2018 Section 5 - Rhinology and Allergic Disorders

Original Investigation Research

Evaluating Surgeon-Specific Performance for Endoscopic Sinus Surgery

progression. In 2016, a US-based study by Smith et al 6 evalu- ated surgeon-specific outcomes for CRS across 3 academic in- stitutions. The results indicated that therewereunadjusteddif- ferences in patient outcomes across the 3 institutions, and the differences appeared to be driven by variations in the degree of baseline CRS-specific quality-of-life impairment, oral cor- ticosteroid dependence, and concurrent septoplasty. Objec- tive measures of CRS (ie, computed tomography and endos- copy) failed to explain the differences in patient outcomes among institutions and were not included in the risk- adjustment model, a finding that suggests that objective dis- ease severity was not driving the differences in surgeon per- formance. The effects of other patient characteristics, such as depression, prior ESS, and acetylsalicylic acid sensitivity, were not assessed because the prevalence was similar among all 3 institutions. The primary limitation of the study by Smith et al 6 was that it only included surgeons from 3 tertiary-level practices anddidnot include community-basedpractices. This model reduces the generalizability of the findings to a broader population-level perspective of care for CRS. Although the study by Smith et al 6 represents the first in- sights into how outcomes can vary across academic institu- tions, the current study evaluated 43 different surgeons across a Canadian province and includes tertiary-level and commu- nity-based rhinology practices. Overall, the results support the notion that it is feasible to compare surgeon-specific perfor- mance for ESS after appropriate risk adjustment has been ap- plied. Althoughmost of the surgeons had similar outcomes, 7 surgeons (16%) had lower-than-expected performance when using an adjusted 5-year ESS revision rate with the 95% CI as a quality metric. This finding indicates that there is variation in surgical outcomes, and delivery of ESS to patients with CRS can be improved. Three variables were identified to affect surgeon perfor- mance outcomes and thusmay be important to include in risk- adjustment models for ESS. First, the presence of nasal pol- yps was associated with higher rates of ESS revision, and this finding has been supported by several previous studies. 28,30,39

Table 1. Association of Adjusted Variables With Surgeon-Specific, 5-Year Endoscopic Sinus Surgery Revision Rate for Chronic Rhinosinusitis Variables Odds Ratio (95% CI) P Value a Age 0.57 (0.39-0.83) .003 Sex 1.02 (0.79-1.31) .88 Geographic region (urban or rural) 1.20 (0.90-1.61) .21 Nasal polyps 2.07 (1.59-2.70) <.001 Allergy 1.06 (0.83-1.34) .65 Asthma 1.03 (0.67-1.59) .89 Depression 1.14 (0.87-1.50) .36 CHF 0.37 (0.12-1.16) .09 Cardiac arrhythmia 0.72 (0.38-1.39) .33 Hypertension 0.82 (0.61-1.11) .20 COPD 1.35 (0.88-2.07) .16 Diabetes 1.58 (0.86-2.88) .14 Renal failure 0.53 (0.15-1.86) .32 Liver disease 0.50 (0.16-1.50) .21 Coagulopathy 0.64 (0.25-1.63) .35 Obesity 0.85 (0.43-1.68) .64 Psychosis 1.44 (0.60-3.50) .42 Topical INS treatment (No. of bottles per year) 1.01 (0.95-1.08) .73

Oral antibiotic treatment (No. of courses per year) Oral corticosteroid treatment (No. of courses per year)

1.09 (1.01-1.17)

.03

1.33 (1.19-1.48)

<.001

Concurrent septoplasty

0.70 (0.55-0.89) 1.19 (1.03-1.39) 1.00 (0.99-1.01) 1.28 (0.99-1.64)

.001

No. of ENT visits before ESS

.02 .55 .05

Surgeon volume (primary ESS cases) Frontal sinusotomy (surrogate for complete ESS)

Abbreviations: CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; ENT, ear, nose, and throat; ESS, endoscopic sinus surgery; INS, intranasal steroid. a After Bonferroni adjustment, P .002 was considered statistically significant. The C statistic was 0.716.

Table 2. Comparison of the Rates of Important Characteristics Between the Top- and Low-Performing Surgeons

Rate of Annual Systemic Corticosteroid Courses, %

Adjusted Mean 5-y ESS Revision Rate, % (95% CI)

Proportion of Nasal Polyps, %

Rate of Concurrent Septoplasty, %

Surgeon No.

1

2

≥3

Top-Performing Surgeons 4

3.1 (0-9.0) 1.8 (0-9.8)

72.8 73.2 73.0 91.1 22.9 38.2 74.1 85.0 47.1 75.0 61.9

11.4 23.3 17.4

1.8 4.7 3.2 3.6 0.0 5.9 3.7 0.0 5.9 0.0 2.7

2.6 7.0 4.8 1.8 0.0 5.9 7.4 0.0 0.0 0.0 2.2

94.7 82.9 88.8 44.6 75.0 70.6 66.7 20.0 70.6 37.5 55.0

18

Mean

NA

Low-Performing Surgeons 14

17.7 (11.3-24.2) 23.0 (14.1-31.9) 24.1 (15.2-32.9) 22.7 (11.6-33.9) 24.2 (11.2-37.0) 28.6 (12.5-44.6) 27.8 (11.9-43.6)

16.1

17 22 26 34 40 42

2.1 5.9 3.7

10.0 23.5

0.0 8.8

Mean

NA

Abbreviations: ESS, endoscopic sinus surgery; NA, not applicable.

(Reprinted) JAMA Otolaryngology–Head & Neck Surgery September 2017 Volume 143, Number 9

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