Patient-centered decision making in the treatment of chronic rhinosinusitis

Abstract

Objectives/hypothesis: To explore possible factors that might impact a patient's choice to pursue endoscopic sinus surgery (ESS) or continue with medical management for treatment of refractory chronic rhinosinusitis (CRS).

Study design: Cross-sectional evaluation of a multicenter prospective cohort.

Methods: Two hundred forty-two subjects with CRS were prospectively enrolled within four academic tertiary care centers across North America with ongoing symptoms despite prior medical treatment. Subjects either self-selected continued medical management (n = 62) or ESS (n = 180) for treatment of sinonasal symptoms. Differences in demographics, comorbid conditions, and clinical measures of disease severity between subject groups were compared. Validated metrics of social support, personality, risk aversion, and physician-patient relationships were compared using bivariate analyses, predicted probabilities, and receiver operating characteristic curves at the 0.05 alpha level.

Results: No significant differences were found between treatment groups for any demographic characteristic, clinical cofactor, or measure of social support, personality, or the physician-patient relationship. Subjects electing to pursue sinus surgery did report significantly worse average quality-of-life (QOL) scores on the 22-item Sinonasal Outcome Test (SNOT-22; P < .001) compared to those electing continued medical therapy (54.6 ± 18.9 vs. 39.4 ± 17.7), regardless of surgical history or polyp status. SNOT-22 score significantly predicted treatment selection (odds ratio, 1.046; 95% confidence interval, 1.028-1.065; P < .001) and was found to accurately discriminate between subjects choosing endoscopic sinus surgery and those electing medical management 72% of the time.

Conclusions: Worse patient-reported disease severity, as measured by the SNOT-22, was significantly associated with the treatment choice for CRS. Strong consideration should be given for incorporating CRS-specific QOL measures into routine clinical practice.

Level of evidence: 2b.

Trial registration: ClinicalTrials.gov NCT01332136.

Keywords: Chronic disease; decision making; drug therapy; general surgery; sinusitis; therapeutics.

Figure 1

SNOT-22 survey scores for treatment cohorts with and without nasal polyposis

Figure 2

SNOT-22 survey scores for treatment cohorts with and without prior sinus surgery

Figure 3

ROC curve for SNOT-22 survey scores. ROC=receiver operating characteristic curve.

Figure 4

ROC curve for Lund-Kennedy endoscopy scores.

Figure 5

ROC curve for Lund-Mackay computed tomography scores

Figure 6

ROC curve for Brief Modified Smell Identification Test scores