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Cosmetic: Evidence-Based Guidelines & Measures

Evidence-Based Performance Measures for Rhinoplasty: A Multidisciplinary Performance Measure Set

Manahan, Michele A. M.D., M.B.A.; Fedok, Fred M.D.; Davidson, Caryn M.A.; Ahmad, Jamil M.D.; Constantinides, Minas M.D.; Davis, Richard M.D.; Friedman, Oren M.D.; Gilman, Robert M.D.; Ishii, Lisa M.D.; Keyes, Geoffrey M.D.; Lin, Samuel J. M.D.; Marcus, Benjamin M.D.; Matarasso, Alan M.D.; Most, Sam P. M.D.; Quereshy, Faisal D.D.S., M.D.; Sinno, Sammy M.D.; Steinbacher, Derek M.D.; Tollefson, Travis M.D., M.P.H.; Rohrich, Rod J. M.D.

Author Information
Plastic and Reconstructive Surgery: February 2021 - Volume 147 - Issue 2 - p 222e-230e
doi: 10.1097/PRS.0000000000007598
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Abstract

Quality and value rank as top priorities on the local and national health care scenes among physicians, patients, and politicians alike. Measurement of quality and performance metrics have demonstrated concomitant increases in importance over the past several years. Development of these measures remains an imperative duty of experts and stakeholders. To this end, the American Society of Plastic Surgeons convened a multidisciplinary stakeholder work group to devise the first nationally accepted performance measures in the field of rhinoplasty, in keeping with its mission to advance quality care by encouraging high standards of training, ethics, physician practice, and research.

The multidisciplinary workgroup comprised members of the fields of plastic and reconstructive surgery, otolaryngology–head and neck surgery, facial plastic surgery, and maxillofacial surgery. Representatives from several leading national organizations were present during the deliberations. The American Society of Plastic Surgeons (ASPS), the largest plastic surgery specialty organization in the world, represents almost 95 percent of all board-certified plastic surgeons in the United States.1 The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) is the world’s largest organization representing specialists who treat the ear, nose, throat, and related structures of the head and neck.2 The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) is the world’s largest specialty association for facial plastic surgery.3 The Rhinoplasty Society4 is the premier organization in the world dedicated to the education of surgeons who are interested in rhinoplasty, both functional and aesthetic nasal surgery. The American Association of Oral and Maxillofacial Surgeons5 is the professional organization representing more than 9000 oral and maxillofacial surgeons in the United States. A patient representative was recruited but unable to participate in the end.

These groups and their representatives sought to develop performance measurements to define parameters for acceptable clinical practice relevant specifically to cosmetic and functional operative rhinoplasty. All ASPS-led workgroups seek to apply the rigorous structure and methodology developed by the ASPS6 to develop measures reflecting the intersection of expert opinion on clinical practices; rigorous, peer-reviewed, clinical evidence; patient-centered outcomes, and specific areas of focused performance improvement to support the Institute of Medicine’s six aims for health quality improvement: safe, effective, patient-centered, timely, efficient, and equitable.7 The newly developed measures reflect reproducible clinical and patient-centered outcomes, safe surgical techniques, equitable use of resources, and maximization of patient safety.

SCOPE AND INTENDED USERS

The ASPS, AAO-HNS, AAFPRS, and The Rhinoplasty Society encourage the use of these measures by health care professionals board-certified or board-eligible to perform cosmetic and functional rhinoplasties. These performance measures aim to facilitate individual and system-level quality improvement, continuing medical education, maintenance of certification, and compliance with regional and national quality reporting programs. These measures can support better outcomes for rhinoplasty patients in the current clinical environment and will likely require revision as the clinical landscape changes.

These performance measures are not clinical guidelines or fixed protocols and do not establish a standard of medical care. Published guidelines for rhinoplasty exist.8 The goal of these performance measures is to serve instead as metrics by which health care providers or facilities can assess their own performance, benchmark against others using national databases, and improve. Clinicians’ independent medical judgments of patients’ unique clinical situations must always drive evaluation and management decisions.

