Healthcare utilisation, follow-up of guidelines and practice variation on rhinosinusitis in adults: A healthcare reimbursement claims study in The Netherlands.

OBJECTIVES: To provide insight into healthcare utilisation of rhinosinusitis, compare data with clinical practice guideline recommendations and assess practice variation. DESIGN: Anonymised data from claims reimbursement registries of healthcare insurers were analysed, from 1 January 2016 until 31 December 2016. SETTING: Secondary and tertiary care in the Netherlands. PARTICIPANTS: Patients ≥18 years with diagnostic code "sinusitis." MAIN OUTCOME MEASURES: Healthcare utilisation (prevalence, co-morbidity, diagnostic testing, surgery), costs, comparison with guideline recommendation, practice variation. RESULTS: We identified 56 825 patients, prevalence was 0.4%. Costs were € 45 979 554-that is 0.2% of total hospital-related care costs (€21 831.3 × 106 ). Most patients were <75 years, with a slight female preponderance. 29% had comorbidities (usually COPD/asthma). 9% underwent skin prick testing, 61% nasal endoscopy, 2% X-ray and 51% CT. Surgery rate was 16%, mostly in daycare. Nearly, all surgical procedures were performed endonasally and concerned the maxillary and/or ethmoid sinus. Seven recommendations (25%) could be (partially) compared to the distribution of claims data. Except for endoscopy, healthcare utilisation patterns were in line with guideline recommendations. We compared results for three geographical regions and found generally corresponding rates of diagnostic testing and surgery. CONCLUSION: Prevalence was lower than reported previously. Within the boundaries of guideline recommendations, we encountered acceptable variation in healthcare utilisation in Dutch hospitals. Health reimbursement claims data can provide insight into healthcare utilisation, but they do not allow evaluation of the quality and outcomes of care, and therefore, results should be interpreted with caution.

Publications on Clinical Research in Otolaryngology-A Systematic Analysis of Leading Journals in 2010.

Background: We wanted to asses and characterize the volume of Otolaryngology publications on clinical research, published in major journals. Methods and Material: To assess volume and study type of clinical research in Otolaryngology we performed a literature search in high impact factor journals. We included 10 high impact factor Otolaryngology journals and 20 high impact factor medical journals outside this field (2011). We extracted original publications and systematic reviews from 2010. Publications were classified according to their research question, that is therapy, diagnosis, prognosis or etiology. Results: From Otolaryngology journals (impact factor 1.8 to 2.8) we identified 694 (46%) publications on original observations and 27 (2%) systematic reviews. From selected medical journals (impact factor 6.0 to 101.8) 122 (2%) publications related to Otolaryngology, 102 (83%) were on original observations and 2 (0.04%) systematic reviews. The most common category was therapy (40%). Conclusion: Half of publications in Otolaryngology concerns clinical research, which is higher than other specialties. In medical journals outside the field of Otolaryngology, a small proportion (2%) of publications is related to Otolaryngology. Striking is that systematic reviews, which are considered high level evidence, make up for only 2% of publications. We must ensure an increase of clinical research for optimizing medical practice.

The "evidence-based practice inventory": reliability and validity was demonstrated for a novel instrument to identify barriers and facilitators for Evidence Based Practice in health care.

OBJECTIVES: To design and validate a practical questionnaire for clinicians, to identify barriers and facilitators for evidence-based practice (EBP), that is, the use of research evidence in patient care. The inventory is ultimately intended for departments to assess local conditions for EBP, to aim and evaluate efforts at improving or maximizing EBP. STUDY DESIGN AND SETTING: We derived candidate items from existing EBP scales, psychology, and behavioral economics. In an online Delphi study, 537 international expert clinicians, researchers, teachers, and policymakers interested in EBP identified items with sufficient face and content validity. We piloted and validated the resulting draft inventory among 127 clinicians from various specialties and career stages. RESULTS: The Delphi study started with 114 items and resulted in a draft inventory with 29 items in five dimensions. During the pilot, the inventory was easy to complete within 15 minutes and the items showed sufficient response variation. In four of five dimensions, test-retest reliability was substantial to almost perfect and the power to discriminate between groups with different expertise was adequate, whereas internal consistency showed that the items generally measured the same construct. On the basis of internal consistency and factor analysis, we excluded three items. The final EBP inventory consists of 26 items in five dimensions: decision making, subjective norm, attitude, perceived behavior control, and intention and behavior. DISCUSSION AND CONCLUSION: The EBP inventory was developed with support of EBP experts and validated among various academic clinicians. It shows adequate face and content validity, internal consistency, test-retest reliability, discriminative power, and completion will take <15 minutes. We recommend further evaluation of its value in field trials.

