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Racial and Ethnic Disparities in the Quality of Asthma Care^*

^* From the Institute for Health Policy Studies (Dr. Cabana), Department of Pediatrics, Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA; UCLA/RAND Program on Latino Children with Asthma (Dr. Lara), UCLA Department of Pediatrics and RAND Health, Los Angeles, CA; and Department of Medicine (Dr. Shannon), Cook County Hospital, Chicago, IL.

Correspondence to: Michael D. Cabana, MD, MPH, Division of General Pediatrics, University of California, San Francisco, 3333 California St, Suite 245, San Francisco, CA 94118; e-mail: michael.cabana{at}ucsf.edu

	Abstract

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Racial and ethnic disparities in the quality of asthma care have been well documented in the United States. There are multiple factors associated with such disparities in asthma care, including structural barriers (eg, ability to access the health-care system), process-of-care barriers (eg, ability to navigate the health-care system), and process-of-care barriers at the interpersonal level (eg, ability to work effectively with a health-care provider) for equitable, quality asthma care. This article summarizes these issues and identifies specific areas for future investigation. At a health-systems level, further work is needed to understand how medical care financing arrangements may or may not be contributing to racial and ethnic disparities in asthma care, as well as how specific organizational initiatives can address these issues. Research needs at the patient/provider level include defining the content and methods for disseminating issues regarding cultural competency to health-care providers.

Key Words: asthma • emergency department • ethnicity • health care • quality of health care • race

	Introduction

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Racial and ethnic disparities in the quality of care have been well documented in the United States. In terms of overall prevalence, asthma is most common among non-Hispanic blacks (9.3%), compared to non-Hispanic whites (7.6%) and Hispanics (5.0%). In terms of access, if emergency department (ED) use is seen as a marker for poor access to primary asthma care, ED visits were greatest for non-Hispanic blacks (37.2%) and Hispanics (26%), compared to non-Hispanic whites (14.5%).¹ Non-Hispanic blacks have higher rates of ED visits, hospitalizations, and morbidity due to asthma compared to non-Hispanic whites, even after controlling for the higher prevalence of asthma in the non-Hispanic black population.²³ In addition, Hispanics demonstrate significant heterogeneity. For example, Puerto Rican populations experience equivalent or higher asthma mortality and morbidity than non-Hispanic blacks, while Mexicans experience equivalent or better outcomes compared to non-Hispanic whites.⁴⁵

In terms of differences in quality of care, non-Hispanic blacks and Hispanics are more likely to receive substandard outpatient care compared to non-Hispanic whites. For example, a review⁶ of the quality of medical care for children admitted between 1989 and 1990 to one pediatric institution found that Hispanic patients were less likely to have access to ß-agonists. Both black and Hispanic patients were also less likely to have preventive antiinflammatory therapy.⁶ These findings have been repeatedly documented in different settings throughout the United States, with African Americans and Hispanics less likely to receive appropriate asthma medications for preventive care, acute exacerbations, or post-ED care.^7891011

	Reasons for Disparities

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The Institute of Medicine has defined disparities in health care as differences in the quality of health care that are due to the operation of the health-care system, as well as those differences due to discrimination (Fig 1 ).¹² Discrimination in this case refers to "differences in care that result from biases, prejudices, stereotyping, and uncertainty in clinical communication and decision-making."¹² In addition, differences in outcomes may be due to inherent patient preferences or genetic differences.¹² The focus of this review is disparities due to the operation of the health-care system and provider biases (ie, differences that are not due to genetics or patient preferences) described in the current published literature.

View larger version (8K): [in this window] [in a new window] [Download PPT slide]   Figure 1.. Sources of disparities in quality of care (adopted from the Institute of Medicine report12).

	Racial Disparities in the Quality of Asthma Care

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Disparities in quality of asthma care may occur at a structural level and include the ease of accessing the system and identifying an appropriate provider. For example, structural barriers related to accessing the system would include lack of insurance and/or limitations in the hours of availability or geographic location of available providers. In such circumstances, the ED may be the only alternative to asthma care. As a result, disparities in ED utilization may increase. In terms of availability of primary care providers, they may not reflect the diversity of the population in underserved areas and/or be appropriately trained in culturally competent asthma care. Referral policies within a health-care organization may affect the quality of care as well because there may be limited access to subspecialty care for asthma when necessary. Finally, for those providers within a community, managed-care arrangements may also limit which providers are allowed to participate in capitated arrangements.

