Asthma Disparities Research Articles

Asthma Disparity Photovoice: The Discourses of Black Adolescent and Public Health Policymakers.

Policies in U.S. public schools that address asthma management for Black adolescents may not sufficiently transform sociocultural determinants of disparities. A critical analysis of public health policy maker and adolescent discourses on asthma management using an ecological framework could inform policy development. This study describes the discourses of asthma management disparities of school and other public health policymakers and Black adolescents with asthma during a statewide asthma planning activity. I conducted a qualitative critical discourse analysis on transcripts and phototexts from a photovoice project with Black adolescents with asthma (n = 19), an asthma-planning meeting with school and public health policymakers (n = 12), and an observation of a photovoice dissemination event that included the same adolescents and policymakers. Policymakers did not discuss sociocultural discourses concerning asthma management disparities such as racism and discrimination, but the adolescents did. The only shared discourses between adolescents and policymakers were on the management of indoor environments, health care quality, inadequate housing, and outdoor air pollution. Including Black adolescents in policymaking activities concerning asthma management disparities furthers the identification of differing and shared discourses. School policies should include multilevel strategies that address structural inequities. Photovoice presents an opportunity for including the voice of marginalized youth in policy-planning processes.

Using Concept Mapping to Explore and Engage Parent and Youth Residents of an Economically Underserved Minority Community around Children's Asthma

Using Concept Mapping to Explore and Engage Parent and Youth Residents of an Economically Underserved Minority Community around Children's Asthma Michael Yonas, DrPH, MPH, Anita Zuberi, PhD, Anna Kasunic, MA, Patricia Bamwine, Stephanie Boddie, PhD, Shannah Tharp-Gilliam, PhD, and John Wallace, PhD COMMUNITY/POLICY BRIEF What is the Purpose of the Study? Our study engages residents of an economically underserved, minority community around the issue of children's asthma to understand the specific triggers and issues of care facing parents and youth in this community, which is a necessary first step in designing a community-based intervention. What Is the Problem? Economically underserved and minority communities continue to shoulder a higher than average burden of asthma among children, where asthma is more likely to go uncontrolled. Thus, it is important to design interventions that target these communities to help reduce racial disparities in children's asthma. For these interventions to be effective, we need to tailor the intervention to the community, and specifically to children with asthma and their caregivers. What Are the findings? Our study finds that there are several themes that are important around the triggers and care of asthma for residents of this economically underserved and minority community, some of which differ for adults and youth. • Asthma triggers. For all residents in the sample, in addition to the more common triggers of asthma that include irritants in the home and community as well as allergies, violence is also important for triggering asthma among children within this community. Not only can violence can trigger asthma by creating fear, but also when children experience bad memories about a violent incident or when a family member died. • Youth ranked emotions and stress related to school more highly than adults as a trigger for asthma. • Adults were more concerned about trouble with access to care or medicine. • Asthma Care. With respect to the care of asthma, medical and other relievers were ranked most as most important by both youth and adults. • Youth ranked supports who help to care for asthma, such as having friends with asthma or music to calm down, more highly in comparison to adults. • Adults were more focused on appliances to help with asthma than youth. [End Page 331] Who Should Care the most? The findings of our study are important for all caregivers of children in an underserved community who are more likely to come in contact with children who have asthma. These include community organizations, schools and school nurses, coaches of sports teams, afterschool program coordinators, and daycare providers, as well as those who have children with asthma living in their homes. These findings are also of importance to public health and social work practitioners who are aiming to reduce racial disparities in children's asthma by targeting communities who shoulder the highest burden. Recommendations for Action These data can be used to tailor interventions for children with asthma in this community, and to focus on different issues for children with asthma and their caregivers. • Youth • Focus on dealing with emotions and past trauma associated with violence and/or death that can precipitate asthma attacks. • Focus on building support networks among youth with asthma, either through school or other after-school / community-based organizations. • Adult Caregivers • Focus on issues related to the care of asthma, specifically the use of medicine and appliances. • Make parents aware of the emotional triggers of asthma and address inconsistencies in local asthma knowledge. Future research also needs to assess whether the issues facing children with asthma and their caregivers in this community are also issues common in other communities, and whether interventions that are aimed at these issues are effective. [End Page 332] Michael Yonas, DrPH, MPH The Pittsburgh Foundation Anita Zuberi, PhD Department of Sociology, Duquesne University Anna Kasunic, MA Homewood Children's Village Patricia Bamwine School of Social Work, University of Pittsburgh Stephanie Boddie, PhD School of Social Work, Baylor University Shannah Tharp-Gilliam, PhD Homewood Children's Village John Wallace, PhD School of Social Work, University of Pittsburgh Copyright © 2017 Johns Hopkins University Press

