AAO-HNSF Quality Knowledge Products
This year witnessed continued growth and maturation of the AAO-HNSF’s efforts at guideline development. The clinical practice guidelines (CPGs) are the most read articles in our journal (representing nine of the top 10 articles in 2012) and provide a strong basis for improving clinical outcomes for patients with the conditions that have been addressed so far based on the best available evidence. The demand for more products is ever increasing and the Guidelines Task Force has been working to grow the leadership group to be able to meet these demands. Our quality products have been used to develop quality measures and to support reimbursement for care by our members. They continue to be adopted by primary care and pediatric clinicians as evidenced by the recent endorsement by the AAFP of the tonsillectomy guideline. The following summary of our efforts highlights the critical and expanding role that CPGs will likely play in the evolving healthcare landscape. Seth R. Schwartz, MD, MPH Guidelines Task Force Chair Director, The Listen for Life Center at Virginia Mason® Since 2006, the AAO-HNSF has developed quality knowledge products (QKPs) including clinical practice guidelines (CPGs) and clinical consensus statements (CCSs) to support evidence-based decisions in patient care for its members, the wider clinical community, and the general public. Since we reported last July, the AAO-HNSF has published four new QKPs: CCS: CT Imaging Indications for Paranasal Sinus Disease (November 2012) CCS: Tracheostomy Care (January 2013) CPG: Improving Voice Outcomes after Thyroid Surgery (June 2013) CPG: Tympanostomy Tubes (July 2013) Three new CPGs (Bell’s Palsy, Tinnitus, and Allergic Rhinitis), and two CPG updates (Acute Otitis Externa and Adult Sinusitis) are currently in development. Oversight: Guideline Task Force (GTF) The GTF oversees the development, dissemination, implementation, and prioritization of topics for AAO-HNSF CPGs and CCSs. Seth R. Schwartz, MD, MPH, chair, and Richard M. Rosenfeld, MD, MPH, past-chair and current AAO-HNSF senior advisor for quality and guidelines lead the GTF. The GTF includes subspecialty society representatives from the American Broncho-Esophagological Association, American Neurotology Society, American Rhinologic Society, American Head and Neck Society, American Laryngological Association, The American Laryngological, Rhinological and Otological Society, Inc. (The Triological Society), American Otological Society, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Society of Pediatric Otolaryngology, and representatives from the AAO-HNS Board of Governors, Association of Otolaryngology Administrators, American Board of Otolaryngology, and Society of Otorhinolaryngology and Head-Neck Nurses. The AAO-HNS Physician, Payment, and Policy (3P) Workgroup also now has a representative on the GTF. The group meets biannually at the Academy’s headquarters and reviews guideline development methodology, progress, and prioritizes upcoming products. All AAO-HNS/F scientific and education committees are encouraged to submit topics to the GTF for consideration. Topics are presented and voted on at the second GTF meeting each year. Approved future CPG/CCS topics include Septoplasty and Rhinoplasty. The GTF produces a newsletter that highlights the group’s activities and provides updates on guideline and consensus statement development; recent editions of the GTF newsletter are available on the Academy’s website. Get Involved with Guidelines In an effort to foster involvement in guideline development and encourage participation in guideline development groups, the AAO-HNSF started the G-I-N Scholars program in 2012. The 2012 G-I-N Scholars program offered four AAO-HNS members travel grants to attend the Guidelines International Network (G-I-N) North America (NA) Conference in New York. Each scholar has agreed to write a commentary for Otolaryngology–Head and Neck Surgery during 2013 related to one of the themes of the G-I-N NA meeting. This is part of our education effort to help bring awareness and understanding about the development of clinical practice guidelines to our members. Closing the Clinical Gap: Translating Best Practice Knowledge to Performance with Guidelines Implementation by Lisa Ishii, MD, MHS (e-published in Otolaryngology–Head and Neck Surgery March 5, 2013) Conflict of Interest Reporting in Otolaryngology Clinical Practice Guidelines by Gordon H. Sun, MD, MS From bench to trench: How evidence and guidelines shape healthcare policy and practice by David O. Francis, MD Making clinical practice guidelines trustworthy by Melissa A. Pynnonen, MD In addition, all G-I-N Scholars agree to serve on an upcoming AAO-HNSF clinical practice guideline panel. Congratulations to the 2013 G-I-N Scholars, who were awarded $2,500 travel grants to attend the 2013 G-I-N Conference