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Interventions to Improve Outcomes for Minority Adultswith Asthma: A Systematic Review
Valerie G. Press, MD, MPH1, Andrea A. Pappalardo, MD2, Walter D. Conwell, MD3,Amber T. Pincavage, MD4, Meryl H. Prochaska, BA5, and Vineet M. Arora, MD, MAPP4
1Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA; 2Comer Children’s Hospital, Department ofPediatrics, University of Chicago, Chicago, IL, USA; 3Division of Pulmonary/Critical Care, Department of Medicine, University of Colorado,Denver, CO, USA; 4Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA; 5School of Law,Loyola University Chicago, Chicago, IL, USA.
OBJECTIVES: To systematically review the literature tocharacterize interventions with potential to improveoutcomes for minority patients with asthma.DATA SOURCES: Medline, PsycINFO, CINAHL,Cochrane Trial Databases, expert review, referencereview, meeting abstracts.STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, ANDINTEVENTIONS: Medical Subject Heading (MeSH)terms related to asthma were combined with terms toidentify intervention studies focused on minority pop-ulations. Inclusion criteria: adult population; interven-tion studies with majority of non-White participants.STUDY APPRAISAL AND SYNTHESIS OF METHODS:Study quality was assessed using Downs and Black(DB) checklists. We examined heterogeneity of studiesthrough comparing study population, study design,intervention characteristics, and outcomes.RESULTS: Twenty-four articles met inclusion criteria.Mean quality score was 21.0. Study populations targetedprimarily African American (n=14), followed by Latino/a(n=4), Asian Americans (n=1), or a combination of theabove (n=5). The most commonly reported post-inter-vention outcome was use of health care resources,followed by symptom control and self-managementskills. The most common intervention-type studied waspatient education. Although less-than half were cultur-ally tailored, language-appropriate education appearedparticularly successful. Several system–level interven-tions focused on specialty clinics with promising find-ings, although health disparities collaboratives did nothave similarly promising results.LIMITATIONS: Publication bias may limit our findings;we were unable to perform a meta-analysis limiting thereview’s quantitative evaluation.CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS:Overall, education delivered by health care professionalsappeared effective in improving outcomes for minoritypatients with asthma. Few were culturally tailored andone included a comparison group, limiting the conclu-sions that can be drawn from cultural tailoring. System-redesign showed great promise, particularly the use ofteam-based specialty clinics and long-term follow-upafter acute care visits. Future research should evaluatethe role of tailoring educational strategies, focus on
patient-centered education, and incorporate outpatientfollow-up and/or a team-based approach.
KEY WORDS: asthma; disparities; interventions; culturally tailored.
J Gen Intern Med 27(8):1001–15
DOI: 10.1007/s11606-012-2058-9
© Society of General Internal Medicine 2012
INTRODUCTION
Despite increasing national efforts over several decades, healthdisparities are widening for numerous illnesses and chronicdiseases. The Healthy People initiative began in 1979 with theSurgeon General’s Report, followed by Healthy People 2000and 2010, with Healthy People 2020 currently underdevelopment.1 Although the goal of Healthy People 2010was to challenge “individuals, communities, and professio-nals…to take specific steps to ensure that good health, as wellas long life, are enjoyed by all,”1 this need has not been metfor minority patients with asthma in the United States (US).Currently, almost 20 million Americans have asthma, and
by the year 2020, asthma is expected to affect 1-in-14Americans.2 Asthma is responsible for a substantial propor-tion of health care utilization, including outpatient visits(over 10 million),3 emergency department (ED) visits (over1.5 million)4 and hospitalizations (over 400,000 annually)nationally.5 This care is costly, with greater than $30 billionspent annually in the US.6 Besides direct costs of treatingasthma, missed work days are also non-trivial, with greaterthan 14 million days missed annually.7
Minority patients, however, assume a greater proportionof burden from asthma. African Americans with asthmasuffer greater morbidity and mortality, with higher ratescompared to whites of ED visits (350 %), hospitalizations(240 %), and mortality (200 %).7 Also, within ethnicpopulations, disparities exist. For instance, the Puerto Ricanpopulation has higher prevalence than any other racial orethnic group, including African Americans.7,8 Canino et al.has attributed the root cause of these disparities to amultitude of factors, including individual, environmental,
1001
provider and health system components that may all play aninter-related role.9
It has been well documented that a disproportionate numberof minority patients have low health literacy, placing them athigher risk for poor health outcomes.1 Further, environmentalfactors, such as neighborhood context, pollution and aller-gens have also been implicated.9 At the provider and healthcare system-levels, access to care, provider beliefs, andcultural sensitivity may all play a role. All of these inter-related components are also affected by the policy context inwhich they exist. For instance, patient-centered medicalhomes (PCMH) have been a recent area of interest by bothpolicy makers and medical professionals and may play anincreasingly important role in addressing disparities.10
Because of the multitude of factors that may play a role inperpetuating health disparities for minority patients withasthma, it is important to critically evaluate the scope andtarget of interventions that aim to improve care for thispopulation. Although hundreds of studies have evaluatedindividual components of asthma management includingeducational and system-level approaches to improving healthoutcomes related to asthma, there is a dearth of studies that areculturally tailored, or that even include a majority of non-White study participants. Through a systematic review of whatlimited literature exists, clinicians, health care organizations,communities, patients, and policymakers can understandwhich interventions are likely to be successful in addressingand decreasing health disparities and will identify what gapsremain for future work in this area. Therefore, the aim of thisreview is to systematically review the literature to answer thefollowing question: what interventions work best to improveoutcomes for minority adult Americans with asthma?
METHODS
Initial Search
In consultation with a biomedical librarian, we conducted anelectronic search of the English literature in Medline from1950 to Fall 2010 by exploding Medical Subject Heading(MeSH) terms related to asthma (e.g., respiratory inhalers,anti-asthmatic agents) combined with terms to identify studiesfocused on minority populations (e.g. MeSH “MinorityGroups” and keyword “dispari*mp”) and with terms toidentify intervention studies. [Text Box 1] Please refer to thetechnical web appendix in the introductory paper by Chin etal. for recommended search strategies for interventions toreduce racial and ethnic disparities in health care.11 Weconducted parallel searches in PsycINFO and CINAHL. Toidentify additional studies that may not have been included inthese search results, we reviewed the Cochrane database ofinterventions and all references from included studies. Finally,an expert reviewer evaluated the included references to ensurekey articles were not inadvertently missed. To explorepublication bias, we reviewed meeting abstracts from 2009
and 2010: American Thoracic Society, American Academy ofAllergy, Asthma and Immunology, and the Society of GeneralInternal Medicine, for studies that may not have yet beenpublished or were not published due to negative findings.
