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Key Points: CRSwNP-specific mean total annual spending ranged from $5,837 (EDS-FLU) to $28,058 (dupilumab). Most CRSwNP patients receiving biologics had comorbid asthma and did not undergo sinus surgery. While biologics were covered by most Medicare Part D plans, only 37% of plans covered EDS-FLU., (© 2024 ARS‐AAOA, LLC.)

Introduction: This study compares the direct healthcare costs associated with asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) from 2013 to 2017 in Catalonia (Spain) with a population control group without these conditions., Methods: A population administrative database containing healthcare information was used. The database contained information on primary care, hospitalisations, and emergency care from 2013 to 2017 in Catalonia. The unit cost of each healthcare procedure was imputed using a complete list of public prices for primary care services, hospital, and speciality services. Differential costs were estimated using a finite mixture model., Results: Individuals diagnosed with asthma or CRSwNP showed a higher incidence of comorbidities than the control group. Mean annual direct costs per patient were €1,102 for asthma, €1,612 for CRSwNP and €2,197 for those with both conditions. According to our estimations, differential costs were €162 - €274 for patients with asthma and €481 - €1,257 for patients with CRSwNP compared to the reference population. These costs were significantly higher when asthma and CRSwNP coexist and especially in their severe condition., Conclusion: This population-based study revealed that asthma and CRSwN are associated with great economic burdens for healthcare systems. These costs were significantly higher when comorbidity was present (asthma and CRSwNP) and especially in their severe condition (€4,441).

Key Points: In 2021, Medicare spending on biologics was $926 million in Part B (FFS) and $1.3 billion in Part D (FFS/MA). Between 2017 and 2021, annual Medicare spending on biologics increased by approximately 200%. Between 2023 and 2025, Medicare Part D OOP costs for biologics will decrease by an estimated 50%-60%., (© 2024 ARS‐AAOA, LLC.)

Social determinants of health (SDHs) have a substantial impact on patient care and outcomes globally, both in low- to middle-income countries and in high-income countries. In the clinic, lack of availability of diagnostic tools, inequities in access to care, and challenges obtaining and adhering to prescribed treatment plans may further compound these issues. This article addresses a case of rhinitis in the context of SDHs and inequities in care that may affect various communities and populations around the world. SDHs may include various aspects of one's financial means, education, access to medical care, environment and living situation, and community factors, each of which could play a role in the rhinitis disease manifestations, diagnosis, and management. Allergic and nonallergic rhinitis are considered from this perspective. Rhinitis epidemiology, disease burden, and risk factors are broadly addressed. Patient evaluation, diagnostic tests, and management options are also reviewed, and issues related to SDHs are noted. Finally, inequities in care, knowledge gaps, and unmet needs are highlighted. It is critical to consider SDHs and care inequities when evaluating and treating patients for rhinitis and other allergic conditions., (Copyright © 2024 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Chronic rhinosinusitis (CRS) is a common and costly health problem in the United States. A better understanding of healthcare resource utilization (HCRU) and healthcare expenditure (HCE) pertaining to CRS is required. The objective of this study is to investigate geographic variations in HCRU and HCE for CRS., Study Type/design: Retrospective study of administrative database., Methods: Patients meeting pre-defined diagnostic criteria for CRS with continuous 1-year pre-index and 2-year post-index data were identified on IBM® Marketscan Research Databases over a 5-year period (2013-2017). Data pertaining to demographics, HCRU, and HCE were analyzed according to geographic region. Multivariable generalized linear models accounted for age, sex, baseline medication utilization, and co-morbidities., Results: About 237,969 patients were included. Antibiotics were the most commonly prescribed medication (95%). Surgery rate (11%), immunotherapy (9.2%), oral steroid use (66%), and antibiotic utilization (mean 6.3 prescriptions) were highest in the South. However, visits with an otolaryngologist were considerably higher in the Northeast (62%). The Northeast region had the highest mean HCE ($2,449), which was 13% greater than HCE for the North Central region ($2,172). HCRU and HCE were higher in urban areas across all metrics, with 2-year HCE being 18% greater in urban areas ($2,374 vs. $2,019). Significant geographic variation in HCE was observed even after adjusting for covariates., Conclusion: Significant geographic variations in HCRU and HCE exist for CRS even after adjusting for covariates. Future studies are needed to help direct quality improvement and cost-saving efforts as well as efficient resource allocation in an era of value-based care., Level of Evidence: 4 Laryngoscope, 131:2641-2648, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc..)

Objective/hypothesis: Determine contemporary incremental increases in healthcare expenditures and utilization associated with chronic rhinosinusitis (CRS)., Study Design: Cross-sectional analysis of national health care survey data., Methods: Patients reporting a diagnosis of CRS were extracted from the 2018 Medical Expenditure Panel Survey medical conditions file and linked to the consolidated expenditures file. CRS patients were then compared to non-CRS patients determining differences in healthcare utilization for office visits, emergency facility visits, and prescriptions filled as well as differences in total healthcare costs, office-based costs, prescription medication costs, and self-expenditures using demographically and comorbidity adjusted multivariate models. Results were compared to 2007, adjusted for inflation., Results: An estimated 7.28 ± 0.36 million adult patients reported CRS in 2018 (3.0 ± 0.1% of the adult U.S. population). The additional incremental healthcare utilizations associated with CRS relative to non-CRS patients for office visits, emergency facility visits, and number of prescriptions filled were 4.2 ± 0.6, 0.10 ± 0.03, and 6.0 ± 0.9, respectively (all P ≤ .003). Similarly, additional incremental healthcare expenditures associated with CRS for total health care expenses, office-based visit expenditures, prescription expenditures, and self-expenditures were $1,983 ± 569, $772 ± 139, $678 ± 213, and $68 ± 17, respectively (all P ≤ .002). Increases in total (+$1,062) and office based expenditures (+$360) compared to 2007 were significant., Conclusion: CRS continues to be associated with a substantial incremental increase in healthcare utilization and expenditures. These expenditures have significantly outpaced inflation expected increases. The national healthcare costs of CRS have increased to an estimated $14.4 billion per year., Level of Evidence: 3 Laryngoscope, 131:2169-2172, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: We conducted a systematic literature review (SLR) of randomized controlled trials and real-world evidence (RWE) studies to determine the humanistic (e.g. health-related/disease-specific quality of life [QOL]) and economic (e.g. direct and indirect costs) burdens of chronic rhinosinusitis with nasal polyposis (CRSwNP)., Methods: The SLR adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Embase, MEDLINE and Evidence-Based Medicine Reviews databases were searched using OVID. Relevant studies involving adult patients with CRSwNP published between 1 January 2008 and 16 February 2019 were included, with relevant conference abstracts from 1 January 2017, onward., Results: Sino-Nasal Outcomes Test (SNOT)-22 was the most frequently used disease-specific health-related QOL/patient-reported outcomes instrument for patients with CRSwNP. Baseline SNOT-22 scores ranged from 25 to 73 for surgical candidates and from 14 to 56 for medically managed patients with CRSwNP. Mean baseline EuroQol-5 Dimensions (EQ-5D) index for patients with CRSwNP ranged from 0.81 to 0.86, and mean baseline Short Form-6 Dimensions (SF-6D) ranged from 0.67 to 0.75. Three months (EQ-5D) and 5 years (SF-6D) post-endoscopic sinus surgery (ESS), rates increased from 0.81 to 0.89 and from 0.69 to 0.80, respectively. One year post-diagnosis, patients with CRSwNP had significantly more systemic prescriptions, underwent significantly more medical procedures, demonstrated greater health care resource utilization and had significantly greater mean health care costs compared with matched controls (all p  < .001). Overall, for patients with initial ESS, CRSwNP was associated with higher disease-related expenditures compared with CRS without nasal polyposis (NP), even for patients who did not undergo revision surgery., Conclusions: This SLR identified substantial humanistic burden among surgery candidates. RWE shows that surgeries were used to treat relatively more severe CRSwNP patients as recommended by guidelines. Patient QOL is improved significantly after surgery; however, there is a lack of evidence on patients with revision surgery. Surgery is also associated with higher costs, and the presence of NP was a predictor of revision surgery. Patients with CRSwNP demonstrate greater health care resource utilization and costs compared to those with CRS without NP. Costs associated with different severity of CRSwNP and revision surgery need to be assessed further.

