The greatest productivity loss from allergic rhinitis comes not from employees taking sick days but from reduced performance among those who come to work.

By Shelly Reese

Shelly Reese is a freelance writer based in Cincinnati, Ohio.

In spite of the sniffling and sneezing and itchy, watery eyes, most employees suffering from allergies manage to drag themselves into work. Their condition, allergic rhinoconjunctivitis (hay fever), is neither life threatening nor usually requires expensive visits to the emergency room. And this condition—which affects up to 40 million Americans—doesn't come with a big price tag from absenteeism, right?¹

That type of quick dismissal may be costing employers a lot. They would not be so swift to write off allergic rhinitis as "just a little hay fever" if they sat down with their spreadsheets and crunched a few numbers. In March, the Task Force on Allergic Disorders (representing 21 major health care organizations including the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology), issued The Allergy Report, which stated that more than 50 million Americans suffer from allergic diseases.¹ Allergic rhinitis, the most common of them, is associated with direct costs of about $4.5 billion annually. In addition, others have estimated that lost productivity due to symptoms of allergic rhinitis and some treatments costs the U.S. an additional $4 billion each year.²

As the saying goes, "a billion here, a billion there, and pretty soon you're talking about real money." Indeed, the costs of allergic rhinitis translate to a financial burden that's nothing to sneeze at.

Absenteeism: The tip of the iceberg

When it comes to assessing the impact of medical conditions in the workplace, many employers start by looking at absenteeism. The Allergy Report estimates that allergic rhinitis accounts for 3.8 million days of lost time at work and school each year.¹

Although staggering in itself, that number belies the true nature of the problem. Absenteeism only skims the surface of allergies' effects on the workforce, says Camille Haltom, a consultant with Hewitt Associates in Lincolnshire, Ill.; the real measure of its costs must also account for the condition's effect on employees who report to work despite their ailment. Haltom estimates the effects of reduced productivity as a result of such "presenteeism" to be seven to 10 times greater than the cost of productivity lost due to absenteeism.

To underscore her point, she highlights a recent Hewitt survey, Effects of Allergies in the Workplace (1998), of more than 5,000 workers, about 90 percent of whom suffer from allergies. On average, respondents reported experiencing symptoms about 69 days a year and missing work 1.7 days per year because of their condition. More than eight out of 10 allergy sufferers interviewed said they were less productive—on average, 26 percent less productive—when suffering from symptoms.

Results collected so far in an ongoing study of seasonal and chronic allergies by the Employer Health Coalition Inc. in Tampa, Fla., are even more unnerving. In Florida, where seasonal allergies can flare for seven months out of the year, the 6,215 allergy sufferers responding to the survey said they estimated a loss of an additional 3.3 days per four-week period—or nearly 42 workdays per year—due to impairment on the job as a result of their symptoms or the sedation associated with medication. Given that 28 percent of the survey's respondents suffer from allergies, that sums up to an exorbitant loss.

In fact, for every 1,000 workers earning an average of $15 per hour, allergies account for more than $1.4 million in lost productivity annually, says Frank Brocato, president and CEO of the coalition, which includes 145 employers who provide health care benefits for some 350,000 workers. That amount is far greater than productivity loss associated with such conditions as hypertension, diabetes, heart disease and breast cancer, he says.

Brocato says many firms are surprised by such findings because their claims data don't identify allergies as a condition that drives people to visit their doctors. (Allergic rhinitis accounted for almost 7.8 million physician visits in 1997, according to the National Center for Health Statistics.³) Like absenteeism, claims data can be deceiving.

Allergy sufferers often treat themselves with over-the-counter medications rather than visiting a doctor. Although estimates vary, one study found that 50 percent of allergic rhinitis patients rely on OTC medications that contain older antihistamines known to produce drowsiness and impair cognitive and motor functions.² Even among those who do visit their physician, many often do so primarily for another condition and have their allergies treated as a secondary concern. Consequently, treatment for allergies doesn't always show up on claims data.

