Economics of Chronic Rhinosinusitis

Rhinosinusitis (J Mullol, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Rhinosinusitis

Abstract

Purpose of Review

The objective of this article is to provide an updated review of the economic burden of chronic rhinosinusitis (CRS) and discuss how both medical and surgical interventions impact direct and indirect costs related to CRS. By understanding the economics of CRS, clinicians may improve the patient-centeredness of their care and help distinguish between low and high value interventions.

Recent Findings

Direct costs related to CRS are primarily driven by outpatient physician visits, prescription medical therapy, and endoscopic sinus surgery (ESS). CRS produces large indirect costs and these costs often vary based on the severity of the patients CRS-specific QoL impairment. The overall direct cost related to CRS is estimated to range between $10 and $13 billion per year in the USA. The overall indirect cost related to CRS-related losses in work productivity is estimated to be in excess of $20 billion per year.

Summary

In the appropriate patients with refractory CRS, ESS provides significant reductions in both direct and indirect costs; however, continued medical therapy alone may be a high value intervention in select patients who have lower severity in their baseline QoL and work productivity.

Keywords

Chronic sinusitis Rhinosinusitis Pharmacoeconomics Cost Economic Burden of disease Value of care 

Notes

Compliance with Ethical Standards

Conflict of Interest

Dr. Rudmik declares no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Funding

None.

