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The Estimation and Inclusion of Presenteeism Costs in Applied Economic Evaluation: A Systematic Review

Open ArchivePublished:January 30, 2017DOI:https://doi.org/10.1016/j.jval.2016.12.006

      Abstract

      Objective

      Given the significant costs of reduced productivity (presenteeism) in comparison to absenteeism, and overall societal costs, presenteeism has a potentially important role to play in economic evaluations. However, these costs are often excluded. The objective of this study is to review applied cost of illness studies and economic evaluations to identify valuation methods used for, and impact of including presenteeism costs in practice.

      Methods

      A structured systematic review was carried out to explore (i) the extent to which presenteeism has been applied in cost of illness studies and economic evaluations and (ii) the overall impact of including presenteeism on overall costs and outcomes. Potential articles were identified by searching Medline, PsycINFO and NHS EED databases. A standard template was developed and used to extract information from economic evaluations and cost of illness studies incorporating presenteeism costs.

      Results

      A total of 28 studies were included in the systematic review which also demonstrated that presenteeism costs are rarely included in full economic evaluations. Estimation and monetisation methods differed between the instruments. The impact of disease on presenteeism whilst in paid work is high.

      Conclusions

      The potential impact of presenteeism costs needs to be highlighted and greater consideration should be given to including these in economic evaluations and cost of illness studies. The importance of including presenteeism costs when conducting economic evaluation from a societal perspective should be emphasised in national economic guidelines and more methodological work is required to improve the practical application of presenteeism instruments to generate productivity cost estimates.

      Keywords

      Introduction

      Productivity costs can be defined as “[c]osts associated with production loss and replacement costs due to illness, disability and death of productive persons, both paid and unpaid” [
      • Brouwer W.B.
      • Koopmanschap M.A.
      • Rutten F.F.
      Productivity costs in cost-effectiveness analysis: numerator or denominator: a further discussion.
      ]. According to the neoclassical theory, the idea of productivity is part of a production function, with labor as a key input contributing to output. Productivity therefore is a measure of output per unit of input [
      • Zhang W.
      • Bansback N.
      • Anis A.H.
      Measuring and valuing productivity loss due to poor health: a critical review.
      ]. Detailed theoretical and methodological discussions on this concept have been extensively discussed elsewhere [
      • Zhang W.
      • Bansback N.
      • Anis A.H.
      Measuring and valuing productivity loss due to poor health: a critical review.
      ]. In the context of this article, productivity loss due to sickness refers to output loss resulting from work absence and/or reduced labor input due to sickness (i.e., it is not concerned with lost income from the individual perspective, but with lost output from the societal perspective). Productivity costs have an important, yet controversial, role in economic evaluation. This is particularly the case when the evaluation is performed from a societal perspective. There have been strong arguments in favor of adopting a societal perspective in economic evaluations [
      ,
      ], although there is no theoretical consensus on the most appropriate perspective [
      • Johannesson M.J.
      • Bengt Jönsson L.
      • Kobelt G.
      • Zethraeus N.
      Why Should Economic Evaluations of Medical Innovations Have a Societal.
      ,
      • Brouwer W.B.
      • van Exel N.J.
      • Baltussen R.M.
      • Rutten F.F.
      A dollar is a dollar is a dollar—or is it?.
      ]. Some have argued that adopting a narrower perspective—such as a specific provider or institution, patient, or third-party provider could lead to biased health policies for society as a result of ignoring important cost categories outside the health care sector [
      ]. Comprehensive discussions on the issue of perspectives are addressed elsewhere in more detail [
      ,
      ]. In theory, when adopting a societal perspective, all relevant costs and consequences to whomsoever they accrue should be considered in the evaluation, including productivity costs. It is important to note that there have been various debates about the inclusion of productivity costs in economic evaluations. These debates include whether productivity costs should be included on the cost or the outcome side, and also the methods used to measure and value productivity costs, especially in relation to paid work [
      • Zhang W.
      • Bansback N.
      • Anis A.H.
      Measuring and valuing productivity loss due to poor health: a critical review.
      ,
      • Tilling C.
      • Krol M.
      • Tsuchiya A.
      • et al.
      In or out? Income losses in health state valuations: a review.
      ,
      • Krol M.
      • Brouwer W.
      • Rutten F.
      Productivity costs in economic evaluations: past, present, future.
      ,
      • Krol M.
      • Brouwer W.
      How to estimate productivity costs in economic evaluations.
      ]. The inclusion of productivity costs has mostly been limited to the context of paid work, which is the broad focus of this article. Another issue often ignored in productivity costs that will not be covered in this article relates to unpaid work. Detailed methodological and practical discussions in relation to unpaid work are provided elsewhere [
      • Krol M.
      • Papenburg J.
      • Tan S.S.
      • et al.
      A noticeable difference? Productivity costs related to paid and unpaid work in economic evaluations on expensive drugs.
      ].
      Paid work broadly consists of productivity loss to society as a result of absence from work (absenteeism) or working with limitations due to illness (presenteeism). Compared with absence from work, the evidence suggests that presenteeism generates significantly higher cost estimates than does absenteeism [
      • Ricci J.A.
      • Stewart W.F.
      • Chee E.
      • et al.
      Pain exacerbation as a major source of lost productive time in US workers with arthritis.
      ]. Productivity costs related to presenteeism seem to be rarely considered in economic evaluations [
      • Pritchard C.
      • Sculpher M.
      Productivity Costs: Principles and Practise in Economic Evaluation.
      ], although there is limited evidence on this. Ignoring these costs could significantly underestimate the value of interventions that reduce limitations at work due to illness.
      The exclusion of societal costs related to presenteeism in economic evaluations may be explained by several factors. First, an overview of most national economic guidelines, in which a societal perspective is recommended, shows there tends to be a bias toward including absenteeism costs, but not presenteeism costs [
      • Knies S.
      • Severens J.L.
      • Ament A.J.
      • Evers S.M.
      The transferability of valuing lost productivity across jurisdictions: differences between national pharmacoeconomic guidelines.
      ]. Second, the theoretical literature suggests a lack of consensus on the most appropriate instrument for measuring presenteeism and on the valuation methods for generating monetary estimates from existing measures. Both are required if presenteeism costs are to be included in economic evaluation [
      • Johns G.
      Presenteeism in the workplace: a review and research agenda.
      ,
      • Brooks A.
      • Hagen S.E.
      • Sathyanarayanan S.
      • et al.
      Presenteeism: critical issues.
      ]. A scoping review [
      • Kigozi J.B.L.
      The economics of back pain: alternative approaches to productivity cost estimation in economic evaluation of healthcare.
      ] of existing productivity loss measurement instruments reported in various systematic reviews identified a total of 24 instruments [
      • Zhang W.
      • Bansback N.
      • Anis A.H.
      Measuring and valuing productivity loss due to poor health: a critical review.
      ,
      • Brooks A.
      • Hagen S.E.
      • Sathyanarayanan S.
      • et al.
      Presenteeism: critical issues.
      ,
      • Beaton D.
      • Bombardier C.
      • Escorpizo R.
      • et al.
      Measuring worker productivity: frameworks and measures.
      ,
      • Lofland J.H.
      • Pizzi L.
      • Frick K.D.
      A review of health-related workplace productivity loss instruments.
      ,
      • Loeppke R.
      • Hymel P.A.
      • Lofland J.H.
      • et al.
      American College of Occupational and Environmental Medicine
      Health-related workplace productivity measurement: general and migraine-specific recommendations from the ACOEM Expert Panel.
      ,
      • Mattke S.
      • Balakrishnan A.
      • Bergamo G.
      • Newberry S.J.
      A review of methods to measure health-related productivity loss.
      ,
      • Nieuwenhuijsen K.
      • Franche R.L.
      • van Dijk F.J.
      Work functioning measurement: tools for occupational mental health research.
      ,
      • Prasad M.
      • Wahlqvist P.
      • Shikiar R.
      • Shih Y.C.
      A review of self-report instruments measuring health-related work productivity: a patient-reported outcomes perspective.
      ,
      • Ozminkowski R.J.
      • Goetzel R.Z.
      • Chang S.
      • Long S.
      The application of two health and productivity instruments at a large employer.
      ,
      • Roy J.S.
      • Desmeules F.
      • MacDermid J.C.
      Psychometric properties of presenteeism scales for musculoskeletal disorders: a systematic review.
      ,
      • Schultz A.B.
      • Chen C.-Y.
      • Edington D.W.
      The cost and impact of health conditions on presenteeism to employers: a review of the literature.
      ,
      • Schultz A.B.
      • Edington D.W.
      Employee health and presenteeism: a systematic review.
      ]. The most commonly reported were the Work Limitations Questionnaire (WLQ) [
      • Lerner D.
      • Amick III, B.C.
      • Rogers W.H.
      • et al.
      The Work Limitations Questionnaire.
      ], the Health and Work Performance Questionnaire (HPQ) [
      • Kessler R.C.
      • Barber C.
      • Beck A.
      • et al.
      The World Health Organization Health and Work Performance Questionnaire (HPQ).
      ], the Work Productivity and Activity Impairment (WPAI) Questionnaire [
      • Reilly M.C.
      • Zbrozek A.S.
      • Dukes E.M.
      The validity and reproducibility of a work productivity and activity impairment instrument.
      ], the Health and Labour Questionnaire (HLQ) [
      • van Roijen L.
      • Essink-Bot M.L.
      • Koopmanschap M.A.
      • et al.
      Labor and health status in economic evaluation of health care. The Health and Labor Questionnaire.
      ], and the Health and Work Questionnaire (HWQ) [
      • Shikiar R.
      • Halpern M.T.
      • Rentz A.M.
      • Khan Z.M.
      Development of the Health and Work Questionnaire (HWQ): an instrument for assessing workplace productivity in relation to worker health.
      ]. These instruments differ in the ways that presenteeism is measured and valued. Inevitably, this will have an impact on comparability between studies that use different instruments.
      The evidence on whether, and how, presenteeism costs are estimated in economic studies and on the size of these costs also appears to be limited. Previous literature has involved assessing the appropriateness of existing instruments [
      • Lofland J.H.
      • Pizzi L.
      • Frick K.D.
      A review of health-related workplace productivity loss instruments.
      ,
      • Prasad M.
      • Wahlqvist P.
      • Shikiar R.
      • Shih Y.C.
      A review of self-report instruments measuring health-related work productivity: a patient-reported outcomes perspective.
      ] and valuation methods [
      • Brooks A.
      • Hagen S.E.
      • Sathyanarayanan S.
      • et al.
      Presenteeism: critical issues.
      ,
      • Mattke S.
      • Balakrishnan A.
      • Bergamo G.
      • Newberry S.J.
      A review of methods to measure health-related productivity loss.
      ] but has not studied which instruments have been used to estimate presenteeism in practice in the context of cost-of-illness studies or economic evaluation. This review goes further by assessing which instruments have been used in practice, and how, to estimate presenteeism costs. A 2009 review of presenteeism considered the impact of presenteeism on the total cost of health conditions from a narrow employer perspective, but did not examine the methods used in economic studies [
      • Schultz A.B.
      • Chen C.-Y.
      • Edington D.W.
      The cost and impact of health conditions on presenteeism to employers: a review of the literature.
      ]. The review found that job-related reduced productivity was a major component of total employer costs for various health conditions, but it was not able to assess presenteeism instruments used in practice, and how, to estimate presenteeism costs at the time. The more up-to-date review presented here aims to extend the earlier review by investigating two related research questions in relation to this area: 1) What methods are economic studies using to estimate presenteeism in current practice? and 2) What is the impact of presenteeism on the total costs of interventions and health conditions in existing economic studies?

