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Asthma morbidity and treatment in the Chicago metropolitan area: one decade after national guidelines
Asthma morbidity and treatment in the Chicago metropolitan area: one decade after national guidelines Evalyn N. Grant, MD*; Anita Malone, MPH†; Christopher S. Lyttle, MA†; and Kevin B. Weiss, MD‡§
Background: A number of studies have demonstrated disproportionate hospitalization and mortality rates in US urban areas. Yet, no published population-based studies have examined the burden of asthma on the residents of a particular urban area known to be at high risk for poor asthma outcomes. Objectives: To examine asthma morbidity and medical care in a population-based sample of adults and children with asthma residing in the greater Chicago, IL, metropolitan area and to explore social and demographic influences on morbidity and treatment. Methods: A telephone survey of adults living in the Chicago metropolitan area was conducted from November 1999 through December 2000. Results: The final sample included 152 adults and children with active asthma. Emergency department visits and hospitalizations for asthma in the previous year were reported by 25.7% and 6.6% of respondents, respectively. Of current medication users, 32.2% reported current regular use of controller medications. After adjusting for age, sex, income, education, and reported current pharmacotherapy, compared with white individuals, African American individuals remained 6.3 times more likely to have experienced an emergency department visit and 12.3 times more likely to have been hospitalized. Conclusions: These findings suggest that poorly controlled asthma remains a prevalent problem for persons with asthma in this metropolitan area and that a large gap remains between the goals of asthma therapy and appropriate treatment as defined by the National Asthma Education and Prevention Program. The reasons for disparate treatment and health outcomes by race/ethnicity and income need further study and intervention. Ann Allergy Asthma Immunol. 2005;95:19–25.
INTRODUCTION Asthma is a serious chronic condition that affects more than 14 million US adults and children.1 Several studies have suggested that the burden of asthma falls disproportionately on low-income racial/ethnic minorities.2,3 A number of studies have also demonstrated disproportionate hospitalization and mortality rates in US urban areas.4 –7 Although it may be expected that asthma burden may be high in those communities, no published population-based studies have examined the burden of asthma on the residents of a particular urban area known to be at high risk for poor asthma outcomes. Studies of the burden of asthma need to be viewed with recognition of the fact that it has been nearly a decade since
the original publication of guidelines for the diagnosis and management of asthma by the National Education and Prevention Program (NAEPP) of the National Heart, Lung, and Blood Institute.8 In Chicago, IL, in addition to widespread dissemination of the guidelines, the past decade also witnessed a proliferation of community and regional efforts to improve the management of asthma.9 As part of the Chicago Asthma Surveillance Initiative,10 the purpose of this study was to examine asthma morbidity and key aspects of asthma care in a sample of adults and children with asthma who reside in the greater Chicago metropolitan area. A secondary aim was to explore social and demographic influences on morbidity and treatment.
* Department of Immunology and Microbiology, Rush-Presbyterian-St Luke’s Medical Center, Chicago, Illinois. † Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois. ‡ Midwest Center for Health Services and Policy Research, Hines Veterans Administration Hospital, Hines, Illinois. § Institute for Healthcare Studies and the Division of General Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Dr Grant is currently Respiratory National Scientific Director in the Academic Affairs Department at Merck & Co Inc. Before June 2001, during the design and implementation of this study, she was on the full-time faculty at Rush-Presbyterian-St Luke’s Medical Center in Chicago, IL. Received for publication December 26, 2003. Accepted for publication in revised form August 27, 2004.
METHODS Data Collection From November 1999 through December 2000, a random, list-assisted telephone survey of Chicago-area households was conducted. The study area included Cook County, Illinois, and the 5 surrounding collar counties (Lake, DuPage, McHenry, Kane, and Will counties). Interviews were conducted from a central telephone facility by trained and experienced study staff using a computer-assisted telephone interviewing (CATI) system (WinCati, Sawtooth Technologies Inc, Northbrook, IL) and a random sample of residential telephone numbers, which was purchased from a commercial
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vendor. The CATI system automated management of the sample list, the contact process, and data entry. Sample Adults (persons ⱖ18 years of age) who were English speaking and who were at home at the time of the call were eligible respondents for the study. To ensure that all household members had an equal chance of being included in the sample, the study subjects were randomly selected by asking the respondent to identify the individual in the household with the most recent birthday.11 In cases where the selected household member was an individual other than the respondent, the respondent served as a proxy to answer questions about the prevalence of wheezing and asthma. If the selected household member was either the respondent or a child of the respondent and was reported to have asthma, additional questions were asked regarding the burden of illness related to asthma, health care utilization for asthma, and specific aspects of asthma treatment. Data collection involved 2 phases: a general public survey and an oversample of persons with asthma. The general public survey, performed from June 1999 to May 2000, was an asthma awareness survey of the general public, with additional items about asthma morbidity and medical care placed at the end of the survey. To avoid introducing response bias, this survey was introduced to the potential respondent as a survey about health and health care. To obtain a larger sample of persons with asthma, additional interviews on a new sample were conducted between June 2000 and December 2000, in which the interview was introduced as a survey about asthma and households were screened for the presence of someone with asthma through responses to the question, “Do any of the individuals in your household have asthma?” If the answer to this question was no, the survey was terminated. Overall, 10,996 telephone numbers were used for attempted contact. Of these, 6,639 were found to be ineligible (business numbers, fax, unanswered, or nonworking numbers). Of the 4,357 individuals contacted, 2,439 (56.0%) agreed to participate. This report focuses on 152 study subjects, representing 6.2% of contacted individuals, who met the following criteria: (1) active asthma and (2) either the respondent or a child of the respondent. Instrument The survey items covered the following content areas: (1) sociodemographics, (2) recent asthma medication use, (3) health services utilization, and (4) selected aspects of the process of asthma care. Demographic variables included age, sex, race/ethnicity, education, and area of residence (ZIP code). Items related to asthma symptoms and morbidity were based on the 1999 National Health and Nutrition Examination Survey.12 Inhaled corticosteroid use was evaluated by a series of items beginning with, “Do you [Does (name)] use a corticosteroid inhaler, such as Aerobid, Azmacort, Beclovent, Flovent, Pulmicort. or Vanceril?” Subsequent questions eval-
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uated the frequency of use during the previous 2 weeks. Use of inhaled bronchodilators, cromolyn, and nedocromil was evaluated similarly. Statistical Analysis Descriptive statistics were used for indices of asthma morbidity and treatment. Where appropriate, tests of significance were performed using the 2 test. All analyses were conducted using computer software (SAS, version 8, SAS Institute Inc, Cary, NC). Multivariate analyses using logistic regression were performed to examine relationships between sociodemographic and treatment variables with asthma morbidity. Definitions Active asthma was defined by affirmative answers to each of the following questions: 1. Have you [has (name)] ever had asthma? 2. Was it diagnosed by a doctor? AND an affirmative response to at least 1 of the following 2 items: 1. Have you [has (name)] had asthma symptoms, such as coughing or wheezing, in the past 12 months? 2. Have you [has (name)] taken medication for asthma in the past 12 months? We considered respondents to be current regular users of bronchodilators if they reported using an inhaled bronchodilator (either metered-dose inhaler or nebulized) at least 3 days per week during the previous 2 weeks. Regular use of controllers was defined as use of inhaled corticosteroid, cromolyn, or nedocromil at least 3 days per week during the previous 2 weeks. We did not include leukotriene antagonists, theophylline, and long-acting -agonists in the definition of controllers, because at the beginning of the study period, these medications were used infrequently. Respondents were not asked to report their income. Instead, respondents were dichotomized into low- and high-income categories based on median income in their area of residence based on the 2000 census.13 Those residing in ZIP codes with a median income of 200% or higher than the federal poverty threshold were classified as high income. The protocol qualified for exempt status from institutional review board review at Rush-Presbyterian-St Luke’s Medical Center because it was minimal risk, was limited to a survey, and had no recorded subject identifiers. RESULTS This study reports on the 152 persons with active asthma who were either self-reporting or responding as a proxy for their child. Of these, 45.0% were children, 61.8% were female, and 72.5% were white (Table 1). Asthma Morbidity Measures of morbidity are given in Table 2. Approximately one third of the respondents reported 1 to 3 wheezing attacks, and 49% experienced 4 or more attacks in the past 12 months. Nineteen percent reported sleep disturbance more than once
ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
Table 1. Sociodemographic Characteristics of Chicago-Area Persons With Active Asthma (n ⫽ 152)* Characteristics Age range, y 0–17 18–34 35–64 ⱖ65 Sex Male Female Race/ethnicity African American White Hispanic/Latino Other Individual household education High school or less Some college or more Community household income, $ ⬍29,000 29,001–39,000 ⬎39,000
Persons with asthma, % 45.0 17.2 31.8 6.0 38.2 61.8 20.4 72.5 4.2 2.8 23.8 76.2 31.4 35.0 33.6
*Response rates for individual items were greater than 90% unless otherwise noted.
