Productivity Cost Questionnaire

Productivity and Health Research Group

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Manual

Drs. C. Bouwmans

Dr. L. Hakkaart-van Roijen

Dr. M. Koopmanschap

Dr. M. Krol

Prof.dr. H. Severens

Prof.dr. W. Brouwer

Manual iMTA Productivity Costs Questionnaire

Productivity & Health Research Group Drs C Bouwmans Dr L Hakkaart- van Roijen Dr M Koopmanschap Dr M Krol Prof dr H Severens Prof dr W Brouwer Institute for Medical Technology Assessment Erasmus Universiteit Rotterdam Rotterdam, February 2013

“All rights reserved. Nothing in this publication may be changed or reproduced without the authors’ permission. Such permission may be obtained under the conditions stated in the Users Conditions.”

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Table of Contents 1. Introduction ................................................................................................................. 4

1.1 Background ........................................................................................................ 4

1.2 Starting points in the development of the iPCQ .................................................. 6

1.3 Sample size, measurement moments and recall period...................................... 7

1.4 Structure of the manual ...................................................................................... 8

2. Structure of the iPCQ .................................................................................................. 9

2.1 General questions .............................................................................................. 9

2.2 General questions about paid work ................................................................. 10

2.3 Productivity losses modules ............................................................................. 10

3. Scoring and valuation of productivity losses .............................................................. 13

3.1 Module 1: Absenteeism. Absences from paid work .......................................... 13

3.2 Module 2: ‘Presenteeism’ ................................................................................. 20

3.3 Module 3: Lost productivity of unpaid work ....................................................... 21

4. Feasibility and validity ............................................................................................... 22

5. Use of the iPCQ ........................................................................................................ 23

5.1 General ............................................................................................................ 23

5.2 Terms of use .................................................................................................... 24

6. References ................................................................................................................ 26

Appendix I iPCQ ............................................................................................................ 28

Appendix III Optional question on short absence from work .......................................... 38

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1. Introduction

1.1 Background Economic evaluations in healthcare serve to analyze the costs and benefits of medical

interventions. The guidelines for pharmaco-economic studies in the Netherlands require

economic evaluations to be conducted from a ‘societal perspective’.(1) Adopting a

societal perspective allows all actors in society to be taken into account: it incorporates

all costs and benefits, regardless of who pays or who receives them. In economic

evaluations, costs are valued according to the concept of opportunity cost, taking as

starting point a situation in which alternative available resources are scarce.

Although arbitrary, in health care economics a distinction is often made between direct

and indirect costs. These can subsequently be allocated to costs incurred within and

outside the health care system. These can be shown in a diagram as follows:

Figure 1. Distribution of costs in health economics.

Within the healthcare system

Outside the healthcare system

Direct costs

• Medical costs

• Patient costs

Indirect costs

• Related costs during life

year gains

• Non-related costs during life year gains

• Productivity losses • Other, including:

Legal costs Special education

The direct costs within the healthcare system refer to all costs that are directly related to

the prevention, diagnostics, therapy, rehabilitation and care of a disease or disorder.

Examples of direct costs outside the healthcare system are the time and travel costs of

patients, which are directly related to the treatment. Indirect costs arise as a secondary

consequence of medical treatment or the disorder. The indirect costs arising within the

scope of the healthcare system encompass related and non-related medical costs

incurred during the life years gained. Indirect costs outside the healthcare system

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include among others the costs of productivity losses due to absence or inefficiency

during paid or unpaid work owing to health problems, and legal and special education

costs.

Adopting a societal perspective implies that all costs and benefits need to be taken fully

into account in an economic evaluation. This means that all costs in Figure 1, if relevant,

must be included in an economic evaluation. While this is recommended by the Dutch

guidelines, discussion is still on-going regarding one specific category: the non-related

costs within the health care system arising during life years gained. Despite the fact that

not a single convincing argument has been advanced against including these in

economic evaluations and a clear consensus appears to be forming in the recent

scientific literature that these costs should be taken into account (2), Dutch national

guidelines nonetheless recommend excluding these costs.

The iPCQ (manual) aims to measure and subsequently value indirect costs arising

outside the scope of the healthcare system, also known as productivity costs. These

form a highly relevant and, not infrequently, very significant cost item, as health

problems tend to have a negative impact on people’s capacity to perform paid or unpaid

work. From a societal perspective, productivity losses due to health problems can be

extensive and as such, play an important role in economic evaluations of healthcare

programs. For this reason, it is vital to incorporate the costs of productivity losses in the

evaluations in an appropriate fashion.

Productivity losses can be caused by people missing work as a result of a health

problem (sick leave) in the case of paid work. This is called absenteeism, and can take

the form of short-term or long-term absences. Yet productivity losses can also occur

even without absenteeism. An example is the employee who, despite a budding

migraine, decides to stay at work. However, the amount or quality of work that is

accomplished on a day like that may well suffer compared to the amount and quality of

work this same person would have performed on a ‘normal’ problem-free workday. In

such cases, productivity losses occur without any actual absenteeism taking place. In

the international literature, this is usually referred to as ‘presenteeism’.

