Asthma - References

Am J Respir Crit Care Med 1999 Sep 1;160(3):919-922

Association Between a Sequence Variant in the IL-4 Gene Promoter and FEV(1) in Asthma.

Burchard EG, Silverman EK, Rosenwasser LJ, Borish L, Yandava C, Pillari A, Weiss ST, Hasday J, Lilly CM, Ford JG, Drazen JM

Pulmonary and Critical Care Division and Channing Laboratory, Departments of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; National Jewish Medical and Research Center, Denver, Colorado; University of Maryland, Baltimore, Maryland; and Harlem Hospital Center, Columbia University, New York, New York.

Recent family-based studies have revealed evidence for linkage of human chromosome 5q31 to the diagnosis of asthma, elevated serum IgE levels, and bronchial hyperresponsiveness. Among the candidate genes in this region is the gene encoding for human interleukin-4 (IL-4). We reasoned that this gene could also serve as a candidate gene with respect to asthma severity as indicated by the FEV(1) measured when bronchodilator treatment was withheld. To test this hypothesis, we examined a large population of patients with asthma (ascertained without respect to genetic characteristics), for associations between a genetic variant in the IL-4 promoter region (C-589T) and asthma severity, as indicated by FEV(1). We used amplification by the polymerase chain reaction followed by BsmF1 restriction digestion to assign genotypes at the IL-4 promoter C-589T locus. We compared genotypes at this locus in 772 Caucasian and African American patients with asthma of varying severity, and we used multiple regression analysis to relate genotypic findings to FEV(1). Among white individuals, the homozygous presence of the C-589T IL-4 promoter genotype (TT) was associated with a FEV(1) below 50% of predicted (p = 0.013; OR, 1.44; 95% CI: 1.09 to 1.90). Subjects with the TT genotype had mean FEV(1) (% predicted) values 4.5% lower than those of subjects with the wild-type (CC) genotype at this locus. FEV(1) values of white patients with a CC or CT genotype were broadly distributed, whereas the TT genotype was associated with a narrow distribution of low FEV(1) values. The frequency of the T allele was significantly greater (p = 1 x 10(-)(23)) among African American asthmatics (0.544) than among white asthmatics (0.183). These data provide the first evidence associating FEV(1) in patients with asthma and genetic determinants at any locus. Our data are consistent with the idea that the FEV(1) in asthma is the result of multiple factors; one of these factors is the genotype at the IL-4 C-589T locus. This locus is associated with a small but significant decrement in pulmonary function among white asthmatic subjects.

PMID: 10471619

Pediatrics 1999 Jul;104(1 Pt 2):151-7

Black and white middle class children who have private health insurance in the United States.

Weitzman M, Byrd RS, Auinger P

Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA. michael.weitzman@viahealth.org

OBJECTIVE: To compare the health, behavior and school problems, and use of medical, mental health, and special education services of privately insured, middle class black and white children in the United States. DESIGN/METHODS: Analyses of the Child Health Supplement to the 1988 National Health Interview Survey, with a nationally representative sample of 17 110 children age 0-17 years. RESULTS: Privately insured middle class black children had fewer chronic health conditions, but were less likely to be reported to be in excellent health (46.2% vs 57.3%) and more likely to have had asthma (8.5% vs 5.8%) or to have been of low birth weight (10.7% vs 5.6%). There were no differences in rates of having a usual source of routine care (92.2% vs 93.8%) or of being up to date with well-child care (79.3% vs 78.2%), but black children made fewer physician visits, were less likely to use physicians' offices, were more likely to lack continuity of care, and were twice as likely to use emergency departments. These differences in use of medical services persisted in multivariate analyses and analyses restricted to more affluent children. Despite similar rates of behavior problems, black children were more likely to repeat a grade (20.0% vs 12.3%) and to have been suspended from school (11.3% vs 5.0%). Although significantly fewer black middle class children received mental health or special education services in bivariate analyses, no differences in receipt of these services were noted in multivariate analyses. All differences reported were significant. CONCLUSIONS: Among middle class children in the United States, black and white children have similar rates of health and behavior problems, but black children experience substantially increased rates of asthma, low birth weight, and school difficulties. Although not differing in the receipt of mental health or special education services, middle class black children, even in the presence of private health insurance, have markedly different sources and patterns of use of medical services.

PMID: 10390282, UI: 99318966

J Asthma 1999 May;36(3):239-51

Asthma hospitalization rates and socioeconomic status in New York State (1987-1993).

Lin S, Fitzgerald E, Hwang SA, Munsie JP, Stark A

Bureau of Environmental and Occupational Epidemiology, New York State Department of Health, Albany 12203, USA.

This study examined the geographic distribution of asthma hospitalizations in New York State (NYS) and its association with socioeconomic status. Statewide asthma hospitalization data (1987-1993) were merged with 1990 census data by residential zip code. The asthma hospitalization rate increased in NYS from 1987 (2.54 per 1000) through 1993 (2.87 per 1000) and the increase is largely attributable to increases for children 4 years old and younger. The risk factors for asthma admission varied in different areas. However, rates of hospitalization because of asthma were generally higher in the zip codes areas with higher proportions of poverty, unemployment, poorly educated residents, African-Americans, and Hispanics.

PMID: 10350220, UI: 99277723

Am J Respir Crit Care Med 1999 May;159(5 Pt 1):1527-32

Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems.

Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G

Department of Pediatrics, Case Western Reserve University, Rainbow Babies and Childrens Hospital, Cleveland, Ohio, USA.

This study examined risk factors for sleep-disordered breathing (SDB) in children and adolescents; specifically, quantifying risk associated with obesity, race, and upper and lower respiratory problems. Subjects were participants in a genetic-epidemiologic study of SDB and included 399 children and adolescents 2 to 18 yr of age, recruited as members of families with a member (a proband) with known sleep apnea (31 index families) or as members of neighborhood control families (30 families). SDB was assessed with home overnight multichannel monitoring and SDB was defined based on an apneahypopnea index >/= 10 (moderately affected) or < 5 (unaffected). SDB of moderate level was significantly associated with obesity (odds ratio, 4.59; 95% confidence interval [CI], 1.58 to 13.33) and African-American race (odds ratio, 3.49; 95% CI, 1.56 to 8.32) but not with sex or age. After adjusting for obesity, proband sampling, race and familial clustering, sinus problems and persistent wheeze each independently (of the other) predicted SDB. These data suggest the importance of upper and lower respiratory problems and obesity as risk factors for SDB in children and adolescents. Increased risk in African Americans appears to be independent of the effects of obesity or respiratory problems.

PMID: 10228121, UI: 99246489

J Asthma 1999;36(2):195-204

A comparison of asthma-related healthcare use between African-Americans and Caucasians belonging to a health maintenance organization (HMO).

Blixen CE, Havstad S, Tilley BC, Zoratti E

Department of Nursing Research P32, Cleveland Clinic Foundation, OH 44195, USA. blixenc@cesmtp.ccf.org

The objective of this study was to determine whether racial differences in patterns of asthma care persist in a healthcare environment when financial barriers to health care are minimized. The study cohort consisted of African-American (AA) and Caucasian (C) patients, 18-50 years old, enrolled in a large HMO and hospitalized for asthma in 1993-1995. Baseline and 1-year follow-up data were collected from the HMO computerized database. Of the 193 patients in the cohort, 124 (65.3%) were AA and 67 (34.7%) were C. AAs were younger (mean = 36.2, SD = 9.9) than Cs (mean = 39.4, SD = 9.1), had a lower median household income, and made more asthma-related emergency department (ED) visits (45.2%) than Cs (22.4%) during the 1 year after the initial hospitalization (all p values <0.001). During the same time period, Cs made more asthma-related primary care (70.2%) and allergy/pulmonary visits (38.8%) than AAs (47.6% and 27%, respectively). Although there were no significant racial differences in the rehospitalization rate, AA Medicaid contract patients (32%) had more rehospitalizations for asthma than AA regular contract patients (15.8%). These differential patterns in the use of asthma-related healthcare in this study indicate that the provision of health insurance alone is not sufficient to promote optimal levels of asthma management by all beneficiaries. Asthma education programs targeted for low-income AA patients may improve inappropriate healthcare use patterns.

PMID: 10227271, UI: 99241810

Nurs Res 1999 Jan-Feb;48(1):2-8

Symptom perception and evaluation in childhood asthma.

Yoos HL, McMullen A

School of Nursing, University of Rochester, University of Rochester Medical Center, NY 14642, USA.

BACKGROUND: Inaccuracies in symptom perception may contribute to morbidity and mortality in childhood asthma. OBJECTIVE: To systematically examine the accuracy of symptom perception on the part of children with asthma and their parents, as well as their interpretation and evaluation of the symptoms. METHOD: Twenty-eight patient/parent pairs from suburban and underserved urban pediatric populations participated in a 5-week protocol tracking subjective assessments of asthma severity (visual analog scales) and peak expiratory flow rates. Relationships between perceptual accuracy and demographic and disease factors were investigated. RESULTS: Adolescents were more accurate than school-aged children, more accurate children had better morbidity outcomes, and African American parents were more accurate than Caucasian parents. Socioeconomic status did not affect accuracy. Both children and parents missed early symptoms and waited too long prior to intervening in an exacerbation. CONCLUSIONS: There are multiple opportunities for error in symptom perception and evaluation. Identification of the source of error is critical to the effective utilization of education on self-management.

PMID: 10029396, UI: 99151854

J Allergy Clin Immunol 1999 Jan;103(1 Pt 1):72-8

The influence of demographic and socioeconomic factors on health-related quality of life in asthma.

Apter AJ, Reisine ST, Affleck G, Barrows E, ZuWallack RL

Department of Medicine, General Clinical Research Center, University of Connecticut Health Center, Farmington, USA.

BACKGROUND: Although health-related quality of life (HRQL) in asthma is strongly influenced by disease severity, demographic and socioeconomic variables may also be important factors. OBJECTIVE: We related demographics, asthma severity, and socioeconomic factors to HRQL. METHODS: We interviewed 50 patients with moderate or severe asthma recruited from outpatient health center-based clinics to determine demographics, socioeconomic status, asthma severity, medication use, and HRQL. For HRQL, the mean total score of the Asthma Quality of Life Questionnaire (AQLQ) and the Medical Outcomes Study Short-Form 36 questionnaires physical and mental component summary scores (PCS and MCS, respectively) were used. RESULTS: The mean patient age was 46 +/- 14 years, and the FEV1 was 75% +/- 21% of predicted value. Twenty-nine subjects had been hospitalized for asthma, 29 belonged to a minority racial/ethnic group, and 16 had less than 12 years of education. The mean total AQLQ score was 4.12 +/- 1.42, the PCS was 37 +/- 10, and the MCS was 45 +/- 13. In univariate analyses, severity (nighttime awakenings, prednisone use, and a history of emergency department visits), racial/ethnic group (African American, white, or Hispanic), and socioeconomic status (low educational level, unemployed, family income under $20,000, public assistance, or no health insurance) were related to HRQL. These factors explained 67% of the variance of AQLQ and 48% of the variance of the PCS. Much of the quality of life variance was shared among these variables. Explanatory variables were not related to MCS in multivariate analysis. CONCLUSION: Socioeconomic status is an additional important independent factor influencing HRQL in asthma. In this study it was difficult to separate out the unique effects of socioeconomic status and race/ethnicity.

PMID: 9893188, UI: 99110789

Arch Pediatr Adolesc Med 1998 Dec;152(12):1197-200

The relationship between asthma and obesity in urban minority children and adolescents.

Gennuso J, Epstein LH, Paluch RA, Cerny F

Department of Pediatrics, State University of New York at Buffalo, 14260, USA.