per week. Wheezing severe enough to limit speech was reported by 44.7% of respondents. In total, 61.2% of respondents reported some degree of activity limitation due to asthma. Ten percent of respondents reported having missed 8 or more days of work or school, and 19.2% had 8 or more days in which they were unable to perform their usual activities. Emergency department visits and hospitalizations for asthma in the previous year were reported by 25.7% and 6.6% of respondents, respectively. Bivariate analyses that examined the relationship between asthma morbidity variables and sociodemographic characteristics are given in Table 3. Compared with males, females reported greater degrees of activity limitation and more days of being unable to perform activities, but these numerical differences did not reach statistical significance. Females were less likely than males to report being hospitalized for asthma in the previous 12 months (12.1% vs 3.2%, P ⫽ .03). Several differences emerged for age, with adult respondents reporting more frequent attacks; 57.3% reported 4 or more attacks compared with 38.2% of children younger than 18 years (P ⫽ .02). Adults were more likely than children to report experiencing severe wheezing (56.5% vs 31.7%, P ⫽ .006), but children were more likely to have missed work or school for more than 7 days (16.2% vs 4.9%; P ⫽ .02), to have visited an emergency department for asthma (39.7% vs 14.5%; P ⬍ .001), and to have been hospitalized (11.8% vs 2.4%; P ⫽ .02). Compared with African American individuals, white individuals were more likely to report more frequent attacks;
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Table 2. Morbidity Reported for the Last 12 Months by ChicagoArea Persons With Active Asthma (n ⫽ 152)* Morbidity No. of wheezing attacks 0 1–3 4–12 ⬎12 How often sleep disturbed due to wheezing Never One time or less per week More than once per week Wheezing severe enough to limit speech Limitation of usual activities due to asthma Not at all A little A fair amount A lot Days unable to perform usual activities 0 1–7 ⱖ8 Days of work or school missed 0 1–7 ⱖ8 Emergency department visit for asthma Admitted to hospital for asthma
Persons with asthma, % 17.2 33.7 31.1 17.9 41.3 39.7 19.0 44.7 38.8 39.5 14.5 7.2 47.7 33.1 19.2 57.3 32.7 10.0 25.7 6.6
*Response rates for individual items were greater than 90% unless otherwise noted.
57.3% vs 32.1% reported 4 or more attacks per year (P ⫽ .01). Yet African American individuals were more likely than white individuals to have visited an emergency department for asthma (44.8% vs 16.5%; P ⫽ .001) and more likely to have been hospitalized (17.2% vs 1.9%; P ⫽ .001). Median community household income was inversely related to emergency department visits, which were reported by 36.1% in low-income communities compared with 16.2% in high-income communities (P ⫽ .008), and hospitalizations, reported by 11.1% of persons in low-income communities compared with 2.9% in high-income communities (P ⫽ .06). No differences occurred in any of the morbidity variables when examined according the respondents’ educational level. A multivariate analysis was performed to further explore the racial/ethnic differences in morbidity, in particular emergency department visits and hospitalizations. The results of a multiple regression analysis showed that when controlled for sex, age, income, and pharmacotherapy, African American race/ethnicity remained a significant predictor of emergency department visits (odds ratio [OR], 6.3; 95% confidence interval [CI], 2.0 –20.0). For hospitalizations, African American race/ethnicity (OR, 12.3; 95% CI, 2.2–70.0) and regular bronchodilator use (OR, 3.3; 95% CI, 1.2–9.5) were independent predictors of risk.
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Table 3. Percentage of Patients According to Self-reported Aspects of Asthma Morbidity by Sex, Age, Race, Household Income, and Household Education Among Chicago-Area Persons With Active Asthma (n ⫽ 152)* Sex
Age, y
Household income‡
Race†
Household education
Asthma morbidity
Four or more attacks Disturbed sleep more than once per week Severe wheezing Activity limitation (fair amount or a lot) Unable to perform activities more than once per week More than 1 day of missed work or school per week Emergency department visits last 12 months Hospitalized last 12 months
M
F
<17
>18
White
African American
Low
High
High school or less
Some college or more
53.5 30.9 31.6 13.8 12.1
46.2 34.8 40.2 26.6 23.7
38.2 22.7 28.4 19.1 20.9
57.3§ 41.3§ 43.0 24.1 16.9
57.3 29.7 39.2 19.4 18.6
32.1¶ 38.5 44.4 31.0 20.7
47.9 37.3 37.1 25.0 22.5
45.6 29.4 34.3 16.2 16.2
41.7 38.2 37.1 19.4 22.2
50.9 32.1 37.2 22.6 18.4
14.0
7.5
16.2
4.9§
10.8
7.1
11.3
9.0
8.6
10.5
29.3 12.1
23.4 3.2§
39.7 14.5储 11.8 2.4§
16.5 1.9
44.8储 17.2储
36.1 11.1
16.2¶ 2.9
33.3 8.3
23.5 6.1
*Response rates for individual items are greater than 90% unless otherwise noted. †n ⫽ 132, after excluding Hispanic/Latino and cases with incomplete race/ethnicity data. ‡Based on above or below the 200% poverty level ($35,206). §P ⱕ .05. ¶P ⱕ .01. 储P ⱕ .001.
