in a gatekeeping system can favourably impact costs. In contrast, we found no evidence that the widely implemented GP program reduces costs for mental health care.

Health care and productivity costs for isolated tibia shaft fracture admissions in The Netherlands

The aim of this study was to provide a detailed overview of age and gender specific health care costs and costs due to lost productivity for hospital admitted patients with an isolated tibia shaft fracture in The Netherlands between 2008 and 2012. Injury cases and length of hospital stay were extracted from the National Medical Registration. Information on extramural health care and work absence were retrieved from a patient follow-up survey on health care use. Medical costs included ambulance care, in- hospital care, general practitioner care, home care, physical therapy, and rehabilitation/nursing care. An incidence-based cost model was applied to calculate direct health care costs and lost productivity in 2012. Total direct health care costs for all patients admitted with a tibia shaft fracture (n = 1,635) were €13.6 million. Costs for productivity loss were € 23.0 million. Total costs (direct health care and lost productivity) per patient were highest for men aged 40-49 years mainly due to lost productivity, and for women aged > 80 years, due to high direct medical costs.

Usual care including home exercise with versus without spa therapy for chronic low back pain: protocol for the LOMBATHERM' study, a multicentric randomised controlled trial

BACKGROUND

Low back pain is highly prevalent and a major source of disability worldwide. Spa therapy is frequently used to treat low back pain, but the associated level of evidence for efficacy is insufficient. To fill this knowledge gap, this protocol proposes an appropriately powered, prospective, evaluator-blinded, multi-centre, two-parallel-arm, randomised (1:1), controlled trial that will compare spa therapy in addition to usual care including home exercise (UCHE) versus UCHE alone for the treatment of chronic low back pain.

METHODS

Eligible patients (anticipated sample size of 358) will have had low back pain for more than 3 months and scores for pain greater than 40 mm on a visual analogue scale (VAS). Following initial consent for UCHE and baseline evaluations, patients are randomised (1:1) to UCHE alone, or UCHE plus spa therapy (18 days of mud packs, underwater massages, showers and water exercises under medical supervision). Patients in the latter arm will be requested to sign an additional consent form as per Zelen randomisation. Follow-up visits will occur at approximately months 1, 6 and 12 and (along with baseline assessments) will cover changes over time in VAS pain scores, the impact of lower back pain on daily life (the Rolland and Morris Disability Questionnaire (RMDQ)), inappropriate fears and beliefs about lower back pain (the fear, avoidance, belief questionnaire (FABQ)), general quality of life (the Euroqol Group 5 dimension, 5 level questionnaire (EQ-5D-5 L)), Patient Acceptable Symptom State (PASS), consumption of analgesic drugs and nonsteroidal anti-inflammatory drugs (NSAIDs), and overall state of health. Health resource use and days of sick leave (and subsequently the associated costs) will also be recorded. The primary outcome is the presence/absence of a clinically relevant change (improvement of at least 30%) in the VAS score for pain at 6 months.

DISCUSSION

Despite the fact that previous, rather dated recommendations encourage spa therapy for the treatment of low back pain, the current literary corpus is methodologically poor. This protocol has been designed to provide results spanning a thorough range of outcomes at the highest evidence level possible.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03910023. Registered on 10 April 2019.

Occupational Injuries Involving Medical Imaging and Radiation Therapy Professionals

PURPOSE

To determine the types of occupational injuries medical imaging and radiation therapy professionals experience in addition to the length of medical leave of absence, receipt of financial compensation, and ability to perform the same job duties on returning to work.

METHODS

Using a quantitative approach, a random sample of 10 000 American Society of Radiologic Technologists members was invited to complete a survey detailing occupational injuries experienced while working as a medical imaging or radiation therapy professional. Data were collected using Qualtrics and analyzed with IBM's SPSS.

RESULTS

Of the 401 participants in this study, more than half (251, 62.6%) experienced occupational injuries, with the majority of those being muscular injuries (205, 81.7%). Of the 251 participants who experienced an occupational injury, 109 (43.4%) reported a medical leave of absence of less than 1 week, 61 (24.3%) received financial assistance from their employer, and 231 (92%) indicated they were able to resume their previous job duties on returning to work.

DISCUSSION

Many study participants acknowledged that despite being injured they continued to work impaired without taking a medical leave of absence or did not report the injury to administration or risk management. Impaired employees can further aggravate pre-existing medical conditions and possibly trigger a permanent disability or chronic ailment by continuing to perform the same work activities as when they were injured initially. Department managers and supervisors should encourage medical imaging and radiation therapy professionals to report all injuries so that appropriate measures (eg, informing risk management, filing a workers' compensation claim, or modifying job responsibilities) can be initiated.

CONCLUSION

Additional research is warranted to explore strategies for preventing or decreasing the incidence of occupational injuries in the medical imaging and radiation therapy profession that can be implemented individually (eg, practicing proper patient handling techniques) or organizationally (eg, staffing an appropriate number of personnel for the workload).

Acute and long-term costs of 268 peripheral nerve injuries in the upper extremity

Background

Peripheral nerve injury in the upper extremity is linked to high socioeconomic burden, yet cost-analyses are rare and from small cohorts. The objective of this study was to determine the costs and long-term socioeconomic effects of peripheral nerve injuries in the upper extremity in Germany.

Methods

We analyzed data of 250 patients with 268 work-related upper extremity nerve injuries from acute treatment to long-term follow-up on rehabilitation, sick-leave and disability-pension.

Results

Patients were on average 39.9±14.2 years old, male (85%) and mean inpatient treatment was 7±6 days. Location of nerve was 8% (N = 19) proximal to the wrist, 26% (N = 65) at the wrist and metacarpus, and 66% (N = 166) at phalangeal level. Acute in-patient treatment for (single) median nerve injury accounted for 66% with hospital reimbursement of 3.570€, ulnar nerve injury for 24% and 2.650€ and radial nerve injury for 10% and 3.166€, all including finger nerve injuries. The remaining were combined nerve injuries, with significantly higher costs, especially if combined with tendon 5.086€ or vascular injury 4.886€. Based on location, nerve injuries proximal to the wrist averaged 5.360±6.429€, at the wrist and metacarpus 3.534±2.710€ and at the phalangeal level 3.418±3.330€. 16% required rehabilitation with average costs of 5.842€ and stay of 41±21 days. Sick leave was between 11–1109 days with an average of 147 days with socioeconomic costs of 197€/day, equaling on average 17.640€. 30% received a mean yearly disability pension of 3.187€, that would account to 102.167€ per lifetime.

Conclusion

This large German patient sample indicates that nerve injury has a major impact on function and employment, resulting in significant health care costs. Both proximal and distal nerve injuries led to long-term disability, subsequent sick-leave and in 30% to permanent disability pension. These data are determined to support future studies and health economical work on prevention, treatment and rehabilitation of these often small injuries with great consequences.

