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An Action Agenda To Eliminate Asthma Disparities^*

Results From the Workgroups of the National Workshop to Eliminate Asthma Disparities

^* From the Institute for Healthcare Studies, Northwestern Feinberg School of Medicine, Chicago, IL.

Correspondence to: Kevin Weiss, MD, Institute for Healthcare Studies, 676 N St. Clair St, Suite 200, Chicago, IL 60611; e-mail: K-weiss{at}northwestern.edu

Key Words: action agenda • asthma • disparities • health policy • public health

	Introduction

TOP Introduction Epidemiology/Risk Factors Genetics and Molecular Sciences Environmental Impact Behavioral Health and... Health-Care Communications and... Health-Care Access, Delivery,... Role of Private Insurance... Inner-city Asthma and the... State and Local Policy

 
The objective of this workshop was to develop a parsimonious set of recommendations that can serve as "next steps" for the research, clinical, policy, and consumer communities to use in reducing asthma disparities. Workshop participants met in small groups and plenary discussion sessions structured around each theme to elicit actionable tasks thought to be instrumental in eliminating asthma disparities. Each group was asked to develop up to three actions. Reported below are the priority actions for each theme, as well as a brief description of the key task related to each action.

	Epidemiology/Risk Factors

TOP Introduction Epidemiology/Risk Factors Genetics and Molecular Sciences Environmental Impact Behavioral Health and... Health-Care Communications and... Health-Care Access, Delivery,... Role of Private Insurance... Inner-city Asthma and the... State and Local Policy

 
Critical Gap
It is necessary to increase the amount of local data on asthma risk factors and health-care use available to states and communities for public accountability. Using this data, efforts should be launched to improve asthma outcomes for high-risk communities.

Solution
Behavioral Risk Factor Surveillance System asthma modules should be enhanced, and methods should be developed so that communities can conduct local asthma surveys to guide community action. Also, the National Committee on Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations, and other performance measure developers should be involved to improve public reporting of asthma care at a community level. Examples of areas of reporting in need of improvement include community profile data and physician performance measurement data. Community profile data can be provided by private and public insurers that use the Health Employers Data Information Set, and physician performance measurement data are collected by regional coalition efforts such as the Massachusetts Health Quality Partnership.

Action Plan
The Centers for Disease Control and Prevention (CDC) should work with states and city health departments to engage health plans, both public (specifically Medicaid) and private. This activity might be advanced through state-supported asthma programs or more general regional health-care quality coalitions.

	Genetics and Molecular Sciences

TOP Introduction Epidemiology/Risk Factors Genetics and Molecular Sciences Environmental Impact Behavioral Health and... Health-Care Communications and... Health-Care Access, Delivery,... Role of Private Insurance... Inner-city Asthma and the... State and Local Policy

 
Critical Gap
There is a lack of policy related to the management of new information on complex traits in minority populations, with respect to ethical, legal, and social implications.

Solution
A policy report that attempts to define the ethics, legal, and social issues regarding the genetics of asthma should be developed, with particular emphasis on minority and culturally diverse populations.

Action Plan
The National Asthma Education Prevention Program (NAEPP) should urge the Institute of Medicine (alternatively a panel of the National Institutes of Health) to convene a working group to address these issues. Although this is a systemic issue, considering an asthma-specific set of solutions may be useful.

	Environmental Impact

TOP Introduction Epidemiology/Risk Factors Genetics and Molecular Sciences Environmental Impact Behavioral Health and... Health-Care Communications and... Health-Care Access, Delivery,... Role of Private Insurance... Inner-city Asthma and the... State and Local Policy

 
Critical Gap
There is a need to generalize and improve on Inner-city Asthma Study intervention.

Solution
A multisite demonstration project based on community capacity is needed to implement such a home-based program.

Action Plan
The CDC, US Environmental Protection Agency (EPA), Bureau of Maternal and Child Health, private foundations (such as the Robert Wood Johnson Foundation), private industry (eg, health insurance plans), and health-care payors (large employers) should be brought together for testing. Most importantly, it will be necessary to enlist Medicaid programs to move this plan forward.

	Behavioral Health and Family/Social Function

TOP Introduction Epidemiology/Risk Factors Genetics and Molecular Sciences Environmental Impact Behavioral Health and... Health-Care Communications and... Health-Care Access, Delivery,... Role of Private Insurance... Inner-city Asthma and the... State and Local Policy

 
Critical Gap
Minority and low-income populations may have low expectations for optimal asthma outcomes. Lack of community assets may negatively impact asthma outcomes.

Solution
A public awareness campaign for minority communities should be launched to change perceptions of optimal asthma outcomes, which are alternatively referred to as "asthma control" (eg, sleep throughout the night, active lifestyle, and patient empowerment).

Action Plan
Consumer organizations and professional organizations concerned with asthma control need to cooperate with health plans and with private industry firms (health insurance plans) or foundations. A set of common educational messages should be developed collaboratively around the new guidelines and integrated with public and private education efforts. A good example of this has been the recent national asthma campaign partnership between the EPA and the Ad Council. This could also be integrated into the dissemination plans for the updated asthma guidelines.

