ORIGINAL ARTICLE
Computed tomography imaging practice paerns in adult chronic rhinosinusitis: survey of the American Academy of Otolaryngology–Head and Neck Surgery and American Rhinologic Society membership Pete S. Batra, MD, FACS1 , Michael Setzen, MD, FACS, FAAP2 , Yan Li, BSc3 , Joseph K. Han, MD4 and Gavin Setzen, MD, FACS, FAAOA5
Background: The objective of this study was to assess the current practice paerns of computed tomography (CT) imaging for diagnosis and management of adult chronic rhinosinusitis (CRS). Methods: A 29-item, electronic, Web-based physician survey was disseminated to the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) and American Rhinologic Society (ARS) membership from November 2012 to January 2013. Results: A total of 331 otolaryngologists completed the survey. Seventy-five percent of respondents did not obtain confirmatory CT imaging prior to initiating medical therapy for CRS. A typical diagnostic scan was considered to be a 3-mm coronal CT with or without 3-mm axial images for 50.6% of participants. On average, the respondents obtained 1 (58.8%) or 2 (36.6%) CT scans prior to proceeding with sinus surgery. CT scanning was most commonly performed in a hospital radiology department (76.4%), followed by a free-standing imaging center (44.5%). An inoffice CT scanner was owned by 24.5% of the respondents, mostly commonly a cone beam CT (74.0%) scanner. Most
respondents (87.1%) did not experience problems with carriers denying ability to image or reimbursing for scans. Overall, 68.4% of the respondents were unaware of the dosage of radiation delivered by the scanner used for CT acquisition. Conclusion: This survey provides a snapshot of the current utility of CT imaging in the management paradigm for CRS. Given that most are unaware of the delivered radiation dose, this clearly represents an important area of imC 2015 ARS-AAOA, LLC. provement in the knowledge gap.
Key Words: computed tomography; imaging; radiology; radiation; sinusitis How to Cite this Article: Batra PS, Setzen M, Li Y, Han JK, Setzen G. Computed tomography imaging practice paerns in adult chronic rhinosinusitis: survey of the American Academy of Otolaryngology–Head and Neck Surgery and American Rhinologic Society membership. Int Forum Allergy Rhinol. 2015;5:506–512.
C
Correspondence to: Pete S. Batra, MD, FACS, Department of Otorhinolaryngology–Head and Neck Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite 550, Chicago, IL 60612; e-mail: [email protected]
hronic rhinosinusitis (CRS) represents one of the most common disorders diagnosed in the United States, with an estimated prevalence of 16% in the general adult U.S. population.1 It poses a significant economic burden, resulting in 26 million outpatient visits annually and $4.3 billion annually in direct medical expenses.2 Accurate diagnosis of CRS rests on presenting symptomatology, supported by demonstrable disease on computed tomography (CT) or endoscopy. Indeed, CT imaging of the paranasal sinuses signifies an important advance in the management of CRS patients. Superior resolution of the bony framework of paranasal sinuses affords the ability to detect subtle
Potential conflict of interest: P.S.B.: Medtronic (Consultant), Merck (Scientific Advisory Board). M.S.: Teva, Meda (Speakers Bureau). J.K.H.: Medtronic and IntersectENT (Consultant), Merck (Scientific Advisory Board). G.S.: Merck and Teva (Scientific Advisory Board), Salvat Pharmaceuticals (Principal Investigator, Clinical Trial), Advance Health Solutions (Medical Advisory Board).
Received: 7 September 2014; Revised: 8 December 2014; Accepted: 16 December 2014 DOI: 10.1002/alr.21483 View this article online at wileyonlinelibrary.com.