Chronic obstructive pulmonary disease (COPD) in Spain and the different aspects of its social impact: a multidisciplinary opinion document

Chronic obstructive pulmonary disease (COPD) is one of the most prevalent diseases in the World, and one of the most important causes of mortality and morbidity. In adults 40 years and older, it affects more than 10% of the population and has enormous personal, family and social burden. Tobacco smoking is its main cause, but not the only one, and there is probably a genetic predisposition that increases the risk in some patients. The paradigm of this disease is changing in Spain, with an increase of women that has occurred in recent years. Many of the physio pathological mechanisms of this condition are well known, but the psychological alterations to which it leads, the impact of COPD on relatives and caregivers, the limitation of daily life observed in these patients, and the economic and societal burden that they represent for the health system, are not so well-known. A major problem is the high under-diagnosis, mainly due to difficulties for obtaining, in a systematic way, spirometries in hospitals and health-care centers. For this reason, the Fundación de Ciencias de la Salud and the Spanish National Network Center for Research in Respiratory Diseases (CIBERES) have brought together experts in COPD, patients and their organizations, clinical psychologists, experts in health economics, nurses and journalists to obtain their opinion about COPD in Spain. They also discussed the scientific bibliometrics on COPD that is being carried out from the CIBERES and speculated on the future of this condition. The format of the meeting consisted in the discussion of a series of questions that were addressed by different speakers and discussed until a consensus conclusion was reached.

Association of long working hours and health-related productivity loss, and its differential impact by income level: A cross-sectional study of the Korean workers

OBJECTIVES

We aimed to explore the association between long working hours and health-related productivity loss (HRPL), due to either sickness, absenteeism or presenteeism, stratified by household income level.

METHODS

From January 2020 to February 2020, data were collected using a web-based questionnaire. A total of 4197 participants were randomly selected using the convenience sampling method. The nonparametric association between weekly working hours and HRPL was determined. Subsequently, a stratified analysis was conducted according to household income (1st, 2nd, and 3rd tertiles). Finally, the differences in HRPL of the different working hour groups (<40, 40, 40-51, and ≥52 hours) were investigated using a multivariate linear regression model.

RESULTS

Long working hours were more significantly associated with HRPL, as compared to the 'standard' working hours (40 hours/week). A larger proportion of productivity loss was associated with the presenteeism of workers, rather than absenteeism. The relationship between HRPL and weekly working hours was more prominent in the lower household income group.

CONCLUSIONS

The results of our study indicate that HRPL is associated with long working hours, especially in the lower household income group. Reducing the workload for the individual employee to a manageable level and restructuring sick leave policies to effectively counteract absenteeism and presenteeism may be a feasible option for better labor productivity and employee health.

Impact of interventions on work-related outcomes for individuals with musculoskeletal injuries after road traffic crash: a systematic review protocol

BACKGROUND

Musculoskeletal injuries are the most common non-fatal injury from road traffic crashes. Even when the injuries are mild, they can cause pain which can affect return to work rates and work ability post-crash. Workplace output losses are the biggest cost from traffic crash-related injuries. There is a need to identify effective interventions that can improve work-related outcomes (e.g. time to return to work, sick leave, and work ability) in this group and a need to understand the intervention components, external factors, and participant characteristics that may be associated with improvement.

METHODS

A systematic review will be conducted using seven databases and search terms related to road traffic crash, musculoskeletal injury, work-related outcomes, and study design. Intervention studies will be eligible if they report on at least one work-related outcome, include adults with a traffic crash-related musculoskeletal injury (e.g. fracture or whiplash), include a comparison group, and are written in English. Interventions can be medical, therapeutic, work-based, multicomponent, or other. Two researchers will independently screen titles and abstracts, review full texts for inclusion in the review, and perform the data extraction. The main outcomes of the review will be time until return to work and duration of sick leave. The results will be narratively described, with meta-analyses conducted where possible.

DISCUSSION

This review will explore the effectiveness of interventions in individuals with traffic crash-related musculoskeletal injury on work-related outcomes and will act as a useful source for researchers, policy makers, and stakeholders when developing and implementing interventions in this group.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018103746.

Facilitators, barriers and ethical values related to the coordination of return-to-work among employees on sick leave due to common mental disorders: a protocol for a qualitative study (the CORE-project)

INTRODUCTION

Diagnoses related to common mental disorders such as anxiety, depression, adjustment disorders and stress-related disorders are one of the leading causes of long-term sick leave for both women and men in Organisation for Economic Co-operation and Development countries. To increase the rate of return-to-work workplace involvement in a coordinated return-to-work process has been included in recent best practice guidelines. This form of cooperation is a complex process, involving political structures and a wide range of stakeholders. The study's first aim is to describe facilitators and barriers to the coordination of return-to-work from the perspectives of: (A) employees on sick leave due to common mental disorders, (B) employers, (C) rehabilitation coordinators, (D) physicians and (E) other stakeholders. The second aim is to identify ethical issues that arise in the coordination of return-to-work and analyse how these can be resolved.

METHODS AND ANALYSIS

The study has a qualitative design using interviews with employees on sick leave due to common mental disorders, employers, rehabilitation coordinators, physicians and other stakeholders. The study is conducted in the Swedish primary healthcare. Employees, employers and rehabilitation coordinators are recruited via primary healthcare centres. Rehabilitation coordinators receive information about the study and those who consent to participation are asked to recruit employees and employers. Interview guides have been developed from the consolidated framework for implementation research and ethical values and norms found in Swedish healthcare, social services and workplace legislation. Data will be analysed with qualitative content analysis reflecting manifest and latent content, and ethical issues will be analysed by means of reflective equilibrium methodology.

ETHICS AND DISSEMINATION

The study was approved by the Regional Ethical Review Board in Stockholm, Sweden (Reg.no 2018/677-31/2 and 2018/2119-32). The findings will be disseminated through publication in scientific journals, social media, seminars and national and international conferences.

Sickness absence and disability pension before and after first childbirth and in nulliparous women: longitudinal analyses of three cohorts in Sweden

OBJECTIVE

Childbirth is suggested to be associated with elevated levels of sickness absence (SA) and disability pension (DP). However, detailed knowledge about SA/DP patterns around childbirth is lacking. We aimed to compare SA/DP across different time periods among women according to their childbirth status.

DESIGN

Register-based longitudinal cohort study.

SETTING

Sweden.

PARTICIPANTS

Three population-based cohorts of nulliparous women aged 18-39 years, living in Sweden 31 December 1994, 1999 or 2004 (nearly 500 000/cohort).

PRIMARY AND SECONDARY OUTCOME MEASURES

Sum of SA >14 and DP net days/year.

