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Original Article |

Small Area Variation in Endoscopic Sinus Surgery Rates Among the Medicare Population FREE

Giri Venkatraman, MD, MBA; Donald S. Likosky, PhD; Daniel Morrison, MD; Weiping Zhou, MS; Samuel R. G. Finlayson, MD, MPH; David C. Goodman, MD, MS
[+] Author Affiliations

Author Affiliations: Section of Otolaryngology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.


Arch Otolaryngol Head Neck Surg. 2011;137(3):253-257. doi:10.1001/archoto.2011.17.
Text Size: A A A
Published online

Objectives  To determine endoscopic sinus surgery (ESS) rates among 306 hospital referral regions (HRRs) and to assess whether variability in ESS rates correlates with population density of beneficiaries, per capita number of otolaryngologists within an HRR, or proportion of patients diagnosed as having chronic rhinosinusitis.

Design  Retrospective cohort analysis.

Setting  Academic research.

Patients  A 20% sample of Medicare beneficiaries aged 65 to 99 years diagnosed as having chronic rhinosinusitis and undergoing ESS in 2006.

Main Outcome Measures  Variation in per capita rates of chronic rhinosinusitis diagnosis and ESS in 2006.

Results  Among 306 HRRs nationally, ESS was performed in sufficient volume to be reported in 148 HRRs. Per capita ESS rates (sinus surgical procedures per 1000 beneficiaries) varied 5-fold, from 0.02 to 0.10, with significant variations within states. Nationally, no geographic or regional patterns were noted, and high-use HRRs were often geographically proximal to low-use HRRs. Higher rates of chronic rhinosinusitis diagnosis and more beneficiaries in particular HRRs did not predict increased ESS within the HRRs.

Conclusions  Local ESS rates in the Medicare population vary considerably across the United States. Variability in high-use vs low-use regions seems to be random and independent of climate or the number of beneficiaries diagnosed as having chronic rhinosinusitis. Given that the appropriate rate of sinus surgery is unknown, this study points to the need for identifying and adopting more rigorous clinical criteria for ESS.

Figures in this Article

Chronic rhinosinusitis is a group of disorders characterized by recurrent or ongoing symptoms of nasal congestion, rhinorrhea, postnasal drip, and occasionally anosmia.1 Standard treatment for these disorders includes variable amounts of antibiotics, oral and intranasal corticosteroids, lavage with normal saline, and mucolytics or decongestants.2 Successive inflammation or infection of the paranasal sinus cavities, exacerbation of lower airway hyperactivity, and occasionally formation of obstructive nasal polyps characterize the natural history of the disease. When medical management fails, endoscopic sinus surgery (ESS) is often performed. Since its introduction in 1985, this minimally invasive technique has essentially supplanted open approaches to management of chronic rhinosinusitis3 and is usually performed in an outpatient setting, with minimal morbidity.4

Although chronic rhinosinusitis is not typically thought of as being prevalent among older populations,5,6 Medicare claims analysis has shown that ESS rates have increased significantly over time from 1998 to 2006, whereas rates of chronic rhinosinusitis diagnosis have remained constant.7 More than 100 MEDLINE articles810 have shown improvement in quality of life after ESS810; however, few studies1113 directly compare medical management with surgical intervention and clinical outcomes. Therefore, the decision to undergo sinus surgery seems to be driven more by patient or surgeon interest and referral patterns than by clearly defined clinical criteria. Similar phenomena have been noted in other disease states, such as musculoskeletal disorders14 and percutaneous coronary intervention for coronary artery disease,15 in which a lack of clear effectiveness data has led to increases in use.

To better understand this apparent paradox of increasing rates of surgery but flat rates of diagnosis, we examined regional variation in per capita ESS rates among Medicare beneficiaries across hospital referral regions (HRRs). These HRRs are defined as local regions in which patients were referred for major cardiovascular or neurosurgical procedures.16 Analysis was restricted to HRRs where ESS was performed in sufficient volumes to be captured. We examined whether rates of chronic rhinosinusitis diagnosis were predictive of ESS rates in individual HRRs using Medicare claims. In addition, we determined whether ESS rates were associated with measures of supply, including the number of practicing otolaryngologists and the number of beneficiaries residing in individual HRRs.

