True Costs of Occupational Asthma

1. True Costs of Occupational Asthma Presentation to HSE Metroeconomica, IOM and University of Aberdeen

2. Overview of Presentation • Project Team • Overview of Project • Preliminary responses to questions

3. The Project Team • Metroeconomica: • Prof Anil Markandya – Senior Economist • Alistair Hunt - Economist • Tim Taylor – Junior Economist • IOM: • Hilary Cowie – Epidemiologist, Statistician • Dr Colin Soutar – Medical Epidemiology, Consultant Chest Physician • Fintan Hurley – Health Impact Assessment • University of Aberdeen: • Prof Jon Ayres – Medical Epidemiology, Consultant Chest Physician

4. Overview of Project • Aims and objectives: • To identify, as fully as possible, the true costs of occupational asthma to the individual, employers and to society. • In response we propose a project with 7 main tasks (2 of which are “optional” depending on the level of accuracy and the level of impact desired from study).

5. Overview of Project • Link to overview diagram

6. Task 1:Overall concept and study design • This task involves the design of the study and will guide the study, based on the outputs of the work in other tasks • We have learned from HIA/ CBA work in other contexts that it is very helpful • To carry out, as early as practicable, a ‘quick-and-dirty’ dry run of the model as a whole. The objectives at this stage are to establish at an early stage: • where are the main information gaps and • if we make simple estimates of these, based on our best judgement, which are the ones that really matter, i.e. which are the ones that are likely to affect the bottom line estimates. Clearly, these are the ones to prioritise in improving the model. • Progressively improve the model, by gaining new and better information on those aspects that matter most.

7. Task 2: Literature Review of International and UK Cost of Asthma studies, to identify potential “benefit-transfer” estimates and to provide a comparison for the results of the overall study • In-depth review of the literature on the cost of asthma (and particularly occupational asthma). • This will include a review of previous work to estimate the overall costs of asthma and of willingness to pay estimates for avoiding asthma exposure. • Will provide inputs to the project in terms of WTP estimates for pain and other cost estimates, as well as providing a basis for validation.

8. Task 3: Desk-based analysis of occupational health statistics – to identify prevalence/incidence of OA in different contexts • Review of UK (and international) statistics on the incidence of OA in different sectors, plus some assessment of severity. • We will make judgements about the reliability of the data and their relevance to our purpose – see later • We will give priority to incidence data because • Occurrence of OA may lead to changes in work practices, including leaving the job – difficult to interpret prevalences. • It seems more relevant to the study – what is happening now. • While considering OA generally, we will pay particular attention to the circumstances of the three case studies.

9. Task 4: Desk-based assessment of cost elements (e.g. medical costs) available from literature • Examination of UK government and EU statistics on the cost elements that can be estimated through use of such secondary sources, including: • CBI – for absenteeism costs, likely to be general, and incidence of absence due to asthma in general – OA not likely to be identified seperately; • HSE – for investigation costs; • NHS – for costs of treatment with inhaled therapy and data on distribution of GPs (ONS); • ABI – for insurance costs, though these are likely to be confidential; • DoT – for travel time unit cost estimates which can be linked to ONS data on distribution of GPs for visit costs;

10. Task 5: Survey of Employers/Employees to ascertain employment effects of OA • Preliminary review of costs of occupational asthma reveals that there are some gaps in the area of costs for employers in particular – with relation to the need for retraining and other related costs. • Costs for employees in terms of lost income have been addressed in some of the literature (e.g. Cannon et al, 1995), though these estimates are based on small sample sizes and are highly aggregated. It would be possible to conduct this costing without this explicit survey, though the results would not be so robust. • We propose two surveys – one of employees and one of employers.

11. Task 5: Survey of Employers • This was not explicit in the proposal but a survey of employers will also be conducted to elicit retraining and other costs associated with OA. • This will be based on contact with employers in person or by email, with follow-up by phone where needed. • Contacts will be sought from the relevant trade associations.