Cost and effect

Clinical studies have reinforced such surveys. A recent study by Stan Finkelstein, MD, a senior research scientist at the Massachusetts Institute of Technology's Sloan School of Management and co-director of the Program on the Pharmaceutical Industry, demonstrates just how the productivity losses play out in the real world.

Allergy sufferers seeking relief generally choose from two options, says Finkelstein: sedating antihistamines that cost between $1 and $1.50 per day and more expensive, non-sedating prescription drugs that generally cost $2.50 to $3 per day.

To determine whether there's a cost-benefit for choosing the more expensive, nonsedating prescription drugs, Finkelstein and his colleagues studied the work output of 682 claims processors at a large insurance company.⁴ The study compared the employees' output in the three days immediately after they filled a prescription for either a sedating or a nonsedating antihistamine with their average output of roughly 185 claims per day per employee. Researchers found the overall productivity of employees taking sedating antihistamines dropped 7.8 percent. Conversely, those on nonsedating antihistamines actually experienced a slight increase in productivity (5.2 percent), which Finkelstein says may be attributed to improved concentration ability as symptoms were alleviated. That represents a productivity differential of 13 percent between the sedating and nonsedating drugs. In dollar amounts, the difference is about $9 per day.

Although the study considered only the number of claims processed—rather than their accuracy—as a measure of impairment, allergies, if untreated, may affect workers' accuracy. Another study⁵ compared a control group and a group of allergic individuals who were not treating their symptoms. Both groups took three different tests. The researchers found that reaction and decision-making times slowed and verbal learning skills suffered among untreated allergic individuals during allergy season.

Pulling it together

Based on evidence of allergic rhinitis' effects on job performance, the MEDSTAT Group, an Ann Arbor, Mich.-based health care consulting firm, created a hypothetical firm model to demonstrate where a typical employer would most likely experience allergy-related costs. MEDSTAT estimated that nearly 70 percent of the costs would be a consequence of drowsiness associated with the use of sedating antihistamines. Only 15 percent of costs were attributable to the effects of symptoms on productivity and 14 percent of costs were due to expenditures for physician visits and nonsedating prescription antihistamines.

Jodi Peters, a manager of MEDSTAT's outcomes research group, estimates that between 30 and 35 percent of allergic rhinitis sufferers treat themselves with sedating antihistamines, "yet they make up nearly 70 percent of the costs for the group." The smallest cost sector—short-term disability and workers' compensation costs—in the MEDSTAT analysis is by no means the least important. Although allergic rhinitis' contribution to such claims represent less than one half of one percent of the condition's costs, it points to a very real threat to employee well-being.

In addition, on-the-job drowsiness associated with sedating drugs has significant safety implications. In analyzing pharmacy and computerized patient records at a large HMO, a group of Seattle researchers tracked the recent and current medication use of nearly 3,400 workers diagnosed with work-related injuries and compared them to control groups matched for age and gender.⁶

Their findings: Employees taking sedating antihistamines were about 1.5 times more likely to suffer an injury than their co-workers.⁶ More specifically, those taking a sedating antihistamine were 1.5 times more likely to suffer an open wound or a contusion, 1.7 times more likely to sustain a fracture and 3.1 times more likely to suffer a burn.⁶ Similar associations between work-related injuries and the use of antidepressants, anti-anxiety medications or narcotics were not found.

Another cost factor associated with allergic rhinitis is that it can't be considered in isolation. Allergic rhinitis goes hand in hand with other conditions, making it a harbinger of greater potential expenses to come. For example, it may exacerbate sinusitis and asthma. One investigation found that 43 percent of rhinitis sufferers studied also had sinusitis and 23 percent were diagnosed with asthma at some point in the past.⁷ Both conditions are costly: According to the Task Force, sinusitis affects more than 14 percent of the U.S. population each year and causes over 58.7 million annual restricted-activity days.¹ Similarly, they estimate that 15 million Americans suffer from asthma and that direct medical care costs for treating the condition are expected to run as high as $14.5 billion this year.¹

"There's no question that these are co-morbid conditions," Brocato says. "The key is to take a look at each one of them individually with the understanding that, in addressing them, you are going to have some domino effect." By reducing the costs associated with allergic rhinitis, employers are likely to enjoy additional reductions in costs from related conditions.