Productivity losses can occur at paid work and unpaid work. Health problems can cause

people to have difficulties in performing unpaid work that has true, economic value, such

as household work, care of children or volunteer work. ‘Production’ is then lost or is

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taken over by others, who must sacrifice scarce time that would have otherwise been

spent on other activities. In an economic definition of costs, the so-called opportunity

costs, these unpaid productivity losses form a relevant, societal cost item.

1.2 Starting points in the development of the iPCQ To measure costs in economic evaluations, questionnaires that are self-completed by

patients taking part in the study are often used. Alternative sources of information for

measuring productivity losses, such as Occupational Health and Safety Service

registrations, are generally limited to information on the amount of absenteeism. In many

cases, the patients are the sole complete source of information for gathering all data

about productivity losses.

The basic idea behind the development of the iPCQ was to enable self-reported

information to be collected about paid and unpaid productivity losses in a consistent and

standardized manner. Not only will standardization increase the comparability between

studies, it will also provide a foundation for broad generalizability.

The questions in the iPCQ are based on the Short Form- Health and Labour

Questionnaire (SF-HLQ) (3), the PROductivity and DISease Questionnaire (PRODISQ)

(4) and the QQ method. (5) The best ingredients were lifted from these questionnaires

and incorporated into the iPCQ. However, the questionnaire had to be suitable for self-

reporting. One of the conditions for valid and reliable measurements is that the questions

must contain no ambiguous wording, i.e., the questions must be comprehensible to the

respondents. To this end, a draft version of the questionnaire was submitted to Bureau

Taal, an agency specialized in clear writing. They rephrased the questions in plain Dutch

(Language Level B1), which means that the texts can be comprehended by 95% of the

population, including those with a low level of educational attainment. More highly

educated people frequently also prefer texts on a basal language level, as these are

easier and faster to read. A feasibility study was conducted in order to test the

consistence and intelligibility of the questions. The results confirmed the consistency and

comprehensibility of the iPCQ (see Chapter 4).

The iPCQ is a generic questionnaire designed to determine the costs of productivity

losses. It is therefore not disease specific. In other words, reference is made to

productivity losses due to illness, disability or psychiatric problems, without specifying a

particular disease. It is not always easy for the patient to define productivity losses

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according to specific diseases or treatments. For this reason, use is preferably made of

generic questions.

The iPCQ is applicable to studies conducted in the Netherlands, as well as to

international studies.

A short list of questions was opted for on which all forms of productivity losses were

included.

The iPCQ consists of 3 modules:

Lost productivity at paid work due to absenteeism

Lost productivity at paid work due to presenteeism

Lost productivity at unpaid work

Modules that may assumed to be irrelevant for the study population may also be

omitted, if desired. It is also possible to combine the iPCQ with a generic questionnaire

that measures medical consumption, the Medical Consumption Questionnaire (iMCQ).

1.3 Sample size, measurement moments and recall period

In an economic evaluation, the minimum group size and number of measurement

moments depends on a variety of factors. With regard to costs, the required number of

respondents depends on the expected differences in costs between the experimental

group and the group of controls, as well as on the cost variance in both groups.

Moreover, next to costs, other effect measurements are generally included in the

analyses (such as clinical effects, quality of life) that are also decisive in determining the

minimum number of respondents to be included. Often, clinical effect measurements are

used to derive the power required for a cost effectiveness analysis. When calculating the

costs, it is assumed that the period of time in which the measurement is carried out, is

representative for the entire period between two measurement moments. The optimum

period between two measurement moments, the number of measurements performed

over the course of the study and the required number of respondents depends on the

expected difference in costs (and other effect measurements), the expected course of

the disease and the treatment. In the standard version of the iPCQ, a recall period of 4

weeks is used. Research has shown that longer recall periods negatively impact on the

accuracy of self-reported measurements of absenteeism.(6) If using a longer recall

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period, therefore, it should be kept in mind that the reliability of the data may be

compromised.

If the period between two measurement moments is longer than 4 weeks, the data are

adjusted for the actual time difference using extrapolation techniques.

1.4 Structure of the manual

The following chapter presents the general structure of the iPCQ and the various

modules for productivity losses.

In chapter 3, the scoring and valuation of the various modules is explained. Also, the

friction cost method, which is the method most commonly used in the Netherlands for

the valuation of productivity losses due to absenteeism, is examined. Chapter 4 reviews

the outcome of the feasibility study that was performed to test the comprehensibility of

the questions.

Chapter 5 contains instructions on how to use the iPCQ and the terms and conditions for

its use.

Appendix I contains the questionnaire; a codebook is presented in Appendix II that can

be used to analyze the data in a data file. Finally, Appendix III contains an optional

question for measuring short episodes of absence from work.

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2. Structure of the iPCQ

The iPCQ may be administered both orally and in writing. It is also possible to have

respondents complete the iPCQ digitally. The questions are preceded by a detailed

explanation and instructions for the respondent on how to complete the questionnaire. If

desired, at this point the researcher can add relevant information for the respondent.

Space has been left at the end of the questionnaire for any comments of the respondent

in connection with the questions. The questionnaire closes with instructions on how to

return the questionnaire. These instructions are to be adapted or added to, as the

specific study requires.

The iPCQ consists of the following parts:

General questions (question A1 through A6)

General questions about paid work (question 1 through 3)

Productivity losses modules:

o Losses of productivity at paid work due to absenteeism (questions 4

through 6)

o Losses of productivity at paid work due to presenteeism (questions 7

through 9)

o Losses of productivity at unpaid work (questions 10 through 12)

The questionnaire contains routing instructions for the respondent. Questions that do not

apply to the respondent can easily be skipped.

