Over 150 potentially low-value health care practices: an Australian study

To the Editor: The recent article by Elshaug and colleagues identifying potentially low-value health care practices1 does not distinguish between surgery for obstructive sleep apnoea (OSA) in adults (which is largely used as an adjunctive or salvage intervention in Australia) and children (which is primarily a first-line intervention).

Their article excludes high-level clinical trials in OSA surgery in adults that reflect closely protocols used in a clinical setting. One article overlooked actually finds that surgery is superior to provision of a continuous positive airway pressure (CPAP) device in a cohort of 20 000 patients.2

Elshaug and colleagues list two articles on airway surgery. The article by Franklin et al3 has been criticised4 and involved an uneven comparison, with effectiveness judged on randomised trials, but complications judged on case series. It chose randomised trials for laser-assisted uvulopalatoplasty and radiofrequency ablation of the palate, neither of which are relevant surgical options in contemporary paradigms. The review by Franklin et al was also limited to subsets of OSA severity, and only looked at minimally invasive surgery, contrary to what is usually required in salvage surgery for CPAP failure. The second article, by Kezirian et al,5 used C-reactive protein level as an outcome indicator, which bears no clinical relevance in the treatment of sleep apnoea.

Elshaug and colleagues discuss meeting “agreed standards for effectiveness and safety”. Literature supports surgery in current protocols6 and, specifically, “low complication risk” in a prospective cohort of surgical patients.

Surgeons in Australia have identified clinical trial targets,7 demonstrated significant improvement in objective parameters of adult OSA,8 and produced quality-of-life outcomes comparable to treatment with devices.9

Treating OSA is a proven, cost-effective intervention. Reduction in OSA markers such as apnoea–hypopnoea index with surgery8 may be more cost-effective than therapies like implantable defibrillators.

OSA surgery does not represent low-value health care practice, but it is necessary to continue developing Australian research protocols and clinical paradigms in OSA surgery. Most significantly, patients require options when they can’t tolerate primary treatment (CPAP). With emerging consensus about the failings of CPAP, identifying patients who may be helped with surgery is necessary.