Direct and indirect costs of allergic and non‐allergic rhinitis in the Netherlands
2020; Wiley; Volume: 75; Issue: 11 Linguagem: Inglês
10.1111/all.14457
ISSN1398-9995
AutoresKlementina Avdeeva, Sietze Reitsma, Wytske J. Fokkens,
Tópico(s)Nasal Surgery and Airway Studies
ResumoAllergyVolume 75, Issue 11 p. 2993-2996 LETTER TO THE EDITOROpen Access Direct and indirect costs of allergic and non-allergic rhinitis in the Netherlands Klementina S. Avdeeva, Corresponding Author Klementina S. Avdeeva k.avdeeva@amsterdamumc.nl orcid.org/0000-0002-3910-4371 Department of Otorhinolaryngology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, The Netherlands Correspondence Klementina S. Avdeeva, KNO research, Amsterdam UMC, location Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. Email: k.avdeeva@amsterdamumc.nlSearch for more papers by this authorSietze Reitsma, Sietze Reitsma Department of Otorhinolaryngology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, The NetherlandsSearch for more papers by this authorWytske J. Fokkens, Wytske J. Fokkens orcid.org/0000-0003-4852-229X Department of Otorhinolaryngology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, The NetherlandsSearch for more papers by this author Klementina S. Avdeeva, Corresponding Author Klementina S. Avdeeva k.avdeeva@amsterdamumc.nl orcid.org/0000-0002-3910-4371 Department of Otorhinolaryngology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, The Netherlands Correspondence Klementina S. Avdeeva, KNO research, Amsterdam UMC, location Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. Email: k.avdeeva@amsterdamumc.nlSearch for more papers by this authorSietze Reitsma, Sietze Reitsma Department of Otorhinolaryngology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, The NetherlandsSearch for more papers by this authorWytske J. Fokkens, Wytske J. Fokkens orcid.org/0000-0003-4852-229X Department of Otorhinolaryngology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, The NetherlandsSearch for more papers by this author First published: 16 June 2020 https://doi.org/10.1111/all.14457Citations: 4AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat To the Editor, Chronic rhinitis is a symptomatic inflammation of nasal mucosa that lasts at least 12 weeks per year. Both allergic (AR) and non-allergic (NAR) rhinitis are highly prevalent: they affect about 30% and 10% of population, respectively.1 About 30% of patients with chronic rhinitis have a mixed form, and several endotypes of chronic rhinitis have been described.2 Considering the high prevalence and the impact on general well-being,3 chronic rhinitis has a significant financial impact due to direct costs (medications, healthcare visits etc) and indirect costs (absenteeism and presenteeism). To our knowledge, no data on financial costs of non-allergic rhinitis are currently available. In order to estimate direct and indirect costs of allergic and non-allergic rhinitis in the Netherlands, we performed a cross-sectional study in patients with allergic and non-allergic rhinitis visiting their family doctors and the patients of the Department of Otorhinolaryngology of Amsterdam UMC, location AMC, in the Netherlands (secondary/tertiary healthcare facility). Details on the materials and methods are given in the online repository (App S1). Questionnaires were obtained from 512 participants with rhinitis and 23 healthy controls. By the nature of these questionnaires, direct costs and absenteeism were not disease-specific, whereas presenteeism was. The characteristics of the study population are presented in Table 1. The baseline characteristics of the control group were comparable to the chronic rhinitis groups. Table 