12. Task 5: Survey of Employees to ascertain employment effects of OA • Employee-based survey will seek to collect supporting cost data on the welfare costs of OA, which would include: • Pain and suffering • net loss of earnings • search for new employment • early retirement • extra expenditure when absent from work • Two main actions: • Focus groups • Survey

13. Task 5: Survey of Employees to ascertain employment effects of OA • Focus Groups: • Two focus groups that would seek to elicit first estimates of the willingness to pay to avoid OA. • On site focus groups at workplaces (with employer’s consent) • The two groups of eight individuals would both be selected from the sectors of interest but be differentiated between • i) those who suffered from OA, and • ii) those who did not, and had not, suffered from OA. • This distinction is important since previous work on valuing morbidity end-points including (public) asthma have found that the experience of having an illness may affect the responses of the interviewees.

14. Task 5: Survey of Employees to ascertain employment effects of OA • Survey: • small-scale sample (e.g. 50 interviewees) of employees in the relevant sectors that seeks to elicit improved estimates of the magnitude of the costs that individuals would expect to incur in the event of their suffering from OA. • The survey will be structured in such a way as to allow elicitation of key determining factors and uncertainties in making their estimates. • On site interviews at locations agreed with employers. • Results will serve as a cross-check against existing cost estimates for these categories.

15. Task 6: Synthesis of results • The work of synthesising the results involves: • Improving the model in the light of the data collected; and • Checking what the model implies for OA costs in the three case study contexts, and overall. • This will include sensitivity analysis of key assumptions, to give credible ranges for the estimates being made. • A summary report will be developed, covering both epidemiology and costing (focusing on costing). • This will be summarised in policy briefs and in leaflets/websites for the purposes of dissemination of results. • We will prepare and submit a paper for publication.

16. Task 7: Workshop on costs of OA including key stakeholders – for dissemination of results of study (*Optional Task*) • A workshop will be held to inform key stakeholders, notably employers, policy makers and trade unions on the costs of OA. Aims: • enhance the profile of OA related costs significantly and • serve as a worthwhile launch for the findings of the report. • Workshop would be held in London in the final month of the project.

17. Budgets • Option 1 – survey and workshop included - £73,120 • Option 2 involves just the secondary analysis with a workshop, which we believe would lead to some useful results but would not be as robust as Option 1. This has been costed at £52,400. • Option 3 involves the narrow secondary analysis. This would yield some useful results as mentioned above, though cost estimates for employers and employees costs would be more limited. The estimate for this option is £40,650.

18. Cost of OA • Short presentation on existing cost estimates side • Fintan – epidemiological side

19. IOM-Aberdeen people and roles • Jon Ayres + Colin Soutar – very wide clinical and epidemiological experience of asthma – general and occupational • Hilary Cowie – very experienced in epidemiology, including occupational asthma; and in design and conduct of surveys. Will do a lot of Task 3. • Fintan Hurley – very experienced in epidemiology and in health impact assessment. Has collaborated with everybody else on the team. Main role is to help ensure effective linkage of the epidemiology and costing parts.

20. Task 3: Desk-based analysis of occupational health statistics – to identify prevalence/incidence of OA in different contexts • Review of UK (and international) statistics on the incidence of OA in different sectors, plus some assessment of severity. • We will make judgements about the reliability of the data and their relevance to our purpose – see later • We will give priority to incidence data because • Occurrence of OA may lead to changes in work practices, including leaving the job – difficult to interpret prevalences. • It seems more relevant to the study – what is happening now. • While considering OA generally, we will pay particular attention to the circumstances of the three case studies.

21. Why do Task 3? What data sources? • Why do this? (Not a requirement of the ToR) • To help ensure that the overall programme of work is well directed • In particular, from the many aspects that are relevant and potentially important, to identify those that are likely to have greatest bearing on the final results • To allow an approximate estimation of the annual costs of occupational asthma in the UK (estimated at £1.1bn) • Sources of information • Papers – starting with BOHRF review • Other HSE sources – see e.g. website • Judgement of team members

22. How would we use this? • In focussing the study activities • Construct a simple model of (new occurrences of) OA in the UK • Four main sectors – the 3 identified plus ‘all else’ • Estimate numbers and if possible, severity (including, e.g., time off work) • Revise model in light of new data; extend to include costs of different outcomes • In collating final results • Give coherence to the whole study • Facilitates communication of where the data are strong, where they are weak • Allows approximate estimates of the overall annual costs of OA • Allows uncertainty estimation of those costs

