Table 2 Case Study 2 Upper airway surgical procedures for adult Obstructive Sleep Apnea (OSA)

Approximately one in five adults has at least mild OSA and one in 15 adults has OSA of moderate or worse severity [31]. The condition is an independent risk factor for substantial morbidity(ies) with implications also for mortality [32]. Currently, upper airway surgery is a second-line treatment alternative to an established non-surgical gold-standard. A recent meta-analysis of these surgical procedures reported success rates at [33]:

• 13% for Phase I procedures (including uvulopalatopharyngoplasty [UPPP], laser-assisted uvulopalatoplasty [LAUP], hyoid suspension [HS], genioglossus advancement [GA], and radiofrequency volume reduction of soft tissue [RFVR])

• 43% for advanced Phase II procedures (maxilla and/or mandible advancement (MMA) requiring up to three days Intensive Care Unit recovery).

• Two reports of patient satisfaction highlight that surgery has a high postoperative morbidity rate, a high patient-reported failure rate and a low level of satisfaction with 53% [34] and 61% [35] patient-reported 'regret' rates.

• The Cochrane review in this area [36] supports the restricted use of these operations and yet Australian Medicare data highlights that these procedures are widespread and increasing.

Despite the existence of these procedures for over a decade, debate regarding their efficacy has recently intensified, as to whether these success rates presented above represent 'highly effective treatment', sufficient enough to confer improved health outcomes [37-39]. Disagreement has occurred primarily between relevant medical specialties (i.e. surgeons and sleep medicine physicians). Importantly, there has been a lag in presentation of the necessary evidence to inform and advance such a debate, principally as no policy group has been assigned a stake in the collection or generation of such evidence, hereto it has accrued via the noble but ad hoc actions of clinical groups.