      Methods

      A systematic review of published applied economic studies, comprising cost-of-illness studies and economic evaluations, was conducted to explore the research aims.

      Search Strategy

      Searches were conducted in MEDLINE (Ovid), PsycINFO (Ovid), and the specific health economics database, the National Health Service Economic Evaluation Database, and were limited to studies published up to August 31, 2015, with no starting date limitation. The search strategies used were based on the following key predefined search keywords: “presenteeism” or “reduced productivity” or “productivity costs” or “lost productivity” or “work limitations” or “work productivity” or “work performance,” subsequently in conjunction with the terms “cost and cost analysis” or “cost-effectiveness analysis” or “cost-utility analysis.” Whenever relevant, Medical Subject Headings were explored. The list of study titles was supplemented by a bibliographic review of articles included in the review, and through searching other electronic sources such as Google Scholar for articles from academics known in this area.

      Study Selection

      Studies were included only if they 1) were original, applied cost-of-illness studies or economic evaluations; 2) incorporated costs related to presenteeism, and described the methods for doing so; and 3) were written in English. After excluding duplicates, the abstracts of the remaining articles were assessed in terms of these inclusion criteria. Full texts were obtained for all studies that appeared to meet the inclusion criteria at this point, and were read to make a final decision on study inclusion. Initial study selection was performed by one of the researchers (J. Kigozi), and when there was any ambiguity about inclusion or exclusion, the study was discussed by the whole research team before a final decision was made.

      Data Extraction and Analysis

      A data extraction form was developed to extract systematic information on study characteristics related to the study country, publication year, type of economic evaluation, and disease area. Methodological characteristics of interest included type of instrument, recall period, productivity loss reported, type of instrument, monetization algorithm used (if available), and the proportion of presenteeism costs in relation to absenteeism and/or overall total costs. Data extraction was performed. Narrative synthesis was used to summarize and explain the findings.

      Results

      Study Selection

      In total, 610 potentially relevant articles were identified, of which 16 were excluded on the ground that they were duplicates. Of the remaining 594 articles, 538 did not meet the inclusion criteria on the basis of the abstract, leaving 56 articles that were read in full. Of these, 35 did not incorporate presenteeism, or were reviews or protocols, and were subsequently excluded. Seven additional articles were identified through searching references of studies identified from the databases and other electronic sources. This resulted in a total of 28 studies that met the criteria for the review.

