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Rural Barriers to Surgical Care for Children With Sleep-Disordered Breathing
Flora Yan1, Dylan A Levy1, Chun-Che Wen2
1Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
Insights
Children in rural areas face longer wait times for tonsillectomy with or without adenoidectomy (TA) due to distance. Rural residence may be a barrier to surgical care for pediatric obstructive sleep-disordered breathing (SDB).
Area of Science:
- Pediatric Otolaryngology
- Sleep Medicine
- Health Services Research
Background:
- Obstructive sleep-disordered breathing (SDB) affects children, with tonsillectomy with or without adenoidectomy (TA) being a common treatment.
- Geographic factors, such as rural-urban residence, may influence access to timely surgical care.
Purpose of the Study:
- To evaluate the impact of rural-urban residence on the timing of TA for children diagnosed with SDB.
- To identify potential barriers to surgical intervention based on geographic location.
Main Methods:
- Retrospective cohort study of 213 children (aged 2-18) recommended for TA between 2016-2018.
- Rural-urban designation based on ZIP codes; analysis of time to TA and loss to follow-up using Cox and logistic regression.
Main Results:
- Rural-dwelling children (32%) had longer median driving distances (74.8 vs 16.8 miles) and were more often insured by Medicaid.
- Cox regression showed rural patients had a 30% reduced likelihood of receiving TA over time compared to urban patients (HR, 0.7; 95% CI, 0.50-0.99).
- No significant predictors for loss to follow-up were identified.
Conclusions:
- Rural residence is associated with longer wait times and increased travel for TA, suggesting it can be a barrier to surgical care for pediatric SDB.
- Further research into geographic access is needed to ensure equitable care for children with SDB.
Objective:
To assess the impact of rural-urban residence on children with obstructive sleep-disordered breathing (SDB) who were candidates for tonsillectomy with or without adenoidectomy (TA).
Study Design:
Retrospective cohort study.
Setting:
Tertiary children's hospital.
Methods:
A cohort of otherwise healthy children aged 2 to 18 years with a diagnosis of obstructive SDB between April 2016 and December 2018 who were recommended TA were included. Rural-urban designation was defined by ZIP code approximation of rural-urban commuting area codes. The main outcome was association of rurality with time to TA and loss to follow-up using Cox and logistic regression analyses.
Results:
In total, 213 patients were included (mean age 6 ± 2.9 years, 117 [55%] male, 69 [32%] rural dwelling). Rural-dwelling children were more often insured by Medicaid than private insurance (P < .001) and had a median driving distance of 74.8 vs 16.8 miles (P < .001) compared to urban-dwelling patients. The majority (94.9%) eventually underwent recommended TA once evaluated by an otolaryngologist. Multivariable logistic regression analysis did not reveal any significant predictors for loss to follow-up in receiving TA. Cox regression analysis that adjusted for age, sex, insurance, and race showed that rural-dwelling patients had a 30% reduction in receipt of TA over time as compared to urban-dwelling patients (hazard ratio, 0.7; 95% CI, 0.50-0.99).
Conclusion:
Rural-dwelling patients experienced longer wait times and driving distance to TA. This study suggests that rurality should be considered a potential barrier to surgical intervention and highlights the need to further investigate geographic access as an important determinant of care in pediatric SDB.
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