title: Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study.
abstract: Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS.
  
  
  
  The RAND/UCLA appropriateness methodology was performed. An international, multi-disciplinary panel of 10 experts in CRS was formed and completed two rounds of a modified Delphi ranking process along with a face-to-face meeting.
  
  
  
  A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20.
  
  
  
  This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment option during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment option and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high quality, patient-centered care to patients with CRS.
authors.affiliation: Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada.
authors.forename: Luke
authors.initials: L
authors.lastname: Rudmik
authors.affiliation: Division of Rhinology and Sinus Surgery, Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina; Charleston, SC, USA.
authors.forename: Zachary M
authors.initials: ZM
authors.lastname: Soler
authors.affiliation: Department of ENT, Guys and St Thomas NHS Trust, London, United Kingdom.
authors.forename: Claire
authors.initials: C
authors.lastname: Hopkins
authors.affiliation: Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
authors.forename: Rodney J
authors.initials: RJ
authors.lastname: Schlosser
authors.affiliation: Department of Internal Medicine, Northwestern University Allergy Division, Chicago, IL, USA.
authors.forename: Anju
authors.initials: A
authors.lastname: Peters
authors.affiliation: Division of Allergy and Immunology, Scripps Clinic, La Jolla, CA, USA.
authors.forename: Andrew A
authors.initials: AA
authors.lastname: White
authors.affiliation: Division of Otolaryngology, Head and Neck Surgery, University of Utah, Salt Lake City, UT, USA.
authors.forename: Richard R
authors.initials: RR
authors.lastname: Orlandi
authors.affiliation: Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Wytske J
authors.initials: WJ
authors.lastname: Fokkens
authors.affiliation: Department of Surgery, University of Auckland, Auckland, New Zealand.
authors.forename: Richard
authors.initials: R
authors.lastname: Douglas
authors.affiliation: Division of Rhinology and Sinus Surgery, Oregon Sinus Center, Department of Otolaryngology, Head and Neck Surgery, Oregon Health and Science University, Portland, OR, USA.
authors.forename: Timothy L
authors.initials: TL
authors.lastname: Smith
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002908:Chronic Disease; D003697:Delphi Technique; D004724:Endoscopy / Q000379:methods*; D006801:Humans; D009298:Nasal Polyps / Q000601:surgery*; D013517:Otorhinolaryngologic Surgical Procedures / Q000379:methods*; D010256:Paranasal Sinuses / Q000601:surgery*; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D012040:Regional Health Planning; D012220:Rhinitis / Q000175:diagnosis / Q000188:drug therapy / Q000601:surgery*; D012852:Sinusitis / Q000175:diagnosis / Q000188:drug therapy / Q000601:surgery*
chemical_list: D000900:Anti-Bacterial Agents