
==== Front
N Am Spine Soc J
N Am Spine Soc J
North American Spine Society Journal
2666-5484
Elsevier

S2666-5484(24)00220-8
10.1016/j.xnsj.2024.100527
100527
Clinical Studies
Quantifying value loss due to presenteeism and absenteeism in workers’ compensation spinal patients
Ogaban Francis BS
Coffman Alex BS
Glass Natalie PhD
Igram Cassim MD
Pugely Andrew MD
Olinger Catherine MD catherine-olinger@uiowa.edu
⁎
Department of Orthopedics and Rehabilitation, University of Iowa Hospitals & Clinics, 200 Hawkins Drive Iowa City, IA 52242, USA
⁎ Corresponding author: Department of Orthopedics and Rehabilitation, University of Iowa Hospitals & Clinics, 200 Hawkins Drive Iowa City, IA 52242 USA. catherine-olinger@uiowa.edu
20 7 2024
9 2024
20 7 2024
19 1005272 5 2024
5 7 2024
9 7 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Background

Recent studies suggest that better outcomes in work productivity following spine surgery eventually offset the higher cost of treatment. By analyzing preoperative and postoperative changes in work productivity, studies can determine if surgery is cost-effective and give patients valuable information about treatment. Prior studies reviewing outcomes in work performance after spine surgery have largely excluded patients on workers’ compensation from the overall cost analysis.

Methods

A retrospective review of 92 eligible patients was conducted. Evaluation of the EHR identified presenteeism and absenteeism from designated work restrictions. Statistical analyses were conducted using JMP Pro 17.

Results

About 84 (83%) spinal surgery cases were able to return to work, 60 (59%) were able to return to work with no restrictions, 26 (26%) received permanent work restrictions, and 12 (12%) were still undergoing treatment. 86 (85%) experienced presenteeism and 99 (98%) experienced absenteeism. Of the cases that were able to return to work without permanent work restrictions, the mean presenteeism length postoperatively was 287.4 days (median 191 days) and the mean absenteeism length postoperatively was 232.5 days (median 142 days). 72 patients were identified as having sedentary or nonsedentary labor. After excluding outliers, the average return-to-work length was 988.62 days for patients with sedentary employment types and 952.15 days for patients with nonsedentary employment types (p=.116).

Conclusion

Following spinal surgery, our worker's compensation patient population's return-to-work rate was at an average of 232.5 days (median of 142 days) for 83% of patients included in this study. This exhibited worse outcomes than a previous study's measurement excluding worker's compensation patients. Presenteeism length within our population contributed more to decreased work productivity postoperatively than absenteeism length. Our results found no significant difference in return-to-work length between patients with sedentary and nonsedentary employment types.

Keywords

Presenteeism
Absenteeism
Return to work
Spine surgery
Workers’ compensation
Employment
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pmcIntroduction

Measurements linking common health problems and their effects on work performance have been examined extensively in recent years. Generally, employee health impacts work productivity through absenteeism (time not at work) and presenteeism (inhibited at-work performance). To date, total loss of work productivity has been quantified using data collected solely on employee absenteeism while excluding the impact of presenteeism. However, current evidence suggests presenteeism has significant costs on work productivity and should be included in cost of illness studies [1]. In the United States, it is estimated that health-related lost productivity cost employers billions of dollars each year with musculoskeletal pain ranking among the most widespread and impactful [2].

Lower back pain is the leading cause of disability and productivity loss with a lifetime prevalence in adult populations as high as 84% [3]. In a 2010 study, lower back pain accounted for 1.3% of the diagnosis for an outpatient office visit. Additionally, the prevalence of lower back pain significantly interfering with work and quality of life for at least 1 day was found to be 12% [3]. For patients suffering from lower back pain, treatment options include medications, physical therapy, injections, and surgical procedures.

