Healthcare costs and loss of productivity in patients with trapeziometacarpal osteoarthritis

Abstract

The objective of this study was to analyse healthcare and productivity costs in patients with trapeziometacarpal osteoarthritis. We included 161 patients who received surgery or steroid injection and calculated their healthcare costs in Euro (€) over 1 year. Patients filled out the Work Productivity and Activity Impairment Questionnaire to assess loss of productivity at baseline, and after 3, and 12 months. In the surgical group, loss of productivity among employed patients first increased and then decreased (50%, 64%, and 25% at 0, 3, and 12 months). Productivity was more stable over time in the injection group (52%, 38%, and 48%). In the surgical group, estimated total annual healthcare and productivity costs were €5770 and €5548, respectively. In the injection group, healthcare and productivity costs were €348 and €3503. These findings highlight the need for assessing productivity costs to get a comprehensive view of the costs associated with a treatment. Level of Evidence III.
© The Author(s) 2015.

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The Journal of Hand Surgery
(European Volume)
XXE(X) 1 –8
© The Author(s) 2015
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DOI: 10.1177/1753193414568293
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Introduction
In recent years, economic evaluations have become
increasingly important because of the growing
emphasis on cost containment. The evaluation of
both costs and benefits allows more comprehensive
consideration of the value of a particular intervention
(Higgins and Harris, 2012). In addition to direct
healthcare expenses, the costs associated with loss
of productivity lead to substantial economic conse-
quences for the patient, the employer, and society (de
Putter et al., 2012; Hill et al., 2010).
People with hand osteoarthritis (OA) report limita-
tions in daily life that may also affect their working
ability (Hill et al., 2010). Loss of productivity arises
from two sources: absenteeism and presenteeism
(Schultz et al., 2009). Absenteeism can be quantified
by the time absent from work due to illness (Schultz
et al., 2009). Presenteeism is defined as the reduction
in productivity while at work because of an individual’s
state of health (Brooks et al., 2010). Costs due to
absenteeism are quite straightforward to record, while
the costs of presenteeism often remain hidden (Schultz
et al., 2009). Studies investigating presenteeism for
patients with OA of any joint (Bushmakin et al., 2011;
Dibonaventura et al., 2011), patients with knee OA
(Hermans et al., 2012), and patients with rheumatoid
arthritis (Bansback et al., 2012; Braakman-Jansen
et al., 2012) showed that the costs associated with
presenteeism were considerably higher than those for
Healthcare costs and loss of productivity
in patients with trapeziometacarpal
osteoarthritis
M. Marks1,2, T. P. M. Vliet Vlieland2, L. Audigé1, D. B. Herren3,
R. G. H. H. Nelissen2 and W. B. van den Hout4
Abstract
The objective of this study was to analyse healthcare and productivity costs in patients with trapeziometacarpal
osteoarthritis. We included 161 patients who received surgery or steroid injection and calculated their
healthcare costs in Euro (€) over 1 year. Patients filled out the Work Productivity and Activity Impairment
Questionnaire to assess loss of productivity at baseline, and after 3, and 12 months. In the surgical group,
loss of productivity among employed patients first increased and then decreased (50%, 64%, and 25% at
0, 3, and 12 months). Productivity was more stable over time in the injection group (52%, 38%, and 48%).
In the surgical group, estimated total annual healthcare and productivity costs were €5770 and €5548,
respectively. In the injection group, healthcare and productivity costs were €348 and €3503. These findings
highlight the need for assessing productivity costs to get a comprehensive view of the costs associated with
a treatment.
Level of Evidence III
Keywords
Carpometacarpal joint, cost analysis, economics, osteoarthritis, thumb
Date received: 13th May 2014; revised: 14th October 2014; accepted: 4th December 2014
1Department of Research and Development, Schulthess Clinic,
Zurich, Switzerland
2Department of Orthopaedics, Leiden University Medical Center,
Leiden, The Netherlands
3Department of Hand Surgery, Schulthess Clinic, Zurich,
Switzerland
4Department of Medical Decision Making, Leiden University
Medical Center, Leiden, The Netherlands
Corresponding author:
M. Marks, Schulthess Clinic, Department of Research and
Development, Lengghalde 2, 8008 Zurich, Switzerland.
Email: Miriam.Marks@kws.ch
568293JHS0010.1177/1753193414568293The Journal of Hand SurgeryMarks et al.
