Addressing asthma health disparities: A multilevel challenge
2009; Elsevier BV; Volume: 123; Issue: 6 Linguagem: Inglês
10.1016/j.jaci.2009.02.043
ISSN1097-6825
AutoresGlorisa Canino, Elizabeth L. McQuaid, Cynthia S. Rand,
Tópico(s)Food Security and Health in Diverse Populations
ResumoSubstantial research has documented pervasive disparities in the prevalence, severity, and morbidity of asthma among minority populations compared with non-Latino white subjects. The underlying causes of these disparities are not well understood, and as a result, the leverage points to address them remain unclear. A multilevel framework for integrating research in asthma health disparities is proposed to advance both future research and clinical practice. The components of the proposed model include health care policies and regulations, operation of the health care system, provider/clinician-level factors, social/environmental factors, and individual/family attitudes and behaviors. The body of research suggests that asthma disparities have multiple, complex, and interrelated sources. Disparities occur when individual, environmental, health system, and provider factors interact with one another over time. Given that the causes of asthma disparities are complex and multilevel, clinical strategies to address these disparities must therefore be comparably multilevel and target many aspects of asthma care. Several strategies that could be applied in clinical settings to reduce asthma disparities are described, including the need for routine assessment of the patient's beliefs, financial barriers to disease management, and health literacy and the provision of cultural competence training and communication skills to health care provider groups. Substantial research has documented pervasive disparities in the prevalence, severity, and morbidity of asthma among minority populations compared with non-Latino white subjects. The underlying causes of these disparities are not well understood, and as a result, the leverage points to address them remain unclear. A multilevel framework for integrating research in asthma health disparities is proposed to advance both future research and clinical practice. The components of the proposed model include health care policies and regulations, operation of the health care system, provider/clinician-level factors, social/environmental factors, and individual/family attitudes and behaviors. The body of research suggests that asthma disparities have multiple, complex, and interrelated sources. Disparities occur when individual, environmental, health system, and provider factors interact with one another over time. Given that the causes of asthma disparities are complex and multilevel, clinical strategies to address these disparities must therefore be comparably multilevel and target many aspects of asthma care. Several strategies that could be applied in clinical settings to reduce asthma disparities are described, including the need for routine assessment of the patient's beliefs, financial barriers to disease management, and health literacy and the provision of cultural competence training and communication skills to health care provider groups. Information for Category 1 CME CreditCredit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the following instructions.Method of Physician Participation in Learning Process: The core material for these activities can be read in this issue of the Journal or online at the JACI Web site: www.jacionline.org. The accompanying tests may only be submitted online at www.jacionline.org. Fax or other copies will not be accepted.Date of Original Release: June 2009. Credit may be obtained for these courses until May 31, 2011.Copyright Statement: Copyright © 2009-2011. All rights reserved.Overall Purpose/Goal: To provide excellent reviews on key aspects of allergic disease to those who research, treat, or manage allergic disease.Target Audience: Physicians and researchers within the field of allergic disease.Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates these educational activities for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.List of Design Committee Members:Authors: Glorisa Canino, PhD, Elizabeth L. McQuaid, PhD, and Cynthia S. Rand, PhDActivity Objectives1. To identify minority populations at highest risk for asthma prevalence, severity, and morbidity.2. To learn that asthma disparities have multiple, complex, and interrelated sources.3. To understand how the health care system, social/environmental factors, provider and individual attitudes, and behaviors play a role in asthma disparity.4. To learn strategies that could be applied in the clinical setting to reduce asthma disparity.Recognition of Commercial Support: This CME activity is supported by an educational grant from Merck & Co., Inc.Disclosure of Significant Relationships with