OBJECTIVE: To investigate the relationship between asthma and obesity in children and adolescents. DESIGN: Medical record review. SETTING: Urban community health center. PARTICIPANTS: One hundred seventy-one children aged 4 to 16 years, 85 with asthma and 86 nonasthmatic controls. MAIN OUTCOME MEASURES: Diagnosis of asthma, age, and sex-adjusted body mass index (weight in kilograms divided by the square of the height in meters). RESULTS: Seventy-eight percent of the sample was Hispanic, 17% was African American, 2% were white, and 3% were other minorities. There were significantly more children with asthma (30.6%) who were very obese (> or =95th body mass index percentile) compared with controls (11.6%) (P=.004). Children with asthma were also significantly more overweight than controls (mean+/-SD, 22.5%+/-28.3% vs 12.0%+/-19.6% overweight; P=.004). The difference in obesity between children with asthma and controls was significant for both sexes and across the 4.5 to 10.9 years and 11 to 16 years age groups. Asthma severity was not related to obesity. CONCLUSION: Asthma is a risk factor for obesity in children and adolescents.

PMID: 9856429, UI: 99072249

J Pediatr Psychol 1998 Dec;23(6):345-9

Treatment adherence among low-income children with asthma.

Celano M, Geller RJ, Phillips KM, Ziman R

Emory University School of Medicine, USA. mcelano@emory.edu

OBJECTIVE: To investigate the adherence behaviors (MDI use, MDI/spacer technique, appointment attendance, smoking in the home) of low-income, urban, primarily African American children with asthma. METHOD: Participants were 55 children ages 6 to 17 with moderate to severe asthma. Adherence to MDI anti-inflammatory agents was estimated primarily from canister weight at the follow-up appointment. RESULTS: The mean use of MDI medication was 44% of prescribed use, with 27% of subjects demonstrating MDI/spacer technique likely to prevent drug delivery. Almost half reported that household members smoked cigarettes, and 21% missed scheduled follow-up appointments. CONCLUSIONS: These findings have implications for how clinicians should assess and improve adherence.

Publication Types:

• Clinical trial

PMID: 9824922, UI: 99042363

Am J Respir Crit Care Med 1998 Oct;158(4):1082-90

Is the asthma quality of life questionnaire a useful measure for low-income asthmatics?

Leidy KN, Chan KS, Coughlin C

Center for Health Outcomes Research, MEDTAP International Inc., Bethesda, Maryland, USA.

The purpose of this study was to evaluate the reliability and validity of the Asthma Quality of Life Questionnaire (AQLQ) in a population-based sample of low-income adults with asthma. A total of 112 subjects (46 African American, 66 Caucasian; mean age = 33 +/- 9 yr; 26% male) were recruited from the Baltimore County, Maryland and Atlanta, Georgia metropolitan areas. Internal consistency reliability (Cronbach's alpha) was high for the overall scale (0. 96); 2-wk reproducibility (intraclass correlation, ICC) was 0.82 (n = 38). Overall score was significantly correlated with FEV1 percentage of predicted (r = 0.20), and the Asthma Disease Severity Scale (r = -0.38). Correlations between overall score and the SF-36 Physical Component Summary (r = 0.49), SF-36 Mental Component Summary (r = 0.37), Cantril's Ladder (r = 0.23), and the Health Utilities Index (r = 0.22) supported the validity of the AQLQ in this sample. Comparison of reliability and validity estimates across racial groups found few substantive differences. Internal consistency, reproducibility, and validity estimates found in this sample were consistent with those of a reliable and valid measure and were comparable to those found in other populations. These results suggest the AQLQ is a useful indicator of health- related quality of life in low-income asthmatics.

PMID: 9769264, UI: 98443299

J Allergy Clin Immunol 1998 Sep;102(3):449-53

Genetic influences of chromosomes 5q31-q33 and 11q13 on specific IgE responsiveness to common inhaled allergens among African American families. Collaborative Study on the Genetics of Asthma (CSGA).

Hizawa N, Freidhoff LR, Ehrlich E, Chiu YF, Duffy DL, Schou C, Dunston GM, Beaty TH, Marsh DG, Barnes KC, Huang SK

Division of Clinical Immunology, The Johns Hopkins Asthma & Allergy Center, Baltimore, MD 21224, USA.

BACKGROUND: We have recently conducted a genome-wide screening for genes influencing Dermatophagoides pteronyssinus-specific IgE responsiveness as a part of the Collaborative Study on the Genetics of Asthma (CSGA), which showed evidence for linkage in some regions, including chromosomes 5131-q33 and 11q13 in African American families. OBJECTIVES: To clarify relative contributions of these regions to atopy in the same African American population, we have conducted further genetic linkage studies of specific IgE responses toward common inhaled allergens. METHODS: We studied 328 individuals in 58 African American families participating in the CSGA. Specific IgE responses toward Dermatophagoides farinae, cat, dog, American cockroach, rye grass, and Bermuda grass, as measured by skin tests, were used for multipoint linkage analysis with polymorphic markers on chromosomes 5q31-q33 and 11q13. RESULTS: Specific IgE response toward American cockroach showed evidence for linkage to chromosomes 5q31-q33 (P = .0050) and 11q13 (P = .017). Specific IgE response toward dog showed evidence for linkage with chromosome 5q31-q33 (P = .0043). Evidence for linkage with chromosome 11q13 was obtained for specific IgE responses toward Dermatophagoides farinae (P = .012), cat (P = .035), and Bermuda grass (P = .017). The presence of a positive ST response for at least 1 of 30 common allergens showed evidence for linkage to chromosomes 5q31-q33 (P = .017) and 11q13 (P = .00058). CONCLUSIONS: These data support that genes on both chromosomes 5q31-q33 and 11q13 confer susceptibility to upregulated IgE-mediated immune responses in this African American population. The putative genes on chromosomes 5q31-q33 and 11q13, however, showed contrasting effects on atopy, which may result from strong gene-environmental interactions.

PMID: 9768587, UI: 98439523

J Allergy Clin Immunol 1998 Sep;102(3):436-42

Genetic regulation of Dermatophagoides pteronyssinus-specific IgE responsiveness: a genome-wide multipoint linkage analysis in families recruited through 2 asthmatic sibs. Collaborative Study on the Genetics of Asthma (CSGA).

Hizawa N, Freidhoff LR, Chiu YF, Ehrlich E, Luehr CA, Anderson JL, Duffy DL, Dunston GM, Weber JL, Huang SK, Barnes KC, Marsh DG, Beaty TH

Johns Hopkins Asthma & Allergy Center, School of Medicine, Baltimore, MD 21224, USA.

BACKGROUND: Dermatophagoides pteronyssinus (Der p) is one of the most frequently implicated allergens in atopic diseases. Although HLA could play an important role in the development of the IgE response to the Der p allergens, genetic regulation by non-HLA genes influences certain HLA-associated IgE responses to complex allergens. OBJECTIVE: To clarify genetic control for the expression of Der p-specific IgE responsiveness, we conducted a genome-wide search for genes influencing Der p-specific IgE antibody levels by using 45 Caucasian and 53 African American families ascertained as part of the Collaborative Study on the Genetics of Asthma (CSGA). METHODS: Specific IgE antibody levels to the Der p crude allergen and to the purified allergens Der p 1 and Der p 2 were measured. Multipoint, nonparametric linkage analysis of 370 polymorphic markers was performed with the GENEHUNTER program. RESULTS: The best evidence of genes controlling specific IgE response to Der p was obtained in 2 novel regions: chromosomes 2q21-q23 (P = .0033 for Caucasian subjects) and 8p23-p21 (P = .0011 for African American subjects). Three regions previously proposed as candidate regions for atopy, total IgE, or asthma also showed evidence for linkage to Der p-specific IgE responsiveness: 6p21 (P = .0064) and 13q32-q34 (P = 0.0064) in Caucasian subjects and 5q23-q33 (P = 0.0071) in African American subjects. CONCLUSIONS: No single locus generated overwhelming evidence for linkage in terms of established criteria and guidelines for a genome-wide screening, which supports previous assertions of a heterogeneous etiology for Der p-specific IgE responsiveness. Two novel regions, 2q21-q23 and 8p23-p21, that were identified in this study merit additional study.

Publication Types:

• Multicenter study

PMID: 9768585, UI: 98439521

Ann Allergy Asthma Immunol 1998 Sep;81(3):266-71

Relationships of race and socioeconomic status with prevalence, severity, and symptoms of asthma in Chicago school children.

Persky VW, Slezak J, Contreras A, Becker L, Hernandez E, Ramakrishnan V, Piorkowski J

Epidemiology/Biostatistics Program, University of Illinois at Chicago, School of Public Health, Erie Family Health Center, 60612-7260 USA.

BACKGROUND: Asthma mortality rates in Chicago are among the highest in the United States, with substantially greater rates in poor and minority populations. How much of the differential can be attributed to differences in prevalence versus severity or access to care has not been determined. OBJECTIVE: To examine rates of asthma prevalence, severity, and symptoms and to explore the relationships of these rates to race and socioeconomic status in a random sample of Chicago school children. METHODS: Self-administered survey. RESULTS: Overall, rates of asthma were higher than previously reported, with 16% of students in the stratified cluster random sample of 3,670 children in the 7th and 8th grades having had asthma. Prevalence rates were significantly higher in schools with >98% African Americans than in other schools, with the highest prevalence rates seen in African American schools in low income neighborhoods. Rates were associated with the percent of African American children in the school and with median income of the school's census tract. Relationships were most consistent with indices of more severe disease. CONCLUSIONS: Asthma prevalence is higher than previously noted, with rates greatest in minority and low income populations. Differences are more striking for measures of severity than for symptoms of wheezing, but are far less than previously reported differences in mortality, suggesting that additional factors, such as differential access to continuous health care, may be affecting high death rates from asthma in Chicago.

Comments:

• Comment in: Ann Allergy Asthma Immunol 1999 Jan;82(1):2-4

PMID: 9759806, UI: 98430606

Am J Respir Crit Care Med 1998 Aug;158(2):371-7

Health service use by African Americans and Caucasians with asthma in a managed care setting.

Zoratti EM, Havstad S, Rodriguez J, Robens-Paradise Y, Lafata JE, McCarthy B

Division of Allergy and Clinical Immunology, Department of Biostatistics and Research Epidemiology, Center for Clinical Effectiveness, Henry Ford Health System, Detroit, Michigan, USA.

Managed care plan members provide a population for analysis that minimizes the financial barriers to routine medical care that have been linked to high rates of asthma-related hospitalization, emergency care, and mortality among urban African Americans. We examined patterns of asthma care among 464 African American (AA) and 1,609 Caucasian (C) asthma patients, age 15 to 45 yr, in a southeast Michigan managed care system during 1993. Compared with C, AA had fewer visits to asthma specialists (0.32 versus 0.50 visits/yr, p = 0.002), and filled fewer prescriptions for inhaled steroids (1.44 versus 1.74 Rx/yr, p = 0.038), while being more likely to visit the emergency department with asthma (0.71 versus 0.28 visits/yr, p < 0. 001), to be hospitalized with asthma (0.08 versus 0.03 admissions/yr, p = 0.002), or to have filled prescriptions for oral steroids (0.91 versus 0.59 Rx/yr, p < 0.001). AA were equally likely to have visited a primary care physician for asthma (0.95 versus 0.93 visits/yr, p = 0.81). Similar physician visit profiles and discrepancies in the use of oral steroids persisted when analyzing exclusively low socioeconomic status subgroups. These results suggest that ethnic differences in patterns of asthma-related health care persist within managed care settings and are only partially due to financial barriers.

PMID: 9700109, UI: 98365525

J Sch Health 1998 May;68(5):196-201

School-based management of chronic asthma among inner-city African-American schoolchildren in Dallas, Texas.

McEwen M, Johnson P, Neatherlin J, Millard MW, Lawrence G

University School of Nursing, Dallas, TX, USA.

Asthma, a chronic disease of the respiratory tract, affects approximately five percent of the U.S. population, including almost five million children. Childhood asthma has been identified as the leading cause of school absences. This study was to examined efficacy of a school-based program to prevent exacerbation of asthma symptoms and manage asthma in school children using measured doses of an inhaled anti-inflammatory medication. The sample consisted of 22 African-American children in one inner-city elementary school in Dallas, Texas, ages 5-12 years with confirmed diagnoses of asthma. For three months, each child came to the school clinic two times per day for medication administration and measurement of respiratory peak flow rates. Data were collected for a number of variables including bronchodilator use, school absences, self-report of asthma symptoms, and number of visits to the physician. During the study, mean peak flow rates improved approximately 15%, and bronchodilator use decreased 66%. Improvement also was evident in several other areas.

