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Dr Gerry Lee (Host): Chronic rhinosinusitis with nasal polyps or CRSwNP affect all races and ethnicities, but certain groups have experienced greater social or economic barriers to diagnosis and treatment. 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 immunology care for all patients and practitioners in all communities.

Welcome to the podcast series from the American College of Allergy, Asthma and Immunology. My name is Gerry Lee, and this is our final part of a three-part series entitled Moving Toward Equity: Disparities in Chronic Rhinosinusitis with Nasal Polyps. In this episode, we will discuss disparities in access to treatment for nasal polyposis.

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

Dr. Keswani is an Associate Professor of Medicine and the Division Director of Allergy and Immunology at George Washington University's School of Medicine and Health Sciences. Her clinical and research interests are optimizing care for patients with chronic rhinosinusitis, as well as the effects of climate change on respiratory health. Thank you once again for joining us, doctors,

Dr Mahboobeh Mahdavinia: Thank you.

Dr Anjeni Keswani: Thanks for having us.

Dr Gerry Lee (Host): Dr. Mahdavinia, we'll start with you. Could you set the stage for this podcast by describing just the various treatments we have available for treating chronic rhinosinusitis with nasal polyposis?

Dr Mahboobeh Mahdavinia: Of course. So, the way I look at it is that the management of CRS with nasal polyps needs a multidisciplinary chronic treatment plan. And I can summarize that into three categories of treatment. The first being topical nasal treatments such as topical nasal steroids that can be used in the form of nasal sprays, lavages, or an expiratory device that is built to deliver steroids better to the sinuses, that delivers fluticasone specifically into the sinus and is FDA approved for nasal polyps.

The second category are systemic medical treatments. Lots of CRSwNP patients need to undergo antibiotic treatments to decrease the burden of bacteria and treat exacerbations, or they might need actually systemic steroids at times. This second group also includes injectable treatments that have all been approved to be used in CRSwNP in the past couple of years. These medications are built to target the allergic inflammation in the body and are called biologics. There are currently three of them that are available and FDA approved for CRSwNP, such as omalizumab, dupilumab, and mepolizumab.

The other aspect of treatment that's a third category and what most of the CRS patients with nasal polyps need at some point are surgical interventions. These interventions are called functional endoscopic sinus surgery, and they clear their large burden of the inflammatory tissue, open up sinuses for better drainage, and also cut out nasal polyps from cavity.

Dr Gerry Lee (Host): Okay. Well, you know, we could explore each treatment in depth. Dr. Keswani, let's actually talk about surgery. So, do we know much about disparities in access to getting surgery for nasal polyps in different populations and what would be the barriers to treatment?

Dr Anjeni Keswani: Yes. So, patients from racial minority groups and individuals with lower socioeconomic status can have difficulty with access to sinus surgery. One study showed that individuals with lower socioeconomic status had a longer duration of CRS prior to surgery with increased surgical wait times, even after the decision for surgery was made. And they also had a higher likelihood of being lost to followup post-surgery.

Another prospective cohort analysis indicated that patients from minority racial and ethnic groups accounted for only about 18% of CRS patients who underwent sinus surgery, while these groups comprised 35% of the United States' population. So, there seems to be a decreased access to the availability of sinus surgery for some patients. And when patients of racial minority groups or individuals with lower socioeconomic status do access healthcare treatment for their CRS, we actually also see differences in post-surgical outcomes following endoscopic sinus surgery. So, the odds of a clinically meaningful improvement in symptoms following sinus surgery is actually more than twice as likely in a patient with a higher income level compared to a patient with a lower income level.

And then, in another study that looked at race and outcomes after sinus surgery, it was demonstrated that both African American and white patients had significant improvements, comparably significant improvements in their symptoms at six months following endoscopic sinus surgery. However, at 12 months following surgery, it was only white patients that noticed a significant symptom improvement at that time, whereas African American patients did not, indicating an earlier relapse from their surgical procedures.

And I'd like to note that we're quite fortunate to have Dr. Mahdavinia with us as she and her research team have really been at the forefront of investigation into healthcare disparities in CRS with nasal polyps. Through some of her research, some of Dr. Mahdavinia's research, we've learned that African American patients have worse symptom scores and fewer followup visits for CRS care, both in medical and surgical areas compared to Latino and Caucasian patients. And they concluded that it's potentially due to these inequities in healthcare access and then the reduced utilization of subspecialists, such as allergists or rhinologists for the CRS care.

Dr Gerry Lee (Host): My goodness. I mean, that is a significant difference between different populations. And certainly, I know post-surgical care also involves access to medication. So, we could start with biologic. Dr. Mahdavinia, you were talking about biologics earlier. Could you talk about some disparities of the access to those treatments and maybe the reasons for those disparities?

Dr Mahboobeh Mahdavinia: So, the issue is all about followup and being connected to healthcare. Using a biologic especially is probably one of the most complex medications that we are dealing with in this condition. This means that patients need adequate and efficient outpatient care, such as close relationship with their specialists, especially when we are talking about medications that need specialty pharmacy. They are injectable, they need training, how they're used and applied, and also close followup and a lot of to do just to get them approved and start. It's also important to note that these medications cost around $25,000 to $40,000 per year. So, if everything else is good, you also need a very good insurance that covers that cost.

