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You Are Here: AHRQ Home > About AHRQ > AHRQ 2008 Annual Conference > Slide Presentation (Text Version)

Determinants of Asthma Morbidity Among Inner-City Populations

Slide Presentation from the AHRQ 2008 Annual Conference

On September 8, 2008, Juan P. Wisnivesky, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (708 KB).

Slide 1

Determinants of Asthma Morbidity Among Inner-City Populations

Juan P. Wisnivesky, MD, MPH
Divisions of General Internal Medicine and Pulmonary, Critical Care,
and Sleep Medicine
Mount Sinai School of Medicine.

Slide 2

Inner-City Asthma

  • Asthma is a chronic disease affecting 15 to 17 million Americans.
  • Minority inner-city populations are disproportionately affected by asthma.
  • African Americans and Hispanics have 2 to 3 times greater rates of death due to asthma when compared to whites.
  • New York City has asthma mortality rates 10 times the national average.

Slide 3

Determinants of Morbidity Among Inner-City Asthmatics

  • Study Goal: to evaluate the role of patient, provider, and environmental factors on outcomes of inner-city asthmatics

Slide 4

Study Outline

  • Month 0-1:
    • Demographics, Asthma regimen, medication beliefs, disease beliefs, communication:
      • Physician Survey: Mount Sinai Hospital Metropolitan Hospital, North General Hospital, Local health centers, Rutgers University
      • Baseline Survey: Mount Sinai Hospital, Rutgers University/Pulmonary function tests, Blood for IgE, serum, DNA Chart review
  • Month 1-3:
    • Electronic measure of adherence*
      • First telephone follow-up.
  • Month 3-12:
    • Adherence, Asthma control, Resource utilization, Quality of life.
      • Second telephone follow-up.
  • Month 12:
    • Third telephone follow-up.
  • Note: *Covers month 1 through 12.

Slide 5

Potential Determinants of Asthma Morbidity in Inner-City Populations

The diagram shows both the internal and external factors in play with a patient's Asthma.

  • Internal Influences:
    • Clinical Factors:
      • Genetics
      • Asthma history
      • Sensitization
      • Smoking
    • Behavioral Processes:
      • Adherence to controller meds
      • Adherence
      • Self-regulation of meds
      • Self-monitoring
      • Trigger avoidance
    • Cognitive/Emotional Processes
      • Self regulation beliefs
      • Knowledge
      • Self efficacy
      • Depression/anxiety
    • Sociodemographics:
      • Age, sex, race, ethnicity
      • Language, culture, education, and income.
  • External Influences:
    • Environmental Factors:
      • Housing conditions
      • Passive smoking
      • Aeroallergens
      • Air pollution
    • Physician Factors:
      • Knowledge
      • Attitudes
      • Communication
      • Language
    • System Factors:
      • Access to care
      • Pt education capacity
      • Gatekeeping
      • Insurance
      • Transportation
  • Outcomes:
    • Symptoms
    • Quality of life
    • Airway function
    • Resource utilization

Slide 6

Characteristics of Study Population (N=326)

Characteristic Value
Age (yrs), mean±SD 48±13
Female (%) 83
Race/Ethnicity (%)  
   Hispanic 56
   African-American 28
   White 12
   Others 4
Insurance (%)  
   Medicaid 62
   Medicare 18
   Commercial 17
   Uninsured 3
Income <$15,000/yr (%) 62
Asthma History  
   Age Onset (yrs), mean±SD 26±15
   ED visit last year (%) 52
   Hospitalized last year (%) 23
Controller Medication (%) 25
Comorbid Conditions (%)  
   Eczema 19
   Chronic sinusitis 23
   Diabetes 25
   Hypertension 46
Environmental Exposure (%)  
   Second hand smoking 25
   Cat 23
   Cockroach 44
   Dampness/Mold 51
   Rodents 40

Slide 7

Disease Beliefs and Asthma Self-Management

  • Self-management is critical for long-term asthma control
  • "Do you think you have asthma all of the time or only when you are having symptoms?"
  • Responses:
    • I have it all of the time.
    • Most of the time.
    • Some of the time.
    • Only when I am having symptoms.
  • 53% of patients were classified as having the no symptoms-no asthma, acute episodic disease belief.

