ORIGINAL ARTICLE
Trends of ambulatory sinus surgery for chronic rhinosinusitis Hossein Mahboubi, MD, MPH and Naveen D. Bhandarkar, MD
Background: We sought to examine the trends in rates and demographics of ambulatory endoscopic and open sinus surgery for chronic sinusitis over a 7-year period in the state of California. Methods: Patient records with Current Procedural Terminology (CPT) codes for endoscopic or open sinus surgery, and diagnosis codes for chronic rhinosinusitis were extracted from the California Ambulatory Surgery Datasets from 2005 to 2011. Population-adjusted surgery rates were calculated as the number of surgeries per 100,000 California residents. Location of surgery was analyzed in 2 contexts: freestanding ambulatory surgery centers (ASCs) vs any hospital seing, and academic (university medical centers) vs nonacademic centers (ASCs and non-university hospitals combined). Patients’ demographics were also examined. Results: A total of 91,984 sinus surgeries were performed during 2005 to 2011. The overall population-adjusted surgery rate declined 24%, from 38.9 to 29.6 (p = 0.004). Although the rates for both endoscopic and open surgeries declined, the percentage of endoscopic procedures
C
hronic rhinosinusitis (CRS) continues to be a major burden to the healthcare system and productivity in the United States. Each year, CRS is responsible for approximately 14 million visits to physicians,1 4 million lost workdays,2 and $12.8 billion in economic burden.3 The average number of workdays lost was estimated at 24.6 days per patient per year in a recent prospective study.3 Despite these substantial consequences, there generally remains no
Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, CA Correspondence to: Naveen D. Bhandarkar, MD, Director of Rhinology and Sinus Surgery, Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, 101 The City Dr. S., Bldg. 56, Ste. 500, Orange, CA 92868–3201; e-mail: [email protected] Potential conflict of interest: None provided. Presented at the 59th Annual ARS on September 28, 2013, Vancouver, BC, Canada. Received: 13 June 2014; Revised: 2 November 2014; Accepted: 11 November 2014 DOI: 10.1002/alr.21473 View this article online at wileyonlinelibrary.com.
increased from 87.3% to 92.5% of all surgeries (p = 0.002). Over the studied period, there was an increase in the proportion of sinus surgeries performed in hospitals (73.2% to 91.3%; p = 0.01), in academic centers (5.9% to 10.1%; p = 65 years (14.7% to 17.8%; p = 0.003), and on non-Caucasians (10.3% to 16.9%; p < 0.001). Gender distribution remained unchanged (51% male; p = 0.25). Conclusion: The overall rate of ambulatory sinus surgery in California declined over the study period. A shi from open to endoscopic procedures, from ASCs to hospitals, and from nonacademic to academic centers was observed. Further investigation of the observed trends may be warC 2014 ARS-AAOA, LLC. ranted.
Key Words: chronic rhinosinusitis; endoscopy; ambulatory surgery; sinus surgery; endoscopic sinus surgery; population-based study How to Cite this Article: Mahboubi H, Bhandarkar ND. Trends of ambulatory sinus surgery for chronic rhinosinusitis. Int Forum Allergy Rhinol. 2015;5:318–325.
cure for the disease, and the mainstay of treatment largely remains initial and long-term medical management with surgery considered in recalcitrant cases.4, 5 According to previous studies, sinus surgeries are not only increasingly being performed in the ambulatory setting, but are also among the most common outpatient procedures performed in the United States.6, 7 Endoscopic sinus surgery (ESS) has revolutionized the landscape of sinus surgeries and progressively replaced open surgery since its introduction in the mid 1980s.7, 8 There is little published about the trends of sinus surgeries for CRS in the outpatient setting in recent years. Specifically, detailed objective data are lacking in the recent rhinology literature regarding where these procedures are performed, what proportion of surgeries are endoscopic vs open, how many procedures are being performed per patient, and more importantly, whether and how these proportions have changed over time. In addition, a number of consensus guidelines on the diagnosis and management of CRS have been published in recent years, which could have affected these trends.8–11
International Forum of Allergy & Rhinology, Vol. 5, No. 4, April 2015
318
Ambulatory sinus surgery in California
Exploring these factors would help otolaryngologists understand how the practice of surgery for chronic sinusitis has evolved in recent years and build a foundation for investigators and policy makers to reevaluate the current protocols. In the current study, we aimed to answer the abovementioned questions by utilizing the California Ambulatory Surgery data to examine the trends in rates, demographics, and outcomes of ambulatory endoscopic and open sinus surgery for chronic sinusitis in recent years. In addition, we sought to investigate what factors were associated with the use of endoscopic over open surgery and use of image guidance.
