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Eliminating Asthma Disparities Through Multistakeholder Partnerships FREE TO VIEW

Carolyn M. Clancy, MD; James P. Kiley, PhD, MS; Kevin B. Weiss, MD
Author and Funding Information

Affiliations: Agency for Healthcare Research and Quality, Rockville, MD,  National Institutes of Health, Bethesda, MD,  Northwestern University Feinberg School of Medicine, Chicago, IL

Correspondence to: Kevin B. Weiss, MD, Institute for Healthcare Studies, Suite 200, 676 N St. Clair St, Chicago, IL 60611; e-mail: kevin.weiss@va.gov



Chest. 2007;132(5):1422-1424. doi:10.1378/chest.07-1947
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For years, the Centers for Disease Control and Prevention (CDC) has produced statistics on the burden of asthma in the United States. Much of the interest in these statistics has focused on the dramatic increase in asthma since the 1980s. However, a second and equally important finding has been the persistent gap between whites and nonwhites, with nonwhites being characterized has having higher asthma prevalence, hospitalization, and mortality rates.1Recent reports23 have highlighted the lack of any substantive reduction in this gap and, disturbingly, the results show that for children this gap may be increasing.

The Agency for Healthcare Research and Quality (AHRQ) has long been concerned about the burden of asthma. Examples of AHRQ efforts focused in this area include research on the quality of care for children in the Medicaid program4and in the State Children’s Health Insurance Program,5guideline implementation in the primary care setting,6as well as asthma care in the emergency room setting.7In situations where successful interventions did not specifically target issues of disparities, the AHRQ is encouraging further research to explore the generalizability of the interventions for use in underresourced settings.8

Because settings that serve largely racial and ethnic minority or low-income children often don’t have the resources to implement effective quality improvement strategies (eg, integrating a nurse educator/care manager into the practice), the AHRQ encourages quality improvement and disparities reduction interventions at higher levels of the health-care “chain of effect” (ie, the policy and health plan levels).910 To this end, the AHRQ recently worked with six state asthma coalitions, five of them located in state government offices. The AHRQ provided the coalitions with evidence about effective strategies, support in mapping disparities using geographic information systems, and a way to calculate the return on investment by focusing on reducing disparities in asthma care for children, as a way to make a business case to influence state leaders.

The National Heart, Lung, and Blood Institute (NHLBI) has also had a long-standing commitment to reducing asthma disparities. For example, since 2002 the NHLBI funded four Centers for Reducing Asthma Disparities.11 These centers are designed to accelerate research aimed at understanding why certain racial, ethnic, and socioeconomic groups are more severely affected by asthma than other populations and determining ways to close the gaps in prevalence and treatment of this common chronic disease. Each center is composed of an academic institution with extensive experience in research paired with a medical school or medical center that predominately serves minority or economically disadvantaged populations.

The NHLBI demonstration and education research program is supporting research to identify strategies that will extend the benefits of asthma management to diverse populations and particularly minorities and economically disadvantaged individuals. These are the populations that are at greatest risk for asthma-related deaths and serious disability due to asthma. Investigators are using nonmedical settings to test culturally sensitive behavior change strategies for children with asthma and their families: community neighborhood centers, peer education for teens, high school computer-based programs for teen self-management, home visitor programs, and telephone counseling. Investigators are also evaluating programs that create new ways of delivering care or improving use of health-care resources, such as mobile asthma clinics, supervised therapy at school, and telemonitoring links between the patient’s home and the asthma clinic. The NHLBI Cultural Competence and Health Disparity Award is another example of a novel program to train health-care providers on the health implications of cultural diversity and how they shape a person’s approach to health and illness. Investigators are developing and implementing relevant curricula in medical and health professional schools for asthma and other diseases.

Because there has been a dramatic increase in asthma prevalence in children < 18 years of age, and children with asthma miss twice as much school as the national average, the NHLBI launched a research initiative in three different inner-city environments to evaluate ways to ensure optimal management of asthma in school. The program evaluated ways to ensure that children with asthma would have access to medications, an environment as free of allergens and irritants as possible, and resources in the school to support the child and family’s efforts to manage asthma. Findings from this program demonstrated that interventions with easily reproducible materials can make the school “asthma friendly” by developing formal policies on medications, educational programs to help teachers help children manage asthma at school, and simple environmental measures to reduce exposures to triggers.