METHODS

We compared crude and standardised mean SA and DP days/year during the 3 years preceding and the 3 years after first childbirth date (Y_-3 to Y₊₃), among women having (1) their first and only birth during the subsequent 3 years (B1), (2) their first birth and at least another delivery (B1+), and (3) no childbirths during follow-up (B0).

RESULTS

Despite an increase in SA in the year preceding the first childbirth, women in the B1 group, and especially in B1+, tended to have fewer SA/DP days throughout the years than women in the B0 group. For cohort 2005, the mean SA/DP days/year (95% CIs) in the B0, B1 and B1+ groups were for Y_-3: 25.3 (24.9-25.7), 14.5 (13.6-15.5) and 8.5 (7.9-9.2); Y_-2: 27.5 (27.1-27.9), 16.6 (15.5-17.6) and 9.6 (8.9-10.4); Y_-1: 29.2 (28.8-29.6), 31.4 (30.2-32.6) and 22.0 (21.2-22.9); Y₊₁: 30.2 (29.8-30.7), 11.2 (10.4-12.1) and 5.5 (5.0-6.1); Y₊₂: 31.7 (31.3-32.1), 15.3 (14.2-16.3) and 10.9 (10.3-11.6); Y₊₃: 32.3 (31.9-32.7), 18.1 (17.0-19.3) and 12.4 (11.7-13.0), respectively. These patterns were the same in all three cohorts.

CONCLUSIONS

Women with more than one childbirth had fewer SA/DP days/year compared with women with one childbirth or with no births. Women who did not give birth had markedly more DP days than those giving birth, suggesting a health selection into childbirth.

Earnings among people with multiple sclerosis compared to references, in total and by educational level and type of occupation: a population-based cohort study at different points in time

OBJECTIVES

To investigate earnings among people with multiple sclerosis (PwMS) before and after MS diagnosis compared with people without MS, and if identified differences were associated with educational levels and types of occupations. Furthermore, to assess the proportions on sickness absence (SA) and disability pension (DP) in both groups.

DESIGN

Population-based longitudinal cohort study, 10 years before until 5 years after MS diagnosis.

SETTING

Working-age population using microdata linked from nationwide Swedish registers.

PARTICIPANTS

Residents in Sweden in 2004 aged 30-54 years with MS diagnosed in 2003-2006 (n=2553), and references without MS (n=7584) randomly selected by stratified matching.

OUTCOME MEASURES

Quartiles of earnings were calculated for each study year prior to and following the MS diagnosis. Mean earnings, by educational level and type of occupation, before and after diagnosis were compared using t-tests. Tobit regressions investigated the associations of earnings with individual characteristics. The proportions on SA and/or DP, by educational level and type of occupation, for the diagnosis year and 5 years later were compared.

RESULTS

Differences in earnings between PwMS and references were observed beginning 1 year before diagnosis, and increased thereafter. PwMS had lower mean earnings for the diagnosis year (difference=SEK 28 000, p<0.05), and 5 years after diagnosis, this difference had more than doubled (p<0.05). These differences remained after including educational level and type of occupation. Overall, the earnings of PwMS with university education and/or more qualified occupations were most like their reference peers. The proportions on SA and DP were higher among PwMS than the references.

CONCLUSIONS

The results suggest that the PwMS' earnings are lower than the references' beginning shortly before MS diagnosis, with this gap increasing thereafter. Besides SA and DP, the results indicate that educational level and type of occupation are influential determinants of the large heterogeneity of PwMS' earnings.

Economic Burden of Adult Patients with Moderate to Severe Atopic Dermatitis Indicated for Systemic Treatment

Given the introduction of new therapies targeting specific immune pathways for atopic dermatitis (AD), information on the economic burden of AD patients is needed. Direct costs (medication use and healthcare resource utilization) and costs of productivity loss were studied in 90 adult patients with AD indicated for systemic treatment. Costs were calculated for patients with controlled (Investigator Global Assessment (IGA) 0-2) and uncontrolled (IGA 3-5) disease at inclusion. Mean (95% confidence interval (95% CI)) total direct costs were €5,191 (€4,382-6,019) per patient per year (PPY), €4,401 (€3,695-5,215) for patients with controlled AD vs. €6,993 (€5,552-8,406), mean difference €2,593 (€820-4,282) (p=0.014) for patients with uncontrolled AD. Costs of productivity loss were €10,040 (€6,260-14,012) PPY for the total group, €6,886 (€4,188-10,129) PPY for patients with controlled AD vs. €13,702 (€6,124-22,996) for patients with uncontrolled AD, mean difference €6,816 (-€1,638-16,677; p=0.148). Total costs (direct costs+costs of productivity loss) were €15,231 (€11,487-19,455) PPY for the total group, €11,287 (€7,974-15,436) for patients with controlled AD vs. €20,695 (€14,068-34,564), mean difference €9,408 (-€119-19,964) (p=0.077) for patients with uncontrolled AD. Patients with AD using systemic immunosuppressive treatment incur considerable direct costs and costs of productivity loss.

Nonreimbursed Costs Incurred by Living Kidney Donors: A Case Study From Ontario, Canada

BACKGROUND

Living donors may incur out-of-pocket costs during the donation process. While many jurisdictions have programs to reimburse living kidney donors for expenses, few programs have been evaluated.

METHODS

The Program for Reimbursing Expenses of Living Organ Donors was launched in the province of Ontario, Canada in 2008 and reimburses travel, parking, accommodation, meals, and loss of income; each category has a limit and the maximum total reimbursement is $5500 CAD. We conducted a case study to compare donors' incurred costs (out-of-pocket and lost income) with amounts reimbursed by Program for Reimbursing Expenses of Living Organ Donors. Donors with complete or partial cost data from a large prospective cohort study were linked to Ontario's reimbursement program to determine the gap between incurred and reimbursed costs (n = 159).

RESULTS

The mean gap between costs incurred and costs reimbursed to the donors was $1313 CAD for out-of-pocket costs and $1802 CAD for lost income, representing a mean reimbursement gap of $3115 CAD. Nondirected donors had the highest mean loss for out-of-pocket costs ($2691 CAD) and kidney paired donors had the highest mean loss for lost income ($4084 CAD). There were no significant differences in the mean gap across exploratory subgroups.

CONCLUSIONS

Reimbursement programs minimize some of the financial loss for living kidney donors. Opportunities remain to remove the financial burden of living kidney donors.

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

OBJECTIVES

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

INTERVENTIONS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Steam ablation versus stripping of great saphenous varicose veins

BACKGROUND

Use of new technology can lead to changes in the treatment course for patients and in treatment costs for the health service. The aim of this study was to compare sickness absence and time to resumption of daily activities, as well as treatment costs, for two surgical treatments for varicose veins: endovenous steam ablation and vein stripping.