Text Box 1: Medline search strategy
Inclusion criteria were: 1) adult population (age 18 or older);2) intervention studies with greater than 50 % minorityparticipants or with a subset analysis of minority patients byrace/ethnicity were included; and 3) intervention studiesaffiliated with a health care delivery setting (i.e., outpatientclinic, ED, hospital). We limited our search to adultpopulations because the Finding Answers program haspreviously published on interventions to address disparitiesfor care of minority children with asthma.12 While communityinterventions are an important part of an overall disparitiesreduction strategy, the current paper focuses on interventionsthat occur in or have a sustained linkage to a health caredelivery setting. Only studies that took place in the UnitedStates and published in English language were included. Allstudy designs were included.
Article Selection
Following the initial searches, duplicates were eliminatedand a title and abstract review was performed whereby each
1002 Press et al.: Minority Patients with Asthma: A Systematic Review JGIM
article was independently reviewed for exclusion by two co-authors (authors VGP, VMA, AAP, WDC, AAP). Articleswere excluded based on title and abstract review if thearticle focused on a topic other than asthma, did not includeadult patients, was not an intervention-based study, did nothave a focus on, or inclusion of, minority patients, or didnot have an affiliation with a health care delivery setting.For any titles or abstracts that were unclear, the authorserred on the side of including for full article review. Thistitle/abstract review was followed by an article extractionreview. To ensure reviewers were consistent across articleextraction, all reviewers participated in a training process.Two articles were then selected at random and werereviewed by all reviewers to ensure the training wassuccessful and definitions were being applied appropriately.All discrepancies were resolved by consensus. Followingthis training, all articles were extracted onto a uniformextraction form first by one author (AAP, WDC, ATP, orVGP), with all articles then undergoing a second indepen-dent extraction by a different author for verification (VMA,VGP, or MHP); a weighted k was calculated to determineinter-rater agreement. The standardized extraction formfocused on identifying the following elements for eachstudy: intervention type (education-based or system-level),study design (RCT, Pre/Post, Cohort, Case control), studypopulation (White, African American, Latino/a, Asian,American Indian, other), setting (community [if linked toa health care delivery setting], outpatient, inpatient), thestudies’ outcome measures, the assigned study quality score(DB score).
Data Analysis and Synthesis. Authors examinedheterogeneity of studies qualitatively through comparingstudy population, study design, intervention characteristics(setting, target), and outcomes.13 Then the studies werebroken down into education-based or systems-levelinterventions. The education-based studies were identifiedas culturally tailored education (CTE) if either the authorsof the study being reviewed self-defined their interventionas culturally tailored, or our review of the interventionindicated that it had at least one foci of cultural tailoring(language appropriate education or use of focus groups forthe target population in the development of theintervention). A structured data abstraction form inMicrosoft Access facilitated collection of these dataelements. Any articles not meeting inclusion criteria wereexcluded. Added to the final included studies were thosemeeting inclusion criteria found from reference mining,meeting review and expert opinion.
Quality and Bias Assessment
This review conforms to the Preferred Reporting Items forSystematic Reviews and Meta-Analyses (PRISMA) standards.
However, because the interventions and outcomes evaluatedby, and reported on, in the included studies in this reviewvaried and did not have a unified methodology or healthoutcome, our systematic review did not meet current guide-lines for submission to a systematic review protocol registry.14
To assess study quality, the previously validated Downs andBlack (DB) checklist was used.15 The original DB score iscalculated by rating each study across a variety of domainsincluding external validity (3 items), bias (7 items), con-founding (6 items), and power (1 item). Instead of using afive-point range for scoring the power item,15 we simplifiedthe scoring to a binary system of granting a point (1) foradequate power calculations, or no points (0) if power wasnot adequately addressed. Additionally, we have added oneitem from the Cochrane tool for bias16 that was not capturedwith the DB tool, for a total maximum modified DB score of29.15 The average DB quality score (out of a maximum of 27points; they did not include the power item or additional biasitem) from a prior set of systematic reviews performed by theFinding Answers team is 17.65 (213 studies total).17 Theinter-rater agreement for data abstraction using the modifiedDB tool was adequate (k=0.67).18 To describe the risk ofmethodological bias for each study, the Cochrane Collabo-ration tool was used, and was captured in the overallmodified DB quality score as above.16 We used the DBscore, rather than other methods for assessing quality, for thefollowing reasons. First, this tool was used in the priorsystematic reviews of health disparities interventions by theFinding Answers team.17 Therefore, the benefit of using itfor our review is to have a benchmark by which to comparethe DB quality scores for studies in our review across otherreviews in this supplement and to prior large systematicreviews of health disparities interventions. Second, the DBchecklist is particularly useful for intervention studies as itassesses the quality of the study method for both RCTs andnon-randomized designs. Finally, it also provides an over-view of the paper, highlighting the strengths and weakness ofeach study.15
RESULTS
From 1637 studies, 24 were eligible for review (Figure 1).Excluded studies did not study asthma (n=821), were notintervention-based (n=526), not an adult population (n=119),not US-based (n=83), did not have sufficient minoritypopulation (n=22), were pharmacologic-based (n=16), dupli-cates (n=14) or were not affiliated with a health care setting(n=12). Meeting abstracts were reviewed (n=1219); three metinclusion criteria, none resulted in mansucripts.19–21 Ulti-mately, 15 educational22–36 and 9 system-level studies wereincluded.37–45 (Table 1) The education-based interventionsprimarily targeted patients while the system-level interventionstargeted providers and/or health systems.
1003Press et al.: Minority Patients with Asthma: A Systematic ReviewJGIM
Study Quality
Study quality ranged from 12 to 26, with a mean of 21.0.Using a previously published categorization of DB scores,46
16 (67 %) were in the very good range (≥20), 6 (25 %) in
the good range (15–19), 2 (8 %) in the fair range (10–14),and none (0 %) were rated as poor (<10). The tenrandomized clinical trials were the most highly rated (range16–26, mean 22.1), following by the six pre/post designstudies (range 17–24, mean 21.7), the two case-control
Total Title/Abstracts Reviewed
1637
Medline 984 PsycINFO 438 CINAHL 215
Articles Included
24 Medline 18 PsycINFO 0 CINAHL 1 Other 5
Education
15
Culturally tailored Education: 5
Systems Interventions
9
Specialty clinics 4
Community health center collaborative 2
Articles identified in other ways
5 Cochrane 0 Review of
Reference/Review articles: 4
Expert review: 1 Abstract review: 0
Excluded (1613)
Not Asthma: 821 Not Intervention: 526
Not Adults: 119 Non-US:83
Did not meet minority criteria: 22
Pharmacologic study: 16
Duplicate: 14 Not affiliated with
health care center: 12
Figure 1. Flow diagram.