The AHRQ and NHLBI initiatives listed above represent only a portion of the federal efforts to reduce asthma disparities. The National Institute for Environmental Health Sciences, the National Institute for Allergy, and Infectious Diseases, the CDC, the Environmental Protection Agency, and the Center for Medicare and Medicaid Services have all invested resources to address asthma disparities. In addition, it is well recognized that this important health problem cannot be solved with federal resources alone and requires input from state, local, and private sectors as well. A number of states, many with support from the CDC, have initiated programs to reduce asthma morbidity and reduce asthma disparities. In the private sector, the Robert Wood Johnson Foundation has demonstrated how a national organization can lead a sustained effort to eliminate these disparities.12Lastly, and perhaps most notably, there have been a number of local foundation efforts, as exemplified by the Otho S. A. Sprague Memorial Institute in Chicago, which have provided the type of local community support that is needed to address this problem at the level of the community neighborhoods most highly affected by these disparities.13

The national workshop documented in a Supplement to this issue of CHEST was organized to bring together the knowledge and experience of more than a decade’s worth of targeted support aimed at reducing asthma disparities.14It was supported by the AHRQ, NHLBI, and many of the above-noted public and private resources. The workshop reflected a broad appraisal of what we understand about health disparities in asthma and strategies to reduce and eliminate this gap.1524 The main objective of this workshop was to design an action plan to help guide a diverse group of stakeholders in solving this problem.25 The plan addresses a broad range of solutions from discovery of risk factors and genetics that may play a role, to solutions that reflect our understanding of the behavioral health, social support, health communications, and environmental factors to be addressed, to health systems changes related to quality and access, and opportunities for state and local policy.

Findings of health disparities are not unique to asthma. Gaps in burden and health care between white and other minority populations are seen across many health conditions and are now the focus of many active surveillance and intervention initiatives sponsored by the Department of Health and Human Services.26 The results of this workshop remind us is that while some of the solutions to reducing asthma health disparities will rest in broad-based public and private actions that span the full spectrum of diseases, other opportunities will be asthma specific. Through its action plan, this workshop provided some direction for eliminating this distressing public health concern.25

What the report of this workshop perhaps best highlights is that any effort to eliminate asthma disparities will require a sustained effort by multiple stakeholders: public and private, national and regional, and local. Within the federal government, there have been efforts to construct multistakeholder investments. Specifically, since 1989, the NHLBI has been supporting the National Asthma Education and Prevention Program as a national multistakeholder effort to raise awareness of the problem of asthma morbidity and encourage solutions to improving care. Since that time, many local coalitions have been established around the country to try and emulate this model to effect change locally. Finally, a focus on the return on investment from improving asthma care for the most vulnerable of child populations would be valuable and add a new aspect to a long-standing problem. Yet, improvements in delivery of asthma care are not always cost-saving to the health-care industry,27 while they may be beneficial to patients, caregivers, employers, and society overall. To get the most from this action plan, it will require multiple stakeholders to review this plan and adopt those elements that are best suited to implement. In this context, we can look forward to making progress on eliminating these disturbing gaps in asthma burden within the United States.

Dr. Clancy is Director, AHRQ, Rockville, MD. Dr. Kiley is Director, Division of Lung Diseases, NHLBI, National Institutes of Health, Bethesda, MD. Dr. Weiss is from the Institute for Healthcare Studies, Northwestern Feinberg School of Medicine, Chicago, Illinois, and Center for the Management of Complex Chronic Care, Hines VA Hospital, Hines, IL.

The authors have no conflicts of interest to disclose.

References

Mannino, DM, Homa, DM, Pertowski, CA, et al (1998) Surveillance for Asthma-United States, 1960–1995.MMWR CDC Surveill Summ47,1-27
 
Gupta, RS, Carrian-Carire, V, Weiss, KB The widening black/white gap in asthma hospitalizations and mortality.J Allergy Clin Immunol2006;117,351-358. [PubMed] [CrossRef]
 
Akinbami, LJ. The state of childhood asthma, United States, 1980–2005. Advance data from vital and health statistics, No. 381. 2006; National Center for Health Statistics. Hyattsville, MD:.
 
Finkelstein, JA, Lozano, P, Farber, HJ, et al Underuse of controller medications among Medicaid-insured children with asthma.Arch Pediatr Adolesc Med2002;156,562-567. [PubMed]
 
Szilagyi, P, Dick, A, Klein, J, et al Improved asthma care after enrollment in the State Children’s Health Insurance Program in New York.Pediatrics2006;117,486-496. [PubMed]
 
Lozano, P, Finkelstein, JA, Carey, VJ, et al A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care: health outcomes of the Pediatric Asthma Care Patient Outcomes Research Team II Study.Arch Pediatr Adolesc Med2004;158,875-883. [PubMed]
 
Lara, M, Duan, NH, Sherbourne, C, et al Children’s use of emergency departments for asthma: Persistent barriers or acute need?J Asthma2003;40,289-299. [PubMed]
 
Research priorities for the Agency for Healthcare Research and Quality: Research on systems and organizational interventions for improving healthcare quality for low-income people served in under-resourced settings and communities. Available at: http://grants.nih.gov/grants/guide/notice-files/NOT-HS-07-045.html. Accessed July 1, 2007.
 