MATERIAL AND METHOD

This prospective observational study included 46 patients treated with steam ablation and 37 treated with vein stripping in the period 2015-2016. The two groups were matched with respect to age, sex, occupational status and classification. After treatment, patients were interviewed every other week until daily activities had been resumed. Detailed information on expenditure related to personnel, equipment, premises and materials was used to calculate the cost of treatment.

RESULTS

Patients treated with steam ablation resumed daily activities after a median of 0 (interquartile range 0-2) days versus 4 (2-7) days for vein stripping (p < 0.001), and sporting activities after 4 (2-9) days versus 11 (3-19) days (p < 0.004). For patients in employment, sickness absence after steam ablation was 2 (2-5) days versus 14 (6-21) for patients treated with vein stripping (p < 0.001). The estimated treatment cost for steam ablation was NOK 5 973, compared with NOK 10 109 for vein stripping.

INTERPRETATION

Steam ablation led to shorter convalescence and sickness absence for the patient, and lower costs for the hospital. Reduced sickness absence also implies lower costs for society.

Structured physiotherapy including a work place intervention for patients with neck and/or back pain in primary care: an economic evaluation

A cluster-randomized controlled trial, WorkUp, was conducted for working-aged patients at risk of sick leave or on short-term sick leave due to acute/subacute neck and/or back pain in Sweden. The purpose of WorkUp was to facilitate participants to stay at work or in case of sick leave, return-to-work. The aim of this study was to study whether the WorkUp trial was cost-effective. Patients in the intervention and reference group received structured evidence-based physiotherapy, while patients in the intervention group also received a work place dialogue with the employer as an add-on. The participants, 352 in total, were recruited from 20 physiotherapeutic units in primary healthcare in southern Sweden. The economic evaluation was performed both from a healthcare and a societal perspective with a 12-month time frame with extensive univariate sensitivity analyses. Results were presented as incremental cost-effectiveness ratios (ICER) with outcomes measured as quality-adjusted life-years (QALY) and proportion working for at least 4 weeks in a row without reported sick leave at 12-month follow-up. From the healthcare perspective, the ICER was €23,606 (2013 price year) per QALY gain. From the societal perspective the intervention was dominating, i.e.. less costly and more effective than reference care. Bootstrap analysis showed that the probability of the intervention to be cost-effective at €50,000 willingness-to-pay per QALY was 85% from the societal perspective. Structured evidence-based physiotherapeutic care together with workplace dialogue is a cost-effective alternative from both a societal and a healthcare perspective for acute/subacute neck and/or back pain patients.Trial registration ClinicalTrials.gov: NCT02609750.

Occasional and persistent frequent attenders and sickness absences in occupational health primary care: a longitudinal study in Finland

OBJECTIVES

Frequent attenders (FAs) create a substantial portion of primary care workload but little is known about FAs' sickness absences. The aim of the study is to investigate how occasional and persistent frequent attendance is associated with sickness absences among the working population in occupational health (OH) primary care.

SETTING AND PARTICIPANTS

This is a longitudinal study using medical record data (2014-2016) from an OH care provider in Finland. In total, 59 676 patients were included and categorised into occasional and persistent FAs or non-FAs. Sick-leave episodes and their lengths were collected along with associated diagnostic codes. Logistic regression was used to analyse associations between FA status and sick leaves of different lengths (1-3, 4-14 and ≥15 days).

RESULTS

Both occasional and persistent FA had more and longer duration of sick leave than non-FA through the study years. Persistent FAs had consistently high absence rates. Occasional FAs had elevated absence rates even 2 years after their frequent attendance period. Persistent FAs (OR=11 95% CI 7.54 to 16.06 in 2016) and occasional FAs (OR=2.95 95% CI 2.50 to 3.49 in 2016) were associated with long (≥15 days) sickness absence when compared with non-FAs. Both groups of FAs had an increased risk of long-term sick leaves indicating a risk of disability pension.

CONCLUSION

Both occasional and persistent FAs should be identified in primary care units caring for working-age patients. As frequent attendance is associated with long sickness absences and possibly disability pensions, rehabilitation should be directed at this group to prevent work disability.

Child Influenza Vaccination and Adult Work Loss: Reduced Sick Leave Use Only in Adults With Paid Sick Leave

INTRODUCTION

Children are a population of interest for influenza. They are at increased risk for severe influenza, comprise a substantial portion of influenza morbidity, and significantly contribute to its transmission in the household and subsequent parental work loss. The association between influenza vaccination and work loss prevention, however, has rarely been studied, and the sparse existing literature has very limited generalizability to U.S. adults, thus requiring better characterization.

METHODS

Using pooled National Health Interview Survey data (2013-2015, analyses conducted in 2018) nationally representative of working U.S. adults with household children (n=23,014), zero-inflated negative binomial regression examined the association of child influenza vaccination (exposure) with sick days (outcome) stratified by paid sick leave (no: n=10,741, yes: n=12,273).

RESULTS

Child influenza vaccination was associated with significantly lower sick day usage, but only among adults with paid sick leave (prevalence rate ratio=0.79, 95% CI=0.67, 0.93), equating to average annual sick days of 4.07 vs 3.29 in adults with unvaccinated versus vaccinated household children (difference=0.78 fewer days annually).

CONCLUSIONS

Influenza vaccination of children is associated with reduced sick leave in household adults, helping to keep the workforce healthy and reduce influenza's costly annual economic burden. This only occurred among adults with paid sick leave, however, which is distributed inequitably by income, education, gender, occupation, and race/ethnicity. Health in All Policies considers downstream health effects of social and economic policy; the failure of federal policy to ensure paid sick leave likely contributes to propagating influenza and health inequities.

Friction Cost Estimates of Productivity Costs in Cost-of-Illness Studies in Comparison with Human Capital Estimates: A Review

Cost-of-illness (COI) studies often include the 'indirect' cost of lost production resulting from disease, disability, and premature death, which is an important component of the economic burden of chronic conditions assessed from the societal perspective. In most COI studies, productivity costs are estimated primarily as the economic value of production forgone associated with loss of paid employment (foregone gross earnings); some studies include the imputed value of lost unpaid work as well. This approach is commonly but imprecisely referred to as the human capital approach (HCA). However, there is a lack of consensus among health economists as to how to quantify loss of economic productivity. Some experts argue that the HCA overstates productivity losses and propose use of the friction cost approach (FCA) that estimates societal productivity loss as the short-term costs incurred by employers in replacing a lost worker. This review sought to identify COI studies published during 1995-2017 that used the FCA, with or without comparison to the HCA, and to compare FCA and HCA estimates from those studies that used both approaches. We identified 80 full COI studies (of which 75% focused on chronic conditions), roughly 5-8% of all COI studies. The majority of those studies came from three countries, Canada, Germany, and the Netherlands, that have officially endorsed use of the FCA. The FCA results in smaller productivity loss estimates than the HCA, although the differential varied widely across studies. Lack of standardization of HCA and FCA methods makes productivity cost estimates difficult to compare across studies.

