title: Low-value care for acute sinusitis encounters: who's choosing wisely?
abstract: OBJECTIVE
  To assess acute sinusitis (AS) encounters in primary care (PC), urgent care (UC), and emergency department (ED) settings for adherence to recommendations to avoid low-value care.
  
  
  METHODS
  A retrospective, observational study of adult AS encounters (2010-2012) within a large integrated healthcare system.
  
  
  METHODS
  We compared ED and UC encounters with PC visits, adjusting for differences in patient characteristics.
  
  
  METHODS
  adherence to recommendations to avoid antibiotics and a computed tomography (CT) scan of the face, head, or sinuses.
  
  
  RESULTS
  length of symptoms and adherence with AS recommendations.
  
  
  RESULTS
  Of 152,774 AS encounters, 89.2% resulted in antibiotics and 1.1% resulted in a CT scan. Compared with PC encounters, ED encounters were less likely to result in antibiotics (adjusted odds ratio [AOR], 0.57; 95% CI, 0.50-0.65) but more likely to result in a CT scan (AOR, 59.4; 95% CI, 51.3-68.7), while UC encounters were more likely to result in both antibiotics (AOR, 1.12; 95% CI, 1.08-1.17) and CT imaging (AOR, 2.4; 95% CI, 2.1-2.7). Chart review of encounters resulting in antibiotics found that 50% were inappropriately prescribed for symptoms of ≤7 days' duration (95% CI, 41%-58%), while 35% were appropriately prescribed for symptoms of ≥14 days' duration (95% CI, 27%-44%). Only 29% (95% CI, 22%-36%) of encounters were consistent with guideline-adherent care.
  
  
  CONCLUSIONS
  AS encounters in an integrated health system infrequently result in CT imaging, but antibiotic treatment is common. Differences exist across acute care settings, but improved antibiotic stewardship is needed in all settings.
authors.affiliation: 100 S Los Robles Ave, 2nd Fl, Pasadena, CA 91101. E-mail: adam.l.sharp@kp.org.
authors.forename: Adam L
authors.initials: AL
authors.lastname: Sharp
authors.forename: Marc H
authors.initials: MH
authors.lastname: Klau
authors.forename: David
authors.initials: D
authors.lastname: Keschner
authors.forename: Eric
authors.initials: E
authors.lastname: Macy
authors.forename: Tania
authors.initials: T
authors.lastname: Tang
authors.forename: Ernest
authors.initials: E
authors.lastname: Shen
authors.forename: Corrine
authors.initials: C
authors.lastname: Munoz-Plaza
authors.forename: Michael
authors.initials: M
authors.lastname: Kanter
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Silver
authors.forename: Michael K
authors.initials: MK
authors.lastname: Gould
mesh_terms: D000208:Acute Disease; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D019983:Guideline Adherence; D006801:Humans; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012852:Sinusitis / Q000000981:diagnostic imaging* / Q000188:drug therapy*; D014057:Tomography, X-Ray Computed
chemical_list: D000900:Anti-Bacterial Agents