Play PodcastPlay Download PodcastDownload

Transcription:

Dr Gerry Lee (Host): Chronic rhinosinusitis with nasal polyps affects all races and ethnicities, but certain groups have experienced greater social and economic barriers to care. The goal of the Moving Toward Equity podcast series is to raise awareness of the challenges, strategies, and resources for moving the needle toward equitable allergy and immunology care for all patients and practitioners in all communities.

Welcome to this podcast series for the American College of Allergy, Asthma and Immunology. My name is Gerry Lee. And this is our first of a three-part series entitled Moving Toward Equity: Disparities in Chronic Rhinosinusitis with Nasal Polyps. In this episode, we'll discuss how chronic rhinosinusitis with nasal polyps disproportionately affects minority and underserved populations.

Let's first hear from Deanna, a patient with chronic rhino sinusitis with nasal polyps, who joined us on allergy talk to describe her journey as a patient.

Dr Gerry Lee: Deanna, thank you so much for letting your voice to allergy talk. So just for the audience, could you tell us a little about yourself? your age, where you're from, and what you do.

Deanna Shaw: I'm 34. I'm from Chicago, Illinois. right now I'm basically like self-employed, due to really bad allergies at this point.

Dr Gerry Lee: And so, This topic of the podcast is about disparities of care and chronic rhino sinusitis with nasal polyps. And so, it's very important for us to understand your story and your experience. So that's how I'd like to start. When did you first start having symptoms or problems with your condition?

How long ago and what was the first problems you expertise?

Deanna Shaw: It's been a couple of years, I wanna say probably about three years. I started with, really bad allergies just to anywhere being, anything touching, anything, being outside. it's more worse when it's like the winter time when I'm sick or when it's hot outside was more polyps and, and stuff going around.

So, it's been about three years. I got diagnosed some days is better than others.

Dr Gerry Lee: you mentioned that you were diagnosed a few years ago. Tell me about how you got diagnosed. did it take a while for people to recognize there was a problem?

Were you diagnosed pretty easily? Tell me that experience of getting the diagnosis of what was the problem.

Deanna Shaw: it actually took a while. I was going in and out of the hospital with, My allergies going crazy, my asthma going crazy. one minute I'll be fine. The next minute I'm, broke out all over the place, or my lips are swell to the point where I can't breathe, or I'll just have a allergi reaction on my feet, on my hands.

So it took a while for them to, Diagnose me with it and to actually figure out what it was now I'm still have, a really bad flare up now. They still really ain't pinpoint exactly how to like control it, so that's what's hard about it.

Dr Gerry Lee: And so, what made the difference for you finally? , getting the diagnosis of nasal polyps, did someone refer you or did you have to fight to get to the right doctor? what did you have to do to get the final diagnosis of why this was happening?

Deanna Shaw: I really had to go see a whole bunch of doctors cuz I was going to the ER so much that I had to go see my doctor, to see a primary care doctor, to be a specialist. So it took a minute to actually get to a, allergist for them to diagnose me to what it was. So it took, quite a while for them to be like, Yeah, okay. Well I think this is exactly what it is.

Dr Gerry Lee: as you know, this is a podcast about healthcare disparities. And so, one reason for disparities of care is, racism and, other sort of stereotypes in the healthcare community. I just wanted to. See, in your experience with that care that you receive in Chicago, have you ever felt that you received different care based on your, know, racial or ethnic background?

Deanna Shaw: I think at one point I did, I felt like I would've gotten diagnosed faster if my skin color was another color.

Dr Gerry Lee: Was there a particular story that you remember, or just in general, what do you think?

Deanna Shaw: this is the one when I went into the emergency room one time when they basically, soon as they looked in the chart, they're like, Okay, you have allergies. We can give you this, we can give you that. But not even, seeing how I actually was or. they just react to, Okay, well she can get this, she can get that.

She can't get that. But I feel like if my skin was another color, they'll be like, Okay, you know what? What can we do to make it better? Or could you take this, It's like a different approach with certain people, and I'm not gonna say all doctors, but you do have some doctors that pretty much just brush you off.

