How to Improve Outcomes in African Americans and Hispanics With Asthma

At least 15 million Americans have asthma.^1-3 Each year, an estimated $12.7 billion is spent on health care for this chronic inflammatory disorder in the United States.⁴ Unnecessary emergency department (ED) visits and hospitalizations contribute substantially to these costs. The number of acute care visits for asthma is highest among minority children from low- income families.⁵

In general, asthma-related morbidity and mortality are greatest among members of ethnic minority groups who live in the inner cities; about 5000 deaths occur in these populations each year in the United States.¹ Mortality is highest in African Americans between the ages of 15 and 24 years.¹ In the diverse US Hispanic population, Puerto Ricans (especially those living in the Northeast) have the greatest annual asthma mortality (40.9 per million); mortality among Cuban Americans and Mexican Americans is 15.8 per million and 9.2 per million, respectively.⁶ Among non-Hispanic blacks, annual asthma mortality is 38.1 per million; among non-Hispanic whites, it is 14.7 per million.⁶

A comprehensive asthma management plan based on the latest NIH guidelines can improve outcomes in minority patients. Here we review the supporting evidence from recent clinical trials; we focus on studies that had the goal of a reduction in the number of ED visits and hospitalizations.

OPTIMAL CARE CAN IMPROVE OUTCOMES

Many patients with asthma suffer needlessly because of inadequate care from providers,^7-12 poor adherence to prescribed treatment,¹³ or a combination of these factors. Poorly managed asthma can result in exercise-induced bronchospasm, nocturnal awakenings, or awakening in the early morning with symp-toms. Reduced sleep quality from asthma or concurrent allergic rhinitis can affect functional status; for example, it can impair performance at school.^14,15

Application of the principles of the NIH guidelines for the management of asthma is essential to improving outcomes. Attention to each of the 4 major components of long-term management is necessary to reduce the number of acute exacerbations that result in ED visits and hospitalizations (Table 1). Adequate drug therapy that is not accompanied by persistent and caring patient education is likely to fail. On the other hand, excellent patient education without individualized pharmacologic treatment and appropriate environmental control will likely result in suboptimal outcomes.

Patient education aimed at achieving a partnership in asthma care may be even more important in African Americans and Hispanics than in white populations in the United States. Include an initial 45- to 60-minute session, with much briefer sessions on subsequent visits (to reinforce initial teaching messages). This initial investment of time saves significant time and costs later. Probably the most realistic way to conduct such education is by scheduling separate small-group sessions taught by nurses, pharmacists, or respiratory therapists who have a special interest in asthma. Other aspects of caring for inner-city minority patients that need to be addressed to help ensure optimal outcomes include psychosocial issues as well as beliefs about health and medication.^16-18

Key recommendations in the NIH guidelines that can help reduce the number of acute care visits and improve quality of life in all patients with asthma include:

• Objective assessment and monitoring.
• Anti-inflammatory therapy, with an emphasis on inhaled corticosteroids for patients with mild, moderate, or severe persistent asthma.
• Management of "endogenous triggers," including allergic rhinitis, sinusitis, gastroesophageal reflux disease, and the premenstrual phase.¹⁹
• A written action plan that offers specific details on home as well as school management of exacerbations.¹

Other strategies are listed in Table 2.

The following studies demonstrate how state-of-the-art management based on the current literature, including the NIH guidelines, can improve outcomes in patients with asthma.

EVIDENCE THAT INTENSIVE TREATMENT IMPROVES OUTCOMES IN AFRICAN AMERICANS AND HISPANICS

Adult trials. Mayo and colleagues²⁰ evaluated 104 patients in New York City who had at least 5 ED visits in the past 24 months or at least 2 hospitalizations in the past 12 months. Most patients in the study were Hispanic. Forty-seven patients were randomly assigned to an intensive outpatient treatment clinic; 57 continued to receive their usual long-term care. After 8 months of usual care, 19 patients with multiple hospitalizations were subsequently crossed over to the intensive-treatment group.

The intensive-treatment group received long-term asthma management consistent with the principles of the NIH guidelines. (Note that this study was conducted and published before the original NIH guidelines were released in 1991.²¹) The intensive management program featured:

• Two initial visits that lasted at least 1 hour and included detailed repetitive discussion of asthma and its treatment as well as self-management techniques.
• Tailored drug regimens that emphasized inhaled corticosteroids with a spacer device and "as-needed" short-acting inhaled β₂-agonists.
• An emergency supply of prednisone (40 mg/d for 3 days) to use based on peak expiratory flow values and severity of symptoms.
• Repetitive education, including observation of patient's use of a metered-dose inhaler with spacer device.
• Easy access to the clinic (with instructions to telephone or come to the clinic if asthma is not well controlled).

Results. During a 32-month follow-up period, the intensive-treatment group had a 3-fold reduction in readmissions and length of hospital stays.

In a study of 25 African Americans and whites with at least 3 ED visits for asthma in the past 12 months, Pauley and associates²² applied the principles of the NIH guidelines in an effort to reduce ED visits. After seeing the clinic physician, patients received intensive education in small groups by a clinical pharmacist.

Results. During the 6-month intervention period (December to June), the total number of ED visits was 6; during the same months 1 year earlier, the total number had been 47.

