Rural Barriers to Surgical Care for Children With Sleep-Disordered Breathing

Medical treatment does not reduce surgery rates in children with adenoid hypertrophy

OBJECTIVE

We sought to study adenoidectomy rates in children with adenoid hypertrophy (AH) who were either treated with medical therapy or not during a 2-year follow-up period in a longitudinal population-based study.

METHODS

We retrospectively identified healthy children aged 1-18 years between 2014 and 2020 with AH diagnosis from the Clalit Health Services database, the largest healthcare maintenance organization in Israel. The main outcome was adenoidectomy alone or in combination with other procedures performed within 2 years after diagnosis. The treatment group consisted of children who received medical therapy, defined as a pharmacy purchase of montelukast, nasal steroid sprays and/or antihistamines (medical therapy aimed to reduce AH) for ≥2 consecutive months, while the control group consisted of untreated children.

RESULTS

We identified 68,356 unique children with AH, of them 56 % were boys, with a mean age of 4.9 ± 3.3 years. Of them, 5310 (7.7 %) received medical therapy. Overall, 6633 (9.7 %) underwent adenoidectomy within 2 years following diagnosis. There was no significant difference in surgery referral rates between the treatment and the control groups, 10 % vs. 9.7 %, respectively (p = 0.3). When adjusted for age and sex, the likelihood of undergoing adenoidectomy was similar in both groups (HR = 0.98, 95 % CI = 0.90-1.07, p = 0.6). Among operated children, the average time from diagnosis to surgery was statistically significantly longer in the treatment group than in the control group, 346 ± 180 vs 311 ± 175 days (p < 0.001).

CONCLUSION

Prescribing montelukast, nasal steroids and/or oral antihistamines was not associated with a reduction in adenoidectomy rates and was associated with an average surgery delay of 35 days.

Hospital Admissions in Pediatric Patients With Tracheostomies Based on Rurality and Insurance Status

OBJECTIVE

Determine whether rurality or public insurance status is associated with greater 30-day readmission after tracheostomy in pediatric patients.

STUDY DESIGN

Retrospective cohort.

SETTING

Pediatric Health Information System (PHIS) Database.

METHODS

Patients within PHIS who underwent tracheostomy from 2013 to 2017 were included. Rural status was defined by rural-urban commuting area codes. Insurance status was based on the primary payer. All-cause 30-day readmissions and tracheostomy-related readmissions were recorded. Multivariate logistic regression was performed to test for differences in readmissions between cohorts.

RESULTS

Among patients, 1092 were rural, and 4329 were publicly insured, with no significant association between rurality and insurance. Compared to nonrural patients, rural patients were more frequently white, less frequently ventilator dependent, and more likely discharged home rather than to a care facility. Publicly insured patients were more frequently non-white. Twenty-eight percent of patients were readmitted within 30 days of discharge. Odds of 30-day readmission were lower in rural patients (odds ratio [OR]: 0.80, 95% confidence interval [CI]: 0.68-0.95, p = .01) but higher in publicly insured (OR: 1.24, 95% CI: 1.09-1.42, p = .001) controlling for age at tracheostomy, sex, race, and ventilator dependence. The odds of tracheostomy-related admission did not differ by rurality but were higher in publicly insured children (1.39, 95% CI: 1.03-1.88, p = .03).

CONCLUSION

Readmission within 30 days following tracheostomy was more likely in publicly insured patients and less likely in rural patients. These findings help identify at-risk patients when considering discharge planning and follow-up. More work is needed to understand long-term tracheostomy outcomes in these groups.

Diversity, Equity, and Inclusion in Otolaryngology-Head and Neck Surgery: The Big Picture

Efforts are being made to achieve equitable health care for all, in addition to providing equal opportunity for those working within the health care system. Many challenges, however, still need to be overcome as research increasingly brings to light new areas of concern. In this commentary, we highlight recently published findings within the field of otolaryngology in the United States. These findings are then discussed within the context of global health care disparities to emphasize the importance of equitable health care on a global scale.

Neurotology Workforce in the United States: Gender Diversity and Geographic Distribution

OBJECTIVE

The workforce of neurotology has changed with increasing numbers of accredited programs and diverse representation among trainees over the past several decades. This study aims to describe the characteristics, density, and geographic variation of the current neurotology workforce in the United States.

STUDY DESIGN

Cross-sectional study.

SETTING

American Board of Otolaryngology-Head and Neck Surgery portal and online search.

METHODS

The study cohort included physicians certified in Neurotology by the American Board of Otolaryngology as of 2021 (n = 372). Physician characteristics including years of practice, gender, practice setting, and location were collected. Geographic variation analysis was performed by the state, county, and hospital referral region. Associations between the number of neurotologists per population and socioeconomic characteristics were assessed using multivariable regression analysis.

RESULTS

Among 372 neurotologists, 65% practiced in academic settings and 13% were female. The percentage of female neurotologists increased from 0% among neurotologists with ≥30 years of practice to 23% among <10 years of practice. There were no differences in a practice setting by gender. The geographical analysis demonstrated that the average number of neurotologists was 1.1 per 1 million Americans. In a multivariable model, the density of neurotologists was significantly higher within counties with the highest quartiles of college education (β = .6 [95% confidence interval, CI: 0.3-0.8]) and income (β = .3 [95% CI: 0.1-0.6]).

CONCLUSION

The number of board-certified neurotologists has gradually increased and there have been trends toward greater gender diversity. The geographical distribution of neurotology practice was concentrated in counties with higher socioeconomic status as expected given the referral-based nature of the subspecialty. There should be efforts to reach out to low socioeconomic communities to ensure equivalent access to neurotological care.

Examining Associations Between Neighborhood-Level Social Vulnerability and Care for Children With Sleep-Disordered Breathing

OBJECTIVE

We aim to investigate the impact of neighborhood-level social vulnerability on otolaryngology care for children with obstructive sleep-disordered breathing (SDB).

STUDY DESIGN

Retrospective cohort study.

SETTING

A tertiary children's hospital.

METHODS

Children aged 2 to 17 years with SDB were included. Residential addresses were geocoded with geographic information systems, and spatial overlays were used to assign census tract-level social vulnerability index (SVI) scores to each participant. Multivariable logistic regression models were used to estimate associations of neighborhood SVI scores and individual factors with attendance of otolaryngology referral appointment and interventions.

RESULTS

The study included 397 patients (mean ± SD age, 5.9 ± 3.7 years; 51% male, n = 203). After adjustment for age and sex, children with higher overall SVI scores (odds ratio [OR], 0.40; 95% CI, 0.16-0.92) and higher socioeconomic vulnerability scores (OR, 0.34; 95% CI, 0.14-0.86) were less likely to attend their referral appointments. The odds of attending referrals were 83% lower (OR, 0.17; 95% CI, 0.09-0.34) for Black children and 73% lower (OR, 0.27; 95% CI, 0.11-0.65) for Hispanic children than for non-Hispanic White children. Medicaid beneficiaries had lower odds of attending their referrals (OR, 0.20; 95% CI, 0.08-0.48) than privately insured children. Overall SVI score was not associated with receiving recommended polysomnography or tonsillectomy.

CONCLUSION

In our study, children living in areas of greater social vulnerability were less likely to attend their otolaryngology referral appointments for SDB evaluation, as were children of Black race, Hispanic ethnicity, and Medicaid beneficiaries. These results suggest that neighborhood conditions, as well as patient-level factors, influence patient access to SDB care.