Redefining success in airway surgery for obstructive sleep apnea : A meta analysis and synthesis of the evidence

The role of upper airway surgery as a treatment for adult obstructive sleep apnea (OSA) remains controversial, with perspectives on treatment efficacy varying considerably. Though debate may occur in the clinical sphere, it is necessary to appreciate the ever-increasing funding and policy focus on cost effectiveness and "efficacy" in health care. In this review, we examine contemporary evidence that highlights the importance of "highly effective treatment" over "sub-therapeutic treatment" as a necessity to confer improved health outcomes in OSA. We highlight that assumptions of surgical success inherent in most articles fail to assimilate contemporary, clinically significant indicators of success. We performed a literature search and present interpolated meta-analyses data from 18 surgical articles. Statistical meta-analyses highlight how surgical success decreases when new evidence-based criteria of success are applied. Specifically, when the traditional definition is applied (50% reduction in apnea-hypopnea index [AHI] and/or < or = 20) the pooled success rate for Phase I procedures is 55% (45% fail). However, at AHI < or = 10, success reduces to 31.5% (68.5% fail) and, at AHI < or = 5, success is reduced to 13% (87% fail). According to these definitions, Phase II success (fail) rates decrease from 86% (14%) to 45% (55%) and 43% (57%), respectively. The evidence for clinical efficacy must define treatment "success". We propose all future surgical audits report "objective cure" rates with success based on AHI outcomes of < or = 5 and/or < or = 10. We hope this paper serves as a catalyst for debate and consensus.