OUT OF COMMITTEE: Outcomes Research and Evidence-Based Medicine | Mind the Gap: Addressing Health Inequity in Pediatric Sleep-Disordered Breathing
Awareness of healthcare disparities in otolaryngology has increased dramatically in the past decade, yet disparities persist.
Erin M. Kirkham, MD, MPH, Stacey L. Ishman, MD, MPH, and Michael J. Brenner, MD, Chair
Awareness of healthcare disparities in otolaryngology has increased dramatically in the past decade, yet disparities persist. Elimination of these disparities requires active effort toward pursuit of health equity, defined as a fair and just opportunity for all individuals to be as healthy as possible. These considerations are highly relevant to pediatric sleep-disordered breathing (SDB), which refers to a continuum of nocturnal respiratory disturbances from primary snoring to obstructive sleep apnea (OSA).
SDB affects 11%-17% of children and predisposes them to neurobehavioral impairments and poor cardiorespiratory health. Untreated pediatric SDB is also associated with higher healthcare utilization.1 We explore the racial, ethnic, and socioeconomic disparities in SDB screening, diagnosis, treatment, and outcomes,2-4 present a socioecological model of the underlying drivers of disparity (Figure 1), and suggest potential solutions.
Scope of the Problem
Disparities in SDB Diagnosis
Compared to White children, Black children have four- to six-fold higher prevalence3 and greater severity5 of SDB. Controlling for race and ethnicity, children who live in lower income homes and socioeconomically disadvantaged neighborhoods are more likely than their relatively advantaged counterparts to have SDB.4,6 Furthermore, children with public insurance experience significant barriers to sleep testing and delays in care compared to those with private insurance.7
In one retrospective cohort, nearly 50% of children with public insurance were lost to follow-up before they obtained a recommended polysomnography. Causes may include difficulty taking time from work, challenges relating to travel, and other direct or indirect costs. Thus, children within historically marginalized groups are more likely to have SDB, have more severe SDB, and are less likely to receive timely testing and diagnosis. This inequity has implications for long-term health and development, as adequate sleep is crucial in the preschool years, and evidence suggests that early sleep patterns may influence long-term sleep health.
Disparities in SDB Treatment
Studies have consistently demonstrated racial and socioeconomic disparities in access to adenotonsillectomy (AT), which is first-line treatment for pediatric SDB. Query of a multistate database demonstrated that Black and Hispanic children underwent AT less commonly than non-Hispanic White children. In addition, AT utilization was lower for children with public, compared to private, insurance and for those who lived in metropolitan versus nonmetropolitan regions.8 Another study found racial disparities in access to AT within the publicly insured. Among children insured under Medicaid, those of Black race and Hispanic ethnicity had lower odds of AT than non-Hispanic White children.9 AT reduces SDB severity and improves symptoms and quality-of-life;5,10 disparate access to surgery might thus impede psychosocial development and health.
Disparities in SDB Outcomes
Black and Hispanic children also experience higher rates of post-AT complications. Analysis of a large multistate database found that Black and Hispanic children are at increased risk for a revisit after tonsillectomy and were 35% more likely to have acute pain at the revisit, compared to their White counterparts.11
The authors also found an inverse relationship between household income and multiple post-tonsillectomy complications, independent of race. The higher burden of complications may be due to many factors, but research has shown that implicit bias among physicians is associated with prescribing practices for pain management after surgery.12
The childhood adenotonsillectomy trial (CHAT) was a multicenter randomized controlled trial of AT versus watchful waiting in over 400 children with OSA. CHAT demonstrated that children of Black race are less likely than non-Black children to experience resolution of OSA whether they underwent AT or six months of observation. Although AT improved the severity of OSA and associated neurobehavioral problems, Black children experienced less improvement overall than their non-Black counterparts.5
Disparities in Persistent OSA Management
Disparities are also evident in management of persistent OSA after AT. Although Black and Hispanic children have an elevated risk of persistent post-AT OSA, they are less likely than non-Hispanic White children to undergo postoperative polysomnogram and to be treated with positive airway pressure for residual post-AT OSA.13 Untreated SDB is associated with negative neurobehavioral consequences and poor school performance.14 Lack of follow-up care for post-AT SDB has implications not just for the individual but for society as a whole, as education is a prerequisite for equal access to the jobs, skill, resources, and overall socioeconomic success.
What Drives Disparities in SDB?