Disparities in quality of asthma care may also occur due to disparities in the process of care at the health-care system level. Without adequate quality assurance or quality management within a system, the providers within a health-care system may not be managing asthma consistent with national guidelines, and thus may also be contributing to disparities. Clinics and hospitals may also be ill prepared to handle a diverse population (eg, lack of interpreter services), which may also add to differences in outcomes.

Disparities in the process of care may also occur at an interpersonal or individual level, due to poor provider communication, lack of cultural competency or biases and stereotyping that may contribute to disparities. One of the key components of proper asthma care is a partnership between the health-care provider and the patient to properly manage asthma. The inability to communicate or recognize biases by providers in their treatment of different patient populations may be a factor contributing to racial disparities in asthma care. For example, a survey of health-care providers involved in postangiogram care noted that health-care providers were more likely to perceive African Americans and members of low socioeconomic groups more negatively regarding feelings of affiliation toward the patient. Providers also assumed a lower likelihood of follow-up adherence with their medical advice.¹⁴ Although this example relates to cardiac care, it is likely to be a nonspecific phenomenon operative in the management many chronic diseases, such as asthma. If physicians a priori are less likely to believe that certain patients are less likely to follow their advice, they may be less likely to counsel and educate these patients.¹⁵ This lack of counseling and education may then contribute to disparities in asthma outcomes.

Based on this framework, the disparities in the outcomes of care for asthma may be due to issues related to the structure and process of care, as described above. The following sections highlight and summarize possible interventions at each of these levels.

	Interventions at a Structural Level

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Programs to increase the diversity of the health-care workforce (eg, through more aggressive recruitment and increased pre-health professional programs) may be one long-term intervention to help address racial disparities in asthma care and outcomes. Although African Americans and Hispanics each constitute approximately 12% of the US population, it is estimated that African Americans compose < 4% of the physician workforce, while Hispanics only account for 5% of the workforce. These disparities in workforce representation are also apparent in subspecialties that treat asthma such as allergy and pulmonology. African-American and Hispanic physicians constitute only 1.4% and 3.7% of the workforce in allergy and immunology, respectively. African-American and Hispanic physicians constitute only 2.6% and 5.2% of the workforce in pulmonology, respectively.¹⁶

Racial concordance of patient and provider is associated with greater patient adherence to treatment and participation in care, which may lead to improved outcomes.¹⁷ As medical school graduates from minority backgrounds are more likely to practice in underserved areas strategies to improve the number of minority medical school graduates may be helpful. A prospective cohort study suggested that intensive summer educational programs for minority college students are associated with increased success for participants (compared to nonparticipants) in applying to medical schools.¹⁸ A more detailed evaluation of the Student Educational Enrichment Program for gifted underrepresented minority students at the Medical College of Georgia noted that early intervention through summer enrichment programs can be helpful; however, mentorship and professional role models are a key component for success.¹⁹ In addition, undergraduate, graduate and continuing medical education must also include curricula to train health-care professionals to work with the growing diversity of the population.

The key components in providing cultural competent asthma care or culturally competent care, in general, have not been defined. However, for culturally competent asthma care, it is suggested that health-care providers should develop a knowledge base of local health practices, an understanding of alternative explanations for disease, as well as the role of diet and/or botanical supplements from the cultures represented in the health care provider’s immediate community.²⁰

Policy interventions may be another means to address racial disparities in asthma outcomes. Specifically, state and federal policies may promote greater responsiveness by health care providers to the diversity and needs of the population. The US Department of Health and Human Services has specifically articulated a goal of eliminating racial disparities in health care, and has set standards for what constitutes culturally and linguistically appropriate services (CLAS) [Table 1 ].²¹ In the clinical setting, examples of CLAS would include programs to recruit and retain staff members who reflect the cultural diversity that the clinic serves, the use of interpreter services or bilingual providers for clients with limited English proficiency, training in cultural competency health-care providers, and the availability of linguistically and culturally appropriate asthma education materials.

