Economic Impact and Quality-of-Life Burden of Allergic Rhinitis

William F. Schoenwetter; Leon Dupclay, Jr; Sireesh Appajosyula; Marc F. Botteman; Chris L. Pashos

Disclosures

Curr Med Res Opin. 2004;20(3) 

In This Article

Health Economics of Allergic Rhinitis and Asthma

Increased absenteeism and reduced productivity due to allergies cost US employers more than $250 million in 1998.[6] ($291.6 million in 2002 dollars). In a study of 5000 employees at 57 companies, 34% of employees with allergies said they missed an average of 1-5 days of work per year as a direct result of allergy symptoms. Further, 82% of those with allergies reported a 26% loss of effectiveness at work due to allergy symptoms. Employees were affected an average of 69.9 days annually.[6]

To evaluate the impact of asthma and rhinitis on the workforce, Blanc et al.[52] conducted a telephone survey in a randomly selected, population-based group of adults in northern California who had asthma with or without rhinitis, and rhinitis alone. Individuals diagnosed with asthma were less likely to be employed after they received this diagnosis than were those with rhinitis (p = 0.002). Interestingly, of the people who were employed after their respiratory disorder had been diagnosed, those with rhinitis alone reported greater decreases in job effectiveness than those with asthma (p = 0.02). Exclusion from analysis of rhinitis patients who were likely to have undiagnosed or unreported asthma did not affect the findings.[52]

Overall health-care costs for allergic rhinitis, which are accelerating at a rate of 12% per year and are projected to soar by 76% by 2005,[53] include direct costs, i.e., costs related to patient care, and indirect costs, i.e., costs of disease consequences, such as absenteeism and reduced productivity at school or work.[7] In addition, there are 'hidden costs' of allergic rhinitis, such as those related to its tendency to lead to inflammatory airway diseases and other respiratory complications and those related to the adverse effects of OTC sedating antihistamines and decongestants used in self-treatment.

When possible, costs reported here are those originally published, with an update to 2002 costs by using the health-care component of the consumer price index (CPI). Updated costs appear in parentheses following the original published costs. When the year was not specified, the year of publication was used.

Direct costs of a disease can be medical - such as the cost of medications, office visits, emergency room visits, diagnostic testing, home health-care devices, and hospitalizations.[7] or nonmedical, including transportation to and from the health-care provider and the purchase of home aids and services (e.g., special diets, home help). Total direct costs for allergic rhinoconjunctivitis differ according to methods of assessment, but were reportedly as high as $5.9 billion in 1996 (2002 cost, $7.3 billion), according to Ray et al.[39] Figure 3). Data for this study were compiled from records that listed allergic rhinitis as either the primary diagnosis or as secondary to asthma, otitis media, or sinusitis, as identified through the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding system. The care of allergic rhinoconjunctivitis in children up to the age of 12 years accounted for 38%, or $2.3 billion (2002, $2.8 billion) of the total. As shown in Figure 3, the greatest single-category expenditure (1996, $3.7 billion; 2002, $4.6 billion) was for outpatient services, mainly visits to a physician or clinic. Another cost-effectiveness study for 1996 estimated that direct costs for allergic rhinitis exceeded $3 billion, with an additional cost of $4 billion from exacerbations of other concomitant conditions, such as asthma or otitis media.[54]

Direct medical expenditures for the diagnosis and treatment of allergic rhinoconjunctivitis (1996 dollars). When extrapolated to 2002 dollars using the Consumer Price Index, the cost of allergic rhinitis as the primary diagnosis would be $2.35 billion; for allergic rhinoconjunctivitis as the secondary diagnosis it would be $4.95 billion. Total expenditures would be $7.3 billion ($4.58 billion for outpatient services, $1.86 billion for medications, and $0.87 billion for inpatient services). Adapted from Ray et al., 1999.[39]

According to 1997 survey data from primary care physicians, 16.9 million office visits were made for sinus problems and nasal congestion, which are symptoms suggestive of, or associated with, allergic rhinitis.[55] Allergic rhinitis itself comprised 7.7 million visits, and related conditions comprised an additional 40.3 million visits. (The latter included otitis media 17.2 million, chronic sinusitis 13.3 million, and asthma 9.8 million.[55])

In a cost-of-illness study using 1994 data, Malone et al. found that direct costs represented 94% of the total cost for allergic rhinitis, and that visits to a primary care provider comprised 68% of these direct costs.[4] Likewise, another assessment of 1994 costs reported a $1.2 billion dollar total expenditure for allergic rhinitis, most of which was attributed to direct costs, but with cost of medication being the single largest component.[56] Lee et al.,[57] in a 2001 review, assessed the medical and pharmaceutical costs of allergic rhinitis for more than 200 000 patients and found that pharmacy charges comprised approximately 50% of the annual (total) costs per patient.