1. Characteristics of the participants NAR N = 159 AR N = 350 Total rhinitis N = 512a a The total number of rhinitis patients is higher than the sum of AR and NAR patients, because in three patients, no allergy test data were available. Their answers were used for calculation of costs in the “Total rhinitis” group. Controls N = 23 Primary care patient 84 (53%) 288 (82%) 375 (73%) n/a Secondary/tertiary care patient 75 (47%) 62 (18%) 137 (27%) n/a Age 44.9 ± 17.7 37.3 ± 13.7 40.0 ± 15.4 43.1 ± 15.6 Gender Male 52 (33%) 128 (36%) 182 (35%) 5 (22%) Female 106 (66%) 219 (63%) 326 (64%) 18 (78%) No answer 1 (1%) 3 (1%) 4 (1%) 0 Education No education 1 (0.5%) 1 (0.5%) 2 (0.5%) 0 Primary education 1 (0.5%) 6 (2%) 7 (1.5%) 1 (4.5%) Lower secondary education 27 (17%) 46 (13%) 74 (15%) 2 (9%) Upper secondary education 61 (38.5%) 139 (39.5%) 201 (40%) 5 (22%) Bachelor or equivalent 43 (27%) 100 (28%) 144 (28%) 7 (30%) Master or equivalent 15 (10%) 39 (11%) 54 (10%) 7 (30%) Other 10 (6%) 16 (5%) 26 (5%) 1 (4.5%) Unknown 1 (0.5%) 3 (1%) 4 (1%) 0 Present employment Student 23 (14%) 49 (14%) 72 (14%) 1 (4%) Paid employment 80 (50%) 222 (63%) 304 (59%) 16 (70%) Self-employed 16 (10%) 26 (7%) 42 (8%) 2 (9%) Housewife 8 (5%) 19 (5%) 28 (6%) 0 Unemployed 4 (3%) 10 (3%) 14 (3%) 0 Disabled 4 (3%) 9 (3%) 13 (2%) 0 Pension 22 (14%) 10 (3%) 32 (6%) 4 (17%) Other 2 (1%) 3 (1%) 5 (1%) 0 Unknown 2 (1%) 2 (1%) 0 ARIA classification Mild 26 (16%) 31 (9%) 57 (11%) n/a Moderate/severe 123 (78%) 304 (87%) 430 (84%) n/a Unknown 10 (6%) 15 (4%) 25 (5%) n/a QoL VAS 71.0 ± 18.8 74.1 ± 19.1 73.1 ± 19.0 85 ± 12.6 CARAT nasal domain 6.5 ± 3.0 6.3 ± 3.0 6.3 ± 3.0 n/a Controlled CARAT, nasal domain, N 56 (40%) 109 (37%) 165 (38%) n/a Blocked nose (Almost) every day 68 (43%) 115 (33%) 183 (36%) n/a More than 2 d a week 34 (21%) 64 (18%) 100 (19%) n/a 1 or 2 d a week 26 (16%) 105 (30%) 131 (26%) n/a Never 31 (20%) 62 (18%) 94 (18%) n/a CARAT pulmonary domain 13.3 ± 3.5 13.3 ± 3.8 13.2 ± 3.7 n/a Controlled CARAT, pulmonary domain, N 42 (28%) 108 (32%) 150 (30%) n/a CARAT total 20.0 ± 5.2 20.0 ± 5.5 20.0 ± 5.4 n/a Presence of asthma/pulmonary complaints 37 (26%) 91 (28%) 129 (27%) 2 (10%) Diagnosed asthma 16 (11%) 73 (22%) 89 (19%) 1 (4%) Smoking status Current smoker 30 (19%) 53 (15%) 84 (17%) 3 (13%) Former smoker 39 (25%) 64 (18%) 104 (21%) 7 (30%) Never smoked 87 (56%) 230 (66%) 318 (62%) 13 (57%) Allergy type Grass/tree pollen 303 (89%) House dust mite 184 (54%) Other 133 (39%) Immunotherapy use SCIT 30 (9%) SLIT 15 (4%) Abbreviations: AR, allergic rhinitis; ARIA, Allergic Rhinitis and its Impact on Asthma; CARAT, Control of Allergic Rhinitis and Asthma Test; NAR, non-allergic rhinitis; SCIT, subcutaneous immunotherapy; SLIT, sublingual immunotherapy; VAS, visual analogue scale. a The total number of rhinitis patients is higher than the sum of AR and NAR patients, because in three patients, no allergy test data were available. Their answers were used for calculation of costs in the “Total rhinitis” group. Total costs of chronic rhinitis were €5042 patient/year (€5258 patient/year of NAR, €4827 patient/year of AR). Direct costs were €1043 patient/year vs €793 in controls. As the direct costs were not disease-specific, the most expensive component was daycare procedures (such as grommets placement, immunotherapy and gastroscopy). In the (relatively small) control group, average direct costs were dominated by specialist visits and hospital admission by some subjects. Indirect costs in the chronic rhinitis group were €3999 patient/year: €1329 for absenteeism, €2390 for (disease-specific) presenteeism and €280 for unpaid work (Table 2). On average, absenteeism costs were increased fourfold