1004 Press et al.: Minority Patients with Asthma: A Systematic Review JGIM
Tab
le1.
AsthmaIntervention
san
dOutcom
es
Reference
Design
Setting
N,Pop
ulation
%Intervention
Typ
eLengthof
Followup
Outcom
esResults
Quality
score
Martin
2009
24
RCTa
Cb
42;AAc10
0%
African
American
adultsrecruitedfrom
prim
arycare
clinicsreceived
4grou
peducationalsessions
ledby
acommun
itysocial
workeralon
gwith
6ho
mevisitsby
commun
ityhealth
workers;education
includ
edgeneralasthmainform
ation,
medicationinform
ationinclud
ing
controllermedication,
inhalertechniqu
e,andspacer
use,
andsymptom
mon
itoring
andavoidance[trigg
ers].Tho
sein
the
controlgrou
pweremailedasthma
educationmaterials.
CTEd
6mon
ths
SFe
NSi :daytim
esymptom
s;no
cturnal
symptom
s24
SM
fNS:Receipt
ofactio
nplansfrom
doctor:
trendtowardsigat
3mon
ths;NSat
6mon
ths
NS:inhaledcorticosteroid
use;
useof
aspacer
A-Q
OLg
12%
absoluteim
prov
ement(4.2
vs.3
.7,
p=0.00
2)in
interventio
ngrou
pat
6mon
thfollo
w-up
Kh
NS:Asthm
akn
owledg
e
Sob
el20
0923
Pre/Po
stC
130;
AA
100%
Ahealth
literacyfocusededucationalp
rogram
thatrecruitedparticipantsfrom
aninternal
medicineclinic,churchor
adulteducatio
ncenter,w
howereprovided
aneducational
videoto
prom
oteself-careconcepts
includingbasicasthmainform
ation,
avoiding
triggers,m
edicationeducationand
self-m
onito
ring
ofcontrol,vialaptop.
CTE
Immediately
post
interventio
n
K>60
%absolute
increase
inmean
posttestkn
owledg
escore(4.2
to6.8,
p<0.00
1)
17
Odegard
2004
26
Pre/Post
C,Oj
32;SAk10
0%
Pharm
acistsor
pharmacystud
entsprov
ided
oral
andwritteneducationin
the
participants’prim
arylang
uage,usingin-
person
,grou
psessions
that
includ
edvideotapes
andwritteninform
ationon
pathop
hysiolog
y,triggers,therapies,inh
aler
techniqu
e,anduseof
PFM
l s.
CTE
6mon
ths
Um
78%
absolute
decrease
inmeanclinic
visitsdecreased(1.8
to0.4,
p<0.00
1)from
6mon
thspriorto
6mon
thspo
stinterventio
n
22
SF
73%
absolute
decrease
inMean#
asthmaattacks(3.7
to1.0,
p<0.00
1)and79
%decrease
inno
cturnal
symptom
s(1.4
to0.3,
p<0.00
1)SM
44%
absolute
increase
inuseof
cham
bers
(22to
56%;p<0.00
1)and
41%
PFM
use(3
to44
%,p<0.00
2)Tatis 2005
25
Coh
ort
O19
8;Ln91
%Patientswereseen
byaspecialist
(pulmonologisto
rallergist)andwere
provided
care
andeducationfirstb
ythe
physicianfollo
wed
byareview
with
atrained
asthmaeducator
usinglung
modelsto
teach
aboutairway
inflam
mation,controller
therapy,inhalertechnique
andtriggercontrol;
bookletsatthe3rdgradereadinglevelwere
provided
inEnglishor
Spanish;interventio
ngroupcomparedto
matched
controls.
CTE
6mon
ths
U28
%absolute
redu
ctionin
EDpvisits
(from
3.9to
2.8,
p=0.00
05);41
%redu
ctionin
hospitaladmission
(from
1.65
to0.97
,p<0.00
1)in
interventio
ngrou
p(interventiongrou
phadhigh
erstartin
gED
visitsthan
matched
controlsby
gend
erandagewith
in10
yearswho
declined
theinterventio
n)
18
QOLo
20%
absolute
improv
ement(for
those
who
completed
four
questio
nnaires)
KNS:Asthm
akn
owledg
eGalbreath
2008
29
RCT
C,O
429;
L51
%,W
r
31%,A
A/other,
18%
Telephonediseasemanagem
ent(6–7calls)
[DM]thatprovided
individualized
education
andan
actionplan
bytrainedrespiratory
nurses;and
[ADM]–thatalsoincluded
telephoneplus
4homevisitsfrom
respiratory
therapistswho
provided
hands-on
equipm
ent
instructionandahome-environm
ent
evaluation;
comparedto
traditionalcare.
Es
1year
UNS:urgent
office
visits;ED
visits;
Inpatient
admission
s24
SF
NS:tim
eto
firstevent
A-Q
OL
14%
absolute
improv
ementin
ADM
t
(4.2
to4.9,
p=0.04
)
1005Press et al.: Minority Patients with Asthma: A Systematic ReviewJGIM
Table
1.(c
ontinue
d)
Reference
Design
Setting
N,Pop
ulation
%Intervention
Typ
eLengthof
Followup
Outcom
esResults
Quality
score
Stiegler
2003
31
Pre/Post
O,I
17;AA
100%
Pharm
acistprov
ided
30minuteintensive
coun
selin
gon
asthmainform
ation,
triggers,
PFM,medications,inhalerandspacer
use
andside
effectsof
therapy,
forpatients
hospitalized
with
acuteexacerbatio
nsof
asthma,
follo
wed
byou
tpatient
teleph
one
follo
w-upat
1weekpo
stdischargeto
reinforceeducationandansw
erqu
estio
nsand5weeks
postdischargeto
reinforce
educationandassess
adherence
E6mon
ths
U78
%absolute
decrease
inho
spital
admission
sandED
visits(from
1.58
to0.35
,p=0.00
16)
24
SM
41%
absolute
improv
ementin
medicationrefill(from
22%
to63
%,
p=0.01
75)
George
1999
30
RCT
O,I
77;AA
Majority
Inpatient
educationby
anasthmanu
rse
educator
ondiseaseinform
ation,
medication
inform
ation,
inhalertechniqu
e,symptom
mon
itoring
andan
actio
nplan,bedside
spirom
etry;aph
onecall24
hoursafter
dischargeto
answ
erqu
estio
nson
discharge
instructions,medicationandasthma
symptom
s;follo
w-upin
anasthmaprog
ram
in1weekpo
stdischargeforspirom
etry,
physicianvisitandasthmanu
rseeducation
toreinforcetheho
spital-basededucation;
controlsweregivenusualcare.
