Geographic Distribution of Otolaryngology Advance Practice Providers and Physicians.

OBJECTIVES: Advanced practice providers (APPs), namely physician assistants (PAs) and nurse practitioners (NPs), play an increasing role in meeting growing demands for otolaryngologic services, particularly in rural communities. This study analyzes the geographic distribution of otolaryngology providers, which is essential to addressing future demands. STUDY DESIGN: Cross-sectional study. SETTING: Medicare Provider Utilization and Payment Data for 2017. METHODS: Current Procedural Terminology codes were used to identify APPs providing 10 common otolaryngologic services. Geographic distribution was evaluated by calculating densities of APPs and otolaryngologists per 100,000 persons in urban versus rural counties as defined by the National Center for Health Statistics Urban-Rural Classification Scheme. RESULTS: We identified cohorts of 8573 otolaryngologists, 1148 NPs, and 895 PAs. There were significantly higher population-controlled densities of otolaryngologists and APPs in urban counties as compared with rural counties. The majority of otolaryngologists (92.1%) and APPs (83.3%) were in urban counties. However, the proportion of APPs (16.7%) in rural counties was significantly higher than the proportion of otolaryngologists (7.9%) in rural counties (P < .01). A significant majority of rural counties (72.2%) had zero identified providers, and a greater proportion of rural counties (5.0%) were served exclusively by APPs as compared with urban counties (3.2%). CONCLUSIONS: Although otolaryngologists and APPs mostly practiced in urban counties, a relatively higher proportion of APPs practiced in rural counties when compared with otolaryngology physicians. The majority of rural counties did not have any otolaryngologic providers. Given the expected shortages of otolaryngology physicians, APPs may play a critical role in addressing these gaps in access.

Advanced Practice Providers Utilization Trends in Otolaryngology From 2012 to 2017 in the Medicare Population.

OBJECTIVE: Nurse practitioners and physician assistants form a growing advanced practice provider (APP) group. We aim to analyze the trends and types of services provided by APPs in otolaryngology. STUDY DESIGN: Cross-sectional study. SETTING: Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use Files, 2012-2017. METHODS: The Medicare database was searched for 13 commonly used otolaryngology-specific Current Procedural Terminology (CPT) codes, and 10 evaluation and management (E/M) codes were evaluated by provider type. Changes in code utilization were compared between physicians and APPs over time. RESULTS: From 2012 to 2017, there was a 51% increase in the number of otolaryngology APPs, compared to a 2.2% increase in physician providers. APPs increased their share of new and established patient visits from 4% to 7%d 11% to 15%, respectively. There was not a significant difference over time in number of patient visits performed annually per provider according to provider type. The increase in number of APP vs physician providers was significantly greater for every procedure except for balloon sinus dilation and tympanostomy tube placement. CONCLUSION: Due to increasing numbers, APPs are accounting for more patient visits and procedures over time. The physician workforce and the numbers of procedures performed per physician have remained relatively stable from 2012 to 2017. Increasing complexity of patients seen and a broader range of procedures offered by work-experienced or postgraduate-trained APPs may further improve access to health care in the face of possible physician shortages.

Analysis of Sinus Balloon Catheter Dilation Providers Based on Medicare Provider Utilization and Payment Data.

BACKGROUND: The use of balloon catheter dilation (BCD) to treat chronic rhinosinusitis has increased dramatically since its conception, necessitating further characterization of BCD providers and trends in its usage. Medicare data on BCD providers have made it possible to study recent demographic patterns. There has also been an increase in mid-level providers' scope of otolaryngologic practice that is not well defined. OBJECTIVE: To better understand BCD adoption by studying volume of BCD procedures as well as training, geography, and practice socioeconomic characteristics of BCD providers for Medicare beneficiaries. METHODS: We reviewed Medicare Provider Utilization and Payment Data Public Use Files for 2014 and 2015 for providers with claims for BCD of the sinuses. We extracted provider zip code, state, gender, and number of services per BCD code. We obtained median household income by zip code and geographic region based on US Census Bureau data. Providers were classified using an Internet search to determine practice setting and type of specialty training/certification. RESULTS: In 2014 and 2015, 428 providers performed 42 494 BCDs billed to Medicare beneficiaries. Among BCD providers, 5.1% were female, 98.1% had Doctor of Medicine/Doctor of Osteopathic Medicine credentials, and 1.9% had nurse practitioner/physician assistant credentials. Over the 2-year period, the median number of BCDs was 63 for physicians and 37 for mid-level providers. Fellowship-trained rhinologists performed a median of 38 BCDs over 2 years. The most common subspecialty certification/training was in facial plastics and reconstructive surgery. The majority of providers (63.8%) performed 1 to 99 BCDs over the 2 years. In the South, there were 21.9 BCD procedures performed per 100 000 people compared to 7.3 in the Northeast, 9.3 in the Midwest, and 8.5 in the West. CONCLUSION: There is a large range in total BCD procedures performed by individual providers, and this varies by certain provider characteristics. Mid-level providers have emerged as a significant population performing BCD.

