Access to Otolaryngologic Telemedicine Care Across the COVID-19 Pandemic at an Urban Tertiary Hospital System.

Objective: To describe associations between patients' demographic characteristics and access to telemedicine services in an urban tertiary academic medical system across the COVID-19 pandemic, and to identify potential barriers to access. Methods: This was a retrospective cohort study conducted at a single-center tertiary academic medical center. The study included adult patients undergoing outpatient otolaryngologic care in person or via telemedicine during 8 week timeframes: before the pandemic, at the onset of the pandemic, and during later parts of the pandemic. Patients were characterized by age, sex, race, insurance type, primary language, portal activation status, income estimate, and visit type. Where appropriate, chi-squared tests, Wilcoxon signed-rank tests, and logistic regression were used to compare demographic factors between the cohorts. Results: A total of 14,240 unique patients [median age, 58 years (range, 18-107 years); 56.5% were female] resulting in a total of 29,457 visits (94.8% in-person and 5.2% telemedicine) were analyzed. Patients seen in person were older than those using telemedicine. Telemedicine visits included a higher proportion of patients with private insurance, and fewer patients with government or no insurance compared to in-person visits. Race, income, and English as primary language were not found to have a significant effect on telemedicine use. Conclusion: In an urban tertiary medical center, we found significant differences in sociodemographic characteristics between patients who accessed otolaryngologic care in person versus via telemedicine through different phases of the COVID pandemic, reflecting possible barriers to care associated with telemedicine. Further studies are needed to develop interventions to improve access.

An Integrative Model of ENT Healthcare for the Homeless Population.

OBJECTIVE: Our aim was to determine the need for otolaryngology care within the homeless population, identify barriers to access that the homeless population may face, and develop a model system which would address these needs with respect to the barriers. METHODS: A retrospective chart review of 812 patients seen between 1/25/16-3/21/2020 was performed. Charts were obtained from homeless patients seen at free general clinics held shelters in Chicago, IL (781 charts) and in Champaign, IL (31 charts). Records reporting at least one otolaryngology disease in a patient experiencing homelessness were included in this study. Patients were considered homeless if they resided at the shelter at the time of their appointment. To determine common barriers to care, a simple yes/no questionnaire was administered to residents at west-side Chicago homeless shelters. Questions addressed barriers to health care access that had been mentioned by patients seen at free clinics. RESULTS: Chart review findings demonstrated that 14.3% (n = 142) of all homeless patients seen at free in-shelter clinics were seen for ENT-related disorders. Survey results revealed that 76.3% (n = 71) of respondents believed that telemedicine services would be useful in shelters. 74.2% (n = 69) stated they were unable to afford prescribed medications. 93.5% (n = 87) stated that better access to transportation would increase their likelihood of seeking care. CONCLUSIONS: In our attempt to bridge this inequity, we have launched a hybrid in-person/virtual care program to improve access to otolaryngology care for the homeless community. LEVEL OF EVIDENCE: N/A Laryngoscope, 134:2705-2709, 2024.

The Impact of Socioeconomic Status on Hospital Accessibility in Otorhinolaryngological Disease in Korea.

This study aimed to investigate the impact of socioeconomic status (SES) on otorhinolaryngology disease severity status diagnosed at the first hospital visit. We conducted a retrospective study over 20 years (2000-2019). Otorhinolaryngological diseases included chronic rhinosinusitis (CRS), sensorineural hearing loss (SNHL), oral ulcer, and malignant neoplasms. A logistic regression model was employed to assess the effect of SES on the severity of each disease at the first hospital visit. The severity of CRS increased in patients with lower SES (P = .028). The severities of SNHL (P = .032) and oral ulcer (P < .001) also associated with SES. In contrast, between the low- and high-SES groups observed no differences in cancer stage (P = .845). Patients with SNHL, oral ulcer, and CRS had a more severe disease status in the low-SES group than in the high-SES group at the first hospital visit. Efforts to increase hospital accessibility for low-SES otorhinolaryngological patients should be made.

Telemedicine Services Provided to Medicare Beneficiaries by Otolaryngologists Between 2010 and 2018.

