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Original Research: ASTHMA |

Racial and Ethnic Disparities in Asthma Medication Usage and Health-Care Utilization: Data From the National Asthma Survey FREE TO VIEW

Deidre Crocker, MD; Clive Brown, MBBS, MPH; Ronald Moolenaar, MD, MPH; Jeanne Moorman, MS; Cathy Bailey, MS; David Mannino, MD, MPH, FCCP; Fernando Holguin, MD, MPH
Author and Funding Information

Affiliations: From the Air Pollution and Respiratory Health Branch (Dr. Crocker, Ms. Moorman, and Ms. Bailey), the Division of Global Migration and Quarantine (Dr. Brown), and the Division of Global Public Health Capacity Development (Dr. Moolenaar), Centers for Disease Control and Prevention, Atlanta GA; the Division of Pulmonary and Critical Care Medicine (Dr. Mannino), University of Kentucky, Lexington KY; and the Department of Medicine (Dr. Holguin), University of Pittsburgh, Pittsburgh, PA.

Correspondence to: Deidre Crocker, MD, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS F-58, Chamblee, GA 30341; e-mail: dvj4@cdc.gov


This study was funded by Air Pollution and Respiratory Health Branch, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(4):1063-1071. doi:10.1378/chest.09-0013
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Background:  Despite the availability of effective treatment, minority children continue to experience disproportionate morbidity from asthma. Our objective was to identify and characterize racial and ethnic disparities in health-care utilization and medication usage among US children with asthma in a large multistate asthma survey.

Methods:  We analyzed questions from the 2003–2004 four-state sample of the National Asthma Survey to assess symptom control, medication use, and health-care utilization among white, black, and Hispanic children < 18 years old with current asthma who were residing in Alabama, California, Illinois, or Texas.

Results:  Of the 1,485 children surveyed, 55% were white, 25% were Hispanic, and 20% were black. Twice as many black children had asthma-related ED visits (39% vs 18%, respectively; p < 0.001) and hospitalizations (12% vs 5%, respectively; p = 0.02) compared with white children. Significantly fewer black and Hispanic children reported using inhaled corticosteroids (ICSs) in the past 3 months (21% and 22%, respectively) compared to white children (33%; p = 0.001). Additionally, 26% of black children and 19% of Hispanic children reported receiving a daily dose of a short-acting β-agonist compared with 12% of white children (p = 0.001). ED visits were positively correlated with short-acting β-agonist use and were negatively correlated with ICS use when stratified by race/ethnicity.

Conclusions:  Children with asthma in this large, multistate survey showed a dramatic underuse of ICSs. Black and Hispanic children compared with white children had more indicators of poorly controlled asthma, including increased emergency health-care utilization, more daily rescue medication use, and lower use of ICSs, regardless of symptom control.

Figures in this Article

In the United States, asthma affects > 6 million children and accounts for an estimated $19.7 billion dollars in health-care costs annually,1 making it one of the most common chronic pediatric illnesses. Despite advances in asthma disease management and treatment, asthma morbidity and mortality continue to affect minority populations disproportionately.27 Black children have three to six times higher rates of ED visits, hospitalizations, and mortality for asthma compared to white children.7 Hispanic children, especially those of Puerto Rican descent, also have higher asthma morbidity.79 Inappropriate use of asthma medications, lower socioeconomic status, and greater symptom severity have all been proposed as reasons for racial and ethnic disparities in asthma morbidity. Yet, separating how these independent risk factors contribute to disease outcomes has proven to be difficult.2,10

Several studies11,12 have suggested that differences in asthma medication use may contribute to asthma morbidity in minority populations. Inhaled corticosteroids (ICSs) have been shown to improve long-term outcomes of patients with asthma,1315 and current practice guidelines16 recommend daily use of ICSs in patients with persistent asthma. Unfortunately, less than one-half of patients with persistent asthma report the use of ICSs on a regular basis.17,18 Moreover, several studies11,12,1922 have documented a disproportionately lower use of ICSs among racial and ethnic minority groups. In addition, compared with other racial groups, blacks have been shown to more frequently use short-acting β-agonists, which is a key indicator of poor asthma control.12,23,24 Few studies have conducted a comprehensive analysis of racial and ethnic disparities in asthma medication use among a large, multistate sample of children with asthma.

The objectives of this study were to analyze data from the National Asthma Survey (NAS) in order to determine whether racial and ethnic disparities in medication usage exist among children with asthma and, if found, determine how these disparities are associated with health-care utilization.