Pediatric Asthma Health Disparities: Race, Hardship, Housing, and Asthma in a National Survey

ObjectiveWe sought to determine if racial disparities in pediatric asthma are explained by material hardship and home ownership. MethodsWe performed a secondary analysis of the 2011 American Housing Survey. A total of 33,201 households with children age 6 to 17 years were surveyed regarding childhood asthma diagnosis and emergency department (ED) visits for asthma (for the youngest child with asthma in the household). Material hardship included poor housing quality, housing crowding, lack of amenities, and no vehicle access. We used logistic regression to determine the association between race, material hardship, and asthma diagnosis or ED visits, adjusting for potential confounders. ResultsNon-Hispanic black heads of household had a higher odds of having a child diagnosed with asthma in the home compared with non-Hispanic white heads of household (odds ratio, 1.72; 95% confidence interval [CI], 1.50–1.96), and a higher odds of ED visits for asthma (odds ratio, 3.02; 95% CI, 2.29–3.99). The race–asthma association was decreased but not eliminated after adjusting for material hardship and home ownership (ED visit adjusted odds ratio [AOR], 2.07; 95% CI, 1.50–2.86). Poor housing quality was independently associated with asthma diagnosis (AOR, 1.45; 95% CI, 1.28–1.66) and ED visits (AOR, 1.59; 95% CI, 1.21–2.10). Home ownership was associated with a lower odds of asthma-related ED visits (AOR, 0.62; 95% CI, 0.46–0.84). ConclusionsObserved racial disparities in pediatric asthma are lessened after controlling for material hardship. Poor housing quality in particular is strongly associated with asthma morbidity. Policy makers could target improving housing quality as a means of potentially reducing asthma disparities.

Pediatric Asthma Care Coordination in Underserved Communities: A Quasiexperimental Study.

To assess the effect of care coordination on asthma outcomes among children in underserved urban communities. We enrolled children, most of whom had very poorly or not well-controlled asthma, in medical-social care coordination programs in Los Angeles, California; Chicago, Illinois; Philadelphia, Pennsylvania; and San Juan, Puerto Rico in 2011 to 2014. Participants (n = 805; mean age = 7 years) were 60% male, 50% African American, and 42% Latino. We assessed asthma symptoms and health care utilization via parent interview at baseline and 12 months. To prevent overestimation of intervention effects, we constructed a comparison group using bootstrap resampling of matched control cases from previous pediatric asthma trials. At follow-up, intervention participants had 2.2 fewer symptom days per month (SD = 0.3; P < .01) and 1.9 fewer symptom nights per month (SD = 0.35; P < .01) than did the comparison group. The relative risk in the past year associated with the intervention was 0.63 (95% confidence interval [CI] = 0.45, 0.89) for an emergency department visit and 0.69 (95% CI = 0.47, 1.01) for hospitalization. Care coordination may improve pediatric asthma symptom control and reduce emergency department visits. Expanding third-party reimbursement for care coordination services may help reduce pediatric asthma disparities.

Family connectedness and pediatric asthma management: The roles of child age and race or ethnicity

ABSTRACTFamily connectedness has been linked to better than expected asthma health in youth at risk for asthma disparities, yet it is unclear whether benefits exist across child development. The association between family connectedness and asthma management was examined in 245 youth (6–15 years), as well as whether this relationship varied by child age and race or ethnicity. Youth and caregivers completed family connectedness and asthma management semi-structured interviews. Higher levels of family connectedness were related to better asthma management across racial/ethnic groups. Child age was a significant moderator of the relation between family connectedness and asthma management for non-Latino White youth only, suggesting that for this group, the effect of family connectedness on asthma management was weaker for older youth. Conversely, family connectedness may consistently promote asthma management for Latino and non-Latino Black youth throughout development.