Process of Asthma Care and Controller Use The analysis of patterns of medication use was restricted to those currently taking medications and having complete pharmacotherapy data (n ⫽ 115). Of these, 42 (36.5%) reported current (past 2 weeks) regular use of inhaled bronchodilators, and 37 (32.2%) reported current use of controller medications. The most common pattern of current use was low or no use of both medication classes (55.7%). Current regular use of both medications was reported by 24.4% of respondents. The pattern most clearly considered to be suboptimal therapy (high bronchodilator, low controller) was reported by 12.2% of respondents, and regular inhaled corticosteroid use with low or no use of bronchodilator was reported by 7.8% of respondents. The items about care processes were only asked of respondents who reported having received care from a regular source in the past year. Therefore, the analyses that explored the relationship among care processes, pharmacotherapy, and morbidity were restricted to individuals who reported having received care from a regular source in the past year (n ⫽ 75). Reported processes of care among those who received asthma care in the past year are shown in Figure 1. Nearly all (94.7%) reported that their physician had inquired about asthma symptoms, and 82.0% reported that they received instruction in inhaler technique. Only 44.6% reported having a written treatment plan, 41.9% reported that home peak flow monitoring had been recommended to them, and 34.4% had received formal asthma education. Process of care variables had no consistent relationship to asthma morbidity (not shown), but a relationship was noted between several processes of care variables and sociodemographic characteristics (Table 4). Age was related to having
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Figure 1. Processes of care reported by Chicago-area persons with active asthma (n ⫽ 75). Process of care items were asked only of persons who reported having a physician, office, or clinic who/that they regularly go to for medical treatment of asthma and persons who have been to this physician, office, or clinic at least once in the last 12 months.
received instruction in inhaler technique, with 96.4% of adults and 75.6% of children reporting having received instruction. Compared with white individuals, a smaller proportion of African Americans individuals reported having received inhaler instruction (70.6% vs 95.5%; P ⫽ .006), and a larger proportion reported a suboptimal pharmacotherapy pattern (40.0% vs 6.8%; P ⫽ .002). Low community household income was associated with lower rates of inhaler technique instruction (71.1% vs 93.3%; P ⫽ .02) and an increased likelihood of suboptimal pharmacotherapy (27.0% vs 3.5%; P ⫽ .01) compared with respondents who lived in communities of higher income. Persons with higher educational levels were more likely than those with less education to have a written treatment plan (50.9%
ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
Table 4. Percentage of Patients According to Care Practices by Sex, Age, Race, Household Income, and Household Education Reported by Chicago-Area Persons With Active Asthma (n ⫽ 75)* Sex
Age, y
Race†
Care process
Peak flow in office Home peak flow recommended Physician asked about symptoms Physician asked about activity limitation Written treatment plan Received formal asthma education Received instruction in inhaler technique Pharmacotherapy possibly suboptimal
M
F
73.9 52.0 96.2 80.8 46.2 31.8 84.6
65.2 36.7 93.9 67.4 43.8 35.7 81.3
<17
>18
68.3 67.9 40.9 44.8 93.8 100 77.8 65.4 44.4 46.4 26.5 44.8 75.6 96.4§
12.0 17.0 19.1
6.9
White
Household income‡
Household education
African <200% > 200% High school Some college American Poverty Poverty or less or more
67.4 40.9 97.7 71.4 47.7 41.0 95.5
81.3 58.8 88.9 76.5 41.2 25.0 70.6¶
67.6 41.0 92.3 64.9 36.8 31.3 71.1
73.1 44.8 96.7 80.0 50.0 30.8 93.3§
62.5 38.9 94.4 47.1 23.5 18.8 72.2
69.8 42.9 94.7 80.0¶ 50.9§ 39.6 85.7
6.8
40.0¶
27.0
3.5¶
29.4
10.9
*Items were limited to persons with physician, office, or clinic who/that they regularly go to for medical treatment for asthma and persons who have been to this physician, office, or clinic at least once in the last 12 months. Response rates for individual items are greater than 90% unless otherwise noted. †n ⫽ 132, after excluding Hispanic/Latino and cases with incomplete race/ethnicity data. ‡Based on above or below 200% poverty level ($35,206). §P ⱕ .05. ¶P ⱕ .01.
vs 23.5%; P ⫽ .05) and to report that their physician had asked about activity limitation (80.0% vs 47.1%; P ⫽ .008). The relationship between sociodemographic features and these 2 key care processes (inhaler instruction and suboptimal pharmacotherapy) were explored further in a multivariate analysis. Multiple linear regression analysis examined the contribution of sex, age, race, income, and education. Results for inhaler technique instruction showed that none of these variables were independently predictive. For suboptimal pharmacotherapy, the results showed that only community household income remained significant (OR, 7.0; 95% CI, 1.4 –34.4). Suboptimal pharmacotherapy was not predictive of any of the morbidity variables after correction for sociodemographic variables. DISCUSSION In this study of Chicago-area adults and children with asthma, a substantial burden of asthma morbidity was seen, which appears to underlie the problem of asthma mortality in this community. Furthermore, this study showed a large gap between the goals of asthma therapy and appropriate treatment as defined by the NAEPP. For example, the NAEPP goals of therapy specify no missed work or school due to asthma, but in this study, a substantial proportion of persons with asthma reported missed work or school in the past year. Many persons reported wheezing-related sleep disturbance at a frequency of more than once per week and treatment in an emergency department for asthma in the previous year. These findings suggest that poorly controlled asthma remains a prevalent problem for persons with asthma in this metropolitan area. These findings are particularly concerning in the context of the broad array of asthma care improvement efforts that
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began in the Chicago area in 1995. At that time, the disproportionately high rates of asthma morbidity and mortality attracted the attention of the medical care community, as well as several private foundations, most notably the Otho S. A. Sprague Memorial Institute. The result was the creation in 1996 of the Chicago Asthma Consortium and the initiation of a diverse group of asthma improvement projects that involve peer education, surveillance, physician education, school programs, and others.14 Several studies based in health care settings or systems have documented a discrepancy between the goals of therapy identified by the NAEPP and the level of control achieved by asthma patients.15–17 Few studies have examined asthma morbidity and care in general population-based samples. Recently, results from a national population survey conducted in 1998 suggested inadequate use of anti-inflammatory medications by persons with active asthma.18 Few studies to date have explored how well the goals of therapy are being met by examining morbidity and treatment as experienced by the population of a high-risk community. A notable but perhaps not surprising finding of this study was the relationship of race/ethnicity, age, and sex to several key aspects of morbidity. The study showed that after adjusting for age, sex, income, education, and pharmacotherapy, compared with white individuals, African American individuals remained 6.3 times more likely to have experienced an emergency department visit and 12.3 times more likely to have been hospitalized. Racial/ethnic disparities in asthma hospitalizations were first reported in several studies published in the late 1980s to early 1990s.3,4,19 The current study suggests that these disparities have persisted during the past decade, despite intense broad-based institutional focus on asthma care improvement