      Study Characteristics

      A summary of the 28 studies included in the review is presented in Table 1. Most of the studies identified (57%) were conducted in the United States. The others were from the Netherlands [
      • Boonen A.
      • Brinkhuizen T.
      • Landewé R.
      • et al.
      Impact of ankylosing spondylitis on sick leave, presenteeism and unpaid productivity, and estimation of the societal cost.
      ,
      • Uegaki K.
      • Stomp-van den Berg S.G.
      • de Bruijne M.C.
      • et al.
      Cost-utility analysis of a one-time supervisor telephone contact at 6-weeks post-partum to prevent extended sick leave following maternity leave in The Netherlands: results of an economic evaluation alongside a randomized controlled trial.
      ], Canada [
      • Zhang W.
      • Bansback N.
      • Guh D.
      • et al.
      Short-term influence of adalimumab on work productivity outcomes in patients with rheumatoid arthritis.
      ,
      • Daley M.
      • Morin C.M.
      • LeBlanc M.
      • et al.
      The economic burden of insomnia: direct and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good sleepers.
      ,
      • Li X.
      • Gignac M.A.
      • Anis A.H.
      The indirect costs of arthritis resulting from unemployment, reduced performance, and occupational changes while at work.
      ], the United Kingdom [
      • Finkelstein E.A.
      • DiBonaventura Md
      • Burgess S.M.
      • Hale B.C.
      The costs of obesity in the workplace.
      ,
      • Cooksey R.
      • Husain M.J.
      • Brophy S.
      • et al.
      The cost of ankylosing spondylitis in the UK using linked routine and patient-reported survey data.
      ,
      • Rafia R.
      • Ara R.
      • Packham J.
      • et al.
      Healthcare costs and productivity losses directly attributable to ankylosing spondylitis.
      ], Sweden [
      • Hellgren J.
      • Cervin A.
      • Nordling S.
      • et al.
      Allergic rhinitis and the common cold—high cost to society.
      ], and Thailand [
      • Thavorncharoensap M.
      • Teerawattananon Y.
      • Yothasamut J.
      • et al.
      The economic costs of alcohol consumption in Thailand, 2006.
      ]. There were two multicountry studies, with one set across Australia, the United States, and the United Kingdom [
      • Hilton M.F.
      • Scuffham P.A.
      • Sheridan J.
      • et al.
      Mental ill-health and the differential effect of employee type on absenteeism and presenteeism.
      ], and the other reporting cost estimates from eight European countries including Germany, Italy, Lithuania, the Netherlands, Luxembourg, Austria, France, and Spain [
      • Linde M.
      • Gustavsson A.
      • Stovner L.J.
      • et al.
      The cost of headache disorders in Europe: the Eurolight project.
      ].
      Table 1Overview of studies included in this review
      AuthorCountryClinical areaType of study
      Boonen et al.
      • Boonen A.
      • Brinkhuizen T.
      • Landewé R.
      • et al.
      Impact of ankylosing spondylitis on sick leave, presenteeism and unpaid productivity, and estimation of the societal cost.
      The NetherlandsAnkylosing spondylitisCOI
      Braakman-Jansen et al.
      • Braakman-Jansen L.M.
      • Taal E.
      • Kuper I.H.
      • van de Laar M.A.
      Productivity loss due to absenteeism and presenteeism by different instruments in patients with RA and subjects without RA.
      United StatesRheumatoid arthritisCOI
      Burton et al.
      • Burton W.N.
      • Conti D.J.
      • Chen C.Y.
      • et al.
      The economic burden of lost productivity due to migraine headache: a specific worksite analysis.
      United StatesMigraineCOI
      Burton et al.
      • Burton W.N.
      • Chen C.Y.
      • Conti D.J.
      • et al.
      The association of health risks with on-the-job productivity.
      United StatesVarious health conditionsCOI
      Cisternas et al.
      • Cisternas M.G.
      • Blanc P.D.
      • Yen I.H.
      • et al.
      A comprehensive study of the direct and indirect costs of adult asthma.
      United StatesAsthmaCOI
      Collins et al.
      • Collins J.J.
      • Baase C.M.
      • Sharda C.E.
      • et al.
      The assessment of chronic health conditions on work performance, absence, and total economic impact for employers.
      United StatesChronic conditionsCOI
      Cooksey et al.
      • Cooksey R.
      • Husain M.J.
      • Brophy S.
      • et al.
      The cost of ankylosing spondylitis in the UK using linked routine and patient-reported survey data.
      United KingdomAnkylosing spondylitisCOI
      Daley et al.
      • Daley M.
      • Morin C.M.
      • LeBlanc M.
      • et al.
      The economic burden of insomnia: direct and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good sleepers.
      CanadaInsomniaCOI
      Finkelstein et al.
      • Finkelstein E.A.
      • DiBonaventura Md
      • Burgess S.M.
      • Hale B.C.
      The costs of obesity in the workplace.
      United KingdomObesityCOI
      Fishman and Black
      • Fishman P.
      • Black L.
      Indirect costs of migraine in a managed care population.
      United StatesMigraineCOI
      Goetzel et al.
      • Goetzel R.Z.
      • Long S.R.
      • Ozminkowski R.J.
      • et al.
      Health, absence, disability, and presenteeism cost estimates of certain physical and mental health conditions affecting U.S. employers.
      United StatesVarious conditionsCOI
      Goetzel et al.
      • Goetzel R.Z.
      • Gibson T.B.
      • Short M.E.
      • et al.
      A multi-worksite analysis of the relationships among body mass index, medical utilization, and worker productivity.
      United StatesObesityCOI
      Hellgren et al.
      • Hellgren J.
      • Cervin A.
      • Nordling S.
      • et al.
      Allergic rhinitis and the common cold—high cost to society.
      SwedenAllergic rhinitis and common coldCOI
      Henke et al.
      • Henke C.J.
      • Levin T.R.
      • Henning J.M.
      • Potter L.P.
      Work loss costs due to peptic ulcer disease and gastroesophageal reflux disease in a health maintenance organization.
      United StatesPUD and GERDCOI
      Hilton et al.
      • Hilton M.F.
      • Scuffham P.A.
      • Sheridan J.
      • et al.
      Mental ill-health and the differential effect of employee type on absenteeism and presenteeism.
      United States, United Kingdom, AustraliaPsychological distressCOI
      Lamb et al.
      • Lamb C.E.
      • Ratner P.H.
      • Johnson C.E.
      • et al.
      Economic impact of workplace productivity losses due to allergic rhinitis compared with select medical conditions in the United States from an employer perspective.
      United StatesAllergic rhinitisCOI
      Lerner et al.
      • Lerner D.
      • Mirza F.G.
      • Chang H.
      • et al.
      Impaired work performance among women with symptomatic uterine fibroids.
      United StatesFibroidsCEA
      Li et al.
      • Li X.
      • Gignac M.A.
      • Anis A.H.
      The indirect costs of arthritis resulting from unemployment, reduced performance, and occupational changes while at work.
      CanadaArthritisCOI
      Linde et al.
      • Linde M.
      • Gustavsson A.
      • Stovner L.J.
      • et al.
      The cost of headache disorders in Europe: the Eurolight project.
      Eight European countriesHeadacheCOI
      Rafia et al.
      • Rafia R.
      • Ara R.
      • Packham J.
      • et al.
      Healthcare costs and productivity losses directly attributable to ankylosing spondylitis.
      United KingdomAnkylosing spondylitisCOI
      Ricci and Chee
      • Ricci J.A.
      • Chee E.
      Lost productive time associated with excess weight in the U.S. workforce.
      United StatesObesityCOI
      Smit et al.
      • Smit F.
      • Willemse G.
      • Koopmanschap M.
      • et al.
      Cost-effectiveness of preventing depression in primary care patients: randomised trial.
      The NetherlandsDepressionCEA
      Stewart et al.
      • Stewart W.F.
      • Ricci J.A.
      • Chee E.
      • Morganstein D.
      Lost productive work time costs from health conditions in the United States: results from the American Productivity Audit.
      United StatesHeadache, back pain, arthritisCOI
      Stewart et al.
      • Stewart W.F.
      • Ricci J.A.
      • Chee E.
      • et al.
      Lost productive time and cost due to common pain conditions in the US workforce.
      United StatesHeadache, back pain, arthritisCOI
      Thavorncharoensap et al.
      • Thavorncharoensap M.
      • Teerawattananon Y.
      • Yothasamut J.
      • et al.
      The economic costs of alcohol consumption in Thailand, 2006.
      ThailandAlcohol consequencesCOI
      Uegaki et al.
      • Uegaki K.
      • Stomp-van den Berg S.G.
      • de Bruijne M.C.
      • et al.
      Cost-utility analysis of a one-time supervisor telephone contact at 6-weeks post-partum to prevent extended sick leave following maternity leave in The Netherlands: results of an economic evaluation alongside a randomized controlled trial.
      The NetherlandsMaternityCEA
      Wilson et al.
      • Wilson D.A.
      • Bork K.
      • Shea E.P.
      • et al.
      Economic costs associated with acute attacks and long-term management of hereditary angioedema.
      United StatesAcute attacks/hereditary angioedemaCOI
      Zhang et al.
      • Zhang W.
      • Bansback N.
      • Guh D.
      • et al.
      Short-term influence of adalimumab on work productivity outcomes in patients with rheumatoid arthritis.
      CanadaRheumatoid arthritisCOI
      CEA, cost-effectiveness analysis; COI, cost of illness; GERD, gastroesophageal reflux disease; PUD, peptic ulcer disease.
      The studies evaluated a wide range of diseases and varied from national survey–based costing studies covering various conditions to cost estimates from specific disease conditions. The most common conditions considered were obesity [
      • Finkelstein E.A.
      • DiBonaventura Md
      • Burgess S.M.
      • Hale B.C.
      The costs of obesity in the workplace.
      ,
      • Ricci J.A.
      • Chee E.
      Lost productive time associated with excess weight in the U.S. workforce.
      ,
      • Goetzel R.Z.
      • Gibson T.B.
      • Short M.E.
      • et al.
      A multi-worksite analysis of the relationships among body mass index, medical utilization, and worker productivity.
      ], rheumatoid arthritis [
      • Zhang W.
      • Bansback N.
      • Guh D.
      • et al.
      Short-term influence of adalimumab on work productivity outcomes in patients with rheumatoid arthritis.
      ,
      • Li X.
      • Gignac M.A.
      • Anis A.H.
      The indirect costs of arthritis resulting from unemployment, reduced performance, and occupational changes while at work.
      ,
      • Stewart W.F.
      • Ricci J.A.
      • Chee E.
      • Morganstein D.
      Lost productive work time costs from health conditions in the United States: results from the American Productivity Audit.
      ], migraine [
      • Linde M.
      • Gustavsson A.
      • Stovner L.J.
      • et al.
      The cost of headache disorders in Europe: the Eurolight project.
      ,
      • Fishman P.
      • Black L.
      Indirect costs of migraine in a managed care population.
      ,
      • Burton W.N.
      • Conti D.J.
      • Chen C.Y.
      • et al.
      The economic burden of lost productivity due to migraine headache: a specific worksite analysis.
      ], and ankylosing spondylitis [
      • Boonen A.
      • Brinkhuizen T.
      • Landewé R.
      • et al.
      Impact of ankylosing spondylitis on sick leave, presenteeism and unpaid productivity, and estimation of the societal cost.
      ,
      • Cooksey R.
      • Husain M.J.
      • Brophy S.
      • et al.
      The cost of ankylosing spondylitis in the UK using linked routine and patient-reported survey data.
      ,
      • Rafia R.
      • Ara R.
      • Packham J.
      • et al.
      Healthcare costs and productivity losses directly attributable to ankylosing spondylitis.
      ]. Most of the studies were cross-sectional in design, but two used information from randomized clinical trials [
      • Uegaki K.
      • Stomp-van den Berg S.G.
      • de Bruijne M.C.
      • et al.
      Cost-utility analysis of a one-time supervisor telephone contact at 6-weeks post-partum to prevent extended sick leave following maternity leave in The Netherlands: results of an economic evaluation alongside a randomized controlled trial.
      ,
      • Smit F.
      • Willemse G.
      • Koopmanschap M.
      • et al.
      Cost-effectiveness of preventing depression in primary care patients: randomised trial.
      ]. Of the 28 studies, 25 were cost-of-illness studies and the remaining 3 were cost-effectiveness analyses [
      • Uegaki K.
      • Stomp-van den Berg S.G.
      • de Bruijne M.C.
      • et al.
      Cost-utility analysis of a one-time supervisor telephone contact at 6-weeks post-partum to prevent extended sick leave following maternity leave in The Netherlands: results of an economic evaluation alongside a randomized controlled trial.
      ,
      • Smit F.
      • Willemse G.
      • Koopmanschap M.
      • et al.
      Cost-effectiveness of preventing depression in primary care patients: randomised trial.
      ,
      • Snedecor S.J.
      • Botteman M.F.
      • Bojke C.
      • et al.
      Cost-effectiveness of eszopiclone for the treatment of adults with primary chronic insomnia.
      ].
      In total, nine instruments measuring presenteeism were identified from the 28 studies. Presenteeism was measured by either a study-specific questionnaire or a visual analogue scale or an existing standardized questionnaire. The most commonly used standard questionnaires were the WPAI (n = 6), the WLQ (n = 5), and the Work and Health Interview (WHI) (n = 3). Other currently used multiquestion instruments included the Stanford Presenteeism Scale (SPS) (n = 1), the HLQ (n = 1), the PROductivity and DISease Questionnaire (PRODISQ) (n=1), the Quantity and Quality questionnaire (QQ) (n = 1), and the HPQ (n = 1). Other studies used a self-constructed global presenteeism question, which was based on a global response 0 to 10 scale adapted from standard questionnaires (n = 8). One study used a modified version of the WLQ [
      • Burton W.N.
      • Chen C.Y.
      • Conti D.J.
      • et al.
      The association of health risks with on-the-job productivity.
      ].