Financial Disclosures

Scientific advisory board for BioInspire and 480 Biomedical.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Payne SC, Borish L, Steinke JW. Genetics and phenotyping in chronic sinusitis. J Allergy Clin Immunol. 2011;128:710–20. Quiz 721–712 CrossRefPubMedGoogle Scholar
  2. 2.
    Soler ZM, Hyer JM, Ramakrishnan V, et al. Identification of chronic rhinosinusitis phenotypes using cluster analysis. International forum of allergy & rhinology. 2015;5:399–407.CrossRefGoogle Scholar
  3. 3.
    •• Rudmik L, Soler ZM. Medical therapies for adult chronic sinusitis: a systematic review. JAMA. 2015;314:926–39. Robust systematic review outlining the literature on various forms of medical therapy for CRS and provides a helpful evidence-based approach to managing CRS. CrossRefPubMedGoogle Scholar
  4. 4.
    Fokkens WJ. Phenotyping, endotyping and clinical decision-making. Rhinology. 2016;54:97–8.PubMedGoogle Scholar
  5. 5.
    Soler ZM, Mace J, Smith TL. Symptom-based presentation of chronic rhinosinusitis and symptom-specific outcomes after endoscopic sinus surgery. Am J Rhinol. 2008;22:297–301.CrossRefPubMedGoogle Scholar
  6. 6.
    Alt JA, Smith TL. Chronic rhinosinusitis and sleep: a contemporary review. International forum of allergy & rhinology. 2013;3:941–9.CrossRefGoogle Scholar
  7. 7.
    Schlosser RJ, Storck K, Cortese BM, Uhde TW, Rudmik L, Soler ZM. Depression in chronic rhinosinusitis: a controlled cohort study. American journal of rhinology & allergy. 2016;30:128–33.CrossRefGoogle Scholar
  8. 8.
    Steinke JW. The relationship between rhinosinusitis and asthma sinusitis. Current allergy and asthma reports. 2006;6:495–501.CrossRefPubMedGoogle Scholar
  9. 9.
    Rudmik L, Smith TL. Quality of life in patients with chronic rhinosinusitis. Current allergy and asthma reports. 2011;11:247–52.CrossRefPubMedGoogle Scholar
  10. 10.
    Smith KA, Rudmik L. Medical therapy, refractory chronic rhinosinusitis, and productivity costs. Curr Opin Allergy Clin Immunol. 2017;17:5–11.CrossRefPubMedGoogle Scholar
  11. 11.
    Smith KA, Orlandi RR, Rudmik L. Cost of adult chronic rhinosinusitis: a systematic review. Laryngoscope. 2015;125:1547–56.CrossRefPubMedGoogle Scholar
  12. 12.
    Gawande AA, Colla CH, Halpern SD, Landon BE. Avoiding low-value care. N Engl J Med. 2014;370:e21.CrossRefPubMedGoogle Scholar
  13. 13.
    Porter ME, Lee TH. From volume to value in health care: the work begins. JAMA. 2016;316:1047–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Hirsch SD, Reiter ER, DiNardo LJ, Wan W, Schuman TA. Elimination of pain improves specificity of clinical diagnostic criteria for adult chronic rhinosinusitis. The Laryngoscope 2017.Google Scholar
  15. 15.
    Stankiewicz JA, Chow JM. A diagnostic dilemma for chronic rhinosinusitis: definition accuracy and validity. Am J Rhinol. 2002;16:199–202.PubMedGoogle Scholar
  16. 16.
    Hsu J, Pacheco JA, Stevens WW, Smith ME, Avila PC. Accuracy of phenotyping chronic rhinosinusitis in the electronic health record. American journal of rhinology & allergy. 2014;28:140–4.CrossRefGoogle Scholar
  17. 17.
    Novis SJ, Akkina SR, Lynn S, Kern HE, Keshavarzi NR, Pynnonen MA. A diagnostic dilemma: chronic sinusitis diagnosed by non-otolaryngologists. International forum of allergy & rhinology. 2016;6:486–90.CrossRefGoogle Scholar
  18. 18.
    Macdonald KI, Kilty SJ, van Walraven C. Chronic rhinosinusitis identification in administrative databases and health surveys: a systematic review. Laryngoscope. 2016;126:1303–10.CrossRefPubMedGoogle Scholar
  19. 19.
    Halawi AM, Smith SS, Chandra RK. Chronic rhinosinusitis: epidemiology and cost. Allergy and asthma proceedings. 2013;34:328–34.CrossRefPubMedGoogle Scholar
  20. 20.
    Hastan D, Fokkens WJ, Bachert C, et al. Chronic rhinosinusitis in Europe—an underestimated disease. A GA(2)LEN study. Allergy. 2011;66:1216–23.CrossRefPubMedGoogle Scholar
  21. 21.
    Xu Y, Quan H, Faris P, et al. Prevalence and incidence of diagnosed chronic rhinosinusitis in Alberta, Canada. JAMA otolaryngology-- head & neck surgery. 2016;142:1063–9.CrossRefGoogle Scholar
  22. 22.
    Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: national health interview survey, 2012. Vital and health statistics Series 10, Data from the National Health Survey 2014:1–161.Google Scholar