Annual costs attributed to atrial fibrillation management: cross-sectional study of primary healthcare electronic records

Atrial fibrillation (AF) is the most common chronic arrhythmia, with increasing healthcare and economic burden and a prevalence which increases with progressive ageing. This study aims to describe overall annual costs per patient for management of non-valvular AF in a primary healthcare (PHC) setting and compare these costs between the groups of patients treated with vitamin K antagonists, antiplatelets or non-treated through a population-based study conducted with electronic health records. We analysed annual costs per person of 19,787 patients in 2012; PHC visits, hospital admissions, AF-related events requiring hospital admission, referrals to secondary specialists, sick leave, diagnostic tests and laboratory tests at PHC level, including INR determinations performed in PHC, and drug therapy. Higher costs of AF management were associated with increasing age, male sex, stroke and bleeding risks, comorbidities and occurrence of events associated to AF. The sensitivity analyses conducted showed that PHC visits and hospitalizations represented the most important part of overall costs for all patients.

Does experience rating reduce sickness and disability claims? Evidence from policy kinks

We study whether the experience rating of employers' disability insurance premiums affects the inflow to disability benefits in Finland. To identify the causal effect of experience rating, we exploit kinks in the rule that specifies the degree of experience rating as a function of firm size. Using comprehensive matched employer-employee panel data, we estimate the effects of experience rating on the inflow to sickness and disability benefits. We find that experience rating has little or no effect on either of these outcomes.

[Social costs of diseases: How relevant are they for economic evaluations?]

BACKGROUND

In the field of the economic evaluation (EE), there is an open debate on the most appropriate perspective to apply. Despite the relevance of the topic, there are hardly any studies that have analyzed the practical consequences of applying the social perspective vs. health care funder. The aim of this study was performed a systematic review of the available evidence to analyze whether the inclusion/exclusion of informal care and/or loss of productivity influence the results and conclusions of economic evaluations.

METHODS

A systematic review of the literature was carried out using PubMed and Econlit databases, to determine the publications that contained EE on Alzheimer, Parkinson and Stroke. Inclusion criteria were: a) full EE of the diseases under study; b) from January 2006-July 2016; and c) in English or Spanish.

RESULTS

6,292 references were identified, of which 245 publications meet the selection criteria and were analyzed. After the full-text analysis, 20 references were selected, of which 27 full EE were obtained (20 corresponding to Alzheimer, 1 to Parkinson and 6 to Stroke). In 20 EE (74.1%) the change of the perspective modifies the results, becoming dominant or increasing the saving of the resources by comparing the alternatives from the social perspective. In the remaining 7, the inclusion of social costs involves an increase in the costs of the intervention evaluated against its control. In a single EE, the conclusions vary when including social costs.

CONCLUSIONS

The inclusion of social costs can modify the results of EE but their impact on the conclusions is not relevant.

Increasing return-to-work among people on sick leave due to common mental disorders: design of a cluster-randomized controlled trial of a problem-solving intervention versus care-as-usual conducted in the Swedish primary health care system (PROSA)

BACKGROUND

Common mental disorders affect about one-third of the European working-age population and are one of the leading causes of sick leave in Sweden and other OECD countries. Besides the individual suffering, the costs for society are high. This paper describes the design of a study to evaluate a work-related, problem-solving intervention provided at primary health care centers for employees on sick leave due to common mental disorders.

METHODS

The study has a two-armed cluster randomized design in which the participating rehabilitation coordinators are randomized into delivering the intervention or providing care-as-usual. Employees on sick leave due to common mental disorders will be recruited by an independent research assistant. The intervention aims to improve the employee's return-to-work process by identifying problems perceived as hindering return-to-work and finding solutions. The rehabilitation coordinator facilitates a participatory approach, in which the employee and the employer together identify obstacles and solutions in relation to the work situation. The primary outcome is total number of sick leave days during the 18-month follow-up after inclusion. A long-term follow-up at 36 months is planned. Secondary outcomes are short-term sick leave (min. 2 weeks and max. 12 weeks), psychological symptoms, work ability, presenteeism and health related quality of life assessed at baseline, 6 and 12-month follow-up. Intervention fidelity, reach, dose delivered and dose received will be examined in a process evaluation. An economic evaluation will put health-related quality of life and sick leave in relation to costs from the perspectives of society and health care services. A parallel ethical evaluation will focus on the interventions consequences for patient autonomy, privacy, equality, fairness and professional ethos and integrity.

DISCUSSION

The study is a pragmatic trial which will include analyses of the intervention's effectiveness, and a process evaluation in primary health care settings. Methodological strengths and challenges are discussed, such as the risk of selection bias, contamination and detection bias. If the intervention shows promising results for return-to-work, the prospects are good for implementing the intervention in routine primary health care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03346395 Registered January, 12 2018.

Long-Term Health and Economic Value of Improved Mobility among Older Adults in the United States

BACKGROUND

Mobility impairments have substantial physical and mental health consequences, resulting in diminished quality of life. Most studies on the health economic consequences of mobility limitations focus on short-term implications.

OBJECTIVES

To examine the long-term value of improving mobility in older adults.

METHODS

Our six-step approach used clinical trial data to calibrate mobility improvements and estimate health economic outcomes using a microsimulation model. First, we measured improvement in steps per day calibrated with clinical trial data examining hylan G-F 20 viscosupplementation treatment. Second, we created a cohort of patients 51 years and older with osteoarthritis. In the third step, we estimated their baseline quality of life. Fourth, we translated steps-per-day improvements to changes in quality of life using estimates from the literature. Fifth, we calibrated quality of life in this cohort to match those in the trial. Last, we incorporated these data and parameters into The Health Economic Medical Innovation Simulation model to estimate how mobility improvements affect functional status limitations, medical expenditures, nursing home utilization, employment, and earnings between 2012 and 2030.

RESULTS

In our sample of 12.6 million patients, 66.7% were female and 70% had a body mass index of more than 25 kg/m2. Our model predicted that a 554-step-per-day increase in mobility would reduce functional status limitations by 5.9%, total medical expenditures by 0.9%, and nursing home utilization by 2.8%, and increase employment by 2.9%, earnings by 10.3%, and monetized quality of life by 3.2% over this 18-year period.

CONCLUSIONS

Interventions that improve mobility are likely to reduce long-run medical expenditures and nursing home utilization and increase employment.