Surgery is becoming more common for lower back and leg pain in patients who do not respond to nonsurgical treatment. In the United States, the volume of elective lumbar fusion procedures increased 62.3% from 2004 to 2015 [4]. However, the upfront costs of surgical intervention for lower back and leg pain are still relatively high. A retrospective cohort study analysis identified that of the 1.2% of patients who received surgery for lower back pain, they accounted for 29.3% of the total 12-month costs [5]. In 1 estimation, low back and neck pain contributed to the highest amount of healthcare spending at around $134.5 billion in 2016 [6].

The decision concerning surgical and nonsurgical treatment for spinal pathologies is a recurring discussion between patients and spine surgeons. Among the concerns weighed into the decision is the patient's ability for improvement in work performance following various treatment options. Musculoskeletal disorders, particularly those related to the lumbar spine, are responsible for large losses in workplace performance.

Studies calculating outcomes following surgical intervention, such as presenteeism, absenteeism, and return to work rates, have consequently become significant for the informed surgical decision-making process between patients and physicians. These outcomes also have been used to analyze the cost-effectiveness of lumbar spine surgery. By accounting for the indirect costs of worker productivity, 1 study observed that the increased worker earnings following lumbar discectomy offset the direct medical costs associated with the procedure over time [7]. Another study using a prospective cohort approach measured presenteeism before and after single-level lumbar spine fusion surgery and found that increases in at-work performance after surgery significantly offset some of the direct and indirect costs of treatment [8].

It is important to note that outcomes following spinal surgery are susceptible to variations based on patient population variables such as compensation status (whether through workers’ compensation or not receiving workers’ compensation). Earlier studies have shown that workers’ compensation patients report an increased risk of unsatisfactory outcomes compared to noncompensated patients after spine surgery [9].

Previous studies reviewing absenteeism and presenteeism in lumbar spine surgery outcomes have largely excluded patients on workers’ compensation from the overall analysis of cost-effectiveness. Thus, this study aimed to address this knowledge gap and utilize data already collected to accurately measure the value loss in work productivity. This study additionally identified gaps in patient-reported outcomes at the Work Injury Recovery Center at the University of Iowa Hospitals and Clinics and assessed the need for additional survey questions to quantify absenteeism and presenteeism more accurately.

Methods

An electronic retrospective data pull was performed at the beginning of the study on patients at the Work Injury Recovery Center at the University of Iowa Hospitals and Clinics (UIHC) who underwent spinal surgery from January 2008 to May 2023. Information collected included the type of surgical procedure performed, procedure date, patient-reported outcome (PRO) scores of Oswestry Disability Index (ODI), age, body mass index (BMI), comorbidities, demographics, and alcohol/tobacco use.

Following the retrospective data pull, an in-depth chart review from electronic medical records (EMR) was conducted on each patient to determine eligibility into the research study. Patients were eligible if they had a definitive workers’ compensation case related to a spinal injury and underwent surgery on 3 or fewer spinal levels (Fig. 1). In addition to research eligibility, information on a patient's injury date, employment type, return-to-work status, and work restriction plan was collected from a patient's electronic medical record during the chart review. Descriptions of a patient's employment from their medical chart were used to further categorize a patient as having sedentary or nonsedentary employment types. The study was approved by the institutional review board at the University of Iowa.Fig. 1 Retrospective data pull and chart review. 278 patients at the Work Injury Recovery Center receiving spinal decompressions/fusions were received at the beginning of the study. A subsequent chart review was conducted to determine research eligibility criteria that consisted of confirming a legitimate workers’ compensation case related to spine and a spinal surgery of ≤3 levels. 92 met the research criteria and were included in the study.

Fig 1

Work status electronic smart form

At UIHC, an electronic Smart Form within the EMR pertaining to each patient's return-to-work status at the Work Injury Recovery Center was completed by a physician at each workman's compensation visit overseeing the case. This electronic form documented a patient's eligibility to return to work along with any work restrictions associated with their recovery plan. Assigned return-to-work status and work restrictions were updated by the physician at each patient's follow-up visit.

