Determinants of Asthma Morbidity Among Inner-City Populations (Text Version)

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)

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

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)

• 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

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

Slide 23

Multivariate Predictors of Adherence to the NHLBI Guideline Components

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.