Because many inner-city indigent patients use the ED as their primary site of medical care, Kelso and colleagues²³ initiated long-term intervention in the ED. In a group of 30 African Americans who had at least 5 ED visits for asthma in the past 2 years, at least 3 ED visits in the past year, or at least 2 hospitalizations in the past 2 years, clinical pharmacist investigators provided 1 hour of individual education about asthma and its treatment after the patients had responded to ED therapies. Patient education focused on the role of airway inflammation and inhaled corticosteroids, trigger avoidance, and use of inhalation devices. In addition, correct use of peak flow meters and colored-zone management were reviewed. Patient use of the devices was observed. Patients were urged to visit an asthma clinic with the same clinical pharmacist and physician investigators for follow-up visits.

Results. These patients were compared with a retrospective control group of 22 inner-city indigent patients for 1 year before and after the intervention in the ED. In addition, the number of ED visits for patients who received intervention was compared with the number of their visits during the 2 previous years. ED visits in the intervention group decreased by a mean 41%; visits in the control group did not decrease.

Kelso and associates²⁴ also conducted a 2-year trial in middle- or low-income working adult African Americans with poorly controlled asthma (at least 5 ED visits in past 2 years or at least 2 hospitalizations in the past 2 years). The 21 patients in the intervention group received detailed education in an initial 1-hour session. Easy access to the investigators was stressed, and frequent telephone contact was made. Treatment was based on the NIH guidelines, with an emphasis on inhaled corticosteroids. Each patient was given an emergency supply of prednisone (40 mg/d for 3 days). During each clinic visit, the patient's use of the inhaler and peak flow meter was observed, and reminders were given about the importance of inhaled corticosteroids. The 18 patients in the control group received usual care.

Results. The mean number of ED visits in the intervention group decreased by 74%, compared with a 23% decrease in the control group. This change was not statistically significant. Moreover, 62% of patients who received intensive treatment had no ED visits or hospitalizations.

Pediatric trials. Greineder and coworkers²⁵ studied 53 patients with asthma aged 1 to 17 years in an outreach program aimed at reducing ED visits and hospitalizations. Of these children and adolescents, 70% were African American.

Patients received an initial 1- to 2-hour individual instruction session about asthma and its treatment, triggers, and use of inhalers as well as peak flow meters. Drug therapy was tailored for each patient according to NIH guidelines.¹¹ A key feature of this program was that the study outreach nurse telephoned families weekly during the early part of the trial to ensure that appointments were kept. This continuing contact established a rapport and was important in the study's success.

Results. The number of ED visits and hospitalizations was tracked for 6 to 24 months after the intervention and compared with the number during an equal time before the study. In the intervention group, ED visits were reduced by 79% and hospital admissions by 86%.

In a follow-up study, Greineder and coworkers²⁶ randomized 57 patients to a usual-care group or to an intervention group after a single intensive asthma education session. Both groups received drug therapy recommended in the NIH guidelines.¹¹ The intervention group also received consistent follow-up from the study outreach nurse as in the earlier study.²⁵

Results. ED visits and hospitalizations were compared for 1 year before and 1 year after the study. The intervention group had greater reductions in ED visits (73%) and hospitalizations (84%). Estimated cost savings ranged from $7.69 to $11.67 for every dollar spent on the outreach nurse's salary.

In a study of children aged 2 to 16 years who were enrolled in Medicaid, an asthma outreach nurse maintained monthly contact for 1 year with the 38 patients in the intervention group after extensive individual asthma education and treatment based on the NIH guidelines.²⁷

Results. Mean ED visits decreased 51% in the intervention group (significantly more than in the control group). Average asthma health care costs per year were reduced by $721 per child in the intervention group and by $178 per child in the control group.

A study by Stout and associates²⁸ included home visits by community-based lay workers who collaborated with a pediatrician, pharmacist, and public health nurse. Twenty-three children (87% African American) were evaluated for 1 year before and after the intervention. Initial intervention included asthma evaluation and treatment by a physician, pharmacist review of medication use, peak expiratory flow assessment, and training in inhalation devices. After the study nurse trained the lay outreach worker, patients were visited at least monthly for the first 6 months of the program and then at least quarterly. The outreach workers reinforced the comprehensive asthma management plan, including environmental control.

Results. There were 20 ED visits the year before study enrollment, and only 7 in the year after the intervention. The families indicated that while they trusted the investigators who were health professionals, they felt more comfortable sharing information and concerns with the lay outreach workers. Other studies have also used community health workers.²⁹

OTHER CLINICAL TRIALS THAT SHOWED IMPROVED OUTCOMES

George and colleagues³⁰ assessed the effect of a comprehensive educational program on outcomes in 77 adults with asthma. Following hospitalization for asthma, patients were randomized to comprehensive or usual care at a university asthma clinic.

Results. During the next 6 months, there was a total of 3 ED visits among patients who received comprehensive care (compared with 27 during the 6 months before the intervention) and a total of 15 ED visits in the usual-care group (compared with 17 during the previous 6 months).

McGill and associates³¹ evaluated the effect of an educational and therapeutic intervention program in children enrolled in Head Start. The study used clinical pharmacist asthma counselors, and interventions were done in partnership with the child's physician and Head Start personnel. The intervention consisted of personalized management skill training, development of an asthma treatment plan, and family empowerment to use health care resources.

Results. Intervention resulted in a 66% reduction in ED visits.

A very recent study evaluated inner-city elementary schoolchildren with asthma who have access to school-based health centers.³²

Results. Access to such centers may reduce hospitalization rates and missed school days.

References:

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