Asthma morbidity and treatment in the Chicago metropolitan area: one decade after national guidelines

Ethnic variation in asthma healthcare utilisation and exacerbation: systematic review and meta-analysis

Background

Patients from ethnic minority groups (EMGs) frequently report poorer asthma outcomes; however, a broad synthesis summarising ethnic disparities is yet to be undertaken. What is the magnitude of ethnic disparities in asthma healthcare utilisation, exacerbations and mortality?

Methods

MEDLINE, Embase and Web of Science databases were searched for studies reporting ethnic variation in asthma healthcare outcomes (primary care attendance, exacerbation, emergency department (ED) visits, hospitalisation, hospital readmission, ventilation/intubation and mortality) between White patients and those from EMGs. Estimates were displayed using forest plots and random-effects models were used to calculate pooled estimates. We conducted subgroup analyses to explore heterogeneity, including by specific ethnicity (Black, Hispanic, Asian and other).

Results

65 studies, comprising 699 882 patients, were included. Most studies (92.3%) were conducted in the United States of America (USA). Patients from EMGs had evidence suggestive of lower levels of primary care attendance (OR 0.72, 95% CI 0.48-1.09), but substantially higher ED visits (OR 1.74, 95% CI 1.53-1.98), hospitalisations (OR 1.63, 95% CI 1.48-1.79) and ventilation/intubation (OR 2.67, 95% CI 1.65-4.31) when compared to White patients. In addition, we found evidence suggestive of increased hospital readmissions (OR 1.19, 95% CI 0.90-1.57) and exacerbation rates (OR 1.10, 95% CI 0.94-1.28) among EMGs. No eligible studies explored disparities in mortality. ED visits were much higher among Black and Hispanic patients, while Asian and other ethnicities had similar rates to White patients.

Conclusions

EMGs had higher secondary care utilisation and exacerbations. Despite the global importance of this issue, the majority of studies were performed in the USA. Further research into the causes of these disparities, including whether these vary by specific ethnicity, is required to aid the design of effective interventions.

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

BACKGROUND

Prior studies investigating the effect of socioeconomic status (SES) on asthma health care outcomes have been heterogeneous in the populations studied and methodologies used.

OBJECTIVE

We sought to systematically synthesize evidence investigating the impact of SES on asthma health care utilization, exacerbations, and mortality.

METHODS

We searched Embase, Medline, and Web of Science for studies reporting differences in primary care attendance, exacerbations, emergency department attendance, hospitalization, ventilation/intubation, readmission, and asthma mortality by SES. Study quality was assessed using the Newcastle Ottawa Scale, and meta-analyses were conducted using random-effects models. We conducted several prespecified subgroup analyses, including by health care system (insurance based vs universal government funded) and time period (before vs after 2010).

RESULTS

A total of 61 studies, comprising 1,145,704 patients, were included. Lower SES was consistently associated with increased secondary health care utilization including emergency department attendance (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.40-1.84), hospitalization (OR, 1.63; 95% CI, 1.34-1.99), and readmission (OR, 1.31; 95% CI, 1.19-1.44). Substantial associations were also found between SES and ventilation/intubation (OR, 1.76; 95% CI, 1.13-2.73), although there was no association with primary care attendances (OR, 0.79; 95% CI, 0.51-1.24). We found evidence of borderline significance for increased exacerbations (OR, 1.18; 95% CI, 0.98-1.42) and mortality (OR, 1.12; 95% CI, 0.92-1.37) among more deprived groups. There was no convincing evidence that disparities were associated with country-level health care funding models or that disparities have narrowed over time.

CONCLUSIONS

Patients with a lower SES have substantially increased secondary care health care utilization. We found evidence suggestive of increased exacerbations and mortality risk, although CIs were wide. These disparities have been consistently reported worldwide, including within countries offering universally funded health care systems. Systematic review registration: CRD42020173544.

