Supplements Economic Impact of Irritable Bowel Syndrome: What Does the Future Hold?
Total Costs of IBS: Employer and Managed Care Perspective
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 Floridaexamined 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 WorkplaceSteps 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
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
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
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
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 surgeriesall 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.
1. American College of Gastroenterology Functional Gastrointestinal Disorders Task Force. Evidence-based position statement on the management of irritable bowel syndrome in North America. Am J Gastroenterol. 2002;97(11 suppl):S1-S5.
2. Drossman DA, Whitehead WE, Camilleri M. Irritable bowel syndrome: a technical review for practice guideline development. Gastroenterology. 1997;112:2120-2137.
3. Drossman DA, Thompson WG. The irritable bowel syndrome: review and a graduated multicomponent treatment approach. Ann Intern Med. 1992;116:1009-1016.
4. Silk DB. Impact of irritable bowel syndrome on personal relationships and working practices. Eur J Gastroenterol Hepatol. 2001;13:1327-1332.
5. International Foundation for Functional Gastrointestinal Disorders. IBS in the Real World Survey: Summary Findings. Milwaukee, Wis: International Foundation for Functional Gastrointestinal Disorders; 2002.
6. American Gastroenterological Association. The Burden of Gastrointestinal Diseases. Bethesda, Md: American Gastroenterological Association; 2001:1-86. Available at: http://www.gastro.org/clinicalRes/pdf/burden-report.pdf. Accessed November 16, 2004.
7. Martin R, Barron JJ, Zacker C. Irritable bowel syndrome: toward a cost-effective management approach. Am J Manag Care. 2001;7(8 suppl):S268-S275.
8. Camilleri M, Heading RC, Thompson WG. Consensus report: clinical perspectives, mechanisms, diagnosis and management of irritable bowel syndrome. Aliment Pharmacol Ther. 2002;16:1407-1430.
9. Goetzel RZ, Hawkins K, Ozminkowski RJ, Wang S. The health and productivity cost burden of the "top 10" physical and mental health conditions affecting six large U.S. employers in 1999. J Occup Environ Med. 2003;45:5-14.
10. Dean BB, Aguilar D, Barghout V, et al. Impairment in work productivity and health-related quality of life in patients with irritable bowel syndrome. Am J Manag Care. 2005;11(suppl):S17-S26.
11. Leong SA, Barghout V, Birnbaum HG, et al. The economic consequences of irritable bowel syndrome: a US employer perspective. Arch Intern Med. 2003;163:929-935.
12. Drossman DA, Li Z, Andruzzi E, et al. U.S. householder survey of functional gastrointestinal disorders: prevalence, sociodemography, and health impact. Dig Dis Sci. 1993;38:1569-1580.
13. Hahn BA, Yan S, Strassels S. Impact of irritable bowel syndrome on quality of life and resource use in the United States and United Kingdom. Digestion. 1999;60:77-81.
14. Inadomi JM, Fennerty MB, Bjorkman D. The economic impact of irritable bowel syndrome. Aliment Pharmacol Ther. 2003;18:671-682.
15. Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel syndrome. Gastroenterology. 2002;123:2108-2131.
16. Centers for Disease Control and Prevention. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 1998. Washington, DC: Department of Health and Human Services; 2002:1-114.
17. Centers for Disease Control and Prevention. Fact Sheets: Facts About Asthma. Atlanta, Ga: CDC Office of Communication Media Relations; August 8, 1997.
18. Hu XH, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden of migraine in the United States: disability and economic costs. Arch Intern Med. 1999;159:813-818.
19. American Heart Association. Heart and Stroke Statistical Update1999. Dallas, Tex: American Heart Association; 1998.
20. Mitchell CM, Drossman DA. Survey of the AGA membership relating to patients with functional gastrointestinal disorders. Gastroenterology. 1987;92:1282-1284.
21. Russo MW, Gaynes BN, Drossman DA. A national survey of practice patterns of gastroenterologists with comparison to the past two decades. J Clin Gastroenterol. 1999;29:339-343.
22. Shih YC, Barghout VE, Sandler RS, et al. Resource utilization associated with irritable bowel syndrome in the United States 1987-1997. Dig Dis Sci. 2002;47:1705-1715.
23. Patel RP, Petitta A, Fogel R, Peterson E, Zarowitz BJ. The economic impact of irritable bowel syndrome in a managed care setting. J Clin Gastroenterol. 2002;35:14-20.
24. Eisen GM, Weinfurt KP, Hurley J, et al. The economic burden of irritable bowel syndrome in a managed care organization [abstract]. Am J Gastroenterol. 2000;95:2628-2629.
25. Ofman J, Wilson A, Knight K, et al. Healthcare utilization and the irritable bowel syndromea U.S. managed care perspective [abstract]. Am J Gastroenterol. 2001;96(suppl 1):S276. Abstract 879.