Absenteeism and presenteeism were ultimately determined for each patient using this recorded electronic form. A patient was labeled as having experienced absenteeism if their return-to-work status indicated that they were ineligible to return to work. On the other hand, a patient was labeled as having experienced presenteeism if their return-to-work status indicated they were eligible to return to work with any documented work restriction. The dates of the visits in which the electronic forms were recorded were used to track the lengths of experienced absenteeism and presenteeism. Additionally, any changes to the return-to-work status designations and/or work restrictions on follow-up visits were logged. The cut-off date for the study was May 10, 2023.

Analyses

A quantitative analysis of work productivity trends (return-to-work, absenteeism, and presenteeism) on all eligible patients within the research study was conducted. Percentages of return-to-work rate, experienced absenteeism rate, and experienced presenteeism rate were calculated using data collected from electronic forms within the EMR. The total number of spinal operations performed, cases able to return to work without work restrictions, cases concluding with permanent work restrictions, and cases still undergoing follow-up treatment were also reported.

The postoperative experienced absenteeism and presenteeism lengths for the cases without permanent work restrictions were calculated using the date of the procedure and the latest experienced absenteeism and/or presenteeism date. The average and median days to return to work were reported. Since patients could have experienced both absenteeism and presenteeism during their recoveries, the latest date recorded of either absenteeism or presenteeism was used. The quantitative analysis of work productivity trends was conducted using JMP Pro 17.

For patients with recorded employment descriptions (sedentary or nonsedentary employment type), descriptive statistics were used to summarize patient characteristics, including demographics (age, BMI, gender), clinical characteristics (ODI score, injury site), and other health characteristics (tobacco status, comorbidities). Total injury time, calculated as the number of days between the workers’ compensation claim date and the latest experienced absenteeism and/or presenteeism date, was also quantified using the same dataset. We further investigated if the total injury time between patients with sedentary and nonsedentary employment types showed a statistical difference using a 2-sided t-test. Outliers from the dataset used in the calculation were removed using first and third quartile cut-offs.

Results

We initially received 278 patients from the initial data pull at the beginning of the study. Of those patients, 92 (33%) underwent spinal surgery of ≤ 3 levels and had an eligible workers’ compensation case related to a spine injury. A total of 101 spinal operations were performed for the 92 patients included in the study (Table 1).Table 1 Outcomes of spinal operation cases.

Table 1Spinal Operations Performed	101	
Return to work (RTW)	84 (83%)	
RTW without restrictions	60 (59%)	
Permanent work restrictions	26 (26%)	
Still undergoing treatment	12 (12%)	
Experienced absenteeism	99 (98%)	
Experienced presenteeism	86 (85%)	
Quantitative analysis on work productivity trends (return-to-work, absenteeism, and presenteeism) on all 92 patients included in the study.

Of the spinal operations performed, 84 (83%) spinal surgery cases were able to return to work, 60 (59%) were able to return to work with no restrictions, 26 (26%) received permanent work restrictions, and 12 (12%) were still undergoing treatment. Furthermore, 86 (85%) experienced some form of presenteeism and 99 (98%) experienced some form of absenteeism (Table 1).

For the cases that were able to return to work without permanent work restrictions, the mean presenteeism length postoperatively was 287.4 days (median 191 days) and the mean absenteeism length postoperatively was 232.5 days (median 142 days) (Fig. 2).Fig. 2 Of the cases that were able to return to work without permanent work restrictions, the mean absenteeism length postoperatively was 232.5 days (median 142 days) and the mean presenteeism length postoperatively was 287.4 days (median 191 days).

Fig 2

Among patients with recorded employment descriptions, 72 were identified as having sedentary or nonsedentary labor. The combined mean age was 50.8 years (median 51) and 73.6% were male. The mean BMI was 32.3 kg/m^2 (median 31.0). In terms of clinical characteristics, the mean ODI score was 56.8/100 (median 59/100) and the most common injury site was the lumbar spine (95.8%). Of the patients with recorded tobacco status, most patients quit (39.2%). Of the patients with recorded comorbidities, hypertension and obesity were the 2 most common (Tables 2 and 3).Table 2 Combined data quantitative variables.