The paucity of ethical analysis in allergology

While a growing body of research is uncovering the aetiology and effective treatments for allergy, research that assess the broader ethical implications of this disease is lacking significantly. This article will demonstrate both the paucity of academic research concerning ethical implications in allergy and explain why ethical analysis is integral to formulating effective health strategies for allergic disease. An exhaustive literature search of publications in French and English identified less than 35 academic articles focussed on the topic of ethics and allergy; this is a miniscule number when compared to the amount of articles published on ethical issues related to other chronic illnesses, such as obesity. It is important to demonstrate to allergy specialists the need for, and utility of, further incorporating ethical analyses in allergology; the current success of Ethical, Legal, Social Implications (ELSI) research programmes in human genetics and nanotechnology will serve as notable examples. Indeed, future research and innovation in allergy will undoubtedly encounter ethical dilemmas and the allergology community should play a significant role in helping to address these issues. However, incorporating ethical analyses in allergology does not imply that the allergology community must acquire extensive knowledge in bioethics; instead, interdisciplinary research that incorporates expertise from allergology and bioethics would enable allergy specialists to advance critical knowledge development in this largely overlooked domain of study.

Computer-assisted school-based asthma management: a pilot study

Background

The high prevalence of asthma among children continues to be a major public health issue. In particular, low-income African-American and Hispanic children often receive asthma care in the emergency department and lack access to continuity of care.

Objective

The aim of the current study was to test the feasibility of implementing a computerized program for empowering low-income children with asthma to manage their own disease. This pilot program consisted of a guided, personalized, Web-based computer program as the main component of a school-based asthma intervention.

Methods

The Automated Live E-Health Response Tracking System (ALERTS), a computer-assisted, Web-based tracking program, was tested for implementation in a school in East Harlem, New York. The program required children with asthma, assisted by trained researchers, to routinely measure their peak flow meter readings and answer a symptom questionnaire. The program provided individualized feedback on their disease status based on peak flow meter input. The computer program sent reports to the child’s physician and the nurse practitioner at the on-site school health center. The children were also encouraged to bring the reports home to their parents. A pre/post study design was employed such that each participant acted as his/her own control. Comparisons of preintervention and postintervention outcomes were calculated using the paired t-test and the McNemar test for dichotomous data.

Results

Twenty-four children (6 to 12 years) participated in the program over 2 to 15 months. Improvements in health outcomes showed the greatest significance among the group of participants who were enrolled for 8 months or longer. Statistically significant improvements were seen in the average physical health score of the children (from 65.64 preintervention to 76.28 postintervention, P = .045). There was a significant decrease in the number of participants experiencing wheezing episodes (n = 9 to n = 2, P = .03), and in the average number of wheezing episodes per child (1.86 to 0.43, P = .02). Although not statistically significant, decreases were also seen in the number of children experiencing an asthma attack and in the average number of asthma attacks among participants. There was also a significant decrease in the average number of visits to doctors’ offices or clinics (1.23 to 0.38, P = .04). There were no overnight hospitalizations in the two-week period following the end of the pilot program, a nonsignificant reduction from an average of 0.21 per child.

Conclusion

This individualized, computer-assisted intervention resulted in improvements in some health outcomes among low-income children in an urban, public school-based setting. Consistent peak flow meter self-measurements, management of medication usage, and a computerized approach to symptom tracking resulted in fewer asthma exacerbations and improved overall physical health among this pediatric population with asthma.

The use of telemedicine access to schools to facilitate expert assessment of children with asthma

Research has shown that access to an asthma specialist improves asthma outcomes. We hypothesized that we could improve access to expert asthma care through a telemedicine link between an asthma specialist and a school-based asthma program. We conducted a prospective cohort study in 3 urban schools to ascertain the feasibility of using an asthma-focused telemedicine solution. Each subject was seen by an asthma expert at 0, 8, and 32 weeks. The assessment and recommendations for care were sent to the primary care physician (PCP) and parents were told to contact their physician for follow-up care. Eighty three subjects participated in the study. Subjects experienced improvement (P < .05) in family social activities and the number of asthma attacks. Ninety four percent of subjects rated the program as good or excellent. This study demonstrates the feasibility and acceptance of a school-based asthma program using a telemedicine link to an asthma specialist.

Trends in admissions for pediatric status asthmaticus in New Jersey over a 15-year period

OBJECTIVE

Status asthmaticus accounts for a large portion of the morbidity and mortality associated with asthma, but we know little about its epidemiology. We describe here the hospitalization characteristics of children with status asthmaticus, how they changed over time, and how they differed between hospitals with and without PICUs.

PATIENTS AND METHODS

We used administrative data from New Jersey that included all hospitalizations in the state from 1992, 1995, and 1999-2006. We identified children with status asthmaticus by using International Classification of Diseases, Ninth Revision, diagnosis codes that indicate status asthmaticus and the use of mechanical ventilation by using procedure codes. We designated hospitals with a PICU as "PICU hospitals" and those without as "adult hospitals."