Inconclusive evidence that age predicts a prolonged or chronic course of acute rhinosinusitis in adults: a systematic review of the evidence base.

OBJECTIVE: To review the evidence whether the risk for a prolonged or chronic course increases with age in adult patients with acute rhinosinusitis. DATA SOURCES: PubMed, EMBASE, and the Cochrane Library. REVIEW METHODS: A comprehensive literature search was performed on March 24, 2013, and articles were screened and selected using predefined inclusion and exclusion criteria. Articles reporting studies on age as a predictor for the course in patients with acute rhinosinusitis were included. For included articles, the design of reported studies was assessed for directness of evidence and risk of bias. We aimed to extract hazard ratios for age as a continuous variable. RESULTS: Out of 13,382 unique publications, 3 articles with moderate risk of bias were included, with a maximum follow-up period of 30 days. The reported hazard ratios for recovery at 10, 15, and 30 days are 1.0 (95% confidence interval, 0.9-1.1) for age as a continuous variable, 0.86 (0.66-1.11) for age dichotomized at 38 years, and 0.58 (0.40-0.84) for age dichotomized for an increase with 20 years, respectively. CONCLUSION AND RECOMMENDATION: There is no evidence that age increases the risk for chronic rhinosinusitis in adult patients with acute rhinosinusitis. The literature is inconclusive that age increases the risk for a prolonged course of acute rhinosinusitis and, therefore, does not provide grounds for different management according to age of patients. As such, patients can be managed according to clinical practice guidelines with expectant observation and symptomatic treatment.

Inconclusive evidence for allergic rhinitis to predict a prolonged or chronic course of acute rhinosinusitis.

OBJECTIVE: To systematically review the evidence on allergic rhinitis as a predictor for a prolonged or chronic course in adult patients with acute rhinosinusitis. DATA SOURCES: Pubmed, EMBASE, and the Cochrane library. REVIEW METHODS: A systematic literature search was performed on March 15, 2013. During screening of title and abstract, 3 authors independently selected studies on allergic rhinitis as a predictor for the course of acute rhinosinusitis in adults. The reported study design was assessed for directness of evidence and risk of bias. We aimed to extract prior and posterior probabilities for a prolonged or chronic course of acute rhinosinusitis. RESULTS: Of 13,202 retrieved articles, 2 articles were eligible for study assessment. They provided a high directness of evidence but carried a high risk of bias. The studies showed an incidence of a prolonged and chronic course of, respectively, .19 (95% confidence interval [CI] .16-.23) and .05 (95% CI, .02-.13). In patients with allergic rhinitis, the incidence was .25 (95% CI, .18-.35) and .14 (95% CI, .04-.34), so the added value of allergic rhinitis to predict a prolonged course is 6% and to predict a chronic course 8%. CONCLUSION AND RECOMMENDATION: While the 2 included studies suggest that allergic rhinitis adds little to the prediction of a prolonged or chronic course in patients with acute rhinosinusitis, they carry a high risk of bias. As the available evidence does not provide grounds for different management of patients with and without allergic rhinitis, namely, according to clinical practice guidelines, both can be managed with expectant observation and symptomatic treatment.

No evidence for distinguishing bacterial from viral acute rhinosinusitis using symptom duration and purulent rhinorrhea: a systematic review of the evidence base.

