Since its approval in 2005, balloon sinus dilation procedures have increased dramatically among certain providers, causing concern for some medical experts, including WashU Medicine rhinologist Nyssa Farrell, MD, and comprehensive otolaryngologist Jay Piccirillo, MD.
Together, they and collaborators recently published a series of articles in the prestigious JAMA Otolaryngology-Head & Neck Surgery that document the procedural abuse, identify areas of concern, and promote the need for new guidelines for use of the treatment.
Balloon sinuplasty, also known as balloon sinus dilation, is a minimally invasive procedure used to treat chronic rhinosinusitis and recurring acute rhinosinusitis, inflammatory conditions affecting millions of adults in the US.
The procedure is used to open blocked sinus passages and may be used alone or concurrent with endoscopic sinus surgery, the preferred surgical procedure in cases unresponsive to steroid or antibiotic treatment. Three bilateral sinuses – frontal, sphenoid and maxillary – present a total of six dilation options, though the presence of disease in all six is actually contraindicated for balloon sinuplasty according to current guidelines.
Did high reimbursement rates promote misuse?
According to Farrell, the core of the issue likely lies with the very high reimbursement rates for this procedure. Those rates exceed the rates for endoscopic sinus surgery. Surprisingly, the use of ESS did not see a decline in use that coincides with the explosion of balloon sinuplasty.
“We suspect there are providers whose financial success relies too heavily on the high reimbursement rates,” she said. “The procedure is not without risk, and overuse may predispose patients to complications – like eye swelling and nosebleed – from potentially unnecessary procedures.”
What the data shows
The three studies (linked to online publications) each documented different aspects of this potentially ethical dilemma for the field of otolaryngology. The data was obtained from Medicare claims databases and included more than 500 otolaryngologists.
- Evaluation of Practice Patterns for 6-Sinus Balloon Sinus Dilation
Smith KA, Farrell NF, Romashko A, Kallogjeri D, Saenz MP and Piccirillo JF
This study documented a total of 21,290 balloon sinus dilation cases. The data showed an unusually high rate of 6-sinus dilations and a small number of physicians responsible for a significant percentage of those, suggesting a potential overuse of the procedure. - Balloon Sinus Dilation Use
Saenz MP, Farrell NF, Romashko A, Smith KA, Kallogjeri D and Piccirillo JF
This study further evaluated the incidence of 6-sinus dilation, identifying a small number of physicians that was not only responsible for a large percentage of 6-sinus dilations but did so in 100% of their balloon dilation patients. - Preoperative Computed Tomography Utilization in Patients Undergoing Balloon Sinus Dilation
Romashko A, Farrell NF, Kallogjeri D, Saenz MP, Smith KA and Piccirillo JF
This study examined the use of CT scans prior to balloon dilation procedures as recommended by Clinical Consensus Guidelines. It found that most physicians adhered to guidelines but did identify 30 otolaryngologists who accounted for 50% of cases done without preprocedural CT imaging, again suggesting the need for improved monitoring of adherence to clinical guidelines.
Monitoring adherence should be guided by data
For Piccirillo, co-director of the Outcomes Research Office at WashU Medicine, these three studies reflect a much-needed evaluation of a common procedure being overused due to high reimbursement rates. Retrospective studies like these provide the data necessary for ongoing monitoring of the profession.
“This form of self-policing is both warranted and essential to help identify abuses or lack of adherence to clinical guidelines,” he said. “It is vitally important for maintenance of the contract of trust we hold with our patients.”