in San Francisco, CA, August 18-21. Scott E. Brietzke, MD, MPH, Walter Reed Army Medical Center Richard K. Gurgel, MD, University of Utah Benjamin R. Roman, MD, University of Pennsylvania Jennifer J. Shin, MD, SM, Massachusetts Eye & Ear Infirmary Sharing and Expanding our Knowledge In addition to sponsoring members to attend the 2013 G-I-N Conference, we will also be presenting three posters: Engaging consumers in the guideline development process—the U.S. perspective, presented by Peter Robertson, MPA; How cultural differences in treatment approach affect interpretation of literature and guideline recommendations, presented by Caitlin Drumheller; and Including the exclusion: the importance of addressing at risk populations in guidelines, presented by Heather M. Hussey, MPH. Payers Paying Attention to the CPGs and CCSs In October 2012, several members brought to our attention changes that were made to the Anthem/Empire Blue Cross Blue Shield Pediatric Tonsillectomy Medical Policy, which cited the CPG: Tonsillectomy in Children inappropriately. A call took place with the parent company WellPoint in November 2012. The Medical Policy and Technology Assessment Committee (MPTAC) reviewed the Academy’s comments during its November meeting and on November 12, 2012, WellPoint revised the policy on Tonsillectomy for Children, incorporating many of the Academy’s comments. In August of 2012, the four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) changed their Local Coverage Determinations (LCDs) such that providers can now only order replacement tracheostomy tubes every 90 days. Previously, providers were able to replace trach tubes every 30 days, which comports with what we believe is the most typical, and best, standard of care for patients with trach tubes. CMS has stated that this change was related to our CCS panel failing to reach consensus on the question of whether tubes should be changed weekly or bi-weekly. In response, the Academy submitted a letter to CMS in April 2013 requesting that CMS national, and the DME MACs, modify their LCDs and return to the prior 30 day policy, and attempted to clearly define “non-consensus” and how it should be interpreted by the Agency. Guideline Usage AAO-HNS Guidelines Usage Summary: The following table contains the cumulative number of page views for each AAO-HNSF guideline listed on the National Guidelines Clearinghouse (NGC) website from the time the guideline was posted to the NGC through December 2012 (provided by NGC and the number of citations for each product collected from Google Scholar through January 2013). Dissemination The AAO-HNSF is proud to have joined 16 other specialty groups—each of which released a list of “Five Things Physicians and Patients Should Question” on February 21, 2013, as part of the American Board of Internal Medicine (ABIM) Foundation Choosing Wisely® Campaign. The AAO-HNSF’s list of recommendations was carefully selected after a review of the current evidence including AAO-HNSF clinical practice guidelines. Each list includes when a particular test or treatment may be appropriate based on the current clinical evidence. Consumer Reports, along with a coalition of consumer partner organizations, is also a part of the Choosing Wisely® effort and is working with many of the societies to help patients understand the tests and treatments that are right for them. For more information visit http://www.entnet.org/choosingwisely. See page 32 for the “List of Five Things.” American Academy of Family Physicians (AAFP) Commission on Health of the Public and Science and AAFP Board of Directors has given qualified endorsement of the AAO-HNSF Clinical Practice Guideline: Tonsillectomy in Children. Voice Therapy: An administrative supplement to the CHEER Practice-based Research Network grant was awarded by the NIDCD in May 2012. This study focuses on usage of voice therapy and perceptions and barriers from both the patient and provider perspective. This will provide useful information for the eventual dissemination of all related guidelines including the Clinical Practice Guideline: Improving Voice Outcomes after Thyroid Surgery. This study has kicked off in 11 CHEER sites and as of March 1 was 20 percent of the way toward a recruitment goal of 500 patients. Implementation With funding from AAO-HNSF, the CHEER Practice-based Research Network is exploring awareness of and barriers to implementation of the AAO-HNSF Sudden Hearing Loss Guideline. This study has a physician survey and a patient data collection component. The physician survey component was fielded in 2012 and preliminary results were presented in a miniseminar at the AAO-HNSF 2012 Annual Meeting & OTO EXPOSM. These results will be incorporated into the manuscript that is developed from the multi-site study, which kicked off in March. Twenty-seven CHEER sites are participating in this study, which