Publication Types:

• Clinical trial

PMID: 9672858, UI: 98336729

Respir Med 1998 Apr;92(4):642-8

Variations in hospitalization rates for asthma among black and minority ethnic communities.

Gilthorpe MS, Lay-Yee R, Wilson RC, Walters S, Griffiths RK, Bedi R

National Centre for Transcultural Oral Health, Eastman Dental Institute for Oral Care Sciences, London, U.K.

In response to the introduction of ethnic monitoring within the U.K. hospital inpatient data set, this study investigates the variations in secondary healthcare utilization by Black and minority ethnic communities whose cause of admission is related to asthma. The study examines all residents of the West Midlands: over 5 million people, of whom 8.5% are from Black and minority ethnic groups. A retrospective study of 15,921 asthma-related hospital admissions, from 1 April 1995 to 31 March 1996, was carried out. Age-standardized admission rates were higher in all Black and minority ethnic groups studied than in the White group. There were elevated rates in Black children aged 5-14 years, and particular differences were observed for Indian and Bangladeshi men and women aged 65 years or over. Emergency admissions to hospital for asthma were strongly associated with patients' socioeconomic background but this was largely observed for Black and minority ethnic groups that also generally experience high levels of deprivation. The findings support previous studies which suggest that hospital utilization rates for asthma among people from Black and minority ethnic groups are high compared with the White group, despite little evidence in measured prevalence. This study suggests that ethnic background is more important in asthma admissions than deprivation, which raises serious concerns on the appropriateness and quality of asthma care for these patient groups within our society. Future studies need to examine pathways to care, that is the health-seeking behaviour of Black and minority ethnic groups, the type of treatment received at the primary care level and referral patterns to secondary care.

PMID: 9659530, UI: 98323715

Pediatrics 1998 Jul;102(1 Pt 1):77-83

Asthma in non-inner city Head Start children.

McGill KA, Sorkness CA, Ferguson-Page C, Gern JE, Havighurst TC, Knipfer B, Lemanske RF Jr, Busse WW

Department of Medicine, University of Wisconsin Medical School, Madison, WI 53792, USA.

OBJECTIVE: Asthma is a significant cause of morbidity and mortality in children. The objective of this study was to determine whether the federal program Head Start in Dane County, Wisconsin, could be used as a mechanism to identify preschool-aged children with asthma. DESIGN: Five-year, cross-sectional survey of parents with children enrolled in Head Start. METHODS: Investigator-administered asthma screening questionnaire to parents of enrolling Head Start children in Dane County, Wisconsin. MEASUREMENTS: Asthma prevalence and asthma-related health care use, including emergency department visits, hospitalizations, and medication usage, were measured using an asthma screening questionnaire developed by investigators. RESULTS: Information was gathered on 2215 children. The prevalence of physician-diagnosed asthma in the screened children was 15.8%. Parental reports of physician-diagnosed asthma were validated in a subset of 133 children, with a 98.5% confirmation rate. Independent risk factors for asthma included male gender (relative risk, 1.4) and African-American ethnicity (relative risk, 1.4). Asthma-related morbidity was substantial with 26.7% of identified children hospitalized for asthma and 54.5% with an emergency department visit during their lifetime. The majority of children (46.4%) were treated with intermittent, quick relief medications (beta-agonists) alone, whereas only 6.1% were on daily, long-term controller medications. CONCLUSIONS: Asthma screening through a Head Start program provides an effective means of targeting preschool-aged children from socioeconomic groups at high risk for asthma. Identification of children early in the disease course and those at high risk for asthma provides an ideal opportunity for the implementation of preventive and therapeutic interventions.

PMID: 9651417, UI: 98358032

Vital Health Stat 13 1998 May;(137):1-23

Ambulatory health care visits by children: principal diagnosis and place of visit.

Freid VM, Makuc DM, Rooks RN

OBJECTIVES: This report presents national estimates of ambulatory health care use by children under 15 years of age according to principal diagnosis, place of visit (physician office, hospital outpatient department, and hospital emergency department), and patient characteristics (age, sex, and race). METHODS: Data were from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Data were from 1993-95. RESULTS: In 1993-95 children under 15 years of age made 165.3 million visits per year (289 visits per 100 children). Visit rates were highest among infants and varied inversely with age. Visit rates were 43 percent higher among white children than black children. Three-quarters of ambulatory visits occurred in physician offices, 8 percent in hospital outpatient departments, and 14 percent in hospital emergency departments. Visits by white children were more likely to occur in physician offices than visits by black children (81 percent and 54 percent). Conversely, visits by black children were more likely to occur in hospital outpatient departments (19 percent and 7 percent) and hospital emergency departments (28 percent and 12 percent) than visits by white children. The following principal diagnoses accounted for almost 40 percent of visits: well-child visit, 15 percent; middle ear infection, 12 percent; and injury, 10 percent. Rates for well-child visits were almost 80 percent higher among white infants than black infants. Continued monitoring of these differences in use of ambulatory care among children are needed, particularly in view of the possible impact of changes in the health care system on these differences.

Publication Types:

• Review
• Review, tutorial

PMID: 9631643, UI: 98295121

J Allergy Clin Immunol 1998 May;101(5):594-601

Difficult-to-control asthma: clinical characteristics of steroid-insensitive asthma.

Chan MT, Leung DY, Szefler SJ, Spahn JD

Department of Pediatrics, National Jewish Medical and Research Center, Denver, Colo 80206, USA.

BACKGROUND: Although widely used, little is known regarding the patterns of response that subjects with severe asthma exhibit to oral glucocorticoid (GC) therapy. METHODS: We retrospectively reviewed the charts of 164 consecutive adolescents admitted to the National Jewish Medical and Research Center for difficult-to-control asthma. Data collected included medical history, pulmonary function measures by plethysmography, methacholine challenge results, AM cortisol levels, serum IgE, total eosinophil counts (TEC), serum eosinophil cationic protein (ECP), soluble IL-2 receptor (sIL-2R), and spirometry. RESULTS: Eighty-seven patients (53%) required a GC burst during the hospitalization secondary to poor asthma control. Those requiring a GC burst had a significantly longer history of asthma, a greater degree of bronchial hyperresponsiveness, and lower pulmonary function. Twenty-one patients (24%) failed to respond with a greater than 15% improvement in their AM prebronchodilator FEV1 after the GC burst and were termed steroid insensitive (SI). Although those with SI asthma had a similar duration of asthma, they required oral GC therapy at a younger age, required a larger maintenance oral GC dose on admission, and were more likely to be African-American, compared with those with steroid-sensitive asthma. Furthermore, two distinct spirometry patterns were noted among the SI asthmatic subjects: "chaotic" and "nonchaotic." Patients with the chaotic pattern were characterized by a significant degree of variability (greater than 30%) in daily pulmonary function, whereas those with nonchaotic, SI asthma were characterized by less than 15% variability in daily lung function. Those with nonchaotic SI were diagnosed with asthma and treated with oral GCs at a later age. CONCLUSIONS: This retrospective study suggests that SI asthma is quite common (25%) among adolescents with severe asthma evaluated at a national referral center. In addition, two distinct patterns of SI asthma have been identified that may constitute different pathophysiologic processes. Finally, the overrepresentation of African-Americans in the SI group supports the need for further epidemiologic studies investigating the prevalence of SI asthma and the impact early asthma intervention may have on this severe form of asthma.

PMID: 9600494, UI: 98261121

J Pediatr 1998 Apr;132(4):699-703

Association of being overweight with greater asthma symptoms in inner city black and Hispanic children.

Luder E, Melnik TA, DiMaio M

Jack and Lucy Clark Department of Pediatrics, Mount Sinai School of Medicine, New York, NY 10029, USA.

OBJECTIVE: To determine whether the weight status of inner city black and Hispanic children with asthma differs from that of their peers and to assess whether overweight asthmatic children experience greater asthma symptoms. STUDY DESIGN: A cross-sectional study in an ambulatory chest clinic of an inner city medical center. METHODS: We studied black and Hispanic children aged 2 to 18 years (n = 209) with the single diagnosis of asthma. The peer control subjects consisted of a sample of black and Hispanic children aged 6 to 13 years (n = 1017), enrolled in the New York City schools. Asthma symptoms, the number of asthma medications prescribed, and peak expiratory flow rate (PEFR) measurements were used to classify asthma severity and relate to body mass index (BMI). Bivariate categorical analysis and chi 2 tests were performed to examine the relationship between high BMI and the individual measures of asthma severity. RESULTS: The prevalence of overweight was significantly higher in children with moderate to severe asthma than in their peers. The risk of overweight based on a BMI in the 85th percentile or greater was significantly associated with the following measures of asthma severity: (1) the number of school days missed per year; (2) a PEFR less than or equal to 60% of the predicted PEFR; and (3) the number of asthma medications prescribed. CONCLUSIONS: The prevalence of overweight was significantly higher in children with moderate to severe asthma than in their peers, and being overweight was associated with significantly more severe asthma symptoms. Further studies in overweight asthmatic children are needed, including the effect of weight loss on lung function and other markers of asthma severity.

PMID: 9580773, UI: 98241874

J Allergy Clin Immunol 1998 Apr;101(4 Pt 1):484-90

Racial differences in emergency department use persist despite allergist visits and prescriptions filled for antiinflammatory medications.

Joseph CL, Havstad SL, Ownby DR, Johnson CC, Tilley BC

Henry Ford Health System, Detroit, MI 48202-3450, USA.

BACKGROUND: African-American children use the emergency department (ED) for asthma care more than their Caucasian counterparts. OBJECTIVE: We sought to compare ED utilization for asthma care by race, adjusting for prescriptions filled for antiinflammatory medications, type of index visit (specialist vs nonspecialist), and demographic variables. METHODS: An index asthma visit was identified for a cohort of managed care enrollees aged 4 to 11 years. Information on asthma encounters and drug claims data was evaluated during a prospective observation period of 12 months. RESULTS: African-American race was associated with one or more ED visits during the observation period (relative risk [RR] = 1.8, 95% CI = 1.3 to 2.5, p < 0.01). After adjusting for index visit type, prescriptions filled, and selected demographic variables, African-American race remained associated with post-index ED utilization (adjusted RR = 1.6, 95% CI = 1.0 to 2.4, p = 0.05). Additional findings included an inverse relationship between African-American race and antiinflammatory medications among children with nonspecialist index visits (RR = 0.5, 95% CI = 0.3 to 0.9, p = 0.02) and a positive relationship between African-American race and hospitalization after an ED visit for asthma care (RR = 10.2, 95% CI = 1.4 to 74.8, p < 0.01). CONCLUSION: African-American children were more likely to use ED asthma care even after adjusting for the type of index visit, prescriptions filled for antiinflammatory medications, and selected demographic variables. Racial differences in ED utilization for asthma care could be caused by a higher prevalence of uncontrolled or undertreated disease among African-American children not receiving specialty care.

PMID: 9564801, UI: 98224471

Acta Clin Belg 1998 Feb;53(1):22-7

[Chronic eosinophilic pneumopathy in a black African patient].

Brancaleone P, Roy T, Fally P, Dorzee J, Fastrez J, Castelain T, d'Odemont JP

Service de Thoracique, Clinique Saint-Joseph, Mons, Belgique.

The authors report a case of a black African patient who suffers from a chronic eosinophilic pneumonia. In view of the lack of precise reporting in the literature of such a case in black Africans, the initial difficulty of strictly excluding a parasitologic etiology is discussed. From the comparison of paraclinical and clinical data with those of the literature, the authors emphasize the close relationship between asthma and chronic eosinophilic pneumonia and the role of alveolar eosinophils in the physiopathology of that illness.

Publication Types:

• Review
• Review of reported cases

PMID: 9562702, UI: 98223795

Ethn Health 1997 Nov;2(4):329-39

Health outcomes among African American and Caucasian adults following a randomized trial of an asthma education program.

