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From February 1, 2019 to October 31, 2021, 1,047 ESS-treated CRS patients were enrolled in this study (Table 1, Figure 1). The median age of patients at surgery in this cohort was 36 (IQR 27–46) years. Of the patients, 600 (57.3%) patients were male, 764 (73.0%) patients had CRSwNP, 315 (30.1%) patients belonged to low-income status, and 362 (34.6%) patients were farmers, temporary workers, or unemployed, and 172 (16.4%) patients had no medical insurance and paid at their own expense. Compared with patients in the middle SES group, those in the low or high SES groups were older at the time of surgery (P < 0.001) and had higher preoperative FnNO levels (P = 0.039). In addition, the proportion of patients with medical insurance in the high SES group was higher than that in the low and middle SES groups (P < 0.001).
Characteristics Total (n = 1,047) Low (n = 310) Middle (n = 399) High (n = 338) P-value Age at operation years 34.2 (27.5−46.1) 36.8 (31.8−50.8) 30.6 (24.3−48.9) 36.6 (30.6−44.1) < 0.001 Sex, n (%) 0.626 Males 600 (57.3) 183 (59.0) 230 (57.6) 187 (55.3) Females 447 (42.7) 127 (41.0) 169 (42.4) 151 (44.7) BMI, kg/m2 22.6 (20.6−27.2) 22.8 (20.7−27.3) 22.5 (20.6−27.6) 22.0 (20.4−26.7) 0.594 Educationa, n (%) < High school 92 (8.8) 83 (27.0) 9 (2.2) 0 (0.0) < 0.001 High school 273 (26.2) 178 (58.0) 92 (23.1) 3 (0.9) ≥ College 676 (65.0) 46 (15.0) 298 (74.7) 332 (99.1) Occupation, n (%) < 0.001 Low 362 (34.6) 169 (54.5) 187 (46.9) 6 (1.8) Medium 313 (29.9) 138 (44.5) 89 (22.3) 86 (25.4) High 372 (35.5) 3 (1.0) 123 (30.8) 246 (72.8) Household income/montha, n (%) < 0.001 < ¥5,000 315 (30.2) 124 (40.0) 151 (37.8) 40 (11.9) ¥5,000–8,000 638 (61.1) 186 (60.0) 243 (60.9) 209 (62.4) > ¥8,000 91 (8.7) 0 (0.0) 5 (1.3) 86 (25.7) Nasal polyposis, n (%) 0.607 Without 283 (27.0) 80 (25.8) 105 (26.3) 98 (29.0) With 764 (73.0) 230 (74.2) 294 (73.7) 240 (71.0) Smoking, n (%) 0.538 No 683 (65.2) 203 (65.5) 267 (66.9) 213 (63.0) Yes 364 (34.8) 107 (34.5) 132 (33.1) 125 (37.0) Alcohol, n (%) 0.302 No 697 (66.6) 212 (68.4) 271 (67.9) 214 (63.3) Yes 350 (33.4) 98 (31.6) 128 (32.1) 124 (36.7) Dietary patternsa, n (%) 0.466 Vegetarian-based 134 (13.3) 36 (13.2) 56 (14.0) 42 (12.4) Meat-based 67 (6.6) 24 (8.8) 25 (6.3) 18 (5.3) Mixed 809 (80.1) 213 (78.0) 318 (79.7) 278 (82.2) Furry/feathery Pets, n (%) 0.356 No 892 (85.2) 271 (87.4) 339 (85.0) 282 (83.4) Yes 155 (14.8) 39 (12.6) 60 (15.0) 56 (16.6) New furniture/redecoration, n (%) 0.593 No 902 (86.2) 267 (86.1) 339 (85.0) 296 (87.6) Yes 145 (86.1) 43 (13.9) 60 (15.0) 42 (12.4) Stressful work or family events during the first 1 yearab, n (%) 0.235 No 711 (68.1) 207 (66.8) 284 (71.2) 220 (65.7) Yes 333 (31.9) 103 (33.2) 115 (28.8) 115 (34.3) Often stay up late, n (%) 0.296 No 788 (75.3) 243 (78.4) 293 (73.4) 252 (74.6) Yes 259 (24.7) 67 (21.6) 106 (26.6) 86 (25.4) Before surgery, n (%) FeNO, ppb 24.0 (16.0−34.0) 22.0 (15.0−36.0) 24.0 (18.0−33.0) 26.0 (19.0−33.0) 0.293 FnNO, ppb 201.0 (151.0−322.0) 220.0 (168.0−335.0) 187.0 (145.0−311.0) 213.0 (169.0−323.0) 0.039 Hb, g/L 146.0 (136.0−161.0) 146.5 (140.0−166.0) 142.0 (121.0−162.0) 146.0 (136.0−157.0) 0.711 IgE, IU/mL 44.4 (30.8−66.0) 42.3 (30.3−77.4) 46.0 (31.1−56.0) 47.6 (34.9−60.8) 0.284 Medical insurance, n (%) < 0.001 No 172 (16.4) 83 (26.8) 86 (21.6) 3 (0.9) Yes 875 (83.6) 227 (73.2) 313 (78.4) 335 (99.1) Note. aTotal numbers were not equal to 1,047 for these characteristics due to missing data. bAmong work, separation/divorce, loss of job, serious health problem, or death of a family member or close relative. Values are n (%) or median (IQR). Table 1. Baseline characteristics and clinical features of patients with severe chronic rhinosinusitis (CRS) (n = 1,047) by socioeconomic status tertiles
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Kaplan-Meier analysis (Figure 2, Supplementary Table S1, available in www.besjournal.com) showed that the recovery rates of 1,047 CRS patients at 12 weeks and 24 weeks after operation were 19.1% (95% CI: 18.3%–19.9%) and 44.7% (95% CI: 43.7%–45.7%), respectively.