has a primary observational study on treatment pathways and patterns in SHL patients and a sub-study (observational) on IT and oral steroid use (solo, combined, sequential). The Adult Sinusitis Performance Measurement Set was approved by the PCPI on July 2, 2012, and has been submitted by PCPI to the National Quality Forum for endorsement. The measures are also being submitted to CMS for inclusion in PQRS. CPG/CCS Date published National Guidelines Clearinghouse Page views from publication through March 2013 Citations through 4/8/2012 (Source: Google Scholar) CPG: acute otitis externa 7/14/2006 70,430 94 CPG: adult sinusitis 8/22/2008 61,861 384 CPG: cerumen impaction 4/17/2009 32,376 40 CPG: benign paroxysmal positional vertigo 4/17/2009 40,706 164 CPG: hoarseness (dysphonia) 4/23/2010 22,216 60 CCS: nasal valve compromise 7/1/2010 N/A 10 CPG: tonsillectomy in children 5/13/2011 20,735 83 CPG: polysomnography for sleep-disordered breathing prior to tonsillectomy in children 12/16/2011 10,048 26 CPG: sudden hearing loss 4/26/2012 15,428 32 CCS: tracheotomy care 9/18/2012 N/A 3 CCS: CT for paranasal sinus disease 10/10/2012 N/A 1 TOTALS 273,800 897 The 2012 AAO-HNS/F Voice of the Member survey showed a 10 percent increase in AAO-HNS members indicating they were “very satisfied” with the AAO-HNSF’s efforts to build quality guidelines and performance measures (from 28 percent in 2010 to 38 percent in 2012). Sunday, September 29 Title: AAO-HNSF Clinical Practice Guideline: Bell’s Palsy Time: 10:30-11:50 am Moderator: Reginald F. Baugh, MD Presenters: Gregory J. Basura, MD, PhD; Lisa Ishii, MD, MHS; Seth R. Schwartz, MD, MPH Room: West 304-305 Monday, September 30 Title: AAO-HNSF Clinical Practice Guideline: Tympanostomy Tubes Time: 8:00-9:20 am Moderator: Richard M. Rosenfield, MD, MPH Presenters: Melissa A. Pynnonen, MD, MS; David E. Tunkel, MD; Seth R. Schwartz, MD, MPH Room: West 301 Wednesday, October 2 Title: Understanding Clinical Practice Guidelines Time: 1:45-2:45 pm Instructors: Richard M. Rosenfeld, MD, MH Room: West Ballroom A
This year witnessed continued growth and maturation of the AAO-HNSF’s efforts at guideline development. The clinical practice guidelines (CPGs) are the most read articles in our journal (representing nine of the top 10 articles in 2012) and provide a strong basis for improving clinical outcomes for patients with the conditions that have been addressed so far based on the best available evidence. The demand for more products is ever increasing and the Guidelines Task Force has been working to grow the leadership group to be able to meet these demands. Our quality products have been used to develop quality measures and to support reimbursement for care by our members. They continue to be adopted by primary care and pediatric clinicians as evidenced by the recent endorsement by the AAFP of the tonsillectomy guideline. The following summary of our efforts highlights the critical and expanding role that CPGs will likely play in the evolving healthcare landscape.
Seth R. Schwartz, MD, MPH
Guidelines Task Force Chair
Director, The Listen for Life Center at Virginia Mason®
Since 2006, the AAO-HNSF has developed quality knowledge products (QKPs) including clinical practice guidelines (CPGs) and clinical consensus statements (CCSs) to support evidence-based decisions in patient care for its members, the wider clinical community, and the general public.
Since we reported last July, the AAO-HNSF has published four new QKPs:
- CCS: CT Imaging Indications for Paranasal Sinus Disease (November 2012)
- CCS: Tracheostomy Care (January 2013)
- CPG: Improving Voice Outcomes after Thyroid Surgery (June 2013)
- CPG: Tympanostomy Tubes (July 2013)
Three new CPGs (Bell’s Palsy, Tinnitus, and Allergic Rhinitis), and two CPG updates (Acute Otitis Externa and Adult Sinusitis) are currently in development.
The GTF oversees the development, dissemination, implementation, and prioritization of topics for AAO-HNSF CPGs and CCSs. Seth R. Schwartz, MD, MPH, chair, and Richard M. Rosenfeld, MD, MPH, past-chair and current AAO-HNSF senior advisor for quality and guidelines lead the GTF. The GTF includes subspecialty society representatives from the American Broncho-Esophagological Association, American Neurotology Society, American Rhinologic Society, American Head and Neck Society, American Laryngological Association, The American Laryngological, Rhinological and Otological Society, Inc. (The Triological Society), American Otological Society, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Society of Pediatric Otolaryngology, and representatives from the AAO-HNS Board of Governors, Association of Otolaryngology Administrators, American Board of Otolaryngology, and Society of Otorhinolaryngology and Head-Neck Nurses. The AAO-HNS Physician, Payment, and Policy (3P) Workgroup also now has a representative on the GTF.
