ORIGINAL ARTICLE

Geographic and temporal trends in frontal sinus surgery Peter F. Svider, MD1 , Vibhav Sekhsaria, MD1 , David S. Cohen, MD1 , Jean Anderson Eloy, MD, FACS2,3,4 , Michael Setzen, MD, FACS5,6 and Adam J. Folbe, MD 1

Background: The purpose of this study was to evaluate geographic and temporal trends in frontal sinus surgery procedures. Methods: Medicare Part B data files from 2000 to 2011 were examined for temporal trends in various frontal sinus procedures, and the most recent year containing geographic information (2010) was evaluated for Current Procedural Terminology (CPT) code use. Additionally, nationwide charges per procedure were recorded. Regional populations of individuals ࣙ65 years old were obtained from the 2010 U.S. Census, and surgical society websites were used to determine the number of practicing rhinologists and otolaryngologists in each region. Results: The use of open approaches declined by one third, while endoscopic procedures went from 6463 to 19262 annually, with the most marked increases occurring from 2006 through 2011. Geographic variation was noted, with practitioners in the South Atlantic states performing the greatest number of endoscopic procedures in 2010, whereas the East South Central states had the greatest number when controlling for population. There was an inverse relationship between endoscopic procedures performed and number of fellowship-trained rhinologists (controlling for re-

T

echnological innovations have facilitated changes in frontal sinus surgery practice patterns over the past

1 Department

of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI; 2 Department of Otolaryngology–Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ; 3 Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ; 4 Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ; 5 Rhinology Section, North Shore University Hospital, Manhasset, NY; 6 Department of Otolaryngology, New York University School of Medicine, New York, NY Correspondence to: Peter F. Svider, MD, Department of Otolaryngology– Head and Neck Surgery, Wayne State University School of Medicine, 4201 St. Antoine, 5E-UHC, Detroit, MI 48201; e-mail: [email protected] Potential conflict of interest: M.S. is a speaker for TEVA and MEDA on their Speakers Bureau (not related to current subject). Presented at the ARS 2014 Spring Meeting at the Combined Sections Meeting on May 16, 2014, Las Vegas, NV. [Correction added on 18 November 2014, after first online publication 3 November 2014: A minor text change was made in the Discussion section.]

gional populations) (R2 = 0.66). The first year frontal sinus ballooning had a unique CPT code illustrated decreased reimbursements for non-balloon endoscopic surgery ($609) relative to balloon approaches ($2635). Conclusion: Declines in open frontal sinus surgery and marked increases in endoscopic approaches have potential implications for residency training. Potential reasons for marked increases in endoscopic approaches include the rising popularity of balloon technologies, although this is speculative. Geographic variation exists in frontal sinus surgery paerns, including an inverse relationship between endoscopic approaches and the number of fellowship-trained C 2014 ARS-AAOA, LLC. rhinologists. 

Key Words: frontal sinusotomy; frontal sinus obliteration; osteoplastic flap; frontal sinus surgery; endoscopic frontal sinus surgery; frontal sinus balloon How to Cite this Article: Svider PF, Sekhsaria V, Cohen DS, Eloy JA, Setzen M, Folbe AJ. Geographic and temporal trends in frontal sinus surgery. Int Forum Allergy Rhinol. 2015;5:46–54.

15 years. Advances in endoscopic techniques have limited indications for invasive “open” approaches to only a few situations, with some questioning whether there is still a role for open frontal sinus surgery.1–8 The current healthcare and political climate, along with increasing consciousness of rising costs, has renewed interest in identifying costeffective medical practices. Consequently, recognition of geographic and temporal trends regarding management of specific disease processes may be of interest to practitioners and policymakers. Examining billing trends in sinus and septal surgery from 2007 to 2009, Psaltis et al.9 detailed a marked increase in frontal sinusotomy during this time period. Although reasons for this development were unclear, the authors Received: 6 February 2014; Revised: 2 August 2014; Accepted: 23 August 2014 DOI: 10.1002/alr.21425 View this article online at wileyonlinelibrary.com.