26. Levy RL, Von Korff M, Whitehead WE, et al. Costs of care for irritable bowel syndrome patients in a health maintenance organization. Am J Gastroenterol. 2001;96:3122-3129.
27. Gore M, Frech F, Yokoyama K, Tai K-S. Symptom burden and management of irritable bowel syndrome: a patient perspective [abstract]. Am J Gastroenterol. 2002;97:S239-S240. Abstract 731.
28. Druss BG, Marcus SC, Olfson M, Tanielian T, Elinson L, Pincus HA. Comparing the national economic burden of five chronic conditions. Health Aff (Milwood). 2001;20:233-241.
29. Akazawa M, Sindelar JL, Paltiel AD. Economic costs of influenza-related work absenteeism. Value Health. 2003;6:107-115.
30. Tanner LA, Reilly M, Meltzer EO, Bradford JE, Mason J. Effect of fexofenadine HCI on quality of life and work, classroom, and daily activity impairment in patients with seasonal allergic rhinitis. Am J Manag Care. 1999;5(suppl):S235-S247.
31. Meltzer EO, Casale TB, Nathan RA, Thompson AK. Once-daily fexofenadine HCl improves quality of life and reduces work and activity impairment in patients with seasonal allergic rhinitis. Ann Allergy Asthma Immunol. 1999;83:311-317.
32. Andreasson E, Svensson K, Berggren F. The validity of the work productivity: an activity impairment questionnaire for patients with asthma (WPAI-asthma): results from a web-based study [abstract]. Value Health. 2003;6:780. Abstract PRP11.
33. Reilly MC, Lavin PT, Kahler KH, Pariser DM. Validation of the Dermatology Life Quality Index and the Work Productivity and Activity Impairment-Chronic Hand Dermatitis questionnaire in chronic hand dermatitis. J Am Acad Dermatol. 2003;48:128-130.
34. Wahlqvist P, Carlsson J, Stalhammar NO, Wiklund I. Validity of a Work Productivity and Activity Impairment questionnaire for patients with symptoms of gastroesophageal reflux disease (WPAI-GERD)results from a cross-sectional study. Value Health. 2002;5:106-113.
35. Dean BB, Crawley JA, Reeves JD, et al. The cost of gastroesophageal reflux disease: it's what you don't see that counts. J Manag Care Med. 2003;7:6-13.
36. Reilly MC, Bracco A, Ricci JF, Santoro J, Stevens T. The validity and accuracy of the Work Productivity and Activity Impairment questionnaireirritable bowel syndrome version (WPAI:IBS). Aliment Pharmacol Ther. 2004;20:459-467.
37. Kobelt G, Borgstrom F, Mattiasson A. Productivity, vitality and utility in a group of healthy professionally active individuals with nocturia. BJU Int. 2003;91:190-195.
38. Wittchen HU, Beloch E. The impact of social phobia on quality of life. Int Clin Psychopharmacol. 1996;11(suppl 3):15-23.
39. Weber FH, McCallum RW. Clinical approaches to irritable bowel syndrome. Lancet. 1992;340:1447-1452.
40. Camilleri M, Williams DE. Economic burden of irritable bowel syndrome: proposed strategies to control expenditures. Pharmacoeconomics. 2000;17:331-338.
41. Hungin AP, Chang L, Barghout V, Kahler K. The impact of IBS on absenteeism and work productivity: United States and eight European countries. Presented at: 68th Annual Meeting of the American College of Gastroenterology; October 13-15, 2003; Baltimore, Md.
42. Hungin APS, Tack J, Mearin F, Whorwell PJ, Dennis E, Barghout V. Irritable bowel syndrome (IBS): prevalence and impact in the USAthe truth in IBS (TIBS) survey [abstract]. Am J Gastroenterol. 2002;97 (suppl):S280-S281. Abstract 854.
43. Bramley TJ, Lerner D, Sarnes M. Productivity losses related to the common cold. J Occup Environ Med. 2002;44:822-829.
44. Fendrick AM, Monto AS, Nightengale B, Sarnes M. The economic burden of non-influenza-related viral respiratory tract infection in the United States. Arch Intern Med. 2003;163:487-494.
45. Chiou CF, Wilson A, Longstreth G, et al. The relationship between irritable bowel syndrome, abdominal discomfort/pain, and indirect costs. Presented at: 2002 Digestive Diseases Week Conference; May 19-22, 2002; San Francisco, Calif.
46. Dancey CP, Backhouse S. Towards a better understanding of patients with irritable bowel syndrome. J Adv Nurs. 1993;18:1443-1450.
47. Hungin APS, Whorwell PJ, Tack J, Mearin F. The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40,000 subjects. Aliment Pharmacol Ther. 2003;17:643-650.