2.1 General questions

Question A1 through A6 are general questions. Based on the answers to these

questions a description can be given of the study population. The answers can also be

used for subgroup analyses, if desired.

Except for a question about the date on which the questionnaire was filled in, the general

questions are about the age, gender, level of educational attainment and work status of

the respondent.

2.2 General questions about paid work

Questions 1 through 3 provide information about the amount of paid work (in hours) and

number of days per week a person works. The latter offers insight into the average

number of hours worked per workday by the respondent. This information is necessary

to calculate the costs of productivity losses.

2.3 Productivity losses modules

The questions about productivity losses make up the following modules:

- Absenteeism: absence from paid work (question 4 through question 6)

- ‘Presenteeism’: productivity losses during worked days (question 7 through

question 9)

- Lost productivity of unpaid work (question 10 through question 12)

2.3.1 Module 1: Absenteeism. Absence from paid work

Questions 4 through 6 deal with sick leave of the respondent. Question 4 measures the

number of missed workdays in the past 4 weeks.

Figure 1. Question about missed workdays in the past 4 weeks

The respondent fills in the number of workdays that he or she has missed during the

past 4 weeks. We refer to respondents’ absences from work of no longer than 4 weeks

as short-term absences. If the respondent’s sick leave commenced prior to the recall

period (question 5), the respondent is asked to state the date on which he or she called

in sick (question 6). In that case, we refer to long-term absence.

Question 4. Have you missed work in the last 4 weeks as a result of being sick?

No Yes, I have missed ………… days. (Only count the missed workdays in the last 4 weeks)

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Figure 2. Distinction between short-term absence and long-term absences from work

Figure 3. Question about the date on which the respondent called in sick in the case of work absences exceeding 4 weeks

2.3.2 Module 2: ‘Presenteeism’

Health problems can lead to absenteeism. However, health problems can also result in

lost workplace productivity, without leading to work absences - as, for example, when

the symptoms are not particularly severe, such as in the case of a mild chronic disorder.

Studies have shown that on average, 7% of employees indicate that they are bothered

by their health problems at work. In some cases, productivity losses at work are also

associated with (previous or later) absence from work. Brouwer et al. reported that 25%

of the employees had problems at work prior to their sick leave and 20% after their work

absence (7). This can amount to a substantial cost component. Questions 7 through 9

measure the amount of lost productivity at paid work due to health problems. This is

known as ‘presenteeism’. All respondents who missed no work or who did not miss the

full 4 weeks must answer the questions. Question 7 selects between those who were,

and those who were not hindered by health problems while performing paid work. If they

indicated that they had not been bothered by these conditions at work, no presenteeism-

related productivity losses have occurred. The remaining questions in module 2 may

then be skipped. Question 8 measures the number of workdays on which the respondent

was bothered by health problems at work. Question 9 asks the respondent to estimate

Question 6. When did you call in sick?

day month year

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the amount of work he or she could perform on such days, compared with a normal

workday.

Figure 4. Question about efficiency on days at work when bothered by health problems.

This estimate is expressed as a score ranging from 0 (present at work but unable to

function) to 10 (bothered, but able to do just as much as during a normal work day.

2.3.3 Module 3: Productivity losses of unpaid word

Questions 10 through 12 deal with the losses of productivity of unpaid work. A

respondent might well be hindered by health problems to such an extent that he/she is

partly or wholly unable to perform normal unpaid labour, such as household work or

volunteer work. Question 10 is a selection question. Respondents not bothered by their

health condition when performing unpaid labour can skip questions 11 and 12. Question

11 measures the number of days on which the respondent has performed less unpaid

work because of health problems. He or she is subsequently asked to estimate the

number of lost hours of unpaid work. To do this, the respondent is asked to give an

estimate of the average number of hours per day that a family member or friend would

need to help him/her on such days (question 12).

Question 9. On the days that you were bothered by these problems, was it perhaps difficult to get as much work finished as you normally do? On these days how much work could you do on average? Look at the figures below. A 10 means that you were able to do as much work as you normally do. A 0 means that you were unable to do any work on these days. Circle the figure that fits best. On these days I was able I was able to I could not to do half do just as do anything as much as I much as I

normally do normally do 0 1 2 3 4 5 6 7 8 9 10

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Figure 5. Question about quantifying productivity losses of unpaid work.

3. Scoring and valuation of productivity losses

In order to calculate the costs of productivity losses, the volumes are multiplied by the

cost price per unit. This chapter explains about the scoring system of the various

modules of the iPCQ and the valuation methods that can be used subsequently to

calculate the costs. The costs per unit are valued with standard cost prices. For more

information about the valuation of cost units, refer to the Dutch ‘Manual for costing in

economic evaluations in health care’.(8)

3.1 Module 1: Absenteeism. Absences from paid work

3.1.1 Scoring A distinction is made in module 1 between short-term absence and long-term absence.

Short-term absenteeism is measured based on the number of workdays missed by the

respondent in the past 4 weeks (question 4).

