1. Utilization of Balloon versus Traditional Endoscopic Sinus Surgery
Elisabeth Ference, James Schroeder, Madeline Graber, Hannan Quereshi, David Conley, Rakesh Chandra, Melissa Pynnonen,
Charlesnika Evans, Bruce Tan, Stephanie Smith

2. Balloon Catheter Dilation
Approved by FDA in 2005
Received CPT codes January 1, 2011
Few trials comparing traditional endoscopic sinus surgery with balloon catheter dilation (BCD)
EPOS: “the place of these systems in the sinus surgeon’s armamentarium remains unclear”
--Became reimburseable in 2011

3. Pros and Cons Advantages Less mucosal disruption
Management of critically ill patients with acute rhinosinusitis
Office setting with minimal anesthetic requirements
Disadvantages
Instrumentation not reuseable
Cost of disposable instruments increase total cost of procedure
Offset by reduced OR time?
Complex pneumatization patterns, significant osteogenesis, extensive mucosal disease
Surgeon must be able to perform traditional surgery if needed
Ethmoid sinuses

4. Study Objectives Quantify how often being performed
Describe demographics
Determine how utilization varies based on surgical volume
Compare mean charges and mean OR times
--Current literature suggests balloon technology is safe and provides the ability to dilate the frontal, sphenoid and maxillary sinuses and achieve patency in a large number of cases for up to two years
--However not much is known about how the technology is being used

5. Methods
State Ambulatory Surgery Database (SASD) for CA, FL, MD, and NY for 2011
Extracted patients via CPT codes
Looked at adults (> 18 years old) and pediatric (<18 years old) separately
Considered traditional ESS vs hybrid procedure
Hybrid procedure: any procedure which used balloon technology alone or in conjunction with endoscopic techniques

6. Adult Sample Size
33,776 balloon or endoscopic sinus surgeries were performed at 738 facilities.
Within the subset of patients from Florida and Maryland, 581 surgeons performed 12,827 sinus surgeries
--In 2011 in California, Florida, Maryland and New York, 33,776 balloon or endoscopic sinus surgeries were performed at 738 facilities.
--Within the subset of patients from Florida and Maryland who had unique surgeon identifier codes, 581 surgeons performed 12,827 sinus surgeries

7. Number of Sinus Procedures Performed in Adults
---4.6% of maxillary sinus surgery performed with balloon, versus 13.9% of frontal sinus surgery

8. Regression for Odds of Balloon Procedure Compared to Traditional
Adjusted analyses found increased use of BCD in patients with chronic diseases(p<0.001).
Patients who had a limited sinus surgery were less likely to have BCD compared to patients who had all 4 sinuses instrumented(p<0.001).
BCD used more in patients with chronic disease,
and less in patients with limited surgery

9. Surgeon Volume
High and medium volume surgeons were more likely to use balloons
We thought there might be a relationship between surgeon volume and percentage of cases which used balloons, BUT…..
NO RELATIONSHIP between the Percentage of Hybrid Procedures and Surgeon Volume
Percent of Hybrid Procedures
Terciles
Low: < 30 procedures/year
Medium: procedures/year
High: > 60 procedures/year
Total Number of Surgeries Per Surgeon

10. Total Charge in Dollars
Comparison of Charge * * *
Total Charge in Dollars
--Because the total charge and OR time data (and the log of total charge and log of OR time) were not normally distributed, we used the Wilcoxon Rank Sum nonparametric test for bivariate analyses assessing cost and OR time. We also utilized a generalized linear model for adjusted analysis and a matched cohort analysis.
--Compared to traditional ESS, the median charges for Maxillary sinus antrostomy, maxillary/ethmoid procedures(Mini-ESS), maxillary/ethmoid/sphenoid/frontal procedures(Pan-ESS), and overall were greater when a balloon was utilized
Median Charge greater for cases utilizing balloon catheter dilation compared to traditional endoscopic sinus surgery

11. Total OR Time in Minutes
Comparison of OR Time *
Total OR Time in Minutes
median OR time involving BCD was 8 minutes less for Mini-ESS procedures but not statistically different for maxillary antrostomy or Pan-ESS procedures
Median OR time was 8 minutes less for Mini-ESS procedures involving BCD but not different for maxillary antrostomy or Pan-ESS procedures

12. Pediatric Sinus Surgery
Indications for surgery different than in adults
Surgical intervention for CRS in children controversial
EPOS recommends begin with adenoidectomy and possible irrigation or BCD with traditional ESS for treatment failures
Children without enlarged adenoids or with significant mucosal disease may be treated immediately with traditional ESS

13. Pediatric Sample Size
2,662 sinus surgery cases at 448 facilities in 2011
11.9% utilized balloon technology

14. Regression for Odds of Balloon Procedure Compared to Traditional
Looked more closely at co-morbidities in pediatric patients as more important to surgical decision making
--Children with asthma, allergic rhinitis, GERD or with concomitant adenoidectomy were more likely to have a hybrid sinus procedure
--Patients with cystic fibrosis where less likely to have a BCD compared to patients without cystic fibrosis
Children with asthma, allergic rhinitis, GERD or also having adenoidectomy more likely to have BCD,
and children with CF less likely

15. Comparison of Charge
--The Wilcoxon Rank Sum test found that the mean total charge for patients undergoing only maxillary sinus surgery or maxillary sinus surgery and adenoidectomy incorporating BCD was greater than the mean total charge of patients undergoing traditional procedures
--No decrease in OR time for the BCD group
Median Charge greater for cases utilizing balloon catheter dilation compared to traditional endoscopic sinus surgery, with no decrease in OR time

16. Limitations
Not include office based procedures using balloon technology
Challenges of administrative data
Disparities in collected variables across states
Procedures or co-morbidities may be miscoded
Not possible to know indications for surgery
Unable to differentiate rhinology specialist with complex case mix from general otolaryngologist
Inability to distinguish unilateral from bilateral

17. Adult Conclusions 8% of cases involved BCD
Significant geographic and demographic disparities in use of balloon technology
Procedures using balloon technology on average more expensive with minimal decrease in OR time

18. Pediatric Conclusions
12% of cases involved BCD
Difference in practice patterns based on co-morbidities such as asthma, allergic rhinitis, GERD and cystic fibrosis
Increased utilization of balloon technology during sinus surgery concurrent with adenoidectomy
Maxillary sinus procedures, with or without adenoidectomy, using balloon technology significantly more expensive and no decrease in OR time

19. Thank You: Senior Author: Co-authors: Stephanie Shintani Smith
Charlesnika Evans
Melissa Pynnonen
Medical Students:
David Conley
Madeline Graber
Rakesh Chandra
Hannan Quereshi
Bruce Tan
James Schroeder