Physician payment methods: a focus on quality and cost control

With rising health care costs, governments must develop innovative methods to deliver efficient and equitable health care services. With physician remuneration being the third largest health care expense, the design of remuneration methods is a priority in health care policy. Otolaryngology-Head and Neck surgeons should have an understanding of the behavioural incentives associated with different physician payment methods. This article will outline the different physician payment methods with a focus on discussing the impact on quality of care and health care costs

CHronic Rhinosinusitis Outcome MEasures (CHROME), developing a core outcome set for trials of interventions in chronic rhinosinusitis

Statement of Problem: Evaluating the effectiveness of treatments in chronic rhinosinusitis (CRS) have been limited by both a paucity of high quality randomised trials, and the heterogeneity of outcomes in those that have been reported. Core outcome sets (COS) are an agreed, standardized set of outcomes that should be measured and reported by future trials as a minimum and will facilitate future meta-analysis of trial results in systematic reviews (SRs). We set out to develop a core outcome set for interventions for adults with CRS. Method(s) of study: A long-list of potential outcomes was identified by a steering group utilising a literature review, thematic analysis of a wide range of stakeholders’ views and systematic analysis of currently available Patient Reported Outcome Measures (PROMs). A subsequent e-Delphi process allowed 110 patients and healthcare practitioners to individually rate the outcomes in terms of importance, on a Likert scale. Main Results: After 2 rounds of the iterative Delphi process, the 54 initial outcomes were distilled down to a final core-outcome set of 15 items, over 4 domains. Principal Conclusions: The authors hope inclusion of these core outcomes in future trials will increase the value of research on interventions for CRS in adults. It was felt important to make recommendations regarding how these outcomes should be measured, although additional work is now required to further develop and revalidate existing outcome measures

Evidence-based clinical practice in otolaryngology /

Get a quick, expert overview of the many key facets of today's otolaryngology practice with this concise, practical resource. Dr. Luke Rudmik and a leading team of experts in the field address high-interest clinical topics in this fast-changing field.Online resource; title from PDF title page (EBSCO, viewed February 12, 2018).Includes bibliographical references and index.Front Cover; Evidence-Based Clinical Practice in Otolaryngology; Evidence-Based Clinical Practice in Otolaryngology; Copyright; List of Contributors; Contents; 1 -- Evidence-Based Practice: Management of Acute Vertigo; BENIGN PAROXYSMAL POSITIONAL VERTIGO; Introduction; Pathophysiology; Diagnosis; Posterior canal benign paroxysmal positional vertigo; Lateral canal benign paroxysmal positional vertigo; Superior canal benign paroxysmal positional vertigo; Management; Physical maneuvers; Surgery for refractory benign paroxysmal positional vertigo; Vestibular rehabilitation therapyVESTIBULAR NEURITISIntroduction; Pathophysiology; Diagnosis; Management; Vestibular suppressants; Antiemetics; Betahistine; Antivirals; Steroids; Vestibular rehabilitation therapy; REFERENCES; 2 -- Management of Adult Sensorineural Hearing Loss; OVERVIEW; ETIOLOGIES; Age-Related Hearing Loss (Presbycusis); Autoimmune; Endolymphatic Hydrops and CNS Disease; Genetic; Idiopathic; Infection; Neoplasm; Noise-Induced Hearing Loss; Ototoxicity; Trauma; Vascular; EVIDENCE-BASED CLINICAL ASSESSMENT; Audiometric Testing; Auditory Brainstem Response; Vestibular Assessment; Magnetic Resonance ImagingComputed TomographyLaboratory Tests; EVIDENCED-BASED MANAGEMENT; Autoimmune Inner Ear Disease; Intratympanic steroids; Antivirals; Hyperbaric oxygen; Rheopheresis; BOTTOM LINE; CRITICAL POINTS WITH EVIDENCE; REFERENCES; 3 -- Laryngopharyngeal Reflux in Chronic Rhinosinusitis: Evidence-Based Practice; INTRODUCTION; EPIDEMIOLOGIC ASSOCIATION BETWEEN REFLUX AND CHRONIC RHINOSINUSITIS; PATHOGENIC ROLE OF REFLUX IN CHRONIC RHINOSINUSITIS; PROGNOSTIC IMPACT OF REFLUX ON CHRONIC RHINOSINUSITIS SYMPTOMS; EFFECT OF MEDICAL TREATMENT OF REFLUX ON CHRONIC RHINOSINUSITIS SYMPTOMS; REFERENCES4 -- Evidence-Based Practice: Balloon Catheter Dilation in RhinologyBACKGROUND ON CHRONIC RHINOSINUSITIS; OVERVIEW OF BALLOON CATHETER TECHNOLOGIES; Balloon Sinuplasty; LacriCATH; FinESS; EVIDENCE-BASED CLINICAL ASSESSMENT; EVIDENCE-BASED SURGICAL TECHNIQUE; Adult Medically Refractory Chronic Rhinosinusitis; Pediatric Medically Refractory Chronic Rhinosinusitis; Frontal Sinus Disease; WHAT DOES THE EVIDENCE TELL US?; REFERENCES; 5 -- Epistaxis: An Update on Contemporary Evidence-Based Approach; INTRODUCTION; METHODS; RESULTSâ#x80;#x93;A MANAGEMENT PATHWAY; ManagementPathway progressionâ#x80;#x94;uncontrolled epistaxisProtocol completionâ#x80;#x94;treated epistaxis; Refractory Acute Epistaxis; Adjunctive Treatments; Preventing Epistaxis Deaths; DISCUSSION; REFERENCES; 6 -- Evidence-Based Practice: Functional Rhinoplasty; BACKGROUND; Scope of the Problem; Anatomy and Pathophysiology; EVALUATION OF NASAL OBSTRUCTION; History and Physical Examination; Endoscopy and Imaging; Objective Measures of Nasal Obstruction; NONSURGICAL MANAGEMENT OF THE NASAL VALVE; SURGICAL MANAGEMENT OF THE NASAL VALVE; Perioperative Management; Batten grafts; Lateral crural reposition and strutsGet a quick, expert overview of the many key facets of today's otolaryngology practice with this concise, practical resource. Dr. Luke Rudmik and a leading team of experts in the field address high-interest clinical topics in this fast-changing field.Elsevie

