This study used several independent data sources to explore CRS in the context of race and ethnicity. The NHIS, NAMCS, and NHAMCS suggest that CRS is a significant health condition for all major race/ethnic groups in the United States and accounts for a substantial portion of physician visits regardless of race or ethnic background. Not surprisingly, these data also suggested that differences in insurance status, specialist visits, and treatment exist across race/ethnic groups with CRS. Specific data regarding race/ethnicity in patients undergoing ESS were sparse, with most studies failing to provide adequate breakdowns along race/ethnicity subgroups. In-depth analysis of a single, large cohort did show baseline differences across race/ethnic groups with regard to socioeconomic factors and QOL. Importantly, QOL did appear to improve significantly in all groups regardless of racial or ethnic background.
Health differences across groups defined by race and ethnicity could be explained by true biological differences or simply by confounding from other socioeconomic variables. Given the rarity of true biological differences defined by race/ethnicity, many researchers prefer to avoid discussion of this patient characteristic altogether. Adjustment for socioeconomic factors such as insurance status, income, and education will often account for a sizable portion of health differences by race.5
However, there remain reasons to study the impact of race and ethnicity on medical conditions. In the clinical research setting, adjustment for a limited set of socioeconomic factors rarely accounts fully for the impact of race or ethnicity. Oftentimes, as in this study, some difference by race/ethnicity will persist, most likely representing some degree of residual confounding.
Disregarding information on race/ethnicity can also obscure inequalities with health care access and/or service use. A major question that remains is whether minority groups with CRS receive appropriate levels of medical and surgical care. The national studies reviewed here are not designed to fully answer this question, especially with regard to surgery, but do suggest that differences may exist. Additionally, results of the literature review from this study highlight the fact that very little published information exists regarding ESS outcomes in minority groups. This may simply represent authors choosing to not include information regarding race/ethnicity, or it might indicate underrepresentation of minorities in surgical cohorts. When reviewing data from our cohort, minority groups accounted for only 18%, when compared with the national average of 35%. African Americans and Hispanics were especially underrepresented. Although some of this disparity might represent geographic distribution of minority groups with regard to study sites, it is equally if not more plausible that differences in income, insurance status, or referral pattern are causal. Further research is needed to quantify rates of ESS in patients with CRS and better qualify possible barriers to health care.
In the cohort analysis, Hispanic patients were found to report worse baseline scores on the RSDI instrument after controlling for socioeconomic factors. The difference in RSDI far exceeded statistical and clinical significance but was not mirrored on the CSS instrument, CT, or endoscopy. One possibility is that Hispanic patients present for surgery when symptoms reach a more severe threshold. Another explanation is that their disease is of equal severity, but Hispanic patients express QOL impacts more forcefully, possibly reflecting differences in language or culture. Although highly significant, this finding could also represent a false positive or be specific to our population. Further research in this group is needed to explore QOL impacts of CRS.
There are several important limitations that may affect study conclusions. The NHIS reported prevalence of physician-diagnosed “sinusitis” over the preceding year. This estimate was assumed to represent CRS, but in some instances patients may have been diagnosed with acute sinusitis. Additionally, estimates regarding specialist visits and surgery may not represent care for sinusitis specifically and thus should be considered hypothesis generating as opposed to firm estimates. It should also be kept in mind that the present study used national survey data from 2006 (NAMCS/NHAMCS) and 2009 (NHIS). Although this represents the latest data made publicly available, recent trends over the last several years would not be identified. The NAMCS/NHAMCS sampling scheme uses patient-weighted estimates from participating centers/physicians and thus may not fully capture the true national prevalence of ambulatory patients with CRS. The incorporated literature review was limited to surgical cohort studies because of the paucity of QOL outcomes research involving continued medical therapy for CRS. Potential misclassification bias of multiracial patients may also exist within the surgical cohort analysis, because patients with CRS were prompted to select a single race or ethnic group.