Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study

Luke Rudmik, Zachary M. Soler, Claire Hopkins, Rodney J. Schlosser, Anju Peters, Andrew A. White, Richard R. Orlandi, Wytske J. Fokkens, Richard Douglas, Timothy Smith

Research output: Contribution to journalArticle

24 Citations (Scopus)

Abstract

Background: Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS. Methods: The RAND/UCLA appropriateness methodology was performed. An international, multidisciplinary panel of 10 experts in CRS was formed and completed 2 rounds of a modified Delphi ranking process along with a face-to-face meeting. Results: A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20. Conclusion: This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment “option” during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment “option” and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high-quality, patient-centered care to patients with CRS.

Original languageEnglish (US)
Pages (from-to)557-567
Number of pages11
JournalInternational Forum of Allergy and Rhinology
Volume6
Issue number6
DOIs
StatePublished - Jun 1 2016

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Nasal Polyps
Adrenal Cortex Hormones
Anti-Bacterial Agents
Patient-Centered Care
Quality of Health Care
Therapeutics
Patient Selection
Anti-Inflammatory Agents
Incidence

Keywords

  • appropriateness criteria
  • chronic rhinosinusitis
  • maximal medical therapy
  • patient selection
  • quality of health care
  • RAND
  • sinus surgery
  • sinusitis
  • surgery indications

ASJC Scopus subject areas

  • Immunology and Allergy
  • Otorhinolaryngology

Cite this

Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis : a RAND/UCLA appropriateness study. / Rudmik, Luke; Soler, Zachary M.; Hopkins, Claire; Schlosser, Rodney J.; Peters, Anju; White, Andrew A.; Orlandi, Richard R.; Fokkens, Wytske J.; Douglas, Richard; Smith, Timothy.

In: International Forum of Allergy and Rhinology, Vol. 6, No. 6, 01.06.2016, p. 557-567.

Research output: Contribution to journalArticle

Rudmik, Luke ; Soler, Zachary M. ; Hopkins, Claire ; Schlosser, Rodney J. ; Peters, Anju ; White, Andrew A. ; Orlandi, Richard R. ; Fokkens, Wytske J. ; Douglas, Richard ; Smith, Timothy. / Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis : a RAND/UCLA appropriateness study. In: International Forum of Allergy and Rhinology. 2016 ; Vol. 6, No. 6. pp. 557-567.
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abstract = "Background: Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS. Methods: The RAND/UCLA appropriateness methodology was performed. An international, multidisciplinary panel of 10 experts in CRS was formed and completed 2 rounds of a modified Delphi ranking process along with a face-to-face meeting. Results: A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20. Conclusion: This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment “option” during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment “option” and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high-quality, patient-centered care to patients with CRS.",
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AU - Schlosser, Rodney J.

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