OBJECTIVE: To evaluate the diagnostic value of symptom duration and purulent rhinorrhea in adults suspected of having acute bacterial rhinosinusitis. DATA SOURCES: PubMed, EMBASE, and the Cochrane Library. REVIEW METHODS: We performed a comprehensive systematic search on March 28, 2013. We included studies on the diagnostic value of duration of symptoms and purulent rhinorrhea in patients suspected of having acute bacterial rhinosinusitis. We assessed study design of included articles for directness of evidence and risk of bias. We extracted prevalence and positive and negative predictive values. RESULTS: Of 4173 unique publications, we included 1 study with high directness of evidence and moderate risk of bias. The prior probability of bacterial rhinosinusitis was 0.29 (95% confidence interval [CI], 0.24-0.35); we could not extract posterior probabilities. Odds ratios (95% CI) from univariate analysis were 1.03 (0.78-1.36) for duration of symptoms and 2.69 (1.39-5.18) for colored discharge on the floor of the nasal cavity. CONCLUSION AND RECOMMENDATION: We included 1 study with moderate risk of bias, reporting data in such a manner that we could not assess the value of symptom duration and purulent rhinorrhea in adults suspected of having acute bacterial rhinosinusitis. Recommendations to distinguish between a viral and a bacterial source based on purulent rhinorrhea are not supported by evidence, and the decision to prescribe antibiotic treatment should not depend on its presence. Based on judgment driven by theory and subsidiary evidence of a greater likelihood of bacterial rhinosinusitis after 10 days, antibiotic therapy may seem a reasonable empirical option.

No evidence for distinguishing bacterial from viral acute rhinosinusitis using fever and facial/dental pain: a systematic review of the evidence base.

OBJECTIVE: To assess the diagnostic value of fever and facial and dental pain in adults suspected of acute bacterial rhinosinusitis. DATA SOURCES: PubMed, EMBASE, and the Cochrane Library. REVIEW METHODS: A comprehensive systematic search was performed on March 18, 2013. We included articles reporting studies on the diagnostic value of fever or facial and dental pain in patients suspected of acute bacterial rhinosinusitis. For included articles, the reported study design was assessed for directness of evidence and risk of bias. Prevalences, positive predictive values, and negative predictive values were extracted. RESULTS: Of 3171 unique records, we included 1 study with a high directness of evidence and a moderate risk of bias. The prior probability of bacterial rhinosinusitis was 0.29 (95% confidence interval: 0.24 to 0.35). We could not extract posterior probabilities with accompanying positive and negative predictive values. The study reported an odds ratio from univariate analysis for fever of 1.02 (0.52 to 2.00) and 1.65 (0.83 to 3.28) for facial and dental pain. In subsequent multivariate analysis, the odds ratio of facial and dental pain was 1.86 (1.06 to 3.29). CONCLUSION AND RECOMMENDATION: There is 1 study with moderate risk of bias, reporting data in such a manner that we could not assess the value of fever and facial and dental pain in adults suspected of an acute bacterial rhinosinusitis. Therefore, these symptoms should not be used in clinical practice to distinguish between a bacterial and viral source of acute rhinosinusitis or for decision making about prescribing antibiotic treatment.

Limited evidence: higher efficacy of nasal saline irrigation over nasal saline spray in chronic rhinosinusitis--an update and reanalysis of the evidence base.

OBJECTIVE: To assess the effectiveness of nasal saline irrigation in adult patients with chronic rhinosinusitis. DATA SOURCES: PubMed, EMBASE, the Cochrane Library. REVIEW METHODS: A comprehensive search was performed, and 2 authors independently screened publications. The design of selected studies was assessed on directness of evidence and risk of bias. RESULTS: Of 1596 publications, 1 open-label randomized trial with high directness of evidence and moderate risk of bias was included. In this study, 127 patients were randomly allocated to isotonic nasal saline irrigation or isotonic nasal saline spray, as added to their usual medication. The mean 20-Item Sinonasal Outcome Test (SNOT-20) scores of those treated with nasal irrigation improved more than those allocated to nasal spray. While the authors consider an improvement of 16 or more to be clinically meaningful, the changes from baseline in mean SNOT-20 scores of those treated with irrigation (and the differences with those treated with nasal spray) at 2, 4, and 8 weeks were 12.2 (difference 5.5, [95% confidence interval -0.04 to 11.0]), 16.2 (difference 8.8 [3.2 to 14.4]), and 15.0 (difference 6.5 [0.4 to 12.6]), respectively. Side effects of posttreatment nasal dripping were common but minor and did not lead to discontinuation of treatment. CONCLUSION AND RECOMMENDATION: It should be explained to adult patients with chronic rhinosinusitis that there is limited information on the relative effect of nasal saline irrigation and nasal saline spray on subjective symptom improvement, since there is only 1 trial available with a moderate risk of bias showing limited benefit of irrigation over spray.

Nasal endoscopy is recommended for diagnosing adults with chronic rhinosinusitis.