IMPORTANCE: Clinicians are increasingly adopting telemedicine in an effort to expand patient access and efficiently deliver care. However, the extent to which otolaryngologists provide telemedicine services is unclear. OBJECTIVE: To characterize recent trends in the use of telemedicine by otolaryngologists to deliver care to Medicare beneficiaries. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cross-sectional analysis was conducted between January 1, 2010, and December 31, 2018, using publicly available Medicare Physician/Supplier Procedure Summary data on physicians practicing in the field of otolaryngology and benchmark specialties (dermatology and psychiatry) that provided telemedicine services to Medicare beneficiaries. MAIN OUTCOMES AND MEASURES: Primary outcomes were the mean annual number of telemedicine services delivered per active physician and mean annual payment per active physician for these services. Secondary outcomes included the number, setting, and complexity of telemedicine services. RESULTS: Between 2010 and 2018, otolaryngologists provided 2127 total telemedicine services (7 unique service types) to Medicare beneficiaries and received $88 574 in total payment for these services. During this period, the mean number of telemedicine services increased at a compound annual growth rate (CAGR) of 11.0%, and the mean Medicare payment per otolaryngologist increased at a CAGR of 21.8%. In comparison, telemedicine use during this period generally increased at a higher rate in the fields of dermatology (mean number of services per active physician at CAGR of 13.0%; mean Medicare payment per active physician at CAGR of 12.5%) and psychiatry (mean number of services per active physician at CAGR of 25.8%; mean Medicare payment per active physician at CAGR of 26.6%). In 2018, outpatient evaluation and management visits accounted for most telemedicine services provided (337 of 353 [95.5%]) and the payments received ($17 542.13 of $18 470.47 [95.0%]) by otolaryngologists. In contrast, physicians in other specialties also provided substantial portions of telemedicine services in the inpatient (psychiatry, 18 403 of 198 478 [9.3%]; dermatology, 231 of 1034 [22.3%]) and skilled nursing facility settings (psychiatry, 14 690 of 198 478 [7.4%]; dermatology, 46 of 1034 [4.4%]). CONCLUSIONS AND RELEVANCE: This study suggests that the extent to which otolaryngologists used telemedicine to deliver care to Medicare beneficiaries between 2010 and 2018 was rare. Although there was relative growth in the use of telemedicine by otolaryngologists during this period, absolute growth remained low. Policy makers and provider organizations should support otolaryngologists in the adoption of telemedicine technologies, especially while coronavirus disease 2019 (COVID-19) viral suppression efforts necessitate prolonged restriction of physical clinic throughput.

ENT management of children with adenotonsillar disease during COVID-19 pandemic. Ready to start again?

Clinical manifestations of COVID-19 in children are milder, but the real burden of disease is unknown. After the lockdown, in our Region Lombardia we have been requested to progressively resume medical services including outpatient assessment and priority surgery. Therefore, we screened surgical waiting lists with identification of 47 children candidates to priority surgery (among 358). No homogeneous national health surveillance/screening programs are ongoing or have been conceived to test susceptible population among children/healthcare workers in preparation of coming down to routinely daily activities, and diagnostic strategies are not completely accurate in children. So, restoring medical services now might be untimely.

Health Disparities in the Access and Cost of Health Care for Otolaryngologic Conditions.

OBJECTIVE: To demonstrate whether race, education, income, or insurance status influences where patients seek medical care and the cost of care for a broad range of otolaryngologic diseases in the United States. STUDY DESIGN: Retrospective cohort study using data from the Medical Expenditure Panel Survey, from 2007 to 2015. SETTING: Nationally representative database. SUBJECTS AND METHODS: Patients with 14 common otolaryngologic conditions were identified using self-reported data and International Classification of Diseases, 9th Revision Clinical Modification diagnosis codes. To analyze disparities in the utilization and cost of otolaryngologic care, a multivariate logistic regression model was used to compare outpatient and emergency department visit rates and costs for African American, Hispanic, and Caucasian patients, controlling for sociodemographic characteristics. RESULTS: Of 78,864 respondents with self-reported otolaryngologic conditions, African American and Hispanic patients were significantly less likely to visit outpatient otolaryngologists than Caucasians (African American: adjusted odds ratio [aOR], 0.57; 95% CI, 0.5-0.65; Hispanic: aOR, 0.64; 95% CI, 0.56-0.73) and reported lower average costs per emergency department visit than Caucasians (African American: $4013.67; Hispanic: $3906.21; Caucasian: $7606.46; P < .001). In addition, uninsured, low-income patients without higher education were significantly less likely to receive outpatient otolaryngologic care than privately insured, higher-income, and more educated individuals (uninsured: aOR, 0.38; 95% CI, 0.29-0.51; poor: aOR, 0.75; 95% CI, 0.64-0.87; no degree: aOR, 0.67; 95% CI, 0.54-0.82). CONCLUSION: In this study, significant racial and socioeconomic discrepancies exist in the utilization and cost of health care for otolaryngologic conditions in the United States.