If the period of absence was not longer than the past 4 weeks, the number of workdays

of productivity losses can be determined on the basis of the answer to question 4. The

minimum number of workdays missed is ‘0’; the maximum number of workdays is

theoretically ‘28’. However, the majority of respondents will work a maximum of 5 days

per week, and miss a maximum of 20 workdays in the past 4 weeks. The number of

hours per workday is calculated by dividing the number of hours per working week

(question 2) by the number of days that the respondent works per week (question 3).

The total work time missed is subsequently calculated by multiplying the number of days

missed by the number of hours per workday of the respondent.

Question 12. Imagine that somebody, for example your partner, family member or friend helped you on these days, and he or she did all the unpaid work that you were unable to do for you. How many hours on average did that person spend doing this on these days? On average ………….. hours on these days

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In the case of respondents who indicate that their absence from work has lasted longer

than 4 weeks, the work time missed is determined on the basis of the data from question

6. Long-term absence is measured in calendar days by calculating the difference in

number of days between the date on which the respondent completed the iPCQ and the

date he or she called in sick (question 6).

The scoring on short-term absence (question 4) needs to be adjusted for respondents

reporting a long-term absence, in order to avoid double counting. This, because

respondents are first asked to fill in the number of workdays he or she has missed during

the past 4 weeks, after which they are asked to provide information about long-term

absence. Hence, the short-term absence reported at question 4 by respondents who had

missed more than 4 weeks of work should be scored as 0.

3.1.2 Valuation

Several approaches may be used to determine the value of lost production due to

absence from paid work. The methods that are most commonly used are the friction cost

method (FCM) and the Human Capital method (HCM). The choice of valuation method

can strongly affect the results of an economic evaluation, and should therefore be

thoroughly weighed and considered. The discussion about which valuation method is

‘better’ is still in full spate. The FCM is the recommended method in the Netherlands, as

this fits well with the societal perspective.(1) An important argument against the use of

the HCM in economic evaluations is that valuation according to this method is based on

individualized patient perspectives.(9)

Productivity costs may be defined as follows:

‘productivity losses and/or costs incurred to maintain the production level, in connection

with illness and medical treatment of the employee’ (10)

The FCM is based on the idea that people in the production process are replaceable.

From a societal perspective, therefore, given sufficient replacement possibilities

productivity losses are temporary and limited mainly to the losses suffered during the

time before a vacancy is filled. This period is known as the friction period. If a person is

absent from work for a period that is longer than the friction period, the related

productivity losses are limited to the duration of the friction period. In other words, after

that period, the absent worker has been replaced and no further losses of productivity

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occur. Hence the length of the friction period depends on the speed with which a

vacancy can be filled. The latter is in turn dependent on the unemployment rate and

labour market mobility. The vacancy duration is an indication for the length of the friction

period. In addition, an extra period of an estimated 4 weeks before a decision is made to

take measures to compensate the productivity lost should also be factored in. The

friction period therefore equals the estimated vacancy duration plus 4 weeks. For more

details about the FCM we refer to Koopmanschap and Rutten.(11) The costs of lost

productivity are valued on the basis of the standard cost prices of productivity per hour.

The most current information about the duration of the friction period and standard cost

of productivity may be found in the Manual for costing in economic evaluations. (8)

Calculating the costs of lost productivity due to short-term absenteeism

The number of workdays missed during the past 4 weeks is multiplied by the average

number of hours worked per workday by the respondent (question 2/ question3) and the

standard cost price of productivity per hour. If the recall period can be considered

representative for the period between two consecutive measurements, the results may

be adjusted through extrapolation according to the length of the period between the two

measurements.

Example calculation costs of lost productivity due to short-term absence Respondent A has a 3-day, 24-hour working week. Hence an average workday consists of 8 hours. The respondent has missed 2 days of work in the past 4 weeks. We assume a money-valued productivity of €30 per hour. The work absence costs during the 4-week recall period are therefore: 2 days * 8 hours per workday * € 30 = €480. There is a period of 6 months, or 26 weeks, between each follow-up measurement. The total costs for this period are computed using extrapolation, as follows: (26 weeks / 4 weeks recall =) 6.75 * €480= € 3240.

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Calculation of the costs of productivity losses due to long-term absence

The productivity costs of long-term absence are determined by taking into account: the

absence start date in combination with the length of the period between successive

measurement moments.

This can result in 3 different situations, each of which affects the calculation of the

productivity loss according to the FCM:

1) The total length of absence from work is longer than 4 weeks but shorter than the

friction period

2) The length of absence from work is longer than the friction period, but part of the

friction period falls within period between two consecutive measurement

moments.

3) The length of absence from work is longer than the friction period and the entire

friction period has elapsed prior to the date of the measurement previous to this.

Each of the above situations is demonstrated by means of an example. A schematic

representation of the situation is also provided, together with the corresponding

calculations of the costs of lost productivity. Unlike short-term absence, which is

measured in workdays, long-term absence is expressed in calendar days. Hence

when calculating the costs of lost productivity due to long-term absence, the number

of calendar days must be converted into number of workweeks missed in order to

determine the number of workdays missed.

Situation 1: the absence duration is shorter than the friction period

Respondent B has a 24-hour, 4-day working week (respondent B works 6 hours per workday). Respondent B has missed more than 4 weeks of work. Based on the absence start date reported in question 6, the total length of absence is calculated at 56 (calendar) days. We assume a money-valued productivity of €30 per hour and a friction period of 160 days. The period between the current measurement and the previous measurement is 6 months (26 weeks).