Advances in asthma 2015: Across the lifespan

In 2015, progress in understanding asthma ranged from insights to asthma inception, exacerbations, and severity to advancements that will improve disease management throughout the lifespan. 2015's insights to asthma inception included how the intestinal microbiome affects asthma expression with the identification of specific gastrointestinal bacterial taxa in early infancy associated with less asthma risk, possibly by promoting regulatory immune development at a critical early age. The relevance of epigenetic mechanisms in regulating asthma-related gene expression was strengthened. Predicting and preventing exacerbations throughout life might help to reduce progressive lung function decrease and disease severity in adulthood. Although allergy has long been linked to asthma exacerbations, a mechanism through which IgE impairs rhinovirus immunity and underlies asthma exacerbations was demonstrated and improved by anti-IgE therapy (omalizumab). Other key molecular pathways underlying asthma exacerbations, such as cadherin-related family member 3 (CDHR3) and orosomucoid like 3 (ORMDL3), were elucidated. New anti-IL-5 therapeutics, mepolizumab and reslizumab, were US Food and Drug Administration approved for the treatment of patients with severe eosinophilic asthma. In a clinical trial the novel therapeutic inhaled GATA3 mRNA-specific DNAzyme attenuated early- and late-phase allergic responses to inhaled allergen. These current findings are significant steps toward addressing unmet needs in asthma prevention, severity modification, disparities, and lifespan outcomes.

Temporal and Spatial Trends in Childhood Asthma-Related Hospitalizations in Belo Horizonte, Minas Gerais, Brazil and Their Association with Social Vulnerability.

Introduction: Asthma is a multifactorial disease and a serious public health problem. Environmental factors and poverty are the main determinants of this disease. Objective: To describe the spatial and temporal distribution of asthma-related hospitalizations and identify the areas with the highest prevalence of and vulnerability to severe asthma in a major Brazilian city. Methods: An ecological study of hospitalizations for asthma from 2002 to 2012, in children and adolescents under 15 years of age, living in Belo Horizonte, Southeast Brazil. All events were geocoded by residence address using Hospital Information System data. The socioeconomic vulnerability of residence address was ranked using the Health Vulnerability Index. Raster surfaces were generated and time-series plots were constructed to determine spatial and time trends in the frequency of asthma-related hospitalizations, respectively. Results: Asthma-related hospitalization rates were highest in children aged 0–4 years and in boys. There was a decreasing trend in the number of asthma-related hospitalizations across the study period. Approximately 48% of all hospitalizations were children living in health vulnerable areas. Seasonal trends showed a hospitalization peak in March, April, and May, coinciding with the post-rainy period. Conclusion: Our findings suggest that social and environmental factors may be determinants of disparities in severe asthma.

Explaining Racial Disparities in Child Asthma Readmission Using a Causal Inference Approach.

Childhood asthma is characterized by disparities in the experience of morbidity, including the risk for readmission to the hospital after an initial hospitalization. African American children have been shown to have more than 2 times the hazard of readmission when compared with their white counterparts. To explain why African American children are at greater risk for asthma-related readmissions than white children. This study was completed as part of the Greater Cincinnati Asthma Risks Study, a population-based, prospective, observational cohort. From August 2010 to October 2011, it enrolled 695 children, aged 1 to 16 years, admitted for asthma or wheezing who identified as African American (n = 441) or white (n = 254) in an inpatient setting of an urban, tertiary care children's hospital. The main outcome was time to asthma-related readmission and race was the predictor. Biologic, environmental, disease management, access, and socioeconomic hardship variables were measured; their roles in understanding racial readmission disparities were conceptualized using a directed acyclic graphic. Inverse probability of treatment weighting balanced African American and white children with respect to key measured variables. Racial differences in readmission hazard were assessed using weighted Cox proportional hazards regression and Kaplan-Meier curves. The sample was 65% male (n = 450), and the median age was 5.4 years. African American children were 2.26 times more likely to be readmitted than white children (95% CI, 1.56-3.26). African American children significantly differed with respect to nearly every measured biologic, environmental, disease management, access, and socioeconomic hardship variable. Socioeconomic hardship variables explained 53% of the observed disparity (hazard ratio, 1.47; 95% CI, 1.05-2.05). The addition of biologic, environmental, disease management, and access variables resulted in 80% of the readmission disparity being explained. The difference between African American and white children with respect to readmission hazard no longer reached the level of significance (hazard ratio, 1.18; 95% CI, 0.87-1.60; Cox P = .30 and log-rank P = .39). A total of 80% of the observed readmission disparity between African American and white children could be explained after statistically balancing available biologic, environmental, disease management, access to care, and socioeconomic and hardship variables across racial groups. Such a comprehensive, well-framed approach to exposures that are associated with morbidity is critical as we attempt to better understand and lessen persistent child asthma disparities.