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in Chicago. Additionally, because this was a populationbased study of persons with asthma, the findings of this study suggest that previously noted racial/ethnic differences in hospital and emergency department utilization5,20 are not likely due to differences in asthma prevalence alone. This study also suggests room for improvement in several key processes of care, such as the use of written treatment plans and formal asthma education. Although there were few significant age, race, or sex differences in most aspects of care studied, a notable finding emerged for pharmacotherapy. African American individuals and individuals residing in low-income areas were less likely to have received instruction in inhaler technique and to use an NAEPP-recommended medication regimen, suggesting that these aspects of medical care may be important causes of the disparate morbidity seen in this study. Differences in instruction in inhaler technique may represent one aspect of the quality of the clinical encounter that may underlie health disparities.21 These findings about racial/ethnic differences in asthma care are consistent with findings from recent studies of patients enrolled in managed care organizations, showing that even among insured populations, African American individuals were less likely to receive inhaled corticosteroids and to obtain care consistent with guidelines.21–24 As with all studies, a number of limitations deserve highlighting. All information was obtained by self-report, and many of the items used in the survey have not been formally validated. Also, the modest response rate, increasingly problematic in telephone surveys, may somewhat limit our ability to generalize these findings to or beyond the Chicago-area population at large. Yet this response rate does not compromise the study’s internal validity in terms of examining differences in asthma care and outcomes. Because we did not collect information about health insurance, we cannot evaluate the effect of access to health care on the social demographic disparities identified. The survey did not collect information about environmental exposures, such as tobacco smoke, making it impossible to comment on the relationship of smoking and its impact on asthma. Finally, as with all cross-sectional studies, we cannot make inferences about causality between aspects of asthma treatment and morbidity. Specifically, because we could not adequately evaluate and control for severity in such a cross-sectional design, we were limited in our ability to examine relationships between the process of care variables and asthma morbidity. Alternatively, one of the key strengths of this study is community-based sampling designs; nearly all published reports of factors that contribute to differences in asthma care and morbidity have been conducted in clinic-, hospital-, or health plan– based samples. Studies in population-based samples such as this can help to better characterize the burden of poorly controlled asthma among the public. The findings have several implications. First, serious concern remains about the quality of asthma care and the effect of poorly controlled asthma on this community. Second, the reasons for disparate health outcomes by race/ethnicity and
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income need further study. For example, little is known about appropriate strategies for cultural adaptation of educational programs and about the effect of social or cultural differences in health care seeking behavior. Recent evidence suggests that in some cases health care practitioner prejudice or bias may influence treatment.25,26 Nearly 10 years after national guidelines first advocated for the use of controller medications, our findings suggest that increasing the use of controller medications remains an important issue for persons with asthma in Chicago and, more broadly, that we have a long distance to go to achieve the goals of the NAEPP in this high-risk urban community. ACKNOWLEDGMENTS The Chicago Asthma Surveillance Initiative was funded by the Otho S. A. Sprague Memorial Institute. We thank the following individuals for their contribution to this project: Rob Sprengel for his supervision of the telephone interview process and Pearl Burks, Mary Marre, David Novy, and Nada Smith for their work in conducting telephone interviews. REFERENCES 1. Mannino DM, Homa DM, Akinbami LJ, Moorman JE, Gwynn C, Redd SC. Surveillance for asthma—United States, 1980 –1999. MMWR Surveill Summ. 2002;51(No. SS-1):1–13. 2. Gergen PJ, Weiss KB. Changing patterns of asthma hospitalization among children: 1979 to 1987. JAMA. 1990;264: 1688 –1692. 3. Wissow L, Gittelsohn AM, Szklo M, Starfield B, Mussman M. Poverty, race and hospitalization for childhood asthma. Am J Public Health. 1988;78:777–782. 4. Carr W, Zeitel L, Weiss KB. Variations in asthma hospitalizations and deaths in New York City. Am J Public Health. 1992;82:59 – 65. 5. Marder D, Targonski P, Orris P, Persky V, Addington W. Effect of racial and socioeconomic factors on asthma mortality in Chicago. Chest. 1992;101:426S– 429S. 6. Weiss KB, Wagener DK. Changing patterns of asthma mortality: identifying target populations at high risk. JAMA. 1990;264:1683–1687. 7. Lang DM, Polansky M. Patterns of asthma mortality in Philadelphia from 1969 –1991. N Engl J Med. 1994;331:1542–1546. 8. National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health; 1991. Publication 91-3642. 9. Addington WW, Weiss KB. Chicago’s response to the public health challenge of urban asthma. Chest. 1999;116:132S–134S. 10. Weiss KB, Grant EN. The Chicago Asthma Surveillance Initiative: a community-based approach to understanding asthma care. Chest. 1999;116:141S–145S. 11. Aday LA. Designing and Conducting Health Surveys. San Francisco, CA: Jossey-Bass Inc Publishers; 1989. 12. National Health and Nutrition Examination Survey. Available at: http://www.cdc.gov/nchs/nhanes.htm. Accessibility confirmed October 11, 2003. 13. PCensus-USA United States-STF3A Data. 1990 Census of Population and Housing. 14. Alexander JN. Preface: civic support and leadership as a cata-
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lyst for addressing the problem of urban asthma: The Otho S.A. Sprague Memorial Institute’s Asthma Initiative. Chest. 1999; 116:129S–130S. Diette GB, Skinner EA, Markson LE, et al. Consistency of care with national guidelines for children with asthma in managed care. J Pediatr. 2001;138:59 – 64. Hartert TV, Windom HH, Peebles RS Jr, Fiedhoff LR, Togias A. Inadeaquate outpatient medical therapy for patients with asthma admitted to two urban hospitals. Am J Med. 1996;100: 386 –394. Friday GA Jr, Khine HJ, Lin MS, Calaguiri LA. Profile of children requiring emergency treatment for asthma. Ann Allergy Asthma Immunol. 1997;78:221–224. Adams RJ, Fuhlbrigge A, Guilbert T, Lozano P, Martinez F. Inadequate use of asthma medication in the United States: results of the Asthma in America national population survey. J Allergy Clin Immunol. 2002;110:58 – 64. Targonski PV, Persky VW, Orris P, Addington W. Trends in asthma mortality among African Americans and whites in Chicago, 1968 –1991. Am J Public Health. 1994;84:1830 –1833. Thomas SD, Whitman S. Asthma hospitalizations and mortality in Chicago: an epidemiologic overview. Chest. 1999;116: 135S–141S. Assessing potential sources of racial and ethnic disparities in care: the clinical encounter. In: Smedley, BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: Institute of Medicine, National Academy Press; 2002:127–141.
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22. Krishnan JA, Diette G, Skinner EA, Clark BD, Steinwachs D, Wu AW. Race and sex differences in consistency of care with national asthma guidelines in managed care organizations. Arch Intern Med. 2001;161:1660 –1668. 23. Zoratti EM, Havstad S, Rodriguez J, Robens-Paradise Y, Lafata J, McCarthy B. Health service use by African Americans and Caucasians with asthma in a managed care setting. Am J Respir Crit Care Med. 1998;158:371–377. 24. Finkelstein JA, Lozano P, Farber HJ, Miroshnik I, Lieu TA. Underuse of controller medications among Medicaid-insured children with asthma. Arch Pediatr Adolesc Med. 2002;156: 562–567. 25. van Ryn M, Burke J. The effect of patient race and socioeconomic status on physician’s perceptions of patients. Soc Sci Med. 2000;50:813– 828. 26. Weisse CS, Sorum PC, Sanders KN, Syat BL. Do gender and race affect decisions about pain management? J Gen Intern Med. 2001;16:211–217.
