Assessing Current Practices in the Evaluation and Treatment of Acute Sinusitis: A Comparison of Primary Care, Urgent Care and Emergency Department Care

Background/Aims: Acute sinusitis (AS) affects 1 in 7 adults and costs over $5.8 billion annually. As part of the American Board of Internal Medicine’s Choosing Wisely campaign, three organizations make recommendations regarding appropriate sinus imaging and antibiotics for uncomplicated AS. The extent to which AS recommendations are followed is unknown; our aim is to measure adherence with recommendations for AS and to compare AS encounters in primary care (PC), urgent care (UC) and emergency (ED) departments. Methods: A retrospective, observational study of AS care using structured data from electronic health records, complemented by more extensive chart review in a smaller subsample of encounters. All immunocompetent adults with an initial AS encounter (ICD-9 code 461.x) from 2010 to 2012 were included. Primary outcomes (structured data) were filled antibiotic prescriptions and the performance of a face, head or sinus computerized tomography (CT) scan, and secondary outcomes (chart review) were length of symptoms and adherence to AS recommendations. Results: The median age of patients was 46 (interquartile range: 34–58), 67.5% were female and the mean Elixhauser comorbidity score was 1.5 (±1.6 standard deviation). Of 152,774 AS encounters (77% PC, 22% UC and 1% ED), 89.2% resulted in a filled antibiotic prescription and 1.1% in a CT scan. Compared with the PC setting, UC encounters were more likely to result in antibiotics (adjusted odds ratio [OR]: 1.12, 95% confidence interval [CI]: 1.08–1.17) or obtaining a CT scan (adjusted OR: 2.4, 95% CI: 2.1–2.7, and ED encounters were less likely to result in antibiotics (adjusted OR: 0.57, 95% CI: 0.50–0.65) but more likely to result in a CT scan (adjusted OR: 59.4, 95% CI: 51.3–68.7). Chart review of 300 encounters resulting in antibiotics determined that 50% were for symptoms ≤ 7 days (95% CI: 41–58%) and 35% for symptoms ≥ 14 days (95% CI: 27–44%). Only 29% (95% CI: 22–36%) of encounters resulted in guideline adherent care (30% PC, 26% UC, 16% ED). Discussion: Among adults with AS in a large, integrated health care system, CT imaging is infrequent but antibiotic treatment is common, even for uncomplicated cases with a short duration of symptoms