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Total Costs of IBS: Employer and Managed Care Perspective
Brooks Cash, MD, FACP; Sean Sullivan, JD; and Victoria Barghout, MSPH
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Total Costs of IBS: Employer and Managed Care Perspective

Brooks Cash, MD, FACP; Sean Sullivan, JD; and Victoria Barghout, MSPH

Irritable bowel syndrome (IBS) is a common gastrointestinal motility disorder that typically affects persons of working age and is costly to employers. The financial burden attributable to the direct (use of healthcare resources) and indirect (missed days from work [absenteeism] and loss of productivity while at work [presenteeism]) costs of IBS is similar to that of other common long-term medical disorders, such as asthma, migraine, hypertension, and congestive heart failure. The symptoms of IBS are significantly bothersome and place a substantial burden on the personal and working lives of patients. As with other long-term medical conditions that have a significant impact on productivity, directed efforts by employers can address IBS in the workplace and thereby potentially decrease its impact. In this article, the symptoms of IBS and its impact on patients and on society as a whole are discussed; options are outlined by which employers can help reduce the total costs of IBS, including lost productivity (both absenteeism and presenteeism), in the workplace.

(Am J Manag Care. 2005;11:S7-S16)

Irritable bowel syndrome (IBS) is a common gastrointestinal (GI) motility disorder, characterized by abdominal pain or discomfort and altered bowel function, that has been estimated to affect up to 10% to 15% of North Americans.1 IBS can affect persons of all ages, but it is most often diagnosed in working-aged persons, typically those between the ages of 30 and 50 years.2 Although IBS is estimated to affect millions, only 25% of persons with IBS actually seek medical treatment for their symptoms.3

Partly because of its chronicity, many patients with IBS experience symptoms for years before they seek medical attention.4,5 For example, 42% of respondents to the IBS in the Real World Survey reported that they had IBS symptoms for an average of 10 years before diagnosis.5 Similar results were obtained from the IBS Bulletin Survey, in which 50% of respondents reported that they had IBS symptoms for 11 years or longer.4

Given its prevalence and epidemiology, it is not surprising that IBS has the potential to impose a substantial financial burden on society.6-8 IBS has been shown to be associated with significant direct (use of healthcare resources) and indirect (absenteeism [missed days of work] and presenteeism [loss of productivity while at work]) costs. In fact, indirect costs appear to account for most of the financial burden associated with IBS.9,10

Recently, interest in the relationship between this burden and employers has grown—perhaps, in part, because of the availability of newer agents for treatment—and substantial employer costs have been identified.11 Because IBS remains a poorly recognized and understood condition, formally addressing IBS in the workplace and educating employers and employees about the disorder may reduce the burden of IBS by improving the delivery of effective therapies to employees with IBS.

Total Costs of IBS

Total costs attributable to any medical condition are composed of direct (ie, physician visits, outpatient care, inpatient/emergency care, diagnostic tests) and indirect (ie, lost worker productivity—both absenteeism and presenteeism) costs.

Previously, the socioeconomic impact of IBS on the workforce was difficult to measure objectively—researchers had to rely on observations of crude absenteeism rates. Several studies have demonstrated that these rates are significantly higher for IBS patients than for matched controls.12,13 For example, a survey of 5430 persons from a random sample of US households found that illness caused the average patient with IBS to miss 13.4 days per year from work or school, whereas the average subject without a GI disorder missed only 4.9 days per year because of illness.12 In another survey of identified IBS patients in the United States (n = 287), 30% of respondents reported that they had missed work completely because of their IBS symptoms, and 46% reported that their symptoms had forced them to leave early or to report late for work.13

Direct costs attributable to IBS have been estimated to be approximately $1.5 billion6,14,15; however, based on an estimate of $8 billion in 1992, one report estimated the adjusted direct costs to be as high as $10 billion, excluding the costs of prescription and over-the-counter (OTC) drugs. In addition, the indirect costs of IBS, which are largely borne by the employer, have been estimated to be as high as $20 billion.6 However, given that this estimate is based on costs associated with IBS patients who sought medical attention—only a minority of patients with IBS—unmeasured indirect costs may be significantly higher than current best estimates.

For perspective, the prevalence of IBS1,8 appears to be similar to that of other long-term conditions, such as asthma,16 coronary heart disease (CHD),16 diabetes,16 hypertension, 16 and migraine16 (Figure 1). However, the estimated total cost of IBS6,7 is greater than that of asthma17 or migraine18 (long-term, episodic conditions) and comparable with that of hypertension19 and congestive heart failure19 (long-term, persistent conditions) (Figure 2).