TABLE 1. List of ICD-9-CM and CPT codes used to define
variables CPT codes
Sinus surgery Endoscopic
31254–31256, 31267, 31276, 31287–31288
Open
31020, 31030, 31032, 31050–31051, 31070, 31075, 31080–31081, 31084–31087, 31090, 31200–31201, 31205
Image guidance
61782, 61795 ICD-9-CM codes
Chronic sinusitis
Materials and methods Data source The California Ambulatory Surgery data sets are collected and maintained by the California Office of Statewide Health Planning and Development (OSHPD). Patient level data, such as demographic, payor, and facility information, are acquired from all licensed ambulatory surgery facilities in California. All records are deidentified and each represents an encounter during which at least 1 ambulatory surgery procedure was performed. Ambulatory surgery was defined as any outpatient procedures performed in the general operating rooms, ambulatory surgery rooms, endoscopy units, or cardiac catheterization laboratories of a hospital or a freestanding ambulatory surgery clinic. In-office procedures were not included in these datasets. Further information on data collection instruments and methodology is available on the website of OSHPD.12 Patients’ diagnoses were coded using the International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM). Procedures were coded using the Current Procedural Terminology (CPT) codes. All available datasets from 2005 to 2011 were obtained and merged. Cases with ICD-9-CM diagnosis codes for chronic sinusitis and CPT codes for either endoscopic or open sinus surgery were extracted. Cases with ICD-9-CM diagnosis codes for nasal and sinus neoplasms were excluded. Table 1 provides a list of all codes used to define the variables in this study.
471–471.9, 473–473.9 a
Sinonasal neoplasms
160–160.9, 212.0
a Patient records were specifically excluded from analysis if they listed any of these codes for sinonasal neoplasms. CPT = Current Procedural Terminology; ICD-9-CM = International Classification of Diseases, 9th edition, Clinical Modification.
the relevant CPT codes (Table 1). Furthermore, university medical centers, as determined by the Association of American Medical Colleges, were compared with all other facilities (non-university hospitals and freestanding ASCs). Disposition was defined as the consequent arrangement or event ending a patient’s encounter, which was analyzed as routine discharge (home residence) vs other-than-routine (acute, other, and long-term care within the hospital, and acute and other care at another hospital; “other” included skilled nursing/intermediate care, residential care facility, prison/jail, left against medical advice, and home health service). Finally, principal payor was defined as the type of entity or organization expected to pay the greatest share of the patient’s bill. Principal payor was regrouped into: (1) Medicare; (2) Medi-Cal (California’s Medicaid program); (3) private coverage (ie, health maintenance organization [HMO], preferred provider organization [PPO], Blue Cross, and Blue Shield); and (4) other (ie, self-pay, worker’s compensation, health benefits for U.S. military retirees and dependents [TRICARE], charity, county indigent programs, other government and indigent programs: includes out of state Medicaid).
Variables and definitions
Statistical analysis
Total number of surgeries and population-adjusted surgery rates (number of surgeries per 100,000 California residents) were calculated. Patients’ age was grouped into 0 to 17 years, 18 to 34 years, 35 to 64 years, and 65 years and older. Gender was analyzed as males vs females. Ethnicity was re-coded as Caucasian vs non-Caucasian (representing African-Americans, Native-Americans/Eskimo/Aleut, Asian/Pacific Islanders, and others). Location of surgery was determined based on the license type of the reporting facility and was classified as freestanding ambulatory surgery centers (ASCs) vs hospitals. Use of image guidance was determined through examining
Population-adjusted surgery rates were calculated as the total numbers of surgeries per year divided by the total population of California during that year and multiplied by 100,000. California population estimates were obtained from the U.S. Census Bureau website.13 Linear regression analysis was used to investigate whether the populationadjusted rates, demographics, and outcomes followed a specific trend over time. Furthermore, a multivariate logistic regression model was fit to determine if any of the surgery year, location, patient demographics, or principal payor was associated with incidence of endoscopic surgery. The results of the multivariate analysis were reported as
319
International Forum of Allergy & Rhinology, Vol. 5, No. 4, April 2015
Mahboubi and Bhandarkar
FIGURE 1. Absolute number of sinus surgeries performed in California.