Instrument

This analysis used data from the 2003 four-state sample of the NAS. The NAS is a stand-alone, comprehensive survey that utilized the sampling frame of the State and Local Area Integrated Telephone Survey, a random-digit-dial household telephone survey designed to provide in-depth state and local health-care data. The survey asked specific questions that examined health outcomes, medication usage, access to care, and risk factors related to asthma symptom control. The four-state sample of the NAS was conducted in people with self-reported asthma in Alabama, California, Illinois, and Texas.25 Interviews were administered to Spanish-speaking participants in Spanish using a professionally translated Spanish-language version of the NAS survey.25

Case Definition

We limited our analysis to children < 18 years of age in the four-state sample with current asthma. The period of data collection was March 2003 to March 2004. For all children under the age of 18 years, a knowledgeable family member provided responses to questions. We included children of black or white race and Hispanic or non-Hispanic ethnicity. Due to small sample sizes, children of other races were excluded. We classified asthma status based on responses to the questions “Has your child ever been told by a doctor or other health professional that he or she has asthma?” and “Does your child still have asthma?” Positive responses to both questions were categorized as “children with current asthma,” which is consistent with the Council for State and Territorial Epidemiologists case definition.26 Positive responses to the first question and negative responses to the second question were categorized as “children with former asthma” and were excluded from this analysis.

Race and Ethnicity

Proxy respondents were read a list of racial categories and asked to choose one or more categories that best describe the race of the child. Race choices included white, black, American Indian, Alaska Native, Asian, Native Hawaiian, and Pacific Islander. If a respondent answered “yes” to more than one category, the child was classified as “multiple race.” Due to the small sample size, all races other than single-race white and single-race black were classified as “other” and were excluded. Hispanic ethnicity was identified based on a positive response to the question “Is the child of Hispanic or Latino origin?” Race and ethnicity responses were combined to create a single classification with the following three categories: white non-Hispanic; black non-Hispanic; and Hispanic. Hereafter, these categories will be referred to as white, black, and Hispanic.

Other Demographic Characteristics

Variables analyzed included age group (< 5 years, 5 to 11 years, and 12 to 17 years), sex, annual household income (< $15,000 and > $15,000), insurance status (yes/no), BMI for age (underweight [< 5th percentile], normal weight [5th to 89th percentile], overweight risk [90th to 95th percentile], and overweight [> 95th percentile]), environmental tobacco smoke (ETS) [one or more smokers in the household], residence in a metropolitan statistical area (MSA) [area with a population of at least 500,000 based on each participant's zip code], parental history of asthma, low birthweight (< 2,500 g), and state of residence (Alabama, California, Illinois, or Texas).

Symptom Control

Proxy respondents were asked the following questions to estimate the frequency of daytime asthma symptoms for each child: “During the past 30 days, how many days did your child have any symptoms of asthma?”; and “Does your child have symptoms all the time?” To estimate nighttime symptoms, respondents were asked “During the past 30 days, on how many days did symptoms of asthma make it difficult for your child to stay asleep?” Each child was given a 30-day index score from 1 to 4 based on the number of symptomatic days or nights that occurred in a 1-month period. The 30-day index score was based on four categories (mild intermittent asthma, mild persistent asthma, moderate persistent asthma, and severe persistent asthma) that were consistent with guidelines from the National Asthma Education and Prevention Program(NAEPP) expert panel report.27 The highest score between daytime and nighttime symptoms was used to place the child in a category. Since the NAEPP categories were intended to indicate severity before treatment and required the use of spirometry, which cannot be assessed in survey data, we will use the term “symptom control” rather than “asthma severity” to refer to the result of the classification.

Medication Usage

Respondents for children with current asthma were asked to list any prescription asthma medications taken by the child within the last 3 months. We categorized the medications listed into relief medications and preventive medications. Medication variables were based on any use or daily use of relief and preventive medications in the past 3 months.

Asthma Morbidity

Emergency health-care utilization was estimated by asking the respondent if the child had had at least one asthma-related hospitalization or ED visit within the previous 12 months.

Statistical Analysis

Data were analyzed using a statistical software package (SAS, version 9.1; SAS Institute; Cary, NC). Survey weights were used to calculate the estimates and confidence intervals that represented the population of each of the four surveyed states. We used χ2 tests to examine baseline differences across racial and ethnic groups and to evaluate the association between race/ethnicity (independent variable) and symptom control, health-care utilization, and asthma medication usage (dependent variables). Additionally, scatterplots of ED visits by asthma medication usage were produced for children with intermittent and persistent asthma stratified by race/ethnicity. Multivariate regression models were used to determine whether any racial/ethnic variations in health-care utilization and asthma medication usage persisted after adjusting for multiple covariates, including age, symptom control, sex, BMI, insurance status, ETS exposure, household income, state of residence, and residence in an MSA.