Direct Costs of IBS

Healthcare Utilization. IBS is commonly diagnosed by primary care physicians and gastroenterologists2,20; patients with IBS constitute one of the largest diagnostic groups in the gastroenterology setting.20,21 According to the American Gastroenterological Association, patients with IBS made 3.65 million visits to physicians in 1998.6

Many consultations result in interventions, such as diagnostic tests and prescriptions. According to the 1997 National Ambulatory Medical Care Survey, medications for the treatment of IBS symptoms were prescribed at an estimated 2.5 million visits per year, and 89% of IBS-related consultations in 1997 resulted in at least 1 IBS-related prescription.22 This considerable use of healthcare resources has resulted in high costs to managed care, patients, and employers.

Costs to Managed Care. Patients with IBS make a significantly greater number of healthcare visits per year than population controls.23-25 This substantial use of healthcare resources results in considerable managed care costs. For example, analyses of use and cost data obtained through the computerized information systems of a large, staff-model health maintenance organization (HMO) in western Washington demonstrated that the total costs of all healthcare provided by the HMO during a 12-month period were slightly more than $4000 for patients with IBS (n = 3153) compared with approximately $2700 for population controls (a 49% difference).26

Costs to Patients. A commonly overlooked component of the total cost of IBS is the time and cost expenditure for individual patients with IBS. Many patients report substantial out-of-pocket expenses for IBS therapies.27 For example, a recent survey of 657 members of the Intestinal Disease Foundation found that patients with IBS spent an average of $288 on OTC and alternative therapies for their IBS symptoms during the 3 months preceding the survey.27

Costs to Employers. Although IBS imposes a significant financial burden on patients and managed care, employers shoulder a large proportion of the total costs—both direct costs (insurance payments) and indirect costs (absenteeism and presenteeism)—attributable to IBS. Regarding direct costs, a recently published survey of beneficiaries with IBS (n = 1509; subset of employees, n = 504) who were identified from administrative claims data of a national Fortune 100 manufacturing company found that employees with IBS cost this employer 1.5 times more than employees in a matched control sample ($6364 [employees with IBS] compared with $4245 [controls]; P < .001; Figure 3),11 resulting in an estimated $1.9 million per year in additional costs to the employer. Presumably, this is an underestimation—because this study analyzed claims data, indirect costs included only absenteeism costs; adding presenteeism costs would probably have increased the total cost estimate substantially. Of note, the most significant incremental costs to the employer in this analysis were related to the greater use of ambulatory care and prescription drugs by IBS patients than by controls. IBS did not appear to result in high levels of disability, nor did it cause substantial use of inpatient care11—which employers typically equate with high cost—most likely because this condition waxes and wanes.


Indirect Costs of IBS

Although direct costs are more easily quantified and tracked, long-term and episodic conditions, such as IBS, also result in substantial indirect costs. In fact, it is estimated that direct costs account for less than half the total costs of IBS that employers incur.9 Disease-related indirect costs, including absenteeism from work, disability program use, worker compensation program costs, worker turnover, family medical leave, and presenteeism, account for most of the financial burden for employers.9

Productivity Costs. The effects on worker productivity caused by the symptoms and treatment of several long-term (ie, diabetes, asthma, hypertension, heart disease, mood disorders)28 and acute (ie, influenza)29 conditions have been documented. The Table,30-38 which shows baseline Work Productivity and Activity Impairment (WPAI) scores for several common long-term and episodic conditions, illustrates this point. WPAI is a productivity questionnaire that was developed as a general health measure and has been modified and validated for specific health conditions, including IBS.10 It is designed to measure work impairment attributed to absenteeism (missed days from work) and presenteeism (reduced productivity at work) and impairment in daily activities, such as housework, shopping, child care, and exercising.10 WPAI outcomes are expressed as impairment percentages, with higher numbers indicating greater impairment and less productivity (ie, worse outcomes). Another measure of lost productivity, the work productivity score, enumerates reduced productivity attributed to IBS symptoms as a percentage of potential total work productivity during a full-time workweek.


Indirect costs associated with absenteeism and presenteeism as a result of IBS are substantial. In 1992, IBS was the second leading cause, behind the common cold, of workplace absenteeism,39 and recent data suggest that the gap may be shrinking.40-42 In a study of 2143 patients with IBS identified from 47 074 telephone screening interviews in the United States and in 8 European countries (United Kingdom, Netherlands, Italy, Switzerland, Germany, Belgium, Spain, and France), Europeans with IBS reported missing an average of 4 to 10.9 days of work during the previous year compared with 1.5 to 5.6 days reported by control subjects; Americans with IBS reported missing, on average, 6.4 days compared with 3 days reported by matched controls.41 These findings are consistent with previous surveys, which indicate that patients with IBS miss more than 6 days of work per year because of their symptoms.42 By way of comparison, a recent analysis concluded that affected workers lost roughly 1 day of work (9 hours) per common cold episode.43 Another survey found that 67% of adults experience at least 1 cold per year and that among those adults the average is 2.2 cold episodes per year.44

Copyright AJMC 2006-2018 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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