Ford ME, Havstad SL, Tilley BC, Bolton MB

Center for Medical Treatment Effectiveness Programs (MEDTEP), Detroit, MI, USA.

OBJECTIVES: Re-analysis of a randomized trial of an asthma education program designed to assess the effects of the intervention on emergency department visits, limited days of activity and asthma knowledge and beliefs separately for African American and Caucasian adults with asthma. DESIGN: Two hundred and forty-one respondents between the ages of 18 and 70 were evaluated in two emergency departments (one inner city and one suburban location) of a large, midwestern health care system and were randomized to an intervention or control group. RESULTS: Regardless of race, members of the intervention group showed a decrease in the number of post-intervention emergency department visits (ANOVA interaction between race and group effect p value = 0.93). The greatest decrease occurred during the first four post-intervention months. No differential effect of the asthma education intervention by race was found on the change in asthma knowledge and beliefs over the study period (ANCOVA interaction between race and group effect p value = 0.60). CONCLUSION: This study demonstrates that post-intervention, both African American and Caucasian study participants showed a decrease in emergency department visits and an increase in asthma self-management. This finding is especially important for African Americans, who face increasing asthma mortality and morbidity.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 9526696, UI: 98187444

Mt Sinai J Med 1998 Mar;65(2):139-45

Immunoglobulin and IgG subclass levels in the African American and Hispanic populations of east Harlem.

Lewis M, Miyashiro M, Huton J, Miller L, Sperber K

Division of Clinical Immunology, Mount Sinai School of Medicine, New York, NY 10029, USA.

BACKGROUND: The normal levels of immunoglobulin and IgG subclasses in African American and Hispanic populations are uncertain. To determine immunoglobulin and IgG subclass levels in this community, we measured serum IgG, IgM, and IgA levels along with IgG subclasses in 303 African American and Hispanic patients in a general medical clinic and an allergy/asthma clinic in East Harlem in New York City. METHODS: Prospective measurement of immunoglobulins and IgG subclasses in a general medical clinic and an allergy/asthma clinic in East Harlem. RESULTS: Ten (3.4%) patients had IgG levels below the lower limit of normal values, two (0.07%) patients had IgA levels below the lower limit of normal values, and two (0.07%) patients had an IgM level below the lower limit of normal values. Twenty-four (8.1%) patients had IgG subclass levels below the lower limit of normal values; 1 patient had low levels of IgG1 and IgG3, 5 patients had low levels of IgG2, and 18 patients had low levels of IgG3. Because low IgG subclasses and allergy/asthma appeared to be associated, we compared IgG subclass levels of the patients with and without allergy/asthma. The mean IgG2 level in the patients without allergy/asthma was 425.1 +/- 199.1 mg/dL (p = 0.05) compared with 345.5 +/- 133.1 mg/dL in the allergy/asthma group, the mean IgG3 level in the patients without allergy/asthma was 85.0 +/- 57.1 mg/dL compared with 64 +/- 34.1 mg/dL in the allergy/asthma group (p = 0.016) but there were no differences in IgG1 and IgG4 levels between the two groups. CONCLUSION: Altogether, our data indicate that humoral immunoglobulin and IgG subclass levels below the lowest normal values occur in the low socioeconomic African American and Hispanic populations, especially in patients with asthma in East Harlem.

PMID: 9520518, UI: 98181133

Arch Intern Med 1998 Mar 9;158(5):457-64

Compliance with national asthma management guidelines and specialty care: a health maintenance organization experience.

Legorreta AP, Christian-Herman J, O'Connor RD, Hasan MM, Evans R, Leung KM

Quality Initiatives Division, Health Net, Woodland Hills, CA 91637, USA.

BACKGROUND: To improve asthma disease management, the National Asthma Education Program (NAEP) Expert Panel published Guidelines for the Diagnosis and Management of Asthma in 1991. OBJECTIVES: To compare the current status of asthma disease management among patients in a large health maintenance organization with the NAEP guidelines and to identify the factors that may be associated with medical care (eg, emergency department visits and hospital admissions) and adherence to the guidelines. METHODS: Analyses of 1996 survey data from 5580 members with asthma (age range, 14 to 65 years) covered by a major health maintenance organization in California (Health Net). RESULTS: In general, adherence to NAEP guidelines was poor. Seventy-two percent of respondents with severe asthma reported having a steroid inhaler, and of those, only 54% used it daily. Only 26% of respondents reported having a peak flowmeter, and of those, only 16% used it daily. Age (older), duration of asthma (longer), increasing current severity of disease, and treatment by an asthma specialist correlated with daily use of inhaled steroids. Ethnicity (African American and Hispanic) correlated negatively with inhaled steroid use but positively with emergency department visits and hospital admissions for asthma. Increasing age and treatment by an asthma specialist were also identified as common factors significantly related to the daily use of a peak flowmeter and, interestingly, to overuse of beta2-agonist metered-dose inhalers. CONCLUSIONS: Although the NAEP guidelines were published 7 years ago, compliance with the guidelines was low. It was especially poor for use of preventive medication and routine peak-flow measurement. Furthermore, the results showed that asthma specialists provided more thorough care than did primary care physicians in treating patients with asthma. Combining the results of the regression analyses revealed that some of the variation in rates of emergency department visits and hospitalizations among some subpopulations can be explained by the underuse of preventive medication. This study serves the goal of documenting the quality of care and services currently provided to patients with asthma through a large health maintenance organization and provides baseline information that can be used to design and assess effective population-based asthma disease management intervention programs.

Comments:

• Comment in: Arch Intern Med 1998 Aug 10-24;158(15):1720, 1723

PMID: 9508223, UI: 98167648

Pediatrics 1998 Mar;101(3):E1

Impact of a Medicaid primary care provider and preventive care on pediatric hospitalization.

Gadomski A, Jenkins P, Nichols M

Research Institute, Bassett Healthcare, Cooperstown, NY 13326, USA.

OBJECTIVE: This study evaluates the impact that a Medicaid managed care program had on avoidable hospitalization, a form of health care misuse that we hypothesize can be reduced by improved access to and quality of primary care in the context of a managed care program. Ambulatory care sensitive (ACS) hospitalizations, a previously defined categorization of hospitalization, as well as all pediatric hospitalizations were also studied. INTERVENTION: The Maryland Access to Care (MAC) was a fee-for-service, gatekeeper, Medicaid managed care program with assigned primary medical providers and required Early Periodic Screening, Diagnosis, and Treatment (EPSDT) examinations. Medicaid managed care elements include: 1) assignment to primary medical provider (PMP) either by voluntary choice or mandatory enrollment of eligible Aid to Families With Dependent Children (AFDC), Medical Assistance (medical needy), and Supplemental Security Income; 2) a medical home accessible 24 hours a day, 7 days a week; 2) PMP must authorize emergency department (ED), inpatient, and specialty care but there were no disincentives to PMP for referral; 3) fee-for-services reimbursement (with a physician rate increase) for primary care, authorized specialist care, and hospitalization; and 4) an on-line eligibility verification system was available to all medical providers. Pre-enrollment as well as publicity allowed MAC to be phased in rapidly, resulting in 70% to 80% enrollment by the end of the first program year. DESIGN: The design of this study is that of a pre- and postevaluation of the MAC program using Medicaid claims analysis of data 3 years pre-MAC and 2 years post-MAC. In multivariate analyses, this study also compares MAC-enrolled children to non-MAC-enrolled children (before and after MAC began) to estimate the impact of MAC enrollment while controlling for potential confounders. SETTING: State of Maryland from 1989 to 1993. PATIENTS: MAC-eligible children 18 years of age. OUTCOME MEASURES: Claims data were used to define avoidable hospitalization (based on ambulatory care received before hospitalization), to define ACS hospitalizations (based on the International Classification of Diseases-Clinical Modification, Ninth Revision [ICD-9-CM] codes), and to summarize use of ambulatory and inpatient care. ACS hospitalizations have been defined as those conditions for which timely and effective primary care can help to reduce the risk of hospitalizations. These are based solely on ICD-9-CM discharge codes that were studied by Billings and Teicholz in 1990 and used by an Institute of Medicine report in 1993. Examples include hospital discharge diagnoses of asthma (ICD-9-CM = 493), gastroenteritis (ICD-9-CM = 558.9), and dehydration (ICD-9-CM = 276.5). Usage measures, such as preventive care visits or ED visits, were created using Maryland Medicaid codes, Current Procedural Terminology codes, and ICD-9-CM codes. Linear regression was used to model trend. Logistic regression was used to model the probability of ambulatory and inpatient care given MAC enrollment and other covariates. First, logistic regression was used to predict the probability of any ambulatory care use among all MAC-eligible children during a quarter to model changes in access that may have occurred during MAC. Then, among users of ambulatory care or inpatient care, logistic regression was used to predict the probability of hospitalization. RESULTS: Most of the children studied were in the AFDC program, about half were African-American, one third resided in Baltimore City, and 9% of children had ICD-9-CMs reflecting chronic disease. The mean percentage of time children were MAC-eligible per quarter was 91%. Only 5% of children were continuously enrolled for all 20 quarters included in this study. Per-capita ambulatory care visits, especially per-capita preventive care visits, increased significantly during the study period (b = 0.003) whereas per-capita ED visits did not change. The mean n

PMID: 9481020, UI: 98374547

Nurs Res 1997 Nov-Dec;46(6):338-41

Quality of life, medication use, and health care utilization of urban African Americans with asthma treated in emergency departments.

Blixen CE, Tilley B, Havstad S, Zoratti E

Department of Nursing Research and Education, Cleveland Clinic Foundation 44195, USA.

PMID: 9422053, UI: 98083971

Pediatr Pulmonol 1997 Oct;24(4):234-6

Psychosocial influences on asthma among inner-city children.

Klinnert MD

Publication Types:

• Editorial

PMID: 9368257, UI: 98034627

Pediatr Pulmonol 1997 Oct;24(4):231-3

Asthma among inner city children.

Platts-Mills TA

Publication Types:

• Editorial

PMID: 9368256, UI: 98034626

MMWR Morb Mortal Wkly Rep 1997 Sep 19;46(37):877-80

Asthma mortality -- Illinois, 1979-1994.

Asthma is a chronic inflammatory disorder of airways characterized by variable airflow obstruction with airway hyperresponsiveness. In the United States, the mortality rate associated with asthma has increased steadily since 1979. Uneven distributions of deaths attributable to asthma have been observed among different racial/ethnic groups. To examine the distribution of asthma deaths in Illinois, trends in asthma death rates were analyzed for 1979-1994 for Illinois residents. This report presents the findings of this analysis, which indicated that, compared with asthma death rates in the United States for 1982-1991, rates in Illinois were higher and the asthma mortality ratio for blacks to whites was higher.

PMID: 9310212, UI: 97454137

Int Arch Allergy Immunol 1997 May-Jul;113(1-3):87-95

Evaluating the factors that relate to asthma severity in adolescents.

Togias A, Horowitz E, Joyner D, Guydon L, Malveaux F

Division of Clinical Immunology, Johns Hopkins University School of Medicine at the Johns Hopkins Asthma and Allergy Center, Baltimore, Md. 21224, USA.