E1week
U89
%relativ
edecrease
inED
visitsand
88%
relativ
edecrease
inho
spital
admission
sin
interventio
n(27to
3,p=
0.04
;26
to3,
p=0.04
)vs.control(17
to15
,NS;14
to12
,NS)
22
LOSu:NS
Castro
2003
32
RCT
O,I
96;AA
78–8
6%
Multi-facetededucationalprog
ram
includ
ing
review
ofregimen,adaily
‘asthm
acare’
flow
sheet,educationtailo
redto
patient
prov
ided
byasthmanu
rsespecialist,
psycho
social
supp
ort,individu
alized
self-
managem
entplan,dischargeplanning
and
outpatient
follo
w-upwith
phon
econtact,
homevisitsandph
ysicianfollo
w-up
appo
intm
entsas
needed.
E6mon
ths
U50
%fewer
hospitalre-adm
ission
s(21
interventio
n;42
control,p=0.04
)and
61%
relativ
edecrease
inLOS(53
total,1.1perpatient
interventio
n;12
9total,2.8perpatient
control;p=0.04
)
24
NS:health
care
prov
ider
visits
A-Q
OL
33%
relativ
eincrease
ininterventio
ngrou
p(2.7
to4.02
;p<0.00
1)and30
%relativ
eincrease
incontrolgrou
p(2.74
to3.9;
p<0.00
1)Blix
en22
RCT
Iq28
;AA
100%
Anu
rse-runasthmaeducationprog
ram
that
prov
ided
31-ho
urindividu
aleducationalsessions
onasthmaself-
managem
entutilizingapreviously
validatedworkb
ookandavideoon
MDItechniqu
eandPFM;controlgrou
preceived
usualcare.
CTE
6mon
ths
A-Q
OL
NS:difference
inasthmaQOLbetween
interventio
nandcontrolat
3or
6mon
ths
25
Press
VG
2011
33
Pre/
Post
I10
0;Non
white
(AA,AIv,ANw,
PIx)89
%
Teach-to-Goalstrategy
provided
byresearch
staffusingcycles
ofassessmentand
demonstrationtoinstructhospitalized
patients
onuseof
MDI's
yandDiskus®
devices.
EIm
mediate
posteducation
SM
100%
mastery
ofMDIandDisku
s®techniqu
ewith
atmost2roun
ds21
Paasche-
Orlow
2005
27
Coh
ort
I73
;AA
84%
One-on-on
e,30
minute,
guideline-based,
writtenandoral
instructions
abou
tasthma
dischargeregimen
andMDItechniqu
eprov
ided
byresearch
assistants.
E2weeks
SM
100%
mastery
ofMDItechniqu
ewith
atmost3roun
dsin
theho
spital
18
21%
absolute
improv
ementin
mean
MDItechniqu
escoreat
follo
w-upvisit
comparedto
dischargevisit(3.8
to4.8,
p<0.00
1)
1006 Press et al.: Minority Patients with Asthma: A Systematic Review JGIM
Table
1.(c
ontinue
d)
Reference
Design
Setting
N,Pop
ulation
%Intervention
Typ
eLengthof
Followup
Outcom
esResults
Quality
score
Ford
1997
28
RCT
I(ED)
537;
AA
72%,
W27
%,Other
1%
The
interventio
ngroupattended
3sm
allgroup
educationsessions
inEDby
health
care
professional,ondisease,complianceand
self-care;thosewho
didnotattend
received
thematerialsinthemail.Those
inthecontrol
groupdidnotreceive
education.
E12
mon
ths
UNS:ED
visits/yearby
race
26SF
NS:differentialeffect
ofinterventio
nby
race
onchange
inlim
itedactiv
itydays
dueto
asthma
KNS:differentialeffect
onkn
owledg
eof
interventio
nby
race
Kelso,
1995
36
Case
Con
tol
I(ED)
52,AA
100%
1-hour
educationsessioninEDby
unspecified
educators(presumablyresearch
staff)on
disease,triggersandself-m
anagem
entw
ithinhalertechniqueinstruction(with
spacer);
PFMswereprovided
with
demonstration;
1wkf/uappt
atfree
clinic.
E1year
U41
%absolutereductionin
EDvisits(4.4
to2.6,p<0.01)and62
%in
hospital
admissions(1.3
to0.5[62%]p<0.01),
forinterventio
ngroup;
NScontrolgroup
19
Bolton
1991
35
Coh
ort
I(ED)
241;
NW
69%,
W31
%The
interventio
ngroupreceived
usualcare
plus
threein-personeducationalg
roup
sessions
over
anunspecifiedtim
e-period,
provided
byan
asthmanurseeducator
onbasicasthmapathophysiologyandself-
mangementinformation(1
stsession);
pharmacologyandinhelrtechnique(2
nd
session);avoidanceof
triggers
(3rdsession).
E12
mon
ths
U59
%absolute
deceased
ED
visitsfor
interventio
ngrou
p(16per10
0person
s)comparedto
controlg
roup
(39
per10
0person
s)in
12mon
thsof
follo
wup
(p=0.00
05);strong
estdu
ring
first4mon
ths(68vs.22
0per10
0person
s;p=0.00
3),bu
tno
tas
strong
during
last4mon
ths(69vs.9
8per10
0person
s;NS)
23
NS:Hospitaladmission
s;consultatio
nswith
health
profession
als:no
dif
SF
30%
fewer
days
oflim
itedactiv
itydu
eto
asthmain
interventio
nvs.control
(622
vs.88
8,p=0.03
)in
first4and
averaged
over
all12
mon
ths(161
vs.
246,
p=0.04
),no
tin
thelast4mon
ths
(939
vs.63
3,NS)
Maiman
1979
34
RCT
I(ED)
245;
AA
92%,
Non
-AA
8%
Asthm
anurseprovided
educationon
preventio
nandcontrolo
fexacerbatio
ns,
medicationcomplianceandself-efficacy
follo
wed
bya6weeks
post-EDdischarge
phonecallto
reinforceED-based
education
E6mon
ths
U20
%relativ
edifference
inpercentage
ofpatientswith
nofurtherEDvisitsin
the
interventio
ngrou
p(asthm
atic
nurse
educationwith
book
let)comparedto
thosein
thecontrolgrou
p(ED
nurse)
(82vs.66
%,p<0.05
)
16
Hicks
2010
40
Pre/Post
O38
87;W
38.4
%,
AA
22.4
%,L
25.8
%,Other
13.4
%
Health
DisparitiesCollabo
rativ
edeveloped
toim
prov
ethecare
ofpatientswith
chronicdiseases
includ
ingasthmaby
dissem
inatingqu
ality
improv
ement
techniqu
esdevelopedby
theInstitu
tefor
Health
care
Improv
ement.
