The care of asthmatic African Americans falls short of many recommendations contained in national guidelines, compared to whites, according to a new study by Johns Hopkins researchers, reported in the July 9th issue of Archives of Internal Medicine. The finding, say researchers, may explain, in part, why African Americans are more likely to have more severe asthma symptoms. The researchers also found that asthmatic women of both races are less likely to comply with daily medication use and to see an asthma specialist.
"The discrepancy in care is striking because it cannot easily be explained by socioeconomic factors or access to care," says Jerry Krishnan, M.D., an instructor in the Hopkins School of Medicine's division of pulmonary and critical care medicine and lead author of the study. "We need to further investigate whether these differences in asthma care were due to doctor, patient or health care system-related barriers."
In a study of 5,062 adults enrolled in managed care organizations, fewer African-Americans than whites reported care consistent with guidelines from the National Asthma and Education Prevention Program (NAEPP). Differences existed even after researchers adjusted for age, education, employment and asthma severity. The group included individuals with at least moderate asthma symptoms and was 14 percent African American and 72 percent female. Roughly 35 percent of African Americans reported using inhaled corticosteroids daily, compared to 54 percent of whites. Forty-two percent of African-Americans had enough information provided to them on how to manage their asthma during an attack, compared to 54 percent of Caucasians. Thirty-eight percent of African-Americans reported receiving adequate information about how to avoid asthma triggers, compared to 54 percent of whites. And while 41 percent of whites were seen by asthma specialists, only 28 percent of African Americans were.
The researchers say the study was not designed to determine whether deficiencies in asthma care were due to doctors, patients or some combination, except when it comes to seeing a specialist. "The asthma specialist discrepancy doesn't appear to be explained by patient preferences, since many of these patients said they wanted to see a specialist," says Gregory Diette, M.D., an assistant professor of pulmonary and critical care medicine at Hopkins.
The study was undertaken because while researchers have known that misuse of medications contributes to poor asthma health in the United States, less is known about the relationships of race and gender to asthma care, particularly non-medication aspects of care recommended by national guidelines.
To fill this gap in knowledge, Hopkins researchers and their colleagues launched the Managed Health Care Association Outcomes Management System Asthma Project. The doctors gathered and analyzed information from 6,612 sicker-than-average asthmatic patients who were employees and dependents of some of the largest U.S. companies and had health insurance coverage through managed care.
In contrast to the consistent differences in care by race, the researchers discovered that asthma care did not favor either gender exclusively. Women tended to report better care except for two areas. Women did not use their daily asthma medications as frequently as men (50 percent versus 58 percent) and they tended to report seeing an asthma specialist less frequently than men (38 percent versus 43 percent).
"Why there are differences is a ripe area for more research," says Krishnan. "It could be factors related to how care is provided by health care providers, how care is accepted or received by different patients, or how a health system provides its care." Factors such as whether a physician is available by phone or after hours, or whether a patient has difficulty getting medications are examples of health system factors, he adds.
Between 12 million and 15 million people in the United States, including 5
million children, have asthma, a chronic disease in which airflow in and
out of the lungs may be blocked by swelling and excess mucus in the
airways. In 1997, more than 30.5 million prescriptions were filled for
asthma medication, and patients had approximately 1.2 million emergency
room visits and 445,000 hospitalization days. For more information on
research in asthma and other lung diseases at Johns Hopkins, visit
Other authors include Don Steinwachs, Ph.D., Albert Wu, M.D., M.P.H., Elizabeth Skinner, and Becky Clark. The study was supported by the Chest Foundation, a Glaxo Wellcome Clinical Research Trainee Award for Asthma (JAK), a National Heart, Lung and Blood Institute training grant, and the Managed Health Care Association Outcomes Management System Project Consortium..
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