Measuring Worker Productivity: Frameworks and

Measures
DORCAS BEATON, CLAIRE BOMBARDIER, REUBEN ESCORPIZO, WEI ZHANG, DIANE LACAILLE,
ANNELIES BOONEN, RICHARD H. OSBORNE, ASLAM H. ANIS, C. VIBEKE STRAND, and PETER S. TUGWELL

ABSTRACT. Worker productivity is a combination of time off work (absenteeism) due to an illness and time at
work but with reduced levels of productivity while at work (also known as presenteeism). Both can
be gathered with a focus on application as a cost indicator and/or as an outcome state for interven-
tion studies. We review the OMERACT worker productivity groups’ progress in evaluating measures
of worker productivity for use in arthritis using the OMERACT filter. Attendees at OMERACT 9
strongly endorsed the importance of work as an outcome in arthritis. Consensus was reached (94%
endorsement) for fielding a broader array of indicators of absenteeism. Twenty-one measures of
at-work productivity loss, ranging from single item indicators to multidimensional scales, were
reviewed for measurement properties. No set of at-work productivity measures was endorsed
because of variability in the concepts captured, and the need for a better framework for the meas-
urement of worker productivity that also incorporates contextual issues such as job demands and
other paid and unpaid life responsibilities. Progress has been made in this area, revealing an ambiva-
lent set of results that directed us back to the need to further define and then contextualize the meas-
urement of worker productivity. (J Rheumatol 2009;36:2100–9; doi:10.3899/jrheum.090366)

Key Indexing Terms:

ABSENTEEISM OUTCOMES PRESENTEEISM
RHEUMATOID ARTHRITIS WORK PRODUCTIVITY

Arthritis is recognized to be a leading cause of pain and dis- still working is less well described and is inconsistently
ability and, more recently, as placing people at increased measured. At OMERACT 7 the psoriatic arthritis group
risk of work loss. The impact of arthritis on those who are voted work role participation as a desired outcome, but one

From the Mobility Program Clinical Research Unit, St Michael’s Hospital Therapy, University of Toronto; C. Bombardier, MD, FRCPC, Professor
and the Institute for Work and Health, University of Toronto; the Division of Medicine and Rheumatology Division Director, Division of
of Clinical Decision Making and Health Care, Toronto General Research Rheumatology and Department of Health Policy, Management, and
Institute and the University Health Network, Toronto, Canada; the Evaluation, University of Toronto; Division of Clinical Decision Making
Department of Physical Therapy, Leesburg Regional Medical Center, and Health Care, Toronto General Research Institute, University Health
Leesburg, Florida, USA; Des Moines University, College of Health Network; Co-Scientific Director, Canada Arthritis Network; Senior
Sciences, Des Moines, Iowa, USA; School of Population and Public Scientist, Institute for Work and Health and Toronto General University
Health, University of British Columbia; Centre for Health Evaluation and Health Network; Rheumatologist, Mount Sinai Hospital; R. Escorpizio,
Outcome Sciences, St. Paul’s Hospital, Vancouver, Canada; Division of PT, MSc, DPT, ICF Research Branch, WHO Collaborating Centre,
Rheumatology, University of British Columbia; and the Arthritis Research Nottwill, Switzerland; W. Zhang, MA, PhD Student, School of Population
Centre of Canada, Vancouver, Canada; Department of Rheumatology, and Public Health, University of British Columbia, and Centre for Health
Maastricht University Medical Center, and Caphri Research Institute, Evaluation and Outcome Sciences, St. Paul’s Hospital; D. Lacaille, MD,
Maastricht; Centre for Rheumatic Diseases, The Royal Melbourne MHSc, FRCPC, Assistant Professor, Division of Rheumatology, University
Hospital, Department of Medicine, University of Melbourne, Melbourne, of British Columbia; Research Scientist, Arthritis Research Centre of
Australia; Division of Immunology and Rheumatology, Stanford Canada; A. Boonen, MD, PhD, Assistant Professor of Rheumatology,
University School of Medicine, Palo Alto, California, USA; and Department of Rheumatology, Maastricht University Medical Center, and
Epidemiology and Community Medicine, University of Ottawa, Ottawa, Caphri Research Institute; R.H. Osborne, PhD, Associate Professor,
Canada. Centre for Rheumatic Diseases, The Royal Melbourne Hospital,
Supported by the Canadian Arthritis Network and The Arthritis Society. Department of Medicine, University of Melbourne; A.H. Anis, PhD,
C. Bombardier holds a Canada Research Chair in Knowledge Transfer for Professor, School of Population and Public Health, University of British
Musculoskeletal Care. W. Zhang is funded by a Canadian Arthritis Columbia; Director, Centre for Health Evaluation and Outcomes
Network Graduate Training Award. D. Lacaille is supported by an Sciences, Providence Health Care; C.V. Strand, MD, FACP, FACR,
Investigator Award from The Arthritis Society of Canada and is the Nancy Adjunct Clinical Professor, Division of Immunology and Rheumatology,
and Peter Paul Saunders Scholar. R. Osborne is supported in part by a Stanford University School of Medicine; P.S. Tugwell, MD, Professor,
National Health and Medical Research Council Population Health Career Medicine, Epidemiology & Community Medicine, University of Ottawa;
Development Fellowship. Director, Centre for Global Health, Institute of Population Health,
D. Beaton, BSc, OT, PhD, Scientist and Director, Mobility Program University of Ottawa; and Rheumatologist, Ottawa Hospital.
Clinical Research Unit, St Michael’s Hospital; Scientist, Institute for Work Address correspondence to D. Beaton, St. Michael’s Hospital,
and Health; Associate Professor, Graduate Department of Health Policy, 30 Bond St, Toronto, ON, Canada, M5B 1W8.
Management, and Evaluation, Graduate Department of Rehabilitation E-mail: [email protected]
Science and Department of Occupational Science and Occupational

