Collaboration, technology may combat persistent disparities in asthma care

Key takeaways:

• Black and Hispanic patients have a higher asthma burden than white patients.
• The impact of historic redlining on asthma outcomes is still present today.
• Collaboration may mitigate barriers to care.

ANAHEIM, Calif. — Although disparities remain in asthma care, innovative strategies may close these gaps, according to a presentation at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

“Asthma disparities persist despite all of our medical advances,” Tamara T. Perry, MD, professor and chief of allergy and immunology at University of Arkansas for Medical Services and Arkansas Children’s Hospital, said during her presentation.

“But we can address that with some more large-scale interventions that really look at the social and contextual factors that are associated with asthma disparities,” she continued.

Defining, locating disparities

Perry noted that the CDC defines health and health care disparities as differences in health outcomes between groups that reflect social inequalities.

Tamara T. Perry

Disparities also refer to preventable differences in the burden of disease, injury, violence or opportunities to achieve optimal health care that are experienced by socially disadvantaged populations, she said.

“We’re talking about differences, and those differences really show up in a lot of different ways,” Perry said.

These include access to care, quality of care, life opportunities, stress and exposures.

“Those are the structural and social determinants that will drive health decisions and health outcomes for our patients,” Perry said.

Twenty percent of health care outcomes are related to what physicians can impact directly, such as access to care and the quality of that care, Perry said. The remaining 80% is related to the patient’s physical environment, social determinants and behaviors.

“Think about how you can help to impact the other 80%,” she said.

Patients who identify as Black, Hispanic or Indigenous have the highest burdens of asthma in the United States, Perry said, adding that compared with white patients, patients who are Black are nearly 1.5 times as likely and patients who are Puerto Rican are nearly twice as likely to have asthma.

“Black Americans visit the emergency room at a rate five times higher compared to white individuals, and [Black patients] are more than three times more likely to die due to asthma,” she continued.

Black women have the highest rates of death due to asthma as well, Perry added, with these disparities consistent between 2001 and 2017. Asthma is more likely among patients from impoverished environments as well.

Perry cautioned that race itself does not cause these disparities.

“Poor housing quality, material hardship, health literacy, income, insurance and neighborhood walkability are really the mediators of these disparities,” Perry said.

Practices such as historical redlining led to these disparities, as the Home Owners’ Loan Corporation created and maintained a discriminatory four-tier grading system to appraise mortgage applications in more than 200 metropolitan areas.

Neighborhoods classified as “A” or “green” neighborhoods were rated the “best,” and “D” or “red” neighborhoods were considered “hazardous.”

“Those living practices that were practices almost a hundred years ago still have an impact on today’s asthma outcomes,” Perry said.

In a study published in 2022 in American Journal of Respiratory and Critical Care Medicine, researchers studied 2008 to 2019 data from 1,034 patients in the Pittsburgh/Allegheny County asthma registry who had been subjected to historical redlining and lived in “D” neighborhoods.

These patients had higher rates of uncontrolled asthma, severe asthma exacerbations, exacerbation-prone asthma, daytime asthma and missed school or work, in addition to current diabetes, worse lung function and current eczema, Perry said.

Additionally, she said, these patients were less likely to be prescribed an allergen immunotherapy or receive biologic therapy for their asthma.

These neighborhoods also included disproportionate industrial, commercial and transportation-related land use, with higher levels of carbon monoxide emissions, filterable particulate matter, sulfur dioxide and volatile organic compounds.

“This was correlated with worse asthma outcomes,” Perry said.

In another study of eight cities in California, Nardone and colleagues found higher percentages of Black and Hispanic residents in “D” neighborhoods, with higher percentages of poverty, higher exposure to particulate matter at the 2.5 µm scale, higher exposure to diesel particulate matter, and higher rates of ED visits as well.

In a third study of more than 36,000 children who had approximately 186,000 ED visits, Correa-Agudelo and colleagues found that Black children were almost twice as likely to have an ED visit and have Medicaid, live in socially deprived neighborhoods and have less green space.

“Looking at all those determinants, they concluded that 55% of that effect was actually due to social, economic and environmental factors, and not race,” Perry said.

Patients in these circumstances may miss appointments and fall short in medication adherence, Perry said, underscoring the importance of good patient-provider relationships.

