Socioeconomic disparities in asthma health care utilization, exacerbations, and mortality: A systematic review and meta-analysis

Social inequalities in childhood asthma

Asthma is a complex, heterogeneous condition, broadly characterized by chronic airway inflammation with variable expiratory airflow limitation, but with several subtypes underpinned by different (although likely overlapping) pathological mechanisms. It is one of the most common chronic diseases of childhood and represents a significant cost for healthcare systems and affected families. Evidence suggests that a disproportionate proportion of this burden falls on families from disadvantaged socioeconomic circumstances (SECs). In this review, we describe the extent to which growing up in disadvantaged SECs is associated with an increased risk of childhood asthma diagnosis and asthma outcomes, including how this differs geographically and across different asthma subtypes. We also discuss the complex and interdependent mediating pathways that may link disadvantaged SECs with childhood asthma and asthma-related outcomes. In high-income countries (HICs), there is a fairly consistent association between growing up in disadvantaged SECs and increased prevalence of childhood asthma. However, evidence suggests that this social patterning differs across different asthma subtypes, with asthma phenotypes associated with disadvantaged SECs being less likely to be associated with atopy and more likely to begin in infancy and persist into adolescence. Disadvantaged SECs are also associated with worse asthma outcomes, which may contribute to the persistence of symptoms among disadvantaged children. In low- and middle-income countries (LMICs), the patterns are more variable and data more limited, but there is some evidence that disadvantaged SECs and atopic asthma are similarly negatively associated. There are also clear disparities in asthma outcomes, with LMICs having disproportionately high asthma-related morbidity and mortality, despite having lower asthma prevalence. A lack of accessibility to essential medication and appropriate care no doubt contributes to these disparities. The pathways leading to social inequalities in asthma are complex and interdependent, and as yet not fully understood. There is a clear need for further research into the relative importance of potential mediating pathways, including how these vary across the life course and across asthma subtypes. A stronger understanding of these pathways will help identify the most effective policy entry points for intervention, ultimately reducing inequalities across the life course.

Occupational agents-mediated asthma: From the perspective of autophagy

Occupational asthma (OA) is a common occupational pulmonary disease that is frequently underdiagnosed and underreported. The complexity of diagnosing and treating OA creates a significant social and economic burden, making it an important public health issue. In addition to avoiding allergens, patients with OA require pharmacotherapy; however, new therapeutic targets and strategies need further investigation. Autophagy may be a promising intervention target, but there is a lack of relevant studies summarizing the role of autophagy in OA. In this review consolidates the current understanding of OA, detailing principal and novel agents responsible for its onset. Additionally, we summarize the mechanisms of autophagy in HMW and LMW agents induced OA, revealing that occupational allergens can induce autophagy disorders in lung epithelial cells, smooth muscle cells, and dendritic cells, ultimately leading to OA through involving inflammatory responses, oxidative stress, and cell death. Finally, we discuss the prospects of targeting autophagy as an effective strategy for managing OA and even steroid-resistant asthma, encompassing autophagy interventions focused on organoids, organ-on-a-chip systems, nanomaterials vehicle, and nanobubbles; developing combined exposure models, and the role of non-classical autophagy in occupational asthma. In briefly, this review summarizes the role of autophagy in occupational asthma, offers a theoretical foundation for OA interventions based on autophagy, and identifies directions and challenges for future research.

Clinical remission attainment, definitions, and correlates among patients with severe asthma treated with biologics: a systematic review and meta-analysis

BACKGROUND

Clinical remission has emerged as an important treatment goal in severe asthma; however, studies have reported variable attainment due to differences in study populations, definitions, and methods. We aimed to perform a systematic review and meta-analysis of clinical remission attainment, definitions, and correlates among patients with severe asthma who have been treated with biologics.

METHODS

In this systematic review and meta-analysis, we searched Web of Science, Embase, and MEDLINE, using the keywords "asthma" and "remission", for studies published between database inception and June 13, 2024, that reported clinical remission among patients with severe asthma treated with biologics. Studies were eligible for inclusion in both the systematic review and meta-analysis if they were published in English language peer-reviewed journals and reported rates of clinical remission for patients treated with biologics for severe asthma. There were no limitations by study design. Two reviewers independently screened identified papers (AS and CR), with disagreements resolved through consensus or referral to a third reviewer (JB). Study-level data on study characteristics, clinical remission definitions, clinical remission attainment, and the potential correlates of clinical remission were extracted independently by two reviewers (AS and CR) using Covidence. We defined a three-component definition of clinical remission, which included use of maintenance oral corticosteroids, exacerbations, and asthma symptom burden, and a four-component definition, which additionally included lung function. We meta-analysed the rate of attainment of clinical remission and assessed the correlates of clinical remission using DerSimonian-Laird random-effects models. Statistical heterogeneity was assessed using the I2 statistic. This study was registered with PROSPERO, CRD42024507233.

