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Health Disparities
Asthma
Fiona R. Prabhu, MD, Associate Professor
Department of Family & Community Medicine
Texas Tech University Health Sciences Center
June 16th, 2010
Objectives
• What are the health disparities in relation
to asthma?
• Why do these health disparities exist?
• What can we do to minimize or eliminate
the disparities?
Asthma
• Asthma is a disease of inflammation of the airways
– The symptoms associated with asthma are:
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Chest tightness
Wheezing
Shortness of breath
Coughing
– The inflammation that results in the symptoms is treatable
and the progressive damage that occurs to the airways is
easier to delay with today’s medications
• Causes of asthma – not well known
– Genetics
– Linked to allergies and atopic dermatitis
– Could be triggered by environmental allergens and
infections
Asthma Statistics
Morbidity
• Number of non-institutionalized adults who currently have asthma: 16.4
million
– % of non-institutionalized adults who currently have asthma: 7.3%
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Number of children who currently have asthma: 7.0 million
– % of children who currently have asthma: 9.4%
Health care use
• Number of visits (to physician offices, hospital outpatient and emergency
departments) with asthma as primary diagnosis: 13.3 million
• Number of discharges with asthma as first-listed diagnosis: 444,000
• Average length of stay: 3.2 days
Mortality
• Number of deaths per annum: 3,613
• Deaths per 100,000 population per annum: 1.2
Summary Health Statistics for U.S.
Adults: National Health Interview
Survey, 2008. Tables 1, 2, 3, 4.
African Americans
• In 2008, about 3,807,000 African Americans reported that they
currently have asthma.
• In 2006, African Americans were three times more likely to die from
asthma related causes than the White population.
• Black children have a 260% higher emergency department visit rate,
a 250% higher hospitalization rate, and a 500% higher death rate
from asthma, as compared with White children.
– From 2003-2005, African American children had a death rate 7
times that of non-Hispanic White children.
• African Americans had asthma-related emergency room visits 4.5
times more often than Whites in 2004
• African American women were 30% more likely to have asthma than
non-Hispanic White women, from 2001-2003.
Asthma Data/Statistics. The Office of Minority Health. U.S.
Dept of Health and Human Services. Last updated
04/22/2010.
Asian Americans
• Asian Americans generally have lower rates of
asthma than the White population, but they had
a 40% greater death rate in 2006.
• Native Hawaiians/Pacific Islanders have a higher
percentage of asthma than non-Hispanic Whites.
• Chinese Americans also show a higher asthma
rate than the White population.
• Native Hawaiian/Pacific Islander children were
three times more likely to have asthma, in 2008.
Asthma Data/Statistics. The Office of Minority Health. U.S.
Dept of Health and Human Services. Last updated
04/22/2010.
American Indian/Alaska Native
• American Indian/Alaska Native adults are
20% more likely to have asthma as nonHispanic Whites
• American Indian/Alaska Native children
had a 40% higher rate of asthma
occurrence in 2008.
Asthma Data/Statistics. The Office of Minority Health. U.S.
Dept of Health and Human Services. Last updated
04/22/2010.
Hispanic Americans
• In 2008, about 2,696,000 Hispanics reported that they
currently have asthma.
• Puerto Rican Americans have over twice the asthma rate
as compared to the overall Hispanic population.
• The rate of asthma attacks for Puerto Ricans was 2.5
times that of Whites.
• Hispanics are twice as likely to use outpatient clinics for
asthma visits, rather than physician offices.
• Hispanic children are 60% more likely to have asthma,
as compared to non-Hispanic Whites.
Asthma Data/Statistics. The Office of Minority Health. U.S.
Dept of Health and Human Services. Last updated
04/22/2010.
WHY?
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Socio-economics
Genetics
Environment
Quality of care
Socioeconomics
• Low-income households
– Higher level of indoor allergens in urban
households compared to rural areas and suburbs
• Cockroach, dust mites, mold
• Low-income neighborhoods
– Poor housing – difficult to adhere to prescribed
medical and environmental interventions
– Fewer supportive and essential resources
– Chronic stresses related to fewer supportive and
essential resources; for example:
• Higher crime rates – interferes with patients’ and
caregivers’ ability to access safe transportation
Asthma and ethnic minorities: socioeconomic status and
beyond. Forno E, Celedon JC. Curr Opin Allergy Clin
Immunol 9:154-160.
