ORIGINAL ARTICLE

Wait times for endoscopic sinus surgery influence patient-reported

outcome measures in patients with chronic rhinosinusitis who fulfill
appropriateness criteria
Jonathan Yip, MD, FRCSC1 , Weibo Hao, MD1 , Antoine Eskander, MD, ScM, FRCSC2 and John M. Lee, MD,
MSc, FRCSC1

Background: Previous studies on the impact of wait times scores significantly improved postoperatively. Wait time
for endoscopic sinus surgery (ESS) in medically recalcitrant for ESS was negatively correlated with change in SNOT-22
chronic rhinosinusitis (rCRS) have not examined its influ- global, rhinologic, extranasal rhinologic, and ear/facial do-
ence on the 5 distinct symptoms domains of the 22-item main scores (p < 0.05), and a wait time threshold of 287,
Sino-Nasal Outcome Test (SNOT-22), and have not applied 452, 421, and 381 days corresponded to a decrease equiva-
evidence-based surgical indications. Our primary study ob- lent to the MCID, respectively.
jective was to investigate the impact of ESS wait times on
Conclusion: We identified less improvement in HRQoL
postoperative SNOT-22 global and symptom domain scores
in patients with rCRS deemed “appropriate” surgical candi- aer ESS with increasing surgical wait time. Moreover,
prolonged wait times may result in less improvement in
dates.
disease-specific symptoms, but do not appear to worsen
Methods: This was a retrospective analysis of adult pa- psychological or sleep dysfunction. 
C 2018 ARS-AAOA,

tients with rCRS undergoing ESS, categorized as “appro- LLC.

priate” surgical candidates. Primary outcome measure was
change in SNOT-22 global/symptom domain score (preop- Key Words:
erative – 6-month postoperative). Correlational analyses chronic rhinosinusitis; SNOT-22; patient-reported outcome
were performed between wait time and change in SNOT- measure; sinus surgery; endoscopic sinus surgery; quality-
22 global and symptom domain scores. For significant neg- of-life; disease severity
ative correlations, the threshold wait time to generate a
worsening in health-related quality-of-life (HRQoL) equiva- How to Cite this Article:
Yip J, Hao W, Eskander A, Lee JM. Wait times for en-
lent to the mean clinically important difference (MCID) was
calculated. doscopic sinus surgery influence patient-reported out-
come measures in patients with chronic rhinosinusitis who
Results: A total of 104 patients with a mean ± standard fulfill appropriateness criteria. Int Forum Allergy Rhinol.
deviation (SD) wait time of 310.8 ± 155.9 days were ana- 2019;9:396–401.
lyzed. Postoperative SNOT-22 global and symptom domain

I n an era of increasing constraints on economic resources

and large variations in healthcare utilization, there is
a growing emphasis to improve the quality of healthcare
delivery. To carry out this endeavor, 6 parameters are to
be addressed: safety, effectiveness, patient centeredness, ef-
ficiency, equity, and timeliness.1, 2 Within the context of
1 Divisionof Rhinology, Department of Otolaryngology–Head and Neck medically recalcitrant chronic rhinosinusitis (CRS), there is
Surgery, St. Michael’s Hospital, University of Toronto, Toronto, ON, evidence to suggest that timeliness of surgery represents
Canada; 2 Division of Head and Neck Oncology, Department of
an opportunity to improve care, because early surgical
Otolaryngology–Head and Neck Surgery, Sunnybrook Health Sciences
Centre and Michael Garron Hospital, University of Toronto, Toronto, intervention may prevent the progression of CRS patho-
ON, Canada physiology and the development of comorbid conditions,
Correspondence to: John M. Lee, MD, MSc, FRCSC, Division of Rhinology, thereby reducing healthcare utilization.3–6 Benninger et al.5
University of Toronto; St. Michael’s Hospital, 30 Bond Street, 8 Cardinal reported that CRS patients with longer delays from diag-
Carter, Toronto, ON, M5B 1W8, Canada; e-mail: [email protected]
nosis to endoscopic sinus surgery (ESS) had greater postop-
Potential conflict of interest: None provided.
erative rhinosinusitis-related outpatient medical visits and
Received: 19 August 2018; Revised: 16 October 2018; Accepted:
13 November 2018
prescription drug use. Moreover, delaying surgery in CRS
DOI: 10.1002/alr.22257
View this article online at wileyonlinelibrary.com.

