Presenteeism: Measuring Employee Productivity Debra Lerner, MS, PhD Director, Program in Health, Work & Productivity Senior Scientist, Institute for Clinical Research & Health Policy Studies Debra Lerner, MS, PhD is a Senior Scientist within the Tufts Medical Center Institute for Clinical Research and Health Policy Studies (ICRHPS), where she directs the Program on Health, Work and Productivity. She is also a Professor within the Departments of Medicine and Psychiatry within the Tufts University School of Medicine and the Sackler School of Biomedical Sciences. Dr. Lerner is a leader in research concerning the work and productivity impact of health problems. Under her leadership, Dr. Lerner and her colleagues developed the Work Limitations Questionnaire (WLQ). The WLQ is used throughout the world and has become a standard of measurement. WLQ users include employers, insurers, pharmaceutical companies, health and wellness providers and academic researchers. Hundred of thousands of employees complete the WLQ annually as part of routine health assessment and corporate health strategy. In addition, Dr. Lerner’s program team has developed a new program aimed at preventing productivity loss due to depression. The effectiveness and economic impact of this program is being tested in the United States in multiple companies. Sponsorship for this research has been provided by the National Institute on Aging, the National Institute of Mental Health and the Centers for Disease Control and Prevention. Dr. Lerner’s program is involved in health and productivity improvement projects with employers and other high profile organizations such as Aetna, Mayo Clinic Health Care Solutions, Ortho-McNeil Janssen and many health and wellness firms.

1. Advancing the Evidence Base for Health and Productivity
Improvement: The Work Limitations Questionnaire
The Tufts Program in Health, Work and Productivity
Institute for Clinical Research and Health Policy Studies
Tufts Medical Center
Debra Lerner, MS, PhD

2. Today’s Topics
• Health and Productivity (H&P) Improvement as a Strategy
• Tools for H&P Improvement
• An H&P Improvement Intervention for Depression

3. H & P Improvement
Generally refers to strategies undertaken to prevent,
reduce or otherwise manage the adverse effects of a
population’s health problems on its work performance and
productivity.

4. Health and Productivity Improvement
Contributes to Value
Health and Productivity Improvement Contributes to Value

5. Why Focus on Productivity?
The Value Perspective
(Adapted from Peter Neumann, ScD, Medical Center, 2007)
Impact on cost
Cost-saving Cost-Neutral Cost-Increasing
Depends on
Higher Adopt Adopt
Willingness
Effectiveness (big winner) (winner)
To Pay
Impact on
outcome Similar Adopt Other factors may
Do not adopt (loser)
Effectiveness (winner) decide
Depends on
Lower Do not adopt (big
Willingness Do not adopt (loser)
Effectiveness loser)
To Pay

6. Components of Health-Related Productivity Loss
• Presenteeism WLQ
• Absenteeism Time Loss Module

7. The Science of Self-Report Has
Advanced Considerably

8. The US Food and Drug Administration Guidelines
Patient-Reported Outcome Measure Development Process
Cultural & Language Identify Concept & Establish
Adaptations Conceptual Framework
• Cultural adaptation • Intended population
• Linguistic validation • Intended application
• Psychometric validation • Concepts & domains measured
• How concepts relate to other
endpoints
Modify Instrument
• Concepts measured
• Population studied Develop Instrument
• Instrumentation • Item generation
• Application • Choice of response option
• Administration • Recall period
• Item reduction
• Scoring
• Relationship among concepts, items, domains
Assess • Instructions and format
• Respondent and administrative burden
Measurement Properties
• Reliability
• Validity
• Ability to detect change
• Minimum important difference

9. The Work Limitations Questionnaire (WLQ)
• Presenteeism measured in 25 or 8-item versions
• Questions cover 4 domains of work: time, physical,
mental-interpersonal, and output demands
• Scale scores range from 0 (Limited None of the Time)
to 100 (Limited All of the Time)
• Validated
• Available in multiple versions (mail, phone, web) and
40+ languages
• WLQ Absenteeism module available