1 Department
of Otorhinolaryngology–Head and Neck Surgery, Rush University Medical Center, Chicago, IL; 2 Michael Setzen Otolaryngology, Great Neck, NY; 3 Bioinformatics, Department of Internal Medicine, Rush University Medical Center, Chicago, IL; 4 Department of Otolaryngology–Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, VA; 5 Albany ENT and Allergy Services, PC, Albany, NY
International Forum of Allergy & Rhinology, Vol. 5, No. 6, June 2015
506
CT practice pattern survey
changes in mucosal thickening and retained secretions relative to the air-bone interface.3 CT imaging helps delineate paranasal sinus anatomy, defines the extent and nature of underlying inflammatory disease, and provides a roadmap for functional endoscopic sinus surgery (FESS). A recent analysis of the National Ambulatory Medical Care Survey from 2005 through 2008 showed that otolaryngologists use advanced radiographic imaging at a statistically significant higher rate than primary care physicians per outpatient visit for diagnosis of CRS (16.0% vs 1.93%).4 This widespread utility underscores the concerns related to sinus CT imaging, including potential for overutilization, substantial costs, and excessive radiation exposure. A recent clinical consensus statement by the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) convened an expert panel be convened to codify appropriate usage of CT for paranasal sinus disease.5 Further, the American College of Radiology (ACR) recently published appropriateness criteria to guide imaging decisions for paranasal sinus disease.2 Despite these guidelines, the exact usage patterns for CT imaging in adult CRS for practicing otolaryngologists remain largely unknown. With this in mind, the current survey, supported by the AAO-HNS and American Rhinologic Society (ARS), was conducted to better ascertain clinical practice patterns of CT imaging and financial implications of point-of-care (POC) imaging in the management of CRS. The impact of key variables, eg, years and type of practice and owning a scanner, was ascertained on CT utilization patterns.
Materials and methods A 29-item survey was created and vetted by the Patient Advocacy Committee of the ARS and the Imaging Committee of the AAO-HNS. It was subsequently reviewed by the AAO-HNS Research, Quality, and Health Policy Department and approved by the ARS and AAO-HNS Board of Directors. The electronic survey (http://www.surveymonkey.com/s/ctimaging) was disseminated to the AAO-HNS and ARS membership through multiple mechanisms: electronic messenger service (twice each by AAO-HNS and ARS), ENT Advocate (once), and AAO-HNS Bulletin (once). The target group included 8000 practicing U.S. otolaryngologists. Percentages for each response were calculated based on number of responses for each question (range, 73 to 331 responses). Due to rounding, not all percentages added to 100%. The study did not involve direct patient contact or access to their health information; therefore, it was exempt from Institutional Review Board (IRB) approval. Particular areas explored included number of years in practice, type of practice, and geographic location of the clinical practice. The percentage of practice devoted to rhinology and number of patients presenting with nasal and sinus complaints per week were determined. Specific practice patterns for the role of CT imaging of the paranasal
507
International Forum of Allergy & Rhinology, Vol. 5, No. 6, June 2015
sinuses in the diagnosis of adult CRS was assessed. The role of CT imaging in FESS was also ascertained. The location of CT scan acquisition and socioeconomic aspects of POC imaging in the office setting were evaluated. The radiation dosage of the CT scanning was also queried. Geographic regions for the survey were defined as follows: New England (Maine, Vermont, New Hampshire, Massachusetts, Connecticut, Rhode Island); Mid-Atlantic (New York, New Jersey, Pennsylvania); Mountain (Wyoming, Idaho, Montana, Nevada, Utah, Colorado, New Mexico, Arizona); North Central (North Dakota, South Dakota, Nebraska, Kansas, Missouri, Iowa, Minnesota, Wisconsin, Illinois, Michigan, Indiana, Ohio); South Central (Texas, Oklahoma, Arkansas, Kentucky, Tennessee, Mississippi, Alabama, Louisiana); Southeast (Washington, DC, Maryland, Delaware, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida); and West (Washington, Oregon, California, Alaska, Hawaii).
Statistical methodology The chi-squared test was performed to determine the association between key variables, including years in practice (>10 years), academic vs private practice, geographic location, percentage of practice devoted to rhinology (>50%), and presence of in-office CT scanner with usage of CT scans in clinical practice (whether the scan was performed for confirmation prior to initiating therapy, after 1 round of medical therapy, and to rule out sinusitis in patients with headaches). For those associations that were statistically significant, the odds ratio was computed to assess the direction of the dependence. Calculations were performed using IBM SPSS version 20 (IBM, Armonk, NY). A p value 3 physicians) in 74 (22.4%), single specialty (1 to 3 physicians) in 52 (15.8%), multispecialty in 45 (13.6%), and solo in 30 (9.1%). Figure 1 shows the geographic location of the 320 responding physicians.
Batra et al.
