No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Chronic Rhinosinusitis in Children: Race and Socioeconomic Status
Abstract
PurposeAlthough chronic rhinosinusitis (CRS) is common in children, the influence of race and socioeconomic status (SES) on the diagnosis/treatment of CRS has not been evaluated. We describe the epidemiology of children with CRS in a pediatric otolaryngology clinic and evaluate demographic differences when compared to a group of children referred for a general pediatric otolaryngology evaluation.Study DesignHistorical cohort study.SettingTertiary academic care center.Subjects and Methods
All new/consult patients (March 1, 2008-July 1, 2011) in a tertiary pediatric otolaryngology clinic with primary diagnosis of CRS were compared to a control group that consisted of all new/consult patients seen in the same clinic over 3 months. Records were evaluated for variables including age, sex, race, and insurance. Characteristics were compared between groups using Mann-Whitney and Fisher's exact tests.ResultsOne hundred and seventy-four children with CRS were compared to 430 controls. When compared to the general pediatric otolaryngology population, children with CRS were older (8.2 ± 4.4 years vs 5.9 ± 4.8 years; P < .0001) and more commonly male (63% vs 52%; P = .018). When compared to controls, children with CRS were more likely to be white (CRS 77% white, 10% black, 13% other vs control 47% white, 33% black, 20% other; P < .0001, risk ratio [RR] = 2.7; 95% confidence interval [CI], 2.0-3.7). Likewise, children with CRS were less commonly insured with medical assistance (CRS 14% vs control 44%; P < .0001; RR = 0.3; 95% CI, 0.21-0.45).Conclusions
When compared to the general population of children seen in this academic urban pediatric otolaryngology setting, children with CRS were more likely to be white and privately insured. This study is the first to evaluate race and SES in relationship to pediatric CRS. Future research should employ nationally representative data to assess the true demographic variation in children with CRS.
... In contrast to the extensive attention paid to potential sex-based differences in MS anatomy and sinusitis prevalence, the possible existence of geographic/ancestry-based differences or racial/ethnic differences has been comparatively understudied (Jabbour, Robey, & Cunningham, 2018;Shay, Shapiro, & Bhattacharyya, 2017;Smith, Ishman, Tunkel, & Boss, 2013), especially among adults (see Soler, Mace, Litvack, & Smith, 2012). Further, while previous studies (Lieu & Feinstein, 2000;Smith, Davidson, & Murphy, 2009;Soler et al., 2012) have shown significant racial/ethnic differences in sinusitis prevalence, such results are commonly attributed to confounding socioeconomic issues. ...
... Finally, while the current study joins a growing body of literature Ikeda, 1996;Ikeda et al., 1998;S anchez Fern andez et al., 2000;Souza et al., 2016;Worrall, 2011) suggesting that morphological variation in MS anatomy may contribute to sinusitisrelated health disparities, we wish to reiterate that numerous social, structural, environmental, and behavioral determinants also undoubtedly influence disparities in sinonasal disease (Jabbour et al., 2018;Lieu & Feinstein, 2000;Smith et al., 2013;Soler et al., 2012). As such, we must emphasize that variation in MS anatomy represents, at most, a co-participant in the complex interplay of factors that influence an individual's susceptibility to sinusitis and related morbidities (e.g., sinonasal cancers, asthma, upper respiratory infections, and allergies). ...
... Moreover, as our study found individuals of Asian ancestry-on average-possess taller MSs, our results suggest MS height dimensions may contribute to population-level disparities in sinonasal health. Etiologies underlying health disparities in sinusitis remain under investigated (Jabbour et al., 2018;Shay et al., 2017;Smith et al., 2013), particularly among adults (Soler et al., 2012). The current F I G U R E 9 Wireframe configurations corresponding to extreme negative and positive CV1 scores in anterior and lateral views. ...
Paranasal sinus drainage is mediated by mucociliary transport and gravity. However, human orthograde posture, along with the superior positioning of the maxillary sinus (MS) ostium, increases reliance on the mucociliary system. Previous research has thus suggested that differences in MS size and shape may impede mucociliary clearance, potentially contributing to disparities in sinusitis susceptibility. To further investigate this hypothesis, this study collected 29 three‐dimensional (3D) coordinate landmarks and seven linear measurements of MS morphology from 167 computed tomography (CT) scans of crania of European, East Asian, or Equatorial African ancestry. MANOVA results reveal the Asian‐derived individuals are characterized by both a significantly taller MS (F = 14.15, p < 0.0001) and a significantly greater distance from the MS floor to the ostium (F = 17.22, p < 0.0001) compared to those of European and African ancestry. A canonical variate (CV) analysis conducted on 3D landmark data provides corroborative results, distinguishing Asian‐derived individuals predominantly on the basis of a relatively lower MS floor. As a greater distance between the MS floor and ostium may impede mucociliary clearance, our results suggest MS anatomy may be a more prominent factor in chronic sinusitis among individuals of Asian ancestry compared to those of European and African ancestries. This provides tentative evidence of an anatomical etiology for chronic sinusitis even in the absence of anatomical variants/abnormalities (e.g., nasal polyps, concha bullosa, Haller's cells, and Agger nasi cells). Further research into the relationship between MS anatomy and sinusitis, in addition to socioeconomic inequalities of healthcare, is warranted to continue evaluating possible contributions to health disparities.
... I n North America, chronic rhinosinusitis (CRS) affects roughly 5-6% of the general population 1,2 and accounts for approximately $8.3 billion in overall direct health care costs annually. 3 CRS is associated with significant morbidity and has quality-of-life consequences similar to patients with angina, congestive heart failure, chronic obstructive pulmonary disease, and chronic back pain. 2 Despite a high prevalence, cost, and substantial quality-of-life implications, CRS research has been limited and contradictory with regard to its association with social determinants of health. According to the World Health Organization, social determinants of health involve the fundamental aspects of one's living and working circumstances, including socioeconomic status (SES), employment, insurance status, education, and race, that can directly or indirectly affect one's health. ...
... 4 In general, patients with a lower SES have poorer access to care and are less likely to seek medical assistance or be referred to subspecialists, despite having higher disease burdens and, subsequently, worse clinical outcomes. 3,[5][6][7][8][9] The same paradox of high disease burden among those with a lower SES and less utilization of care seem to exist for CRS. 2,3,10,11 Disparities in health care have major implications. ...
... 3,[5][6][7][8][9] The same paradox of high disease burden among those with a lower SES and less utilization of care seem to exist for CRS. 2,3,10,11 Disparities in health care have major implications. Both the National Institutes of Health and the Institute of Medicine recognized this and highlighted that certain groups are underrepresented in clinical trials and surgical outcomes research. ...
Background:
Chronic rhinosinusitis (CRS) has a high prevalence and significant cost and quality of life implications. Many types of practitioners care for patients with rhinosinusitis; however, patients with chronic or complicated conditions are often referred for tertiary rhinology services. It is unclear how social determinants of health affect access and utilization of these services. A better understanding of social barriers to tertiary rhinology care is needed to reduce health care disparities and improve health outcomes. The aim of the present study was to measure whether income, insurance status, race, and education affect utilization of tertiary rhinology care.
Methods:
All adult patients diagnosed with CRS by rhinologists at a single tertiary care hospital were identified (2010-2014). Patient characteristics (age, gender, race, insurance status) were compared with population-level data from the hospital and from Davidson County, Tennessee, which includes Nashville. Rhinology utilization rates were calculated for each ZIP code within the county. The association between determinants of health (race, insurance status, education, median income) and tertiary rhinology utilization were measured by using multivariable regression analyses.
Results:
A total of 1341 unique patients with CRS (median age, 50 years; 55% women, 80% white, 82% with private insurance) from Davidson County used tertiary rhinology services. These patients were significantly older and more likely to be female, white, and privately insured than patients seen hospital-wide or among the population of Davidson County (p < 0.001). Utilization rates were higher in ZIP codes with a lower proportion of minorities, a higher median income, and higher rates of private insurance and college education. However, in adjusted analysis, only attainment of a college education was independently associated with utilization of tertiary rhinology services. Utilization was 4% higher for every 1% increase in college-educated population (coefficient 0.04 [95% CI, 0.01-0.07]; p = 0.01).
Conclusion:
Results of this study indicated that some social determinants of health (race, income, educational level, insurance status) do affect utilization of tertiary rhinology services. Higher utilization among those with higher income and educational attainment are contradictory to the data, which indicated that lower socioeconomic status was associated with a higher CRS rate. Further study is required to understand the disparities in rhinology utilization rates.
... However, in two smaller studies, one in South Korea with 91 patients and one in the USA with 93 patients, the relation between CRS and socioeconomic conditions was not shown to be significant [10,11]. In one cross-sectional questionnaire survey performed in the USA, findings suggest that children from socioeconomic minorities experience CRS less often but this result is related to significant disparity to access to appropriate diagnosis, subspecialty care, referral patterns, or perception of disease burden [12]. The same study showed increased prevalence of CRS in patients with less than median household income although the results did not reach statistical significance (Table 1). ...
... Smith DF, 2013 USA [12] Cohort Case n = 496 By analyzing extensive pedigrees in a unique population database, we environment, using air conditioning in the summer, or having a pet at home [6, 10, 19•, 20]. Also, in one study, a direct relationship was found between the prevalence of the disease and the pollutant levels of the cities (carbon monoxide, nitrous dioxide, sulfur dioxide, and particulate matter) [21••]. ...
Purpose of review:
In an era where prevention is paramount, understanding social factors for chronic rhinosinusitis (CRS) may facilitate preventive interventions that mitigate risk factors associated with the initiation or progression of the disease.
Recent findings:
Both passive and active smoking are clearly and unequivocally associated with both the incidence and the severity of rhinosinusitis, while there an increasing body of evidence linking social deprivation and low socioeconomic status with rhinosinusitis and its complications. However, overall, only a handful of studies were longitudinal, while the available studies suffer from lack of standardized definitions of rhinosinusitis. In this systematic review, we assessed the available evidence linking CRS with social factors, such as socioeconomic status and class, educational status, family status, living and working location and conditions, and use of toxins or recreational drugs as well as exercise and diet. Thirty studies from 1995 onwards fulfilled our inclusion criteria and were used for this review. Social deprivation and low socioeconomic level seem to be directly associated with rhinosinusitis, as there are pollutants in living or working environment. A clear and direct association between smoking (both active and passive) and rhinosinusitis was also shown. However, the link between rhinosinusitis and education level, and exercise and diet, if any, seems to be more complex.