10. The Work Limitations Questionnaire (WLQ)
Sample from 25 Q Version: Time Management Scale
In the past 2 weeks, how much of the time did your physical health or emotional problems
make it difficult for you to do the following?
(Mark one box on each line a. through e.)
All of Most of Some of A Slight None of Does
the Time the Time the Time Bit of the Time Not
(100%) (About the Time (0%) Apply to
50%) My Job
a. work the required number of
1 2 3 4 5 0
hours . . . . . . . . . . . . . . . .
b. get going easily at the
beginning of the 1 2 3 4 5 0
workday . . . . . . . . . . . . . .
c. start on your job as soon as
1 2 3 4 5 0
you arrived at work . . . . .
d. do your work without
stopping to take breaks or 1 2 3 4 5 0
rests . . . . . . . . . . . . . . . . .
e. stick to a routine or
1 2 3 4 5 0
schedule . . . . . . . . . . . . . .
Note: For permission to use the WLQ, contact WLQ@tuftmedicalcenter.org

11. The Work Limitations Questionnaire (WLQ)
Sample from 25 Q Version: Output Scale
In the past 2 weeks, how much of the time did your physical health or emotional
problems make it difficult for you to do the following?
(Mark one box on each line a. through e.)
All of Most of Some of the A Slight None of Does
the the Time Time (About Bit of the Time Not
Time 50%) the Time (0%) Apply to
(100%) My Job
a. handle the workload . 1 2 3 4 5 0
b. work fast enough . . . 1 2 3 4 5 0
c. finish work on time . . 1 2 3 4 5 0
d. do your work without
1 2 3 4 5 0
making mistakes. . . .
e. feel you’ve done what
1 2 3 4 5 0
you are capable of
doing. . . .
Note: For permission to use the WLQ, contact WLQ@tuftsmedicalcenter.org

12. How the WLQ is Used
• Employee health assessment
• Employer health improvement initiatives
• Clinical trials within the pharmaceutical industry
• Services research

13. Levels of WLQ Data
Summary Score Job Level Task Level
% Productivity Lost % Time with % Time with
Compared to Impaired Job Impaired Task
Benchmark Performance Performance
Time Physical Mental- Output 25 Items
Management Demands Interpersonal Demands
Demands

14. How is Presenteeism Impacting the Company?
Cathy Baase MD, Dow Chemical
Employee Medical (US)
14%
Global Presenteeism
Retiree Medical (US)
48%
19%
Other Admin
13%
Global Absenteeism
6%

15. The Impact of Different Medical Conditions on
Presenteeism at Bank One
Arthritis**
Back Pain**
Odds of Work Performance Limitation
3.0 Depression**
Diabetes*
Heart disease
2.5 Heartburn**
Irritable Bowel*
2.0
1.5
1.0
0.5
0.0
time>0 physical>0 mental>0 output>0
WLQ
Source: Burton et al., JOEM, 2004; 46 (6 Suppl): S38-S45

16. Burden of Pain on Performance at Work:
Difficulty in Meeting Job Demands
60
50
Type of Work Demand
Type of Work Demand
Extent of Limitation
Extent of Limitation
40
Time
(0-100)
(0-100)
30 Physical
Mental / Interpers
20
Output
10
0
Healthy Low Moderate High The Harris Allen Group
Pain Severity
Pain Severity

17. Making the Case for Change With the WLQ:
Impact of Chronic Conditions
% Per Person
Productivity Productivity
N (%) Loss TypeCost ($) Demand
of Work
Total Number of
Chronic Conditions
0 7037 (53.1) 1.2 1446
1 3184 (24.0) 1.5 1792
2 1647 (12.4) 1.9 2240
3 734 (5.5) 2.5 3020
4 349 (2.6) 3.0 3597
5+ 312 (2.4) 4.2 5044
Pain Severity

18. Making the Case for Change With the WLQ: Impact
of Risk Factors
Health Risk Factor Summary Profile - Means
WLQ Scale Scores
Mental-
Time Interpers
Manage Physical onal Output Per Person
N (%) ment Tasks Tasks Tasks % Productivity Loss Productivity Cost ($)
Total Risks
0 160 (1.2) 1.7 4.1 2.5 1.4 0.6 616
1 601 (4.5) 3.4 5.4 3.7 2.4 1.0 963
2 1573 (11.9) 3.7 6.0 3.8 2.5 1.0 1,018
3 2738 (20.6) 4.5 6.9 5.0 3.5 1.3 1,307
4 2853 (21.5) 6.3 7.6 5.7 4.8 1.6 1,619
5 2469 (18.6) 6.8 8.3 6.6 4.9 1.8 1,762
6 1619 (12.2) 8.8 8.6 7.7 6.3 2.1 2,116
7 840 (6.3) 10.2 9.7 8.8 6.9 2.4 2,386
8+ 410 (3.1) 12.3 9.8 10.1 8.4 2.8 2,764

