title: Primary care and upfront computed tomography scanning in the diagnosis of chronic rhinosinusitis: a cost-based decision analysis.
abstract: OBJECTIVE
  To diagnose chronic rhinosinusitis (CRS), current guidelines require either endoscopic or computed tomography (CT) findings of sinus disease. To a primary care physician, this means a referral to an otolaryngologist or obtaining a CT scan. Unfortunately, the sensitivity of endoscopy for detecting CRS is low, and examination by the Otolaryngologist may not yield a definitive diagnosis. This leaves CT scanning. However, this is contradicted by recommendations to limit CT scanning for only preoperative planning purposes due to cost concerns. This study aims to provide an evidence-based cost-efficient recommendation for primary care practice.
  
  
  METHODS
  Health care economics-based decision analysis model.
  
  
  METHODS
  A cost-based decision analysis based on literature-reported probabilities and Medicare costs was constructed for two scenarios: 1) primary care physicians who are comfortable initiating first-line treatment for chronic rhinosinusitis, rhinitis, and atypical facial pain; and 2) primary care physicians who are less comfortable with medical management of these conditions.
  
  
  RESULTS
  Under both scenarios and the extremes of sensitivity analysis, upfront CT scanning provides cost-efficient diagnosis over presuming a diagnosis of chronic rhinosinusitis. Primary care physicians who attempt first-line treatment can expect $503 (range = $296-$761) saved per patient. Meanwhile, primary care physicians who prefer to refer may expect $326 (range = $299-$353) saved per patient.
  
  
  CONCLUSIONS
  In all scenarios, confirming diagnosis with CT scanning prior to treatment or referral is more cost-efficient than presuming a diagnosis of CRS based on symptoms alone.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Randy M
authors.initials: RM
authors.lastname: Leung
authors.forename: Rakesh K
authors.initials: RK
authors.lastname: Chandra
authors.forename: Robert C
authors.initials: RC
authors.lastname: Kern
authors.forename: David B
authors.initials: DB
authors.lastname: Conley
authors.forename: Bruce K
authors.initials: BK
authors.lastname: Tan
mesh_terms: D002908:Chronic Disease; D003365:Costs and Cost Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D006801:Humans; D011320:Primary Health Care; D012220:Rhinitis / Q000150:complications / Q000000981:diagnostic imaging* / Q000191:economics*; D012852:Sinusitis / Q000150:complications / Q000000981:diagnostic imaging* / Q000191:economics*; D014057:Tomography, X-Ray Computed / Q000191:economics*
keywords: Chronic rhinosinusitis; computed tomography scanning; corticosteroids; empiric medical therapy; evidence-based medicine; health economics; imaging