2018 Section 5 - Rhinology and Allergic Disorders

Batra et al.

FIGURE 4. Radiation dose typically delivered by the scanner for sinus CT acquisition. CT = computed tomography.

tioners with varying lengths of experience, type of clinical practice, and geographic distribution is essential, given that they would likely have differing opinions on the utility of CT imaging for CRS, and, thus, contribute to a more robust survey. The respondents had a significant portion of their prac- tice devoted to rhinology, comprising > 50% of the clinical practice for 53.3% of respondents. Moreover, 68.7% re- ported seeing between 26 and 75 patients with sinonasal complaints in a typical week. Overall, 27% and 50.3% of the respondents obtained < 5 and 5 to 10 scans over the course of a given week, respectively. Another 18.2% acquired between 11 and 20 scans, whereas only 4.5% obtained > 20 scans in a typical week. Though exact uti- lization rates cannot be determined from this data, approx- imately 10% of the visits involved CT imaging ( 5 scans in 50 patients). This would appear to be in congruence with the utilization rates of between 10.4% and 16.0% reported. 4,8 This further corroborates the recent study by Bhattacharyya, 8 noting that despite widespread availability of imaging and strong prevalence of sinonasal diagnoses, CT ordering patterns in otolaryngologists did not result in increased utilization over a 6-year period. The recent ACR Appropriateness Criteria for sinonasal disease endorsed CT of the paranasal sinuses without con- trast to be the imaging study of choice in patients with CRS, especially to define sinus anatomy prior to surgery. 2 How- ever, the exact timing of this imaging relative to medical therapy received by the patient remains a matter of de- bate. In the present study, a majority of respondents (75%) obtained confirmatory imaging < 25% of the time prior to initiating medical treatment for suspected CRS. This appears to be in accordance with the Clinical Consensus Statement by Setzen et al., 5 with 92% of the experts agree- ing that CT imaging is indicated in patients not respond- ing appropriately to medical management. Further, 100% agreed that CT imaging is indicated in patients treated re- peatedly with antibiotics for presumed sinusitis or with persistent complaints, to rule out other potential etiolo- gies and to avoid repeated inappropriate antibiotic admin- istration. Though exact prescriptive recommendations on the timing of the CT imaging cannot be determined from

TABLE 2. Impact of key variables on CT utilization patterns*

CT scan after 1st round of medical therapy

CT scan to rule out sinusitis in headache patient

CT scan prior to medical therapy

Variable

Years in clinical practice ( > 10 years)

0.949 (0.881)

0.376 ( < 0.001)

0.609 (0.033)

Academic practice 1.156 (0.679)

2.466 ( < 0.001)

1.316 (0.236)

Practice devoted to rhinology ( > 50%)

1.411 (0.326)

2.289 (0.001)

1.592 (0.039)

In-office CT scanner

2.227 (0.024)

0.808 (0.475)

1.462 (0.157)

*Values are odds ratio ( p ). CT = computed tomography.

imaging of the paranasal sinuses could potentially represent an area of concern for overutilization in medicine. Further, until recently, little had been written to better define the appropriate indications of CT scanning in rhinosinusitis. The recent clinical consensus statement by the AAO-HNS and appropriateness criteria for sinonasal disease set forth by the ACR have helped to better guide and refine proper use of CT imaging for rhinosinusitis. 2,5 Despite this, lit- tle is known about how practicing otolaryngologists actu- ally use CT imaging in the diagnostic and management scheme of CRS in their clinical practice. This provided the impetus for this survey sanctioned by AAO-HNS and ARS. The survey group of 331 participants included in the study lends itself to several important observations. The re- spondents comprised a wide spectrum in terms of the num- ber of years spent in clinical practice. Though the type of clinical practice was most commonly academic in 39.1%, participants were well-represented from single-specialty, multispecialty, and solo private practices. Further, the re- spondents represented all regions of the country, mostly commonly from the North Central (20.6%) and Southeast (17.2%) states. The inclusion of a diverse group of practi-

International Forum of Allergy & Rhinology, Vol. 5, No. 6, June 2015

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