Requests for reprints should be addressed to: Kevin Weiss, MD Institute for Healthcare Studies 676 N. St. Clair St. Suite 200 Chicago, IL 60611 E-mail: [email protected]
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Background: A number of studies have demonstrated disproportionate hospitalization and mortality rates in US urban areas. Yet, no published population-based studies have examined the burden of asthma on the residents of a particular urban area known to be at high risk for poor asthma outcomes. Objectives: To examine asthma morbidity and medical care in a population-based sample of adults and children with asthma residing in the greater Chicago, IL, metropolitan area and to explore social and demographic influences on morbidity and treatment. Methods: A telephone survey of adults living in the Chicago metropolitan area was conducted from November 1999 through December 2000. Results: The final sample included 152 adults and children with active asthma. Emergency department visits and hospitalizations for asthma in the previous year were reported by 25.7% and 6.6% of respondents, respectively. Of current medication users, 32.2% reported current regular use of controller medications. After adjusting for age, sex, income, education, and reported current pharmacotherapy, compared with white individuals, African American individuals remained 6.3 times more likely to have experienced an emergency department visit and 12.3 times more likely to have been hospitalized. Conclusions: These findings suggest that poorly controlled asthma remains a prevalent problem for persons with asthma in this metropolitan area and that a large gap remains between the goals of asthma therapy and appropriate treatment as defined by the National Asthma Education and Prevention Program. The reasons for disparate treatment and health outcomes by race/ethnicity and income need further study and intervention. Ann Allergy Asthma Immunol. 2005;95:19–25.
INTRODUCTION Asthma is a serious chronic condition that affects more than 14 million US adults and children.1 Several studies have suggested that the burden of asthma falls disproportionately on low-income racial/ethnic minorities.2,3 A number of studies have also demonstrated disproportionate hospitalization and mortality rates in US urban areas.4 –7 Although it may be expected that asthma burden may be high in those communities, no published population-based studies have examined the burden of asthma on the residents of a particular urban area known to be at high risk for poor asthma outcomes. Studies of the burden of asthma need to be viewed with recognition of the fact that it has been nearly a decade since
the original publication of guidelines for the diagnosis and management of asthma by the National Education and Prevention Program (NAEPP) of the National Heart, Lung, and Blood Institute.8 In Chicago, IL, in addition to widespread dissemination of the guidelines, the past decade also witnessed a proliferation of community and regional efforts to improve the management of asthma.9 As part of the Chicago Asthma Surveillance Initiative,10 the purpose of this study was to examine asthma morbidity and key aspects of asthma care in a sample of adults and children with asthma who reside in the greater Chicago metropolitan area. A secondary aim was to explore social and demographic influences on morbidity and treatment.
* Department of Immunology and Microbiology, Rush-Presbyterian-St Luke’s Medical Center, Chicago, Illinois. † Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois. ‡ Midwest Center for Health Services and Policy Research, Hines Veterans Administration Hospital, Hines, Illinois. § Institute for Healthcare Studies and the Division of General Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Dr Grant is currently Respiratory National Scientific Director in the Academic Affairs Department at Merck & Co Inc. Before June 2001, during the design and implementation of this study, she was on the full-time faculty at Rush-Presbyterian-St Luke’s Medical Center in Chicago, IL. Received for publication December 26, 2003. Accepted for publication in revised form August 27, 2004.
METHODS Data Collection From November 1999 through December 2000, a random, list-assisted telephone survey of Chicago-area households was conducted. The study area included Cook County, Illinois, and the 5 surrounding collar counties (Lake, DuPage, McHenry, Kane, and Will counties). Interviews were conducted from a central telephone facility by trained and experienced study staff using a computer-assisted telephone interviewing (CATI) system (WinCati, Sawtooth Technologies Inc, Northbrook, IL) and a random sample of residential telephone numbers, which was purchased from a commercial
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vendor. The CATI system automated management of the sample list, the contact process, and data entry. Sample Adults (persons ⱖ18 years of age) who were English speaking and who were at home at the time of the call were eligible respondents for the study. To ensure that all household members had an equal chance of being included in the sample, the study subjects were randomly selected by asking the respondent to identify the individual in the household with the most recent birthday.11 In cases where the selected household member was an individual other than the respondent, the respondent served as a proxy to answer questions about the prevalence of wheezing and asthma. If the selected household member was either the respondent or a child of the respondent and was reported to have asthma, additional questions were asked regarding the burden of illness related to asthma, health care utilization for asthma, and specific aspects of asthma treatment. Data collection involved 2 phases: a general public survey and an oversample of persons with asthma. The general public survey, performed from June 1999 to May 2000, was an asthma awareness survey of the general public, with additional items about asthma morbidity and medical care placed at the end of the survey. To avoid introducing response bias, this survey was introduced to the potential respondent as a survey about health and health care. To obtain a larger sample of persons with asthma, additional interviews on a new sample were conducted between June 2000 and December 2000, in which the interview was introduced as a survey about asthma and households were screened for the presence of someone with asthma through responses to the question, “Do any of the individuals in your household have asthma?” If the answer to this question was no, the survey was terminated. Overall, 10,996 telephone numbers were used for attempted contact. Of these, 6,639 were found to be ineligible (business numbers, fax, unanswered, or nonworking numbers). Of the 4,357 individuals contacted, 2,439 (56.0%) agreed to participate. This report focuses on 152 study subjects, representing 6.2% of contacted individuals, who met the following criteria: (1) active asthma and (2) either the respondent or a child of the respondent. Instrument The survey items covered the following content areas: (1) sociodemographics, (2) recent asthma medication use, (3) health services utilization, and (4) selected aspects of the process of asthma care. Demographic variables included age, sex, race/ethnicity, education, and area of residence (ZIP code). Items related to asthma symptoms and morbidity were based on the 1999 National Health and Nutrition Examination Survey.12 Inhaled corticosteroid use was evaluated by a series of items beginning with, “Do you [Does (name)] use a corticosteroid inhaler, such as Aerobid, Azmacort, Beclovent, Flovent, Pulmicort. or Vanceril?” Subsequent questions eval-
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uated the frequency of use during the previous 2 weeks. Use of inhaled bronchodilators, cromolyn, and nedocromil was evaluated similarly. Statistical Analysis Descriptive statistics were used for indices of asthma morbidity and treatment. Where appropriate, tests of significance were performed using the 2 test. All analyses were conducted using computer software (SAS, version 8, SAS Institute Inc, Cary, NC). Multivariate analyses using logistic regression were performed to examine relationships between sociodemographic and treatment variables with asthma morbidity. Definitions Active asthma was defined by affirmative answers to each of the following questions: 1. Have you [has (name)] ever had asthma? 2. Was it diagnosed by a doctor? AND an affirmative response to at least 1 of the following 2 items: 1. Have you [has (name)] had asthma symptoms, such as coughing or wheezing, in the past 12 months? 2. Have you [has (name)] taken medication for asthma in the past 12 months? We considered respondents to be current regular users of bronchodilators if they reported using an inhaled bronchodilator (either metered-dose inhaler or nebulized) at least 3 days per week during the previous 2 weeks. Regular use of controllers was defined as use of inhaled corticosteroid, cromolyn, or nedocromil at least 3 days per week during the previous 2 weeks. We did not include leukotriene antagonists, theophylline, and long-acting -agonists in the definition of controllers, because at the beginning of the study period, these medications were used infrequently. Respondents were not asked to report their income. Instead, respondents were dichotomized into low- and high-income categories based on median income in their area of residence based on the 2000 census.13 Those residing in ZIP codes with a median income of 200% or higher than the federal poverty threshold were classified as high income. The protocol qualified for exempt status from institutional review board review at Rush-Presbyterian-St Luke’s Medical Center because it was minimal risk, was limited to a survey, and had no recorded subject identifiers. RESULTS This study reports on the 152 persons with active asthma who were either self-reporting or responding as a proxy for their child. Of these, 45.0% were children, 61.8% were female, and 72.5% were white (Table 1). Asthma Morbidity Measures of morbidity are given in Table 2. Approximately one third of the respondents reported 1 to 3 wheezing attacks, and 49% experienced 4 or more attacks in the past 12 months. Nineteen percent reported sleep disturbance more than once
ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
Table 1. Sociodemographic Characteristics of Chicago-Area Persons With Active Asthma (n ⫽ 152)* Characteristics Age range, y 0–17 18–34 35–64 ⱖ65 Sex Male Female Race/ethnicity African American White Hispanic/Latino Other Individual household education High school or less Some college or more Community household income, $ ⬍29,000 29,001–39,000 ⬎39,000
Persons with asthma, % 45.0 17.2 31.8 6.0 38.2 61.8 20.4 72.5 4.2 2.8 23.8 76.2 31.4 35.0 33.6
*Response rates for individual items were greater than 90% unless otherwise noted.
