Q&A: Disparities persist despite progress in asthma care

Key takeaways:

• Asthma prevalence remained flat between 2017 and 2021.
• Minorities and children experience greater prevalence of asthma.
• Medicare and Medicaid reform can improve access to care.

The medical community recognizes World Asthma Day on the first Tuesday of each May to spotlight the progress made in asthma care and the challenges that remain.

Healio spoke with Paul V. Williams, MD, president of the American Academy of Allergy, Asthma & Immunology, about the state of asthma care today.

Healio: Could you summarize the prevalence and burden of asthma in 2024?

Williams: I can only provide a guesstimate for 2024, as the data from the latest National Health Interview Survey for 2021 to 2023 are still being processed. Since the 2021 numbers show a relatively flat curve over the previous few years, I would venture to say that there probably will be little change. The only exception is 2020, where COVID-19 ended up with reduced asthma hospitalizations. I don’t think there have been enough advances in therapy to change these numbers over the last few years.

The prevalence of asthma In 2021 was 7.7%. This represents about 25 million people, 5 million of whom are aged younger than 18 years. These numbers were relatively flat from 2017 to 2021. There remains a marked difference racially/ethnically with the prevalence in non-Hispanic Black individuals at 10.9% compared with non-Hispanic white individuals at 7.6%, and Hispanic individuals at 5.5%. This difference is markedly higher in children, with non-Hispanic Black children having a prevalence of 11.6% whereas non-Hispanic white children are at 5.5%.

Ambulatory visit data from the National Ambulatory Medical Care Survey show that visits declined from 40.2 to 30.1 per 1,000 persons from 2001 to 2016. In 2016, there were 9.8 million asthma visits. If you look at the at-risk population (visit burden among the population of persons with asthma, as opposed to the general population), the visits are higher, but still declining from 55.5 to 36.7 per 100 persons with asthma. Visits were highest for children aged 0 to 4 years and lowest for those aged 15 to 24 years. Visits were similar across sex, racial and ethnic groups.

According to the CDC, ED visits declined from 62.6 to 29.8 per 10,000 persons from 2001 to 2020, with the rate in white individuals at 13.9 per 10,000 persons and Black individuals at 82.8 per 10,000 persons. We can’t tell from the data how much this difference is related to a lack of primary care. Similar to ambulatory visits, the ED visits were highest for children aged 0 to 4 years at 42 per 10,000 persons.

Hospitalizations declined from 13 per 10,000 persons in 2001 to 2.9 per 10,000 persons in 2020, but the rate was relatively flat from 2016 to 2019. Black individuals, however, were almost five times as likely to be hospitalized as those who were white (1.5 vs. 7.1). This difference was almost six times larger in children. Again, the highest hospitalization rate was for children aged 0 to 4 years.

Asthma deaths have declined from 15 per 1 million persons in 2001 to 10.6 per 1 million persons in 2021, but again, there has been no change since 2016. About 3,500 deaths each year are due to asthma. The death rate for Black individuals is almost 2.5 times as great compared with white individuals (24.4 vs. 9.8 per 1 million persons, respectively). Most deaths occur in those aged 65 years and older.

These data may be a bit skewed compared with 2024 due to the change in ICD coding that occurred in 2016, which allowed for better classification of asthma severity and control, and most ambulatory visits had no documentation of severity or control. Also, there have been additional biologic therapies for asthma since late 2018.

Healio: Why is it important for the specialty and the public to recognize World Asthma Day?

Williams: For the specialty, so we can highlight the need for individual care for our asthma patients, and to highlight the ongoing morbidities and financial burden of proper management. There is still some degree of underdiagnosis and certainly undertreatment, and an increased awareness would help both. Changes in the cost of maintenance inhaled therapy coming later this year may make a big difference for the majority of those with asthma.

Healio: What have been some of the most significant advances in asthma treatment over the past year?

Williams: The treatment approach to asthma has changed over the past several years, from symptom control to reduction of exacerbations and now more individualized therapy. There is now a clinical research focus on asthma remission, and whether any of the therapies we have can bring about asthma remission.