FINDINGS

Our search identified 3014 potentially eligible studies, of which 1812 were screened. 25 studies were included, which reported 28 analyses of clinical remission attainment. 68 definitions of clinical remission were identified, of which 48 were unique. Little consensus was found between studies in terms of the clinical remission definition, particularly for symptoms and lung function. Eight analyses used the three-component definition of clinical remission and 25 used the four-component definition. The pooled proportion of patients who attained clinical remission was 38% (95% CI 29-47; I2=93%) for the three-component definition and 30% (27-34; I2=83%) for the four-component definition. Several pulmonary factors were associated with lower clinical remission rates, including worse FEV1 (odds ratio 0·09 [95% CI 0·01-0·92]; I2=87%), worse asthma symptoms (0·23 [0·17-0·33]; I2=0%), longer asthma duration (0·49 [0·32-0·76]; I2=22%), and use of maintenance oral corticosteroids (0·57 [0·40-0·79]; I2=49%). The presence of comorbidities, in particular depression (0·38 [0·23-0·61]; I2=6%) and obesity (0·41 [0·31-0·54]; I2=0%), were important non-pulmonary barriers to clinical remission.

INTERPRETATION

Clinical remission is an achievable goal for a minority of patients with severe asthma treated with biologics. Definitions of clinical remission varied substantially between studies, and materially affected attainment, suggesting an urgent need for further consensus-driven definitions. Longer disease duration, higher asthma severity, and the presence of comorbidities were identified as important barriers to clinical remission, suggesting that earlier intervention with effective treatments and a broader treatable traits approach might improve outcomes.

FUNDING

Health Data Research UK, Inflammation and Immunity driver project.

Association between socioeconomic deprivation, ethnicity and health outcomes in preschool children with recurrent wheeze in England: a retrospective cohort study

BACKGROUND

Preschool-aged children have among the highest burden of acute wheeze. We investigated differences in healthcare use, treatment and outcomes for recurrent wheeze/asthma in preschoolers from different ethno-socioeconomic backgrounds.

METHODS

Retrospective cohort study using data from the Clinical Practice Research Datalink linked to Hospital Episode Statistics in England. We reported number of acute presentations and hospitalisations stratified by index of multiple deprivation (IMD) and ethnicity; and factors associated with treatment non-escalation, and hospitalisation rates using multivariable logistic and Poisson regression models.

RESULTS

194 291 preschool children were included. In children not trialled on asthma preventer medications, children from the most deprived IMD quintile (adjusted OR 1.67; 95% CI 1.53 to 1.83) and South Asian (1.77; 1.64 to 1.91) children were more likely to have high reliever usage and where specialist referral had not occurred, the odds of referral being indicated was higher in the most deprived quintile (1.39; 1.28 to 1.52) and South Asian (1.86; 1.72 to 2.01) children compared with the least deprived quintile and white children, respectively.Hospitalisation rates for wheeze/asthma were significantly higher in children from the most deprived quintile (adjusted IRR 1.20; 95% CI 1.13 to 1.27) compared with the least, and in South Asian (1.57; 1.44 to 1.70) and black (1.32; 1.22 to 1.42) compared with white children.

CONCLUSIONS

We identified inequalities in wheeze/asthma treatment and morbidity in preschool children from more deprived, and non-white backgrounds. A multifaceted approach to tackle health inequality at both the national and local levels, which includes a more integrated and standardised approach to treatment, is needed to improve health outcomes in children with preschool wheeze/asthma.

The frequency of asthma and its related factors: results of the enrolment phase of Tabari cohort study

INTRODUCTION

A large portion of the world's population has asthma. This study aimed to ascertain asthma prevalence and related factors in the Tabari cohort study (TCS).

METHODS

The TCS included 10,255 35-70-year-olds from urban and mountainous Sari (northern Iran) between June 2015 and November 2017. Education, occupation, domicile, socioeconomic position, history of psychiatric disorders, smoking (including hookah smoking), opium usage, and daily physical activity level were determined.

