Determinants of Asthma Morbidity Among InnerCity Populations

1
Determinants of Asthma Morbidity Among Inner-City
Populations
Juan P. Wisnivesky, MD, MPH Divisions of General
Internal Medicine and Pulmonary, Critical Care,
and Sleep Medicine Mount Sinai School of Medicine
2
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

3
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

4
Study Outline
Physician Survey Mount Sinai Hospital Metropolitan
Hospital North General Hospital Local health
centers Rutgers University
Baseline Survey Mount Sinai Hospital Rutgers
University Pulmonary function tests Blood for
IgE, serum, DNA Chart review
1st Telephone Follow-up
2nd Telephone Follow-up
3rd Telephone Follow-up
Demographics Asthma regimen Medication
beliefs Disease beliefs Communication
Electronic measure of adherence
Adherence Asthma control Resource
utilization Quality of life
0
12
3
1
Time (months)
5
Potential Determinants of Asthma Morbidity in
Inner-City Populations
Environmental Factors Housing conditions Passive
smoking Aeroallergens Air Pollution
PATIENT
Behavioral Processes Adherence to controller
meds Adherence Self-regulation of
meds Self-monitoring Trigger avoidance
Clinical Factors Genetics Asthma
history Sensitization Smoking
Outcomes Symptoms Quality of life Airway
function Resource utilization
Physician Factors Knowledge Attitudes Communicat
ion Language
Sociodemographics Age, sex, race,
ethnicity Language, Culture, Education, Income
Cognitive/Emotional Processes Self Regulation
beliefs Knowledge Self efficacy Depression/anxiety

System Factors Access to care Pt education
capacity Gatekeeping Insurance Transportation
6
Characteristics of Study Population (N326)
Value
Characteristic
Value
Characteristic
Age (yrs), meanSD 4813 Female ()
83 Race/Ethnicity () Hispanic
56 African-American
28 White 12 Others
4 Insurance () Medicaid
62 Medicare 18
Commercial 17 Uninsured
3 Income lt15,000/yr () 62 Asthma
History Age Onset (yrs), meanSD 2615 ED
visit last year () 52 Hospitalized
last year () 23
Controller Medication () 87 Comorbid
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
7

• 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

Disease Beliefs and Asthma Self-Management
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.
8
Associations Between the No Symptoms, No Asthma
Belief and Other Key Asthma Beliefs and Behaviors
9
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
10
Medication Beliefs Associated with ICS Adherence
(MARS)
Repeated measures regression adjusted for age,
sex, prior intubation, and frequency of oral
steroid use
11
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

12
Asthma Control in Relationship to English
Proficiency
Non-Hispanics Hispanics, Proficient in
English Hispanics, Limited Proficiency
4
P0.01
Plt0.0001
3
Asthma Control Score
2
1
1-Month Follow-up
3-Month Follow-up
Wisnivesky J, et al. Assessing the Relationship
between Language Proficiency and Asthma Morbidity
amongst Inner-city Asthmatics. Medical Care, In
Press.
13
Resource Utilization in Relationship to English
Proficiency
Non-Hispanics Hispanics, Proficient in
English Hispanics, Limited Proficiency
40
P0.007
P0.004
30
Percentage
20
10
Outpatient Exacerbations
ED Visits- Hospitalizations
14
Quality of Life in Relationship to English
Proficiency
Non-Hispanics Hispanics, Proficient in
English Hispanics, Limited Proficiency
6
P0.002
P0.0001
5
Quality of Life Score
4
3
1-Month Follow-up
3-Month Follow-up
15
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 lt0.0001 0.19 0.009 0.02 0.00
3 0.02 lt0.0001
Non-Hispanics n141 40 24 85 28 72 84 95 86
Hispanic, Proficient n120 51 31 80 42 62 7
6 92 76
Hispanics, Limited Proficiency n57 69 46 73
47 53 56 79 49
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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

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Prevalence of Sensitization to Indoor Allergens
Among Inner-city Asthmatics
50
40
30
Percent Sensitized
20
10
0
Dust Mites
Cockroach
Mouse
Cat
Molds
Wisnivesky J, et al. Association between indoor
allergen sensitization and asthma morbidity in
inner-city asthmatics. JACI, 2007.
18
Asthma Control According to Sensitization Status
Cockroach Sensitization
Cat Sensitization
4
4
3
3
Asthma Control Score
Asthma Control Score
2
2
Sensitized Not sensitized
Sensitized Not sensitized
p gt0.4
p gt0.15
1
1
0
1
3
0
1
3
Time (months)
Time (months)
Mouse Sensitization
Mold Sensitization
4
4
3
3
Asthma Control Score
Asthma Control Score
2
2
Sensitized Not sensitized
Sensitized Not sensitized
p gt0.2
p gt0.6
1
1
0
1
3
0
1
3
Time (months)
Time (months)
19
Resource Utilization According to Sensitization
Status
Cockroach Sensitization
Cat Sensitization
30
30
Sensitized Not sensitized
P0.06
20
20
Percentage
Percentage
10
10
0
0
Steroid Use
ED Visit
Steroid Use
ED Visit
Mouse Sensitization
Mold Sensitization
30
30
Sensitized Not sensitized
Sensitized Not sensitized
20
20
Percentage
Percentage
10
10
0
0
Steroid Use
ED Visit
Steroid Use
ED Visit
20
Barriers to Adherence to Asthma Management
Guidelines among Primary Care Providers
Attitudes
Behavior
Knowledge
Lack of Outcome Expectancy

• Lack of Agreement
• specific items
• guidelines in
• general

• Lack of Familiarity
• volume
• time
• accessibility

• External Barriers
• patient factors
• guideline factors
• environmental
• factors

Lack of Self-efficacy
Lack of Motivation/ Inertia

• Lack of Awareness
• volume
• time
• accessibility

Adapted from Cabana MD, et al. Why dont
physicians follow clinical practice guidelines? a
framework for improvement. JAMA 1999.
21
Primary Care Provider Adherence to NHLBI Asthma
Guideline Recommendations
100
80
60
Provider Adherence ()
40
20
0
Peak Flow Monitoring
ICS
Action Plan
Allergy Testing
Influenza Vaccination
22
Multivariate Predictors of Adherence to the NHLBI
Guideline Components
Barrier Familiarity Expect Patient
Adherence Self-Efficacy Insufficient Time
PF Monitoring
ICS Use
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
23
Multivariate Predictors of Adherence to the NHLBI
Guideline Components
Barrier Familiarity Expect
Patient Adherence Self-Efficacy Insufficient
Time
Action Plan
All Testing
Vaccination
OR 5.5 - 1.3 0.6
P-value 0.02 - 0.46 0.46
OR 1.8 1.0 4.9 1.3
P-value 0.31 0.99 0.03 0.62
OR 2.0 3.5 3.5 1.2
P-value 0.05 0.01 0.05 0.83
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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

25
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

26
Acknowledgments

• Department of Medicine
• Ethan A. Halm, MD, MPH Stephen
  Berns, MD
• Thomas McGinn, MD, MPH Jessica Lorenzo,
  MPH
• Michael Iannuzzi, MD Julian Baez
• Diego Ponieman, MD Jessica Segni
• Department of Pediatrics
• Hugh Sampson, MD Michelle Mishoe
• Department of Geriatrics
• Albert Siu, MD, MSPH
• Rutgers University
• Tamara Musumeci, PhD Howard
  Leventhal, PhD