Direct and indirect costs of allergic and non‐allergic rhinitis in the Netherlands
Authors: Klementina S. Avdeeva, Sietze Reitsma, Wytske J. Fokkens
Journal: Allergy (2020)

Chronic rhinitis is a symptomatic inflammation of nasal mucosa that lasts at least 12 weeks per year. Both allergic (AR) and non-allergic (NAR) rhinitis are highly prevalent: they affect about 30% and 10% of population, respectively.1 About 30% of patients with chronic rhinitis have a mixed form, and several endotypes of chronic rhinitis have been described.2 Considering the high prevalence and the impact on general well-being,3 chronic rhinitis has a significant financial impact due to direct costs (medications, healthcare visits etc) and indirect costs (absenteeism and presenteeism). To our knowledge, no data on financial costs of non-allergic rhinitis are currently available. In order to estimate direct and indirect costs of allergic and non-allergic rhinitis in the Netherlands, we performed a cross-sectional study in patients with allergic and non-allergic rhinitis visiting their family doctors and the patients of the Department of Otorhinolaryngology of Amsterdam UMC, location AMC, in the Netherlands (secondary/tertiary healthcare facility). Details on the materials and methods are given in the online repository (App S1). Questionnaires were obtained from 512 participants with rhinitis and 23 healthy controls. By the nature of these questionnaires, direct costs and absenteeism were not disease-specific, whereas presenteeism was. The characteristics of the study population are presented in Table 1. The baseline characteristics of the control group were comparable to the chronic rhinitis groups. Total costs of chronic rhinitis were €5042 patient/year (€5258 patient/year of NAR, €4827 patient/year of AR). Direct costs were €1043 patient/year vs €793 in controls. As the direct costs were not disease-specific, the most expensive component was daycare procedures (such as grommets placement, immunotherapy and gastroscopy). In the (relatively small) control group, average direct costs were dominated by specialist visits and hospital admission by some subjects. Indirect costs in the chronic rhinitis group were €3999 patient/year: €1329 for absenteeism, €2390 for (disease-specific) presenteeism and €280 for unpaid work (Table 2). On average, absenteeism costs were increased fourfold in rhinitis patients compared with controls, while presenteeism costs were increased eightfold. As such, the average total costs in rhinitis patients were increased with around €3650 patient/year, mainly due to a significant increase in presenteeism costs. Indeed, presenteeism costs were the highest component in all employed subgroups, except for those with mild rhinitis and those currently smoking. According to the Central Bureau of Statistics, each year 5% of the Dutch population are seeking medical care due to allergic rhinitis complaints, which is about 730 000 patients of 16 years and older. Costs of these patients alone are around €3.5-€4.0 billion a year (€750 million due to direct, €3 billion due to indirect costs). Chronic rhinosinusitis (CRS) costs per patient are even higher than chronic rhinitis costs. In the Netherlands, CRS costs were found to be € 7160 patient/year (€1501 for direct and €5659 for indirect costs).4 But due to a lower prevalence, total annual costs of CRS are lower than those of chronic rhinitis, corresponding to €2 billion annually. The presented data could also be used as an estimation of the true costs of chronic rhinitis in the Netherlands. The current numbers could be an overestimation: the study included patients seeking medical care, mainly suffering from moderate/severe rhinitis, while in the general population, the proportion of mild chronic rhinitis cases is higher.5 As such, the average costs per patient in the general population are probably lower. Indeed, compared to the TOTALL study conducted in Sweden, rhinitis costs in our study were higher: €5042 vs €961 patient/year for total costs, while the same trends could be observed with presenteeism being the most expensive component.6 The TOTALL study included participants with self-reported allergic rhinitis, leading to 62% of the sample having mild rhinitis (compared to 11% in our study). Indeed, in studies including patients seeking medical care, the costs were higher: in Germany, in 2003 the total costs of allergic rhinitis (excluding productivity costs) were estimated to be around €1.543 patient/year.7 Ten years after, the direct costs of AR patients in Germany were estimated to be €1546 patient/year.8 Of course, other factors contributed largely to the found differences such as inclusion of NAR, reference prices and general healthcare expenditures. Still, if we would assume the same 62% of rhinitis patients to be mild in the Dutch population, the average costs would be €3761 patient/year. Assuming a prevalence of chronic rhinitis of 30%, the total costs in the general population would be at least €19.6 billion. On the other hand, there are several factors that could lead to underestimation of the costs. First, the last update of the used reference standard is based on prices of 2014, negating inflation of costs between 2015 and 2020. Second, for the calculation of medication costs we used a price of only one package of each reported medication at the lowest price reported by the Pharmacotherapeutic Compass of the Dutch National Healthcare Institute. Moreover, the participants only reported medication that they were currently using. We would estimate that both factors combined would give a 10% rise of the costs, meaning on average €4137 patient/year, or €21.6 billion annually in the Netherlands. Since the largest portion of costs is rhinitis-related presenteeism, one could argue that these costs could possibly be reduced by appropriate management of chronic rhinitis. Indeed, two thirds of participants had uncontrolled nasal complaints (CARAT score) and more than a half had nasal congestion on more than 2 days a week. Currently, a lot of patients are not being treated according to the guidelines and often self-medicate.9 Possibly, if the patients will receive care according to the guidelines, their complaints, and consequently presenteeism, could be reduced. Future prospective studies evaluating costs of patients receiving the treatment according to the guidelines are needed. To our knowledge, this is the first study to report costs of NAR. Future studies are needed to understand the costs of chronic rhinitis (especially of non-allergic rhinitis) in the general population. The costs of both allergic and non-allergic rhinitis are high, with presenteeism being the most expensive component. Dr Avdeeva reports grants from ALK, from Allergy Therapeutics, from Mylan BV, during the conduct of the study. Dr Reitsma reports grants from ALK, from Allergy Therapeutics , from Mylan BV, during the conduct of the study. Dr Fokkens reports grants from ALK, from Allergy Therapeutics , from Mylan BV, during the conduct of the study. This study was helped with an educational grant of MEDA, ALK and Allergy Therapeutics. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.