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2100 The Journal of Rheumatology 2009; 36:9; doi:10.3899/jrheum.090366

that required more research to find a measure that passes the Combining perspectives and the focus of the measurement
OMERACT filter1. At OMERACT 8 we introduced a group (absenteeism or presenteeism), we can see that the measure-
taking up this challenge2, and in this article we report our ment of worker productivity can span 4 quadrants or
ongoing work with measures of absenteeism and at-work domains (see Figure 1).
productivity loss presented at OMERACT 9. We describe a
conceptual framework that helps us understand the dynamic RELATIONSHIP BETWEEN HEALTH STATUS AND
nature of the impact of arthritis on work, a review of exist- WORKER PRODUCTIVITY
ing measures, the outcomes of OMERACT 9, and the direc- The productivity loss experienced by a worker is highly con-
tions we are suggesting for future research. textualized. It is a person–environment state where the
demands of a given job (physical, social, psychological
CONCEPTUAL FRAMEWORK FOR MEASURING aspects) are weighed against the capacity of the person in
WORKER PRODUCTIVITY that job. The relationship between worker health/ability and
Work productivity, in its simplest definition, is the output productivity loss is not a direct, linear one where more pain
per unit of input, for example production output per labor and disability will lead to a direct, predictable change in pro-
hours. At a workplace level, work productivity is influenced ductivity levels. It is one in which the person is trying to
by many factors (e.g., technology, market forces) including adapt, and modifications may be made to the job (environ-
the input of the individual worker — worker productivity. ment) to enable a return to work or to avoid work
The measurement of individual worker productivity is of absence/difficulties. This can also vary with disease activity
interest from several perspectives. For a society or an indus- over time.
try, worker productivity is one of many factors that con- We have modified a model of Brouwer, et al8 to demon-
tribute to indicators of the success of the workplace or the strate a possible course of worker productivity over time and
well being of that business or society. In the field of health how this course would translate into a set of outcomes (see
economics, the loss of worker productivity due to an illness Figure 2). This model helps demonstrate not only the con-
is counted in the indirect costs of the analysis3,4. Models for tinuum of absenteeism and presenteeism, but also the con-
health economics vary and are beyond the scope of this arti- textual factors that must be considered.
cle, but one approach, that of human capital, directly links In Figure 2 the vertical axis describes the health state and
the worker’s productivity loss with a cost. Hence, changes abilities the worker needs to put into the job. Along this axis
in labor input, i.e., the number of work days lost due to ill- are 2 thresholds, Q1 and Q2, which are job dependent
ness, are translated directly to lost productivity using market thresholds of the amount of worker ability needed to be able
wage rates. The final perspective is at an individual work- to complete the job without any loss in productivity (Q1)
er/patient level, where there is interest in measuring individ- and the level of worker health/ability below which he/she is
ual worker productivity in order to describe the impact of a unable to be at work doing this job (Q2). Between Q1 and
condition on ability to work, or the effects of an intervention Q2, the individual is working, but with some difficulty or
such as work station changes on the ability of a person to some loss in productivity. Q1 and Q2 will vary between jobs
work productively. In this way worker productivity is meas- — heavy versus light work will have different thresholds for
ured as an outcome state. Loss of either type of productivi- the level of health where the individual simply cannot per-
ty (cost or ability/difficulty) has often been quantified by form the job tasks. The thresholds can also vary with job
days absent from work (absenteeism). Equally important are accommodations (modified duties for example). Efforts to
the difficulties experienced on the job, where the person is lower the job demands would allow an individual at the
working but perhaps with some difficulty or inefficiency, same level of health to stay on the job. The horizontal axis
referred to as at-work productivity loss or at-work disabili- depicts “time” and, as shown in this hypothetical example,
ty. It is also known in the literature as “presenteeism”5-7. an episode of illness may lead to absence from work and