RESULTS

The final analysis included 9939 individuals. The asthma rate was 7.4%. Multiple factors increased asthma risk, according to statistical analysis. These factors included being female (OR, 1.337; 95% CI, 1.142-1.565), retired (OR, 1.553; 95% CI, 1.205-2.002), living in the city (OR, 1.268; 95% CI, 1.083-1.484), using opioids (OR, 1.689; 95% CI, 1.299-2.197), having lower socioeconomic status (SES) (OR, 0.723; 95% CI, 0.579-0.903), history of psychiatric disorders (OR, 2.313; 95% CI, 1.826-2.930), and aged 60-70 (OR, 2.325; 95% CI, 1.765-3.064), and BMI above 30 kg/m2 (OR, 1.499; 95% CI, 1.220-1.841). Several factors increased asthma probability in multivariate regression analysis. These factors include being female (OR = 1.389, p = 0.015), ages between 60 and 70 (OR = 2.034, p < 0.001), using opioids (OR = 1.940, p < 0.001), lower SES (OR = 0.738, p = 0.012), history of psychiatric disorders (OR = 2.035, p < 0.001), BMI above 30 kg/m2 (OR = 1.518, p < 0.001), and being a smoker (OR = 1.337, p = 0.056).

CONCLUSION

This study has identified that the prevalence of asthma in the Tabari cohort group is high. In addition, it was demonstrated that various factors are related to asthma.

Increasing awareness regarding the relationship between environmental exposures and allergic disease

This review highlights studies from the past 3 years that add to the understanding of the impact of environmental exposures on allergic disease. These include aeroallergens, air quality, prenatal or early-life exposures, and occupational exposures. Recent studies have focused on the relationship between the environment, the microbiome, and allergic disease, and new therapeutic options have also been reviewed. Lastly, there has been significant recent research improving our knowledge of the link between health disparities and environmental exposures. These scientific advances have resulted in a better understanding that sets the foundation for current and future research dedicated to improving health outcomes by modifying environmental exposures.

Asthma Inception: Epidemiologic Risk Factors and Natural History Across the Life Course

Asthma is a descriptive label for an obstructive inflammatory disease in the lower airways manifesting with symptoms including breathlessness, cough, difficulty in breathing, and wheezing. From a clinician's point of view, asthma symptoms can commence at any age, although most patients with asthma-regardless of their age of onset-seem to have had some form of airway problems during childhood. Asthma inception and related pathophysiologic processes are therefore very likely to occur early in life, further evidenced by recent lung physiologic and mechanistic research. Herein, we present state-of-the-art updates on the role of genetics and epigenetics, early viral and bacterial infections, immune response, and pathophysiology, as well as lifestyle and environmental exposures, in asthma across the life course. We conclude that early environmental insults in genetically vulnerable individuals inducing abnormal, pre-asthmatic airway responses are key events in asthma inception, and we highlight disease heterogeneity across ages and the potential shortsightedness of treating all patients with asthma using the same treatments. Although there are no interventions that, at present, can modify long-term outcomes, a precision-medicine approach should be implemented to optimize treatment and tailor follow-up for all patients with asthma.

Racial differences in odds of asthma exacerbations among Aspergillus fumigatus-sensitized adults with asthma

BACKGROUND

Allergic sensitization to mold is a risk factor for poor asthma outcomes, but whether it accounts for disparities in asthma outcomes according to race or socioeconomic status is not well-studied.

OBJECTIVE

To identify factors associated with allergic sensitization to molds and evaluate associations of sensitization to molds with asthma exacerbations after stratifying by race.

METHODS

We conducted a retrospective cohort study of adults with asthma who had an outpatient visit to a large health system between January 1, 2017 and June 30, 2023 and received aeroallergen testing to Aspergillus fumigatus, Penicillium, Alternaria, and Cladosporium. We used logistic regression models to evaluate factors associated with mold sensitization and the effect of mold sensitization on asthma exacerbations in the 12 months before testing, overall and then stratified by race.

RESULTS

A total of 2732 patients met the inclusion criteria. Sensitization to each mold was negatively associated with being a woman (odds ratios [ORs] ≤ 0.59, P ≤ .001 in 5 models) and positively associated with the Black race (ORs ≥ 2.16 vs White, P < .0005 in 5 models). In the full cohort, sensitization to molds was not associated with asthma exacerbations (ORs = 0.95-1.40, P ≥ .003 in 5 models and all above the corrected P value threshold). Among 1032 Black patients, sensitization to A fumigatus, but not to other molds, was associated with increased odds of asthma exacerbations (OR = 2.04, P < .0005).

CONCLUSION

Being a man and Black race were associated with allergic sensitization to molds. Sensitization to A fumigatus was associated with asthma exacerbations among Black patients but not the overall cohort, suggesting that A fumigatus allergy is a source of disparities in asthma outcomes according to race.

Mepolizumab in children and adolescents with severe eosinophilic asthma not eligible for omalizumab: a single Center experience

BACKGROUND

Mepolizumab is an anti-interleukin-5 monoclonal antibody shown to reduce asthma exacerbations in adults and adolescents with severe eosinophilic asthma.