  23. 23.
    Chen Y, Dales R, Lin M. The epidemiology of chronic rhinosinusitis in Canadians. Laryngoscope. 2003;113:1199–205.CrossRefPubMedGoogle Scholar
  24. 24.
    Bhattacharyya N. Incremental health care utilization and expenditures for chronic rhinosinusitis in the United States. The Annals of otology, rhinology, and laryngology. 2011;120:423–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Pilan RR, Pinna FR, Bezerra TF, et al. Prevalence of chronic rhinosinusitis in Sao Paulo. Rhinology. 2012;50:129–38.PubMedGoogle Scholar
  26. 26.
    Fokkens WJ, Lund VJ, Mullol J, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology. 2012;50:1–12.PubMedGoogle Scholar
  27. 27.
    Bhattacharyya N, Orlandi RR, Grebner J, Martinson M. Cost burden of chronic rhinosinusitis: a claims-based study. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2011a;144:440–5.CrossRefGoogle Scholar
  28. 28.
    Akkina SR, Novis SJ, Keshavarzi NR, Pynnonen MA. Academic institution pilot study shows far fewer diagnoses of sinusitis than reported nationally. Laryngoscope investigative otolaryngology. 2016;1:124–9.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Smith KA, Rudmik L. Cost collection and analysis for health economic evaluation. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2013;149:192–9.CrossRefGoogle Scholar
  30. 30.
    Dieleman JL, Baral R, Birger M, et al. US spending on personal health care and public health, 1996–2013. JAMA. 2016;316:2627–46.CrossRefPubMedGoogle Scholar
  31. 31.
    • Caulley L, Thavorn K, Rudmik L, Cameron C, Kilty SJ. Direct costs of adult chronic rhinosinusitis by using 4 methods of estimation: results of the US medical expenditure panel survey. J Allergy Clin Immunol. 2015;136:1517–22. Using four different methods of cost estimation, the overall annual direct cost of CRS in the US ranged between $4.5 and $12.5 billion. CrossRefPubMedGoogle Scholar
  32. 32.
    Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: a systematic review. JAMA. 2015;314:2384–400.CrossRefPubMedGoogle Scholar
  33. 33.
    Zeller JL, Fontanarosa PB. Shared accountability, appropriateness, and quality of surgical care. JAMA. 2009;302:1590–1.CrossRefPubMedGoogle Scholar
  34. 34.
    Rudmik L, Mace J, Soler ZM, Smith TL. Long-term utility outcomes in patients undergoing endoscopic sinus surgery. Laryngoscope. 2014a;124:19–23.CrossRefPubMedGoogle Scholar
  35. 35.
    Soler ZM, Wittenberg E, Schlosser RJ, Mace JC, Smith TL. Health state utility values in patients undergoing endoscopic sinus surgery. Laryngoscope. 2011;121:2672–8.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Patel ZM, Thamboo A, Rudmik L, Nayak JV, Smith TL, Hwang PH. Surgical therapy vs continued medical therapy for medically refractory chronic rhinosinusitis: a systematic review and meta-analysis. International forum of allergy & rhinology 2016.Google Scholar
  37. 37.
    Gross CW, Zachmann GC, Becker DG, et al. Follow-up of University of Virginia experience with the modified Lothrop procedure. Am J Rhinol. 1997;11:49–54.CrossRefPubMedGoogle Scholar
  38. 38.
    Gliklich RE, Metson R. Economic implications of chronic sinusitis. Otolaryngology - Head & Neck Surgery. 1998a;118:344–9.CrossRefGoogle Scholar
  39. 39.
    Wang PC, Chu CC, Liang SC, Tai CJ. Cost-utility analysis for endoscopic sinus surgery. Otolaryngology - Head & Neck Surgery. 2004;130:31–8.CrossRefGoogle Scholar
  40. 40.
    Bhattacharyya N, Orlandi RR, Grebner J, Martinson M. Cost burden of chronic rhinosinusitis: a claims-based study. Otolaryngology - Head & Neck Surgery. 2011b;144:440–5.CrossRefGoogle Scholar
  41. 41.
    Au J, Rudmik L. Cost of outpatient endoscopic sinus surgery from the perspective of the Canadian government: a time-driven activity-based costing approach. International forum of allergy & rhinology. 2013;3:748–54.CrossRefGoogle Scholar
  42. 42.
    Chatterjee S, Laxminarayan R. Costs of surgical procedures in Indian hospitals. BMJ open 2013; 3.Google Scholar
  43. 43.
    Benninger MS, Holy CE. Endoscopic sinus surgery provides effective relief as observed by health care use pre- and postoperatively. Otolaryngology - Head & Neck Surgery. 2014a;150:893–900.CrossRefGoogle Scholar
  44. 44.