OBJECTIVE: To assess the diagnostic value of nasal endoscopic findings in adults suspected of chronic rhinosinusitis. DATA SOURCES: PubMed, EMBASE, and the Cochrane Library. REVIEW METHODS: A comprehensive search was performed up to March 5, 2013. Articles that assessed the diagnostic value of nasal endoscopy in adults suspected of chronic rhinosinusitis were included. For selected articles, the study design was assessed for directness of evidence and risk of bias. Prevalence, positive, and negative predictive values were extracted from reported data. RESULTS: Out of 3899 unique publications, we included 3 diagnostic studies with a high directness of evidence and a low or moderate risk of bias for data extraction. They showed a prevalence of chronic rhinosinusitis (diagnosed with computed tomography) of .40 to .56. Compared with posterior probabilities we found an added value for ruling in chronic rhinosinusitis by a positive nasal endoscopy of 25% to 28% and an added value for ruling out chronic rhinosinusitis by a negative nasal endoscopy of 5% to 30%. CONCLUSION AND RECOMMENDATION: Computed tomography is not considered necessary in case of a positive nasal endoscopy. While nasal endoscopy cannot rule out chronic rhinosinusitis, we advise computed tomography only for patients with a prolonged or complicated course of rhinosinusitis.

Absence of evidence for enhanced benefit of antibiotic therapy on recurrent acute rhinosinusitis episodes: a systematic review of the evidence base.

OBJECTIVE: To systematically review the evidence base on the effectiveness of short-course antibiotic therapy in adult patients with a recurrent episode of acute rhinosinusitis as part of a disease pattern on severity and duration of symptoms and recurrences. DATA SOURCES: PubMed, EMBASE, and the Cochrane Library. REVIEW METHODS: A comprehensive search was performed up to March 21, 2013. Articles reporting studies on the effects of short-course antibiotic therapy compared with placebo in patients with recurrent acute rhinosinusitis were included. For included articles, the design of reported studies was assessed for directness of evidence and risk of bias. RESULTS: In total, 3473 unique publications were retrieved, of which 30 were considered eligible based on title and abstract screening. In addition, 8 eligible articles were retrieved using cross-reference checking. Based on full-text evaluation, none of the retrieved 38 articles satisfied our predefined selection criteria. They did not compare antibiotic treatment with placebo, excluded patients with recurrent acute rhinosinusitis, or did not report findings for a subgroup of patients with recurrent acute rhinosinusitis. CONCLUSION AND RECOMMENDATION: To date, there is no evidence available on differences in effect of antibiotic therapy in primary or sporadic and recurrent episodes of acute rhinosinusitis. As such, decisions for or against initial antibiotic therapy in patients with recurring episodes of acute rhinosinusitis should be based on the same criteria used in managing primary or sporadic episodes of uncomplicated acute rhinosinusitis.

Limited evidence for effects of intranasal corticosteroids on symptom relief for recurrent acute rhinosinusitis.

OBJECTIVE: To systematically review the evidence base on the effectiveness of intranasal corticosteroids in adult patients with recurrent acute rhinosinusitis. Data Sources Pubmed, EMBASE, and the Cochrane Library. REVIEW METHODS: A comprehensive search was performed up to March 20, 2013. Two reviewers independently screened publications on title and abstract. Design of selected studies was assessed on directness of evidence and risk of bias. For included studies, risk differences with 95% confidence intervals were extracted or recalculated. RESULTS: Of 1850 unique records, 3 trials were included. Risk of bias was high and directness of evidence was low for 2 trials, the third trial had low risk of bias with moderate directness of evidence. They found a statistical significant difference for the median number of days to clinical success (defined as patients' report of symptoms to be cured or much improved) favoring intranasal corticosteroids (6 days) over placebo (9 days), while the difference in proportion of patients reporting clinical success after 21 days of treatment was 20% favoring intranasal corticosteroids over placebo. CONCLUSION AND RECOMMENDATION: The evidence for the benefit of intranasal corticosteroids on symptom relief in adult patients with recurrent acute rhinosinusitis is rather limited (ie, 3 trials are available; the best evidence is derived from 1 low risk of bias trial providing moderate directness of evidence that intranasal corticosteroids may speed up relief of symptoms in patients with recurrent acute rhinosinusitis). A large methodologically rigorous randomized trial in antibiotic-naïve patients is needed to provide a more definite recommendation.