Racial and ethnic health disparities are not due to biology but rather social and economic factors that influence health.15 As an illustration, Wang, et al. conducted a neighborhood-level analysis of patients enrolled in CHAT and found that the association between race and disease severity was largely explained by poverty rate or percentage of single-female-headed households within the neighborhoods in which subjects resided.4
Racial disparities in pediatric SDB are complex and multifactorial, reflecting the interaction of factors at multiple levels.16 Socioecological models convey how health outcomes are influenced by individual, interpersonal, organizational, community, and structures or systems. At the societal level, insurance coverage and structural inequities can shape outcomes. At the community or neighborhood level, safety, noise pollution, school environment, environmental toxins, and air quality can influence sleep quality and rates of prematurity, obesity, and asthma. At the organizational level, healthcare systems can influence access and care delivery. Then, family-level factors, including belief systems, sleep and work schedules, challenges related to transportation and childcare, parental income, and education, might also predispose to health inequity.
Elimination of Health Inequity in SDB
Ameliorating health inequity requires a shift in research focus from identifying disparities to elucidating root causes and taking purposeful steps to reduce them.15 Potential solutions are shown in Figure 1. These can range from window coverings to combat light pollution to altering school start time intended to improve sleep duration. Moreover, improving sleep health literacy and access to diagnosis and surgical care are key preliminary steps. Additional approaches include promoting effective cross-cultural communication. Individual providers can assess their own implicit bias (https://implicit.harvard.edu/implicit/takeatest.html) and applying a broader lens to patient care, advocating for social services. Engagement with advocacy efforts can also shape health policy. Ultimately, efforts on individual, organizational, and societal levels will be required to close the gaps in SDB diagnosis, treatment, and outcomes. Concerted effort on multiple fronts can promote equitable access and care, helping all children to achieve their full potential.
- Tarasiuk A, Greenberg-Dotan S, Simon-Tuval T, et al. Elevated morbidity and health care use in children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2007;175(1):55-61.
- Chervin RD, Clarke DF, Huffman JL, et al. School performance, race, and other correlates of sleep-disordered breathing in children. Sleep Med. 2003;4(1):21-27.
- Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G. Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. Am J Respir Crit Care Med. 1999;159(5 Pt 1):1527-1532.
- Wang R, Dong Y, Weng J, et al. Associations among Neighborhood, Race, and Sleep Apnea Severity in Children. A Six-City Analysis. Ann Am Thorac Soc. 2017;14(1):76-84.
- Marcus CL, Moore RH, Rosen CL, et al. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366-2376.
- Boss EF, Smith DF, Ishman SL. Racial/ethnic and socioeconomic disparities in the diagnosis and treatment of sleep-disordered breathing in children. Int J Pediatr Otorhinolaryngol. 2011;75(3):299-307.
- Boss EF, Benke JR, Tunkel DE, Ishman SL, Bridges JF, Kim JM. Public insurance and timing of polysomnography and surgical care for children with sleep-disordered breathing. JAMA Otolaryngol Head Neck Surg. 2015;141(2):106-111.
- Cooper JN, Koppera S, Boss EF, Lind MN. Differences in Tonsillectomy Utilization by Race/Ethnicity, Type of Health Insurance, and Rurality. Acad Pediatr. 2021;21(6):1031-1036.
- Pecha PP, Chew M, Andrews AL. Racial and Ethnic Disparities in Utilization of Tonsillectomy among Medicaid-Insured Children. J Pediatr. 2021;233:191-197 e192.
- Garetz SL, Mitchell RB, Parker PD, et al. Quality of life and obstructive sleep apnea symptoms after pediatric adenotonsillectomy. Pediatrics. 2015;135(2):e477-486.
- Bhattacharyya N, Shapiro NL. Associations between socioeconomic status and race with complications after tonsillectomy in children. Otolaryngol Head Neck Surg. 2014;151(6):1055-1060.
- Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. Am J Public Health. 2012;102(5):988-995.
- Qian ZJ, Howard JM, Cohen SM, et al. Use of Polysomnography and CPAP in Children Who Received Adenotonsillectomy, US 2004 to 2018. Laryngoscope. 2022.
- Galland B, Spruyt K, Dawes P, McDowall PS, Elder D, Schaughency E. Sleep Disordered Breathing and Academic Performance: A Meta-analysis. Pediatrics. 2015;136(4):e934-946.
- Williams DR, Costa MV, Odunlami AO, Mohammed SA. Moving upstream: how interventions that address the social determinants of health can improve health and reduce disparities. J Public Health Manag Pract. 2008;14 Suppl:S8-17.
- Williamson AA, Johnson TJ, Tapia IE. Health disparities in pediatric sleep-disordered breathing. Paediatr Respir Rev. 2022.