Purpose of Review: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a highly prevalent disease that results in significant healthcare-related costs as well as costs to society with lost productivity and time. Unfortunately, a significant percentage of patients who suffer with this disease will not find relief from current standard of care medications and surgery. With ongoing efforts to understand the pathophysiology of CRSwNP has come the introduction of monoclonal antibodies, or "biologics," targeting specific elements of the inflammatory pathway in CRSwNP. Despite efficacy, these come at significant cost and, to date, no studies on the cost-efficacy of these biologics in CRSwNP have been published., Recent Findings: Multiple studies have now demonstrated efficacy for biologics in the treatment of CRSwNP as a primary indication. However, the gains in quality of life and objective measures, while consistent, are small and, arguably, the clinical significance is still unclear. In addition, the high cost of these medications may be hard to justify when evaluated in cost-efficacy studies against standard of care therapy in CRSwNP. Furthermore, while the current literature is most robust in showing the benefit of the biologics in asthma, it does not fully support cost-efficacy for biologics. This review evaluates the current literature regarding efficacy of monoclonal antibodies for the treatment of CRSwNP and considers this efficacy in light of the cost implications to individuals and society.

Introduction: Chronic rhinosinusitis (CRS) is highly prevalent, affecting 11% of the population. Studies evaluating the socio-economic impact of CRS are mostly limited to the US population. Currently there is no study that has evaluated the socio-economic costs of CRS in the UK., Methods: A case-control study of patients with CRS and healthy controls was conducted to investigate the wider socio-economic impact of the disease. Data on demographic and socioeconomic characteristics, out-of-pocket expenditure (OOPE), health resource utilisation, productivity losses and health-related quality of life (HRQoL) via the EQ-5D and SNOT-22 instruments, were collected from questionnaires., Results: A total of 139 CRS participants and 67 control participants completed the questionnaires. The average total OOPE per patient extrapolated to a 12-month period was £304.84. Other important findings include significantly higher reported primary care interactions (4.14 vs. 1.16) as well as secondary care interactions (2.61 vs 0.4) in CRS group as compared to controls over three-months. The average total missed workdays was estimated to be 18.7 per patient per year. The estimated incremental healthcare cost of CRS per year is £16.8 billion or £2.8 billion per million inhabitants. Factors predictive of a higher OOPE include higher household occupancy and income and these accounted for only 9.7% of the total variance in total OOPEs. Other socioeconomic, demographic and HRQoL variables were not found to be predictive factors of OOPE., Conclusions: This study showed that CRS has a significant wider economic burden beyond the immediate direct healthcare costs. CRS participants had a high level of healthcare service use, OOPE and productivity loss. Results from this study will add to the existing limited data both for the UK and abroad and emphasises the need for effective treatments for these patients to reduce the disease impact.

Objectives/hypothesis: Establish treatment patterns and economic burden in US patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) versus without chronic rhinosinusitis (CRS). Determine comparative costs of subgroups with high clinical burden., Study Design: Observational, retrospective, case-control study., Methods: This study matched patients with CRSwNP to patients without CRS (1:1) using the Truven Health MarketScan US claims database. Categorical and continuous variables were compared using McNemar test and paired t test (normal distribution) or Wilcoxon signed rank tests (non-normal distribution). Within subgroups, χ 2 and Wilcoxon or t tests were used (normal distribution)., Results: There were 10,841 patients with CRSwNP and 10,841 patients without CRS included. Mean age in the CRSwNP cohort was 45.8 years; 56.2% were male. During follow-up, patients with CRSwNP had an increased diagnosis of asthma versus patients without CRS (20.8% vs. 8.1%, respectively; P < .001). Annual incremental costs were $11,507 higher for patients with CRSwNP versus those without CRS. Costs were higher in subgroups of patients with CRSwNP undergoing functional endoscopy sinus surgery (FESS), with a comorbid diagnosis of asthma, receiving oral corticosteroids, or macrolides versus the overall CRSwNP group. Patients with CRSwNP undergoing FESS had the highest costs of the four subgroups ($26,724, $22,456, $20,695, and $20,990, respectively)., Conclusions: Annual incremental costs were higher among patients with CRSwNP versus without CRS. Patients with CRSwNP with high clinical burden had higher overall costs than CRSwNP patients without., Level of Evidence: NA Laryngoscope, 129:1969-1975, 2019., (© 2019 The Authors. The Laryngoscope published by Wiley Periodicals, Inc. on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To identify the need for cost-effectiveness analysis of biologic therapies in the treatment of chronic rhinosinusitis (CRS)., Data Sources: Clinical trials of monoclonal antibodies (omalizumab, benralizumab, mepolizumab and dupilumab) for nasal polyposis or chronic rhinosinusitis published on PubMed., Study Selections: Clinical trials of biologic therapies in CRS and nasal polyposis., Results: No cost-effectiveness analyses of biologic therapies in CRS have been performed., Conclusion: As more clinical trials of biologic therapies for CRS are conducted, there is a need for cost-effectiveness analysis. Future analyses should consider these therapies as part of medical therapeutic options compared with surgery. To increase generalizability, analyses should include samples from allergy and primary care clinics rather than only otolaryngology clinics., (Copyright © 2019 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Objective: Chronic rhinosinusitis (CRS) is a popular and tiring disease with significant impacts on the economy and on the Health-related Quality of Life (HRQOL) of patients. This study aims to estimate the cost of illness (COI) and to assess the Health-related Quality of Life (HRQOL) in patients with CRS who underwent surgery in Vietnam and to analyse the relationship between socio-demographic characteristics and the COI as well as the HRQOL., Methods: A cross-sectional study was conducted in Ear, Nose, Throat Hospital in Ho Chi Minh City (ENT Hospital HCMC), Vietnam between August and October 2018. The direct medical and non-medical costs, the indirect costs (productivity loss), and the HRQOL of patients with CRS were measured. A subjective assessment of quality of life (QOL) using EuroQol 5 Dimensions 5 Levels (EQ-5D-5L) was used to evaluate the health status of these patients after surgery. Characteristics related with the COI and the HRQOL were identified by multiple regression., Results: A total of 264 inpatients with CRS participated in the study. The mean COI for inpatients with CRS was $812.83 and direct costs accounted for a major proportion (89.32%) of the total cost. In addition, the surgery represented the most significant direct medical cost with 58.57% of the total cost. Most of the patients reported no problems with mobility (89.1%), self-care (93.9%), usual activities (77.2%), and anxiety/depression (64.0%). The mean EQ-5D-5L utility score was 0.76 (SD = 0.17), and the mean Visual Analogue Scale (EQ-VAS) score was 76.57 (SD = 13.34). The results of multiple regression showed that gender, occupations, monthly income, prior surgery and family history of CRS affected the total cost while the HRQOL of patients were related to education, smoking behaviour, exercise behaviour and family history of CRS., Conclusions: This study showed that although endoscopic sinus surgery (ESS) accounted for the largest expense in the COI, this surgical treatment helped to improve the HRQOL in patients with CRS. The findings provided a reference for policy makers in CRS management as well as for adjustment of costs for patients so as to reduce disease burden and to enhance their QOL.

