In-hospital outcomes for asthma exacerbations vary by race

Rachel L. Miller, MD

I am not surprised at all by these findings. I was fortunate to participate in research led by Antonella Zanobetti, PhD, and referenced in the article, which found that lower-income households, poverty and high population density were associated with higher incidence of asthma among children.

Just this month, we published in The Journal of Allergy and Clinical Immunology that non-Hispanic and Hispanic Black children had higher rates of asthma with recurrent exacerbations than non-Hispanic white children (adjusted incidence rate ratios [aIRR] = 2.51; 95% CI, 2.1-2.99; vs. aIRR = 2.04; 95% CI, 1.22-3.39).

Even though their findings are not surprising, the well-conducted research by Debnath et al among adult inpatients deserves much attention. Their work contributes to the growing research that suggests that race is a social construct associated with a power hierarchy.

Public policies and societal or institutional practices may reflect some structural racism that may impact rates of hospital admissions and their associated clinical courses through social, educational or economic determinants of health.

Multi-level socioeconomic and environmental exposures, such as air pollution, allergens, nutritional inadequacies, inadequate health care/medication access or adherence, and co-morbid mental or physical health conditions, may impact access to optimal treatment or heighten the need for proper care and thereby increase the risk for asthma exacerbations and/or hospitalizations and how they recover once they are hospitalized.

Like other physicians involved in the care of patients with asthma, I continue to observe patients presenting to the ED for the treatment of asthma flares that could have been addressed earlier in the time course or possibly even prevented with optimal regular medical surveillance and treatment. We know from an abundance of data that not everyone has such access to proper medical care.

Doctors can continue to strive to overcome unconscious bias and help their patients overcome any barriers they face to obtain best medical care. They can review updated asthma management guidelines such as those published by the National Asthma Education and Prevention Program and strive to practice them for all patients or refer to specialists if they need more expertise.

Also, doctors can evaluate whether air pollution, allergens, nutritional inadequacies or co-morbid mental or physical health conditions may contribute to the asthma and should be addressed. Doctors can consider whether there is inadequate access to medications or issues related to adherence and address potential solutions with patients as well.

Furthermore, doctors can do their best to advocate for removing any barriers they observe in their own practice or system. This could be related to encouraging virtual visits if onsite visits are too challenging for patients or promoting practices that vaccinate patients against infectious asthma triggers (eg, influenza and other viruses, pneumococcus) according to CDC guidelines.

Doctors additionally can promote systems and workflows that communicate with insurers on behalf of their patients to be sure the medications advised are authorized and advocate for programs or local policies that address triggers of asthma such as mold remediation or smoking cessation.

Further interrogation of what elements play into these research findings could be very helpful. Rigorous research that analyzes policies as well as social, educational or economic determinants of risk for asthma hospitalizations and their inpatient clinical courses is important. Studies of interventions against these factors may help prevent inpatient admissions and reduce the mortality when they do occur.

References:

Cloutier MM, et al. J Allergy Clin Immunol. 2020;doi:10.1016/j.jaci.2020.10.003.

Miller RL, et al. J Allergy Clin Immunol. 2023;doi:10.1016/j.jaci.2023.03.016.

Zanobetti A, et al. JAMA Pediatr. 2022;doi:10.1001/jamapediatrics.2022.1446.

Hayden Bosworth, PhD

The findings were surprising. Given prior studies that have documented the impact of socioeconomic status and environmental factors on asthma outcomes such as poor asthma control, ED visits and increased mortality, one would expect that these patterns would continue in the hospital.

However, the authors reported that while Black patients were more likely to require noninvasive ventilation, intubation and longer use of mechanical ventilation, suggesting they may be entering the hospital with more asthma exacerbation, this severity did not necessarily translate into asthma mortality differences in the hospital.

The authors conclude that structural barriers such as access to care contribute to these well-documented racial and socioeconomic disparities, but once someone is able to get in the hospital, it becomes a more even playing field.

While I have not looked at this issue of pre-asthma and current asthma hospitalization, we do see a similar pattern for cardiovascular disease in my practice. Work in progress with our team has seen racial differences in cardiovascular disease pre-hospitalization. But during hospitalization, there is not much difference by race or gender, although 90 days after discharge, racial and gender disparities increase. Implicit biases and structural barriers may be less impactful in the hospital, but outside, this may not be the case.

It is becoming more apparent that structural inequities such as access to health care may play an important role in contributing to health inequities. One recent study supports this need to consider structural barriers. The authors found, for example, that historical redlining years later may impact mortality.

Redlining is a discriminatory practice in which services and investments are withheld from neighborhoods because of the racial or ethnic composition of the residents. These neighborhoods often are characterized by having significant numbers of low-income residents. The Debnath et al paper suggests the need to study and further identify structural inequities if we are to truly improve care for all.

Physicians can consider screening for social determinants of health such as access to care, transportation and food insecurity as quality measures. While it is important to screen for these barriers, it is only ethical to do so if there are adequate solutions in place if these barriers are identified. Do not ask if you do not know what you will do. Health care plans and payors are increasingly incorporating these social determinants of health screeners, knowing that many factors that impact health occur outside the four walls of the hospital and clinic.

We need data demonstrating the return on investment of addressing these structural barriers. While one can argue that screening for and intervening in these structural barriers are morally the right things to do, we also need better data demonstrating that it is also better for the payors financially, for the patients from a productivity and quality of life perspective, and from a clinician perspective that may help alleviate burnout.

Reference:

Burke CA, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.22673.