Reality bites: The establishment of accountable care organizations in otolaryngology

Although United States health care costs are significantly higher than any other industrialized country, we still lag behind many countries in health care equity and quality metrics. One feature of the Affordable Care Act that intended to address this was the establishment of Accountable Care Organizations (ACO). ACOs create a network of physicians that ostensibly will enhance care coordination among providers, improve patient experience and health outcomes, and lower overall costs. ACOs emphasize prevention and management of chronic diseases, and reward quality and cost-effective care, while attempting to move away from fee-for-service medicine. Unfortunately, although not always responsible for many of the metrics that determine cost or quality of care, physicians are largely held accountable for the delivery of high-quality and low-cost care. With otolaryngology having been slow to transition to this new payment model, it is imperative that we stay engaged and take a proactive role in this process because it has great implications on our patients’ outcomes and our own practices. Several articles in this issue of American Journal of Rhinology & Allergy contain themes relevant to this type of change. First is an intriguing article by Barry et al.,1 who examined what the contemporary literature shows about early versus aggressive management of chronic rhinosinusitis (CRS) as it relates to patient experience, health outcomes, and overall cost burden. Their review demonstrated that early intervention with endoscopic sinus surgery in appropriately selected patients has the potential to improve outcomes and reduce the long-term cost burden of CRS. Besides early surgical intervention, medical management is another area that is likely to be affected by the ACO model. Aggressive medical management as a first-line therapy option may potentially improve clinical outcomes and reduce health care costs. Novel topical medicines in the treatment of CRS provide targeted therapy and reduce the adverse effects associated with systemic use of certain medications. Sodium hyaluronate has been described to promote wound and mucosal healing, but it has not been described in its use in CRS therapy. Cantone and Iengo2 evaluated it use in combination with topical steroids and found improvement in symptoms, endoscopic examinations, and discomfort associated with CRS with nasal polyps (CRSwNP) compared with steroids alone. The impact that the quality metrics will have on physician reimbursements makes it imperative that otolaryngologists provide input into what specialty-specific performance measures are used. Dorresteijn et al.3 reported on a newly developed severity metric, the Nasal Mucus Index. They studied the association of various inflammatory biomarkers and self-reported severity measures with the newly developed Nasal Mucus Index. The Nasal Mucus Index was found to correlate significantly with same-day interleukin-8 levels, polymorphonuclear neutrophils count, and Wisconsin Upper Respiratory Symptom Survey-21 scores. It is proposed that this method of measuring acute respiratory infection severity is an affordable, nonbiased, validated, and easy-to-administer tool that can be used in settings in which costs and laboratory facilities are limited. Another focus of ACOs is preventative health care and at-risk populations. With the increasing rates of obesity among youth, rhinologists must be vigilant in detecting breathing abnormalities in children. Leal et al.4 conducted a cross-sectional study in children ages 9 and 10 years to determine the impact of mouth breathing on quality of life (QOL) in school children. Sociodemographic data and the Mouth Breather QOL questionnaire was used. The prevalence of mouth breathers was 54.81%. In addition, mouth breathing had a greater negative impact on QOL in comparison with the children who were nose breathers. Over the past 3 decades, the extent of endoscopic surgery has continued to expand to realms outside of the sinonasal cavity and to also include resection of both benign and malignant tumors. As these innovative techniques become common place, it is imperative that we establish improved QOL and other metrics that demonstrate that these are good treatment options. Endoscopic dacryocystorhinostomy is becoming increasing popular in the surgical management of nasolacrimal blockage and dacryocystitis; however, little is known on how it affects sinonasal QOL measures. Miyake et al.5 performed a retrospective review of patients who had an endoscopic dacryocystorhinostomy and measured preand postprocedure 22-item Sino-Nasal Outcome Test scores. Although there was an increase in the 22-item Sino-Nasal Outcome Test scores immediately after surgery, these scores returned to baseline levels within 30–60 days. Ference et al.6 studied the rates of endoscopic versus open orbital decompression in various geographic regions and found that endoscopic medial orbital decompression was performed in 22.9% of cases and was more likely to be performed in cases of infection compared with other diagnoses. In addition, open procedures were 33 minutes shorter on bivariate analysis but were not significantly different after controlling for covariables. Next, Roxbury et al.7 performed a retrospective review of the endoscopic sellar tumor resections and reconstructions closed with avascular free grafts. In their analysis, demographic factors and comorbidities that contribute to graft failure were identified. High-flow leaks were a significant predictor of reconstructive failure. Although a rare entity, sinonasal lymphoma can have a dramatic impact on patients’ QOL and survival. The presenting symptoms often mimic chronic sinusitis, but the clinical outcomes differ greatly. Steele et al.8 performed a retrospective review and described their patients with sinonasal lymphoma. Clinical presentations, patient demographics, imaging finding, treatment modalities, and survival rates were presented. Sinonasal lymphoma was found to have an overall 2and 5-year survival rate of 67% and 57%, respectively. In addition, combined chemotherapy and radiation treatment resulted in significantly higher survival rate than chemotherapy alone. Troy D. Woodard MD, FACS