in rhinitis patients compared with controls, while presenteeism costs were increased eightfold. As such, the average total costs in rhinitis patients were increased with around €3650 patient/year, mainly due to a significant increase in presenteeism costs. Indeed, presenteeism costs were the highest component in all employed subgroups, except for those with mild rhinitis and those currently smoking. Table 2. Subgroup analyses of patients with chronic rhinitis, mean costs per individual/year, € N Direct costs Indirect costs: absenteeism Indirect costs: presenteeism Indirect costs: unpaid work Total costsa a Total direct costs are different from a sum of costs presented in the table due to rounding up of the numbers. Controls 23 793 330 285 0 1408 All rhinitis 512 1043 1329 2390 280 5042 NAR 159 1110 1374 2195 580 5258 AR 350 1001 1252 2429 145 4827 Primary patient 375 621 1408 2118 72 4218 Secondary/tertiary patient 137 2200 1113 3135 850 7298 Gender Male 182 1197 1866 3146 175 6384 Female 326 959 1045 1997 342 4343 Age subgroups 16-18 4 259 853 0 0 1112 18-29 155 1066 1202 2011 309 4588 30-44 150 740 1324 2325 431 4821 44-65 159 934 1837 3079 163 6013 65+ 36 2294 0 1243 112 3649 Education No education 2 1776 0 0 420 2196 Primary education 7 4987 2726 542 0 8256 Lower secondary education 74 892 238 1347 95 2572 Upper secondary education 201 1073 1608 2634 95 5410 Bachelor or equivalent 144 884 1797 2808 502 5991 Master or equivalent 54 919 887 2234 442 4482 Other 26 1455 534 2302 782 5043 Employment status Student 72 1320 525 1202 306 3353 Paid employment 304 703 1884 3007 160 5754 Self-employed 42 947 1377 5045 308 7677 Housewife 28 1613 0 262 2052 3927 Unemployed 14 849 0 0 0 849 Disabled 13 3657 0 0 65 3722 Pension 32 2276 0 118 42 2436 Other 5 1165 2427 0 0 4072 ARIA classification Mild 57 970 1443 242 0 2655 Moderate/severe 430 1041 1389 2804 333 5566 Diagnosed with asthma 89 1506 470 1511 242 3728 Self-reported asthma/pulmonary complaints 129 1391 651 2456 255 4753 No self-reported asthma/pulmonary complaints 345 950 1586 2489 303 5328 Smoking status Current smoker 84 1382 2613 1702 598 6294 Former smoker 104 967 1293 3286 126 5674 Never smoked 318 990 1026 2310 252 4578 Abbreviations: AR, allergic rhinitis; ARIA, Allergic Rhinitis and its Impact on Asthma; NAR, non-allergic rhinitis. a Total direct costs are different from a sum of costs presented in the table due to rounding up of the numbers. According to the Central Bureau of Statistics, each year 5% of the Dutch population are seeking medical care due to allergic rhinitis complaints, which is about 730 000 patients of 16 years and older. Costs of these patients alone are around €3.5-€4.0 billion a year (€750 million due to direct, €3 billion due to indirect costs). Chronic rhinosinusitis (CRS) costs per patient are even higher than chronic rhinitis costs. In the Netherlands, CRS costs were found to be € 7160 patient/year (€1501 for direct and €5659 for indirect costs).4 But due to a lower prevalence, total annual costs of CRS are lower than those of chronic rhinitis, corresponding to €2 billion annually. The presented data could also be used as an estimation of the true costs of chronic rhinitis in the Netherlands. The current numbers could be an overestimation: the study included patients seeking medical care, mainly suffering from moderate/severe rhinitis, while in the general population, the proportion of mild chronic rhinitis cases is higher.5 As such, the average costs per patient in the general population are probably lower. Indeed, compared to the TOTALL study conducted in Sweden, rhinitis costs in our study were higher: €5042 vs €961 patient/year for total costs, while the same