In an analysis of Stempel and Woolf,[58] the cost of prescription drugs to treat allergic rhinitis in the year 2000 amounted to $6 billion. Of the two most commonly prescribed medications - nonsedating antihistamines and intranasal corticosteroids - these investigators, citing recent studies, recommended the latter. When used on an as-needed basis, they stated, intranasal corticosteroids are highly effective in relieving nasal symptoms, cost less than nonsedating antihistamines, and thus are more cost effective. Other studies support the conclusions of these investigators.[54,59,60] The safety record of intranasal corticosteroids has been called into question, however, since some of these agents have been associated with effects on hypothalamic-pituitary-adrenal (HPA) function.[61,62,63,64] This may be of particular concern in children since negative effects on the HPA axis may have an adverse effect on growth. In one study, beclomethasone nasal spray, which is not recommended for use in the pediatric population, was shown to retard children's growth.[65,66]

Law et al.[67] used data from the 1996 Medical Expenditure Panel Survey (MEPS) to estimate total direct expenditures for allergic rhinitis. Their analysis showed that the majority of total direct costs for that year ($3.4 billion) was attributable to prescription medications (46.6%) and outpatient visits (51.9%). Second-generation antihistamines accounted for 51% of prescription drug expenditures, intranasal corticosteroids for 25%, and first-generation antihistamines for 5%. The investigators concluded that direct costs for allergic rhinitis have increased substantially since the introduction of second-generation antihistamines and intranasal corticosteroids, especially costs attributable to prescription medications.

Mast cell stabilizers, such as cromolyn sodium, are available OTC and have also gained support for their efficacy in treating symptoms of SAR and PAR.[68,69,70,71] While further studies are needed comparing the efficacy of cromolyn with second-generation antihistamines, one study reported equal efficacy for cromolyn and first-generation antihistamines in patients with SAR.[70] To date, mast cell stabilizers have had an excellent safety record: they are nonsedating and have not shown evidence of the reduced growth velocity associated with some intranasal corticosteroids. Their availability OTC also suggests a cost-saving potential.

As discussed above, symptoms related to allergic rhinitis result in a total of 28 million days of reduced function or productivity each year,[7] including a loss of 3.5 million workdays and 2 million school days due to absenteeism.[44]

In the cost-of-illness data reported by Malone and coworkers,[4] 94% of total health-care costs were attributable to direct costs, leaving 6% for indirect costs.[4] However, because the study did not specify that the components of indirect costs were used as endpoints, this finding may be questioned. Further, in this 1987 analysis, approximately 38.9 million people in the United States experienced allergic rhinitis, but only 4.8 million of these sought medical treatment and received a primary diagnosis of allergic rhinitis. Only these patients were included in the analysis, making the findings difficult to interpret.

Using the extensive MEPS database, Law et al.,[72] in 2002, surveyed the insurance records of 20.86 million outpatients with allergic rhinitis as either the primary or secondary listed diagnosis ( Table 3 ). Total costs in 1996 were $3.930 billion (2002 cost, $4.863 billion). Direct and indirect costs for allergic rhinitis comprised 86.3% and 13.7%, respectively, of total costs. Direct costs represented visits to the emergency room, outpatient services, and prescription medicines. Indirect costs were identified as losses in productivity, calculated as the number of school days or workdays missed in a year due to allergic rhinitis. National wage data were used as the multiplier. Patient-specific sampling weights were provided by the 1996 MEPS.[44]

The Law study.[72] may have underestimated the true costs of allergic rhinitis because of the following: (1) The patient sample was skewed toward white patients (86.3% white versus 8.5% black and 5.2% other races). (2) Calculations of direct costs did not include OTC medications or prescriptions for comorbid airway diseases, even though allergic rhinitis was the secondary diagnosis in some cases. (3) Calculations of indirect costs did not include productivity slowdowns (i.e., reduced workflow), nor did it consider the number of workdays missed by parents because their children required parental home care for allergic rhinitis.

In a study by Berger[73] in 1999, SAR was shown to incur indirect costs attributed to the loss of productivity of $2.39 billion for men (2002 cost, $2.7 billion) and $1.4 billion for women (2002, $1.58 billion).[9,21,73] Crystal-Peters et al.,[74] using data contained in the 1995 National Health Interview Survey, estimated productivity losses associated with a diagnosis of allergic rhinitis to be $601 million. When use of sedating OTC antihistamines and workers' assessment of their reduction in at-work productivity were considered, estimated productivity loss increased dramatically to range from $2.4 to $4.6 billion.

