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270

International consensus statement on rhinosinusitis

TABLE VI-1 Common rhinosinusitis disease measurement tools Abbreviation

Score Range

MCID Reference

Patient Reported QoL Tools 22-item Sinonasal Outcome Test

71,266,271

SNOT-22

0-110 0-100 0-120

8.9, 12*

64

Chronic Sinusitis Survey

CSS

9.75

72

Rhinosinusitis Disability Index

RSDI

10.35

Endoscopic Tools Lund-Kennedy

253

LK

0-10** 0-6**

- - -

272

Modified Lund-Kennedy Nasal Polyp Score Radiographic Tools Lund Mackay

mLK NPS

257

0-3**

262

LM

0-12**

-

*Several observational studies have used different treatment cohorts to evaluate MCID values for the SNOT-22. A change in total SNOT-22 score of 8.9 and 12 have been defined as the MCID among patients receiving surgical vs medical therapy, respectively. **Each nasal cavity is scored independently.

Inter-rater and test-retest reliability varies depending on the domain assessed (polyp, discharge, crusting, etc.) and the specific scoring system. 258 These endoscopic scor ing systems typically correlate only weakly with QoL measures. 259,260 However, the correlation between certain endoscopic (polyps, edema) and QoL subdomains (rhi nological symptoms) is stronger than overall aggregate scores. 261 CT is also widely used clinically in the diagnosis of CRS. Similar to endoscopy, findings are often abstracted with various scoring systems such as the Lund Mackay, but correlation with QoL measures and patient symptoms is limited. 262–264 One radiographic finding, neo-osteogenesis, has been found to correlate with other objective measures of disease severity (endoscopic score, olfactory function) as well as diminished improvement following intervention for CRS. 265 Sinonasal inflammation is paramount to the diagnosis of CRS. Objective assessment with standardized reporting is necessary both clinically and in research. Numerous patient-reported, disease-specific QoL assessments such as the SNOT-22, RSDI, and Chronic Sinusitis Survey (CSS) can be used individually or in conjunction with other disease-, or health-related out come measures to assess patient QoL. 266–268 Individual measures may be designed to assess a patients’ physical symptoms while others measure emotional wellbeing, productivity, or other domains. With a range of lengths, they represent varying degrees of survey burden which can impact patient experience and clinical workflow. Overall, patients’ responses on these tools can assist with evaluation of disease impact, decision to pursue surgery and quantification of treatment outcomes. 269,270 Objective findings of sinonasal inflammation with nasal endoscopy and CT are essential for the diagnosis of CRS and treatment planning. Disease-specific QoL is the pri mary clinically relevant outcome measure that drives patient decision making. Assessment of both, with reli

able and valid measures, is key for the diagnosis and management of CRS. In the future, more fundamental objective measures of pathophysiology such as genetic, microbiome, or immune function may better predict QoL outcomes. VI.D CRS Quality Metrics There is a dearth of evidence regarding quality metrics for assessment of physician practice patterns for CRS (Table VI-2). While some RS-specific quality metrics have been developed, none have been tested or shown to improve patient outcomes or alter physician practices. The major ity of these metrics appear to either be used for reporting to the Merit-based Incentive Payment System (MIPS) of the Centers for Medicare and Medicaid Services (CMS), or are not tracked at all. All currently available metrics are process metrics, which serve to only provide data on the actions providers take rather than how patients fare as a result of those actions. For example, in 2018 the Ameri can Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS), supported only 1 CRS-specific metric. 273 This involved measuring whether a provider ordered more than one CT sinus within a 90-day period. However, in the 2019 and 2020 quality metrics publication of the AAO-HNS, this CRS metric is no longer listed, and the only RS met rics currently supported by the AAO-HNS relate strictly to ARS. 274,275 Other measures relevant to CRS exist, and these have mostly been developed as a result of a partnership between the AAO-HNS and the American Medical Asso ciation Physician Consortium for Practice Improvement (AMA-PCPI). 276 All of these remain process metrics, and while one of these metrics deals with patient-reported out comes measures (PROMs), it simply asks whether or not a PROM was administered.