RHINOPLASTY IN THE LITERATURE

Surgical rhinoplasties are considered to be procedures that address and aim to improve the nasal airway and/or external nasal appearance. This term encompasses a wide variety of surgical techniques, including open and closed approaches. The techniques are performed to address myriad patient goals, including functional and aesthetic endpoints. Outcomes may be judged by patient satisfaction, measurement tools, or complications. Over 200,000 of these operations were performed in 2018.9

With regard to patient-reported outcomes as endpoints to judge the quality of rhinoplasties, the literature demonstrates increasing numbers of options. These may be divided into tools to elicit functional self-assessments, aesthetic self-assessments, and combined functional and aesthetic self-assessments.10 Tools to document patient-reported outcomes not only are vital to determine relative successes at an individual level but will likely also increasingly be used as patient education tools for shared surgical decision-making.11 This application may be particularly useful in the field of rhinoplasty where close communication between surgeon and patient is necessary to fully elucidate surgical goals.

As with many surgical fields, accurate measurement and documentation of preoperative, intraoperative, and postoperative factors has been shown to contain value in obtaining and assessing favorable outcomes.12 An abundance of literature exists to address each of these aspects, and the literature continues to grow rapidly following guideline dissemination. For example, prospective, randomized, controlled trials and reviews have been conducted to examine numerous aspects of surgical techniques.13–15 Varying postoperative protocols exist and have been linked to outcomes in systematic reviews and meta-analyses.16,17 Both subjective and objective methodology may be used preoperatively for patient assessment.18 Nasal anatomy is complex. The preoperative assessment of appearance requires understanding of how this translates to anatomical differences. These factors influence intraoperative choices.19–23

The value of successful rhinoplasty in both aesthetic and functional realms has been well-established in the literature and clinical practice. The diversity of practices encompassed by the general term “rhinoplasty” challenges the development of widely applicable performance measures. It is intended that these measures will be used primarily for educational and not punitive purposes by regulatory bodies. Overly stringent measures may discourage performance of the procedures and critically decrease access to care. Alternatively, measures easily optimized by the large majority of practitioners will fail to drive assessment and improvement. The rhinoplasty measures were designed to incorporate validated guidelines and burgeoning evidence-based literature, refined by practical expert opinion, to be equitable and robust but not overzealous. These are grounded in practical actions that should facilitate optimal patient care.

Limitations to the process relate to the diversity of practice and literature. Valid comparisons between many studies are unable to be accurately performed because of varying patient populations, methodologies, and study endpoints. Publication bias may occur, particularly with regard to negative consequences. Constant evolution of clinical practice makes chronology an important confounding factor.

The rhinoplasty work group elected to focus on overarching issues of importance, widely held by practicing surgeons to be applicable to most rhinoplasties. The measure development work group followed a rigorous development process that included a multidisciplinary work group, management of conflict of interest, in addition to a period of public commentary. The process can be found on our performance measures Web page.6 Our focus was therefore on preoperative evaluation and patient engagement, intraoperative complications, and patient-centered outcomes.

METHODS

ASPS members were invited to apply to the work group by means of Society e-mail communications. All applicants were required to submit an online conflict-of-interest disclosure form for membership consideration. Members of the ASPS Quality and Performance Measurement Committee reviewed and selected work group members to ensure a diverse representation of U.S. regions, practice type (i.e., large multispecialty group practice, small group practice, solo practice, and academic practice), experience in clinical research, and evidence-based medicine expertise. The AAO-HNS and the AAFPRS also nominated members from their respective organizations to serve on the work group, and these members were similarly vetted. Patient representatives were also identified and invited to participate but ultimately were unable to participate.

The technical specifications drafted for this performance measurement set were drafted as registry specifications, because many ASPS members are in solo and small group practices and have not yet implemented electronic health records. Electronic health record specifications have also been developed for implementation in the ASPS Qualified Clinical Data Registry. For performance measure exceptions, the ASPS uses the Physician Consortium for Performance Improvement for exception criteria, which are divided by medical and patient/nonmedical reasons.24

CLINICAL EVIDENCE BASE

Performance measure development is a part of the ASPS Evidence-Based Medicine Initiative. This performance measure set was predominantly based on the guideline published by the AAO-HNS Foundation in 2017, entitled “Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty.”8 Some additional supplemental evidence relating to pain management and patient-reported outcomes was also used.