odds ratios (ORs) along with their 95% confidence interval (CI). As a secondary analysis, the use of image guidance in ESS and its association with each CPT code was analyzed through univariate and multivariate analyses. All data analyses were performed using PASW Statistics 18.0 (SPSS, Inc., Chicago, IL). A p value of less than 0.05 was considered significant.
Results During 2005 to 2011, 83,452 endoscopic and 8532 open surgeries were performed in California, amounting to a total of 91,984 sinus surgeries. The total number of sinus surgeries decreased by 20%, from 13,930 surgeries in 2005 to 11,150 surgeries in 2011 (adjusted R2 = 0.75; p = 0.007). As illustrated in Figure 1, this number decreased for both endoscopic and sinus surgeries (adjusted R2 = 0.56; p = 0.03 and adjusted R2 = 0.92; p < 0.001, respectively). The population-adjusted rate for all sinus surgeries declined 24%, from 38.9 per 100,000 California residents to 29.6 per 100,000 California residents (adjusted R2 = 0.81; p = 0.004) as shown in Figure 2. This rate for endoscopic surgeries decreased by 19%, from 33.9 to 27.4 (adjusted R2 = 0.67; p = 0.02), and for open surgeries by 55%, from 4.9 to 2.2 during the same period (adjusted R2 = 0.92; p < 0.001). Although the rates for both endoscopic and open surgeries declined, the 55% decline for open surgeries was greater than the decline seen for endoscopic surgeries. Patient demographics also changed during the 7-year study period (Table 2). From 2005 to 2011, there was an increase in the proportion of sinus surgeries on patients >65 years (14.7% to 17.8%; p = 0.003) and on nonCaucasians (10.3% to 16.9%; p < 0.001). Gender distribution remained unchanged (50.8% male; p = 0.25). The percentage of patients with Medi-Cal as principal payor increased from 2.8% to 5.4% (p = 0.003) while the percentages for Medicare and private payors did not change significantly (p = 0.13 and p = 0.48, respectively). Over the studied period, sinus surgeries shifted from being performed in ASCs toward hospitals (Table 3). The per-
FIGURE 2. Population-adjusted rates for sinus surgeries performed in California.
centage of sinus surgeries performed in hospitals rose from 73.2% in 2005 to 91.3% in 2011 (p = 0.01) and the percentage of surgeries performed in university medical centers rose from 5.9% to 10.1% during the same period (p = < 0.001). With respect to surgery type, a shift was also noted from open toward endoscopic surgeries. The percentage of endoscopic surgeries increased from 87.3% to 92.5% of all surgeries (p = 0.002). This shift was associated with a slight increase in the mean number of procedures performed per patient, from 2.10 ± 1.05 to 2.33 ± 1.12 during 2005 to 2011 (p = 0.003). Finally, the proportion of patients who were routinely discharged to their home residence increased from 98.4% of all surgeries in 2005 to 99.7% of all surgeries in 2011 (p = 0.02). The multivariate analysis revealed that the year of surgery, age, principal payor, and location and setting of the surgeries correlated with patients undergoing endoscopic rather than open surgery (Table 4). Patients were more likely to undergo endoscopic surgery in years 2008 through 2011 compared to 2005 (all p < 0.001). Patients 65 years or older were also 1.28 times more likely to undergo endoscopic surgery (95% CI, 1.06 to 1.54; p = 0.009). The odds of patients with Medicare and Medi-Cal undergoing endoscopic surgery were 0.78 (95% CI, 0.70 to 0.88; p < 0.001) and 0.64 (95% CI, 0.55 to 0.75; p < 0.001), respectively, Hospitals were more likely to perform