Determinants of Asthma Morbidity Among Inner-City Populations

Juan P. Wisnivesky, MD, MPHDivisions of General Internal Medicine and Pulmonary, Critical Care, and Sleep Medicine Mount Sinai School of Medicine

Inner-City Asthma

Asthma is a chronic disease affecting 15 to 17 million Americans

Minority inner-city populations are disproportionately affected by asthma

African Americans and Hispanics have 2 to 3 times greater rates of death due to asthma when compared to whites

New York City has asthma mortality rates 10 times the national average

Determinants of Morbidity Among Inner-City Asthmatics

Study Goal: to evaluate the role of patient, provider, and environmental factors on outcomes of inner-city asthmatics

Baseline SurveyMount Sinai HospitalRutgers University

Pulmonary function testsBlood for IgE, serum, DNA

Chart review

1st Telephone Follow-up

2nd Telephone Follow-up

0Time (months)

1231

Electronic measure of adherence

DemographicsAsthma regimen

Medication beliefsDisease beliefsCommunication

AdherenceAsthma control

Resource utilizationQuality of life

3rd Telephone Follow-up

Study OutlinePhysician SurveyMount Sinai HospitalMetropolitan HospitalNorth General HospitalLocal health centersRutgers University

Physician FactorsKnowledge Attitudes

CommunicationLanguage

Behavioral ProcessesAdherence to controller meds

AdherenceSelf-regulation of meds

Self-monitoringTrigger avoidance

OutcomesSymptoms

Quality of lifeAirway function

Resource utilization

System Factors

Access to carePt education capacity

Gatekeeping Insurance

Transportation

Cognitive/Emotional Processes

Self Regulation beliefsKnowledgeSelf efficacy

Depression/anxiety

Clinical FactorsGenetics

Asthma historySensitization

Smoking

PATIENTEnvironmental

FactorsHousing conditions

Passive smokingAeroallergensAir Pollution

Potential Determinants of Asthma Morbidity in Inner-City Populations

SociodemographicsAge, sex, race, ethnicity

Language, Culture,Education, Income

Characteristics of Study Population (N=326)

Age (yrs), mean+SD 48+13Female (%) 83Race/Ethnicity (%) Hispanic 56 African-American 28 White 12 Others 4 Insurance (%) Medicaid 62 Medicare 18 Commercial 17 Uninsured 3Income <$15,000/yr (%) 62Asthma History Age Onset (yrs), mean+SD 26+15 ED visit last year (%) 52 Hospitalized last year (%) 23

ValueCharacteristic

Controller Medication (%) 87Comorbid Conditions (%) Eczema 19 Chronic sinusitis 23 Diabetes 25 Hypertension 46 Environmental Exposure (%) Second hand smoking 25 Cat 23 Cockroach 44 Dampness/Mold 51 Rodents 40

ValueCharacteristic

Disease Beliefs and Asthma Self-Management Self-management is critical for long-term asthma control

"Do you think you have asthma all of the time or only when you are having symptoms?"

Responses: I have it all of the time Most of the time Some of the time Only when I am having symptoms

53% of patients were classified as having the no symptoms-no asthma, acute episodic disease belief

Halm EA, et al. No Symptoms, No Asthma. The Acute Episodic Disease Belief Is Associated With Poor Self-Management Among Inner-City Adults With Persistent Asthma. Chest, 2006.

Beliefs and Behaviors AcuteBelief, %

Chronic Belief, % OR (CI)

 I will not always have asthma 31 9 4.49 (1.94–10.42)

 My lungs are always inflamed/irritated 43 67 0.36 (0.20–0.66)

Medication beliefs

 ICS use is important when no symptoms 56 77 0.38 (0.19–0.74)

Medication adherence (ICS)

 Use it all/most of the time when no symptoms 45 70 0.35 (0.19–0.64)

Other self-management behaviors

 Routine asthma visits when no symptoms 50 65 0.54 (0.30–0.97)

 Use PFM all/most of the days 14 30 0.39 (0.19–0.80)