Over the past 5 years, we have been engaged in a cross-sectional evaluation of risk factors for higher asthma severity in adolescents aged 13-18. All recruitment takes place through public and private schools. The sample from which our current findings are derived includes 151 adolescents covering a wide spectrum of asthma severity and socioeconomic status (SES) and representing both African American and Caucasians. An asthma severity instrument has been developed and validated for the purpose of this study. This yields an asthma severity score which is a continuous variable. Female gender and the number of positive skin tests are the best independent correlates to the asthma severity score. Among the 18 aeroallergens used in the study, the American cockroach Periplaneta americana is the only one that relates to the asthma severity score in a stepwise regression model. The two other cockroaches, German and oriental, as well as the dust mites Dermatophagoides farinae and Dermatophagoides pteronyssinus, correlate with the asthma severity only in simple regression analysis. The relationship between asthma severity and cockroach sensitivity is strongest within the lowest-income per family member quartile. This is consistent with the additional observations that (1) significantly higher rates of sensitization for cockroaches are observed in the lowest-income quartile subjects and (2) higher levels of the cockroach allergen Bla g 1 are found in their homes. Preliminary analysis suggests that ethnic background may interact with environmental exposure in that, within the lowest-income quartile, Caucasians have lower sensitization rates to cockroaches and other allergens compared to African Americans. Within the Caucasian population, income does not appear to influence sensitization rates. The treatment that adolescents with asthma receive for their respiratory disease is characterized by an overall low rate of prescribed inhaled corticosteroids (37% in the moderately severe and severe groups). This inadequacy in treatment is accentuated by SES: 28% of adolescents in the highest and 6% in the lowest-income quartile are prescribed these medications. Our findings are consistent with the hypothesis that the higher asthma morbidity and mortality observed in the African American population is related to higher exposure and sensitization to allergens such as those from cockroaches that are more prevalent in lower SES environments. It is possible that genetic factors contribute to the higher degree of sensitization. In addition, individuals of low SES are subjected to inadequate medical management of their asthma.

PMID: 9130491, UI: 97276798

Stat Bull Metrop Insur Co 1997 Apr-Jun;78(2):26-32

Average hospital charges for asthma treatment: United States, 1995.

Mushinski M

Asthma is a chronic condition that affects some 14 to 15 million persons in the United States and is one of the most frequent causes for hospitalizations among children as well as adults. Asthma-related morbidity and mortality rates have been increasing for more than a decade in this country as have hospital admissions and visits to doctors' offices for acute episodes of this condition. In 1995, the average total hospital plus physicians' charges for treating 3,559 group health insured hospitalized asthma patients was $5,710. The highest regional charge was reported for the Pacific area states (28 percent above the U.S. average) and the lowest in the East South Central states, where the total was 20 percent below the average and 38 percent below that in the Pacific area. Variation in charges was even more pronounced between study states. Arizona, Colorado and California had average charges from 30 to 47 percent above the U.S. average, whereas Washington, Tennessee and Ohio had averages 32 to 35 percent below. Hospital charges (room and board plus ancillary fees) accounted for 92 percent of the total charge to insurance with the per diem charge averaging $1,640. Physicians' charges were less the $500 for the country as a whole but ranged from $710 in Florida (54 percent above the average) to $260 in Michigan (43 percent below the norm). The average length of stay was 3.48 days, with patients in Washington averaging 2.92 days and those in Pennsylvania and New York 4.10.

PMID: 9134613, UI: 97280262

Ann Allergy Asthma Immunol 1997 Mar;78(3):265-9

Trends in asthma prevalence: the Bogalusa Heart Study.

Farber HJ, Wattigney W, Berenson G

Section of Pediatric Pulmonology, Tulane University Medical Center, New Orleans, Louisiana, USA.

BACKGROUND: Epidemiologic surveys from different parts of the developed world are showing increases in asthma prevalence; the causes are not known. OBJECTIVE: To describe trends in prevalence of childhood asthma measured across serial cross-sectional surveys of the school age population of Bogalusa, Louisiana. METHODS: The Bogalusa Heart Study is a long-term epidemiologic study of risk factors for cardiovascular disease in children in a stable, semirural, biracial community. Part of the examination includes a parent-completed health history questionnaire. The item, "Does your child have or has your child had in the past...asthma?" was included in the 1983-5, 1987-8, and 1992-4 surveys. Data analysis was restricted to subjects aged 5 to 17 years. RESULTS: Three thousand two hundred seventy-six subjects participated in 1983-5, 3256 in 1987-8, and 3128 in 1992-4. Reported asthma prevalence increased from 9.2% to 15.9% between 1983-5 and 1992-4. Maternal smoking was associated with asthma in all three surveys. Young age and African American ethnicity were associated with asthma only in the 1992-4 survey. CONCLUSIONS: The prevalence of asthma among the school age population of Bogalusa, Louisiana increased by 73% between the 1983-5 and the 1992-4 surveys. Whether the increase in asthma prevalence represents an increase in disease presence or an increase in disease recognition cannot be determined from these data.

PMID: 9087150, UI: 97242094

J Clin Epidemiol 1997 Feb;50(2):167-74

Health care use by inner-city patients with asthma.

Murray MD, Stang P, Tierney WM

Department of Pharmacy Practice, Purdue University School of Pharmacy, West Lafayette, Indiana 47907-1335, USA.

The purpose of this study was to describe patterns of health care use by inner-city patients with asthma and to identify patients at risk for hospitalization. We performed a retrospective cohort study of 1788 patients with asthma aged 5 to 34 years from a large hospital-based multi-specialty practice in inner-city Indianapolis from 1985 to 1992. Compared with 633 white patients, 1155 African-American patients had fewer outpatient encounters including primary care visits, urgent visits to the emergency department and urgent care centers, and prescription refills. Emergency department use was greater for African-American males compared with white males. With patients 30 years of age as the referent, survival analysis revealed three to sixfold greater relative risk of hospitalization for asthma for younger patient age groups, and greatest risk among young African-American males. Adolescent patients had the highest cumulative percentage hospitalization and the longest lengths of stay. We conclude that inadequate routine primary care among African-American patients may increase their risk of asthma exacerbation requiring hospitalization. Age, gender, and race are all important predictors of hospitalization for asthma. Further studies are needed to explore the relation between sources of care and asthma exacerbation.

PMID: 9120510, UI: 97246651

Pediatrics 1997 Feb;99(2):157-64

Improving care for minority children with asthma: professional education in public health clinics.

Evans D, Mellins R, Lobach K, Ramos-Bonoan C, Pinkett-Heller M, Wiesemann S, Klein I, Donahue C, Burke D, Levison M, Levin B, Zimmerman B, Clark N

Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA.

OBJECTIVE: Recent studies have shown that lack of continuing primary care for asthma is associated with increased levels of morbidity in low-income minority children. Although effective preventive therapy is available, many African-American and Latino children receive episodic treatment for asthma that does not follow current guidelines for care. To see if access, continuity, and quality of care could be improved in pediatric clinics serving low-income children in New York City, we trained staff in New York City Bureau of Child Health clinics to provide continuing, preventive care for asthma. METHODS: We evaluated the impact of the intervention over a 2-year period in a controlled study of 22 clinics. Training for intervention clinic staff was based on National Asthma Education and Prevention Program guidelines for the diagnosis and management of asthma, and included screening to identify new cases and health education to improve family management. The intervention included strong administrative support by the Bureau of Child Health to promote staff behavior change. We hypothesized that after the intervention, clinics that received the intervention would, compared with control clinics, have increased numbers of children with asthma receiving continuing care in the clinics and increased staff use of new pharmacologic and educational treatment methods. RESULTS: In both the first and second follow-up years, the intervention clinics had greater positive changes than control clinics on measures of access, continuity, and quality of care. For second year follow-up data these include: for access, greater rate of new asthma patients (40/1000 vs 16/1000; P < .01); for continuity, greater percentage of asthma patients returning for treatment 2 years in a row (42% vs 12%; P < .001) and greater annual frequency of scheduled visits for asthma per patient (1.85 vs .88; P < .001); and for quality, greater percentage of patients receiving inhaled beta agonists (52% vs 15%; P < .001) and inhaled antiinflammatory drugs (25% vs 2%; P < .001), and greater percentages of parents who reported receiving patient education on 12 topics from Bureau of Child Health physicians (71% vs 58%; P < .01) and nurses (61% vs 44%; P < .05). CONCLUSION: We conclude that the intervention substantially increased the Bureau of Child Health staff's ability to identify children with asthma, involve them in continuing care, and provide them with state-of-the-art care for asthma.

Publication Types:

• Clinical trial
• Controlled clinical trial

Comments:

• Comment in: Pediatrics 1997 Feb;99(2):252-4

PMID: 9024439, UI: 97176900

J Health Care Poor Underserved 1997 Feb;8(1):83-98

Differences in follow-up visits between African American and white Medicaid children hospitalized with asthma.

Ali S, Osberg JS

Harvard School of Public Health, Boston, MA, USA.

Asthma-related hospitalizations and mortality have risen at alarming rates in the past two decades, taking a disproportionate toll on African American children. Adverse asthma outcomes have been attributed to inadequacies in primary care, raising concerns about the quality of primary care delivered to African American children. To assess differences in care between African American and white children, the authors identified 500 children enrolled in Massachusetts Medicaid and hospitalized for asthma, and reviewed their medical claims data for the six-month period after hospitalization. It was found that African American children had significantly fewer primary care visits than their white counterparts, even after adjusting for potential confounding variables. In contrast, emergency service utilization did not differ by race. The authors conclude that racial disparity exists in primary care access among children with asthma. Interventions should be designed to target poor African American children who suffer disproportionately from this life-threatening yet treatable disease.

PMID: 9019028, UI: 97171859

J Asthma 1997;34(3):243-8

Characteristics of predominantly nonwhite patients with frequent hospitalizations for acute asthma in Chicago.

Olopade CO, Alikakos Z, Abubaker J, Rubinstein IR

Department of Medicine, University of Illinois at Chicago 60612-7323, USA.

The purpose of this study was to determine the characteristics of predominantly nonwhite patients with recurrent visits to the emergency department (ED) and admissions to an inner-city hospital in Chicago for acute asthma. Over a 21-month period, two groups of age and gender-matched individuals with asthma seen at the University of Illinois at Chicago Medical Center were studied: group I included 26 patients with frequent visits to the ED and no more than one admission for acute asthma/year; and group II included 28 patients with recurrent visits to the ED and two or more admissions for acute asthma/year. We found that 70% of all patients (38/54) were females and 72% (39/54) were African-Americans. The latter predominated in group II (25/28; 89%). There were no significant differences in public aid recipients, baseline FEV1, type of antiasthma medications used, and illicit drug use between the two groups. However, group II reported more asthma onset before the age of 11 years and used higher daily doses of inhaled corticosteroids than group I (p < 0.05). The average duration of hospital stay in group II was significantly longer (3.3 +/- 0.4 days vs. 2.4 +/- 0.3 days, respectively, mean +/- SEM, p < 0.05), and the average cost per hospitalization in group II significantly exceeded that of group I ($5122 +/- $590 vs. $3740 +/- $450, respectively, p < 0.05). We conclude that African-American females are seen more frequently in the ED for acute asthma and admitted to the hospital in Chicago. They develop asthma before the age of 11 years, use higher daily doses of inhaled corticosteroids, and contribute significantly to the high cost of asthma care.

PMID: 9168852, UI: 97312411

Psychopharmacol Bull 1997;33(1):143-7

Methylphenidate patterns among Medicaid youths.

Zito JM, Safer DJ, dosReis S, Magder LS, Riddle MA

Department of Pharmacy Practice and Science, University of Maryland at Baltimore 21201, USA.

Treatment of attentional disorders in America has increased dramatically in recent years. This trend is accounted for partly by lengthening the duration of treatment into adulthood for some individuals as well as by increased treatment among girls. Beyond these factors, the role of economic status, race, and geographic region to explain the variation in methylphenidate use is not well understood. Computerized administrative data were used to explore the influence of several sociodemographic factors on the prevalence of methylphenidate use. The data source consisted of Maryland Medicaid prescription drug reimbursement claims data for FY1991 for children ages 5 to 14 years. In effect, the study was restricted to a sample of patients with limited income. The study aims included (1) measuring gender-, age-, race-, and region-specific methylphenidate prevalence for this restricted income population; (2) comparing the Caucasian:African-American (C:A-A) ratio for methylphenidate with the C:A-A ratio for several drug therapies having non-psychotropic uses, specifically the anti-asthma drug, theophylline, and antibiotics for infections; and (3) estimating the average daily dose of methylphenidate from prescription claims data. Total drug-specific prevalence among the 5-14 year olds was 2.2 percent for methylphenidate while age-specific prevalence varied from 0.4 percent (5 year olds) to 3.4 percent (9 year olds). The gender ratio was 3.7:1 (M:F), confirming the increasing trend for girls to receive this medication. Substantial variation across eight defined regions of the state was observed. Racial differences were pronounced: African-Americans were 2.5 times less likely to receive methylphenidate than Caucasian youths. As hypothesized, non-psychotropic drug use was distinctly different from psychotropic drug use in terms of race: theophylline was 1.5 times more likely to be found for African-Americans than Caucasians, whereas antibiotic prescriptions were 1.5 times more likely to be prescribed to Caucasian youths. Average daily dose of methylphenidate was estimated to be 18.7 +/- 10.4 mg for 5-9 year olds and 26.8 +/- 14.0 mg for 10-14 year olds. This brief report confirms the typically lower rate among African-American Medicaid youths for most prescription drugs. The dramatic racial disparity for the psychotropic agent methylphenidate is a new and compelling finding which should be verified among other economic groups. Diagnostic, referral, and cultural bias should be ruled out as possible explanations for the observed differences.

