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20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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International consensus statement on rhinosinusitis

alone. Bhattacharyya and Lee determined that compared to using a symptom-based criteria alone to predict the pres ence of CRS (specificity and positive predictive value of 12% and 39%, respectively, using a CT-based gold stan dard), the addition of nasal endoscopy to a symptom-based assessment substantially increases the diagnostic accuracy of CRS, with specificity and positive predictive values esti mated at 84% and 66%, respectively, in 1 study; and 82% and 84% in another. 513,547 Despite the high specificity and positive predictive value of nasal endoscopy in confirming a CRS diagnosis, endoscopy has been shown to be notably less sensitive, having false negative rates between 35% and 70%, when compared to CT. 480,529,546,554–556 The lower sensitivity is related to the inability of rigid and/or flexible endoscopy to assess the interior of all sinus cavities in un-operated patients. From a cost-efficiency standpoint, the only prior deci sion analysis compared an algorithm where patients were seen in the otolaryngologist’s office underwent nasal endoscopy followed by initiation of medical treatment with one where a patient underwent a CT scan after nasal endoscopy. In this analysis, it became less costly to treat a patient prior to obtaining the CT scan if the pre-CT CRS probability was over 50% using average medication, visit and diagnostic costs. Since the presence of objective find ings on endoscopy have concordance with CT findings of over 80%, obtaining further CT confirmation at that visit will result in increased costs of USD$150 per patient (range: USD$25 to USD$250 more depending on costs of visits and prescriptions). However, if the endoscopy was negative, the pre-CT CRS probability of the symptomatic patient falls to below 50% and obtaining a CT to confirm the diagnosis is less costly due to savings from unnecessary future medical treatment and otolaryngologist visits. There has not been a cost decision analysis comparing empiric medical therapy to nasal endoscopy as the sole diagnostic test. Using Endoscopy to Diagnose CRS Aggregate Grade of Evidence: B (Level 2: 2 studies; level 3: 3 studies; Table IX-2). Benefit: Higher positive predictive value and speci ficity for a CRS diagnosis compared to using symp toms alone, allowing for the avoidance of CT uti lization costs and potential radiation exposure of imaging. Harm: If the clinician still suspects CRS, a neg ative nasal endoscopy exam will still require a CT scan of the sinuses due to the potential for a

false-negative endoscopy. Mild discomfort associ ated with the procedure. Cost: For 2019, the Centers for Medicare & Medicaid Services in the United States set a national payment average for a diagnostic nasal endoscopy (Current Procedural Terminology 31231) at USD$197.77, which accounts for both service and facility reimbursements. This cost reflects the specialists’ time to perform and review findings of endoscopy, capital needed to purchase the essential equipment, and expenses related to sterilizing and maintaining the endoscopes. 557 Benefits-Harm Assessment: Preponderance of benefit as the initial technique to objectively estab lish CRS diagnosis by trained endoscopists, but the technique is limited by a reduced sensitivity relative to CT imaging. Value Judgments: Endoscopy is an important diag nostic intervention that should be used in conjunc tion with a thorough history and physical exam for patients suspected of having CRS. It should be complemented with other diagnostic testing in the event of a negative endoscopy where CRS is still suspected. Policy Level: Recommendation. Intervention: Nasal endoscopy is recommended in conjunction with a history and physical examina tion for a patient being evaluated for CRS. CT is an option for confirming CRS along with or instead of nasal endoscopy. IX.B.3.c. CRS Workup with Diagnostic Imaging Clinical practice guidelines uniformly state that CT imaging, as opposed to the plain radiography or MRI, is the radiologic modality of choice for confirming CRS or as an alternative to nasal endoscopy. 88,547 In the settings where nasal endoscopy is unavailable (eg, in the primary care setting), imaging is the preferred modality to confirm CRS and, depending on the relative costs within a health system, may be preferred prior to a trial of medical therapy. Using expected pre-test probabilities in the patient with appropriate symptoms, a cost based decision analysis in the US context has demonstrated a strategy utilizing CT prior to initiating extended systemic antibiotic treatment or specialty referral results in USD$503 lower costs per patient (range USD$296-USD$761) due to reduction in unnecessary antibiotics and inappropriate referrals. 558 A similar study in the Canadian context however suggested this strategy would result in increased costs of CAD$1500 per patient diagnosed with CRS but would improve the accuracy of referrals. 559 The differences between the