title: Public insurance and timing of polysomnography and surgical care for children with sleep-disordered breathing.
abstract: OBJECTIVE
  Although children with low socioeconomic status (SES) have increased risk for sleep-disordered breathing (SDB), their access to subspecialty care is often limited. Polysomnography (PSG) is the gold standard diagnostic test used to characterize SDB and diagnose obstructive sleep apnea; however, it is unknown whether SES impacts timeliness of obtaining PSG and surgical treatment with adenotonsillectomy (AT).
  
  
  OBJECTIVE
  To evaluate the impact of SES on the timing of PSG, surgery with AT, and loss to follow-up for children with SDB.
  
  
  METHODS
  Retrospective cohort analysis conducted in tertiary outpatient pediatric otolaryngology clinics among patients newly evaluated for SDB over a 3-month period who did not have prior PSG ordered and had a minimum of 1-year follow-up.
  
  
  METHODS
  Public insurance (Medical Assistance [MA]) was used as a proxy for low SES. Demographics and disposition between groups were compared using t tests and χ2 analysis. Logistic regression adjusting for disposition and insurance was used to predict loss to follow-up. Days to PSG and days to AT were evaluated using the Kaplan-Meier estimator, and the log-rank test was used to compare distribution of time to events between insurance groups.
  
  
  RESULTS
  A total of 136 children (without PSG) were evaluated for SDB over the course of 3 months; 62 (45.6%) had MA. Polysomnography was recommended for 55 children (27 of 55 [49%] with MA vs 28 of 55 [50%] with private insurance; P > .99). After the initial visit, 24 of 55 children with PSG requested (44%) were completely lost to follow-up (9 of 27 [33%] with MA vs 15 of 28 [54%] private insurance; P = .34). Children with MA who obtained PSG experienced longer intervals between initial encounter and PSG (mean interval, 141.1 days) than privately insured children (mean interval, 49.9 days) (P = .001). For those children who ultimately underwent AT surgery after obtaining PSG (n = 14), mean (SD) time to AT was longer for children with MA (222.3 [48.2] days vs 95.2 [66.1] days; P = .001).
  
  
  CONCLUSIONS
  Children with public insurance experienced longer intervals from initial evaluation to PSG or surgery. Almost half of patients with PSG requested were lost to follow-up, regardless of SES. These findings suggest that PSG may be a deterrent for definitive care for all children, and particularly for children with public insurance or low SES. This study emphasizes the need to understand factors contributing to disparities surrounding delay in care with PSG and surgery for children with SDB.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland2Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: Emily F
authors.initials: EF
authors.lastname: Boss
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.
authors.forename: James R
authors.initials: JR
authors.lastname: Benke
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.
authors.forename: David E
authors.initials: DE
authors.lastname: Tunkel
authors.affiliation: Divisions of Otolaryngology-Head and Neck Surgery and Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio4Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio.
authors.forename: Stacey L
authors.initials: SL
authors.lastname: Ishman
authors.affiliation: Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: John F P
authors.initials: JF
authors.lastname: Bridges
authors.affiliation: Department of Pediatrics, Division of Quality and Safety, Johns Hopkins School of Medicine, Baltimore Maryland.
authors.forename: Julia M
authors.initials: JM
authors.lastname: Kim
mesh_terms: D000233:Adenoidectomy; D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016015:Logistic Models; D059012:Lost to Follow-Up; D008297:Male; D008396:Maryland; D017286:Polysomnography; D012189:Retrospective Studies; D012891:Sleep Apnea Syndromes / Q000175:diagnosis* / Q000601:surgery*; D012923:Social Class; D013221:State Health Plans; D013997:Time Factors; D061665:Time-to-Treatment; D014068:Tonsillectomy