PEDIATRIC ASTHMA, ALLERGY & IMMUNOLOGYVolume 20, Number 4, 2007© Mary Ann Liebert, Inc.DOI: 10.1089/pai.2007.003

Use of Asthma Specialist Care in High-Risk Inner-CityBlack Children

SANDE O. OKELO, M.D.,1 CECILIA M. PATIÑO, M.D.,2NADIA N. HANSEL, M.D., M.P.H.,2 PEYTON A. EGGLESTON, M.D.,1

JEAN CURTIN-BROSNAN, M.A.,1 JERRY A. KRISHNAN, M.D., Ph.D.,2,3

CYNTHIA S. RAND, Ph.D.,2 and GREGORY B. DIETTE, M.D., M.H.S.2,3

ABSTRACT

Innercity Black children are at high risk for asthma morbidity. Asthma specialists may im-prove asthma outcomes. Understanding specialist use among innercity Black children mayprovide insight into asthma care in this population. We hypothesized that increased asthmamorbidity would be associated with increased use of and parental desire for specialist care.Participants were recruited from Baltimore City health plans. Parents of children (2–6 yearsof age) with asthma were surveyed about their child’s asthma, including use of or desire forasthma specialist care. We compared asthma specialist care status (yes or no) and desire forspecialist care to asthma morbidity and criteria for specialist referral based on nationalasthma guidelines. Of 135 children, 23% had severe asthma, but 9% had seen a specialistand 43% met criteria for asthma specialist referral. Forty percent of parents of children notseen by a specialist expressed a desire to see one. Compared to children of parents who didnot desire a specialist, children of parents who desired a specialist were more likely to havesevere asthma (38% vs. 10%; p � 0.01), poor asthma control (22% vs. 7%; p � 0.02), andparent report that their child was not receiving good medical care (22% vs. 6%, p � 0.01).Among this population with significant asthma morbidity, asthma specialist care is infre-quent, despite parent preference for it. Eliciting parental preference for specialist care maybe an efficient method to identify children appropriate for specialist care. Improvements inspecialist use may improve asthma care and outcomes in innercity Black children. (PediatrAsthma Allergy Immunol 2007; 20[4]:255–262.)

INTRODUCTION

BLACK CHILDREN suffer greater morbidity from asthma compared to White children, with threefold highermortality, emergency department visits, and hospitalizations.1 These disparities are not fully accounted

for by differences in symptom severity2 or asthma prevalence.1 Furthermore, Black children are less likelythan White children to receive care recommended by the National Institutes of Health (NIH) asthma guide-lines, regardless of socioeconomic status, insurance status, or access to care.3–5

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1Department of Pediatrics, School of Medicine, 2Department of Medicine, School of Medicine,3 Department of Epi-demiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.

Referral to asthma specialists is one facet of asthma care. NIH guidelines recommend referral to a spe-cialist for asthma that is complicated, difficult to control, or severe. Specialist referral is also recommendedwhen patients are dissatisfied with current asthma care or when goals of treatment remain unmet.6 Use ofasthma specialists can help ensure that overall asthma care is consistent with the NIH guidelines,7 and mayalso improve asthma outcomes.8 Studies of asthma specialist use among Black children9,10 have not ex-amined asthma morbidity, so it is unclear if the rates of specialist use were appropriate. Furthermore, thesestudies did not examine parental preferences for asthma specialist care, so it is unknown to what extentparental attitudes about specialist care affected the observed rates of specialist use.

To identify factors associated with use of and desire for asthma specialist care among innercity Blackchildren with asthma, we tested three hypotheses: (1) asthma specialist use would be low, (2) parental de-sire for specialist care would be high, and (3) parental desire for specialist care would be associated withhigher levels of asthma morbidity in their children.

MATERIALS AND METHODS

Study population and recruitment procedures

This study used parent-reported cross-sectional data from surveys conducted as part of the Baltimore In-door Environment Study of Asthma in Kids (BIESAK).11 Potential participants were between 2 and 6 yearsof age, were residents of nine contiguous zip codes in innercity Baltimore, Maryland, and were cared forat Johns Hopkins Community Physicians or Bayview Pediatrics, two centers that provide care to more than70% of the residents in these zip codes.

