xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

221

Orlandi et al.

I.C.4 Societal Burden of Disease The combined prevalence of acute and chronic RS (12 15.2%) exceeds that of other common respiratory condi tions such as hay fever (8.9%), acute asthma (3.8%), and chronic bronchitis (4.8%). 9,87 The direct costs of man aging ARS and CRS are thought to exceed USD$11 bil lion per year. 88 In a study of 4.4 million patients, Bhat tacharyya et. al. identified 4460 patients undergoing ESS. 89 The healthcare costs for CRS in the year leading up to ESS (therefore, medically refractory patients) were USD$2449, USD$1789 of which were attributable to facility and physi cians’ charges. In a recent population-based assessment Bhattacharyya determined that CRS patients are asso ciated with significantly increased incremental health care utilization costs relative to adults without CRS. 90 Chung et al. also found that non-US patients with CRS diagnoses incurred significantly higher outpatient costs (USD$953 vs USD$665; p < 0.001) and total healthcare costs (USD$1318 vs USD$946; p < 0.001) than those with out CRS. 91 With respect to CRSwNP, Bhattacharyya et al. found an incremental increase in annual direct medical costs of USD$1067 for patients relative to controls without CRS. 92 Among medically refractory patients, a systematic review specific to surgery found that the cost of outpa tient ESS ranges from USD$8200 to USD$10,500 per pro cedure in 2014 USD. A large claims-based study found that although the mean surgical cost of ESS was USD$7,782, direct healthcare costs decreased steadily in the 3 years after surgery with greater than half of the patients resolv ing direct costs attributable to CRS. 93 In contrast to these direct healthcare costs, the indirect healthcare costs of CRS include societal costs related to absence from work (absenteeism), decreased work produc tivity while at work (presenteeism) and other forms of lost productivity (eg, leisure time lost). Among the 15.2% of those reporting RS (ARS or CRS) annually in a national survey, an estimated 61.2 million potential workdays were missed per year among adults in the United States. 87,94 Ina comprehensive review, DeConde and Soler found that the indirect costs related to total decreased productivity from CRS were estimated at USD$12.8 billion per year in the US. 14

ventions with aggregate grade A or B evidence regarding their use and their associated policy levels (Tables I-3 and I-4, Figure I-3). I.C.5.b. Evidence Based Recommendations for Surgical Timing and Indications in RS Statements regarding indications for sinus surgery have generally cited “failure of maximal medical therapy” as a requirement before proceeding. Some evidence indicates that prolonging the time between diagnosis and surgery for CRS may negatively impact outcomes. Data from both the UK prospective audit of surgery for CRS and UK pri mary care electronic datasets were analyzed by Hopkins et al. 95,96 Patients were classified according to the duration of their CRS until their first surgical intervention for CRS. Patients in the early group (eg, less than 12 months) had not only a greater percentage improvement in their symptoms, but the improvement was better maintained over 5 years. It has also been shown, using both UK and US datasets, that ESS was associated with a reduction in the incidence of new asthma diagnoses following surgery, and that the risk of asthma was lowest in those having early surgery. 97 The term “appropriate” medical therapy (AMT) has there fore become preferred in order to suggest striking a balance between proceeding to surgery before appropriate nonsur gical options have been tried and delaying too long so that outcomes are negatively impacted. While high level evi dence for what constitutes AMT is lacking, both in terms of composition and duration, the current best evidence is summarized below. I.C.5.c. Evidence Based Surgical Management Recommendations for RS With regards to once a surgical intervention has been embarked upon, the ICAR-RS document provides an evidence-based review with recommendations on 17 indi vidual surgical and/or peri-surgical related therapies for RS. The following tables represent all interventions with aggregate grade A or B evidence regarding their use and their associated policy levels (Tables I-5 through I-8). I.C.5.d. Surgical Complications and Prevention Techniques in ESS ESS outcomes have improved over the years due to advances in technology and surgical training. Despite these improvements, complications still occur during surgery due to the close proximity of the sinuses to the skull base and orbit. The reported complication rate of ESS for CRS ranges from 0.36% to 5.8%, with minor and major complications occurring in up to 5.7% and 1.5% respectively. 98–104 Up to 15% of patients will require revi sion surgery, with reported major complication rates of

I.C.5 Management of RS I.C.5.a. Evidence-Based Medical Management Recommendations for RS

The ICAR-RS document provides an evidence-based review with recommendations on 55 individual medical therapies for RS. The following tables represent all inter