The group meets biannually at the Academy’s headquarters and reviews guideline development methodology, progress, and prioritizes upcoming products. All AAO-HNS/F scientific and education committees are encouraged to submit topics to the GTF for consideration. Topics are presented and voted on at the second GTF meeting each year. Approved future CPG/CCS topics include Septoplasty and Rhinoplasty.
The GTF produces a newsletter that highlights the group’s activities and provides updates on guideline and consensus statement development; recent editions of the GTF newsletter are available on the Academy’s website.
Get Involved with Guidelines
In an effort to foster involvement in guideline development and encourage participation in guideline development groups, the AAO-HNSF started the G-I-N Scholars program in 2012.
The 2012 G-I-N Scholars program offered four AAO-HNS members travel grants to attend the Guidelines International Network (G-I-N) North America (NA) Conference in New York. Each scholar has agreed to write a commentary for Otolaryngology–Head and Neck Surgery during 2013 related to one of the themes of the G-I-N NA meeting. This is part of our education effort to help bring awareness and understanding about the development of clinical practice guidelines to our members.
- Closing the Clinical Gap: Translating Best Practice Knowledge to Performance with Guidelines Implementation by Lisa Ishii, MD, MHS (e-published in Otolaryngology–Head and Neck Surgery March 5, 2013)
- Conflict of Interest Reporting in Otolaryngology Clinical Practice Guidelines by Gordon H. Sun, MD, MS
- From bench to trench: How evidence and guidelines shape healthcare policy and practice by David O. Francis, MD
- Making clinical practice guidelines trustworthy by Melissa A. Pynnonen, MD
In addition, all G-I-N Scholars agree to serve on an upcoming AAO-HNSF clinical practice guideline panel.
Congratulations to the 2013 G-I-N Scholars, who were awarded $2,500 travel grants to attend the 2013 G-I-N Conference in San Francisco, CA, August 18-21.
- Scott E. Brietzke, MD, MPH, Walter Reed Army Medical Center
- Richard K. Gurgel, MD, University of Utah
- Benjamin R. Roman, MD, University of Pennsylvania
- Jennifer J. Shin, MD, SM, Massachusetts Eye & Ear Infirmary
Sharing and Expanding our Knowledge
In addition to sponsoring members to attend the 2013 G-I-N Conference, we will also be presenting three posters: Engaging consumers in the guideline development process—the U.S. perspective, presented by Peter Robertson, MPA; How cultural differences in treatment approach affect interpretation of literature and guideline recommendations, presented by Caitlin Drumheller; and Including the exclusion: the importance of addressing at risk populations in guidelines, presented by Heather M. Hussey, MPH.
Payers Paying Attention to the CPGs and CCSs
In October 2012, several members brought to our attention changes that were made to the Anthem/Empire Blue Cross Blue Shield Pediatric Tonsillectomy Medical Policy, which cited the CPG: Tonsillectomy in Children inappropriately. A call took place with the parent company WellPoint in November 2012. The Medical Policy and Technology Assessment Committee (MPTAC) reviewed the Academy’s comments during its November meeting and on November 12, 2012, WellPoint revised the policy on Tonsillectomy for Children, incorporating many of the Academy’s comments.
In August of 2012, the four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) changed their Local Coverage Determinations (LCDs) such that providers can now only order replacement tracheostomy tubes every 90 days. Previously, providers were able to replace trach tubes every 30 days, which comports with what we believe is the most typical, and best, standard of care for patients with trach tubes. CMS has stated that this change was related to our CCS panel failing to reach consensus on the question of whether tubes should be changed weekly or bi-weekly. In response, the Academy submitted a letter to CMS in April 2013 requesting that CMS national, and the DME MACs, modify their LCDs and return to the prior 30 day policy, and attempted to clearly define “non-consensus” and how it should be interpreted by the Agency.
AAO-HNS Guidelines Usage Summary: The following table contains the cumulative number of page views for each AAO-HNSF guideline listed on the National Guidelines Clearinghouse (NGC) website from the time the guideline was posted to the NGC through December 2012 (provided by NGC and the number of citations for each product collected from Google Scholar through January 2013).