Shortell, S Increasing value: a research agenda for addressing the managerial and organizational challenges facing health care delivery in the United States.Med Care Res Rev2004;61(suppl),12S-30S
 
Berwick, D A user’s manual of the IOM’s “quality chasm” report.Health Aff (Millwood)2002;21,80-90. [PubMed]
 
National Heart, Lung, and Blood Institute, National Institutes of Health. Initiative creates partnerships between research intensive and minority-serving institutions: NHLBI funds Centers for Reducing Asthma Disparities. Available at: http://www.nhlbi.nih.gov/new/press/02-10-30a.htm. Accessed July 1, 2007.
 
Robert Wood Johnson Foundation. Allies against asthma: a program to combine clinical and public health approaches to chronic illness. Available at: http://www.rwjf.org/applications/solicited/npo.jsp?FUND_ID=55058. Accessed July 1, 2007.
 
The Otho S.A. Sprague Memorial Institute. Available at: http://spragueinstitute.org/_wsn/page2.html#Asthma. Accessed July 1, 2007.
 
Weiss, K Eliminating asthma disparities: a national workshop to set a working agenda.Chest2007;132(suppl),753S-756S
 
Wright, RS, Subramanian, SV Advancing theories of environmental risk factors for asthma disparities research.Chest2007;132(suppl),757S-769S
 
Scirica, CV, Celedón, JC Genetics of asthma in ethnic minority populations in the United States.Chest2007;132(suppl),770S-781S
 
Eggleston, PA The environment and asthma in US inner cities.Chest2007;132(suppl),782S-788S
 
Mangan, JM, Wittich, A, Gerald, L Behavioral health and family/social function.Chest2007;132(suppl),789S-801S
 
Diette, GB, Rand, C The contributing role of health care communication to health disparities for minority patients with asthma.Chest2007;132(suppl),802S-809S
 
Cabana, MD, Lara, M, Shannon, J Racial and ethnic disparities in asthma care: health care access, delivery and quality of care workgroup.Chest2007;132(suppl),810S-817S
 
Shields, A Trends in private insurance, Medicaid/SCHIP and the health care safety net: implications for asthma disparities.Chest2007;132(suppl),818S-830S
 
Persky, V, Turyk, M, Piorkowski, J, et al Inner city asthma: the role of the community.Chest2007;132(suppl),831S-839S
 
Naureckas, ET, Thomas, S Are we closing the disparities gap? Small area analysis of asthma in Chicago.Chest2007;132(suppl),858S-865S
 
Shannon, JJ, Catrambone, CD, Coover, L Targeting improvements in asthma morbidity in Chicago.Chest2007;132(suppl),866S-873S
 
Weiss, KB An action agenda to eliminate asthma disparities: results from the workgroups of the National Workshop to Eliminate Asthma Disparities.Chest2007;132(suppl),853S-855S
 
Agency for Healthcare Research and Quality. National healthcare disparities report, 2006. Available at: http://www.ahrq.gov/qual/nhdr06/nhdr06.htm. Accessed July 1, 2007.
 
Sullivan, SD, Lee, TA, Blough, DK, et al A multisite randomized trial of the effects of physician education and organizational change in chronic asthma care: cost-effectiveness analysis of the Pediatric Asthma Care Patient Outcomes Research Team II (PAC-PORT II).Arch Pediatr Adolesc Med2005;159,428-434. [PubMed]
 

Figures

Tables

References

Mannino, DM, Homa, DM, Pertowski, CA, et al (1998) Surveillance for Asthma-United States, 1960–1995.MMWR CDC Surveill Summ47,1-27
 
Gupta, RS, Carrian-Carire, V, Weiss, KB The widening black/white gap in asthma hospitalizations and mortality.J Allergy Clin Immunol2006;117,351-358. [PubMed] [CrossRef]
 
Akinbami, LJ. The state of childhood asthma, United States, 1980–2005. Advance data from vital and health statistics, No. 381. 2006; National Center for Health Statistics. Hyattsville, MD:.
 