Relevant CommercialCompanies/Organizations: E. L. McQuaid has received research support from the National Institute of Nursing Research and the National Heart, Lung, and Blood Institute. C. S. Rand has served as a scientific advisor for the Merck Foundation and the Schering-Plough Leadership Council. G. Canino has declared that she has no conflict of interest.GlossaryASTHMA ACTION PLANA written asthma plan, including peak flows, symptoms, and medications, can change asthma exacerbations and urgent care visits, especially if used in conjunction with a more intensive asthma education program.CULTURAL COMPETENCE TRAININGAn increased emphasis on understanding cultural barriers to health care has led to the development of specific programs, especially at the medical school level, to teach the health care effect of cultural differences. There are standardized assessment tools to gauge cultural training and online courses to meet cultural competency requirements. Although studies have shown that cultural competence training can improve cultural understanding among medical providers, the effect of such training on health outcomes for patients continues to be assessed.DISPARITIES MODELSDisparities models are theoretic models used to explain health disparities among patient populations. Examples include the racial-genetic model, the health behavior model, the SES model, and the psychosocial stress model. These models can then be compared with one another by using multivariate analysis to assess which differences most accurately account for health disparities between racial and ethnic groups.GENETIC RISK FACTORSStudies on the genetics of asthma include the discovery of genes that predispose to asthma, genes that interact with the environment to predispose to asthma, and pharmacogenomics (ie, the likelihood of therapeutic response based on genetics). Gene-environment examples include the relationship between environmental tobacco smoke exposure and genes involved in oxidative stress (GSTM1 and GSTM2) and immunity genes (CD14 and IL13). A recent large population study shows early-onset asthma susceptibility, especially with concurrent exposure to tobacco smoke, associated with genes on chromosome 17q21.1.HOME REMEDIESCultural beliefs change a patient's view about asthma causes, and these beliefs might lead to the institution of home remedies before or instead of seeking traditional medical care. For example, Latino patients can believe that asthma is caused by strong emotions and an imbalance of hot and cold and might treat asthma with behavior changes, physical remedies (eg, rubbing the back), and herbal teas or syrups. In time, some culture-specific remedies have proved to have significant medical utility, such as Chinese herbal therapy for the treatment of food allergy and asthma.MEDICAIDCreated in 1965 as part of the Social Security Act, Medicaid is a program to provide health care to low-income families. States can have various names for Medicaid, including MassHealth (Massachusetts) and Medi-Cal (California). Other government-run health care systems include Military Health Systems, CHIP (see below), TRICARE, and the Department of Veterans Affairs.MINORITYThe Office of Minority Health and Health Disparities of the Centers for Disease Control and Prevention defines racial and ethnic minorities as American Indian and Alaska Native populations, Asian American populations (Far East, Southeast Asia, and Indian subcontinent), black or African American populations, Hispanic or Latino populations (Cuban, Mexican, Puerto Rican, and South/Central American), Native Hawaiian, and other Pacific Islander.PREVALENCEPrevalence is defined epidemiologically as the number of persons in the population with a disease at a given time divided by the number of persons in the population at risk for the disease plus the number of persons with the disease. Unlike incidence, prevalence reflects cumulative cases rather than the new cases of a disease in a given population over a period of time.SECOND HAND SMOKEEnvironmental tobacco smoke exposure is associated with increased asthma symptoms, increased medical visits, and decreased lung function in asthmatic subjects. Animal models demonstrate that exposure to passive cigarette smoke (or smoke extract) increases allergic sensitization to ovalbumin.SOCIOECONOMIC STATUSA combination of factors determines a person's SES, including occupation (unemployment), income (poverty line and median household income), education level, wealth (property values), and housing (crowded). The current poverty guideline for the 48 contiguous states for a family of 4 is $22,050.S-CHIPThe State Children's Health Insurance Program (now known as CHIP) was created in 1997 to provide health insurance to children who were ineligible for Medicaid but who could not afford private health insurance. In February 2009, the Children's Health Insurance Program Reauthorization Act (CHIPRA) was signed into law to extend and expand CHIP.The Editors wish to acknowledge Seema Aceves, MD, PhD, for preparing this glossary.Substantial evidence across multiple avenues of research has documented pervasive asthma disparities between minorities and non-Latino whites (NLWs). Higher rates of asthma prevalence are consistently found among certain minority racial/ethnic groups, particularly African American, American Indian, and Puerto Rican populations.1Lara M. Akinbami L. Flores G. Morgenstern H. Heterogeneity of childhood asthma among Hispanic children: Puerto Rican children bear a disproportionate burden.Pediatrics. 