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Physician Specialty Is Associated With Differences in the Evaluation and Management of Acute Bacterial Rhinosinusitis
John W. Werning, MD, DMD;
Todd W. Preston, MD;
Sadik Khuder, PhD
Arch Otolaryngol Head Neck Surg. 2002;128:123-130.
ABSTRACT
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Background Acute bacterial rhinosinusitis (ABRS) is a common illness that is routinely
managed by physicians from several different specialties. However, the actual
diagnostic and treatment preferences of physicians from these different specialties
are not known.
Objective To determine whether the radiographic evaluation and management of community-acquired
ABRS differs according to medical specialty.
Design, Setting, and Participants Randomized survey of 450 board-certified physicians in the United States
from family medicine, general internal medicine, and otolaryngology.
Main Outcome Measures Responding physicians' use of diagnostic radiography as well as choice
and duration of antimicrobial and adjunctive treatments of ABRS.
Results Otolaryngologists were more likely to use supportive diagnostic radiography
(P = .04). They were also more likely to treat patients
with adjunctive therapy, such as topical decongestants (P = .01), guaifenesin (P = .01), and saline
nasal irrigation (P = .01), in addition to antibiotics.
Otolaryngologists prescribed more medications to treat patients with ABRS
than primary care physicians (P = .01). There were
no significant differences in diagnosis and management by family physicians
and general internists.
Conclusions Otolaryngologists use more health care resources to diagnose and treat
ABRS than primary care physicians despite an absence of evidence that such
tests and treatments lead to better outcomes. Otolaryngologists typically
treat a patient population with a higher prevalence of ABRS and frequently
see referred patients with recurrent acute sinusitis and chronic rhinosinusitis,
which may explain their tendency to treat patients more aggressively. Nevertheless,
these survey results illustrate a lack of consensus within the medical community
regarding the evaluation and management of community-acquired ABRS, suggesting
that widely accepted evidence-based practice guidelines need to be developed.
INTRODUCTION
IN 1996, the primary diagnosis of rhinosinusitis led to expenditures
of approximately $3.39 billion in the United States.1
More than 1 billion cases of viral rhinosinusitis are estimated to occur in
the United States annually.2 Acute bacterial
rhinosinusitis (ABRS) complicates approximately 0.5%3
to 2%4 of cases of viral rhinosinusitis. Assuming
a 2% bacterial complication rate, 20 million cases of viral rhinosinusitis
may be complicated by ABRS annually.
Even though ABRS is an illness that is commonly diagnosed by primary
care physicians and specialists, no guidelines for the diagnosis and management
of ABRS have been established that are universally accepted by the medical
community. Because maxillary sinus aspiration and culture (the gold standard
for the diagnosis of ABRS) is usually impractical, physicians typically must
distinguish between viral rhinosinusitis and ABRS using their "clinical impression."
The role of radiography also remains unclear. Because patients with viral
rhinosinusitis also frequently demonstrate radiographic paranasal sinus abnormalities,
the ability of diagnostic radiography to differentiate between viral rhinosinusitis
and ABRS remains poorly defined.5
Although sinusitis is the fifth most common diagnosis for which an antibiotic
is prescribed, according to National Ambulatory Medical Care Survey data,6 a plethora of different antibiotics are used by clinicians
to treat community-acquired ABRS. The choice of antibiotic therapy for ABRS
has been complicated by the increasing prevalence of drug-resistant Streptococcus pneumoniae and ß-lactamase–producing
isolates of Haemophilus influenzae and Moraxella catarrhalis. The constantly changing susceptibility profiles
of these organisms have prevented the establishment of recommendations for
antibiotic therapy that remain applicable from year to year. A broad array
of adjunctive pharmacologic and nonpharmacologic treatments are also available
to treat community-acquired ABRS. These adjunctive treatment options are largely
used empirically because there is a paucity of prospective, well-controlled
trials to support their efficacy.
