Willard C. Harrill

Objective: To provide a comprehensive state‐of‐the‐art review from the perspective of the surgeon and the surgical specialty academies of the conceptual shift from a volume‐driven fee‐for‐service payment model to one of value‐based accountable care payment. This field guide attempts to clarify drivers of surgical value‐based performance and outline a comprehensive strategy to successfully engage this healthcare reform paradigm.Data Source: Pubmed/MEDLINE/Google search.Review Methods: Pubmed/MEDLINE/Google search was performed during June 1, 2024–May 17, 2025 for value‐based initiatives, administrative, and government agency publications, Centers for Medicare and Medicaid Services, and Center for Medicare and Medicaid Innovation value‐based care policy, directives, and programs.Conclusions: The transition from volume‐based to value‐based payment models necessitates rethinking how surgeons define, quantify, and engage the care they deliver. The social contract between the surgeon and patient is poorly aligned within the current fragmented fee‐for‐service payment model. Relative value units continue to function as a poor benchmark measure of the physician‐patient relationship, which is foundational to achieving consistent patient engagement and favorable clinical outcomes. To facilitate this value‐based realignment within surgical care, we introduce a novel three‐dimensional framework for patient experience management (EM³) focusing on three core elements driving value‐based surgical care: clinical outcomes, patient engagement, and episode‐of‐care spend. EM³ is proposed as a strategic roadmap to operationalize episode‐of‐care transparency within the traditional value equation: Value = Outcomes/Cost. EM³ lays out a comprehensive pathway to facilitate improvements in surgical value‐chain competency, team‐based care leadership, and longitudinal care management skills. These represent the essential core components for competitiveness within a new era of performance metrics relevant to alternative payment arrangements within bundle payments and value‐based referrals. At the academy and peer‐review leadership level, each surgical specialty will need to invest in developing clinically valid next generation assessment measures and care plans encompassing EM³ dimensional elements to remain both relevant and competitive in a new era of evolving accountable care models.

Objectives: Allergen‐specific immunotherapy (AIT) is an effective treatment for allergic disease but requires long treatment duration and premature cessation is of significant concern. Drivers of premature cessation remain poorly understood and no predictive models currently exist. We hypothesized that a novel patient journey map and de novo real‐time patient electronic health status instruments (eHSIs) could effectively capture patient perceived cost, commitment, and treatment benefit to identify individual patients at risk for premature AIT cessation.Study Type: Cross‐Sectional Observational Study.Methods: A single Otolaryngology allergy immunotherapy (AIT) program was studied over 5 years. Instances of premature cessation were classified. An Otolaryngic Allergy Patient Journey Map was developed to identify and target automated, real‐time, patient‐reported, electronic health status instrument responses.Results: Data capture was robust, with 61,406 data points collected and an eHSI survey completion rate of 81.3%. However, based on correlation analysis and logistic regression alone, real‐time eHSI responses were not predictive of individual patient premature AIT cessation. A total of 597 AIT patients discontinued treatment prematurely: 64.4% stopping within the first year. Specifically, 74.0%–76.3% of subcutaneous AIT patients and 88.5%–100% of sublingual AIT patients did not complete the minimum recommended treatment duration of 3 years.Conclusion: Patient journey mapping can aid in the design of longitudinal care models and patient engagement strategies. Yet, eHSI patient responses of perception of AIT cost, benefit, and convenience did not correlate with the likelihood of premature treatment cessation. Our imperfect clinical intuition may not account for the dynamic drivers of premature AIT discontinuation. Future development of predictive tools feed by large patient‐centric data sets may be incorporated into routine practice resulting in delivery of a more streamlined and personalized approach with reduced premature AIT cessation, improved outcomes, and reduced health care expenditures.Level of Evidence: NA Laryngoscope, 134:S1–S14, 2024