Emerging Trends in Nasal Surgery: What Is the Impact of a Bioabsorbable Nasal Implant?

BACKGROUND: A bioabsorbable nasal valve implant (NVI) was introduced in 2016 as a minimally invasive solution to nasal valve collapse. Historically the introduction of less invasive procedures performable in-office has resulted in an increase in volume. Our objective is to evaluate this trend as it relates to nasal vestibular repair, and its impact on healthcare utilization. METHODS: We interrogated the Medicare Part B national database for nasal vestibular repair (CPT code: 30465), Unlisted nasal procedure (30999) and septoplasty (30520) from 2010 to 2017. Septoplasty was used as a surrogate for overall nasal procedural rate. Linear regression modeling was used to examine the changes in reported vestibular repair rate adjusting for septoplasty rate. RESULTS: In the Medicare population, the rate of septoplasty was stable from 2010 to 2017, increasing from 26,962 to 30,194 at an annual rate of 1.5%. Coding for unlisted nasal procedure increased from 272 to 333 at an adjusted annual rate of 1.1% over this time period. Coding for nasal vestibular repair increased from 2026 to 5331 over this interval at an adjusted annual rate of 0.9% from 2010 to 2016 but significantly increased to 5% between 2016 to 2017 (P < .0001). CONCLUSION: The reported volume of nasal vestibular repair increased significantly in the year following Food and Drug Administration approval of NVIs. In the absence of a corresponding increase in septoplasty, this temporal relationship suggests that the introduction of NVIs impacted the utilization of this procedural code. LEVEL OF EVIDENCE: N/A Laryngoscope, 2020.

How often is sinus surgery performed for chronic rhinosinusitis with versus without nasal polyps?

BACKGROUND: There currently are no data on the relative frequency of endoscopic sinus surgeries (ESS) performed for chronic rhinosinusitis with nasal polyposis (CRSwNP) versus chronic rhinosinusitis without nasal polyposis (CRSsNP) in the United States. OBJECTIVES: To compare the rate of surgical interventions for CRSwNP and CRSsNP. METHODS: Cases identified by CPT codes were extracted from the 2009-2011 State Ambulatory Surgery Databases for California, Florida, Maryland, and New York. Patient demographics, extent of surgery, mean charges, and operating room (OR) time were compared. RESULTS: A total of 97,228 ESS cases were performed in the four states; 29.3% of surgeries were for patients with CRSwNP, 66.0% of patients with CRSsNP, and 4.8% for other indications. The proportion of ESS for CRSwNP varied across states, with California having the highest percentage (34.6%) and Maryland having the lowest (26.4%) (p < 0.0001). Patients with Medicaid (33.8%) and Medicare (32.2%) had higher rates of surgery for CRSwNP compared with patients with private insurance (29.9%) (p < 0.001). Surgeons who performed a higher volume of sinus surgery compared to lower volume surgeons performed a lower percentage of surgery for CRSwNP (24.4 versus 33.5%; p < 0.001). ESS cases for CRSwNP were more extensive (relative risk of four sinus surgeries of 1.88; p < 0.0001), used image guidance more frequently (relative risk, 1.39; p < 0.0001), and were less likely to include a balloon procedure (relative risk, 0.69; p < 0.0001). Patients with CRSwNP had longer OR times (ESS that involved all four sinuses took 14 minutes longer) (p < 0.0001), but no difference in charges compared with patients with CRSsNP who underwent a similar extent of surgery. CONCLUSION: Almost 30% of ESS were performed for CRSwNP, and these cases were, on average, more extensive, used more OR time, and more often used image guidance than surgeries for CRSsNP. The rate of surgery performed for CRSwNP varied based on geography, payer, and surgical volume, which indicted that patient selection impacted surgical management.

Trends in sinusitis research: a systematic review of extramural funding.

BACKGROUND: Innovation represents a core value of the American Rhinologic Society (ARS), with multiple efforts to promote research in the advancement rhinologic care. We therefore sought to identify trends in extramural sinusitis funding and underutilized sources of support to facilitate future efforts. METHODS: A systematic review of the National Institutes of Health (NIH) Research Portfolio Online Tools (RePORTER) database (fiscal year 1993 to 2017) was completed with the search strategy: ("chronic sinusitis" OR rhinosinusitis). All identified studies were accepted for review, with comparison to ARS membership rolls to identify studies supported by ARS investigators. Foundation awards were surveyed to identify and characterize additional sources of support. RESULTS: The systematic review identified 958 projects receiving NIH funding, of which 120 remain active. The percentage of sinusitis-related awards and total funding relative to all NIH awards increased over the past 10 years (2006 to 2016) from 0.06% (8 / 9128) and 0.09% ($2,151,152 / $3,358,338,602) to 0.87% (86 / 9540) and 0.90% ($37,201,095 / $4,300,145,614). Among active studies, 9 investigators maintain membership in the ARS and serve as principal investigator or project leader in 12 (10%) studies. ARS investigators received the greatest number of awards from the National Institute on Deafness and Other Communication Disrders (n = 8,66.7%), while only receiving 2.2% of awarded funding from the National Institute of Allergy and Infectious Diseases ($607,500/$26,873,022), the largest source of awards for sinusitis research. CONCLUSION: Support for sinusitis research is significantly growing, with the largest source of active funding not being fully utilized by members of the ARS. Further efforts to promote funding priorities among extramural sources is necessary to facilitate increased funding for ARS member initiatives.

