Surgery “justified” for sleep apnoea

NEW evidence shows surgery for adult obstructive sleep apnoea can have excellent outcomes even when a complete cure is not achieved, according to the authors of a Perspectives article in the MJA. (1)

Improvements in long-term health, short-term symptoms and quality of life made surgery justifiable, according to Professor Stuart MacKay, of the Illawarra ENT Head and Neck Clinic in Wollongong, and Dr Edward Weaver from the University of Washington in the USA.

“It is unrealistic and inappropriate to expect that surgery must result in a cure to be considered worthwhile”, they said. “Well controlled studies are showing important benefits of surgery and, moreover, of combinations of surgical procedures.”

The MJA article continues the debate over the use of surgery for the treatment of obstructive sleep apnoea (OSA) which began when OSA surgery was included in a list of 150 potentially low-value health care practices by Associate Professor Adam Elshaug and coauthors. (2)

Professor MacKay responded in a letter to the MJA saying the authors had excluded high-level clinical trials on OSA surgery, one of which found that surgery was superior to a continuous positive airway pressure (CPAP) device in a cohort of 20 000 patients. (3),  (4)

Professor Ron Grunstein, head of research at the Woolcock Institute of Medical Research and staff specialist at Sydney’s Royal Prince Alfred Hospital Sleep Investigation Unit, told MJA InSight that he felt the claims about the lack of value of OSA surgery had been overblown.

“Taking an absolutist approach to this is not helpful”, he said.

“I think OSA surgery is done a lot less than has been suggested, and there is now increasing evidence that a certain surgical approach is reasonably effective.

“A lot of people with heavy snoring and mild sleep apnoea can benefit from nasal surgery, for example.”

Professor Grunstein said it was one thing to say OSA surgery was of low value and another to come to a clinic and tell that to a patient.

“From the patient’s point of view there [often] is benefit”, he said.

Associate Professor Elshaug, now principal research fellow with the Menzies Centre for Health Policy at the University of Sydney, told MJA InSight he stood by the research findings that first brought these procedures into question.

“As gleaned from dozens of international trials, surgical success rates have been low and highly variable; patients experience significant pain and side effects from the procedures; and there is clear evidence that, in Australia, clinical practice guidelines are not always being followed”, he said.

“In Australia, such surgery is mainly done in the private sector, which has different incentive mechanisms from the public system.

“In a Cochrane review of seven randomised controlled trials in 2005, the results of surgery were inconsistent: significant improvement in polysomnography occurred in only three trials, and health-related quality of life improved in only four trials”, he reported in an analysis he and others published in the BMJ. (5)

Professor Elshaug welcomed the latest MJA article as “fostering a positive dialogue for a set of beleaguered procedures” but questioned some citations.

“This might be a clear-cut case where less would actually represent more. OSA is a complex condition and patients are faced with an ever-growing number of treatment options available, subsidised by taxpayers. Therefore, it is only fair and proper that a critical eye is cast over these and all other treatment options to ensure maximum safety, quality and appropriateness within the Australian health care system.”

1. MJA 2013;  199: 450-451
2. MJA 2012; 197: 556-560
3. MJA 2013; 198: 83
4. Otolaryngol Head Neck Surg 2004; 13: 144
5. BMJ 2008; 336: 44