FIGURE 1. Geographic location of the 320 participating physicians. Eleven survey respondents did not provide their location.
FIGURE 2. Number of sinus CT scans ordered by respondents in a typical week. CT = computed tomography.
Clinical practice parameters The percentage of clinical practice devoted to rhinology was as follows: 75% (107; 32.4%). The number of patients with nasal and sinus complaints seen in a typical week was as follows: 100 (14; 4.3%). Figure 2 illustrates the number of sinus CT scans ordered in a typical week.
CT utilization variables Table 1 lists the frequency of times practicing otolaryngologists obtain confirmatory CT imaging for CRS prior to initiating medical therapy, after first and second rounds of medical therapy, and in patients with severe headaches. It also provides the frequency of times the respondents obtain plain films and magnetic resonance imaging (MRI) for diagnosis of CRS. The respondents considered a typical diagnostic sinus CT scan as follows: 5-mm axial (1; 0.3%), 5-mm coronal (33; 10.1%), 3-mm axial (8; 2.4%), 3-mm coronal (66; 20.1%), 3-mm coronal and axial (100;
30.5%), 2-mm axial with reconstruction (69; 21.0%), and 1-mm axial with reconstruction (51; 15.5%). On average, the total number of CT scans obtained prior to proceeding with primary FESS in a typical patient, including those ordered by primary care, urgent care, or other providers, was as follows (values are number of scans in number of respondents): 0 in 1 (0.3%), 1 in 193 (58.8%), 2 in 120 (36.6%), 3 in 9 (2.7%), 4 in 0 (0%), and 5 or more in 5 (1.5%). Overall, 131 respondents (40.1%) obtained a new CT scan for image guidance prior to surgery. The types of sinus CT scan obtained prior to FESS are listed in Figure 3. The frequency of usage of surgical navigation was 75% of the time in 86 (26.3%). In the group above, 35 (10.7%) did not use navigation during FESS. Overall, 26 respondents (8.0%) used intraoperative CT imaging during FESS. The location of CT imaging acquisition was as follows: hospital radiology (252; 76.4%), free-standing imaging center (147; 44.5%), and in-office CT scanner (79; 23.9%). An in-office CT scanner and X-ray machine was owned by
International Forum of Allergy & Rhinology, Vol. 5, No. 6, June 2015
508
CT practice pattern survey
TABLE 1. Practice patterns of the respondents in obtaining confirmatory imaging for suspected chronic sinusitis in different
clinical scenarios* Frequency Never
75%
CT scan prior to initiating medical therapy
69 (21)
177 (54)
44 (13.4)
22 (6.7)
16 (4.9)
CT scan after completion of first round of medical therapy
56 (17.1)
124 (37.9)
58 (17.7)
44 (13.5)
45 (13.8)
CT scan after completion of second round of medical therapy
35 (10.6)
107 (32.4)
69 (20.9)
47 (14.2)
72 (21.8)
CT scan to rule out sinusitis in patients with severe headaches
5 (1.5)
58 (17.6)
70 (21.3)
76 (23.1)
120 (36.5)
Plain films to diagnose chronic rhinosinusitis
295 (89.7)
23 (7.0)
5 (1.5)
3 (0.9)
3 (0.9)
MRI to diagnose chronic rhinosinusitis
258 (78.4)
70 (21.3)
1 (0.3)
0 (0)
0 (0)
Scenario
*Values are n (%). CT = computed tomography; MRI = magnetic resonance imaging.
FIGURE 3. Type of sinus CT scan typically obtained by respondents prior to sinus surgery. CT = computed tomography.
80 (24.5%) and 20 (6.1%) of the physicians, respectively. Cone beam CT (CBCT) and conventional CT was owned by 57 (74.0%) and 20 (26.0%) of respondents, respectively. For those owning a CT scanner, 44 (60.3%) billed for interpretation and performance of the CT imaging, whereas 4 (5.5%) billed for interpretation but not for performance, and 8 (11.0%) reviewed but did not bill for the interpretation or performance of the CT scan. A radiologist read and billed for the interpretation and performance of the scan for 17 (23.3%) respondents. The respondents reported experiencing problems with carriers denying ability to image or reimbursing for the scans as follows: 75% of the time (2; 0.6%). The radiation dose typically delivered by the CT scanner is illustrated in Figure 4. Table 2 illustrates the statistical association between key variables, including years in practice (>10 years), academic vs private practice, percentage of practice devoted to rhinology (>50%), and presence of in-office CT scanner with CT usage patterns in clinical practice. Figure 5 shows
509
International Forum of Allergy & Rhinology, Vol. 5, No. 6, June 2015
the odds of CT utilization patterns based on geographic location.