 Use PFM to self-adjust medicines 15 25 0.53 (0.25–1.09)

Associations Between the No Symptoms, No Asthma Belief and Other Key Asthma Beliefs and Behaviors

Adherence to Inhaled Corticosteroids (ICS)Adherence to Inhaled Corticosteroids (ICS)

ICS are the cornerstone of asthma therapy

Adherence to ICS is often suboptimal

Medication Adherence Reporting Scale (MARS)

60 patients were given an electronic monitoring device

53% of prescribed days used ICS, 35% of the doses prescribed

Identify key medication beliefs independently associated with adherence with ICS

MDI Log

Medication Beliefs Associated with ICS Adherence (MARS)

Repeated measures regression adjusted for age, sex, prior Repeated measures regression adjusted for age, sex, prior intubation, and frequency of oral steroid useintubation, and frequency of oral steroid use

Medication Belief OR P-valueImportant to take when asymptomatic 4.2 <0.001

Confident in ability to use ICS as prescribed 2.2 <0.001

Worry about side effects 0.5 <0.001

Medication regimen hard to follow 0.5 0.04

The Relationship Between Language Barriers and Outcomes of Inner-city Asthmatics

11 million people living in the US have no or limited English-language skills

Limited English proficiency can impair access to quality health care

Adequate patient-provider communication is a key aspect of asthma management

The objective of this analysis was to assess how language barriers affect the outcomes of adult inner-city asthmatics

1-MonthFollow-up

1

2

3

4

Ast

hma

Con

trol

Sco

re

3-MonthFollow-up

P=0.01 P<0.0001

Non-HispanicsHispanics, Proficient in EnglishHispanics, Limited Proficiency

Asthma Control in Relationship to English Proficiency

Wisnivesky J, et al. Assessing the Relationship between Language Proficiency and Asthma Morbidity amongst Inner-city Asthmatics. Medical Care, In Press.

Non-HispanicsHispanics, Proficient in EnglishHispanics, Limited Proficiency

10

20

30

40

Perc

enta

ge

OutpatientExacerbations

P=0.004

ED Visits-Hospitalizations

P=0.007

Resource Utilization in Relationship to English Proficiency

Qua

lity

of L

ife S

core

1-MonthFollow-up

3

4

5

6

3-MonthFollow-up

P=0.002 P=0.0001

Non-HispanicsHispanics, Proficient in EnglishHispanics, Limited Proficiency

Quality of Life in Relationship to English Proficiency

Medication and Disease Beliefs, Self-Efficacy, and Adherence According to English Proficiency

Variable

Medication Beliefs (%) Worry Side Effects ICS Worry Addiction to ICS ICS are Controller Meds

Disease Beliefs (%) No Symptoms, No Asthma Asthma is Chronic Disease

Self-efficacy (%) Confident Control Asthma Confident Use ICS Control Over Future Health

P-value

0.002<0.0001

0.19

0.0090.02

0.0030.02

<0.0001

Non-Hispanics

n=141

402485

2872

849586

Hispanic,Proficient

n=120

513180

4262

769276

Hispanics, Limited Proficiency

n=57

694673

4753

567949

The Role of Allergic Sensitization on Asthma Morbidity

Inner-city residents are often exposed to high levels of indoor allergens

Sensitization to cockroach allergen has been linked to increased asthma morbidity in children

Recent data suggest that sensitization to indoor allergens may worsen asthma in elderly patients and pregnant women

Objective of the study was to evaluate the role of sensitization to indoor allergens on asthma control among inner-city asthmatics

Prevalence of Sensitization to Indoor Allergens Among Inner-city Asthmatics

Per

cent

Sen

sitiz

ed

10

20

40

0

30

50

Wisnivesky J, et al. Association between indoor allergen sensitization and asthma morbidity in inner-city asthmatics. JACI, 2007.