Africa's challenged ENT services: highlighting challenges in Zambia.

BACKGROUND: Diseases of the ear, nose and throat (ENT) are common and are a major cause of morbidity and mortality. In many low income countries like Zambia, the high ENT disease burden has not received the required resources for treatment. We investigated ENT service provision in hospitals in Zambia by documenting the profile of hospitals offering ENT services and examining the country's ENT services with regards to human resource, infrastructure and availability of equipment based on the levels of care of various hospitals. METHODS: The study was a cross-sectional descriptive survey conducted using a structured and piloted questionnaire which was administered to the 109 Ministry of Health (MoH) registered hospitals across the country. Ethical clearance was granted by University of KwaZulu-Natal and the Zambia National Health Research Authority. Participation in the study was voluntary and all respondents signed informed consent. Descriptive statistics were used to analyse the data. RESULTS: Of the 109 hospitals approached to participate in the study, 61 (55.9%) hospitals responded. This represented 83.3% (n = 5) of Third Level Hospitals (TLH), 89.5% (n = 17) of Second Level Hospitals (SLH) and 41.7% (n = 35) of First Level Hospitals (FLH) countrywide. Of the participating hospitals, 6.6% (n = 4) were unclassified. Within this sample, 8.6% (n = 3) FLH, 11.8% (n = 2) SLH and 60.0% (n = 3) TLH had an ENT examination room. Only 2.9% (n = 4) hospitals had an audiology booth and 1.6% (n = 1) had a speech therapy room. Of the second and third level hospitals, 9.1% (n = 2) had flexible rhinolaryngoscopes, 18.2% (n = 4) had operating microscopes and 68.2% (n = 15) adenotonsillectomy sets. The data revealed that there were 4 ENT surgeons, 1 Audiologist and no Speech Therapists across the country. CONCLUSION: Zambia's ENT services were deficient at all levels of hospital care. There were deficiencies in infrastructure, human resource and equipment in hospitals. With the current burden of disease, critical intervention is required. These findings should be used to direct national policy on the improvement of ENT service provision in Zambia.

Evidence-Based Medicine in Otolaryngology Part 10: Cost-Effectiveness Analyses in Otolaryngology.

Clinicians seek to pursue the most clinically effective treatment strategies, but costs have also become a key determinant in contemporary health care. Economic analyses have thus emerged as a valuable resource to both quantify and qualify the value of existing and emerging interventions and programs. Cost-effectiveness analyses estimate the benefits gained per monetary unit, providing insights to guide resource allocation. Herein, we delineate the related concepts and considerations to facilitate understanding and appraisal of these analyses, so as to better inform the stakeholders in our otolaryngology community.

The increasing cost of pediatric otolaryngology care.

INTRODUCTION: Defining the costs associated with healthcare is vital to determining and understanding ways to reduce costs and improve quality of healthcare delivery. The objective of the present study was to identify the current public health burden of inpatient admissions for conditions commonly treated by pediatric otolaryngologists and compare trends in healthcare utilization with other common surgical diagnoses. METHODS: A retrospective cohort study using the Kids' Inpatient Database for pediatric discharges in the United States from 2000 to 2012. A list of the top 500 admission diagnoses was identified and subsequently grouped into surgical diagnoses typically managed by otolaryngologists and those managed by any other surgical discipline with the top 10 in each category included. Database analyses generated national estimates of summary statistics and comparison of trends over the twelve-year period. RESULTS: Of the top pediatric admission diagnoses, the most common conditions managed by surgical specialties involved inflammatory or infectious causes. Hospital charges significantly increased during this time across all diagnoses. On average, the charges for otolaryngologic diagnoses increased by 37.13% while costs increased by almost 12%. In comparison, the charges for non-otolaryngologic diagnoses increased by 35.87% and the costs by 10.43%. CONCLUSIONS: The public health impact and rising costs of healthcare are substantial. It is of critical significance that the healthcare system be aware of opportunities and lessons that may be learned across specialties to identify the primary drivers of healthcare cost while maintaining high quality standards for patient care.