Eligibility criteria for children included: (1) doctor-diagnosed asthma, (2) symptoms or use of asthmamedications within the last 6 months, and (3) at least one health care encounter for asthma within the last12 months (ICD-9 code 493.xx).

Participants were recruited between September, 2001 and December, 2003. All potential subjects receiveda mailing describing the study. After the mailing, study staff (trained research assistants) contacted the par-ent by phone and a screening survey was used to determine eligibility. If eligible, a home visit by studystaff was scheduled to obtain written informed consent from the parent or legal guardian. The Johns Hop-kins Medical Institutional Review Board approved the study protocol. For successful completion of thestudy, caregivers received $30 and the child received a toy valued at $10. Enrollment in the BIESAK studystopped after the planned sample of parents of 150 eligible children was attained.

Because our interest was in the asthma care of innercity Black children and 90% of the child participantsare Black, all of the analyses in this report are restricted to the 135 Black participants.

Data collection

An interviewer-administered survey was completed at the home visit. Details on relevant survey itemsare described below.

Survey items

Patient and parent characteristics. Interviewers obtained demographic information about the child andthe child’s parent, including age, race, gender, parental history of asthma, environmental tobacco smokeexposure, and health insurance status. Information regarding parental employment status and educationallevel was obtained. Ninety-four percent of caregivers reported their status as a parent of the child, so theterm “parent” is used in this report to refer to the child’s caregiver.

Parental desire for specialist asthma care. Parents were asked about the doctor primarily responsible formanaging their child’s asthma, including the doctor’s specialty, gender, and race. Parents were asked if theirchild was cared for by an asthma specialist (“Does your child see a specialist doctor for care of his/herasthma?”). Response options were “Yes,” “No, but he/she doesn’t need to,” and “No, but I would likehim/her to.” No other questions regarding specialist referral status were asked.

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Level of asthma control. Subjects with asthma were categorized as having mild intermittent, mild per-sistent, moderate persistent or severe persistent asthma based on parent reports of daytime symptoms, night-time symptoms, medication use, and activity limitation, over the prior 2 weeks, according to 1997 NIHguidelines.6 Additional information was collected on parental reports of quality of asthma control and oralsteroid use over the prior 2 weeks.

Health beliefs and perceptions of child’s asthma status. Parents were asked about how much they werebothered getting the child to take asthma medications, and whether they were worried that their child wasnot receiving good asthma care. These questions were examined because they were felt to be indicative ofunmet goals of therapy (e.g., because of a parent’s inability to consistently administer medication or thechild’s resistance to the current medication regimen) and dissatisfaction with care, respectively, both rea-sons for asthma specialist referral according to NIH asthma guidelines. The source of these questions wasthe Child Health Survey on Asthma.12

Quality of asthma care. Parents were asked to rate the quality of the instructions they received for man-agement of their child’s asthma, and the quality of the communication they had with the physician primarilyresponsible for managing their child’s asthma by responding to the request, “Thinking about your child’scare from the doctor who mainly takes care of his or her asthma, how would you rate: (1) the instructionsthe doctor gives you or your child on how to take care of asthma; (2) how well the doctor listens and paysattention to you and your child’s concerns.” A five-point Likert-type scale of responses was provided, rang-ing from poor to excellent.

Indication for asthma specialist care. Based on NIH guidelines,13 we estimated the proportion of chil-dren who met criteria for asthma specialist referral. Indication for referral to an asthma specialist was sep-arated into two criteria: (1) those who definitely should be referred (severe asthma, moderate asthma amongchildren 5 years and younger, or two or more urgent doctor visits, emergency department visits, or hospi-talizations over the prior 3 months); (2) those who possibly should be referred (mild persistent asthma forchildren 5 years and younger, atopy confirmed by a positive skin prick test, or parent reporting being both-ered getting their child to take asthma medications).

Urgent health care use. Frequency of unscheduled doctor visits, emergency department visits, and hos-pitalizations for asthma during the prior 3 months was collected at the home visit. These outcomes wereselected as indicators of suboptimal asthma control in this insured population of children with an identifiedpediatrician as the regular source of their asthma care.