... 6 The pathophysiology of CRS has drawn a lot of attention, leading to an increasing number of studies investigating the risk factors associated with CRS. [7][8][9] There are two studies of the Korea National Health and Nutrition Examination Survey that identified several risk factors, such as septal deviation, allergic rhinitis, and influenza vaccination. Moreover, there was an increase in the prevalence of CRS in machinery and plant workers, and with occupational exposure to several factors such as dust, gases, and fumes. ...
Objectives:
To find the association between environmental and occupational exposures and chronic rhinosinusitis (CRS) development.
Methods:
The Preferred Reporting Items Of Systematic Reviews Guidelines were used when a systematic literature review was conducted to find all published cases of CRS by searching PubMed database and Google Scholar. Published articles between 1989 and 2021 that reported chronic and occupational rhinosinusitis were included. However, articles that reported allergic rhinitis or upper airway diseases and non-English articles were excluded from this study.
Results:
A total of 97 articles were extracted initially, and 15 articles were reviewed after excluding 82 articles that did not match our inclusion criteria. Most studies linked CRS development to smoke exposure (n=9734), followed by living in rural areas as farms (n=5504). Exposure to pesticides (n=4248) contributed to a higher prevalence of CRS. Blue-collar occupations, such as fire fighters, farmers, and fishermen were significantly related to CRS development in a total of 5260 patients. Chronic rhinosinusitis mainly affected more men (n=8912) than women (n=8076).
Conclusion:
We found that smoking was the most aggravating environmental factor. Chronic rhinosinusitis symptoms' severity increased with direct contact with allergens. Thus, the greatest proportion of patients with CRS was those with blue-collar occupations, such as firefighters, farmers, and fishermen.
... Black children are more likely to present with epistaxis[33]. Yet chronic rhinosinusitis is more commonly diagnosed in white and insured children[34]. Pecha et al. in 2020 using the National Surgical Quality Improvement Program Pediatric (NSQIP-P) database to investigate outcomes in patients 18 years or less of age undergoing endoscopic sinus surgery (ESS) from 2015 to 2017, reported black patients had a higher incidence of emergent operations (P < 0.001) than their white peers. Black and Hispanic patients had higher rates of urgent operations (P ¼ 0.003 and P < 0.001, respectively), and after adjusting for sex, age, comorbidities, and surgical indication, Hispanic children with elective ESS had increased post- ...
Purpose of review: The current article reviews the current literature and selected sentinel papers on health disparities particularly relevant to the field of pediatric otolaryngology. The discussion will explore racial disparities in otologic and airway intervention areas, as well as general adenotonsillar disease management. Access to and quality of care will be examined, and disparate outcomes discussed.
Recent findings: Growing published data demonstrate children from nonwhite backgrounds receive disparate specialty care in representative fields of pediatric otolaryngology.
Summary: Racial disparities exist in specialty care pediatric otolaryngology. Such disparities should be viewed in the light of generational inequalities in the United States and the foundational inequities that perpetuate them. Parity in the delivery of such specialty care depends on recognizing our current state and intentional efforts to modulate the impact of such effectual factors.
... 31 Of note, Smith et al. identified that pediatric patients presenting for CRS management were more likely to be White and privately insured. 32 Variability in patient access to care may directly impact opportunities for trial enrollment and affect the demographics of research participants. Clinical trials routinely require repeated patient encounters, and they are generally conducted by tertiary academic medical centers, many of which are in urban or metropolitan areas. ...
Objective/Hypothesis
The aim of this study is to assess the ethnic and racial demographics of patients enrolled in prospective chronic rhinosinusitis (CRS) studies relative to the corresponding geographic demographics of the United States (U.S.) census data.
Study Design
Systematic Review and Population analysis.
Methods
A systematic review was performed to identify CRS clinical trials, conducted in the U.S. and published between 2010 and 2020 in which patients were prospectively enrolled. Pooled racial and ethnicity data were compared to national and corresponding regional census data.
Results
Eighty‐three studies were included, comprising 12,027 patients. 50.4% were male and the average age was 49.2 years. 8,810 patients underwent a surgical procedure. Of the 12,027 patients, 81.67% were identified as White, 5.35% as Black, 1.27% as Asian, 0.02% as Pacific Islander, 0.12% as American Indian, and 11.57% were classified as Other. The racial and ethnic composition of the pooled study population differs significantly from the national U.S. census data with the underrepresentation of each minority population (P ≤ .0002). Regional sub‐analyses yield variable results. In the Northeast and West, there was an underrepresentation of all minority populations. In the South and Midwest, Black enrollment was similar to the U.S. census data, while all other minorities were underrepresented.
Conclusions
The racial and ethnic composition of patients enrolled in prospective CRS clinical trials differs significantly from the demographics of the U.S. population. The generalizability and external validity of findings derived from studies comprised of demographically mismatched populations has not been established. Future efforts to enroll more representative populations should be emphasized by the research community, funding bodies, and editorial boards.
Level of Evidence
N/A Laryngoscope, 2021
... This is in agreement with previous studies that found differences in race and socioeconomic status of children who received care for CRS at an outpatient otolaryngology clinic. 12 problem. Additionally, there were limited data on severity, symptoms, and clinical phenotype. ...
Chronic rhinosinusitis (CRS) is characterized by persistent inflammation of the sinus cavities, and in pediatric patients is responsible for 5.6 million outpatient visits annually1. Although previous studies have established substantial activity, work, and social limitations among adults with CRS2, studies in children have been single‐center analyses of tertiary hospitals and focused on establishing the efficacy of surgical intervention in improving quality of life (QOL)3,4. Data are limited on QOL in pediatric CRS in the broader, non‐surgical population.
... Currently over 70 genes have been associated with CRS, summarised by a number of recent reviews (37,38) . Genes were more likely to be white and privately insured (49) ; this however may simply reflect inequality of access to healthcare. ...
Prevention of chronicity of disease and minimising its impact with individualized treatment is a fundamental tenet of precision medicine. A review of the literature has been undertaken to explore how this may apply to chronic rhinosinusitis (CRS). Prevention may be thought of across 3 main domains. Primary prevention of CRS focuses on the avoidance of exposure to environmental factors associated with increased incidence of disease. This includes avoidance of tobacco smoke and occupational toxins. Although allergic rhinitis, respiratory infections and gastro-oesophageal reflux have been shown to be risk factors, there is no evidence as yet that treatment of these conditions is associated with reduced incidence of CRS. Secondary prevention of CRS is concerned with detecting a disease in its earliest stages, intervening to achieve disease and symptom control and preventing future exacerbations. Evidence based guidelines facilitate early diagnosis and appropriate use of medical and surgical interventions. In the future the use of endotypes to direct optimal is like to allow more clinically and cost-effective use of current and emerging treatments, such as monoclonal antibodies. Tertiary prevention aims to minimise the impact of an ongoing illness or injury that has lasting effects. Anxiety and depression have been shown to be associated with symptom amplification and may require treatment. The role of disease-related factors such as the role of the microbiome and osteo-neogenesis in the development of chronicity, and the development of severe combined upper airway disease needs further research.
... Previous studies have shown that children with low socioeconomic status have longer wait times to outpatient subspecialty care and may have less access to otolaryngology surgical services in particular. [12][13][14][15][16][17][18]37 Children with low socioeconomic status often have public insurance and reimbursement concerns may affect physicians' willingness and ability to deliver timely care. 33 Therefore, future efforts to eliminate socioeconomic disparities in SDB healthcare may also focus on improving or equalizing insurance policy and reimbursement. ...
Objective
To evaluate follow-up and timing of sleep-disordered breathing diagnosis and treatment in urban children referred from primary care.
Study Design
Retrospective longitudinal cohort analysis.
Setting
Tertiary health system.
Subjects and Methods
Pediatric outpatients with sleep-disordered breathing, referred from primary care for subspecialty appointment or polysomnography in 2014, followed for 2 years. Timing of polysomnography or subspecialty appointments, loss to follow-up, and sleep-disordered breathing severity were main outcomes. Chi-square and t-test identified differences in children referred for polysomnography, surgery, and loss to follow-up. Logistic regression identified predictors of loss to follow-up. Days to polysomnography or surgery were evaluated using the Kaplan-Meier estimator, with Cox regression comparing estimates by polysomnography receipt and disease severity.
Results
Of 216 children, 188 (87%) had public insurance. Half (109 [50%]) were lost to follow-up after primary care referral. More children were lost to follow-up when referred for polysomnography (50 [76%]) compared with subspecialty evaluation (35 [32%]; P < .001). Children referred to both polysomnography and subspecialty were more likely to be lost to follow-up (odds ratio = 2.73, 95% confidence interval = 1.29-5.78; P = .009). For children who obtained polysomnography, an asymmetric distribution of obstructive sleep apnea severity was not observed ( P = .152). Median time to polysomnography and surgery was 75 and 226 days, respectively. Obstructive sleep apnea severity did not influence time to surgery ( P = .410).
Conclusion
In this urban population, half of the children referred for sleep-disordered breathing evaluation are lost to follow-up from primary care. Obstructive sleep apnea severity did not predict follow-up or timeliness of treatment. These findings suggest social determinants may pose barriers to care in addition to the clinical burden of sleep-disordered breathing.
... (CRS group: 77% white, 10% black, 13% other; control group: 47% white, 33% black, 20% other). [52] Different study types with different populations and different definitions of ethnicities and rhinosinusitis may explain the conflicting findings on this subject. It may be a genetical issue, but habits/environment may also play a role. ...
Background
This study was conducted to assess the effect of comorbidity, ethnicity, occupation, smoking and place of residence on allergic rhinitis (AR), acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS).
Methods
A GA²LEN (The Global Allergy and Asthma European Network) screening questionnaire was sent to a random sample of the Dutch population (n = 16700) in three different areas of the Netherlands.
Results
Fifty percent (8347) of the questionnaires sent were returned. A total of 29% respondents (27–31% in different areas) met the criteria for AR, 18% (17–21%) for ARS and 16% (13–18%) for CRS. Risk factors for AR were itchy rash, eczema, adverse response after taking a painkiller, asthma, CRS and ARS. Moreover, the risk of AR was twice as low for full-time housewives/househusbands than for people with jobs. The risk of ARS or CRS was significantly higher in respondents with a doctor’s diagnosis of CRS, AR, itchy rash or smoking. The risk of CRS was also significantly higher in respondents with an adverse response after taking painkillers, active smoking or asthma. Caucasians are generally less likely to have AR or CRS than Latin-Americans, Hindustani and African-Creoles, and more likely to have ARS than Asian, Hindustani, Mediterranean and African-Creoles.