AIM

To assess the impact of mepolizumab on children and adolescents over 12 months by examining steroid usage, asthma-related hospitalizations, Asthma Control Test (ACT) scores, fractional exhaled nitric oxide concentration (FeNO), forced expiratory volume in 1 s (FEV1), mid expiratory flow (FEF25-75%), and blood eosinophil count.

METHODS

Retrospective analysis performed between October 2015 and December 2022. Data was reviewed 12 months before and after commencing mepolizumab. Mepolizumab was offered if the patient had severe eosinophilic asthma and were unresponsive to or ineligible for omalizumab.

RESULTS

Sixteen participants (age 7-17, 8 males, 8 females) received subcutaneous mepolizumab monthly with no serious adverse reactions. Incidence of hospital admissions fell significantly (IRR 0.33, p = 0.007). Among the 11 patients receiving daily oral corticosteroids, 3 were weaned off daily oral steroids and 3 patients' daily dose was significantly reduced (mean Δ-0.095 ± 0.071 mg/kg, p = 0.0012). Eosinophil count was decreased (mean Δ-0.85 x 109/L, p < 0.001). There was no significant change in mean overall steroid burden per patient (mean Δ-1445.63 ± 1603.18 mg, p = 0.10), ACT scores (mean Δ2.88 ± 6.71, p = 0.17), FEV1 z-scores (mean Δ-0.99 ± 1.88, p = 0.053), FEF25-75% z-scores (mean Δ-0.65 ± 1.61, p = 0.13), FeNO (mean Δ-20.09 ± 80.86, p = 0.34), or number of courses of oral steroids given for asthma attacks (IRR 0.71, p = 0.09).

CONCLUSION

Among children and adolescents with severe eosinophilic asthma ineligible for or not responsive to omalizumab, mepolizumab therapy exhibited significant reduction in rate of asthma-related hospitalizations and significant decrease in daily steroid dosage.

Understanding the determinants of self-reported asthma in Turkey: insights from national data on individual, lifestyle, socioeconomic, and healthcare access factors

Asthma, influenced by genetic, environmental, and social factors is leading to poor outcomes and preventable mortality due to inadequate care and limited access to effective treatments. This study aimed to analyze self-reported asthma prevalence in Turkey, focusing on its determinants, such as individual factors, lifestyle, socioeconomic status, and healthcare access.This study conducts a secondary analysis of the 2019 Turkiye Health Survey (THS), employing a nationally representative cross-sectional design by the Turkish Statistical Institute. The sampling utilized a stratified, two-stage cluster sampling method, with data from 16,976 adults (aged 15 years and older) analyzed for asthma determinants. The independent variables are categorized into four domains: individual factors, lifestyle assessment, socioeconomic factors, and access to the healthcare services.The prevalence of asthma is 9.8%, varying significantly across demographics. Higher asthma rates are observed among older, divorced/widowed individuals, those with communication difficulties, and obese individuals. Cost-related unmet healthcare needs and appointment scheduling delays increase asthma risk. Logistic regression models identified age, marital status, obesity, education level, and healthcare access as significant predictors of asthma.This study underscores the multifaceted determinants of asthma in Turkey, highlighting the necessity for targeted interventions addressing individual, lifestyle, socioeconomic, and healthcare access factors.

The Child Opportunity Index and asthma morbidity among children younger than 5 years old in Washington, DC

BACKGROUND

Place-based social determinants of health are associated with pediatric asthma morbidity. However, there is little evidence on how social determinants of health correlate to the disproportionately high rates of asthma morbidity experienced by children <5 years old.

OBJECTIVES

This study sought to evaluate census tract associations between the Child Opportunity Index ±COI) and at-risk rates (ARRs) for pediatric asthma-related emergency department (ED) encounters and hospitalizations in Washington, DC.

METHODS

This was a cross-sectional study of children <5 years old with physician-diagnosed asthma included in the DC Asthma Registry between January 2018 and December 2019. Census tract COI score (1-100) and its 3 domains (social/economic, health/environmental, and educational) were the exposures (source: www.diversitydatakids.org). ED and hospitalization ARRs (outcomes) were created by dividing counts of ED encounters and hospitalizations by populations with asthma for each census tract and adjusted for population-level demographic (age, sex, insurance), clinical (asthma severity), and community (violent crime and limited English proficiency) covariates.

RESULTS

Within a study population of 3806 children with a mean age of 2.4 ± 1.4 years, 2132 (56%) had 5852 ED encounters, and 821 (22%) had 1418 hospitalizations. Greater census tract overall COI, social/economic COI, and educational COI were associated with fewer ED ARRs. There were no associations between the health/environmental COI and ED ARRs or between the COI and hospitalization ARRs.

CONCLUSION

Improving community-level social, economic, and educational opportunity within specific census tracts may reduce ED ARRs in this population.

