Redefining success in airway surgery for obstructive sleep apnea: a meta analysis and synthesis of the evidence.
OBJECTIVE
The role of upper airway surgery as a treatment for adult obstructive sleep apnea (OSA) remains controversial, with perspectives on treatment efficacy varying considerably. Though debate may occur in the clinical sphere, it is necessary to appreciate the ever-increasing funding and policy focus on cost effectiveness and "efficacy" in health care.


METHODS
In this review, we examine contemporary evidence that highlights the importance of "highly effective treatment" over "sub-therapeutic treatment" as a necessity to confer improved health outcomes in OSA. We highlight that assumptions of surgical success inherent in most articles fail to assimilate contemporary, clinically significant indicators of success. We performed a literature search and present interpolated meta-analyses data from 18 surgical articles. Statistical meta-analyses highlight how surgical success decreases when new evidence-based criteria of success are applied.


RESULTS
Specifically, when the traditional definition is applied (50% reduction in apnea-hypopnea index [AHI] and/or < or = 20) the pooled success rate for Phase I procedures is 55% (45% fail). However, at AHI < or = 10, success reduces to 31.5% (68.5% fail) and, at AHI < or = 5, success is reduced to 13% (87% fail). According to these definitions, Phase II success (fail) rates decrease from 86% (14%) to 45% (55%) and 43% (57%), respectively.


CONCLUSIONS
The evidence for clinical efficacy must define treatment "success". We propose all future surgical audits report "objective cure" rates with success based on AHI outcomes of < or = 5 and/or < or = 10. We hope this paper serves as a catalyst for debate and consensus.
Elshaug
Adam G
AG
Discipline of Public Health, The University of Adelaide, Australia. adam.elshaug@adelaide.edu.au
Moss
John R
JR
Southcott
Anne Marie
AM
Hiller
Janet E
JE
D017321:Clinical Trials, Phase I as Topic; D019317:Evidence-Based Medicine; D006801:Humans; D009960:Oropharynx / Q000601:surgery*; D010043:Outcome and Process Assessment, Health Care; D016032:Randomized Controlled Trials as Topic; D020181:Sleep Apnea, Obstructive / Q000175:diagnosis / Q000601:surgery*