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Supplements Economic Impact of Irritable Bowel Syndrome: What Does the Future Hold?
Economic Impact of Irritable Bowel Syndrome: What Does the Future Hold?
Brooks Cash, MD, FACP
Tegaserod Treatment for IBS: A Model of Indirect Costs
Dean G. Smith, PhD; Victoria Barghout, MSPH; and Kristijan H. Kahler, SM
Effectiveness of Tegaserod Therapy on GI-related Resource Utilization in a Managed Care Population
Judith J. Stephenson, SM; Victoria Barghout, MSPH; Kristijan H. Kahler, SM; Joaquim Fernandes, BA; Jane F. Beaulieu, MSN; Samuel Joo, MS; and Stephen J. Boccuzzi, PhD
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Total Costs of IBS: Employer and Managed Care Perspective
Brooks Cash, MD, FACP; Sean Sullivan, JD; and Victoria Barghout, MSPH
Impairment in Work Productivity and Health-related Quality of Life in Patients With IBS
Bonnie B. Dean, PhD; Daniel Aguilar, MPH; Victoria Barghout, MSPH; Kristijan H. Kahler, SM; Feride Frech, MPH; David Groves, PhD; and Joshua J. Ofman, MD
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Total Costs of IBS: Employer and Managed Care Perspective

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

In addition to absenteeism, IBS symptoms are responsible for significant presenteeism. In fact, because IBS symptoms wax and wane, presenteeism actually results in greater costs for employers than absenteeism. 10 Patients with IBS tend to miss work sporadically rather than for long stretches of time.11 A 2-part survey of the employees of Comerica Incorporated (N = 11 806)—a nationwide bank with major branches in Michigan, California, Texas, and Florida—examined worker productivity (both absenteeism and presenteeism) using the WPAI. Results showed a reduced work productivity rate of 21.1% among employees with IBS, which is equivalent to working only 4 days of a 5-day workweek.10 Another study surveyed members of a managed care organization who had IBS (n = 574) and found that the average indirect costs incurred for productivity losses caused by the restriction of normal activities (ie, presenteeism) was $2837 per year among employed respondents (n = 151). Average costs resulting from absenteeism were estimated to be $996 per year.45 These data clearly indicate that IBS symptoms result in a significant loss of productivity.

Impact on Patients. Patients with IBS often tolerate the symptoms for years before they seek diagnosis.4,5 IBS symptoms restrict or otherwise negatively impact many aspects of patients'lives, including diet, travel, sleep, intimacy, and leisure activities.4,5,13,42,46,47 It has been demonstrated that the quality of life of IBS patients is substantially diminished compared not only with the general population but also with patients who have gastroesophageal reflux disease, asthma, diabetes, or migraine.48,49 Patients with IBS report that symptoms often cause them to be late for work or to leave work early.5,46,50 Because of their IBS symptoms, many have made job decisions they would not otherwise have made, such as cutting back on days of work, working fewer hours, turning down promotions or advancements, and working from home.4,5,13,42,46

Because of the nature of IBS symptoms and the fact that some employers do not accept these symptoms as valid reasons for work absence, patients often do not disclose that they have IBS. For example, in the IBS Bulletin Survey, 47% of respondents reported that they had not informed their employers of their IBS.4

All of these factors contribute to the complexity of managing IBS and have important ramifications for the implementation of IBS educational programs in the workplace. Developing and implementing an appropriate program for IBS awareness, similar to that for other long-term medical disorders, requires that employers be cognizant of the potential presence and scope of the problem in their workforces and that they understand the specific issues surrounding the diagnosis and treatment of this prevalent and costly disorder.

IBS in the Workplace—Steps for Developing an IBS Program

Despite the absence of biochemical or structural markers for IBS, a positive diagnosis of IBS can be confidently made when a stepwise, symptom-based approach is followed.1 A recent systematic review50 suggests that in the absence of "red flags" (Figure 4), which may be indicative of organic GI disease, routine diagnostic tests are not required or even particularly discriminatory for making a positive and durable diagnosis of IBS.50,51 These findings corroborate those of an early study by Hamm and colleagues.51 However, early and accurate diagnosis is essential for the cost-effective management of IBS. The diagnosis of IBS is often delayed, causing patients to consult multiple physicians, make multiple office visits, and undergo unnecessary and often repetitive diagnostic testing and procedures, including, in some cases, unnecessary abdominal surgeries.5,52,53


Effective therapies that are well tolerated and treat the multiple symptoms of IBS are also essential to cost-effective management.54 Many patients are dissatisfied with traditional IBS therapies such as fiber, antispasmodics, antidiarrheals, and laxatives, which typically address only individual IBS symptoms (eg, constipation, diarrhea, bloating, or abdominal pain) and often switch medications or use multiple medications to alleviate all of their IBS symptoms.55 Additional effective, well-tolerated agents that provide global relief of the multiple symptoms of IBS could help diminish the use of polypharmacy and thus reduce the total costs of prescription and OTC medications.