RESULTS

We identified 28 309 admissions of children with status asthmaticus (22.8% of all asthma hospitalizations). From 1992 to 2006, the rate of hospital admissions decreased by half (from 1.98 in 1000 to 0.93 in 1000 children), and there was a 70% decrease in the number of children admitted to adult hospitals. The rate of ICU care in PICU hospitals more than tripled. However, the rate of mechanical ventilation remained low, and the number of deaths was small and unchanged (n=14 total). Hospital costs climbed from $6.6 million to $9.5 million.

CONCLUSIONS

Although fewer children are being admitted with status asthmaticus, the proportion of patients managed in PICUs is climbing. There has been no substantial change in rates of mechanical ventilation or death. Additional research is needed to better understand how patients and physicians decide on the appropriate site for hospital care and how that choice affects outcome.

The association between community crime and childhood asthma prevalence in Chicago

BACKGROUND

Little attention has been given to exposure to crime as a possible socioenvironmental contributor to variability in urban childhood asthma prevalence.

OBJECTIVE

To determine the association of violent crime, property crime, and drug abuse violations with childhood asthma prevalence in Chicago.

METHODS

In 2003-2005, the Chicago Initiative to Raise Asthma Health Equity conducted an asthma screening survey of children in grades K to 8 attending Chicago public and Catholic schools. Crime data were obtained from the Chicago Police Department. In addition to simple regression analysis, multilevel logistic regression analysis was performed to estimate the effect of criminal activity on neighborhood asthma variance.

RESULTS

Of the surveys returned, 45,371 (93%) were geocoded into 247 neighborhoods. Neighborhoods were divided into quartile groups by mean asthma prevalence (9%, 12%, 17%, and 22%). Criminal activity (annual incidence per 100,000 people) was significantly higher (P < .001) in neighborhoods with a high asthma prevalence, especially drug abuse violations, which increased more than 6-fold (461 vs 2,921), and violent crimes, which increased more than 3-fold (448 vs 1,566). After adjusting for community race/ethnicity, only violent crime continued to be significantly associated with the neighborhood asthma prevalence (odds ratio, 1.27; 95% confidence interval, 1.04-1.55, P < .05). When considered alongside sociodemographic and individual characteristics, violence continued to contribute significantly (P < .05), explaining 15% of neighborhood variation in childhood asthma.

CONCLUSIONS

Evidence suggests an association between violent crime and childhood asthma prevalence in Chicago. A deeper understanding of the mechanisms that underlie this association may lend insight into potential interventions to address urban asthma.

Unawareness and undertreatment of asthma: follow-up in a different geographic area in Denmark

BACKGROUND

Early detection and treatment of asthma is important to minimize morbidity and healthcare costs. The objective of this study was to investigate asthma awareness and management in a western society.

METHODS

In a random sample of 10 400 subjects aged 14-44 years, 686 (6.6%) reported symptoms of asthma in a standardized screening questionnaire. All 686 were evaluated by respiratory specialists and diagnosed by history, symptoms, lung function tests, bronchial challenges and allergy testing. Of these 686 participants, 69 (10%) had asthma alone, 205 (30%) had rhinitis alone and 217 (32%) had both asthma and rhinitis; 195 (28%) had nonasthmatic respiratory reports.

RESULTS

Awareness of asthma was found among 163 (57%) of the 286 asthmatics, and 204 (95%) had doctor-diagnosed rhinitis as well. In a multivariate regression analysis, comorbidity with rhinitis (beta = 0.489, P < 0.001), smoking (beta = -0.116, P < 0.01), doctor-diagnosed bronchitis (beta = 0.086, P < 0.05), and earlier emergency visits at hospital (beta = 0.147, P < 0.001) was significantly associated with awareness. A difference in awareness was found between those who had asthma and rhinitis (62.2%) and those who had asthma alone (40.6%) (P < 0.01). Inhaled corticosteroids (ICS) were used by 27% of those with asthma, including 12% who used both ICS and long-acting beta-agonist.

CONCLUSIONS

More than half of the persons with asthma were aware of their disorder; and the awareness was more likely in those with comorbidity of rhinitis. In general, asthma management was inadequate.

