Cost-Efficient Workup and Management of Patients with Chronic Rhinosinusitis: Challenges and Unmet Needs

Abstract

Chronic rhinosinusitis (CRS) is a common disease, estimated to occur in 12-16% of the United States population. This prevalence creates a significant health burden with an estimated 15 million ambulatory visits for the condition annually. Consequently, practice guidelines have been designed to assist both the primary care provider and specialist in establishing a CRS diagnosis and prescribing effective treatment for CRS. The guidelines for CRS diagnosis have evolved since the United States Rhinosinusitis Task Force first published its symptom-based guidelines in 1997. Contemporary practice guidelines still require 12 weeks of appropriate symptoms, but now include corroboration of objective sinonasal inflammation demonstrated on physical exam, imaging, or endoscopy to arrive at a CRS diagnosis. While these diagnostic criteria are seemingly straightforward and are regarded as the gold standard for the diagnosis, the appropriate timing of imaging and endoscopy remain unspecified and continue to present challenges for both primary care and specialty providers. These considerations have to be measured by the direct and indirect costs of the diagnostic workup including office visits, CT scanning, endoscopy, as well as the potential for overuse of treatment modalities such as antibiotics and steroid medications. The goal of this review is to update the primary care provider and otolaryngologist on current evidence regarding the diagnosis and treatment of chronic rhinosinusitis, including the costs and timing of endoscopy and imaging.

A pathway to value‐based care of chronic rhinosinusitis using a claims database

“…In that group, 40.9% of the ESS patients had both a CT scan and diagnostic sinus endoscopy prior to surgery. This data demonstrates a consistent pattern of diagnostic testing that is being followed in the preoperative workup of patients with CRS, confirming the condition with diagnostic endoscopy and/or a CT scan of the sinuses prior to a surgical procedure . It is somewhat surprising that roughly one third of the patients undergoing ESS did not have a preoperative sinus endoscopy.…”

“…19 The definition of CRS for this study required two CRS diagnoses within 12 weeks of one another with an intervening CT scan or nasal endoscopy with or without septal deviation. Additionally, an initial diagnosis of 20 It is somewhat surprising that roughly one third of the patients undergoing ESS did not have a preoperative sinus endoscopy. However, the standard at the time dictated a CT scan or sinus endoscopy and there was considerable issue with precertifications at the time of the study.…”

International consensus statement on allergy and rhinology: rhinosinusitis 2021

“…Diagnostic imaging, especially CT imaging, is strongly recommended for evaluation for pre‐operative planning for sinus surgery, and complications for CRS, 547 but also is critical for evaluating patients with unilateral CRS given the high prevalence of alternate pathology (eg, odontogenic, fungal or neoplastic). It is also helpful with the symptomatic patient with equivocal or normal findings on endoscopy where treatment with oral antibiotics or corticosteroids is being considered 1,548,549 . Furthermore, discussion of the cost efficiency of CRS diagnosis is highly dependent on healthcare system‐specific direct costs and availability of professionals, diagnostic modalities, and therapeutic regimens for CRS.…”

“…The symptom‐based component for CRS diagnosis currently emphasizes the 4 cardinal symptoms of nasal obstruction, nasal discharge, facial pain or pressure, and reduction or loss of smell. Of note, component symptoms no longer utilize the “minor” symptoms (headache, fever, halitosis, fatigue, dental pain, cough, and ear symptoms) advanced by prior guidelines due to their frequent absence in CRS and overlap with other medical conditions 13,514,515,549 . Nonetheless, the cardinal symptoms, even when used in the combinations recommended by consensus statements, are common in the general population with between 10% and 13% of US and European adults meeting current CRS symptom‐combination and duration definitions 13,515 .…”

Headaches and Facial Pain in Rhinology

“…43,44 Modeling these costs in the context of Redbook estimates for cost of empiric medical therapy reveals that it is more cost effec- tive to screen patients first with a CT. 43,44 This strategy may have further implications regarding timely referral for nonrhinologic causes of headache and facial pain, and for reduction of unnecessary antibiotic prescriptions that may cultivate resistance. 45 An alternate management algorithm is outlined in Fig. 1.…”