      Methods of Estimating Presenteeism Loss

      One of the main prerequisites for including presenteeism in economic evaluations is the ability to convert the data collected in the measurement instrument to an estimate of lost productivity. The instruments differed in the way they measured the extent of presenteeism loss. The WPAI, HLQ, and HPQ instruments generated productivity loss estimates that were directly translatable into monetary costs, whereas the estimates from the SPS, WLQ, WHI, PRODISQ, and QQ (quantity and quality) instruments could be indirectly quantified into reduced productivity loss with some assumptions. On the basis of a previous categorization by Mattke et al. [
      • Mattke S.
      • Balakrishnan A.
      • Bergamo G.
      • Newberry S.J.
      A review of methods to measure health-related productivity loss.
      ], the estimation of presenteeism in the studies reported was categorized into three approaches: direct estimation of productivity loss in hours (19%), estimation of perceived percentage loss (77%), and the comparison of productivity loss obtained from an individual with that obtained from a colleague in a similar role (12%).
      The direct approach generates productivity loss values in a way similar to the approach used in obtaining absenteeism productivity loss. For example, using the WHI, presenteeism loss is estimated from a combination of questions such as the average number of hours with low concentration at work, when working more slowly than usual, when feeling fatigued at work, and the time in between arriving at work and starting work on the days when an employee is sick [
      • Ricci J.A.
      • Chee E.
      Lost productive time associated with excess weight in the U.S. workforce.
      ]. Alternatively, respondents are asked to estimate the extra hours that would be needed to compensate for inefficient hours, a method used by the HLQ [
      • Boonen A.
      • Brinkhuizen T.
      • Landewé R.
      • et al.
      Impact of ankylosing spondylitis on sick leave, presenteeism and unpaid productivity, and estimation of the societal cost.
      ,
      • Zhang W.
      • Bansback N.
      • Guh D.
      • et al.
      Short-term influence of adalimumab on work productivity outcomes in patients with rheumatoid arthritis.
      ]. The direct translation approach was found in five studies (19%).
      The second approach involved asking respondents to provide a perceived overall estimate of how much illness has hindered or affected their performance at work. This was the most common approach (in 22 studies [77%]). One productivity loss measurement approach (perceived percentage loss) required respondents to provide an estimate of their percentage loss of productivity at work due to illness [
      • Linde M.
      • Gustavsson A.
      • Stovner L.J.
      • et al.
      The cost of headache disorders in Europe: the Eurolight project.
      ,
      • Snedecor S.J.
      • Botteman M.F.
      • Bojke C.
      • et al.
      Cost-effectiveness of eszopiclone for the treatment of adults with primary chronic insomnia.
      ]. For example, studies using the WLQ obtained an estimate of the percentage presenteeism loss (or gain) from respondents compared with a baseline or benchmark value for each individual [
      • Goetzel R.Z.
      • Gibson T.B.
      • Short M.E.
      • et al.
      A multi-worksite analysis of the relationships among body mass index, medical utilization, and worker productivity.
      ,
      • Lerner D.
      • Mirza F.G.
      • Chang H.
      • et al.
      Impaired work performance among women with symptomatic uterine fibroids.
      ]. An alternative version of this approach involved asking respondents to provide an estimate of how illness has affected their performance at work on a 0 to 10 scale, which was then converted into a percentage productivity loss [
      • Finkelstein E.A.
      • DiBonaventura Md
      • Burgess S.M.
      • Hale B.C.
      The costs of obesity in the workplace.
      ,
      • Wilson D.A.
      • Bork K.
      • Shea E.P.
      • et al.
      Economic costs associated with acute attacks and long-term management of hereditary angioedema.
      ]. Studies using the WLQ [
      • Li X.
      • Gignac M.A.
      • Anis A.H.
      The indirect costs of arthritis resulting from unemployment, reduced performance, and occupational changes while at work.
      ,
      • Cooksey R.
      • Husain M.J.
      • Brophy S.
      • et al.
      The cost of ankylosing spondylitis in the UK using linked routine and patient-reported survey data.
      ,
      • Goetzel R.Z.
      • Gibson T.B.
      • Short M.E.
      • et al.
      A multi-worksite analysis of the relationships among body mass index, medical utilization, and worker productivity.
      ,
      • Lerner D.
      • Mirza F.G.
      • Chang H.
      • et al.
      Impaired work performance among women with symptomatic uterine fibroids.
      ] and the SPS [
      • Collins J.J.
      • Baase C.M.
      • Sharda C.E.
      • et al.
      The assessment of chronic health conditions on work performance, absence, and total economic impact for employers.
      ] also assessed perceived limitations in different work function domains and for different work aspects. The output from these different domains was then summarized to generate an index that was interpreted as a percentage loss attributed to reduced productivity. In the remaining studies, a perceived reduced productivity was estimated using nonstandard, stand-alone, single-item questions as part of a wider questionnaire, with a global question asking respondents to estimate either perceived impairment on a scale of 0 to 10 or percentage reduction at work due to illness [
      • Daley M.
      • Morin C.M.
      • LeBlanc M.
      • et al.
      The economic burden of insomnia: direct and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good sleepers.
      ,
      • Hellgren J.
      • Cervin A.
      • Nordling S.
      • et al.
      Allergic rhinitis and the common cold—high cost to society.
      ,
      • Linde M.
      • Gustavsson A.
      • Stovner L.J.
      • et al.
      The cost of headache disorders in Europe: the Eurolight project.
      ,
      • Fishman P.
      • Black L.
      Indirect costs of migraine in a managed care population.
      ,
      • Burton W.N.
      • Conti D.J.
      • Chen C.Y.
      • et al.
      The economic burden of lost productivity due to migraine headache: a specific worksite analysis.
      ,
      • Cisternas M.G.
      • Blanc P.D.
      • Yen I.H.
      • et al.
      A comprehensive study of the direct and indirect costs of adult asthma.
      ,
      • Henke R.M.
      • Carls G.S.
      • Short M.E.
      • et al.
      The relationship between health risks and health and productivity costs among employees at Pepsi Bottling Group.
      ]. Such a question has recently been validated in the context of low back pain [
      • Kigozi J.
      • Lewis M.
      • Jowett S.
      • et al.
      Construct validity and responsiveness of the single-item presenteeism question in patients with lower back pain for the measurement of presenteeism.
      ].
      The final approach, used in the HPQ [
      • Uegaki K.
      • Stomp-van den Berg S.G.
      • de Bruijne M.C.
      • et al.
      Cost-utility analysis of a one-time supervisor telephone contact at 6-weeks post-partum to prevent extended sick leave following maternity leave in The Netherlands: results of an economic evaluation alongside a randomized controlled trial.
      ,
      • Zhang W.
      • Bansback N.
      • Guh D.
      • et al.
      Short-term influence of adalimumab on work productivity outcomes in patients with rheumatoid arthritis.
      ,
      • Hilton M.F.
      • Scuffham P.A.
      • Sheridan J.
      • et al.
      Mental ill-health and the differential effect of employee type on absenteeism and presenteeism.
      ], involved comparing global presenteeism estimates of a respondent with those of a colleague in a similar role both reported by the respondent. The respondent is asked to report a global rating for an average worker on their job, and their usual work performance, alongside a recent performance so as to estimate presenteeism-related work loss. This is done on a scale of 0 (worst performance at work) to 10 (best performance).

