Asthma.

Abstract

Asthma is the most common chronic respiratory disease of childhood, a leading cause of emergency department visits, and 1 of the top 3 indications for hospitalization in children. Despite advances in the management of pediatric asthma, significant disparities in care and outcomes persist. To bridge these gaps, we must embrace the concept of asthma care across the continuum and extend our reach beyond the immediate patient-provider visit.After completing this article, readers should be able to:Asthma is defined by episodic and reversible airway constriction and inflammation in response to infection, environmental allergens, and irritants. It is a complex, multifactorial, and immune-mediated process that presents with various clinical phenotypes.Despite novel treatments and guideline-based care, asthma remains a significant public health problem. Medical care, missed school, and missed work related to asthma continue to burden our communities, costing more than $80 billion each year. (1) Furthermore, asthma disproportionately affects minorities and socioeconomically disadvantaged children. (2) Black children have the highest asthma morbidity and mortality rates of any US group, with twice the emergency department (ED) visit/hospitalization rate and 9 times the mortality rate as white children. (3)(4)(5)In 2012, the President’s Task Force on Environmental Health Risks and Safety Risks to Children commissioned a cabinet-level, multiagency group to address overall asthma morbidity and its racial and ethnic disparities. (6) The group chose 4 integrated strategies.Asthma affects 1 in 12 US children aged 0 through 17 years. (3) After decades of increases, the prevalence of asthma in this group plateaued between 2010 and 2012, (2) decreased in 2013 from 9.3% in 2012 to 8.3%, and remained stable through 2016. (2)(3) In contrast, pediatric asthma prevalence in black children increased between 2001 and 2009, leveling off by 2013. (2) In 2016, asthma prevalence in black children rose sharply to 15.7% (a 2.3% increase from 2014 and 2015), twice that of white children. (3) This rate surpassed that of Puerto Rican children, who previously had the highest prevalence of asthma of all US children. (3) The prevalence of asthma in children in poverty did not decrease between 2001 and 2013 and remained high in 2016 (10.5%). (2)(3)Asthma exacerbation is a leading cause of (ED) visits (7) and 1 of the top 3 indications for hospitalization in children. (8) Comparing asthma outcomes between subgroups, an at-risk rate (ARR) is preferred over the traditional population-based rate (PBR). (9) An ARR is the number of children with the outcome (eg, asthma hospitalization or death) divided by the total number of children at risk for that outcome (those with asthma). Conversely, a PBR is the number of children with the asthma outcome divided by the total population. PBRs measure the overall burden of disease in a particular population or subgroup, whereas an ARR accounts for differences in prevalence between subgroups to describe disparities.(4) Between 2001 and 2010, ARRs for black and white children revealed a decrease in racial disparities for ED visit and hospitalization rates and no change in death rate due to asthma. (4) It is important to note, however, that ARRs do not account for differences in underlying asthma severity. A 2013 analysis of hospitalizations for chronic conditions in the Pediatric Health Information System database found that black children had the highest asthma readmission rate (21.4%) of any race or ethnicity. (10) Finally, because ARRs rely on prevalence estimates, any undercounting of