For example, cultural competency policies within health-care organizations have been associated with better quality of asthma care. An analysis of the quality of care for 1663 patients in five health plans in California, Washington, and Massachusetts showed that those patients who received care at practice sites with the highest cultural competence scores were more likely to use preventive medications for asthma. The same parents of patients also reported better ratings of care. The study suggested that policies at practice sites to promote cultural competence are associated with better quality of care.²³

The distribution of health-care plans may also affect health-care disparities. For example, the Institute of Medicine has noted that "disadvantaged minority groups in lower-end health plans may be a major source for disparities in healthcare provision." The report notes a "fragmentation" of care that creates "different clinical cultures, with different practice norms, tied to varying per capita constraints." As a result, the report recommends that "medical care financing arrangements should discourage fragmentation of healthcare provision into separate tiers of providers who adhere to different standards of care and disproportionately serve separate racial and ethnic minority segments."¹²

Community health centers are institutions designed to address the problem of lack of access to primary health care and may help reduce racial and ethnic disparities. Community health centers, in general, are community-owned, nonprofit businesses that provide access to primary and preventive health care to underserved communities. Shi et al²⁴ analyzed data from the Bureau of Primary Health Care and found that disparities in birth outcomes were reduced at community health centers compared to outcomes in the general population.

	Interventions To Change the Process of Care at the Health-Care System Level

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Improved adherence to an evidence-based asthma clinical practice guidelines, such as the National Heart, Lung, and Blood Institute Guidelines for the Management of Asthma, may be a potentially powerful tool for reducing or eliminating such racial/ethnic disparities in asthma treatment. Clinical guidelines consist of strict, explicit recommendations that are based on symptoms, not race, ethnicity, socioeconomic status, or insurance coverage. Because such guidelines can be viewed as "colorblind," variations in provider guideline adherence by race and ethnicity may prove to be an excellent method for detecting and monitoring racial/ethnic and other disparities in asthma care.²⁵

In general, passive interventions (traditional continuing medical education, physician mailing) are unlikely to be useful in changing provider behavior. Multifaceted interventions are more likely to improve provider adherence to clinical practice guidelines. In addition, specific skills/training regarding patient/provider communication, utilizing direct feedback and audit may also be useful strategies for introducing new practice behaviors.²⁶

Quality improvement interventions to address disparities in other conditions provide an example of the potential of quality improvement interventions. For example, Wells et al²⁷ conducted a randomized controlled trial of quality improvement to address disparities in care for depression. Clinics were randomly assigned to usual care or to programs supporting quality improvement teams, provider training, nurse assessment, and patient education, plus additional resources to support medication management or psychotherapy for 6 to 12 months. Compared to control programs, the quality improvement programs for depressed primary care patients reduced health outcome disparities and unmet needs among Latinos and African Americans relative to white patients.²⁷ Quality improvement activity has also been shown to reduce race-related disparities with regard to hemodialysis.²⁸

Language barriers may also lead to poor exchange of information, inadequate treatment, and worse health-care outcomes. Language discordance between clinicians and patients has also been shown to be associated with worse continuity of care for asthma.³⁷ Errors in medical interpretation are more common when translation is provided by ad hoc interpreters. Furthermore, these errors are more likely to have important clinical consequences.²⁹

Health-care organizations that serve diverse populations should provide professional interpreter services. An alternative to ad hoc interpreters is the use of telephonic interpreters, which may be necessary for rarely encountered languages. However, these telephonic interpreters should not replace on-site, professional, medical interpretation services for commonly encountered languages. Professional interpreters have been shown to improve communication, clinical outcomes, satisfaction with care and decrease avoidable health-care utilization.³⁸

	Interventions To Change the Process of Care at the Interpersonal Level

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The creation of categories or stereotypes and the use of pattern recognition can be common subconscious strategies used to help simplify memorization and decision making.¹⁴ The use of these techniques is more likely to occur when there are time pressures or multiple tasks that needed to be accomplished simultaneously. However, the use of stereotyping is more likely to occur in relation to age, gender, and race, and may contribute to conscious or subconscious differences in how health-care providers treat different groups of patients, with possible implications for disparities in health-care outcomes. If the issues are not addressed, the effect of stereotyping may be exacerbated if the effect is bidirectional with patients responding to different providers in different ways.