396 International Forum of Allergy & Rhinology, Vol. 9, No. 4, April 2019
 Wait times in appropriately selected CRS patients

in favor of continuing medical therapy may lead to poorer therapy (AMT) consisting of oral, broad-spectrum, or
disease-specific quality-of-life (QOL).7, 8 culture-directed antibiotics (ࣙ2 weeks), high-volume
Examining the impact of interventions on patient- sinonasal saline irrigations (ࣙ12 weeks), topical nasal
reported outcome measures (PROMs) is paramount in corticosteroid sprays (ࣙ12 weeks), and/or a short-course
quality improvement initiatives, because PROMs can of oral systemic corticosteroid (ࣙ1 week).
capture aspects of care that result in tangible benefits in Patients were categorized into surgical appropriateness
patient health status and satisfaction, as well as measure determinations based on CRS phenotype (CRS with or
safety, processes of care, and institutional performance.9 without polyposis), preoperative medical therapy regimens,
Several studies have attempted to characterize the impact post-AMT SNOT-22 scores, and Lund-Mackay scores, as
of timing of sinus surgery on PROMs in CRS by measuring defined by Rudmik et al.14 Analysis was restricted to pa-
the postoperative change in health-related QOL, namely tients who were deemed “appropriate” surgical candidates.
the 22-item Sino-Nasal Outcome Test (SNOT-22) global The senior author (J.M.L.) performed all surgical proce-
scores.6, 10 It is important to consider, however, that dures, and the extent of ESS was based on individual disease
aggregate SNOT-22 scores measure more than 1 disease- processes and intraoperative clinical judgment. Postopera-
specific construct, and can be further categorized into 5 tive management consisted of daily sinonasal saline irri-
distinct health domains: rhinologic, extranasal rhinologic, gations, and topical corticosteroid sprays or oral systemic
ear/facial symptoms, psychological dysfunction, and sleep corticosteroids (for CRS with nasal polyposis [CRSwNP]
dysfunction.11 Understanding how interventions differ- only).
entially impact these separate domains has implications
in value-based healthcare, as it can help optimize the Exclusion criteria
appropriate use of treatment modalities. Although there Patients with recurrent acute rhinosinusitis or rhinosinusi-
is evidence that ESS impacts all of these subdomains,12, 13 tis secondary to cystic fibrosis, cilia dysfunction phenotype
it is uncertain whether timing of surgery differentially (ie, primary ciliary dyskinesia), autoimmune disease, or im-
influences them. mune deficiency were excluded because of the heteroge-
The increasing focus on the judicious provision of re- neous nature of these disease processes. Additional exclu-
sources and interventions has also led to the development sions were applied to patients undergoing revision surgery
of appropriateness criteria for ESS, with the intent of pro- in order to restrict variability in surgical intervention and
viding “the correct surgery to the correct patient at the reduce any potential confounding effect. Furthermore, pa-
correct time.”14 Disparate postoperative outcomes in CRS tients who were categorized as “uncertain” or “inappropri-
have been shown based on appropriateness categorizations, ate” surgical candidates, as defined by the appropriateness
which further emphasizes that careful selection of ESS can- criteria for ESS,14 were excluded. Patients were also re-
didates is critical to achieving successful outcomes.16 As moved from the final analysis if they failed to complete
these selection criteria move closer to identifying the “cor- their baseline or 6-month follow-up evaluations.
rect patient” for ESS, the “correct time” remains an unre-
solved parameter. Measures of disease severity
The goal of the present study was to investigate the im- At each clinical visit, patients completed a detailed medical
pact of surgical wait times on SNOT-22 global and sub- history, head and neck clinical examination, and sinonasal
domain scores in patients with medically recalcitrant CRS, endoscopy. Endoscopic examinations were rated using the
who fulfilled appropriateness criteria for ESS. Prolonged Lund-Kennedy endoscopy (LKES) scoring system (range,
surgical wait times in Canada exist due to an imbalance 0 to 20), which quantified the pathological state of the
between supply and demand for elective procedures, and paranasal sinuses by characterizing the severity of poly-
provide a unique setting to study this research question. posis, discharge, edema, scarring, and crusting.17 Radio-
graphic evaluation of the paranasal sinuses was performed
Patients and methods in the preoperative period using high-resolution computed
tomography (CT). Images were staged according to the
Patient population and inclusion criteria Lund-Mackay scoring system (range, 0 to 24), in which
We conducted an Institutional Review Board (IRB)- higher scores signified worse disease.18
approved retrospective study of adult patients (>18 years In addition, at baseline (ie, time of consent for ESS) and
of age) with a diagnosis of medically recalcitrant CRS, who 6-month follow-up, study patients completed the SNOT-
were referred to a tertiary, academic rhinology practice 22, a 22-item validated survey that quantifies the severity
(St. Michael’s Hospital, University of Toronto, Toronto, of sinonasal symptoms, impact of chronic sinonasal con-
ON, Canada) for primary ESS between January 2014 and ditions on QOL, and CRS treatment outcomes ( C 2006,