The log-rank tests showed that after follow-up at 24 weeks, the recovery rate (90.4%, 95% CI: 89.6%–91.2%) of patients of middle SES was higher than those of patients of low SES (13.5%, 95% CI: 12.8%–14.2%) and high SES (31.7%, 95% CI: 30.7%–32.7%) (log-rank P < 0.001). In addition, multivariate Cox regression model analysis showed that SES had no association with nasal polyps (Pinteraction = 0.189), medical insurance mode (Pinteraction = 0.143), and dietary pattern (Pinteraction = 0.438) (Supplementary Table S2, available in www.besjournal.com).
Interaction β Wald HR (95% CI) P−Value SES × nasal polyps 0.001 1.722 1.001 (0.999−1.003) 0.189 SES × medical insurance −0.056 2.144 0.946 (0.877−1.019) 0.143 SES × dietary patterns 0.092 0.601 1.097 (0.868−1.385) 0.438 Note. HR, hazard ratio; NA, not applicable. Table S2. Multivariable Cox regression model of an interaction between socioeconomic status (SES) and nasal polyposis, medical insurance, and dietary patterns
Based on the literature, we selected variables (surgical age, BMI, nasal polyps, smoking, dietary pattern, stress events, FeNO, FnNO, Hb, and medical insurance mode) that might affect prognosis and carried out univariate Cox regression model analysis, followed by multivariate Cox regression model analysis to determine their association with SES. Next, we obtained the influence of SES after adjusting the covariates for recovery rate (Figure 3, Table 2).
Figure 3. Adjusted survival curves for all-cause recurrence by socioeconomic status. Models were adjusted for age at operation, sex, BMI, nasal polyposis, smoking, dietary patterns, stressful family events during the year that precede the operation, FeNO, FnNO, Hb, and medical insurance. FeNO, fractional exhaled nitric oxide; FnNO, fractional nasal nitric oxide; and Hb, hemoglobin.
Characteristics All-cause non-recovery Crude HR (95% CI) P-value Adjusted HR* (95% CI) P-value Socioeconomic status Low 10.42 (8.55−12.66) < 0.001 7.69 (6.17−9.71) < 0.001 High 6.54 (5.49−7.81) < 0.001 6.19 (4.78−7.93) < 0.001 Middle 1 (ref) 1 (ref) Age at operation, years 1.01 (1.00−1.02) 0.013 1.01 (0.99−1.02) 0.128 Sex Males 0.86 (0.72−1.01) 0.27 0.93 (0.79−1.08) 0.313 Females 1 (ref) 1 (ref) BMI, kg/m2 1.02 (1.00−1.03) 0.19 NA Nasal polyposis Without 0.75 (0.65−0.87) < 0.001 0.83 (0.69−1.00) 0.039 With 1 (ref) 1 (ref) Smoking NA No 0.87 (0.76−0.99) 0.039 Yes 1 (ref) Alcohol NA No 1.03 (0.89−1.19) 0.648 Yes 1 (ref) Dietary patterns* Vegetarian-based 2.11 (1.69−2.64) < 0.001 1.45 (0.87−2.42) 0.149 Meat-based 1.66 (1.23−2.22) 0.001 0.88 (0.50−1.52) 0.631 Mixed 1 (ref) 1 (ref) Furry/feathery Pets NA No 0.94 (0.78−1.13) 0.511 Yes 1 (ref) New furniture/redecoration NA No 0.89 (0.73−1.08) 0.231 Yes 1 (ref) Stressful work or family events
during the first 1 yearNo 0.80 (0.66−0.99) 0.032 1.02 (0.80−1.30) 0.871 Yes 1 (ref) 1 (ref) Often stay up late No 1.00 (0.85−1.17) 0.989 NA Yes 1 (ref) Before surgery FeNO, ppb 1.00 (1.00−1.01) < 0.001 1.00 (0.98−1.02) 0.954 FnNO, ppb 0.99 (0.99−1.00) 0.001 0.99 (0.99−1.01) 0.196 Hb, g/L 1.00 (1.00−1.01) 0.025 0.99 (0.98−1.01) 0.122 IgE, IU/mL 1.00 (0.99−1.01) 0.538 1.00 (1.00−1.01) 0.032 Medical insurance No 1.26 (1.19−1.33) < 0.001 1.23 (1.07−1.42) 0.003 Yes 1 (ref) 1 (ref) Note. CRS, chronic sinusitis; FeNO, fractional exhaled nitric oxide; FnNO, fractional nasal nitric oxide; HR, hazard ratio; NA, not applicable. *Adjusted for age at operation, sex, BMI, nasal polyposis, smoking, dietary patterns, stressful work or family events during the first 1 year, FeNO, FnNO, Hb, and medical insurance. Table 2. Univariable and multivariable Cox regression model of factors associated with all-cause recurrence