PMID: 9133766, UI: 97279313

Thorax 1996 Nov;51(11):1134-6

Exercise-induced bronchoconstriction by ethnicity and presence of asthma in British nine year olds.

Jones CO, Qureshi S, Rona RJ, Chinn S

Department of Public Health Medicine, St Thomas' Hospital, London, UK.

BACKGROUND: The prevalence of exercise-induced bronchoconstriction among British children by ethnicity has not been studied. METHODS: Peak expiratory flow rate (PEFR) was measured before and after an exercise challenge test using a cycle ergometer in 593 nine year olds from Scottish and inner city English schools. Logistic regression analysis was carried out to assess the association between changes in PEFR with exercise by reported asthma, ethnicity, and sex. RESULTS: The probability of exercise-induced bronchoconstriction was greater among the asthmatics than in either the children without asthma attacks or wheeze, or in the children with only wheeze (p < 0.01). Asian children were 3.6 times more likely to have exercise-induced bronchoconstriction than white inner city children, and also were more likely to have exercise-induced bronchoconstriction than those from the other ethnic groups (p < 0.01). CONCLUSION: Exercise challenge can assess the prevalence of asthma in the community and detect under-reporting of asthma in ethnic minorities.

PMID: 8958899, UI: 97118016

Diabetes Res Clin Pract 1996 Oct;34 Suppl:S173-9

Patterns of hospital use, family history and co-existing conditions among urban African-American and Hispanic-American children with insulin-dependent diabetes mellitus.

Lipton RB

University of Illinois, School of Public Health, Division of Epidemiology and Biostatistics, Chicago 60612, USA.

Little information is available about insulin-dependent diabetes mellitus (IDDM) when it occurs among US minorities. The incidence of IDDM among African-American and Hispanic children < 18 years of age was determined in the city of Chicago. Hospital records were used as the primary source of cases, and a small amount of additional data was collected from the medical charts. Cases were drawn from records at 37 hospitals in Cook County, IL. African-American and Hispanic patients using insulin, residing in the city of Chicago, and < 18-years-old at onset were registered. Three secondary sources were used and overall ascertainment was estimated at 86%. There were 413 new cases during the 6-year interval 1985 through 1990. The age-standardized incidence of IDDM was 13.2/100,000 (95% confidence interval (C.I.) 11.8-14.8) among African-Americans and 10.8/100,000 (95% C.I. 9.5-12.3) among Hispanics. Hospital use differed between African-Americans and Hispanics, presumably based on geographic, cultural and financial factors. Diabetes among the first degree relatives of children from both ethnic groups was common, and the most frequently listed co-morbid conditions were asthma and obesity. The risk for IDDM in Chicago is among the highest for both African-origin and Hispanic children worldwide. The prevalence of asthma and obesity parallels the high prevalence of these conditions among non-diabetic children in Chicago. The ongoing epidemic of non-insulin-dependent diabetes mellitus (NIDDM) among African-Americans and US Hispanics is likely to be the reason for the large number of minority IDDM patients who have a first-degree relative with diabetes.

PMID: 9015688, UI: 97168071

J Med Syst 1996 Oct;20(5):255-66

Practice variations in treating urban minority asthmatics in Chicago.

McDermott M, Silva J, Rydman R, Giachello AL, Yarzagaray E, Robinson D, Peragallo N, Barquero H, Arrom JO

Emergency Department at Cook County Hospital, Chicago, IL 60637, USA.

This study explores provider adherence to national guidelines in treating Latino and African-American asthmatics. We hypothesized that there would be more variations in asthma treatment existing for minorities as a result of variation in physician's adherent to the guidelines. A 96-item survey was administered to 138 Latino and African-American asthmatics attending a hospital emergency department. Data were obtained on demography, severity, access, patient satisfaction, and patient's assessment of physician asthma management. Results were analyzed by ethnicity, gender, practice site of regular provider, and severity. Variation in physician practice was found in these variables. Asthma treatment received by Latino and African-American respondents was deficient compared to guidelines. Regression analyses showed that Latinos fared more poorly on the number of prednisone bursts taken, use of written crisis plans and dispensation of peak flow meters controlling for gender, practice site and severity. African-Americans expressed less dissatisfaction in obtaining services, while both groups expressed high degrees of satisfaction with their providers.

PMID: 9001993, UI: 97155279

Am J Respir Crit Care Med 1996 Oct;154(4 Pt 1):894-9

Asthma among Puerto Rican Hispanics: a multi-ethnic comparison study of risk factors.

Beckett WS, Belanger K, Gent JF, Holford TR, Leaderer BP

Division of Environmental Health Sciences, Yale University School of Medicine, New Haven, Connecticut, USA.

For a study of childhood asthma we interviewed 9,276 mothers during 1993-1994, ascertaining whether they had asthmatic children younger than 18 yr of age and asking about genetic and environmental risk factors for asthma. Independent risk factors for asthma in 7,776 children were: Hispanic and African American ethnicity, maternal history of asthma, lower socioeconomic status (SES) of the mother, and the presence of a cigarette smoker in the household. Hispanic ethnicity was also a strong risk factor for asthma in the mother. The prevalence of asthma among children of Hispanic (mainly Puerto Rican) mothers with one or more children older than 9 mo of age was 18.4%, for blacks it was 1 1.3%, and for non-Hispanic whites it was 7.4%. The marked increased risk for asthma in children of Hispanic mothers was not explained by SES or maternal age. In addition, increased risk for asthma in these children was not associated with higher reporting of environmental tobacco smoke (ETS) exposure. In this study of asthma in primarily Puerto Rican Hispanics, the risk of physician-diagnosed asthma as reported by mothers was significantly associated with Hispanic ethnicity, and it was not confounded by SES or active smoking in the home.

PMID: 8887582, UI: 97042382

Pediatr Nurs 1996 Jul-Aug;22(4):285-90

Illness narratives of children with asthma.

Yoos HL, McMullen A

A child's own story of the illness experience is a necessary starting point for intervention strategies and outcomes research. A descriptive study of perceptions of asthma among 28 children (6-18 years old) with moderate or severe asthma was part of a larger study of symptom perception of asthma in childhood. The study sample included 36% Caucasian, 46% African American, and 18% other ethnic groups, encompassing a range of socioeconomic groups. Open-ended, semi-structured interviews were used to elicit children's perceptions of the impact of asthma on their lives, things that bothered them about having asthma, and worries they experienced. Visual analogue scales were used to assess several values. Themes that emerged in data analysis included (a) "I can't," (b) restrictions, (c) symptoms and treatments, (d) death, and (e) adaptation. Overall, asthma had a profound impact on study children, and certain themes were more predominant among subgroups of race and age; notably, the death theme was more prominent among African-American children.

PMID: 8852106, UI: 97004795

Ann Pharmacother 1996 Jul-Aug;30(7-8):782-6

Cisplatin nephrotoxicity in a patient with a single kidney.

Udeani GO, Singh K, Mullane MR, Lad TE

Department of Pharmacy Practice (M/C 886), College of Pharmacy, University of Illinois at Chicago, USA. gudeani@uic.edu

OBJECTIVE: To describe a patient with a single kidney who experienced cisplatin-associated nephrotoxicity. CASE SUMMARY: A 78-year-old African-American woman with squamous cell carcinoma of the base of her tongue (T4N2M1) was admitted electively to our institution for the first cycle of chemotherapy. Her past medical history was significant for a left nephrectomy secondary to well-differentiated papillary transitional cell carcinoma of the left renal pelvis, hypothyroidism, asthma, and coronary artery disease. Her blood urea nitrogen (BUN) was 27 mg/dL of urea, and serum creatinine was 1.2 mg/dL. On admission she was hydrated adequately, and was treated with an evening dose of cisplatin 100 mg/m2 (180 mg) in 250 mL of NaCl 0.9% solution in a 3-hour infusion, and a 5-day course of fluorouracil 1000 mg/m2 (1800 mg) in a 24-hour infusion. Serum creatinine and BUN concentrations following cisplatin administration were 1.1 mg/dL and 8 mg/dL, respectively. Four days after cisplatin therapy, a decline in renal function was observed, with an increase in serum creatinine and BUN concentrations to 4.0 mg/dL and 31 mg/dL, respectively. These tests remained elevated throughout her hospitalization. With hemodialysis treatments a resolution in altered mental status was observed; however, her chronic renal failure persisted. She was subsequently discharged and followed in the outpatient renal, geriatric, and oncology clinics. DISCUSSION: Cisplatin is a principal chemotherapeutic agent used in the treatment of a variety of solid tumors. Nephrotoxicity is a major complication associated with this compound. Although many clinicians believe that cisplatin nephrotoxicity is unlikely to occur in patients with a single kidney, recent reports have suggested otherwise. The physiologic changes of the aging kidney are such that they should foster cisplatin clearance rather than expose the kidney to the drug's nephrotoxic potential. In addition, evening administration of cisplatin is thought to minimize nephrotoxicity. We describe a 78-year-old woman with a single kidney who developed nephrotoxicity following a single evening dose of cisplatin. Details of the patient's history and cisplatin-associated complication and therapy are discussed. CONCLUSIONS: Cisplatin circadian rhythmic pharmacotherapy to minimize cisplatin toxicity in patients with a single kidney appears to be controversial and needs further evaluation.

PMID: 8826561, UI: 96423961

Am J Med Sci 1996 Jun;311(6):272-80

Comprehensive long-term management program for asthma: effect on outcomes in adult African-Americans.

Kelso TM, Abou-Shala N, Heilker GM, Arheart KL, Portner TS, Self TH

Department of Clinical Pharmacy, University of Tennessee, Memphis 38163, USA.

To determine if a comprehensive long-term management program, emphasizing inhaled corticosteroids and patient education, would improve outcomes in adult African-American asthmatics a nonrandomized control trial with a 2-year intervention was performed in a university-based clinic. Inclusion criteria consisted of (> or = 5) emergency department (ED) visits or hospitalizations (> or = 2) during the previous 2 years. Intervention patients were volunteers; a comparable control group was identified via chart review at hospitals within the same area and time period as the intervention patients. Individualized doses of beclomethasone with a spacer, inhaled albuterol "as needed," and crisis prednisone were the primary therapies. Environmental control, peak flow monitoring, and a partnership with the patient were emphasized. Detailed patient education was an integral part of management. Control patients received usual care from local physicians. ED visits and hospitalizations for 2 years before and 2 years during the intervention period were compared. Quality of life (QOL) measurements were made at baseline and every 6 months in the intervention group. Study group (n = 21) had a significant reduction in ED visits (2.3 +/- 0.2 pre-intervention versus 0.6 +/- 0.2 post-intervention; P = 0.0001). Control group (n = 18) did not have a significant change in ED visits during the 2-year post-intervention period (2.6 +/- 0.2 pre-intervention versus 2.0 +/- 0.2 post-intervention; P = 0.11). Both groups had significant reductions in hospitalizations, but the study group had a greater reduction. Sixty-two percent of study patients had complete elimination of ED visits and hospitalizations, whereas no control patients had total elimination of the need for institutional acute care. QOL in the study patients revealed significant improvements for most parameters. A comprehensive long-term management program emphasizing inhaled corticosteroids combined with other state-of-the-art management, including intensive patient education, improves outcomes in adult African-American asthmatics.