      Methods of Valuing Presenteeism Loss

      Having obtained a measure of productivity loss (such as hours lost or percentage effort made), this metric can then be converted into a monetary estimate. All studies in the review used salary-based conversion approaches, more specifically the human capital approach, with the exception of Smit et al. [
      • Smit F.
      • Willemse G.
      • Koopmanschap M.
      • et al.
      Cost-effectiveness of preventing depression in primary care patients: randomised trial.
      ], who used the friction cost approach. Various measures were used to assess the value of foregone earnings and these included an average wage for all groups (n = 11), age-sex–dependent wage rates (n = 6), and a self-reported gross salary (n = 4) (Table 2). The wage rates used were expressed variously as hourly, daily, or annual wage rates.
      Table 2Methods for including presenteeism and overall impact of costs
      StudyInstruments usedRecall periodLabor measure usedValuation methodProductivity metrics consideredPrimary measure reportedPresenteeism summary approachFindings (percentage of total costs)
      Boonen et al.
      • Boonen A.
      • Brinkhuizen T.
      • Landewé R.
      • et al.
      Impact of ankylosing spondylitis on sick leave, presenteeism and unpaid productivity, and estimation of the societal cost.
      HLQ2 wkAverage wageHCMPresenteeism and absenteeismExtra work hours needed to compensate for inefficient hoursDirect approachAnnual presenteeism costs: €967; absenteeism: €1,832 per patient per year; % of total: NS
      Braakman-Jansen et al.
      • Braakman-Jansen L.M.
      • Taal E.
      • Kuper I.H.
      • van de Laar M.A.
      Productivity loss due to absenteeism and presenteeism by different instruments in patients with RA and subjects without RA.
      QQ, WPAI1 wkAverage wage rate per hourHCMPresenteeism and absenteeismWPAI: degree of problems affecting work productivityPerceived change approachWPAI: annual presenteeism: 318 (73%) and 72 (92%) for intervention and control
      QQ: quantity and quality of work on an 11-point NRS from 0 to 10PRODISQ: annual presenteeism: 299 (71%) and 154 (95%) for intervention and control
      Burton et al.
      • Burton W.N.
      • Conti D.J.
      • Chen C.Y.
      • et al.
      The economic burden of lost productivity due to migraine headache: a specific worksite analysis.
      Global presenteeism question from interview questionnaireNSDaily wage ratesHCMPresenteeism onlyWork days of reduced productivityPerceived change approachAnnual presenteeism costs: $21.5 million (60%)
      Burton et al.
      • Burton W.N.
      • Chen C.Y.
      • Conti D.J.
      • et al.
      The association of health risks with on-the-job productivity.
      Modified WLQ2 wkNSNSPresenteeism only% of time the respondent was limited in performing a specific dimension of job tasksPerceived change approachAnnual presenteeism costs: $1,392–$2,592 per employee per year; annual extrapolated to $99 million–$185 million entire population
      Cisternas et al.
      • Cisternas M.G.
      • Blanc P.D.
      • Yen I.H.
      • et al.
      A comprehensive study of the direct and indirect costs of adult asthma.
      Global presenteeism question from surveyNSMean hourly wage from census surveyHCMPresenteeism onlyReduced work hours due to sicknessPerceived change approachAnnual costs: $4,912; indirect costs: $1,732 (35%); presenteeism (28%)
      Collins et al.
      • Collins J.J.
      • Baase C.M.
      • Sharda C.E.
      • et al.
      The assessment of chronic health conditions on work performance, absence, and total economic impact for employers.
      SPS and WOS4 wkNational average wage rates per job typeHCMPresenteeism onlyPercentage of “usual” productivity not achievedPerceived change approachAnnual costs per employee: $6,721 for presenteeism; 10% of total productivity costs; 6.8% presenteeism
      Cooksey et al.
      • Cooksey R.
      • Husain M.J.
      • Brophy S.
      • et al.
      The cost of ankylosing spondylitis in the UK using linked routine and patient-reported survey data.
      WLQ, WPAI2 wk, 1 wkAverage gross wageHCMPresenteeism and absenteeismWPAI: degree of problems affecting work productivityPerceived change approachAnnual costs: absenteeism: £411; presenteeism £3,425; total cost: £19,016
      WLQ: work limitations over different domainsDirect approach
      Daley et al.
      • Daley M.
      • Morin C.M.
      • LeBlanc M.
      • et al.
      The economic burden of insomnia: direct and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good sleepers.
      Global presenteeism question3 moAge-sex mean salariesHCMPresenteeism onlyExtent to which insomnia is responsible for reduced productivity on a 0–10 scalePerceived change approachPresenteeism: $5 billion (76% of total); total cost: $6.6 billion
      Finkelstein et al.
      • Finkelstein E.A.
      • DiBonaventura Md
      • Burgess S.M.
      • Hale B.C.
      The costs of obesity in the workplace.
      WPAI7 dAge-sex– specific wageHCMPresenteeism and absenteeism% reduction in productivity and estimate of time lost during the past 7 dPerceived change approachPresenteeism: $555–$3,792; % of total costs: NS
      Fishman and Black
      • Fishman P.
      • Black L.
      Indirect costs of migraine in a managed care population.
      Global presenteeism question6 moAge-sex working, educational, mental status– specific wageHCMPresenteeism onlyDegree to which headache affects normal activities on a scale of 0–10Perceived change approachPresenteeism greater than absenteeism; % of total costs: NS
      Goetzel et al.
      • Goetzel R.Z.
      • Long S.R.
      • Ozminkowski R.J.
      • et al.
      Health, absence, disability, and presenteeism cost estimates of certain physical and mental health conditions affecting U.S. employers.
      Global questions in survey2 wk, 3 mo, 12 moNational hourly wage ratesHCMPresenteeism onlyRate at which performance was reduced because of health problemsPerceived change approachAnnual presenteeism: 61% of total cost in 10 conditions
      Goetzel et al.
      • Goetzel R.Z.
      • Gibson T.B.
      • Short M.E.
      • et al.
      A multi-worksite analysis of the relationships among body mass index, medical utilization, and worker productivity.
      WLQ2 wkNational average wage ratesHCMPresenteeism only% of time the respondent was limited in performing a specific dimension of job tasks because of obesityPerceived change approachAnnual absenteeism and presenteeism combined: $2,596; direct costs: $2,842; % of total costs: NS
      Hellgren et al.
      • Hellgren J.
      • Cervin A.
      • Nordling S.
      • et al.
      Allergic rhinitis and the common cold—high cost to society.
      Global question from HRAcurrent episodeSelf-reported salaryHCMPresenteeism onlyNumber of days at work with rhinitis and self-reported productivity while at work during the last month/yearPerceived change approachAnnual costs: €2.7 billion; presenteeism (37%); absenteeism (44%)
      Henke et al.
      • Henke C.J.
      • Levin T.R.
      • Henning J.M.
      • Potter L.P.
      Work loss costs due to peptic ulcer disease and gastroesophageal reflux disease in a health maintenance organization.
      General question as part of interview questionnaire3 moSelf-reported salaryHCMPresenteeism onlyReduced productivity because of PUD or GERDPerceived change approachPresenteeism: annual PUD costs per year: $205 (28% of total); annual GERD costs per year: $72 (27% of total)
      Hilton et al.
      • Hilton M.F.
      • Scuffham P.A.
      • Sheridan J.
      • et al.
      Mental ill-health and the differential effect of employee type on absenteeism and presenteeism.
      HPQ4 wkMean wage rates ONS from United Kingdom and AustraliaHCMPresenteeism and absenteeismSelf-reported scale of performance of 0–10 (worst to best)Comparative approachAnnual total costs: $11.1 billion; % of total costs: NS
      Lamb et al.
      • Lamb C.E.
      • Ratner P.H.
      • Johnson C.E.
      • et al.
      Economic impact of workplace productivity losses due to allergic rhinitis compared with select medical conditions in the United States from an employer perspective.