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Figure 6. The length of absence is shorter than the friction period

Situation 2: the length of absence is longer than the friction period, but part of the friction period falls within the period between two consecutive measurements

In this situation, the following is important to take into account:

This respondent’s absence from work commenced in advance of the first measurement

(T=0). The absence started 20 days before T=0. Hence the costs of these first 20 days

had already been calculated at T=0. This means that the absence costs are confined to

a period of 182 days (the period between the first and the second measurement).

The friction period starts the moment the work absence commences. Hence at the time

of the first measurement, 20 days of the friction period had already elapsed. (see figure

7).

The costs of absence are computed directly for the entire period between measurements. The length of absence is shorter than the friction period of 160 days. Hence the costs of lost productivity are calculated over the entire period of absence from work. 56 calendar days absence = 56/7= 8 workweeks =8*4=32 workdays. In this case, the costs of absence from work between the 2 consecutive measurements are: 32 workdays * 6 hours per day * €30 = €5760.

Respondent C has a 36-hour, 4-day working week. Hence an average workday consists of 9 hours. Based on the reported absence start date, the duration of Respondent C’s absence from work was 202 calendar days at the time of measurement. The period between the current measurement and the previous measurement is 6 months (182 days). The standard cost of 1 hour of productivity is €30 and the friction period is 160 days.

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In other words, when computing the costs of lost productivity for situation 2, the number

of absence days in the period between two consecutive measurements that still fall

within the friction period must be taken into account.

Figure 7. The absence duration is longer than the friction period. Part of the friction period falls between two consecutive measurements.

The costs of lost productivity are subsequently calculated as follows:

The calculation of productivity costs in situation 2

- The total absence duration of the respondent is 202 days - The absence duration between T=0 and T= 6 months is 182 days - This respondent’s first 20 days of absence therefore fall outside the period for which

the costs of T= 6 months are computed - The total duration of absence is longer than the friction period. Hence the costs are

calculated over a maximum of 160 days (=the duration of the friction period). - The friction period starts the moment the absence starts - The costs of the first 20 days of absence were calculated at the first measurement

(T=0) - The remaining number of days in the friction period between the first (T=0) and the

second measurement (T= 6 months) is now 160 -20= 140 calendar days (or = 20 workweeks). The costs of lost productivity are calculated over this period.

In this example, the costs of absence between T=0 and T= 6 months amount to: 20 weeks * 4 workdays* 9 hours per workday * €30= € 21,600.

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Situation 3: the absence duration is longer than the friction period and the entire friction period has elapsed prior to the date of the measurement previous to this.

Figure 8. The absence start date occurred prior to the previous measurement and the friction period has completely elapsed before the previous measurement.

We conclude with one final remark. If measurements are performed every 4 weeks,

calculations may also be performed at the individual level, as extrapolation to

subsequent measurements is then no longer necessary. In practice, however,

consecutive measurements will tend to be made over a longer period. In that case,

calculations based on extrapolation are valid only at the aggregate level, and not at the

individual level.

Respondent D has a 24-hour, 3-day working week. Based on respondent D’s absence start date, the absence duration is 400 calendar days at the time of measurement. The period between the present measurement and the previous measurement is 6 months (=182 days).

The entire friction period has elapsed prior to the date on which the previous measurement (measurement 1) was performed (400 absence days -160 days of friction period = 240 days before measurement 2; there are 182 days between measurement 1 and 2. In this situation, where the number of days of absence exceeds the number of days in the friction period plus the number of days between the 2 measurements, the additional costs of lost productivity are €0 in the calculation. In the above example, the number of days in the friction period (160) + the number of days between the two consecutive measurements (182)= 342

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3.2 Module 2: ‘Presenteeism’

3.2.1 Scoring To calculate lost productivity due to workplace presenteeism, the number of days

worked while impaired is multiplied by ‘one minus the efficiency divided by 10’ for these

days.

Question 8 measures the number of workdays on which the respondent’s performance

was hindered by health problems. Dependent on the number of days the respondent

works per week, the minimum number of workdays is 0 and the maximum (in theory) 28.

Lost productivity is computed on the basis of the respondent’s efficiency on these days,

which is assessed based on the scores on question 9.

The formula for calculating the number of hours of lost productivity due to ‘presenteeism’

is:

Number of workdays impaired * [1 – (efficiency score/10)] * number of hours per workday

3.2.2 Valuation The costs of ‘presenteeism’ are calculated by multiplying the number of hours of lost

productivity by the standard cost price of productivity.

Example. A respondent indicates that he/she experienced hinder from health problems on 3

workdays and gave their efficiency on these days a rating of 8. The respondent works 8

hours per workday. The amount of productivity lost is therefore 3*(1-(8/10)) * 8= 0.6

workday, or 4.8 hours.

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3.3 Module 3: Lost productivity of unpaid work

3.3.1 Scoring Question 10 distinguishes respondents whose ability to do unpaid work was hindered by

their health problems and respondents whose ability to do unpaid work was not

hindered. Unpaid productivity losses is determined by multiplying the number of days

missed (question 11) by the number of hours of help needed per day to make up the

work (question 12).

3.3.2 Valuation The cost of unpaid productivity loss is calculated by multiplying the productivity losses by

a standard hourly rate for household care (see ‘Manual for costing in economic

evaluations in healthcare’).