Figure 1. Two-by-two table depicting the 4 subcomponents of worker productivity, defined by the perspective and
the component of worker productivity considered.

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Beaton, et al: Worker productivity outcome measure 2101

 Figure 2. Model of an individual’s health state and impact on their (worker) productivity over time, from
Brouwer, et al8: (Pharmacoeconomics 2005;23:209-18, adapted with permission). The vertical axis
depicts a level of functioning and health, or quality of life (“Health Status”). Q1 and Q2 are defined by
the job. Q1 is the first intersection with job demands, defined as the threshold above which the loss of
health does not affect functioning on the job. Q2 defines a threshold below which the individual is not able
to work. Between Q1 and Q2 lies the range of at-work productivity loss (presenteeism), where the indi-
vidual is at work, but is unable to be as productive as the job demands.

at-work productivity loss (presenteeism) on one occasion, whereas another may choose to be absent from work in
but the next time may lead to only a loss in at-work produc- order to maintain the energy needed for parenting, care-
tivity. This flexibility is important in describing arthritis, a giving, or other responsibilities at home or in the communi-
condition that will likely have an ongoing episodic course. ty. There might be an absence of volition. An individual may
Through our OMERACT experience, we have found that not be able to leave the work force or take time off because
it is also important to begin defining the contextual factors of economic needs (family income, access to work-related
that influence worker productivity4. The International benefits).
Classification of Functioning, Disability, and Health (ICF)9 This model demonstrates that absenteeism and presen-
classifies contextual factors in 2 broad domains — person teeism are more about a balance of job demands, health
and environmental factors. Badley defines them more specif- state, and contextual factors. In an effort to measure worker
ically into those that are “scene setters”10 — defining the productivity, one must consider the individual with arthritis
nature of the job, or the features of the person that precede and their individual course over time, with all the complex-
the illness episode. Equipment, methods used to do the job ities of the contextual factors around work. We have used the
tasks, hours of work, proximity to transportation, as well as ICF9 to help define the core and contextual variables to be
the age, gender, and height of the worker are “scene setters.” measured. The ICF also reminds us of secondary causes of
Badley also defines “barriers”10 (or enablers) as a second disability: a limitation in work ability may cause decondi-
group of contextual factors. These are potentially more mod- tioning, which might lead to further problems at the point of
ifiable and could include the ability to accommodate the dis- return to work; or work loss could cause stress and have
ease flare, ability to share work or modify duties, access to secondary effects on an individual’s psychosocial well
benefits, supervisory support and support for at-home roles. being. Considering all these factors, as our next task we
Gignac, et al have reported examples of adaptations made by reviewed the measures currently available.
people with arthritis in order to stay at work11.
In addition to the above, one must consider the work–life MEASURES OF WORKER PRODUCTIVITY
balance that individuals with arthritis must manage. Badley At OMERACT 8 we reviewed the available measures of
suggests the term “volition”10 to reflect that there are often presenteeism and absenteeism2. There were over 16 differ-
choices made by individuals with arthritis about their abili- ent scales that captured presenteeism. Only 11 had been
ty to work. Balancing the demands of activities of daily used in arthritis or other musculoskeletal disorders. There
work (ADW) and activities of daily living (ADL), one indi- were also several different states described under “absen-
vidual may need to work in order to maintain a sense of self, teeism” — temporary, short term or permanent disability