Conclusions
This study found shared and distinct risk factors for AR, ARS and CRS and therefore provides support for the belief that they have shared symptoms but are different diseases with different aetiologies.
... Several SES factors, such as income, education and occupation, probably affect NCDs. 7 Medical insurance is also widely considered as one of the SES indicators, 8 which may be associated with NCDs. 9 Many lifestyle and behavioural risk factors are associated with NCDs [10][11][12] and are closely linked to SES. 13 Lifestyle and behavioural factors have been found to mediate the relationship between SES and self-rated health, 14 which is a strong predictor of NCDs and mortality with SES gradient. 15 16 Self-rated health is negatively associated with depressed mood, which may affect physical health problems, particularly NCDs. ...
Objective
To investigate the role of socioeconomic status (SES) in chronic non-communicable diseases (NCDs) and offer theoretical evidence for the prevention and control of NCDs.
Design
Cross-sectional survey and structural equation modelling.
Setting
Nationwide, China.
Participants
Female participants in the 2008 National Health Services Survey in China who were 15 years and older.
Results
SES factors were associated with the increased risk of NCDs in Chinese women. Education was identified as the most important factor with a protective role (factor loading=−0.115) for NCDs. Income mainly affected NCDs directly, whereas occupation mainly affected NCDs indirectly. The effects of SES on NCDs were more significant than that of smoking. Medical insurance, smoking and self-reported health played a mediating role in the correlations between those SES factors and NCDs.
Conclusions
In China, socioeconomic disparities associated with the prevalence of NCDs exist among women. Educational and social interventions are needed to mitigate their negative consequences on health outcomes in Chinese women.
... P=0.004) [75]. Finally, children with CRS seem to have more often a private health insurance and thus benefit from a higher economic standard [76]. It might also be possible that a better access to the health care institutions for those children is responsible for those data in contrast to children with a lower social status. ...
Chronic rhinosinusitis (CRS) is a relevant and prevalent medical condition in Germany, Europe and the world. If analysed in detail, the prevalence of CRS shows regional and temporary variety. In this review, currently available data regarding the prevalence of CRS is therefore sorted by country and/or region, time point of data collection and the CRS-definition employed. Risk factors like smoking and gastroesophageal reflux are discussed regarding their influence on CRS prevalence. Moreover, comorbidities of CRS, like asthma, conditions of the cardiovascular system and depression are listed and their influence on CRS is discussed. Furthermore, data on CRS prevalence in special cohorts, like immunocompromised patients, are presented. To estimate the economic burden of CRS, current data e.g. from Germany and the USA are included in this review.
... It is evident that CRS is associated with a substantially impaired quality of life [6], reduced workplace productivity and serious medical treatment costs [5,7]. As the pathophysiology of this chronic condition has attracted high amounts of attention [8], an increasing number of studies [9,10] have focused on potential risk factors associated with CRS. Two studies of the Korea National Health and Nutrition Examination Survey [11,12] identified several risk factors for CRS, including influenza vaccination, septal deviation and allergic rhinitis. ...
Background
Chronic rhinosinusitis (CRS) is defined as a condition of inflammation in the paranasal sinus mucosa persisting for more than 12 weeks. We previously reported that the prevalence of CRS was about 8 % in China. Here, we aim to investigate the occupational and environmental risk factors associated with CRS.
Methods
Data were collected from seven Chinese cities: Urumqi, Changchun, Beijing, Wuhan, Chengdu, Huaian and Guangzhou. CRS was diagnosed according to the European Position Paper on Rhinosinusitis and Nasal Polyps (EP3OS) document. Participants were asked to complete a standardized questionnaire, which was developed by the Global Allergy and Asthma European Network (GA2LEN) project and covered sociodemographic characteristics, CRS-related symptoms and occupational and environmental exposures. We evaluated the association between CRS and various occupational and environmental factors using odds ratios (ORs) and 95 % confidence intervals (95 % CIs).
Results
The total study population consisted of 10,633 subjects, 850 (7.99 %) of whom were defined as having CRS according to the EP3OS criteria. We found that there were significant associations between occupational and environmental factors and CRS. Specifically, having a clearance-related job, occupational exposure to dust, occupational exposure to poisonous gas, a pet at home or carpet at home or at the workplace were risk factors for CRS. Additionally, the method used to keep warm in winter, the duration of time spent using air conditioning in summer and the frequency of exposure to mouldy or damp environments were significantly different in subjects with and without CRS.
Conclusions
Our data showed that some occupational and environmental exposures are strongly associated with CRS, which aids in understanding the epidemiology of CRS.
... P=0.004) [75]. Finally, children with CRS seem to have more often a private health insurance and thus benefit from a higher economic standard [76]. It might also be possible that a better access to the health care institutions for those children is responsible for those data in contrast to children with a lower social status. ...
Chronic rhinosinusitis (CRS) is a relevant and prevalent medical condition in Germany, Europe and the world. If analysed in detail, the prevalence of CRS shows regional and temporary variety. In this review, currently available data regarding the prevalence of CRS is therefore sorted by country and/or region, time point of data collection and the CRS-definition employed. Risk factors like smoking and gastro-oesophageal reflux are discussed regarding their influence on CRS prevalence. Moreover, co-morbidities of CRS, like asthma, conditions of the cardiovascular system and depression are listed and their influence on CRS is discussed. Furthermore, data on CRS prevalence in special cohorts, like immunocompromised patients, are presented. To estimate the economic burden of CRS, current data e.g. from Germany and the USA are included in this review.
© Georg Thieme Verlag KG Stuttgart · New York.
Rhinosinusitis is defined as inflammation of the paranasal and nasal sinus mucosa. Both acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) are common problems in the paediatric age group. The assessment and management of both domains will be addressed within this chapter. The diagnosis and management of children with CRS is challenging due to the frequency of nasal symptoms in this population and similarity of presentation with allergic rhinitis and adenoid hypertrophy.
Background:
Sinusitis can significantly decrease quality of life, is costly in both healthcare expenditure and lost productivity, and can lead to complications if treatment is delayed. Our objective was to explore disparities in healthcare access among adults with sinusitis based on sociodemographic factors.
Methods:
32,994 participants (representing 244,838,261 U.S. adults) who completed the 2016 National Health Interview Survey were analyzed, of which 12.17% were diagnosed with sinusitis at least once in the prior 12 months. Multivariate regression analyses were performed.
Results:
In regression analyses, female sex (OR = 2.00; [95% CI, 1.79-2.24]; p<0.001) and older age groups were associated with increased odds of having sinusitis. Within the sinusitis cohort, Asian race (OR = 5.97; [1.61-22.12]; p = 0.008) and Hispanic ethnicity (OR = 6.97; [3.22-15.06]; p<0.001) were associated with increased odds of obtaining foreign medications. Individuals with Medicaid had decreased odds of delaying care (OR = 0.37; [0.25-0.56]; p<0.001) or not receiving care due to cost (OR = 0.40; [0.24-0.65]; p<0.001), but increased odds of delaying care due to transportation barriers (OR = 4.64; [2.52-8.55]; p<0.001). Uninsured individuals had higher odds for delaying care (OR = 4.97; [3.35-7.38]; p<0.001) and not receiving care (OR = 5.46; [3.56-8.38]; p<0.001) due to cost. Income > $100,000 was associated with a nearly 90% reduction in inability to obtain care due to cost (OR = 0.11; [0.05-0.21]; p-value<0.001) and an over 99% reduction in inability to obtain care due to transportation issues compared to income < $35,000 (OR = 0.01; [0.00-0.04]; p-value<0.001).
Conclusion:
Significant disparities in healthcare access based on race, health insurance status, and income exist among adults with sinusitis in the United States. This article is protected by copyright. All rights reserved.
Objectives Few studies have assessed the role of socioeconomic health care disparities in skull base pathologies. We compared the clinical history and outcomes of pituitary tumors at private and public hospitals to delineate whether health care disparities exist in pituitary tumor surgery.
Methods We reviewed the records of patients who underwent transsphenoidal pituitary tumor resection at NYU Langone Health and Bellevue Hospital. Seventy-two consecutive patients were identified from each hospital. The primary outcome was time-to-surgery from initial recommendation. Secondary outcomes included postoperative diabetes insipidus, cerebrospinal fluid (CSF) leak, and gross total resection.
Results Of 144 patients, 23 (32%) public hospital patients and 24 (33%) private hospital patients had functional adenomas (p = 0.29). Mean ages for public and private hospital patients were 46.5 and 51.1 years, respectively (p = 0.06). Private hospital patients more often identified as white (p < 0.001), spoke English (p < 0.001), and had private insurance (p < 0.001). The average time-to-surgery for public and private hospital patients were 46.2 and 34.8 days, respectively (p = 0.39). No statistically significant differences were found in symptom duration, tumor size, reoperation, CSF leak, or postoperative length of stay; however, public hospital patients more frequently required emergency surgery (p = 0.03), developed transient diabetes insipidus (p = 0.02), and underwent subtotal resection (p = 0.04).
Conclusion Significant socioeconomic differences exist among patients undergoing pituitary surgery at our institution's hospitals. Public hospital patients more often required emergency surgery, developed diabetes insipidus, and underwent subtotal tumor resection. Identifying these differences is an imperative initial step in improving the care of our patients.
Background
Social determinants of health (SDOH) and comorbid conditions (CMCs) influence the setting of presentation for care; however, few studies have explored this relationship in the context of sinus disease.
Objective
This study aims to characterize the relationship of SDOH and CMCs with acuity of health care presentation setting in adults with sinusitis.
Methods
A retrospective analysis based on medical records (demographics, visit types, and ICD-10 codes) of 1842 adult patients presenting with sinusitis to an urban academic medical center was conducted. Chi-square analysis was used to assess bivariate associations of SDOH (age, race/ethnicity, sex, insurance type, and employment status) and CMCs (depression, body mass index [BMI], allergy, and gastroesophageal reflux disease [GERD]) with high-acuity visit types—including emergency department (ED) and inpatient visits. Multivariable binary logistic regression was performed to examine the adjusted associations between SDOH and high-acuity visits.