Introduction Nasal endoscopy (NE) is an essential element of office-based clinical rhinology, including the evaluation of chronic rhinosinusitis. Despite the presence of guidelines, variability exists regarding coding and billing for NE especially with regard to inclusion of evaluation and management (E&M) codes and use of the 25 modifier. The goal of this survey was to assess the billing patterns for NE among American Rhinologic Society (ARS) members. Methods An invitation to participate in a web-based survey was electronically sent to all ARS members. Survey participants were queried regarding demographics and billing patterns for NE in several different clinical scenarios using a 5-point Likert-type scale, with a score of 5 representing "always" and a score of 1 representing "never" for billing E&M. Results A total of 93 respondents successfully completed the survey with a range of the number of years since completing training, practice type (50.5% private, 44.1% academic) and completion of a rhinology fellowship (40.9%). Variable responses for billing patterns for distinct clinical scenarios were noted. Higher scores for billing both E&M and NE for the queried clinical scenarios were noted for new patients (mean 4.50) compared to established patients (mean 3.81) and postoperative patients (mean 3.04). Inclusion of a septoplasty as part of the surgery impacted billing an E&M code 28% of the time. Practice type and history of performing a fellowship did not significantly influence billing patterns for NE. Conclusions Significant variability exists among ARS respondents with regard to billing patterns for NE, despite the presence of coding guidelines. Additional teaching of standard coding practices for NE may limit variability among otolaryngologists.

Objectives/hypothesis: Patients with Medicaid or self-pay insurance status are more likely to present to the emergency department (ED) for uncomplicated acute rhinosinusitis (ARS). Our aim was to determine if this pattern holds true for both pediatric and adult visits., Study Design: Cross-sectional study using the 2005 to 2012 National Hospital Ambulatory Medical Care Surveys and National Ambulatory Medical Care Surveys., Methods: We included all visits with International Classification of Diseases, Ninth Revision codes for ARS and without codes for ARS complications. We tested for associations between insurance type and presentation to an ED versus a primary care physician (PCP), stratifying children versus adults. We used univariate and multivariable logistic regression modeling, controlling for clinical and demographic characteristics for analysis., Results: There were 51,579,977 uncomplicated ARS visits to PCPs (48,213,335 visits) and EDs (3,366,642 visits). Medicaid and uninsured patients were under-represented for ARS visits. Medicaid insurance was significantly associated with ED presentation for ARS for both children (adjusted odds ratio [OR] = 7.0, P < 0.001) and adults (adjusted OR = 6.8, P < 0.001). Children with ARS and self-pay insurance status were much more likely to present to the ED (adjusted OR = 48.8, P < 0.001) than adults (adjusted OR = 5.2, P < 0.001); this difference between children and adults with self-pay insurance was significant (P = 0.001)., Conclusion: With respect to absolute numbers of visits, patients with Medicaid or no insurance use less care overall for uncomplicated ARS than do privately insured patients. Medicaid is associated with ED presentation for ARS for pediatric and adult visits. Self-pay insurance status is strongly associated with ED presentation for adult and pediatric visits, and is significantly more common for children. These results suggest limitations in primary care access for uncomplicated ARS based on insurance status, particularly for uninsured pediatric patients., Level of Evidence: 4. Laryngoscope, 128:299-303, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Previous studies have shown declines in productivity due to chronic rhinosinusitis (CRS) are correlated with disease-specific quality-of-life (QOL) measures. However, it is unclear which symptom domains contribute primarily to productivity loss. This investigation sought to assess the association between CRS-specific QOL subdomain impairment and productivity loss., Study Design: Prospective, multi-institutional, observational cohort study., Methods: There were 198 patients with refractory CRS enrolled between August 2012 and June 2015. Baseline QOL measures were obtained across five subdomains of the 22-item SinoNasal Outcome Test (SNOT-22). Lost productivity time was determined from patient-reported measures of annual absenteeism, presenteeism, and lost leisure time, and then monetized using annual daily wage rates from the 2012 US National Census and 2013 Department of Labor statistics., Results: Productivity losses correlated with impairments in both SNOT-22 psychological dysfunction (Spearman correlation coefficient [Rs] = 0.428, P < .001), and sleep dysfunction domain scores (Rs = 0.355, P < .001). Higher SNOT-22 total scores also significantly correlated with increased monetized productivity losses (Rs = 0.366, P < .001). The mean annual productivity cost was $11,820/patient, whereas patients with comorbid immunodeficiency ($23,285/patient), tobacco use ($23,195/patient), and steroid dependency ($18,910/patient) reported higher than average annual productivity costs. Multivariate linear regression found maximum annual productivity costs in adjusted psychological ($13,300/patient, P < .001) and sleep dysfunction ($9,275/patient, P < .001) domains., Conclusions: Impairments in sleep and psychological SNOT-22 domains correlate with productivity losses. Patients with comorbid immunodeficiency, smoking, and steroid dependency had higher than average productivity losses. Targeted management of psychological and sleep dysfunction in combination with standard symptom control may improve patient-centered care and reduce the annual economic burden of CRS., Level of Evidence: 2c. Laryngoscope, 128:23-30, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: The objective of this work was to evaluate the impact of asthma on the cost-effectiveness profile of endoscopic sinus surgery (ESS) compared to medical therapy for patients with chronic rhinosinusitis with nasal polyps (CRSwNP)., Methods: The study design consisted of a cohort-style Markov decision-tree cost utility analysis with a 35-year time horizon. Matched cohorts of CRSwNP patients with (n = 95) and without (n = 95) asthma who underwent ESS were compared with cohorts of patients from the national Medical Expenditures Survey Panel (MEPS) database who underwent medical management for chronic rhinosinusitis (CRS). Baseline, 1-year, and 2-year health utility values were calculated from responses to the EuroQol-5 Dimension (EQ-5D) instrument in both cohorts. The primary outcome measure was the incremental cost effectiveness ratio (ICER) for each cohort., Results: The reference cases for CRSwNP patients with and without asthma yielded ICERs for ESS vs medical therapy alone of $12,066 per quality-adjusted life year (QALY) and $7,369 per QALY, respectively. At a willingness-to-pay threshold of $50,000/QALY, the ICER scatter plots demonstrated 86% and 99% certainty that the ESS strategy was the most cost-effective option for CRSwNP patients with and without asthma, respectively. ESS was not significantly more cost effective for CRSwNP patients without asthma (p = 0.494)., Conclusion: ESS remains cost effective compared to medical therapy for patients both with and without asthma. While the comorbidity of asthma results in an inferior ICER result, it does not result in a statistically significant negative impact on the overall cost effectiveness of ESS., (© 2017 ARS-AAOA, LLC.)

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. 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.

