Very Poorly Controlled Asthma in Urban Minority Children: Lessons Learned

Abstract

To identify risk factors for poor asthma control in low-income children.The study was conducted as a subanalysis of a randomized controlled trial in an inner-city population of 222 children age 3 to 12 years with uncontrolled, persistent asthma. The trial was designed to investigate an environmental control intervention.The main outcome of interest was asthma control at baseline and 6 months after enrollment. Asthma control was classified as well controlled (WC), not well controlled (NWC), and very poorly controlled (VPC) on the basis of National Asthma Education and Prevention Program guidelines.The population was predominantly black (93%), male (65%), on Medicaid insurance (94%), and low income (61% with household income <$30 000). At baseline, all participants had persistent asthma (25.5% mild, 45.7% moderate, and 29.0% severe). Regarding control at baseline, 47% had NWC asthma and 53% had VPC asthma. At the 6-month follow-up, 12.7% had WC asthma, 41.1% had NWC asthma, and 46.2% had VPC asthma. Of those with baseline NWC asthma, 43% still had NWC asthma, 39% had worsened to VPC asthma, and 18% improved to WC asthma. Of those with baseline VPC asthma, 52.7% continued to have VPC asthma. Risk factors for VPC asthma included children with caregivers who reported concern about side effects of asthma medications, having positive skin test results, hay fever, and being assessed in the spring or fall. There was incomplete agreement between caregiver perception of asthma control and objective control: 40% of the caregivers of those with VPC asthma reported the asthma as WC. Having VPC asthma was associated with a larger number of outpatient visits for asthma.Over the course of the study, most patients with NWC and VPC asthma continued to have asthma that was not WC. There were several risk factors, including sensitization to environmental allergens and caregiver concern regarding asthma medication side effects.The study provides important insights into the epidemiology of poorly controlled asthma in a high-risk population. Investigators in the study highlight risk factors that may identify children at risk for poor control and ones that may be addressed in counseling (such as concerns about medications). Researchers in the study also highlight the importance of caregiver knowledge and education in potentially altering outcomes. Nonurgent outpatient visits represent an area of opportunity for education. Interventional studies are needed to further assess whether intervening on these factors improves asthma control outcomes in this vulnerable population.