Results
The sample's mean age was 46.8 years, with 68.5% females and 31.5% males. In adjusted models, the odds of high-acuity visit presentation was higher for males than females (odds ratio [OR]: 1.57; confidence interval [CI]: 1.22–2.01); non-Hispanic Blacks (OR: 2.21; CI: 1.58–3.09) as well as Hispanics/Latinos (OR: 2.10; CI:1.43–3.08) than Whites; unemployed (OR: 1.90; CI: 1.47–2.46.) than employed. Age was positively associated with high-acuity presentation. While GERD was associated with increased odds of high-acuity presentation (OR: 2.80; CI: 1.64–4.78), BMI, allergy, and depression did not have a statistically significant association with these visit types. These associations were independent of insurance coverage, which was not statistically associated with high-acuity visits.
Conclusion
SDOH and CMCs were associated with high-acuity healthcare presentation in adults with sinusitis. While this study highlights how SDOH affect healthcare usage patterns among people with sinusitis, further investigation is needed to identify and address the causes of these patterns.
As an important heterogeneous disease, chronic rhinosinusitis (CRS) is a very common inflammatory condition of the paranasal sinuses in the respiratory system, and can be divided into two distinct phenotypic subtypes: chronic rhinosinusitis without nasal polyposis (CRSsNP) and chronic rhinosinusitis with nasal polyposis (CRSwNP). When diagnosed according to European and American clinical practice guidelines, CRSsNP accounts for >66% of CRS cases and CRSwNP accounts for <33% of cases [1, 2]. At present, CRS creates a substantial health and economic burden on both sufferers and society, and adversely affects a person’s quality of life. As the second most frequent disorder and one of the “top ten” physical health problems affecting businesses in the USA [3, 4], medical complaints due to CRS lead to more than 18 million outpatient visits by adults and 5.6 million visits by individuals 0–20 years old each year [5, 6]. Consequently, approximately 4.5% of all U.S. health-care expenditure are devoted to CRS patients annually [7]. In Germany, the Institute of Medical Statistics reported that CRS was diagnosed 2.6 million times, and 2.2 million CRS patients consulted a doctor for medical assistance in the year 2002 [8]. Recently, a study conducted by the Asia-Pacific Burden of Respiratory Diseases (APBORD) investigated consecutive adult patients who were seeking care for a respiratory disease in six Asian countries. That study revealed that rhinosinusitis was diagnosed in 9% of 13,902 patients with different airway problems. Based on diagnostic criteria in the International Classification of Diseases, 10th revision (ICD-10), the rates of CRS diagnosis ranged from 2.4% in Thailand to 10.7% in Singapore [9]. When taking into consideration the vast global population distribution, reliable and ample epidemiologic studies are absolutely essential for accurately assessing the prevalence and risk factors for CRS. The results of those studies could be used to formulate public health policies and provide medical resources required to meet the needs of CRS patients.
Objective
The Food and Drug Administration and the National Institutes of Health (NIH) have asserted that diverse demographic representation in clinical trials is essential. In light of these federal guidelines, the objective of this study is to assess the racial, ethnic, and gender demographics of patients enrolled in clinical trials registered with the NIH that evaluate chronic rhinosinusitis with nasal polyposis (CRSwNP) relative to the demographics of the US population.
Study Design
Cross-sectional study.
Setting
Not applicable.
Methods
ClinicalTrials.gov was queried to identify all prospective clinical trials for CRSwNP. Individual study and pooled data were compared with national US census data.
Results
Eighteen studies were included comprising 4125 patients and evaluating dupilumab, mepolizumab, omalizumab, fluticasone/OptiNose, MediHoney, mometasone, and SINUVA. Women constituted 42.7% of clinical trial participants. Of the 4125 participants, 69.6% identified as White, 6.6% as Black, 20.8% as Asian, 0.1% as Pacific Islander, 0.4% as American Indian, 8.0% as Hispanic, and 2.4% as other. The racial, ethnic, and gender composition of the pooled study population differs significantly from national US census data, with underrepresentation of Black, Hispanic, Pacific Island, and American Indian individuals, as well as females ( P < .05).
Conclusion
The racial, ethnic, and gender demographics of patients enrolled in CRSwNP clinical trials registered with the NIH differ significantly from the demographics of the US population, despite federal guidelines advising demographically representative participation. Proactive efforts to enroll participants that better represent anticipated treatment populations should be emphasized by researchers, institutions, and editorial boards.
Children admitted to the pediatric intensive care unit represent a vulnerable population because of the seriousness of their health conditions and the delivery of critical care measures that include sedation and invasive procedures. Critically ill children of low socioeconomic status may be more at risk for greater illness severity upon admission to the pediatric intensive care unit and worst outcomes after discharge. We know that socioeconomic factors can adversely affect the health of children but how these factors specifically interact with aspects of pediatric critical care is not well understood. Current measurement practices of socioeconomic status in healthcare research vary widely, making comparisons between studies challenging. Furthermore, the choice of one socioeconomic measure over another in health research can result in different findings and subsequent conclusions. A new look into current socioeconomic status measurement practices is warranted; in addition, how a particular socioeconomic status measure is associated with critical illness and outcomes has not been studied in a large, United States-based, geographically diverse cohort of children mechanically ventilated for acute respiratory failure. This dissertation will use data from the RESTORE clinical trial [U01HL086622 and U01 HL086649(PI: Curley & Wypij), a 31-site cluster randomized trial of a nurse-implemented sedation management intervention on mechanically ventilated children hospitalized for acute respiratory failure] to conduct secondary analyses on measures of illness severity, socioeconomic status, and health outcomes that include resource use and health-related quality of life. By exploring associations between socioeconomic status, illness severity, and post-discharge outcomes, this dissertation will contribute new knowledge regarding how children of various socioeconomic backgrounds present upon admission and how they fare when they return home to their families.
Objectives
To determine if socioeconomic disadvantage impacts perioperative outcomes after tracheostomy.
Methods
We performed a retrospective case series of children who underwent tracheostomy. Children were divided into less and more disadvantaged groups based on their community's Area Deprivation Index (ADI), a validated socioeconomic vulnerability measure. Primary outcomes were the length of stay, total cost, in‐hospital mortality, and 30‐day all‐cause readmission after tracheostomy placement. Length of stay was further analyzed using parametric survival analysis.
Results
A total of 239 patients met inclusion criteria, with 153 (64%) residing in more disadvantaged communities. Children from more disadvantaged communities were less likely to be White (42% vs. 26%, P = .009) and more likely to have Medicaid coverage (90% vs. 62%, P < .001). The two groups had similar medical complexity and comorbidities. The main outcome measures showed differences in median total length of stay (113 vs. 79 days, P = .04) and median total cost ($461 000 vs. $279 000, P = .01). Children with tracheostomies who were from more disadvantaged communities also had increased risk of prolonged hospitalizations (HR = 0.63, 95% CI = 0.48–0.83, P = .001). Readmissions, mortality rates, and quality of life scores were similar between groups.
Conclusions
Community disadvantage was associated with differences in hospitalization length and costs after pediatric tracheostomy placement. Further research should continue to describe how health disparities impact children's safe and efficient care with tracheostomies.
Level of Evidence
4 Laryngoscope, 2021
Objective:
To determine the impact of race and ethnicity on 30-day complications following pediatric endoscopic sinus surgery (ESS).
Study design:
Cross-sectional cohort study.
Subjects and methods:
Patients ≤ 18 years of age undergoing ESS from 2015 to 2017 were identified in the Pediatric National Surgical Improvement Program-Pediatric database. Patient demographics, comorbidities, surgical indication, and postoperative complications were extracted. Patient race/ethnicity included non-Hispanic black, non-Hispanic white, Hispanic, and other. Multivariable logistic regression was performed to determine if race/ethnicity was a predictor of postoperative complications after ESS.
Results:
A total of 4,337 patients were included in the study. The median age was 10.9 (interquartile range: 14.5-6.7) years. The cohort was comprised of 68.3% non-Hispanic white, 13.9% non-Hispanic black, 9.7% Hispanic, and 2.1% other. The 30-day complication rate was 3.2%, and the mortality rate was 0.3%. The rate of reoperation was 3.8%, and readmission was 4.1%. Black and Hispanic patients had higher rates of urgent operations (P = .003 and P < .001, respectively), and black patients had a higher incidence of emergent operations (P < .001) compared to their white peers. For elective ESS cases, multivariable analysis adjusting for sex, age, comorbidities, and surgical indication indicated that children of Hispanic ethnicity had increased postoperative complications (odds ratio: 1.57, 95% confidence interval: 1.04-2.37).
Conclusion:
This analysis demonstrated that black and Hispanic children disproportionately undergo more urgent and emergent ESS. Hispanic ethnicity was associated with increased 30-day complications following elective pediatric ESS. Further studies are needed to elucidate potential causes of these disparities and identify areas for improvement.
Level of evidence:
3 Laryngoscope, 2020.
Rhinosinusitis is defined by uncontrolled inflammation of the paranasal sinuses and nasal cavity. Rhinosinusitis, especially in its chronic form, results in significant symptoms impacting the quality of life of patients. Disparities in the medical care of patients with rhinosinusitis are not fully understood, yet important differences have been noted. Overuse of emergency department (ED) care for rhinosinusitis is likely due to barriers to outpatient healthcare access. African American patients are shown to have more ED visits for rhinosinusitis compared to other racial groups. In children with chronic rhinosinusitis, white and privately insured patients are most likely to be evaluated by specialist including tertiary care center otolaryngologist. White patients are more likely than African Americans to be seen by a specialist or receive surgery despite having similar rates of rhinosinusitis. Impertinently, lower-socioeconomic status has been associated with higher subjective chronic rhinosinusitis symptomatology which might be caused by above differences in healthcare access and use. As rhinosinusitis is a common condition with significant potential morbidity, healthcare disparities may have a large effect on a population level.
Background
Chronic rhinosinusitis (CRS) is an inflammatory disease process characterized by different phenotypes and histopathology profiles. Race and access to care have been implicated in CRS disease severity. Structural histopathology reporting may aid in delineating the inflammatory burden responsible for this effect.
Methods
A structured histopathology report of 14 variables was utilized to assess sinus tissue removed during functional endoscopic sinus surgery (FESS). Histopathology variables and 22‐item Sino‐Nasal Outcome Test (SNOT‐22) scores were compared by race (Black, White, Latino, and Asian) and insurance status (Medicare, Medicaid, and private insurance).
