https://www.ajmc.com/journals/supplement/2005/2005-04-vol11-n1suppl/apr05-2021ps07-s16
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 (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).

Figure

Figure

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.

Figure

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.

Figure

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

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

Figure

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.

Summary

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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