Rural-Urban Disparities in Otolaryngology: The State of Illinois

Rural Health Disparities in Allergy, Asthma, and Immunologic Diseases: The Current State and Future Direction for Clinical Care and Research

Rural health disparities are well documented and continue to jeopardize the long-term health and wellness for the millions of individuals who live in rural America. The disparities observed between urban and rural residents encompass numerous morbidity and mortality measures for several chronic diseases and have been referred to as the "rural mortality penalty." Although the unmet health needs of rural communities are widely acknowledged, little is known about rural health disparities in allergies, asthma, and immunologic diseases. Furthermore, the intersection between rural health disparities and social determinants of health has not been fully explored. To achieve a more complete understanding of the factors that perpetuate rural health disparities, greater research efforts followed by improved practice and policy are needed that account for the complex social context within rural communities rather than a general comparison between urban and rural environments or focusing on biomedical factors. Moreover, research efforts must prioritize community inclusion throughout rural areas through meaningful engagement of stakeholders in both clinical care and research. In this review, we examine the scope of health disparities in the rural United States and the impact of social determinants of health. We then detail the current state of rural health disparities in the field of allergy, asthma, and immunology. To close, we offer future considerations to address knowledge gaps and unmet needs for both clinical care and research in addressing rural health disparities.

Rural-urban otolaryngologic observational workforce analysis: The state of Nebraska

Objective

To analyze the rural-urban access to otolaryngology (OHNS) care within the state of Nebraska.

Design

Cross-sectional study.

Methods

Counties in Nebraska were categorized into rural versus urban status based upon the 2013 National Center for Health Statistics urban-rural classification scheme with I indicating most urban and VI indicating most rural. The information on otolaryngologists was gathered utilizing the Health Professions Tracking System. Otolaryngologists were categorized based on the county of their primary and outreach clinic location(s). Travel burden was estimated using census tract centroid distance to the nearest clinic location, aggregated to county using weighted population means to determine the average county distance to the nearest otolaryngologist.

Results

Nebraska is a state with a population of 1.8 million people unequally distributed across 76,824 square miles, with rural counties covering 2/3 of the land area. Nebraska has 78 primary OHNS clinics and 70 outreach OHNS clinics distributed across 93 counties. More than half (54.8%) of the counties in Nebraska lacked any OHNS clinic. Overall, a statistically significant difference was found when comparing mean primary OHNS per 100,000 population and mean miles to a primary OHNS clinic with Level III counties being 5.17 linear miles from primary OHNS compared to Level V counties being 29.94 linear miles.

Conclusion

Overall, a clear discrepancy between rural and urban primary OHNS clinics in Nebraska can be seen visually and statistically with rural Nebraskans having to travel at least 5.5 times farther to primary OHNS clinics when compared to urban Nebraskans.

Addressing disparities in speech-language pathology and laryngology services with telehealth

The COVID-19 pandemic disproportionately affected the health and well-being of marginalized communities, and it brought greater awareness to disparities in health care access and utilization. Addressing these disparities is difficult because of their multidimensional nature. Predisposing factors (demographic information, social structure, and beliefs), enabling factors (family and community) and illness levels (perceived and evaluated illness) are thought to jointly contribute to such disparities. Research has demonstrated that disparities in access and utilization of speech-language pathology and laryngology services are the result of racial and ethnic differences, geographic factors, sex, gender, educational background, income level and insurance status. For example, persons from diverse racial and ethnic backgrounds have been found to be less likely to attend or adhere to voice rehabilitation, and they are more likely to delay health care due to language barriers, longer wait times, a lack of transportation and difficulties contacting their physician. The purpose of this paper is to summarize existing research on telehealth, discuss how telehealth offers the potential to eliminate some disparities in the access and utilization of voice care, review its limitations, and encourage continued research in this area. A clinical perspective from a large volume laryngology clinic in a major city in northeastern United States highlights the use of telehealth in the provision of voice care by a laryngologist and speech-language pathologist during and after the COVID19 pandemic.

Evaluation of Wait Times for Otolaryngology Appointments in Illinois

Objective

The objective of this study was to quantify the wait times that patients may encounter for common clinical diagnoses when seeking otolaryngology care, while determining whether a wait time disparity exists based on geographic location within Illinois.