Efforts to reduce stereotyping include social cognitive interventions or feedback. For example, Galinsky and Moskowitz³⁰ studied the impact of asking white study subjects to "imagine a day in the life of" a black person, and found that there was less implicit stereotyping. Other research suggests that offering feedback about racial disparities stimulates reexamination by providers regarding their therapeutic decisions. Although efficacious in controlled settings, these approaches have not been tested for effectiveness in health-care settings or for asthma care.³¹

Finally, improving patient education and patient empowerment may also be a useful intervention for addressing disparities in care. The National Heart, Lung, and Blood Institute guidelines³² recommend that clinicians teach patients these essential skills and integrate and reinforce patient education into clinical care. For all aspects of asthma care, patient education is the common pathway for patients to successfully manage their disease. Furthermore, systematic reviews suggest that patient education for asthma self-management is effective in improving objective measures of lung function, frequency of asthma symptoms, and health-care utilization.³³³⁴ If such programs are to be successful in addressing racial disparities, further research is needed regarding how to establish such patient programs in different communities with different cultures and customs.³⁵

	Summary and Future Directions for Research

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Research demonstrating the impact of quality-of-care interventions to reduce asthma health disparities is limited and may not generalizable. Cooper et al³⁶ note that,

important limitations of previous studies need to be addressed, including the lack of control groups, nonrandom assignment of subjects to experimental interventions, and use of health outcome measures that are not validated. Interventions might be improved by targeting high-risk populations, focusing on the most important contributing factors, including measures of appropriateness and quality of care and health outcomes, and prioritizing dissemination efforts.

There are multiple factors associated with racial and ethnic disparities in asthma care (Table 2 ). These factors include structural barriers (eg, ability to access the health-care system), process-of-care barriers (eg, ability to navigate the health-care system), and process-of-care barriers at the interpersonal level (eg, ability to work effectively with a health-care provider) for equitable, quality asthma care. There is a dearth of evidence regarding the most effective and efficient methods to address these factors, due to the lack of controlled evaluations of interventions. In addition to cross-disciplinary research (integrating medical, public health, and social sciences approaches), cooperation and coordination among private, public, and voluntary groups and stakeholders to evaluate current and proposed programs to address disparities will be needed.

At an organizational level, it is important to assess how specific initiatives (eg, cultural competency policies, application of CLAS, use of informatics to track racial disparities and provide feedback) can address disparities. Work is needed to determine how to best translate research and policy into actual provider practice. It is not clear which methods (eg, audit and feedback, use of opinion leaders, penalties, and incentives) are most useful to improve provider practice in this area. Furthermore, with the advent of pay-for-performance initiatives to health-care organizations and providers, it is unclear if such incentives will improve or exacerbate racial disparities in asthma care. At a health systems level, further work is needed to understand how medical care financing arrangements (eg, the distribution of health plans, coverage for pharmaceuticals and durable medical equipment) may or may not be contributing to racial and ethnic disparities in asthma care.

Further work is needed to understand how to attract and recruit a more diverse health-care workforce by creating a pipeline for minorities to enter the health professions. The wide range of strategies include the development of health profession-magnet high schools, health-related jobs, internships and volunteer programs for minority youth, college programs to assist minority applications to graduate health professional schools, as well as mentorship programs. These strategies and programs to promote health-related careers for students from the high school to postdoctoral levels need to be evaluated, and successful programs should be promoted. However, successful evaluation is challenging, given all the potential confounding factors affecting career choice and the long time horizon for evaluation.

Finally, as asthma is a multifactorial disease, interventions may require a far broader approach. For example, strategies to address disparities in asthma may also need to simultaneously address issues in education, day care, transportation, housing, and urban planning, among others.

	Footnotes

 
Abbreviations: CLAS = culturally and linguistically appropriate services; ED = emergency department

This work was funded, in part, by the National Institutes of Health (HL-70771).

The authors have no conflicts of interest to disclose.

Received for publication December 20, 2006. Accepted for publication August 2, 2007.

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This Article Abstract Full Text (PDF) Free Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Article Archive Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cabana, M. D. Articles by Shannon, J. Search for Related Content PubMed PubMed Citation Articles by Cabana, M. D. Articles by Shannon, J.