Atopic status. Allergic sensitization status was assessed, after responses were obtained by questionnaire,by skin prick test (Multi-Test II, Lincoln Diagnostics, Decatur, IL) to 14 common aero-allergens and twocontrols (histamine and glycerine) (Hollister-Stier Laboratories, Spokane, WA and Greer Laboratories,Lenoir, NC). A positive skin test was defined as a net wheal diameter of at least 2 mm. A child was con-sidered atopic if he/she had at least one positive skin test to the panel of allergens tested.

Analysis

Variables were examined using descriptive frequencies and crosstabulations. Bivariate, chi-square analy-ses of responses to categorical survey items were made between parents who reported their child currentlysaw an asthma specialist and parents whose children were not seeing a specialist. Among children not see-ing an asthma specialist, we made additional comparisons between parents who desired an asthma special-ist and those who did not, using chi-square and logistic regression. Kruskall-Wallis analysis was used toexamine the relationships between continuous variables and parental desire to see an asthma specialist. Atwo-tailed p � 0.05 denoted statistical significance for all analyses. All analyses were performed with SPSS12.0 software (Chicago, IL).

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RESULTS

Demographics (Table 1)

The mean age of children in this study was 4.5 years, while 55% were boys. The majority of parentswere single, high school graduates, reported a household income less than $25,000 per year, and nearly allhad public health insurance. Seventy-one percent of children were atopic and 40% of children had at leastone parent with a history of asthma. A majority of parents reported current household environmental to-bacco smoke exposure.

Asthma specialist care

While 95% of children had a pediatrician to care for their asthma, few saw an asthma specialist (9%).Among those not seen by a specialist, 40% of parents expressed a desire to see one. Indicators of highersocioeconomic status were associated with the desire to see a specialist (Table 1). This association remainedsignificant after adjusting for the child’s asthma severity. In particular, parents who expressed a desire foran asthma specialist were more likely to be a high school graduate (odds ratio [OR] � 5.7, 95% confidenceinterval [CI] 1.5–21.4) and to report a household annual income more than $25,000 (OR � 6.8, 95% CI1.5–30.3), compared to parents who did not want to see a specialist. Parental desire for specialist care wasnot significantly associated with insurance status, marital status, history of asthma, or mean age, gender, oratopic status of the child.

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TABLE 1. CHARACTERISTICS OF CHILDREN AND THEIR PARENTS BY ASTHMA SPECIALIST STATUS

Child does not see a specialist (n � 120)

Parent desires a No parental desirespecialist for a specialist(n � 50) (n � 70) p-value

Mean age of child (years) 4.6 4.4 4.4 NSGender (%male) 60.0 52.9 58.0 NSMarital status of parent 80.0 62.0 72.9 NS

(%single)Parent education 80.0 70.0 50.7 0.04a0

(% �high school graduate)Parent incomeb 22.2 39.3 9.1 0.005c

(% �$25,000/year)Insurance status 90.0 80.0 90.0 NS

(% with public insurance)�1 Parent with a history of asthma 60.0 40.0 37.1 NSAtopy 88.9 72.7 68.2 NS

(% of children with �1positive skin prick test)

Environmental tobacco 50.0 54.0 58.0 NSsmoke exposure

NS represents no statistically significant difference between any of the comparison groups: (1) those seeing a special-ist; (2) those not seeing a specialist; (3) those who desire an asthma specialist referral; (4) those who do not want an asthmaspecialist referral.

aStatistically significant by chi-square test for comparison between parents who desire a specialist and parents who donot desire a specialist.

bResults based on 76 respondents.cStatistically significant by chi-square test for comparison between parents who desire a specialist and parents who do

not desire a specialist.