per week. Wheezing severe enough to limit speech was reported by 44.7% of respondents. In total, 61.2% of respondents reported some degree of activity limitation due to asthma. Ten percent of respondents reported having missed 8 or more days of work or school, and 19.2% had 8 or more days in which they were unable to perform their usual activities. Emergency department visits and hospitalizations for asthma in the previous year were reported by 25.7% and 6.6% of respondents, respectively. Bivariate analyses that examined the relationship between asthma morbidity variables and sociodemographic characteristics are given in Table 3. Compared with males, females reported greater degrees of activity limitation and more days of being unable to perform activities, but these numerical differences did not reach statistical significance. Females were less likely than males to report being hospitalized for asthma in the previous 12 months (12.1% vs 3.2%, P ⫽ .03). Several differences emerged for age, with adult respondents reporting more frequent attacks; 57.3% reported 4 or more attacks compared with 38.2% of children younger than 18 years (P ⫽ .02). Adults were more likely than children to report experiencing severe wheezing (56.5% vs 31.7%, P ⫽ .006), but children were more likely to have missed work or school for more than 7 days (16.2% vs 4.9%; P ⫽ .02), to have visited an emergency department for asthma (39.7% vs 14.5%; P ⬍ .001), and to have been hospitalized (11.8% vs 2.4%; P ⫽ .02). Compared with African American individuals, white individuals were more likely to report more frequent attacks;
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Table 2. Morbidity Reported for the Last 12 Months by ChicagoArea Persons With Active Asthma (n ⫽ 152)* Morbidity No. of wheezing attacks 0 1–3 4–12 ⬎12 How often sleep disturbed due to wheezing Never One time or less per week More than once per week Wheezing severe enough to limit speech Limitation of usual activities due to asthma Not at all A little A fair amount A lot Days unable to perform usual activities 0 1–7 ⱖ8 Days of work or school missed 0 1–7 ⱖ8 Emergency department visit for asthma Admitted to hospital for asthma
Persons with asthma, % 17.2 33.7 31.1 17.9 41.3 39.7 19.0 44.7 38.8 39.5 14.5 7.2 47.7 33.1 19.2 57.3 32.7 10.0 25.7 6.6
*Response rates for individual items were greater than 90% unless otherwise noted.
57.3% vs 32.1% reported 4 or more attacks per year (P ⫽ .01). Yet African American individuals were more likely than white individuals to have visited an emergency department for asthma (44.8% vs 16.5%; P ⫽ .001) and more likely to have been hospitalized (17.2% vs 1.9%; P ⫽ .001). Median community household income was inversely related to emergency department visits, which were reported by 36.1% in low-income communities compared with 16.2% in high-income communities (P ⫽ .008), and hospitalizations, reported by 11.1% of persons in low-income communities compared with 2.9% in high-income communities (P ⫽ .06). No differences occurred in any of the morbidity variables when examined according the respondents’ educational level. A multivariate analysis was performed to further explore the racial/ethnic differences in morbidity, in particular emergency department visits and hospitalizations. The results of a multiple regression analysis showed that when controlled for sex, age, income, and pharmacotherapy, African American race/ethnicity remained a significant predictor of emergency department visits (odds ratio [OR], 6.3; 95% confidence interval [CI], 2.0 –20.0). For hospitalizations, African American race/ethnicity (OR, 12.3; 95% CI, 2.2–70.0) and regular bronchodilator use (OR, 3.3; 95% CI, 1.2–9.5) were independent predictors of risk.
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Table 3. Percentage of Patients According to Self-reported Aspects of Asthma Morbidity by Sex, Age, Race, Household Income, and Household Education Among Chicago-Area Persons With Active Asthma (n ⫽ 152)* Sex
Age, y
Household income‡
Race†
Household education
Asthma morbidity
Four or more attacks Disturbed sleep more than once per week Severe wheezing Activity limitation (fair amount or a lot) Unable to perform activities more than once per week More than 1 day of missed work or school per week Emergency department visits last 12 months Hospitalized last 12 months
M
F
<17
>18
White
African American
Low
High
High school or less
Some college or more
53.5 30.9 31.6 13.8 12.1
46.2 34.8 40.2 26.6 23.7
38.2 22.7 28.4 19.1 20.9
57.3§ 41.3§ 43.0 24.1 16.9
57.3 29.7 39.2 19.4 18.6
32.1¶ 38.5 44.4 31.0 20.7
47.9 37.3 37.1 25.0 22.5
45.6 29.4 34.3 16.2 16.2
41.7 38.2 37.1 19.4 22.2
50.9 32.1 37.2 22.6 18.4
14.0
7.5
16.2
4.9§
10.8
7.1
11.3
9.0
8.6
10.5
29.3 12.1
23.4 3.2§
39.7 14.5储 11.8 2.4§
16.5 1.9
44.8储 17.2储
36.1 11.1
16.2¶ 2.9
33.3 8.3
23.5 6.1
*Response rates for individual items are greater than 90% unless otherwise noted. †n ⫽ 132, after excluding Hispanic/Latino and cases with incomplete race/ethnicity data. ‡Based on above or below the 200% poverty level ($35,206). §P ⱕ .05. ¶P ⱕ .01. 储P ⱕ .001.