We used a 20% sample of non–health maintenance organization Medicare beneficiaries aged 65 to 99 years from January 1, 2006, to December 31, 2006, to identify patients diagnosed as having chronic rhinosinusitis and patients undergoing endoscopic or open sinus surgery. Identified from the physician and supplier file were clinician claims with Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes (Table 1), date of procedure, and race/ethnicity of the beneficiary. The denominator file provided information on the beneficiary's age, sex, race/ethnicity, and information about eligibility by year for the Medicare Part B program.

Table Graphic Jump LocationTable 1. Study Inclusion Diagnostic Codes for Chronic Rhinosinusitis and Procedure Codes for Endoscopic Sinus Surgery

We determined the incidence of CPT codes for the various endoscopic sinus surgical procedures at the HRR level. To capture patients diagnosed as having chronic rhinosinusitis, we identified beneficiaries with an ICD-9 code for chronic rhinosinusitis during the year. We excluded patients with ICD-9 codes for nasal tumors (benign or malignant) to ensure that the surgical procedures were performed to manage chronic rhinosinusitis and not endonasal tumors. Per capita rates of chronic rhinosinusitis diagnosis were calculated using the number of beneficiaries diagnosed as having chronic rhinosinusitis as the numerator and the total number of beneficiaries as the denominator. Per capita ESS rates were analyzed using procedure and patient counts as the numerator and the total number of beneficiaries as the denominator. Provider information was obtained using American Medical Association files.

Rates of endoscopic sinus surgery and rates of chronic rhinosinusitis diagnosis in each HRR were sorted from highest to lowest and divided into quintiles. The range of each quintile and upper and lower confidence intervals were calculated using commercially available software (STATA; StataCorp LP, College Station, Texas); t test comparison of the mean rates among quintiles was also performed. Scatterplots were generated of ESS rates within each HRR vs the number of beneficiaries within the HRR, per capita number of otolaryngology providers, and per capita rate of chronic rhinosinusitis diagnosis. Correlation coefficients and P values were obtained using STATA and a commercially available spreadsheet (Excel; Microsoft, Redmond, Washington).

In 2006 among 306 HRRs in the United States, 148 HRRs had ESS performed in sufficient volume (>11 Medicare beneficiaries undergoing ESS) to be included in our analysis. The HRRs with 10 Medicare beneficiaries or fewer undergoing ESS are not reported because of patient privacy concerns. Per capita ESS rates (sinus surgery procedures per 1000 beneficiaries) in 148 HRRs ranged from 0.02 to 0.10, a 5-fold variation. Per capita rates of patients diagnosed as having chronic rhinosinusitis showed an approximate 3-fold variation, from 14.04 to 45.44 per 1000 beneficiaries within each HRR. The rural southeastern part of the United States had the greatest proportion of HRRs with beneficiaries diagnosed as having chronic rhinosinusitis, suggesting increased allergy burden as a reason. However, these HHRs did not have correspondingly high ESS rates (Table 2).

Table Graphic Jump LocationTable 2. Hospital Referral Regions (HRRs) With the Most Medicare Beneficiaries Diagnosed as Having Chronic Rhinosinusitis and Corresponding Endoscopic Sinus Surgery Rates of the HRRs

Endoscopic sinus surgery rates within HRRs were divided into quintiles. Rates of ESS rates varied considerably within and between quintiles (national range, 0.02-0.10; interquartile range, 0.03-0.05). t Test comparing the mean ESS rates between the first and fifth quintiles demonstrated a significant difference (P < .001) (Figure 1). Further analysis of the quintiles showed that the highest -use quintile had the lowest rate of patients diagnosed as having chronic rhinosinusitis. This difference in diagnosis rates between the first and fifth quintiles was statistically significant (P = .002). The range of per capita ESS rates in select states is shown in Figure 2. Every state had low-use and high-use regions.

Place holder to copy figure label and caption
Figure 1.