Dust Mites

Cockroach MouseCat Molds

Sensitized

Not sensitized

0 1 31

2

3

4

Ast

hma

Con

trol S

core

Time (months)

Cockroach Sensitization

0 1 31

2

3

4

Ast

hma

Con

trol S

core

Time (months)

Cat Sensitization

p >0.4 p >0.15

0 1 31

2

3

4

Ast

hma

Con

trol S

core

Time (months)

Mouse Sensitization

0 1 31

2

3

4

Ast

hma

Con

trol S

core

Time (months)

Mold Sensitization

p >0.2 p >0.6

Sensitized

Not sensitized

Sensitized

Not sensitizedSensitized

Not sensitized

Asthma Control According to Sensitization Status

SteroidUse

0

10

20

30

Per

cent

age

Cockroach Sensitization Cat Sensitization

Mouse Sensitization Mold Sensitization

Resource Utilization According to Sensitization Status

EDVisit

SteroidUse

EDVisit

0

10

20

30

Per

cent

age

0

10

20

30

Per

cent

age

0

10

20

30

Per

cent

age

SteroidUse

EDVisit

SteroidUse

EDVisit

Sensitized

Not sensitized

Sensitized

Not sensitizedSensitized

Not sensitized

**P=0.06

Attitudes BehaviorKnowledge

Lack of Familiarity• volume• time• accessibility

Lack of Awareness• volume• time• accessibility

Lack of Agreement

• specific items• guidelines in general

Lack of Outcome

Expectancy

Lack of Self-efficacy

Lack of Motivation/

Inertia

External Barriers• patient factors• guideline factors• environmental factors

Adapted from Cabana MD, et al. Why don’t physicians follow clinical practice guidelines? a framework for improvement. JAMA 1999.

Barriers to Adherence to Asthma Management Guidelines among Primary Care Providers

ICS0

40

80

Prov

ider

Adh

eren

ce (%

)

Peak Flow Monitoring

20

60

100

Action Plan

Allergy Testing

Influenza Vaccination

Primary Care Provider Adherence to NHLBI Asthma Guideline Recommendations

Multivariate Predictors of Adherence to the NHLBI Guideline Components

Barrier

Familiarity

Expect Patient Adherence

Self-Efficacy

Insufficient Time

OR

1.4

1.2

2.8

0.43

P-value

0.34

0.87

0.03

0.07

OR

1.1

3.3

2.3

0.68

P-value

0.75

0.03

0.05

0.25

ICS Use PF Monitoring

Multivariate Predictors of Adherence to the NHLBI Guideline Components

Barrier

Familiarity

Expect Patient Adherence

Self-Efficacy

Insufficient Time

OR

1.8

1.0

4.9

1.3

P-value

0.31

0.99

0.03

0.62

Action PlanOR

5.5

-

1.3

0.6

P-value

0.02

-

0.46

0.46

All TestingOR

2.0

3.5

3.5

1.2

P-value

0.05

0.01

0.05

0.83

Vaccination

Limitations

May not be generalizable to other inner-city populations

Used self-reported measures of adherence

Unable to directly observe patient-provider encounters

Used self-reported data on provider adherence to the guidelines

Conclusions Outcomes of inner-city asthmatics remain poor

Problem appears to be multifactorial

Suboptimal disease and medication beliefs are associated with poor asthma self-management

Language barriers may also explain the increased levels of asthma morbidity among inner-city Hispanics

The role of allergic sensitization appears to be more important among children than adults with asthma

Familiarity and adherence to key treatment recommendations remains suboptimal amongst providers who take care of a large number of inner-city asthmatics

AcknowledgmentsDepartment of Medicine

Ethan A. Halm, MD, MPH Stephen Berns, MDThomas McGinn, MD, MPH Jessica Lorenzo, MPHMichael Iannuzzi, MD Julian BaezDiego Ponieman, MD Jessica Segni

Department of PediatricsHugh Sampson, MD Michelle Mishoe

Department of Geriatrics

Albert Siu, MD, MSPH

Rutgers University

Tamara Musumeci, PhD Howard Leventhal, PhD

Columbia UniversityDavid Evans, PhD Mayer Kattan, MD

These studies were funded by AHRQ and NYC Department of Health