Is it cost effective for primary care physicians (PCPs) to obtain a CT scan prior to treatment/referral in patients presenting with chronic rhinosinusitis (CRS) symptoms?
Background: Current clinical CRS diagnosis guidelines leave a void for PCPs. Evidence suggests that symptom criteria specificity alone is a poor diagnostic, leaving CT scanning as the only other option to confirm CRS diagnosis; however, this option is often contradicted by expert opinion calling for CT scans to be used only in pre-operative planning.
Explore This IssueJanuary 2014
Study design: Healthcare economics-based decision analysis model.
Setting: Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Ontario, Canada; Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago.
Synopsis: This study compared two PCP-centered management paradigms: 1) to obtain a CT scan prior to treatment and/or referral; or 2) to presume a diagnosis of CRS based on symptom criteria and treat/refer, with CT scanning reserved for surgical planning. Under the first paradigm, the cost savings for the upfront CT algorithm is greater than $503.10 per patient. Under the second paradigm the cost savings favors the upfront CT algorithm by $326.04 per patient. Even using tertiary rhinology setting pretest probabilities and in both paradigms, obtaining an upfront CT scan is consistently more cost efficient. There are limitations to the study, including having to extrapolate values for objective criteria to characterize CRS epidemiology from studies published in specialty-based practice whenever primary care studies were unavailable and a difficulty in predicting the actual pretest probability of true CRS in the setting of symptoms in the PCP office.
Bottom line: In both paradigms, confirming CRS diagnosis with CT scanning prior to treatment or referral is more cost efficient than presuming a diagnosis of CRS based on symptoms alone. Using this strategy for patients with chronic CRS symptoms, the U.S. healthcare system can save more than $3 billion each year.
Citation: Leung RM, Chandra RK, Kern RC, Conley DB, Tan BK. Primary care and upfront computed tomography scanning in the diagnosis of chronic rhinosinusitis: a cost-based decision analysis. Laryngoscope. 2014;124:12-18.