The Agency for Healthcare Research and Quality (AHRQ), formerly the
Agency for Health Care Policy and Research (AHCPR), published an evidence-based
review of the diagnosis and management of ABRS in 1999,7
and guidelines for the diagnosis and management of ABRS were subsequently
published by the Sinus and Allergy Health Partnership (SAHP) in 2000.8 Although these evidence-based reports were developed
to standardize and improve the quality of health care delivery to patients
with ABRS, the degree to which these reports have been disseminated to and
accepted by the medical community is unknown.
Physician specialty has been associated with differences in the evaluation
and management of a number of disorders, including prostate cancer, heart
failure, atrial fibrillation, and preterm labor.9-12
The absence of widely accepted guidelines for ABRS has led us to investigate
whether there are differences in the evaluation and management of ABRS based
on medical specialty. In the present study, we surveyed a nationwide random
sample of board-certified practicing family physicians, general internal medicine
physicians, and otolaryngologists to compare their clinical approach to community-acquired
ABRS.
METHODS
A random sample of physicians from family medicine, general internal
medicine, and otolaryngology were selected from The Official
ABMS Directory of Board Certified Medical Specialists, 1999.13 Internists with subspecialty interests listed in
the ABMS directory were excluded. The offices of the sampled physicians were
contacted by telephone to verify their specialty, and the survey was forwarded
to 150 physicians of each specialty by either fax or mail based on the physician's
preference. Physicians were randomly selected from all 50 states as well as
the District of Columbia. Physicians who did not respond within 1 month were
forwarded a second copy of the survey.
All physicians were surveyed using the same instrument, which contained
the following clinical scenario:
A 30-year-old man presents to your office with a history and
physical examination findings that, you believe, is consistent with acute
maxillary sinusitis. His symptoms developed following a recent viral upper
respiratory tract infection, and he denies any history of sinusitis. His past
medical and surgical history is unremarkable. He is not taking any medication
and has no known drug allergies. The patient is a nonsmoker. He denies any
known history of environmental allergies.
The survey instrument contained items pertaining to the above scenario
regarding the surveyed physician's preferences for the use of supportive diagnostic
radiography and choice and duration of antibiotic therapy as well as other
pharmacologic and nonpharmacologic forms of adjunctive therapy. Commercially
available combination medications recommended by the respondents were divided
into their individual generic ingredients and dosages for the purpose of data
analysis (eg, Entex LA [WelPharm Inc, Irvine, Calif] was composed of 75 mg
of phenylpropanolamine hydrochloride and 400 mg of guaifenesin when the survey
was conducted). When duration of therapy was listed as a range (ie, 7-10 days),
the longer period was chosen (10 days). Demographic information about the
surveyed physician was also obtained, including age, number of years in practice,
and whether the physician practiced in an urban or rural setting.
Statistical analysis for the data was carried out using analysis of
variance (ANOVA) for continuous variables and  2 or Fisher
exact test for categorical variables. All analyses were carried out using
SAS statistical software (SAS Institute Inc, Cary, NC).
RESULTS
The characteristics of the respondents are summarized in Table 1. Of 450 physicians surveyed, 225 returned the survey for
an overall response rate of 50%. The geographic distribution of the respondents'
practice sites was evaluated according to the geographic regions defined by
the US Bureau of the Census.14 The greatest
number of respondents practiced in the South (33%), which was also the most
common practice location for physicians from these 3 specialties according
to the ABMS directory (31%).13 The Midwest
represented the second most common practice location of the respondents (24%),
followed by the West (24%) and the Northeast (19%). More family physicians
were from rural areas (P = .01). Otherwise, the respondents
from each specialty were demographically similar.
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Table 1. Characteristics of Respondents*
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Table 2 illustrates the
use of diagnostic radiographs by each group of specialists. Of the surveyed
otolaryngologists, 15% chose to use supportive diagnostic radiography compared
with 7% of primary care physicians (P = .04). There
was no difference in the use of radiographs by family physicians or internists.
