pii: sp- 00504-16
http://dx.doi.org/10.5665/sleep.6150
COMMENTARY
Value-Based Sleep in the Workplace Commentary on Thiart et al. Internet-based cognitive behavioral therapy for insomnia: a health economic evaluation. SLEEP 2016;39(10):1769–1778. Emerson M. Wickwire, PhD Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD; Sleep Disorders Center, Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, MD
Insomnia is the most common sleep disorder among adults and is robustly associated with adverse health outcomes and diminished quality of life. By any measure, insomnia also constitutes a major public health and economic burden, with very conservative estimates of total annual costs in the US exceeding $100 billion.1 Yet, in spite of the availability of highly effective treatments, insomnia remains widely under-recognized and undertreated. One important barrier restricting access to care is uncertain financial return on investment (ROI) of insomnia therapies from the perspective of those who pay for services. In the modern healthcare climate of rising costs and limited resources, evidence demonstrating financial gain from treating insomnia could provide a powerful catalyst for increasing access to care for the millions of Americans suffering insomnia. The majority of insomnia-related expenditures are indirect costs such as increased health care utilization (HCU), lost workplace productivity, and increased accident risk. For example, a seminal study found 14.9% of total insomnia-related costs to be associated with days missed from work (i.e., absenteeism) and 75.6% of costs to be attributable to lost workplace productivity (i.e., presenteeism).2 Thus over 90% of insomnia-related costs are borne by employers. In the US, insomnia-related absenteeism has been shown to increase costs to employers by $405 (in 2007 USD) per employee over six months,3 and insomniarelated presenteeism increases employer costs by $2,280 (in 2011 USD) per employee per year.4 Insomnia also accounts for a disproportionate amount of expenses due to workplace accidents and errors. For example, although insomnia was found to explain only 7.2% of workplace accidents and errors, it accounted for 23.7% of the total costs of all accidents and errors.5 Although many employers are not naïve to these costs, there is uncertainty regarding the ROI of insomnia treatments from the employer perspective. Evaluation of such economic outcomes typically include cost-benefit analyses to determine the ROI of treatment (i.e., costs expended on treatment compared to costs saved through reduced absenteeism and presenteeism) as well as cost-effectiveness analyses (CEAs) to assess the relationship between changes in costs and clinical treatment response. A recent review identified ten studies evaluating the cost-effectiveness of insomnia pharmacotherapy and in-person cognitive-behavioral treatment for insomnia (CBTI).1 Although methodologies varied widely, results consistently supported the cost-effectiveness of insomnia treatments from the perspective of the payer, patient, and population. However, to date no study has examined the health economic aspects of insomnia treatment from the perspective of the employer. As a result, it is uncertain whether the benefits of treating insomnia outweigh the costs, in terms of outcomes that matter most to employers. SLEEP, Vol. 39, No. 10, 2016
In this issue of SLEEP, Thiart and colleagues present health economic outcomes from the employer perspective of a randomized clinical trial (RCT) of a digital cognitive-behavioral treatment for insomnia (dCBTI).6 German schoolteachers with significant insomnia symptoms and work-related rumination were recruited via email and randomized to a workplace-tailored, 6-week guided dCBTI with email coaching support (n = 128) or waitlist control (n = 128). Reductions in insomnia severity were evident post-treatment and maintained at 6-month follow-up, with large between groups effect sizes. HCU and productivity losses were measured using an established questionnaire. Assuming intervention costs of €200 ($245 USD), cost-benefit analyses revealed a net benefit of €418/$512 per participant, resulting in a return on investment of 208%. Although there was a moderate 66% probability of positive financial return, these results did not reach statistical significance at the P < 0.05 level. Subsequent cost effectiveness analyses revealed at least 87% likelihood that the intervention would be more cost effective than treatment as usual , which is considered favorable. In light of the substantial costs of untreated insomnia disorder, it is important to consider possible explanations for the lower than expected probability of positive financial return. It is possible, as the authors note, that a longer follow-up period would have captured additional cost savings. Indeed, other CEAs of insomnia treatments have found cost effectiveness to increase over time.1 Another possible explanation is that it is common for CEAs conducted alongside RCTs to be underpowered to detect statistically significant differences in health economic outcomes. It is also important to consider potential cost-savings from decreases in workplace accidents and errors, which were not addressed in this study. At the same time, in spite of the findings regarding positive financial return, the intervention was at least 87% likely to be more cost effective than treatment as usual. Thus, based on the results presented, future studies with larger samples of employees from a range of workplace settings are clearly warranted. Tailoring interventions for the workplace requires decisionmaking regarding which key treatment components to adapt, who should provide healthcare services, and how to engage employees. Each of these areas is highly relevant to economic outcomes and was thoughtfully addressed in the paper by Thiart and colleagues. The addition of specific treatment components to reduce work-related worry and increase recreational engagement is particularly noteworthy. One advantage of CBTI and behavioral approaches in general is that individual components can be seamlessly incorporated or removed in order to optimize treatment for specific goals, populations,