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2 The Journal of Hand Surgery (Eur)
absenteeism. Economic evaluations in orthopaedics,
especially for the hand, are scarce. Examples of eco-
nomic studies for the hand include the treatment of
Dupuytren’s disease (Chen et al., 2011; Macaulay
et al., 2011; Webb and Stothard, 2009), hand and wrist
injuries (de Putter et al., 2012; Ljungberg et al., 2008),
and for ganglia and trigger fingers (Kerrigan and
Stanwix, 2009; Webb and Stothard, 2009), with only
limited information about the economic consequences
due to absenteeism and presenteeism.
The objective of this study was to analyse the eco-
nomic aspects of surgical treatment and steroid
injection in patients with osteoarthritis of the trapezi-
ometacarpal joint (TMC OA), with regard to the costs
associated with healthcare and loss of productivity.
Methods
Study design
This economic evaluation is part of a mono-centre,
prospective cohort study on the outcomes of conserv-
ative and surgical treatment in patients with TMC OA.
Patients
The parent study included all patients, with a radio-
graphically proven diagnosis of TMC OA, who under-
went either conservative or surgical treatment for
that condition in the months from September 2011 to
November 2012. Exclusion criteria were: TMC OA
was not the main problem at the time of consulta-
tion, rheumatoid arthritis, concomitant surgery on
other fingers, legal incompetence, poor general con-
dition precluding study participation, previous inclu-
sion in the study for the other hand, and insufficient
knowledge of the German language to complete the
questionnaires. All eligible patients were asked to
participate by their treating hand surgeon, and were
consecutively enrolled in the study after they had
given written informed consent.
For the present economic analysis, the surgical
group included patients who received the following
treatment: trapeziectomy with ligament reconstruc-
tion and tendon interposition (LRTI) or arthrodesis of
the TMC joint. Trapeziectomy with LRTI was carried
out according to Epping (Epping and Noack, 1983),
Weilby (Weilby, 1988), or Sigfusson and Lundborg
(Sigfusson and Lundborg, 1991) using whichever
method was preferred and routinely performed by
each surgeon. Additional procedures, such as carpal
tunnel release or arthrodesis of the thumb metacar-
pophalangeal joint were also performed, if required.
In the conservatively treated group, the analysis only
included patients given steroid injections into the
TMC joint by their treating hand surgeon. In each
case the treatment strategy was made by the treating
surgeon in discussion with the patient. Physical or
occupational therapy, including splinting, was in
either group if indicated.
Assessments
Baseline assessments were made at the preopera-
tive consultation for surgical patients and on the day
of injection for the conservatively treated patients.
Sociodemographic and disease-related data were
gathered at this visit. Follow-up assessments were
scheduled at 3, 6, and 12 months after treatment. If
routine medical care did not require a check-up at
these times, patients came for a study visit with an
independent examiner, for which they were not
charged.
At each study visit, patients completed a question-
naire set consisting of the Michigan Hand Questionnaire
(MHQ) (Chung et al., 1998) and the Work Productivity
and Activity Impairment Questionnaire (WPAI) (Reilly
et al., 1993). Additionally, we asked about the duration
of sick leave due to the TMC OA, work status, and
income.
The MHQ, developed by Chung et al. (1998), is a
hand-specific questionnaire that yields results for
each hand separately. The psychometric properties
of the MHQ have been assessed in patients with TMC
OA and show overall good reliability, validity, and
responsiveness (Marks et al., 2014). The total score
ranges from 0 to 100, with a higher score indicating
better performance. The German version (Knobloch
et al., 2011) has been used for this study and the data
for the affected hand were analysed.