Asthma exacerbations in New Zealand 2010-2019: A national population-based study

INTRODUCTION

Asthma is one of the most common long-term conditions in the world, with New Zealand (NZ) having one of the highest rates of asthma symptoms. Despite the significant burden of asthma in NZ, there is a lack of data on asthma exacerbation rates in NZ and how these have varied over time. This study is a national population-based study of asthma exacerbation rates in NZ between 2010 and 2019, and explores how these rates vary amongst different demographic groups.

METHODS

A retrospective population-based observational cohort study covering the ten years 2010-2019 to determine asthma prevalence, and asthma exacerbation and hospitalisation rates, using de-identified data from five national healthcare datasets. Exacerbations were defined based on hospital discharge diagnoses or oral corticosteroid dispensing.

RESULTS

Total number of patients with asthma was 447,797 in 2010 to 512,627 in 2019, equating to approximately 10% of the population. Of these 19.4% experienced an exacerbation in 2010 (a population rate of 376.2 per 1000 patient-years); this exacerbation rate increased to 25.1% in 2019 (438.3 per 1000 patient-years). Exacerbations rates were consistently higher for females than males, and among Pacific peoples and Māori. In contrast, hospital admissions 25% lower in 2019 than 2010, decreasing from 1.4% to 0.9%, however over 50% of these admissions were in Māori and Pacific peoples.

CONCLUSION

Asthma exacerbation rates in NZ have increased over 2010-2019, however hospitalisation rates have decreased. This potentially suggests a move away from secondary to primary care management of exacerbations and provides important information for asthma care planning.

Readmission Rates After Acute Respiratory Distress Syndrome in Children

Importance

An increasing number of children survive after acute respiratory distress syndrome (ARDS). The long-term morbidity affecting these survivors, including the burden of hospital readmission and key factors associated with readmission, is unknown.

Objective

To determine 1-year readmission rates among survivors of pediatric ARDS and to investigate the associations of 3 key index hospitalization factors (presence or development of a complex chronic condition, receipt of a tracheostomy, and hospital length of stay [LOS]) with readmission.

Design, Setting, and Participants

This retrospective cohort study used data from the commercial or Medicaid IBM MarketScan databases between 2013 and 2017, with follow-up data through 2018. Participants included hospitalized children (aged ≥28 days to <18 years) who received mechanical ventilation and had algorithm-identified ARDS. Data analysis was completed from March 2022 to March 2023.

Exposures

Complex chronic conditions (none, nonrespiratory, and respiratory), receipt of tracheostomy, and index hospital LOS.

Main Outcomes and Measures

The primary outcome was 1-year, all-cause hospital readmission. Univariable and multivariable Cox proportional hazard models were created to test the association of key hospitalization factors with readmission.

Results

One-year readmission occurred in 3748 of 13 505 children (median [IQR] age, 4 [0-14] years; 7869 boys [58.3%]) with mechanically ventilated ARDS who survived to hospital discharge. In survival analysis, the probability of 1-year readmission was 30.0% (95% CI, 29.0%-30.8%). One-half of readmissions occurred within 61 days of discharge (95% CI, 56-67 days). Both respiratory (adjusted hazard ratio [aHR], 2.69; 95% CI, 2.42-2.98) and nonrespiratory (aHR, 1.86; 95% CI, 1.71-2.03) complex chronic conditions were associated with 1-year readmission. Placement of a new tracheostomy (aHR, 1.98; 95% CI, 1.69-2.33) and LOS 14 days or longer (aHR, 1.87; 95% CI, 1.62-2.16) were associated with readmission. After exclusion of children with chronic conditions, LOS 14 days or longer continued to be associated with readmission (aHR, 1.92; 95% CI, 1.49-2.47).

Conclusions and Relevance

In this retrospective cohort study of children with ARDS who survived to discharge, important factors associated with readmission included the presence or development of chronic medical conditions during the index admission, tracheostomy placement during index admission, and index hospitalization of 14 days or longer. Future studies should evaluate whether postdischarge interventions (eg, telephonic contact, follow-up clinics, and home health care) may help reduce the readmission burden.

Race, Racism, and Respiratory Health

The study and practice of pulmonary medicine have been profoundly influenced by race theory, which was ascendant at the time of key developments within the specialty. We explore how, as a social determinant of health, race remains a powerful driver of present-day health disparities in respiratory diseases. Both legacy and contemporary inequities are identified through Dr DR Williams's model of cultural, structural, and interpersonal racism.

