Advancing the Evidence Base for Health and Productivity Improvement: The Work Limitations Questionnaire

The Tufts Program in Health, Work and ProductivityInstitute for Clinical Research and Health Policy Studies Tufts Medical Center

Debra Lerner, MS, PhD

Today’s Topics

• Health and Productivity (H&P) Improvement as a Strategy• Tools for H&P Improvement• An H&P Improvement Intervention for Depression

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.

Health and Productivity Improvement Contributes to Value

Health and Productivity Improvement Contributes to Value

Why Focus on Productivity?The Value Perspective

Impact on cost

Impact on outcome

Cost-saving Cost-Neutral Cost-Increasing

Higher Effectiveness

Adopt (big winner)

Adopt (winner)

Depends on Willingness

To Pay

Similar Effectiveness

Adopt (winner)

Other factors may decide Do not adopt (loser)

Lower Effectiveness

Depends on Willingness

To PayDo not adopt (loser) Do not adopt (big

loser)

(Adapted from Peter Neumann, ScD, Medical Center, 2007)

Components of Health-Related Productivity Loss

• Presenteeism WLQ

• Absenteeism Time Loss Module

The Science of Self-Report Has Advanced Considerably

Develop Instrument• Item generation• Choice of response option • Recall period• Item reduction• Scoring • Relationship among concepts, items, domains• Instructions and format• Respondent and administrative burden

Identify Concept & Establish Conceptual Framework

• Intended population• Intended application • Concepts & domains measured• How concepts relate to other

endpoints

Assess Measurement Properties

• Reliability• Validity• Ability to detect change• Minimum important difference

Modify Instrument• Concepts measured• Population studied• Instrumentation• Application• Administration

Cultural & Language Adaptations

The US Food and Drug Administration GuidelinesPatient-Reported Outcome Measure Development Process

• Cultural adaptation• Linguistic validation• Psychometric validation

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

The Work Limitations Questionnaire (WLQ)

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 the Time (100%)

Most of the Time

Some of the Time (About 50%)

A Slight Bit of

the Time

None of the Time

(0%)

Does Not

Apply to My Job

a. work the required number of hours . . . . . . . . . . . . . . . . 1 2 3 4 5 0

b. get going easily at the beginning of the workday . . . . . . . . . . . . . .

1 2 3 4 5 0

c. start on your job as soon as you arrived at work . . . . . 1 2 3 4 5 0

d. do your work without stopping to take breaks or rests . . . . . . . . . . . . . . . . .

1 2 3 4 5 0

e. stick to a routine or schedule . . . . . . . . . . . . . . 1 2 3 4 5 0

Note: For permission to use the WLQ, contact WLQ@tuftmedicalcenter.org

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 the

Time (100%)

Most of the Time

Some of the Time (About

50%)

A Slight Bit of

the Time

None of the Time

(0%)

Does Not

Apply to 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 making mistakes. . . . 1 2 3 4 5 0

e. feel you’ve done what you are capable of doing. . . .

1 2 3 4 5 0

Note: For permission to use the WLQ, contact WLQ@tuftsmedicalcenter.org

The Work Limitations Questionnaire (WLQ)Sample from 25 Q Version: Output Scale

How the WLQ is Used

• Employee health assessment• Employer health improvement initiatives• Clinical trials within the pharmaceutical industry• Services research

Levels of WLQ Data

Summary Score

% Productivity Lost Compared to Benchmark

Job Level

% Time with Impaired Job Performance

Task Level

% Time with Impaired Task Performance

Time Management

Physical Demands

Mental-Interpersonal Demands

Output Demands

25 Items

How is Presenteeism Impacting the Company?Cathy Baase MD, Dow Chemical

Employee Medical (US)14%

Retiree Medical (US)19%

Other Admin13%

Global Absenteeism6%

Global Presenteeism48%

The Impact of Different Medical Conditions on Presenteeism at Bank One

0.0

0.5

1.0

1.5

2.0

2.5

3.0

time>0 physical>0 mental>0 output>0

Arthritis**

Back Pain**

Depression**

Diabetes*

Heart disease

Heartburn**

Irritable Bowel*

Odd

s of

Wor

k Pe

rfor

man

ce L

imita

tion

WLQSource: Burton et al., JOEM, 2004; 46 (6 Suppl): S38-S45

Burden of Pain on Performance at Work: Difficulty in Meeting Job Demands

The Harris Allen Group

Exte

nt o

f Lim

itatio

n(0

-100

)

