Association of Socioeconomic Status, Race and Insurance Status with Chronic Rhinosinusitis Patient-Reported Outcome Measures

The Impact of Acute Peri-operative Particulate Matter Exposure on Endoscopic Sinus Surgery Outcomes: A Preliminary Multi-site Investigation

BACKGROUND

Environmental exposures have been postulated to play an important role in the pathophysiology of chronic rhinosinusitis (CRS). Particulate matter (PM) is one of the most widely studied ambient air pollutants, but its peri-operative impact on CRS is unknown.

OBJECTIVE

To determine the effect of acute, peri-operative PM exposure on outcomes after endoscopic sinus surgery (ESS).

METHODS

Participants with CRS who self-selected ESS were prospectively enrolled. The 22-item SinoNasal Outcome Test (SNOT-22) and Medical Outcomes Study Questionnaire Short-Form 6-D (SF-6D) health utility values scores were recorded. Using residence zip codes, a secondary analysis of patient exposure to PM <2.5 μm and <10 μm (PM2.5 and PM10, respectively) was performed for the month of surgery utilizing data from Environmental Protection Agency air quality monitors. Spearman's correlation coefficients (ρ), 95% confidence intervals (CIs), and effect estimates (β) were used to determine the magnitudes of association. Simple, multivariate regression analysis was also completed.

RESULTS

One hundred and seven patients from four geographically unique institutions across the US were enrolled with a follow-up of 6 months. Patients with higher peri-operative PM2.5 exposure had less improvement in their SNOT-22 scores after ESS compared to those with less exposure using both univariate analysis (ρ = 0.26, 95% CI: 0.08, 0.43; P  =  .01) and after covariate adjustment with multivariate analysis (B  =  1.06, 95% CI: 0.001, 2.14, P  =  .05). Similar associations were not found with SF-6D outcomes or with PM10 as an exposure of interest. No significant correlations were found between peri-operative PM levels and Lund-Kennedy endoscopy scores post-operatively.

CONCLUSION

Preliminary data from this pilot study reveal that PM exposure at the time of ESS may negatively associate with post-operative improvement in sinonasal quality-of-life. Larger, population-based studies with more standardized PM exposure windows are needed to confirm the clinical significance of the present findings.

Race and Area of Deprivation Index Predict Outcomes of Endoscopic Sinus Surgery for Chronic Sinusitis

OBJECTIVE

The purpose of this study is to characterize the presentation, outcomes, and barriers to care for White and non-White patients undergoing endoscopic sinus surgery (ESS).

BACKGROUND

ESS is often successful in providing long-term relief for patients suffering from chronic rhinosinusitis (CRS). Literature that uses robust measures of socioeconomic status (SES) and barriers to care to assess ESS outcomes is limited.

METHODS

A retrospective matched cohort study of patients who underwent ESS for CRS between 1/1/2015 and 6/1/2021 at a single tertiary care academic center was conducted. White and non-White patients were matched 1-to-1 by sex and age (± 5 years). SES was evaluated using the area of deprivation index (ADI).

RESULTS

Of the 298 patients included in the study, 149 are White and 149 are non-White, 111 (37.2%) have CRS with nasal polyposis (CRSwNP), 141 (47.3%) had allergic rhinitis, 90 (30.2%) had asthma and 22 (7.4%) required revision ESS. Non-White patients were 3.62 times more likely to present with CRSwNP (95% confidence interval [CI] 2.2-5.96) and had 2.87 times increased odds for requiring revision ESS than age and sex-matched White patients (95% CI 1.090-7.545). The median ADI for non-White (6.00) patients was higher than for White patients (3.00) (P < .001) and 21.5% more non-White patients presented with Medicaid (P < .001).

CONCLUSION

Non-White patients undergoing ESS for CRS are more likely to present from areas with fewer resources and be underinsured. Using robust measures of SES, such as ADI, may allow for care to be tailored to patients with barriers to care.

The Impact of Gender on Long-Term Quality of Life After Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVE

To identify the impact of gender on the clinical outcomes of endoscopic sinus surgery (ESS) through the comparison of quality of life measures in female and male patients who undergo surgical treatment for chronic rhinosinusitis (CRS).

STUDY DESIGN

Prospective observational cohort study.