Technology-Based Interventions for Asthma—Can They Help Decrease Health Disparities?

Asthma is a condition that has consistently demonstrated significant health outcome inequalities for minority populations. One approach used for care of patients with asthma is the incorporation of technology for behavioral modification, symptom monitoring, education, and/or treatment decision making. Whether such technological interventions can improve the care of black and inner-city patients is unknown. We reviewed all randomized controlled trial technological interventions from 2000 to 2015 performed in minority populations. A total of 16 articles met inclusion and exclusion criteria; all but 1 was performed in a childhood or adolescent age group. The interventions used MPEG audio layer-3 players, text messaging, computer/Web-based systems, video games, and interactive voice response. Many used tailored content and/or a specific behavior theory. Although the interventions were based on technology, most required additional special staffing. Subject user satisfaction was positive, and improvements were noted in asthma knowledge, medication adherence, asthma symptoms, and quality of life. Unfortunately, health care utilization (emergency department visits and/or hospitalizations) was typically not improved by the interventions. Although no single intervention modality was vastly superior, the computer-based interventions appeared to have the most positive results. In summary, technology-based interventions have a high level of user satisfaction among minority and urban/low-income individuals with asthma, and can improve asthma outcomes. Further large-scale studies are needed to assess whether such interventions can decrease health disparities in asthma.

Exploring racial differences in IgE-mediated food allergy in the WHEALS birth cohort

BackgroundSuspected food allergies are the cause of more than 200,000 visits to the emergency department annually. Racial differences in the prevalence of food allergy have also been reported, but the evidence is less conclusive. Researchers continue to struggle with the identification of food allergy for epidemiologic studies. ObjectiveTo explore racial differences in IgE-mediated food allergy (IgE-FA) in a birth cohort. MethodsWe used a panel of board-certified allergists to systematically identify IgE-FA to egg, milk, or peanut in a multiethnic birth cohort in which patient medical history, patient symptoms, and clinical data were available through 36 months of age. ResultsOf the 590 infants analyzed, 52.9% were male and 65.8% African American.Sensitization (serum specific IgE >0.35 IU/mL) to the food allergens was significantly higher for African American children compared with non–African American children as has been previously reported. No statistically significant racial/ethnic differences in IgE-FA were observed; however, a higher proportion of African American children were designated as having peanut allergy, and the percentage of African American children with an IgE level greater than 95% predictive decision points for peanut was 1.7% vs 0.5% for non–African American children. With the use of logistic regression, race/ethnicity was not significantly associated with IgE-FA (adjusted odds ratio, 1.12; 95% confidence interval, 0.58–2.17; P = .75) but was associated with sensitization to more than 1 of the food allergens (adjusted odds ratio, 1.80; 95% confidence interval, 1.22–2.65; P = .003). ConclusionWe did not observe an elevated risk of IgE-FA for African American children, although established differences in sensitization were observed. Racial/ethnic differences in sensitization must be taken into consideration when investigating disparities in asthma and allergy.