Plain film radiography was used by each specialty more frequently than computed
tomography.
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Table 2. Use of Diagnostic Radiographs*
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Table 3 summarizes the first-line
antimicrobial therapeutic preferences of each specialty. More than 92% of
the responding physicians prescribed antibiotics, with a mean duration of
therapy of 11.5 days. There was no significant difference in the use or duration
of antibiotic therapy. Amoxicillin was the most common selection (42%) by
all 3 specialties. The second most common antibiotic chosen by otolaryngologists
was amoxicillin-clavulanate, whereas family physicians and internists more
frequently preferred trimethoprim-sulfamethoxazole (P
= .01). Nineteen physicians (8%) chose to use cephalosporins, while 12 (5%)
chose macrolides, and 1 otolaryngologist prescribed a fluoroquinolone as first-line
therapy.
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Table 3. First-Line Antibiotic Therapy*
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Table 4 summarizes the physicians'
antibiotic choices and their accordance with the evidence-based report published
by the AHRQ and the SAHP guidelines. Of the primary care physicians who used
antibiotic therapy, 70% prescribed 1 of the 2 antibiotics (amoxicillin or
trimethoprim-sulfamethoxazole) supported by the AHRQ findings, while only
53% of otolaryngologists prescribed them (P = .01).
Otolaryngologists tended to prescribe antibiotic therapy that conformed to
the recommendations of the SAHP, although this trend was not statistically
significant (P = .14). Of the responding otolaryngologists,
81% prescribed 1 of the 4 suggested antibiotics, whereas only 61% of primary
care physicians prescribed 1 of these antibiotics.
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Table 4. Accordance of Antibiotic Therapy Choice With the AHRQ Report
and SAHP Guidelines*
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Table 5 summarizes the use
of decongestants and guaifenesin by each specialty. Of the 225 physicians
who responded, 85% advocated the use of a decongestant. Topical decongestant
therapy was recommended by 21% of the physicians, with a mean treatment duration
of 4.2 days. Internists were least likely to use topical decongestants, while
otolaryngologists were most likely to use them. Together, primary care physicians
used topical decongestants less frequently than otolaryngologists (P = .01). Overall, 70% of the physicians advocated the use of oral
decongestants, with a mean treatment duration of 10.3 days. There was no significant
difference in the frequency or duration of use of oral decongestants among
the 3 specialty groups. Twenty-one physicians (9%) advocated using both topical
and oral decongestants.
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Table 5. Use of Decongestants and Guaifenesin*
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Guaifenesin is an oral expectorant with mucokinetic properties. Otolaryngologists
were most likely to use guaifenesin (P = .01). We
also evaluated the dosage that was prescribed because the literature only
supports the clinical efficacy of guaifenesin at dosages of 2400 mg/d or more.15-16 This dosage was recommended by 40%
of otolaryngologists vs only 16% of primary care physicians, which was a statistically
significant difference (P = .01). None of the respondents
advocated using more than 2400 mg/d.
Table 6 reviews the use
of nasal steroid therapy, antihistamines, saline irrigation, and steam-heated
mist. Of the respondents, 25% would prescribe nasal steroid therapy, and 12%
would use antihistamines. Steam was advocated by 45% of the physicians. There
was no significant difference in the use of these treatments by any of the
physician groups. However, otolaryngologists recommended saline irrigation
more than primary care physicians (P = .01). Additional
therapeutic recommendations by the respondents included oral steroid therapy
(n = 3), ascorbic acid supplementation (n = 2), warm compresses (n = 5), and
abstinence from histamine-containing foods (n = 1).