Objectives/hypothesis: To determine the primary diagnoses for which balloon catheter dilation (BCD) of sinus ostia is being employed in a profit-blind health care system, the Department of Defense., Study Design: Retrospective chart review., Methods: From January 1, 2011 to December 31, 2013, 319 consecutive patient charts were reviewed for International Classification of Diseases, Ninth Edition (ICD-9) diagnoses, presence of chronic rhinosinusitis (CRS) defined by the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS), preoperative Lund-Mackay scores, nasal endoscopy findings, sinuses dilated, postoperative outcomes, and complications., Results: Of the 319 patients identified, 217 had sufficient documentation to be included. A CRS ICD-9 code was applied in 182 of 217 (83.9%) and recurrent acute rhinosinusitis in 12 of 217 (5.6%). Only 50.5% of CRS patient charts met criteria using EPOS guidelines. In contrast, 39.6% met the ICD-9 criteria for atypical facial pain. Patients with Lund-Mackay scores ≤ 4 were reviewed for number of sinuses dilated. Eighty-eight of 123 patients (71.5%) had sinuses dilated that were free from opacification/mucosal edema on preoperative imaging., Conclusions: Balloon dilation of sinus ostia has an expanding role in treating sinus disease. In the studied population, BCD is often utilized for alternate indications for which there is currently no evidence of efficacy. Future studies are needed to evaluate the efficacy of this technology in treating these alternate indications., Level of Evidence: 4. Laryngoscope, 127:544-549, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose of Review: The purpose of this review is to address the most recent advances in the medical therapy for chronic rhinosinusitis (CRS), define recalcitrant and refractory CRS, and discuss the productivity costs associated with CRS., Recent Findings: Recent studies evaluating anti-IL-4 receptor α antibodies and calcium channel blockers have demonstrated promising early results during management of CRS. Recent appropriateness criteria have been developed to assist clinicians with defining which patients have 'refractory' CRS and may be considered candidates for endoscopic sinus surgery. Productivity costs appear to be associated with disease severity and can be reduced with appropriate interventions., Summary: Topical corticosteroid therapy and high volume saline irrigation continue to be the cornerstone to medical therapy, whereas use of systemic corticosteroids and antibiotics depends on CRS phenotype and presence of acute exacerbation. More research is needed before routine use of novel immunomodulatory therapies such as anti-IL5, anti-IgE, anti-IL4, and calcium channel blockers. Clinicians should apply an appropriate definition for refractory CRS when discussing role of sinus surgery. Assessing the degree of work productivity impairment can assist in treatment decision-making and may help predict treatment outcomes.

Introduction: Management of the frontal sinus places great demands on the otolaryngologist. Given that the fronto-ethmoidal region is susceptible to recurrent inflammation, scarring, and stenosis, maintaining long-term patency of the frontal sinus is a difficult challenge. Oral and topical anti-inflammatory therapy, post-operative stenting, and 'home-brew' drug elution have been used for the treatment of the frontal sinus with mixed success. Recently an implant has been approved for post-operative placement into the frontal recess. This implant provides reliable and consistent steroid drug elution to address inflammation of the frontal recess secondary to chronic sinusitis. Areas covered: This review discusses the development and application of steroid eluting implants in the postoperative care of patients with chronic frontal sinusitis. All randomized controlled trials evaluating steroid eluting implants are discussed. Relevant supporting material discussing background, economics, safety are included. Expert commentary: Steroid eluting implants fulfill a unique niche in the treatment following frontal sinus surgery. They are shown to decrease the need for post-operative interventions and improve outcomes in patients with chronic sinusitis. There is significant potential for growth in the use of steroid eluting implants.

Background: Chronic rhinosinusitis with nasal polyps is a chronic disease frequently seen in otorhinolaryngological practice. Along with its chronic disease burden it creates high societal costs. Therapy consists of long-term use of medication and, if insufficient, endoscopic sinus surgery. No consensus exists on the right timing and extent of disease that warrants surgery. Furthermore, there is lack of clinical knowledge about the benefit of surgery over medication only. The current trial evaluates the clinical effectiveness and cost-effectiveness of endoscopic sinus surgery in addition to drug treatment versus medication exclusively in the adult patient group with nasal polyps., Methods: A prospective, multicentre, superiority, randomised controlled (PolypESS) trial in 238 patients aged 18 years or older selected for primary or revision endoscopic sinus surgery by the otorhinolaryngologist was designed. Patients will be randomised to either endoscopic sinus surgery in addition to medication or medical therapy only. Relevant data will be collected prior to randomisation, at baseline and 3, 6, 12, 18 and 24 months after start of treatment. Complete follow-up will be 24 months. Primary outcome is disease-specific Health-related Quality of Life quantified by the SNOT-22 after 12-month follow-up. Secondary outcomes are generic Health-related Quality of Life, cost-effectiveness, objective signs of disease and adverse effects of treatment. Subgroup analyses will be performed to verify whether treatment effects differ among patient phenotypes., Discussion: The PolypESS trial will investigate tailored care in adult patients with chronic rhinosinusitis with nasal polyps and will result in improved clinical pathways to help to determine in which circumstances to perform surgery., Trial Registration: Dutch Trial Register, NTR4978 . Registered on 27 November 2014.

Background: Chronic rhinosinusitis (CRS) has significant impacts upon productivity, economic metrics, and medication usage; however, factors that are associated with these economic outcomes are unknown., Methods: We evaluated olfactory dysfunction in 221 patients with CRS using the Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS) and the 40-item Smell Identification Test (SIT) and assessed whether an association existed between these olfactory metrics and healthcare utilization, productivity, and medication usage over the preceding 90 days., Results: After adjusting for CRS-associated comorbidities, objective measures of disease, demographics, and CRS-specific quality of life (QOL), patients with lower QOD-NS scores (worse patient-reported olfaction) had more missed days of normal productivity and employment, worse productivity levels, more hours of missed employment due to physician visits, more time caring for sinuses, greater distance traveled to medical appointment, more days of oral steroid use, and higher odds of being on disability insurance. Clinical olfaction, as measured by SIT, was associated with greater distance traveled to medical appointment and higher odds of being on disability insurance, but did not correlate with other productivity measures., Conclusion: Impaired olfactory-specific QOL is associated with significantly worse economic and productivity metrics and increased medication usage even after adjusting for CRS-specific comorbidities, objective measures of disease, demographics, and severity of CRS-specific QOL. Future studies are warranted to determine if targeting the impaired olfactory-specific QOL noted in patients with CRS results in improved productivity and economic outcomes., (© 2016 ARS-AAOA, LLC.)

Introduction: Accountable care organizations (ACO) and alternative payment models are a sign of the change in reimbursement from fee-for-service to value-based reimbursement. The focus of health care under ACOs is represented by the Triple Aim: to improve the experience of health care, improve the health of populations, and reduce the per capita costs. Individuals with chronic rhinosinusitis (CRS) are heavy consumers of health care services. Results of recent studies have indicated that there is the potential for improved outcomes and cost savings from early surgical intervention. Adhering to the principles of the Triple Aim may signal a paradigm shift in regard to timing of intervention for CRS in certain patients., Methods: A scoping review was performed to analyze the current literature related to management of CRS and the impact on cost, population health outcomes, and the patient's experience of health care., Results: A growing body of literature indicates that, in appropriately selected patients, when compared with medical management, endoscopic sinus surgery has the potential to improve patient outcomes and reduce the long-term cost burden of CRS., Conclusion: With the advent of ACOs, a paradigm shift in the treatment of CRS is inevitable to better conform to the goals of the Triple Aim. Future treatment algorithms will need to account for the heterogeneity within CRS and seek to identify appropriate timing and interventions for patients on an individual basis if the value of health care is to be improved.

Already for years we have ample evidence of the severe impact of allergic and non-allergic rhinitis and maybe even more rhinosinusitis on quality of life of our patients and the severe costs these diseases inflict on society. Despite this evidence we have difficulty convincing the politicians, health insurance companies and the public that more attention, research and money is needed to prevent these diseases to occur and to further prevent the sometimes serious sequalae of the disease.