23. Prognosis of OA – from BOHRF • D1: Symptoms and functional impairment may persist for many years after cessation of exposure • D2-D5: Improvement better if: • No further exposure • Lung function relatively normal @ diagnosis • Shorter duration of symptoms before diagnosis; before avoidance of exposure

24. Some implications of OA – from BOHRF • D5: Re-deployment may help • D8: Approximately 1/3 of workers with OA are unemployed after 6 years • D9: Evidence of financial loss (may be mitigated if exposure is reduced rather than avoided) • May be possible to use data on ‘general’ asthma - though re-employment may be harder for OA

25. Numbers of cases – HSE, BOHRF; SWORD; OPRA; THOR..… • Numbers, by sector and/or by agent • Information on severity – direct? indirect? • Hope to tap into HSE experience of the schemes, e.g. • To use data from SWORD and OPRA for estimating overall numbers, by occupation/ sector • To take account of under-reporting and to estimate corrections for it. (Under-reporting is related to severity. In OPRA, depends also on coverage by OPs. Different schemes ‘catch’ different kinds of severity.)

26. One way of looking at the project – • A project to extend and to quantify the experience summarised in BOHRF, using • The source papers • Information from reporting schemes and HSE’s experience of them; • Limited new data collection • Expert judgement • The ability of modelling to examine which uncertainties and approximations really matter, and which do not.

27. What sorts of cost data will be used for desk-based analysis? • Cost data eg: • CBI info on absenteeism and costs • NHS cost of treating asthma (cost of illness – derived from drug and treatment cost) • Transfer of asthma values from economic valuation literature • “Grey” literature – eg law reports

28. What are the benefits of the proposed workshop? • Dissemination: • Raise profile of OA • Answer major questions from stakeholders • Provide a launch for the results of the project • Press involvement • Stakeholder feedback on results

29. Question Responses • Is the survey of employees and employers? • Yes. This was not clear in the proposal but we would carry out interviews with both employers and employees.

30. Survey of Employees • Survey of employees: • Not done specifically on OA sufferers because of time of project. • However, such “what if?” questions may put into perspective OA costs in literature, which are old and rather aggregated in nature. • Focus groups would give a good first idea of WTP to avoid OA and validate transfer of values for asthma from literature to the OA case. • What if not done? Estimates for loss of earnings still possible, though given time lags between studies in literature the values may be different in reality. Estimate of WTP for OA may be possible to elicit. • Robustness of estimates – from survey a sample of 50, the survey would be representative of population affected. Population affected determines survey size – of course if 100 surveyed then would be more robust, but 50 is a large enough sample for this case. • Reliability – other studies have used a “what if” scenario, eg to value impact on welfare of health changes. The reliability of estimates will depend critically on description of impacts of OA on possibility to work and question framing to assess likely employment impacts. Metroeconomica has experience in this from value of health risk study for European Commission.

31. How can the cost information be presented in a sufficiently robust way to influence employers and withstand challenge? • Uncertainty bounds for cost/epidemiological data with assessment of uncertainty shown • Cost broken down into elements and double counting taken into account in any aggregation • Stakeholder consultation in the collection of data and before results presented to raise major issues and to provide for clarification of any issues raised. • Employers will be surveyed as part of the project. • Case studies of examples of potential adaptation options will be presented to encourage employers to think of potential adaptations in their health and safety policies.

32. How much confidence is there that the methodology for the survey is likely to provide information needed? • Ideally we would want to survey OA sufferers directly but ethics panel requirements means this impossible. • Our method will yield estimates on WTP to avoid OA, based on an established technique (contingent valuation) for pain and suffering. • Has been used in the past, requires a good explanation of the scenario which Metroeconomica would construct with the epidemiologists. • This analysis will also be used to attempt to firm up estimates of income effects from literature. The literature presents at too aggregate a level for sufficient accuracy on this – so what if is the only way we can go.