The WPAI (Reilly et al., 1993) is a quantitative
assessment of absenteeism, presenteeism, and over-
all productivity loss attributable to a specific health
problem during the previous 7 days. Absenteeism is
defined as the employee’s time away from work due to
illness, disability, or workers` compensation (Schultz
et al., 2009). Presenteeism occurs when an employee
goes to work despite a physical or psychological
health problem that will prevent him or her from
fully functioning at work. The given health condition
will lead to a reduced on-the-job productivity
(Gosselin et al., 2013; Schultz et al., 2009; Widera
et al., 2010). There are several versions of the WPAI
available. We used the Swiss-German translation of
the WPAI Specific Health Problem version 2.0 with the
generic term ‘problem’ being replaced by the word
‘Daumensattelgelenksarthrose’ [osteoarthritis of the
thumb saddle joint]. The WPAI is the instrument most
frequently used to measure health-related produc-
tivity and its psychometric properties have been
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Marks et al. 3
assessed for various medical conditions (Prasad
et al., 2004). It consists of six questions regarding
employment status (Q1), hours absent from work due
to TMC OA (Q2), hours absent from work due to other
reasons (Q3), hours actually worked (Q4), the extent to
which the person was limited at work due to TMC OA
(Q5), and the extent to which TMC OA affected daily
activities other than work (Q6). WPAI outcomes are
expressed as impairment percentages, with higher
numbers indicating greater impairment and less pro-
ductivity (Lofland et al., 2004; Reilly, 2013).
Healthcare costs
Healthcare costs were measured by the clinic’s
earnings, as extracted from the hospital accounting
system for the following treatment events: preoper-
ative consultations, intervention, follow-up consul-
tations, and treatment of complications. Earnings
from the baseline date until the date of the 1 year
follow-up were recorded. All monetary numbers
were recorded in Swiss francs and converted into
Euro (€) using the purchase power parity of 2012
(Organisation for Economic Co-operation and
Development (OECD), 2012).
Furthermore, the length of hospital stay for post-
operative patients, as well as the type of insurance,
was extracted from the hospital accounting system.
There are three types of inpatient hospital care in
Switzerland, depending on whether the patient has
general, semi-private, or private health insurance.
All outpatient treatment (conservative treatment and
consultations) is covered by the general insurance,
so the insurance type was not specified for these
patients. The earnings of the clinic for patients with a
general insurance are based on flat rate payments.
For patients with additional (semi-) private insur-
ance, the hospital charges additional fees.
Loss of productivity
Loss of productivity over 1 week was calculated for
employed patients. We chose the human capital
method, because the duration of absenteeism is typi-
cally less than 6 months and patients usually return to
work following treatment for TMC OA. The human
capital method counts any hour not worked as an
hour lost. Other methods, such as the friction-cost
method, only count as lost those hours not worked
until another employee takes over the patient’s work
(van den Hout, 2010). Using the WPAI data, we calcu-
lated the percentage of absenteeism, presenteeism,
and overall work productivity loss for 1 week (Lofland
et al., 2004; Reilly, 2013): Absenteeism = Q2/(Q2 + Q4);
Presenteeism = Q5/10; Overall work productivity
loss = Absenteeism + [(1-absenteeism/100) × pres-
enteeism]. The costs associated with loss of produc-
tivity were calculated by multiplying the corresponding
score with the weekly working hours and the hourly
wage. For the wages, we used norm values for the
monthly income of the Swiss population, stratified by
sex and age (Schweizerische Eidgenossenschaft
et al., 2010). Hourly wages were calculated from the
monthly wage (divided by 21.75 × 8, with 21.75 being
the average monthly working days and 8 being the
daily working hours) (Heller, 2010), resulting in values
of €16 to €24 per hour for our patients.
Statistics
Baseline differences between the treatment groups
were evaluated with a two-group, two-tailed t-test for
continuous variables. For nominal data, we used the
Fisher’s exact test. We used one-way analysis of vari-
ances (ANOVAs) to determine any differences in the
earnings of the clinic, the length of hospital stay, age,
and the MHQ total score between patients with differ-
ent types of insurance. Loss of productivity was com-
pared between the treatment groups using a two-group,
two-tailed t-test. Within-group changes regarding pro-
ductivity over the year were analysed using an ANOVA
without adjustments for multiple testing.
The WPAI provides data on loss of productivity for
only 1 week. As we were interested in the annual
costs, we made a linear extrapolation of each meas-
urement time point for absenteeism and presentee-
ism and calculated the area under the curve. For this
analysis, the value for absenteeism at baseline in the
surgical group was set at 100%, because all patients
were on full sick leave during the first day after sur-
gery. This analysis was not feasible if follow-up data
for a patient were missing. Based on the assumption
of values missing at random (MAR), we substituted
missing data for absenteeism and presenteeism by
multiple imputation. An imputation model for each
follow-up was built containing the absenteeism/pres-
enteeism data of the other follow-ups. We created 20
imputed datasets and pooled them using Rubin’s
combination rules. The annual healthcare and pro-
ductivity costs were estimated with these data for all
patients irrespective of their working status. For non-
working patients, loss of productivity was set at 0.