Asthma disparities in urban environments. BryantStephens T. J Allergy Clin Immunol 2009; 123:1202-1203.
Genetics
• Several genes of interest:
– Over 118 genes have been associated with asthma; no gene
that has been studied in multiple racial and ethnic populations
has shown a positive association in every group
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Thymic stromal lymphopoietin gene (TSLP)
Interleukin 13
Alpha -1B-Beta adrenergic receptor
Beta2-adrenergic receptor (differences in response to bronchodilators)
Disintegrin
Metalloproteinase 33
Orosmucoid 1-like 3
• Latino population: heterogeneous
– Many Hispanics have complex proportions of European, Native
American, and African ancestry
– Diseases within the community may also differ by country of
origin
Race, ethnicity, and social class and the complex etiologies of
asthma. Drake KA, Galanter JM, Burchard EG.
Pharmacogenomics. 2008 Apr;9(4):453-462
Genetics and asthma disease susceptibility in the
US Latino population. Mt Sinai J Med. 2010
Mar;77(2):140-8.
Environmental Exposures
• Indoor allergens
• Cigarette smoking
– 20% of U.S. adults smoke, resulting in second hand smoke exposure for
their children as well
• Socioeconomic differences
– 46% for those with a GED vs. 7% for those with a graduate degree
– Smoking > below federal poverty level
• Ethnicity – smoking in adults
– American-Indians and Alaska Natives = 32%
– African-Americans and Caucasians = 23%
– Asians = 10%
• Ethnicity – smoking in utero
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American-Indians = 20%
Whites = 16%
Puerto-Ricans and non-Hispanic Blacks = 10%
Japanese = 5%
Mexicans = 3%
Central/South Americans = 1.5%
Asthma and ethnic minorities: socioeconomic status
and beyond. Forno E, Celedon JC. Curr Opin Allergy
Clin Immunol 9:154-160.
Environmental Exposures
• Air pollution
– Non-whites are more likely to live in areas with elevated levels of
air pollutants, including particulates, carbon monoxide, ozone,
and sulfur dioxide
– Nitrogen oxide and diesel exhaust particles (traffic-related air
pollution) have also been associated with increased asthma
symptoms
• Stress and co-morbidities
– Exposure to stress and violence
– Obesity
• Proportion of overweight was higher in blacks and Hispanics than in
whites and members of other races
– Depression and anxiety
• More prevalent in youth of lower SES and/or with limited education
Asthma and ethnic minorities: socioeconomic status
and beyond. Forno E, Celedon JC. Curr Opin Allergy
Clin Immunol 9:154-160.
Quality of Care
• Access to care – “Usual Source”
– Significant ethnic differences exist
• “Usual source of care” (Primary Care Physician)
– Caucasians 96%; Blacks 92%; non-English speaking Hispanics
89%;
• Specific physician
– Whites 52%; blacks 44%; Spanish-speaking Hispanics 40%
– Primary physician may not monitor as closely; patient
comprehension is not as good
• African-Americans
• More likely to receive treatment in EDs, to use inhaled
bronchodilators instead of controller medications, and to
receive care in poorer facilities with irregular follow-up
• More likely to be seen by general hospital providers rather
than by asthma specialists
Asthma disparities in urban environments.
Bryant-Stephens T. J Allergy Clin Immunol
2009;123-1199-1206.
Quality of Care
• Communication between patients and providers
– Providers frequently underestimate symptom severity
– Caregiver factors:
• Literacy, language barriers, lack of self-efficacy
• Differences in words used to describe symptoms
– Physician factors:
• Unintentional racial biases in interpreting symptoms
• Poor understanding of the patient’s cultural and educational context;
low expectations
– 1/3 of patients did not take their controller medications because of their
health beliefs
– Inattention to cross-cultural communication and health beliefs
negatively affect asthma care and management
• More verbally dominant and engaged in less patient-centered
communication with black than with white patients
Asthma disparities in urban environments.
Bryant-Stephens T. J Allergy Clin Immunol
2009;123-1199-1206.
