1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
2 Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
Otolaryngol Head Neck Surg. 2018 Aug;159(2):371-378. doi: 10.1177/0194599818772035. Epub 2018 Apr 24.
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.
目的 评估从初级保健机构转介的城市儿童睡眠呼吸障碍诊断和治疗的随访和时间安排。
研究设计 回顾性纵向队列分析。
设置 三级医疗系统。
研究对象和方法 2014 年，因睡眠呼吸障碍从初级保健机构转介至专科就诊或行多导睡眠图检查的儿科门诊患儿。随访 2 年。主要结局为多导睡眠图或专科就诊的时间安排、失访情况和睡眠呼吸障碍严重程度。卡方检验和 t 检验用于比较转至多导睡眠图检查、手术和失访的患儿之间的差异。Logistic 回归用于识别失访的预测因素。使用 Kaplan-Meier 估计评估多导睡眠图检查或手术的时间，Cox 回归比较多导睡眠图检查结果和疾病严重程度的估计值。
结果 在 216 名患儿中，188 名（87%）有公共保险。一半（109 名[50%]）在初级保健转介后失访。与专科评估（35 名[32%]）相比，更多患儿在转至多导睡眠图检查时失访（50 名[76%]；P<0.001）。同时被转至多导睡眠图检查和专科的患儿更有可能失访（比值比=2.73，95%置信区间=1.29-5.78；P=0.009）。对于接受多导睡眠图检查的患儿，阻塞性睡眠呼吸暂停严重程度的分布不对称（P=0.152）。多导睡眠图检查和手术的中位时间分别为 75 天和 226 天。阻塞性睡眠呼吸暂停严重程度并不影响手术时间（P=0.410）。
结论 在这个城市人群中，一半因睡眠呼吸障碍评估而被转介的患儿从初级保健机构失访。阻塞性睡眠呼吸暂停严重程度不能预测随访或治疗的及时性。这些发现表明，社会决定因素可能除了睡眠呼吸障碍的临床负担之外，还会对治疗造成障碍。