The study was approved by the local ethics
committee.
Results
This study included 161 patients with a mean age of
64 years. Surgery was performed in 103 patients (102
LRTI and one arthrodesis) and 58 patients received a
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4 The Journal of Hand Surgery (Eur)
steroid injection (Table 1). A total of 41% of the
patients treated surgically only had general insur-
ance, while 59% had additional (semi-) private insur-
ance. At 1 year, data were available from 130 patients,
corresponding to a follow-up rate of 81%.
Healthcare costs
Average earnings of the clinic were €5770 and €348
for the surgery and injection group, respectively
(p ⩽ 0.001). In three patients, complications affecting
the flexor carpi radialis tendon occurred after sur-
gery. Overall, average costs for complications were
€32 per operated patient (Table 2).
Comparing the different types of insurance, surgi-
cal patients with only general insurance were signifi-
cantly younger, provided lower earnings for the clinic
and had shorter hospital stays, although no differ-
ence in the outcome could be detected (Table 3).
Regardless of their type of insurance, surgical
patients showed significant improvements measured
with the MHQ, with the average change of the total
score being higher than the minimal important
change of 17 points (Marks et al., 2014).
Loss of productivity
At baseline, 58 patients in both groups had paid
work. Employed patients had an average of 10 weeks’
complete sick leave following surgery. In addition,
nine patients also had partial sick leave (50%–80%,
for 3 to 4 weeks). Three patients reported that they
had no sick leave at all.
Overall, except for the 3-month follow-up in the
surgical group, costs for loss of productivity due to
presenteeism were considerably higher than costs
for absenteeism (Table 4). The total productivity loss
in the surgical group increased from baseline to
3 months (50% versus 64%), but decreased signifi-
cantly to 25% at 1 year. Total productivity loss in the
injection group decreased from 52% at baseline to
48% at 1 year (p = 0.051). At baseline, no differences
were found between the two groups. At 1 year, how-
ever, patients treated conservatively reported 48%
loss of productivity, which is significantly more than
in the surgical group with only 25%.
The estimated costs due to loss of productivity for
1 year showed that surgery was about €7500 more
expensive than injection (Table 5). Costs from absen-
teeism were higher in the surgical group, while costs
from presenteeism were higher for those treated
with injection.
Discussion
The results of this economic analysis showed that
healthcare costs for steroid injection were much lower
than for surgery in patients with TMC OA. Patients with
Table 1. Baseline sociodemographic data of the 161 patients with TMC OA. Values p ⩽ 0.05 are shown in bold.
Characteristics Total group (n = 161) Surgery (n = 103) Injection (n = 58) p-value
Female sex: no. (%) 136 (84) 90 (87) 46 (79) 0.182
Age in years: mean (SD) 63.9 (9.1) 63.6 (8.8) 64.4 (9.8) 0.590
MHQ total score: mean (SD) 52 (16) 48 (15) 59 (13) ⩽0.001
Insurance for surgery: no. (%)
General 42 (41)
Semi-private 34 (33)
Private 27 (26)
Employment status; no. (%)
Employed, fully able to work 46 (29)a31 (30) 15 (26)
Employed, partly unable to work due
to TMC OA
4 (2) 4 (4) 0 (0)
Employed, partly unable to work for
other reasons
6 (4) 2 (2) 4 (7)
Employed, unable to work for TMC OA 1 (1) 1 (1) 0 (0)
Employed, unable to work due to
other reasons
1 (1) 1 (1) 0 (0)
Unemployed/retired/housewife 101 (63) 64 (62) 37 (64)
No information 2 (1) 2 (3)
Contractual weekly working hours:
mean (SD)b
31 (12) 31 (12) 31 (13) 0.968
SD: standard deviation; TMC OA: trapeziometacarpal osteoarthritis; MHQ: Michigan Hand Questionnaire.
aThe sum of the percentages is more than 100 due to rounding of the figures.
bPatients in employment only.
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Marks et al. 5
private insurance provided the clinic with more earn-
ings than patients with general insurance, although
we found no differences in the treatment outcome.