Note: Halm EA, et al. No Symptoms, No Asthma. The Acute Episodic Disease Belief Is Associated With Poor Self-Management Among Inner-City Adults With Persistent Asthma. Chest, 2006.

Slide 8

Associations Between the No Symptoms, No Asthma Belief and Other Key Asthma Beliefs and Behaviors

Beliefs and Behaviors Acute Belief, % Chronic Belief, % OR (CI)
I will not always have asthma 31 9 4.49 (1.94—10.42)
My lungs are always inflamed/irritated 43 67 0.36 (0.20—0.66)
Medication beliefs
ICS use is important when no symptoms 56 77 0.38 (0.19—0.74)
Medication adherence (ICS)
Use it all/most of the time when no symptoms 45 70 0.35 (0.19—0.64)
Other self-management behaviors
Routine asthma visits when no symptoms 50 65 0.54 (0.30—0.97)
Use PFM all/most of the days 14 30 0.39 (0.19—0.80)
Use PFM to self-adjust medicines 15 25 0.53 (0.25—1.09)

Slide 9

Adherence to Inhaled Corticosteroids (ICS)

  • ICS are the cornerstone of asthma therapy.
  • Adherence to ICS is often suboptimal.
  • Medication Adherence Reporting Scale (MARS).
  • 60 patients were given an electronic monitoring device.
  • 53% of prescribed days used ICS, 35% of the doses prescribed.
  • Identify key medication beliefs independently associated with adherence with ICS.

Slide 10

Medication Beliefs Associated with ICS Adherence (MARS)

Medication Belief OR P-value
Important to take when asymptomatic 4.2 <0.001
Confident in ability to use ICS as prescribed 2.2 <0.001
Worry about side effects 0.5 <0.001
Medication regimen hard to follow 0.5 0.04
  • Note: Repeated measures regression adjusted for age, sex, prior intubation, and frequency of oral steroid use.

Slide 11

The Relationship Between Language Barriers and Outcomes of Inner-city Asthmatics

  • 11 million people living in the U.S. have no or limited English-language skills.
  • Limited English proficiency can impair access to quality health care.
  • Adequate patient-provider communication is a key aspect of asthma management.
  • The objective of this analysis was to assess how language barriers affect the outcomes of adult inner-city asthmatics.

Slide 12

Asthma Control in Relationship to English Proficiency

The bar graph shows:

  • Asthma Control Scores for 1-month follow-up (P=0.01):
    • Non-Hispanics: approximately, 2.7
    • Hispanics, proficient in English: approximately, 2.8
    • Hispanics, limited proficiency: approximately, 3.3
  • Asthma Control Scores for 3-month follow-up (P<0.0001):
    • Non-Hispanics: approximately, 2.6
    • Hispanics, proficient in English: approximately, 2.8
    • Hispanics, limited proficiency: approximately, 3.6
  • Note: Wisnivesky J, et al. Assessing the Relationship between Language Proficiency and Asthma Morbidity amongst Inner-city Asthmatics. Medical Care, In Press.

Slide 13

Resource Utilization in Relationship to English Proficiency

The bar graph shows:

  • Percentage of Outpatient Exacerbations (P=0.004):
    • Non-Hispanics: approximately, 19
    • Hispanics, proficient in English: approximately, 17
    • Hispanics, limited proficiency: approximately, 38
  • Percentage of ED Visits-Hospitalizations (P=0.007):
    • Non-Hispanics: approximately, 18
    • Hispanics, proficient in English: approximately, 21
    • Hispanics, limited proficiency: approximately, 35

Slide 14

Quality of Life in Relationship to English Proficiency

The bar graph shows:

  • Quality of Life Score for 1-month follow-up (P=0.002):
    • Non-Hispanics: approximately, 4.8
    • Hispanics, proficient in English: approximately, 4.4
    • Hispanics, limited proficiency: approximately, 4
  • Quality of Life Score for 3-month follow-up (P=0.0001):
    • Non-Hispanics: approximately, 4.8
    • Hispanics, proficient in English: approximately, 4.5
    • Hispanics, limited proficiency: approximately, 3.7