    Benninger MS, Holy CE. The impact of endoscopic sinus surgery on health care use in patients with respiratory comorbidities. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2014b;151:508–15.CrossRefGoogle Scholar
  45. 45.
    Holy CE, Ellison JM, Schneider C, Levine HL. The impact of balloon catheter dilation on frequency of sinus surgery in the United States. Med Devices (Auckl). 2014;7:83–9.CrossRefGoogle Scholar
  46. 46.
    Al Badaai Y, Valdes CJ, Samaha M. Outcomes and cost benefits of functional endoscopic sinus surgery in severely asthmatic patients with chronic rhinosinusitis. J Laryngol Otol. 2014;128:512–7.CrossRefPubMedGoogle Scholar
  47. 47.
    Chaker L, Falla A, van der Lee SJ, et al. The global impact of non-communicable diseases on macro-economic productivity: a systematic review. Eur J Epidemiol. 2015;30:357–95.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Bhattacharyya N. Contemporary assessment of the disease burden of sinusitis. American journal of rhinology & allergy. 2009;23:392–5.Google Scholar
  49. 49.
    Bhattacharyya N. Functional limitations and workdays lost associated with chronic rhinosinusitis and allergic rhinitis. American journal of rhinology & allergy. 2012;26:120–2.CrossRefGoogle Scholar
  50. 50.
    • Rudmik L, Smith TL, Schlosser RJ, Hwang PH, Mace JC, Soler ZM. Productivity costs in patients with refractory chronic rhinosinusitis. Laryngoscope. 2014b;124:2007–12. Patients with refractory CRS who choose to undergo sinus surgery had a mean indirect cost of approximately $10,000 per year. Indirect costs were associated with the degree of quality of life impairment. CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Alobid I, Benitez P, Bernal-Sprekelsen M, et al. Nasal polyposis and its impact on quality of life: comparison between the effects of medical and surgical treatments. Allergy. 2005;60:452–8.CrossRefPubMedGoogle Scholar
  52. 52.
    Baguley C, Brownlow A, Yeung K, Pratt E, Sacks R, Harvey R. The fate of chronic rhinosinusitis sufferers after maximal medical therapy. International forum of allergy & rhinology. 2014;4:525–32.CrossRefGoogle Scholar
  53. 53.
    Smith KA, Rudmik L. Impact of continued medical therapy in patients with refractory chronic rhinosinusitis. International forum of allergy & rhinology. 2014;4:34–8.CrossRefGoogle Scholar
  54. 54.
    Smith TL, Kern R, Palmer JN, et al. Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi-institutional study with 1-year follow-up. International forum of allergy & rhinology. 2013;3:4–9.CrossRefGoogle Scholar
  55. 55.
    Jafari A, DeConde AS. Outcomes in medical and surgical treatment of nasal polyps. Adv Otorhinolaryngol. 2016;79:158–67.PubMedGoogle Scholar
  56. 56.
    Dautremont JF, Rudmik L. When are we operating for chronic rhinosinusitis? A systematic review of maximal medical therapy protocols prior to endoscopic sinus surgery. International forum of allergy & rhinology. 2015;5:1095–103.CrossRefGoogle Scholar
  57. 57.
    Lund VJ. Maximal medical therapy for chronic rhinosinusitis. Otolaryngol Clin N Am. 2005;38:1301–10. x CrossRefGoogle Scholar
  58. 58.
    •• Rudmik L, Soler ZM, Hopkins C, et al. Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study. Rhinology. 2016a;54:117–28. To optimize the value of care, patients with uncomplicated CRS who receive sinus sugery should have a minimum degree of quality of life impairment (SNOT-22 >20), fail a defined trial of appropriate medical therapy, and have objective evidence of inflammation on CT imaging. PubMedGoogle Scholar
  59. 59.
    Lee VS, Kawamoto K, Hess R, et al. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016;316:1061–72.CrossRefPubMedGoogle Scholar
  60. 60.
    Gliklich RE, Metson R. Economic implications of chronic sinusitis. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 1998b;118:344–9.CrossRefGoogle Scholar
  61. 61.
    Benninger MS, Holy CE. Endoscopic sinus surgery provides effective relief as observed by health care use pre- and postoperatively. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2014c;150:893–900.CrossRefGoogle Scholar
  62. 62.
    Stankiewicz J, Tami T, Truitt T, et al. Impact of chronic rhinosinusitis on work productivity through one-year follow-up after balloon dilation of the ethmoid infundibulum. International forum of allergy & rhinology. 2011;1:38–45.CrossRefGoogle Scholar
  63. 63.