Between baseline and the 1-year follow-up, there was
at first an increase due to absenteeism after surgery
and then a significant decrease in loss of productivity
in the surgical group, whereas productivity loss was
more stable over time in the injection group. Estimated
combined annual healthcare and productivity costs
were considerably higher in the surgical group, where
both types of costs almost equally contributed to the
total costs. In contrast, in patients treated with injec-
tion, most of the total annual costs were attributable to
loss of productivity.
As expected, the clinic earns significantly more
money from patients with additional (semi-) private
insurance. Although these patients received extra
services, they did not have a better treatment out-
come. The longer hospital stay of these patients can
be explained by their higher age, which might be
accompanied by more comorbidities requiring more
intensive aftercare. Furthermore, patients with an
additional insurance tend to be more discerning and
are more likely to ask for a longer stay. Further stud-
ies are needed to determine whether these results
can be extrapolated to other medical facilities and
other countries. In the United States, for example,
where a different health insurance system exists,
patients with private insurance have been shown to
have lower risk-adjusted mortality rates than patients
in other payer groups (Spencer et al., 2013).
Regarding absenteeism, our patients had an aver-
age of 10 weeks’ sick leave after surgery, which is
2 weeks longer than reported by Hohendorff et al.
(2008), leading to high productivity losses. The rele-
vance of costs associated with absenteeism in
patients with hand and wrist injuries is substantiated
by data from the Netherlands, where these costs
were found to be higher than the healthcare costs (de
Putter et al., 2012). In our patients, the costs associ-
ated with presenteeism were considerably higher
than for absenteeism at all points in time, except
3 months after surgery when some patients were still
on sick leave. Higher loss of productivity while at
work than when absent from work has also been
shown in studies investigating employees with arthri-
tis (Goetzel et al., 2004; Ricci et al., 2005), patients
with knee OA, generalized OA (Bushmakin et al.,
2011; Dibonaventura et al., 2011; Hermans et al.,
2012), and patients with rheumatoid arthritis
(Bansback et al., 2012; Braakman-Jansen et al.,
2012). Goetzel et al. (2004) concluded that 77% of the
total costs for arthritis are attributable to presentee-
ism. This number is similar to the 88% we found in
our conservatively treated patients, but is considera-
bly higher than the 21% in our surgically treated
patients. In contrast to absenteeism, the quantifica-
tion of presenteeism remains a complex task (Brooks
Table 2. Average earnings of the clinic in Euros by treatment event and intervention group showing mean values and stan-
dard deviations.
Earnings
Surgery (n = 103) Injection (n = 58)
Preoperative consultation 178 (81)
Treatment 4966 (2028) 348 (189)b
Follow-up consultations 594 (301)
Complicationsa32 (221)
Total earnings 5770 (2089) 348 (189)
aMean calculated for all 103 surgical patients, three of whom actually had complications.
bIncludes follow-up consultations for patients treated with injection.
Table 3. Average clinic earnings in Euros, length of inpatient stay, age, and health status measured with the MHQ for
surgically treated patients (n = 103) with respect to insurance cover. Mean values and standard deviations are given. Values
p ⩽ 0.05 are shown in bold.
General insurance
(n = 42)
Semi-private
insurance (n = 34)
Private insurance
(n = 27)
p-value
Earnings from surgery 3031 (928) 5761 (1070) 6975 (1502) ⩽0.001
Length of inpatient stay (days) 1.7 (0.7) 2.1 (0.5) 2.1 (0.5) 0.012
Age (years) 61 (9.5) 65 (7.0) 66 (8.7) 0.032
MHQ total score baseline 45 (15) 48 (17) 51 (61) 0.223
MHQ total score 1 year 78 (16) 79 (17) 81 (16) 0.771
MHQ: Michigan Hand Questionnaire.
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6 The Journal of Hand Surgery (Eur)
et al., 2010). Several questionnaires for loss of pro-
ductivity are available, but there are no clear guide-
lines on which one to choose and the way to quantify
the economic burden (Beaton et al., 2010; Brooks
et al., 2010; Brown et al., 2014). Furthermore, it has
to be acknowledged that the costs of presenteeism
may be overestimated (Bansback et al., 2012).
This study has some limitations. The costs pre-
sented here are based on the earnings of our institu-
tion and do not necessarily reflect the true costs.
These values are therefore influenced by the number
of patients with an additional insurance and may be
lower for other institutions with fewer (semi-)private
patients. In addition, surgery in our clinic is usually
followed by an inpatient stay, which influences the
costs. In other institutions, surgery for TMC OA is
performed as day surgery leading to lower costs.