2006; 117: 43-53Crossref PubMed Scopus (235) Google Scholar, 2Hunninghake G.M. Weiss S.T. Celedon J.C. Asthma in Hispanics.Am J Respir Crit Care Med. 2006; 173: 143-163Crossref PubMed Scopus (106) Google Scholar, 3Center for Disease Control and Prevention. The state of childhood asthma, United States: 1980-2005. Available at: www.cdc.gov/nchs. Accessed May 6, 2009.Google Scholar There is also substantial evidence of worse asthma control among minority populations compared with that seen among NLWs, including significantly higher rates of asthma exacerbations and missed days from school or work,4Canino G. Koinis-Mitchell D. Ortega A.N. McQuaid E.L. Fritz G.K. Alegria M. Asthma disparities in the prevalence, morbidity, and treatment of Latino children.Soc Sci Med. 2006; 63: 2926-2937Crossref PubMed Scopus (98) Google Scholar, 5Lieu T.A. Lozano P. Finkelstein J.A. Chi F.W. Jensvold N.G. Capra A.M. et al.Racial/ethnic variation in asthma status and management practices among children in managed Medicaid.Pediatrics. 2002; 109: 857-865Crossref PubMed Scopus (322) Google Scholar, 6Haselkorn T. Lee J.H. Mink D.R. Weiss S.T. Racial disparities in asthma-related health outcomes in severe or difficult-to-treat asthma.Ann Allergy Asthma Immunol. 2008; 101: 256-263Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar greater rates of emergency department (ED) use,7Ginde A.A. Espinola J.A. Camargo Jr., C.A. Improved overall trends but persistent racial disparities in emergency department visits for acute asthma, 1993–2005.J Allergy Clin Immunol. 2008; 122: 313-318Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar, 8Kruse L.K. Deshpande S. Vezina M. Disparities in asthma hospitalizations among children seen in the emergency department.J Asthma. 2007; 44: 833-837Crossref PubMed Scopus (19) Google Scholar, 9Shields A.E. Comstock C. Weiss K.B. Variations in asthma care by race/ethnicity among children enrolled in a state Medicaid program.Pediatrics. 2004; 113: 496-504Crossref PubMed Scopus (91) Google Scholar higher hospitalization rates,9Shields A.E. Comstock C. Weiss K.B. Variations in asthma care by race/ethnicity among children enrolled in a state Medicaid program.Pediatrics. 2004; 113: 496-504Crossref PubMed Scopus (91) Google Scholar, 10Akinbami L. The state of childhood asthma, United States, 1980–2005.Adv Data. 2006; 381: 1-24PubMed Google Scholar, 11Erickson S.E. Iribarren C. Tolstykh I.V. Blanc P.D. Eisner M.D. Effect of race on asthma management and outcomes in a large, integrated managed care organization.Arch Intern Med. 2007; 167: 1846-1852Crossref PubMed Scopus (38) Google Scholar, 12Gupta R.S. Carrion-Carire V. Weiss K.B. The widening black/white gap in asthma hospitalizations and mortality.J Allergy Clin Immunol. 2006; 117: 351-358Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar and greater asthma mortality risk.13Akinbami L.J. Schoendorf K.C. Trends in childhood asthma: prevalence, health care utilization, and mortality.Pediatrics. 2002; 110: 315-322Crossref PubMed Scopus (643) Google Scholar, 14Homa D.M. Mannino D.M. Lara M. Asthma mortality in U.S. Hispanics of Mexican, Puerto Rican, and Cuban heritage, 1990–1995.Am J Respir Crit Care Med. 2000; 161: 504-509Crossref PubMed Scopus (172) Google Scholar Credit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the following instructions. Method of Physician Participation in Learning Process: The core material for these activities can be read in this issue of the Journal or online at the JACI Web site: www.jacionline.org. The accompanying tests may only be submitted online at www.jacionline.org. Fax or other copies will not be accepted. Date of Original Release: June 2009. Credit may be obtained for these courses until May 31, 2011. Copyright Statement: Copyright © 2009-2011. All rights reserved. Overall Purpose/Goal: To provide excellent reviews on key aspects of allergic disease to those who research, treat, or manage allergic disease. Target Audience: Physicians and researchers within the field of allergic disease. Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates these educational activities for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. List of Design Committee Members:Authors: Glorisa Canino, PhD, Elizabeth L. McQuaid, PhD, and Cynthia S. Rand, PhD Activity Objectives 1. To identify minority populations at highest risk for asthma prevalence, severity, and morbidity. 2. To learn that asthma disparities have multiple, complex, and interrelated sources. 3. To understand how the health care system, social/environmental factors, provider and individual attitudes, and behaviors play a role in asthma disparity. 4. To learn strategies that could be applied in the clinical setting to reduce asthma disparity. Recognition of Commercial Support: This CME activity is supported by an educational grant from Merck & Co., Inc. Disclosure of Significant Relationships with Relevant Commercial Companies/Organizations: E. L. McQuaid has received research support from the National Institute of Nursing Research and the National Heart, Lung, and Blood Institute. C. S. Rand has served as a scientific advisor for the Merck Foundation and the Schering-Plough Leadership Council. G. Canino has declared that she has no conflict of interest. A written asthma plan, including peak flows, symptoms, and medications, can change asthma exacerbations and urgent care visits, especially if used in conjunction with a more intensive asthma education program. An increased emphasis on understanding cultural barriers to health care has led to the development of specific programs, especially at the medical school level, to teach the health care effect of cultural differences. There are standardized assessment tools to gauge cultural training and online courses to meet cultural competency requirements. Although studies have shown that cultural competence training can improve cultural understanding among medical providers, the effect of such training on health outcomes for patients continues to be assessed. Disparities models are theoretic models used to explain health disparities among patient populations. Examples include the racial-genetic model, the health behavior model, the SES model, and the psychosocial stress model. These models can then be compared with one another by using multivariate analysis to assess which differences most accurately account for health disparities between racial and ethnic groups. Studies on the genetics of asthma include the discovery of genes that predispose to asthma, genes that interact with the environment to predispose to asthma, and pharmacogenomics (ie, the likelihood of therapeutic response based on genetics). Gene-environment examples include the relationship between environmental tobacco smoke exposure and genes involved in oxidative stress (GSTM1 and GSTM2) and immunity genes (CD14 and IL13). A recent large population study shows early-onset asthma susceptibility, especially with concurrent exposure to tobacco smoke, associated with genes on chromosome 17q21.1. Cultural beliefs change a patient's view about asthma causes, and these beliefs might lead to the institution of home remedies before or instead of seeking traditional medical care. For example, Latino patients can believe that asthma is caused by strong emotions and an imbalance of hot and cold and might treat asthma with behavior changes, physical remedies (eg, rubbing the back), and herbal teas or syrups. In time, some culture-specific remedies have proved to have significant medical utility, such as Chinese herbal therapy for the treatment of food allergy and asthma. Created in 1965 as part of the Social Security Act, Medicaid is a program to provide health care to low-income families. States can have various names for Medicaid, including MassHealth (Massachusetts) and Medi-Cal (California). Other government-run health care systems include Military Health Systems, CHIP (see below), TRICARE, and the Department of Veterans Affairs. The Office of Minority Health and Health Disparities of the Centers for Disease Control and Prevention defines racial and ethnic minorities as American Indian and Alaska Native populations, Asian American populations (Far East, Southeast Asia, and Indian subcontinent), black or African American populations, Hispanic or Latino populations (Cuban, Mexican, Puerto Rican, and South/Central American), Native Hawaiian, and other Pacific Islander. Prevalence is defined epidemiologically as the number of persons in the population with a disease at a given time divided by the number of persons in the population at risk for the disease plus the number of persons with the disease. Unlike incidence, prevalence reflects cumulative cases rather than the new cases of a disease in a given population over a period of time. Environmental tobacco smoke exposure is associated with increased asthma symptoms, increased medical visits, and decreased lung function in asthmatic subjects. Animal models demonstrate that exposure to passive cigarette smoke (or smoke