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Table 6. Use of Nasal Steroids, Antihistamines, Saline Irrigation,
and Steam*
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Table 7 reviews the number
of drugs advocated by the respondents from each specialty for the treatment
of community-acquired ABRS. While 13% of primary care physicians prescribed
only 1 medication, 4% of the otolaryngologists prescribed only 1. Otolaryngologists,
however, tended to prescribe 4 or more medications (31%), whereas only 15%
of the primary care physicians prescribed more than 3 medications. Otolaryngologists
tended to prescribe more drugs than primary care physicians (P = .01), whereas no statistically significant difference was identified
between internists and family physicians (P = .66).
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Table 7. Number of Medications Used for the Treatment of ABRS*
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COMMENT
The clinical scenario used in our survey instrument depicts a commonly
encountered situation in the daily practices of the physicians who responded
to this survey, but the clinical diagnosis of ABRS continues to present a
difficult challenge for the physician. A number of researchers have assessed
the value of clinical assessment as a diagnostic tool for ABRS. One prospective
study that evaluated the diagnostic use of the recognized signs and symptoms
of ABRS in primary care offices found that the overall clinical impression
was more accurate than any single clinical finding.17
Moreover, the patients' reported symptoms were found to conflict with examination
findings. Most of these studies used radiography or ultrasound as the diagnostic
criterion standard and cannot be interpreted as "true" estimates of sensitivity
and specificity. One study compared clinical criteria with that of sinus puncture
with culture (the diagnostic reference standard for ABRS) but no valid conclusions
can be made because of methodological problems within the study design.18 Consequently, there are no reliable data for how
well clinical examination compares with sinus puncture as a reference.
Because the clinical evaluation for ABRS is fraught with limitations,
diagnostic radiography has frequently been used by clinicians to improve diagnostic
accuracy. The frequent presence of paranasal sinus abnormalities on computed
tomographic scans of 87% of patients with viral rhinosinusitis, however, further
complicates the ability to diagnose ABRS.5
These findings suggest that ABRS would be frequently overdiagnosed by computed
tomographic scan findings. Other researchers, however, suggest that plain
film radiography is of limited value compared with computed tomographic scans
in the evaluation of acute sinusitis.19 Interestingly,
plain film radiography has been used as a benchmark for the diagnosis of acute
sinusitis in a number of prospective studies.17, 20
The role of radiography was also evaluated by a recent meta-analysis of 6
studies that showed a sensitivity of 76% and a specificity of 79% in patients
who also underwent sinus aspiration and culture.7
These findings led the authors to conclude that performing sinus radiography
was not a cost-effective diagnostic strategy at any prevalence level. However,
our survey suggests that disagreement over the role of diagnostic radiography
in ABRS exists within the medical community. Nearly 10% of the responding
physicians used radiography, and otolaryngologists were more likely to recommend
radiography than their primary care colleagues (P
= .04). These findings highlight the lack of consensus regarding the role
of radiography in the diagnosis of ABRS.
A significant number of patients with ABRS clinically improve without
treatment. In fact, the spontaneous resolution rate in patients with culture-proven
ABRS has been predicted to be 47%8 in adults,
while 63%8 to 69%21
of adults with a clinical diagnosis of ABRS would be expected to undergo spontaneous
resolution. Therefore, any treatment that is advocated should be cost-effective
and increase the rate of cure.
Antibiotic therapy is the most common treatment used for ABRS. A meta-analysis
of randomized controlled trials of antibiotic treatment for ABRS performed
between 1970 and 1997 showed that antibiotics were significantly more effective
than placebo, reducing treatment failures by almost 50%.21
The AHRQ in 1999 published a summary of the published evidence on the diagnosis
and treatment of community-acquired ABRS.7
Their meta-analysis of 28 randomized clinical trials on the antibiotic treatment
of acute sinusitis did not suggest a clinically meaningful superiority of
newer, more expensive antibiotics over amoxicillin or folate inhibitors, such
as trimethoprim-sulfamethoxazole. In fact, the AHRQ analysis concluded that
a clinician would need to treat 118 patients with newer, more expensive antibiotics
instead of amoxicillin to prevent 1 case of clinical failure. However, many
of these clinical trials were carried out prior to the development of rapidly
rising levels of antibiotic-resistant organisms in community-acquired ABRS.