Table 2Quantitative
Variables	No. of Records	Range	Mean	SD	Q1	Median	Q3	
Min	Max	
Age	72	31	72	50.79	10.99	40.75	51	60.25	
BMI	69	20	66.44	32.3	8.01	27.37	31.01	35	
ODI Score	12	22	76	56.83	17.82	46	59	72	
Total injury time	72	80	9635	965.83	1420.98	313	500	865	
Combined quantitative data from patients with recorded employment descriptions (sedentary and nonsedentary employment types). BMI: The closest BMI measurement within 30 days of procedure date. ODI Score: The ODI Score within 30 days of the procedure date. Total Injury Time: The number of days between the date of patient injury to the date they were able to return to work with no restrictions.

Table 3 Combined data qualitative variables.

Table 3Qualitative Variables	No. of Records	Unique Values	Top	Frequency	
Gender	72	(``Male,'' ``Female'')	``Male''	53	
Tobacco status	79	(``Never,'' ``Not Asked,''
``Quit,'' ``Yes'')	``Quit''	31	
Injury site	71	(``lumbar,'' ``thoracic'')	``lumbar''	69	
Comorbidities	8	(``hypertension,''
``obesity,'' ``diabetes'')	``hypertension,''
``obesity''	3, 3	
Combine qualitative data from patients with recorded employment descriptions (sedentary and nonsedentary employment types). Tobacco Status: The closest tobacco status within 6 months of procedure date. Comorbidities: diabetes, obesity, hypertension, and heart disease. Top: Most frequent value. Frequency: Frequency of top value.

After excluding outliers, the average total injury time, calculated as the date of a patient's injury to the date they were able to return to work with no restrictions, was 988.62 days for patients classified with sedentary employment types and 952.15 days for patients classified with nonsedentary employment types (p=.116) (Tables 4 and 5, and Fig. 3).Table 4 Sedentary vs nonsedentary quantitative variables.

Table 4Qualitative Variables	Sedentary	No. of Records per Group	Range	Mean	SD	Q1	Median	Q3	
Min	Max	
Age	Yes	8	39	66	48.50	10.03	39.75	46	55.50	
No	65	31	72	50.91	11.14	41	52	61	
BMI	Yes	9	23.40	56.35	32.61	10.08	26.55	28.80	34.89	
No	60	20	66.44	32.35	7.75	27.53	31.73	35.03	
ODI Score	Yes	0	–	–	–	–	–	–	–	
No	12	22	76	56.83	17.82	46	59	72	
Total Injury
Time	Yes	8	142	4515	988.62	1470.05	314	470.50	715.5	
No	65	142	9635	952.15	1418.18	314	506	863	
Quantitative data from patients with recorded employment descriptions (sedentary vs nonsedentary employment types). BMI: The closest BMI measurement within 30 days of procedure date. ODI Score: The ODI Score within 30 days of theprocedure date. Total Injury Time: The number of days between the date of patient injury to the date they were able to return to work with no restrictions.

Table 5 Sedentary vs nonsedentary qualitative variables.

Table 5Qualitative variables	Sedentary	No. of records per Group	Unique values	Top	Frequency	
Gender	Yes	8	(“Male,” “Female”)	"Female"	4	
No	65	(“Male,” “Female”)	"Male"	49	
Tobacco status	Yes	9	(“Never,” “Quit,” “Yes”)	"Yes"	4	
No	70	(“Never,” “Not Asked,”
“Quit,” “Yes”)	"Quit"	29	
Injury site	Yes	8	("lumbar")	"lumbar"	8	
No	64	(“lumbar,” “thoracic”)	"lumbar"	62	
Comorbidities	Yes	0	–	–	–	
No	8	(“hypertension,”
“obesity,” “diabetes”)	"hypertension,"
"obesity"	3, 3	
Qualitative data from patients with recorded employment descriptions (sedentary vs. nonsedentary employment types). Tobacco Status: The closest tobacco status within 6 months of procedure date. Comorbidities: diabetes, obesity, hypertension, and heart disease. Top: Most frequent value. Frequency: Frequency of top value.

Fig. 3 Two-sided t-test to investigate any statistically significant group (sedentary vs nonsedentary) difference. Q1 and Q3 of each group were used as cut-offs for outliers. p-value=0.116, there was no statistically significant difference between sedentary and nonsedentary employment types.