Sz
1year
QOL
NS:qu
ality
improv
ementscore
22M
13%
absolute
improv
ementin
disparity
score(39.3to
45.4,p<0.05
)
Lando
n20
0741
Pre/
Post
O33
92;W
41.4
%,
AA
21.3
%,L
23.7
%,Other
13.7
%
Health
DisparitiesCollabo
rativ
edeveloped
toim
prov
ethecare
ofpatientswith
chronicdiseases
includ
ingasthmaby
dissem
inatingqu
ality
improv
ement
techniqu
esdevelopedby
theInstitu
tefor
Health
care
Improv
ement.
S1year
SM
70%
absolute
increase
inuseof
asthma
managem
entplan
(from
8to
27%,
p<0.00
1)
24
QOL
25%
absolute
increase
inscore(from
38.7
to51
.7,p<0.00
1)
1007Press et al.: Minority Patients with Asthma: A Systematic ReviewJGIM
Table
1.(c
ontinue
d)
Reference
Design
Setting
N,Pop
ulation
%Intervention
Typ
eLengthof
Followup
Outcom
esResults
Quality
score
Keslo
1996
44
RCT
O39;W
39.7%,
AA31.8
%,L
17.1%,O
ther
25.7%
Com
prehensive
long
-term
managem
ent
prog
ram
ataun
iversity-based
clinic
with
a1-hou
rph
armacistprov
ided
education
ontriggercontrol,PFM
use,
asthma
educationandmedication;
tailored
pharmacolog
ictreatm
entand
emph
asis
onthepartnershipbetw
eenclinic
and
patient.
S2years
U74
%absolutedecrease
inEDvisitsin
interventiongroup(2.3to
0.6,p=
0.0001);notin
controlgroup(2.6
to2.0,
NS)
16
83%
absolute
decrease
inho
spital
admissionsforinterventio
ngroup(from
0.6to0.1;p=0.002)
and54
%in
control
group(from
1.3to
0.6;
p=0.004)
SF
39%
absolute
improv
ementforsleep
loss
score(3.50to
2.13
,p=0.00
)and
44%
fornigh
tsaw
akened
(4.28to
2.44
,p=0.01
)SM
48%
absolute
improv
ementin
inhaler
techniqu
e(52to
100%);
86%
increaseduseof
spacer
device
(14to
100%);
100%
increaseduseof
homePFMs(0
to10
0%);
52%
increaseduseof
dailyIC
Sβ(48to
100%)
QOL
Significant
absolute
improv
ementsfor6
of8do
mains
(allexcept
physical
functio
nandbo
dily
pain),change
from
baselin
eto
2years:
23%
forhealth
perception
(44.86
to57
.99,
p=0.04
);98
%forph
ysical
limitations
(11.53
to63
.81,
p=0.00
);47
%forem
otionallimitations
(42.22
to80
,p=0.01
);32
%forsocial
function
ing(55.81
to82
.50,
p=0.00
);20
%formentalhealth
(62.57
to78
.29,
p=0.4);and49
%forenergy
/fatigu
e(38.75
to61
.85,
p=0.2)
A-Q
OL
23–4
2%
decrease
inscores
forthe
asthmabo
ther
profileforthe12
of15
statisticallysign
ificantdo
mains
(NS:em
baressmentof
taking
asthma
medication;
worry
abou
tasthma
attack
innew
place;
worry
catch
acold)
K10
0%
improv
ementin
asthma
know
ledg
ewith
regard
todifference
inICSandbeta
agon
ist(0
to10
0%)and
self-m
anagem
entandcrisisprednisone
(0to
100%)
1008 Press et al.: Minority Patients with Asthma: A Systematic Review JGIM
Table
1.(c
ontinue
d)
Reference
Design
Setting
N,Pop
ulation
%Intervention
Typ
eLengthof
Followup
Outcom
esResults
Quality
score
Pauley
1995
45
Case
Con
trol
O25
;AA
76%
Participantsattend
edaspecialasthma
clinic
that
prov
ided
grou
p-based
educationabou
tasthmatriggers
and
prop
eruseof
asthmamedications,
teleph
onecontactwithph
armacistand
anop
en-doo
rclinic
policy.
S6mon
ths
U87
%relativ
edecrease
inmeanper
patient
ED
visit(1.88to
0.24
,p=
0.00
6)whencomparing
controlperiod
tothestud
yperiod
(1year
interval
betweenthetwo)
21
Sperber
1995
42
Coh
ort
O84
;PRaa48
%,
M/C
bb27
%,A
A24
%
All
patients
inon
eclinic
referred
toasthmaspecialist
(allergist/
immun
olog
ist);thosewho
wentwere
“interventiongrou
p”andreceived
educationon
useof
inhalers,triggers,
PFM
use;
controlgrou
pwas
seen
bygeneralpractition
er.
S2years
U63
%relative
decrease
inclinic
walk-
invisits
(73vs.27
,p<
0.00
1),83
%fewer
ED
visits
(30
vs.5,p<0.00
1)and88
%fewer
hospital
admission
s(16vs.2,
p<
0.00
1)in
theintervention
grou
pcomparedto
theno
n-intervention
grou
p;NSchangesexcept
for68
%increasedED
visits
(7vs.22
,p<0.05
)
12
Mayo
1990
43
RCT
O10
4;L80
%,AA
15%,W
4%
Anintensivetreatm
entprog
ram
consisting
oftw
o1-
hour
clinic
visits
onpathop
hysicology
andself-
managem
entstrategies,follow
edby
asneeded
½ho
urfollow
-upvisits
prov
ided
byph
ysicianor
nursepractition
erwas
comparedto
routineclinic,forpatients
withmultiplepriorho
spitalizations
for
asthmaexacerbation
s.
S32
mon
ths
U67
%absolute
decrease
inho
spital
readmission
s(0.4
vs.1.2per
patient,p=<0.00
4)and54
%shorterLOS(3.1
perpatient
days
vs6.7;
p<0.02
)
22
Mayo
1996
39
Coh
ort
O,I
126;
L79
%,W
10%
AA
9%
Ateam
intervention
whereby
hospitalized
patients
who
didno
thave
aprivateph
ysicianwereevaluated
andtaug
htpathop
hysiolog
y,MDI
techniqu
e,andspacer
and
PFM
use,
byanu
rse;
housestaff
andattend
ingwerealso
taug
ht.The
nurseprov
ided
one-on
-one
education
andleft
adetailed
note
forho
usestaff
team
.Atdischarge,
patientwas
prov
ided
aon
e-weekfollow
-up
appo
intm
ent.
