A multi-center research team from Kaiser Permanente and the University of California Irvine conducted a study to evaluate the management and treatment of patients with suspected chronic rhinosinusitis (CRS) by primary care providers (PCP) before referral through specialist evaluation. The study findings were presented at the American Rhinologic Society, Combined Otolaryngology Spring Meeting (ARS-COSM) in Boston, Massachusetts (May 4-5, 2023). Kaiser Permanente (KP) is an integrated managed care organization with vast clinical data accessible from primary care through specialty care, providing a unique insight into the continued treatment of patients.
CRS is a clinical syndrome associated with persistent inflammation of the mucosa of the nose and paranasal sinuses. It is characterized by significant physical impairment, adversely impacting patient quality of life and psychosocial well-being. Despite its prevalence, CRS remains a challenging and, at times, controversial disease entity. Studies have highlighted that managing patients with CRS requires a multidisciplinary approach to evaluate the symptoms and clinical history, confirm diagnoses, and identify the best treatment strategy to control the disease and prevent clinical exacerbations.
The researchers collected data on patients diagnosed with CRS within KP Orange County between April 1 and September 30, 2021. Electronic medical records were reviewed for clinical data, including demographics, comorbidities, pre-referral treatments 1 year before the referral, and other relevant clinical data. A number of statistical analyses were performed to evaluate the associations between pre-referral management patterns.
According to study results, 370 patients were enrolled, with a higher proportion of female (58.5%) and white (51.4%) patients. Among them, 150 patients were definitively diagnosed with CRS. Moreover, multivariate analysis showed that olfactory dysfunction (OD) and comorbid asthma were associated with increased odds of confirmed CRS.
Notably, the study observed low rates of pre-referral treatment involving intranasal steroids and saline irrigations. Besides, 26% of patients underwent three or more antibiotic courses within 1 year before their referral. It was observed that patients who underwent CT sinus before specialist consultation had a shorter time to decide on surgical intervention (mean days 27.7 vs. 46.3) than after consultation.
These findings suggest that patients referred for CRS have high rates of divergent diagnoses upon specialist evaluation. Furthermore, specific items in patient history, including OD and asthma, raise suspicion for CRS. “Examination of the longitudinal care of CRS patients may help identify opportunities to streamline care of these patients, “the authors wrote.
The researchers further noted that there is still some concern for over-treatment with antibiotics and oral steroids in the pre-referral setting. “Improved education in clinically identifying CRS and consideration of limits on courses of antibiotics/oral steroids may help reduce unnecessary medical therapy, ” the author concluded.
The authors of the study include Isaac Obermeyer, MD; Christopher Pool, MD; David Keschner, MD, JD; Rohit Garg, MD. MBA; Frederick Yoo, MD; from Kaiser Permanente County – Department of Head and Neck Surgery, and University of California Irvine, Department of Otolaryngology, Head and Neck Surgery.
Reference:
Obermeyer I, Pool C, Keschner D, et al. Pre-Referral Management Patterns and Descriptive Analysis of 370 Chronic Rhinosinusitis Patients: From Primary Care to Specialty Care. ARS-COSM. May 4-5, 2023.