Demographic Characteristics

Of the 5,741 persons with asthma in the four-state sample of the NAS, 2,003 persons (35%) were < 18 years of age (Table 1). Of this group, we excluded 381 persons (19%) who did not have current asthma (ie, children with former asthma or missing data). Of the 1,622 respondents with current asthma, 50 children (3%) were excluded from analysis due to missing race/ethnicity data. Also, 87 children (5%) of non-Hispanic ethnicity were categorized as “other race” and excluded from analysis due to small sample size. Of the remaining 1,485 children included in the final analysis, 822 were white, 294 were black, and 369 were Hispanic.

Table Graphic Jump Location
Table 1 Characteristics of Children 0 to 17 With Current Asthma by Race-Ethnicity: NAS Four-State Sample, 2003 (n = 1,485)

Percentages are based on weighted estimates to represent the population of the four states in the sample.

*Includes children of black race, white race, and Hispanic ethnicity.

†Non-Hispanic.

‡Based on unweighted percentages.

Demographic percentages were weighted to the population in the four states sampled. The majority of children in the sample were male, lived in an urban area, and were covered by health insurance. Nearly one-half of the children in the sample were overweight or at risk of being overweight. Proportionally, more black and Hispanic children were younger, overweight, and from low-income households. Black children were also more likely to have at least one smoker in the home. Sex, MSA, parental history of asthma, and insurance status did not differ by race or ethnicity.

Bivariate Analysis
Symptom Control:

There were no significant differences in reported asthma symptom control or in the proportion of children with attacks lasting > 24 h among the three race/ethnicity groups (Table 2).

Table Graphic Jump Location
Table 2 Symptom Control, Health-Care Utilization, and Medication Use in Children With Current Asthma, by Race and Ethnicity: NAS Four-State Sample, 2003 (n = 1,485)

Percentages are based on weighted estimates to represent the population of the four states in the sample.

*Includes children of black race, white race, and Hispanic ethnicity.

†Non-Hispanic.

‡Based on unweighted percentages.

§Denominator includes only children with at least one reported asthma attack in the past 12 mo (n = 457).

‖Includes ICSs, long-acting β-agonists, leukotriene antagonists, and mast cell stabilizers.

Health-Care Visits:

Black children had the largest proportion of those with at least one hospitalization or ED visit due to asthma in the past year; both were more than twice that of white children. Compared with whites, Hispanics had a similar percentage of children with at least one asthma hospitalization but had a significantly higher percentage of children with one or more asthma ED visits within the past year.

Medication Usage:

Asthma medications were categorized into short-acting β-agonists and preventive medications. The percentage of children using short-acting β-agonists daily was significantly higher for blacks (26%) and Hispanics (19%) compared with whites (12%). Preventive medication use was low among all children with current asthma (37%). However, blacks and Hispanics had a significantly lower proportion of children using preventive medications (particularly ICSs, leukotriene antagonists, and long-acting β-agonists) in the past 3 months and on a daily basis compared with white children.

Multivariate Analysis

In the multivariate analysis, black children had twice the odds of whites for having at least one ED visit (adjusted odds ratio [AOR], 2.3; 95% CI, 1.3 to 4.1) or hospitalization (AOR, 2.7; 95% CI, 1.1 to 6.8) due to asthma in the past year after adjusting for asthma symptom control and other sociodemographic variables (Table 3). There were no significant differences in health-care utilization between Hispanic and white children. Compared with whites, blacks had significantly higher odds of using a short-acting β-agonists on a daily basis (AOR, 2.2; 95% CI, 1.1 to 4.4). Both blacks and Hispanics had decreased odds of using preventive medications compared with whites, but the association was only significant among Hispanic children.

Table Graphic Jump Location
Table 3 AORs and CIs of Designated Outcomes for Children With Current Asthma, by Race and Ethnicity: NAS Four-State Sample, 2003 (n = 1,485)

*Derived from logistic regression analysis using white children as the referent group.

†Logistic regression models adjusted for the following covariates: age, symptom severity, gender, income, BMI, health insurance, ETS, MSA, state of residence, and family history.