Results
A total of 201 CRS patients (124 White, 38 Black, 28 Latino, and 9 Asian) undergoing FESS were included. Black patients demonstrated increased SNOT‐22 scores (50.74 ± 20.32 vs 41.47 ± 22.75, p < 0.022) and number of eosinophils per high‐power field (>5/HPF) (60.5% vs 44.8%, p < 0.05). White patients demonstrated decreased eosinophil aggregates (22.6% vs 35.1%, p < 0.039) and eosinophils/HPF (<5/HPF) (42.7% vs 55.8%, p < 0.048). Medicaid patients showed increased SNOT‐22 score (55.50 ± 24.46 vs 41.39 ± 21.74, p < 0.003), polypoid disease (61.5% vs 42.3%, p < 0.05), subepithelial edema (80.8% vs 53.1%, p < 0.006), hyperplastic/papillary changes (23.1% vs 8.0%, p < 0.028), fibrosis (61.5% vs 38.5%, p < 0.036), eosinophil aggregates (46.2% vs 24.6%, p < 0.022), and eosinophils/HPF (>5/HPF) (65.4% vs 45.1%, p < 0.043). When controlling for insurance status, Black race was no longer associated with increased SNOT‐22 (p < 0.104) or eosinophils/HPF (>5/HPF) (p < 0.183).
Conclusion
Black and Medicaid patients demonstrated more severe disease by histopathology and SNOT‐22 scores. These findings were no longer significant among Black patients after adjusting for insurance status, suggesting that the prevailing factor influencing worse disease may be access to care.
Objectives:
Multiple studies have reported healthcare disparities in particular settings and conditions within pediatric otolaryngology, but a systematic examination of the breadth of the problem within the field is lacking. This study's objectives are to synthesize the available evidence regarding healthcare disparities in pediatric otolaryngology, highlight recurrent themes with respect to etiologies and manifestations, and demonstrate potential impacts from patient and provider standpoints.
Methods:
A qualitative systematic review of the PubMed, Ovid, and Cochrane databases for articles focusing on racial, ethnic, or socioeconomic disparities related to pediatric otolaryngology conditions or settings was conducted. United States-based studies of any design or publication date with analysis of children 0 to 18 years old were included.
Results:
Of 711 abstracts identified, 39 met inclusion criteria. Manual review of references from these articles yielded 22 additional studies, for a total of 61. Disparities were identified in nearly every subspecialty within pediatric otolaryngology, with otologic conditions the most frequently studied (33 of 61). The most commonly cited disparities involved low socioeconomic status (25 of 61), inadequate insurance (23 of 61), nonwhite race (21 of 61), and barriers to accessing care (21 of 61). Only six articles found no disparities regarding the condition examined in their study.
Conclusion:
Through a variety of study topics, designs, and settings, a growing body of literature documents disparities across the spectrum of pediatric otolaryngology care. The etiologies and manifestations of such disparities are myriad. This evidence suggests the need for interventions to address these disparities at various professional and institutional levels, ideally with methodological rigor to assess the effectiveness of such interventions. Laryngoscope, 2017.
Introduction:
This study describes safety outcomes of pediatric endoscopic sinus surgery (ESS) to identify risk factors for 30-day postoperative adverse events using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database.
Methods:
We performed a retrospective cohort study involving patients in the 2012-2015 NSQIP-P database who underwent ESS. Predictors included demographics, comorbidities and surgical acuity. Outcomes included 30-day complications, reoperations, and readmissions.
Results:
Among 2,061 ESS cases identified, 1,829 (88.7%) were elective and 232 (11.3%) were urgent/emergent. There were 92 (4.5%) readmissions, 54 (2.6%) unplanned reoperations, and 61 (3.0%) complications. On multivariate analysis, readmission was associated with urgent/emergent procedures (OR 2.31, CI 1.36-3.93, p<0.01) and history of bleeding disorder (OR 2.24, CI 1.12-4.44, p = 0.02), reoperation was associated with urgent/emergent procedures (OR 5.78, CI 3.24-10.34, p<0.01), and complications were associated with urgent/emergent procedures (OR 3.81, CI 2.13-6.82, p<0.01) and history of bleeding disorder (OR 5.30, CI 2.74-10.20, p<0.01). Bleeding requiring transfusion was associated with urgent/emergent procedures (OR 9.61, CI 2.90-31.80, p<0.01), history of bleeding disorder (OR 14.16, CI 4.41-45.45, p<0.01), and age <3 years (OR 3.92, CI 0.99-15.61, p = 0.05). Black children were significantly more likely to undergo urgent/emergent surgery than white children (19.7% vs. 9.6%, p<0.01).
Conclusions:
This multi-institutional study confirms that while pediatric ESS is largely safe, urgent/emergent procedures carry the greatest risk of postoperative adverse events, and black children are significantly more likely to undergo higher acuity surgery than white children. Regardless of procedure acuity, young age and bleeding disorder are associated with higher risk of 30-day adverse events.
Background:
The management of pediatric chronic rhinosinusitis (PCRS) is evolving.
Objective:
To assess current practice patterns of members of the American Rhinologic Society (ARS) in managing PCRS.
Methods:
A 27-item Web-based survey on treatment of PCRS was electronically distributed to the ARS membership.
Results:
The survey was completed by 67 members, 40% of whom had completed a rhinology fellowship. The most frequently used medical therapies as part of initial treatment for PCRS were nasal saline solution irrigation, (90%), topical nasal steroids (93%), oral antibiotics (52%), and oral steroids (20%). For initial surgical therapy, 90% performed adenoidectomy; in addition, 31% also performed sinus lavage, 17% performed balloon catheter dilation (BCD), and 17% performed endoscopic sinus surgery (ESS). Sixty percent performed adenoidectomy before obtaining computed tomography imaging. When initial surgical treatment failed, 85% performed traditional ESS. In patients with pansinusitis, 50% of the respondents performed frontal sinusotomy and 70% performed sphenoidotomy. BCD was not frequently used; overall, 66% never or rarely used it, 20% sometimes used it, 12% usually used it, and 3% always or almost always used BCD.
Conclusions:
Most aspects of PCRS management among ARS members were aligned with published consensus statements. Adenoidectomy was almost always included as part of first-line surgical treatment but was also combined with adjunctive surgical procedures with moderate frequency. ESS was performed by a minority of rhinologists as a primary procedure for medically refractory PCRS but was favored when previous surgery failed. BCD was uncommonly used in PCRS.
Objectives/hypothesis:
Determine the national incidence and disparities for common pediatric otolaryngologic conditions.
Study design:
Cross-sectional analysis of a nationally representative database.
Methods:
The National Health Interview Survey (2012) was analyzed, extracting children with frequent ear infections (FEI), nonstreptococcal sore throat (NSST), streptococcal pharyngitis (SP), hay fever, and sinusitis. Demographic data including age, sex, race, Hispanic ethnicity, geographic region, poverty level, and insurance status were extracted. The annual incidences of these conditions were determined. Disparities in the incidence of each condition was determined according to race and ethnicity, adjusting for other demographic variables.
Results:
Among 73.3 million children (average age, 8.6 years; 51.1% male), the incidences were: FEI (4.0 million, 5.5% of children), NSST (11.9 million, 20.6% of children), SP (8.0 million, 13.8% of children), hay fever (6.6 million, 9.0% of children), and sinusitis (4.5 million, 7.9% of children). Black and Hispanic children were less likely to be diagnosed with FEI than white children (odds ratio: 0.503 [95% confidence interval: 0.369-0.686] and odds ratio: 0.661 [95% confidence interval: 0.515-0.848]), adjusting for all other demographic variables. Black and Hispanic children were also less likely to be diagnosed with SP than white children (odds ratio: 0.433 [95% confidence interval: 0.342-0.547] and odds ratio: 0.487 [95% confidence interval: 0.401-0.592], respectively). Similar decreased odds ratios for black and Hispanic children were evident for hay fever (odds ratio: 0.704 [95% confidence interval: 0.556-0.890] and odds ratio: 0.708 [95% confidence interval: 0.565-0.888], respectively) and for sinusitis (odds ratio: 0.701 [95% confidence interval: 0.543-0.905] and odds ratio: 0.596 [95% confidence interval:0.459-0.773], respectively).
Conclusions:
Black and Hispanic children are consistently less likely to be identified or diagnosed with FEI, hay fever, SP, and sinusitis compared to white children. These data likely highlight a significant health care disparity according to race/ethnicity in otolaryngology.
Level of evidence:
2b Laryngoscope, 2016.
Acute bacterial sinusitis is a common disease in the pediatric population that typically resolves without significant complications. Children who do suffer from complications involving the orbit or the brain often experience significant morbidity and potential mortality, typically requiring hospitalization for management. Numerous studies have demonstrated that children from low-income families with public or no insurance are less likely to receive adequate preventative care, are more likely to present with later disease stages, and ultimately endure worse health outcomes. We review the literature to examine if there are socioeconomic disparities in the presentation of complications of acute bacterial sinusitis in the pediatric population.
The primary objective of this study is to evaluate the differences in socioeconomic, demographic, and disease severity factors between patients with chronic rhinosinusitis (CRS) and those with allergic fungal rhinosinusitis (AFRS).
A retrospective cohort analysis was performed.
The study was conducted at the hospital of the University of North Carolina at Chapel Hill.
A total of 186 patients were included (93 AFRS, 93 CRS with and without nasal polyps). Socio- economic and demographic data were obtained from the North Carolina State Data Center. Indicators of disease severity were measured by Lund-Mackay scores, serum immunoglobulin E (IgE) levels, diagnosis of asthma and/or allergic rhinitis, and the number of surgeries and computed tomography scans performed. Associations were analyzed with Fisher's exact, Wilcoxon rank sum, and Pearson's correlations tests.
Compared with patients with AFRS, patients in both CRS groups were predominantly white (P < .0001), were older at the time of diagnosis (P < .0001), had higher county-based income per capita (P = .004), had lower quantitative serum IgE level (P < .001), and had lower Lund-Mackay scores (P < .0001). No associations between disease severity, socioeconomic status, and demographic factors were found within the CRS groups.
Within our cohort of patients residing in North Carolina, those with CRS have higher income, more access to primary care, and lower markers of disease severity than those with AFRS. These data continue to support the notion that AFRS merits classification as a distinct subtype of CRS.
© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.