By talking with their patients, she continued, physicians may find out that their patients have barriers such as a high copay or a lack of insurance. Also, they might not understand or forget the instructions, or they might not have transportation to get to the appointment or to the pharmacy.

Further, patients who work may not have personal time off to attend appointments, or they may be denied time off despite the Family and Medical Leave Act. Competing priorities and parental stress interfere with getting care too.

Patients with multiple ED visits may seek care there because they cannot find a specialist who accepts their insurance, they have run out of prescribed refills, there is no pharmacy nearby, they have been triggered by an environmental exposure or because they have undertreated their disease.

“You feel like you’re banging your head against the wall. You’re like, ‘Why aren’t you picking up your meds?’ Just ask the patient why, because oftentimes, you’ll be surprised,” Perry said.

Potential interventions

Physicians can address these inequities with guidelines-based asthma care, Perry said.

Challenges at the system level include medication coverage, asthma health literacy, limited access to quality services and inequitable receipt of care.

Solutions can include improved care coordination, collaboration with pharmaceutical agencies, taking steps to counter implicit and explicit bias, addressing health equity, enhancing community-based programming and telemedicine, Perry recommended.

At the patient level, challenges include treatment preferences, adherence issues, limited health literacy, the social environment, economic instability, and health and risk behavior.

Again, solutions may include telemedicine and care coordination, along with referrals to local services, improved educational and professional opportunities, and improved access to social services.

Challenges for physicians and health care workers may include the availability of asthma specialists, linguistic and cultural competency and limitations from payers.

Improvements here may include efforts to increase access to specialists, telemedicine and technology, and better medication coverage.

Perry, who also is the medical director of telemedicine for the Arkansas Children’s system, said that telemedicine can level the playing field for many patients who may not be able to travel to asthma specialists or who may not have a specialist in their hometown.

“We’re able to really deliver high-quality asthma and comprehensive care,” Perry said.

Arkansas Children’s telemedicine program has respiratory therapists on staff who collaborate with clinics across the state to provide remote pulmonary function testing including spirometry for adults and children alike.

There have not been any adverse patient outcomes in the program, and pulmonologists have been able to interpret 84% of the tests. Also, lung function has not declined over time.

Perry emphasized the impact that care coordination may have on outcomes as well, including partnerships between patients and their families, primary care providers, specialists and schools and school nurses.

“I want to also encourage our allergy/immunology colleagues to partner with patients and families because I think you will be really surprised at how much more productive your relationship is with your patient or their family if you just slow down a little bit to figure out what their goals are,” she said.

“Also, address some of the barriers. That could be a really simple thing that is a big determinant in the patient receiving care,” she continued.

For example, Perry described a patient whose family was having issues with transportation to appointments. Perry and her colleagues then found free transportation for that patient, which she said made a significant difference.

“There are some local services, oftentimes, that can address some of these determinants that are impeding the care that patients are receiving,” Perry said.

Mobility may have an impact on outcomes as well, as residents in Baltimore who lived in neighborhoods with high levels of poverty moved to neighborhoods with low levels of poverty and then experienced reductions in asthma exacerbations and symptoms.

“This reduction happened just while simply moving,” Perry said.

These reductions were comparable or greater than reductions achieved via inhaled corticosteroids or biologic therapy, she continued.

Next steps

Perry called for greater representation of diverse groups in asthma research and in the design of interventions.

“We can go into communities and go to these target populations and find out what their concerns are and design our interventions around the things that are important to families and patients that will be more fruitful in our dissemination long term,” she said.

Also, she said a better understanding of the epigenetics of asthma is important.

“If we don’t know the transgenerational and epigenetic consequences of living in — or your father, grandfather, mother, grandmother living in — those grade D neighborhoods for decades, how does that equate to a child or patient in today’s times?” she said. “Then we’ll get to innovative strategies to decrease disparities.”

Overall, Perry called for more efforts across health care including collaboration and technology at the individual, neighborhood and societal levels to combat these disparities.

“We need to address those social barriers, including systemic and structural racism,” she said.

References:

• Correa-Agudelo E, et al. J Allergy Clin Immunol. 2022;doi:10.1016/j.jaci.2022.07.024.
• Nardone A, et al. Lancet Planet Health. 2020;doi:10.1016/S2542-5196(19)30241-4.
• Schuyler and Wenzel. Am J Respir Crit Care Med. 2022;doi:10.1164/rccm.202112-2707OC.