Finkelstein, JA, Lozano, P, Farber, HJ, et al Underuse of controller medications among Medicaid-insured children with asthma.Arch Pediatr Adolesc Med2002;156,562-567. [PubMed]
 
Szilagyi, P, Dick, A, Klein, J, et al Improved asthma care after enrollment in the State Children’s Health Insurance Program in New York.Pediatrics2006;117,486-496. [PubMed]
 
Lozano, P, Finkelstein, JA, Carey, VJ, et al A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care: health outcomes of the Pediatric Asthma Care Patient Outcomes Research Team II Study.Arch Pediatr Adolesc Med2004;158,875-883. [PubMed]
 
Lara, M, Duan, NH, Sherbourne, C, et al Children’s use of emergency departments for asthma: Persistent barriers or acute need?J Asthma2003;40,289-299. [PubMed]
 
Research priorities for the Agency for Healthcare Research and Quality: Research on systems and organizational interventions for improving healthcare quality for low-income people served in under-resourced settings and communities. Available at: http://grants.nih.gov/grants/guide/notice-files/NOT-HS-07-045.html. Accessed July 1, 2007.
 
Shortell, S Increasing value: a research agenda for addressing the managerial and organizational challenges facing health care delivery in the United States.Med Care Res Rev2004;61(suppl),12S-30S
 
Berwick, D A user’s manual of the IOM’s “quality chasm” report.Health Aff (Millwood)2002;21,80-90. [PubMed]
 
National Heart, Lung, and Blood Institute, National Institutes of Health. Initiative creates partnerships between research intensive and minority-serving institutions: NHLBI funds Centers for Reducing Asthma Disparities. Available at: http://www.nhlbi.nih.gov/new/press/02-10-30a.htm. Accessed July 1, 2007.
 
Robert Wood Johnson Foundation. Allies against asthma: a program to combine clinical and public health approaches to chronic illness. Available at: http://www.rwjf.org/applications/solicited/npo.jsp?FUND_ID=55058. Accessed July 1, 2007.
 
The Otho S.A. Sprague Memorial Institute. Available at: http://spragueinstitute.org/_wsn/page2.html#Asthma. Accessed July 1, 2007.
 
Weiss, K Eliminating asthma disparities: a national workshop to set a working agenda.Chest2007;132(suppl),753S-756S
 
Wright, RS, Subramanian, SV Advancing theories of environmental risk factors for asthma disparities research.Chest2007;132(suppl),757S-769S
 
Scirica, CV, Celedón, JC Genetics of asthma in ethnic minority populations in the United States.Chest2007;132(suppl),770S-781S
 
Eggleston, PA The environment and asthma in US inner cities.Chest2007;132(suppl),782S-788S
 
Mangan, JM, Wittich, A, Gerald, L Behavioral health and family/social function.Chest2007;132(suppl),789S-801S
 
Diette, GB, Rand, C The contributing role of health care communication to health disparities for minority patients with asthma.Chest2007;132(suppl),802S-809S
 
Cabana, MD, Lara, M, Shannon, J Racial and ethnic disparities in asthma care: health care access, delivery and quality of care workgroup.Chest2007;132(suppl),810S-817S
 
Shields, A Trends in private insurance, Medicaid/SCHIP and the health care safety net: implications for asthma disparities.Chest2007;132(suppl),818S-830S
 
Persky, V, Turyk, M, Piorkowski, J, et al Inner city asthma: the role of the community.Chest2007;132(suppl),831S-839S
 
Naureckas, ET, Thomas, S Are we closing the disparities gap? Small area analysis of asthma in Chicago.Chest2007;132(suppl),858S-865S
 
Shannon, JJ, Catrambone, CD, Coover, L Targeting improvements in asthma morbidity in Chicago.Chest2007;132(suppl),866S-873S
 
Weiss, KB An action agenda to eliminate asthma disparities: results from the workgroups of the National Workshop to Eliminate Asthma Disparities.Chest2007;132(suppl),853S-855S
 
Agency for Healthcare Research and Quality. National healthcare disparities report, 2006. Available at: http://www.ahrq.gov/qual/nhdr06/nhdr06.htm. Accessed July 1, 2007.
 
Sullivan, SD, Lee, TA, Blough, DK, et al A multisite randomized trial of the effects of physician education and organizational change in chronic asthma care: cost-effectiveness analysis of the Pediatric Asthma Care Patient Outcomes Research Team II (PAC-PORT II).Arch Pediatr Adolesc Med2005;159,428-434. [PubMed]
 
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