Little is known regarding the epidemiology of chronic rhinosinusitis (CRS) in racial and ethnic minorities in the United States. This study was designed to comprehensively evaluate the current prevalence of CRS across various treatment settings to identify possible disparities in health care access and use between racial and ethnic populations.
The National Health Interview Survey (NHIS), National Ambulatory Medical Care Survey (NAMCS), and National Hospital Ambulatory Medical Care Survey (NHAMCS) database registries were extracted to identify the national prevalence of CRS in race/ethnic populations and resource use in ambulatory care settings. Systematic literature review identified studies reporting treatment outcomes in minority patients electing endoscopic sinus surgery (ESS). Data were supplemented using a multi-institutional cohort of patients undergoing surgical treatment.
National survey data suggest CRS is a significant health condition for all major race/ethnic groups in the United States, accounting for a sizable portion of office, emergency, and outpatient visits. Differences in insurance status, work absenteeism, and resource use were found between race/ethnic groups. Despite its prevalence, few published studies include information regarding minority patients with CRS. Most (90%) cohort studies did not provide details of race/ethnicity for ESS outcomes. Prospective cohort analysis indicated that minority surgical patients accounted for only 18%, when compared with national census estimates (35%).
CRS is an important health condition for all major race/ethnic groups in the United States. Significant differences may exist across racial and ethnic categories with regard to CRS health status and health care use. Given current demographic shifts in the United States, specific attention should be given to understanding CRS within the context of racial and ethnic populations. Public clinical trial registration (www.clinicaltrials.gov) I.D. No. NCT00799097.
Demographic changes in the United States bring diverse cultures, languages, and challenges to health care delivery, particularly for children. Providing high-quality health care that is patient centered and equitable requires tailored care and a focus on both health care disparities and health literacy.1 Major connections between health literacy and disparities include a common focus on improving quality of care, improving patient-provider communication, overcoming language barriers, understanding the health beliefs of patients, and a need for pediatric-focused research.
Reports by the Institute of Medicine have highlighted health-disparity reduction and health-literacy improvement as critical components for high-quality health and health care for Americans.1–5 Although more is understood about the state of child health disparities and health literacy since …
Address correspondence to Tina L. Cheng, MD, MPH, Johns Hopkins University School of Medicine, Bloomberg School of Public Health, Division of General Pediatrics and Adolescent Medicine, 200 N Wolfe St, Room 2055, Baltimore, MD 21287. E-mail: tcheng2{at}jhmi.edu
The objective of this study was to determine the disease burden of sinusitis relative to other medical conditions.
The adult sample of the National Health Interview Survey for calendar years 1997 to 2006 was analyzed, extracting 1-year prevalence data for the disease conditions sinusitis, hay fever, peptic ulcer, acute asthma, and chronic bronchitis. Disease burden data for emergency room visits, general and specialist visits, health care spending, and workdays lost were also extracted. The influence of each disease condition on disease burden variables was statistically determined. Comparisons among outcomes variables were conducted across disease conditions to determine their relative economic and health care impacts.
Adult patients were studied (313,982; mean age, 45.2 years). The 1-year disease prevalences were: sinusitis (15.2%), hay fever (8.9%), ulcer (2.4%), acute asthma (3.8%), and chronic bronchitis (4.8%). Patients with sinusitis were significantly more likely to: visit the emergency room (22.7% versus 17.4%, p < 0.001), spend greater than $500/year on health care (55.8% versus 45.0%, p < 0.001), and see a medical specialist (33.6% versus 22.3%, p < 0.001), than those without sinusitis. Patients with sinusitis missed an average of 5.67 workdays per 12 months versus 3.74 workdays for those without (p < 0.001). The number of workdays lost with sinusitis was similar to that of acute asthma (5.79 workdays, p > 0.05), and health care spending with sinusitis was significantly greater than that of ulcer disease, acute asthma, and hay fever (p < 0.004).
Sinusitis imparts a significant disease burden both within and outside of the health care system that is comparable with or exceeds that of other conditions commonly thought to be more serious.
Invasive group A Streptococcus (GAS) infections can be fatal and can occur in healthy children. A case-control study identified factors associated with pediatric disease. Case-patients were identified when Streptococcus pyogenes was isolated from a normally sterile site, and matched controls (>or=2) were identified by using sequential-digit dialing. All participants were noninstitutionalized surveillance-area residents <18 years of age. Conditional regression identified factors associated with invasive disease: other children living in the home (odds ratio [OR]=16.85, p=0.0002) and new use of nonsteroidal antiinflammatory drugs (OR=10.64, p=0.005) were associated with increased risk. More rooms in the home (OR=0.67, p=0.03) and household member(s) with runny nose (OR=0.09, p=0.002) were associated with decreased risk. Among children, household-level characteristics that influence exposure to GAS most affect development of invasive disease.
Island and mainland Puerto Rican children have the highest rates of asthma and asthma morbidity of any ethnic group in the United States.
We evaluated the effectiveness of a culturally adapted family asthma management intervention called CALMA (an acronym of the Spanish for "Take Control, Empower Yourself and Achieve Management of Asthma") in reducing asthma morbidity in poor Puerto Rican children with asthma.
Low-income children with persistent asthma were selected from a national health plan insurance claims database by using a computerized algorithm. After baseline, families were randomly assigned to either the intervention or a control group.
No significant differences between control and intervention group were found for the primary outcome of symptom-free days. However, children in the CALMA intervention group had 6.5% more symptom-free nights, were 3 times more likely to have their asthma under control, and were less likely to visit the emergency department and be hospitalized as compared to the control group. Caregivers receiving CALMA were significantly less likely to feel helpless, frustrated, or upset because of their child's asthma and more likely to feel confident to manage their child's asthma.
A home-based asthma intervention program tailored to the cultural needs of low income Puerto Rican families is a promising intervention for reducing asthma morbidity.
Background
The objective of this study was to determine the disease burden of sinusitis relative to other medical conditions.
Methods
The adult sample of the National Health Interview Survey for calendar years 1997 to 2006 was analyzed, extracting 1-year prevalence data for the disease conditions sinusitis, hay fever, peptic ulcer, acute asthma, and chronic bronchitis. Disease burden data for emergency room visits, general and specialist visits, health care spending, and workdays lost were also extracted. The influence of each disease condition on disease burden variables was statistically determined. Comparisons among outcomes variables were conducted across disease conditions to determine their relative economic and health care impacts.
Results
Adult patients were studied (313,982; mean age, 45.2 years). The 1-year disease prevalences were: sinusitis (15.2%), hay fever (8.9%), ulcer (2.4%), acute asthma (3.8%), and chronic bronchitis (4.8%). Patients with sinusitis were significantly more likely to: visit the emergency room (22.7% versus 17.4%, p < 0.001), spend greater than $500/year on health care (55.8% versus 45.0%, p < 0.001), and see a medical specialist (33.6% versus 22.3%, p < 0.001), than those without sinusitis. Patients with sinusitis missed an average of 5.67 workdays per 12 months versus 3.74 workdays for those without (p < 0.001). The number of workdays lost with sinusitis was similar to that of acute asthma (5.79 workdays, p > 0.05), and health care spending with sinusitis was significantly greater than that of ulcer disease, acute asthma, and hay fever (p < 0.004).
Conclusions
Sinusitis imparts a significant disease burden both within and outside of the health care system that is comparable with or exceeds that of other conditions commonly thought to be more serious.
I determined incremental increases in health care expenditures and utilization associated with chronic rhinosinusitis (CRS).
Patients with a reported diagnosis of CRS were extracted from the 2007 Medical Expenditure Panel Survey medical conditions file and linked to the consolidated expenditures file. The patients with CRS were then compared to patients without CRS to determine differences in health care utilization (office visits,emergency facility visits, and prescriptions filled), as well as differences in health care expenditures (total health care costs, office visit costs, prescription medication costs, and self-expenditures) by use of demographically adjusted and comorbidity-adjusted multivariate models.
An estimated 11.1+/-0.48 million adult patients reported having CRS in 2007 (4.9%+/-0.2% of the US population). The additional incremental health care utilizations associated with CRS relative to patients without CRS for office visits, emergency facility visits, and number of prescriptions filled were 3.45+/-0.42, 0.09+/-0.03, and 5.5+/-0.8, respectively (all p<or=0.001). Similarly, additional health care expenditures associated with CRS for total health care expenses, office-based expenditures, prescription expenditures, and self-expenditures were $772+/-$300, $346+/-$130, $397+/-$88, and $90+/-$24, respectively (all p<or=0.01).
Chronic rhinosinusitis is associated with a substantial incremental increase in health care utilization and expenditures due to increases in office-based and prescription expenditures. The national health care costs of CRS remain very high, at an estimated $8.6 billion per year.
To determine the difference between children with private and public insurance at the time of referral to a pediatric otolaryngologist.
Prospective study.
Tertiary care hospital.
Data relating to the severity of a patient's otitis media (number of infections, doctor visits, antibiotic courses) were collected by phone interview. All patients referred to a pediatric otolaryngologist at an urban tertiary care hospital over a 5-month period were included.
One hundred eighty-three children were studied: 87 consecutive patients in the private third-party insurance group (PIN) and 96 patients in the state-based Medicaid insurance group (PA). During the 6 months prior to referral, children in the PIN group had a median 4 acute otitis media infections with 5 courses of oral antibiotics and 6 primary care visits compared to 3 infections with 3 courses of antibiotics and 4 primary care visits for the PA group (P = .0009, P ≤ .0001, P = .0003, respectively). For recurrent acute otitis media, the PA group had a significantly longer time with disease prior to referral than the PIN group (P = .0478).
Children in this metropolitan area referred for tympanostomy tube placement with PIN are younger, have more episodes of acute otitis media, receive more antibiotic courses, and have more primary care visits in the 6 months prior to referral than their PA counterparts. Additional research is required to determine why these differences exist, especially in light of ongoing changes to the health care system.
To determine variations in resource utilization in the management of pediatric acute sinusitis.
Retrospective analysis of a publicly available national dataset.
The Kids' Inpatient Database 2006 was analyzed using ICD-9 codes for acute sinusitis.