Predictors of High Costs of Care among Otolaryngology Patients.

OBJECTIVES: Identify predictors of high-cost otolaryngology care. STUDY DESIGN: Cross-sectional. SETTING: Tertiary academic multispecialty hospital. SUBJECTS/METHODS: All patients undergoing ≥1 otolaryngologic procedures from 2011 to 2015. Encounter costs were standardized using previously described methods approximating Medicare reimbursement. Patients were stratified by adult/pediatric and inpatient/outpatient. "Outliers" were defined as total encounter costs ≥95th percentile. Logistic regression measured predictors of outlier status. RESULTS: In total, 2433 adult inpatient encounters (95th percentile $57,611), 10,031 adult outpatient encounters ($10,772), 346 pediatric inpatient encounters ($84,639), and 3027 pediatric outpatient encounters ($8978) were included. For adult inpatient and outpatient, isolated head and neck oncologic procedures were the reference group. Among adult inpatients, laryngology and facial plastics procedures predicted higher odds of outlier status (odds ratio [OR] = 4.1 and 7.2). Involvement of multiple otolaryngology subspecialties increased the odds (OR = 4.7). Neck dissection and reconstructive procedures were the most common primary operations for adult inpatient outliers. For adult outpatients, several subspecialties had lower odds than head and neck (OR ≤0.44). Increased comorbidities predicted outliers for adult inpatient care (OR = 1.5); sex, age, race, and ethnicity did not. Cochlear implant was the most common primary operation among adult and pediatric outpatient outliers. Greater subspecialty involvement and increasing age predicted pediatric outpatient outliers (OR = 8.0 and 1.1); younger age and female sex predicted pediatric inpatient outliers (OR = 0.8 and 3.5). Airway procedures dominated pediatric inpatient outliers. CONCLUSION: This is the first large-scale study of high-cost otolaryngology care across multiple subspecialties. Specific procedures and subspecialties and increased comorbidities predicted high-cost care. Contrary to previous studies, patient sex, race, and ethnicity did not.

Regional Overview of Specific Populations, Workforce Considerations, Training, and Diseases in Latin America.

Latin America has significant disparities that make the region vulnerable in the delivery of health care. There is a need to plan comprehensive health care strategies that result in a more robust trained health care workforce, while improving the quality and efficiencies of tertiary public hospitals. This article introduces a survey conducted among otorhinolaryngology leaders in the region that identified the need to strengthen postgraduate programs. Although all countries in Latin America have at least one residency program, more otorhinolaryngology-trained specialists are necessary to address the workforce shortages that are present in about 50% of Latin American countries.

Otolaryngology in Low-Resource Settings: Practical and Ethical Considerations.

Providing otolaryngology care in low-resource settings requires careful preparation to ensure good outcomes. The level of care that can be provided is dictated by available resources and the supplementary equipment, supplies, and personnel brought in. Other challenges include personal health and safety risks as well as cultural and language differences. Studying outcomes will inform future missions. Educating and developing ongoing partnerships with local physicians can lead to sustained improvements in the local health care system.

Pediatric otolaryngologic conditions: Racial and socioeconomic disparities in the United States.