Practice Variation in Management of Childhood Asthma Is Associated with Outcome Differences

Although specialist asthma care improves children's asthma outcomes, the impact of primary care management is unknown. To determine whether variation in preventive and acute care for asthma in pediatric practices affects patients' outcomes. For 22 practices, we aggregated 12-month patient data obtained by chart review and parent telephone interviews for 948 children, 3 to 12 years old, diagnosed with asthma to obtain practice-level measures of preventive (≥1 asthma maintenance visit/year) and acute (≥1 acute asthma visit/year) asthma care. Relationships between practice-level measures and individual asthma outcomes (symptom-free days, parental quality of life, emergency department [ED] visits, and hospitalizations) were explored using generalized estimating equations, adjusting for seasonality, specialist care, Medicaid insurance, single-family status, and race. For every 10% increase in the proportion of children in the practice receiving preventive care, symptom-free days per child increased by 7.6 days (P= .02) and ED visits per child decreased by 16.5% (P= .002), with no difference in parental quality of life or hospitalizations. Only the association between more preventive care and fewer ED visits persisted in adjusted analysis (12.2% reduction; P= .03). For every 10% increase in acute care provision, ED visits per child and hospitalizations per child decreased by 18.1% (P= .02) and 16.5% (P < .001), respectively, persisting in adjusted analyses (ED visits 8.6% reduction, P= .02; hospitalizations 13.9%, P= .03). Children cared for in practices providing more preventive and acute asthma care had improved outcomes, both impairment and risk. Persistence of improved risk outcomes in the adjusted analyses suggests that practice-level interventions to increase asthma care may reduce childhood asthma disparities.

The effectiveness of school-based family asthma educational programs on the quality of life and number of asthma exacerbations of children aged five to 18 years diagnosed with asthma: a systematic review protocol.

REVIEW QUESTION / OBJECTIVE The objective of this review is to identify the best available quantitative evidence related to the effectiveness of school-based family asthma educational programs on the quality of life and number of asthma exacerbations of children aged five to18 years with a diagnosis of asthma. INCLUSION CRITERIA Types of participants This review will consider studies that include children, five to 18 years of age, of any gender, race, or ethnicity with a clinical diagnosis of asthma, who has participated in school-based asthma education programs that include their caregivers. Studies that include children younger than age five and older than age 18, with respiratory diseases other than asthma, who have not participated in school-based asthma education programs that include their caregivers will be excluded. Types of intervention(s) This review will consider studies that evaluate the effectiveness of school-based family asthma education interventions on the quality of life and number of asthma exacerbations of children with asthma compared to absence of school-based family asthma education programs. Types of outcomes This review will consider studies that include the following outcome measures: primary outcomes of quality of life and asthma exacerbations, and secondary outcomes of absences from school or work, physical activity intolerance, and emergency hospital visits as a result of asthma exacerbations. Quality of life can be measured by a valid and reliable tool such as the Pediatric Asthma Quality of Life Questionnaire. The number of asthma exacerbations can be measured by valid and reliable tools such as the TRUNCATED AT 250 WORDS

The Influence of Setting on Care Coordination for Childhood Asthma.

Asthma affects 7.1 million children in the United States, disproportionately burdening African American and Latino children. Barriers to asthma control include insufficient patient education and fragmented care. Care coordination represents a compelling approach to improve quality of care and address disparities in asthma. The sites of The Merck Childhood Asthma Network Care Coordination Programs implemented different models of care coordination to suit specific settings—school district, clinic or health care system, and community—and organizational structures. A variety of qualitative data sources were analyzed to determine the role setting played in the manifestation of care coordination at each site. There were inherent strengths and challenges of implementing care coordination in each of the settings, and each site used unique strategies to deliver their programs. The relationship between the lead implementing unit and entities that provided (1) access to the priority population and (2) clinical services to program participants played a critical role in the structure of the programs. The level of support and infrastructure provided by these entities to the lead implementing unit influenced how participants were identified and how asthma care coordinators were integrated into the clinical care team.