Asthma and Chronic Obstructive Pulmonary Disease

In the United States, asthma and chronic obstructive pulmonary disease (COPD) disproportionately affect African Americans, Puerto Ricans, and other minority groups. Compared with non-Hispanic whites, minorities have been marginalized and more frequently exposed to environmental risk factors such as tobacco smoke and outdoor and indoor pollutants. Such divergent environmental exposures, alone or interacting with heredity, lead to disparities in the prevalence, morbidity, and mortality of asthma and COPD, which are worsened by lack of access to health care. In this article, we review the burden and risk factors for racial or ethnic disparities in asthma and COPD and discuss future directions in this field.

Asthma control in children, socioeconomic inequality and health care

INTRODUCTION

Socioeconomic inequality (SEI) can adversely affect asthma control. The aim of this study was to establish the association of SEI with asthma control in children and caregiver quality of life.

METHODS

We assessed socioeconomic status based on the area of residence, according to the at risk of poverty rate (ARPR). After stratifying the paediatric population of Castilla y León (Spain) in ARPR tertiles, we selected participants by stratified random sampling, and identified children with asthma aged 6-14 years from the health records of primary care centres. We collected data through questionnaires completed by parents. The primary outcomes were asthma control and caregiver quality of life. We assessed their association with SEI, health care quality measures and individual factors (such as parental educational attainment) by means of multivariate regression models.

RESULT

The ARPR tertile was not associated with asthma control, quality of life or health care quality. A medium or high maternal educational attainment was associated with a lower risk of making an unscheduled or urgent visit (OR = .50; 95% CI, .27-.95; P = .034) and paternal educational attainment was associated with a lower risk of uncontrolled asthma (OR = 0.51; 95% CI, .28-.94; P = .030).

CONCLUSION

In the sample under study, SEI assessed at the local level was not associated with asthma control in children. Other factors, such as parental educational attainment, may have a protective effect.

Reducing asthma exacerbations in vulnerable children through a medical-legal partnership

BACKGROUND

Asthma health disparities are widely recognized, with worse outcomes in children from low income families. In a Medical-Legal Partnership (MLP), an attorney is embedded in a healthcare setting to address social determinants of health. We studied whether an MLP could impact asthma exacerbation rates in a vulnerable urban population at an academic children's hospital.

METHODS

The study population comprised children with asthma who were referred to the MLP between 2013 and 2017. We compared healthcare utilization for asthma exacerbations managed in primary care, emergency department and inpatient settings in the year before and year after MLP intervention.

RESULTS

98 children with asthma were included in the study. The mean total encounters per person per year decreased from 1.16 to 0.66 (relative reduction 44.2%, p < 0.01). The largest effect was on hospitalizations, with a reduction from 0.33 to 0.10 hospitalizations per patient per year (relative reduction 69.7%, p < 0.01). Encounters for asthma exacerbations in the primary care office and emergency department also decreased but these changes did not meet statistical significance.

CONCLUSION

In a pediatric population with asthma, an MLP intervention was associated with a significant reduction in asthma exacerbation encounters and hospitalizations comparing the year before and after MLP intervention. Further studies are needed to better understand which interventions are most effective, and for which patient groups MLP referral would be particularly useful. MLPs may be an important way to reduce health disparities in patients with asthma and other chronic illnesses.

New considerations of health disparities within allergy and immunology

The pandemic, political upheavals, and social justice efforts in our society have resulted in attention to persistent health disparities and the urgent need to address them. Using a scoping review, we describe published updates to address disparities and targets for interventions to improve gaps in care within allergy and immunology. These disparities-related studies provide a broad view of our current understanding of how social determinants of health threaten patient outcomes and our ability to advance health equity efforts in our field. We outline next steps to improve access to care and advance health equity for patients with allergic/immunologic diseases through actions taken at the individual, community, and policy levels, which could be applied outside of our field. Key among these are efforts to increase the diversity among our trainees, providers, and scientific teams and enhancing efforts to participate in advocacy work and public health interventions. Addressing health disparities requires advancing our understanding of the interplay between social and structural barriers to care and enacting the needed interventions in various key areas to effect change.

Ensuring equitable access to guideline-based asthma care across the lifespan: Tips and future directions to the successful implementation of the new NAEPP 2020 guidelines, a Work Group Report of the AAAAI Asthma, Cough, Diagnosis, and Treatment Committee

The most recent recommendations from the 2020 National Asthma Education and Prevention Program Update and Global Initiative for Asthma 2021 guide evidence-based clinical decision making. However, given the present state of health disparities by age, income, and race, the equitable implementation and dissemination of these guidelines will be unlikely without further guidance. This work group report reviews the current state of the new asthma guideline implementation; presents updated evidence-based therapeutic options with attention to specific patient populations; and addresses barriers to the implementation of these guidelines in minoritized, historically marginalized, and underresourced communities. Allergists and immunologists can use practical ways to accomplish the goals of improved asthma care access and advanced asthma care across the life span, with specific considerations to historically marginalized populations. Modifiable barriers to guideline implementation include financial barriers, environmental factors, and allergy subspecialty access and care coordination. Various programs to improve access to guideline-based asthma care include community programs, school-based asthma programs, and digital health solutions, with an emphasis on reducing disparities by race.