endoscopic surgery (OR = 1.47; 95% CI, 1.35 to 1.60; p < 0.001). The association was even stronger in university medical centers (OR = 2.75; 95% CI, 2.27 to 3.33; p < 0.001). Table 5 presents the analysis of the use of image guidance in ESSs. The use of image guidance increased over the studied period, and was more prevalent in ASCs, universities, total ethmoidectomies, maxillary antrostomies with or without tissue removal, frontal sinusotomies, and sphenoidotomies with or without tissue removal. The multivariate analysis revealed that the odds of using image
International Forum of Allergy & Rhinology, Vol. 5, No. 4, April 2015
320
Ambulatory sinus surgery in California
TABLE 2. Patient characteristics and payor information for all sinus surgeries performed in California* Age (years)
Ethnicity ࣙ65
0–17
18–34
35–64
Total
5.2
16.3
63.0
15.5
2005
5.6
16.4
63.3
2006
5.6
16.0
2007
5.2
2008
Non-Caucasian
Medicare
Private
Other
86.9
13.1
11.7
3.7
79.6
5.0
14.7
89.7
10.3
11.7
2.8
78.5
7.0
65.0
13.4
89.2
10.8
10.6
3.2
80.0
6.3
16.7
63.5
14.7
88.5
11.5
11.4
2.8
80.7
5.1
4.8
16.2
63.6
15.4
87.4
12.6
12.1
3.3
80.6
3.9
2009
5.0
16.5
62.3
16.3
85.4
14.6
12.2
4.0
80.0
3.8
2010
5.0
16.2
61.9
16.9
83.8
16.2
11.9
4.8
79.1
4.1
5.0
16.4
60.8
17.8
83.1
16.9
12.1
5.4
77.8
4.7
Adjusted R
0.54
−0.19
0.65
0.82
0.96
0.28
0.83
−0.07
0.54
p
0.03
0.88
0.01
0.003
Trends of ambulatory sinus surgery for chronic rhinosinusitis Hossein Mahboubi, MD, MPH and Naveen D. Bhandarkar, MD
Background: We sought to examine the trends in rates and demographics of ambulatory endoscopic and open sinus surgery for chronic sinusitis over a 7-year period in the state of California. Methods: Patient records with Current Procedural Terminology (CPT) codes for endoscopic or open sinus surgery, and diagnosis codes for chronic rhinosinusitis were extracted from the California Ambulatory Surgery Datasets from 2005 to 2011. Population-adjusted surgery rates were calculated as the number of surgeries per 100,000 California residents. Location of surgery was analyzed in 2 contexts: freestanding ambulatory surgery centers (ASCs) vs any hospital seing, and academic (university medical centers) vs nonacademic centers (ASCs and non-university hospitals combined). Patients’ demographics were also examined. Results: A total of 91,984 sinus surgeries were performed during 2005 to 2011. The overall population-adjusted surgery rate declined 24%, from 38.9 to 29.6 (p = 0.004). Although the rates for both endoscopic and open surgeries declined, the percentage of endoscopic procedures
C
hronic rhinosinusitis (CRS) continues to be a major burden to the healthcare system and productivity in the United States. Each year, CRS is responsible for approximately 14 million visits to physicians,1 4 million lost workdays,2 and $12.8 billion in economic burden.3 The average number of workdays lost was estimated at 24.6 days per patient per year in a recent prospective study.3 Despite these substantial consequences, there generally remains no
Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, CA Correspondence to: Naveen D. Bhandarkar, MD, Director of Rhinology and Sinus Surgery, Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, 101 The City Dr. S., Bldg. 56, Ste. 500, Orange, CA 92868–3201; e-mail: [email protected] Potential conflict of interest: None provided. Presented at the 59th Annual ARS on September 28, 2013, Vancouver, BC, Canada. Received: 13 June 2014; Revised: 2 November 2014; Accepted: 11 November 2014 DOI: 10.1002/alr.21473 View this article online at wileyonlinelibrary.com.
