title: Upfront computed tomography scanning is more cost-beneficial than empiric medical therapy in the initial management of chronic rhinosinusitis.
abstract: BACKGROUND
  Current treatment algorithms for patients with symptoms of chronic rhinosinusitis (CRS) recommend a trial of empiric medical therapy prior to obtaining a sinus computed tomography (CT) scan, even in cases of negative nasal endoscopy. This empiric approach evolved in an era when same day conventional CT was both impractical and economically irresponsible. The objective of this work was to determine whether upfront CT scanning is more cost-beneficial than empiric medical therapy for patients presenting with CRS symptoms but negative endoscopic findings.
  
  
  METHODS
  A Markov economic model was employed. Medication costs, CT costs, treatment response rates, and treatment associated adverse event rates were included as model parameters. Treatment cost values were derived from Medicare.
  
  
  RESULTS
  There is a clear cost advantage to the upfront CT algorithm over empiric therapy regardless of the availability of point-of-care CT scanning (POC-CT). This advantage persists during the sensitivity analysis when costs and response rates are fully biased toward empiric therapy. If POC-CT is available, upfront CT can save $320.50 per patient (range, $138.5-671.5). When POC-CT CT is unavailable, upfront CT savings persist at $296.60 (range, $106.09-655.40).
  
  
  CONCLUSIONS
  In patients meeting symptom criteria for CRS but without endoscopic evidence of inflammation, upfront CT scanning is more cost-beneficial than empiric medical therapy. Adopting upfront CT scanning can save the U.S. healthcare system $1.2 billion dollars per year. Further, POC-CT can offer same day diagnosis, facilitate prompt treatment, and decrease unnecessary antibiotic prescriptions.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Northwestern Memorial Hospital, Northwestern University, Chicago, IL 60611, USA. randy.leung@utoronto.ca
authors.forename: Randy
authors.initials: R
authors.lastname: Leung
authors.forename: Robert
authors.initials: R
authors.lastname: Kern
authors.forename: Neil
authors.initials: N
authors.lastname: Jordan
authors.forename: Stella
authors.initials: S
authors.lastname: Almassian
authors.forename: David
authors.initials: D
authors.lastname: Conley
authors.forename: Bruce K
authors.initials: BK
authors.lastname: Tan
authors.forename: Rakesh
authors.initials: R
authors.lastname: Chandra
mesh_terms: D002908:Chronic Disease; D003362:Cost-Benefit Analysis; D017048:Health Care Costs; D006801:Humans; D008390:Markov Chains; D006278:Medicare / Q000706:statistics & numerical data; D018803:Models, Economic; D012220:Rhinitis / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000191:economics; D012852:Sinusitis / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000191:economics; D014057:Tomography, X-Ray Computed / Q000191:economics*; D014481:United States