Satisfaction Level With Current Treatments for Allergic Rhinitis

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patient with doctorHow well do we manage our patients who have been diagnosed with allergic rhinitis? Do patients and healthcare providers have a similar outlook? This presentation was given at the American College of Allergy, Asthma and Immunology Annual Meeting, and largely is drawn from data obtained from "Allergies in America: A Landmark Survey of Nasal Allergy Sufferers," the largest and most comprehensive national survey of patients with allergic rhinitis, and the healthcare providers who treat them, which was released in 2006.[1]

The purpose of this survey was to describe the symptoms, burden of disease, and treatment of allergic rhinitis. As a brief summary, a national sample of 31,470 American households were screened by telephone interview to obtain a national probability sample of 2500 adults, aged 18 and over, who had been diagnosed by a physician with allergic rhinitis, nasal allergies, or "hay fever" and who had nasal allergy symptoms, or had taken prescription medication for allergies within the past 12 months

This group was interviewed by the national public opinion research organization, Schulman, Ronca, & Bucuvalas, Inc, in a 35-minute phone interview with questions concerning their condition and treatment. A parallel survey was conducted among 400 healthcare practitioners, including 100 adult primary care specialists, 100 otolaryngologists, 100 allergists, 50 nurse practitioners, and 50 physician assistants.

The survey questions were developed by a group of physicians with specialties in allergy, otolaryngology, and primary care, and included Michael Blaiss, MD; Jennifer Derebery, MD; James Hadley, MD; Eli Meltzer, MD; Robert Naclerio, MD; Harold Nelson, MD; and Stuart Soloff, MD.

Although the survey itself looked at the current state of adults with allergic rhinitis, and included questions about prevalence, medications, and symptom burden, this summary specifically reviews medication side effects and efficacy, as well as patient and healthcare practitioner perspectives on efficacy.

Medication Types and Expenditures

The most current estimate of the economic impact of allergic rhinitis is approximately $5 billion.[2,3]

Outpatient and emergency department visits and prescription medications are the big drivers of cost, estimated at 86.3% (or $4.2 billion), whereas indirect costs of lost productivity constitute 13.7% (or $665.8 million). This estimate likely underestimates the true cost because it did not include expenditures for over-the-counter medications by allergy sufferers.

Consistent with the large direct cost of treatment, 70% of our survey group of allergy sufferers reported having taken a medication for their nasal allergies in the 4-week period prior to the telephone survey. Fifty-three percent reported having taken an over-the-counter medication, whereas 45% had taken a prescription medication. Thirty-six percent had taken a prescription nasal spray, usually an intranasal steroid, whereas 22% reported taking some other prescription medication in the same time period.

Medication Changes

Patients with allergies are known to change medications for their condition frequently. In the survey, 1723 individuals were reported to have changed their prescription or over-the-counter medication for their allergy symptoms at some point during the course of their disease symptoms. Thirty-seven percent of the participants changed their medication due to lack of efficacy.

A doctor recommended changing the medication in 23% of cases, and the patient wanted to try another medication (reason unspecified) in 11% of cases. Approximately one third (869 patients) of respondents had specifically requested a change of medication from their care provider. Of these, 66% were due to lack of efficacy. Although lack of efficacy may be the reason to change medication, the study found that bothersome side effects were also significant, representing 21% of the reason for change. Surprisingly, in today's managed care market, cost/copayment and lack of coverage accounted for only 1% in each case for the reason to change medication.

Side Effects: What Are They and How Much Do They Matter?

The Allergies in America survey looked at the specific side effects that bothered patients with allergic rhinitis the most. Commonly reported side effects that are considered to be moderately or extremely bothersome from medications for allergic rhinitis that patients considered to be moderately or extremely bothersome include a drying sensation (34%), dripping down the throat (33%), and drowsiness (33%). In addition, headaches (25%), bad taste (22%), and burning (18%) were also reported as bothersome. These symptoms have been reported to significantly and negatively affect the daily lives of the sufferer. For example, Blaiss and colleagues[4] in their presentation concluded that many patients perceive nasal allergy symptoms as extremely bothersome and that nasal symptoms may reduce performance and productivity and negatively affect patient quality of life.

One challenge in interpreting data on side effects is the overlap between the side effects from medications and the disease symptoms themselves. For example, headaches, cited as a significant side effect in 25% of respondents, may also be seen in nasal congestion with edematous nasal mucosa affecting the nasal septum. Was the headache really a side effect or a symptom caused by unresponsive nasal congestion?

Mahadevia and colleagues[5] posed a similar question especially concerning attributes of intranasal steroids in a group of 120 adult patients with allergic rhinitis, and attempted to determine their marginal willingness to pay a copayment to avoid these when presented with different hypothetical intranasal steroids of equal efficacy and side effects. As opposed to the Allergies in America survey, he found the top 6 offenders to be sensory in nature, and did establish an amount for each that patients said they would pay per month to avoid. In the study by Mahadevia and colleagues,[5] the top offenders were strong aftertaste ($19.8), strong overall taste ($12.2), large amount of nasal runoff ($11), strong smell ($10.9), large amount of pharyngeal runoff ($10.5), and dry sensation ($5.92).

More important than bothersome side effects was lack of efficacy. Fifty-four percent of respondents in the Allergies in America survey said that they had changed a medication for allergic rhinitis at least once because of lack of efficacy. Because the most commonly used class of medication for treatment of allergic rhinitis, oral antihistamines, is notorious for its propensity for tachyphylaxis, a significant number of responders treated with intranasal steroids noted dissatisfaction with treatment effectiveness. Of the 760 patients who had used an intranasal steroid, 48% complained of lack of 24-hour coverage. Specifically 70% of patients reported that their prescription intranasal spray lost effectiveness in less than 11 hours, with 50% complaining of loss of effectiveness in less than 7 hours.

Satisfaction With Disease Management: Healthcare Provider vs Patient Perspective

The survey had established that the burden of illness for allergic rhinitis from the patient's perspective was significant, and that there was good correlation between the patient and healthcare provider's awareness of the degree of discomfort experienced during a nasal allergy attack. However, there appeared to be a disconnect between the patients and the clinicians at the level of satisfaction with allergy treatment. For example, between 82% and 91% of healthcare providers believe that patients get their money's worth from their prescription medication. In contrast, only 55% of patients would agree with that assessment.

Patients and healthcare providers were also queried about patient satisfaction specifically from treatment of their allergic rhinitis with intranasal steroids. All of the allergists surveyed, and 96% of otolaryngologists, 98% of primary care physicians, and 96% of nurse practitioners and physician assistants, reported that their patients were somewhat or very satisfied with their intranasal steroids. In contrast, only 75% of patients indicated that they were satisfied.

Perhaps this disconnect between patient and provider perspectives arose from the fact that most patients with nasal congestion continue to take or be treated with oral antihistamines, regardless of the recommendation by an expert panel convened by the American Academy of Allergy, Asthma & Immunology that an intranasal steroid should be first-line therapy in those patients.[6]

Patients and providers were also asked to rate how satisfied they were with their overall disease management and treatment. Ninety-one percent of allergists believed that all or most of their patients were very satisfied with their disease management, whereas 81% of otolaryngologists and 72% primary care physicians believed that patients would rate themselves as very satisfied. 65%Nurse practitioners and physician assistants agreed with that assessment.

In contrast, only 58% of patients who had seen a healthcare practitioner in the past 12 months said that they were very satisfied with their disease management. Of interest, there was no significant difference in satisfaction between these patients and the 56% who had not seen a healthcare practitioner in the past year. Perhaps, and as reported in the presentation by Blaiss and colleagues,[7] treatment that is associated with complete symptom relief and improved tolerability profile may improve satisfaction with treatment with better clinical benefit and outcomes for patients with allergic rhinitis.

Both healthcare providers and patients all agreed that there was a need for better education, particularly for patients, on allergic rhinitis and its treatment.

Conclusion

Healthcare providers surveyed in the Allergies in America study recognized the burden of allergic rhinitis on the sufferer. The majority believed that all or most of their patients are very satisfied with their disease management. However, patients report much less satisfaction with their disease management. One factor that may contribute to this disconnect and patient dissatisfaction is the fact that less than half of patients diagnosed with allergic rhinitis have seen a healthcare provider within the last year, even though they frequently use medication -- both prescribed and over-the-counter. Although this may be a classic case of "out of sight, out of mind," even those patients who have sought the help of a physician in the past 12 months for treatment of nasal allergies are not as satisfied with either disease management or medication as assumed by healthcare providers. Future therapies and better disease education will need to meet these unmet needs to improve patient satisfaction.

References

  1. Allergies in America: A Landmark Survey of Nasal Allergy Sufferers. Available at: http://www.myallergiesinamerica.com/Healthcare/overview.aspx Accessed December 11, 2006.
  2. Schoenwetter WF, Dupclay L Jr, Appajosyula S, et al. Economic impact and quality-of-life burden of allergic rhinitis. Curr Med Res Opin. 2004;20:305-317.
  3. Lamb CE, Ratner PH, Johnson CE, et al. Economic impact of workplace productivity losses due to allergic rhinitis compared with select medical conditions in the United States from an employer perspective. Curr Med Res Opin. 2006;22:1203-1210.
  4. Blaiss MS, Boyle JM, Droar J. Patient perspective on the symptoms of allergic rhinitis and the effect of allergic rhinitis on daily living. Program and abstracts of the American College of Allergy, Asthma and Immunology 2006 Annual Meeting; November 9-15, 2006; Philadelphia, Pennsylvania. Abstract 29.
  5. Mahadevia P, Shah S, Mannix S, et al. Willingness to pay for sensory attributes of intranasal corticosteroids among patients with allergic rhinitis. J Manag Care Pharm. 2006;12:143-151.
  6. American Academy of Allergy, Asthma & Immunology (AAAAI). The Allergy Report: Science Based Findings on the Diagnosis & Treatment of Allergic Disorders, 1996-2001. Milwaukee: American Academy of Allergy, Asthma & Immunology (AAAAI); 2001.
  7. Blaiss MS, Naclerio RM, Boyle JM, Droar J. More effective and better tolerated intranasal corticosteroids may improve patient satisfaction with allergic rhinitis treatment. Program and abstracts of the American College of Allergy, Asthma and Immunology 2006 Annual Meeting; November 9-15, 2006; Philadelphia, Pennsylvania. Abstract 32.
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