Pain Severity

Type of Work Demand

0

10

20

30

40

50

60

Healthy Low Moderate High

Time

Physical

Mental / Interpers

OutputExte

nt o

f Lim

itatio

n(0

-100

)

Pain Severity

Type of Work Demand

Making the Case for Change With the WLQ:Impact of Chronic Conditions

Pain Severity

Type of Work Demand Total Number of Chronic Conditions

0 7037 (53.1) 1.2 14461 3184 (24.0) 1.5 17922 1647 (12.4) 1.9 22403 734 (5.5) 2.5 30204 349 (2.6) 3.0 3597

5+ 312 (2.4) 4.2 5044

N (%)

% Productivity

Loss

Per Person Productivity

Cost ($)

Making the Case for Change With the WLQ: Impact of Risk Factors

Health Risk Factor Summary Profile - Means

Time Manage

mentPhysical

Tasks

Mental-Interpers

onal Tasks

Output Tasks % Productivity Loss

Per Person Productivity Cost ($)

Total Risks

0 160 (1.2) 1.7 4.1 2.5 1.4 0.6 6161 601 (4.5) 3.4 5.4 3.7 2.4 1.0 9632 1573 (11.9) 3.7 6.0 3.8 2.5 1.0 1,0183 2738 (20.6) 4.5 6.9 5.0 3.5 1.3 1,3074 2853 (21.5) 6.3 7.6 5.7 4.8 1.6 1,6195 2469 (18.6) 6.8 8.3 6.6 4.9 1.8 1,7626 1619 (12.2) 8.8 8.6 7.7 6.3 2.1 2,1167 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

N (%)

WLQ Scale Scores

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

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

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

0.0

5.0

10.0

15.0

20.0

25.0

Baseline 6 Month 12 Month 18 Month

PH

Q-9

Dep

ress

ion

Sev

erity

MDDDoubleDysthymiaAll DepressionControl GroupRA Group

The Health & Work Study 2000-2004Depression’s Burden Persists

Depression Groups:

Months from Baseline

Source: Depression and Productive Work Activity Study, D. Lerner, Principal Investigator,

The Health & Work Study 2000-2004The Work Productivity Gap

0

2

4

6

8

10

12

14

16

18

20

Baseline 6 Months 12 Months 18 Months

WLQ

: Per

cent

age

Pro

duct

ivity

Los

t

Improved or Remitted n=47Same n=176Worse n=63Healthy Employee Controls n=193

Source: Depression and Productive Work Activity Study, D. Lerner, Principal Investigator, 2004.

Employees with Depression:

Months after Baseline

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)

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)

Pre-Intervention Presenteeism and Absenteeism WHI Treatment and Usual Care Groups:

State Government RCT

43.7

18.3

38.5 39.1

10.1

26.6

45.6

23.3

37.340.7

10.3

31.2

0

10

20

30

40

50

60

70

80

90

100

Time Management

Physical Tasks Mental-Interpersonal

Tasks

Output Tasks Productivity Lost

(Presenteeism)

Productivity Lost

(Absenteeism)WLQ Scales, Productivity Lost and Absenteeism*

Bas

elin

e Sc

ore

Usual CareWHI Group

* No significant differences between groups on any baseline score

Percent of Post-Intervention Change from Baseline:State Government RCT

2.110.9 4.2

-2.6

3.0

-100.0

-75.6

-4.9

39.7 46.831.6 34.9

47.1 42.8 41.234.0

-120

-100

-80

-60

-40

-20

0

20

40

60

80

100

TimeManagement

Physical Tasks Mental-Interpersonal

Tasks

Output Tasks Productivity Lost Days Missed Absenteeism DepressionSeverity

Outcome Criteria

Per

cent

Cha

nge

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