Methods

In November 2022, a list of Illinois otolaryngologists was obtained from www.entnet.org. Using a uniform script, each of the 291 otolaryngologists were contacted. The caller posed as a new patient with either sudden sensorineural hearing loss, a neck mass, or chronic sinusitis. Each clinic was called 3 times and wait times were recorded. One hundred fifty-eight otolaryngologists were included in the analysis.

Results

The average statewide wait time for a new patient presenting with sudden unilateral hearing loss, a neck mass, and chronic sinusitis was 18.0, 22.6, and 25.5 days, respectively. There was no statistically significant difference between urban and rural wait times.

Discussion

Although wait time differences were noted, the lack of urban versus rural p value significance may be attributed to the small sample size (n = 11) of rural otolaryngologists in Illinois. However, the overall wait times in this study were longer compared to those reported in other studies, suggesting that the current number of otolaryngologists in Illinois is inadequate to meet the public need.

Implications for Practice

We have demonstrated that the current demand for otolaryngology care is outstripping the existing supply in Illinois. This suggests that an emphasis should be placed on training more otolaryngologists, or increasing the use of physician extenders, while incentivizing otolaryngologists to practice in rural areas.

Level of Evidence

5.

Telehealth Adoption and Perspectives Among Pediatric Otolaryngologists Following the COVID-19 Pandemic

OBJECTIVES

To assess use of and physician experiences with pediatric otolaryngology telehealth visits as impacted by the COVID-19 pandemic.

STUDY DESIGN/SETTING

Cross sectional survey.

METHODS

A 15-question survey was electronically distributed to 656 members of the American Society of Pediatric Otolaryngology in August 2021, addressing member demographics, experiential practice elements, and use pre-pandemic, during the initial shutdown period of March-May 2020, and current use at the time of survey inquiry.

RESULTS

There were 124 respondents (response rate = 18.9%). Incident use pre-pandemic and during the shutdown were 21.0% (n = 26), and 92.7% (n = 115), respectively. Current use was 83.9% (n = 104) and the percentage of new current users (79.5%, n = 78) was significant (P < .0001,95% CI = 70.6%-86.4%). Estimated median telehealth visit rates pre-pandemic, during shutdown, and currently were 0 to 1, 4 to 5, and 2 to 3 per week, respectively (P < .0001). A difference in post-covid adoption rates was noted only for location (P = .008), with no differences for years out of training or practice type. Compared to in-person visits, physician satisfaction with telehealth visits was rated equivalent (49.0%) or worse/much worse (48.1%). The most common telehealth uses were follow-up visits (83.7%), pre-operative counseling (76.9%), and post-operative evaluation (69.2%). The need for a detailed exam (89.4%) and initial visits (32.7%) were reasons a telehealth visit was not offered.

CONCLUSIONS

The COVID-19 pandemic appears to have precipitated a rapid increase in telehealth adoption among surveyed pediatric otolaryngologists, regardless of age or practice type. The most significant limitations remain the need for a detailed exam, perceived low patient technological literacy, and limitations to interpretive services. Technology-based optimization of these barriers could lead to increased use and physician satisfaction.

The Role of Access and Cost-Effectiveness in Managing Asthma: A Systematic Review

Background

Inconsistent and unequal access to medical care is an issue that predates the COVID19 pandemic, which only worsened the problem. Limited access to care from asthma specialists and other specialists treating comorbid diseases may adversely affect asthma.

Objective

The purpose of this review is to identify health disparities associated with access to care for asthma, and cost-effectiveness of therapies and interventions addressing this health disparity.

Methods

A narrative systematic review was undertaken using MeSH searches of English language articles published in CINAHL, Scopus, or PubMed.

Results

A total of 725 articles were identified. Barriers recognized from the literature included access to diagnostic spirometry, access to specialists, medication formulary restrictions, and issues leading to medical nonadherence. Telemedicine, school-based health care interventions, digital applications, and non–office-based digital spirometry could be used to address these gaps in access to asthma care while potentially being cost-effective.

Conclusion

With the widespread adoption of telemedicine because of the pandemic, and adoption of other mobile services, we now have potential tools that can increase access to asthma care, which can help address this health care inequity. Evidence is limited, but favorable, that some of these tools may be cost-effective.

