Boss Emily F, Benke James R, Tunkel David E, Ishman Stacey L, Bridges John F P, Kim Julia M
Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland2Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.
JAMA Otolaryngol Head Neck Surg. 2015 Feb;141(2):106-11. doi: 10.1001/jamaoto.2014.3085.
Although children with low socioeconomic status (SES) have increased risk for sleep-disordered breathing (SDB), their access to subspecialty care is often limited. Polysomnography (PSG) is the gold standard diagnostic test used to characterize SDB and diagnose obstructive sleep apnea; however, it is unknown whether SES impacts timeliness of obtaining PSG and surgical treatment with adenotonsillectomy (AT).
To evaluate the impact of SES on the timing of PSG, surgery with AT, and loss to follow-up for children with SDB.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort analysis conducted in tertiary outpatient pediatric otolaryngology clinics among patients newly evaluated for SDB over a 3-month period who did not have prior PSG ordered and had a minimum of 1-year follow-up.
Public insurance (Medical Assistance [MA]) was used as a proxy for low SES. Demographics and disposition between groups were compared using t tests and χ2 analysis. Logistic regression adjusting for disposition and insurance was used to predict loss to follow-up. Days to PSG and days to AT were evaluated using the Kaplan-Meier estimator, and the log-rank test was used to compare distribution of time to events between insurance groups.
A total of 136 children (without PSG) were evaluated for SDB over the course of 3 months; 62 (45.6%) had MA. Polysomnography was recommended for 55 children (27 of 55 [49%] with MA vs 28 of 55 [50%] with private insurance; P > .99). After the initial visit, 24 of 55 children with PSG requested (44%) were completely lost to follow-up (9 of 27 [33%] with MA vs 15 of 28 [54%] private insurance; P = .34). Children with MA who obtained PSG experienced longer intervals between initial encounter and PSG (mean interval, 141.1 days) than privately insured children (mean interval, 49.9 days) (P = .001). For those children who ultimately underwent AT surgery after obtaining PSG (n = 14), mean (SD) time to AT was longer for children with MA (222.3 [48.2] days vs 95.2 [66.1] days; P = .001).
Children with public insurance experienced longer intervals from initial evaluation to PSG or surgery. Almost half of patients with PSG requested were lost to follow-up, regardless of SES. These findings suggest that PSG may be a deterrent for definitive care for all children, and particularly for children with public insurance or low SES. This study emphasizes the need to understand factors contributing to disparities surrounding delay in care with PSG and surgery for children with SDB.
尽管社会经济地位（SES）较低的儿童患睡眠呼吸障碍（SDB）的风险增加，但他们获得专科护理的机会往往有限。多导睡眠图（PSG）是用于确定SDB特征和诊断阻塞性睡眠呼吸暂停的金标准诊断测试；然而，SES是否会影响进行PSG检查和腺样体扁桃体切除术（AT）手术治疗的及时性尚不清楚。
评估SES对SDB患儿进行PSG检查的时间、AT手术治疗时间以及失访情况的影响。
设计、地点和参与者：在三级儿科耳鼻喉科门诊进行的回顾性队列分析，研究对象为在3个月内新接受SDB评估且之前未进行过PSG检查且至少有1年随访的患者。
使用公共保险（医疗救助[MA]）作为低SES的替代指标。使用t检验和χ²分析比较各组之间的人口统计学和处置情况。使用调整了处置情况和保险因素的逻辑回归来预测失访情况。使用Kaplan-Meier估计器评估进行PSG检查的天数和进行AT手术的天数，并使用对数秩检验比较保险组之间事件发生时间的分布情况。
在3个月的时间里，共对136名（未进行PSG检查）儿童进行了SDB评估；62名（45.6%）有MA。建议对55名儿童进行多导睡眠图检查（55名中有27名[49%]有MA，55名中有28名[50%]有私人保险；P＞0.99）。在初次就诊后，55名被要求进行PSG检查的儿童中有24名（44%）完全失访（27名中有9名[33%]有MA，28名中有15名[54%]有私人保险；P = 0.34）。获得PSG检查的有MA的儿童在初次就诊和进行PSG检查之间的间隔时间（平均间隔141.1天）比有私人保险的儿童（平均间隔49.9天）更长（P = 0.001）。对于那些在获得PSG检查后最终接受AT手术的儿童（n = 14），有MA的儿童进行AT手术的平均（标准差）时间更长（222.3[48.2]天对95.2[66.1]天；P = 0.001）。
有公共保险的儿童从初次评估到进行PSG检查或手术的间隔时间更长。几乎一半被要求进行PSG检查的患者失访，无论其SES如何。这些发现表明，PSG检查可能对所有儿童，尤其是有公共保险或SES较低的儿童的确定性治疗具有威慑作用。本研究强调需要了解导致SDB患儿在PSG检查和手术治疗延迟方面存在差异的因素。
