International Forum of Allergy & RhinologyEarly View RESEARCH NOTEOpen Access Disparities in access to health care: A survey-based, pilot investigation of sinonasal complaints in the community care setting Robert Hagedorn BS, Robert Hagedorn BS Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USASearch for more papers by this authorJorgen Sumsion BS, Jorgen Sumsion BS Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USASearch for more papers by this authorJeremiah A. Alt MD, PhD, Jeremiah A. Alt MD, PhD orcid.org/0000-0003-0560-5028 Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USASearch for more papers by this authorAmarbir S. Gill MD, Corresponding Author Amarbir S. Gill MD asingill@med.umich.edu orcid.org/0000-0002-6776-0712 Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA Department of Otolaryngology, Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA Correspondence Amarbir S. Gill, MD, University of Michigan Department of Otolaryngology, Head and Neck Surgery, 1500 East Medical Center Drive, 1904 TC, SPC 5312,Ann Arbor, MI 48109, USA. Email: asingill@med.umich.eduSearch for more papers by this author Robert Hagedorn BS, Robert Hagedorn BS Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USASearch for more papers by this authorJorgen Sumsion BS, Jorgen Sumsion BS Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USASearch for more papers by this authorJeremiah A. Alt MD, PhD, Jeremiah A. Alt MD, PhD orcid.org/0000-0003-0560-5028 Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USASearch for more papers by this authorAmarbir S. Gill MD, Corresponding Author Amarbir S. Gill MD asingill@med.umich.edu orcid.org/0000-0002-6776-0712 Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA Department of Otolaryngology, Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA Correspondence Amarbir S. Gill, MD, University of Michigan Department of Otolaryngology, Head and Neck Surgery, 1500 East Medical Center Drive, 1904 TC, SPC 5312,Ann Arbor, MI 48109, USA. Email: asingill@med.umich.eduSearch for more papers by this author First published: 08 July 2022 https://doi.org/10.1002/alr.23055AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat 1 INTRODUCTION Social determinants of health, such as education, income, insurance, and race/ethnicity, can significantly impact access to care and health outcomes for various otolaryngologic conditions.1 Nevertheless, little is known regarding the impact of these social factors on access to care among patients with sinonasal symptoms. The majority of studies focusing on chronic rhinosinusitis underrepresent low-income and ethnic minority patients compared with national census estimates.2, 3 This limits generalizability of study results to those population groups. Although studies have shown the negative effects of patient-provider language differences,4 there is a dearth of prospective literature relating to the differences in patient-provider language in otolaryngology and its impact on access to care. We sought to prospectively analyze the relationship between social determinants of health and access to nonspecialist care to determine whether the primary language spoken was a predictor of access to care. 2 METHODS International review board approval (00141714) was obtained from the University of Utah and written consent was obtained from each patient for participation in this study. A brief survey, designed to ascertain information on social determinants of health, access to care, and history of sinonasal symptoms was adapted from prior work done by the group5 (see Figure S1 for sample survey, originally created in English and then translated to Spanish). The survey was prospectively administered to a cross-section of patients in two distinct primary clinic waiting rooms between June 2021 and January, 2022. Clinic A was primarily Spanish-speaking, whereas the majority of patients seeking care at clinic B was English-speaking. The two clinics demonstrated similar area deprivation indices, which is a measure of neighborhood socioeconomic disadvantage.6 Demographic data, outlined in Table 1, were collected for each patient. Patients were queried about sinonasal symptoms, including nasal congestion, yellow or green drainage from the nose, facial or ear pain, and inability to smell. Quantitative variables were assessed using two-sample t tests and categorical variables were assessed using chi-square and Fisher exact tests; a p value of < 0.05 was defined as significant. A univariate analysis was conducted to assess the relationship between various social determinants of health and access to care for sinonasal complaints (R Core Team). Effect size and 95% confidence intervals were calculated. TABLE 1. Demographics of each clinic cohort Clinic A (n = 48) Clinic B (n= 51) p Value Mean age (SD) (year) 45.3 (13.3) 43.4 (16.4) 0.58 Sex 0.99 Women 18 23 Men 21 27 Primary language <0.01 Spanish 48 0 English 0 51 Ethnicity <0.01 Hispanic 44 4 Non-Hispanic 4 44 Race <0.01 Native American 2 1 White 1 46 Hispanic 42 0 Other 0 2 Income (US$) <0.01 0–25k 22 13 26–50k 12 5 51–75k 0 8 76–100k 2 19 > 100k 1 3 Unknown 5 1 Education 0.06 Less than junior high school 1 2 Junior high school 5 0 High school 15 12 College 15 24 Graduate school 8 13 Insurance <0.01 Medicaid 2 7 Medicare 1 5 Employer-provided 0 22 State-assisted 0 1 Private 1 8 Federal 0 1 Tricare/VA 0 0 None 42 5 Smoking 0.02 Never 40 (87%) 36 (71%) Former 2 (4%) 12 (24%) Current 4 (9%) 3 (6%) Alcohol <0.01 Never 37 (88%) 26 (51%) Former 4 (10%) 15 (29%) Current 3 (7%) 10 (20%) SD = standard deviation; VA = Veterans Affairs. 