Background: The purpose of this work was to evaluate the cost-effectiveness of endoscopic sinus surgery (ESS) compared to medical therapy for patients with chronic rhinosinusitis (CRS)., Methods: The study design consisted of a microsimulation Markov decision-tree economic model with a 31-year time horizon. A cohort of 489 patients who underwent ESS for CRS were matched 1 to 1 with a cohort of 489 patients from the national Medical Expenditures Panel Survey database who underwent medical management for CRS. Utility scores were calculated from responses to the EuroQol 5-Dimension instrument in both cohorts. Decision-tree analysis and a subsequent 10-state Markov model utilized published event probabilities as well as primary data from a large multisurgeon prospective outcomes study to calculate long-term costs and utility. The primary outcome measure was incremental cost per quality-adjusted life year (QALY). Multiple sensitivity analyses were performed., Results: The incremental cost-effectiveness ratio (ICER) for ESS vs medical therapy alone was $13,851.26 per QALY. The cost effectiveness acceptability curve demonstrated 85.84% and 98.69% certainty that the ESS strategy was the most cost-effective option at willingness-to-pay thresholds of $25,000 and $50,000 per QALY, respectively., Conclusion: This study shows ESS to be a cost-effective intervention compared to medical therapy alone for the management of patients with CRS., (© 2016 ARS-AAOA, LLC.)

Background: Chronic rhinosinusitis (CRS) is based on sinonasal symptoms coupled with sinonasal tissue inflammation. Establishing the epidemiology and prevalence of CRS, therefore, is challenging given that confirming objective evidence of sinonasal inflammation on a large scale is not feasible. Although the sinonasal symptoms are well documented at the sinonasal level, analysis of emerging data indicates that the impact on the general-health-related domains of health are the symptoms that are most bothersome to patients' quality of life., Objective: To review the literature on the epidemiology and the societal and individual burdens of CRS., Methods: A literature review., Results: A refinement of questionnaire-based surveys coupled with sampling of respondents for accuracy likely provides the most accurate assessment of prevalence. There is geographic variation, but, in North American and European countries, the rates range from 4.5 to 12%. Although CRS is marked by sinonasal symptoms, the most problematic symptoms for patients seem to be the symptoms that affect general-health-related domains. Diminished sleep, productivity, cognition, mood, and fatigue are associated with the decision to elect surgical intervention and are associated with diminished healthy utility values. Direct costs of CRS have been well documented, but new data on the indirect costs of decreased productivity surpass direct costs, at $12.8 billion dollars per year in the United States., Conclusion: CRS is a common disease with a large and vast symptom burden with high indirect costs. Although clinicians are focused by guidelines on sinus-specific symptoms, patients seem to be most impacted by the general-health-related consequences of CRS. An expanded understanding of the extent and costs of these symptoms will allow for a cost-effective allocation of limited health care resources.

Objectives: To explore the experience of CRS and its management from the perspective of patients with CRS. To our knowledge, this is the first qualitative study exploring sinus disease., Design: Semi-structured qualitative interviews., Setting: ENT outpatient clinic., Participants: Twenty-one adult patients with CRS: 11 male, 10 female. Patients suffered from a range of types of CRS (including polyps and fungal disease) and differing durations of symptoms (1.5-47 years). Participants were purposively selected. Thematic analysis was used., Outcome Measures: Patient experience of CRS and its management., Results: Patients had concerns regarding management of their symptoms by both healthcare professionals and themselves, including delays to referral and repeated medications. They reported reduced quality of life and high financial and psychosocial costs associated with living with CRS., Conclusions: Despite guidelines for CRS treatment, outcomes remain variable leading to dissatisfaction with treatment. Adherence to existing guidelines may result in fewer repeated consultations in primary care and earlier referrals to secondary care., (© 2015 John Wiley & Sons Ltd.)

Background: Chronic rhinosinusitis (CRS) is an inflammatory disease that affects 2% to 16% of the US population. Despite its increasing prevalence, there are currently limited data in the literature evaluating the economic burden of this disease., Objective: This study aimed to determine the direct health care costs of CRS from the perspective of the US government., Methods: A prevalence-based approach was used to estimate cost of illness for CRS from the 2011 Medical Expenditure Panel Survey database by using a 4-part model: (1) an estimated sum of all health care expenditures, (2) an attribution model for disease-specific estimation of expenditures, (3) an estimation based on a propensity score model, and (4) estimated disease-specific expenditure by using a linear regression-based approach. A disease prevalence of 3.5% was used., Results: The mean CRS-specific annual expenditure was $5955 (95% CI, $5087-$6823) by using method 1 compared with $5560 (95% CI, $4689-$6431) by using method 2 and $5560 (95% CI, $4653-$6467) by using method 3. The annual expenditure, as estimated by using method 4, was $5589 (95% CI, $4986-$6192). Ambulatory expenses accounted for the largest proportion of expenditures, followed by prescription and in-hospital expenses., Conclusions: This study provided a range of estimates of the direct medical expenditures associated with CRS. We demonstrated that the economic burden attributable to this disease was an estimated $60.2 to $64.5 billion US dollars in 2011, with a wide variation in the total and incremental direct expenditures depending on the type of estimation model used and the prevalence assumed., (Copyright © 2015 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: A health utility value represents an individual's preference for living in a specific health state and is used in cost-utility analyses. This study investigates the impact of continuing medical therapy on health utility outcomes in patients with chronic rhinosinusitis (CRS)., Methods: The Medical Outcomes Study Short Form-6D (SF-6D) questionnaire was administered to patients prospectively enrolled in a longitudinal study examining treatment outcomes for CRS. Patients were prescribed robust, initial medical therapy and then elected to continue with medical therapy (n = 40) or undergo endoscopic sinus surgery (ESS), followed by medical therapy (n = 152). Patients observed through treatment crossover to ESS were also evaluated (n = 20). Health utility values (SF-6D) were generated at baseline, 6-months, and 12-months follow-up for both cohorts and evaluated using repeated measures analysis of variance (ANOVA)., Results: Treatment crossover patients were found to have a significantly higher prevalence of previous sinus surgery compared to medical management (χ(2) = 6.91; p = 0.009) and surgical intervention (χ(2) = 8.11; p = 0.004) subgroups. Mean baseline utility value for the medical therapy cohort was significantly better compared to the ESS cohort (mean ± standard deviation; 0.76 ± 0.12 vs 0.70 ± 0.15; p = 0.023). Significant improvement in health utility was reported in the ESS cohort (F(2) = 37.69; p < 0.001), whereas values remained stable, without significant improvement, in both the medical therapy cohort (F(2) = 0.03; p = 0.967) and treatment crossover cohort (F(2) = 2.36; p = 0.115)., Conclusion: Patients electing continued medical management report better baseline health utility compared to patients electing ESS. Patients electing ESS show significant improvement in health utility, whereas those electing continued medical management demonstrate stable health utility over 12 months., (© 2015 ARS-AAOA, LLC.)

Importance: It is estimated that lost productivity related to chronic rhinosinusitis (CRS) costs society in excess of $13 billion per year in the United States. Given this tremendous cost to society, it is important to evaluate the effect of current interventions on improving this productivity loss., Objective: To define the change in productivity costs in patients with refractory CRS who select continued medical therapy., Design, Setting, and Participants: Observational cohort study. Thirty-eight patients with a guideline-based diagnosis of CRS whose initial appropriate medical therapy failed were enrolled from 4 tertiary-level rhinology clinics. The study was conducted from December 6, 2010, to April 23, 2013, and data analysis was performed from December 6, 2010, to June 1, 2015., Interventions: Continued medical therapy for CRS., Main Outcomes and Measures: The human capital approach was applied to quantify productivity costs. Absenteeism, presenteeism, and lost leisure time were quantified to define annual lost productive time, which was measured at enrollment (baseline) and at a minimum of 6 months after treatment. Lost productive time was monetized using the annual daily wage rates obtained from the 2012 US National Census and the 2013 US Department of Labor statistics., Results: Thirty-eight patients with refractory CRS who selected continued medical therapy had a mean (SD) baseline annual productivity cost of $3464 ($4900) per patient. After continued medical therapy for a mean of 12.8 (4.8) months, productivity costs were $2730 ($3720) (before vs after continued medical therapy productivity cost, P = .74). Mean annual absenteeism was reduced from 5 (12) days to 2 (8) days (P = .02). Mean annual presenteeism (17 [27] days reduced to 15 [23] days; P = .93) and mean annual household days lost (7 [7] days reduced to 6 [6] days; P = .51) were maintained at baseline levels. There were no significant differences in productivity outcomes based on endoscopy, the 22-item Sinonasal Outcome Test score, age, or polyp status (all P ≥ .11)., Conclusions and Relevance: Patients with refractory CRS often make treatment decisions based on the degree of quality-of-life and productivity impairment. Outcomes from this study suggest that productivity in patients with refractory CRS who have minor reductions in baseline productivity can remain stable with continued medical therapy. Physicians can use this information to inform appropriate patients with CRS of their expected outcomes from continued medical therapy.