extract) increases allergic sensitization to ovalbumin. A combination of factors determines a person's SES, including occupation (unemployment), income (poverty line and median household income), education level, wealth (property values), and housing (crowded). The current poverty guideline for the 48 contiguous states for a family of 4 is $22,050. The State Children's Health Insurance Program (now known as CHIP) was created in 1997 to provide health insurance to children who were ineligible for Medicaid but who could not afford private health insurance. In February 2009, the Children's Health Insurance Program Reauthorization Act (CHIPRA) was signed into law to extend and expand CHIP. The Editors wish to acknowledge Seema Aceves, MD, PhD, for preparing this glossary. Although the literature on asthma disparities is evolving rapidly, considerably more research has been conducted with certain minority groups, such as African Americans and Latinos, compared with others, such as Native Americans. Additionally, the manifestation of disparities across different racial/ethnic groups can differ substantially. For example, Latinos of Mexican origin present with lower asthma prevalence and morbidity compared with whites,1Lara M. Akinbami L. Flores G. Morgenstern H. Heterogeneity of childhood asthma among Hispanic children: Puerto Rican children bear a disproportionate burden.Pediatrics. 2006; 117: 43-53Crossref PubMed Scopus (235) Google Scholar, 2Hunninghake G.M. Weiss S.T. Celedon J.C. Asthma in Hispanics.Am J Respir Crit Care Med. 2006; 173: 143-163Crossref PubMed Scopus (106) Google Scholar and children of African American and Puerto Rican origin appear to have the highest prevalence compared with NLWs,3Center for Disease Control and Prevention. The state of childhood asthma, United States: 1980-2005. Available at: www.cdc.gov/nchs. Accessed May 6, 2009.Google Scholar with Puerto Ricans exhibiting the highest prevalence of any other ethnic/racial group.1Lara M. Akinbami L. Flores G. Morgenstern H. Heterogeneity of childhood asthma among Hispanic children: Puerto Rican children bear a disproportionate burden.Pediatrics. 2006; 117: 43-53Crossref PubMed Scopus (235) Google Scholar On the other hand, African Americans demonstrate higher rates of hospitalization9Shields A.E. Comstock C. Weiss K.B. Variations in asthma care by race/ethnicity among children enrolled in a state Medicaid program.Pediatrics. 2004; 113: 496-504Crossref PubMed Scopus (91) Google Scholar, 10Akinbami L. The state of childhood asthma, United States, 1980–2005.Adv Data. 2006; 381: 1-24PubMed Google Scholar, 12Gupta R.S. Carrion-Carire V. Weiss K.B. The widening black/white gap in asthma hospitalizations and mortality.J Allergy Clin Immunol. 2006; 117: 351-358Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar, 15Fisher-Owens S.A. Turenne W.M. Chavanu K. Slonim A.D. Racial disparities in children hospitalized with asthma at Academic Childrens' Hospitals.Pediatr Asthma Allergy Immunol. 2006; 19: 162-171Crossref Scopus (6) Google Scholar and higher rates of asthma mortality13Akinbami L.J. Schoendorf K.C. Trends in childhood asthma: prevalence, health care utilization, and mortality.Pediatrics. 2002; 110: 315-322Crossref PubMed Scopus (643) Google Scholar, 14Homa D.M. Mannino D.M. Lara M. Asthma mortality in U.S. Hispanics of Mexican, Puerto Rican, and Cuban heritage, 1990–1995.Am J Respir Crit Care Med. 2000; 161: 504-509Crossref PubMed Scopus (172) Google Scholar compared with NLW and Latino populations. These findings suggest that what constitutes “disparity” might differ by racial/ethnic group. Although ethnic/racial disparities in asthma have been well established, the underlying causes of these disparities are poorly understood, and as a result, the leverage points to address them remain unclear. In the present article we present a brief review of current findings that have emerged in key areas of research on health care disparities in asthma and propose a multilevel framework for integrating this substantial literature. Our model is derived from the Institute of Medicine's 2002 landmark report on unequal care, which focused on health care policies and regulations, operation of the health care system, and provider/clinician-level factors. In addition to these health care system factors, we also consider broader social/environmental factors and individual/family attitudes and behaviors that might have a role in asthma disparities. Below we present empiric support for the processes included in the main domains of our proposed model and suggest how this model can be helpful in advancing both future research and clinical practice. There is evidence that certain health care policies might contribute to disparities in asthma outcomes and that cost-control strategies implemented by public health plans might differentially affect minority populations. Minorities are overrepresented in government-sponsored health plans, such as Medicare, which are federally and state regulated for cost control. As a result, minority populations might receive restricted access to specialists and preventive care, thus resulting in lower quality of health care.16Shields A.E. Trends in private insurance, Medicaid/State Children's Health Insurance Program, and the health-care safety net: implications for asthma disparities.Chest. 