Studies show racial, ethnic disparities in allergy care
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Researchers discussed racial and ethnic disparities in various aspects of allergy at this year’s virtual meeting of the American College of Allergy, Asthma and Immunology.
In one presentation, Jonathan I. Silverberg, MD, PhD, MPH, director of clinical research and patch testing and associate professor in the department of dermatology at the George Washington University School of Medicine and Health Sciences, discussed studies on racial disparities in atopic dermatitis among children and adults in the United States and provided solutions to address these disparities.
In another presentation, researchers reported racial disparities in food allergy-related quality of life and determined that those of Asian descent had lower quality of life compared with other patient populations.
Racial disparities in atopic dermatitis
Silverberg cited data that showed the prevalence of atopic dermatitis was higher among Black children than white children in the United States. In addition, Black children had more severe and persistent symptoms, more sleep disturbances and “poorer overall health,” he told Healio Primary Care.
“Black children were also less likely to have an ambulatory visit for [atopic dermatitis] and more likely to have an emergency department or urgent care visit for [atopic dermatitis] and be hospitalized for [atopic dermatitis],” he said.
During the presentation, Silverberg also said that studies have found that Black and Hispanic children who have atopic dermatitis live in households with lower incomes and were more likely to be uninsured or underinsured. In addition, they were more likely to report that they had insufficient time with physicians during office visits.
“When we look into these interactions and dive deeply into the data, there’s a clear pattern — there’s definitely an effect of lower income and lack of private insurance, but this doesn’t explain the whole story,” Silverberg said during the presentation. “The effect sizes don’t add up, it doesn’t explain the whole story.”
He said that access to care is one problem contributing to these disparities. To address this, he suggested that physicians extend their office hours to include nights and weekends, provide flexible appointment slots for urgent visits, accept Medicaid, offer telehealth visits and provide 24-hour phone coverage to patients.
Silverberg added that increasing training for PCPs and other health care workers on how to manage atopic dermatitis is also important.
“There are not enough specialists in the country to handle every one of these patients, so at least the milder ones can be managed by our primary care colleagues, and we have to do a better job in assisting them,” he said during the presentation
To address bias, which could contribute to racial disparities in atopic dermatitis, Silverberg noted that completing implicit bias and health equity training, increasing diversity among practice staff and providers, and spending enough time with patients to educate them about their condition and treatments can help. Additionally, he said that understanding different phenotypic and psychosocial factors in atopic dermatitis in different patient populations can help address disparities, along with increasing community engagement to build trust among patients.
Recognizing biological and genetic differences can also help address disparities in atopic dermatitis care, according to Silverberg.
He noted that while most physicians believe FLG1 gene mutations are behind atopic dermatitis, they were only present in 20% to 50% of patients of Northern European and Asian descent, and studies have shown they are found in less than 5% of patients of African descent. While additional work has shown that an FLG2 mutation could be more prevalent in these patients, additional studies are needed.
But genetics are not the only driver behind disparities in atopic dermatitis, Silverberg said.
“There are other factors at play,” he added.
Silverberg stressed that one of the biggest issues is that there is a lack of awareness among physicians about how they should assess skin of color.
For instance, he explained that erythema, which is typically taught as being light pink or red in textbooks, appears differently in people of color. According to Silverberg, it often appears in shades of purple or brown.
“Darker skin pigment can mask redness and make it challenging to reliably assess the extent and severity of eczema lesions,” he told Healio Primary Care. “Black children and adults can present with different morphology than white children, including more follicular eczema, papular lichenoid lesions, nummular lesions and prurigo nodules.
“It is important for primary care physicians to recognize that atopic dermatitis can present very differently in Black and Hispanic children, and to get comfortable assessing atopic dermatitis in all patient subsets,” he said.
During the presentation, Silverberg said a multitiered approach — including improving access to care, reducing bias and improving physicians’ understanding of how atopic dermatitis presents in patients and their response to treatment — is needed to address racial and ethnic disparities in atopic dermatitis.
Tania Elliott, MD, a clinical instructor at NYU Langone Health and a spokesperson for the American College of Allergy, Asthma and Immunology, told Healio Primary Care that “more attention needs to be paid to health care disparities for common childhood diseases.”
She added that this attention “starts with education and training of the health care community as well as schools to recognize some of the common symptoms of atopic dermatitis, such as frequent itching and scratching, and daytime sleepiness which can be a result of uncomfortable atopic dermatitis that isn't properly treated.”
Disparities in food allergy quality of life
Other data presented at the meeting showed that Asian children and their parents have significantly lower food allergy-related quality of life compared with white and Black patients and parents.
“This is important for clinicians to know so they have increased awareness that these families may be at higher risk for stresses related to food allergy and can screen for this at visits,” Christine Rubeiz, MD, lead author of study and a member of ACAAI, told Healio Primary Care.
Rubeiz and colleagues reviewed information collected from allergy clinic visits from July 2014 through October 2019. They assessed data from 6,829 Food Allergy Quality of Life Questionnaires – Child, Teen and modified Parental Burden forms.
They found that Asian patients and parents had significantly higher scores than white and Black patients and parents, corresponding to a lower quality of life.
The researchers also found that total food allergy-related quality of life scores did not significantly differ based on patients’ insurance type.
However, they determined that Asian patients and parents in the non-Medicaid group had significantly higher scores than white and Black patients without Medicaid.
When specifically examining Medicaid patients, Rubeiz and colleagues found that Black and Hispanic patients and parents had significantly greater food allergy-related quality of life scores compared with white patients and their parents.
Amal Assa’ad, MD, associate director and director of clinical services in the division of allergy and immunology at Cincinnati Children's Hospital Medical Center, told Healio that there are multiple factors that could contribute to lower food allergy-related quality of life. These factors include parents who are first-generation U.S. immigrants who may be anxious about how food allergies are handled, a shift in the child’s diet from home to school, and anxiety related to education and social class.
Assa’ad said the findings can help physicians address “concerns and anxiety of the family in a culturally sensitive way.”
“With improved awareness, clinicians can screen at-risk families for worsened food allergy-related quality of life and gain more insight into the reasons behind the disparity in quality of life,” Rubeiz added. “Additionally, better screening tools and culturally targeted interventions would be an eventual goal.”
References:
Rubeiz C, et al. A041. Presented at: ACAAI Annual Scientific Meeting; Nov. 13-15, 2020; Virtual.
Silverberg J, et al. Addressing Racial and Ethnic Disparities in Allergy/Immunology Populations. Presented at: ACAAI Annual Scientific Meeting; Nov. 13-15, 2020; Virtual.