Slide 15

Medication and Disease Beliefs, Self-Efficacy, and Adherence According to English Proficiency

Variable Non-Hispanics N=141 Hispanic, Proficient N=120 Hispanics, Limited Proficiency N=57 P-value
Medication Beliefs (%)        
Worry Side Effects ICS 40 51 69 0.002
Worry Addiction to ICS 24 31 46 <0.0001
ICS are Controller Meds 85 80 73 0.19
Disease Beliefs (%)        
No Symptoms, No Asthma 28 42 47 0.009
Asthma is Chronic Disease 72 62 53 0.02
Self-efficacy (%)        
Confident Control Asthma 84 76 56 0.003
Confident Use ICS 95 92 79 0.02
Control Over Future Health 86 76 49 <0.0001

Slide 16

The Role of Allergic Sensitization on Asthma Morbidity

  • Inner-city residents are often exposed to high levels of indoor allergens.
  • Sensitization to cockroach allergen has been linked to increased asthma morbidity in children.
  • Recent data suggest that sensitization to indoor allergens may worsen asthma in elderly patients and pregnant women.
  • Objective of the study was to evaluate the role of sensitization to indoor allergens on asthma control among inner-city asthmatics.

Slide 17

Prevalence of Sensitization to Indoor Allergens Among Inner-city Asthmatics

The bar graph shows:

  • Percent Sensitized:
    • Dust Mites: approximately, 43%
    • Cat: approximately, 40%
    • Cockroach: approximately, 55%
    • Mouse: approximately, 20%
    • Molds: approximately, 15%
  • Note: Wisnivesky J, et al. Association between indoor allergen sensitization and asthma morbidity in inner-city asthmatics. JACI, 2007.

Slide 18

Asthma Control According to Sensitization Status

The line graphs show:

  • Asthma Control Scores for Cockroach Sensitization (p>0.4):
    • Sensitized:
      • Month 0: approximately, 3.3
      • Month 1: approximately, 2.8
      • Month 3: approximately, 3.2
    • Not Sensitized:
      • Month 0: approximately, 3.1
      • Month 1: approximately, 3.0
      • Month 3: approximately, 3.4
  • Asthma Control Scores for Mouse Sensitization (p>0.2):
    • Sensitized:
      • Month 0: approximately, 3.4
      • Month 1: approximately, 3.3
      • Month 3: approximately, 3.6
    • Not Sensitized:
      • Month 0: approximately, 3.2
      • Month 1: approximately, 3.0
      • Month 3: approximately, 3.2
  • Asthma Control Scores for Cat Sensitization (p>0.15):
    • Sensitized:
      • Month 0: approximately, 3.1
      • Month 1: approximately, 3.1
      • Month 3: approximately, 3.1
    • Not Sensitized:
      • Month 0: approximately, 3.1
      • Month 1: approximately, 2.8
      • Month 3: approximately, 2.9
  • Asthma Control Scores for Mold Sensitization (p>0.6):
    • Sensitized:
      • Month 0: approximately, 3.3
      • Month 1: approximately, 3.0
      • Month 3: approxiamately, 3.3
    • Not Sensitized:
      • Month 0: approximately, 3.1
      • Month 1: approximately, 2.8
      • Month 3: approximately, 3.1

Slide 19

Resource Utilization According to Sensitization Status

The bar graphs show:

  • Percentage of Cockroach Sensitization:
    • Steroid Use:
      • Sensitized: approximately, 26%
      • Not Sensitized: approximately, 24%
    • ED Visit:
      • Sensitized: approximately, 19%
      • Not Sensitized: approximately, 18%
  • Percentage of Mouse Sensitization
    • Steroid Use:
      • Sensitized: approximately, 18%
      • Not Sensitized: approximately, 25%
    • ED Visit:
      • Sensitized: approximately, 22%
      • Not Sensitized: approximately, 18%
  • Percentage of Cat Sensitization (**P=0.06)
    • Steroid Use:
      • Sensitized: approximately, 20%
      • Not Sensitized: approximately, 28%
    • ED Visit:
      • Sensitized: approximately, 11%
      • Not Sensitized: approximately, 21%
  • Percentage of Mold Sensitization
    • Steroid Use:
      • Sensitized: approximately, 15%
      • Not Sensitized: approximately, 20%
    • ED Visit:
      • Sensitized: approximately, 15%
      • Not Sensitized: approximately, 20%