Spatial, temporal and demographic patterns in asthma mortality in China: A systematic analysis from 2014 to 2020

Background

Asthma is an important contributor to the burden of non-communicable diseases in China. Understanding spatial, temporal, and demographic patterns in asthma mortality is relevant to the design and implementation of targeted interventions.

Methods

This study collected information on asthma deaths occurring across 605 disease surveillance points (DSPs) as recorded in the population-based national mortality surveillance system (NMSS) of China. Asthma was defined according to the International Classification of Diseases, 10th Revision code J45-J46. Estimates of age-standardized mortality rates and total national asthma deaths were calculated based on yearly population data. Statistical analysis was performed to investigate the influence of various factors on asthma mortality.

Results

Between 2014 and 2020, a total of 40 116 asthma deaths occurred in DSPs. Standardized asthma mortality per 100 000 people decreased from 1.79 (95% CI: 1.74-1.83) in 2014 to 1.07 (95% CI: 1.03-1.10) in 2020 in China. In 2020, the overall asthma mortality rate was higher for male patients than for female patients, and asthma mortality rates increased substantially with age. Age-standardized asthma mortality per 100,000 people exhibited significant geographic variation, ranging from 0.93 (95% CI: 0.89-0.98) in Eastern China to 1.04 (95% CI: 0.98-1.10) in Central China and 1.37 (95% CI: 1.29-1.45) in Western China in 2020. Asthma mortality in urban areas appeared to be higher than in rural areas. Socioeconomic factors, including gross domestic product per capita and density of hospital beds per 10,000 population, may be related to asthma mortality. Male asthma patients who lived in rural areas and were aged 65 years and above were generally at high risk of asthma-related mortality.

Conclusions

This study found a spatial and temporal trend for a reduction in asthma deaths over seven years in China; however, there remain important sociodemographic groups that have not secured the same decrease in mortality rates.

Trial registration

This was a purely observational study and thus registration was not required.

The 340B Program and Health Disparities Among Medicare Beneficiaries With Chronic Asthma

The study objective was to determine whether the discounts provided under the 340B program help address disparities in drug treatment and adverse outcomes among Medicare Fee-For-Service (FFS) beneficiaries initially Medicare-diagnosed with moderate to severe chronic asthma. Using Medicare FFS claims data from 2017 to 2019, we conducted a cross-sectional study that compared risk-adjusted differences in 5 treatment measures and 5 adverse outcomes among beneficiaries treated within 340B and non-340B hospital systems that met the disproportionate share (DSH) criteria and the ownership classification requirement to qualify as a 340B DSH hospital. Our analysis focused on potential disparities that are historically associated with challenges to accessing quality health care. We did not observe fewer disparities in drug treatments or adverse outcomes for beneficiaries with moderate to severe asthma treated at 340B hospital systems compared to non-340B hospital systems. These results raise questions as to whether 340B hospital systems are effectively using discounts to focus on improved access and outcomes for vulnerable beneficiaries.

Diversity, Equity, and Inclusion within Pediatric Adherence Science

Given the long-standing history of systemic racism in psychological science, diversity, equity, and inclusion (DEI) efforts are increasingly vital to the advancement and improvement of the field. This commentary extends the seminal work of the article Upending Racism in Psychological Science: Strategies to Change How Our Science is Conducted, Reported, Reviewed, and Disseminated (Buchanan et al., Am Psychol, https://doi.org/10.31234/osf.io/6nk4x , 2020) by providing tangible applications and recommendations to improve DEI integration into pediatric adherence science. Real-world adherence examples are discussed regarding the challenges faced in systematically integrating DEI principles, potential solutions to overcoming barriers, and the implications of these efforts on scientific advancement in an effort to address and dismantle research practices that perpetuate inequity and White supremacy. Specifically, we provide discourse and practical guidance related to the conduct, reporting, reviewing, and dissemination of pediatric adherence science to promote dialog and produce actionable change toward the promotion of health equity and social justice.

Benefits of specialist severe asthma management: demographic and geographic disparities

BACKGROUND

The benefits of specialist assessment and management have yet to be evaluated within the biologic era of UK severe asthma treatment, and potential disparities have not been considered.

METHODS

In an uncontrolled before-and-after study, we compared asthma symptoms (Asthma Control Questionnaire-6 (ACQ-6)), exacerbations, unscheduled secondary care use, lung function (forced expiratory volume in 1 s (FEV1)) and oral corticosteroid (OCS) dose after 1 year. We compared outcomes by sex, age (18-34, 35-49, 50-64 and ≥65 years), ethnicity (Caucasian versus non-Caucasian) and hospital site after adjusting for demographics and variation in biologic therapy use.