3 RESULTS There were no significant differences in age (p = 0.58) or sex (p = 0.99) between the English-speaking and Spanish-speaking cohorts (Table 1). Spanish speakers were more likely to report low income, low education level, lack of insurance, and never smoking compared with English speakers (p < 0.02). English-speaking patients were noted to have significantly more self-reported medical diagnoses than Spanish-speaking patients, including asthma (p < 0.01), gastroesophageal reflux (p = 0.02), and anxiety (p < 0.01) (Table 1). Although both patient populations demonstrated the same prevalence of sinonasal symptoms (p = 0.41, Cohen w = 0.09 [95% confidence interval, 0.004–0.29]) (Table 2), English-speaking patients were significantly more likely to have seen a physician for sinonasal symptoms compared with the Spanish-speaking population (p = 0.03) (Table 2). Similarly, White patients were more likely to have seen a physician compared with Hispanic and Native American patients (p < 0.01). There was no meaningful association between education level (p = 0.89), income (p = 0.61), or sex (p = 0.74) and the likelihood to have seen a physician for sinonasal symptoms (Table 2). TABLE 2. Social determinants of health as predictors of access to care for sinonasal complaints Sinonasal symptomsa (n = 39) Social determinants of health Seen a physician (n = 18) Not seen a physician (n = 21) p Value Effect size (Cohen w) 95% CI (of w) Primary language spoken 0.03 0.38 0.10–0.65 English 12 6 Spanish 6 15 Ethnicity 0.20 0.23 0.02–0.53 Hispanic 7 13 Non-Hispanic 11 8 Sex 0.74 0.11 0.00–0.45 Women 9 7 Men 9 11 Race <0.01 0.52 0.30–0.78 Native American 2 0 White 11 6 Hispanic 3 13 Other 0 0 Income (US$) 0.61 0.34 0.31–0.66 0–25k 6 8 26–50k 3 4 51–75k 3 2 76–100k 3 3 >100k 1 0 Unknown 0 3 Education 0.89 0.18 0.15–0.56 Less than junior high school 1 1 Junior high school 1 1 High school 5 6 College 8 6 Graduate school 3 6 Insurance <0.01 0.55 0.37–0.80 Medicaid 5 0 Medicare 0 0 Employer-provided 4 2 State-assisted 0 0 Private 2 1 Federal 0 0 Tricare/VA 0 0 None 6 17 Smoking 0.84 0.12 0.05–0.46 Never 14 18 Former 2 1 Current 2 2 Alcohol 0.24 0.23 0.02–0.52 Never 10 15 Former 4 4 Current 4 1 VA = Veterans Affairs. aDefined as presence of any sinonasal symptom as reported on the survey. 4 DISCUSSION Both English- and Spanish-speaking patients demonstrated a similar prevalence of sinonasal symptoms in a nonspecialty setting; however, English-speaking patients were significantly more likely to have seen a physician for their sinonasal symptoms compared with Spanish-speaking patients. There may be several factors that can explain this difference. First, the lack of interpretative services for patients who are not native English speakers may result in a breakdown of communication between provider and physician regarding symptoms, diagnosis, and treatment plan.7 Second, there may be cultural bias in play. Data have demonstrated that different ethnic groups can have different views on health care and pain; it may be possible that they do not perceive sinonasal symptoms as serious enough to justify a discussion with their physician.8 Third, primary care physicians may have difficulty in achieving successful referral to specialists for minority patients as a result of insurance issues or geographic disparities for specialists.7 To the best of our knowledge, the present investigation is the first to examine the impact of the primary language spoken on access to a nonspecialist, in a community care setting, as it relates to self-reported sinonasal symptoms, arguing against inherent differences that might predispose one to sinonasal symptoms based on this variable alone. Unlike prior retrospective examinations of social determinants of health related to otolaryngologic symptoms,9, 10 the present study was prospectively conducted. Prior studies examining healthcare disparities in otolaryngology show low enrollment numbers of minorities9, 10 and are typically conducted in tertiary care centers,9, 10 which limits generalizability to the larger population of non–English-speaking patients. Here, we achieved equal enrollment of both English-speaking and Spanish-speaking patients within community clinics, which may help increase the generalizability of the results to a greater proportion of Spanish-speaking patients. There are several important limitations to this study. The sample size was limited because of the pilot nature of the study. We were unable to determine the independent effect of primary language spoken/race/insurance status on access to care using logistic regression because of the small sample size and the large number of variables that demonstrated differences among the two cohorts. Future studies should incorporate a larger sample size to further assess the relationship among these factors. CONFLICT OF INTEREST Robert Hagedorn: none. Jorgen Sumsion: none. Jeremiah A. Alt: consultant for Medtronic, Optinose, and GlycoMira. Amarbir S. Gill: none. Supporting Information Filename Description alr23055-sup-0001-FigureS1.tiff21.4 MB Supporting Information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. REFERENCES 1Bergmark RW, Sedaghat AR. Disparities in health in the United States: an overview of the social determinants of health for otolaryngologists. Laryngoscope Investig Otolaryngol. 2017; 2(4): 187- 193. Wiley Online LibraryPubMedWeb of Science®Google Scholar 2Soler ZM, Mace JC, Litvack JR, Smith TL. Chronic rhinosinusitis, race, and ethnicity. Am J Rhinol Allergy. 2012; 26(2): 110- 116. CrossrefPubMedWeb of Science®Google Scholar 3Spielman DB, Liebowitz A, Kelebeyev S, et al. 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Disparities in Access to Health Care: A Survey-Based, Pilot Investigation of Sinonasal Complaints in the Community Care Setting