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2102 The Journal of Rheumatology 2009; 36:9; doi:10.3899/jrheum.090366

and off work but looking for employment. We conducted validity and responsiveness of the WPS-RA, Osterhaus, et al
reviews and, although we found evidence for the feasibility reported a single item standardized response mean of 1.10
of many of these different scales, there was much less or no for the interference scale to change of American College of
evidence for truth or discriminative features2. For OMER- Rheumatology response criteria (ACR-20) responders over
ACT 9, three activities were conducted: (1) A pre-OMER- non-responders13. The WPS-RA was also found to discrim-
ACT survey of attendees to obtain background perspectives; inate between combination therapy (Certilozumab Pegol
(2) a review of the available literature to update the tables; and methotrexate) versus methotrexate alone12. Table 3 pro-
and (3) a workshop to address issues of absenteeism and vides a summary of one study that directly compared the
presenteeism (at-work productivity loss) measurement, to measurement properties (internal consistency, feasibility,
obtain an OMERACT vote on a set of outcome measures to validity, and responsiveness) of 5 at-work productivity loss
consider at this point, and to define directions for research scales, conducted in part to support this OMERACT initia-
for the next 2 years. tive14. The Work Activity Limitations Scale (WALS), Work
Pre-OMERACT survey. One hundred and twenty-eight per- Instability Scale (WIS), and Work Limitations Question-
sons responded to this anonymous survey. Nearly all respon- naire (WLQ-25) were the strongest contenders and were
dents (96.8%) agreed that work was an important part of the also preferred by the study participants14. WALS and WIS
life of an individual with arthritis. There was strong endorse- were more sensitive to difficulty experienced at work, and
ment for the measurement of both absenteeism and presen- WLQ to self-perceived loss in productivity. Although con-
teeism in clinical trials in arthritis. There was a definite tributing to the OMERACT evidence, this study also raised
recognition that work was an important issue for individuals the issue of how task-specific the instruments seem to be,
with arthritis (76% said agree/strongly agree) and recogni- and whether they measure productive work performed out-
tion that this is poorly addressed in most clinical encounters side the workplace. From this review of the literature, it was
(59% said few or very few have the work issue addressed felt that there were 6 main contenders with at least some evi-
well in current arthritis care and 87.4% stated that work was dence satisfying each component of the OMERACT filter
not being addressed sufficiently). A list of available instru- evidence: WALS, WIS, WLQ-25, Work Productivity and
ments to measure work productivity was posted. Few partic- Activity Impairment (WPAI), Work Productivity Scale-
ipants recognized these scales; even fewer had experience Rheumatoid Arthritis version (WPS-RA), and Health
using them in arthritis care or research. Very few of these Productivity Questionnaire (HPQ).
instruments were endorsed as having passed the OMERACT Workshop at OMERACT 9. At the workshop held at OMER-
filter, and fewer than 5 of 128 respondents endorsed any sin- ACT 9, after brief background presentations, participants
gle instrument. Finally, 90.2% believed that, in addition to reviewed the available evidence for 21 instruments in break-
the level of productivity, worker productivity should be out groups with trained facilitators. They were asked to dis-
measured in the context of job demands, accommodations at cuss and vote on which instruments they believed to be the
work, and coworker/supervisor support at work. In summa- strongest contenders to advance for further work and valida-
ry, it was agreed that measurement of worker productivity tion. Additionally, they discussed and defined variables to be
was very important but rarely addressed, was highly contex- considered when assessing absenteeism.
tualized, and that there were no clear candidates for instru- Several concerns were raised during the process. Many
mentation.
participants had not previously seen all 21 questionnaires.
Update of the literature review. In 2007 a review of the 19 Many felt that the instruments were too simplistic to capture
available scales for absenteeism and presenteeism was pub- the complexity of the person/job fit and its likely course over
lished2. In the update we found 21 instruments, with time and thus were unable to adequately measure presen-
increasing evidence for meeting the OMERACT filter. Table teeism. They reiterated the point raised at OMERACT 8 that
1 summarizes these instruments. Table 2 provides an the different questionnaires really assess different aspects of
overview of the evidence from published literature within worker productivity, and that no one instrument was able to
musculoskeletal populations for meeting the OMERACT measure absenteeism and also presenteeism in the context of
filter. Not all the instruments listed in Table 1 are included the individual and their “job fit.” Finally, although OMER-
in Table 2, as many have not been used in musculoskeletal ACT filter evidence was acknowledged, the heterogeneity of
conditions. Table 2 also provides additional assessments the results with no clearly outstanding winner raised con-
based on 2 studies soon to be published on the Work cerns about moving forward with one or even several of the
Productivity Survey (WPS-RA) presented at EULAR top 6 contender instruments, rather than revisiting core
200812,13. In this instrument, the mean number of days per measurement concepts.
month with reduced productivity and the mean degree of OMERACT 9 participants were asked to vote on endors-
interference of arthritis with work were both sensitive to dif- ing questionnaires found among the top 6 in order to identi-
ferences between methotrexate treatment alone and fy a working set of instruments. As shown in Figure 3, the
methotrexate plus Certolizumab Pegol12. In a study of the votes ranged from WIS-RA (54%), WPS-RA (48%) and