48. Frank L, Kleinman L, Rentz A, Ciesla G, Kim JJ, Zacker C. Health-related quality of life associated with irritable bowel syndrome: comparison with other chronic diseases. Clin Ther. 2002;24:675-689.
49. Gralnek IM, Hays RD, Kilbourne A, Naliboff B, Mayer EA. The impact of irritable bowel syndrome on health-related quality of life. Gastroenterology. 2000;119:654-660.
50. Cash BD, Schoenfeld P, Chey WD. The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review. Am J Gastroenterol. 2002;97:2812-2819.
51. Hamm LR, Sorrells SC, Harding JP, et al. Additional investigations fail to alter the diagnosis of irritable bowel syndrome in subjects fulfilling the Rome criteria. Am J Gastroenterol. 1999;94:1279-1282.
52. Feld AD, Von Korff M, Levy R, Palsson O, Turner M, Whitehead W. Excess surgery in irritable bowel syndrome (IBS) [abstract]. Gastroenterology. 2003;124 (suppl 1):A-388. Abstract M1637.
53. Barghout V, Yokoyama K, Gause D, Frech F. IBS-related hospitalizations and procedures. Gastroenterology. 2002;122(suppl):A-570. Abstract W1125.
54. Ofman J, Wilson A, Knight K, et al. The relationship between symptom severity and healthcare utilization in irritable bowel syndrome patients in a managed care setting [abstract]. Am J Gastroenterol. 2001;96(suppl 1):S276. Abstract 880.
55. Lembo A. Irritable Bowel Syndrome Medications Side Effects Survey. J Clin Gastroenterol. 2004;38:776-781.
56. Nyhlin H, Jonsson BG, Bracco A, Ricci J, Drummond M. Tegaserod is cost-effective in the treatment of patients with IBS: an economic analysis of the TENOR (TEgaserod in NORdic countries) study [abstract]. Gut. 2004;53(suppl VI):A211. Abstract TUE-G-295.
57. Smith DG, Barghout V, Kahler KH. Tegaserod treatment for IBS: a model of indirect costs. Am J Manag Care. 2005;11(suppl):S43-S50.
58. Reilly MC, Barghout V, Ruegg P, Pecher E, Ricci JF. Tegaserod significantly reduces work productivity loss and daily activity impairment in patients with IBS with constipation [abstract]. Am J Gastroenterol. 2004;99:S241. Abstract 743.
59. Shen B, Soffer E. The challenge of irritable bowel syndrome: creating an alliance between patient and physician. Cleve Clin J Med. 2001;68:224-233, 236.
60. O'Sullivan MA, Mahmud N, Kelleher DP, Lovett E, O'Morain CA. Patient knowledge and educational needs in irritable bowel syndrome. Eur J Gastroenterol Hepatol. 2000;12:39-43.
61. Verne GN. The public awareness of the prevalence and impact of irritable bowel syndrome in the United States: perception versus reality. J Clin Gastroenterol. 2004;38:419-424.
62. Thompson WG, Heaton KW, Smyth GT, Smyth C. Irritable bowel syndrome in general practice: prevalence, characteristics, and referral. Gut. 2000;46:78-82.
63. Heitkemper M, Carter E, Ameen V, Olden K, Cheng L. Women with irritable bowel syndrome: differences in patients'and physicians'perceptions. Gastroenterol Nurs. 2002;25:192-200.
64. Riotto M. Depression in the workplace: negative effects, perspective on drug costs and benefit solutions. Benefits Q. 2001;17:37-48.
65. Burton WN, Connerty CM. Evaluation of a worksite-based patient education intervention targeted at employees with diabetes mellitus. J Occup Environ Med. 1998;40:702-706.
66. Garrett DG, Martin LA. The Asheville Project: participants' perceptions of factors contributing to the success of a patient self-management diabetes program. J Am Pharm Assoc (Wash). 2003;43:185-190.
67. Biddle AK, Shih YC, Kwong WJ. Cost-benefit analysis of sumatriptan tablets versus usual therapy for treatment of migraine. Pharmacotherapy. 2000;20:1356-1364.
68. Lofland JH, Johnson NE, Batenhorst AS, Nash DB. Changes in resource use and outcomes for patients with migraine treated with sumatriptan: a managed care perspective. Arch Intern Med. 1999;159:857-863.
69. Schulman EA, Cady RK, Henry D, et al. Effectiveness of sumatriptan in reducing productivity loss due to migraine: results of a randomized, double-blind, placebo-controlled clinical trial. Mayo Clin Proc. 2000;75:782-789.
70. Mayo KW, Osterhaus JT. Health outcomes evaluations: estimating the impact of almotriptan in managed care settings. Am J Manag Care. 2002;8:S85-S93.