Health DisparitiesAsthma

Fiona R. Prabhu, MD, Associate ProfessorDepartment of Family & Community Medicine

Texas Tech University Health Sciences CenterJune 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:

• 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 StatisticsMorbidity• Number of non-institutionalized adults who currently have asthma: 16.4

million – % of non-institutionalized adults who currently have asthma: 7.3%

• 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 non-Hispanic 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?

• 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. Bryant-Stephens 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

• 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

Genetics and asthma disease susceptibility in the US Latino population. Mt Sinai J Med. 2010 Mar;77(2):140-8.

Race, ethnicity, and social class and the complex etiologies of asthma. Drake KA, Galanter JM, Burchard EG. Pharmacogenomics. 2008 Apr;9(4):453-462

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– 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

• 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• 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

• 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 • 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 long-term 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 careEffect 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

• 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, telephone-based, 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• Alliance of Community Health Plans (ACHP)

– 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."

• Allies Against Asthma (Allies)– 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)– 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)– 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– 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• 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):665-70.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