According to Bousquet and the Allergic Rhinitis and Its Impact on Asthma (ARIA) Workshop Group,[27] literature on the economic impact of allergic rhinitis is much more modest than that of asthma. In Japan, all people belong to government, union, or community health insurances, making healthcare expenditures much easier to quantify than in other countries. In 1994, using databases of these organizations, total costs for allergic rhinitis in Japan, including direct, indirect, and OTC charges, were $1.15 billion.

Inadequately treated or untreated allergic rhinitis can be associated with a dramatic increase in the cost of caring for comorbid conditions such as asthma, recurrent nasal polyps, sinusitis, and chronic otitis media.[75] These are among the hidden costs of allergic rhinitis. A survey of over 34,000 patients with asthma demonstrated that costs for those with allergic rhinitis and asthma were roughly twice those for patients with asthma alone.[76] These findings reinforce the results of Yawn et al.,[77] who found that annual medical charges for patients with coexistent allergic rhinitis and asthma were 46% higher than those for patients with asthma alone. Included were costs for the patient's total medical care and for specific respiratory care services at several medical centers in Minnesota.[77]

Allergic rhinitis and asthma are common comorbidities linked by epidemiologic, pathologic, and physiologic characteristics.[27,29,78] The link between the nasal passages and lungs is unidirectional, from the nasal passages and sinuses down to the lungs via the contiguous mucous membranes.[76] It is thus clinically prudent to require that all patients diagnosed with allergic rhinitis be evaluated for signs of asthma, and conversely, that all patients with asthma be checked for signs of allergic rhinitis to reduce risk of disease progression and help ensure optimal treatment. It may also be cost effective since the cost of treatment in allergic rhinitis patients who also have asthma is significantly increased.[27] Conversely, rhinitis increases asthma costs. In one study cited by Bousquet et al.,[27] yearly medical charges for those with asthma and concomitant allergic rhinitis were 46% higher than for those with asthma alone.

Out-of-pocket costs are those incurred directly by the patient. They are frequently not included in cost-of-illness studies done from the perspective of health plans because they are not incurred by third-party payers, are often derived from patient self-reports, and are difficult to quantify and validate. However, in the context of allergic rhinitis, these costs can represent a significant portion of the total cost of care. Most people self-medicate with OTC medications or home remedies. This treatment approach can present drawbacks, as indicated by studies cited here showing a reduction in workplace productivity due to sedating antihistamines.40 Further, patients may experience rhinitis recurrences and an increase in disease severity.

Allergic rhinitis and its comorbidities are associated with extensive use of outpatient resources, especially visits to physicians' offices.[4,33,55] However, as noted, the majority (87.6%) of patients with allergic rhinitis do not seek medical attention.[4] Costs incurred by patients who do see a physician may thus represent only a fraction of the total expenditure for this disease.

Various methodological limitations of health economic studies may modify the conclusions drawn concerning the economic burden of allergic rhinitis. Omissions may account for certain discrepancies. For example, in the study by Crystal-Peters et al.[74] of cost of lost productivity, work losses of parents caring for children who missed school were not taken into consideration. Evidence on the potential existence of comorbid conditions, which could add to the overall cost of treatment, was also not examined. Further, cost estimates for OTC antihistamines were based on self-reports, which may have been inaccurate, rather than objective measurements.

Two recent reviews of the Agency for Healthcare Research and Quality, conducted under its Evidencebased Practice Program (EPC), discussed general diagnosis and treatment issues related to allergic rhinitis.[60,79] While the reviews basically agreed on the substantial economic burden resulting from direct and indirect costs of allergic rhinitis, they also demonstrated that most cost-effectiveness evidence comes from clinical trials using low-quality methodologies. For example, neither of the reviews found studies that distinguished between allergic rhinitis, which is triggered by seasonal and perennial allergens, and nonallergic rhinitis, which lacks identifiable allergic triggers. Only 13 trials on the efficacy of treatments for nonallergic rhinitis were identified, whereas numerous treatment modalities for allergic rhinitis have been studied.

Cost-effectiveness literature on allergic rhinitis was also found to be relatively small in quantity and often lacking in several variables, for example, standardized measures of effectiveness, prospectively collected cost or resource utilization data, and extrapolation of effectiveness data in short-term trials to long-term economic analyses.[79] Subjective versus objective measurements of productivity loss was another weakness uncovered in these reviews, with the former method tending to overemphasize productivity limitations. Thus exact measurements of indirect costs may be called into question in some of the health economic analyses conducted to date.[79]

Other limitations of health economic studies uncovered by investigators in the EPC included a focus on air filtration systems, which do not appear to decrease rhinitis symptoms; lack of consideration of racial variations in treatment outcomes; and lack of accurate assessments of OTC medication use.

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