Healthcare disparities for the development of airway stenosis from the medical intensive care unit

Objectives/hypothesis

Study design

Methods

Results

Conclusion

Level of evidence

Practice Consolidation in Otolaryngology: The Decline of the Single-Provider Practice

Objective

To observe trends in practice consolidation within otolaryngology by analyzing changes in size and geographic distribution of practices within the United States from 2014 to 2021.

Study Design

Retrospective analysis based on the Physician Compare National Database from the US Centers for Medicare and Medicaid Services.

Setting

United States.

Methods

Annual files from the Physician Compare National Database between 2014 and 2021 were filtered for all providers that listed “otolaryngology” as their primary specialty. Organization affiliations were sorted by size of practice and categorized into quantiles (1 or 2 providers, 3-9, 10-24, 25-49, and ≥50). Both the number of practices and the number of surgeons within a practice were collected annually for each quantile. Providers were also stratified geographically within the 9 US Census Bureau divisions. Chi-square analysis was conducted to test significance for the change in surgeon and practice distributions between 2014 and 2021.

Results

Over the study period, the number of active otolaryngology providers increased from 7763 to 9150, while the number of practices fell from 3584 to 3152 in that time span. Practices with just 1 or 2 otolaryngology providers accounted for 80.2% of all practices in 2014 and fell to 73.1% in 2021. Similar trends were observed at the individual provider level. Regional analysis revealed that New England had the largest percentage decrease in otolaryngologists employed by practices of 1 or 2 active providers at 45.7% and the Mountain region had the lowest percentage decrease at 17.4%.

Conclusion

The otolaryngology practice marketplace has demonstrated a global trend toward practice consolidation.

Analysis of socioeconomic factors in laryngology clinic utilization for treatment of dysphonia

OBJECTIVE

To evaluate the association between patient socioeconomic and demographic factors and tertiary care utilization for dysphonia in a localized metropolitan area of the American Midwest.

METHODS

Multivariate regression analysis was used to correlate patient demographics and population level data (e.g., age, gender, race, insurance, median income, education level) with tertiary laryngology utilization for dysphonia care at our institution between 2000 and 2019. Initial analyses characterized tertiary laryngology utilization rates for all regional ZIP codes and correlated these data with census information for household income and education. Dysphonia patient demographics were compared among populations cared for in our entire academic Otolaryngology department, our health system, and the regional population.

RESULTS

Among 1,365,021 patients in our health system, there were 7066 tertiary laryngology visits with a diagnosis of dysphonia. Dysphonia patients as compared to the overall health system were older (62.0 vs. 50.8 years), more likely to be female (63.7 vs. 50.2%) and more likely to have insurance (98.4 vs. 87.5%, all p < .001). Patient and population-level factors including insurance status, education, and black race showed positive correlation with laryngology utilization while median income did not.

CONCLUSIONS AND RELEVANCE

Insurance status, education level, and race correlated with utilization of tertiary laryngology services for the evaluation of dysphonia in our community, while median income did not. Black patients utilized tertiary laryngology care at higher rates compared to departmental and regional population utilization data. These results underscore important demographic and disease-specific factors that may affect utilization of subspecialty care in Otolaryngology.

LEVEL OF EVIDENCE

IV.

Rural Otolaryngology Care Disparities: A Scoping Review

OBJECTIVE

To broadly synthesize the literature regarding rural health disparities in otolaryngology, categorize findings, and identify research gaps to stimulate future work.

STUDY DESIGN

Scoping review.

DATA SOURCES

A comprehensive literature search was performed in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, and CINAHL.

REVIEW METHODS

The methods were developed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Peer-reviewed, English-language, US-based studies examining a rural disparity in otolaryngology-related disease incidence, prevalence, diagnosis, treatment, or outcome were included. Descriptive studies, commentaries, reviews, and letters to the editor were excluded. Studies published prior to 1980 were excluded.

RESULTS

The literature search resulted in 1536 unique abstracts and yielded 79 studies that met final criteria for inclusion. Seventy-five percent were published after 2010. The distribution of literature was as follows: otology (34.2%), head and neck cancer (20.3%), endocrine surgery (13.9%), rhinology and allergy (8.9%), trauma (5.1%), laryngology (3.8%), other pediatrics (2.5%), and adult sleep (1.3%). Studies on otolaryngology health care systems also accounted for 10.1%. The most common topics studied were practice patterns (41%) and epidemiology (27%), while the Southeast (47%) was the most common US region represented, and database study (42%) was the most common study design.