A total of 8,381 patients (55% male, mean age 8.5 years [SE = 0.2]) were admitted with acute sinusitis. Mean total charges was $20,062 (SE = 1,159.1). Mean length of stay was 4.2 days (SE = 0.12), with 4.8 diagnoses (SE = 0.06) and 0.85 procedures (SE = 0.06). Thirty-six percent had concomitant respiratory diseases, 11% otitis media, and 8% orbital symptoms. A total of 703 patients underwent operations on the upper aerodigestive tract (534 were nasal sinusectomies); 582 patients underwent lumbar puncture and 162 underwent orbital surgery. The primary payer was private insurance in 50% and Medicaid in 41%. Predictors of increased total charges were male gender (P =.028), being a teaching hospital (P < .0001), metropolitan patient location (P < .0001), hospitals in the western region (P < .0001), admission source from another hospital (P < .0001), and discharge status to another inpatient hospital or home healthcare (P < .0001). There is a large geographic variation in resource utilization (range = $5,837 [Arkansas] to $48,327 [California]). Race, primary payer, admission type, and urgency were not significant predictors of increased resource utilization.
Despite being a common diagnosis, there exists a large national variation in management of acute pediatric sinusitis. Predictors of increased resource utilization included male gender, teaching hospital status, metropolitan patient location, western hospital region, admission source, and discharge status. Knowledge of these variables may allow interventions and potentially facilitate benchmarking to reduce the economic burden of this entity while ensuring optimal outcomes.
Although racial/ethnic and socioeconomic disparities in child health are prevalent, little is known about them within common pediatric otolaryngic problems. Otitis media (OM) is a frequent diagnosis in children, and tympanostomy tube placement is the most common surgical treatment for OM. We sought to identify current knowledge regarding racial/ethnic and socioeconomic disparities in children with OM or tympanostomy tube placement.
Qualitative systematic review of MEDLINE database for U.S.-based articles reporting on racial/ethnic or socioeconomic disparities in diagnosis or surgical treatment of OM over the last 30 years.
Of 428 abstracts identified, 15 met inclusion criteria. Articles addressed OM prevalence (12 of 15), risk factors (9 of 15), and tympanostomy tube insertion (4 of 15). Minority racial/ethnic groups studied were Black (11 of 15), Hispanic (6 of 15), American Indian/Alaska Native (2 of 15), and Asian (1 of 15). Predominant findings showed: 1) the most common identified risk factor for OM is socioeconomic status; 2) considerable variability exists concerning racial/ethnic disparities in disease prevalence; and 3) White children are more likely to undergo tympanostomy tube insertion compared to Black or Hispanic children.
Racial/ethnic and socioeconomic disparities exist for the prevalence and treatment of children with OM. Socioeconomic deprivation increases the risk of OM in children. Despite the frequency of tympanostomy tube insertion in children in the United States, few studies have addressed inequalities in access or utilization of surgical therapy. Given the changing healthcare climate and the social and economic impact of OM in children, further investigation of racial/ethnic and socioeconomic disparities targeting access to surgical treatment of OM should take precedence in health services research.
To evaluate discrepancies in presentation and postoperative outcomes in a population of allergic fungal sinusitis (AFS) patients.
Prospective cohort study.
Clinical and demographic records of 48 patients (26 males, 22 females) who underwent endoscopic sinus surgery (ESS) for treatment of AFS were collected from 2003 to 2008. All patients completed pre- and postoperative Sinonasal Outcome Test (SNOT)-20 questionnaires. Patients also underwent objective grading via the Lund-Kennedy nasal endoscopy and the Lund-Mackay computed tomography (CT) scan scoring systems. This data was interrogated by means of both univariate and multivariate analysis through the use of Mann-Whitney and chi-square tests to calculate statistical significance.
Preoperatively African-Americans had significantly higher Lund-Mackay and mean endoscopy scores (P < .05) than Caucasians. However, there was no significant difference among SNOT-20 scores. Postoperative symptom and endoscopy scores improved in all patient groups with significantly greater improvement in women (both P < .05) versus men at 12 months. Improvement ratio of preoperative versus postoperative endoscopy scores trended toward significance at 6 months (P = .08), with African-Americans improving more than Caucasians.
Epidemiologic factors may play an important role in the presentation and progression as well as in surgical outcomes of patients diagnosed with allergic fungal sinusitis.
This paper provides an overview of racial variations in health and shows that differences in socioeconomic status (SES) across racial groups are a major contributor to racial disparities in health. However, race reflects multiple dimensions of social inequality and individual and household indicators of SES capture relevant but limited aspects of this phenomenon. Research is needed that will comprehensively characterize the critical pathogenic features of social environments and identify how they combine with each other to affect health over the life course. Migration history and status are also important predictors of health and research is needed that will enhance understanding of the complex ways in which race, SES, and immigrant status combine to affect health. Fully capturing the role of race in health also requires rigorous examination of the conditions under which medical care and genetic factors can contribute to racial and SES differences in health. The paper identifies research priorities in all of these areas.
1. Characterize patient visits for chronic rhinosinusitis on the basis of age, gender, race, diagnostic services, and medication use. 2. Evaluate regional differences in patient visits for chronic rhinosinusitis.
Analysis of cross-sectional survey data from two national databases of ambulatory medical encounters.
Not applicable.
Four years (2003-2006) of data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey were analyzed. Visits involving chronic rhinosinusitis were identified by using reported diagnostic codes from the International Classification of Diseases, Ninth Revision. They were weighted to provide national estimates of care. Data were analyzed with the Pearson chi(2) test using the SPSS 16.2 Complex Samples Module, taking into account the complex survey design and multiple time periods.
A total of 4617 patient visits for chronic rhinosinusitis were identified, accounting for 1.95 percent of all visits. With the application of weights to this sample, these visits represent 91.2 million national visits. A significantly higher proportion of visits in the South involved African Americans (Pearson chi(2) = 69.5, F = 6.7, df = 2.8, 2118, P < 0.01). Significantly fewer diagnostic services were provided or ordered in the Northeast (Pearson chi(2) = 64.8, F = 4.0, df = 4.3, 3247, P < 0.01). Providers in the Northeast were also significantly less likely to order or renew more than three medications at the visit (Pearson chi(2) = 54.0, F = 3.1, df = 2.6, 1930, P < 0.05). No regional differences were seen for age, gender, or setting type.
Significant regional variations exist for chronic rhinosinusitis in patient demographics, diagnosis, and management. Continuing research is needed to refine physician awareness, evaluation, and treatment of this disorder.
A national survey of pediatric cochlear implantation (PCI) audiologists was conducted with three aims: (1) to determine if PCI audiologists perceive within their clinical practice a negative effect of low socioeconomic status (SES) on postimplant speech and language outcomes; (2) to understand their perceptions of the underlying factors leading to outcome disparities; and (3) to elicit suggestions for improving outcomes in disadvantaged populations. We hypothesized that audiologists would perceive reduced speech and language outcomes within their lower SES patient population, and that this noted disparity would be related to parental adherence (compliance) and access to habilitation.
A survey containing 22 quantitative and open-ended questions was electronically mailed to a data base of 234 PCI audiologists. Forty-four percent (N = 103 of 234) responded to the survey, with the majority (98 of 103) answering all questions. Quantitative responses were analyzed using the Stata 9 statistical package with significance at p < 0.05. Qualitative responses were analyzed using standardized codebook and content analysis. Transcripts were read and coded for the main ideas expressed in each response. The codes were then analyzed for patterns and organized into subthemes that were then grouped into themes.
Seventy-eight percent (N = 76 of 98) of respondents perceived an effect of SES on postimplant speech and language outcomes. Qualitative responses uniformly demonstrated audiologists' perception that lower SES patient populations were more likely to experience reduced speech and language outcomes. Two major themes emerged in audiologists' explanations of SES-related disparities: internal factors of parental influence (i.e., parental self-efficacy, adherence, and habilitation carryover), and external factors (i.e., inadequate therapy and lack of available resources). Three primary suggestions were offered for reducing the disparity: improvement in cochlear implant services (92%), increased emphasis on parental education and intervention (87%), and the development of stricter candidacy requirements (15%).
This study offers evidence to show that PCI audiologists note an SES-related disparity in the field of PCI. Respondents suggest the need for a broad and culturally sensitive effort to both increase access to qualified healthcare professionals and develop approaches that will aid parents in the at-home habilitation process.
To determine the rationale for using a community hospital's emergency department for minor illness care on weekdays, we surveyed 150 parents of children 15 years of age or younger. Fifty (33.3%) participants had no identified source of routine pediatric care, and 31 (20.7%) had pediatric providers not locally available. For participants with local providers, major reasons for use of the emergency department included economic factors, parental knowledge, parent/provider communication, convenience, and insurance coverage. The results of this study demonstrate that the utilization pattern and sociodemographic profile of children seen in our emergency department on weekdays is more characteristic of an inner-city hospital than of a non-metropolitan setting. There are a number of feasible measures which could improve access to routine pediatric care for low socioeconomic families and reduce unnecessary emergency department utilization.
To assess the relationship between pubertal maturation and obesity in 9- and 10-year-old black and white girls.
Cross-sectional analysis of cohort baseline data.
A cohort of 2379 girls recruited from selected schools in Richmond, Calif., and greater Cincinnati, Ohio, and from the membership rolls of a prepaid group practice in greater Washington, D.C.
Sixty-four percent of black girls had begun pubertal maturation compared with 33% of white girls. In prepubertal girls, racial differences in height, weight, body mass index (kilograms per square meter) and skin-fold thickness were not significant. Within each race, onset of pubertal maturation was associated with greater height, weight, body mass index, and skin-fold measurements. Within 9-year-old girls who had begun pubertal maturation but not reached menarche, black girls were taller and heavier than white girls. Among pubertal but premenarcheal 10-year-old subjects, black girls were taller and heavier and had greater body mass index and subscapular skin-fold values. After analyses were adjusted for pubertal maturation stage by means of pubic hair development, 10-year-old pubertal black girls remained taller and heavier, but racial differences in body mass index and the sum of skin-fold measurements ceased to be significant.
These findings suggest that the initiation of racial differences in obesity are related, at least temporally, to pubertal maturation.
To report and quantify the health-related quality of life of children who require surgical intervention for chronic recurrent rhinosinusitis and to assess the perspective of the child vs that of the parent.
Prospective, observational.
Twenty-one of a consecutive sample of 35 children undergoing endoscopic sinus surgery for infectious indications completed, along with their parents, the Child Health Questionnaire. The Child Health Questionnaire measures in parallel both child and parent perceptions of health by means of separate parent proxy report (Child Health Questionnaire-Parent Form 50) and child self-report (Child Health Questionnaire-Child Form 87) questionnaires concerning physical and psychosocial functioning.