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Beaton, et al: Worker productivity outcome measure 2103

Table 1. Content and structure of measures of presenteeism found in the literature. Not all have been used in MSK/Arthritis.

Instruments Concept Scored Scales and No. of Items () Timeframe

HLQ ($) Proportion of time experiencing various Module 2: reduced productivity at paid work due to illness (7) 2 wks
A&P aspects of decreased performance
WHO-HPQ ($) Section 1: Proportion of time 1. Presenteeism scale (7) 1 to 4 wks
A&P Section 2: Overall work performance (0–10 scale) 2. Global items on overall performance of self, usual self, and
Section 3: Self vs others in level of usual other workers for presenteeism relative to “usual” (3)
performance 3. Performance relative to other workers (1)
HRPQ-D ($) No. of hours Single scale (1) Daily for 1 wk
A&P
HWQ ($) Quality, quantity and efficiency of work and 1. Productivity (11) 1 wk
P impact on well being a. personal assessment of productivity (5/11)
b. other’s assessment of the worker’s productivity (6/11)
2. Impatience/irritability (3)
3. Concentration/focus (4)
4. Work satisfaction (4)
5. Satisfaction with supervisor (2)
6. Non-work (personal life) satisfaction (4)
OST ($) % effectiveness at doing job while Single score 1 mo
A&P symptomatic
QQ## ($) No. of hours of reduced productivity 1. Quality of work done compared to normal (1) Daily
P 2. Quantity of work done (1)
SPS6 Degree of agreement with limitations 1. Completing work (3) 4 wks
P at work 2. Avoiding distraction (3)
SPS13 ($) Proportion of the time encountering a 1. Work impairment score (10) 4 wks
A&P difficulty a. Completing work (5)
b. avoiding distraction (5)
2. Work output score (1)
WALS Amount/level of difficulty Single scale (11) NA
P
WHI ($) Proportion of time encountering a work Lost productive time for days at work 2 wks
A&P limitation a. decreased productive work (4)
b. 1 item asking lag to beginning productive work each day when
ill (h/day)
WIS No. of difficulties encountered (stress, pace); Single scale (23) “Now”
P work instability = degree of mismatch between
self and job
WLQ25 ($) Proportion of time having difficulty 1. Physical demands (6) 2 wks
P 2. Mental-interpersonal (9)
3. Time management (5)
4. Output demands (5)
WLQ16 ($) Proportion of time having difficulty 1. Physical demands (4) 4 wks
P 2. Mental-interpersonal (6)
3. Time management (2)
4. Output demands (4)
WLQ8 ($) Proportion of time having difficulty 1. Physical demands (2) 2 wks
P 2. Mental-interpersonal (2)
3. Time management (2)
4. Output demands (2)
WPAI-GH ($) Degree of impairment 1. % work time missed due to health (2) 1 wk
A&P 2. % impairment while working due to health (1)
3. % overall work impairment due to health (3)
4. % activity impairment due to health (1)
WPSI ($) No. of hours Single scale (1) 2 wks–1 yr
A&P
WRF/WL26 ($) Proportion of time having difficulty 1. Work scheduling (6) 4 wks
P 2. Physical demands (8)
3. Mental demands (4)
4. Social demands (3)
5. Output demands (5)
ORQ ($) Degree of “interference with job” Two subscales: NA
P 1. Productivity scale (4)
2. Satisfaction scale (4)

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2104 The Journal of Rheumatology 2009; 36:9; doi:10.3899/jrheum.090366

Table 1. Continued.