Discussion The relative ease of access and rapid expansion of utilization of CT scanning has led to concerns about overuse with increased costs to the healthcare system and excessive radiation exposure with associated risk of radiation-induced malignancies. Diagnostic imaging costs rank among the fastest growing expenditures for Medicare. It is estimated that 62 million CT scans, including 4 million in children, were obtained in 2006, compared to 3 million in 1980.6 Fazel et al.7 followed 952,420 nonelderly adults (between 18 and 64 years of age) in 5 healthcare markets across the United States between 2005 and 2007. During the 3-year study period, 68.8% enrollees underwent at least 1 imaging procedure, with mean cumulative effective radiation dose of 2.4 millisieverts (mSv). Given the high prevalence of rhinosinusitis in the general population, it would seem to be intuitive that CT
Batra et al.
FIGURE 4. Radiation dose typically delivered by the scanner for sinus CT acquisition. CT = computed tomography.
TABLE 2. Impact of key variables on CT utilization patterns*
CT scan prior to
CT scan after 1st round of medical
CT scan to rule out sinusitis in
medical therapy
therapy
headache patient
Years in clinical practice (>10 years)
0.949 (0.881)
0.376 (50% of the clinical practice for 53.3% of respondents. Moreover, 68.7% reported seeing between 26 and 75 patients with sinonasal complaints in a typical week. Overall, 27% and 50.3% of the respondents obtained 20 scans in a typical week. Though exact utilization rates cannot be determined from this data, approximately 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 contrast to be the imaging study of choice in patients with CRS, especially to define sinus anatomy prior to surgery.2 However, the exact timing of this imaging relative to medical therapy received by the patient remains a matter of debate. In the present study, a majority of respondents (75%) obtained confirmatory imaging
Computed tomography imaging practice paerns in adult chronic rhinosinusitis: survey of the American Academy of Otolaryngology–Head and Neck Surgery and American Rhinologic Society membership Pete S. Batra, MD, FACS1 , Michael Setzen, MD, FACS, FAAP2 , Yan Li, BSc3 , Joseph K. Han, MD4 and Gavin Setzen, MD, FACS, FAAOA5
Background: The objective of this study was to assess the current practice paerns of computed tomography (CT) imaging for diagnosis and management of adult chronic rhinosinusitis (CRS). Methods: A 29-item, electronic, Web-based physician survey was disseminated to the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) and American Rhinologic Society (ARS) membership from November 2012 to January 2013. Results: A total of 331 otolaryngologists completed the survey. Seventy-five percent of respondents did not obtain confirmatory CT imaging prior to initiating medical therapy for CRS. A typical diagnostic scan was considered to be a 3-mm coronal CT with or without 3-mm axial images for 50.6% of participants. On average, the respondents obtained 1 (58.8%) or 2 (36.6%) CT scans prior to proceeding with sinus surgery. CT scanning was most commonly performed in a hospital radiology department (76.4%), followed by a free-standing imaging center (44.5%). An inoffice CT scanner was owned by 24.5% of the respondents, mostly commonly a cone beam CT (74.0%) scanner. Most
respondents (87.1%) did not experience problems with carriers denying ability to image or reimbursing for scans. Overall, 68.4% of the respondents were unaware of the dosage of radiation delivered by the scanner used for CT acquisition. Conclusion: This survey provides a snapshot of the current utility of CT imaging in the management paradigm for CRS. Given that most are unaware of the delivered radiation dose, this clearly represents an important area of imC 2015 ARS-AAOA, LLC. provement in the knowledge gap.
Key Words: computed tomography; imaging; radiology; radiation; sinusitis How to Cite this Article: Batra PS, Setzen M, Li Y, Han JK, Setzen G. Computed tomography imaging practice paerns in adult chronic rhinosinusitis: survey of the American Academy of Otolaryngology–Head and Neck Surgery and American Rhinologic Society membership. Int Forum Allergy Rhinol. 2015;5:506–512.