Scatterplots of ED Visits by Medication Use

We also studied the relationship between having at least one asthma-related ED visit in the past year and the use of ICSs (Fig 1) and daily short-acting β-agonists (Fig 2) in the past 3 months, stratified by race/ethnicity for both intermittent asthma and persistent asthma categories. The proportion of children with an asthma-related ED visit, when stratified by race/ethnicity, was negatively correlated with ICS use and positively correlated with daily short-acting β-agonist use. Both persistent asthma and intermittent asthma categories showed a similar pattern, with blacks having the highest proportion of children with one or more asthma-related ED visits, the lowest proportion of children using ICSs, and the highest proportion of children with daily use of short-acting β-agonists.

Figure Jump LinkFigure 1 Scatterplot depicting the percentage of children with at least one ED visit in the past year by the percentage of children using ICSs in the past 3 months stratified by race/ethnicity for intermittent and persistent asthma.Grahic Jump Location
Figure Jump LinkFigure 2 Scatter plot depicting the percentage of children with at least one ED visit in the past year by the percentage of children using short-acting β-agonists in the past 3 months stratified by race/ethnicity for intermittent and persistent asthma.Grahic Jump Location
Major Findings

In this large sample of children with current asthma, black children had over twice the odds of having made a visit to the ED or having been hospitalized due to asthma within the past year compared to white children. These differences persisted even after adjusting for symptom control and sociodemographic factors. Compared with white children, both black and Hispanic children with asthma had decreased odds of using ICSs in the past 3 months and had increased odds of using short-acting β-agonists on a daily basis. The racial and ethnic differences in ICS use were most pronounced among children with persistent asthma, while the racial and ethnic differences in daily short-acting β-agonist use were most pronounced among children with intermittent asthma. Finally, in all three race/ethnicity categories ED visits for asthma were negatively correlated with use of ICSs and were positively correlated with the daily use of short-acting β-agonists.

Interpretation of Findings

Analysis of the sample revealed significant racial and ethnic disparities in asthma health-care utilization and treatment. Black children with persistent asthma had the greatest percentage of children with asthma-related ED visits and the lowest percentage of ICS use. The daily use of short-acting β-agonists was also higher among black children compared with both Hispanic and white children, regardless of symptom severity. Although additional research is needed, this study suggests that differences in asthma medication usage may be a significant factor in racial and ethnic differences in asthma hospitalizations and ED visits. Additionally, differences in household income (used as a rough measure of socioeconomic status) did not fully explain the differences in asthma hospitalizations, ED visits, or medication use among the three groups.

Decreased utilization of preventive asthma medications and overuse of short-acting β-agonists in racial and ethnic minority groups may be surrogates for underlying differences in social determinants of health such as access to care, quality of care delivery, and cultural beliefs.28 The underuse of ICSs in minority groups may be due in part to the disproportionate amount of asthma care received by minority patients in emergency facilities.29,30 These facilities are less likely to prescribe controller medications, thus contributing to the differences in asthma medication usage. Potential reasons for decreased access to primary care services by minorities include insurance issues, lack of social support, and transportation issues.31 The quality of asthma care must also be considered. Minority patients are less likely to be referred to an asthma specialist for treatment compared to white patients.32 Decreased access to asthma specialty care could in turn affect appropriate asthma medication usage.

Additionally, there are disparities in asthma medication prescribing patterns. A study by Ferris et al33 found that providers are less likely to prescribe newer medications and technologies to minority patients. Finally, cultural beliefs regarding asthma and steroids may also influence medication use. A large study34 of parental beliefs about asthma medications found that minority parents reported greater concern about preventive medications as well as less need for preventive medications in managing their child's asthma, both of which greatly affect adherence to a medication regimen.28 Despite these barriers, studies35,36 have shown that it is possible to improve the quality asthma care and outcomes in minorities through provider education and culturally competent patient education.

Genetic factors may also play a role in racial and ethnic differences in medication use, particularly short-acting β-agonists. People with certain genetic polymorphisms in the β-adrenergic receptor are known to have increased asthma exacerbations and desensitization of the β-agonist receptor.3739 The frequency of these polymorphisms differs by race/ethnicity, which may lead to more deleterious effects of the regular use of short-acting β-agonists in patients of certain racial or ethnicity groups.40 Genetic differences in medication response must be examined within a broader context, including the social and cultural factors that influence racial differences in asthma medication usage.

