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Wise et al.

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billion, with more than one-half of the AR direct costs coming from prescription medications. 760-762 The direct costs attributed to AR include physician office visits, laboratory tests, medications, and AIT. 763 Compared with matched controls, patients with AR have an almost 2-fold increase in medication costs and a 1.8-fold increase in visits to a healthcare provider. 756,764,765 Hidden direct costs include treatment of comorbid conditions that occur at an increased incidence in patients with AR. Recently, the TOTALL (TOTal costs of ALLergic rhinitis in Sweden) study estimated the total cost of AR using a sample representing the entire Swedish working-age population. Data from this study suggested that patients with mild AR have less impact on the health economy, with costs averaging about 25% of the costs for those with moderate to severe disease. 667,766 Patients with moderate to severe AR reported visiting their primary care provider for their AR more frequently than those with mild AR (1.61 vs 1.19 times per year). 753 The indirect costs of AR, such as absenteeism and presenteeism, are also significant and actually make up the majority of the cost burden of AR. 767,768 Impaired productivity and/or missed work occurred as a result of AR in 52% of patients. 753 In a survey of over 8000 U.S. employees at 47 employer locations, 55% reported AR symptoms for an average of 52.5 days per year. They reported missing 3.6 days of work per year because of AR and reported being unproductive 2.3 hours per workday when symptomatic. The mean total productivity losses (absenteeism and presenteeism) for AR were calculated at $593 per employee per year. 769 In another UK study, patients with moderate to severe AR reported 37.7 days a year when their productivity was affected by their AR symptoms; this is almost double that reported by patients in the same study with mild AR symptoms (21.0 days). 753 Health impairments associated with AR are often not severe enough to cause absenteeism, but they do interfere with cognitive functioning, resulting in fatigue and an impaired ability to learn, concentrate, and make decisions. 770 In a study by Blanc et al., 771 more than one third of AR patients reported reduced workplace performance. In the United States, AR results in 3.5 million lost workdays and 2 million lost school days annually. 772 On any given school day in the United States, approximately 10,000 children are absent from school because of AR. 773 This absence from school may also affect parents’ productivity or cause them to be absent from work themselves. In a study by Hellgren et al., 774 the average productivity loss for all Swedish workers because of absenteeism, presenteeism, and caregiver absenteeism during a year was 5.1 days, of which 2.3 days were accounted for by absenteeism and 2.0 days by presenteeism. If only those with children aged 0 to 7 years in their household were included in the analyses, the average number of days for caregiver absenteeism was 3.6 days. The cost of caregiver absenteeism comprised 19% of the mean total costs per year in this study. The cost related to caregiver absenteeism was highest for women aged 30 to 44 years. AR is the most common chronic disorder in the pediatric population. AR can affect sleep, result in daytime sleepiness, and impair cognition and memory, which may significantly affect the learning process and impact school performance. Even when present during school

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Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.