1. The use patterns of Wisconsin family physicians surrounding saline nasal irrigation 11-5-08 David Rabago, MD Aleksandra Zgierska MD PhD, Amy Bamber BS, Paul Peppard PhD UW Department of Family Medicine, NIH David.Rabago@fammed.wisc.edu http://www.fammed.wisc.edu/research/past- projects/nasal-irrigation

2. Why do we care? ► Viral upper respiratory infections (URIs) ► Rhinosinusitis  Viral, bacterial, allergic, irritant, URI induced asthma ► Billions of clinic/ED visits annually ► Direct costs: $billions / year ► Patients care about it:  Quality of Life ► Often refractory to treatment ► Serious complications

3. Adjunctive Nasal Irrigation (NI)…?

4. Biological Rationale Sino-nasal Disease: ↑ Mucus viscosity ↓ CBF ↓ MCC ↑ Inflammation ↑ Edema Nasal Irrigation: ↓ Mucus viscosity ↑ CBF ↑ MCC ↓ Inflammation (?) ↓ Edema (?)

5. Anatomy

7. NI: Chronic Sinus Symptoms

8. NI: Other Indications/Techniques ► Chronic Sinus Symptoms  0.9-3% liquid saline 1-2 times daily ► Allergic Rhinitis: 2 studies  Spray or liquid ► Viral URI (Common Cold): 2 studies  Spray or liquid ► Acute Bacterial Rhinosinusitis: 0 studies

10. NPR story

11. Purchase of NI devices Climbing ► 100,000 households surveyed using consumer tracking techniques  Ownership of NI spray device from March 2007 to March 2008 stable at 9%  Ownership of liquid NI device climbed from.6 to 1.7% in same period

12. What about the docs? ► What is the awareness of NI in Family Medicine? ► What are the characteristics of NI prescribers? ► For which conditions is NI recommended? ► How is NI recommended?

13. Methods ► Summer 2007 ► Electronic survey using WREN and WAFP docs ► Rigorously reviewed, professionally vetted  (Family Medicine, ENT, Population Health)  5 minutes or less to complete ► 131 to WREN, 1695 to WAFP ► Greeting email, survey, 2 reminder emails

14. Results ► Surveys returned: 330  WAFP: 313 (18.5%)  WREN: 17 (13%) ► Users, 286 ► Aware, non-users, 27 ► Not aware, 17

15. Physician Age

16. Physician Gender

17. Practice Location

18. Physician Race  Caucasian94%  Non-Caucasian6%  Missing4%

19. Practice Years

20. How did you learn about SNI?  Colleague 71%  Conference or Journal 56%  Patient 34%  Missing9%  Media6%

21. Awareness and Recommendations of SNI Methods

22. How is SNI recommended?  Verbal 90%  Print 50%  Other 4%  Missing 1%

23. Who Shows SNI Method?

24. Frequency of SNI Recommended

25. What salinity of SNI is recommended?  As printed51%  0.9 %44%  Don’t know25%  2-3%5%  >3%1%

26. Do you advise adjusting salt, pH to comfort?

27. For what age do you recommend SNI?  Adult98%  Child > 7 yr80%  Child < 7 yr26%

28. Conditions for which SNI is Recommended

29. Patients Satisfied with SNI

30. Do you recommend SNI ever prior to antibiotics?  Yes77%  No23%

31. Correlations ► Women more likely to recommend NI (p<0.05) ► MDs ≤ 45 years old are likely to recommend NI…  more often (p<0.06)  more often prior to Abx ► MDs practicing for ≤ 10 yrs recommend:  more often (p<0.06)  more likely to recommend for children (p<0.02)  more likely to advise gravity based method (neti pot) (p<0.03)

32. Is our group representative of Wisconsin family doctors? ► Respondents were more likely to be:  female (43% compared to 35%)  younger than 35 years old (18% compared to 9%)

33. Conclusions ► First study to assess physician use of NI ► Unable to draw conclusions about the true awareness of WI family physicians and NI ► Those who recommend NI do so for a number of indications c/w published studies ► Patient education, solution composition and dosing schedules inconsistent ► A majority of docs report having used NI prior to antibiotics ► More research needed

35. Thanks! www.fammed.wisc.edu/research/ past-projects/nasal-irrigation