December 2016. The diagnosis of CRS was confirmed Washington University, St. Louis, MO). Scores were aggre-
using guidelines defined by the American Academy of gated into a global score ranging from 0 to 110, with higher
Otolaryngology–Head and Neck Surgery (AAO-HNS).16 scores indicating a larger rhinosinusitis-related health
Medically recalcitrant CRS was defined as incomplete burden. The mean clinical important difference (MCID),
symptom control despite a trial of appropriate medical defined as the smallest change in global score that reflects a

International Forum of Allergy & Rhinology, Vol. 9, No. 4, April 2019 397
Yip et al.

tangible change in health status, of the SNOT-22 has been TABLE 1. Patient demographics
shown to be 8.9 points.19 At each time point, the 22 items
of the SNOT-22 were further categorized into 5 discrete Demographic Value
symptom domains, based on previous factor analysis con-
Total sample size, n 104
ducted by DeConde et al.11 : rhinologic (range, 0 to 30);
extranasal rhinologic (range, 0 to 15); ear/facial (range, 0 Age (years), mean ± SD 49.1 ± 15.6
to 25); psychological dysfunction (range, 0 to 35); and sleep Male, n (%) 68 (65.4)
dysfunction (range, 0 to 25). Average MCID values for the
CRSwNP, n (%) 87 (83.7)
rhinologic, extranasal rhinologic, ear/facial, psychological,
and sleep domain scores have recently been described to be Wait time (days), mean ± SD 310.8 ± 155.9
3.8, 2.4, 3.2, 3.9, and 2.9, respectively.20 Comorbidities, n (%)
Asthma 44 (42.3)
Data collection and analysis
Environmental allergies 53 (51.0)
The sociodemographic, medical history, wait times, sur-
gical, Lund-Mackay CT scores, LKES, and follow-up data ASA sensitivity 20 (19.2)
were extracted through chart review. Wait time was defined AERD 18 (17.3)
as the duration (ie, number of months) between consent
for surgery and ESS. For each patient, a risk adjustment Charlson comorbidity index, mean ± SD 1.5 ± 1.5
score was calculated using the Charlson comorbidity in- Preoperative Lund-Kennedy endoscopy score, mean ± SD 5.1 ± 3.6
dex, which represented the morbidity burden of non-CRS Preoperative Lund-Mackay score, mean ± SD 14.6 ± 5.1
conditions.21
All statistical analysis was performed using commer- AERD = aspirin-exacerbated respiratory disease; ASA = acetylsalicylic acid; CR-
SwNP = chronic rhinosinusitis with nasal polyposis; SD = standard deviation.
cially available software (SPSS, version 24; IBM Corp.,
Armonk, NY). Descriptive statistics (means, standard devi- 14.6 ± 5.1. The average wait time for ESS was 310.8 ±
ations [SDs], frequencies) were calculated for all measures. 155.9 days.
Matched pairs t testing was used to determine improve-
ments in SNOT-22 global and subdomain scores between Change in SNOT-22 global and subdomain scores
baseline and postoperative assessments. Univariate analysis after ESS
was performed between wait times and patient variables. Preoperative (baseline), 6-month postoperative, and change
Pearson correlation coefficients (rp ) were used to evalu- in SNOT-22 aggregate and subdomain scores are shown in
ate the linear associations between wait times for ESS and Table 2. The mean baseline SNOT-22 aggregate score was
change in SNOT-22 scores (preoperative – postoperative 56.3 ± 20.6. On closer examination of the mean preop-
