Dr. Citardi pointed to another drawback to the study: its treatment of refractory sinus disease as a single disease entity. “That’s likely not truly reflective of what we see in clinical practice,” he said. “There are probably subgroups of patients with different disease profiles in whom sinus surgery is extremely valuable and cost effective, and there are others where it is likely to be of dubious benefit.”
Explore This Issue
November 2014Both Drs. Smith and Rudmik agreed that was a limitation to the study and actually identified it as such in their paper. They also cited another factor that makes it difficult to aggressively extrapolate the findings to clinical practice: The NIH patient data it relies on was not derived from randomized controlled trials comparing ESS and medical therapy. “Basically, there are no such trials,” Dr. Rudmik said. The reasons for that evidence gap are many, including the ethical problem of withholding surgery from refractory patients when it is clear that surgery may be superior to drug therapy alone. Plus, said Dr. Smith, these patients would need to be followed for the rest of their lives. “There’s no funding mechanism for that,” he added. Hence the need, at least initially, for an economic modeling approach.
Is It Really All about the Money?
And then there’s the larger question of whether economic considerations should be given so much prominence when weighing the relative benefits of treatment strategies for refractory sinus disease—or any otolaryngic procedure, for that matter.
Dr. Citardi noted, “There clearly are problems with the entire reimbursement paradigm for what we do as ENT physicians and surgeons. But it certainly is not unique to sinus surgery; it’s across the board.”
“Physicians sometimes get too caught up in the question of finances for a given treatment,” Dr. Citardi said. “But the payment challenge is separate from the issue of determining who is a good candidate for sinus surgery. In fact, I don’t ask patients about their ability to pay, or their insurance status, etc. Instead, I try to make the right decision based on the clinical facts at hand.”
The issue that is relevant to sinus surgery, he stressed, is the lack of any clinical trials identifying who is the best candidate for sinus surgery. “This is very ill-defined,” Dr. Citardi said. “And that’s on us, on otolaryngology, for not answering that question. If we can ultimately define the patient population for whom ESS is most beneficial, then we could go to governmental and private payers and make a strong case for more rational, consistent payment policies.”