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4. Feasibility and validity The iPCQ has been developed on the basis of questions derived from the SF-HLQ and

the PRODISQ. A number of studies have assessed the validity of measures of work

absences from paid jobs. (3,12,13) Please refer to Brouwer et al. (5) for information

about the validity of the calculation of lost productivity due to presenteeism. The

questions on unpaid productivity losses were designed on the basis of brainstorming

sessions held by the Productivity & Health Research working group at the iMTA.

Additional studies are required to establish the validity of this module.

The reliability of self-reported data also depends on the comprehensibility of the

questions for the patient. Researchers are often biased due to their need for information

and their knowledge of the effect question formulation can have. A specialized agency

‘translated’ the iPCQ questions into clear, plain language. Next, a pilot study was

conducted to evaluate the applicability of the questions. In this feasibility study,

respondents were asked to complete all the questions on the questionnaire and to

indicate the questions they considered to be unclear. Also, the amount of time needed

by the respondents to complete the iPCQ was tested. A total of 195 respondents aged

18 and over took part in this study. Some 36% was male; 25% had a middle level

education and 62% reported that they held a paid job. Of the group with paid work, 30%

indicated that they were hindered in their work performance by health problems, and

10% had missed work in the past 4 weeks. The number of respondents experiencing

problems in completing the questionnaire was small. A number of respondents indicated

that the routing from short-term to long-term absence was unclear. The instructions on

this question were rephrased. Finally, some respondents (n=8) found it difficult to

estimate the amount of time that would be needed for other people to perform the unpaid

work lost. As a more workable alternative is currently unavailable, this question was

retained. The average amount of time required to complete the iPCQ was around 5

minutes.

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5. Use of the iPCQ

5.1 General The iPCQ can be administered orally and in writing. It can also be completed digitally.

The general instructions for completing the questionnaire and the instructions on how to

return the questionnaire are to be further adapted by the researcher to fit the specific

context of the study to be performed. Modules deemed irrelevant to the study population

may be omitted, if desired. A more refined measurement method can be used for short

episodes of sick leave, if desired. Certain chronic conditions can have a strongly

fluctuating effect on the patient’s work absence. For example, patients with migraines

may be able to work one day, yet be incapacitated the next. Or they may develop pain at

work and have to leave early. This strongly fluctuating pattern of work absence makes it

extremely difficult to report total work absence per recall-period. The use of a log to

recall absence from work may be a help. Appendix III includes a question in the form of

a log about absence from work (question 4a). The question is derived from the Health &

Labour Questionnaire (HLQ) and is used as an amplification to question 4. Question 4

currently only asks whether the respondent has been ill. Respondents who have

answered ‘yes’ are asked to proceed to question 4a (see Appendix III).

Follow-up measurements

The iPCQ contains 6 general questions. If administering the iPCQ at various

measurement moments, it is not necessary to include all of the general questions at the

follow-up measurements. However, question A1 (date of completion of the

questionnaire) and question A6 must be included each time the questionnaire is re

administered.

5.2 Terms of use

This questionnaire was developed by the Institute for Medical Technology Assessment,

(iMTA), Erasmus University Rotterdam. The questionnaire may be used under the

following conditions:

• You are required to obtain permission to use the questionnaire in advance. To

apply for use of the questionnaire, please complete the online registration form,

which is available on the website of iMTA

(http://www.bmg.eur.nl/english/imta/publications/questionnaires_manuals).

We will notify you as soon as possible. You are not permitted to copy and/or

distribute the questionnaire without prior consent.

• There are no financial conditions attached to the use of the iPCQ by academic

organizations. For studies that are (partially) funded by commercial organizations

a license fee applies. The license fee depends on type of study, size of

population and duration of the study, and is based on information from the

registration form. Permission will be granted on receipt of the licensing fee. Filling

out the registration form does not oblige you to purchase.

• The notice of copyrights printed on the title page of this manual must always be

included when using the questionnaire. The source is required to be explicitly

stated in all publications as follows:

www.imta.nl (C. Bouwmans, L. Hakkaart-van Roijen, M. Koopmanschap, M. Krol,

H. Severens, W. Brouwer. Manual of the iMTA Productivity Cost Questionnaire

(iPCQ). Rotterdam: iMTA, Erasmus University Rotterdam, 2013)

• Changes are permitted to be made in the questionnaire without prior consent. It

must be stated in the study report that use has been made of an adapted version

of this questionnaire.

• Exclusion of liability: The user shall indemnify the Institute for Medical

Technology Assessment (Erasmus University Rotterdam) and the authors of this

publication against claims from third parties arising from/related to the use of this

publication or in case of changes made by the user and/or translations or

resulting from errors, omissions and misinterpretations or any consequences

arising out of such use.

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• The user should provide a reference of all manuscripts, articles or other

publications featuring this questionnaire or containing results obtained with the

help of this instrument to the authors.

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6. References

(1) Guidelines for pharmacoeconomic research, updated version. Diemen: College Voor

Zorgverzekeringen; Maart 2006 .

(2) Rappange DR, van Baal PH, van Exel NJ, Feenstra TL, Rutten FF, Brouwer WB. Unrelated

medical costs in life-years gained: should they be included in economic evaluations of

healthcare interventions? Pharmacoeconomics 2008;26(10):815-830.