Instruments Concept Scored Scales and No. of Items () Timeframe

RA-WPS ($) No. of days of reduced productivity, degree Eight items + one sociodemographic: 1 mo
A&P of interference with work Missed days at work/household work (2)
Degree of interference (2)
Days with productivity at work/household work reduced by half or
more (2)
Days missed family, social, or social activities (1)
Days with outside help (1)
WLQ (by Munir) Frequency/proportion of time 6 items: 12 mo
($) Physical demands (2) Cognitive demands (3) Social demand (1)
P
WSL ($) Degree to which various items described Part 1: Characteristic responses at work (categorical items): 57 items NA
P behaviors at work or to indicate how often 1. Working Through Pain (13)
they engaged in certain thoughts at work. 2. Social Reactivity (12)
Behaviors, symptoms, and emotions 3. Limited Workplace Support (10)
experienced “during periods of high work 4. Deadlines/Pressure (10)
demands.” 5. Self-Imposed Workpace/Workload (10)
6. Breaks (2)
Part 2: Response to increased work demands (dichotomous items) 34 items
1. Mood (feelings of Anger, Grumpiness, and Dread) (14)
2. Pain/Tension (Neck Pain, Shoulder Tension, and Back Tension) (7)
3. Autonomic Response (Cold Feet, Clammy Hands, and Heartburn or
Upset Stomach) (8)
4. Numbness/Tingling and accounts (Hand/Finger Numbness, Feel Tingling
Down Hands, and Feel Weaker) (5)
WSS ($) Same as WSL Part 1: Characteristic responses at work (24)
P 1. Working through pain (6)
2. Social reactivity (5)
3. Limited workplace support (4)
4. Deadlines/pressure (4)
5. Self-imposed workload/workload (3)
6. Breaks (2)
Part 2: Response to increased work demands (8)
1. Mood (6)
2. Autonomic response (2)

A: absenteeism; P: presenteeism, MSK: musculoskeletal, NA: insufficient information available, or not stated. Measures in bold were used in arthritis/MSK
studies. Measures with “$” in parentheses indicates potential or current ulilization in economic costing analyses. For definitions of instruments see Table 2.

WALS (47%) to a handful of endorsements for the instru- ADDITIONAL FACTORS AND INDICATORS FOR
ments outside the top 6. All these votes were below the 75% MEASUREMENT OF WORKER PRODUCTIVITY
threshold considered to reflect an endorsement by OMER- At OMERACT 9, several additional factors were identified
ACT. The facilitators received substantial feedback regard- that should be considered in the measurement of worker pro-
ing the lack of a strong endorsement. Because work and ductivity (see Table 4).
work productivity are so contextualized, there was a resist- In terms of absenteeism indicators, there was 94%
ance to recommend moving forward until a better conceptu- endorsement of the following to be considered when
al and measurement framework for worker productivity measuring absenteeism: work days missed due to arthri-
could be developed. Discussion supported the need for tis (sick days), vacation days taken because of arthritis,
ongoing work to define this type of instrument, a framework part days/hours missed because of arthritis, change in
for measurement and interpretability that would encompass number of hours worked per week, temporary work ces-
transitions between all the states — absenteeism, presen- sation (work disability/sick leave), and permanent work
teeism, changes in job demands, changes in employer, and cessation due to arthritis. These indicators have been
part-time versus full-time work — transitions that may have endorsed by OMERACT 9. Additional consideration will
nothing or everything to do with personal choices made be given to assessment of permanent work cessation due
because of arthritis. Several breakout groups named specif- to (a) health other than arthritis; (b) choice; and (c) retire-
ic challenges faced in conceptualizing and therefore meas- ment; as well as unemployed but looking for work
uring worker productivity. (employable). It is recommended that these queries be

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Beaton, et al: Worker productivity outcome measure 2105

Table 2. Summary of the position of presenteeism measures on the OMERACT filter. This table focuses on the level of evidence available for the measure-
ment properties of the presenteeism scales. Evidence had to be available in an arthritis population, or in data that had been stratified and showed separate
results for arthritis/musculoskeletal disorders (A/MSK). If evidence was available on a given feature but in another population, we would use parentheses ()
to indicate that it was promising but might not generalize to A/MSK.