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TABLE 1. CPT codes used CPT/HCPCS code

31276 31296

Procedure

Nasal/sinus endoscopy, surgical, frontal sinusotomy a

Balloon with dilation of frontal sinus ostium

31070

Frontal sinus trephine

31075

Frontal sinusotomy, transorbital, Lynch

31080

Frontal sinusotomy, obliterative w/o osteoplastic flap, brow incision

31081

Frontal sinusotomy, obliterative, w/o osteoplastic flap, coronal incisions

31084

Frontal sinusotomy obliterative, osteoplastic, brow incision

31085

Frontal sinusotomy obliterative, osteoplastic, coronal incision

31086

Frontal sinusotomy, non-obliterative, osteoplastic, brow incision

31087

Frontal sinusotomy, non-obliterative, osteoplastic, coronal incision

a Code 31296 was only available starting 2011; 31296 cannot be reported in conjunction with 31276 when performed on the same sinus. CPT = Current Procedural Terminology; HCPCS = Healthcare Common Procedure Coding System; w/o = without.

posited that the popularization of balloon catheter dilation technology during this time period may have played a role: there was no separate Current Procedural Terminology (CPT) code for this procedure until 2011, and practitioners performing this technique billed using CPT code 31276, the primary code for endoscopic frontal sinusotomy. This prior study offers an important starting point in exploring frontal sinus surgery trends. In the present analysis, the authors aim to expand this discussion, because we were interested in looking at whether this marked increase has continued beyond 2009 and whether any trends were noted prior to 2007. Additionally, our objectives also included studying temporal trends in “open” frontal sinus approaches to characterize their relative use nationwide, along with a comparison of geographic trends in the use of frontal sinus surgery techniques. Our hope is that this analysis adds to the growing body of literature delineating how changes in technology may be affecting practice patterns.

Materials and methods Medicare Part B National Summary data files from 2000 through 2011 (https://www.cms.gov/Research-StatisticsData-and-Systems/Files-for-Order/NonIdentifiableData Files/PartBNationalSummaryDataFile.html) were evaluated for temporal trends involving CPT codes for frontal sinus surgery (Table 1). In addition to reporting the number of billed procedures for each CPT code, these files report total allowed charges, defined as “the amount Medicare determines to be reasonable payment for a provider or service covered under Part B.” These

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allowed charges include both the technical and facility fee components (facility fee may include the cost of equipment such as balloons). Codes including 31276 and 31296 were considered endoscopic procedures (31296 is a new code first available in 2011), whereas all other CPT codes analyzed were considered “open” approaches. Individual Medicare Part B Carrier files describe the number of billed procedures and allowed charges for each CPT code associated with individual carriers. Each carrier covers a different state, thus allowing information from carriers to provide insight into geographic differences. The most recent set of carrier files available were from 2010 (https://www.cms.gov/Research-Statistics-Data-andSystems/Files-for-Order/NonIdentifiableDataFiles/Part-BCarrier-Summary-Data-File-Items/CMS1252860.html), and each individual carrier file was analyzed for number of procedures available by CPT code. To preserve privacy, Medicare does not report the exact number of procedures reported within a state if there were less than 11 procedures, but still lists charges allowed. Using nationwide charges allowed per procedure averages from the 2010 national summary data file, the number of procedures performed was extrapolated in instances where it was not available, a methodology that has been used in prior analyses of regional practice patterns.10, 11 Regional results were organized using U.S. Census Bureau–designated regions: the West (including Mountain and Pacific states), Northeast (Mid-Atlantic and New England), Midwest (East North Central, West North Central), and South (West South Central, East South Central, South Atlantic). Additionally, regional rates per population were calculated using state and region-specific populations of individuals ࣙ65 years of age as counted by the 2010 census (https://www.census.gov/2010census). The American Rhinologic Society (ARS) online fellowship listing was used to access a list of previous fellows. A total of 103 fellowshiptrained rhinologists confirmed to be in practice in 2010 in the United States (ie, graduated fellowship by spring of 2010) were organized by their location of practice to facilitate further analysis of regional practice patterns in frontal sinus surgery. Additionally, data from the American College of Surgeons Health Policy Research Institute (http://www.acshpri.org/atlas/loadflash.php?s=0) was used to obtain information about the number of otolaryngologists in practice in each state. Data collection was completed in October 2013.