METHODS

Patients with CRS completed the 22-item Sino-Nasal Outcome Test (SNOT-22) and EuroQol 5-Dimension Survey (EQ-5D) preoperatively and annually for 5 years following ESS. Health utility values (HUV) were calculated from EQ-5D scores. Comparisons of cohort characteristics were performed with chi-square and t-tests. A multivariable linear mixed effects model evaluated changes in SNOT-22 and HUV over time by gender.

RESULTS

Among the 1268 patients (54% female) enrolled, 789 and 343 completed postoperative surveys at one and 5 years, respectively. Preoperatively, females experienced more severe symptoms: mean SNOT-22 score (51.1 ± 20.9 female vs. 44.7 ± 20.0 male, p < 0.001) and HUV (0.80 ± 0.14 female vs. 0.84 ± 0.11 male, p < 0.001). These gender differences were resolved by year one postoperatively (SNOT-22: p = 0.083; HUV: p = 0.465). Two years after surgery, however, females reported more severe symptoms (SNOT-22: 25.6 ± 20.7 female vs. 21.5 ± 17.4 male, p = 0.005; HUV: 0.88 ± 0.12 female vs. 0.90 ± 0.11 male, p = 0.018), a difference that persisted at year five. These gender-related differences remained after adjusting for age, race, ethnicity, nasal polyps, history of prior ESS, and smoking status (p < 0.001). Within-subject improvement was comparable between genders (SNOT-22: p = 0.869; HUV: p = 0.611).

CONCLUSION

Females with CRS reported more severe symptoms both before and 5 years after surgery compared to their male counterparts. Understanding the mechanism behind these gender-related differences is important for optimizing CRS treatment.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:3319-3326, 2023.

Demographic Factors and Comorbid Conditions Related to Health Care Presentation Among Patients With Sinusitis

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.

Laryngopharyngeal Reflux: Effect of Race and Insurance Status on Symptomology

OBJECTIVES

Laryngopharyngeal reflux (LPR) is an extraesophageal variant of gastroesophageal reflux disease associated with intermittent dysphonia, throat-clearing, and chronic cough. This study aims to evaluate the impact of race and insurance status on symptoms often attributable to LPR.

METHODS

Retrospective review of all patients with suspected LPR from 2017 to 2019 was performed at a tertiary care center. The diagnostic criteria comprised evaluation by a fellowship trained laryngologist and Reflux Symptom Index (RSI) scores. Demographics, patient history, and insurance status were recorded. Descriptive statistics were calculated for each parameter using SPSS version 22.

RESULTS

A total of 170 patients (96 White, 44 Black, 26 Latinx, 4 Asian) were included in this study. About 57.1% had private insurance, 30.6% had Medicare, and 11.8% had Medicaid. Black and Latinx patients demonstrated higher RSI scores (26.67 ± 8.61, P = .017) when compared to their White and Asian counterparts. RSI scores between all 3 insurance types also varied significantly (P = .035). Medicaid patients reported higher RSI scores (28.65 ± 10.09, P = .028), while private insurance patients reported significantly lower scores (23.75 ± 7.88, P = .03). Controlling for insurance type eliminates the statistically significant association between RSI scores and Black and Latinx patients. Particularly, within the Medicaid group, Black, Latinx, and White patients did not have statistically different RSI scores.

CONCLUSIONS

Black and Latinx patients presented with higher RSI scores than White and Asian patients. Similarly, Medicaid patients reported higher RSI scores than the Non-Medicaid cohort. These findings suggest that access to appropriate healthcare, due to varied insurance coverage and socioeconomic, may potentially influence symptoms attributed to LPR.

Epidemiology of Chronic Rhinosinusitis: Prevalence and Risk Factors

Knowledge of chronic rhinosinusitis (CRS) epidemiology may directly impact patient care: aiding patient identification and establishing accurate diagnosis as well as informing treatment decisions. The objective of this review is to summarize the current evidence on the epidemiology of CRS, with a focus on prevalence and risk factors. Although the presence of either symptoms or objective findings alone have yielded CRS prevalence estimates of over 10%, the presence of both-consistent with guideline-based diagnostic criteria for CRS-has suggested that the true prevalence of CRS is consistently less than 5%, with approximately one-third of patients with CRS having nasal polyps, in epidemiologic studies from around the world. In comparison, the prevalence of CRS endotypes-pathophysiologic subclassification of CRS most commonly as related to type 2 or non-type 2 inflammation-has been found to vary significantly by region. The epidemiology of CRS is modified and ultimately determined by risk factors: genetic/hereditary, demographic, environmental, and imparted by predictive pre-/comorbid disease. The understanding of these epidemiologic relationships may help the provider to optimally identify and understand each individual's CRS disease process, thereby improving both diagnosis and treatment.