Objective/study Design: The objective of this systematic review was to summarize the literature evaluating the costs associated with the management of adult chronic rhinosinusitis (CRS) using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines., Methods: Two separate authors systematically searched eight commonly used medical databases. Included articles were categorized into seven domains: 1) overall healthcare cost (direct and indirect), 2) resource utilization, 3) medical management strategies, 4) overall procedure cost of endoscopic sinus surgery (ESS), 5) intraoperative technologies, 6) ESS litigation, and 7) CRS diagnostics. To maintain a common currency for comparison, all costs were converted to 2014 United States dollars (USD) using an inflation calculator in September 2014., Results: Forty-four studies were identified for inclusion. The range for overall CRS-related healthcare costs was $6.9 to $9.9 billion 2014 USD per year. Indirect costs were estimated as $13 billion 2014 USD per year. Annual medication costs prior to ESS ranged between $1,547 and $2,700 2014 USD per patient, with a uniform reduction in costs after ESS. The overall US cost of outpatient ESS ranged from $8,200 to $10,500 2014 USD per case. The overall annual economic burden of CRS in the United States was estimated to be $22 billion 2014 USD (direct and indirect costs)., Conclusion: The results of this systematic review have demonstrated substantial direct and indirect costs associated with the management of adult CRS. Future research should continue to improve the costing data, which can be used to improve the value of care provided for this chronic inflammatory disease., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Importance: Previous work suggests an association between insurance status and location of presentation (emergency department vs outpatient clinic) for evaluation of uncomplicated acute rhinosinusitis (ARS)., Objective: To investigate whether the quality of outpatient care for ARS likewise differs based on insurance status., Design, Setting, and Participants: Cross-sectional study of 13 680 145 pediatric and adult patients from the 2009 and 2010 National Ambulatory Medical Care Survey diagnosed with uncomplicated ARS at an outpatient care facility., Exposures: Health insurance status., Main Outcomes and Measures: The primary outcome measures were continuity of care with the patients' primary care physician (PCP) and time spent with a physician, which were chosen as proxies for quality of care. We evaluated associations between insurance status and these quality measures while controlling for clinical, demographic and socioeconomic patient characteristics, and outpatient practice setting., Results: Most patients (76.4%) had private insurance vs Medicare (12.3%), Medicaid (8.6%), or self-pay (2.8%). There was no association between insurance status and presentation of patients to their PCP. Physicians spent more time with Medicaid patients compared with patients with private insurance (β = 4.59; P = .01), independent of other factors. Provision of health education (β = 4.42; P < .001), necessity of a follow-up visit (β = 3.20; P = .002), and increasing patient age (β = 0.07; P = .01) were associated with longer visits. In multivariate analysis, living in a medium or small metropolitan area was associated with higher likelihood of being seen by one's own PCP than living in a large metropolitan area (odds ratio, 6.37; 95% CI, 2.13-19.05; P = .001)., Conclusions and Relevance: This study did not identify any quality of care issues with respect to insurance coverage and primary care encounters for patients with ARS. In contrast to expectations, patients with Medicaid had longer outpatient physician visits and were equally likely to see their own PCP compared with patients with private insurance or Medicare.

Background: This study investigates how endoscopic sinus surgery (ESS) impacts total direct healthcare costs, medication usage, and frequency of imaging among patients with chronic rhinosinusitis (CRS)., Methods: Data were obtained from the MarketScan® Commercial Claims and Encounters databases (Truven Health Analytics); patients who underwent ESS for CRS in 2008 were identified. Healthcare costs, days of antibiotic and oral steroid usage, and number of computed tomography (CT) and magnetic resonance imaging (MRI) studies were collected for 12 months prior to and 36 months after surgery and compared in 1-year intervals., Results: A total of 8963 surgical patients were included. Median total direct costs fell from $4750 at preoperative baseline (95% confidence interval [CI], $4661 to $4838) to $4212 by year 3 after surgery (95% CI, $4078 to $4346). Disease-specific costs related to conditions commonly associated with CRS-asthma, allergy, depression, and headache-all decreased in the years after surgery; the reduction was significant for all conditions but asthma. Mean days of antibiotic usage per year decreased from 28.2 days before surgery to 15.9 days by year 3 after surgery, p value <0.001. Days of oral corticosteroid usage remained stable at just over 7 days. Mean number of imaging studies fell from an average of 1.6 in the year before surgery to 0.2 by year 3 after surgery, p value <0.001., Conclusion: Among patients who underwent ESS for CRS, total direct healthcare costs, antibiotic usage, and number of imaging studies decreased after surgery, and remained below preoperative levels throughout all 3 years of follow-up. Oral corticosteroid usage remained stable., (© 2015 ARS-AAOA, LLC.)