Quality Measures

To review all the components of the measures, please see Tables 1 through 4.

Table 1. - Measure 1: Presurgical Discussion of Motivations and Outcomes for Patients Undergoing Rhinoplasty
Description
Measure components
 Measure description Percentage of patients aged ≥15 yr who had a rhinoplasty procedure with whom motivation for surgery and outcome expectations were discussed and for whom the following information was documented:
 1. Discussion of motivations and expectations
 2. Surgical goals were realistic and exclusion criteria were reviewed
 Definitions: Documentation of any of words motivation, expectation, realistic, or unrealistic and one of the following terms or phrases will meet the measure:
  Independent/preference/desire/look like/appearance
  Size [big(ger), small(er)]
  Shape [straight, crooked, bent, hook, hump, bump, droop, flare, wide, thin, narrow, bulbous, pug, pointy, projection, rotation, flare, round, long(er), short(er)]
  Proportion/balance [tip, bridge, overly prominent nostrils/nostril asymmetry, change of appearance with smiling (pulling or widening), general asymmetry]
  External shaming/ridicule/advice/critical/teas(ing)/self-esteem/self-conscious
  Facial harmony/gender characteristics/ethnicity
  Function (breathe, breathing, repair injury, snoring, olfaction, recurrent infection, altered sensation, voice change)
  Proportion/balance: This is a process measure. It can function as a quality improvement and accountability measure. Relevant care settings include inpatient, surgical center, and ambulatory care.
 Numerator statement Patients with whom motivation for surgery and outcome expectations were discussed and for whom the following information was documented:
 1. Discussion of motivations and expectations
 2. Surgical goals were realistic and exclusion criteria were reviewed
 Definitions: *Documentation of any of words motivation, expectation, realistic, or unrealistic AND one of the following terms or phrases will meet the measure:
  Independent/preference/desire/look like/appearance
  Size: big(ger), small(er)
  Shape: Straight, crooked, bent, hook, hump, bump, droop, flare, wide, thin, narrow, bulbous, pug, pointy, projection, rotation, flare, round, long(er), short(er)
  Proportion/balance: Tip, bridge, overly-prominent nostrils/nostril asymmetry, change of appearance with smiling (pulling or widening), general asymmetry
  External shaming/ridicule/bullying/advice/critical/tease(ing)
  Self-esteem/self-conscious
  Facial harmony/gender characteristics/ethnicity
  Function
  Breathe/breathing
  Repair injury
  Snoring
  Olfaction
  Recurrent infection
  Altered sensation
  Voice change
  Captured by attestation in the work flow of the ASPS QCDR
 Denominator statement All patients aged ≥15 yr who had a rhinoplasty procedure
 Specification:
  Age >15 yr
   and
  CPT code for encounter: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, or 30465
 Denominator exceptions None
 Supporting guideline Statement 1: Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. Recommendation based on observational studies, with a preponderance of benefit over harm.8
Measure importance
 Relationship to desired outcome The purpose of this measure is to diminish the potential for poor surgical outcomes caused by unrealistic patient motivations and expectations regarding rhinoplasty. These can result from a variety of factors, including poor understanding of the surgical procedure and its capabilities, and psychological abnormality (e.g., body dysmorphic disorder). The surgical team is responsible for identifying and clarifying these factors. Failure to understand patients’ desires can lead to their dissatisfaction with the outcome, despite achieving the desired surgical results from the surgeon’s perspective.8
 Opportunity for improvement Revision rates for rhinoplasty are approximately 10%,25,26 and that is thought to be an underestimate, as it does not generally account for revisions performed by other surgeons. Having a discussion around motivations and setting realistic expectations helps to decrease that rate. The 2017 guideline is the first evidence-based guideline for rhinoplasty; thus, studies of adherence have not yet been conducted. The expert clinicians on the Guideline Panel and on the Measures Work Group felt that this was an important area for improvement.
 Exception justification N/A
 Harmonization with existing measures No existing measures for rhinoplasty
Measure designation
 Measure purpose • Quality improvement
• Accountability
 Type of measure • Process
 Setting • Ambulatory care
• Inpatient
 Data source • Administrative data
• Medical record
• Electronic health record system
• Prospective data collection flow sheet
ASPS, American Society of Plastic Surgeons; QCDR, Qualified Clinical Data Registry; N/A, not applicable.

