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TABLE VI-2 Evidence for quality measurement of physician practices in chronic rhinosinusitis Study Year LOE Conclusions Mattos 278 2018 4

Defining metrics that assess key components to CRS care prior to offering surgery has the potential to further improve upon an already successful treatment paradigm, reduce unwarranted practice variation, and to ensure that patients are receiving a similar level of high-quality care. 4 The current status of quality measurement for RS has focused primarily on the quality domain of efficiency and process measures for ARS. More work is needed to develop, validate, and track outcome-based quality metrics along with CRS-specific metrics. Major gaps and challenges remain that need to be considered during the development of future metrics.

Rudmik 277 2017

The Quality Improvement (QI) Committee of the Amer ican Rhinologic Society compiled all available quality metrics for RS in 2017 outlining these shortcomings. 277 In that study, several quality metrics for CRS were identified as established by the AMA-PCPI and AAO-HNS. These metrics primarily focused on efficiency; and specifically assessed (1) appropriate diagnostic testing (percentage of adult CRS patients who had either a CT or nasal endoscopy at the time or within 90 days of diagnosis), (2) unnecessary imaging (percentage of adult CRS patients who had more than 1 sinus CT within 90 days of diagno sis), and (3) QoL measurements (percentage of adult CRS patients who completed a validated QoL instrument at time of diagnosis and follow-up). 277 None of these metrics were outcomes-based RS quality metrics that evaluated patient response to treatment (ie, symptom improve ment, work productivity, etc.), safety, or timeliness of care. 277 In 2018, the QI committee of the ARS developed a framework for quality measurement in the presurgi cal care of CRS termed “CRS Appropriate Presurgical Algorithm (CAPA).” Based on the available evidence, the following quality metrics were supported as part of the presurgical care for CRS: (1) a guideline-based diagnosis should be verified, (2) appropriate medical management should be attempted, (3) a CT scan should be obtained, and (4) a patient-centered discussion should take place encompassing risks and benefits of available treatment options, long-term medical compliance, and patient preferences and expectations. 278 However, actual imple mentation and validation of this framework is still yet to be determined. The above review highlights the need to implement outcomes-based metrics to evaluate physicians treating CRS. However, several logistical obstacles will need to be overcome before this next step becomes a reality. First, agreement would have to coalesce around a single outcome measure, or perhaps a core set of outcome metrics. Next, individual physicians would need a means of accurately and efficiently collecting individual-level patient data and submitting it to a centralized registry in a manner that safeguards patient privacy. Finally, methods would need

to be developed to regularly analyze and share this data in order to provide benchmarking and inform individual physicians on how their outcomes compare to the larger group. VI.E Necessity of and Approach to Evaluating the Cost-Effectiveness of CRS Treatments As the number and breadth of treatment options for CRS continues to expand, treating physicians are faced with increasingly complicated decisions regarding treat ment choices. While factors such as clinical effectiveness and patient preference play important roles in treatment choices, the cost-effectiveness of treatments should also be considered. Cost-effectiveness analysis allows one to weigh the benefit/cost ratio of 1 treatment relative to an alternative option, most often using the incremental cost effectiveness ratio (ICER) which describes the cost per additional improvement of outcome that a treatment offers over the alternative. 279 The benefit, or outcome measure, of treatment options that is often used in cost-effectiveness analysis is the quality-adjusted life year (QALY) which is defined as the additional year(s) of life gained secondary to the intervention weighted by the quality of the additional year(s). 279,280 Thus ICER is often described as cost per addi tional QALY. These analyses have been previously used in CRS to study ESS vs continued medical management for medically refractory disease. 281,282 With the increas ing number of therapeutic options available, more cost effectiveness analyses are needed to determine when and for which patients new CRS treatment options should be used. Cost-effectiveness analysis requires development of a clinical decision-making model that clearly delineates possible treatment choices such as what constitutes the alternative treatment, against which a new treatment is compared. Presently for CRS, the current standard of care treatments include a trial of appropriate medi cal treatment followed by ESS for those with medically