I can give you an example. To start one of these biologics, we need to first demonstrate they have failed previous medications. So, we need to have past followup data to demonstrate that. Then, we have to get it approved with the help of a pharmacist and bring the patient back to train how to use the medication, at least one more visit just to start that. After that is the issue of adherence to an injection that needs to happen every two to four weeks. So, if there's any question or concern, it needs to be addressed in a very timely manner, so the patient does not actually miss a dose, because that can really set back their treatment plan. And every step of the way is about being connected. So if someone's living an hour away from their specialist or doesn't have an easy way to get to them, this becomes really hard.

Dr Anjeni Keswani: I agree with Dr. Mahdavinia that our research has shown that patients of certain racial minorities such as African Americans have difficulty with access to specialist care. And in fact, many of these biologics are limited to being prescribed by specialists. So, this can compound the concerns that we have in healthcare disparities for patients with CRS with nasal polyps.

Dr Gerry Lee (Host): I was just very struck by my interview of one of your patients, Dr. Mahdavinia. Your patient, Deanna, told a very poignant story about her struggle to get the medication she needed for her treatment. Dr. Keswani, I mean, you were mentioning the fact that specialists are not the gatekeepers, but a lot of these biologic treatments are primarily prescribed by specialists, but we know that also there's some data potentially about access to emerging therapies as well. So, what do we know about participation and research of these emerging or just new studies about treatments for nasal polyps in underserved populations?

Dr Anjeni Keswani: So, there certainly needs to be a greater emphasis on inclusion of minorities in clinical trials for therapeutics, which we are now seeing. But in many cases, clinical trials are performed at specific sites around the country and they require a lot of followup visits and a lot of different markers for care for patients of different electronics, items that they need to do early on in the studies or throughout the studies. So, we need to ensure that we're making this an equitable access for patients of different groups to be able to participate in studies.

As we've seen, there was a systemic meta-analysis of CRS patients that found that 90% of our historical cohort studies did not provide details of race or ethnicity for their outcomes. So, I think it's been difficult to generalize some of our current research to different patient groups. Newer clinical trials have been more inclusive of diverse groups, and I think we need to have greater outreach to ensure that we are really truly studying individuals that will provide greater data to a diverse population.

Dr Gerry Lee (Host): So, we've really talked in this podcast about the barriers and challenges our patients have about getting the adequate followup and the followthrough or making the case to get more specialized therapies. So, there seems to be multiple challenges in terms of access or other barriers to therapy for these polyps. Dr. Mahdavinia, if you wanted to think about how we in the healthcare system or even individual clinicians can prove access, what would be your thoughts or recommendations?

Dr Mahboobeh Mahdavinia: I want to say that it takes a village. Obviously, it starts with the physician and increasing the awareness of the providers. But as the healthcare force, we need to work together to combat such a big problem. For example, we can create a home in the clinic for our patients. Reports starts from the front desk staff, CMAs, nurses, asthma educators, and clinic managers. As those patients actually interact with them even before seeing the physician. Patients that are known to clinic staff tend to stay connected with the clinic longer and get the benefit longer. Simple examples like calling patients when they miss an appointment over and over and, again, giving them a chance at a new appointment keeps them connected to the clinic. And they need to communicate efficiently and frequently with other providers because this is a multidisciplinary care. Simple things like forwarding all our clinic notes to ENT colleagues, pulmonologists, their primary care doctor. And communicate within inpatient providers when our patients are hospitalized can actually help them a lot. And we need to let the patient know we are communicating because when patients are aware that we care and we are spending time trying to help them, they will be more engaged in their care as well.

Dr Gerry Lee (Host): I absolutely agree a lot about, you know, and especially the role that we take to advocate for the patient. So, I can definitely tell you're a very strong patient advocate. Dr. Keswani, did you want to add anything else about how we could potentially improve some of the pretty significant disparities in getting treatments?

Dr Anjeni Keswani: I think as Dr. Mahdavinia mentioned, access is the most important thing, or one of the most important things that we can do for our patients with CRS with nasal polyps. And this is really in the entire healthcare system as a whole, ensuring patients, that their primary care physicians are able to recognize when a patient has CRS, has CRS with nasal polyps, and to be easily facilitate an appropriate referral to a specialist. And that we as specialists are able to easily facilitate having these patients come into our clinic and to be able to be seen.

And I think Dr. Mahdavinia made an excellent point about trying to, in some respects, complete a lot of a visit in the first visit, knowing that it can be challenging for some patients to present for follow up appointments, but to be able to try to understand or think through how their disease severity may progress, and seeing if there's ways that we can curtail that earlier on in the process in order to prevent this progression, knowing that there may be some additional limitations to access for certain patients.

Dr Gerry Lee (Host): Well, both of you have given very great advice, and again, I really appreciate your expertise and thoughts and experience in discussing about this very important issue. So, that's the end of part three of our three-part series on Moving Toward Equity: Disparities in Chronic Rhinosinusitis with Nasal Polyps from the ACAAI.

If you really want to access some of the resources we've talked about during the podcast or some of the studies, please visit education.acaai.org/disparities. We do have two other Moving Toward Equity series on atopic dermatitis and primary immune deficiency. If you'd like to listen to those or other interesting episodes from the Allergy Talk channel, please visit college.acaai.org/allergytalk.

I immensely enjoyed this conversation. I hope you did too. My name is Gerry Lee. I'm speaking for the American College of Allergy, Asthma and Immunology. Thank you so much for listening, and I hope you enjoy the rest of your day.