Promoting Equity When Using the SNOT-22 Score: A Scoping Review and Literature Review

It is established that non-white people experience worse health outcomes than white people within the same population. Equity addresses differences between patient subgroups, allowing needs-based distribution of resources. The use of quality-of-life (QoL) tools to assist clinical decision making such as the SNOT-22 for chronic rhinosinusitis promotes equality, not equity, as quality-of-life (QoL) tools provide the same criteria of symptom scoring across diverse populations. We considered the effects of ethnicity and race on SNOT-22 scores and whether these scores should be adjusted to improve equity. PubMed and MEDLINE provided papers for a scoping review. A combination of the following search terms was used: patient-reported outcome measures (PROM) (OR) quality of life; (AND) race (OR) ethnicity (OR) disparities; (AND) otolaryngology (OR) SNOT-22 (OR) sinusitis. The first study identified no evidence of ethnic variability in SNOT-22 scores. However, the study did not represent the local population, including 86% white people. Other studies identified baseline SNOT-22 disparities with respect to population demographics, gender, and age. Ethnic differences appear to exist in acute sinusitis symptomatology. In other fields both within and outside of otorhinolaryngology, ethnic differences exist with regard to QoL tools. This scoping review identified a paucity of data in rhinology. However, evidence implies some form of correction to QoL scores could help promote equity for non-white patients.

Socioeconomic Factors Affect Presentation Stage and Survival in Sinonasal Squamous Cell Carcinoma

OBJECTIVES

Socioeconomic factors affect oncologic outcome in sinonasal squamous cell carcinoma (SNSCC). However, the relationship between these factors and stage at presentation (SAP)-a critical, early point in the care cycle-is not known. This study sought to determine the role of race/ethnicity, treatment facility type, insurance status/carrier, and other socioeconomic factors in SAP and survival among patients with advanced SNSCC.

STUDY DESIGN

Retrospective cohort study.

METHODS

Using the National Cancer Database, 6,155 patients with SNSCC were identified and divided into those with "early" (Stage I or II; 2,212 (35.9%)) versus "advanced" (Stage III or IV; 3,943 (64.1%)) disease. Associations between sociodemographic and socioeconomic factors on SAP and survival were analyzed using multivariable logistic regression and Cox proportional hazard models.

RESULTS

Black (odds ratio [OR]: 2.18, CI: 1.74-2.76), Asian and Pacific Islander (API) (OR: 2.37, CI: 1.43-4.14), and Medicaid or uninsured (OR: 2.04, CI: 1.66-2.53) patients were more likely to present with advanced disease. Among patients with advanced disease, API patients demonstrated the highest 10-year survival rate (30.2%), and Black patients had the lowest 2-, 5-, and 10-year survival rates (47.7%, 31.9% and 19.2%, respectively). Older age (HR:1.03, CI:1.03-1.04), Black race (HR:1.39, CI:1.21-1.59), Medicaid or uninsured status (HR:1.48, CI:1.27-1.71), and treatment at a community hospital (HR:1.25, CI:1.14-1.37) were associated with poorer overall survival among patients with advanced disease.

CONCLUSIONS

Factors including race/ethnicity, treatment facility type, insurance status/carrier, and other socioeconomic factors influence SAP and survival in SNSCC. An improved understanding of how these factors relate to outcomes may elucidate opportunities to address gaps in education and access to care in vulnerable populations.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Comparison of tracheal resection outcomes at a university hospital vs county hospital setting

OBJECTIVES

To evaluate the role of hospital setting on outcomes in open airway surgery by comparing patients who underwent surgery (cricotracheal resection [CTR] or tracheal resection [TR]) at a publicly funded county hospital vs a private university hospital.

METHODS

Retrospective chart review of patients undergoing CTR or TR at two institutions; a private university hospital and a publicly funded county hospital from September 2014 to September 2019. Length of intensive care unit (ICU) stay, total time to discharge, minor and major complications were the primary endpoints. Significance was defined as a P-value less than .05.

RESULTS

There were a total of 43 patients (17 county, 26 university) who had CTR or TR during the study period. Length of stay outcomes was reported as mean length of stay ± SD. There was a significant difference in ICU stay at the county hospital (7.17 (±5.36 days) compared to the university hospital (2.52 ± 1.85 days, P < .003) and a nearly significant total length of stay difference at the county hospital (12.4 ± 9.06 days) compared to the university hospital (7.84 ± 4 days, P < .072) There was overall a low incidence of complications but slightly more in the county compared to the university population.