"What we've found is that people who were treated for their allergic rhinitis had fewer asthma-related emergency room visits and fewer asthma-related hospitalizations," Peters says.

Employer proactivity

To get employers to better focus their resources, the Florida coalition has launched a four-year study to assess the cost of individual medical conditions like allergic rhinitis.

Affixing a productivity cost to a condition, Brocato says, "gets people's attention and says there's a lot more left on the table than just direct medical costs." Armed with such data, medical directors, benefits execs and other managers can make a stronger case for implementing health care initiatives and measuring their impact. He adds, "They can bring the financial people that govern the budget dollars more tangible evidence that it's worth spending a little more to get a better outcome and a healthier employee."

Once they capture those costs, the Tampa group hopes to propose interventions and track the return on investment achieved by employers who implement them over the next two years. Although the coalition hasn't yet identified initiatives regarding allergic rhinitis, Hewitt's Haltom says employers can begin to address the problem by investigating the causes of allergic reactions in their industry or geographic area.

"They can educate themselves about allergy triggers and what they can do to control or reduce them," she says. Employers also need to understand when seasonal allergies are likely to affect workers, especially when they are operating heavy machinery or working outdoors. Employers also need to ensure their policies regarding sedating medications are clear and comprehensive.

Only after increasing their awareness can employers assess whether their health plans are taking the most effective steps to reduce allergy-related productivity losses, says Haltom. Savvy employers can then direct workers to helpful Internet sites and distribute educational literature about allergic rhinitis and its non-sedating treatment options. That type of education, she says, has the potential to bear a quick return on investment.

References

1. The Allergy Report. American Academy of Allergy, Asthma and Immunology. Available at: http://TheAllergyReport.com. Accessed March 27, 2000.

2. Fireman P. Treatment of allergic rhinitis: effect on occupation productivity and work force costs. Allergy and Asthma Proceedings. 1997;18:63-67.

3. National Center for Health Statistics. 1997 Summary National Ambulatory Medical Care Survey (AD 305).

4. Cockburn IM, Bailit HL, Berndt ER, Finkelstein SN. Loss of work productivity due to illness and medical treatment. Journal of Occupational and Environmental Medicine. 1999;41:948-953.

5. Marshall PS, Colon EA. Effects of allergy season on mood and cognitive function. Annals of Allergy. 1993;71:251-258.

6. Gilmore TM, Alexander BH, Mueller BA, Rivara FP. Occupational injuries and medication use. American Journal of Industrial Medicine. 1996;30:234-239.

7. Storms W, Meltzer EO, Nathan RA, Selner JC. The economic impact of allergic rhinitis. Journal of Allergy and Clinical Immunology. 1997;99:S820-S824.

Allergic rhinitis and your workforce

Allergy's greatest costs to employers come from reduced worker productivity, often due to inadequate or inappropriate treatment of symptoms.

"Allergic rhinitis is certainly not a 'lifestyle' issue; it's a distinct, symptomatic—and costly—illness and it deserves a remedy."
William Schneider, MD
J.P. Morgan

"The major costs of allergic rhinitis arise from lost productivity among people who come to work suffering from symptoms. Absenteeism is not as much of an issue as lost productivity on the job."
Ron Goetzel
The MEDSTAT Group

"There are three levels of productivity loss. First is the decrease the allergic employee has without treatment of symptoms. Then, if you treat them with a sedating antihistamine, their productivity goes down even further. With the use of a nonsedating antihistamine, productivity improves."
George Anstadt, MD
Eastman Kodak Company

"Two thirds of the people for whom we provide benefits do not work for us; they're retirees, dependents or spouses. We therefore have to make some tremendous productivity gains from the other one third to cover the cost of treating the total covered population."
Jim Astuto
GTE Corporation

"If you have educated patients, they're going to be more compliant, more informed, and their outcomes are going to be much better."
Emil J. Bardana, Jr., MD
Oregon Health Sciences University