Nearly 37% of the physicians in the present survey chose to use 1 of the newer,
more expensive antibiotics for the patient in our clinical scenario.
The SAHP, a not-for-profit organization created through the joint efforts
of the American Academy of Otolaryngic Allergy, the American Academy of Otolaryngology–Head
and Neck Surgery, and the American Rhinologic Society, published antimicrobial
treatment guidelines in July of 2000 in response to the changing profile of
antimicrobial susceptibility in community-acquired ABRS.8
Like the AHRQ report, the SAHP guidelines were developed by contributors with
expertise in evidence-based medicine. Antibiotic therapy recommendations were
developed using a mathematical model to determine the calculated bacteriologic
efficacy of each antibiotic. These evidence-based practice guidelines have
not been subjected to clinical evaluation. For initial therapy for adults
with mild or moderately severe ABRS, the SAHP recommended amoxicillin-clavulanate,
amoxicillin, cefpodoxime proxetil,8 or cefuroxime
axetil.
In our study, there were remarkable differences in the choices of antibiotic
therapy by each specialty. While amoxicillin was the most common choice by
all 3 specialties, trimethoprim-sulfamethoxazole was the second most frequently
recommended antibiotic by primary care physicians, whereas amoxicillin-clavulanate
was the second most common choice by otolaryngologists. When the prescribing
preferences of each specialty were compared with the evidence-based findings
of the AHRQ and the SAHP, there were also notable differences. Primary care
physicians more frequently chose antibiotics supported by the AHRQ report
(P = .01), whereas otolaryngologists' choices were
more closely aligned with the guidelines of the SAHP primarily because of
their preference for amoxicillin-clavulanate over trimethoprim-sulfamethoxazole.
Because this survey was performed before the SAHP guidelines were published,
the antibiotic choices were not influenced by this publication. The SAHP guidelines
and the AHRQ report, however, demonstrate that a lack of uniformity exists,
which may confuse clinicians regarding appropriate antibiotic management.
Several other adjunctive therapies exist for the treatment of ABRS,
but research supporting their use is scant. The AHRQ reviewed 10 randomized
controlled trials regarding nonantibiotic treatment of ABRS.7
In most of these studies, the medications were used in conjunction with antibiotics,
preventing evaluation of their role in the treatment of ABRS in the absence
of antibiotic therapy. In addition, none of these randomized trials compared
antibiotic therapy with nonantibiotic therapy.
Topical and systemic decongestant therapies have been recommended to
adjunctively treat ABRS. Therapy with decongestants results in vasoconstriction
of mucosal capillaries with shrinkage of edematous mucosa and constriction
of submucosal capacitance vessels. Decreased mucosal swelling and submucosal
engorgement could therefore potentially improve paranasal sinus drainage and
mucociliary clearance. However, there are no well-designed studies that demonstrate
the efficacy of decongestants in ABRS. Despite the paucity of available data,
however, more than 70% of the respondents prescribed oral decongestants, and
nearly 21% of the physicians recommended topical decongestants. Of the 158
respondents who prescribed oral decongestants, 41 (26%) used medications containing
phenylpropanolamine, which was recently demonstrated to be an independent
risk factor for hemorrhagic stroke in women.22
These findings have resulted in a request by the Food and Drug Administration
for all drug companies to discontinue marketing products containing phenylpropanolamine.
Our survey, however, was conducted prior to the disclosure of these research
findings.
Expectorants are mucokinetic agents that are capable of improving mucus
quality and enhancing mucociliary clearance. A few studies suggest that guaifenesin,
an expectorant, may be effective as a mucokinetic agent in dosages of 2.4
g/d or greater.15-16 The use of
guaifenesin in the treatment of paranasal sinusitis is, however, primarily
anecdotal. One article has shown some benefit in human immunodeficiency virus–positive
patients with chronic rhinosinusitis,16 but
to our knowledge no well-controlled studies exist that evaluate the benefits
of guaifenesin for ABRS. Nevertheless, nearly 50% of the responding physicians
in our survey used guaifenesin to adjunctively treat ABRS, and almost 75%
used a subtherapeutic dosage of less than 2.4 g/d.