Solutions
Minimize or eliminating disparities
School-based asthma programs
• Can potentially improve:
– Health education focused on assisting
students to manage asthma, food allergy, and
other chronic diseases
– Access to care
– School personnel management skills
Advances in pediatric asthma in 2009:
Gaining control of childhood asthma. Szefler
SJ. J Allergy Clin Immunol 2010;125:69-78
Home-based asthma programs
• CALMA
– pilot program in Puerto Rico which exposed
parents to a culturally adapted family asthma
management intervention
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Resulted in 6.5% more symptom-free nights
3 times more likely to have their asthma under control
Less likely to visit the ED and be hospitalized
Caregivers less likely to feel helpless, frustrated, or
upset because of their child’s asthma and more likely to
feel confident to manage their child’s asthma
Reducing asthma health disparities in Puerto Rican children: the
effectiveness of a culturally tailored family intervention. J Allergy
Clin Immunol. 2008- Mar;121(3):665-70.Epub 2007 Dec 3
Home-based asthma programs
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Easy Breathing
– Program entry begins with the Easy Breathing Survey, which is completed by the
parent at a clinic visit regardless of the reason for the visit and includes 4 validated
questions to assist in diagnosing asthma.
– These 4 questions ask about asthma symptoms in the previous 12 months, nocturnal
cough, exercise-related symptoms, and the duration of a cough with colds.
– For children with asthma, the clinician completes the Provider Evaluation, a set of
questions to determine disease severity and control, and creates a severity-specific
asthma treatment plan
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The Provider Evaluation asks about the frequency of daytime and nocturnal symptoms,
restrictions to exercise, and use of oral steroids.
– A written asthma management plan is placed in the medical record
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Results:
– Hospitalizations rates were high and decreased 53% for black children and 33% for
Hispanic children after the intervention.
– ED visits decreased for Hispanic children
– Outpatient visits decreased for both black and Hispanic children
– ICS (inhaled corticosteroids) prescription rates increased with a subsequent decrease
in usage of bronchodilators for both black and Hispanic children
Effectiveness of an asthma management program in reducing
disparities in care in urban children. Ann Allergy Asthma
Immunol. 2008 Jun;100(6):545-50
Home-based asthma programs
• Parent Mentors
– Experienced parents of asthmatic children
received specialized training.
– Parent mentors met monthly with children and
families at community sites, phoned parents
monthly, and made home visits
– 10 asthma outcomes and costs were monitored
for 1 year
• Results:
– Children who underwent the intervention
experienced significantly reduced rapid-breathing
episodes, asthma exacerbations, and ED visits
Improving asthma outcomes in minority children: a
randomized, controlled trial of parent mentors. Pediatrics.
2009 Dec;124(6):1522-1532.
Community-based asthma program
• Homeless adults
– Offered transitional housing after hospital
discharged, followed by placement in longterm housing
– Case management offered on-site at primary
study sites, transitional housing and stable
housing sites
• Results:
– Fewer hospital days and ED visits compared
with usual care
Effect of a Housing and Case Management Program on
Emergency Department Visits and Hospitalizations Among
Chronically Ill Homeless Adults. A randomized trial.
JAMA.2009;301(17):1771-1778.
Community-based asthma
program
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The Philadelphia Allies Against Asthma coalition developed and
implemented the Child Asthma Link Line, a telephone-based care
coordination and system integration program, which has been in operation
since 2001.
Results. Link Line intervention children were significantly less likely to have
follow-up hospitalizations than matched sample children (p = .02). Children
enrolled in the Link Line were also more likely to attend outpatient office
visits in the follow-up year (p = .045). In addition, Link Line children with
multiple emergency department visits in 2003 were significantly less likely to
have an emergency department visit in 2004 (p = .046).
Conclusion. This coalition-developed, telephone-based, system-level
intervention had a significant impact on childhood asthma morbidity as
measured by utilization endpoints of follow-up hospitalizations and
emergency department visits. Telephone-based care coordination and
service integration may be a viable and economic way to impact childhood
asthma and other chronic diseases
The Child Asthma Link Line: a coalition-initiated, telephonebased, care coordination intervention for childhood asthma. J
Asthma. April 2010;47(3):303-309.
