May 23, 2016

Early Surgical Intervention May Lessen the Need for Postoperative Care and Improve Outcomes in Patients with Chronic Rhinosinusitis

A new HNI study suggests the sooner the better

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By Raj Sindwani, MD, and Michael Benninger, MD

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In chronic rhinosinusitis (CRS), endoscopic sinus surgery (ESS) has traditionally been reserved for those patients who have not responded to medical therapy. Sinus surgery has been shown in recent prospective trials to be more effective than continuous medical management in terms of patient-reported outcomes and CRS-related drug utilization. Over long periods of time, the effectiveness of medical management alone has also been shown to diminish. The long-term impact of persistent unchecked inflammation in the sinuses of patients with CRS is not known.

Two-year follow-up of postoperative care

In a recently published study of CRS patients, we compared the impact that early versus delayed ESS had on postoperative healthcare utilization. We based our analysis on a U.S. administrative claims database (MarketScan™ Commercial Claims and Encounters Database), which contained information on 2,833 CRS patients who had undergone ESS in 2010 and for whom complete medical records from 2004 to 2012 were available. We subcategorized these patients into six groups based on the number of years between their first diagnosis of sinusitis to the time of their surgery (< 1, 1 to 2, 2 to 3, 3 to 4, 4 to 5 and > 5). We evaluated the postoperative use of healthcare resources in these groups for two years following surgery.

We found that healthcare use in terms of outpatient visits (Figure 1), procedures and prescriptions (Figures 2 and 3) associated with sinusitis increased in a near-linear fashion as the interval from diagnosis to surgery lengthened. Those CRS patients with the longest delay from diagnosis to surgery utilized the greatest amount of sinus-related healthcare resources postoperatively. Conversely, patients who had undergone early ESS utilized only limited healthcare resources, presumably because they had milder symptoms and better overall outcomes. This finding was true for patients with and without polyps Figure 5), and it was independent of whether or not they had asthma (Figure 4).

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Figure 1
Figure 3
15-ENT-2840-Sindwani-Consult-QD-Inset-Figure-05

Figure 5

We also found that by the time of surgery, asthma was significantly more common in the group with the longest delay (> 5 years) than in the group with the shortest delay (< 1 year).

No need to wait

These initial results, as well as other recent findings by our group, suggest that patients’ overall respiratory conditions worsen as the preoperative period lengthens. This raises the question: Does reducing the burden of sinus disease through early ESS modify the relationship between CRS and the development of other comorbidities such as asthma? This is an intriguing spin on the “one-airway, one disease” hypothesis.

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Despite the limitations of this claims-based study, the potential implications of our findings may be significant. Earlier intervention in CRS may become an effective strategy to improve patient outcomes and quality of life and reduce healthcare resource utilization. More inquiry into this exciting new development is needed.

Dr. Sindwani is Vice Chairman of the Head & Neck Institute and Section Head of Rhinology, Sinus & Skull Base Surgery. He is also Co-Director of the Minimally Invasive Cranial Base and Pituitary Surgery Program, and he has a joint appointment in Cleveland Clinic’s Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center. He can be reached at 216.445.2845 or sindwar@ccf.org. Dr. Benninger is Chairman of the Head & Neck Institute. He can be reached at 216.444.6686 or benninm@ccf.org.

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