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or perspectives. Further, this study also provides novel insight into the cost-effectiveness of guided dCBTI. dCBTI is among the most promising and understudied approaches to delivering CBTI, which is itself now widely accepted as first-line treatment for insomnia disorder.7–9 In addition to these strengths, this study also presents several missed opportunities and highlights directions for future sleep health economic research. First, to understand the viability of sleep treatments in the workplace, more detail is needed regarding the workforce, including the number of employees who received recruitment solicitations. Such population-level insight would provide valuable guidance to large employers weighing the pros and cons of treating sleep disorders among their employees. Second, reliance on self-report costs data is a limitation. Future studies will benefit from close collaboration with employers to define objective endpoints of interest, such as days missed, annual performance evaluations, and so forth. Third, participants completed the intervention at home and on their own time, which suggests a highly motivated sample, and time spent completing the program was not included in cost estimates. Finally, sleep parameters were not reported.10 Reports of sleepiness would be especially useful, as the sleep restriction component of CBTI increases risk for daytime sleepiness and performance impairments,11,12 which presumably also increase risk and costs of workplace accidents and errors. In summary, the important paper by Thiart and colleagues6 adds to a growing body of evidence regarding cost-benefit and cost-effectiveness regarding treatment of insomnia in particular and sleep disorders more broadly.13 The primary strengths of this study are the workplace-tailored intervention and focus on workplace costs from the employer’s perspective. In a business setting, improved productivity and medical cost savings result in improved business performance. As health insurance self-funding among large employers continues to increase,14 the opportunity for sleep medicine to provide value in the workplace will continue to increase. CITATION Wickwire EM. Value-based sleep in the workplace. SLEEP 2016;39(10):1767–1768.
2. Daley M, Morin CM, LeBlanc M, Gregoire JP, Savard J, Baillargeon L. Insomnia and its relationship to health-care utilization, work absenteeism, productivity and accidents. Sleep Med 2009;10:427–38. 3. Ozminkowski RJ, Wang S, Walsh JK. The direct and indirect costs of untreated insomnia in adults in the United States. Sleep 2007;30:263–73. 4. Kessler RC, Berglund PA, Coulouvrat C, et al. Insomnia and the performance of US workers: results from the America insomnia survey. Sleep 2011;34:1161–71. 5. Shahly V, Berglund PA, Coulouvrat C, et al. The associations of insomnia with costly workplace accidents and errors: results from the America Insomnia Survey. Arch Gen Psychiatry 2012;69:1054–63. 6. Thiart H, Ebert DD, Lehr D, et al. Internet-based cognitive behavioral therapy for insomnia: a health economic evaluation. Sleep 2016;39:1769–78. 7. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2016;165:125–33. 8. National Institutes of Health. National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005. Sleep 2005;28:1049–57. 9. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med 2008;4:487–504. 10. Thiart H, Lehr D, Ebert DD, Berking M, Riper H. Log in and breathe out: internet-based recovery training for sleepless employees with work-related strain—results of a randomized controlled trial. Scand J Work Environ Health 2015;41:164–74. 11. Kyle SD, Miller CB, Rogers Z, Siriwardena AN, Macmahon KM, Espie CA. Sleep restriction therapy for insomnia is associated with reduced objective total sleep time, increased daytime somnolence, and objectively impaired vigilance: implications for the clinical management of insomnia disorder. Sleep 2014;37:229–37. 12. Drake CL. The promise of digital CBT-I. Sleep 2016;39:13–4. 13. Watson NF, Iftikhar IH, Simon Jr RD, et al. Health care savings: the economic value of diagnostic and therapeutic care for obstructive sleep apnea. J Clin Sleep Med 2016;12:1075–7. 14. Fronstin P. Self-Insured health plans: state variation and recent trends by firm size. EBRI Notes 2012;33:11.
SUBMISSION & CORRESPONDENCE INFORMATION Submitted for publication August, 2016 Submitted in final revised form August, 2016 Accepted for publication August, 2016 Address correspondence to: Emerson M. Wickwire, PhD, FAASM, 100 N. Greene St, 2nd Floor, Baltimore, MD 21201; Tel: (410) 706-4771; Fax: (410) 706-0235; Email: [email protected]
REFERENCES
DISCLOSURE STATEMENT
1. Wickwire EM, Shaya FT, Scharf SM. Health economics of insomnia treatments: the return on investment for a good night’s sleep. Sleep Med Rev 2015;30:72–82.
SLEEP, Vol. 39, No. 10, 2016
Dr. Wickwire has moderated non-commercial scientific discussion for Merck and is an equity shareholder in WellTap.