      WPSINot reportedStandard hourly wageHCMAbsenteeism/presenteeismNumber of unproductive hours spent at work during the recall periodDirect approach% of total costs: NS
      Lerner et al.
      • Lerner D.
      • Mirza F.G.
      • Chang H.
      • et al.
      Impaired work performance among women with symptomatic uterine fibroids.
      WLQ2 wkAverage wageHCMPresenteeism only% of time the respondent was limited in performing a specific dimension of job tasks (%)Perceived change approachAnnual presenteeism costs: $2,341 for intervention group; $836 for control group; % of total costs: NS
      Li et al.
      • Li X.
      • Gignac M.A.
      • Anis A.H.
      The indirect costs of arthritis resulting from unemployment, reduced performance, and occupational changes while at work.
      WLQ2 wkAnnual average wage rateHCMPresenteeism only% of time the respondent was limited in performing a specific dimension of job tasks (%)Perceived change approachAnnual total costs: $11,553; presenteeism: $4,724 (41% of total costs)
      Linde et al.
      • Linde M.
      • Gustavsson A.
      • Stovner L.J.
      • et al.
      The cost of headache disorders in Europe: the Eurolight project.
      General presenteeism question3 moAverage sex- specific wage rateHCMAbsenteeism and presenteeismDays at work when the amount done was ≥50% reduced productivity (counted as 1 d of reduced productivity)Perceived change approachAnnual cost per person: £1,222; presenteeism: £765 (63% of total costs)
      Rafia et al.
      • Rafia R.
      • Ara R.
      • Packham J.
      • et al.
      Healthcare costs and productivity losses directly attributable to ankylosing spondylitis.
      WPAI3 moAverage wageHCMPresenteeism and absenteeismWPAI: degree of problems affecting work productivityPerceived change approachTotal 3-mo cost of £2,802; absenteeism (1.4%) and presenteeism (19%)
      Ricci and Chee
      • Ricci J.A.
      • Chee E.
      Lost productive time associated with excess weight in the U.S. workforce.
      WHI2 wkSelf-reported salaryHCM variantPresenteeism and absenteeismSelf-reported reduced work productivity on the basis of responses from five specific domainsPerceived change approachAnnual costs: $11.70 billion/y; presenteeism (67% of total costs)
      Smit et al.
      • Smit F.
      • Willemse G.
      • Koopmanschap M.
      • et al.
      Cost-effectiveness of preventing depression in primary care patients: randomised trial.
      Presenteeism question from questionnaireNSAge-sex wage rateHCMPresenteeism onlyReduced productivity at work (work cut-back days)Perceived change approachAnnual presenteeism, intervention: €2,232 (33% of total costs); annual total costs: €6,766; annual presenteeism, control: €3,175 (39% of total costs); annual total costs: €8,614
      Stewart et al.
      • Stewart W.F.
      • Ricci J.A.
      • Chee E.
      • Morganstein D.
      Lost productive work time costs from health conditions in the United States: results from the American Productivity Audit.
      WHI2 wkSelf-reported salaryHCM variantPresenteeism and absenteeismSelf-reported reduced work productivity on the basis of responses from five specific domainsPerceived change approachTotal cost: $61.2 billion; presenteeism: $46.9 billion (76.6%); presenteeism for arthritis (84.4%) and back pain (69.7%)
      Stewart et al.
      • Stewart W.F.
      • Ricci J.A.
      • Chee E.
      • et al.
      Lost productive time and cost due to common pain conditions in the US workforce.
      WHI2 wkSelf-reported salaryHCM variantPresenteeism and absenteeismSelf-reported reduced work productivity on the basis of responses from five specific domainsPerceived change approachTotal productivity costs: $225.8 billion/y; on average, presenteeism: 71% of total costs
      Thavorncharoensap et al.
      • Thavorncharoensap M.
      • Teerawattananon Y.
      • Yothasamut J.
      • et al.
      The economic costs of alcohol consumption in Thailand, 2006.
      Questions from WPAI1 wkAverage income per yearFCAPresenteeism and absenteeismReduced productivity at work and during regular activitiesDirect approachAnnual total costs: $9,627 million; annual presenteeism: $2,804 million (29% of total costs); mortality costs: $6,422 million
      Uegaki et al.
      • Uegaki K.
      • Stomp-van den Berg S.G.
      • de Bruijne M.C.
      • et al.
      Cost-utility analysis of a one-time supervisor telephone contact at 6-weeks post-partum to prevent extended sick leave following maternity leave in The Netherlands: results of an economic evaluation alongside a randomized controlled trial.
      HPQ2 wkNot includedHCMPresenteeism and absenteeismReduced work performance due to sicknessComparative approachAnnual presenteeism, intervention: €765 (40%); annual total costs: €1,911; annual presenteeism, control: €655 (38%); annual total costs: €1,734; overall costs, indirect costs (37%) and presenteeism (52%)
      Wilson et al.
      • Wilson D.A.
      • Bork K.
      • Shea E.P.
      • et al.
      Economic costs associated with acute attacks and long-term management of hereditary angioedema.
      WPAI-GH included in survey7 dSelf-reported gross salaryHCM variantPresenteeism and absenteeismReduced productivity at work and during regular activitiesDirect approachTotal costs: $41,992; indirect costs: $16,108; absenteeism: $3,402; presenteeism: $5,750; presenteeism (14% of total costs)
      Zhang et al.
      • Zhang W.
      • Bansback N.
      • Guh D.
      • et al.
      Short-term influence of adalimumab on work productivity outcomes in patients with rheumatoid arthritis.
      HLQ, HPQ, WPAI, WLQHLQ, 2 wk; HPQ, 4 wk; WPAI, 1 wk; WLQ, 2 wkAge-sex employee-type– specific wage rateHCMPresenteeism and absenteeismHLQ: extra hours workedDirect approach, comparative approach$30.03, $83.05, $284.07, and $285.10 (HLQ, WLQ, HPQ, and WPAI) over a period of 2 wk; % of total costs: NS
      WPAI: reduced productivity while working
      WLQ: work limitations over different domains
      HPQ: work performance during the past 7 d
      FCA, friction cost approach; GERD, gastroesophageal reflux disease; HCM, human capital method; HLQ, Health and Labour Questionnaire; HPQ, Health and Work Performance Questionnaire; HRA, health risk appraisal; NRS, numerical rating scale; NS, not stated; ONS, office for national statistics; PRODISQ, PROductivity and DISease Questionnaire; PUD, peptic ulcer disease; QQ, quantity and quality; SPS, Stanford Presenteeism Scale; WLQ, Work Limitations Questionnaire; WHI, Work and Health Interview; WOS, work output score; WPAI, Work Productivity and Activity Impairment; WPAI-GH, WPAI General Health; WPSI, Work Productivity Short Inventory.
      Studies were also assessed for whether they considered the impact of presenteeism on output, teamwork productivity, and substitutability, often known as multiplier effects, and any compensation mechanisms [
      • Nicholson S.
      • Pauly M.V.
      • Polsky D.
      • et al.
      Measuring the effects of work loss on productivity with team production.
      ]. Multiplier effects are additional costs that could result from the negative impact of sick coworkers on productivity particularly when team work is involved [
      • Pauly M.V.
      • Nicholson S.
      • Polsky D.
      • et al.
      Valuing reductions in on-the-job illness: “presenteeism” from managerial and economic perspectives.
      ]. Compensation mechanisms are adjustments for productivity loss through internal employee substitution mechanisms or as a result of ill employees compensating for lost time [
      • Krol M.
      • Brouwer W.B.
      • Severens J.L.
      • et al.
      Productivity cost calculations in health economic evaluations: correcting for compensation mechanisms and multiplier effects.
      ]. These have been reported to have a significant impact on overall productivity costs [
      • Zhang W.
      • Bansback N.
      • Boonen A.
      • et al.
      Development of a composite questionnaire, the valuation of lost productivity, to value productivity losses: application in rheumatoid arthritis.
      ]. None of the studies identified adjusted presenteeism costs for aspects of compensation mechanisms or included multiplier effects.