However, this variability in costs would not, in our
opinion, change the conclusions of this article.
Furthermore, on the basis of our data, we cannot
make any treatment recommendations, as the two
patient groups are not comparable regarding either
indication or outcome. We have, in fact, described the
outcomes of two different treatment strategies in two
groups of patients with different characteristics.
Making any direct comparison between the two inter-
ventions would be prone to confounding by indication.
Future studies, preferably with a randomized design,
Table 4. Absenteeism, presenteeism, overall productivity loss, and associated costs for 1 week for employed patients
(n = 58) during the study. Mean values and standard deviations are given; p-values are given for between-group and within-
group comparisons. Values p ⩽ 0.05 are shown in bold.
Surgery (n = 39
at baseline)
Injection (n = 19
at baseline)
p-value (between-group
comparison)
Absenteeism (%)
Baseline (n = 58) 7 (19) 3 (7) 0.421
3-month follow-up (n = 56) 43 (47) 6 (23) 0.002
6-month follow-up (n = 47) 8 (22) 1 (2) 0.226
1-year follow-up (n = 41) 2 (10) 4 (11) 0.560
p-value (within-group comparison) ⩽0.001 0.525
Costs of absenteeism per week (€)
Baseline 44 (108) 25 (55) 0.485
3-month follow-up 241 (296) 24 (81) 0.003
6-month follow-up 55 (165) 4 (18) 0.262
1-year follow-up 12 (47) 19 (49) 0.688
p-value (within-group comparison) ⩽0.001 0.815
Presenteeism (%)
Baseline 45 (28) 50 (24) 0.544
3-month follow-up 24 (29) 33 (22) 0.284
6-month follow-up 28 (24) 40 (27) 0.151
1-year follow-up 24 (21) 46 (23) 0.006
p-value (within-group comparison) ⩽0.001 0.003
Costs of presenteeism (€) per week
Baseline 268 (202) 307 (204) 0.492
3-month follow-up 134 (166) 177 (175) 0.369
6-month follow-up 146 (112) 232 (184) 0.055
1-year follow-up 150 (153) 205 (191) 0.339
p-value (within-group comparison) ⩽0.001 0.010
Overall work productivity loss (%)
Baseline 50 (29) 52 (23) 0.742
3-month follow-up 64 (37) 38 (26) 0.010
6-month follow-up 33 (28) 40 (27) 0.403
1-year follow-up 25 (23) 48 (23) 0.007
p-value (within-group comparison) ⩽0.001 0.051
Costs of overall work productivity loss (€) per week
Baseline 311 (224) 332 (201) 0.736
3-month follow-up 375 (263) 201 (176) 0.012
6-month follow-up 202 (194) 237 (187) 0.565
1-year follow-up 162 (168) 224 (211) 0.330
p-value (within-group comparison) ⩽0.001 0.025
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Marks et al. 7
should focus on the cost-utility analysis of compara-
ble interventions in order to provide treatment rec-
ommendations, bearing in mind the costs (Higgins
and Harris, 2012; Krummenauer and Landwehr,
2005). Missing values for absenteeism and presen-
teeism forced us to impute these data, so that the
results are more of an approximation than actual
figures. Our data regarding costs due to loss of pro-
ductivity should be extrapolated carefully. The mon-
etary values are strongly dependent on the income,
contractual weekly working hours, and ratio of the
employed to non-working patients in the study
population.
In summary, we can conclude that both estimated
annual healthcare and productivity costs were con-
siderably higher in the surgical group, where both
types of costs almost equally contributed to the total
costs. In contrast, in patients treated with injection,
most of the total annual costs are attributable to loss
of productivity. This highlights the need for assessing
productivity costs in patients with hand disorders in
order to get a comprehensive view of the costs asso-
ciated with a treatment.
Acknowledgements
We would like to thank Dr Meryl Clarke for her support in
preparing the manuscript, PD Dr Jörg Goldhahn for his sci-
entific input in the study planning, Dr Stephan Schindele,
Dr Sebastian Kluge, and Dr Lisa Reissner for their contri-
butions to patient recruitment, and Stefanie Hensler,
Franziska Kohler, and Tobias Pressler for their assistance
in data collection.
Conflict of interests
None declared.
Ethical approval
The research protocol was approved by the local ethical com-
mittee (Kantonale Ethikkommission Zurich, Switzerland).