1768
Commentary—Wickwire
http://dx.doi.org/10.5665/sleep.6150
COMMENTARY
Value-Based Sleep in the Workplace Commentary on Thiart et al. Internet-based cognitive behavioral therapy for insomnia: a health economic evaluation. SLEEP 2016;39(10):1769–1778. Emerson M. Wickwire, PhD Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD; Sleep Disorders Center, Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, MD
Insomnia is the most common sleep disorder among adults and is robustly associated with adverse health outcomes and diminished quality of life. By any measure, insomnia also constitutes a major public health and economic burden, with very conservative estimates of total annual costs in the US exceeding $100 billion.1 Yet, in spite of the availability of highly effective treatments, insomnia remains widely under-recognized and undertreated. One important barrier restricting access to care is uncertain financial return on investment (ROI) of insomnia therapies from the perspective of those who pay for services. In the modern healthcare climate of rising costs and limited resources, evidence demonstrating financial gain from treating insomnia could provide a powerful catalyst for increasing access to care for the millions of Americans suffering insomnia. The majority of insomnia-related expenditures are indirect costs such as increased health care utilization (HCU), lost workplace productivity, and increased accident risk. For example, a seminal study found 14.9% of total insomnia-related costs to be associated with days missed from work (i.e., absenteeism) and 75.6% of costs to be attributable to lost workplace productivity (i.e., presenteeism).2 Thus over 90% of insomnia-related costs are borne by employers. In the US, insomnia-related absenteeism has been shown to increase costs to employers by $405 (in 2007 USD) per employee over six months,3 and insomniarelated presenteeism increases employer costs by $2,280 (in 2011 USD) per employee per year.4 Insomnia also accounts for a disproportionate amount of expenses due to workplace accidents and errors. For example, although insomnia was found to explain only 7.2% of workplace accidents and errors, it accounted for 23.7% of the total costs of all accidents and errors.5 Although many employers are not naïve to these costs, there is uncertainty regarding the ROI of insomnia treatments from the employer perspective. Evaluation of such economic outcomes typically include cost-benefit analyses to determine the ROI of treatment (i.e., costs expended on treatment compared to costs saved through reduced absenteeism and presenteeism) as well as cost-effectiveness analyses (CEAs) to assess the relationship between changes in costs and clinical treatment response. A recent review identified ten studies evaluating the cost-effectiveness of insomnia pharmacotherapy and in-person cognitive-behavioral treatment for insomnia (CBTI).1 Although methodologies varied widely, results consistently supported the cost-effectiveness of insomnia treatments from the perspective of the payer, patient, and population. However, to date no study has examined the health economic aspects of insomnia treatment from the perspective of the employer. As a result, it is uncertain whether the benefits of treating insomnia outweigh the costs, in terms of outcomes that matter most to employers. SLEEP, Vol. 39, No. 10, 2016
In this issue of SLEEP, Thiart and colleagues present health economic outcomes from the employer perspective of a randomized clinical trial (RCT) of a digital cognitive-behavioral treatment for insomnia (dCBTI).6 German schoolteachers with significant insomnia symptoms and work-related rumination were recruited via email and randomized to a workplace-tailored, 6-week guided dCBTI with email coaching support (n = 128) or waitlist control (n = 128). Reductions in insomnia severity were evident post-treatment and maintained at 6-month follow-up, with large between groups effect sizes. HCU and productivity losses were measured using an established questionnaire. Assuming intervention costs of €200 ($245 USD), cost-benefit analyses revealed a net benefit of €418/$512 per participant, resulting in a return on investment of 208%. Although there was a moderate 66% probability of positive financial return, these results did not reach statistical significance at the P < 0.05 level. Subsequent cost effectiveness analyses revealed at least 87% likelihood that the intervention would be more cost effective than treatment as usual , which is considered favorable. In light of the substantial costs of untreated insomnia disorder, it is important to consider possible explanations for the lower than expected probability of positive financial return. It is possible, as the authors note, that a longer follow-up period would have captured additional cost savings. Indeed, other CEAs of insomnia treatments have found cost effectiveness to increase over time.1 Another possible explanation is that it is common for CEAs conducted alongside RCTs to be underpowered to detect statistically significant differences in health economic outcomes. It is also important to consider potential cost-savings from decreases in workplace accidents and errors, which were not addressed in this study. At the same time, in spite of the findings regarding positive financial return, the intervention was at least 87% likely to be more cost effective than treatment as usual. Thus, based on the results presented, future studies with larger samples of employees from a range of workplace settings are clearly warranted. Tailoring interventions for the workplace requires decisionmaking regarding which key treatment components to adapt, who should provide healthcare services, and how to engage employees. Each of these areas is highly relevant to economic outcomes and was thoughtfully addressed in the paper by Thiart and colleagues. The addition of specific treatment components to reduce work-related worry and increase recreational engagement is particularly noteworthy. One advantage of CBTI and behavioral approaches in general is that individual components can be seamlessly incorporated or removed in order to optimize treatment for specific goals, populations,