Child sees aspecialist(n � 10)

Associations with parental desire for asthma specialty care

Level of asthma control (Figs. 1 and 2). Forty-five percent of the children were categorized as eithermoderate or severe persistent asthma, including 23% with severe persistent asthma. Asthma specialist carestatus was related to level of asthma control. Those seeing a specialist were more likely to have moderateor severe persistent asthma than those not seeing a specialist (80% vs. 42%, p � 0.02). Forty percent ofchildren seen by a specialist were classified as having severe persistent asthma. Among parents of childrennot seeing a specialist but desiring one, 38% of their children had severe persistent asthma, compared to10% of children whose parents did not desire a specialist (Fig. 1). The odds of desire for a specialist weresignificantly higher among parents of children with severe asthma, even after adjusting for parent educa-tion and income (OR � 19.7, 95% CI 3.8–102.3). Perceptions of poorly controlled asthma were more com-

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FIG. 1. Severe persistent asthma and asthma specialist status. *p � 0.92, children who see a specialist versus chil-dren of parents who want a specialist. †p � 0.01, children who see a specialist versus children of parents who do notwant a specialist. §p � 0.001, children whose parents want a specialist versus children whose parents do not want aspecialist.

FIG. 2. Level of child’s asthma control and asthma specialist status. *p � 0.04 compared to those seeing a special-ist. §p � 0.01 for difference between those who desire a specialist and those who do not desire a specialist in propor-tion of children with severe asthma. †p � 0.01 compared to those seeing a specialist. The remainder of comparisons bychi-square test are not statistically significant (p � .05).

mon among parents who wished to see an asthma specialist (21% vs. 7%, p � 0.02). In contrast, amongchildren with mild or moderate persistent asthma, 67% of parents did not want a specialist (Fig. 2), evenafter adjusting for parental education and income [mild persistent asthma (OR � 0.25, 95% CI .04–1.5);moderate persistent asthma (OR � 0.5, 95% CI .13–2.3)].

Oral steroid use and health care use. There were no statistically significant differences in reports of oralsteroid use (11% vs. 7%), emergency department visits (28% vs. 21%), or hospitalizations for asthma (3%vs. 2%) between parents who desired asthma specialist referral and those who did not.

Burden of asthma. Parents who desired asthma specialist care reported a greater burden from their child’sasthma than parents who did not desire a specialist. Specifically, parents who desired a specialist were morelikely to report being bothered getting their child to take asthma medicines (22% vs. 7%, p � 0.02). In asimilar trend, parents who desired a specialist expressed more worry about poor asthma care for their child(22% vs. 6%, p � 0.08). These parents were also more likely to rate their child’s doctor as fair–poor forquality of instructions given (22% vs. 5%, p � 0.01) and how well the doctor listens and pays attention(22% vs. 7%, p � 0.02). Similar, but nonsignificant, fair–poor ratings were seen for how well doctors ex-plain things (22% vs. 12%, p � 0.10).

Indication for referral. Overall, more than 40% of the children in the study met at least one “definite”criterion for asthma specialist referral. Among the parents who expressed a desire for a specialist referral51% met at least one “definite” criterion for asthma specialist referral, compared to 33% of children whoseparents who did not want referral (p � 0.06). Over the prior three months, more children of parents whodesired asthma specialist referral met criteria for “definite” referral than children of parents who did notwant to see a specialist, based upon emergency department visits (16% vs. 6%, p � 0.06) and urgent doc-tor visits for asthma (6% vs. 0%, p � 0.04), but not based upon frequency of hospitalizations.

DISCUSSION

In this study of innercity Black children with asthma, we found that there is both a significant need anddesire for asthma specialty referral, suggesting that underreferral may be a problem for these children. Poorerasthma symptom control and a higher burden of asthma were observed among parents who desired spe-cialist asthma care compared to parents who did not desire such care, indicating that parental desire forasthma specialist referral was a valid, unmet need, and was not the major barrier to this type of care in thispopulation. Parental desire for specialist care appeared to be appropriate, based on a variety of indicators,including level of morbidity, unmet goals of therapy, and frequent health care use for worsening asthma.Notably, many parents of children with moderate persistent asthma who met National Asthma Educationand Prevention Program (NAEPP) criteria for asthma specialist referral did not desire it, although they mayhave benefited from such care. Taken together, these findings suggest that appropriate asthma specialistcare is underutilized within innercity communities.

Few studies have focused on the use of asthma specialist care among innercity Black children. Lieu9 andShields,8 reported 14% and 11% of Black children insured by Medicaid were seen by a specialist, respec-tively. Neither study differentiated levels of asthma severity among their participants, so the appropriate-ness of their rates of specialist use is unclear. Using NIH criteria, which are much broader than our studycriteria, we estimated that at least 43% of the children in our study not seeing a specialist warranted spe-cialist referral. Twenty-three percent of our participants had severe persistent asthma, so we expected therate of specialist use to be significantly higher than the 9% we observed.