CONCLUSION

Patients who underwent open airway surgery at the county hospital were more likely to have a longer ICU stay and slight increase in complications despite having a lower ASA (American Society of Anesthesiologists) classification and younger age. These outcomes are multifactorial and may be related to poorer access to primary care preoperatively leading to delay in diagnosis and treatment, poorly controlled or undiagnosed medical comorbidities, and differences in hospital resources.

LEVEL OF EVIDENCE

IV.

Socioeconomic, comorbidity, lifestyle, and quality of life comparisons between chronic rhinosinusitis phenotypes

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous group of inflammatory sinonasal disorders with key defining symptoms, but traditionally separated into phenotypes by clinical/endoscopic findings. It is not known whether the two phenotypes have differing socioeconomic, comorbidity, and lifestyle differences. This analysis of the Chronic Rhinosinusitis Epidemiology Study (CRES) database sought to analyze any key differences in the socioeconomic variables between those with CRS with nasal polyps (CRSwNPs) and those without nasal polyps (CRSsNPs). We also sought to analyze differences in comorbidities, lifestyle, and quality of life.

METHODS

Patients with a confirmed diagnosis of CRS in secondary and tertiary care outpatient settings in the UK were invited to participate in a questionnaire-based case-control study. Variables included demographics, socioeconomic factors, comorbidities, lifestyle factors, and health-related quality of life (HRQoL) (level 3 evidence).

RESULTS

A total of 1204 patients' data were analyzed: 553 CRSsNP and 651 CRSwNP participants. The key socioeconomic variables did not demonstrate any notable differences, nor did lifestyle variables other than alcohol consumption being higher in those with CRSwNP (P = .032), but the latter was not significant after adjusting for age and sex. Aside from confirmation of asthma being more common in CRSwNP, it was notable that this group complained less of upper respiratory tract infections (URTIs), and CRSsNP participants showed evidence of worse HRQoL scores in respect of body pain (P = .001).

CONCLUSIONS

Patients with CRSwNP experience higher rates of asthma and lower rates of URTIs; patients with CRSsNP have worse body pain scores. Otherwise, there are no demonstrable significant socioeconomic, comorbidity, lifestyle, or quality of life differences between the two phenotypes.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Race in Rhinology Clinical Trials: A Decade of Disparity

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

NA Laryngoscope, 131:1722-1728, 2021.

Predictors of Long-Term Nasal Obstruction Symptom Evaluation Score Stability Following Septoplasty With Inferior Turbinate Reduction

OBJECTIVES/HYPOTHESIS

Determine the postoperative Nasal Obstruction Symptom Evaluation (NOSE) score stability between 1 and ≥6 months after septoplasty with inferior turbinate reduction (ITR). Education level and occupation were evaluated to determine their effects on NOSE score stability during the postoperative period.

STUDY DESIGN

Retrospective case series.

METHODS

This was a retrospective case series. Patients were included if they underwent septoplasty with ITR for nasal obstruction due to septal deviation and inferior turbinate hypertrophy. NOSE scores were collected preoperatively, and at 1 and ≥6 months postoperatively. Education level and occupation were collected postoperatively via telephone survey. Changes in NOSE scores were compared between the different time points. Education level and occupation were analyzed to determine if they affected NOSE scores.

RESULTS

There were 98 patients included, and 56 were male (57.1%). Mean NOSE scores preoperatively and at 1 and ≥6 months postoperatively were 72.1, 17.1, and 12.0, respectively. Patients demonstrated a statistically and clinically significant reduction in NOSE score at 1 month (-54.9, P < .001) and at ≥6 months postoperatively (-60.0, P < .001). The mean 6.2-point decrease in NOSE score from 1 to ≥6 months was statistically, but not clinically significant. There were no significant differences in NOSE score changes based on educational level and occupation.

CONCLUSIONS

Patients achieved statistically and clinically significant reductions in NOSE scores at 1 months, with no clinically significant differences in NOSE scores at ≥6 months, suggesting NOSE score stability between these postoperative time points. Neither education level nor occupation influenced NOSE scores.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2105-E2110, 2021.