	Health-Care Communications and Cultural Competency

TOP Introduction Epidemiology/Risk Factors Genetics and Molecular Sciences Environmental Impact Behavioral Health and... Health-Care Communications and... Health-Care Access, Delivery,... Role of Private Insurance... Inner-city Asthma and the... State and Local Policy

 
Critical Gap
There is a lack of cultural competencies at many sites of asthma care.

Solution
A "toolkit" focused on cultural competency in asthma care should be developed on the basis of upcoming asthma guidelines. The toolkit would include training modules related to known common communication issues that interfere with guideline-based care. The toolkit would also include patient directed materials to support providers that care for culturally diverse populations.

Action Plan
Each key consumer or professional organization should begin to work with NAEPP as soon as possible in developing this toolkit.

	Health-Care Access, Delivery, and Quality of Care

TOP Introduction Epidemiology/Risk Factors Genetics and Molecular Sciences Environmental Impact Behavioral Health and... Health-Care Communications and... Health-Care Access, Delivery,... Role of Private Insurance... Inner-city Asthma and the... State and Local Policy

 
Critical Gap
Medicaid reimbursement is not supportive of preventive visits, self-management, and care coordination. New models of reimbursement based on newer models of long-term care delivery are needed.

Solution
Medicaid should modify reimbursement for asthma to be more responsive to evidence-based asthma management. Particularly, demonstration projects on new models of long-term care delivery are needed.

Action Plan
The NAEPP should convene leadership from several state Medicaid programs along with key asthma stakeholders to forge a partnership. The primary purpose of this partnership will be to develop plans for 1115 waivers (or the equivalent) to demonstrate new models of care. Ideally, this will happen in most of the states.

	Role of Private Insurance and Medicaid/State Children’s Health Insurance Program, and Safety Net Care Providers

TOP Introduction Epidemiology/Risk Factors Genetics and Molecular Sciences Environmental Impact Behavioral Health and... Health-Care Communications and... Health-Care Access, Delivery,... Role of Private Insurance... Inner-city Asthma and the... State and Local Policy

 
Critical Gap
Care for children in near poverty by means of State Children’s Health Insurance Program (SCHIP) programs and private insurers needs to be addressed more effectively.

Solution
SCHIP programs in 2007 should be reauthorized and expanded to provide accessible, affordable, quality asthma care and support for self-management training. This may require working with state policy leadership for reauthorization. Also, it will require working with health benefit managers to develop best practices in health benefit design for asthma care, particularly care for minority populations and persons of lower socioeconomic status.

Action Plan
Consumer groups focused on asthma and professional groups concerned with children with asthma should begin working to educate key members of health-care plan leadership. Partners in this effort might include state Medicaid programs or other SCHIP service providers.

	Inner-city Asthma and the Role of the Community

TOP Introduction Epidemiology/Risk Factors Genetics and Molecular Sciences Environmental Impact Behavioral Health and... Health-Care Communications and... Health-Care Access, Delivery,... Role of Private Insurance... Inner-city Asthma and the... State and Local Policy

 
Critical Gap
There is a lack of community infrastructure, trust, and empowerment with respect to asthma-care issues.

Solution
Asthma "chronic care empowerment zones" should be developed.

Action Plan
Program directors of relevant asthma programs should convene with the CDC, the EPA, leadership from a couple of State Health Departments, state social services programs (eg, the Department of Labor and Department of Education), and community leadership from high-risk inner-city neighborhoods. Testable models for community empowerment with respect to asthma should be developed, and public health or private funds to test models should be sought.

	State and Local Policy

TOP Introduction Epidemiology/Risk Factors Genetics and Molecular Sciences Environmental Impact Behavioral Health and... Health-Care Communications and... Health-Care Access, Delivery,... Role of Private Insurance... Inner-city Asthma and the... State and Local Policy

 
Critical Gap
Health plans vary in their benefit designs in ways that may negatively impact medication access and adherence, continuity of care, and preventative care, therefore creating barriers to access of specialty services. This variability in benefit design creates confusion for families with asthma, particularly vulnerable populations who are underinsured.

Solution
State-based legislation or policy that can be used to improve asthma-related health benefits for insured persons should be promoted.

Action Plan
In collaboration with other voluntary health organizations, leading insurers, state Medicaid program directors, and the American Lung Association should be enlisted to draft a series of model state bills to be introduced to improve asthma care in targeted communities. In addition, voluntary health organizations such as the American Lung Association, the Asthma and Allergy Foundation of American, and the Allergy and Asthma Network Mothers of Asthmatics should be enlisted to work with university-based policy researchers to develop model state and local policies aimed at eliminating asthma disparities. Voluntary health organizations could then use these model policies to educate state and local governments on best practices.

	Footnotes

 
Abbreviations: CDC = Centers for Disease Control and Prevention; EPA = Environmental Protection Agency; NAEPP = National Asthma Education Prevention Program; SCHIP = State Children’s Health Insurance Program

The author has no conflict of interest to disclose.

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

This article has been cited by other articles:

				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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