Publication Types:

• Clinical trial
• Controlled clinical trial

PMID: 8659554, UI: 96264730

J Allergy Clin Immunol 1996 Jun;97(6):1393-401

Socioeconomic status and race as risk factors for cockroach allergen exposure and sensitization in children with asthma.

Sarpong SB, Hamilton RG, Eggleston PA, Adkinson NF Jr

Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287-3923, USA.

BACKGROUND: The domestic cockroach has been identified as an important source of indoor aeroallergens worldwide in both temperate and tropical climates. Because cockroach populations are highest in crowded urban areas, some have suggested that the increased asthma morbidity and mortality rates in inner cities could be related in part to cockroach allergen exposure. We have examined cockroach allergen exposure in the homes of children with asthma in both urban and suburban locations and have related the rates of exposure and sensitization to socioeconomic, racial, and demographic factors. OBJECTIVE: The study was designed to determine the independent contribution of race, socioeconomic status, and place of residence to the risk of cockroach allergen exposure and sensitization in children with asthma. METHODS: Eighty-seven children with moderate to severe allergic asthma, aged 5 to 17 years, participating in a prospective trial of immunotherapy, were evaluated. Extracted dust samples from three home locations were analyzed by using two-site monoclonal immunoassays for major cockroach allergens (Bla g 1 and Bla g 2). A puncture skin test with a mixed cockroach allergen extract was performed in 81 of the 87 subjects. RESULTS: In the 87 homes evaluated, 26% of the bedroom dust samples had detectable levels of cockroach allergen. In homes with detectable bedroom cockroach allergen levels, mean Bla g 1 and Bla g 2 concentrations in urban and suburban homes were similar. Over 80% of children with bedroom Bla g 1 or Bla g 2 of 1 U/gm or greater demonstrated skin sensitivity to cockroach allergen. The rate of cockroach sensitization was directly related to the level of bedroom exposure. African-American race was the only factor that was independently associated with cockroach allergen exposure (p = 0.05). Lower socioeconomic status, age greater than 11 years, cockroach exposure, and African-American race were all independently associated with cockroach allergen sensitization on the basis of stepwise multiple linear regression analysis. CONCLUSIONS: African-American race and low socioeconomic status were both independent, significant risk factors for cockroach allergen sensitization in children with atopic asthma. Cockroach allergen is detectable throughout the house, including the critical bedroom environment.

PMID: 8648037, UI: 96243721

BMJ 1996 May 18;312(7041):1246

US in the dark on doubling in asthma death rates.

Roberts J

Publication Types:

• News

PMID: 8634608, UI: 96225299

Environ Health Perspect 1996 May;104(5):464-6

Helping schoolchildren with asthma breathe easier: partnerships in community-based environmental health education.

O'Neill MS

Indoor Environments Division, U.S. Environmental Protection Agency, Washington, DC 20460, USA.

Hospitalizations and deaths attributed to asthma are increasing, and the disease has disproportionate impacts on children and minority populations, particularly African-Americans. Because asthma hospitalizations and deaths are viewed by many experts as preventable events, and because asthma's toll is so significant in economic terms, increased efforts to reverse these trends, particularly among the most affected groups, are warranted. Reducing exposures to airborne pollutants known to trigger asthma in both indoor and outdoor environments is one important preventive strategy. The public-private partnership effort to implement the Open Airways for Schools asthma management curriculum in urban elementary schools, with its emphasis on pollution prevention, is an example of a community-based effort that may help decrease the toll asthma takes on society.

PMID: 8743428, UI: 96336456

Pediatr Pulmonol 1996 Apr;21(4):203-10

Short-term compliance with peak flow monitoring: results from a study of inner city children with asthma.

Redline S, Wright EC, Kattan M, Kercsmar C, Weiss K

From the Department of Medicine, Cleveland VA Hospital, Case Western Reserve University, Cleveland, Ohio, USA.

The objective of the study was to assess the feasibility of initiating daily peak flow monitoring in a research study of asthma in inner city children. We performed a descriptive study of patterns of peak flow monitoring in children randomized to receive a simple mini-Wright (SM) or an electronic recording meter (ERM). The ERM served as a "covert" meter, providing objective documentation of actual peak flow use. Sixty-five Hispanic or African-American children, ages 5-9 years, with a history of physician-diagnosed asthma participated in the study. All children resided in census tracts with 40% or more of the population living at or below the poverty level. Subjects were instructed to use a peak flow meter (the SM or ERM) at least twice daily over a 3 week period, and to record peak flow values in a paper diary. Subjects who received the ERM were not made aware that measurements were also recorded electronically. Differences in patterns of use of the SM and ERM were assessed with the Wilcoxon signed rank test and Wilcoxon sum rank test. Adherence to peak flow monitoring was evaluated by comparing the percent days with missing values in the manually completed diary with those obtained by computer record. The Friedman statistic was used to compare changes in compliance (percent of days with missing peak flow entries) over time. Accuracy of peak flow readings was assessed by comparing the manual and electronic recordings with paired and unpaired t-tests and with Pearson product moment correlations. The percent of days with missing peak flow entries on diaries increased from 1.4% to 10.6% from the first to third week of monitoring (P < 0.004). The ERMs indicated a significantly greater percent of missing data than did the manual records (P < 0.0002). The difference in the percent of missing data for the electronic and manual records was most notable during the third study week, when the ERM and the manually completed records indicated that 52% and 15% of days, respectively, were without peak flow measures. Large inter-subject variations in the relationship between manually and electronically recorded peak flow measurements were observed, suggesting that errors in reading and transcribing peak flow rates occur in a subset of asthmatics. We conclude that children and caretakers in the inner city may have considerable difficulty initiating and maintaining peak flow recordings. Data obtained by manual records may considerably overestimate actual use. Compliance with monitoring decreases markedly between the first and third week of monitoring.

Publication Types:

• Clinical trial
• Multicenter study
• Randomized controlled trial

PMID: 9121848, UI: 97012753

Clin J Sport Med 1996 Apr;6(2):119-23

Screening adolescent athletes for exercise-induced asthma.

Feinstein RA, LaRussa J, Wang-Dohlman A, Bartolucci AA

Division of Adolescent Medicine, University of Alabama at Birmingham, USA.

OBJECTIVE. To pilot test an exercise-induced asthma (EIA) screening program using a submaximal step-test and pulmonary function test (PFT) to identify athletes with EIA and to determine if a physical examination or self-reported history could be used to predict the existence of EIA. DESIGN. Screening and diagnostic testing using a convenience sample. SETTING. Birmingham, Alabama, during athletic preparticipation examination (PPE). SUBJECTS. Fifty-two African-American, male football players aged 14-18 years being evaluated for participation in scholastic athletics. No athlete refused participation. Four were excluded because of need for further evaluation unrelated to any pulmonary condition. INTERVENTION. Each athlete completed a medical history, allergy history, physical examination, preexercise pulmonary function test (PFT), submaximal step-test, and a series of postexercise PFTs. MAIN OUTCOME MEASURES. Major outcome measurements were changes in forced expiration volume in 1s (FEV1) or peak expiratory flow rate (PEFR) after completing an exercise challenge. RESULTS. Seventeen of 48 athletes had a > or = 15% decrease in PEFR after exercise. Nine of 48 athletes had a > or = 15% decrease in FEV1 after exercise. The only self-reported item that differentiated subjects with normal and abnormal PFTs was a personal history of asthma (p < 0.05). CONCLUSION. Many athletes can be identified as having abnormal PFTs by use of a submaximal step-test as an exercise challenge. Self-reporting questionnaires and PPEs do not appear to be sensitive enough to identify athletes with this condition. If validated by future studies, this protocol could be used for the diagnosis of EIA.

PMID: 8673569, UI: 96254836

Am J Epidemiol 1996 Mar 15;143(6):570-7

Pre- and perinatal risk factors for asthma in inner city African-American children.

Oliveti JF, Kercsmar CM, Redline S

Rainbow Babies and Children's Hospital, University Hospitals, Case Western Reserve University, Cleveland, Ohio, USA.

The relations between pre- and perinatal risk factors and asthma were investigated using a case-control study of 262 African-American children aged 4-9 years, both asthmatic and nonasthmatic, all of whom resided in a poor urban area and received health care at a local hospital-based clinic. Risk factors were ascertained through review of obstetric, perinatal, and pediatric records. Asthmatic children had significantly lower birth weights and gestational ages than nonasthmatic children and were more likely to have required oxygen supplementation and positive pressure ventilation after birth than nonasthmatics (p < 0.05). The mothers of asthmatic children were more likely to have smoked during pregnancy (50% vs. 27%), to have gained less weight during pregnancy (26.3 pounds (11.9 kg) vs. 34.5 pounds (15.7 kg)), and to have had no prenatal care (12% vs. 2% ) than mothers of nonasthmatic children. Multiple logistic regression demonstrated that the strongest independent predictors of asthma were maternal history of asthma (adjusted odds ratio (OR) = 9,7), lack of prenatal care (OR = 4.7), history of bronchiolitis (OR = 4.7), positive pressure ventilation at birth (OR = 3.3), low maternal weight gain (<20 pounds (<9 kg)) (OR = 3.4), and maternal smoking during pregnancy (OR = 2.8). These data suggest that pre- and perinatal exposures may increase susceptibility to asthma in inner city children.

PMID: 8610674, UI: 96208409

N J Med 1996 Mar;93(3):176-9

Asthma: The inner-city problem in New Jersey.

Bielory L

Asthma & Allergy Research Center, UMDNJ-New Jersey Medical School, Newark 07103-2499, USA.

There continues to be difficulties with asthma management. Significant concerns about morbidity and mortality persist, particularly in minority, lower-income populations, living in urban areas. Patients in urban areas and lower-income groups are less likely to have access to comprehensive treatment.

PMID: 8819910, UI: 96417119

Health Soc Work 1996 Feb;21(1):70-5

An empowerment-centered, church-based asthma education program for African American adults.

Ford ME, Edwards G, Rodriguez JL, Gibson RC, Tilley BC

Center for Medical Treatment Effectiveness Programs, Henry Ford Health System, Detroit, MI 48202, USA.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 8626161, UI: 96211917

J Asthma 1996;33(5):313-25

Articulation of asthma and its care among low-income emergency care recipients.

Munro JF, Haire-Joshu D, Fisher EB, Wedner HJ

Center for Health Behavior Research, Washington University School of Medicine, St. Louis, Missouri, USA.

Low-income minority patients from East St. Louis, Illinois, a depressed midwestern urban city, who had visited acute care settings with asthma symptoms, participated in a focus group. Questions were constructed around the Health Belief Model to characterize participants' experiences in receiving asthma care, their confidence in long-term asthma self-management, barriers they perceived to managing their asthma, and recommendations they would make for improving asthma care in their community. Analysis of comments suggests an appreciable understanding of asthma triggers, limited coping behaviors for asthma symptoms, very limited practice of active asthma management, perception of the health care system as frequently insensitive to their needs or their knowledge of their own care, exchange of well-articulated information regarding how to deal with the system, and an apparent lack of awareness of any potential contribution of patient education or support system.

PMID: 8827938, UI: 96425548

J Asthma 1996;33(5):299-311

Asthma management by preschool children and their families: a developmental framework.

Brown JV, Avery E, Mobley C, Boccuti L, Golbach T

Georgia State University, Atlanta 30303-3083, USA.

Sixty-one low-income, African-American mothers of preschool children with asthma were interviewed about asthma management. Additionally, 15 nurses provided information for a developmental schedule of asthma self-management activities. Most children had been diagnosed with asthma prior to age 18 months. Children participated in asthma management by 20 months, yet their mothers did not expect them to be able to manage their asthma by school age. Mothers expended considerable effort in coordinating asthma management with others. We suggest that asthma education with this population promote developmentally appropriate parent-child partnerships and effective involvement of family members and secondary settings.

PMID: 8827937, UI: 96425547

Clin Pediatr (Phila) 1995 Nov;34(11):581-90

Social factors associated with behavioral problems in children with asthma.