OBJECTIVES/HYPOTHESIS: Determine the national incidence and disparities for common pediatric otolaryngologic conditions. STUDY DESIGN: Cross-sectional analysis of a nationally representative database. METHODS: The National Health Interview Survey (2012) was analyzed, extracting children with frequent ear infections (FEI), nonstreptococcal sore throat (NSST), streptococcal pharyngitis (SP), hay fever, and sinusitis. Demographic data including age, sex, race, Hispanic ethnicity, geographic region, poverty level, and insurance status were extracted. The annual incidences of these conditions were determined. Disparities in the incidence of each condition was determined according to race and ethnicity, adjusting for other demographic variables. RESULTS: Among 73.3 million children (average age, 8.6 years; 51.1% male), the incidences were: FEI (4.0 million, 5.5% of children), NSST (11.9 million, 20.6% of children), SP (8.0 million, 13.8% of children), hay fever (6.6 million, 9.0% of children), and sinusitis (4.5 million, 7.9% of children). Black and Hispanic children were less likely to be diagnosed with FEI than white children (odds ratio: 0.503 [95% confidence interval: 0.369-0.686] and odds ratio: 0.661 [95% confidence interval: 0.515-0.848]), adjusting for all other demographic variables. Black and Hispanic children were also less likely to be diagnosed with SP than white children (odds ratio: 0.433 [95% confidence interval: 0.342-0.547] and odds ratio: 0.487 [95% confidence interval: 0.401-0.592], respectively). Similar decreased odds ratios for black and Hispanic children were evident for hay fever (odds ratio: 0.704 [95% confidence interval: 0.556-0.890] and odds ratio: 0.708 [95% confidence interval: 0.565-0.888], respectively) and for sinusitis (odds ratio: 0.701 [95% confidence interval: 0.543-0.905] and odds ratio: 0.596 [95% confidence interval:0.459-0.773], respectively). CONCLUSIONS: Black and Hispanic children are consistently less likely to be identified or diagnosed with FEI, hay fever, SP, and sinusitis compared to white children. These data likely highlight a significant health care disparity according to race/ethnicity in otolaryngology. LEVEL OF EVIDENCE: 2b Laryngoscope, 127:746-752, 2017.

[The influence of current social, medical, and political trends on the future of otorhinolaryngology]. / Auswirkungen aktueller Trends in Gesellschaft, Medizin und Politik auf die Zukunft der HNO-Heilkunde.

BACKGROUND: All medical specialties are changing permanently, including otorhinolaryngology. Analyzing trends in social changes, medical progress, and political decisions will allow the effects of these on ENT medicine to be at least partially anticipated. TRENDS: Demographic changes and medical progress lead to an increasing demand for medical treatments. In addition, increasing numbers of female physicians are observed, as are many changes in the lifestyles of young physicians. Medical treatment will develop toward more individualized therapies in the future. ENT surgery will become a more ambulatory medical specialty. Driven by political decisions, digital medicine will become more important. Particular services once provided by physicians will be delegated to non-physician professionals. DISCUSSION: The lack of physicians and the progress in medicine require better networking between in- and outpatient services in the future. The potential of such collaborations is currently not completely realized. However, these developments will also increase the cost of health care. CONCLUSION: These trends will develop otorhinolaryngology into a conservative and surgical ambulatory care driven medical specialty. Embedded in decentralized networks and cooperations, and supported by IT technologies and specialized non-physician professionals, ENT physicians will work in hospitals as well as in practices on a permanent basis. Nevertheless, the question of funding these changes has yet to be clarified.

Longitudinal treatment of cleft lip and palate in developing countries: dentistry as part of a multidisciplinary endeavor.

Cleft lip and palate affects roughly 1 in 600 children and predisposes patients to a lifetime of functional and esthetic discrepancies. Disparities in access as well as quality of care exist worldwide, with many children in developing countries unable to receive treatment. In the late 20th century, humanitarian medical missions emerged as a means of delivering surgical expertise to patients in resource-limited settings. These early missions took on a patient-centered approach focused solely on cleft repair, with little emphasis on treating the dental abnormalities that arose after the initial surgery. However, modern cleft care is characterized by a multidisciplinary, team-based approach with significant dental involvement. Recent cleft lip and palate endeavors have shifted from a mission-based approach to a developmental approach facilitating growth of an independent care center. This strategy focuses on creating an institution with expanded access to dental services, thus facilitating the long-term treatment inherent in modern cleft care. One clinic in a developing country that has experienced successful transitioning from a mission site to an independent craniofacial clinic is Operation Smile's Cleft Comprehensive Care Clinic in Guwahati, India. This article will summarize the rationale and planning of the clinic, underscore the team-based approach required in longitudinal treatment of cleft lip and palate, and demonstrate how treatment methodology may differ in resource-limited settings by outlining the therapeutic considerations of each provider in the Guwahati Clinic.