Low back pain: a call for action

Low back pain is the leading worldwide cause of years lost to disability and its burden is growing alongside the increasing and ageing population.¹ Because these population shifts are more rapid in low-income and middle-income countries, where adequate resources to address the problem might not exist, the effects will probably be more extreme in these regions. Most low back pain is unrelated to specific identifiable spinal abnormalities, and our Viewpoint, the third paper in this Lancet Series,^2,3 is a call for action on this global problem of low back pain.

Trajectories of disposable income among people of working ages diagnosed with multiple sclerosis: a nationwide register-based cohort study in Sweden 7 years before to 4 years after diagnosis with a population-based reference group

OBJECTIVES

To describe how disposable income (DI) and three main components changed, and analyse whether DI development differed from working-aged people with multiple sclerosis (MS) to a reference group from 7 years before to 4 years after diagnosis in Sweden.

DESIGN

Population-based cohort study, 12-year follow-up (7 years before to 4 years after diagnosis).

SETTING

Swedish working-age population with microdata linked from two nationwide registers.

PARTICIPANTS

Residents diagnosed with MS in 2009 aged 25-59 years (n=785), and references without MS (n=7847) randomly selected with stratified matching (sex, age, education and country of birth).

PRIMARY AND SECONDARY OUTCOME MEASURES

DI was defined as the annual after tax sum of incomes (earnings and benefits) to measure individual economic welfare. Three main components of DI were analysed as annual sums: earnings, sickness absence benefits and disability pension benefits.

RESULTS

We found no differences in mean annual DI between people with and without MS by independent t-tests (p values between 0.15 and 0.96). Differences were found for all studied components of DI from diagnosis year by independent t-tests, for example, in the final study year (2013): earnings (-64 867 Swedish Krona (SEK); 95% CI-79 203 to -50 528); sickness absence benefits (13 330 SEK; 95% CI 10 042 to 16 500); and disability pension benefits (21 360 SEK; 95% CI 17 380 to 25 350). A generalised estimating equation evaluated DI trajectory development between people with and without MS to find both trajectories developed in parallel, both before (-4039 SEK; 95% CI -10 536 to 2458) and after (-781 SEK; 95% CI -6988 to 5360) diagnosis.

CONCLUSIONS

The key finding of parallel DI trajectory development between working-aged MS and references suggests minimal economic impact within the first 4 years of diagnosis. The Swedish welfare system was responsive to the observed reductions in earnings around MS diagnosis through balancing DI with morbidity-related benefits. Future decreases in economic welfare may be experienced as the disease progresses, although thorough investigation with future studies of modern cohorts are required.

Does the Length of Disability between Injury and Functional Restoration Program Entry Affect Treatment Outcomes for Patients with Chronic Disabling Occupational Musculoskeletal Disorders?

Purpose Functional restoration programs (FRPs), for patients with chronic disabling occupational musculoskeletal disorders (CDOMDs), have consistently demonstrated positive socioeconomic treatment outcomes, including decreased psychosocial distress and increased work return. The pre-treatment length of disability (LOD), or time between injury and treatment admission, has been shown to influence FRP work outcomes. Some studies have found that shorter LOD is associated with better work outcomes. However, few studies have actually examined cohorts with LOD duration longer than 18 months. This present study evaluated the effects of extended LOD (beyond 18 months) on important treatment outcomes. Methods A total cohort of 1413 CDOMD patients entered an FRP. Of those, 312 did not complete the program, so they were eliminated from outcome analyses. The 1101 patients who completed the FRP were classified based on LOD: Late Rehabilitation (LR, 3-6 months, n = 190); Chronic Disability (CD, 7-17 months, n = 494); and Late Chronic Disability (LCD). The LCD, in turn, consisted of four separate subgroups: 18-23 months (LCD-18, n = 110); 24-35 months (LCD-24, n = 123); 36-71 months (LCD-36, n = 74); and 72+ months (LCD-72, n = 110). Patients were evaluated upon admission and were reassessed at discharge. Those patients who chose to pursue work goals post-treatment (n = 912) were assessed 1-year later. Results Longer LOD was associated with less likelihood of completing the FRP (p < .001). Compared to the other LOD groups, a relatively large percentage of patients (47%) in the longest- disability group were receiving social security disability benefits. Associations were found between longer LOD and more severe patient-reported pain, disability, and depressive symptoms at treatment admission. At discharge, symptom severity decreased for these patient-reported variables in all LOD groups (p < .001). Using binary logistic regressions, it was found that LOD significantly predicted work-return (Wald = 11.672, p = .04) and work-retention (Wald = 11.811, p = .04) after controlling for covariates. Based on the LOD groups, the percentage of patients returning to, and retaining work, ranged from 75.6 to 94.1%, and from 66.7 to 86.3%, respectively. The odds of LCD-24 and LCD-72 patients returning to work were 2.9, and 7.4, respectfully, less likely, compared to LR patients. Furthermore, the odds of LCD-24 and LCD-72 patients retaining work were 3.3 and 3.8 times, respectively, less likely, compared to LR patients. Conclusions Long LOD was a risk factor for FRP non-completion, and was associated with more severe patient-reported variables, including pain intensity and perceived disability. Furthermore, long LOD was a significant predictor for work outcomes at 1 year following FRP discharge. Nevertheless, a large percentage of longer LOD (>24 months) patients had returned to work within the year after discharge (above 85%), and had retained at least part-time work 1-year later (above 66%). These results support the effectiveness of the FRP in mitigating the effects of extended LOD in a large percentage of long-term LOD patients.

Paid sick leave status in relation to government sponsored welfare utilization

Nearly a third of all U.S. workers, primarily lower-paid employees, do not have paid sick leave benefits, prompting some lawmakers to consider mandating paid sick leave for all U.S. employees so workers can access timely health care without lost wages. A representative sample of 19,537 workers in current paid employment was examined, searching for the association between access to paid sick leave benefits and receipt of six different welfare and welfare-related services. After controlling for relevant demographic, work, income, and medical/health care variables, results of the logistic models indicate that, among working adults age 18-64, those without paid sick leave are 1.41 times more likely to receive income from a state or county welfare program, 1.36 times more likely to receive other welfare assistance (transportation and child care supports), 1.33 times more likely to received sponsored rental assistance, and 1.34 times more likely to receive Supplemental Nutrition Assistance Program benefits (referred to as food stamps commonly and in this article). Mandating paid sick leave benefits may impact usage of social welfare assistance since families with paid sick leave do not have to lose wages when work is missed because of health and caregiver responsibilities. (PsycINFO Database Record

Workers not Paid for Sick Leave after Implementation of the New York City Paid Sick Leave Law

This study examined factors associated with being paid for sick leave after implementation of the New York City (NYC) paid sick leave law. A random sample of NYC residents was surveyed by telephone multiple times over a 2-year period. Participants (n = 1195) reported socio-demographics, awareness of the law, income, work hours per week, and payment for sick time off work. In the year after implementation of the law, part-time workers were significantly more likely to attend work while sick than full-time workers (relative risk = 1.25, 95% CI = 1.1, 1.4). Seventy percent of workers who missed work due to illness (n = 249) were paid for sick leave. Part-time workers, respondents not aware of the benefit (30% of workers), and workers without a college degree were the least likely to be paid for sick days. More than one third (37%) of persons not paid for sick leave worked in retail, food service, or health care. Although 70% of respondents were paid for sick leave after implementation of the law, part-time workers and workers with low education were least likely to access the benefit and more likely to work while sick. The disparity in paid sick leave may have public health consequences as many persons not paid for sick leave had occupations that carry a high risk of disease transmission to others.