Objective: A consolidated state‐of‐the‐art review of U.S. healthcare reform efforts that documents the evolution towards value‐based healthcare (VBH) is lacking in peer‐review literature. This field guide attempts to clarify working definitions and conceptual boundaries within the lexicon of U.S. healthcare reform efforts that predated and have common thematic perspectives within the evolving VBH reform paradigm.Data Sources: Pubmed/MEDLINE/Google search.Review Methods: Pubmed/MEDLINE/Google search was performed during August 1, 2020‐January14, 2021 for U.S. healthcare reform terms, legislative and government agency publications. Those citing relevant legislative, regulatory, philosophical and technological advancements integral to the development and function of VBH were catalogued according to the targeted stakeholders and evolving reform strategy or technology.Conclusions: Eight healthcare reform paradigms were identified as influential precursors to VBH: Patient‐Centered Care Model, Patient‐Centered Medical Home, Population Health, Personalized Medicine, P4 Medicine, Precision Medicine, Managed Care, and Accountable Care. Several of these models have similar nomenclature and, confusingly, many have multiple interpretations of the terms used to describe these models. However, consistent stakeholders identified within these paradigms are key to VBH; notably the patient, the physician and the payer (the “Big 3”). Demonstrable healthcare spending reductions have been best achieved when the Big 3 stakeholder interests are aligned within healthcare reform legislation. The definition of “Value” within each reform model was found to be based upon the perspective of the targeted stakeholder. Within VBH, the perspectives of the Big 3 stakeholders form a multidimensional meaning of “Value” that can be represented by the equation Value = Patient Experience Management³.

Objectives: Investigate the current trends in otolaryngic allergy (OA).Study Design: Cross‐sectional survey.Methods: Survey of active AAOA membership.Results: Response rate was 27.3%. Regional response distribution rates were proportional to the AAOA membership distribution within the United States (R2 = 0.95; P < 0.001), with no significant regional response bias demonstrated (P = 0.428).Self‐reported duration to OA competency was 5.8 years. Physicians reporting OA competency were more likely to be board‐certified (P < 0.001) and have AAOA fellowship status (P < 0.001). The AAOA was reported to be the most valuable educational resource toward achieving OA competency, with residency training being least valuable (P < 0.001).91.5% of respondents’ practices offered OA services. Subcutaneous injections predominated at twice the utilization of sublingual immunotherapy. Allergy immunotherapy tablets were rarely utilized. Home allergy shots were offered by 45.2% of respondents. In‐office immunotherapy vial compounding was preferred (95.8%) to third‐party vendors. 94% of AAOA respondents identified patient compliance to be an issue within OA.Non‐inhalant allergy service integration included food allergy (63.5%), asthma (44.9%), allergic fungal sinusitis (43.8%), penicillin allergy (18%), stinging insect allergy (12.6%), and aspirin desensitization (3.9%).Conclusion: Reported duration to OA competency after residency was surprisingly long. Further investigation of current and future educational/clinical training is warranted given clinical integration reported for OA. Otolaryngology is in the unique position to develop a comprehensive sino‐allergy evidence‐based strategy integrating the extensive diagnostic and medical treatment arms alongside the surgical expertise of the specialty within a clinical sino‐allergy home concept.Level of Evidence: 5 Laryngoscope, 130:283–289, 2020

Objectives/Hypothesis To investigate contemporary issues facing practicing otolaryngologists including workforce dynamics, ancillary service modeling, otolaryngic allergy integration, ambulatory surgery center utilization, and relevant certificate of need legislation. Study Design A cross‐sectional survey analysis of academic and private practicing otolaryngologists in North and South Carolina in 2016. Methods A cross‐sectional survey was e‐mailed to 510 practicing otolaryngologists in North and South Carolina. Results A 21.3% survey response rate was achieved. Otolaryngology workforce was defined by horizontal aggregation of otolaryngologists into larger group models, with fewer solo practitioners being replaced by younger otolaryngologists or employing otolaryngology extenders. Excluding academic practice, few otolaryngologists have chosen direct hospital employment as a career option, although otolaryngologists with fewer years of practice are pursuing that option with greater frequency. Ancillary services showed audiology and hearing aid services being the most common, followed by otolaryngic allergy, point‐of‐service computed tomography, and ultrasound. Although otolaryngologists tend to avoid vertical integration, ambulatory surgery center (ASC) ownership trends favor a joint venture model with a hospital system partner. Most otolaryngologists favor changes to certificate of need legislation to improve patient access to these lower‐cost facilities, regardless of whether they currently utilize or have access to an ASC. Conclusions Otolaryngology is uniquely positioned to adapt and respond to current paradigm shifts within ambulatory medicine. Further analysis is needed to prepare current and future otolaryngologists for the demands and opportunities these challenges pose as patient‐centered care models and consumer dynamics shape future patient expectations and utilization of healthcare. Level of Evidence 5. Laryngoscope, 2018