Initiating and developing clinical services, training and research in a low resource setting: the Malawi ENT experience.

BACKGROUND: Sub-Saharan Africa countries like Malawi have a paucity of ear, nose and throat (ENT) data, services and training opportunities. OBJECTIVE: To reflect on new Malawian ENT experience and to propose guidelines to poorly resourced countries. DESIGN: Analysis of data predating and following establishment of ENT services in Malawi. RESULTS: In 2008 the first and only Malawian ENT specialist established ENT services with external funding. Fifteen clinical officers have been trained and a nurse placed at each outreach hospital. In 2012, 15,284 consultations were recorded: 543 (3.6%) from outreach clinics. Forty-nine percent needed medical treatment, while 45% needed medical advice. Surgery was performed on 2.7% of patients; 21% for foreign bodies in the nose and throat and 18% for foreign bodies and biopsies of ears. CONCLUSIONS: To establish accessible and sustainable specialist ENT services in a poor country requires building on an established local health delivery system, careful planning and investment in personnel, infrastructure, training and data collection.

Survey of otolaryngology services in Central America: need for a comprehensive intervention.

In the developing world, there exists a scarcity of services and training in otolaryngology, audiology, and speech therapy, which is reflected by the gap between health care delivery in high-income countries and low-income countries. We surveyed, by questionnaire, the countries of Central America, except for Belize, because of the lack of otolaryngology services, on the following issues: availability of otolaryngology, audiology, and speech therapy services and equipment; otolaryngologist, audiologist, and speech therapist training; and availability of services in rural areas. Surveys were distributed via email and by hand at the 2011 Central American Congress of Otolaryngology, in San Salvador, El Salvador, to otolaryngologists, audiologists, and speech therapists. Not to our surprise, there is a shortfall in services and training in all three professions. The data collected and presented in this commentary will provide a basis by which change might take place.

Implementation of a novel otolaryngology clinic for indigent patients.

OBJECTIVES/HYPOTHESIS: This study was designed to describe the implementation, utilization, and outcomes of an otolaryngology clinic for indigent patients employing a novel design. STUDY DESIGN: Pilot study. METHODS: A tertiary-care academic otolaryngology department partnered with a nonprofit outpatient clinic for indigent patients in order to provide free subspecialty consultation services. A novel format was utilized in which the department provided on-site, scheduled outpatient multidisciplinary consultation on weekends, staffed by volunteer health care providers and ancillary staff. A review of the program was conducted using prospectively collected data. Clinic design, staffing, utilization, and feasibility were described, along with demographic and clinical data for all patients participating in the clinic from October 2010 through January 2012. RESULTS: Five clinics were held over 15 months, totaling 74 patient visits, with positive feedback regarding accessibility and quality of services provided. A total of 60 procedures were performed, including audiograms, endoscopies, otologic procedures, biopsies and/or excisions. The estimated value of medical services that were provided was $37,302. Four potentially life-threatening conditions were newly diagnosed. Twenty patients received conclusive evaluation and treatment at the time of their first visit. Eighteen patients required further subspecialty treatment and/or surgery that could not be provided in the outpatient setting, and were referred appropriately. CONCLUSIONS: The partnership between an academic otolaryngology department and a nonprofit clinic provided free on-site consultation for indigent patients. Such an arrangement is feasible, well utilized, and successful in delivering comprehensive specialized services to indigent patients who lack traditional access to medical care.

[Management of patients with risk factors]. / Management von Risikopatienten.

This review deals with concomitant diseases and risk factors in patients treated for otorhinolaryngologic disease in outpatient and hospital services. Besides heart disease, lung disease, liver disease and kidney disease this article also covers disorders of coagulation (including the therapy with new anticoagulant drugs) of electrolyte hemostasis. Special attention is paid to prophylaxis, diagnosis and treatment of delirium. Also information is provided to optimize preparation of surgical procedures and pharmacotherapy.