19. Depression Viewed Through the H & P Improvement Lens
• Common chronic illness adversely effects how people
think, feel and behave
• Attacks motivation, self-confidence, energy, thought
processes and social skills many of which are essential
to good work performance
• Working-age adults with depression experience high
rates of job loss, turnover, premature retirement,
disability, absences and at-work performance deficits
with productivity losses in the billions of dollars annually

20. The Work Burden of Depression
• Between 10-20% of the population stricken at least once
during lifetime
• One of the top 5 leading sources of health-related
productivity loss
• The average depressed worker misses from 0.5-4
workdays per month
• The average depressed worker is limited in his or her
ability to work 35% of the time

21. What is Behind the Staggering Work and
Productivity Impact?
• Variability in treatment efficacy and effectiveness
• Persistent barriers to obtaining high quality
screening, diagnosis and treatment
• Limits of the biomedical approach for reducing
disability and productivity loss
• Slow progress in engaging key stakeholders
(employees, employers and healthcare
professionals) in solving the problem

22. The Health & Work Study 2000-2004
Depression’s Burden Persists
25.0
PHQ-9 Depression Severity
Depression
20.0 Groups:
MDD
Double
15.0
Dysthymia
All Depression
10.0 Control Group
RA Group
5.0
0.0
Baseline 6 Month 12 Month 18 Month
Months from Baseline
Source: Depression and Productive Work Activity Study, D. Lerner, Principal Investigator,

23. The Health & Work Study 2000-2004
The Work Productivity Gap
20
WLQ: Percentage Productivity Lost
18
16
Employees with Depression:
14
12 Improved or Remitted n=47
Same n=176
10
Worse n=63
8 Healthy Employee Controls n=193
6
4
2
0
Baseline 6 Months 12 Months 18 Months
Months after Baseline
Source: Depression and Productive Work Activity Study, D. Lerner, Principal Investigator, 2004.

24. The Health & Work Initiative (WHI)
A New Workplace Intervention
• Opportunity to detect depression in a community setting
• Uses an existing resource: Employee Assistance Program
(EAP)
• May encourage employer investment by demonstrating
“return on investment” (ROI)

25. The Work and Health Initiative (WHI)
Aeronautics Manufacturer and State Government Pilot Tests
• Web-Based Employee Health Screening with Feedback
• Depressed and Work-Impaired Employees Enrolled in
16-Week WHI Program
• Care Provided by EAP Counselors On the Phone
• Three Care Components
• Medical Care Coordination
• Self-Help using Cognitive Behavioral Therapy Strategies
• Work Coaching
(Lerner, Adler, Rogers and Hermann, 2004-7)

26. Pre-Intervention Presenteeism and Absenteeism
WHI Treatment and Usual Care Groups:
State Government RCT
100
90
Usual Care
80 WHI Group
70
Baseline Score
60
50 45.6
43.7
38.5 37.3 39.1 40.7
40
31.2
30 26.6
23.3
18.3
20
10.1 10.3
10
0
Time Physical Tasks Mental- Output Tasks Productivity Productivity
Management Interpersonal Lost Lost
Tasks (Presenteeism) (Absenteeism)
WLQ Scales, Productivity Lost and Absenteeism*
* No significant differences between groups on any baseline score

27. Percent of Post-Intervention Change from Baseline:
State Government RCT
100
80
60 46.8 47.1 42.8
39.7 41.2
31.6 34.9 34.0
40
Percent Change
20 10.9
2.1 4.2 3.0
0
-2.6 -4.9
-20
-40
-60
-80
-75.6
-100
-100.0
-120
Time Physical Tasks Mental- Output Tasks Productivity Lost Days Missed Absenteeism Depression
Management Interpersonal Severity
Tasks
Outcome Criteria

28. Summary of Results
• The WHI was superior to Usual Care on every metric
• The WHI resulted in an average reduction in at-work
productivity cost of $3,500 per employee vs. $300 per
employee in Usual Care
• The WHI resulted in an average 50% improvement
(reduction) in absences per employee vs. an average
100% increase in absences per employee in Usual Care