CONCLUSION

Overall, there was low-quality evidence with large gaps in the literature in all subspecialties, most notably facial plastic surgery, laryngology, adult sleep, and pediatrics. Importantly, there were few studies on intervention and zero studies on resident exposure to rural populations, which will be critical to making rural otolaryngology care more equitable in the future.

Graduating Otolaryngology Residents' Ideal Practice Expectations: A Longitudinal Analysis

OBJECTIVE

Prior literature has indicated that the number of trained otolaryngologists required to meet the need of our growing population may be insufficient. Therefore, identifying trends in the subspecialty composition of future otolaryngology practices will elucidate workforce needs.

STUDY DESIGN

One-page anonymous questionnaire.

SETTING

The survey was completed by examinees at the conclusion of their American Board of Otolaryngology-Head and Neck Surgery oral examination from 2011 to 2019.

METHODS

Data included age, gender, fellowship, practice type, and ideal future practice components.

RESULTS

A total of 2286 examinees were included: 58.1% were male and 57.2% completed a fellowship. Ideal practice specialties included general otolaryngology (19%), rhinology (15%), head and neck (13%), and pediatrics (11%). General and pediatric otolaryngology had a negative correlation over time (r = -0.81, P = .01, and r = -0.75, P = .03, respectively). An overall 45% of graduates reported 1 ideal practice area (r = 0.61, P = .10), with a statistically significant decline in the number of ideal practice areas over time (r = -0.79, P = .018). Men more commonly reported allergy, head and neck, otology, rhinology, and sleep medicine as part of their ideal practice (P < .05), while women more commonly reported pediatric otolaryngology (P < .05). There was a higher mean number of ideal practice areas among men than women (2.58 vs 2.1, P < .001).

CONCLUSION

There is a growing trend for more specialized otolaryngology practices. The data demonstrate a decline in considering general and pediatrics otolaryngology as part of practices, which portends a gap in access to comprehensive otolaryngology in the future.

Incidence and Risk of Suicide Among Patients With Head and Neck Cancer in Rural, Urban, and Metropolitan Areas

Importance

Patients with head and neck cancer (HNC) are known to be at increased risk of suicide compared with the general population, but there has been insufficient research on whether this risk differs based on patients' rural, urban, or metropolitan residence status.

Objective

To evaluate whether the risk of suicide among patients with HNC differs by rural vs urban or metropolitan residence status.

Design, Setting, and Participants

This cross-sectional study uses data from the Surveillance, Epidemiology, and End Results database on patients aged 18 to 74 years who received a diagnosis of HNC from January 1, 2000, to December 31, 2016. Statistical analysis was conducted from November 27, 2020, to June 3, 2021.

Exposures

Residence status, assessed using 2013 Rural Urban Continuum Codes.

Main Outcomes and Measures

Death due to suicide was assessed by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes (U03, X60-X84, and Y87.0) and the cause of death recode (50220). Standardized mortality ratios (SMRs) of suicide, assessing the suicide risk among patients with HNC compared with the general population, were calculated. Suicide risk by residence status was compared using Fine-Gray proportional hazards regression models.

Results

Data from 134 510 patients with HNC (101 142 men [75.2%]; mean [SE] age, 57.7 [10.3] years) were analyzed, and 405 suicides were identified. Metropolitan residents composed 86.6% of the sample, urban residents composed 11.7%, and rural residents composed 1.7%. The mortality rate of suicide was 59.2 per 100 000 person-years in metropolitan counties, 64.0 per 100 000 person-years in urban counties, and 126.7 per 100 000 person-years in rural counties. Compared with the general population, the risk of suicide was markedly higher among patients with HNC in metropolitan (SMR, 2.78; 95% CI, 2.49-3.09), urban (SMR, 2.84; 95% CI, 2.13-3.71), and rural (SMR, 5.47; 95% CI, 3.06-9.02) areas. In Fine-Gray competing-risk analyses that adjusted for other covariates, there was no meaningful difference in suicide risk among urban vs metropolitan residents. However, compared with rural residents, residents of urban (subdistribution hazard ratio, 0.52; 95% CI, 0.29-0.94) and metropolitan counties (subdistribution hazard ratio, 0.55; 95% CI, 0.32-0.94) had greatly lower risk of suicide.

