The use patterns of Wisconsin The use patterns of Wisconsin family physicians surrounding family physicians surrounding

saline nasal irrigation saline nasal irrigation

11-5-0811-5-08David Rabago, MDDavid Rabago, MD

Aleksandra Zgierska MD PhD, Amy Bamber BS, Paul Peppard PhDAleksandra Zgierska MD PhD, Amy Bamber BS, Paul Peppard PhDUW Department of Family Medicine, NIHUW Department of Family Medicine, NIH

David.Rabago@fammed.wisc.eduDavid.Rabago@fammed.wisc.edu

http://www.fammed.wisc.edu/research/past-http://www.fammed.wisc.edu/research/past-projects/nasal-irrigationprojects/nasal-irrigation

Why do we care?Why do we care?

►Viral upper respiratory infections (URIs)Viral upper respiratory infections (URIs)►RhinosinusitisRhinosinusitis

Viral, bacterial, allergic, irritant, URI Viral, bacterial, allergic, irritant, URI induced asthmainduced asthma

►Billions of clinic/ED visits annuallyBillions of clinic/ED visits annually►Direct costs: $billions / yearDirect costs: $billions / year►Patients care about it: Patients care about it: Quality of Life Quality of Life►Often refractory to treatmentOften refractory to treatment►Serious complicationsSerious complications

Adjunctive Nasal Irrigation (NI)Adjunctive Nasal Irrigation (NI)…?…?

Biological RationaleBiological Rationale

Sino-nasal Disease:

↑ Mucus viscosity

↓ CBF

↓ MCC

↑ Inflammation

↑ Edema

Nasal Irrigation:

↓ Mucus viscosity

↑ CBF

↑ MCC

↓ Inflammation (?)

↓ Edema (?)

AnatomyAnatomy

NI: Chronic Sinus SymptomsNI: Chronic Sinus Symptoms

NI: Other NI: Other Indications/TechniquesIndications/Techniques

►Chronic Sinus SymptomsChronic Sinus Symptoms 0.9-3% liquid saline 1-2 times daily0.9-3% liquid saline 1-2 times daily

►Allergic Rhinitis: 2 studiesAllergic Rhinitis: 2 studies Spray or liquidSpray or liquid

►Viral URI (Common Cold): 2 studiesViral URI (Common Cold): 2 studies Spray or liquidSpray or liquid

►Acute Bacterial Rhinosinusitis: 0 Acute Bacterial Rhinosinusitis: 0 studiesstudies

Neti pot sales: 1/7/07 to 2/24/07

3229 3097 2719 3075 3207 3249 3006 5313

$3

6,1

29

$3

4,3

31

$2

9,7

65

$3

3,9

29

$3

5,5

72

$3

5,8

47

$3

2,9

50

$5

7,5

52

0

1000

2000

3000

4000

5000

6000

1/6/

2007

1/13

/200

7

1/20

/200

7

1/27

/200

7

2/3/

2007

2/10

/200

7

2/17

/200

7

2/24

/200

7

Un

it S

ales

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

Units

Dollars

NPRstory

Purchase of NI devices Purchase of NI devices Climbing Climbing

►100,000 households surveyed using 100,000 households surveyed using consumer tracking techniquesconsumer tracking techniques Ownership of NI spray device from Ownership of NI spray device from

March 2007 to March 2008 stable at March 2007 to March 2008 stable at 9%9%

Ownership of liquid NI device climbed Ownership of liquid NI device climbed from .6 to 1.7% in same periodfrom .6 to 1.7% in same period

What about the docs?What about the docs?

►What is the awareness of NI in Family What is the awareness of NI in Family Medicine?Medicine?

►What are the characteristics of NI What are the characteristics of NI prescribers?prescribers?

►For which conditions is NI For which conditions is NI recommended?recommended?

►How is NI recommended?How is NI recommended?