Especially if they know You come in a lot because you have allergies, but it's like it's on you that you can't control, but they'll like brush you off. And sometimes you do feel like, if my skin was different, would you brush me off like that. it sometimes that's how it be and some of 'em is not like that.

Some of 'em are very caring. Some of my sleep or some of 'em are I don't really care. And you can here get him that medicine. You can get outta here like that. So yeah, it happens sometimes.

Dr Gerry Lee (Host): Deanna has experienced difficulty in obtaining the diagnosis of CRS with nasal polyps. So let's now continue discussion with our expert panel.

Joining me are Dr. Mahboobeh Mahdavinia and Dr. Anjeni Keswani. Dr. Mahdavinia is a physician scientist and Associate Professor of Medicine Pediatrics at Rush University Medical Center. She's a board-certified allergist immunologist with a background of immunology of allergic diseases and a PhD in molecular epidemiology. She runs an active academic clinical practice with both adult and pediatric allergy, while leading a clinical and translation research team on food allergy and chronic rhinosinusitis. In addition to being the research director of the Rush Center of Sinusitis, Asthma and Allergies. Dr. Mahdavinia Is also involved in several national international collateral studies.

Dr. Keswani is an Associate Professor of Medicine and the Division Director of Allergy and Immunology at George Washington University School of Medicine and Health Sciences. Her clinical research interests are in optimizing the care of patients with chronic rhinosinusitis, as well as the effects of climate change on respiratory health. Welcome to the show, both of you doctors.

Dr Anjeni Keswani: Hello. Thank you.

Dr Mahboobeh Mahdavinia: Thank you.

Dr Gerry Lee (Host): We'll start with you, Dr. Mahdavinia. How would you define chronic rhinosinusitis with nasal polyps and its subtypes just to set the stage?

Dr Mahboobeh Mahdavinia: Sure. Chronic rhinosinusitis or CRS in short is an inflammatory disease that affects the sinus and nasal cavity, that per definition lasts more than 12 weeks. A major subgroup of these patients also develop inflammatory polyps in their nose, which are essentially inflammatory sacs. This subgroup is called as chronic rhinosinusitis with nasal polyp or CRSwNP. There are also other subgroups, such as patients who have comorbid asthma and aspirin allergy along with the CRSwNP and they are referred to as AERD or aspirin-exacerbated respiratory disease. There's also another subgroup of CRS patients who have an allergic inflammatory response linked to fungal disease in the sinuses, and that subgroup is referred to as allergic fungal rhinosinusitis or AFRS for short.

Dr Gerry Lee (Host): Dr. Keswani, of all these different nasal polyps syndromes in various populations, do we know if any group is more likely to have nasal polyps?

Dr Anjeni Keswani: Well, chronic rhinosinusitis with nasal polyps is a very heterogeneous disorder. And as Dr. Mahdavinia, I mentioned it can be accompanied by asthma and allergic rhinitis. But at present, there is a lack of data on the prevalence of different racial and ethnic groups with chronic rhinosinusitis with nasal polyps.

In many early studies, these demographics weren't even included in trials of medications or surgical options. So, we're still trying to understand the epidemiology of CRS with nasal polyps as it relates to race and ethnicity. But we do know that racial minorities may have a greater severity of their nasal polyps and are more likely to have these comorbid diseases such as asthma and obstructive sleep apnea.

Dr Gerry Lee (Host): Okay. So, it sounds like there's a gap in the literature about at least the various prevalence of disease. But, Dr. Mahdavinia, you know, Dr. Keswani is mentioning at least disparities and the burden of chronic rhinosinusitis with nasal polyps. So, what do we know about that?

Dr Mahboobeh Mahdavinia: So, studies by our group and others have shown that certain racial minority groups deal with higher burden of CRSwNP. For example, African American patients have a higher severity of disease when they're diagnosed and they have higher need for emergency visits compared to their white counterpart.

This includes how often they have exacerbations, need antibiotics, and how their nasal polyps affect their coexisting asthma. Similarly, a study in Florida has shown that Latino patients are at risk for more severe CRS, and this is more likely due to the fact that their disease is often diagnosed later, and therefore they're prone to worse outcomes. And as you can imagine, this is just a recipe for worse burden on the patients and increased need for urgent care, which is a suboptimal care for any chronic condition.