      Impact of Presenteeism on Total Costs

      Overall, 19 studies (67%) provided enough detail to assess the impact of presenteeism on total costs. On average, presenteeism costs comprised 52% (range 19%–85%) of the total costs of the interventions or disease conditions investigated (Table 2). The proportion of presenteeism was the highest in rheumatoid arthritis, back pain, and insomnia conditions. A further inspection of studies that did not report the overall total costs [
      • Boonen A.
      • Brinkhuizen T.
      • Landewé R.
      • et al.
      Impact of ankylosing spondylitis on sick leave, presenteeism and unpaid productivity, and estimation of the societal cost.
      ,
      • Finkelstein E.A.
      • DiBonaventura Md
      • Burgess S.M.
      • Hale B.C.
      The costs of obesity in the workplace.
      ,
      • Linde M.
      • Gustavsson A.
      • Stovner L.J.
      • et al.
      The cost of headache disorders in Europe: the Eurolight project.
      ,
      • Lerner D.
      • Mirza F.G.
      • Chang H.
      • et al.
      Impaired work performance among women with symptomatic uterine fibroids.
      ,
      • Collins J.J.
      • Baase C.M.
      • Sharda C.E.
      • et al.
      The assessment of chronic health conditions on work performance, absence, and total economic impact for employers.
      ] showed that presenteeism costs were greater than absenteeism costs. The three cost-effectiveness studies within this review included productivity losses related to presenteeism, but did not provide enough detail to assess the impact of presenteeism on cost-effectiveness outcomes [
      • Uegaki K.
      • Stomp-van den Berg S.G.
      • de Bruijne M.C.
      • et al.
      Cost-utility analysis of a one-time supervisor telephone contact at 6-weeks post-partum to prevent extended sick leave following maternity leave in The Netherlands: results of an economic evaluation alongside a randomized controlled trial.
      ,
      • Smit F.
      • Willemse G.
      • Koopmanschap M.
      • et al.
      Cost-effectiveness of preventing depression in primary care patients: randomised trial.
      ,
      • Lerner D.
      • Mirza F.G.
      • Chang H.
      • et al.
      Impaired work performance among women with symptomatic uterine fibroids.
      ].