National endoscopic sinus surgery rates per 1000 Medicare beneficiaries, divided into the highest-use (quintile 1) and lower-use (quintiles 2-5) quintiles. Error bars indicate confidence intervals; box, range of endoscopic sinus surgery rates within the quintile; boxed line, mean for quintile; and dot, outlier.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Endoscopic sinus surgery rates per 1000 Medicare beneficiaries within select regions of the country. Black bar indicates hospital referral region with the highest endoscopic sinus surgery rate within the state; light bar, the hospital referral region with the lowest endoscopic sinus surgery rate with the state.

Graphic Jump Location

To postulate possible reasons for this regional discrepancy, we correlated ESS rates with the proportion of patients diagnosed as having chronic rhinosinusitis (Figure 3), population density of Medicare beneficiaries within an HRR (Figure 4), and per capita number of otolaryngology providers within each HRR (Figure 5). No appreciable correlation was noted between ESS rates and per capita rates of beneficiaries diagnosed as having chronic rhinosinusitis nationally (R2 = 0.06, P < .01). Similarly, no appreciable correlation was noted between ESS rates and per capita number of otolaryngology providers per 100 000 residents in an HRR (R2 = 0.00, P < .01). To determine the association of rates strictly with population, we correlated ESS rates with the number of beneficiaries within the HRR. Again, no appreciable correlation was noted (R2 = 0.08, P < .01).

Place holder to copy figure label and caption
Figure 3.

Endoscopic sinus surgery rates relative to the rate of chronic rhinosinusitis diagnosis. R2 = 0.06. Dashed line indicates trend.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Endoscopic sinus surgery rates relative to the number of Medicare beneficiaries. R2 = 0.08. Dashed line indicates trend.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

Endoscopic sinus surgery rates relative to the per capita number of otolaryngology providers. R2 = 0.00. Dashed line indicates trend.

Graphic Jump Location

In 2006, per capita ESS rates varied significantly across US HRRs. When rates in individual HRRs were grouped into quintiles, statistically significant differences were noted between the highest and lowest quintiles. Our analysis indicated that per capita rates of patients diagnosed as having chronic rhinosinusitis were lower in regions with the highest ESS rates. Endoscopic sinus surgery rates within HRRs did not correlate significantly with population density of beneficiaries within each HRR, per capita number of otolaryngologists, or proportion of beneficiaries diagnosed as having chronic rhinosinusitis. Our findings indicate that ESS rates in many areas of the country seem to be dictated by local practice patterns and patient and physician expectations and not by disease burden or clinical guidelines.

Several reasons may account for our present findings. The treatment of chronic rhinosinusitis is variable because of a lack of clear effectiveness data for medical vs surgical interventions,12 detection biases from the use of computed tomography,17,18 and technological advances that lead to less surgical morbidity and inconsistent medical management of the disease.19,20 Variability in sinus surgery rates cannot be rationalized on the basis of environmental factors, as noted by ESS rates in geographically proximal HRRs such as San Francisco (ESS rate, 0.059) and Sacramento (ESS rate, 0.045), California, or York, Pennsylvania (ESS rate, 0.074), and Baltimore, Maryland (ESS rate, 0.040). Indeed, high-use and low-use HRRs were noted within every region of the country (eg, in the Southeast and in the Midwest), further indicating that local climate did not influence sinus surgery rates.

Our findings are not unique to the treatment of chronic rhinosinusitis. Deyo et al21,22 observed similar patterns in lumbar spine surgery. As in chronic rhinosinusitis, surgical treatment of lumbar spine is preference sensitive, whereby surgeon bias and patient input may dictate treatment choices given a lack of clear effectiveness data. In both instances, the use of expensive technology for diagnosing disease has outpaced understanding of the epidemiological factors and natural history of the diseases.17 Laparoscopic antireflux surgery23,24 and laparoscopic gallbladder surgery25,26 are further examples of similar increases in the use and decreases of clinical thresholds for surgical intervention when minimally invasive (and less morbid) alternatives are introduced. Another possible contributing factor to variability of ESS rates could be the mean age of practicing physicians within an HRR. Because ESS is a fairly new technological advance, recent graduates from residency training and fellowship programs would be more likely to offer these services to patients and more comfortable in performing the surgery. We are planning further analyses to answer this question.

There are a few possible limitations to our analysis. As mentioned previously, Medicare beneficiaries may not be the ideal population in which to study use patterns because chronic rhinosinusitis is more prevalent among young adults.5,6 Despite this, significant variability has been observed, and we assume that similar patterns would be seen in younger cohorts. Although the cost of care was not directly addressed in our study, we would hypothesize that significant savings could be achieved if high-use HRRs adopted more conservative rates even within the Medicare population. Also, because patients were not followed up longitudinally, beneficiaries undergoing surgery in early 2006 could have been diagnosed as having chronic rhinosinusitis in late 2005. However, we believe that this would be balanced by patients diagnosed in late 2006 and undergoing surgery in 2007. Furthermore, patients undergoing revision procedures could not be differentiated because CPT codes for revision and primary surgical procedures are the same. Regardless, we think that the significant variability and random patterns of use cannot be explained by this alone.

Endoscopic sinus surgery has improved chronically low quality of life among significant numbers of patients,2729 with less morbidity than open approaches. Our findings showing national increases in ESS rates, as well as significant variability at the regional level among Medicare beneficiaries, point to the need for clearer clinical guidelines for practicing otolaryngologists and rhinologists who manage the complex disease of chronic rhinosinusitis. Such patterns of variability—neighboring regions with significant differences in surgical rates, haphazard geographic distribution, and scientific uncertainty regarding clinical effectiveness—are hallmarks of preference-sensitive care.14 Addressing this variability in surgical care will not be easy but would be helped by widespread dissemination of patient decision aids, individual education along with multi-institutional randomized controlled trials, and establishment of chronic rhinosinusitis registries to minimize the scientific and clinical uncertainty and provide data on the natural history of the disease.

Correspondence: Giri Venkatraman, MD, MBA, Section of Otolaryngology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Ste 4-F, Lebanon, NH 03766 (giridhar.venkatraman@hitchcock.org).

Submitted for Publication: July 12, 2010; final revision received September 15, 2010; accepted November 25, 2010.

Author Contributions: Drs Venkatraman, Finlayson, and Goodman and Mr Zhou had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Venkatraman, Likosky, Finlayson, and Goodman. Acquisition of data: Goodman. Analysis and interpretation of data: Venkatraman, Likosky, Morrison, Zhou, and Finlayson. Drafting of the manuscript: Venkatraman and Likosky. Critical revision of the manuscript for important intellectual content: Likosky, Morrison, Zhou, Finlayson, and Goodman. Statistical analysis: Morrison and Zhou. Obtained funding: Venkatraman. Administrative, technical, and material support: Venkatraman, Finlayson, and Goodman. Study supervision: Morrison and Finlayson.

Financial Disclosure: Dr Goodman reports the following possible conflicts: (1) government extramural funding from the National Institutes of Health, National Cancer Institute, and US Department of Health and Human Services; (2) nongovernmental funding from the Robert Wood Johnson Foundation; (3) 18 speaking engagements, each with fees less than $5000; and (4) consulting fees for HealthDialog and Colorado Foundation for Medical Care. These grants, contracts, and fees were not used toward publication of this article.

Funding/Support: This study was supported by the Harmes Surgical Scholarship, Dartmouth-Hitchcock Medical Center (Dr Venkatraman).

Benninger  MSFerguson  BJHadley  JA  et al.  Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg 2003;129 (3) ((suppl)) S1- S32
PubMed Link to Article
Chan  YKuhn  FA An update on the classifications, diagnosis, and treatment of rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg 2009;17 (3) 204- 208
PubMed Link to Article
Kennedy  DWZinreich  SJRosenbaum  AEJohns  ME Functional endoscopic sinus surgery: theory and diagnostic evaluation. Arch Otolaryngol 1985;111 (9) 576- 582
PubMed Link to Article
Acquadro  MASalman  SDJoseph  MP Analysis of pain and endoscopic sinus surgery for sinusitis. Ann Otol Rhinol Laryngol 1997;106 (4) 305- 309
PubMed
Blackwell  DLCollins  JGColes  R Summary health statistics for U.S. adults: National Health Interview Survey, 1997. Vital Health Stat 10 2002; (205) 1- 109
PubMed
Pleis  JRLethbridge-Cejku  M Summary health statistics for U.S. adults: National Health Interview Survey, 2006. Vital Health Stat 10 2007; (235) 1- 153
PubMed
Venkatraman  GLikosky  DSZhou  WFinlayson  SRGoodman  DC Trends in endoscopic sinus surgery rates in the Medicare population. Arch Otolaryngol Head Neck Surg 2010;136 (5) 426- 430
PubMed Link to Article
Soler  ZMSmith  TL Quality of life outcomes after functional endoscopic sinus surgery. Otolaryngol Clin North Am 2010;43 (3) 605- 612, x
PubMed Link to Article
Soler  ZMMace  JSmith  TL Symptom-based presentation of chronic rhinosinusitis and symptom-specific outcomes after endoscopic sinus surgery. Am J Rhinol 2008;22 (3) 297- 301
PubMed Link to Article
Gliklich  REMetson  R Effect of sinus surgery on quality of life. Otolaryngol Head Neck Surg 1997;117 (1) 12- 17
PubMed Link to Article
Ragab  SMLund  VJScadding  G Evaluation of the medical and surgical treatment of chronic rhinosinusitis: a prospective, randomised, controlled trial. Laryngoscope 2004;114 (5) 923- 930
PubMed Link to Article
Khalil  HSNunez  DA Functional endoscopic sinus surgery for chronic rhinosinusitis. Cochrane Database Syst Rev 2006; (3) CD004458
PubMed
Hartog  Bvan Benthem  PPPrins  LCHordijk  GJ Efficacy of sinus irrigation versus sinus irrigation followed by functional endoscopic sinus surgery. Ann Otol Rhinol Laryngol 1997;106 (9) 759- 766
PubMed
Lurie  JDBell  JEWeinstein  J What rate of utilization is appropriate in musculoskeletal care? Clin Orthop Relat Res 2009;467 (10) 2506- 2511
PubMed Link to Article
Lucas  FLDeLorenzo  MASiewers  AEWennberg  DE Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993-2001. Circulation 2006;113 (3) 374- 379
PubMed Link to Article
Wennberg  JE The Dartmouth Atlas of Health Care.  Chicago, IL American Hospital Publishing, Inc1996;
Black  WCWelch  HG Advances in diagnostic imaging and overestimations of disease prevalence and the benefits of therapy. N Engl J Med 1993;328 (17) 1237- 1243
PubMed Link to Article
Anzai  YWeymuller  EA  JrYueh  BMaronian  NJarvik  JG The impact of sinus computed tomography on treatment decisions for chronic sinusitis. Arch Otolaryngol Head Neck Surg 2004;130 (4) 423- 428
PubMed Link to Article
Dubin  MGLiu  CLin  SYSenior  BA American Rhinologic Society member survey on “maximal medical therapy” for chronic rhinosinusitis. Am J Rhinol 2007;21 (4) 483- 488
PubMed Link to Article
Dubin  MGKuhn  FAMelroy  CT Radiographic resolution of chronic rhinosinusitis without polyposis after 6 weeks vs 3 weeks of oral antibiotics. Ann Allergy Asthma Immunol 2007;98 (1) 32- 35
PubMed Link to Article
Deyo  RAGray  DTKreuter  WMirza  SMartin  BI United States trends in lumbar fusion surgery for degenerative conditions. Spine (Phila Pa 1976) 2005;30 (12) 1441- 1447
PubMed Link to Article
Deyo  RAMirza  SKMartin  BIKreuter  WGoodman  DCJarvik  JG Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 2010;303 (13) 1259- 1265
PubMed Link to Article
Finlayson  SRBirkmeyer  JDLaycock  WS Trends in surgery for gastroesophageal reflux disease: the effect of laparoscopic surgery on utilization. Surgery 2003;133 (2) 147- 153
PubMed Link to Article
Finlayson  SRLaycock  WSBirkmeyer  JD National trends in utilization and outcomes of antireflux surgery. Surg Endosc 2003;17 (6) 864- 867
PubMed Link to Article
Escarce  JJBloom  BSHillman  ALShea  JASchwartz  JS Diffusion of laparoscopic cholecystectomy among general surgeons in the United States. Med Care 1995;33 (3) 256- 271
PubMed Link to Article
Escarce  JJChen  WSchwartz  JS Falling cholecystectomy thresholds since the introduction of laparoscopic cholecystectomy. JAMA 1995;273 (20) 1581- 1585
PubMed Link to Article
Chester  ACAntisdel  JLSindwani  R Symptom-specific outcomes of endoscopic sinus surgery: a systematic review. Otolaryngol Head Neck Surg 2009;140 (5) 633- 639
PubMed Link to Article
Gliklich  REMetson  R The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg 1995;113 (1) 104- 109
PubMed Link to Article
Gliklich  REHilinski  JM Longitudinal sensitivity of generic and specific health measures in chronic sinusitis. Qual Life Res 1995;4 (1) 27- 32
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

National endoscopic sinus surgery rates per 1000 Medicare beneficiaries, divided into the highest-use (quintile 1) and lower-use (quintiles 2-5) quintiles. Error bars indicate confidence intervals; box, range of endoscopic sinus surgery rates within the quintile; boxed line, mean for quintile; and dot, outlier.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Endoscopic sinus surgery rates per 1000 Medicare beneficiaries within select regions of the country. Black bar indicates hospital referral region with the highest endoscopic sinus surgery rate within the state; light bar, the hospital referral region with the lowest endoscopic sinus surgery rate with the state.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Endoscopic sinus surgery rates relative to the rate of chronic rhinosinusitis diagnosis. R2 = 0.06. Dashed line indicates trend.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Endoscopic sinus surgery rates relative to the number of Medicare beneficiaries. R2 = 0.08. Dashed line indicates trend.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

Endoscopic sinus surgery rates relative to the per capita number of otolaryngology providers. R2 = 0.00. Dashed line indicates trend.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Study Inclusion Diagnostic Codes for Chronic Rhinosinusitis and Procedure Codes for Endoscopic Sinus Surgery
Table Graphic Jump LocationTable 2. Hospital Referral Regions (HRRs) With the Most Medicare Beneficiaries Diagnosed as Having Chronic Rhinosinusitis and Corresponding Endoscopic Sinus Surgery Rates of the HRRs

References

Benninger  MSFerguson  BJHadley  JA  et al.  Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg 2003;129 (3) ((suppl)) S1- S32
PubMed Link to Article
Chan  YKuhn  FA An update on the classifications, diagnosis, and treatment of rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg 2009;17 (3) 204- 208
PubMed Link to Article
Kennedy  DWZinreich  SJRosenbaum  AEJohns  ME Functional endoscopic sinus surgery: theory and diagnostic evaluation. Arch Otolaryngol 1985;111 (9) 576- 582
PubMed Link to Article
Acquadro  MASalman  SDJoseph  MP Analysis of pain and endoscopic sinus surgery for sinusitis. Ann Otol Rhinol Laryngol 1997;106 (4) 305- 309
PubMed
Blackwell  DLCollins  JGColes  R Summary health statistics for U.S. adults: National Health Interview Survey, 1997. Vital Health Stat 10 2002; (205) 1- 109
PubMed
Pleis  JRLethbridge-Cejku  M Summary health statistics for U.S. adults: National Health Interview Survey, 2006. Vital Health Stat 10 2007; (235) 1- 153
PubMed
Venkatraman  GLikosky  DSZhou  WFinlayson  SRGoodman  DC Trends in endoscopic sinus surgery rates in the Medicare population. Arch Otolaryngol Head Neck Surg 2010;136 (5) 426- 430
PubMed Link to Article
Soler  ZMSmith  TL Quality of life outcomes after functional endoscopic sinus surgery. Otolaryngol Clin North Am 2010;43 (3) 605- 612, x
PubMed Link to Article
Soler  ZMMace  JSmith  TL Symptom-based presentation of chronic rhinosinusitis and symptom-specific outcomes after endoscopic sinus surgery. Am J Rhinol 2008;22 (3) 297- 301
PubMed Link to Article
Gliklich  REMetson  R Effect of sinus surgery on quality of life. Otolaryngol Head Neck Surg 1997;117 (1) 12- 17
PubMed Link to Article
Ragab  SMLund  VJScadding  G Evaluation of the medical and surgical treatment of chronic rhinosinusitis: a prospective, randomised, controlled trial. Laryngoscope 2004;114 (5) 923- 930
PubMed Link to Article
Khalil  HSNunez  DA Functional endoscopic sinus surgery for chronic rhinosinusitis. Cochrane Database Syst Rev 2006; (3) CD004458
PubMed
Hartog  Bvan Benthem  PPPrins  LCHordijk  GJ Efficacy of sinus irrigation versus sinus irrigation followed by functional endoscopic sinus surgery. Ann Otol Rhinol Laryngol 1997;106 (9) 759- 766
PubMed
Lurie  JDBell  JEWeinstein  J What rate of utilization is appropriate in musculoskeletal care? Clin Orthop Relat Res 2009;467 (10) 2506- 2511
PubMed Link to Article
Lucas  FLDeLorenzo  MASiewers  AEWennberg  DE Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993-2001. Circulation 2006;113 (3) 374- 379
PubMed Link to Article
Wennberg  JE The Dartmouth Atlas of Health Care.  Chicago, IL American Hospital Publishing, Inc1996;
Black  WCWelch  HG Advances in diagnostic imaging and overestimations of disease prevalence and the benefits of therapy. N Engl J Med 1993;328 (17) 1237- 1243
PubMed Link to Article
Anzai  YWeymuller  EA  JrYueh  BMaronian  NJarvik  JG The impact of sinus computed tomography on treatment decisions for chronic sinusitis. Arch Otolaryngol Head Neck Surg 2004;130 (4) 423- 428
PubMed Link to Article
Dubin  MGLiu  CLin  SYSenior  BA American Rhinologic Society member survey on “maximal medical therapy” for chronic rhinosinusitis. Am J Rhinol 2007;21 (4) 483- 488
PubMed Link to Article
Dubin  MGKuhn  FAMelroy  CT Radiographic resolution of chronic rhinosinusitis without polyposis after 6 weeks vs 3 weeks of oral antibiotics. Ann Allergy Asthma Immunol 2007;98 (1) 32- 35
PubMed Link to Article
Deyo  RAGray  DTKreuter  WMirza  SMartin  BI United States trends in lumbar fusion surgery for degenerative conditions. Spine (Phila Pa 1976) 2005;30 (12) 1441- 1447
PubMed Link to Article
Deyo  RAMirza  SKMartin  BIKreuter  WGoodman  DCJarvik  JG Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 2010;303 (13) 1259- 1265
PubMed Link to Article
Finlayson  SRBirkmeyer  JDLaycock  WS Trends in surgery for gastroesophageal reflux disease: the effect of laparoscopic surgery on utilization. Surgery 2003;133 (2) 147- 153
PubMed Link to Article
Finlayson  SRLaycock  WSBirkmeyer  JD National trends in utilization and outcomes of antireflux surgery. Surg Endosc 2003;17 (6) 864- 867
PubMed Link to Article
Escarce  JJBloom  BSHillman  ALShea  JASchwartz  JS Diffusion of laparoscopic cholecystectomy among general surgeons in the United States. Med Care 1995;33 (3) 256- 271
PubMed Link to Article
Escarce  JJChen  WSchwartz  JS Falling cholecystectomy thresholds since the introduction of laparoscopic cholecystectomy. JAMA 1995;273 (20) 1581- 1585
PubMed Link to Article
Chester  ACAntisdel  JLSindwani  R Symptom-specific outcomes of endoscopic sinus surgery: a systematic review. Otolaryngol Head Neck Surg 2009;140 (5) 633- 639
PubMed Link to Article
Gliklich  REMetson  R The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg 1995;113 (1) 104- 109
PubMed Link to Article
Gliklich  REHilinski  JM Longitudinal sensitivity of generic and specific health measures in chronic sinusitis. Qual Life Res 1995;4 (1) 27- 32
PubMed Link to Article

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Indicate what change(s) you will implement in your practice, if any, based on this CME course.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

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