Rural Barriers to Surgical Care for Children With Sleep‐Disordered Breathing

Abstract

ObjectiveTo 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 DesignRetrospective cohort study.SettingTertiary children’s hospital.MethodsA 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.ResultsIn 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).ConclusionRural‐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.