Childhood asthma prevalence has plateaued and may have declined for the first time since 1980.1 Although this news is promising, it is important not to lose sight of the significant disparities in asthma outcomes that remain by race, ethnicity, and socioeconomic status. We must reduce these disparities, and health care organizations’ increasing focus on population health presents a prime opportunity to do so. Now is a critical time to invest in research and quality improvement initiatives that directly target the persistent disparities in childhood asthma outcomes.
Disparities in asthma outcomes have been documented since the 1980s. Children of racial or ethnic minorities face higher morbidity and mortality due to asthma when compared with white children. Non-Hispanic African American children have 2 to 3 times higher rates of hospitalization and emergency department visits compared with non-Hispanic white children. African American children face a 4.9-fold higher asthma mortality rate. In addition, Hispanic children are 2 times more likely to visit an emergency department and 1.5 times more likely to die due to asthma when compared with non-Hispanic children.2
Numerous individual- and system-level factors contribute to asthma disparities, including health care policies, health systems operations, and clinician, patient, family, and environmental factors. For example, minority children are less likely to be prescribed a controller medication when indicated and are less likely to adhere to therapy that is prescribed. Additional factors driving disparities include clinic-centric care, indoor allergen exposure, limited primary care and subspecialty access, and poor health literacy.3
Disparities may persist due to the lack of a comprehensive approach for asthma care that is scalable, sustainable, and widely disseminated. Previous programs have provided written action plans for daily management, supplies for home environment remediation, and education to children with asthma and their families. Other initiatives have used case managers or asthma educators, or alternatively partnered with schools and housing authorities. Some efforts have shown positive results on a local level or in the short-term; however, no single program has demonstrated widespread and sustainable reductions in our nation’s asthma disparities.4
Solutions must comprehensively address the medical, environmental, and social drivers of disparities, which is nearly impossible when interventions are limited to the clinic or home alone. In addition, a one-size-fits-all approach to interventions is unlikely to be generalizable. Programs must be tailored to the unique characteristics of diverse populations and local environments. Lastly, few asthma interventions, other than education curricula, have been broadly disseminated. Interventions may be resource intensive, potentially prohibiting expansion.
Therefore, to impact disparities in asthma outcomes, research must investigate promising comprehensive and sustainable programs. Systematic reviews of the disparities literature indicate characteristics of successful interventions.4–6 These interventions target 6 levels of influence, patient/family, provider, microsystem, organization, community, and policy, based on a conceptual model developed by Robert Wood Johnson Foundation’s Finding Answers: Disparities Research for Change Program.5 This model has effectively examined and designed interventions addressing disparities across adult and pediatric diseases. The model shows it is prudent to move beyond existing interventions that target 1 level to build multilevel, well-integrated programs reaching children across multiple settings. Examples of promising pediatric asthma interventions that reduce disparities and remaining research gaps are outlined in Table 1.
To address disparities in the health care sector, evidence-based guidelines detail essential elements that providers and health care organizations should deliver for high-quality asthma care. However, traditional 15-minute primary care visits do not enable these guidelines to be implemented, contributing to providers not routinely adhering to guidelines.3 Furthermore, population health management has gained popularity to reduce disparities partly because of its potential to influence health care organizations to address care delivery in the clinic and factors traversing home and school environments. Clinics should adopt streamlined workflows, well-functioning electronic health records, clinical decision support tools, and patient registries to assess asthma control, step-up/down therapy, and ensure appropriate follow-up and preventive care. Health care organizations must also confront health literacy about triggers, symptoms, and care access; medication adherence and proper inhaler technique; and bidirectional coordination with schools. Research and quality improvement efforts should focus on evaluating pragmatic systems for children with asthma to consistently receive high-quality care.
To link asthma care across clinical and nonclinical sectors, emerging work focuses on the multidisciplinary team to reduce disparities. Nonmedical professionals, such as community health workers, play an integral role in new models that engage patients, families, and care providers in the clinic, home, school, and community. Previous studies demonstrate the efficacy of tailored approaches with patients and families to identify needs and address risk factors by using education, home assessments, and community linkages. Many questions remain about how to do this within team-based, integrated programs. Who are key team members? What adaptations are needed for disease severity, risk factors, and local environments? How can social determinants best be addressed across settings? How can these programs be financed to support broad dissemination?
Funders play a critical role in enabling asthma disparities research. The National Institutes of Health disburses $250 million annually for asthma research and recently funded planning phase projects for a clinical trial to evaluate Asthma Care Implementation Programs in diverse populations (Creating Asthma Empowerment Collaborations to Reduce Childhood Asthma Disparities and Asthma Empowerment Collaborations to Reduce Childhood Asthma Disparities). These programs aim to integrate proven interventions from multiple settings into a comprehensive program, thus adding to the limited knowledge base about multilevel programs. Additional promising aspects include a strong emphasis on reaching children where they are (home, school, and community), rather than only in the clinical setting.
The Patient-Centered Outcomes Research Institute is also bringing evidence into action to improve outcomes for minority children with asthma23 . This institute uses a novel approach: involving stakeholders in all research aspects and focusing on patient-centered outcomes. Stakeholders are directly engaged in projects from beginning to end, providing an essential and often underrepresented voice to ensure interventions align with community needs and present pragmatic solutions. In addition, the measures of project success emphasize those that are important to patients and families, such as symptom-free days and quality of life, which are complementary to the traditional metrics of emergency department visits and hospital admissions.
Research funding is critical, and health care organizations and payers are also important drivers of the work to reduce disparities. With evolving care delivery and financial systems, health care organizations are increasingly facing global and bundled payments, thus incentivizing them to develop population health management strategies and form partnerships across clinical and nonclinical areas to address the social factors within asthma care. Demonstration projects can build on existing quality improvement efforts to test care transformation models that bridge clinical and community settings. One caveat is that wide-scale payment policies may not affect all systems equally and care must be taken to avoid widening disparities if financial penalties are on the line. In fact, payment systems should be proactively designed to incentivize and reward the reduction of disparities.24
As we celebrate the stabilization of childhood asthma prevalence, we must not lose sight of the ongoing disparities in morbidity and mortality based on race, ethnicity, and socioeconomic status. Catalyzed by changes in health care payment and delivery, clinicians, researchers, health care organizations, and insurers are in a prime position to partner with those beyond the walls of the hospitals and clinics to reach children with asthma where they live, learn, and play.
- Accepted October 31, 2016.
- Address correspondence to Anna Volerman, MD, Departments of Medicine and Pediatrics, University of Chicago, 5841 S Maryland Ave, MC 2007, Chicago, IL, 60637. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Dr Volerman is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (KL2TR000431). Dr Chin is supported by the Chicago Center for Diabetes Translation Research (P30 DK092949), a National Institute of Diabetes and Digestive and Kidney Diseases Midcareer Investigator Award in Patient-Oriented Research (K24 DK071933), and the Robert Wood Johnson Foundation Finding Answers: Solving Disparities Through Payment and Delivery System Reform Program Office. Dr Press is supported by the National Heart, Lung, and Blood Institute (K23 HL118151). Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2017 by the American Academy of Pediatrics