Fig 3

Discussion

After receiving spinal surgery, our workers’ compensation patient population's 83% return-to-work rate taking an average of 232.5 days (median of 142 days) exhibited considerably worse outcomes than a previous study's measurement with a population excluding workers’ compensation patients [8]. In the prior study [8], 96% of the surveyed patient population who were employed returned to work 12 months after surgery taking an average of 46 days (median of 29 days) to return to work. These worse outcomes in workers’ compensation patients compared to nonworkers’ compensation patients are consistent with prior published studies [9,10]. It is hypothesized that multiple factors such as higher severity of work injuries, psychosocial factors, and potential secondary gain from benefits, contribute to this known discrepancy.

Prior research on workers’ compensation patients undergoing spinal surgery has largely focused on return-to-work rates. In 1 study, workers’ compensation patients with single-level lumbar discectomies had a calculated return-to-work rate of 55.3% [11]. In another study from New South Wales, patients following lumbar fusion and decompression procedures had a 19% and 39% return-to-work rate respectively [12]. Although our patient population's return-to-work rates are comparatively different, they all show worse outcomes compared to nonworkers’ compensation patients.

Our results also demonstrated that patients who experienced presenteeism length within our workers’ compensation population contributed more to decreased work productivity postoperatively than experienced absenteeism length. This is consistent with prior reports of presenteeism contributing as much (or more than) absenteeism to reduced work productivity [2]. Notably, the study most like ours, which used a prospective survey method, investigated presenteeism and absenteeism before and after single-level lumbar spine surgery. They found that presenteeism and absenteeism contributed approximately evenly to lost work productivity before surgery and concluded that improvements in presenteeism postoperatively could offset some of the costs associated with surgery [8].

Interestingly, our results found no significant difference in total injury time between patients with sedentary and nonsedentary employment types from the date of their injury to the date they were able to return to work. Although one would assume that less rigorous, sedentary jobs should report less missed time/limitations to return to work after injury, our results indicate that there is no difference in total injury time based on employment type in workers’ compensation patients.

Our study has several limitations. First, we could not accurately quantify absenteeism and presenteeism values in workers’ compensation patients using a retrospective approach with our previous data collected. Some of the limitations that prevented us from accurately measuring these values include the inability to directly measure at-work performance with our current set of PROMs and the inability to accurately assess how many hours a patient worked vs how many hours they were expected to work. Simply put, some of the data needed to quantify absenteeism and/or presenteeism was missing or not collected at the time the study was performed. This ultimately prevented us from measuring absenteeism/presenteeism in units of hours or percentages and hindered our ability to compare values pre and postoperatively.

We also acknowledge that although we were able to identify absenteeism and/or presenteeism using the EMR based on office visits, the calculated lengths for each represent an estimation that can deviate from the true amount. Future studies utilizing a tailored, prospective survey method can bridge the gap in the current PROM that prevents us from accurately quantifying presenteeism and absenteeism. This survey method can include questions asking about hours expected to work per week, hours worked, and ratings of at-work performance between 0 and 10.

In conclusion, our study is the first attempt to utilize a retrospective approach to identify presenteeism and absenteeism in spinal patients receiving worker's compensation. Our findings suggest that presenteeism contributes more to decreased work productivity than absenteeism and should be considered when evaluating outcomes in worker's compensation patients receiving spine surgery.

Declarations of competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix Supplementary materials

Image, application 1

Acknowledgments

Venous Roshdibenam and Jill Corlette all contributed meaningfully to the research process. The research study was conducted as part of the Summer Research Fellowship Program at Carver College of Medicine at the University of Iowa. All funding for this project was provided by the study institution. No additional funding or grants were utilized.

FDA device/drug status: Not applicable.

Author disclosures: FO: Nothing to disclose. AC: Nothing to disclose. NG: Nothing to disclose. CI: Nothing to disclose. AP: Nothing to disclose. CO: Nothing to disclose.

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.xnsj.2024.100527.
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