increased from 87.3% to 92.5% of all surgeries (p = 0.002). Over the studied period, there was an increase in the proportion of sinus surgeries performed in hospitals (73.2% to 91.3%; p = 0.01), in academic centers (5.9% to 10.1%; p = 65 years (14.7% to 17.8%; p = 0.003), and on non-Caucasians (10.3% to 16.9%; p < 0.001). Gender distribution remained unchanged (51% male; p = 0.25). Conclusion: The overall rate of ambulatory sinus surgery in California declined over the study period. A shi from open to endoscopic procedures, from ASCs to hospitals, and from nonacademic to academic centers was observed. Further investigation of the observed trends may be warC 2014 ARS-AAOA, LLC. ranted.
Key Words: chronic rhinosinusitis; endoscopy; ambulatory surgery; sinus surgery; endoscopic sinus surgery; population-based study How to Cite this Article: Mahboubi H, Bhandarkar ND. Trends of ambulatory sinus surgery for chronic rhinosinusitis. Int Forum Allergy Rhinol. 2015;5:318–325.
cure for the disease, and the mainstay of treatment largely remains initial and long-term medical management with surgery considered in recalcitrant cases.4, 5 According to previous studies, sinus surgeries are not only increasingly being performed in the ambulatory setting, but are also among the most common outpatient procedures performed in the United States.6, 7 Endoscopic sinus surgery (ESS) has revolutionized the landscape of sinus surgeries and progressively replaced open surgery since its introduction in the mid 1980s.7, 8 There is little published about the trends of sinus surgeries for CRS in the outpatient setting in recent years. Specifically, detailed objective data are lacking in the recent rhinology literature regarding where these procedures are performed, what proportion of surgeries are endoscopic vs open, how many procedures are being performed per patient, and more importantly, whether and how these proportions have changed over time. In addition, a number of consensus guidelines on the diagnosis and management of CRS have been published in recent years, which could have affected these trends.8–11
International Forum of Allergy & Rhinology, Vol. 5, No. 4, April 2015
318
Ambulatory sinus surgery in California
Exploring these factors would help otolaryngologists understand how the practice of surgery for chronic sinusitis has evolved in recent years and build a foundation for investigators and policy makers to reevaluate the current protocols. In the current study, we aimed to answer the abovementioned questions by utilizing the California Ambulatory Surgery data to examine the trends in rates, demographics, and outcomes of ambulatory endoscopic and open sinus surgery for chronic sinusitis in recent years. In addition, we sought to investigate what factors were associated with the use of endoscopic over open surgery and use of image guidance.
TABLE 1. List of ICD-9-CM and CPT codes used to define
variables CPT codes
Sinus surgery Endoscopic
31254–31256, 31267, 31276, 31287–31288
Open
31020, 31030, 31032, 31050–31051, 31070, 31075, 31080–31081, 31084–31087, 31090, 31200–31201, 31205
Image guidance
61782, 61795 ICD-9-CM codes
Chronic sinusitis
Materials and methods Data source The California Ambulatory Surgery data sets are collected and maintained by the California Office of Statewide Health Planning and Development (OSHPD). Patient level data, such as demographic, payor, and facility information, are acquired from all licensed ambulatory surgery facilities in California. All records are deidentified and each represents an encounter during which at least 1 ambulatory surgery procedure was performed. Ambulatory surgery was defined as any outpatient procedures performed in the general operating rooms, ambulatory surgery rooms, endoscopy units, or cardiac catheterization laboratories of a hospital or a freestanding ambulatory surgery clinic. In-office procedures were not included in these datasets. Further information on data collection instruments and methodology is available on the website of OSHPD.12 Patients’ diagnoses were coded using the International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM). Procedures were coded using the Current Procedural Terminology (CPT) codes. All available datasets from 2005 to 2011 were obtained and merged. Cases with ICD-9-CM diagnosis codes for chronic sinusitis and CPT codes for either endoscopic or open sinus surgery were extracted. Cases with ICD-9-CM diagnosis codes for nasal and sinus neoplasms were excluded. Table 1 provides a list of all codes used to define the variables in this study.