SHospital
Discharge
U17
%absolutedecrease
inLOS(4.8
to4,
p<0.00
1)23
NS:Hospitalreadmission
SM
36%
increasedPFM
byresidents(42to
77%,p<0.00
1)and55
%increased
useof
spacersby
patients(38to
85%,
p<0.00
1)K
57%
increasedpatient
education(31to
72%,p<0.00
1)and34
%increased
resident
education(0
to34
%,
p<0.00
1)
Akerm
an19
9938
Coh
ort
I(ED)
200;
AA
88%,L
8%,W
0.7%,
Other
3.3%
Acontinuo
usqu
alityim
prov
ementproject
toim
prov
easthmacare
andou
tcom
esin
aninner-city
ED
implem
enting
asthma
treatm
entgu
idelines.
S2years
U20
%absolute
decrease
ofadmission
s(4.85to
3.90
per10
0ED
visits,
p<0.05
)
14
SF
36%
decrease
inrelapse(from
12.18to
7.83
,p<0.00
1)
1009Press et al.: Minority Patients with Asthma: A Systematic ReviewJGIM
Table
1.(c
ontinue
d)
Reference
Design
Setting
N,Pop
ulation
%Intervention
Typ
eLengthof
Followup
Outcom
esResults
Quality
score
Ryd
man
1998
37
RCT
I(ED)
113;
AA
74%,
Other
74%
Patientsrecruitedfrom
ED
after3ho
ursof
therapythen
rand
omized
toEDob
servation
unitor
controlgrou
pwhich
received
inpatient
admission
.
S8weeks
SF
NS:PEFRcc;Relapse
22QOL
sign
ificantim
prov
ementfor5of
8do
mains
(interventionvs.control):
19%
physical
functio
n(72vs.58
,p=
0.011);42
%em
otionalfunctio
nrole
(78vs.45
,p=0.00
1);15
%social
functio
n(80vs.68
,p=0.02
1);14%
mentalhealth
(78vs.67
,p=0.00
8);
20%
vitality(59vs.4
7,p=0.01
6);N
S:
physical
functio
ning
role,bo
dily
pain,
generalhealth
perceptio
ns
aRCT:
Ran
domized
Con
trolledTrial
bC:Com
mun
ityc AA:African
American
dCTE:Culturally
Tailo
redEdu
catio
ne SF:Symptom
frequency
f SM:Self-man
agem
entbeha
viors
gAQOL:Asthm
a-relatedQOL
hK:Kno
wledg
ei NS:
Not
sign
ificant
j O:Outpa
tient
k SA:So
uthAsian
l PFM:PeakFlowMeter
mU:Health
care
utilizatio
nnL:Latino
oQOL:Qua
lityof
Life
pED:EmergencyDepartment
qI:Inpa
tient
r W:White
s E:Edu
catio
nt ADM:Aug
mentDisease
Man
agem
ent
uLOS:
Lengthof
Stay
v AI:American
Indian
wAN:Alaskan
Native
x PI:PacificIsland
ery M
DI:Metered-D
oseInha
ler
z S:System
Level
Interventio
naaPR:PuertoRican
bbM/C:Mexican
/Colum
bian
ccPEFR:PeekExpiratoryFlow
Rate
1010 Press et al.: Minority Patients with Asthma: A Systematic Review JGIM
studies (range 19–21, mean 20), and the six cohort studies(range 12–23, mean 18).
Race/Ethnicity
The majority of studies included participants from severalrace/ethnicity populations; studies focusing on AfricanAmericans predominated. Five studies focused entirely onone race/ethnicity; four on African Americans; one onAsian Americans. There were an additional ten studieswhere the majority of participants were African American,and four where the majority were Latinos.
Intervention Sub-TypesEducation-Based Interventions (N=15; Mean StudyQuality Score (DB) 21.5). The majority of theinterventions were education-based (n=15);five wereculturally tailored; three defined by the studies’authors22,23,25 and two by our review.24,26 None of theCTE studies included a comparison group. Three focusedon the African American population,22–24 one on the Latinocommunity,25 and one used language-appropriate educationfor different Asian populations.26 Four CTE interventionsdemonstrated improved outcomes.23–26 The remaining teneducational interventions were not specifically culturallytailored, but did include a majority of non-whiteparticipants; most included a majority of AfricanAmerican participants, though one included a majority ofLatino/a participants. Of these ten interventions, all but onetook place at least partially in the hospital setting,29 incontrast to the CTE interventions that were primarilyoutpatient-based.