MethodsMethods

►Summer 2007 Summer 2007 ►Electronic survey using WREN and WAFP Electronic survey using WREN and WAFP

docsdocs►Rigorously reviewed, professionally vettedRigorously reviewed, professionally vetted

(Family Medicine, ENT, Population Health)(Family Medicine, ENT, Population Health) 5 minutes or less to complete5 minutes or less to complete

►131 to WREN, 1695 to WAFP131 to WREN, 1695 to WAFP►Greeting email, survey, 2 reminder emails Greeting email, survey, 2 reminder emails

ResultsResults

►Surveys returned: 330Surveys returned: 330 WAFP: 313 (18.5%) WAFP: 313 (18.5%) WREN: 17 (13%)WREN: 17 (13%)

►Users, 286Users, 286►Aware, non-users, 27Aware, non-users, 27►Not aware, 17Not aware, 17

36%18%

30%

17%

<3535-4445-54>55

Physician Physician AgeAge

57%43%

FM

Physician Physician GenderGender

60%

17%

24% C enter

S uburban

R ural

Practice Practice LocationLocation

Physician Physician RaceRace Caucasian 94%

Non-Caucasian 6%

Missing 4%

42%31%

27%

0-10

10-20

>20

Practice Practice YearsYears

How did you learn How did you learn about SNI?about SNI? Colleague 71%

Conference or Journal 56%

Patient 34%

Missing9%

Media 6%

0%10%20%30%40%50%60%70%80%90%

100%

G ravity P os itiveP res s ure

S pray

Awarenes s ofMethods

MethodsR ec ommended

Awareness and Awareness and Recommendations of SNI Recommendations of SNI

MethodsMethods

How is SNI How is SNI recommended?recommended?

Verbal 90%

Print 50%

Other 4%

Missing 1%

18%

10%

79%

Phys ic ian

Nurs e/As s is tant

No one

Who Shows SNI Who Shows SNI Method?Method?

3%

41%

20%

6%5%

27%Daily

Daily w/ Symptoms

More than once daily

> daily with symptoms

As needed

Other

Frequency of SNI Frequency of SNI RecommendedRecommended

What salinity of SNI is What salinity of SNI is recommended?recommended?

As printed 51%

0.9 % 44%

Don’t know 25%

2-3% 5%

>3% 1%

36%

64%

yes

no

Do you advise adjusting Do you advise adjusting salt, pH to comfort?salt, pH to comfort?

For what age do you For what age do you recommend SNI?recommend SNI?

Adult 98%

Child > 7 yr 80%

Child < 7 yr 26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

C hronic R S Ac ute B ac t.R S

S eas onalAllerg icrhinitis

Viral upperres p.

infec t.

O therallerg icrhinitis

Irritantbas ed

c ong es tion

R hinitis ofpreg nanc y

Nas alP olypos is

UR E -induc edas thma

C onditions

Conditions for which SNI Conditions for which SNI is Recommendedis Recommended

0%

10%

20%

30%

40%

50%

60%

0-25% 25-50% 50-75% 75-100% don’t know

Percent Satisfaction

Patients Satisfied Patients Satisfied with SNIwith SNI

Do you recommend Do you recommend SNI ever prior to SNI ever prior to

antibiotics?antibiotics? Yes 77%

No 23%

CorrelationsCorrelations►Women more likely to recommend NI Women more likely to recommend NI

(p<0.05)(p<0.05)►MDs ≤ 45 years old are likely to MDs ≤ 45 years old are likely to

recommend NI…recommend NI… more often (p<0.06)more often (p<0.06) more often prior to Abxmore often prior to Abx

►MDs practicing for ≤ 10 yrs recommend:MDs practicing for ≤ 10 yrs recommend: more often (p<0.06)more often (p<0.06) more likely to recommend for children more likely to recommend for children

(p<0.02)(p<0.02) more likely to advise gravity based method more likely to advise gravity based method

(neti pot) (p<0.03)(neti pot) (p<0.03)

Is our group representative of Is our group representative of Wisconsin family doctors?Wisconsin family doctors?

►Respondents were more likely to Respondents were more likely to be:be: female (43% compared to 35%)female (43% compared to 35%) younger than 35 years old (18% younger than 35 years old (18%

compared to 9%)compared to 9%)

ConclusionsConclusions

►First study to assess physician use of NIFirst study to assess physician use of NI►Unable to draw conclusions about the true Unable to draw conclusions about the true

awareness of WI family physicians and NIawareness of WI family physicians and NI►Those who recommend NI do so for a Those who recommend NI do so for a

number of indications c/w published number of indications c/w published studiesstudies

►Patient education, solution composition Patient education, solution composition and dosing schedules inconsistentand dosing schedules inconsistent

►A majority of docs report having used NI A majority of docs report having used NI prior to antibioticsprior to antibiotics

►More research neededMore research needed

Thanks!Thanks!

www.fammed.wisc.edu/research/www.fammed.wisc.edu/research/past-projects/nasal-irrigationpast-projects/nasal-irrigation