Strategies for diagnosing and treating suspected acute bacterial sinusitis: a cost-effectiveness analysis.
OBJECTIVE
Symptoms suggestive of acute bacterial sinusitis are common. Available diagnostic and treatment options generate substantial costs with uncertain benefits. We assessed the cost-effectiveness of alternative management strategies to identify the optimal approach.


METHODS
For such patients, we created a Markov model to examine four strategies: 1) no antibiotic treatment; 2) empirical antibiotic treatment; 3) clinical criteria-guided treatment; and 4) radiography-guided treatment. The model simulated a 14-day course of illness, included sinusitis prevalence, antibiotic side effects, sinusitis complications, direct and indirect costs, and symptom severity. Strategies costing less than 50,000 dollars per quality-adjusted life year gained were considered "cost-effective."


RESULTS
For mild or moderate disease, basing antibiotic treatment on clinical criteria was cost-effective in clinical settings where sinusitis prevalence is within the range of 15% to 93% or 3% to 63%, respectively. For severe disease, or to prevent sinusitis or antibiotic side effect symptoms, use of clinical criteria was cost-effective in settings with lower prevalence (below 51% or 44%, respectively); empirical antibiotics was cost-effective with higher prevalence. Sinus radiography-guided treatment was never cost-effective for initial treatment.


CONCLUSIONS
Use of a simple set of clinical criteria to guide treatment is a cost-effective strategy in most clinical settings. Empirical antibiotics are cost-effective in certain settings; however, their use results in many unnecessary prescriptions. If this resulted in increased antibiotic resistance, costs would substantially rise and efficacy would fall. Newer, expensive antibiotics are of limited value. Additional testing is not cost-effective. Further studies are needed to find an accurate,low-cost diagnostic test for acute bacterial sinusitis.
Balk
E M
EM
Evidence-based Practice Center, Division of Clinical Care Research, Tufts University School of Medicine, New England Medical Center, Boston, MA 02111, USA.
Zucker
D R
DR
Engels
E A
EA
Wong
J B
JB
Williams
J W
JW
Lau
J
J
D000208:Acute Disease; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D006801:Humans; D008390:Markov Chains; D019057:Quality-Adjusted Life Years; D011859:Radiography; D012852:Sinusitis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000191:economics; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents