A New Direction for Sleep: New OSA guidelines fuel another evidence-based medicine debate

Recent publication of practice parameters for surgery in adults with obstructive sleep apnea (OSA) by the American Academy of Sleep Medicine (AASM) has set off another round of debate on the need for otolaryngologists to get involved in generating their own guidelines. Although otolaryngologists have yet to agree on whether or not the time is right for guidelines on surgical treatment for sleep apnea, consensus can be claimed regarding the need perceived by the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) to get on the evidence-based bandwagon.

“As a specialty, it is very important that we work on developing a way of measuring outcomes that can be applied universally so we can work toward studies that will help us determine best practices,” said John Harwick, MD, an assistant professor of otolaryngology at the University of Florida in Gainesville and a member of the AAO-HNS Sleep Disorders Committee.

Dr. Harwick’s remark points to what is perhaps the key challenge faced by otolaryngologists and other specialties in attempting to develop guidelines: the need to determine the most relevant outcomes and metrics by which to measure optimal diagnosis and treatment. Once metrics are determined, studies are needed to lay the foundation on which guidelines are developed.

Randomized, controlled clinical trials continue to be the so-called “gold standard” of evidence. But these trials require time, money and sufficient patient numbers to detect meaningful outcomes and are, therefore, often lacking. This is particularly true in surgical specialties like otolaryngology (Arch Otolaryngol Head Neck Surg. 2002;128:631-634).

Given this problem, many so-called clinical guidelines are more aptly called “consensus statements” or “practice parameters,” because they rely on other types of evidence such as expert opinion and less rigorous published data like retrospective analyses and case-control studies.

The problem that faces otolaryngologists, as it does physicians in other specialties, is how to generate appropriate and relevant guidelines, given the dearth of evidence. At stake is the reality that other specialties that cross over into areas related to otolaryngology will develop these guidelines, as highlighted this year by the AASM’s publication of the surgical management of sleep apnea (SLEEP. 2010;33(10):1408-1413).

Response to the AASM Guidelines

Last year it was hoarseness, this year sleep apnea. “Each of the guidelines that has come out has created spirited discussion,” said Pell Wardrop, MD, chair of the AAO-HNS Sleep Disorders Committee. “The hoarseness guidelines that came out in 2009 were a hot topic at the Academy last year. The biggest stir this year was the AASM sleep surgery practice parameters.”