scores), and graphical analysis was generated to demon- erative subdomain scores, psychological dysfunction (18.6
strate linear trends. Based on the linear trend, the threshold ± 9.5) represented the highest scoring subdomain followed
wait time for ESS to generate a worsening in health-related by rhinologic symptoms (14.4 ± 6.1). There was a sig-
QOL equivalent to the MCID. Significant associations were nificant improvement after ESS in all SNOT-22 subdomain
determined at a 0.050 alpha level. and global scores at 6 months postoperatively (all p < 0.05).
The majority of patients (93.3%) reported an improvement
in SNOT-22 aggregate scores after surgery, and 90.4%
Results achieved a MCID at 6 months post-ESS. Additionally, a
reduction across all subdomain scores was appreciated at
Cohort characteristics
6 months postoperatively. Psychological dysfunction had
A total of 162 patients were deemed eligible for study in- the greatest absolute reduction (10.5 ± 9.7). Meanwhile,
clusion. The final cohort consisted of 104 patients after rhinologic symptoms experienced the largest relative im-
the application of exclusion criteria. Among the patients provement (61.8%), defined as a percentage of improve-
excluded, 50 patients were removed due to incomplete ment from baseline. In contrast, ear/facial symptom sub-
follow-up data and 8 subjects were classified as “uncertain” domain scores had the least relative improvement (55.4%).
candidates according to the ESS appropriateness criteria.14 A total of 83.7%, 80.8%, 76.0%, 72.1%, and 73.1% of
Baseline demographics, clinical characteristics, comorbidi- subjects achieved MCID at 6 months postoperatively for
ties, and disease severity measures of the cohort are sum- rhinologic, extranasal rhinologic, ear/facial, psychological,
marized in Table 1. The majority of patients (83.7%) had and sleep domains, respectively.
CRSwNP and 72.1% had a Charlson comorbidity index
ࣙ1. With respect to specific comorbidities, 42.3% had con-
current asthma, 49% had a history of allergies, 19.2% Association between wait times and SNOT-22
had acetylsalicylic acid (ASA) sensitivity, and 17.3% had scores
aspirin-exacerbated respiratory disease (AERD). Preopera- On univariate analysis, there was no association be-
tive LKES was 5.1 ± 3.6 and Lund-Mackay CT score was tween wait times for ESS and clinicopathological factors

398 International Forum of Allergy & Rhinology, Vol. 9, No. 4, April 2019
 Wait times in appropriately selected CRS patients

TABLE 2. Change in SNOT-22 global and symptom domain scores

Change in score Achieving mean

(preoperative – clinically important
Patient-reported Preoperative score Postoperative score postoperative) difference at 6 months
outcome measure (mean ± SD) (mean ± SD) (mean ± SD) t (test of change) postoperatively (%)

Global 56.3 ± 20.6 23.4 ± 18.1 32.9 ± 21.7 <0.001 90.4

Symptom domain
Rhinologic 14.4 ± 6.1 5.5 ± 4.8 8.9 ± 6.5 0.001 83.7
Extranasal rhinologic 9.7 ± 3.0 4.0 ± 3.0 5.7 ± 3.7 0.012 80.8
Ear/facial 12.1 ± 5.4 5.4 ± 4.4 6.7 ± 5.4 <0.001 76.0
Psychological 18.6 ± 9.5 8.2 ± 7.7 10.5 ± 9.7 <0.001 72.1
dysfunction
Sleep dysfunction 11.9 ± 6.3 4.7 ± 4.7 7.2 ± 6.5 0.001 73.1

SD = standard deviation; SNOT-22 = 22-item Sino-Nasal Outcome Test.