Dr Gerry Lee (Host): I see. So, I mean, we do know that certain populations have difficulty with access to care. But Dr. Keswani, do we know of any other theories why there's disparities in black and Latinx patients in terms of nasal polyps?

Dr Anjeni Keswani: Sure. There are likely several contributing factors to healthcare disparities in CRS with nasal polyps. Poor access to healthcare, as you mentioned, is one of them. Economic barriers, societal stress and increased air pollution in urban areas are others. And these contributing factors often coexist as studies have demonstrated that neighborhoods with residents with lower socioeconomic status actually also predict that areas of higher exposure to air pollution and consequent increased disease severity for CRS.

Studies have demonstrated that individuals with lower socioeconomic status have a longer duration of disease prior to having sinus surgery, and were actually less likely to achieve a clinically meaningful increase in quality of life following sinus surgery compared to individuals with higher income levels.

Racial disparities also play a role with reduced access to specialist care seen in African American patients. And while race has been postulated to be involved in more severe histopathologic disease as a potential driver of healthcare disparities, it actually appears that insurance status and the lack of access to healthcare are likely the greater factors for worse CRS outcomes.

Dr Gerry Lee (Host): Okay. Wow. There seems to be a lot of barriers to patients in underserved and minor populations to get the care that they need. And, you know, we talked about insurance status or lack of access, but I think referral is the first step that having physicians recognize a patient who may be having untreated nasal polyps in getting the care that they need. In terms of just physician education, Dr. Mahdavinia, what resources do we think could help physicians better recognize patients with specifically chronic rhinosinusitis with nasal polyps?

Dr Mahboobeh Mahdavinia: There are a couple of resources that in general we use when we take care of CRSwNP patients. There's a practice parameter Published by the American Academy and American College of Allergy. And there's also a very well-written document on diagnosis and treatment of CRS published by the International Forum of Brain Allergy and Allergy that are actually linked in the handout that is in this podcast as well.

However, really, there is not much of an emphasis on how to take care of patients from minority populations with CRSwNP specifically. So, maybe just more awareness that these patients might have poorer outcome and need more thorough evaluation on the first time we see them would be another addition needed for future handouts and future resources.

Dr Gerry Lee (Host): Oh, thank you. And, again, we will send the link at the end of this podcast. But, Dr. Keswani, you mentioned a whole bunch of different barriers to care for this population. What else can researchers, medical societies, what else can we do to address some of these disparities in the burden of disease from nasal polyps?

Dr Anjeni Keswani: We've mentioned that healthcare disparities in the care of those with nasal polyps is likely driven, at least in part by access to healthcare. So, advocating for greater insurance coverage for treatments and management strategies for CRSwNP, as well as reducing economic and transportation barriers for our patients to access healthcare are very important. And as I mentioned earlier, many historical studies didn't even provide details on race and ethnicity for both surgical and medical outcomes. So, specific attention should be given to research, understanding CRS outcomes in racial minority populations, and across differing levels of socioeconomic status to help to reduce this burden of disease.

Dr Gerry Lee (Host): Yeah, I think the first step is to really understand the problem better, and I think we'll get a better handle on what are the specific ways we can close disparity. So, I appreciate both of your insights. So, I really want to thank our guests and the listeners. This is the conclusion of part one of our three-part series on Moving Toward Equity: Disparities in Chronic Rhinosinusitis with Nasal Polyps from the ACAAI.

Make sure you join us for the future episodes. We'll talk about the environment on nasal polyps as well as therapies and disparities in care. If you want to look at some of the resources we talked about today, we have a website, it's education.acaai.org/disparities. And we have other interesting episodes in the Allergy Talk channel including two other episodes, one on atopic dermatitis and immune deficiency and disparities. To listen to those, just go to college.acaai.org/allergytalk. This is Gerry Lee from the American College of Allergy, Asthma and Immunology. I hope you enjoy the rest of your day. Thank you for listening.