Statistical analysis Chi-square statistical testing was used for comparison of categorical variables as appropriate, with threshold for significance set at p < 0.05. SPSS version 20 (IBM, Armonk, NY) was used for statistical analysis.

Results The proportion of cases performed endoscopically did not differ among geographic regions (p > 0.05) (Table 2). The

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TABLE 2. Regional choice of endoscopic vs open frontal

sinus procedures in 2010 Region

Total frontal sinus procedures (n)

Endoscopic (%)

East North Central

2041

96.1

East South Central

1540

97.6

Mid-Atlantic

1460

96.4

Mountain

1351

96.7

New England

502

97.6

Pacific

1846

97.2

South Atlantic

3999

97.8

West North Central

1335

95.7

West South Central

2046

97.2

FIGURE 2. Total number of open frontal sinus procedures billed to Medicare annually. CPT = Current Procedural Terminology.

FIGURE 1. Total number of endoscopic frontal sinus procedures billed to Medicare annually. Note that balloon dilation did not have its own separate code until 2011. CPT = Current Procedural Terminology.

use of endoscopic techniques has risen since 2000, with the steepest increase occurring from 2007 through 2011 (Fig. 1). In the first year performance of frontal sinus balloons had a distinct available CPT code (31296), in 2011, there were 3209 procedures billed with this CPT code vs 16053 procedures billed with 31276 (endoscopic frontal sinusotomy); it is unclear the extent to which practitioners were familiar with new and separate billing codes (31296), so these 2 categories were combined for the year 2011 in Figure 1. During this time period, the use of open frontal sinus approaches has decreased, particularly from 2006 onward (Fig. 2). The use of endoscopic sinus procedures has

increased over this time period, although the percentage increase was far higher among endoscopic frontal sinus procedures relative to ethmoid, maxillary, and sphenoid procedures (Table 3, Fig. 3). In the most recent year for which state-by-state carrier files were available (2010), Florida had the highest overall number of endoscopic frontal sinus procedures billed to Medicare (1512), although upon controlling for size of population, Washington, DC, led the nation with 18.5 endoscopic frontal sinus procedures per 10,000 individuals over the age of 65 years (129 endoscopic procedures in total) (Fig. 4). In addition to state-by-state values, these trends were also organized by region (Fig. 5), revealing that the South Atlantic states had the greatest number of endoscopic procedures, and East South Central states had the greatest rate of procedures when adjusted by population over 65 years of age. States in the Northeast had the lowest rate of population-adjusted endoscopic procedures (Fig. 5). Upon examination of open frontal sinus procedures in 2010, South Atlantic states had the greatest number (88 total), whereas West North Central and Mountain states had the great population-adjusted rates (Fig. 6). Normalized by population of individuals ࣙ65 years of age, the regional relationship between endoscopic and open procedures and number of fellowship-trained rhinologists was examined. This comparison revealed an inverse relationship for both endoscopic and open procedures, and linear regression (Fig. 7) illustrates a stronger (inverse)

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TABLE 3. Temporal patterns in nasal/sinus endoscopic procedures, 2000–2011* Year

Ethmoid

Maxillary

Sphenoid

Frontal

2000

22912

11706

3591

6463

2001

23585 (2.9)

12411 (6.0)

4003 (11.5)

7232 (11.9)

2002

24380 (6.4)

13745 (17.4)

4301 (19.8)

