Severe asthma patients facing social disparities see gaps in care

Key takeaways:

• A significant number of patients with uncontrolled severe asthma (SA) had no record of specialist visits or medication escalation.
• Uncontrolled SA led to more health care resource use and exacerbations.

Patients with severe asthma saw less escalation of care after uncontrolled disease, with non-white patients showing significantly less care, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.

These results emphasize the possibility of racial disparities existing within asthma care in the United States as well as the need to improve care-delivery guidelines for those facing social disparities, Joseph Tkacz, MS, associate vice president, health economics and outcomes research, Inovalon, and colleagues wrote.

“The need for a more up-to-date analysis of the care received among patients with severe asthma after events indicating uncontrolled disease, and the relationship of this care to disease exacerbations, health care resource use and costs, and factors associated with social disparity” prompted this study, Tkacz told Healio.

Methods

The observational, retrospective study analyzed administrative claims from Medicaid and Medicare databases of patients who had severe and persistent asthma between Jan. 1, 2015, and Dec. 31, 2020.

Patients aged 12 years and older with severe asthma (SA) with no biologics use and no other major respiratory diseases were recruited for a 12-month enrollment period. The SA index date was determined by the earliest appearance of severe disease.

Twelve months after the index date, patients needed to meet the Health Care Effectiveness Data and Information Set definition of persistent asthma. The data were then indexed hierarchically on asthma-related events indicating uncontrolled disease (EUD), which included instances of hospitalizations, ED visits with systemic corticosteroid (SCS) treatment, and outpatient visits with SCS treatment.

The patients that had SA but did not experience EUDs served as controls. Control patients were matched in a 1:1 ratio. The hierarchy was assigned by EUD severity classification in four tiers.

The first tier included the most severe, with one or more asthma-related hospitalizations. The second consisted of two or more asthma-related ED visits followed by SCS use within 7 days.

The third consisted of one asthma-related non-ED outpatient visit and one asthma-related ED visit within 12 months, both needing SCS. The fourth tier was the least severe and had patients with two or more asthma-related non-ED outpatient visits within 12 months with SCS use.

Patients were examined for comorbidities, asthma treatments and clinical characteristics using the Elixhauser Comorbidity Index as well as demographics such as age, sex, insurance type and U.S. Census region. Specialist visits, medication escalations and exacerbation events were assessed during follow-up.

Results

The final sample of patients with SA included 90,368 in both the uncontrolled and control groups. During the post-index period, 50.5% of the uncontrolled group and 22.9% of the controls had a specialist visit.

Post-index medication escalation was also seen in 27.6% of patients in the uncontrolled group vs. 10.6% of the controls. New controller medication was the most common escalation, added by 15.4% of the full cohort, 21.5% of the uncontrolled group and 9.2% of the control group. 

During this period, percentages of patients with SA and an EUD but no specialist visit or medication escalation after an uncontrolled index event ranged from 34.9% for those with a hospitalization for asthma to 51% for those with two or more ED visits.

Across EUD tiers, percentages of patients who experienced follow-up exacerbations ranged from 50.7% among those with one ED and one outpatient visit to 63.9% among those with two ED visits, compared with 12.9% in the controls.

Specifically within the Medicare Fee-for-Service database (n = 48,582), 6,787 patients identified as Black, 1,505 as Hispanic/Latino, 37,261 as non-Hispanic White, and 3,029 as “other,” which included Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, and an unknown race category.

In the uncontrolled group, 41% of Black patients had no evidence of a specialist visit or a medication escalation after an uncontrolled event, as did 38% of Hispanic/Latino patients, 33% of non-Hispanic white patients, and 39% of patients of other races.

Following an asthma-related hospitalization, percentages of patients who did not have specialist visits or medication escalation included 35% of Black patients, 32% of Hispanic/Latino patients, 28% of non-Hispanic white patients, and 33.4% of patients of other races.

The authors concluded that their findings emphasize the existence of care gaps and disparities in the management of severe asthma in the United States, with data indicating that a guideline-recommended specialist visit did not occur for 45% to 63% of patients with uncontrolled disease.

“Guideline-appropriate treatment of severe asthma entails referral to a specialist for consultation or co-management, especially after an exacerbation,” Tkacz said. “In the current study, approximately 40% of patients with uncontrolled severe asthma presented no evidence of escalation of care after an event indicative of uncontrolled disease, such as a hospitalization or multiple emergency department visits.”

These findings also highlight that gaps in care were significantly worse in non-white populations as well as among those with two or more asthma-related ED visits.

“Uncontrolled severe asthma patients who were Black or Hispanic/Latino were less likely to show an escalation of care following an event indicative of uncontrolled disease, compared with non-Hispanic white patients,” Tkacz said.

The authors called for updated health policy and future research to ensure equitable access to care and to address the existing disparities.

“The present study provides compelling evidence that a substantial proportion of the population of U.S. patients with severe asthma are not receiving the appropriate level of care escalation following an event indicating uncontrolled disease, and that non-white patients are even less likely to receive such escalation of care,” Tkacz noted.

He further stated that providers should utilize formalized protocols or computer decision-support systems to improve guideline adherence and clinical outcomes, including improved screening for biologic treatment eligibility, particularly among racial minorities.

“The present findings can be leveraged to initiate multifaceted quality improvement programs designed for patients with severe asthma to enhance provider education and increase delivery of guideline-directed medical therapy,” Tkacz said.