Process of Asthma Care and Controller Use The analysis of patterns of medication use was restricted to those currently taking medications and having complete pharmacotherapy data (n ⫽ 115). Of these, 42 (36.5%) reported current (past 2 weeks) regular use of inhaled bronchodilators, and 37 (32.2%) reported current use of controller medications. The most common pattern of current use was low or no use of both medication classes (55.7%). Current regular use of both medications was reported by 24.4% of respondents. The pattern most clearly considered to be suboptimal therapy (high bronchodilator, low controller) was reported by 12.2% of respondents, and regular inhaled corticosteroid use with low or no use of bronchodilator was reported by 7.8% of respondents. The items about care processes were only asked of respondents who reported having received care from a regular source in the past year. Therefore, the analyses that explored the relationship among care processes, pharmacotherapy, and morbidity were restricted to individuals who reported having received care from a regular source in the past year (n ⫽ 75). Reported processes of care among those who received asthma care in the past year are shown in Figure 1. Nearly all (94.7%) reported that their physician had inquired about asthma symptoms, and 82.0% reported that they received instruction in inhaler technique. Only 44.6% reported having a written treatment plan, 41.9% reported that home peak flow monitoring had been recommended to them, and 34.4% had received formal asthma education. Process of care variables had no consistent relationship to asthma morbidity (not shown), but a relationship was noted between several processes of care variables and sociodemographic characteristics (Table 4). Age was related to having
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Figure 1. Processes of care reported by Chicago-area persons with active asthma (n ⫽ 75). Process of care items were asked only of persons who reported having a physician, office, or clinic who/that they regularly go to for medical treatment of asthma and persons who have been to this physician, office, or clinic at least once in the last 12 months.
received instruction in inhaler technique, with 96.4% of adults and 75.6% of children reporting having received instruction. Compared with white individuals, a smaller proportion of African Americans individuals reported having received inhaler instruction (70.6% vs 95.5%; P ⫽ .006), and a larger proportion reported a suboptimal pharmacotherapy pattern (40.0% vs 6.8%; P ⫽ .002). Low community household income was associated with lower rates of inhaler technique instruction (71.1% vs 93.3%; P ⫽ .02) and an increased likelihood of suboptimal pharmacotherapy (27.0% vs 3.5%; P ⫽ .01) compared with respondents who lived in communities of higher income. Persons with higher educational levels were more likely than those with less education to have a written treatment plan (50.9%
ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
Table 4. Percentage of Patients According to Care Practices by Sex, Age, Race, Household Income, and Household Education Reported by Chicago-Area Persons With Active Asthma (n ⫽ 75)* Sex
Age, y
Race†
Care process
Peak flow in office Home peak flow recommended Physician asked about symptoms Physician asked about activity limitation Written treatment plan Received formal asthma education Received instruction in inhaler technique Pharmacotherapy possibly suboptimal
M
F
73.9 52.0 96.2 80.8 46.2 31.8 84.6
65.2 36.7 93.9 67.4 43.8 35.7 81.3
<17
>18
68.3 67.9 40.9 44.8 93.8 100 77.8 65.4 44.4 46.4 26.5 44.8 75.6 96.4§
12.0 17.0 19.1
6.9
White
Household income‡
Household education
African <200% > 200% High school Some college American Poverty Poverty or less or more
67.4 40.9 97.7 71.4 47.7 41.0 95.5
81.3 58.8 88.9 76.5 41.2 25.0 70.6¶
67.6 41.0 92.3 64.9 36.8 31.3 71.1
73.1 44.8 96.7 80.0 50.0 30.8 93.3§
62.5 38.9 94.4 47.1 23.5 18.8 72.2
69.8 42.9 94.7 80.0¶ 50.9§ 39.6 85.7
6.8
40.0¶
27.0
3.5¶
29.4
10.9
*Items were limited to persons with physician, office, or clinic who/that they regularly go to for medical treatment for asthma and persons who have been to this physician, office, or clinic at least once in the last 12 months. Response rates for individual items are greater than 90% unless otherwise noted. †n ⫽ 132, after excluding Hispanic/Latino and cases with incomplete race/ethnicity data. ‡Based on above or below 200% poverty level ($35,206). §P ⱕ .05. ¶P ⱕ .01.
vs 23.5%; P ⫽ .05) and to report that their physician had asked about activity limitation (80.0% vs 47.1%; P ⫽ .008). The relationship between sociodemographic features and these 2 key care processes (inhaler instruction and suboptimal pharmacotherapy) were explored further in a multivariate analysis. Multiple linear regression analysis examined the contribution of sex, age, race, income, and education. Results for inhaler technique instruction showed that none of these variables were independently predictive. For suboptimal pharmacotherapy, the results showed that only community household income remained significant (OR, 7.0; 95% CI, 1.4 –34.4). Suboptimal pharmacotherapy was not predictive of any of the morbidity variables after correction for sociodemographic variables. DISCUSSION In this study of Chicago-area adults and children with asthma, a substantial burden of asthma morbidity was seen, which appears to underlie the problem of asthma mortality in this community. Furthermore, this study showed a large gap between the goals of asthma therapy and appropriate treatment as defined by the NAEPP. For example, the NAEPP goals of therapy specify no missed work or school due to asthma, but in this study, a substantial proportion of persons with asthma reported missed work or school in the past year. Many persons reported wheezing-related sleep disturbance at a frequency of more than once per week and treatment in an emergency department for asthma in the previous year. These findings suggest that poorly controlled asthma remains a prevalent problem for persons with asthma in this metropolitan area. These findings are particularly concerning in the context of the broad array of asthma care improvement efforts that
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began in the Chicago area in 1995. At that time, the disproportionately high rates of asthma morbidity and mortality attracted the attention of the medical care community, as well as several private foundations, most notably the Otho S. A. Sprague Memorial Institute. The result was the creation in 1996 of the Chicago Asthma Consortium and the initiation of a diverse group of asthma improvement projects that involve peer education, surveillance, physician education, school programs, and others.14 Several studies based in health care settings or systems have documented a discrepancy between the goals of therapy identified by the NAEPP and the level of control achieved by asthma patients.15–17 Few studies have examined asthma morbidity and care in general population-based samples. Recently, results from a national population survey conducted in 1998 suggested inadequate use of anti-inflammatory medications by persons with active asthma.18 Few studies to date have explored how well the goals of therapy are being met by examining morbidity and treatment as experienced by the population of a high-risk community. A notable but perhaps not surprising finding of this study was the relationship of race/ethnicity, age, and sex to several key aspects of morbidity. The study showed that after adjusting for age, sex, income, education, and pharmacotherapy, compared with white individuals, African American individuals remained 6.3 times more likely to have experienced an emergency department visit and 12.3 times more likely to have been hospitalized. Racial/ethnic disparities in asthma hospitalizations were first reported in several studies published in the late 1980s to early 1990s.3,4,19 The current study suggests that these disparities have persisted during the past decade, despite intense broad-based institutional focus on asthma care improvement