Neighborhood poverty, urban residence, race/ethnicity, and asthma: Rethinking the inner-city asthma epidemic

Although it is thought that inner-city areas have a high burden of asthma, the prevalence of asthma in inner cities across the United States is not known. We sought to estimate the prevalence of current asthma in US children living in inner-city and non-inner-city areas and to examine whether urban residence, poverty, or race/ethnicity are the main drivers of asthma disparities. The National Health Interview Survey 2009-2011 was linked by census tract to data from the US Census and the National Center for Health Statistics. Multivariate logistic regression models adjusted for sex; age; race/ethnicity; residence in an urban, suburban, medium metro, or small metro/rural area; poverty; and birth outside the United States, with current asthma and asthma morbidity as outcome variables. Inner-city areas were defined as urban areas with 20% or more of households at below the poverty line. We included 23,065 children living in 5,853 census tracts. The prevalence of current asthma was 12.9% in inner-city and 10.6% in non-inner-city areas, but this difference was not significant after adjusting for race/ethnicity, region, age, and sex. In fully adjusted models black race, Puerto Rican ethnicity, and lower household income but not residence in poor or urban areas were independent risk factors for current asthma. Household poverty increased the risk of asthma among non-Hispanics and Puerto Ricans but not among other Hispanics. Associations with asthma morbidity were very similar to those with prevalent asthma. Although the prevalence of asthma is high in some inner-city areas, this is largely explained by demographic factors and not by living in an urban neighborhood.

The effect of parental social support and acculturation on childhood asthma control

Objective: There exists large ethnic disparities in asthma among Latino children; Puerto Ricans (PRs) are disproportionately affected, while Mexicans have the lowest prevalence and morbidity. Disparities are poorly understood, however, acculturation and social support are suggested to influence asthma control among children. This study investigated the relationship between acculturation, social support and asthma control among PR and Mexican children and their caregivers. Methods: Primary caregiver-child dyads (n = 267) of PR (n = 79) and Mexican (n = 188) descent were recruited from clinics at two inner-city hospitals in Bronx, NY and three clinics in Phoenix, AZ. Children were 5–12 years of age and had a confirmed asthma diagnosis. Dyads completed measures of social support, acculturation and asthma control; logistic regression was used for analysis. Results: Mexican children had better asthma control than PR children (p < 0.001). PR caregivers were more acculturated than Mexican caregivers (p < 0.05); however, acculturation did not predict control. Across Latino subgroups caregivers’ total level of social support predicted better asthma control among children (p < 0.05), and support received from family and friends each independently predicted better control (p < 0.05). Conclusions: Results suggest that social support reduces some of the burden associated with asthma management enabling caretakers to better control their children’s asthma.

A MYLK variant regulates asthmatic inflammation via alterations in mRNA secondary structure.

Myosin light-chain kinase (MYLK) is a gene known to be significantly associated with severe asthma in African Americans. Here we further examine the molecular function of a single-nucleotide polymorphism (SNP), located in the non-muscle myosin light-chain kinase isoform (nmMLCK), in asthma susceptibility and pathobiology. We identified nmMLCK variant (reference SNP: rs9840993, NM_053025: 721C>T, c.439C>T) with a distinct mRNA secondary structure from the other variants. The nmMLCK variant (721C) secondary structure exhibits increased stability with an elongated half-life in the human endothelial cell, and greater efficiency in protein translation initiation owing to an increased accessibility to translation start site. Finally, nmMLCK expression of 721C- and 721T-containing MYLK transgenes were compared in nmMLCK−/− mice and confirmed deleterious effects of nmMLCK expression on asthmatic indices and implicated the augmented influence of MYLK 721C>T (c.439C>T) SNP on asthma severity. The confirmation of the novel mechanism of the regulation of asthmatic inflammation by a MYLK advances knowledge of the genetic basis for asthma disparities, and further suggests the potential of nmMLCK as a therapeutic target. Our study suggests that in addition to altering protein structure and function, non-synonymous SNPs may also lead to phenotypic disparity by altering protein expression.