SES was an independent predictor of postoperative all-cause non-recovery in CRS patients after adjusting for other covariates. During the whole follow-up period of 72 weeks, the risk of non-recovery of patients of low and high SES was significantly higher than that of patients of middle SES.
Patients of low SES had the highest risk of non-recovery, with an HR of 7.69 (95% CI: 6.17–9.71, Ptrend < 0.001), followed by patients of high SES, with HR of 6.19 (95 % CI: 4.78–7.93, Ptrend < 0.001) (Figure 3, Table 2).
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In sensitivity analysis, we assumed that all the 44 patients lost to follow-up had reached the end point of recovery. Therefore, we performed univariate and multivariate Cox regression analyses, which yielded similar outcomes: HRs for recurrence were 8.77 (95% CI: 7.09–10.87) for the low SES group and 7.19 (95% CI: 5.95–8.70) for the high SES group, compared with the middle SES group (Ptrend < 0.001) (Supplementary Table S3, available in www.besjournal.com).
Characteristics All-cause non-recovery Adjusted HR* (95% CI) P-value Socioeconomic status Low 8.77 (7.09−10.87) < 0.001 High 7.19 (5.95−8.70) < 0.001 Middle 1 (ref) Age at operation, years 0.99 (0.98−1.00) 0.111 Sex Males 0.97 (0.83−1.13) 0.722 Females 1 (ref) Nasal polyposis Without 0.88 (0.74−1.05) 0.026 With 1 (ref) Dietary patterns Vegetarian-based 1.52 (0.98−2.51) 0.747 Meat-based 0.64 (0.54−1.54) 0.058 Mixed 1 (ref) Stressful work or family events during the first 1 year No 0.99 (0.80−1.23) 0.919 Yes 1 (ref) Before surgery FeNO, ppb 1.00 (1.00−1.00) 0.527 FnNO, ppb 1.00 (1.00−1.00) 0.224 Hb, g/L 1.00 (1.00−1.01) 0.113 IgE, IU/mL 1.00 (1.00−1.00) 0.538 Medical insurance No 1.23 (1.06−1.56) 0.023 Yes 1 (ref) Note. CRS, chronic sinusitis; FeNO, fractional exhaled nitric oxide; FnNO, fractional nasal nitric oxide; HR, hazard ratio; NA, not applicable. *Adjusted for age at operation, sex, BMI, nasal polyposis, smoking, dietary patterns, stressful work or family events during the first 1 year, FeNO, FnNO, Hb, and medical insurance. Table S3. Univariable and multivariable Cox regression model of factors associated with all-cause recurrence (All chronic sinusitis patients lost to follow-up are regarded as recovery)
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The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
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Time (week) Total (n = 1,047) Low (n = 310) Middle (n = 399) High (n = 338) 12 19.1 (18.3−19.9) 3.2 (2.1−4.9) 30.9 (29.2−31.8) 4.7 (3.1−5.9) 24 44.7 (43.7−45.7) 13.5 (12.8−14.2) 90.4 (89.6−91.2) 31.7 (30.7−32.7) Table S1. Kaplan-Meier analysis of the recovery rate (%) (95 % confidence interval) and Log-rank tests after 24 weeks follow-up
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Participants’ Characteristics
Kaplan-Meier Analysis
Sensitivity Analysis
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