Evidence-Based Medicine Comes to Otolaryngology

Recognizing that specialties can’t develop guidelines in a vacuum, Dr. Rosenfeld has brought all stakeholders to the table. They include otolaryngologists, allergists, immunologists, infectious disease specialists, oncologists, family practice physicians, APNs, a neuroradiologist, pulmonologists, a methodologist, representatives of non-profit disease-specific associations, and insurance company representatives. Our conversations are entirely different than when only ENTs were present. Stakeholders have different perspectives and objectives, and we need all of them to define the scope of the proposed guidelines, to prioritize hot issues for process improvement, and to work toward key action statements, added Dr. Rosenfeld.

An outside observer, James Schnibanoff, Editor-in-Chief of Milliman Care Guidelines LLC, applauded the AAO-HNSF’s decision to move forward with evidence-based guidelines. Milliman Care Guidelines witnessed a broadening acceptance of guidelines by physicians, including ENT and head and neck surgeons. These guidelines include both those developed by Milliman and those produced by the American Academy of Otolaryngology-Head and Neck Surgery, he said.

Barriers

Although EBM is inextricably tied to payers’ push for pay-for-performance and the need to cut costs from the health care system by eliminating practices of questionable value, it still meets substantial physician resistance. The most common sources of pushback are a lack of awareness or agreement with consensus guidelines, clinical practice inertia, fear of losing professional autonomy, and a belief that reimbursement and board certification won’t be affected by doctors who ignore guidelines and don’t produce desired outcomes.

A major obstacle faced by EBM developers is an inadequate level of evidence, based on published studies, on which clinical practices are based. On that count, otolaryngology’s research base leaves a lot to be desired. To identify levels of evidence in otolargynology journals, Wasserman and Wynn reviewed 2854 original research articles published between 1993 and 2003 and rated each on a scale of 1 (strongest evidence) to 5 (weakest). The authors found that, for most published studies, sample sizes were modest, most articles lacked control groups, and significant confidence intervals were rare. The authors noted that published findings in otolaryngology had improved somewhat between 1998 and 2003-sample size increased from 22 to 30 subjects, 43% in 2003 had control groups versus 36% in 1998, and p values increased from 26% to 45% (Wasserman JM, Wynn R. Otolaryngol Head Neck Surg 2006;134(5):717-23).

Moving Ahead

Otolaryngology-head and neck surgery may be late to the party, but its professional society’s leaders have met the challenge to operationally define what constitutes good medicine. It has engaged its members and other stakeholders in a complicated, time-consuming, and expensive journey that had to be undertaken.