System-Level Interventions (N=9, Mean Study QualityScore (DB=19.6). Nine system-level studies met criteria forthis review. The setting was primarily outpatient;40–45 threewere inpatient-based.37–39 Two utilized health disparitiescollaboratives to introduce quality improvementinterventions.40,41
Intervention Outcomes
Almost all of the interventions had at least one successfulcomponent; several studies reported on similar outcomes(e.g., ED visits, hospitalizations). However, a meta-analysiswas not performed as the interventions themselves were tooheterogeneous to provide a valid conclusion. The interven-tions varied in their setting, design, and follow-up. Forexample, some studies utilized pharmacists while othersutilized nurses or asthma educators, and some utilizedmultiple education sessions, sometimes in different settings.Several lessons can still be learned by comparing, when
possible, across the studies’ measured elements. A summa-ry by the most commonly reported outcome measuresfollows. (Table 1)
Health Care Utilization. The most common outcomemeasured among the 24 studies was health care utilization(16/24, 67 %). There was not, however, a unifying item thatcould be compared across studies, as the specific utilizationcomponent(s) differed among the studies.Among the education-based interventions two-thirds (10/15)
followed utilization; eight evaluated ED visits,25,28–31,34–36 7followed hospital admissions,25,29–32,35,36 3 followed outpa-tient visits,26,29,32 and 2 followed length of stay (LOS).30,32
The education provided by these interventions was multi-faceted and included in varying degrees: basic diseaseinformation, self-management skills, medication informationand trigger control. The education was provided in theoutpatient,25,26 inpatient,30–32 ED28,29,34–36 or communitysetting.29 Of note, all three inpatient studies30–32 and 2/4 EDbased interventions34,36 included an outpatient follow-upcomponent (phone call or visit). The education was providedby a range of trained clinical or research staff, includinghealth care professionals,28 pharmacists,26,31 asthma edu-cators,25 asthma nurse educators,29,30,32,34,35 respiratorytherapists (RT) 29 or research staff.36 All of the educationwas provided to the individual participant except for twoof the ED-based interventions28,35 and an outpatientpharmacist based intervention that utilized group ses-sions.26 Several provided more than one session, includingGalbreath’s telephone plus home visit intervention,29 allthree inpatient interventions,30–32 and all but one of theED studies.36
Of the 8 studies that followed ED visits, all buttwo28,29 demonstrated absolute reductions post-education(22–89 %)25,31,36 or relative reductions compared tocontrol (16–59 %).30,34,35 The most successful interven-tions (≥50 % reduction) included two inpatient-basedstudies provided by a pharmacist31 or asthma nurse30 andBolton’s ED multiple-group session intervention.35 Tatis’specialty clinic with asthma educator intervention25 andthree of four ED-based interventions showed slightly less-impressive reductions.28,34,36 The two interventions withnon-significant findings, included Galbreath’s respiratorynurse telephone education +/- home visits by RTs29 andFord’s ED, multiple-session, group-based education.28
Of the seven studies that followed hospital admissions,all but two29,35 demonstrated absolute25,31,36 or relative30,32
reductions (41–88 %). All but Tatis’ asthma educatorstrategy25 showed reductions of ≥50 %, including the threeinpatient interventions,30–32 and Kelso’s one-hour ED-basedintervention.36 The three studies that followed outpatientvisits included Odegard’s language-appropriate pharmacist-based, Galbreath’s telephone, and Castro’s nurse-specialistinpatient, education.26,29,32 However, only Odegard’s
1011Press et al.: Minority Patients with Asthma: A Systematic ReviewJGIM
showed a significant absolute decrease (78 %) in visits.26
Finally, only two inpatient-based education interventions,both provided by asthma nurses, followed LOS.30,32 Theresults were split: Castro found 59 % relative fewer days forthe intervention group compared to the control group,32
while George did not find a relative decrease in LOS.30
Because only one CTE study evaluated ED visits,25 hospitaladmissions,25 and outpatient visits,26 and none evaluatedLOS, conclusions based on the effectiveness of CTE onreducing utilization cannot be made from this data.Two-thirds (6/9) of system-based studies evaluated
utilization post-intervention. Half followed ED visits.42,44,45
These interventions were similar in that they were clinic-based and utilized experts, including pharmacists44,45 andspecialty-based clinics (e.g., allergists).42,45 All three founda relative42,45 or absolute44 decrease between 63–87 %; thecontrol group in one study actually had increased ED visitsby 71 %.42 These three studies, along with another clinic-based intervention that used multiple sessions and ahospital-based nurse-led intervention, both by Mayo,followed hospital admissions.39,43 All but Mayo’s hospital-based study39 found an absolute decrease by 20–88 % inpost-intervention admissions. LOS decreased in both ofMayo’s studies (17 %, inpatient; 54 %, outpatient).39,43
Sperber found a relative decrease in urgent outpatient clinicvisits of 63 %.42
Symptom Control and Self-Management. The next mostcommonly measured items fell under the topics of symptomcontrol/asthma severity (8/24; 33 %) and self-managementtools (6/24; 24 %). However, as with the general topic of‘health care utilization,’ these topic areas were also diverseand varied. For instance, with respect to asthma control,some studies specifically measured the frequency of day/night symptoms, while others used symptom scales, limitedactivity days, etc. Similarly, with respect to measuring self-management, these ranged from the use of spacers or peak-flow meters PFM], to action plans, to respiratory inhalertechnique.Of the five education-based studies that followed
symptoms,24,26,28,29,35 only two found improvements.26,35
Odegard’s language-appropriate pharmacist-based educa-tion demonstrated a 73 % absolute reduction in asthmaattacks and a 79 % absolute reduction in nocturnalsymptoms.26 Bolton’s asthma nurse inpatient educationdemonstrated a 30 % relative decrease in number of daysof limited activity (intervention group vs. control group).35
The three studies that did not find a reduction in symptomsincluded Martin’s social-work led group educational ses-sions with community health workers home visits,24
Galbreath’s telephone +/- RT home visits,29 and Ford’smulti-session ED-based intervention.28 The results for self-management (5/15) were more favorable;24,26,27,31,33 all butone24 found improvements in participants’ self-management
skills. Two pharmacist-based education interventions26,31
showed absolute improvement of chambers (34 %),26
PFMs (41 %),26 and/or medication refills (41 %).31 Simi-larly, two inpatient interventions that used repeated roundsof inhaler technique instruction demonstrated 100 % mas-tery after two or three rounds.27,33 The only study that didnot demonstrate improvements in self-management wasMartin’s community-based intervention.24 Again, few CTEstudies evaluated symptoms and self-management;24,26
therefore conclusions based on the effectiveness of culturaltailoring on improving patient self-care or symptoms cannotbe made.One-third (3/9) of system-based interventions evalu-
ated symptoms.37,38,44 Kelso’s comprehensive long-termmanagement program decreased sleep loss by 63 % andnight awakenings by 43 %.44 Akerman’s continuousquality improvement program at an inner-city ED36
decreased absolute relapse rates by 83 %. However,Rydman’s ED observation unit37 did not show a relativedecrease in relapse rates. Of the three studies thatfollowed self-management, Landon’s use of qualityimprovement collaborative at community health centers41
demonstrated a 19 % absolute increase in use of self-management plans. Both Pauley and Mayo found arelative increase in spacers use (47–86 %) and PFMs(35–100 %).39,45 Pauley also demonstrated relative im-proved inhaler technique (48 %) and use of inhaledcorticosteroids (52 %).45
Overall Health Status and Asthma Quality of Life. Aboutone-third (8/24) of the studies evaluated some aspect ofquality of life (QOL). Some measured overall QOL (n=4),25,40,41,44 while others used asthma-related QOLinstruments (A-QOL, n=5).22,24,29,32,44
Of the five education-based studies that measured QOL,all but one25 looked at A-QOL.22,24,25,29,32 All but onedemonstrated a relative32or absolute24,29 improvement inQOL of 12–33 % (scores of 0.5 to 1.32) post-intervention.Blixen’s inpatient asthma-nurse education did not find arelative improvement in A-QOL.22 Tatis’ was the onlystudy25to evaluate improvement in overall QOL scores andfound a 20 % absolute improvement for those completingthe four rounds of questionnaires. Three CTE studiesevaluated QOL (2 A-QOL, 1 QOL);22,24,25 there is notenough data to make any conclusive role on culturaltailoring and improvements in QOL.Four system-based studies evaluated QOL,37,40,41,44
one of which also studied A-QOL.44 Hicks and Landonboth studied health disparities collaborative.40,41 WhileLandon demonstrated a 25 % absolute improvement in hisoverall quality improvement score,41 Hicks did not findsignificant absolute improvement in QOL.40 Kelso’scomprehensive community clinic and Rydman’s ED-basedobservation unit showed absolute and relative improve-
1012 Press et al.: Minority Patients with Asthma: A Systematic Review JGIM
ments, respectively, of 14–98 % in the majority of SF-36domains they studied (6/8 and 5/8, respectively).37,44
Neither study found significant results for the bodily paindomain. Kelso also evaluated A-QOL using the asthmabother profile and found that 12/15 domains decreasedsignificantly by 23 to 42 %.