Objective: To evaluate the impact of early versus delayed endoscopic sinus surgery (ESS) in terms of postoperative health care utilization, using a patient cohort with chronic rhinosinusitis (CRS)., Study Design: Retrospective administrative database analysis., Setting: US-based primary and secondary sites of care., Subjects and Methods: CRS patients with ESS in 2010-with no other ESS before 2010 and with complete medical history from 2004 to 2012-were identified within the MarketScan database. Patients were characterized by time interval of first sinusitis or nasal polyposis diagnosis to ESS and grouped as following: group 1, <1 year (n=818); group 2, 1 to <2 years (n=247); group 3, 2 to <3 years (n=274); group 4, 3 to <4 years (n=364); group 5, 4 to <5 years (n=595); and group 6, ≥5 years (n=535). Outpatient visits/procedures and prescriptions associated with sinusitis and/or nasal polyps were analyzed for 1 year preoperatively and 2 years postoperatively. Subanalyses were conducted on separate cohorts with or without asthma or polyps, within each group., Results: Patients in group 1 had significantly fewer visits and prescriptions than patients in group 6 (postoperative visits: group 1, 4.45 [95% CI, 4.06-4.84]; group 6, 6.70 [95% CI, 6.10-7.30; prescriptions: group 1, 4.54 [95% CI, 4.12-4.96]; group 6, 7.61 [95% CI, 6.92-8.31]). Gradual increases in utilization were observed from groups 1 to 6. Subanalysis of patients with and without asthma or polyps showed similar findings., Conclusion: Early intervention after diagnoses of CRS, with or without asthma or polyps, is associated with lower health care utilization than intervention after many years of medical management., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Chronic rhinosinusitis (CRS) is a relevant and prevalent medical condition in Germany, Europe and the world. If analysed in detail, the prevalence of CRS shows regional and temporary variety. In this review, currently available data regarding the prevalence of CRS is therefore sorted by country and/or region, time point of data collection and the CRS-definition employed. Risk factors like smoking and gastro-oesophageal reflux are discussed regarding their influence on CRS prevalence. Moreover, co-morbidities of CRS, like asthma, conditions of the cardiovascular system and depression are listed and their influence on CRS is discussed. Furthermore, data on CRS prevalence in special cohorts, like immunocompromised patients, are presented. To estimate the economic burden of CRS, current data e.g. from Germany and the USA are included in this review., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives/hypothesis: To evaluate the long-term cost-effectiveness of endoscopic sinus surgery (ESS) compared to continued medical therapy for patients with refractory chronic rhinosinusitis (CRS)., Study Design: Cohort-style Markov decision-tree economic evaluation., Methods: The economic perspective was the U.S. third-party payer with a 30-year time horizon. The two comparative treatment strategies were: 1) ESS, followed by appropriate postoperative medical therapy; and 2) continued medical therapy alone. Primary outcome was the incremental cost per quality-adjusted life year (QALY). Costs were discounted at a rate of 3.5% in the reference case. Multiple sensitivity analyses were performed, including differing time-horizons, discounting scenarios, and a probabilistic sensitivity analysis (PSA)., Results: The reference case demonstrated that the ESS strategy cost a total of $48,838.38 and produced a total of 20.50 QALYs. The medical therapy alone strategy cost a total of $28,948.98 and produced a total of 17.13 QALYs. The incremental cost effectiveness ratio for ESS versus medical therapy alone is $5,901.90 per QALY. The cost-effectiveness acceptability curve from the PSA demonstrated that there is a 74% certainty that the ESS strategy is the most cost-effective decision for any willingness to pay a threshold greater than $25,000. The time-horizon analysis suggests that ESS becomes the cost-effective intervention within the third year after surgery., Conclusion: Results from this study suggest that employing an ESS treatment strategy is the most cost-effective intervention compared to continued medical therapy alone for the long-term management of patients with refractory CRS., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: The management of chronic rhinosinusitis with nasal polyposis (CRSwNP) becomes unclear when patients require multiple courses of corticosteroids to maintain quality of life. Repeated courses of corticosteroids carry increased risks to patients. Although endoscopic sinus surgery (ESS) is an effective therapeutic modality, it also carries inherent risks. This study aims to identify the threshold at which the risks of repeated courses of corticosteroid exceed the risks of surgery., Methods: An evidence-based risk analysis was simulated using literature-reported complication rates, quality of life changes, and Medicare costs. Simulations were performed from the Medicare patient perspective, societal perspective, and the universal healthcare patient perspective., Results: All 3 simulations demonstrate a breakeven threshold favoring surgery over medical therapy when patients require oral corticosteroids (OCS) more often than once every 2 years in CRSwNP, once per year in CRSwNP/asthma, or twice per year for Samter's triad patients., Conclusion: This represents the first rationalized evidence-based analysis for when surgery should be considered in place of repeated courses of oral corticosteroids. This threshold provides a guide for otolaryngologists to use when making clinical decisions with patients., (© 2014 ARS-AAOA, LLC.)

Background: Routine histopathological assessment is standard practice for nasal polyp specimens obtained during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Retrospective studies suggest that routine histopathology of nasal polyps shows few unexpected diagnoses that alter patient management. Our objective was to study the use of routine pathological analysis, and its cost to the healthcare system, in a prospective manner., Methods: A multicenter prospective assessment was performed from data collected between 2007 and 2013. Only cases of patients undergoing ESS for bilateral CRS were included. We excluded unilateral disease cases, and cases in which diagnoses other than polyps were suspected either preoperatively or intraoperatively. We then compared the preoperative diagnosis with the final histopathology and identified the rate of unexpected pathologies. A cost analysis was performed., Results: Only 4 of 866 pathological specimens were identified as having a clinically significant unexpected diagnosis. All unexpected pathologies in this series were benign. These 4 cases account for 0.46% of all specimens reviewed. This translates to a number needed to screen of 217 cases of bilateral CRS to discover 1 unexpected pathology. The associated cost for making an unexpected diagnosis was $19,192.73., Conclusion: Routine histopathology of nasal polyps in ESS for bilateral CRS with polyps yields few unexpected and management-altering diagnoses. It carries a significant cost to the healthcare system. In cases of bilateral CRS with no other concerning clinical features, clinicians should exercise judgment in submitting polyp specimens for pathology rather than routinely sending polyps for histopathologic analysis., (© 2014 ARS-AAOA, LLC.)

Objectives/hypothesis: Disease-specific reductions in patient productivity can lead to substantial economic losses to society. The purpose of this study was to: 1) define the annual productivity cost for a patient with refractory chronic rhinosinusitis (CRS) and 2) evaluate the relationship between degree of productivity cost and CRS-specific characteristics., Study Design: Prospective, multi-institutional, observational cohort study., Methods: The human capital approach was used to define productivity costs. Annual absenteeism, presenteeism, and lost leisure time was quantified to define annual lost productive time (LPT). LPT was monetized using the annual daily wage rates obtained from the 2012 U.S. National Census and the 2013 U.S. Department of Labor statistics., Results: A total of 55 patients with refractory CRS were enrolled. The mean work days lost related to absenteeism and presenteeism were 24.6 and 38.8 days per year, respectively. A total of 21.2 household days were lost per year related to daily sinus care requirements. The overall annual productivity cost was $10,077.07 per patient with refractory CRS. Productivity costs increased with worsening disease-specific QoL (r = 0.440; p = 0.001)., Conclusion: Results from this study have demonstrated that the annual productivity cost associated with refractory CRS is $10,077.07 per patient. This substantial cost to society provides a strong incentive to optimize current treatment protocols and continue evaluating novel clinical interventions to reduce this cost., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: We investigated early post 9/11 factors that could predict rhinosinusitis healthcare utilization costs up to 11 years later in 8,079 World Trade Center-exposed rescue/recovery workers., Methods: We used bivariate and multivariate analytic techniques to investigate utilization outcomes; we also used a pyramid framework to describe rhinosinusitis healthcare groups at early (by 9/11/2005) and late (by 9/11/2012) time points., Results: Multivariate models showed that pre-9/11/2005 chronic rhinosinusitis diagnoses and nasal symptoms predicted final year healthcare utilization outcomes more than a decade after WTC exposure. The relative proportion of workers on each pyramid level changed significantly during the study period., Conclusions: Diagnoses of chronic rhinosinusitis within 4 years of a major inhalation event only partially explain future healthcare utilization. Exposure intensity, early symptoms and other factors must also be considered when anticipating future healthcare needs., (© 2014 Wiley Periodicals, Inc.)

Objectives: To evaluate the outcomes (using validated outcome tools) and cost benefits of functional endoscopic sinus surgery in a population of severely asthmatic patients with chronic rhinosinusitis., Methods: A prospective cohort study was conducted. The study comprised consecutive patients diagnosed with asthma and chronic rhinosinusitis for whom medical treatment had failed and who were scheduled for functional endoscopic sinus surgery. General health and disease-specific outcome questionnaires were completed pre- and post-operatively. Costs associated with both functional endoscopic sinus surgery and out-patient visits to a comprehensive asthma clinic were calculated., Results: A total of 47 patients completed the surveys. The average improvement in Chronic Sinusitis Survey scores following functional endoscopic sinus surgery was 17 per cent. The average reduction in out-patient asthma clinic visits was 50 per cent, which translates to an average cost saving of $1035 Canadian dollars per patient per year., Conclusion: Functional endoscopic sinus surgery is a cost-effective treatment modality for asthmatic patients with chronic rhinosinusitis. This information is important for: the distribution and planning of resources, prioritising health programmes, and establishing practice guidelines.