(3) Roijen vL, Essink-Bot M, Koopmanschap M, Bonsel G, Rutten F. Labor and health status in

economic evaluation of health care. The Health and Labor Questionnaire. Int J Technol Assess

Health Care 1996;12(3):405-15.

(4) Koopmanschap MA. PRODISQ: a modular questionnaire on productivity and disease for

economic evaluation studies. Expert Rev Pharmacoecon Outcomes Res 2005;Feb;5(1):23-8.

(5) Brouwer W, Koopmanschap M, Rutten F. Productivity losses without absence: measurement

validation and empirical evidence. Health Policy 1999;48(1):13-27.

(6) Severens J, Mulder J, Laheij R, AL AV. Precision and accuracy in measuring absence from

work as a basis for calculating productivity costs in The Netherlands. Soc Sci Med

2000;51(2):243-9.

(7) Brouwer W, van Exel N, Koopmanschap M, Rutten F. Productivity costs before and after

absence from work: as important as common? Health Policy 2002;61(2):173-87.

(8) Hakkaart- van Roijen L., Tan S.S., Bouwmans C.A.M. Manual for costing in economic

evaluation. Methods and reference prices for economic evaluations in health care. Update 2010.

(in Dutch) Diemen: College Voor Zorgverzekeringen; Januari 2011.

(9) Brouwer WB, Koopmanschap MA, Rutten FF. Productivity costs in cost-effectiveness

analysis: numerator or denominator: a further discussion. Health Econ 1997 Sep-Oct;6(5):511-

514.

(10) Brouwer WB, Koopmanschap MA. How to calculate indirect costs in economic evaluations.

Pharmacoeconomics 1998 May;13(5 Pt 1):563-569.

(11) Koopmanschap M, Rutten F. A practical guide for calculating indirect costs of disease.

Pharmacoeconomics 1996;10(5):460-6.

(12) Bouwmans,C. de Jong,K. Timman,R. Tan, S.S. Vlasveld,M. van der Felz-Cornelis,C.

Hakkaart-van Roijen,L. Feaibility, reliability and validity of a questionnaire on health care

utlization and productivity losses (TiC-P). (submitted).

(13) Meerding WJ, IJzelenberg W, Koopmanschap MA, Severens JL, Burdorf A. Health

problems lead to considerable productivity loss at work among workers with high physical load

jobs. J Clin Epidemiol 2005 May;58(5):517-523.

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Appendix I

Questionnaire about your health and work

Researchers call this questionnaire the iMTA PCQ.

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Explanation

Please read this first! Who is this questionnaire for? This questionnaire is for you. There are different possibilities:

• You received this form from your (family) doctor or from (the) hospital. • You received this form in the post with your name posted on the envelope.

You cannot fill in the form on your own? If you are unable to fill in the form on your own, maybe someone can help you, for example a member of the family. What is the questionnaire about? The questionnaire is about your health and work during the last four weeks. We will start with general questions, for example about your gender and date of birth. How long does it take to fill in the form? It takes about 10 minutes to fill in the form. How should you fill in the form?

• Start with the first question and follow the numbering. • Put 1 x in the question box, unless the question states that you may put more than 1 x. • For some of the questions you may fill in a number or otherwise on the dotted line. • There are no wrong answers.

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Do you want to change an answer? • Cross out the old answer. • Put an x in the new answer box. • Put an arrow in front of the new answer.

old answer

new answer What happens to your answers? Your answers will be used for research. Only the researchers will see your answers. That means therefore no one else. The researchers do not write your name anywhere. And they will not tell anyone that you have participated in this research project. We greatly appreciate that you are willing to fill in this form for us!

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General questions Question A1. What is the date while you are filling in this questionnaire?

day month year

Question A2. What is your date of birth?

day month year

Question A3. What is your gender?

Male Female

Question A4. What is the highest degree in education that you have achieved? Look for your highest degree in education and fill in an x in the box.

I never finished school or training programme Primary school or elementary school Junior vocational education Lower general secondary school Intermediate vocational education Higher general secondary education School for higher vocational education University I achieved another degree, namely……………

…………………………………………………………………….

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Question A5. What do you do? Place an x in the box for what you usually do.

I go to school, I am studying I am employed I am self employed I am a housewife, househusband

I am unemployed I am unable to work, for …. % I am retired or on a pre-pension plan I do something else, namely……………………………………

……………………………………………………………………

Question A6. Do you have a paying job?

No Yes

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Question 1. What is your occupation? ..…………………………………………………………………. Question 2. How many hours a week do you work? Count only the hours that you get paid. …….. hours Question 3. How many days a week do you work? ………………………. days

Question 4. Have you missed work in the last 4 weeks as a result of being sick?

No Yes, I have missed ………… days. (Only count the missed work days in the last 4 weeks)

Did you check "Yes"? Go to question 5. Otherwise skip to question 7.

The following questions refer to your work. That is work that you get paid for. You do not have a paying job? Skip to question 10. Please first read the explanation above the question.

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Question 5. Did you miss work earlier than the period of 4 weeks due to being sick? This is referring to one whole uninterrupted period of missed work as a result of being sick.

