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Children From Vulnerable Neighborhoods Less Likely to Receive Specialist Care for Sleep-Disordered Breathing


A recent study found that children with sleep-disordered breathing who live in areas with greater socioeconomic vulnerability are less likely to meet with an otolaryngologist after being referred by their primary care physician.

Children with sleep-disordered breathing (SDB) were less likely to attend a referral appointment with an otolaryngologist based on their socioeconomic status, ethnic background, and insurance type, according to a study published in Otolaryngology–Head and Neck Surgery.

The goal of the study was to investigate the impact of neighborhood-level social vulnerability on otolaryngology referral attendance for children diagnosed with SDB. The researchers performed a retrospective chart review of data from Shawn Jenkins Children’s Hospital, which is a tertiary medical facility at the Medical University of South Carolina, to gather the data used in this study.

The researchers used the social vulnerability index (SVI) constructed by the CDC to identify the social vulnerability of patients’ neighborhoods. According to the study, the SVI consists of an overall measure of social detriments linked to health care disparities and 4 subthemes: socioeconomic status, household composition and disability, minority status and language, and housing and transportation. Higher SVI scores indicate higher levels of deprivation in an area.

The study included children aged 2 to 17 years with a diagnosis of SDB who were referred to an otolaryngologist between April 2016 and December 2018. Patients with SDB were identified by the International Classification of Diseases, Tenth Revision codes found in their medical chart. A minimum of a 12-month follow-up was required after the referral to the otolaryngologist. Patients were excluded if they did not have a diagnosis of SDB, received care from an outside institution, or had concomitant infectious etiologies, such as recurrent tonsillitis.

Patients were categorized by ethnicity into groups of non-Hispanic White, non-Hispanic Black, Hispanic, and other. Insurance status was categorized as having Medicaid, private insurance, or other. Medical comorbidities were identified by the guideline recommendations of the polysomnography (PSG) test.

For neighborhood contextual data, the researchers extracted patient addresses from their medical records and entered them in ArcGIS version 10.8. Census tracts were identified through spatial overlay analysis. SVI scores were then assigned to participants by Census tracts. The primary dependent variable of the study was whether patients attended their otolaryngology referral appointment at their institution after orders were placed by their primary care provider (PCP).

In total, 397 patients were included in the study with a mean (SD) age of 5.9 (3.7) years. Of the participants, 51% were male. The participants identified as 42.7% White, 37.3% Black, 13.6% Hispanic, and 7.1% other. Most children were insured by Medicaid (58.7%) followed by private insurance (29.2%). The patients’ mean SVI rating was 0.51, which was similar to the median SVI of the nation, 0.50. The mean (SD) scores for SVI subthemes were also similar to the national median: socioeconomic status, 0.52 (0.29); household composition/disability, 0.52 (0.28); minority status/language, 0.47 (0.22), and housing type/transportation, 0.50 (0.29).

The researchers found that most patients (81.1%) attended their referral appointment. Although the sex of the patients was not associated with otolaryngology appointment attendance, older age correlated with lower odds of attendance (odds ratio [OR], 0.89; 95% CI, 0.84-0.95). Non-Hispanic Black children had 83% lower odds of attendance (OR, 0.17; 95% CI, 0.09-0.34) and Hispanic children had 73% lower odds of attendance (OR, 0.27; 95% CI, 0.11-0.65) than non-Hispanic White children. Patients insured by Medicaid had 80% lower odds of attending the otolaryngology appointment compared with privately insured patients (OR, 0.20; 95% CI, 0.08-0.48).

In unadjusted analyses, higher overall SVI scores (OR, 0.40; 95% CI, 0.16-0.92) and higher socioeconomic status subscores (OR, 0.34; 95% CI, 0.14-0.86) were associated with lower odds of attending referral appointments. Patients who attended their referral appointment had mean (SD) overall (0.50 [0.30]) and socioeconomic (0.51 [0.29]) SVI scores lower than those in patients who did not attend their appointment (0.58 [0.29] and 0.59 [0.28], respectively). No statistical significance was found between appointment attendance and other SVI subscores.

The researchers also found that participants who had not attended their referral appointments had an overall SVI score 0.27 SD [CM6] higher than those who had attended. They found that the effect size was similar for the socioeconomic status subscore (0.30) but significantly lower for all other subscores (household composition and disability, 0.18; minority status and language, 0.24; housing and transportation, 0.19).

Of the children who were evaluated by an otolaryngologist, 135 were recommended a diagnostic PSG, with 92.6% obtaining the study. Insurance was correlated with patients receiving the PSG. Participants on Medicaid were 6 times more likely to get a recommended PSG than participants on private insurance. Although the overall SVI score was not associated with likelihood of receiving PSG, lower socioeconomic status and household composition scores in SVI (ie, less neighborhood-level vulnerability) were associated with significantly higher odds of receiving PSG.

Of the 320 patients whose clinicians recommended tonsil removal, 92.8% received the treatment. The investigators’ logistic regression analyses did not reveal any significant associations between surgery and the patient characteristics.

There were some limitations to this study. Although the CDC’s SVI is a validated measurement, this index is not the only way to measure social vulnerability and may not include all relevant markers. The null findings of other subthemes of the SVI may be due to limited power to detect small effects given the study sample size. Because there were no data on receipt of PSGs and/or tonsillectomies for patients who did not come to their referral appointments, it was unknown whether those patients would be recommended to get a PSG or a tonsillectomy. Lastly, because this study involved patients referred to care at a single academic medical center, the results may not be generalizable to other patient populations.

The authors of the study wrote that their research found that children who live in socially vulnerable areas are less likely to attend their otolaryngology appointments after being referred by their PCP. They also noted that they had found a disparity between White patients and Black and Hispanic patients in their otolaryngology appointment attendance. Lastly, although Medicaid patients were less likely to go to their referral appointment, if they did go, they were more likely to receive PSG for diagnostic testing.

They concluded that the findings “underscore the importance [of] individual and neighborhood factors in the referral process of SDB care.”


Yan F, Pearce JL, Ford ME, Nietert PJ, Pecha PP. Examining associations between neighborhood-level social vulnerability and care for children with sleep-disordered breathing. Otolaryngol Head Neck Surg. Published online March 8, 2022. doi:10.1177/01945998221084203

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