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* From the Midwest Center for Health Services and Policy Research, Hines VA Hospital, Hines, IL.
Correspondence to: Kevin B. Weiss, MD, Institute For Healthcare Studies, 676 N St. Clair St, Suite 200, Chicago, IL 60611; e-mail: K-weiss{at}northwestern.edu
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Abstract |
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 TOP Abstract IntroductionThe 2005 National Workshop...References |
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Key Words: asthma • epidemiology • health administration
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Introduction |
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TOPAbstractIntroductionThe 2005 National Workshop...References |
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Asthma is a health condition that affects > 20.5 million persons in the United States,5 and its prevalence, morbidity, and mortality are known to be higher in some racial and ethnic minority groups. Long-term trends in the white/black gap in hospitalization and mortality rates have shown very little improvement, even in the 10 years since the publication of national guidelines on the diagnosis and management of this disease.67 Of even greater concern is that this white/black gap may be increasing for children 5 to 18 years old.8 Such trends regarding racial differences in hospitalization and mortality rates, however, do not seem to be reflected in similar changes in asthma prevalence related to racial differences. Furthermore, although national surveillance data have been used to characterize differences between white persons and black persons, there are no data that can be used to characterize trends among other racial and ethnic minority groups.
In 1990, differences in asthma outcomes among ethnic minorities gained national attention because of a number of studies910111213 of geographic variation in these outcomes. Collectively, this body of literature identified inner-city populations as having the highest rates of asthma hospitalization and mortality in the country. The results of those publications led to a series of important national studies intended to improve understanding of the phenomenon of "inner-city" asthma and how it might relate to the broader concern of racial and ethnic disparities in asthma outcomes. The first major results from the largest of these studies—The National Cooperative Inner-city City Asthma Study—were first published in 199714 and, as of October 2006, nearly 400 studies have been published that characterize and attempt to solve this public health concern.
Although much of the attention on racial and ethnic differences in asthma outcomes has been focused on African-American and inner-city communities, during the past decade there has been a growing body of literature that suggests important differences in other populations as well. Most notably, asthma outcomes in the Hispanic community appear to be a large public health problem. The emerging literature suggests that Hispanic populations are at a higher risk for asthma after migrating to the United States,15 and that Hispanic persons have different rates of asthma prevalence, depending on their Latino ethnic background.16 New evidence is suggesting that genetic variations partly may be observed among differing racial and ethnic samples.1718 Research in this area is only beginning to emerge, and there is little understanding of gene and environment interactions and of how any gene-related racial/ethnic expression relates to population ancestry.
Also, during the past decade, research on the difference in asthma outcomes in racial and ethnic minority groups has led to an advancement of our understanding of the important influence that lower socioeconomic status (SES) has on the increasing prevalence, morbidity, and mortality of asthma. Much of the literature on the relationship between SES and asthma outcomes has used community-level measures of SES.192021 Recently, some studies2223 have begun to explore how community factors associated with SES might affect asthma morbidity.
This collective epidemiologic literature has served as the benchmark for a number of public and private investments to address this problem. The most notable response has been from the US Department of Health and Human Services. With appropriations of $35.2 million in the fiscal year 2002, the National Asthma Control Program of the Centers for Disease Control and Prevention (CDC) funded 11 asthma tracking projects, 48 asthma interventions, and 33 asthma partnership projects. Through its adolescent and school health program, the CDC also funded six urban school districts, one state education agency, and six national, nongovernmental organizations to support and address asthma control in a coordinated school health program.
The National Institutes of Health have funded asthma coalitions in seven communities with exceptionally high asthma death rates. The National Heart, Lung, and Blood Institute (NHLBI) has awarded contracts designed to establish partnerships with local asthma coalitions to develop innovative, model programs to improve asthma care. The coalitions will implement activities to eliminate disparities in asthma morbidity and mortality in their communities, especially among children, minorities, and persons with low incomes. Most recently, the NHLBI created a program to accelerate research aimed at understanding why certain racial, ethnic, and socioeconomic groups are more affected by asthma than other populations and at determining ways to close the gaps in prevalence and treatment of this common chronic disease. The research and related training activities are being conducted through four NHLBI Centers for Reducing Asthma Disparities. This combined body of literature has set the stage for a national dialogue on this problem of serious concern.
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The 2005 National Workshop To Eliminate Asthma Disparities |
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TOPAbstractIntroductionThe 2005 National Workshop...References |
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To achieve this goal, we assembled a multidisciplinary group of > 100 national experts in the fields of clinical research, clinical practice implementation, health-care administration, minority health, health services research, public health practice, health care financing, health policy, and consumer advocacy. In a 2-day conference, this group of experts reviewed key issues related to asthma health disparities; considered current research, clinical care, and policy related to this problem; and developed a practical set of recommendations ("action agenda") to reduce these disparities by means of new research opportunities, to propose new directions in clinical and public policy, and to innovative consumer strategies to promote change.
The workshop was structured around key themes. Each theme was introduced through discussions of related background papers. Each of the background articles are presented in this supplement and include the following:
Genetics:
The literature suggests that one or more asthma-related bimolecular asthma pathway smay have genetic polymorphisms that may differ among minority populations.