No Yes

Did you check "Yes"? Go to question 6. Otherwise skip to question 7. Question 6. When did you call in sick?

day month year

Skip to question 10. Please first read the explanation above question 10. Question 7. During the last 4 weeks have there been days in which you worked but during this time were bothered by physical or psychological problems?

No Yes

Did you check "Yes"? Go to question 8 and 9. Otherwise skip to question 10. First read the explanation above question 10.

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Question 8. How many days at work were you bothered by physical or psychological problems? (Only count the days at work in the last 4 weeks) ................... work days Question 9. On the days that you were bothered by these problems, was it perhaps difficult to get as much work finished as you normally do? On these days how much work could you do on average? Look at the figures below. A 10 means that you were able to do as much work as you normally do. A 0 means that you were unable to do any work on these days. Circle the figure that fits best. On these days I was able I was able o I could not to do half do just as do anything as much as I much as I

normally do normally do 0 1 2 3 4 5 6 7 8 9 10 Question 10. Were there days in which you were forced to do less unpaid work because of physical or psychological problems? Only days in the last four weeks.

No Yes

Did you check "Yes"? Go to question 11 and 12. Otherwise skip to the end of the questionnaire.

Explanation Even for unpaid work, you can be bothered by physical or psychological problems. Sometimes as a result you (might) do less. For example you have trouble caring for your children or doing voluntary work. Or you are unable to run errands and pick up groceries, or to work in the garden. The following questions refer to this.

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Question 11. How many days did this happen? Only count the days in the last 4 weeks. ………………………. Days Question 12. Imagine that somebody, for example your partner, family member or friend helped you on these days, and he or she did all the unpaid work that you were unable to do for you. How many hours on average did that person spend doing this on these days? On average ………….. hours on these days That was the last question. Do you have any questions or comments? Perhaps you have some questions or comments? Please write these here below. ……………………………………………………………………………………………. ……………………………………………………………………………………………. ……………………………………………………………………………………………. ……………………………………………………………………………………………. ……………………………………………………………………………………………. ……………………………………………………………………………………………. ……………………………………………………………………………………………. ……………………………………………………………………………………………. ……………………………………………………………………………………………. ……………………………………………………………………………………………. ……………………………………………………………………………………………. ……………………………………………………………………………………………. ……………………………………………………………………………………………. ……………………………………………………………………………………………. …………………………………………………………………………………………….

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What should you do with the questionnaire now that it is filled in? Did you fill everything in? Please put the questionnaire in the envelope. Postage is not necessary. Please put the envelope in the post at your earliest convenience, and in any case before xxx. Have you lost the envelope? In that case you can put the questionnaire in another envelope without postage and send it to: xxx xxx xxx Thank you very much!

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Apendix II

Optional question on short absence from work The next questions are alternative for question 4 in the standard version of the PCQ

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Question 4. Have you missed work in the last 4 weeks as a result of being sick?

No Yes

Did you check "No"? Go to question 7. Question 4a. How many days were you unable to work due to the fact that you were sick? This is referring to only days from the last four weeks. Please use the chart below. An example is given below. Example This example is for Ms De Groot. Ms De Groot works 4 days a week. She has Wednesdays and the weekends off. Last week she was sick for a few days. We have filled in the chart below for her. For each day we filled in whether Ms De Groot worked in the morning or the afternoon, or was sick or had a day off.

• Ms De Groot worked last week on Monday morning. In the box under Monday, in morning, we write worked.

• At the end of the morning Ms De Groot got sick and in the afternoon she went home. She did not work Monday afternoon and all of Tuesday, due to the fact that she was sick. In the boxes Monday afternoon, Tuesday morning and Tuesday afternoon we write sick.

• Ms De Groot had Wednesday off. She was still sick, but that does not make any difference to her work schedule. In the boxes for Wednesday morning and Wednesday afternoon we write day off.

• On Thursday morning Ms De Groot took time off from her work. In the box under Thursday morning we write day off.

• Thursday afternoon Ms De Groot returned to work. She worked the entire day on Friday as well. Therefore we write in the three boxes worked.

• Saturday and Sunday Ms De Groot did not work, because she always has these days off. Therefore we write in the three boxes day off. The chart for Ms De Groot’s schedule last week looks like this: Last week – Ms De Groot (Example) Last week Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Morning worked sick day off day off worked day off day off

Afternoon sick sick day off worked worked day off day off

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Please fill in the days you worked or had off or were sick in the chart below. These are from the last 4 weeks. Please Note: use your planner! And start with last week. Fill in each box for this week with one of the following words: worked, day off or sick. Last week Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Morning

Afternoon

The chart below is for the week before week 1. That is 2 weeks ago. Please refer to your planner. Fill in each box for this week with one of the following words: worked, day off or sick. 2 weeks ago Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Morning

Afternoon

The chart below is for the week before week 2. That is 3 weeks ago. Please refer to your planner. Fill in each box for this week with one of the following words: worked, day off or sick. 3 weeks ago Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Morning

Afternoon

The chart below is for the week before week 3. That is 4 weeks ago. Again, please refer to your planner. Fill in each box for this week with one of the following words: worked, day off or sick. 4 weeks ago Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Morning

Afternoon

Did you fill in each and every box? Then you have answered the question correctly. Are there any empty boxes? Please go back and check your planner and try and think whether you worked, had the day off or were sick for each and every morning and afternoon. Please then fill in all the boxes that are still empty.

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