C
Correspondence to: Pete S. Batra, MD, FACS, Department of Otorhinolaryngology–Head and Neck Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite 550, Chicago, IL 60612; e-mail: [email protected]
hronic rhinosinusitis (CRS) represents one of the most common disorders diagnosed in the United States, with an estimated prevalence of 16% in the general adult U.S. population.1 It poses a significant economic burden, resulting in 26 million outpatient visits annually and $4.3 billion annually in direct medical expenses.2 Accurate diagnosis of CRS rests on presenting symptomatology, supported by demonstrable disease on computed tomography (CT) or endoscopy. Indeed, CT imaging of the paranasal sinuses signifies an important advance in the management of CRS patients. Superior resolution of the bony framework of paranasal sinuses affords the ability to detect subtle
Potential conflict of interest: P.S.B.: Medtronic (Consultant), Merck (Scientific Advisory Board). M.S.: Teva, Meda (Speakers Bureau). J.K.H.: Medtronic and IntersectENT (Consultant), Merck (Scientific Advisory Board). G.S.: Merck and Teva (Scientific Advisory Board), Salvat Pharmaceuticals (Principal Investigator, Clinical Trial), Advance Health Solutions (Medical Advisory Board).
Received: 7 September 2014; Revised: 8 December 2014; Accepted: 16 December 2014 DOI: 10.1002/alr.21483 View this article online at wileyonlinelibrary.com.
1 Department
of Otorhinolaryngology–Head and Neck Surgery, Rush University Medical Center, Chicago, IL; 2 Michael Setzen Otolaryngology, Great Neck, NY; 3 Bioinformatics, Department of Internal Medicine, Rush University Medical Center, Chicago, IL; 4 Department of Otolaryngology–Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, VA; 5 Albany ENT and Allergy Services, PC, Albany, NY
International Forum of Allergy & Rhinology, Vol. 5, No. 6, June 2015
506
CT practice pattern survey
changes in mucosal thickening and retained secretions relative to the air-bone interface.3 CT imaging helps delineate paranasal sinus anatomy, defines the extent and nature of underlying inflammatory disease, and provides a roadmap for functional endoscopic sinus surgery (FESS). A recent analysis of the National Ambulatory Medical Care Survey from 2005 through 2008 showed that otolaryngologists use advanced radiographic imaging at a statistically significant higher rate than primary care physicians per outpatient visit for diagnosis of CRS (16.0% vs 1.93%).4 This widespread utility underscores the concerns related to sinus CT imaging, including potential for overutilization, substantial costs, and excessive radiation exposure. A recent clinical consensus statement by the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) convened an expert panel be convened to codify appropriate usage of CT for paranasal sinus disease.5 Further, the American College of Radiology (ACR) recently published appropriateness criteria to guide imaging decisions for paranasal sinus disease.2 Despite these guidelines, the exact usage patterns for CT imaging in adult CRS for practicing otolaryngologists remain largely unknown. With this in mind, the current survey, supported by the AAO-HNS and American Rhinologic Society (ARS), was conducted to better ascertain clinical practice patterns of CT imaging and financial implications of point-of-care (POC) imaging in the management of CRS. The impact of key variables, eg, years and type of practice and owning a scanner, was ascertained on CT utilization patterns.
