New study: Downsizing is a health risk
A recent study has found a significant association between downsizing and medically certified sick leave among employees, with the risk varying according to factors such as age, workplace size, worker health, and socioeconomic status.1
Finnish researchers used employers’ occupational health records to investigate the relationship between downsizing and subsequent absenteeism due to ill health in 981 local government workers who were employed in southwestern Finland during a period of economic decline (1991-1995). Data were separated into three time periods: 1991, before downsizing; 1993, major downsizing in some workplaces and occupations; and 1993-1995, after downsizing.
The researchers’ analysis also included whether the effects of downsizing were dependent on 10 other predictors of sick leave.
They found that absenteeism rates were 2.3 times greater after major downsizing than after minor downsizing. Effects of downsizing by workplace depended on the age distribution of employees. When the proportion of employees who were older than 50 years was high, downsizing increased the individual risk of absence because of ill health by 3.2 to 14 times, depending on diagnostic category. When the proportion of employees over 50 years was low, downsizing had only slight effects on health.
Other risk factors that increased rates of sick leave after downsizing were age over 44 years, a large workplace, poor health before downsizing, and high income.
Reference
1. Vahtera J, Kivimaki M, Pentti J. Effect of organisational downsizing on health of employees. Lancet 1997; 350:1124-1128.
Smith S, Weber S, Wiblin T, et al. Cost-effectiveness of hepatitis A vaccination in healthcare workers. Infect Control Hosp Epidemiol 1997; 18:688-691.
Because health care workers are at risk of exposure to patients with infectious hepatitis A, prevention is a potentially important employee health issue. However, large-scale studies of seropositivity rates among HCWs have not been performed. While a vaccine is available, the Centers for Disease Control and Prevention does not recommend its routine use for HCWs. The authors of this study evaluated the cost-effectiveness of immunizing medical students with hepatitis A vaccine and of pre-vaccination serologic screening. They also assessed the threshold incidence rate of HAV above which vaccination would result in a net cost savings.
Costs and outcomes were calculated for 66,629 students in medical schools in 1994. Data from the University of Iowa Hospitals and Clinics in Iowa City were used to determine costs. The vaccine cost of $40 per dose ($80 for the two-dose series) was based on hospital acquisition costs. Cost per case of hepatitis A among HCWs was estimated to be $8,123, including total outpatient costs (three clinic visits and three sets of liver function tests) and inpatient costs (assuming that 20% of infected people are hospitalized and using a mean hospitalization cost of $1,450 for University of Iowa HCWs who contracted HAV). The monetary cost of one month’s sick leave, determined by multiplying time off work by the average salary assessed over the individual’s lifetime, was included as well.
The risk of hepatitis A in medical students and physicians is not known, but for the study the incidence was assumed to be nine cases per 100,000. The researchers assumed that 10% of the medical students would have had previous HAV infection. The model calculated the total cost, total number of lives saved, and total number of cases prevented, assuming total compliance with vaccine having an efficacy rate of 94%. It was assumed that a booster dose would be given at 20-year intervals.
Two major strategies were evaluated: (1) vaccinate all medical students, and (2) serotest all medical students and vaccinate those who are seronegative. The net cost of each strategy was assessed by comparing the cost of vaccination and serology to the savings. The savings due to averted cases were subtracted from the cost of each vaccination strategy to determine its net cost or benefit. Outcomes also were expressed as quality-adjusted life-years (QALY), assuming that the quality of a life-year during which a person contracted HAV was worth only 91.7% of a life-year in perfect health.
Study results showed that if no vaccine was offered, there would be 286 hepatitis A cases with four deaths and 107 life-years lost over the lifetimes of the medical students. With routine vaccination, the numbers would decrease to 17, 0.3, and six, respectively. Total cost for primary and booster vaccinations for all students would be $6.6 million. If students were serotested pre-vaccination, the total cost would rise to $10 million. When savings for averted cases were subtracted from the cost of vaccination, the net cost without serotesting was $5.8 million, or $88 per student.
If all students were vaccinated, the cost per case prevented was $22,000. If all students had serologic testing and only seronegative students were vaccinated, the cost per case prevented would be $34,000. For those two strategies, costs per life-year saved were $58,000 and $92,000, respectively. If the analysis focused on the costs per QALY saved, vaccination alone cost $47,000 per QALY saved vs. $75,000 if pre-vaccination serologic testing were done.
The researchers state that a key parameter is the incidence of nosocomial hepatitis A in medical students. If the incidence were underestimated by a factor of five, the cost per life-year saved would decrease to $5,500. If incidence were underestimated by a factor of 10, vaccination would result in a net cost savings. For vaccination to result in a net cost savings, the cost of a case of hepatitis A would have to exceed $110,000.
Routine vaccination of medical students against HAV would not result in a net cost savings if the risk of disease is correctly reflected by the rates reported for the general population; however, incidence in health care workers is unknown. But the authors suggest that incidence may be higher than their estimates.
Conversely, if the risk to HCWs is lower than they assumed, vaccination would be even less cost-effective. They note that results of their analysis could be applied to other hospital HCWs who have direct patient contact, such as nurses, aides, and housekeepers. Cost per year of life saved is similar to many other medical interventions, they point out, but less favorable than for other vaccines.
"At this time, routine vaccination of healthcare workers cannot be recommended on a cost basis alone," they conclude. "More studies are needed to determine if the incidence of hepatitis A in healthcare workers warrants vaccination."
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