Cost-effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: economic evaluation alongside a stepped-wedge cluster-randomised trial

OBJECTIVES

To evaluate the cost-effectiveness and cost-utility of an internet-based perioperative care programme compared with usual care for gynaecological patients.

DESIGN

Economic evaluation from a societal perspective alongside a stepped-wedge cluster-randomised controlled trial with 12 months of follow-up.

SETTING

Secondary care, nine hospitals in the Netherlands, 2011-2014.

PARTICIPANTS

433 employed women aged 18-65 years scheduled for a hysterectomy and/or laparoscopic adnexal surgery.

INTERVENTION

The intervention comprised an internet-based care programme aimed at improving convalescence and preventing delayed return to work (RTW) following gynaecological surgery and was sequentially rolled out. Depending on the implementation phase of their hospital, patients were allocated to usual care (n=206) or to the intervention (n=227).

MAIN OUTCOME MEASURES

The primary outcome was duration until full sustainable RTW. Secondary outcomes were quality-adjusted life years (QALYs), health-related quality of life and recovery.

RESULTS

At 12 months, there were no statistically significant differences in total societal costs (€-647; 95% CI €-2116 to €753) and duration until RTW (-4.1; 95% CI -10.8 to 2.6) between groups. The incremental cost-effectiveness ratio (ICER) for RTW was 56; each day earlier RTW in the intervention group was associated with cost savings of €56 compared with usual care. The probability of the intervention being cost-effective was 0.79 at a willingness-to-pay (WTP) of €0 per day earlier RTW, which increased to 0.97 at a WTP of €76 per day earlier RTW. The difference in QALYs gained over 12 months between the groups was clinically irrelevant resulting in a low probability of cost-effectiveness for QALYs.

CONCLUSIONS

Considering that on average the costs of a day of sickness absence are €230, the care programme is considered cost-effective in comparison with usual care for duration until sustainable RTW after gynaecological surgery for benign disease. Future research should indicate whether widespread implementation of this care programme has the potential to reduce societal costs associated with gynaecological surgery.

TRIAL REGISTRATION NUMBER

NTR2933; Results.

Economic burden of COPD in a Swedish cohort: the ARCTIC study

Background

We assessed direct and indirect costs associated with COPD in Sweden and examined how these costs vary across time, age, and disease stage in a cohort of patients with COPD and matched controls in a real-world, primary care (PC) setting.

Patients and methods

Data from electronic medical records linked to the mandatory national health registers were collected for COPD patients and a matched reference population in 52 PC centers from 2000 to 2014. Direct health care costs (drug, outpatient or inpatient, PC, both COPD related and not COPD related) and indirect health care costs (loss of income, absenteeism, loss of productivity) were assessed.

Results

A total of 17,479 patients with COPD and 84,514 reference controls were analyzed. During 2013, direct costs were considerably higher among the COPD patient population (€13,179) versus the reference population (€2,716), largely due to hospital nights unrelated to COPD. Direct costs increased with increasing disease severity and increasing age and were driven by higher respiratory drug costs and non-COPD-related hospital nights. Indirect costs (~€28,000 per patient) were the largest economic burden in COPD patients of working age during 2013.

Conclusion

As non-COPD-related hospital nights represent the largest direct cost, management of comorbidities in COPD would offer clinical benefits and relieve the financial burden of disease.

Healthcare Expenditure and Productivity Cost Savings from Reductions in Cardiovascular Disease and Type 2 Diabetes Associated with Increased Intake of Cereal Fibre among Australian Adults: A Cost of Illness Analysis

An ageing population and growing prevalence of chronic diseases including cardiovascular disease (CVD) and type 2 diabetes (T2D) are putting increased pressure on healthcare expenditure in Australia. A cost of illness analysis was conducted to assess the potential savings in healthcare expenditure and productivity costs associated with lower prevalence of CVD and T2D resulting from increased intake of cereal fibre. Modelling was undertaken for three levels of increased dietary fibre intake using cereal fibre: a 10% increase in total dietary fibre; an increase to the Adequate Intake; and an increase to the Suggested Dietary Target. Total healthcare expenditure and productivity cost savings associated with reduced CVD and T2D were calculated by gender, socioeconomic status, baseline dietary fibre intake, and population uptake. Total combined annual healthcare expenditure and productivity cost savings of AUD$17.8 million-$1.6 billion for CVD and AUD$18.2 million-$1.7 billion for T2D were calculated. Total savings were generally larger among adults of lower socioeconomic status and those with lower dietary fibre intakes. Given the substantial healthcare expenditure and productivity cost savings that could be realised through increases in cereal fibre, there is cause for the development of interventions and policies that encourage an increase in cereal fibre intake in Australia.

[Disability leave and sick leave in Spain. 2016 legislative update]

In Spanish, the concepts of discapacidad (disability leave) and incapacidad (sick leave) jointly refer to the impairment of a person due to injuries, diseases or deficiencies that limit their activity in a social, personal or occupational field. However, this common link does not imply that both concepts are the same. Statistical data from INE (Instituto Nacional de Estadística: Statistic National Institute) show that Spain had in 2015 3.85 million persons with a disability (59.8% were women). Statistical data from 2015 from INSS (Instituto Nacional de Seguridad Social: Social Security National Institute) show high levels in the number of processes and in workers affected by temporary sick leave, with social costs to the social security system. Both concepts have been updated: about disability leave, Law 39/2006 adjusted terminology by avoiding the use of concepts with discriminating or pejorative connotation. Regarding sick leave, the Ley General de Seguridad Social (General Social Security Law)has been amended and came into effect in January, 2016. It is necessary to know and distinguish these aspects for a better administrative management, and a more oriented information to the affected patient.

[Costs and sick leave due to chikungunya in the Instituto Mexicano del Seguro Social in Guerrero, Mexico]

BACKGROUND

Chikungunya fever (CHIK) generally causes temporary sick leave, affecting groups of productive age, which represents a significant economic impact from the labor point of view. The objective was to estimate costs of disability due to chikungunya in the Instituto Mexicano del Seguro Social (IMSS) in Guerrero, Mexico.