Asthma-Related Knowledge. Only six of the studiesmeasured knowledge related to asthma such as disease-related information, triggers, and medication post-intervention.23–25,28,39,44 Four education-based studiesevaluated asthma-knowledge;23–25,28 of these, only Sobel’seducational video promoting self-care concepts increasedknowledge (>60 %).23 The others included Martin’s multi-session social-work intervention, Tatis’ outpatient specialty-clinic, and Ford’s multi-session ED-based study.24,25,28
Only two system-based studies evaluated knowledge.39,44
Kelso’s comprehensive clinic improved participants’understanding of medications and self-managementknowledge from 0–100 %.44 Mayo’s hospital-basededucation increased patient and resident education (41 %,34 %).39
DISCUSSION
This review demonstrates that, first and foremost, asurprising dearth of intervention studies exist that addressthe health disparities of racial and/or ethnic minority adultswith asthma in the US. Since these disparities overwhelm-ingly affect African Americans and Puerto Ricans, it is notsurprising that the majority of studies focused on these twopopulations. Unfortunately, few studies utilized adequatecontrol groups, limiting our ability to endorse interventionsthat would specifically address racial disparities for patientswith asthma.However, our review still provides guidance for clini-
cians and health care systems about what modalities havebeen tried and successfully implemented. For instance, weare unable to determine which educational intervention ismost likely to reduce disparities for minority patients withasthma, but we can report that a variety of educationalmodalities appeared effective at improving outcomes forminority patients with asthma, including point-of-careeducation by health-care professionals (e.g., pharmacists,asthma nurses) or technological approaches (e.g., videos).Further, although our review is unable to definitivelyconclude CTE interventions are superior due to limitationsin study design, despite prior documented success with CTEinterventions,47 it is still noteworthy that education thatincluded language-appropriate materials (e.g., Spanish,Chinese, health literacy focus) for the patient seemed toplay an important role in the majority of the CTEinterventions.
When looking at specific outcomes, group-based educa-tion appeared less-successful in reducing health careutilization, as 1/3 found non-significant reductions in EDvisits and 2/3 in admissions. Neither symptoms norknowledge improved across most of the education-basedstudies; there was no unifying theme that directs thesuccess or lack thereof. Self-management was oftenimproved when education was provided by pharmacists(~40 %) and/or was inpatient skill-based education (100 %mastery). Studies that measured Asthma-related QOLfound improvements of up to 33 %. Finally, educationalstrategies that began in the hospital but continued withoutpatient follow-up demonstrated some of the morepromising findings with greater than 50 % reductions inhealth care utilization.22 Clinicians should recognize thatreproducible educational programs that target health-disparities for sub-populations of the US need to befurther developed and implemented and the role of culturaltailoring should be further explored.We found that specialty clinics, especially for “high risk”
patients, consistently demonstrated decreased utilizationand improved symptoms, self-management, knowledgeand QOL. Similarly, inpatient-based interventions werenearly uniformly successful across the various outcomesstudied. However, despite the promising nature of healthdisparities collaboratives, results to date have not shownexpected improved outcomes. Therefore, efforts to furtherevaluate and possibly combine the most successful strate-gies should be explored.There are several limitations of this review. Although we
reviewed recent abstracts from key scientific meetings inthe field of asthma and allergy, publication bias may limitour findings. Also, the interpretation of results may beaffected due to the high proportion of data from the studiesbeing at high risk of bias.16 Further, community-basedstudies without a health center affiliation were excluded.Future reviews may seek to understand how they mayimprove outcomes for patients with asthma. Finally, wewere unable to perform a meta-analysis limiting thequantitative evaluation of this review.
CONCLUSION
Overall, education delivered by healthcare professionals(nurses, pharmacists, community health workers or eventechnology) appeared effective in improving processes andoutcomes for minority patients with asthma. Because fewstudies were culturally tailored and lacked adequatecontrol groups, it is currently unclear whether this is asuperior approach for reducing health disparities. Systemredesign showed great promise, particularly the use ofteam-based specialty clinics and long-term follow up afteracute care visits. High-priority future areas of research
1013Press et al.: Minority Patients with Asthma: A Systematic ReviewJGIM
should evaluate the role of tailoring educational strategies,focus on patient-centered education, and incorporateoutpatient follow-up and/or a team-based approach.
Acknowledgements:Contributors: We would like to thank Dr. Jerry Krishnan, MD,PhD, Professor of Medicine and Public Health, Director of Popula-tion Health Sciences, Associate Vice President, Office of the VicePresident for Health Affairs, University of Illinois at Chicago, forproviding an expert review of the included references for thissystematic review. We would also like to thank Deb Werner for theexpertise she provided in developing our literature search. We alsowould like to thank Kathy Fletcher, Darcy Reed and Jack Litrell fortheir expertise in performing systematic reviews. Finally, we wouldlike to thank Morgen Alexander-Young for her assistance early inthe project and Nicole Babuskow for her assistance with theproject.
Funding Source: Support for this publication was provided by agrant from the Robert Wood Johnson Foundation’s Finding Answers:Disparities Research for Change Program. The funding source had norole in the design and conduct of the study; collection, management,analysis, and interpretation of the data; and preparation, review,approval, or decision to submit the manuscript for publication.
Prior Presentations: This work has been presented at the 2011University of Illinois at Chicago 3rd annual Minority Health in theMidwest Conference, the 2011 University of Chicago Pediatrics’Resident Research Day, and the 2011 Society of General InternalMedicine Meeting.
Conflict of Interest: The authors declare that they do not have anyconflicts of interest with this work. Dr. Press reports receivingfunding from the National Cancer Institute (KM1CA156717) andthe Robert Wood Johnson Foundation’s Finding Answers: Dispar-ities Research for Change Program. None of the other authors havefunding to report.
Corresponding Author: Valerie G. Press, MD, MPH; Section ofHospital Medicine, Department of Medicine, University of Chicago,5841 S. Maryland Ave, MC 5000, W305, Chicago, IL 60637, USA(e-mail: [email protected]).
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