Open versus endoscopic medial orbital decompression: Utilization, cost, and operating room time.

BACKGROUND: The advent of endoscopic sinus surgery has created an exciting interface between rhinology and ophthalmology in the area of orbital and optic nerve decompression Objectives: (1) To study the utilization of open versus endoscopic medial orbital decompression based on geography and indication, (2) to describe the demographics of the patient populations who underwent these different techniques, and (3) to compare outcomes, including mean charges and operating room (OR) times Methods: Cases identified by Current Procedural and Terminology codes were extracted from the California, Florida, Maryland, and New York State Ambulatory Surgery Databases from 2009 to 2011. Patient demographics, diagnoses, mean charge, and OR time were compared. RESULTS: A total of 1009 patients underwent orbital decompression; 93.0% of cases involved the medial wall only; 22.9% of medial decompressions were performed endoscopically, 74.5% were open, and 2.6% were via combined approach. Eighty percent of patients had thyroid eye disease. Analyses adjusted for sex, age, race, state, and diagnosis found that surgeries for infection (N = 47) were more likely to be performed endoscopically compared with procedures for other diagnoses (N = 962) (odds ratio 5.27 [2.67-10.40], p < 0.001). Patients in Florida were more likely to undergo endoscopic decompression compared with patients in California (odds ratio 2.35 [1.42-3.62]). The difference in median charge for endoscopic ($13,119) versus open ($11,291; p = 0.085) procedures was not significant on bivariate analysis but was significant on multivariate analysis (p = 0.04). The median OR time for open procedures was, on average, 33 minutes shorter (endoscopic, 132 minutes; open, 98 minutes; p ≤ 0.001) on bivariate analysis but was not significantly different when controlling for covariables (p = 0.08). CONCLUSION: In the study sample, endoscopic orbital decompression was performed in 22.9% of patients, with significant variation in surgical technique based on geography and indication. Procedures that used endoscopic compared with open decompression techniques had no significant difference in charge on bivariate analysis. The OR time for open procedures was shorter on bivariate but not on multivariate analysis. Further research is required regarding the relative effectiveness of open versus endoscopic surgical techniques for various indications.

Trends in the management of pediatric peritonsillar abscess infections in the U.S., 2000-2009.

OBJECTIVES: To analyze temporal trends in the incidence and surgical management of children with peritonsillar abscesses (PTAs), and to examine whether there has been concurrent changes in hospital charges or length of stay. METHODS: The Kids' Inpatient Database (KID) from 2000 to 2009 was examined for children less than 18 years old with ICD-9-CM diagnostic codes for PTA (475). Survey weighted frequency and regression analyses were performed across the entire study period on variables of interest in order to determine estimates of national incidence, demographics and outcomes. RESULTS: A total of 20,546 weighted cases of PTA were identified during the study period. There was no significant change in the incidence of pediatric PTA across the study period (p=0.63) or in the rate of nonsurgical management (p=0.85). There was a significant increase in the rates of I&D from 26.4% to 33.7% (p<0.001) and a significant decrease in the rate of tonsillectomy from 13.0% to 7.8% (p<0.001). Mean inflation-adjusted charges significantly increased from approximately $8400 in 2000 to $13,300 in 2009 (p<0.001), and average length of stay was 2.15 days with no significant change during the study period (p=0.164). Mean inflation-adjusted charges for patients undergoing tonsillectomy alone were approximately $1800 greater than mean charges for those undergoing I&D alone (p=0.003) and length of stay was also significantly longer for tonsillectomy patients versus I&D patients [I&D 1.99 days versus tonsillectomy 2.23 days (p<0.001)]. CONCLUSIONS: There was no change in the incidence of pediatric PTAs from 2000 to 2009 but there was a change in surgical management, with a significant decrease in the rate of tonsillectomy and significant increase in the rate of incision and drainage procedures. Hospital charges during this period increased nearly 60% despite no change in rates of CT imaging, surgical intervention or length of stay.

Chronic rhinosinusitis: epidemiology and cost.

Chronic rhinosinusitis (CRS) is one of the most common chronic diseases and is associated with a high socioeconomic burden from direct and indirect costs. Its estimated prevalence ranges widely, from 2 to 16%. It is more common in female subjects, aged 18-64 years, and in southern and midwestern regions of the United States. CRS is more prevalent in patients with comorbid diseases such as asthma, chronic obstructive pulmonary disease, and environmental allergies. Few studies examine patient ethnicity, socioeconomic status, geographic location, and cultural factors in CRS populations. This article provides an overview of the epidemiology, racial variations, and economic burden of CRS.