Instrument and key OMERACT Truth OMERACT Discrimination OMERACT Feasibility***

reference/s for evidence Face/Content Construct Reliability** Responsiveness
Validity* Validity

Endicott Work Productivity Scale (EWPS)15 (++) (++) (+) – (++)

Life Functioning Questionnaire (LFQ)16 (++) (++) (+) – (++)
Health and Labour Questionnaire (HLQ)17 (++) (++) – – (++)
Health and Work Performance Questionnaire (HPQ)18-21 ++ ++ – (+) ++
Health-Related Productivity Questionnaire Diary (+) – – – (+)
(HRPQ-D)22
Health and Work Questionnaire (HWQ)23 (+) (+) – – (+)
Osterhaus technique (OST)24 (++) (+) – – (++)
Quantity and Quality Method (QQ)25 (++) (+) – – (++)
Stanford Presenteeism Scale-6 items (SPS6)26 (++) (++) – (+) (++)
Stanford Presenteeism Scale-13 items (SPS13)27, 28 + + – – +
Work Activity Limitations Scale (WALS)29 ++ ++ – – ++
Work and Health Interview-The American Productivity ++ – – – ++
Audit (WHI)30,31
Work Instability Scale-Rheumatoid Arthritis (RA-WIS)32 + + + – +
Work Limitations Questionnaire — 25 items (WLQ25)33-35 ++ ++ – (++) ++
Work Limitations Questionnaire — 16 items (WLQ16)36,37 ++ ++ – + ++
Work Limitations Questionnaire — 8 items (WLQ8)38,39 ++ ++ – (+) ++
Work Productivity and Activity Impairment-General + + + (+) +
Health (WPAI-GH)31
Work Productivity Short Inventory (aka Wellness ++ ++ (+) – ++
Inventory by Pfizer) (WPSI)40, 41
Work Role Functioning (WRF)/WL2642 (+) (+) – – (+)
Occupational Role Questionnaire (ORQ)43 + + + – +
RA-Specific Work Productivity Survey (WPS-RA)12,13 + + + + +
Work Limitations Questionnaire (WLQm)36 + + – – +
Workstyle Scale — Long version (WSL)44 + + + – –
Workstyle Scale — Short version (WSS)45 + + + – +

* Includes “sensibility” of the measure; ** includes internal consistency and test-retest reliability (must satisfy both); *** includes easiness to administer
(time, money), interpretation; ## QQ is part of the Productivity and Disease Questionnaire (Prodisq).
Grading System (each element is graded on the level of evidence): ++ = 2 or more studies with evidence supporting this property in A/MSK; + = 1 study with
evidence supporting this property in A/MSK; () = there is evidence of this property, but not in A/MSK; — = no evidence of achievement of this property.
OMERACT filters: Truth = may satisfy the following: face, content, construct, criterion; Discrimination = reliability and responsiveness, and in particular
responsiveness in a clinical trial; Feasibility = easy, time, money, interpretability.

Table 3. Psychometric properties derived from a concurrent comparison of 5 measures of at-work productivity loss in persons with inflammatory arthritis and
osteoarthritis14.

Instrument and Key OMERACT Truth OMERACT Discrimination OMERACT Feasibility

Reference Face/Content Construct Reliability Responsiveness
Validity Validity

EWPS + + – + +
SPS6 + + – + +
WALS29 + + – + +
RA-WIS + + – + +
WLQ Index + + – – +
WLQ-Time management + + – – +
WLQ-Physical demands + – – + +
WLQ-Mental-interpersonal + + – + +
WLQ-Output demands + + – – +

For instrument definitions and details on the OMERACT filter see Table 2.

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2106 The Journal of Rheumatology 2009; 36:9; doi:10.3899/jrheum.090366

 Figure 3. OMERACT 9 plenary votes for the endorsement of each at-work productivity
instrument. WALS: Work Activity Limitations Scale; WIS: Work Instability Scale
(Rheumatoid Arthritis Version); WLQ: Work Limitations Questionnaire; WPAI: Work
Productivity and Activity index; WPS-RA: Work Productivity Survey, Rheumatoid Arthritis
version; HPQ: Health Productivity Questionnaire.

Table 4. Additional factors to be considered in the measurement of worker productivity.