Chronic rhinosinusitis disease burden is associated with asthma-related emergency department usage

PURPOSE

Chronic rhinosinusitis (CRS) disease burden is associated with pulmonary status in asthmatic CRS patients. Asthma-related emergency department (ED) usage is a predictor of asthma-related mortality. We sought to determine whether measures of CRS disease burden are associated with asthma-related ED usage.

METHODS

We prospectively recruited 263 asthmatic CRS patients for this cross-sectional study. CRS burden was measured using the 22-item Sinonasal Outcome Test (SNOT-22), and patient-reported CRS-related antibiotic usage and CRS-related oral corticosteroids usage over the preceding year. Asthma-related ED visits over the prior year were also assessed.

RESULTS

Of all participants, 18.6% had at least 1 asthma-related ED visit (mean 0.3 ED visits for the whole cohort). Asthma-related ED usage was associated with SNOT-22 score [adjusted rate ratio (RR) = 1.02, 95% CI 1.01-1.03, p = 0.040] and CRS-related oral corticosteroids usage in the past year (RR = 1.52, 95% CI 1.26-1.83, p < 0.001). From the SNOT-22 score, asthma-related ED usage was only associated with the nasal subdomain score (RR = 1.08, 95% CI 1.03-1.13, p = 0.001). These measures of CRS disease burden could be used with good sensitivity and specificity to detect patients with asthma-related ED usage in the past year, the majority of whom were undertreated for their asthma.

CONCLUSIONS

Measures of CRS disease burden are associated with and can be used to detect, patients having asthma-related ED usage. These results further solidify the connection between CRS and asthma disease courses, and also present an opportunity to use CRS disease burden as a tool for identifying-and implementing greater treatment of-patients at highest risk for asthma-related mortality.

Socioeconomic status impacts postoperative productivity loss and health utility changes in refractory chronic rhinosinusitis

BACKGROUND

Social determinants of health can have a substantial impact on treatment outcomes. Prior study has shown that socioeconomic status influences the likelihood of improvement in quality-of-life (QOL) following endoscopic sinus surgery (ESS). However, the impact of socioeconomic factors on changes in productivity loss and health utility after ESS remains unknown.

METHODS

Adult patients (≥18 years of age) with chronic rhinosinusitis (CRS) who underwent ESS were prospectively enrolled into a multi-institutional cohort study. Productivity losses were calculated using the human capital approach and monetized using U.S. government-estimated wage rates. Health utility values (HUVs) were derived from the Medical Outcomes Study Short-Form-12 survey using University of Sheffield algorithms. Independent socioeconomic factors of interest included: age, gender, ethnicity, insurance status, educational attainment, and household income categorized via the Thompson-Hickey model.

RESULTS

A total of 229 patients met inclusion criteria, and 163 (71%) provided postoperative follow-up. All subjects reported significant, within-subject improvement in both mean monetized productivity loss (p < 0.001) and HUV postoperatively (p < 0.001). Using paired sample statistics, patients with lowest income (≤$25,000/year) and with Medicare insurance did not report significant improvement in productivity loss (p ≥ 0.112) or HUV (p ≥ 0.081), although sample size limitations may have contributed to this finding. Patients in higher income tiers ($25,001 to $100,000/year and $100,001+/year) and those with employer-provided/private health insurance reported significant postoperative improvements in productivity loss and HUV (all p ≤ 0.003).

CONCLUSION

Socioeconomic factors, including income and insurance provision, may impact improvements in productivity loss and HUV following ESS. Further research to validate these findings, ascertain mechanisms behind these results, and improve these outcomes is warranted.

Intranasal corticosteroids and saline: Usage and adherence in chronic rhinosinusitis patients

OBJECTIVE

Intranasal saline irrigations and intranasal corticosteroids are supported by level-1 evidence for medical management of chronic rhinosinusitis (CRS). We sought to study adherence with these medications.

METHODS

Prospective study of 174 patients with CRS. Patients reported their usage of intranasal saline irrigation and intranasal corticosteroid over the preceding 3 months, at presentation, and a subsequent follow-up visit 3 to 12 months later. Adherence was defined as reported medication usage for ≥6 days per week.