Conclusions and Relevance

The findings of this cross-sectional study suggest that suicide risk is elevated in general among patients with HNC but is significantly higher for patients residing in rural areas. Effective suicide prevention strategies in the population of patients with HNC need to account for rural health owing to the high risk of suicide among residents with HNC in rural areas.

Geographic Distribution of Otolaryngology Advance Practice Providers and Physicians

OBJECTIVES

Advanced practice providers (APPs), namely physician assistants (PAs) and nurse practitioners (NPs), play an increasing role in meeting growing demands for otolaryngologic services, particularly in rural communities. This study analyzes the geographic distribution of otolaryngology providers, which is essential to addressing future demands.

STUDY DESIGN

Cross-sectional study.

SETTING

Medicare Provider Utilization and Payment Data for 2017.

METHODS

Current Procedural Terminology codes were used to identify APPs providing 10 common otolaryngologic services. Geographic distribution was evaluated by calculating densities of APPs and otolaryngologists per 100,000 persons in urban versus rural counties as defined by the National Center for Health Statistics Urban-Rural Classification Scheme.

RESULTS

We identified cohorts of 8573 otolaryngologists, 1148 NPs, and 895 PAs. There were significantly higher population-controlled densities of otolaryngologists and APPs in urban counties as compared with rural counties. The majority of otolaryngologists (92.1%) and APPs (83.3%) were in urban counties. However, the proportion of APPs (16.7%) in rural counties was significantly higher than the proportion of otolaryngologists (7.9%) in rural counties (P < .01). A significant majority of rural counties (72.2%) had zero identified providers, and a greater proportion of rural counties (5.0%) were served exclusively by APPs as compared with urban counties (3.2%).

CONCLUSIONS

Although otolaryngologists and APPs mostly practiced in urban counties, a relatively higher proportion of APPs practiced in rural counties when compared with otolaryngology physicians. The majority of rural counties did not have any otolaryngologic providers. Given the expected shortages of otolaryngology physicians, APPs may play a critical role in addressing these gaps in access.

Rapid telehealth implementation into an otolaryngology practice during the COVID-19 pandemic

OBJECTIVE

Report outcomes of rapid implementation of telehealth across an academic otolaryngology-head and neck surgery department during the COVID-19 pandemic.

METHODS

This is a retrospective, single-institution study of rapid deployment of telehealth during the COVID-19 pandemic. Characteristics of patients were compared between those who agreed and those who declined telehealth care. Reasons for declining telehealth visits were ascertained. Characteristics of telehealth visits were collected and patients were asked to complete a post-visit satisfaction survey.

RESULTS

There was a 68% acceptance rate for telehealth visits. In multivariable analysis, patients were more likely to accept telehealth if they were being seen in the facial plastics subspecialty clinic (odds ratio [OR] 59.55, 95% confidence interval [CI] 2.21-1607.52; P = .015) compared to the general otolaryngology clinic. Patients with Medicare (compared to commercial insurance) as their primary insurance were less likely to accept telehealth visits (OR 0.10, 95% CI 0.01-0.77; P = .027). Two hundred and thirty one patients underwent telehealth visits; most visits (69%) were for established patients and residents were involved in 38% of visits. There was an 85% response rate to the post-visit survey. On a scale of one to ten, the median satisfaction score was 10 and 99% of patients gave a score of 8 or higher. Satisfaction scores were higher for new patient visits than established patient visits (P = .020).

CONCLUSION

Rapid implementation of telehealth in an academic otolaryngology-head and neck surgery department is feasible. There was high acceptance of and satisfaction scores with telehealth.

LEVEL OF EVIDENCE

3.

Challenges in the Delivery of Rural Otolaryngology Care During the COVID-19 Pandemic

Though initially spared from the brunt of the COVID-19 pandemic, rural areas in the United States have been ravaged by the disease. With a higher-risk population at baseline and an already strained health care system, rural hospitals face severe challenges in delivering care during the pandemic. In otolaryngology specifically, there has been difficulty in ensuring patient access to care while maintaining safe environments for patients and staff. Partnership between academic medical centers and critical access rural hospitals is urgently needed to help improve care for vulnerable rural populations.