trends could be observed with presenteeism being the most expensive component.6 The TOTALL study included participants with self-reported allergic rhinitis, leading to 62% of the sample having mild rhinitis (compared to 11% in our study). Indeed, in studies including patients seeking medical care, the costs were higher: in Germany, in 2003 the total costs of allergic rhinitis (excluding productivity costs) were estimated to be around €1.543 patient/year.7 Ten years after, the direct costs of AR patients in Germany were estimated to be €1546 patient/year.8 Of course, other factors contributed largely to the found differences such as inclusion of NAR, reference prices and general healthcare expenditures. Still, if we would assume the same 62% of rhinitis patients to be mild in the Dutch population, the average costs would be €3761 patient/year. Assuming a prevalence of chronic rhinitis of 30%, the total costs in the general population would be at least €19.6 billion. On the other hand, there are several factors that could lead to underestimation of the costs. First, the last update of the used reference standard is based on prices of 2014, negating inflation of costs between 2015 and 2020. Second, for the calculation of medication costs we used a price of only one package of each reported medication at the lowest price reported by the Pharmacotherapeutic Compass of the Dutch National Healthcare Institute. Moreover, the participants only reported medication that they were currently using. We would estimate that both factors combined would give a 10% rise of the costs, meaning on average €4137 patient/year, or €21.6 billion annually in the Netherlands. Since the largest portion of costs is rhinitis-related presenteeism, one could argue that these costs could possibly be reduced by appropriate management of chronic rhinitis. Indeed, two thirds of participants had uncontrolled nasal complaints (CARAT score) and more than a half had nasal congestion on more than 2 days a week. Currently, a lot of patients are not being treated according to the guidelines and often self-medicate.9 Possibly, if the patients will receive care according to the guidelines, their complaints, and consequently presenteeism, could be reduced. Future prospective studies evaluating costs of patients receiving the treatment according to the guidelines are needed. To our knowledge, this is the first study to report costs of NAR. Future studies are needed to understand the costs of chronic rhinitis (especially of non-allergic rhinitis) in the general population. CONCLUSION The costs of both allergic and non-allergic rhinitis are high, with presenteeism being the most expensive component. ACKNOWLEDGMENTS Dr Avdeeva reports grants from ALK, from Allergy Therapeutics, from Mylan BV, during the conduct of the study. Dr Reitsma reports grants from ALK, from Allergy Therapeutics , from Mylan BV, during the conduct of the study. Dr Fokkens reports grants from ALK, from Allergy Therapeutics , from Mylan BV, during the conduct of the study. CONFLICTS OF INTEREST This study was helped with an educational grant of MEDA, ALK and Allergy Therapeutics. Supporting Information Filename Description all14457-sup-0001-AppS1.docxWord document, 75.9 KB App S1 Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. REFERENCES 1Reitsma S, Subramaniam S, Fokkens WWJ, Wang Y. Recent developments and highlights in rhinitis and allergen immunotherapy. Allergy. 2018; 73(12): 2306- 2313. Wiley Online LibraryPubMedWeb of Science®Google Scholar 2Meng Y, Lou H, Wang Y, et al. Endotypes of chronic rhinitis: a cluster analysis study. Allergy. 2019; 74(4): 720- 730. 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