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Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study
Author(s) -
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 L.
Publication year - 2016
Publication title -
international forum of allergy and rhinology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.503
H-Index - 46
eISSN - 2042-6984
pISSN - 2042-6976
DOI - 10.1002/alr.21769
Subject(s) - medicine , chronic rhinosinusitis , nasal polyps , endoscopic sinus surgery , delphi method , sinusitis , quality of life (healthcare) , clinical trial , surgery , statistics , mathematics , nursing
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