Cost-effectiveness analysis of molecular testing for cytologically indeterminate thyroid nodules

Abstract Background Thyroid nodules affect up to 65% of the population. Although fine needle aspirate (FNA) cytology is the gold standard for diagnosis, 15–30% of results are indeterminate. Molecular testing may aid in the diagnosis of nodules and potentially reduce unnecessary surgery. However, these tests are associated with significant costs. The objective of this study was to evaluate the cost-effectiveness of Afirma, a commercially available molecular test, in cytologically indeterminate thyroid nodules. Methods The base case was a solitary thyroid nodule with no additional high-risk features and an indeterminate FNA. Decision tree analysis was performed from the single payer perspective with a 1-year time horizon. Costing data were collected through micro-costing methodology. A probabilistic sensitivity analysis was performed. The primary outcome was the incremental cost effectiveness ratio (ICER) of cost per thyroid surgery avoided. Results Over 1 year, mean cost estimates were $8176.28 with 0.58 effectiveness for the molecular testing strategy and$6016.83 with 0.07 effectiveness for current standard management. The ICER was $4234.22 per surgery avoided. At a willingness-to-pay (WTP) threshold of$5000 per surgery avoided, molecular testing is cost-effective with 63% certainty. Conclusion This cost-effectiveness analysis suggests utilizing Afirma for indeterminate solitary thyroid nodules is a cost-effective strategy for avoiding unnecessary thyroid surgery. With a $5000 WTP threshold, molecular testing has a 63% chance of being the more cost-effective strategy. The cost effectiveness varies based on the cost of the molecular test and the value of Afirma for patients with indeterminate thyroid nodules depends on the WTP threshold to avoid unnecessary thyroid surgery. Graphical Abstrac

Patient‐centered decision making: the role of the baseline SNOT‐22 in predicting outcomes for medical management of chronic rhinosinusitis

BackgroundFor patients with chronic rhinosinusitis (CRS), the decision to elect continued medical management vs surgery is complex and involves tradeoffs between benefits, risks, and overall effectiveness of each therapy. The purpose of this study is to investigate whether baseline disease-specific quality of life (QOL) can assist in predicting outcomes in patients with refractory CRS who elect continued medical management.MethodsCRS patients electing medical management were enrolled in a prospective, multi-institutional cohort study. Patients were stratified into pretreatment 22-item Sino-Nasal Outcome Test (SNOT-22) subgroups based on 10-point score increments (eg, 10 to 19, 20 to 29, 30 to 39, etc.) to capture potential outcome differences by baseline SNOT-22 disease burden. The proportion of patients achieving minimal clinically important difference (MCID≥9 points) and relative improvement (%) for each score category were calculated.ResultsSeventy-five CRS patients with a mean ± standard deviation pretreatment SNOT-22 score of 45.2 ± 16.6 were followed for a mean of 14.9 months. The majority of participants electing medical therapy failed to improve 1 MCID (57%) with a mean relative score improvement of 16%. Overall, 37% of patients maintained baseline SNOT-22 QOL status, whereas 20% of patients deteriorated >1 MCID. When treatment crossover patients (to endoscopic sinus surgery [ESS]) were included (n = 117), approximately 1 in 4 (27%) patients achieved an MCID.ConclusionResults from this study suggest that the majority of CRS patients electing ongoing medical management with low baseline disease-specific QOL impairment maintain stable QOL with continued medical management. Furthermore, of CRS patients electing ongoing medical therapy, approximately 1 in 4 patients achieved MCID, whereas 1 in 5 experienced deterioration by >1 MCID

Topical therapies in the management of chronic rhinosinusitis : an evidence-based review with recommendations

Background: Topical therapies have become an integral component in the management plan for chronic rhinosinusitis (CRS). Several topical therapy strategies have been evaluated, but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence-based approach for the utilization of topical therapies in the management of CRS. Methods: A systematic review of the literature was performed and the guidelines for development of an evidence-based review with recommendations were followed. Study inclusion criteria were: adult population >18 years old; chronic rhinosinusitis (CRS) based on published diagnostic criteria; and clearly defined primary clinical end-point. We focused on reporting higher-quality studies (level 2b or higher), but reported on lower-level studies if the topic contained insufficient evidence. We excluded drug-eluting spacer and stent therapy from this review. Results: This review identified and evaluated the literature on 5 topical therapy strategies for CRS: saline irrigation, topical steroid, topical antibiotic, topical antifungal, and topical alternatives (surfactant, manuka honey, and xylitol irrigations). Conclusion: Based on the available evidence, sinonasal saline irrigation and standard topical nasal steroid therapy are recommended in the topical treatment of CRS. Nonstandard (off-label) topical sinonasal steroid therapies can be an option for managing CRS. The evidence recommends against the use of topical antifungal therapy and topical antibiotic therapy delivered using nebulized and spray techniques in routine cases of CRS. There is insufficient clinical research to provide recommendations for alternative therapies or topical antibiotic therapy delivered using other delivery methods (eg, irrigations).18 page(s