The protective effect of community factors on childhood asthma

BACKGROUND

Asthma burden in the US is not evenly distributed. Although asthma prevalence varies widely across urban neighborhoods, little attention has been paid to the community as a key contributor.

OBJECTIVE

To determine the effect of positive socio-environmental community factors on childhood asthma prevalence in Chicago.

METHODS

From 2003 to 2005, an asthma screening survey was conducted among children attending Chicago Public/Catholic schools from kindergarten through eighth grade. One hundred five schools participated, yielding a stratified representation of 4 race-income groups. Positive community factors, such as social capital, economic potential, and community amenities, were assessed by using the Metro Chicago Information Center's Community Vitality Index.

RESULTS

Of the surveys returned, 45,177 (92%) were geocoded into 287 neighborhoods. Neighborhoods were divided into quartile groups by asthma prevalence (mean, 8%, 12%, 17%, 25%). Community vitality (54% vs 44%; P < .0001) and economic potential (64% vs 38%; P < .0001) were significantly higher in neighborhoods with low asthma prevalence. Neighborhood interaction (36% vs 73%; P < .0001) and stability (40% vs 53%; P < .0001) were significantly higher in neighborhoods with high asthma prevalence. Overall, positive factors explained 21% of asthma variation. Childhood asthma increased as the black population increased in a community (P < .0001). Accordingly, race/ethnicity was controlled. In black neighborhoods, these factors remained significantly higher in neighborhoods with low asthma prevalence. When considered alongside socio-demographic/individual characteristics, overall community vitality as well as social capital continued to contribute significantly to asthma variation.

CONCLUSION

Asthma prevalence in Chicago is strongly associated with socio-environmental factors thought to enrich a community. A deeper understanding of this impact may lend insight into interventions to reduce childhood asthma.

The 2007 National Asthma Education and Prevention Program asthma guidelines: accelerating their implementation and facilitating their impact on children with asthma

Nearly 2 decades have elapsed since the National Center for Health Statistics raised concerns regarding the trends in increasing asthma prevalence. Additional research highlighted the large racial disparities and geographic variations in asthma morbidity and mortality rates. Although there was little national consensus on the care of children with asthma at the time, there were improvements in the understanding of the mechanisms and treatment of asthma. It was in this context that the National Heart, Lung, and Blood Institute launched the National Asthma Education and Prevention Program, which convened its first panel of experts to create the national consensus clinical practice guidelines on the treatment of asthma. More than 15 years have passed since the publication of those first guidelines and, in August 2007, the National Heart, Lung, and Blood Institute released its newest updates, which are the product of the National Asthma Education and Prevention Program third expert panel. The release of the updated guidelines serves as an occasion to examine important issues regarding the dissemination and clinical implementation of National Asthma Education and Prevention Program guidelines. The goals of this report are to examine the adoption of earlier versions of the National Asthma Education and Prevention Program guidelines and to suggest opportunities for rapid adoption of the newly released guidelines.

Racial disparities in asthma-related health outcomes in severe or difficult-to-treat asthma

BACKGROUND

The underlying reasons for racial disparities in asthma morbidity are not well understood. Multivariate epidemiologic studies evaluating the presence and extent of racial differences in a large cohort of adults with severe or difficult-to-treat asthma are lacking.

OBJECTIVE

To analyze an extensive array of clinical and patient-reported outcomes, using multivariate analysis with a sequential approach, to explain racial differences in asthma-related outcomes in one of the largest cohorts of difficult-to-treat asthmatic patients.

METHODS

Black and white patients (> or = 18-years-old at baseline) were included (n = 2,128). Differences between the 2 racial groups were assessed using several outcome measures at month 12. Assessments were adjusted for confounding variables using a sequence of statistical models.

RESULTS

Most patients were white (88.6%). Blacks were slightly younger, less educated, and more likely to live in urban areas than whites. Blacks were more likely to have severe asthma and to be treated with 3 or more long-term controllers. Poorer quality of life, more asthma control problems, and higher risk of emergency department visits were observed in blacks compared with whites; differences were not explained by adjustment for broad sets of confounding variables. Differences in asthma-related health outcomes remained statistically significant after adjusting for asthma severity.

CONCLUSIONS

Asthma is a serious health problem in blacks and is not explained by differences in demographics, severity, or other health conditions.