• Ability to combine information on absenteeism and presenteeism

• Ability to use the same scale to provide information for both outcome (health) state and economic analyses
• How to interpret a part-time or modified job versus a full-time job with the same instrument measure (i.e., level of difficulty at job). For example,
how should days absent from a part-time job be compared to days off from a full-time job?
• Work needs to be placed in the context of the person’s whole life and work–life balance: choices made to stay at work or leave work, or to reduce work
demands and pursue leisure/family responsibilities; decisions made around resources (financial and time) to manage the disease, including medical
appointments, treatments, and medication costs.
• Unpaid work, as that fits into the equation of how a person manages work responsibilities. Child or elder care responsibilities will influence paid work
• Job transitions need to be defined and interpreted. For example, should a switch from full- to part-time work be considered absenteeism if it was due to
arthritis?
• It is questionable whether unemployed, but able to work and looking for work, should be counted as absenteeism. This category is sometimes called
“employable,” as the individual has not left the workforce entirely; rather they don’t have a job to fit into at the moment

included in future studies of arthritis with reports back to workplace, societal level health benefits, and workplace cul-
OMERACT 10. ture regarding illness.
The research agenda for worker productivity was defined 7. What is the impact of arthritis on teamwork at the work-
at OMERACT 9 as follows: place?
1. What role does length of absenteeism have on overall 8. Will we have a disease specific instrument? Or within
worker productivity? arthritis, should we have an osteoarthritis instrument, a
2. What perspective should bear on a measure of productiv- rheumatoid arthritis instrument, and an ankylosing
ity: self, family, society, workplace? spondylitis instrument? Or should we aim for a generic
3. We need a better understanding of what is happening at instrument that can also be used for other diseases?
the decision point to “not work.” In conclusion, worker productivity is an important out-
4. What is going on at home that allows some people to keep come measure in arthritis and an important component of
working? economic evaluations. At OMERACT 9 we reached consen-
5. What impact does work, work absence, and presenteeism sus on several indicators of absenteeism and found addition-
have on self-esteem and self-efficacy? Does that depend on al information on validity and discrimination filter evidence
individual, societal, or workplace variables? for several measures of presenteeism. However, while some
6. How much is workplace and societal culture influencing instruments looked promising, the variability in target con-
open discussion about at-work productivity loss? This cept, validity, and even responsiveness resulted in no single
would include issues such as disclosure of arthritis to the instrument being chosen based on OMERACT filter evi-

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Beaton, et al: Worker productivity outcome measure 2107

dence alone. There are conceptual and theoretical differ- of the job as well as absenteeism and presenteeism related to
ences that must be sorted out. The message from OMER- that job.
ACT participants was to return with a better-developed 2. Having created this framework, we need to find or devel-
framework for the measurement of worker productivity in op measures of absenteeism and presenteeism and job con-
order to inform the final selection and endorsement of an text descriptors. There was strong endorsement for a wider
instrument. array of absenteeism indicators. There are some contender
instruments for assessment of presenteeism, but it may be
LOOKING FORWARD TO OMERACT 10 necessary to take parts from several different instruments to
The Worker Productivity Workshop concluded with 3 assemble a better measure of the entire concept of at-work
defined tasks. productivity loss.
1. We need to develop a framework for the measurement of 3. We need to work on methods to facilitate meaningful
productivity loss within a job context. This context is analyses. These efforts may follow a more modular worker
defined by the individual’s work status (full, normal hours productivity instrument, from which appropriate measures
vs part time or modified duties; unemployed; retired; etc.) are drawn specific to the circumstances at the time of data
and job type (physical, psychological, output demands of collection. For example, there is no need to measure at-work
the current job). This framework should also be sensitive to productivity if an individual is off work on sick leave. Nor is
the balance between paid and unpaid roles — working may there a need to measure absenteeism hours or days if a per-
be considered a success, but not if it is at the cost of home, son is having difficulty only at work. Appropriate measures
family, social, or leisure activities. A template for consider- would also address issues at transition points and how to
ation is shown in Figure 4: horizontal boxes define different model the pathway of an individual’s story over time, which
work states and vertical boxes indicate the need for meas- may include episodes of absenteeism and trials of return to
ures of absenteeism and/or presenteeism given this state. work. Perhaps a set of scales (modular format) would allow
The dotted box reports the job context, which defines the cross talk between states of absenteeism and presenteeism.
nature of the job and work organization, as well as other Additional work is also required to define measurement
contextual factors. Workshop discussions supported the properties, as well as interpretability of these instruments
need for a modular measure that would allow for description (minimal clinically important differences and patient
acceptable states for at-work productivity loss).
Over the course of the next 2 years, the group will be
seeking sponsorship for an international consortium of
researchers, clinicians, and individuals with arthritis — with
expertise in measuring job demands and understanding
work–life balance — to work to understand how the modu-
lar components should be analyzed and interpreted for use
in randomized controlled trials. We will draw from
OMERACT participants, and also from experts outside of
OMERACT in the work and health research arena.

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Beaton, et al: Worker productivity outcome measure 2109