Physician underrecognition of need for referral or parental desire for referral may also explain the lowrates of asthma specialist use we observed. Underestimation of asthma severity by physicians occurs morefrequently in Black than White patients, negatively affects care, and could result in low rates of specialistreferral.14 Black patients report poorer communication with physicians,15,16 and are offered less participa-tion in the decision-making process of care by physicians.17 Complaints by parents in our study of poor lis-

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tening, understanding, and direction giving by physicians may reflect poor communication with physicians,and may contribute to underrecognition of symptom severity, resulting in low rates of specialist use.

Other factors could also explain the low rates of asthma specialist use in this population, including un-derrecognition of asthma symptom severity by parents18 and the effect of race, poor education, low eco-nomic status, public insurance status,19 innercity residence, and availability of and access to asthma spe-cialists. Within our study population, parents expressing desire for specialist care were significantly morelikely to be high school graduates and to have a higher income than parents who did not desire specialistcare, although a significant portion of respondents did not provide income information. Those who are moresocioeconomically advantaged may be more knowledgeable about the option of seeing a specialist, maybetter appreciate the advantages of seeing a specialist, or may just be more confident and willing to expresstheir desires to see a specialist.

This study has several limitations, including the potential for misclassification bias and reporting bias,because we did not interview physicians or review medical charts to confirm parental reports. However,nearly three-fourths of the participants were atopic, a finding associated with a higher likelihood of asthma.20

We do not have objective measures to determine asthma severity (e.g., lung function), although the youngage of our child participants (2–6 years) precluded measurement of lung function in the vast majority. Useof parent reports of asthma care and for doctor diagnosis of asthma have been widely accepted as a method-ology.7,21–23 Also, we do not know if parents were nonadherent with medications, primary care visits, priorreferrals by their physician for asthma specialist care, nor whether a specialist had been seen in the past butwas not being seen at the time of this survey. Our study may not be generalizeable to other populations,including those without health insurance, those with private insurance, and those from other socioeconomicbackgrounds. However, our choice of a population known to be at significant risk for greater morbidity andhigher mortality from asthma than other populations may be seen as a strength. Last, the effect of socioe-conomic status on desire for specialist referral was in part based on income data available for slightly lessthan 60% of our participants, so our conclusions are somewhat limited in that regard.

Underuse of asthma specialists by innercity Black children with significant asthma morbidity, despiteparental desire for this care, may contribute to suboptimal asthma care in this population. We do not knowof other studies examining parental desire for specialist care. Eliciting parental preference may be one ad-ditional simple and efficient way to identify children whose asthma is poorly controlled or severe and whomay benefit from specialist referral. This approach may be particularly beneficial for innercity Black chil-dren with asthma, who appear to be at higher risk for poor asthma care and poor asthma outcomes. How-ever, further studies are needed to explain why underreferral and/or underutilization of specialty care oc-cur in this population and how to improve referral rates for children of parents who do not express a desirefor specialist referral.

ACKNOWLEDGMENTS

This work was supported by grants from the NHLBI (K23 HL04266, K23 HL076322-01, K23 HL67850),NIEHS(ES 09606), the Environmental Protection Agency (R826724), and the Parker B. Francis Founda-tion.

REFERENCES

1. Akinbami LJ, LaFleur BJ, Schoendorf KC. Racial and income disparities in childhood asthma in the United States.Ambul Pediatr 2002; 2:382–387.

2. Ortega AN, Gergen PJ, Paltiel AD, Bauchner H, Belanger KD, Leaderer BP. Impact of site of care, race, and His-panic ethnicity on medication use for childhood asthma. Pediatrics 2002; 109:E1.

3. Finkelstein JA, Lozano P, Farber HJ, Miroshnik I, Lieu TA. Underuse of controller medications among Medicaid-insured children with asthma. Arch Pediatr Adolesc Med 2002; 156:562–567.