Dissemination
- The AAO-HNSF is proud to have joined 16 other specialty groups—each of which released a list of “Five Things Physicians and Patients Should Question” on February 21, 2013, as part of the American Board of Internal Medicine (ABIM) Foundation Choosing Wisely® Campaign. The AAO-HNSF’s list of recommendations was carefully selected after a review of the current evidence including AAO-HNSF clinical practice guidelines. Each list includes when a particular test or treatment may be appropriate based on the current clinical evidence. Consumer Reports, along with a coalition of consumer partner organizations, is also a part of the Choosing Wisely® effort and is working with many of the societies to help patients understand the tests and treatments that are right for them. For more information visit http://www.entnet.org/choosingwisely. See page 32 for the “List of Five Things.”
- American Academy of Family Physicians (AAFP) Commission on Health of the Public and Science and AAFP Board of Directors has given qualified endorsement of the AAO-HNSF Clinical Practice Guideline: Tonsillectomy in Children.
- Voice Therapy: An administrative supplement to the CHEER Practice-based Research Network grant was awarded by the NIDCD in May 2012. This study focuses on usage of voice therapy and perceptions and barriers from both the patient and provider perspective. This will provide useful information for the eventual dissemination of all related guidelines including the Clinical Practice Guideline: Improving Voice Outcomes after Thyroid Surgery. This study has kicked off in 11 CHEER sites and as of March 1 was 20 percent of the way toward a recruitment goal of 500 patients.
Implementation
- With funding from AAO-HNSF, the CHEER Practice-based Research Network is exploring awareness of and barriers to implementation of the AAO-HNSF Sudden Hearing Loss Guideline. This study has a physician survey and a patient data collection component. The physician survey component was fielded in 2012 and preliminary results were presented in a miniseminar at the AAO-HNSF 2012 Annual Meeting & OTO EXPOSM. These results will be incorporated into the manuscript that is developed from the multi-site study, which kicked off in March. Twenty-seven CHEER sites are participating in this study, which has a primary observational study on treatment pathways and patterns in SHL patients and a sub-study (observational) on IT and oral steroid use (solo, combined, sequential).
- The Adult Sinusitis Performance Measurement Set was approved by the PCPI on July 2, 2012, and has been submitted by PCPI to the National Quality Forum for endorsement. The measures are also being submitted to CMS for inclusion in PQRS.
CPG/CCS | Date published | National Guidelines Clearinghouse Page views from publication through March 2013 | Citations through 4/8/2012 (Source: Google Scholar) |
CPG: acute otitis externa | 7/14/2006 | 70,430 | 94 |
CPG: adult sinusitis | 8/22/2008 | 61,861 | 384 |
CPG: cerumen impaction | 4/17/2009 | 32,376 | 40 |
CPG: benign paroxysmal positional vertigo | 4/17/2009 | 40,706 | 164 |
CPG: hoarseness (dysphonia) | 4/23/2010 | 22,216 | 60 |
CCS: nasal valve compromise | 7/1/2010 | N/A | 10 |
CPG: tonsillectomy in children | 5/13/2011 | 20,735 | 83 |
CPG: polysomnography for sleep-disordered breathing prior to tonsillectomy in children | 12/16/2011 | 10,048 | 26 |
CPG: sudden hearing loss | 4/26/2012 | 15,428 | 32 |
CCS: tracheotomy care | 9/18/2012 | N/A | 3 |
CCS: CT for paranasal sinus disease | 10/10/2012 | N/A | 1 |
TOTALS | 273,800 | 897 |
Sunday, September 29 Title: AAO-HNSF Clinical Practice Guideline: Bell’s Palsy Time: 10:30-11:50 am Moderator: Reginald F. Baugh, MD Presenters: Gregory J. Basura, MD, PhD; Lisa Ishii, MD, MHS; Seth R. Schwartz, MD, MPH Room: West 304-305 |
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Monday, September 30 Title: AAO-HNSF Clinical Practice Guideline: Tympanostomy Tubes Time: 8:00-9:20 am Moderator: Richard M. Rosenfield, MD, MPH Presenters: Melissa A. Pynnonen, MD, MS; David E. Tunkel, MD; Seth R. Schwartz, MD, MPH Room: West 301 |
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Wednesday, October 2 Title: Understanding Clinical Practice Guidelines Time: 1:45-2:45 pm Instructors: Richard M. Rosenfeld, MD, MH Room: West Ballroom A |