Objectives/hypothesis: To evaluate National Institutes of Health (NIH) support for rhinosinusitis research and characterize the proportion of funding awarded to otolaryngologists., Study Design: Analysis of the NIH RePORTER database., Methods: Specialty and terminal-degree of primary investigators (PIs) for 131 projects spanning 364 fiscal years (1989 to present) were determined. Awards for projects examining rhinosinusitis were organized by size, academic department, and PI scholarly impact (using h-indices). Analysis of geographic and temporal funding trends was performed and organized by PI specialty., Results: A total of 62.6% of projects were awarded to physicians, one-third of whom were otolaryngologists. Allergists/immunologists had greater median awards than otolaryngologist PIs (P = .02), and pediatric-trained PIs had a greater h-index than otolaryngologist PIs (P = .04). Although year-to-year fluctuation was noted, otolaryngologists have received approximately a quarter of total rhinosinusitis funding since 2000. PIs practicing in the south-Atlantic, east-north-central, and west-north-central states had the greatest funding totals, whereas otolaryngologists had a greater proportion of regional funding in the Pacific and east-south-central states than other regions., Conclusions: Inquiry into the mechanisms underlying rhinosinusitis and optimal therapeutic strategies represents an interdisciplinary venture. PIs in medicine and pediatric departments had greater funding for rhinosinusitis projects than individuals in otolaryngology departments, partly because of greater utilization of PhD faculty. Otolaryngology departments may consider increased recruitment of basic scientists interested in rhinosinusitis as a means to facilitate increased scholarship in this area. Encouraging pursuit of funding opportunities is critical for otolaryngologists, as well-funded practitioners may have greater opportunities to shape advances and serve as an advocate for their approaches., Level of Evidence: NA., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Previous studies showed that chronic rhinosinusitis (CRS) accounts for billions of dollars in healthcare resource utilization. However, all such study estimates of the economic burden of CRS were based on subpopulations in Western societies. This study aimed to investigate differences in the utilization of healthcare services between subjects with CRS and comparison subjects using Taiwan's National Health Insurance database., Study Design: A cross-sectional study., Methods: In total, 5,849 CRS subjects and 17,547 selected comparison subjects were included in this study. We evaluated healthcare resource utilization in a 1-year period. Variables of healthcare resource utilization included the following: numbers of outpatient visits and inpatient days, and the mean costs of outpatient and inpatient treatment. We also divided healthcare resource utilization into ear, nose, and throat (ENT) and non-ENT services., Results: On the utilization of ENT services, CRS subjects had significantly more outpatient visits (3.9 vs. 1.4, P < .001) and significantly higher outpatient costs (US$77.7 vs. US$19.4, P < .001) than comparison subjects. As for the use and costs of all healthcare services, CRS subjects had significantly more outpatient visits (27.9 vs. 18.3, P < .001) and significantly higher outpatient (US$953 vs. US$665, P < .001) and total (US$1319 vs. US$946, P < .001) costs than comparison subjects. Namely, on average, CRS subjects had 152% more outpatient visits and 139% higher total costs than comparison subjects., Conclusions: This study found that subjects with CRS had significantly higher use of all healthcare services and costs than aged-matched controls., Level of Evidence: 2c., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To analyze the impact of endoscopic sinus surgery (ESS) on overall health care utilization for the treatment of chronic rhinosinusitis (CRS)., Study Design: Retrospective administrative database analysis., Setting: All US-based primary and secondary sites of care., Subjects and Methods: A cohort of patients with ESS (Current Procedural Terminology codes 31254-31288) in 2008 and at least 5 years of continuous medical and drug plan enrollment were included (n = 9105). Inpatient and outpatient medical history (including prescriptions) was analyzed from weeks -104 to +104 postoperatively., Results: Health care utilization was constant up to -6 months preoperatively, at a per-patient per-week (PPPW) average of $11.75 (prescriptions, $2.44 [95% confidence interval (CI), $2.32-$2.56]; inpatient care, $ 0.82 [95% CI, $ 0.43-$1.20]; outpatient care, $8.49 [95% CI, $7.90-$9.08]). At -26 weeks preoperatively, a continuous increase from baseline levels was observed up to week -3, reaching an average PPPW of $95.37 (prescriptions, $13.74 [95% CI, $12.51-$14.96]; inpatient care, $2.73 [95% CI, $1.76-$3.70]; and outpatient care, $78.90 [95% CI, 73.65-$84.14]). From week -3 to surgery, outpatient events and prescriptions increased significantly, suggesting a decision to operate and costs associated with preoperative management. Postoperatively, costs declined rapidly, reaching baseline levels by 13 weeks postoperatively. Adverse events were reported in 388 patients (2.94% cases of hemorrhage, 0.14% cases of cerebrospinal fluid leak, 0.58% cases of orbital complications), and 572 (6.28%) patients had revision surgery., Conclusion: Patients with CRS incur ongoing, baseline levels of health care utilization. Preoperatively, CRS-related health care needs are more than 8-fold greater than those at baseline. Following ESS, health care needs declined rapidly and reached baseline levels within 13 weeks postoperatively.

Background: Chronic rhinosinusitis (CRS) is prevalent, morbid, and poorly understood. Extraction of electronic health record (EHR) data of patients with CRS may facilitate research on CRS. However, the accuracy of using structured billing codes for EHR-driven phenotyping of CRS is unknown. We sought to accurately identify CRS cases and controls using EHR data and to determine the accuracy of structured billing codes for identifying patients with CRS., Methods: We developed and validated distinct algorithms to identify patients with CRS and controls using International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology codes. We used blinded clinician chart review as the reference standard to evaluate algorithm and billing code accuracy., Results: Our initial control algorithm achieved a control positive predictive value (PPV) of 100% (i.e., negative predictive value of 100% for CRS). Our initial algorithm for CRS cases relied exclusively on billing codes and had a low case PPV (54%). Notably, ICD-9 code 471.x was associated with a case PPV of 85%, whereas the case PPV of ICD-9 code 473.x was only 34%. After multiple algorithm iterations, we increased the case PPV of our final algorithm to 91% by adding several requirements, e.g., that ICD-9 codes occur with 1 or more evaluations by a CRS specialist to enhance availability of objective clinical data for accurately phenotyping CRS., Conclusion: These algorithms are an important first step to identify patients with CRS, and may facilitate EHR-based research on CRS pathogenesis, morbidity, and management. Exclusive use of coded data for phenotyping CRS has limited accuracy, especially because CRS symptomatology overlaps with that of other illnesses. Incorporating natural language processing (e.g., to evaluate results of nasal endoscopy or sinus computed tomography) into future work may increase algorithm accuracy and identify patients whose disease status may not be ascertained by only using billing codes.

Objectives/hypothesis: To evaluate the cost-effectiveness of preapproval requirements for computed tomography (CT) of the sinuses in the evaluation and management of chronic rhinosinusitis (CRS)., Study Design: Retrospective analysis of prospectively collected data., Methods: Over a 6-month period, all sinus CT scans ordered by an otolaryngology practice and requiring preapproval by a third-party payor were tabulated. Characteristics of the preapproval process that were recorded and analyzed included time spent by office administrative staff, need for peer-to-peer review, and time spent by the ordering physician., Results: All 111 sinus CT scans ordered during the 6-month time period required preapproval based on insurer requirements-38 performed by computer, 71 by telephone, and two required both-costing an average of 8.1 minutes per scan by administrative staff (range, 2.0-20.0 minutes). Thirteen preapprovals required peer-to-peer telephone interaction by the ordering physician, utilizing an average of 7.7 minutes (range, 5-12 minutes). In no case was the insurance company peer an otolaryngologist. Ultimately, no sinus CT scan request was rejected by a third-party payor., Conclusions: Preapprovals for sinus CTs ordered by otolaryngologists are unlikely to save costs for third-party payors, as sinus CT for the evaluation of CRS is well established and therefore unlikely to be rejected. Preapproval in this context comes at the expense of practice administrative and physicians' time. Based on our results, preapproval for sinus CT scans ordered by an otolaryngologist for evaluation of CRS appears to be an unnecessary and costly requirement., Level of Evidence: N/A., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)