TABLE 3. Pearson correlation coefficients (rp ) between wait Discussion

times for ESS and change in SNOT-22 scores*
Seminal studies from Hopkins et al.6, 22 have suggested that
patients with longer duration of CRS symptoms experi-
Threshold wait time
enced less symptomatic improvement and disease-specific
SNOT-22 score until SNOT-22 declines
domains Wait time (rp ) p by MCID (days)
QOL (ie, aggregate SNOT-22 scores) after surgery com-
pared to those with shorter symptom duration. A limita-
Global –0.227 0.020 287 tion of their studies was the reliance on patient-reported
Symptom domain lifetime duration of symptoms, which may have been sub-
ject to recall bias and may have been influenced by patient
Rhinologic –0.203 0.039 452
self-selection of treatment.
Extranasal –0.241 0.014 421 Newton et al.10 attempted to address the aforementioned
rhinologic limitations by examining whether wait time for ESS im-
Ear/facial –0.244 0.013 381 pacted 6-month postoperative SNOT-22 aggregate scores.
Among 150 CRS patients who failed AMT, they found
Psychological –0.143 0.147
dysfunction
that wait times did not affect the degree of improve-
ment in disease-specific QOL. However, a sizeable por-
Sleep –0.164 0.096 tion had post-AMT SNOT-22 scores <20, and as such,
dysfunction
they would be categorized as “uncertain” or “inappro-
*
The threshold wait times (days) for ESS to generate a postoperative worsening priate” candidates for ESS.10, 14 Additionally, among this
in SNOT-22 scores equivalent to the MCID for significant associations are shown. subcohort, only 34.2% achieved a MCID from surgery.
ESS = endoscopic sinus surgery; MCID = mean clinically important difference;
rp = Pearson correlation coefficient; SNOT-22 = 22-item Sino-Nasal Outcome Although appropriateness criteria are not meant to re-
Test. place clinical judgment, they aim to ensure that the de-
cision to pursue an intervention is patient-centered and
to minimize inappropriate healthcare utilization. Further-
(all p > 0.05). There was a significant association between
more, they have also been shown to predict postoperative
surgical wait times and SNOT-22 aggregate (rp = –0.187;
outcomes.15
p = 0.020), rhinologic (rp = –0.203; p = 0.039), extranasal
In this present study, we investigated the impact of surgi-
rhinologic (rp = –0.241; p = 0.011), and ear/facial (rp =
cal wait times on PROMs in CRS patients, who failed AMT,
–0.244; p = 0.013) subdomain scores (Table 3). However,
and were categorized as “appropriate” surgical candidates
there was no correlation between wait times and psycho-
for ESS. Within this patient population, we found that al-
logical or sleep subdomains (p > 0.05). Based on the lin-
though the majority of patients had significant improve-
ear trend (Table 3), for every 287 days on the waitlist,
ments in disease-specific QOL, the duration of wait time
the postoperative SNOT-22 aggregate score would decline
significantly influenced the magnitude of benefit received
by MCID (8.9 points). For rhinologic, extranasal rhino-
from ESS. In other words, there may have been less im-
logic and ear/facial subdomains (Table 3), the duration
provement in health-related QOL after ESS with increasing
of wait time leading to a postoperative worsening equiv-
surgical wait time. This finding supports the observations
alent to the MCID is 452 days, 421 days, and 381 days,
from Hopkins et al.,6, 22 as delaying surgery in refractory
respectively.

International Forum of Allergy & Rhinology, Vol. 9, No. 4, April 2019 399
Yip et al.