8137 (25.9)

2003

24186 (5.6)

14404 (23.0)

4352 (21.2)

8081 (25.0)

2004

25083 (9.5)

15165 (29.5)

4590 (27.8)

8685 (34.4)

2005

24862 (8.5)

15492 (32.3)

4823 (34.3)

8811 (36.3)

2006

24538 (7.1)

15769 (34.7)

4860 (35.3)

9411 (45.6)

2007

24259 (5.9)

15796 (34.9)

4821 (34.3)

9875 (52.8)

2008

30835 (34.6)

20030 (71.1)

6426 (78.9)

13211 (104.4)

2009

34129 (49.0)

22560 (92.7)

7112 (98.1)

15750 (143.7)

2010

33580 (46.6)

22111 (88.9)

7072 (96.9)

16776 (159.6)

2011

34522 (50.7)

22964 (96.2)

7411 (106.4)

19262 (198.0)

*Values are number of cases (% change from 2000). Absolute numbers of cases reported in the Medicare national summary data files shown with percentage increase relative to the year 2000 in parentheses. Ethmoid cases derived from CPT 31255/31254: nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior), nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior). Maxillary antrostomy cases derived from CPT code 31267: nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus). Sphenoid cases derived from CPT code 31288: nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus. CPT = Current Procedural Terminology. Note: See Table 1 for CPT codes for frontal cases.

per procedure, considerably higher than the values detailed for other frontal sinus procedures.

Discussion

FIGURE 3. Percent increase from 2000 in the number of endoscopic procedures billed to Medicare, organized by anatomic location. Left (light blue) bars represent percent change from 2000–2005, right (Red) bars represent percent change from 2000–2011.

relationship between the endoscopic frontal sinus surgery and number of fellowship-trained rhinologists in practice in 2010. There was no relationship between number of practicing otolaryngologists and endoscopic frontal sinus surgery (Fig. 8) when controlling for population and organizing by region. The average allowed charges per procedure are reported in the national summary database files (ie, total number of procedures and total charges), and are detailed in Figure 9. In 2011, the first year frontal sinus balloon procedures had a separate CPT code, average charges allowed were $2635

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Figure 1 reinforces previously anecdotal findings, demonstrating a robust acceleration in endoscopic approaches starting from 2006. Psaltis et al.9 was the first to quantify a portion of this trend, noting that over the 3-year period from 2007 through 2009, there were marked increases in this procedure, along with others considered to be technically difficult. The findings from our current analysis not only augments the prior analysis’s results over a broad range of years, but also provides support to several theories raised regarding reasons for this increase, including the advent and population of balloon sinus dilation techniques. Furthermore, although endoscopic sinonasal procedures overall have increased during this time period, Table 3 makes it clear that this increase is most marked among frontal sinus procedures. With the advent of endoscopic frontal sinusotomy techniques and improving technology, 1 potential reason previously theorized for [anecdotal] increases in frontal sinus procedures was the introduction of novel endoscopic techniques and instruments that general otolaryngologists were more comfortable using, making procedures previously considered “advanced” or “risky” more accessible for the majority of practitioners. Although the number of billed endoscopic frontal sinus procedures has risen dramatically since 2000, the opposite is true of open frontal sinus procedures (Figs. 1 and 2). Given the overall increase

Svider et al.

FIGURE 4. Dorling Cartogram illustrating rate of endoscopic frontal sinus surgery (shading key at inset, based on population over 65 years of age in each state as per 2010 U.S. Census). Area of each circle proportion to total number of endoscopic frontal sinus procedures (CPT 31276) performed in each state in 2010 among Medicare population. CPT = Current Procedural Terminology.