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in Chicago. Additionally, because this was a populationbased study of persons with asthma, the findings of this study suggest that previously noted racial/ethnic differences in hospital and emergency department utilization5,20 are not likely due to differences in asthma prevalence alone. This study also suggests room for improvement in several key processes of care, such as the use of written treatment plans and formal asthma education. Although there were few significant age, race, or sex differences in most aspects of care studied, a notable finding emerged for pharmacotherapy. African American individuals and individuals residing in low-income areas were less likely to have received instruction in inhaler technique and to use an NAEPP-recommended medication regimen, suggesting that these aspects of medical care may be important causes of the disparate morbidity seen in this study. Differences in instruction in inhaler technique may represent one aspect of the quality of the clinical encounter that may underlie health disparities.21 These findings about racial/ethnic differences in asthma care are consistent with findings from recent studies of patients enrolled in managed care organizations, showing that even among insured populations, African American individuals were less likely to receive inhaled corticosteroids and to obtain care consistent with guidelines.21–24 As with all studies, a number of limitations deserve highlighting. All information was obtained by self-report, and many of the items used in the survey have not been formally validated. Also, the modest response rate, increasingly problematic in telephone surveys, may somewhat limit our ability to generalize these findings to or beyond the Chicago-area population at large. Yet this response rate does not compromise the study’s internal validity in terms of examining differences in asthma care and outcomes. Because we did not collect information about health insurance, we cannot evaluate the effect of access to health care on the social demographic disparities identified. The survey did not collect information about environmental exposures, such as tobacco smoke, making it impossible to comment on the relationship of smoking and its impact on asthma. Finally, as with all cross-sectional studies, we cannot make inferences about causality between aspects of asthma treatment and morbidity. Specifically, because we could not adequately evaluate and control for severity in such a cross-sectional design, we were limited in our ability to examine relationships between the process of care variables and asthma morbidity. Alternatively, one of the key strengths of this study is community-based sampling designs; nearly all published reports of factors that contribute to differences in asthma care and morbidity have been conducted in clinic-, hospital-, or health plan– based samples. Studies in population-based samples such as this can help to better characterize the burden of poorly controlled asthma among the public. The findings have several implications. First, serious concern remains about the quality of asthma care and the effect of poorly controlled asthma on this community. Second, the reasons for disparate health outcomes by race/ethnicity and
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income need further study. For example, little is known about appropriate strategies for cultural adaptation of educational programs and about the effect of social or cultural differences in health care seeking behavior. Recent evidence suggests that in some cases health care practitioner prejudice or bias may influence treatment.25,26 Nearly 10 years after national guidelines first advocated for the use of controller medications, our findings suggest that increasing the use of controller medications remains an important issue for persons with asthma in Chicago and, more broadly, that we have a long distance to go to achieve the goals of the NAEPP in this high-risk urban community. ACKNOWLEDGMENTS The Chicago Asthma Surveillance Initiative was funded by the Otho S. A. Sprague Memorial Institute. We thank the following individuals for their contribution to this project: Rob Sprengel for his supervision of the telephone interview process and Pearl Burks, Mary Marre, David Novy, and Nada Smith for their work in conducting telephone interviews. REFERENCES 1. Mannino DM, Homa DM, Akinbami LJ, Moorman JE, Gwynn C, Redd SC. Surveillance for asthma—United States, 1980 –1999. MMWR Surveill Summ. 2002;51(No. SS-1):1–13. 2. Gergen PJ, Weiss KB. Changing patterns of asthma hospitalization among children: 1979 to 1987. JAMA. 1990;264: 1688 –1692. 3. Wissow L, Gittelsohn AM, Szklo M, Starfield B, Mussman M. Poverty, race and hospitalization for childhood asthma. Am J Public Health. 1988;78:777–782. 4. Carr W, Zeitel L, Weiss KB. Variations in asthma hospitalizations and deaths in New York City. Am J Public Health. 1992;82:59 – 65. 5. Marder D, Targonski P, Orris P, Persky V, Addington W. Effect of racial and socioeconomic factors on asthma mortality in Chicago. Chest. 1992;101:426S– 429S. 6. Weiss KB, Wagener DK. Changing patterns of asthma mortality: identifying target populations at high risk. JAMA. 1990;264:1683–1687. 7. Lang DM, Polansky M. Patterns of asthma mortality in Philadelphia from 1969 –1991. N Engl J Med. 1994;331:1542–1546. 8. National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health; 1991. Publication 91-3642. 9. Addington WW, Weiss KB. Chicago’s response to the public health challenge of urban asthma. Chest. 1999;116:132S–134S. 10. Weiss KB, Grant EN. The Chicago Asthma Surveillance Initiative: a community-based approach to understanding asthma care. Chest. 1999;116:141S–145S. 11. Aday LA. Designing and Conducting Health Surveys. San Francisco, CA: Jossey-Bass Inc Publishers; 1989. 12. National Health and Nutrition Examination Survey. Available at: http://www.cdc.gov/nchs/nhanes.htm. Accessibility confirmed October 11, 2003. 13. PCensus-USA United States-STF3A Data. 1990 Census of Population and Housing. 14. Alexander JN. Preface: civic support and leadership as a cata-
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lyst for addressing the problem of urban asthma: The Otho S.A. Sprague Memorial Institute’s Asthma Initiative. Chest. 1999; 116:129S–130S. Diette GB, Skinner EA, Markson LE, et al. Consistency of care with national guidelines for children with asthma in managed care. J Pediatr. 2001;138:59 – 64. Hartert TV, Windom HH, Peebles RS Jr, Fiedhoff LR, Togias A. Inadeaquate outpatient medical therapy for patients with asthma admitted to two urban hospitals. Am J Med. 1996;100: 386 –394. Friday GA Jr, Khine HJ, Lin MS, Calaguiri LA. Profile of children requiring emergency treatment for asthma. Ann Allergy Asthma Immunol. 1997;78:221–224. Adams RJ, Fuhlbrigge A, Guilbert T, Lozano P, Martinez F. Inadequate use of asthma medication in the United States: results of the Asthma in America national population survey. J Allergy Clin Immunol. 2002;110:58 – 64. Targonski PV, Persky VW, Orris P, Addington W. Trends in asthma mortality among African Americans and whites in Chicago, 1968 –1991. Am J Public Health. 1994;84:1830 –1833. Thomas SD, Whitman S. Asthma hospitalizations and mortality in Chicago: an epidemiologic overview. Chest. 1999;116: 135S–141S. Assessing potential sources of racial and ethnic disparities in care: the clinical encounter. In: Smedley, BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: Institute of Medicine, National Academy Press; 2002:127–141.
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22. Krishnan JA, Diette G, Skinner EA, Clark BD, Steinwachs D, Wu AW. Race and sex differences in consistency of care with national asthma guidelines in managed care organizations. Arch Intern Med. 2001;161:1660 –1668. 23. Zoratti EM, Havstad S, Rodriguez J, Robens-Paradise Y, Lafata J, McCarthy B. Health service use by African Americans and Caucasians with asthma in a managed care setting. Am J Respir Crit Care Med. 1998;158:371–377. 24. Finkelstein JA, Lozano P, Farber HJ, Miroshnik I, Lieu TA. Underuse of controller medications among Medicaid-insured children with asthma. Arch Pediatr Adolesc Med. 2002;156: 562–567. 25. van Ryn M, Burke J. The effect of patient race and socioeconomic status on physician’s perceptions of patients. Soc Sci Med. 2000;50:813– 828. 26. Weisse CS, Sorum PC, Sanders KN, Syat BL. Do gender and race affect decisions about pain management? J Gen Intern Med. 2001;16:211–217.
Requests for reprints should be addressed to: Kevin Weiss, MD Institute for Healthcare Studies 676 N. St. Clair St. Suite 200 Chicago, IL 60611 E-mail: [email protected]
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