Butz AM, Malveaux FJ, Eggleston P, Thompson L, Huss K, Kolodner K, Rand CS

Johns Hopkins University, School of Nursing, Baltimore, MD 21205, USA.

The objective of this study was to describe the proportion of children with a behavior problem and examine which independent variables are associated with the presence of a behavior problem in a group of 392 inner-city children with asthma. Data on child asthma symptoms, medication use, health-care utilization, and school absences were obtained from the parent during a structured telephone interview. Included in the interview was a measure of behavior problems and social support questions. Children classified with a high level of asthma symptoms were more than twice as likely to experience a behavior problem than children classified with a low level of asthma symptoms (P = 0.002). Use of theophylline medication was not correlated with behavior problems (P = 0.45). Significant variables were low level of social support and high or moderate level of asthma symptoms. We have identified a group of children at risk for behavior problems, specifically in families that lack adequate social and financial resources.

PMID: 8565388, UI: 96165593

Chest 1995 Nov;108(5):1380-92

Published erratum appears in Chest 1996 Jan;109(1):295

Respiratory diseases disproportionately affecting minorities. The NHLBI Working Group.

PMID: 7587446, UI: 96064627

Am J Emerg Med 1995 Nov;13(6):632-7

Educational and long-term therapeutic intervention in the ED: effect on outcomes in adult indigent minority asthmatics.

Kelso TM, Self TH, Rumbak MJ, Stephens MA, Garrett W, Arheart KL

Department of Clinical Pharmacy, University of Tennessee, Memphis 38163, USA.

Minorities have increased morbidity and mortality rates resulting from asthma. The segment of minorities that is socioeconomically depressed often uses the emergency department (ED) as their primary site of medical care. For these reasons, we provided major long-term therapeutic intervention as well as intensive education in the ED for indigent adult African American asthmatics. We intervened in the cases of 30 patients who were frequent visitors to the ED over the previous 2 years. The intervention consisted of 1 hour of education in the ED before discharge regarding the prevention of asthma, the importance of decreasing inflammation as a means of improving asthma control, self-monitoring with a peak flow meter, and a demonstration of correct inhalation technique with metered-dose inhalers and a spacer device. Further, the intervention included management consistent with recent NIH Guidelines, stressing inhaled corticosteroids. After the intervention in the ED, patients were scheduled for follow-up asthma clinic visits. Outcome measures were ED visits and hospitalizations for 1 year after the ED intervention. Using the same inclusion/exclusion criteria, a retrospective control group of 22 patients for the same time period was compared with the intervention group. Before our intervention, the mean number of ED visits per patient for the previous 2 years was 4.4 +/- 2.7, and after the intervention, 2.6 +/- 2.6 (P < .01). The control group did not show a difference in the number of ED visits (3.4 +/- 2.6 before and 3.5 +/- 2.7 after, P = .96). After the intervention, the mean number of hospitalizations decreased significantly in the study group (P < .01).

PMID: 7575800, UI: 96071686

Stat Bull Metrop Insur Co 1995 Oct-Dec;76(4):10-9

The urgency of visits to hospital emergency departments: data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 1992.

Schappert SM

During 1992, an estimated 89.8 million visits were made to the emergency departments (EDs) of nonfederal, short-stay or general hospitals in the United States. Of these ED visits, 40.1 million (44.6 percent) were labeled urgent by hospital staff. For survey purposes, an urgent visit was defined as one in which the patient requires immediate attention for an acute illness or injury that threatens life or function and where delay would be harmful to the patient. However, visits to hospital EDs, whether reported as urgent or nonurgent by hospital staff, may resemble each other in a number of ways. The "appropriateness" of an ED visit should not be equated solely with staff determinations of urgency, which are often made following evaluation and diagnosis rather than on the patient's presenting condition. Stomach pain was the reason most frequently given by patients for making an ED visit. These visits were reported by hospital staff to be urgent about half the time (47.5 percent of visits). The proportion of urgent visits for the most frequent reasons ranged from three-quarters of visits for chest pain and asthma to one-fifth of visits for throat symptoms and skin rash. About one-third of all ED visits (32.7 percent) received principal diagnoses within the broad category of injury and poisoning; roughly half of these visits were considered urgent. Along with injury and poisoning, diseases of the respiratory system and "signs, symptoms, and ill-defined conditions" accounted for the majority of both urgent and nonurgent ED visits. About one-quarter (24.9 percent) of urgent ED visits resulted in hospital admission. However, the most common disposition at both urgent and nonurgent ED visits was referral to another physician.

Comments:

• Comment in: Stat Bull Metrop Insur Co 1995 Oct-Dec;76(4):20

PMID: 8879068, UI: 97033321

S Afr Med J 1995 Oct;85(10):999-1001

Clinical characteristics of black asthmatic children.

Luyt DK, Davis G, Dance M, Simmank K, Patel D

Department of Anaesthesia, Baragwanath Hospital, Johannesburg.

A prospective study of 455 black asthmatic children (277 boys) attending the Baragwanath Hospital asthma clinic was undertaken. A history was obtained by means of a standardised questionnaire and skin tests were performed. Cough was the commonest presenting symptom and upper respiratory tract infections, exercise and cold weather the commonest symptom precipitants. The relative incidences of the other precipitants reflected the environment of the study population. Associated atopic conditions were present in 75.5% of patients and a family background in 22.2%. Other respiratory diagnoses were commonly made, particularly tuberculosis, which was diagnosed in 7.4%. Fewer than one-third had no positive skin reaction. The commonest allergens were grasses, pollen and house-dust mites. The high proportion of house-dust mite sensitivity (44.2%) contradicts beliefs that they are rare at higher altitudes.

PMID: 8596993, UI: 96096560

JAMA 1995 Aug 9;274(6):469-73

Use of health services by African-American children with asthma on Medicaid.

Lozano P, Connell FA, Koepsell TD

Department of Pediatrics, University of Washington School of Medicine, Seattle, USA.

OBJECTIVE--To determine whether African-American children with asthma use more emergency department (ED) and inpatient medical services and fewer preventive services than white children with similar insurance coverage and family income. DESIGN--Historical cohort study during Medicaid claims data. SETTING--Aid to Families With Dependent Children enrollees aged 3 through 17 years in Seattle-Tacoma, Wash, metropolitan area. PATIENTS--All 576 African-American children and 1369 white children receiving services for asthma between June 1988 and December 1992. MAIN OUTCOME MEASURES--Utilization of asthma services (ED, impatient, office visits, and pharmacy) and well-child services and associated Medicaid reimbursements. RESULTS--African-American children were more likely than white children to make ED visits or to be hospitalized for asthma; adjusted odds ratios (ORs) were 1.70 (95% confidence interval [Cl], 1.34 to 2.15) and 1.42 (95% Cl, 1.03 to 1.96), respectively. African-American children were less likely to have made an office visit for asthma; the adjusted OR was 0.48 (95% Cl, 0.26 to 0.85). The two groups were similarly likely to have filled a prescription for an asthma medication and to have made a well-child visit. Per capita payments for asthma services were 24% higher for African-American children: $436 vs $350 per child-year. CONCLUSIONS--Higher use of ED and inpatient services for asthma among African-American children using Medicaid (compared with white children) cannot be fully explained by poverty or inadequate health insurance. Furthermore, these children appear to make disproportionately few office visits for asthma, suggesting suboptimal use of preventive services for asthma. In contrast, the comparable use of well-child visits in the two groups suggests the problem may not be in access to care in general, but there may be specific problems in the successful management of chronic diseases such as asthma among African-American children.

PMID: 7629955, UI: 95356317

Arch Pediatr Adolesc Med 1995 Apr;149(4):386-92

Health status of children in foster care. The experience of the Center for the Vulnerable Child.

Halfon N, Mendonca A, Berkowitz G

Center for the Vulnerable Child, Children's Hospital, Oakland, CA, USA.

OBJECTIVES: To describe the health status and to illustrate the usefulness of an enhanced primary care model for children in foster care. DESIGN: Cross-sectional analysis of a clinical cohort via chart review. SETTING: Foster Care Program of the Center for the Vulnerable Child at the Children's Hospital, Oakland, Calif. SUBJECTS: Two hundred thirteen children in foster care assessed between August 1988 and June 1991. INTERVENTIONS: None. METHODS: A multidisciplinary assessment protocol was used to collect health and social histories and to conduct developmental, emotional, and behavioral assessments and medical examinations. Cross-tabulations were used to compare distributions of conditions and characteristics of the population, including the reasons for, timing of, and number of placements. RESULTS: The population was largely African-American (83.4%), with a mean age of approximately 3 years. At least 78% of children came from homes where drug use was a primary reason for placement. A history of maternal drug use was present in 94% of infants. The number of placements ranged from one to eight (mean, 2.0). Placement changes were common. Over 20% of children had growth abnormalities, 30% had neurologic abnormalities, and 16% had asthma. Fewer than 20% of children had no medical conditions, while 28.8% had three or more conditions. Over 80% of children had developmental, emotional, or behavioral problems. Emotional, relational, and behavioral problems were more common in children first placed after 2 years of age and in those with a greater number of placements (chi 2 = 12.6, P < .05). CONCLUSION: This comprehensive assessment of children in foster care revealed higher rates of chronic multiple medical and mental health problems than previously reported.

PMID: 7704166, UI: 95218989

Int J Addict 1995 Jan;30(2):135-45

Substance use during pregnancy and peripartum complications in a triethnic population.

Berenson AB, Wilkinson GS, Lopez LA

Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston 77555, USA.

To study the effects of illicit drug use during pregnancy on maternal health, we reviewed the records of women who delivered at the University of Texas Medical Branch between June 1, 1989, and February 28, 1990, for peripartum history and results from drug urinalysis screens. After controlling for age at delivery, gravidity, race/ethnicity, and use of alcohol or tobacco, elevated relative risk estimates were observed among women who had positive urinalysis for syphilis, gonorrhea, pregnancy-induced hypertension, chorioamnionitis, asthma, and postpartum hemorrhage. These findings confirm that pregnant women who use illicit drugs are at increased risk for serious health complications.

PMID: 7759168, UI: 95279012

J Asthma 1995;32(6):405-12

Patterns of asthma death and near-death in an inner-city tertiary care teaching hospital.

Corn B, Hamrung G, Ellis A, Kalb T, Sperber K

Division of Clinical Immunology, Mount Sinai Medical Center, New York, New York 10029, USA.

Although the pathophysiology of asthma is increasingly understood, asthma deaths continue to increase, especially among non-Caucasians in inner-city urban areas including East Harlem, which has the highest mortality rate in the United States. The cause for this increase is uncertain, but several factors, including poor access to appropriate medical management, the overuse of beta agonists, environmental precipitants, or more severe disease, have been proposed as contributing factors. The Mount Sinai Hospital is a 1300-bed, tertiary care university hospital located at the juncture of East Harlem, an inner-city, predominantly Hispanic and African-American neighborhood, and Carnegie Hill, an affluent, predominantly Caucasian residential area. We examined asthma deaths (13) and near-deaths (20) at the Mount Sinai Hospital from 1986 to 1992 to determine risk factors and compared them to an age- and demographically matched control group. All of the information was based on retrospective patient chart reviews, and the parameters considered included ethnicity, insurance status, poverty level, and medications including the use of beta agonists. All of the asthma deaths and near-deaths except 1 occurred in low-income African-American and Hispanic patients (x = 16.9) However, steroid and beta-agonist usage were comparable in the adverse outcome group compared to the control group. Our results confirm that adverse outcome asthma in East Harlem occurred predominantly among non-Caucasians of low socioeconomic status. We conclude that ethnicity and socioeconomic status play an important role in asthma death and near-death at our institution.

PMID: 7592243, UI: 96074288

Chest 1994 Oct;106(4 Suppl):248S-259S

Targeting high risk groups. Neighborhood organization for pediatric asthma management in the Neighborhood Asthma Coalition.

Fisher EB Jr, Sussman LK, Arfken C, Harrison D, Munro J, Sykes RK, Sylvia S, Strunk RC

Washington University, St. Louis.