Overuse of diagnostic tools and medications in acute rhinosinusitis in Spain: a population-based study (the PROSINUS study)

Abstract

Objectives: Acute rhinosinusitis (ARS) has a high incidence. Diagnosis is clinical, and evolution is mostly self-limited. The aim of this study was to describe the sociodemographic characteristics and use of diagnostic tools and medications in patients with ARS.

Design: This is a prospective observational study in real-life clinical practice.

Setting: Patients with clinical diagnosis of ARS (n=2610) were included from ear, nose and throat clinics in Spain. A second visit at resolution was done.

Participants: Patients were classified according to the duration of symptoms: viral ARS (≤10 days), postviral ARS (>10 days, ≤12 weeks) and chronic rhinosinusitis (>12 weeks).

Main outcome measures: Sociodemographic characteristics, symptoms, disease severity, quality of life (Sino-Nasal Outcome Test-16), used diagnostic tools and medications, and the management performed by primary care physicians (PCPs) and by otorhinolaryngologists (ORLs) were assessed.

Results: Of the patients 36% were classified as having viral ARS, 63% postviral ARS and 1% as chronic rhinosinusitis. Working in a poorly air-conditioned environment was a risk factor (OR: 2.26, 95% CI 1.27 to 4.04) in developing postviral ARS. A higher number of diagnostic tools (rhinoscopy/endoscopy: 80% vs 70%; plain X-ray: 70% vs 55%; CT scan: 22% vs 12%; P<0.0001) were performed in postviral than viral cases. PCPs performed more X-rays than ORLs (P<0.0001). Patients, more those with postviral than viral ARS, received a high number of medications (oral antibiotics: 76% vs 62%; intranasal corticosteroids: 54% vs 38%; antihistamines: 46% vs 31%; mucolytic: 48% vs 60%; P<0.0001). PCPs prescribed more antibiotics, antihistamines and mucolytics than ORLs (P<0.0068). More patients with postviral than viral ARS reported symptoms of potential complications (1.5% vs 0.4%; P=0.0603). Independently of prescribed medications, quality of life was more affected in patients with postviral (38.7±14.2 vs 36.0±15.3; P=0.0031) than those with viral ARS. ARS resolution was obtained after 6.04 (viral) and 16.55 (postviral) days, with intranasal corticosteroids being associated with longer (OR: 1.07, 95% 1.02 to 1.12) and phytotherapy with shorter (OR: 0.95, 95% CI 0.91 to 1.00) duration.

Conclusions: There is a significant overuse of diagnostic tools and prescribed medications, predominantly oral antibiotics, by PCPs and ORLs, for viral and postviral ARS.

Figure 1

Flow chart of participants in the PROSINUS study (PROspective epidemiological study about the diagnosis and therapeutic management of Acute RhinoSINUsitis in otorhinolaryngology clinics in Spain). Two phenotypes for ARS and one for CRS were analysed: patients with viral ARS/common cold (36%), postviral ARS (63%) and CRS (1%). VAS, visual analogue scale. ^a% refers to patients selected at visit 1 (n=1678); ^b% refers to patients considered valid at visit 2 (n=1362). ARS, acute rhinosinusitis; CRS, chronic rhinosinusitis; EPOS, European Position Paper on Rhinosinusitis and Nasal Polyps; RS, rhinosinusitis; VAS, visual analogue scale.

Figure 2

Frequency of symptoms in patients with acute rhinosinusitis (ARS). Bars represent the frequency (%) of individual sinonasal symptoms in each level of severity for both viral and postviral ARS. Reported frequency of symptoms was always higher in the highest severity level. *P<0.05; NS, not significant.

Figure 3

Quality of life (SNOT-16) in patients with ARS. Changes in the individual values (solid lines) and in the average values of each group (dashed lines). At baseline, SNOT-16 score was more affected (*P<0.05) in postviral than in viral ARS. SNOT-16 score significantly improved (‡P<0.05) after disease resolution, with no differences between both ARS phenotypes. ARS, acute rhinosinusitis; SNOT-16, Sino-Nasal Outcome Test 16.

Figure 4

Diagnostic tools performed in patients with acute rhinosinusitis. Percentage of patients undergoing different diagnostic tools, for both viral and postviral acute rhinosinusitis, recommended by either primary care physicians or otorhinolaryngologists. *P<0.05; NS, not significant.

Figure 5

Prescribed medications in patients with acute rhinosinusitis (ARS). Percentage of patients being treated with different medications, for both viral and postviral ARS, prescribed by either primary care physicians or otorhinolaryngologists. *P<0.05; NS, not significant.