The Evolving Role of Advanced Practice Providers in Otolaryngology: Improving Patient Access and Patient Satisfaction.

The aging US population requires an increasing volume of otolaryngology-head and neck surgery services, yet the otolaryngologist physician workforce remains static. Advanced practice providers (APPs), including physician assistants and nurse practitioners, improve access across the continuum of primary and subspecialty health care. The rapid growth of APP service is evidenced by a 51% increase in APP Medicare billing for otolaryngology procedures over 5 years. APPs increasingly participate in delivering otolaryngology care; however, reaping the benefits of enhanced patient access and modernizing care delivery is predicated on successful integration of APPs into practices. Few data are available on how best to incorporate APPs into team-based models or how to restructure practices to allow graduated responsibility that supports autonomy and effective teamwork. We compare national APP and physician workforce trends in otolaryngology, consider approaches to optimizing efficiency by integrating APPs, and identify opportunities for improving data collection and practice.

Coding for Optimal Payment (Correct Coding 2022 for Otolaryngology).

The coding process can be confusing to medical professionals; understanding how to do so correctly will optimize reimbursement and keep the provider safe from potential economic and medicolegal problems. This article reviews the coding and valuation processes and provides specific examples to aid the in how to correctly report procedures.

Coding for Otolaryngology Office Procedures.

This review article provides a summary of current correct coding for in-office surgical procedures. The relevant Current Procedural Terminology codes are covered and tips and guidance provided for their correct use. Also, where applicable, facility versus nonfacility reimbursement policy and the associated implications for physicians practicing in hospital-based clinics are discussed.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update) Executive Summary.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published a supplement to this issue of Otolaryngology-Head and Neck Surgery featuring the "Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)." To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed emphasize diagnostic accuracy and efficiency, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing, and increasing the appropriate therapeutic repositioning maneuvers. An updated guideline is needed due to new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).

Objective This update of a 2008 guideline from the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV. Purpose The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV. Action Statements The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.

Analysis of synovial fluid from clinically normal alpacas and llamas.

OBJECTIVE: To establish reference range values for synovial fluid from clinically normal New World camelids. ANIMALS: 15 llamas and 15 alpacas. PROCEDURE: Llamas and alpacas were anesthetized with an IM injection of a xylazine hydrochloride, butorphanol tartrate, and ketamine hydrochloride combination. Synovial fluid (1 to 2 ml) was obtained by aseptic arthrocentesis from the radiocarpal and tarsocrural joints. Synovial fluid evaluation included determination of total nucleated cell count (NCC), absolute number and percentage of polymorphonuclear (PMN) and mononuclear leukocytes, total protein, and specific gravity. RESULTS: Synovial fluid evaluation revealed a total NCC of 100 to 1,400 cells/microl (mean +/- SD, 394.8+/-356.2 cells/microl; 95% confidence interval [CI], 295.2 to 494.6 cells/microl). Mononuclear leukocytes were the predominant cell type with lymphocytes, composing 50 to 90% (mean, 75.6+/-172%; 95% CI, 70.8 to 80.4%) of the mononuclear leukocytes. Approximately 0 to 12% (mean, 1.3+/-2.9%; 95% CI, 0.49 to 2.11%) of the cells were PMN leukocytes. Total protein concentrations ranged from 2.0 to 3.8 g/dl (mean, 2.54+/-0.29 g/dl; 95% CI, 2.46 to 2.62 g/dl); the specific gravity ranged between 1.010 and 1.026 (mean, 1.017+/-0.003; 95% CI, 1.016 to 1.018). CONCLUSION AND CLINICAL RELEVANCE: In llamas and alpacas, significant differences do not exist between species or between limbs (left vs right) or joints (radiocarpal vs tarsocrural) for synovial fluid values. Total NCC and absolute number and percentage of PMN and mononuclear leukocyte are similar to those of other ruminants and horses. However, synovial fluid total protein concentrations in New World camelids are high, compared with other domestic species.