1767
Commentary—Wickwire
or perspectives. Further, this study also provides novel insight into the cost-effectiveness of guided dCBTI. dCBTI is among the most promising and understudied approaches to delivering CBTI, which is itself now widely accepted as first-line treatment for insomnia disorder.7–9 In addition to these strengths, this study also presents several missed opportunities and highlights directions for future sleep health economic research. First, to understand the viability of sleep treatments in the workplace, more detail is needed regarding the workforce, including the number of employees who received recruitment solicitations. Such population-level insight would provide valuable guidance to large employers weighing the pros and cons of treating sleep disorders among their employees. Second, reliance on self-report costs data is a limitation. Future studies will benefit from close collaboration with employers to define objective endpoints of interest, such as days missed, annual performance evaluations, and so forth. Third, participants completed the intervention at home and on their own time, which suggests a highly motivated sample, and time spent completing the program was not included in cost estimates. Finally, sleep parameters were not reported.10 Reports of sleepiness would be especially useful, as the sleep restriction component of CBTI increases risk for daytime sleepiness and performance impairments,11,12 which presumably also increase risk and costs of workplace accidents and errors. In summary, the important paper by Thiart and colleagues6 adds to a growing body of evidence regarding cost-benefit and cost-effectiveness regarding treatment of insomnia in particular and sleep disorders more broadly.13 The primary strengths of this study are the workplace-tailored intervention and focus on workplace costs from the employer’s perspective. In a business setting, improved productivity and medical cost savings result in improved business performance. As health insurance self-funding among large employers continues to increase,14 the opportunity for sleep medicine to provide value in the workplace will continue to increase. CITATION Wickwire EM. Value-based sleep in the workplace. SLEEP 2016;39(10):1767–1768.
2. Daley M, Morin CM, LeBlanc M, Gregoire JP, Savard J, Baillargeon L. Insomnia and its relationship to health-care utilization, work absenteeism, productivity and accidents. Sleep Med 2009;10:427–38. 3. Ozminkowski RJ, Wang S, Walsh JK. The direct and indirect costs of untreated insomnia in adults in the United States. Sleep 2007;30:263–73. 4. Kessler RC, Berglund PA, Coulouvrat C, et al. Insomnia and the performance of US workers: results from the America insomnia survey. Sleep 2011;34:1161–71. 5. Shahly V, Berglund PA, Coulouvrat C, et al. The associations of insomnia with costly workplace accidents and errors: results from the America Insomnia Survey. Arch Gen Psychiatry 2012;69:1054–63. 6. Thiart H, Ebert DD, Lehr D, et al. Internet-based cognitive behavioral therapy for insomnia: a health economic evaluation. Sleep 2016;39:1769–78. 7. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2016;165:125–33. 8. National Institutes of Health. National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005. Sleep 2005;28:1049–57. 9. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med 2008;4:487–504. 10. Thiart H, Lehr D, Ebert DD, Berking M, Riper H. Log in and breathe out: internet-based recovery training for sleepless employees with work-related strain—results of a randomized controlled trial. Scand J Work Environ Health 2015;41:164–74. 11. Kyle SD, Miller CB, Rogers Z, Siriwardena AN, Macmahon KM, Espie CA. Sleep restriction therapy for insomnia is associated with reduced objective total sleep time, increased daytime somnolence, and objectively impaired vigilance: implications for the clinical management of insomnia disorder. Sleep 2014;37:229–37. 12. Drake CL. The promise of digital CBT-I. Sleep 2016;39:13–4. 13. Watson NF, Iftikhar IH, Simon Jr RD, et al. Health care savings: the economic value of diagnostic and therapeutic care for obstructive sleep apnea. J Clin Sleep Med 2016;12:1075–7. 14. Fronstin P. Self-Insured health plans: state variation and recent trends by firm size. EBRI Notes 2012;33:11.
SUBMISSION & CORRESPONDENCE INFORMATION Submitted for publication August, 2016 Submitted in final revised form August, 2016 Accepted for publication August, 2016 Address correspondence to: Emerson M. Wickwire, PhD, FAASM, 100 N. Greene St, 2nd Floor, Baltimore, MD 21201; Tel: (410) 706-4771; Fax: (410) 706-0235; Email: [email protected]
REFERENCES
DISCLOSURE STATEMENT
1. Wickwire EM, Shaya FT, Scharf SM. Health economics of insomnia treatments: the return on investment for a good night’s sleep. Sleep Med Rev 2015;30:72–82.
SLEEP, Vol. 39, No. 10, 2016
Dr. Wickwire has moderated non-commercial scientific discussion for Merck and is an equity shareholder in WellTap.
1768
Commentary—Wickwire