Preliminary evidence suggests that the use of novel IBS therapies, such as the serotonergic agent alosetron, a serotonin (5-HT) type 3 (5-HT3) receptor antagonist indicated for the treatment of women with severe IBS with diarrhea, and tegaserod, a 5-HT4 receptor agonist indicated for use in women with IBS with constipation (IBS-C), may help decrease worker absenteeism and improve worker productivity. Tegaserod has also been shown to be cost-effective.56 An economic model of the indirect costs associated with IBS and their reduction with treatment intervention found that in the base case scenario of employees with IBS-C, tegaserod therapy results in an annual cost savings of $1882 in avoided lost productivity per treated female employee with IBS.57 In addition, in a randomized, double-blind, placebo-controlled, multicenter study of 2600 women with IBS-C, tegaserod treatment was found to significantly reduce work productivity and daily activity impairment.58

In addition to these therapeutic advances, innovative tools are now available for use in workplace educational awareness programs designed to help employees better manage their IBS symptoms.59 Such interventions hold promise for significantly decreasing the impact of this condition in the workplace.

Step 1: Implement an IBS Educational Awareness Campaign. An educational awareness campaign in the workplace would help address the need for awareness about the causes and consequences of IBS. IBS is associated with numerous misconceptions on the part of employers, physicians, and patients. For example, many patients with IBS fear that their IBS could progress to a more serious disease, such as cancer.60 Others believe that their symptoms are caused by lifestyle factors or that they are psychosomatic.46

Many patients with IBS believe they have insufficient information about their disorder.60 When respondents in a recent telephone survey conducted in the United States were asked to select from a list of long-term disorders that included asthma, depression, CHD, and diabetes, almost 50% ranked IBS as the medical disorder about which they knew the least.61 Similar results were found in Europe.60

Evidence also suggests that healthcare providers should acquire a greater understanding of IBS. A study involving 36 general practitioners and 3111 patients in the United Kingdom found that IBS was identified in only 58% of patients whose symptoms warranted the diagnosis.62 Even physicians who recognize and treat IBS seem unaware of the degree to which IBS disrupts and debilitates affected patients. When describing on a scale of 1 ("barely noticeable") to 10 ("completely incapacitating") the pain associated with IBS, IBS patients, on average, rated their pain as 6.3, whereas physicians rated it as 5.163; these results indicate that there is a disconnection between physicians and patients regarding IBS.

Although these observations from the workplace appear bleak, an IBS educational awareness campaign may prove to be an effective intervention. It has been well demonstrated that workplace health improvement programs are effective in managing other long-term conditions.64 Patients who have participated in these programs report that they feel healthier and more in control of their disease; this outcome has resulted in measurable reductions in medical care costs and absenteeism and in enhanced productivity in patients with depression and diabetes.64-66

Step 2: Implement Incentive Programs. Employers may consider implementing incentive programs to encourage employees with IBS to seek and comply with treatment. For example, the educational campaign and incentives program for depression management initiated by First Chicago Corporation in the 1980s resulted in reduced behavioral healthcare costs in each subsequent year after its inception, and, by 1996, the mental health share of total healthcare costs had decreased from 14% to less than 5%.64

It can be seen from the previous discussion that on-site educational or incentive programs can help employees better manage long-term medical disorders and be more productive at work and that employers who provide such programs can reduce total direct healthcare costs and costs resulting from absenteeism and presenteeism.

Step 3: Reevaluate and Monitor Program Impact. Effective programs require reevaluation and monitoring. Reevaluation allows for program updates and for the introduction of new information, such as details about newly available therapies. For example, whereas sumatriptan was once the cost-effective choice for migraine management,67-69 the cost/benefit model shifted when almotriptan was introduced to the market. Almotriptan was found to be as effective and as well tolerated as sumatriptan, but its acquisition cost was lower, making it the more cost-effective choice.70 For them to be most effective, educational programs must be kept current with new developments in disease management, and treatment recommendations should be continually monitored to ensure that they stay current and relevant.


IBS is a long-term, episodic GI motility disorder that is prevalent among adults of working age. It imposes a substantial burden on patients and employers. Although IBS can be confidently diagnosed on the basis of characteristic symptoms, it is often misdiagnosed or underrecognized by patients and physicians, leading to multiple physician visits, multiple medications, and unnecessary diagnostic tests, procedures, and surgeries—all of which contribute to higher direct medical costs. Additionally, employers incur significant costs because of IBS-related absenteeism and presenteeism. Such costs have traditionally been difficult to quantify, but recent efforts have led to better understanding of their magnitude. Educational awareness programs have been used successfully to reduce the costs associated with other long-term disorders; with appropriate implementation, such programs might have similar results for IBS. Finally, ongoing and future development of therapies that effectively and safely provide global relief of the multiple symptoms of IBS may also help to reduce the sizable costs associated with this common condition.

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