Table 2. - Measure 2: Airway Assessment for Patients Undergoing Rhinoplasty
Description
Measure components
 Measure description Percentage of patients aged ≥15 yr who underwent a rhinoplasty procedure for whom the nasal airway was assessed with physical examination by means of anterior rhinoscopy and/or speculum examination (lighted or not) and the status of the septum, turbinates, and valves was documented. This is a process measure. It can function as a quality improvement and accountability measure. Relevant care settings include inpatient, surgical center, and ambulatory care.
 Numerator statement Patients for whom nasal airway was assessed with physical examination by means of anterior rhinoscopy and/or speculum examination (lighted or not) and status of the septum, turbinates, and valves was documented. Captured by attestation in the workflow of the ASPS QCDR.
 Denominator statement All patients aged ≥15 yr who had a rhinoplasty procedure
 Specification:
  Age >15 yr
   and
  CPT code for encounter: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, or 30465
 Denominator exceptions None
 Supporting guideline Statement 3: Nasal Airway Obstruction: The surgeon, or the surgeon’s designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. Recommendation based on observational studies, with a preponderance of benefit over harm.8
Measure importance
 Relationship to desired outcome The purpose of this measure is to evaluate clinician diligence regarding the preoperative evaluation of the rhinoplasty patient for nasal airway obstruction. Evaluation of both function and form is critical in the preoperative workup of the rhinoplasty patient.8 Functional airway problems following rhinoplasty have been reported in the literature ranging from 15–68%. Airway obstruction is the most common reason for revision surgery following rhinoplasty.27 Thus, emphasizing the preoperative airway assessment should lead to better outcomes and in turn lower the revision rate.
 Opportunity for improvement A 2015 study reporting on a survey of American Society of Plastic Surgeons members found that 30% of respondents felt they were not adequately trained in assessing and managing the airway during a rhinoplasty. Twenty percent of respondents reported that they do not routinely perform an internasal examination with a focused light source during the preoperative evaluation. The most frequent comment left by respondents was that “management of the airway is an underappreciated/underemphasized topic and further courses/publications on this topic are long overdue.”27 Thus, there is much opportunity to improve the practice of preoperative airway assessment.
 Exception justification N/A
 Harmonization with existing measures No existing measures for rhinoplasty.
Measure designation
 Measure purpose • Quality improvement
• Accountability
 Type of measure • Process
 Care setting • Ambulatory care
• Inpatient
 Data source • Administrative data
• Medical record
• Electronic health record system
• Prospective data collection flow sheet
ASPS, American Society of Plastic Surgeons; QCDR, Qualified Clinical Data Registry; N/A, not applicable.