of frontal sinus procedures since 2000, it is thus evident that endoscopic procedures have not just increased the number of frontal sinus procedures done overall, but these techniques have likely replaced open frontal sinus procedures in many instances. With the advent of balloon frontal sinus dilation techniques, we would expect that this trend would be even more marked, although this inference is difficult to delineate because until 2011 there was no separate CPT code for balloon sinus dilation. The advent of balloon sinus dilation has raised questions regarding optimal procedures for sinus surgery. In the frontal sinus, this has allowed practitioners, who might have otherwise avoided the more technically demanding endoscopic frontal sinus surgery, to explore the option of performing a minimally invasive and relatively safe technique for frontal sinusotomy. Although reimbursement for balloon dilatation of the frontal sinuses exceeds that of more traditional approaches (Fig. 8), advocates note that overall costs may still be comparable, because less operating room time is used, fewer debridements are needed, and patients are able to return to work/school sooner. Furthermore, balloon sinus dilation may offer an acceptable functional alternative to populations that may not be fit to undergo more extensive procedures. Although the efficacy of using balloon sinus dilation vs typical endoscopic procedures is still the topic of much debate, we have already seen an increase in billed frontal sinus procedures that we believe to be due in part to an increase in the usage of

balloon sinus dilation techniques (Fig. 1). One area of concern includes the lack of double-blind randomized studies comparing these techniques to one another. In a Cochran review published in 2011,12 only 1 study performed by Plaza et al.13 met all of the inclusion criteria for a Cochranbased review of endoscopic vs balloon sinus dilation. This 1 study was severely limited because much of the data was subject to significant risk of bias stemming from limited sample size (34 patients), subjective outcome measures (endoscopic patency analysis), and a selective comparison bias with the conspicuous absence of comparison of symptom scores between groups, as well as a lack of hard numerical data. As such, the efficacy of balloon sinus dilation remains relatively undefined when compared to typical endoscopic sinus procedures. Questions exist regarding financial reimbursements of the various frontal sinus procedures examined. Despite no documented differences in efficacy among endoscopic frontal sinus approaches and balloon sinus dilation, there are differences in charges allowed (Fig. 9), suggesting room for increased reimbursement for performance of endoscopic frontal sinus approaches. Proponents of the balloon techniques claim that the balloon procedures offer a safer, minimally invasive procedure that may offer comparable results to endoscopic techniques in the select patient.14 As more research is performed in this area it may be necessary to consider incentivizing endoscopic frontal sinus procedures in circumstances where its usage would be superior to a

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FIGURE 5. Dorling Cartogram illustrating rate of endoscopic frontal sinus surgery (shading key at inset, based on population over 65 years of age in each region as per 2010 U.S. Census). Area of each circle proportion to total number of endoscopic frontal sinus procedures (CPT 31276) performed in each region in 2010 among Medicare population. CPT = Current Procedural Terminology.

FIGURE 6. Dorling Cartogram illustrating rate of open frontal sinus surgery (shading key at inset, based on population over 65 years of age in each region as per 2010 U.S. Census). Area of each circle proportion to total number of open frontal sinus procedures (CPT 31070, 075, 080, 081, 084, 085, 086, 087) performed in each region in 2010 among Medicare population. CPT = Current Procedural Terminology.

balloon sinus dilation technique, thus reducing the difference in reimbursement and minimizing the predilection of practitioners to choose balloon-sinus dilation from a purely cost-benefit standpoint. While newer techniques such as balloon sinus dilation await validation but are quickly inculcated in today’s prac-

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tice, some established but more technically demanding procedures are decreasing dramatically (Fig. 2). This raises implications not only for the nature of frontal sinus surgery today but also for residency training. As the number of open procedures continues to decrease, it is not unimaginable that residents will finish training and be unprepared

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FIGURE 7. Endoscopic (left) and open (right) frontal sinus procedures normalized by population and compared to number of fellowship-trained rhinologists in each region. Note that each point on the chart represents a different region.