Materials and methods A 29-item survey was created and vetted by the Patient Advocacy Committee of the ARS and the Imaging Committee of the AAO-HNS. It was subsequently reviewed by the AAO-HNS Research, Quality, and Health Policy Department and approved by the ARS and AAO-HNS Board of Directors. The electronic survey (http://www.surveymonkey.com/s/ctimaging) was disseminated to the AAO-HNS and ARS membership through multiple mechanisms: electronic messenger service (twice each by AAO-HNS and ARS), ENT Advocate (once), and AAO-HNS Bulletin (once). The target group included 8000 practicing U.S. otolaryngologists. Percentages for each response were calculated based on number of responses for each question (range, 73 to 331 responses). Due to rounding, not all percentages added to 100%. The study did not involve direct patient contact or access to their health information; therefore, it was exempt from Institutional Review Board (IRB) approval. Particular areas explored included number of years in practice, type of practice, and geographic location of the clinical practice. The percentage of practice devoted to rhinology and number of patients presenting with nasal and sinus complaints per week were determined. Specific practice patterns for the role of CT imaging of the paranasal
507
International Forum of Allergy & Rhinology, Vol. 5, No. 6, June 2015
sinuses in the diagnosis of adult CRS was assessed. The role of CT imaging in FESS was also ascertained. The location of CT scan acquisition and socioeconomic aspects of POC imaging in the office setting were evaluated. The radiation dosage of the CT scanning was also queried. Geographic regions for the survey were defined as follows: New England (Maine, Vermont, New Hampshire, Massachusetts, Connecticut, Rhode Island); Mid-Atlantic (New York, New Jersey, Pennsylvania); Mountain (Wyoming, Idaho, Montana, Nevada, Utah, Colorado, New Mexico, Arizona); North Central (North Dakota, South Dakota, Nebraska, Kansas, Missouri, Iowa, Minnesota, Wisconsin, Illinois, Michigan, Indiana, Ohio); South Central (Texas, Oklahoma, Arkansas, Kentucky, Tennessee, Mississippi, Alabama, Louisiana); Southeast (Washington, DC, Maryland, Delaware, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida); and West (Washington, Oregon, California, Alaska, Hawaii).
Statistical methodology The chi-squared test was performed to determine the association between key variables, including years in practice (>10 years), academic vs private practice, geographic location, percentage of practice devoted to rhinology (>50%), and presence of in-office CT scanner with usage of CT scans in clinical practice (whether the scan was performed for confirmation prior to initiating therapy, after 1 round of medical therapy, and to rule out sinusitis in patients with headaches). For those associations that were statistically significant, the odds ratio was computed to assess the direction of the dependence. Calculations were performed using IBM SPSS version 20 (IBM, Armonk, NY). A p value 3 physicians) in 74 (22.4%), single specialty (1 to 3 physicians) in 52 (15.8%), multispecialty in 45 (13.6%), and solo in 30 (9.1%). Figure 1 shows the geographic location of the 320 responding physicians.
Batra et al.
FIGURE 1. Geographic location of the 320 participating physicians. Eleven survey respondents did not provide their location.
FIGURE 2. Number of sinus CT scans ordered by respondents in a typical week. CT = computed tomography.
Clinical practice parameters The percentage of clinical practice devoted to rhinology was as follows: 75% (107; 32.4%). The number of patients with nasal and sinus complaints seen in a typical week was as follows: 100 (14; 4.3%). Figure 2 illustrates the number of sinus CT scans ordered in a typical week.
CT utilization variables Table 1 lists the frequency of times practicing otolaryngologists obtain confirmatory CT imaging for CRS prior to initiating medical therapy, after first and second rounds of medical therapy, and in patients with severe headaches. It also provides the frequency of times the respondents obtain plain films and magnetic resonance imaging (MRI) for diagnosis of CRS. The respondents considered a typical diagnostic sinus CT scan as follows: 5-mm axial (1; 0.3%), 5-mm coronal (33; 10.1%), 3-mm axial (8; 2.4%), 3-mm coronal (66; 20.1%), 3-mm coronal and axial (100;