2007; 132: 818S-830SCrossref PubMed Scopus (24) Google Scholar, 17Smedley B.D. Stith A.Y. Nelson A.R. Unequal treatment confronting racial and ethnic disparities in health care.in: Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Board of Health Sciences Policy, Institute of Medicine, Washington (DC)2002Google Scholar Factors common to publicly insured plans, such as decreased use of preventive care and limited referrals to asthma specialists, have been associated with higher rates of hospitalization and ED use and increased risk of mortality.18Berman S. Armon C. Todd J. Impact of a decline in Colorado Medicaid managed care enrollment on access and quality of preventive primary care services.Pediatrics. 2005; 116: 1474-1479Crossref PubMed Scopus (17) Google Scholar, 19Joseph C.L. Havstad S.L. Ownby D.R. Johnson C.C. Tilley B.C. Racial differences in emergency department use persist despite allergist visits and prescriptions filled for antiinflammatory medications.J Allergy Clin Immunol. 1998; 101: 484-490Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Restricted access to specialists might contribute to disparities in asthma morbidity, given that there is evidence that specialists are more likely to prescribe controller medications than primary care providers independent of the patient's minority status.19Joseph C.L. Havstad S.L. Ownby D.R. Johnson C.C. Tilley B.C. Racial differences in emergency department use persist despite allergist visits and prescriptions filled for antiinflammatory medications.J Allergy Clin Immunol. 1998; 101: 484-490Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 20Finkelstein J.A. Lozano P. Farber H.J. Miroshnik I. Lieu T.A. Underuse of controller medications among Medicaid-insured children with asthma.Arch Pediatr Adolesc Med. 2002; 156: 562-567Crossref PubMed Scopus (28) Google Scholar In an effort to control costs, many states have enacted policies to reduce Medicaid eligibility and manage prescription drug benefits, either by decreasing the payments to pharmacies or by introducing copayments.16Shields A.E. Trends in private insurance, Medicaid/State Children's Health Insurance Program, and the health-care safety net: implications for asthma disparities.Chest. 2007; 132: 818S-830SCrossref PubMed Scopus (24) Google Scholar There is preliminary evidence that the introduction of these restrictions might negatively affect asthma outcomes among minorities and the poor,16Shields A.E. Trends in private insurance, Medicaid/State Children's Health Insurance Program, and the health-care safety net: implications for asthma disparities.Chest. 2007; 132: 818S-830SCrossref PubMed Scopus (24) Google Scholar hence increasing existing disparities. In support of this notion, one study demonstrated that doubling existing copayments resulted in a 21% reduction in the number of prescriptions filled for asthma.21Goldman D.P. Joyce G.F. Escarce J.J. Pace J.E. Solomon M.D. Laouri M. et al.Pharmacy benefits and the use of drugs by the chronically ill.JAMA. 2004; 291: 2344-2350Crossref PubMed Scopus (442) Google Scholar Rand et al22Rand C.S. Butz A.M. Kolodner K. Huss K. Eggleston P. Malveaux F. Emergency department visits by urban African American children with asthma.J Allergy Clin Immunol. 2000; 105: 83-90Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar found that among African American families covered by Medicaid, out-of-pocket payments for health care were an important predictor of ED use for an asthma exacerbation. These findings suggest that increasing out-of-pocket costs to disadvantaged groups might diminish access to medication and to appropriate strategies for preventive management of exacerbations. National guidelines23National Institutes of Health, National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma. National Institutes of Health, Washington (DC)2007Google Scholar continue to stress that families and health care providers should collaborate actively to manage asthma, with an emphasis on preventive management. Preventive management includes strategies to avert asthma episodes through control of relevant environmental triggers, regular use of controller medications for patients with persistent symptoms, use of an asthma action plan, and referrals to specialists when indicated. In addition, assessment of asthma severity at initial
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