4. Ortega AN, Calderon JG. Pediatric asthma among minority populations. Curr Opin Pediatr 2000; 12:579–583.

ASTHMA SPECIALIST USE IN INNER-CITY CHILDREN

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5. Ortega AN, Belanger KD, Paltiel AD, Horwitz SM, Bracken MB, Leaderer BP. Use of health services by insur-ance status among children with asthma. Med Care 2001; 39:1065–1074.

6. National Heart LBI. Guidelines for the diagnosis and management of asthma: Expert panel report No. 2. 1997. NIHPublication 97-4051.

7. Diette GB, Skinner EA, Nguyen TTH, Markson L, Clark BD, Wu AW. Comparison of quality of care by special-ist and generalist physicians as usual source of asthma care for children. Pediatrics 2001; 108:432–437.

8. Zeiger RS, Heller S, Mellon MH, Wald J, Falkoff R, Schatz M. Facilitated referral to asthma specialist reduces re-lapses in asthma emergency room visits. J Allergy Clin Immunol 1991; 87:1160–1168.

9. Shields AE, Comstock C, Weiss KB. Variations in asthma care by race/ethnicity among children enrolled in a stateMedicaid program. Pediatrics 2004; 113:496–504.

10. Lieu TA, Lozano P, Finkelstein JA, et al. Racial/ethnic variation in asthma status and management practices amongchildren in managed medicaid. Pediatrics 2002; 109:857–865.

11. Breysse PN, Buckley TJ, Williams D, et al. Indoor exposures to air pollutants and allergens in the homes of asth-matic children in inner-city Baltimore. Environ Res 2005; 98:167–176.

12. Asmussen L, Olson LM, Grant EN, Fagan J, Weiss KB. Reliability and validity of the Children’s Health Surveyfor Asthma. Pediatrics 1999; 104:e71.

13. National Asthma Education and Prevention Program. Expert panel report: Guidelines for the diagnosis and man-agement of asthma update on selected topics—2002. J Allergy Clin Immunol 2002; 110[Part 2(5)]:S142–S219.

14. Halterman JS, Yoos HL, Kaczorowski JM, et al. Providers underestimate symptom severity among urban childrenwith asthma. Arch Pediatr Adolesc Med 2002; 156:141–146.

15. Roter DL, Stewart M, Putnam SM, Lipkin M Jr, Stiles W, Inui TS. Communication patterns of primary care physi-cians. JAMA 1997; 277:350–356.

16. Collins KS, Hughes DL, Doty MM, Ives BL, Edwards JN, Tenney K. Diverse communities, common concerns:Assessing health care quality for minority Americans: Findings from the Commonwealth Fund 2001 Health CareQuality Survey. Commonwealth Fund 2002; 523:1–80.

17. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship.JAMA 1999; 282:583–589.

18. Halterman JS, Yoos HL, Kitzman H, Anson E, Sidora-Arcoleo K, McMullen A. Symptom reporting in childhoodasthma: A comparison of assessment methods. Arch Dis Child 2006; 91:766–770.

19. Cabana M, Bruckman D, Rushton JL, Bratton SL, Green L. Receipt of asthma subspecialty care by children in amanaged care organization. Ambul Pediatr 2002; 2:456–461.

20. Taussig LM, Wright AL, Holberg CJ, Halonen M, Morgan WJ, Martinez FD. Tucson Children’s Respiratory Study:1980 to present. J Allergy Clin Immunol 2003; 111:661–675.

21. Diette GB, Skinner EA, Markson LE, et al. Consistency of care with national guidelines for children with asthmain managed care. J Pediatr 2001; 138:59–64.

22. Ortega AN, Gergen PJ, Paltiel AD, Bauchner H, Belanger KD, Leaderer BP. Impact of site of care, race, and His-panic ethnicity on medication use for childhood asthma. Pediatrics 2002; 109:E1.

23. Wu AW, Young Y, Skinner EA, et al. Quality of care and outcomes of adults with-asthma treated by specialistsand generalists in managed care. Arch Intern Med 2001; 161:2554–2560.

Address reprint requests to:Sande Okelo, M.D.

Park 316, Eudowood Division of Respiratory SciencesDepartment of PediatricsJohns Hopkins University

200 North Wolfe Street, Suite 3025Baltimore, MD 21287

E-mail: sokelo1@jhmi.edu

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