Table 3. - Measure 3: Shared-Decision Making for Postoperative Management of Discomfort following Rhinoplasty
Description
Measure components
 Measure description Patients who had documentation of a preoperative shared decision-making strategy for multimodal postoperative management of discomfort.
Definitions: Documentation of discussion of at least two mechanisms of pain management from the following terms or phrases (one term or phrase from each list) will meet the measure:
1. Nonopioid analgesics: Nonnarcotic/nonopioid, acetaminophen/Tylenol, Cox-II inhibitor (celecoxib), local/Marcaine/block, anxiolytic, Tramadol, NSAID/ibuprofen.
2. Nonsystemic: Ice/cooling, elevation, rest, mindfulness, meditation. This a process measure. It can function as a quality improvement and accountability measure. Relevant care settings include inpatient, surgical center and ambulatory care.
 Numerator statement Patients who had documentation of a preoperative shared decision-making strategy for multimodal postoperative management of discomfort.
Definitions: Documentation of discussion of at least two mechanisms of pain management from the following terms or phrases (one term or phrase from each list) will meet the measure:
 Nonnarcotic/nonopioid analgesics: acetaminophen/Tylenol, Cox-II inhibitor (celecoxib), local/Marcaine/block, anxiolytic, Tramadol, NSAID/ibuprofen.
 Nonsystemic: Ice/cooling, elevation, rest, mindfulness, meditation.
 Captured by attestation in the workflow of the ASPS QCDR.
 Denominator statement All patients aged ≥15 yr who had a rhinoplasty procedure
 Specification:
  Age >15 yr
   and
  CPT code for encounter: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, or 30465
 Denominator exceptions Patient reasons for not taking a nonopioid analgesic.
 Supporting guideline Statement 6: Managing Pain and Discomfort: The surgeon, or the surgeon’s designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. Recommendation based on studies of the value of education and counseling, with a preponderance of benefit over harm.8
Measure importance
 Relationship to desired outcome Strategies for minimizing pain are thought to improve patient satisfaction with the procedure. Implementing adjunctive measures to improve pain and expectations will help the clinician better encourage patient engagement in the recovery process, thereby improving the surgical result. Evidence for long-term improved patient satisfaction with the outcome of the rhinoplasty as it relates to the acute management of pain and discomfort is not available and is an area that requires investigation.8
 Opportunity for improvement 173 rhinoplasty cases performed at Massachusetts Eye and Ear Institute over a 1-yr period were reviewed. Of the 173 patients, 168 were prescribed opioids in addition to acetaminophen, at an average of 28 pills per patient. Refills were found to be extremely rare, with only two patients refilling, and with some patients (11.3%) not filling their initial opioid prescription at all. The team confirmed the refill rate by querying the Massachusetts State Registry.28 Patel et al.29 found that patients were typically prescribed 20–30 hydrocodone-acetaminophen combination tablets, but on average, consumed only 8.7 tablets. These findings suggest that physicians are overprescribing opioids for rhinoplasty. A reduction in narcotic prescriptions after rhinoplasty may limit the opportunity for opioid abuse. The 2017 guideline is the first evidence-based guideline for rhinoplasty; thus, studies of adherence have not yet been conducted. Anecdotally, both the expert clinicians on the Guideline Panel and on the Measures Work Group felt that this was an important area for improvement.
 Exception justification N/A
 Harmonization with existing measures No existing measures for rhinoplasty.
Measure designation
 Measure purpose • Quality improvement
• Accountability
 Type of measure • Process
 Care setting • Ambulatory care
• Inpatient
 Data source • Administrative data
• Medical record
• Electronic health record system
• Prospective data collection flow sheet
NSAID, nonsteroidal antiinflammatory drug; ASPS, American Society of Plastic Surgeons; QCDR, Qualified Clinical Data Registry; N/A, not applicable.