FIGURE 8. Endoscopic frontal sinus procedures normalized by population and compared to number of otolaryngologists in each region. Note that each point on the chart represents a different region.

to perform open procedures as a result of lack of exposure and training in these procedures. Although at the moment the relevancy of open sinus procedures is still valid in technically challenging cases, it may be that we are slowly progressing toward the day where open frontal sinus pro-

cedures, much like the Caldwell-Luc procedure, will be rendered relatively obsolete. Over the decade of data covered by our analysis, increases in Medicare billing patterns have been noted for all anatomic locations in which endoscopic procedures were

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FIGURE 9. Charges allowed per procedure organized by CPT code. 2010 and 2011 reported values shown. Note that 31296 was first reported in 2011, so there is no 2010 value. CPT = Current Procedural Terminology.

performed (Table 3, Fig. 3). Although harboring the lowest percentage increase, ethmoid procedures significantly rose, with the increase still exceeding 50%. The increase in frontal sinus procedures, however, dramatically outpaced figures found for other procedures—a nearly 200% increase (Table 3). Reasons for these relative differences are speculative, but may include reimbursement patterns and incentives, evolving technologies, level of training, and general comfort with the performance of these procedures as outlined above. The effect of training techniques can perhaps be seen from a practicing perspective as well. In Figure 7 it is possible to see that the number of both endoscopic cases and open cases billed per year has an inverse relationship with fellowshiptrained rhinologists practicing in the area. Although the reason for this finding is unclear, several points of speculation may be related to complicated cases being referred to fellowship-trained surgeons who can achieve a surgical competence over tertiary level cases that then need fewer revision surgeries. Further studies evaluating the number of revision cases regionally would be needed to validate this relationship. Figures 5 and 6 highlight a regional difference not only in the distribution of endoscopic cases but that of open cases as well. It is worth noting that while these regional

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variations exist, the variations seen in Figure 5 mirror those seen in Figure 6, suggesting that the region where most endoscopic cases are performed is the same region where the most open cases are performed, although inferences from this data are difficult to make without a regional analysis of both practitioners as well as case presentations to look for factors that could explain these differences. Although this analysis comprehensively delineates evolving temporal and geographic trends in both endoscopic and open frontal sinus procedures, there are several limitations inherent to our study design. The most significant limitation deals with this data source’s restriction to the Medicare population; although Medicare is the single largest healthcare payer in the United States, its population is comprised predominantly of patients greater than 65 years of age, making the applicability of these trends to younger patients questionable. An analysis of the patients undergoing sinus surgery has previously noted that greater than 80% of patients are adults younger than 65 years of age.15 Although we are able to evaluate overall trends, there was no publically available information in the Medicare carrier and national summary files that link the use of these specific CPT codes to specific diagnoses; that would have been more helpful in elucidating the reasons as to why these evolving patterns are occurring, making several points in our discussion speculative. Nonetheless, identification of trends by use of CPT code utilization is a crucial first step in directing a subsequent cost analysis for the reasons for described trends. Our analysis has potentially significant implications in that it identifies several notable movements in the field of frontal sinus surgery, one of which includes a steady increase in frontal sinus surgery over the early part of the 2000s, hastening in 2006. As mentioned, frontal sinus balloon dilation was given its own unique CPT identifier in 2011, and as more years pass by and information regarding its utilization is made available, further study would certainly be valuable for general otolaryngologists, fellowshiptrained rhinologists, healthcare payers, and health policy organizations.

Conclusion Our analysis illustrates the declining number of open frontal sinus surgeries, suggesting potential implications on residency training for this procedure. On the other hand, endoscopic approaches have steadily increased, most markedly since 2006. Potential reasons for this are speculative but include the rising popularity of balloon technologies for frontal sinus access. Geographic variation exists in frontal sinus surgery patterns when controlled by population. Interestingly, there was a strong inverse relationship between the performance of endoscopic frontal sinus surgery and the number of fellowship-trained rhinologists when considering individual states.

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Geographic and temporal trends in frontal sinus surgery.

The purpose of this study was to evaluate geographic and temporal trends in frontal sinus surgery procedures...
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