471–471.9, 473–473.9 a
Sinonasal neoplasms
160–160.9, 212.0
a Patient records were specifically excluded from analysis if they listed any of these codes for sinonasal neoplasms. CPT = Current Procedural Terminology; ICD-9-CM = International Classification of Diseases, 9th edition, Clinical Modification.
the relevant CPT codes (Table 1). Furthermore, university medical centers, as determined by the Association of American Medical Colleges, were compared with all other facilities (non-university hospitals and freestanding ASCs). Disposition was defined as the consequent arrangement or event ending a patient’s encounter, which was analyzed as routine discharge (home residence) vs other-than-routine (acute, other, and long-term care within the hospital, and acute and other care at another hospital; “other” included skilled nursing/intermediate care, residential care facility, prison/jail, left against medical advice, and home health service). Finally, principal payor was defined as the type of entity or organization expected to pay the greatest share of the patient’s bill. Principal payor was regrouped into: (1) Medicare; (2) Medi-Cal (California’s Medicaid program); (3) private coverage (ie, health maintenance organization [HMO], preferred provider organization [PPO], Blue Cross, and Blue Shield); and (4) other (ie, self-pay, worker’s compensation, health benefits for U.S. military retirees and dependents [TRICARE], charity, county indigent programs, other government and indigent programs: includes out of state Medicaid).
Variables and definitions
Statistical analysis
Total number of surgeries and population-adjusted surgery rates (number of surgeries per 100,000 California residents) were calculated. Patients’ age was grouped into 0 to 17 years, 18 to 34 years, 35 to 64 years, and 65 years and older. Gender was analyzed as males vs females. Ethnicity was re-coded as Caucasian vs non-Caucasian (representing African-Americans, Native-Americans/Eskimo/Aleut, Asian/Pacific Islanders, and others). Location of surgery was determined based on the license type of the reporting facility and was classified as freestanding ambulatory surgery centers (ASCs) vs hospitals. Use of image guidance was determined through examining
Population-adjusted surgery rates were calculated as the total numbers of surgeries per year divided by the total population of California during that year and multiplied by 100,000. California population estimates were obtained from the U.S. Census Bureau website.13 Linear regression analysis was used to investigate whether the populationadjusted rates, demographics, and outcomes followed a specific trend over time. Furthermore, a multivariate logistic regression model was fit to determine if any of the surgery year, location, patient demographics, or principal payor was associated with incidence of endoscopic surgery. The results of the multivariate analysis were reported as
319
International Forum of Allergy & Rhinology, Vol. 5, No. 4, April 2015
Mahboubi and Bhandarkar
FIGURE 1. Absolute number of sinus surgeries performed in California.
odds ratios (ORs) along with their 95% confidence interval (CI). As a secondary analysis, the use of image guidance in ESS and its association with each CPT code was analyzed through univariate and multivariate analyses. All data analyses were performed using PASW Statistics 18.0 (SPSS, Inc., Chicago, IL). A p value of less than 0.05 was considered significant.
Results During 2005 to 2011, 83,452 endoscopic and 8532 open surgeries were performed in California, amounting to a total of 91,984 sinus surgeries. The total number of sinus surgeries decreased by 20%, from 13,930 surgeries in 2005 to 11,150 surgeries in 2011 (adjusted R2 = 0.75; p = 0.007). As illustrated in Figure 1, this number decreased for both endoscopic and sinus surgeries (adjusted R2 = 0.56; p = 0.03 and adjusted R2 = 0.92; p < 0.001, respectively). The population-adjusted rate for all sinus surgeries declined 24%, from 38.9 per 100,000 California residents to 29.6 per 100,000 California residents (adjusted R2 = 0.81; p = 0.004) as shown in Figure 2. This rate for endoscopic surgeries decreased by 19%, from 33.9 to 27.4 (adjusted R2 = 0.67; p = 0.02), and for open surgeries by 55%, from 4.9 to 2.2 during the same period (adjusted R2 = 0.92; p < 0.001). Although the rates for both endoscopic and open surgeries declined, the 55% decline for open surgeries was greater than the decline seen for endoscopic surgeries. Patient demographics also changed during the 7-year study period (Table 2). From 2005 to 2011, there was an increase in the proportion of sinus surgeries on patients >65 years (14.7% to 17.8%; p = 0.003) and on nonCaucasians (10.3% to 16.9%; p < 0.001). Gender distribution remained unchanged (50.8% male; p = 0.25). The percentage of patients with Medi-Cal as principal payor increased from 2.8% to 5.4% (p = 0.003) while the percentages for Medicare and private payors did not change significantly (p = 0.13 and p = 0.48, respectively). Over the studied period, sinus surgeries shifted from being performed in ASCs toward hospitals (Table 3). The per-
FIGURE 2. Population-adjusted rates for sinus surgeries performed in California.