CRS may lower prognosis due to alteration of the sinonasal However, these findings may be unique to our universal
architecture.3, 22, 23 publicly funded healthcare system or to the patients man-
Our study did not capture the SNOT-22 at the time of aged by a specific practitioner, where patients may generally
surgery, and thus we cannot conclude whether preoperative tolerate longer wait times and are prepared for this at time
disease-specific QOL varied with wait times. The current of consent.
literature reports that patients receiving ongoing medical Based on correlational analyses, we report on thresh-
therapy while awaiting ESS face an absolute increase in old wait times that would lead to a postoperative de-
SNOT-22 global scores during this time period.7, 8, 24 Our cline equivalent to the MCID in SNOT-22 global, rhi-
presumption was that patients across our cohort were nologic, extranasal rhinologic, and ear/facial subdomains.
equally impacted in the preoperative phase, and there- For SNOT-22 global scores, this meant that for every
fore experienced the same degree of worsening in disease- 287 days on the waitlist for ESS, the postoperative disease-
specific QOL. It is, however, possible that longer wait times specific QOL would decrease by the MCID. This does
are associated with further worsening in SNOT-22 scores. not mean that patients who exceed this wait time will
Consequently, it is possible that the magnitude of improve- not benefit from ESS, but it could decrease the magni-
ment from ESS is underestimated in cases of increasing wait tude of benefit in a clinically significant way. A criticism
times, and that the gain in postoperative improvement es- of this analysis is the lack of multivariate regression to
sentially balances out. A future study analyzing the associ- adjust for covariates of wait time. Our cohort was too
ation between the length of surgical wait times and change small to run a regression analysis; however, our univari-
in preoperative SNOT-22 scores will be necessary to verify ate analyses failed to identify significant associations be-
our results. tween wait time and clinicopathological factors, and there-
Although a global SNOT-22 score provides a composite fore, these variables do not meet the threshold definition of
QOL indicator, it is a relatively abstract concept, consider- confounding.
ing that clinicians are faced with discrete patient symptoms Several caveats need to be considered when interpreting
that they are trying to alleviate. The clustering of the SNOT- our results. First, this study is limited by its retrospective de-
22 into 5 specific CRS symptom profiles has enabled bet- sign. Furthermore, wait times vary significantly depending
ter characterization of the natural history of CRS and the on geography and health care reimbursement paradigms,
impact of interventions.11, 25, 26 We report that prolonged and our results may only be applicable to publicly funded
wait times for ESS resulted in significantly less improve- healthcare systems. Smoking status was also not collected
ment in rhinologic, extranasal rhinologic, and ear/facial in our dataset, and this would have been a helpful poten-
symptoms, but it did not influence psychological or sleep tial confounder when assessing our outcomes. However,
domains. To our knowledge, this represents a novel finding, Rudmik et al.28 have found that smoking status did not
where surgical wait times may have a differential impact on alter postoperative improvement in health-related QOL af-
symptom domains in CRS. This has several implications. ter ESS. Finally, the appropriateness criteria for ESS uti-
First, healthcare providers will be able to better counsel lized in this investigation was primarily developed from
patients on the specific clinical deterioration they may ex- best-available evidence and expert opinion.14 Its criteria are
perience while waiting for surgery. Second, we propose that based on imperfect measures, and there may be exceptions
SNOT-22 subdomain scores could be used as outcome and depending on the clinical scenario.
process indicators when assessing the quality of surgical
care for CRS, particularly as it relates to timeliness of the
intervention.27
Conclusion
It is interesting to note that prolonged wait times do In patients with medically recalcitrant CRS who are deemed
not alter psychological dysfunction. This observation is in appropriate surgical candidates, the duration of wait time
keeping with a prior study from our institution, where we for ESS impacts the magnitude of benefit on disease-specific
found that there was no correlation between the length QOL in the postoperative period. Moreover, prolonged sur-
of wait time and degree of psychological distress in CRS gical wait times may result in less improvement in disease-
patients who failed AMT.24 Subjects felt that they had no specific symptoms, but it does not appear to worsen psy-
difficulty coping with their symptoms while they waited for chological or sleep dysfunction. Further efforts will need to
ESS, nor did they feel their disease-specific symptoms con- characterize the clinical and patient features where earlier
tributed to feeling depressed. Instead, they felt they could surgical intervention may be beneficial, and whether target
cope with their illness while being on the waitlist because wait times that minimize the impact on symptom domains
they felt comforted that a treatment plan was established.24 can be established.

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