    Rudmik L, Soler ZM, Smith TL, Mace JC, Schlosser RJ, DeConde AS. Effect of continued medical therapy on productivity costs for refractory chronic rhinosinusitis. JAMA otolaryngology-- head & neck surgery. 2015a;141:969–73.CrossRefGoogle Scholar
  64. 64.
    Rudmik L, Smith TL, Mace JC, Schlosser RJ, Hwang PH, Soler ZM. Productivity costs decrease after endoscopic sinus surgery for refractory chronic rhinosinusitis. Laryngoscope. 2016b;126:570–4.CrossRefPubMedGoogle Scholar
  65. 65.
    Smith TL, Kern RC, Palmer JN, et al. Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi-institutional study. International forum of allergy & rhinology. 2011;1:235–41.CrossRefGoogle Scholar
  66. 66.
    Luk LJ, Steele TO, Mace JC, Soler ZM, Rudmik L, Smith TL. Health utility outcomes in patients undergoing medical management for chronic rhinosinusitis: a prospective multiinstitutional study. International forum of allergy & rhinology. 2015;5:1018–27.CrossRefGoogle Scholar
  67. 67.
    Smith KA, Smith TL, Mace JC, Rudmik L. Endoscopic sinus surgery compared to continued medical therapy for patients with refractory chronic rhinosinusitis. International forum of allergy & rhinology. 2014;4:823–7.CrossRefGoogle Scholar
  68. 68.
    Soler ZM, Hyer JM, Rudmik L, Ramakrishnan V, Smith TL, Schlosser RJ. Cluster analysis and prediction of treatment outcomes for chronic rhinosinusitis. J Allergy Clin Immunol. 2016;137:1054–62.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Akdis CA, Bachert C, Cingi C, et al. Endotypes and phenotypes of chronic rhinosinusitis: a PRACTALL document of the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma & Immunology. J Allergy Clin Immunol. 2013;131:1479–90.CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Bachert C, Zhang L, Gevaert P. Current and future treatment options for adult chronic rhinosinusitis: focus on nasal polyposis. J Allergy Clin Immunol. 2015;136:1431–40. Quiz 1441 CrossRefPubMedGoogle Scholar
  71. 71.
    Bachert C, Mannent L, Naclerio RM, et al. Effect of subcutaneous dupilumab on nasal polyp burden in patients with chronic sinusitis and nasal polyposis: a randomized clinical trial. JAMA. 2016;315:469–79.CrossRefPubMedGoogle Scholar
  72. 72.
    Lopez-Chacon M, Mullol J, Pujols L. Clinical and biological markers of difficult-to-treat severe chronic rhinosinusitis. Current allergy and asthma reports. 2015;15:19.CrossRefPubMedGoogle Scholar
  73. 73.
    • Rudmik L, Drummond M. Health economic evaluation: important principles and methodology. Laryngoscope. 2013;123:1341–7. Discusses important topics such as the various types of economic evaluation, the QALY, incremental cost effectiveness ratio, discounting, and handling of uncertainty. Good resource for clinicians interested in learning more about health economic evaluations. CrossRefPubMedGoogle Scholar
  74. 74.
    Scangas GA, Remenschneider AK, Su BM, Shrime MG, Metson R. Cost utility analysis of endoscopic sinus surgery for chronic rhinosinusitis with and without nasal polyposis. Laryngoscope. 2017;127:29–37.CrossRefPubMedGoogle Scholar
  75. 75.
    Scangas GA, Su BM, Remenschneider AK, Shrime MG, Metson R. Cost utility analysis of endoscopic sinus surgery for chronic rhinosinusitis. International forum of allergy & rhinology. 2016;6:582–9.CrossRefGoogle Scholar
  76. 76.
    Rudmik L, Soler ZM, Mace JC, Schlosser RJ, Smith TL. Economic evaluation of endoscopic sinus surgery versus continued medical therapy for refractory chronic rhinosinusitis. Laryngoscope. 2015b;125:25–32.CrossRefPubMedGoogle Scholar
  77. 77.
    Rudmik L, Soler ZM, Hopkins C. Using postoperative SNOT-22 to help predict the probability of revision sinus surgery. Rhinology. 2016c;54:111–6.PubMedGoogle Scholar
  78. 78.
    Rudmik L, Soler ZM, Mace JC, DeConde AS, Schlosser RJ, Smith TL. Using preoperative SNOT-22 score to inform patient decision for endoscopic sinus surgery. Laryngoscope. 2015c;125:1517–22.CrossRefPubMedGoogle Scholar
  79. 79.
    Soler ZM, Rudmik L, Hwang PH, Mace JC, Schlosser RJ, Smith TL. Patient-centered decision making in the treatment of chronic rhinosinusitis. Laryngoscope. 2013;123:2341–6.PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Division of Otolaryngology—Head and Neck Surgery, Department of Surgery, Richmond Road Diagnostic and Treatment CentreUniversity of CalgaryCalgaryCanada

Personalised recommendations