RESULTS

1140 patients were followed-up for 1370 person-years from 12 specialist centres. At annual review, ACQ-6 score was reduced by a median (interquartile range (IQR)) of 0.7 (0.0-1.5), exacerbations by 75% (33-100%) and unscheduled secondary care by 100% (67-100%). FEV1 increased by a median (IQR) of 20 (-200-340) mL, while OCS dose decreased for 67% of patients. Clinically meaningful improvements occurred across almost all patients, including those not receiving biologic therapy. There was little evidence of differences across demographic groups, although those aged ≥65 years demonstrated larger reductions in exacerbations (69% versus 52%; p<0.001) and unscheduled care use (77% versus 50%; p<0.001) compared with patients aged 18-34 years. There were >2-fold differences between the best and worst performing centres across all study outcomes.

CONCLUSIONS

Specialist assessment and management is associated with substantially improved patient outcomes, which are broadly consistent across demographic groups and are not restricted to those receiving biologic therapy. Significant variation exists between hospitals, which requires further investigation.

Social Inequalities: Do They Matter in Asthma, Bronchitis, and Respiratory Symptoms in Children?

Background: Social inequalities (e.g., poverty and low level of education) generate inequalities in health. Aim: The aim of the study was to determine the relationships between indicators of social inequalities and the frequency of respiratory symptoms, asthma, and bronchitis in children. Material and Methods: In 2019, an epidemiological cross-sectional study on 3237 students from elementary schools in Silesia Voivodships (South Poland) was conducted. The students' parents completed a questionnaire based on the International Study on Asthma and Allergies in Childhood (ISAAC). Social inequalities in the children's families were determined according to parents' education and professional status (working vs. unemployed), self-assessment of economic status, and housing conditions. To determine the influence of social factors on the occurrence of asthma, bronchitis, and respiratory symptoms, the odds ratio (OR) was calculated. Results: Children living in apartments with traces of mold had a higher risk of developing asthma (OR = 1.5, 95%CI: 1.17-1.96; p = 0.002) or bronchitis (OR = 1.4, 95%CI: 1.13-1.72; p = 0.002), wheezing attacks at nights (OR = 1.4; 95%CI: 1.01-1.93), wheezy in the last 12 months (OR = 1.6; 95%CI:1.24-2.08; p < 0.001), and chronic cough (OR = 1.9; 95%CI: 1.49-2.46; p < 0.001). Exposure to environmental tobacco smoke (ETS) was associated with higher risk of cough (OR = 1.5 95%CI: 1.22-1.96; p < 0.001) and dyspnea in the last 12 months (OR = 1.4; 95%CI: 1.04-2.00; p = 0.02). Low socioeconomic status (SES) was associated with increased risk of chronic cough (OR = 1.5; 95%CI: 1.09-2.03; p = 0.009) and increased risk of wheezy in the last 12 months (OR = 1.4; 95%CI: 1.06-1.97; p = 0.008). Asthma and bronchitis were not dependent on parents' education or professional status. Conclusions: Social inequalities have significant impacts on the occurrence of respiratory symptoms, bronchitis, and asthma in children. Interventions aimed at preventing bronchitis and childhood asthma should also focus on social health determinants.

Socioeconomic status is associated with healthcare seeking behaviour and disease burden in young adults with asthma - A nationwide cohort study

Introduction

Specialist management of asthma has been shown to associate with socioeconomic status (SES). However, little is known about the influence of SES on care burden in universal healthcare settings.

Methods

Patients aged 18–45 years using inhaled corticosteroids (ICS) were followed in national databases. Impact of asthma was investigated using negative binomial regression adjusted for age, sex, comorbidity, and GINA 2020 Step. Uncontrolled asthma was defined as >600 annual SABA puffs, ≥2 prednisolone courses and/or ≥1 hospitalization.

Results

A total of 60,534 (55% female, median age 33 (IQR 25–39)) patients were followed for 10.1 years (IQR 5.2–14.3)). Uncontrolled asthma resulted in 6.5 and 0.51 additional annual contacts to primary care and pulmonologists, respectively.

Unscheduled and primary care burden was dependent on SES, increasing with rural residence, lower education, income and receiving welfare. Differences in planned respiratory care were slight, only seen among divorced, low income- or welfare recipients. Lower SES was consistently associated with an increased utilization of SABA and prednisolone. No dose–response relationship between ICS use and SES could be identified.

Conclusion

Lower SES in asthma is a risk factor for a predominance of unscheduled care and adverse outcomes, warranting further attention to patients’ background when assessing asthma care.