As far as advances in the last year, there are not any new therapies available. Although proposed more than a year ago, the newest approach to therapy that has not reached wide use in the U.S. due to a variety of factors is single maintenance and reliever (SMART) or MART therapy, where the same inhaler is used for both maintenance and quick relief. In addition, the concept of using an inhaled steroid along with a short-acting bronchodilator for symptoms and short courses of inhaled steroids with upper respiratory infections has been proposed for those ages and asthma severities that do not qualify for SMART/MART therapy.

Healio: What are some of the biggest challenges in providing asthma care today?

Williams: Clearly based on the data discussed above, we haven’t made much progress in hospitalizations or in disparities in asthma morbidities. There remain problems with access to specialty care and the ability to afford or have access to medications or biologics that are indicated for our patients.

Healio: On a practice level, what can be done to overcome these challenges?

Williams: Earlier diagnosis of asthma, accurate assessment of severity and timely access to indicated medications for the individual patient. Currently, unfortunately, the patient’s physician does not have ideal control of medication access.

Healio: On a policy level, what can be done to mitigate these challenges?

Williams: On the state level, increases in Medicaid payment need to be made to allow for better access to specialty care. On both a state and national level, we need to limit prior authorization policies so that the physician, and not the payer, directs patient care.

Although not policy, to add to access, we need to attract more minorities to health care in general and to the allergy/immunology specialty. This would increase trust in the medical system.

At the federal level, we need to reform the Medicare payment system to further increase access for older patients. Make the telehealth waivers made for the pandemic permanent. Require private payers, and government payers, to cover telehealth at similar levels to in-office care. Advocate for increases in research funding for asthma.

Educate policymakers, payers, primary care physicians and patients about fellowship-trained, board-certified allergists training and disorders that they care for. Improve PCP-specialist communication and cooperation. Finally, reduce the cost of medications for the patient.

Healio: Have there been any impactful advances in advocacy over the past year?

Williams: Some advances in prior authorization and awareness of the need for Medicare reform have been accomplished. Policies relevant to access for “medical foods” for eosinophilic esophagitis patients and access to alternative foods in the Special Supplemental Nutrition Program for Women, Infants, and Children system for food allergic patients also have improved, although we still need better coverage for early introduction of potential food allergens. The AAAAI advocacy committee is following many proposed bills in Congress that would improve access to care, and medications for allergy patients.

Healio: Looking ahead, what trends will have the biggest impact on asthma care?

Williams: The pressure from Congress to lower the cost of medications for patients with chronic disease has led to lower out-of-pocket costs for maintenance inhaled medications for asthma patients, which is likely to impact the largest number of patients, and reduce exacerbations, ED visits and hospitalizations. Removal of prior authorization requirements and step therapy will also have similar impacts when medications cost less for the patient. Continued coverage for telehealth and advances in remote patient monitoring will increase adherence to therapy and better patient follow-up, leading to reductions in morbidity.

References:

• 2021 National Health Interview Survey (NHIS) data. CDC. Reviewed March 29, 2023. Accessed May 6, 2023. https://www.cdc.gov/asthma/nhis/2021/data.htm.
• Akinbami LJ, et al. National Health Statistics Report. CDC. Sept. 20, 2019. Publication 128. Accessed May 7, 2024. https://www.cdc.gov/nchs/data/nhsr/nhsr128-508.pdf.
• Asthma. https://www.cdc.gov/nchs/fastats/asthma.htm#:~:text=1%20Annual%20number%20of%20office%20visits%20for%20asthma%3A,with%20asthma%20indicated%20on%20the%20medical%20record%3A%206.3%25. Reviewed Nov. 6, 2023. Accessed: May 7, 2024.
• Asthma Surveillance Team. Asthma surveillance in the United States, 2001-2021. CDC. Accessed May 7, 2023. https://www.cdc.gov/asthma/asthma-prevalence-us-2023-508.pdf.

For more information:

Paul V. Williams, MD, can be reached at pvwilliams@earthlink.net.