30.5%), 2-mm axial with reconstruction (69; 21.0%), and 1-mm axial with reconstruction (51; 15.5%). On average, the total number of CT scans obtained prior to proceeding with primary FESS in a typical patient, including those ordered by primary care, urgent care, or other providers, was as follows (values are number of scans in number of respondents): 0 in 1 (0.3%), 1 in 193 (58.8%), 2 in 120 (36.6%), 3 in 9 (2.7%), 4 in 0 (0%), and 5 or more in 5 (1.5%). Overall, 131 respondents (40.1%) obtained a new CT scan for image guidance prior to surgery. The types of sinus CT scan obtained prior to FESS are listed in Figure 3. The frequency of usage of surgical navigation was 75% of the time in 86 (26.3%). In the group above, 35 (10.7%) did not use navigation during FESS. Overall, 26 respondents (8.0%) used intraoperative CT imaging during FESS. The location of CT imaging acquisition was as follows: hospital radiology (252; 76.4%), free-standing imaging center (147; 44.5%), and in-office CT scanner (79; 23.9%). An in-office CT scanner and X-ray machine was owned by
International Forum of Allergy & Rhinology, Vol. 5, No. 6, June 2015
508
CT practice pattern survey
TABLE 1. Practice patterns of the respondents in obtaining confirmatory imaging for suspected chronic sinusitis in different
clinical scenarios* Frequency Never
75%
CT scan prior to initiating medical therapy
69 (21)
177 (54)
44 (13.4)
22 (6.7)
16 (4.9)
CT scan after completion of first round of medical therapy
56 (17.1)
124 (37.9)
58 (17.7)
44 (13.5)
45 (13.8)
CT scan after completion of second round of medical therapy
35 (10.6)
107 (32.4)
69 (20.9)
47 (14.2)
72 (21.8)
CT scan to rule out sinusitis in patients with severe headaches
5 (1.5)
58 (17.6)
70 (21.3)
76 (23.1)
120 (36.5)
Plain films to diagnose chronic rhinosinusitis
295 (89.7)
23 (7.0)
5 (1.5)
3 (0.9)
3 (0.9)
MRI to diagnose chronic rhinosinusitis
258 (78.4)
70 (21.3)
1 (0.3)
0 (0)
0 (0)
Scenario
*Values are n (%). CT = computed tomography; MRI = magnetic resonance imaging.
FIGURE 3. Type of sinus CT scan typically obtained by respondents prior to sinus surgery. CT = computed tomography.
80 (24.5%) and 20 (6.1%) of the physicians, respectively. Cone beam CT (CBCT) and conventional CT was owned by 57 (74.0%) and 20 (26.0%) of respondents, respectively. For those owning a CT scanner, 44 (60.3%) billed for interpretation and performance of the CT imaging, whereas 4 (5.5%) billed for interpretation but not for performance, and 8 (11.0%) reviewed but did not bill for the interpretation or performance of the CT scan. A radiologist read and billed for the interpretation and performance of the scan for 17 (23.3%) respondents. The respondents reported experiencing problems with carriers denying ability to image or reimbursing for the scans as follows: 75% of the time (2; 0.6%). The radiation dose typically delivered by the CT scanner is illustrated in Figure 4. Table 2 illustrates the statistical association between key variables, including years in practice (>10 years), academic vs private practice, percentage of practice devoted to rhinology (>50%), and presence of in-office CT scanner with CT usage patterns in clinical practice. Figure 5 shows
509
International Forum of Allergy & Rhinology, Vol. 5, No. 6, June 2015
the odds of CT utilization patterns based on geographic location.
Discussion The relative ease of access and rapid expansion of utilization of CT scanning has led to concerns about overuse with increased costs to the healthcare system and excessive radiation exposure with associated risk of radiation-induced malignancies. Diagnostic imaging costs rank among the fastest growing expenditures for Medicare. It is estimated that 62 million CT scans, including 4 million in children, were obtained in 2006, compared to 3 million in 1980.6 Fazel et al.7 followed 952,420 nonelderly adults (between 18 and 64 years of age) in 5 healthcare markets across the United States between 2005 and 2007. During the 3-year study period, 68.8% enrollees underwent at least 1 imaging procedure, with mean cumulative effective radiation dose of 2.4 millisieverts (mSv). Given the high prevalence of rhinosinusitis in the general population, it would seem to be intuitive that CT
Batra et al.
FIGURE 4. Radiation dose typically delivered by the scanner for sinus CT acquisition. CT = computed tomography.
TABLE 2. Impact of key variables on CT utilization patterns*
CT scan prior to
CT scan after 1st round of medical
CT scan to rule out sinusitis in
medical therapy
therapy
headache patient
Years in clinical practice (>10 years)
0.949 (0.881)
0.376 (50% of the clinical practice for 53.3% of respondents. Moreover, 68.7% reported seeing between 26 and 75 patients with sinonasal complaints in a typical week. Overall, 27% and 50.3% of the respondents obtained 20 scans in a typical week. Though exact utilization rates cannot be determined from this data, approximately 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 contrast to be the imaging study of choice in patients with CRS, especially to define sinus anatomy prior to surgery.2 However, the exact timing of this imaging relative to medical therapy received by the patient remains a matter of debate. In the present study, a majority of respondents (75%) obtained confirmatory imaging