      Discussion

      This review assessed the methods used in estimating presenteeism in current practice and the impact of presenteeism on total costs of health conditions. In the studies reviewed here, only nine instruments were identified in spite of the many existing presenteeism instruments that have been reported in the literature. The findings indicated that losses from reduced productivity at work are rarely included in cost-effectiveness or cost-utility analyses, although presenteeism has been associated with significant costs. Only three full economic evaluations (cost-effectiveness or cost-utility analyses) that included presenteeism costs were identified in this review [
      • Uegaki K.
      • Stomp-van den Berg S.G.
      • de Bruijne M.C.
      • et al.
      Cost-utility analysis of a one-time supervisor telephone contact at 6-weeks post-partum to prevent extended sick leave following maternity leave in The Netherlands: results of an economic evaluation alongside a randomized controlled trial.
      ,
      • Smit F.
      • Willemse G.
      • Koopmanschap M.
      • et al.
      Cost-effectiveness of preventing depression in primary care patients: randomised trial.
      ,
      • Lerner D.
      • Mirza F.G.
      • Chang H.
      • et al.
      Impaired work performance among women with symptomatic uterine fibroids.
      ]. Understanding of the impact of presenteeism is therefore derived largely from cost-of-illness studies. Although these show large costs of presenteeism resulting from illness, it is less clear what the impact of alternative health interventions on presenteeism is likely to be.
      Further assessment of the studies revealed a lack of consensus on the most appropriate instruments and approaches for measuring and valuing presenteeism. The most common approach used in measuring presenteeism was the direct approach, which has the advantage of generating directly usable productivity output values in lost hours that can easily be valued for use in economic evaluations. Comparisons with other presenteeism approaches, however, suggest that this approach potentially underestimates lost productivity [
      • Zhang W.
      • Gignac M.A.
      • Beaton D.
      • et al.
      Canadian Arthritis Network Work Productivity Group
      Productivity loss due to presenteeism among patients with arthritis: estimates from 4 instruments.
      ]. These findings are consistent with those of Schultz et al. [
      • Schultz A.B.
      • Chen C.-Y.
      • Edington D.W.
      The cost and impact of health conditions on presenteeism to employers: a review of the literature.
      ] who found wide variations in approaches to monetary valuation for reduced productivity among different instruments. Moreover, from the few attempts that have been made to compare across measurement instruments within the same population, there is evidence that different instruments produced different estimates [
      • Ozminkowski R.J.
      • Goetzel R.Z.
      • Chang S.
      • Long S.
      The application of two health and productivity instruments at a large employer.
      ,
      • Zhang W.
      • Gignac M.A.
      • Beaton D.
      • et al.
      Canadian Arthritis Network Work Productivity Group
      Productivity loss due to presenteeism among patients with arthritis: estimates from 4 instruments.
      ,
      • Meerding W.J.
      • IJzelenberg W.
      • Koopmanschap M.A.
      • et al.
      Health problems lead to considerable productivity loss at work among workers with high physical load jobs.
      ]. High costs were attributed to presenteeism in the studies included. It should be noted, however, that most of the studies used the human capital method that is known to overestimate productivity loss, and only one study from the Netherlands used the friction cost approach to take account of likely rebalance of labor duties in the workplace. Previous research has found little or no attempt to apply the friction cost approach in valuing presenteeism [
      • Mattke S.
      • Balakrishnan A.
      • Bergamo G.
      • Newberry S.J.
      A review of methods to measure health-related productivity loss.
      ,
      • Kigozi J.
      • Jowett S.
      • Lewis M.
      • et al.
      Estimating productivity costs using the friction cost approach in practice: a systematic review.
      ]. The proportion of estimates using the human capital approach compared with the friction cost approach in this area needs further attention. All studies included in this review were based on subjective measures and therefore are completed by the employees using their own judgment. It remains uncertain how these estimates would compare with measures of productivity loss obtained from employers.
      To date, little evidence exists on presenteeism costs in cost-effectiveness or cost-utility analyses that typically inform the process of health care decision making. Most of the studies included in this review were cost-of-illness studies. There is limited literature on typical economic evaluations incorporating presenteeism costs and consequently their impact on overall cost-effectiveness results. These findings could be attributed to the studies adhering to national guidelines that in most cases do not prescribe inclusion of presenteeism or other related costs such as multiplier effects and compensation mechanisms [
      • Knies S.
      • Severens J.L.
      • Ament A.J.
      • Evers S.M.
      The transferability of valuing lost productivity across jurisdictions: differences between national pharmacoeconomic guidelines.
      ]. Another reason could be a general lack of confidence in methodology regarding how to measure and value presenteeism. Given that presenteeism contributes significantly to overall total costs as has been shown in this review, the exclusion of this cost category in economic evaluations is likely to result in biased societal decision making.
      These conclusions need to be considered in light of the strengths and limitations of this study. One strength is that the review provides an overview of the instruments and methods used to estimate presenteeism in practice. It also comprehensively assesses cost-of-illness studies and economic evaluations from various databases, showing the impact of presenteeism on the total cost of health conditions. There were some limitations with this study. First, we used a limited set of databases for our search of economic evaluations including presenteeism. As a result, although care was taken to include all relevant studies, we could have missed some economic evaluations that considered presenteeism. Nevertheless, the included databases spanned the health economics, medical, and behavioral science disciplines and therefore provide a comprehensive overview of the literature. Second, the selection process in this review did not fully adhere to the Cochrane review selection process. Notably, the review set out to provide an insight into the current role of productivity costs in relation to reduced productivity at work in economic evaluations. It does not seem likely that a more extensive search strategy and selection process would significantly alter the conclusions of this review. Finally, studies could have been missed by excluding non-English articles.
      In spite of the limitations of this study, some important policy and research implications may be drawn. First, there is a need to build a greater awareness about the potential impact of presenteeism-related conditions on productivity, employers, and society in cost-effectiveness or cost-utility analyses to identify the most effective strategies and interventions of managing these conditions. This is particularly important because presenteeism, from this review, appears to contribute significantly to productivity costs (or savings) and overall total costs of certain disease areas such as musculoskeletal pain, migraine, and mental health–related disorders. Economic evaluation recommendations in these disease conditions that do not include estimates of presenteeism may result in less than optimal resource allocation decisions from a societal perspective. Determining the extent to which resource allocation is less than optimal is a research area that needs to be prioritized. To do so, however, it is clear that there is a need for greater consensus on the methods that should be used to estimate presenteeism in economic evaluations. Current proposed cost-effectiveness ratio thresholds may not be truly representative of the willingness of society to pay for interventions from a societal perspective. Evidence in support of changing current willingness-to-pay thresholds remains inconclusive [
      • Donaldson C.
      • Baker R.
      • Mason H.
      • et al.
      The social value of a QALY: raising the bar or barring the raise?.
      ,
      • Claxton K.
      • Martin S.
      • Soares M.
      • et al.
      Methods for the estimation of the NICE cost effectiveness threshold.
      ], and further research on whether and how to explicitly determine acceptable decision-making incremental cost-effectiveness ratio thresholds when incorporating productivity costs in economic evaluations would be very helpful.
      Previous research has highlighted the role of the friction cost approach in estimating more realistic absence-related productivity costs compared with the human capital approach, particularly in the long run [
      • Meerding W.J.
      • IJzelenberg W.
      • Koopmanschap M.A.
      • et al.
      Health problems lead to considerable productivity loss at work among workers with high physical load jobs.
      ]. It is possible that attempts to apply the friction cost approach to generate presenteeism costs may lead to more realistic productivity loss estimates than would current estimates based on the human capital method, as they have in relation to absenteeism [
      • Krol M.
      • Brouwer W.
      How to estimate productivity costs in economic evaluations.
      ]. The application of this approach in the context of presenteeism, however, remains unclear. Additional evidence is needed to determine how to estimate and value presenteeism wage-related multiplier effects and compensation mechanisms at work when estimating productivity costs [
      • Zhang W.
      • Bansback N.
      • Boonen A.
      • et al.
      Development of a composite questionnaire, the valuation of lost productivity, to value productivity losses: application in rheumatoid arthritis.
      ]. The latter issue is particularly important because costs related to presenteeism appear to be greater than those related to absenteeism [
      • Ricci J.A.
      • Chee E.
      Lost productive time associated with excess weight in the U.S. workforce.
      ,
      • Braakman-Jansen L.M.
      • Taal E.
      • Kuper I.H.
      • van de Laar M.A.
      Productivity loss due to absenteeism and presenteeism by different instruments in patients with RA and subjects without RA.
      ]. Additional research is needed to add to this evidence base in these areas.
      Finally, a number of measurement instruments have been reported in the literature, although few studies have used these productivity instruments to estimate the cost of presenteeism in economic evaluation costing practice. The methods used in the instruments varied widely and the impact of the alternative estimation approaches on overall cost-effectiveness results needs to be further assessed. One way forward is to establish a reference case of standard instruments and corresponding validated cost conversion algorithms for estimating the cost of presenteeism. To promote increased transparency, a useful practice could be to cross-compare instruments and also include a brief justification of the instruments chosen (given the number available) with clear reporting of the estimation and valuation methods. Although including presenteeism is not feasible for all conditions, we would suggest that a first step could be for studies to include presenteeism as a sensitivity or secondary care analysis when appropriate to assess the robustness of findings with respect to wider costs associated with lost productivity. Also, studies that exclude presenteeism costs could justify their decision in terms of (ir)relevance to the condition being investigated.

      Conclusions

      The estimation of reduced productivity at work (presenteeism) seems to be very limited in current economic evaluation practice. The development of various presenteeism measurement instruments has also not translated into applied costing practice. To enable wider inclusion of presenteeism costs, a reference case and guidance regarding standard instruments and a methodology for estimating and valuing productivity costs related to presenteeism need to be developed. Given the significance of presenteeism in relation to lost productivity, and its potential impact on diseases and interventions as shown here, more attention needs to be given to the methods used to estimate presenteeism and the methods for its inclusion in economic evaluations.
      Source of financial support: No specific funding was received for this research.

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