Indoor Environment:
Studies such as the National Cooperative Inner-city Asthma Study have demonstrated the unique problems of indoor allergens and cigarette smoke within the inner-city home. New studies are beginning to define ways to address this problem.
Outdoor Environment:
The outdoor environment of the inner city poses unique challenges. Transportation-related and industrial pollution may put minority populations at risk for unique and excessive exposures.
Family/Social Function:
Recent evidence suggests that the role of the family and other social structures may affect asthma outcomes. New studies are beginning to explore this relationship for various racial/ethnic groups.
Behavioral Health:
Emerging literature suggests that stress and coping behaviors can be key mediators in asthma quality of life. The unique stressors of the inner-city environment pose challenges to targeting interventions for these high-risk populations.
Health-Care Delivery:
A number of clinical trials have examined "best practices" in asthma care. The challenge is to understand how findings from well-controlled and highly selective randomized controlled environments may generalize to real-world physician practices and health-care organizations.
Health-Care Communications:
The recent development of health literacy measures has prompted a discussion about the difficulty of communicating health-care messages. Inner-city populations pose a particularly difficult problem that is not only related to disproportionate levels of low literacy, but also to the many unique features of communicating health messages across communities with wide racial/ethnic variation.
Role of the Community:
Although it is assumed that the health-care system plays the key role in addressing asthma outcomes, experience dictates that community resiliency and capacity are also important functions in health populations. What might be the best roles for a community in addressing the challenge of inner-city asthma?
Role of Private Insurance:
Public health insurers play a pivotal role in access to health care for inner-city populations. However, for many "working poor," private insurance is the source of care coverage. In addressing the problem of inner-city asthma, too little discussion on the role of the private insurers has happened.
Role of Safety Net Providers:
The public health systems, public health insurers, and other safety net providers, such as the Federally Qualified Health Centers and local free clinics, provide a safety net of care for inner-city populations. What are the best systems of care for persons with asthma who use these services?
State and Local Policy:
State-sponsored programs play essential roles in addressing asthma morbidity and include Medicaid programs, education, pubic health programs, and surveillance. However, it is unclear which models are best for states to adopt to eliminate asthma disparities.
After presentations of background manuscripts, workshop participants were asked to participate in a series of small and large workgroups to identify current best practices, identify critical gaps in knowledge, and propose solutions. The group-proposed solutions form the basis of the action plans published later in this supplement.24 Both an action agenda for change and a research agenda for studies are needed to further understand and solve this major public health problem.
This workshop could only have been possible with the help and sponsorship of a number of persons and organizations. It is important to acknowledge the Workshop Steering Committee for guiding all aspects of the workshop, including Noreen Clark, PhD; Charles J. Homer, MD; Carol Jones, RN AE-C; Christine Joseph, PhD; Floyd Malveaux, MD; Jay Shannon, MD; Rosalind Wright, MD; Virginia Taggart, MPH; Andrea Apter, MD; and Denise Dougherty, PhD.
This workshop originated with the support of the Otho S.A. Sprague Memorial Institute under the leadership of Dr. Whitney Addington and Mr. James Alexander. Also, the Agency for Healthcare Research and Quality (1 R13 HS015762-01), the National Institutes of Health (NHLBI and the National Institute for Allergy and Infectious Diseases), the National Asthma Education and Prevention Program (NHLBI), and the CDC were also instrumental in supporting this project.
In addition, the following organizations endorsed this workshop, including providing representation to the meeting: the American College of Chest Physicians; the American Academy of Allergy, Asthma, and Immunology; the National Medical Association; the American Lung Association; American Association of Respiratory Care; the American College of Allergy, Asthma and Immunology; the America’s Health Insurance Plans; the American Thoracic Society; Association of Asthma Educators; the National Institute of Environmental Health Sciences; and the National Hispanic Medical Association.
This workshop would not be possible without educational grant support from Merck, sanofi/aventis, GalaxoSmithKline, ALTANA Pharma, AstraZeneca, Sepracor, Genentech, and Novartis. The following individuals provided additional unique contributions to this workshop: Anita Malone served as a project coordinator; Robin Wagner provided assistance in administering the project; Dr. Sydney Parker of American College of Chest Physicians put forth continued efforts in developing the workshop; and Dr. Frances Chesley and Virginia Taggart gave continued encouragement that made this workshop possible.
Finally, it is worth emphasizing that the focus of this workshop was to develop a working agenda to eliminate asthma disparities. To this end, some of the proposed solutions are asthma specific. These may be easiest to address by persons most concerned with asthma. However, as will be seen in the background articles and the workshop findings, some of the problems related the disparities are not unique to asthma. As might be expected, the more-systemic problems will require systemic actions to address socioeconomic, racial, and ethnic disparities. These systemic solutions will require the asthma community to join with other members of the public health and policy community to effect the types of social and health policy change necessary to fully address this challenging social problem.
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Footnotes |
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The author has no conflict of interest to disclose.
Received for publication December 20, 2006. Accepted for publication August 2, 2007.
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References |
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TOPAbstractIntroductionThe 2005 National Workshop...References |
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This article has been cited by other articles:
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  C. M. Clancy, J. P. Kiley, and K. B. Weiss Eliminating Asthma Disparities Through Multistakeholder Partnerships Chest, November 1, 2007; 132(5): 1422 - 1424. [Full Text] [PDF]
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