Slide 20

Barriers to Adherence to Asthma Management Guidelines among Primary Care Providers

  • Knowledge
    • Lack of Familiarity
      • Volume
      • Time
      • Accessibility
    • Lack of Awareness
      • Volume
      • Time
      • Accessibility
  • Attitudes
    • Lack of Outcome Expectancy
    • Lack of Self-efficacy
    • Lack of Motivation/Inertia
    • Lack of Agreement
      • Specific items
      • Guidelines in general
  • Behavior
    • External Barriers
      • Patient factors
      • Guideline factors
      • Environmental factors
  • Note: Adapted from Cabana MD, et al. Why don't physicians follow clinical practice guidelines? a framework for improvement. JAMA 1999.

Slide 21

Primary Care Provider Adherence to National Heart, Lung and Blood Institute (NHLBI) Asthma Guideline Recommendations

The bar graph shows:

  • Provider Adherence (%)
    • ICS: approximately, 65%
    • Peak Flow Monitoring: approximately, 37%
    • Action Plan: approximately, 8%
    • Allergy Testing: approximately, 10%
    • Influenza Vaccination: approximately, 72%

Slide 22

Multivariate Predictors of Adherence to the NHLBI Guideline Components

Barrier ICS Use PF Monitoring
OR P-value OR P-value
Familiarity 1.4 0.34 1.1 0.75
Expect Patient Adherence 1.2 0.87 3.3 0.03
Self-Efficacy 2.8 0.03 2.3 0.05
Insufficient Timer 0.43 0.07 0.68 0.25

Slide 23

Multivariate Predictors of Adherence to the NHLBI Guideline Components

Barrier Action Plan All Testing Vaccination
OR P-value OR P-value OR P-value
Familiarity 1.8 0.31 5.5 0.02 2.0 0.05
Expect Patient Adherence 1.0 0.99 - - 3.5 0.01
Self-Efficacy 4.9 0.03 1.3 0.46 3.5 0.05
Insufficient Timer 1.3 0.62 0.6 0.46 1.2 0.83

Slide 24

Limitations

  • May not be generalizable to other inner-city populations.
  • Used self-reported measures of adherence.
  • Unable to directly observe patient-provider encounters.
  • Used self-reported data on provider adherence to the guidelines.

Slide 25

Conclusions

  • Outcomes of inner-city asthmatics remain poor.
  • Problem appears to be multifactorial.
  • Suboptimal disease and medication beliefs are associated with poor asthma self-management.
  • Language barriers may also explain the increased levels of asthma morbidity among inner-city Hispanics.
  • The role of allergic sensitization appears to be more important among children than adults with asthma.
  • Familiarity and adherence to key treatment recommendations remains suboptimal amongst providers who take care of a large number of inner-city asthmatics.

Slide 26

Acknowledgments

  • Department of Medicine.
    • Ethan A. Halm, MD, MPH.
    • Thomas McGinn, MD, MPH.
    • Michael Iannuzzi, MD.
    • Diego Ponieman, MD.
    • Stephen Berns, MD.
    • Jessica Lorenzo, MPH.
    • Julian Baez.
    • Jessica Segni.
  • Department of Pediatrics.
    • Hugh Sampson, MD.
    • Michelle Mishoe.
  • Department of Geriatrics
    • Albert Siu, MD, MSPH.
  • Rutgers University.
    • Tamara Musumeci, PhD.
    • Howard Leventhal, PhD.
  • Columbia University.
    • David Evans, PhD.
    • Mayer Kattan, MD.
  • Note: These studies were funded by AHRQ and NYC Department of Health.

Current as of January 2009

Internet Citation:

Determinants of Asthma Morbidity Among Inner-City Populations. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/090808slides/Wisnivesky.htm

 
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