METHODS

Cost assessment of working population from IMSS in Guerrero who met the definition of case for CHIK and took sick leave, which was registered in the Original Disability Certificates (OCI, according to its initials in Spanish) processed from January to April, 2015. Paid sick days were multiplied by the current minimum wage of the municipality of Acapulco (geographical area A, general = $ 70.10: seventy pesos with 10 cents per day]).

RESULTS

Of all the OCIs, 31.5% (38 271/12 062) met the criteria for CHIK with a total of 41 197 prescribed days and 14 941 paid sick days with an estimated cost of 2 397 393.40 pesos (two million, three hundred and ninety seven thousand, three hundred and ninety three dollars and forty cents).

CONCLUSIONS

Sick leaves increase the costs in health systems. These costs increase as increases the number of days granted. The average number of days granted is consistent with the information published in different articles.

Health-care utilization of patients with chronic back pain before and after rehabilitation

BACKGROUND

Patients with chronic back pain show an increased use of health-care services leading to high direct costs. Multidisciplinary rehabilitation reduces pain intensity, depression, disability and work inability. The study aims to investigate whether health-care utilization in patients with chronic back pain is lower after rehabilitation than before rehabilitation and if, in addition to sociodemographic, medical and psychological characteristics, changes in these characteristics immediately after rehabilitation can predict health-care utilization.

METHODS

N = 688 patients with chronic back pain were asked about their overall health-care services use and the use of general practitioners, specialists, physiotherapy, psychotherapy, complementary therapist, massages, and admission to hospital both 6 months before and 6 months after rehabilitation. In addition, various sociodemographic, medical and psychological variables were assessed. To measure changes due to rehabilitation, differences in pain intensity, disability, impairment and coping, quality of life, and days on sick leave before and after rehabilitation were calculated. Dependent t-tests and hierarchical regression analyses were used to analyse the data.

RESULTS

Health-care utilization 6 months after rehabilitation was, except for physiotherapy and psychotherapy, significantly lower than before. The effect sizes were rather small (Cohens'd =. 01-.34). After rehabilitation between 15.2% and 39.9% of the variance of health-care utilization could be explained. The baseline values of health-care utilization explained between 3.2% and 15.9% of the incremental variances. The changes in psychological impairment and coping as well as in sick leave after rehabilitation could explain between 0.8% and 2.9% of the variance of health-care utilization after rehabilitation. Its influence was significant for the general use of health-care services, general practitioners and specialists.

CONCLUSIONS

The results indicate that use of health-care services after rehabilitation in the present study is slightly lower than before, which has an impact on direct costs due to chronic back pain in Germany. The predictors show the importance in terms of health-care utilization of improving work ability and psychological impairment.

A health economic lifetime treatment pathway model for low back pain in Sweden

AIMS

To develop a health economic model to evaluate the long-term costs and outcomes over the healthcare treatment pathway for patients with low back pain (LBP).

MATERIALS AND METHODS

A health economic model, consisting of a decision tree structure with a Markov microsimulation model at the end of each branch, was created. Patients were followed from first observed clinical presentation with LBP until the age of 100 years or death. The underlying data to populate the model were based on Swedish national and regional registry data on healthcare resource use and sickness insurance in patients presenting with LBP in the Swedish region Västra Götaland during 2008-2012. Costs (outpatient healthcare visits, inpatient bed days, pharmaceuticals, productivity loss), EUR 2016, and quality-of-life based on EQ-5D data from the registries and published estimates were summarized over the lifetime of the patients with 3% annual discount. A lost quality-adjusted life year (QALY) was valued at €70,000.

RESULTS

Mean lifetime total cost was estimated at €47,452/patient, of which indirect costs were 57%. Total lifetime economic burden for all patients coming to clinical presentation in Sweden per year was €8.8bn. The average LBP patient was estimated to face a loss of 2.7 QALYs over their lifetime compared with the general population. For all patients in Sweden coming to clinical presentation in 1 year this gives 505,407 QALYs lost, valued at €35.3bn. Adding the economic burden, the total societal burden amounts to €44.1bn.

CONCLUSION

This pathway model shows that most patients with LBP receive conservative care, and a minority consume high-cost healthcare interventions like surgery. The model could be used to see broad economic effects of different patterns of healthcare provision in sub-groups with LBP and to estimate where it is possible to influence these pathways to increase utility for patients and for society.

Association Between Improvement in Cardiovascular Risk Profile and Changes in Sickness Absence: Results of the ICARIA Study

INTRODUCTION AND OBJECTIVES

The purpose of this study was to investigate whether changes in cardiovascular risk (CVR) are associated with the length and cost of sickness absence.

METHODS

A prospective cohort of 179 186 participants was evaluated. Each participant's CVR (SCORE) was assessed on 2 consecutive medical examinations, approximately 1 year apart (365 ± 90 days). Cardiovascular risk was categorized as < 4% or ≥ 4%, and participants were divided into 4 groups according to changes in their risk between the 2 assessments. After the second CVR estimate, a 1-year follow-up was carried out to assess sickness absence. Differences between the 4 groups in terms of the total count of sickness absence days during the follow-up period were tested using Poisson regression models.

RESULTS

After adjustment for covariates, participants who showed an improvement in CVR had a lower count of sickness absence days compared with both those who showed a worsening in risk and those who remained stable at ≥ 4% (RR, 0.91; 95%CI, 0.84-0.98). In comparison with participants whose CVR did not improve, more of the participants whose risk did improve had quit smoking (+17.2%; P < .001), and had controlled their blood pressure (+26.0%, P < .001), total cholesterol (+9.3%; P < .001), low-density lipoprotein cholesterol (+14.9%; P < .001), and triglyceride levels (+14.6%; P < .001).

CONCLUSIONS

Our results suggest that an improvement in CVR profile is accompanied by a decrease in sickness absence during a 1-year follow-up.

A Substance Use Cost Calculator for US Employers With an Emphasis on Prescription Pain Medication Misuse

OBJECTIVE

Substance use disorders are among the most common and costly health conditions affecting Americans. Despite estimates of national costs exceeding $400 billion annually, individual companies may not see how substance use impacts their bottom lines through lost productivity and absenteeism, turnover, health care expenses, disability, and workers' compensation.

METHODS

Data on employed adults (18 years and older) from 3 years (2012 to 2014) of the National Survey on Drug Use and Health Public Use Data Files were analyzed.

RESULTS

The results offer employers an authoritative, free, epidemiologically grounded, and easy-to-use tool that gives specific information about how alcohol, prescription pain medication misuse, and illicit drug use is likely impacting workplaces like theirs.

CONCLUSION

Employers have detailed reports of the cost of substance use that can be used to improve workplace policies and health benefits.