Observation Most Cost-Effective in Addressing AECRS in Absence of Bacterial Infection

CLINICAL QUESTION

What is the most cost-effective strategy for the initial management of acute exacerbations of chronic rhinosinusitis (AECRS)?

BOTTOM LINE

Observation is the most cost-effective strategy for the initial management of AECRS when there is a low likelihood of bacterial infection; otherwise, upfront rescue medications are the most cost-effective.

BACKGROUND: The costs of managing chronic rhinosinusitis (CRS) are in the tens of billions. Acute worsening of CRS symptoms, or AECRS, escalates healthcare costs. Although antibiotics and steroids are often used, there are no evidence-based guidelines for managing AECRS, and thus, little guidance on how to manage exacerbations responsibly and cost-effectively.

STUDY DESIGN: Decision-tree economic analysis

SETTING: Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati, Ohio

SYNOPSIS: Researchers used a decision-tree economic model to compare the cost and effectiveness of three initial strategies for managing patient-perceived AECRS: 1) observation, 2) upfront rescue medications (including antibiotics with or without oral steroids), or 3) clinic visit with diagnostic nasal endoscopy (DNE). The primary study outcome was the disease burden of a single AECRS. The model timeframe was 30 days, with treatment beginning after three days of worsening symptoms. If improvement was seen after three days, treatment continued to completion. If not, care escalated to an in-clinic visit with DNE, followed by antibiotics in cases with evidence of bacterial infection. Results showed observation to be the most cost-effective strategy. It was also more effective than upfront rescue medication when the probability of bacterial infection as the cause of AECRS was less than 24.0%. Upfront rescue medications were more cost-effective than observation when the probability of bacterial infection was greater than 49.9%. Authors stressed that, while many factors can shift the most cost-effective strategy toward upfront rescue medications on an individual scale, the dangers of overusing antibiotics must be considered. Clinic visits with DNE were the most effective management strategy, though not cost-effective. Study limitations included a potential lack of correlation with real-world scenarios.

CITATION: Chu MM, et al. A cost utility analysis for the management of acute exacerbations of chronic rhinosinusitis. Int Forum Allergy Rhinol. 2025;15:109-119. https://doi.org/10.1002/alr.23452.

COMMENT: We all receive the patient calls requesting antibiotics about a “sinus infection,” and we need to decide whether to observe, send empiric antibiotics, or call the patient into the clinic to confirm true infection on nasal endoscopy. At the same time, we all know that healthcare costs continue to grow at a rapid pace. This study evaluates the cost-effectiveness of these various strategies when we receive these calls, incorporating disease burden as the primary outcome, determined by health utility value and burden of symptoms. This study finds that if the probability of bacterial infections is less than 24%, an observation strategy is most cost-effective, while empiric antibiotics are most cost-effective when the probability is greater than 49%. Nasal endoscopy in clinic is the most effective clinical strategy, but considerably more costly. As such, the authors suggest that clinicians might consider reserving it only for patients who have failed either an observation or an empiric antibiotic strategy. —Ashoke Khanwalkar, MD