Nasal corticosteroids may be potentially useful in treating patients
with ABRS because of their ability to reduce mucosal inflammation. One recent
prospective randomized trial concluded that intranasal flunisolide spray was
efficacious as an adjunct to oral antibiotic therapy for sinusitis.23 However, 47% of the patients were diagnosed as having
chronic sinusitis, and the patients were recruited from the practices of allergy
specialists, preventing assessment of its use in the nonallergic patient.
There are no existing well-designed studies that demonstrate an unequivocally
beneficial role in the treatment of ABRS. Nevertheless, nearly 25% of the
respondents advocated their use for the nonallergic patient in our scenario.
Antihistamines are not typically recommended in the management of ABRS
because of their anticholinergic activity, which can result in thicker, desiccated
secretions that can impair paranasal sinus drainage. However, to our knowledge
no controlled clinical trials exist that assess the value of antihistamines
in ABRS. Because nearly 12% of the physicians recommended their use, further
research may be indicated to evaluate their role as well as the rationale
for prescribing them.
Nasal saline irrigation has been advocated to minimize nasal crusting
and clear static secretions, thereby improving mucociliary clearance. A recent
study demonstrated improved mucociliary transit times when buffered 3% hypertonic
saline was used as a mucokinetic agent vs buffered nasal saline.24
More than 40% of the responding physicians advocated the use of saline irrigation.
However, its ability to facilitate the resolution of ABRS has not been rigorously
evaluated.
Research on the efficacy of symptom reduction by the nasal inhalation
of steam in patients with viral rhinosinusitis has yielded conflicting findings.
Tyrrell et al25 reported nearly 50% improvement
in cold symptoms after a 20-minute treatment with 43°C humidified air.
More recent research, however, found no beneficial effect of steam inhalation
therapy on cold symptoms.26 Furthermore, the
use of steam does not inhibit rhinovirus replication in patients with viral
rhinosinusitis as previously thought.27 The
benefits of steam in patients with ABRS have not been rigorously evaluated.
Still, nearly 45% of the respondents said they would advocate steam inhalation.
As illustrated in Table 8,
the present survey highlights a significant disparity within the medical community
regarding the management of community-acquired ABRS. There were significant
differences in the diagnosis and management of ABRS between primary care physicians
and otolaryngologists in the use of radiographs, topical decongestants, guaifenesin,
and saline nasal irrigation. Otolaryngologists were more likely to use each
of these treatments. Furthermore, otolaryngologists tended to prescribe more
medications for the treatment of ABRS than primary care physicians. In contrast,
when responses of family physicians and internists were compared, there was
no statistically significant difference in any of these diagnostic or treatment
parameters.
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Table 8. Specialty Most Likely to Use Treatment in Evaluation and Management
of ABRS*
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POSSIBLE EXPLANATIONS FOR THE OBSERVED FINDINGS
Although the differences between specialties are pronounced, the reasons
for these differences in the clinical approach to sinusitis are unclear. A
number of factors may influence the disparity between otolaryngologists and
primary care physicians. Otolaryngologists typically treat a patient population
with a higher prevalence of ABRS, whereas primary care physicians typically
treat a population with a relatively higher prevalence of viral rhinosinusitis.
Furthermore, otolaryngologists frequently treat patients referred from primary
care physicians for whom initial therapy has failed as well as patients with
recurrent acute sinusitis and chronic rhinosinusitis. As a result, otolaryngologists
may be more likely to form the "clinical impression" that a particular patient
has ABRS and treat the patient more aggressively. Moreover, because otolaryngologists
more frequently manage complex patients with rhinosinusitis that has been
unresponsive to initial medical therapy, they may have a treatment bias that
affects their management of all patients with ABRS. As a consequence, uncomplicated
patients with community-acquired ABRS may be more likely to receive therapy
from an otolaryngologist that is typically intended for a patient with recurrent
acute sinusitis or chronic rhinosinusitis.