Table 4. - Measure 4: Patient Satisfaction with Rhinoplasty Procedure
Description
Measure components
 Measure description Percentage of patients aged ≥15 yr who had a rhinoplasty procedure who demonstrated improvement* in functional and/or aesthetic satisfaction using a validated patient satisfaction tool (e.g., SCHNOS, NOSE, SNOT, RHINO) within 1 yr after their procedure. This is a process measure. It can function as a quality improvement and accountability measure. Relevant care settings include inpatient, surgical center, and ambulatory care.
 Numerator statement Patients who demonstrated improvement* in functional and/or aesthetic satisfaction using a validated patient satisfaction tool (e.g., SCHNOS, NOSE, SNOT, RHINO) within 1 yr following their procedure. Captured by attestation in the workflow of the ASPS QCDR.
 Denominator statement All patients aged ≥15 yr who had a rhinoplasty procedure
 Specification:
  Age >15 yr
    and
  CPT code for encounter: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, or 30465
 Denominator exceptions None
 Supporting guideline Statement 10: Outcome Assessment: Clinicians should document patient satisfaction with their nasal appearance and with their nasal function at a minimum of 12 mo after rhinoplasty. Recommendation based on observational studies, with a preponderance of benefit over harm.8
Measure importance
 Relationship to desired outcome The purpose of this measure is to encourage clinicians to assess and document outcome measurements of patient satisfaction after rhinoplasty surgery in a systematic manner. The assessment of patient-reported outcome measures complements the standard postoperative evaluation, such as physical examination and photography. The clinician should assess satisfaction with nasal appearance and with nasal function, which may require ≥1 outcome measurement tool. Some recommended tools are the SCHNOS,30, 31 NOSE,32,33 SNOT,34 and RHINO.35
Validated patient-reported outcome instruments or other tools standardized to the practice can help clinicians with data-driven postoperative communication concerning reasonably expected outcomes. Throughout the healing period (thought to last up to ≥1 yr after rhinoplasty surgery), patient satisfaction should be routinely assessed. The content experts in the Guideline Development Group felt that 12 mo was the minimal acceptable time for a reasonable stable assessment of nasal appearance. However, research publications frequently report postoperative assessments of patient satisfaction with nasal appearance and function at time points far less than 6 mo. Although earlier assessment and documentation may be useful for counseling, the final assessment should be done ideally at 12 mo or later.8
 Opportunity for improvement There currently are no data measuring whether physicians routinely administer PROM tools. However, data on use of PROMs overall generally show low uptake. We believe this measure will be important in moving this practice forward.
 Exception justification N/A
 Harmonization with existing measures No existing measures for rhinoplasty.
Measure designation
 Measure purpose • Quality improvement
• Accountability
 Type of measure • Outcome
 Care setting • Ambulatory care
• Inpatient
 Data source • Administrative data
• Medical record
• Electronic health record system
• Prospective data collection flow sheet
SCHNOS, Standardized Cosmesis and Health Nasal Outcomes Survey; NOSE, Nasal Obstruction Symptom Evaluation; SNOT, Sinonasal Outcome Study; RHINO, Rhinoplasty Health Inventory and Nasal Outcomes; ASPS, American Society of Plastic Surgeons; QCDR, Qualified Clinical Data Registry; PROM, patient-reported outcome measure; N/A, not applicable.
*Pretest and posttest scores must be documented in the patient record.

CONCLUSIONS

Rhinoplasty is an important and multifactorial surgical field procedure. Both of these characteristics make the development of performance measures critical. Thorough assessment of the current state of the literature, in concert with expert opinion to optimize clinical relevance, has led to the development of the first four performance measures for education, benchmarking, and quality improvement.

ACKNOWLEDGMENTS

The Beth Israel Deaconess Medical Center/Harvard Medical School receives institutional grants from Mentor, Synthes, and Allergan. The Dallas Plastic Surgery Institute receives research study funds from Galderma, MTF Biologics, and Allergan. The workgroup offers special thanks to David Lee, M.D., and Raja Mohan, M.D., for contributions as residents and/or fellows throughout the development of the measure set.

APPENDIX

Michele A. Manahan, M,D., ASPS work group co-chair; Fred Fedok, M.D., AAFPRS representative; Caryn Davidson, M.A., ASPS staff lead; Jamil Ahmad, M.D., ASPS member representative, small plastic surgery group practice (two to five plastic surgeons); Minas Constantinides, M.D., AAFPRS representative; Richard Davis, M.D., AAFPRS representative; Oren Friedman, M.D., AAO-HNS representative; Robert Gilman, M.D., ASPS member representative, academic practice; Lisa Ishii, M.D., AAO-HNS representative; Geoffrey Keyes, M.D., The Rhinoplasty Society representative; Samuel J. Lin, M.D., ASPS member representative, academic practice; Benjamin Marcus, M.D., AAO-HNS representative; Alan Matarasso, MD, ASPS Executive Committee liaison; Sam P. Most, M.D., AAFPRS representative; Faisal Quereshy, D.D.S., M.D., American Association of Oral and Maxillofacial Surgeons representative; Sammy Sinno, M.D., ASPS Member Representative, small plastic surgery group practice (two to five plastic surgeons); Derek Steinbacher, M.D., ASPS member representative, academic practice; Travis Tollefson, M.D., M.P.H., AAO-HNS representative; Rod J. Rohrich, M.D., ASPS work group co-chair.

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