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit
sectors.
References
Bansback N, Zhang W, Walsh D et al. Factors associated
with absenteeism, presenteeism and activity impair-
ment in patients in the first years of RA. Rheumatol
(Oxford). 2012, 51: 375–84.
Beaton DE, Tang K, Gignac MA et al. Reliability, validity, and
responsiveness of five at-work productivity measures
in patients with rheumatoid arthritis or osteoarthritis.
Arthritis Care Res (Hoboken). 2010, 62: 28–37.
Braakman-Jansen LM, Taal E, Kuper IH, van de Laar MA.
Productivity loss due to absenteeism and presenteeism
by different instruments in patients with RA and sub-
jects without RA. Rheumatol (Oxford). 2012, 51: 354–61.
Brooks A, Hagen SE, Sathyanarayanan S, Schultz AB,
Edington DW. Presenteeism: critical issues. J Occup
Environ Med. 2010, 52: 1055–67.
Brown HE, Burton N, Gilson ND, Brown W. Measuring
presenteeism: which questionnaire to use in physical
activity research? J Phys Act Health. 2014, 11: 241–8.
Bushmakin AG, Cappelleri JC, Taylor-Stokes G et al.
Relationship between patient-reported disease sever-
ity and other clinical outcomes in osteoarthritis: a
European perspective. J Med Econ. 2011, 14: 381–9.
Chen NC, Shauver MJ, Chung KC. Cost-effectiveness of
open partial fasciectomy, needle aponeurotomy, and
collagenase injection for dupuytren contracture. J Hand
Surg Am. 2011, 36: 1826–34.
Chung KC, Pillsbury MS, Walters MR, Hayward RA. Reliability
and validity testing of the Michigan Hand Outcomes
Questionnaire. J Hand Surg Am. 1998, 23: 575–87.
de Putter CE, Selles RW, Polinder S, Panneman MJ, Hovius
SE, van Beeck EF. Economic impact of hand and wrist
injuries: health-care costs and productivity costs in a
population-based study. J Bone Joint Surg Am. 2012,
94: e56.
Dibonaventura M, Gupta S, McDonald M, Sadosky A.
Evaluating the health and economic impact of osteoar-
thritis pain in the workforce: results from the National
Health and Wellness Survey. BMC Musculoskelet
Disord. 2011, 12: 83.
Epping W, Noack G. [Surgical treatment of the saddle joint
arthrosis]. Handchir Mikrochir Plast Chir. 1983, 15:
168–76.
Goetzel RZ, Long SR, Ozminkowski RJ, Hawkins K, Wang S,
Lynch W. Health, absence, disability, and presenteeism
cost estimates of certain physical and mental health
conditions affecting U.S. employers. J Occupat Environ
Med. 2004, 46: 398–412.
Table 5. Estimated average annual costs (€) for surgery and steroid injection for all patients (n = 161). For non-working
patients, the productivity costs were set at €0.
Surgery (n = 103) Injection (n = 58) p-value
Healthcare costs (% of total costs) 5770 (51%) 348 (9%) ⩽0.001
Loss of productivity costs
Absenteeism (% of total costs) 3220 (28%) 122 (3%) ⩽0.001
Presenteeism (% of total costs) 2328 (21%) 3381 (88%) 0.269
Total annual costs 11,318 3851 ⩽0.001
at Aerzte-Bibliothek on February 2, 2015jhs.sagepub.comDownloaded from

8 The Journal of Hand Surgery (Eur)
Gosselin E, Lemyre L, Corneil W. Presenteeism and absen-
teeism: differentiated understanding of related phe-
nomena. J Occupat Health Psychol. 2013, 18: 75–86.
Heller H. Ferienlohn und andere Ansprüche –
Berechnungsformeln im Arbeitsrecht. HR Today. 2010,
9: 39.
Hermans J, Koopmanschap MA, Bierma-Zeinstra SM et al.
Productivity costs and medical costs among working
patients with knee osteoarthritis. Arthritis Care Res
(Hoboken). 2012, 64: 853–61.
Higgins AM, Harris AH. Health economic methods: cost-
minimization, cost-effectiveness, cost-utility, and cost-
benefit evaluations. Critical Care Clin. 2012, 28: 11–24.
Hill S, Dziedzic KS, Ong BN. The functional and psychologi-
cal impact of hand osteoarthritis. Chronic Illness. 2010,
6: 101–10.