Background: The symptoms and treatments for nasal obstruction are numerous and common. Yet, a consensus on a surgical approach or, even more importantly, how to define the success of any approach is lacking in the literature. A disease‐specific outcomes instrument recently developed by the American Academy of Otolaryngology, known as the Nasal Obstruction Symptom Evaluation (NOSE) scale, has allowed for a validated, uniform method to compare different treatments for nasal obstruction.Methods: Using the NOSE scale, we prospectively compared the use of bilateral radiofrequency inferior turbinate reduction (BRITR) only with that of BRITR with septoplasty in the treatment of nasal obstruction caused by the combination of septal deviation and turbinate hypertrophy. NOSE scores were obtained pretreatment and at 3 month and 6 month follow‐up.Results: Our data demonstrated significant improvement from baseline after 6 months for the NOSE scores in both the BRITR (P < .001) and BRITR/septoplasty groups (P = .023). No statistical difference was noted in the amount of postoperative improvement between the two treatment groups (P = .304). Both groups did demonstrate a large, clinically important effect using a distribution‐based assessment of clinical change. Despite equal clinically effective results, estimated costs for each treatment option differed significantly, with the office‐based BRITR only group providing significant cost savings compared with the hospital‐based BRITR/septoplasty group.Conclusions: This study suggests that BRITR should be considered as an initial treatment option for nasal obstruction rather than a septoplasty with turbinate reduction in patients with the clinical findings of both a septal deviation and turbinate hypertrophy after failure of medical therapy.

TONSILLECTOMY and adenoidectomy (adenotonsillectomy) remains one of the most commonly performed pediatric surgical procedures in the United States,^1-3 although the frequency of adenotonsillectomy has deceased significantly from peak levels in the 1960s.^4,5 Most of the literature on the effectiveness of adenotonsillectomy has focused on changes in objective measures of disease status (such as number of infections) and not on quality of life (QOL) or overall health status. In addition, most studies have examined only one aspect of tonsil and adenoid disease and have enrolled only severely affected children who met stringent entry criteria. Therefore, it is likely that the impact of tonsil and adenoid disease has been underestimated, since patients with mild or moderate disease were excluded from those studies.

Practice guidelines (PGs) are becoming increasingly important in modern medicine. To study the effects of a PG, we performed a pilot study at a large, urban, public teaching hospital according to a prospective, observational research design with both concurrent and historic controls. Specifically, we studied the effects of a multidisciplinary PG for pediatric outpatient tonsillectomy and adenoidectomy on the process of health‐care delivery. Variables in the health‐care process included patient compliance with clinic and surgery appointments, surgery time, operating room turnover, time in recovery room, unplanned admission rate, patient compliance with postoperative follow‐up, provider compliance with guidelines, and hospital charges. Patients in the PG were found to have fewer preoperative laboratory tests, decreased duplication of services, and shorter operating room turnover times. Provider compliance with the PG varied by service and was intermittent at first but improved gradually. There was a trend toward improved compliance with postoperative follow‐up in patients in the PG. Provider opinions concerning the guideline were positive. This pilot study demonstrates several advantages and disadvantages of the use of PGs in the outpatient setting and in a teaching hospital.

Rhinocerebral mucormycosis is a well‐described fulminant fungal infection that typically presents acutely in patients with diabetic ketoacidosis or immunosuppression. Chronic presentations of rhinocerebral mucormycosis have also been described. In the chronic infection, the disease course is indolent and slowly progressive, often occurring over weeks to months. The authors report 2 cases of chronic rhinocerebral mucormycosis (CRM) treated at their institution and review 16 other cases reported in the English‐language literature. In these cases, the median time from symptom onset to diagnosis was 7 months.The most common presenting features of CRM are ophthalmologic and include ptosis, proptosis, visual loss, and ophthalmoplegia. CRM occurs predominantly in patients with diabetes and ketoacidosis. The incidence of internal carotid artery and cavernous sinus thrombosis is higher in CRM patients than in those with the acute disease, although the overall survival rate for CRM patients is 83%. CRM is clinically distinct from chronic Entomophthorales infection.Laryngoscope, 106:1292‐1297, 1996