centage of sinus surgeries performed in hospitals rose from 73.2% in 2005 to 91.3% in 2011 (p = 0.01) and the percentage of surgeries performed in university medical centers rose from 5.9% to 10.1% during the same period (p = < 0.001). With respect to surgery type, a shift was also noted from open toward endoscopic surgeries. The percentage of endoscopic surgeries increased from 87.3% to 92.5% of all surgeries (p = 0.002). This shift was associated with a slight increase in the mean number of procedures performed per patient, from 2.10 ± 1.05 to 2.33 ± 1.12 during 2005 to 2011 (p = 0.003). Finally, the proportion of patients who were routinely discharged to their home residence increased from 98.4% of all surgeries in 2005 to 99.7% of all surgeries in 2011 (p = 0.02). The multivariate analysis revealed that the year of surgery, age, principal payor, and location and setting of the surgeries correlated with patients undergoing endoscopic rather than open surgery (Table 4). Patients were more likely to undergo endoscopic surgery in years 2008 through 2011 compared to 2005 (all p < 0.001). Patients 65 years or older were also 1.28 times more likely to undergo endoscopic surgery (95% CI, 1.06 to 1.54; p = 0.009). The odds of patients with Medicare and Medi-Cal undergoing endoscopic surgery were 0.78 (95% CI, 0.70 to 0.88; p < 0.001) and 0.64 (95% CI, 0.55 to 0.75; p < 0.001), respectively, Hospitals were more likely to perform endoscopic surgery (OR = 1.47; 95% CI, 1.35 to 1.60; p < 0.001). The association was even stronger in university medical centers (OR = 2.75; 95% CI, 2.27 to 3.33; p < 0.001). Table 5 presents the analysis of the use of image guidance in ESSs. The use of image guidance increased over the studied period, and was more prevalent in ASCs, universities, total ethmoidectomies, maxillary antrostomies with or without tissue removal, frontal sinusotomies, and sphenoidotomies with or without tissue removal. The multivariate analysis revealed that the odds of using image
International Forum of Allergy & Rhinology, Vol. 5, No. 4, April 2015
320
Ambulatory sinus surgery in California
TABLE 2. Patient characteristics and payor information for all sinus surgeries performed in California* Age (years)
Ethnicity ࣙ65
0–17
18–34
35–64
Total
5.2
16.3
63.0
15.5
2005
5.6
16.4
63.3
2006
5.6
16.0
2007
5.2
2008
Non-Caucasian
Medicare
Private
Other
86.9
13.1
11.7
3.7
79.6
5.0
14.7
89.7
10.3
11.7
2.8
78.5
7.0
65.0
13.4
89.2
10.8
10.6
3.2
80.0
6.3
16.7
63.5
14.7
88.5
11.5
11.4
2.8
80.7
5.1
4.8
16.2
63.6
15.4
87.4
12.6
12.1
3.3
80.6
3.9
2009
5.0
16.5
62.3
16.3
85.4
14.6
12.2
4.0
80.0
3.8
2010
5.0
16.2
61.9
16.9
83.8
16.2
11.9
4.8
79.1
4.1
5.0
16.4
60.8
17.8
83.1
16.9
12.1
5.4
77.8
4.7
Adjusted R
0.54
−0.19
0.65
0.82
0.96
0.28
0.83
−0.07
0.54
p
0.03
0.88
0.01
0.003