Provider Education
• Increase awareness of racial/ethnic disparities in
health care
• Increase the proportion of under-represented
minorities in the health care workforce
• Integrate cross-cultural education into the training
of all health care professionals
– Improve providers’ ability to understand,
communicate with, and care for patients from diverse
backgrounds different than their own
– Enhance providers’ awareness of socio-cultural
influences on patients’ health beliefs and behaviors
– Provide physicians with the skills to understand and
manage these factors in the medical encounter
Eliminating Racial and Ethnic Disparities in
Health Care: What is the role of academic
medicine? Acad Med. 2006;81:788-792
Additional Resources
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Alliance of Community Health Plans (ACHP)
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Allies Against Asthma (Allies)
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Sponsored by America’s Health Insurance Plans, Taking on Asthma is a national program to improve the
quality of care provided to people with asthma and enhance their quality of life. AHIP offers resources and
tools that may be useful to health insurance plans to improve the overall quality of asthma care.
Center for Health Care Strategies, Inc. (CHCS)
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Allies Against Asthma, a program of the Robert Woods Johnson Foundation, was a national initiative to
improve asthma control for children and adolescents. This site provides tools and resources that may be
useful to other asthma coalitions and programs addressing asthma.
American’s Health Insurance Plans (AHIP)
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This organization works with medical directors, quality improvement staff, and other health plan officials to
improve the health care system and the lives of people in the communities they serve. The site provides
background information about the intervention "Asthma Intervention for Inter-City Children."
This site provides information about the Improving Asthma Care for Children initiative to improve the
management of pediatric asthma in high-risk recipients of Medicaid and State Children's Health Insurance
Programs under managed care.
Communities in Action for Asthma-Friendly Environments Network
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EPA supports this network in partnership with Allies Against Asthma, a program of the Robert Wood
Johnson Foundation. It provides community-based asthma programs with a platform for real-time learning
that can drive ongoing improvement of asthma care.
References
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Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2008.
Tables 1, 2, 3, 4.
Asthma Data/Statistics. The Office of Minority Health. U.S. Dept of Health and
Human Services. Last updated 04/22/2010.
Are Physician Estimates of Asthma Severity Less Accurate in Black than in White
Patients? Okelo SO, Wu AW, Merriman B, Kirshnan JA, Diette GB. Society of
General Internal Medicine 2007;22:976-981.
Asthma and ethnic minorities: socioeconomic status and beyond. Forno E, Celedon
JC. Curr Opin Allergy Clin Immunol 9:154-160.
Asthma disparities in urban environments. Bryant-Stephens T. J Allergy Clin
Immunol 2009;123-1199-1206.
Race, ethnicity, and social class and the complex etiologies of asthma. Drake KA,
Galanter JM, Burchard EG. Pharmacogenomics. 2008 Apr;9(4):453-462
Genetics and asthma disease susceptibility in the US Latino population. Mt Sinai J Med.
2010 Mar;77(2):140-8.
Asthma and ethnic minorities: socioeconomic status and beyond. Forno E, Celedon JC.
Curr Opin Allergy Clin Immunol 9:154-160
References
•
•
•
•
•
•
•
Advances in pediatric asthma in 2009: Gaining control of childhood asthma. Szefler SJ. J
Allergy Clin Immunol 2010;125:69-78
Reducing asthma health disparities in Puerto Rican children: the effectiveness of a
culturally tailored family intervention. J Allergy Clin Immunol. 2008- Mar;121(3):66570.Epub 2007 Dec 3
Effectiveness of an asthma management program in reducing disparities in care in urban
children. Ann Allergy Asthma Immunol. 2008 Jun;100(6):545-50
Improving asthma outcomes in minority children: a randomized, controlled trial of parent
mentors. Pediatrics. 2009 Dec;124(6):1522-1532.
Effect of a Housing and Case Management Program on Emergency Department Visits and
Hospitalizations Among Chronically Ill Homeless Adults. A randomized trial.
JAMA.2009;301(17):1771-1778
Eliminating Racial and Ethnic Disparities in Health Care: What is the role of academic
medicine? Acad Med. 2006;81:788-792
The Child Asthma Link Line: a coalition-initiated, telephone-based, care coordination
intervention for childhood asthma. J Asthma. April 2010;47(3):303-309