Other investigators have concluded that a physician's specialty training,
both formal and informal, plays a key role in his or her treatment decisions.28 Likewise, our findings suggest that educational experiences
may play a significant role in the clinical decision-making process for the
diagnosis and treatment of ABRS. In addition, physicians may be influenced
by other factors including the costs of diagnosis and treatment, as well as
their personal experiences with patient compliance and treatment outcomes.
This physician survey, however, precludes any conclusions regarding the outcome
of patients with ABRS based on differences in therapy. Further research is
necessary to evaluate the relative influence that these factors have on a
physician's approach toward management of different disease processes.
REVIEW OF THE LITERATURE
Differences in health care utilization by generalists and specialists
have been previously demonstrated. Cardiologists and endocrinologists have
been shown to have higher health care utilization rates than general internists
and family physicians after adjusting for differences in patient mix.29 Other investigations have shown that specialists
tend to order more laboratory tests and radiographs and tend to refer more
often to other physicians.30-31
Findings from research on the impact that differences in health care utilization
has on disease-specific outcomes, however, disagree. Care by cardiologists
has been associated with greater costs and resource use with no difference
in survival at 30 days of follow-up for patients hospitalized with congestive
heart failure when compared with the outcomes of patients treated by generalists.32 Two other studies that reviewed the outcome of patients
treated for acute myocardial infarction confirmed the increased health care
utilization by cardiologists, but only one of these investigations demonstrated
a lower adjusted 1-year mortality in those patients treated by cardiologists.33-34 Similarly, patients treated for rheumatoid
arthritis and children treated in pediatric intensive care units have been
shown to benefit from specialty care,35-36
while patients with chronic obstructive pulmonary disease, hypertension, and
type 2 diabetes mellitus have not shown a beneficial effect.37-39
We identified 1 prior publication that evaluated practice variations
in the management of acute sinusitis among primary care physicians in Canada.40 The authors concluded that confusion existed among
primary care physicians regarding the recommended management of acute sinusitis.
To our knowledge, however, no published research has compared the difference
in the diagnosis and management of ABRS between otolaryngologists and primary
care physicians. Furthermore, the impact of specialty care on the outcomes
of patients with ABRS has not been formally investigated.
CONCLUSIONS
There is a lack of consensus between primary care physicians and otolaryngologists
regarding radiographic assessment and management of community-acquired ABRS.
To standardize the treatment of community-acquired ABRS for the medical community
there must be (1) well-designed clinical trials that assess efficacy, (2)
outcomes research that assesses the effectiveness of different treatments,
and (3) the establishment of widely accepted evidence-based practice guidelines.
Furthermore, these evidence-based guidelines will need to be regularly updated
for the medical community to account for the evolving changes in antibiotic
resistance by the causative agents of ABRS.
AUTHOR INFORMATION
Accepted for publication August 31, 2001.
We wish to express our gratitude to Allan M. Rubin, MD, PhD, for his
constructive review of our manuscript. We also wish to acknowledge Peggy Wellman
for her assistance with the preparation of the manuscript.
Corresponding author and reprints: John W. Werning, MD, DMD, Department
of Otolaryngology–Head and Neck Surgery, Medical College of Ohio, 3065
Arlington Ave, Toledo, OH 43614-5807 (e-mail: jwwerning{at}netscape.net).
From the Departments of Otolaryngology–Head and Neck Surgery
(Drs Werning and Preston) and Medicine (Dr Khuder), Medical College of Ohio,
Toledo. Dr Werning is a consultant for Pfizer Inc, New York, NY, and UCB Pharma
Inc, Atlanta, Ga.
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