Tabulated scores from both the Child Health Questionnaire-Parent Form 50 and Child Health Questionnaire-Child Form 87 were compared with published data from age-matched normative populations and several pediatric chronic disease groups.
Significant decrements in the general health of children with chronic recurrent rhinosinusitis compared with a normative sample were observed for both child- and parent-reported data, particularly in the physical domains. Children with rhinosinusitis were perceived by their parents to have significantly more bodily pain (P<.001)and to be more limited in their physical activities (P<.05)than children with asthma, juvenile rheumatoid arthritis, and other chronic disorders. Parent-child perceptions did vary, with parents reporting more pain and general behavioral effects relative to their children's reports in these areas.
The health impact of chronic recurrent rhinosinusitis as reported by the subjective evaluations of pediatric patients and their parents is severe.
To provide an update on insurance coverage, use of health care services, and health expenditures for children and youth in the United States and new information on parents' perceived quality of care for their children and to provide information on variation in hospitalizations for children from a 24-state hospital discharge data source.
The data on insurance coverage, utilization, expenditures, and perceived quality of care come from the Medical Expenditure Panel Survey. The data on hospitalizations come from the Nationwide Inpatient Sample, which is part of the Healthcare Cost and Utilization Project. Both data sets are maintained by the Agency for Healthcare Research and Quality.
In 2000, 64.5% of children were privately insured, 21.6% were insured through public sources, and 13.9% were uninsured. Children aged 15-17 years were more likely to be uninsured than children 1-4 years old. Children without health insurance coverage were less likely to use health care services, and when they did, their rates of utilization and expenditures were lower than insured children. Publicly insured children were the most likely to use hospital inpatient and emergency department (ED) care. Being black or Hispanic and living in families with incomes below 200% of the poverty line were associated with lower utilization and expenditures. A small proportion of children account for the bulk of health care expenditures: approximately 80% of all children's health care expenditures are attributable to 20% of children who used medical services. Although most parents report that their experiences with health care for their children are good, there are significant variations by type of insurance coverage. There are substantial differences in average length of hospitalization across the United States, ranging from 2.9-4.1 days, and rates of hospital admission through the ED, which vary across states from 10%-25%. Injuries are a major reason for hospitalization, accounting for 1 in 6 hospital stays among 10- to 14-year-olds. In the 10- to 17-year age group, more than 1 in 7 hospital stays are due to mental disorders. Among 15- to 17-year-olds, more than one third of all hospital stays are related to childbirth and pregnancy. The top 10 most common conditions treated in the hospital account for 40%-60% of all hospital stays.
Children's use of health care services varies considerably by the type of health insurance coverage, race/ethnicity, and family income. Quality of care, as measured by parents' experiences of care, also varies by type of coverage. There is substantial variation in use of hospital services across states.
The goal was to validate the SN-5 survey as a measure of longitudinal change in health-related quality of life (HRQoL) for children with persistent sinonasal symptoms.
We conducted a before and after study of 85 children aged 2 to 12 years in a metropolitan pediatric otolaryngology practice. Caregivers completed the SN-5 survey at entry and at least 4 weeks later. The survey included 5 symptom-cluster items covering the domains of sinus infection, nasal obstruction, allergy symptoms, emotional distress, and activity limitations.
Good test-retest reliability (R = 0.70) was obtained for the overall SN-5 score and the individual survey items (R >/= 0.58). The mean baseline SN-5 score was 3.8 (SD, 1.0) of a maximum of 7.0, with higher scores indicating poorer HRQoL. All SN-5 items had adequate correlation (R >/= 0.36) with external constructs. The mean change in SN-5 score after routine clinical care was 0.88 (SD, 1.19) with an effect size of 0.74 indicating good responsiveness to longitudinal change. The change scores correlated appropriately with changes in related external constructs (R >/= 0.42).
The SN-5 is a valid, reliable, and responsive measure of HRQoL for children with persistent sinonasal symptoms, suitable for use in outcomes studies and routine clinical care.
Objectives/hypothesis:
Congenital severe to profound sensorineural hearing loss (SNHL) is found in higher proportions of children with minority and/or lower socioeconomic status (SES). Cochlear implants were approved by the U.S. Food and Drug Administration for use in children with bilateral severe to profound SNHL in 1990. The objectives of the study were as follows: 1) to study the epidemiology of pediatric cochlear implantation, assessing whether cochlear implant technology is provided to children with severe to profound SNHL in proportion to their racial/ethnic or SES, and 2) to compare data provided by a national health care database with data provided by cochlear implant manufacturers.
Study design:
Patients aged 0 to 18 years who underwent cochlear implantation in 1997 using a cross-sectional study design.
Methods:
Analyses were made of pediatric cochlear implant patients, using data from the 1997 Health Care and Utilization Project/Kids' Inpatient Database. Relative rates of implantation compared with rates of severe to profound SNHL were calculated using national estimates generated from census and Galludet Research Institution data. Logistic regression analysis was carried out to compare implanted children of different racial/ethnic backgrounds. A surrogate measure of socioeconomic status was used based on the median household income of the patient's home ZIP code. Information was also obtained from the two companies producing U.S. Food and Drug Administration-approved cochlear implants in 1997 and used to determine whether the data obtained from the Health Care and Utilization Project/Kids' Inpatient Database were representative of the national cohort of implanted children.
Results:
The Health Care and Utilization Project/Kids' Inpatient Database identified 124 children who underwent cochlear implant surgery in 1997. White and Asian children were implanted at higher rates than Hispanic and black children. Furthermore, white and Asian children received implants at greater rates than would be expected based on prevalence of severe to profound SNHL. The relative rate (RR) of implantation, defined as the proportion of children who received cochlear implants divided by the proportion of children with severe to profound SNHL (in each race/ethnicity group compared with the same ratio in white children), was similar in white (RR = 1.00) and Asian (RR = 0.93) children but markedly different in Hispanic (RR = 0.28) and black (RR = 0.10) children. Comparison of SES information from the Health Care and Utilization Project/Kids' Inpatient Database population with the manufacturers' database suggested that the Health Care and Utilization Project/Kids' Inpatient Database is representative of all implanted children in the United States. Both sources of information suggested that children receiving cochlear implants in the United States in 1997 resided in above-average SES areas.
Conclusion:
White and Asian children with severe to profound SNHL had higher proportionate rates of cochlear implantation than black and Hispanic children in 1997. Implanted children were more likely to live in areas (represented by ZIP codes) with higher median incomes. Although there was a disparity in rate of cochlear implantation based on race/ethnicity and surrogate measures of SES, these data did not allow the authors to determine the causes for these differences.
Dramatic increases in emergency department (ED) use contribute to rising healthcare costs and decrease continuity of care in the United States. Yet little is known about the acuity, frequency of visits, and demographic characteristics of children using the ED. This study examines general demographic trends over a 3-year period and examines whether there are factors associated with varying acuity at an urban academic pediatric ED.
Analysis of administrative ED records from fiscal years (FY) 1999 to 2001 for children 0 to 18 years was performed to assess demographic characteristics, periodicity of ED use, and acuity level.
Patient demographic characteristics, periodicity, and acuity were comparable for ED visits across each study year with approximately 25,000 annual visits. Among ED users in FY 2001, 42% sought urgent care exclusively, 12% received both urgent and nonurgent care, and 46% used the ED solely for nonurgent care. Of those with only nonurgent visits, 80% had 1 visit. In FY 2001, ED use was predominantly among patients who were black (77.3%) and were 1 to 4 years of age (35.4%). Relative to all patients, a greater percentage of those who used the ED exclusively for nonurgent care were black (87.2% vs. 76.0%, P < 0.05) and lived within 2 miles of the hospital (45.2% vs. 37.4%, P < 0.05).
Nearly half of pediatric emergency visits are for nonurgent care. Racial disparities in use of the ED for nonurgent care may be related to patient's proximity to the hospital. Patterns of use are stable across the 3 years. Further study is needed to identify mutable factors in emergency care use.
To study changes in quality of life in children with chronic sinonasal disease after surgical therapy.
Prospective, nonrandomized quality of life study of children with sinonasal disease who undergo adenoidectomy or functional endoscopic sinus surgery (FESS) at an academic institution. Caregivers completed a preoperative SN-5 quality of life survey and a second survey within 6 months after surgery.
Twenty-two children were enrolled in the study (mean, 6.5 years; range, 1.4 to 15.9). The majority (59%) of children underwent adenoidectomy. The mean total score was 25.8 at initial presentation and 12.0 at follow-up (P>0.001). Postoperative scores for all domains were significantly different from preoperative scores. The domains with the greatest change in mean score were nasal obstruction and emotional distress. There were no significant differences in outcome between children who underwent adenoidectomy and those who underwent FESS.
After either adenoidectomy or FESS, caregivers report a dramatic improvement in the quality of life of children with sinonasal disease. EBM rating: B-3b.
Racial disparities in quality of health are major issues affecting healthcare delivery. While substantial studies have been done in adults with end-stage renal disease (ESRD), similar studies are lacking in pediatric patients with ESRD. We retrospectively analyzed our transplant database from 1978-2002 to identify racial trends in a pediatric ESRD population. Significant racial differences were noted in number of pre-emptive transplants, type of graft received, height at transplant and causes of ESRD.
Low socioeconomic status (SES) is associated with a range of health outcomes. Our objective was to study the relationship between residence in a neighborhood of severe socioeconomic disadvantage and childhood obstructive sleep apnea (OSA).
Cross-sectional analysis of 843 (49% female, 36% African-American) children 8 to 11 years of age from a community-based cohort. Data on neighborhood conditions were obtained from the 2000 US Census. The main outcome measure was OSA, defined as an obstructive apnea hypopnea index >5 events per hour or an obstructive apnea index >1 event per hour.
Residence in a neighborhood of severe socioeconomic disadvantage was significantly associated with OSA after adjusting for effects of previously established risk factors: premature birth, obesity, and African-American ethnicity (OR = 3.44, 95% CI = 1.53-7.75). Secondary analyses showed that neighborhood disadvantage remained significantly associated with OSA: (1) in the African-American subgroup, after controlling for effects of prematurity and obesity; and (2) after controlling for indicators of household-level SES or other health characteristics.
Childhood OSA is associated with low SES as measured by an index describing severe neighborhood disadvantage, emphasizing the potential importance of environmental factors, particularly those associated with neighborhood distress, as risk factors for OSA.