Hohendorff B, Staub L, Kaiser T, von WU. [Working abil-
ity after tendon interposition arthroplasty for degen-
erative arthritis of the thumb trapeziometacarpal joint].
Handchir Mikrochir Plast Chir. 2008, 40: 175–81.
Kerrigan CL, Stanwix MG. Using evidence to minimize the
cost of trigger finger care. J Hand Surg Am. 2009, 34:
997–1005.
Knobloch K, Kuehn M, Papst S, Kraemer R, Vogt PM.
German standardized translation of the michigan hand
outcomes questionnaire for patient-related outcome
measurement in dupuytren disease. Plast Reconstr
Surg. 2011, 128: 39e–40e.
Krummenauer F, Landwehr I. Incremental cost effective-
ness evaluation in clinical research. Eur J Med Res.
2005, 10: 18–22.
Ljungberg EM, Carlsson KS, Dahlin LB. Cost per case or
total cost? The potential of prevention of hand injuries in
young children – retrospective and prospective studies.
BMC Pediatrics. 2008, 8: 28.
Lofland JH, Pizzi L, Frick KD. A review of health-
related workplace productivity loss instruments.
Pharmacoeconomics. 2004, 22: 165–84.
Macaulay D, Ivanova J, Birnbaum H, Sorg R, Skodny P.
Direct and indirect costs associated with Dupuytren’s
contracture. J Med Econ. 2011, 15: 1–8.
Marks M, Audige L, Herren DB, Schindele S, Nelissen RG,
Vliet Vlieland TP. Measurement properties of the ger-
man michigan hand outcomes questionnaire in patients
with trapeziometacarpal osteoarthritis. Arthritis Care
Res (Hoboken). 2014, 66: 245–52.
Organisation for Economic Co-operation and Development
(OECD). StatExtracts: purchasing power parities and
exchange rates 2012. http://stats.oecd.org/index.
aspx?datasetcode=sna_table4 (accessed 20 December
2013).
Prasad M, Wahlqvist P, Shikiar R, Shih YC. A review of self-
report instruments measuring health-related work
productivity: a patient-reported outcomes perspective.
Pharmacoeconomics. 2004, 22: 225–44.
Reilly M. Work Productivity and Activity Impairment
Questionnaire (WPAI). http://www.reillyassociates.net/
Index.html (accessed 20 December 2013).
Reilly MC, Zbrozek AS, Dukes EM. The validity and repro-
ducibility of a work productivity and activity impairment
instrument. Pharmacoeconomics. 1993, 4: 353–65.
Ricci JA, Stewart WF, Chee E, Leotta C, Foley K, Hochberg
MC. Pain exacerbation as a major source of lost produc-
tive time in US workers with arthritis. Arthritis Rheum.
2005, 53: 673–81.
Schultz AB, Chen CY, Edington DW. The cost and impact
of health conditions on presenteeism to employers: a
review of the literature. Pharmacoeconomics. 2009, 27:
365–78.
Schweizerische Eidgenossenschaft, Eidgenössisches
Departement des Innern, Bundesamt für Statistik.
Schweizer Lohnstrukturerhebung. 2010.
Sigfusson R, Lundborg G. Abductor pollicis longus tendon
arthroplasty for treatment of arthrosis in the first car-
pometacarpal joint. Scand J Plast Reconstr Surg Hand
Surg. 1991, 25: 73–7.
Spencer CS, Gaskin DJ, Roberts ET. The quality of care
delivered to patients within the same hospital varies
by insurance type. Health Aff (Millwood). 2013, 32:
1731–9.
van den Hout WB. The value of productivity: human-capital
versus friction-cost method. Ann Rheum Dis. 2010, 69
Suppl 1: i89–91.
Webb JA, Stothard J. Cost minimisation using clinic-based
treatment for common hand conditions-a prospec-
tive economic analysis. Ann R Coll Surg Engl. 2009, 91:
135–9.
Weilby A. Tendon interposition arthroplasty of the first
carpo-metacarpal joint. J Hand Surg Br. 1988, 13:
421–5.
Widera E, Chang A, Chen HL. Presenteeism: a public health
hazard. J Gen Intern Med. 2010, 25: 1244–7.
at Aerzte-Bibliothek on February 2, 2015jhs.sagepub.comDownloaded from