Trends in racial disparities for asthma outcomes among children 0 to 17 years, 2001-2010

Racial disparities in childhood asthma have been a long-standing target for intervention, especially disparities in hospitalization and mortality. Describe trends in racial disparities in asthma outcomes using both traditional population-based rates and at-risk rates (based on the estimated number of children with asthma) to account for prevalence differences between race groups. Estimates of asthma prevalence and outcomes (emergency department [ED] visits, hospitalizations, and deaths) were calculated from national data for 2001 to 2010 for black and white children. Trends were calculated using weighted loglinear regression, and changes in racial disparities over time were assessed using Joinpoint. Disparities in asthma prevalence between black and white children increased from 2001 to 2010; at the end of this period, black children were twice as likely as white children to have asthma. Population-based rates showed that disparities in asthma outcomes remained stable (ED visits and hospitalizations) or increased (asthma attack prevalence, deaths). In contrast, analysis with at-risk rates, which account for differences in asthma prevalence, showed that disparities in asthma outcomes remained stable (deaths), decreased (ED visits, hospitalizations), or did not exist (asthma attack prevalence). Using at-risk rates to assess racial disparities in asthma outcomes accounts for prevalence differences between black and white children, and adds another perspective to the population-based examination of asthma disparities. An at-risk rate analysis shows that among children with asthma, there is no disparity for asthma attack prevalence and that progress has been made in decreasing disparities in asthma ED visit and hospitalization rates.

Addressing asthma disparities using clinical decision support in the electronic health record.

Addressing asthma disparities using clinical decision support in the electronic health record.

Geographic and racial variation in asthma prevalence and emergency department use among Medicaid-enrolled children in 14 southern states

Background: Despite evidence-based prevention and practice guidelines, asthma prevalence, treatment, and outcomes vary widely at individual and community levels. Asthma disproportionate/ly affects low-income and minority children, who comprise a large segment of the Medicaid population. Methods: 2007 Medicaid claims data from 14 southern states was mapped for 556 counties to describe the local area variation in 1-year asthma prevalence rates, emergency department (ED) visit rates, and racial disparity rate ratios. Results: One-year period prevalence of asthma ranged from 2.8% in Florida to 6.4% in Alabama, with a median prevalence rate of 4.1%. At the county level, the prevalence was higher for Black children and ranged from 1.03% in Manatee County, FL, to 21.0% in Hockley County, TX. Black–White rate ratios of prevalence ranged from 0.49 in LeFlore County, MS, to 3.87 in Flagler County, FL. Adjusted asthma ED visit rates ranged from 2.2 per 1000 children in Maryland to 16.5 in Alabama, with a median Black–White ED-visit rate ratio of 2.4. Rates were higher for Black children, ranging from 0.80 per 1000 in Wicomico County, MD, to 70 per 1000 in DeSoto County, FL. Rate ratios of ED visits ranged from 0.25 in Vernon Parish, LA, to 25.28 in Nelson County, KY. Conclusions and relevance: Low-income children with Medicaid coverage still experience substantial variation in asthma prevalence and outcomes from one community to another. The pattern of worse outcomes for Black children also varies widely across counties. Eliminating this variation could substantially improve overall outcomes and eliminate asthma disparities.

Pediatric asthma management within Latino and non-Latino White families.

Pediatric asthma disparities exist with Latino children, especially from Island Puerto Rico (PR), experiencing greater asthma prevalence and morbidity than non-Latino White (NLW) children. Families must balance attention to child asthma with other child and family needs, defined as the "balanced integration of asthma." This study examined the impact of culturally related factors on the balanced integration of asthma in NLW and Latino families in Rhode Island (RI) and PR, as well as associations between balanced integration and asthma morbidity. Participants included 601 caregivers and their children with asthma (7-16 years) from NLW and Latino backgrounds in RI and PR. Caregivers and children completed interview-administered assessments and a semistructured interview related to family asthma management. Balanced integration of asthma differed significantly by ethnic group/site (p < .001), with Island PR families having the lowest levels of balanced integration. Higher balanced integration was associated with fewer concerns about asthma medications, higher levels of Spanish proficiency in RI Latino families, lower levels of functional limitation, and no emergency department visits in the last year (all ps < .05). Findings suggest that Latino families may experience more difficulty adjusting to child asthma in the context of other child and family demands. Medication beliefs and language proficiency may begin to explain these differences. Our study suggests the importance of continuing to understand how families balance asthma with other aspects of daily life, as culturally appropriate interventions to improve family adjustment to asthma may serve to reduce child asthma morbidity.