Finally, the criteria that the medical community uses to diagnose and treat asthma could also contribute to racial and ethnic disparities in medication usage. In this study, 25% of the black children categorized as having intermittent asthma by symptom report had experienced an asthma-related ED visit in the past year, and 17% were using short-acting β-agonist medications on a daily basis. This discrepancy between reported symptom control and other measures of asthma control (rescue medication use and ED visits) among a relatively large percentage of black children in this study indicates that the reported symptoms in black children may not represent the true level of asthma control. Some research41,42 has indicated that physicians are more likely to underestimate asthma symptoms in black patients. This could lead to the misclassification of symptom severity and asthma control, especially if more objective measures are not employed. Our findings corroborate the findings of the 2007 NAEPP guidelines16 expert panel report, which emphasize the importance of using spirometry, a history of severe asthma exacerbations, and rescue medication use together with symptom history to determine asthma control. These measures may help to decrease the disparities in asthma treatment by accurately classifying asthma severity and control in minority patients.

Limitations

This analysis has some potential limitations that may affect the general application of this study. Because this was a cross-sectional study, our results can only show associations; they cannot determine causality. Additionally, only one measure of socioeconomic status (household income) was available in the NAS survey. Other potentially useful information, such as the number of people in each household (to determine the poverty index) and parental education, were not available. Additionally, some demographic variables, such as ETS exposure, were categorized dichotomously, which does not allow for measuring how intensity of exposure is associated with asthma outcomes. Another potential limitation is recall bias. Caretakers were asked to recall symptoms over a 4-week time period, which may have led to memory errors. However, a longer recall period may provide a more representative picture of asthma symptoms. Finally, similar to most national surveys, the NAS did not differentiate between Hispanic subgroups or place of birth, which are factors that impact asthma prevalence, morbidity, and mortality in the Hispanic population.41,42 Despite these limitations, this study shows a clear difference in asthma morbidity and medication use in minority children with asthma.

In this large sample of children with asthma, black children were twice as likely to have had a hospitalization or ED visit for asthma in the past year compared with white children, despite there being no differences in symptom control. Compared with white children, both black and Hispanic children were less likely to use preventive medications, and black children were more likely to use short-acting β-agonists on a daily basis. More longitudinal research is needed to determine the extent to which these medication differences affect asthma morbidity. Sufficient evidence is available, however, to suggest that culturally specific interventions to increase preventive medication use and decrease the use of short-acting β-agonists in minorities should be employed to reduce the disparities in asthma morbidity and mortality in children.

AOR

adjusted odds ratio

ETS

environmental tobacco smoke

ICS

inhaled corticosteroid

MSA

metropolitan statistical area

NAEPP

National Asthma Education and Prevention Program

NAS

National Asthma Survey

Author contributions: Dr. Crocker is the primary author. Dr. Brown contributed to data analysis and editing of the manuscript. Dr. Moolenaar contributed to data analysis and editing of the manuscript. Ms. Moorman contributed to data analysis and methods. Ms. Bailey contributed to data analysis and methods. Dr. Mannino contributed to data analysis and editing of the manuscript. Dr. Holguin contributed to data analysis and the editing of manuscript.

Financial/nonfinancial disclosures: The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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Figures

Figure Jump LinkFigure 1 Scatterplot depicting the percentage of children with at least one ED visit in the past year by the percentage of children using ICSs in the past 3 months stratified by race/ethnicity for intermittent and persistent asthma.Grahic Jump Location
Figure Jump LinkFigure 2 Scatter plot depicting the percentage of children with at least one ED visit in the past year by the percentage of children using short-acting β-agonists in the past 3 months stratified by race/ethnicity for intermittent and persistent asthma.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 Characteristics of Children 0 to 17 With Current Asthma by Race-Ethnicity: NAS Four-State Sample, 2003 (n = 1,485)

Percentages are based on weighted estimates to represent the population of the four states in the sample.

*Includes children of black race, white race, and Hispanic ethnicity.

†Non-Hispanic.

‡Based on unweighted percentages.

Table Graphic Jump Location
Table 2 Symptom Control, Health-Care Utilization, and Medication Use in Children With Current Asthma, by Race and Ethnicity: NAS Four-State Sample, 2003 (n = 1,485)

Percentages are based on weighted estimates to represent the population of the four states in the sample.

*Includes children of black race, white race, and Hispanic ethnicity.

†Non-Hispanic.

‡Based on unweighted percentages.

§Denominator includes only children with at least one reported asthma attack in the past 12 mo (n = 457).

‖Includes ICSs, long-acting β-agonists, leukotriene antagonists, and mast cell stabilizers.

Table Graphic Jump Location
Table 3 AORs and CIs of Designated Outcomes for Children With Current Asthma, by Race and Ethnicity: NAS Four-State Sample, 2003 (n = 1,485)

*Derived from logistic regression analysis using white children as the referent group.

†Logistic regression models adjusted for the following covariates: age, symptom severity, gender, income, BMI, health insurance, ETS, MSA, state of residence, and family history.

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