Combined Effects of Race and Ethnicity With Rurality on Tonsillectomy Rates Among Children Enrolled in Medicaid

OBJECTIVE: To determine whether associations between race and ethnicity and tonsillectomy differ for urban and rural children. METHODS: Tonsillectomy within 6 months of initial otolaryngology visit (January 1, 2017-June 30, 2019) for either throat infection (n = 64,972) or obstructive sleep-disordered breathing (oSDB) (n = 111,756) was examined for children on Medicaid ages 2 to 18 years using the Transformed Medicaid Statistical Information System Analytic Files from 15 States. Poisson regression was used to compare tonsillectomy rates for Black non-Hispanic (Black), Hispanic, and White non-Hispanic (White) children in urban and rural settings, controlling for age, sex, and clinical factors. RESULTS: For children with throat infection at the time of otolaryngology visit, the highest adjusted rates of tonsillectomy were observed among White children (rural 31.9%; urban 31.0%), which were significantly higher than both Black (rural 29.1%, P = .0018; urban 25.1%, P < .0001) and Hispanic (rural 27.2%, P < .0001; urban 25.7%, P < .0001) children. Significant interaction with urban/rural was observed for Black children relative to White (P = .0101). For oSDB, the rate of tonsillectomy for rural White children (42.6%) did not differ significantly from rural Black children (42.8%, P = .8727), but was higher than urban Black (38.4%, P < .0001) and urban White (41.3%, P = .0008) children (interaction P = .003). The rates among rural White children were also significantly higher than for Hispanic children (rural 38.9% P < .0001; urban 36.1%, P < .0001; interaction P = .0124). CONCLUSIONS: These results indicate that racial and ethnic differences in tonsillectomy rates vary between urban and rural settings. These differences merit further exploration to ensure appropriate use of surgical procedures and limit unwarranted variation.