RESULTS

At the time of presentation, 44.3% of patients were using an intranasal corticosteroid spray or irrigation ≥6 days/week, whereas only 24.1% were using saline irrigation ≥6 days per week. At follow-up, 60.3% of patients were using either an intranasal corticosteroid spray or irrigation ≥6 days per week, whereas 35.6% were using saline irrigation ≥6 days per week. Adherence with intranasal corticosteroids was associated with comorbid asthma (adjusted odds ratio [OR] = 2.68, 95% confidence interval [CI]: 1.10-6.50, P = 0.029), allergy (OR = 2.22, 95% CI: 1.05-4.71, P = 0.037), and change in 22-item Sinonasal Outcome Test score (OR = 0.98, 95% CI: 0.96-0.99, P = 0.027). Use of intranasal corticosteroid sprays versus irrigations (OR = 2.56, 95% CI: 0.84-7.83, P = 0.099) was suggestive of association with improved adherence. Adherence with intranasal saline irrigation was associated with age (OR = 1.02, 95% CI: 1.01-1.05, P = 0.034).

CONCLUSION

Usage and adherence with intranasal steroids and saline may be low in CRS patients even with management in a tertiary level, subspecialty rhinology clinic. Adherence with medications represents a major opportunity for improving patient care and outcomes, specifically by targeting patients with lower disease burden and improving convenience of medications.

LEVEL OF EVIDENCE

2C Laryngoscope, 130:852-856, 2020.

Health Care Disparities in Patients Undergoing Endoscopic Sinus Surgery for Chronic Rhinosinusitis: Differences in Disease Presentation and Access to Care

OBJECTIVES

Data on health care disparities by socioeconomic status for chronic rhinosinusitis (CRS) are lacking, and the available literature shows mixed results. The aim of this study was to evaluate several indicators of disease complexity in patients with CRS undergoing endoscopic sinus surgery between a private and a public hospital to determine if there are any disparities in the severity of disease presentation or in access to care.

METHODS

Two hundred patients with CRS who underwent endoscopic sinus surgery from 2015 to 2017 were retrospectively reviewed. Demographics, disease-specific data, and pre- and postoperative management were collected.

RESULTS

Public hospital patients (n = 100) were significantly more likely to be non-Caucasian (73.0% vs 25.0%, P < .0001) and to have Medicaid or no insurance (86.0% vs 4.0%, P < .0001). Patients from the public hospital were more likely to have CRS with nasal polyposis (85.0% vs 60.0%, P < .0001) and to have longer wait times for surgery (68 vs 45 days, P < .0001) and were more likely to be lost to follow-up (26.0% vs 16.0%, P = .031). Patients at the public hospital had CRS symptoms 21% longer ( P = .0206), and if a patient carried a diagnosis of asthma, he or she had on average more severe asthma ( P = .0021).

CONCLUSIONS

This study suggests that patients of lower socioeconomic status had a longer duration of disease prior to surgery, more often had nasal polyposis, and had decreased access to care, as indicated by increased surgical wait times and being lost to follow-up. Acting as a foundation for further investigation, the ultimate intent of this study is to improve care for all patients.

Socioeconomic factors impact quality of life outcomes and olfactory measures in chronic rhinosinusitis

BACKGROUND

Healthcare disparities related to socioeconomic factors may adversely impact disease states and treatment outcomes. Among patients with chronic rhinosinusitis (CRS), the impact of socioeconomic factors on outcomes following endoscopic sinus surgery (ESS) remains uncertain.

METHODS

Adult patients with refractory CRS were prospectively enrolled into an observational, multi-institutional cohort study between March 2011 and June 2015. Socioeconomic factors analyzed included household income, insurance status, years of education completed, race, age, and ethnicity. Income was stratified according to the Thompson and Hickey model. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Brief Smell Identification Test (BSIT) were completed preoperatively and postoperatively.

RESULTS

A total of 392 patients met inclusion criteria. Higher age and male gender were associated with better mean preoperative SNOT-22 scores (both p < 0.02), whereas Medicare insurance status and male gender were associated with worse preoperative mean BSIT scores (both p < 0.02). Postoperatively, higher household income ($100,001+/year) and lower age were associated with a greater likelihood of improving at least 1 minimal clinically important difference (MCID) on SNOT-22 scores (OR = 2.40 and 1.03, respectively, both p < 0.05), while no factors were associated with increased odds of achieving a MCID on BSIT scores.

CONCLUSIONS

Preoperative olfactory function and postoperative quality of life (QOL) improvement were associated with metrics of socioeconomic status in patients with CRS electing ESS. The odds of experiencing a clinically meaningful QOL improvement were more than twice as likely for patients with the highest household income level compared to other income tiers. Further investigation is warranted to identify barriers to postoperative improvement.