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International consensus statement on rhinosinusitis

Acute Bacterial Rhinosinusitis (ABRS) Data for the indirect costs of ABRS are somewhat lim ited, with most data coming from control arms of inter ventional studies for ABRS. Recently, Spanish investigators found the indirect cost of an ABRS episode to range from €224-€439 (approximately USD$264-USD$520) depending on treatment intervention. 239 If patients are assumed to be absent from work during the symptomatic days of an ABRS episode, the indirect costs increase to USD$747-USD$820, depending on whether antibiotic treatment is offered. 94 Chronic Rhinosinusitis (CRS) The indirect cost burden of CRS is substantial and relates to the underlying severity of the CRS. A recent national healthcare expenditure database investigation found that patients with CRS experienced 1.0 ± 0.4 incremental work days lost per year due to CRS. 240 This figure includes both non-refractory and refractory patients and directly com pares those with and without CRS diagnoses. Examining CRS cohorts presenting specifically for disease manage ment, larger costs are noted. European investigators found 57% of CRS patients reported absenteeism from work due toCRS. 241 In patients with relatively limited CRS planning balloon dilatation, Stankiewicz et al. found proportions of time lost with absenteeism, presenteeism and productivity loss of 6.5%, 36.2%, and 38.3%, respectively via a validated work specific survey. 242 Several other recent cohort studies have quantified the temporal and monetary productivity losses associ ated with CRS. Chowdhury et al. found mean annual productivity costs of USD$11,820 per patient with an additional USD$8000-USD$12,000 in incremental losses with comorbid immunodeficiency, tobacco use or steroid dependency. 243 Smith et al. investigated CRS-related facial pain and productivity losses and found that facial pain had a strong correlation with presenteeism, which is a main driver of productivity losses and indirect costs associated with CRS, with an overall lost productivity at USD$20,300 per patient per year. 244 In a multi-institutional study from rhinology clinics, Rudmik et al. found mean annual rates of absenteeism to be 24.6 days and presenteeism to be 38.8 days, with an overall annual productivity cost of USD$10,077 per patient. 245 Yip et al. found that employed Canadian patients demonstrated an average days lost of 12.9 days due to CRS symptoms, 3.3 days for medical appointments, and 2.4 workdays for emergency depart ment visits. Furthermore, even in patients undergoing active continued medical management for CRS, work related productivity losses approximate USD$4510 per 90 days. 246 The indirect costs of CRS are not only work-related. Stankiewicz identified a 40.0% rate of impairment of activ

ity with CRS and Bhattacharyya determined activity, work, social and cognitive limitations in 13.3%, 12.0%, 9.0%, and 6.0%, respectively. 240,242 In a comprehensive review, DeConde and Soler found that the indirect costs related to decreased productivity from CRS were estimated at

USD$12.8 billion per year in the US. 14 Recurrent acute rhinosinusitis (RARS)

The indirect costs of RARS primarily relate to work days lost and productivity decreases due to the acute phase of each episode of RS. Although relatively lim ited RARS data are available, investigators found an aver age of 4.4 workdays missed per year specifically due to RARS. 247 Economic studies of RARS have identified absenteeism and presenteeism rates of 1.7 and 0.66 days per acute episode, respectively. 203 Steele et al. noted that RARS patients reported at baseline 12.6 days that were “missed or impacted due to sinus-related symptoms” in the 90 days prior to assessment. Interestingly, these losses were similar to those reported by patients with CRSsNP (11.7 days). 248 By definition, patients with CRS will suffer with some com bination of cardinal sinonasal symptoms, including nasal congestion, nasal drainage, facial pressure/pain, and loss of smell. However, the impact of CRS often extends beyond the sinonasal region and can have profound effects on functional well-being and general health-related quality of life (QoL). Numerous studies have explored the burden of CRS using either general health-related QoL or health state utility scores and compared these findings to scores from patients with other chronic diseases. 62,65,68 Health state utility scores are particularly useful for comparing the burden of different diseases because these instruments measure disease impacts using a single, common metric. Using transformations of the Short Form 6D instrument (SF-6D), health states of 230 patients with CRS were found to average 0.65 (0 = death, 1 = perfect health), a valuation that was worse than what has been reported for conges tive heart failure, chronic obstructive pulmonary disorder, and Parkinson’s disease. 62 Similar studies have been per formed showing severe impairment in general QoL and wellbeing using the Short-Form 36 (SF-36) and Euroqol 5 Dimension (EQD-5) questionnaires. 63–65 When responses of CRS patients are examined in detail, the most com mon extra-sinus disease manifestations include fatigue and bodily pain, sleep dysfunction, cognitive function, and depression. Importantly, these extra-sinus manifestations VI.B Individual Burden of Rhinosinusitis