Asthma burden in a citywide, diverse sample of elementary schoolchildren in Chicago

OBJECTIVE

The purposes of this study are to describe and develop preliminary models of the burden of diagnosed asthma and symptoms of possible undiagnosed asthma in a large, citywide, ethnically and socioeconomically diverse sample of Chicago elementary schoolchildren. We hypothesized that considering possible asthma would give a more complete picture of race/ethnic disparities in pediatric asthma.

METHODS

We studied 35,583 students aged 6 to 12 years attending Chicago Public and Archdiocese elementary schools for the Chicago Initiative to Raise Asthma Health Equity (CHIRAH) study. The full enrollments of 105 schools were surveyed for asthma and possible undiagnosed asthma by the Brief Pediatric Asthma Screen Plus (BPAS+) respiratory symptoms. The child had to be 6 to 12 years old, the valid age range for the BPAS+. Questionnaires included the BPAS+, basic demographic information, and household asthma information; they were sent home with each schoolchild for completion by the parent and returned to school for collection and scoring.

RESULTS

Overall, 13.9% of students had diagnosed asthma. For children aged 6 to 12 years, rates of diagnosed asthma varied from 13.1% to 14.5%, whereas the rates of possible undiagnosed asthma varied from 14.8% to 10.9%. The rate of diagnosed asthma was 21.2% for African Americans, 9.7% for whites, 11.8% for Hispanics, with similar rates of possible undiagnosed asthma. By multinomial logistic regression, African Americans were more than twice as likely and Hispanics were 1.57 times more likely than whites to have diagnosed asthma at all school district income levels and controlling for other household members with asthma, type of school, age of the child, gender, and language preference. The odds of African Americans being diagnosed with asthma rather than having possible asthma were 76% higher and for Hispanics were 46% higher compared with whites, at all school district income levels and controlling for other household members with asthma, type of school, age of the child, gender, and language preference.

CONCLUSIONS

Our study confirms national disparities in diagnosed asthma by race/ethnicity. Respiratory symptoms consistent with possible undiagnosed asthma increase the total potential burden of asthma overall to more than one-quarter of the school enrollees. Among students with respiratory symptoms, African Americans, Hispanics (controlling for language), and families where another person has asthma are more likely to have diagnosed rather than possible asthma. Improved knowledge about asthma, recognition of symptoms, and access to high-quality care are necessary to ascertain how much of the possible undiagnosed asthma represents additional cases of asthma requiring treatment.

Geographic variability in childhood asthma prevalence in Chicago

BACKGROUND

Childhood asthma prevalence has been shown to be higher in urban communities overall without an understanding of differences by neighborhood.

OBJECTIVE

To characterize the geographic variability of childhood asthma prevalence among neighborhoods in Chicago.

METHODS

Asthma screening was conducted among children attending 105 Chicago schools as part of the Chicago Initiative to Raise Asthma Health Equity. Additional child information included age, sex, race/ethnicity, and household members with asthma. Surveys were geocoded and linked with neighborhoods. Neighborhood information on race, education, and income was based on 2000 census data. Bivariate and multilevel analyses were performed.

RESULTS

Of the 48,917 surveys, 41,255 (84.3%) were geocoded into 287 neighborhoods. Asthma prevalence among all children was 12.9%. Asthma rates varied among neighborhoods from 0% to 44% (interquartile range, 8% to 24%). Asthma prevalence (mean, SD, range) in predominantly black neighborhoods (19.9, +/-7, 4% to 44%) was higher than in predominantly white neighborhoods (11.4, +/-4.7, 2% to 30%) and predominantly Hispanic neighborhoods (12.1, +/-6.8, 0% to 29%). Although sex, age, household members with asthma, and neighborhood income significantly affected asthma prevalence, they did not explain the differences seen between neighborhoods. Race explained a significant proportion (about 80%) but not all of this variation.

CONCLUSION

Childhood asthma prevalence varies widely by neighborhood within this urban environment. Adjacent areas in Chicago were identified with significantly different asthma prevalence. A better understanding of the effect of neighborhood characteristics may lend insight into potential interventions to reduce childhood asthma.

Part II: Inhaler technique and adherence to therapy

Although the importance of effective asthma management has been well established, in many patients asthma control remains suboptimal. While numerous factors likely contribute to inadequate control of asthma symptoms, studies have demonstrated that many patients fail to use their inhaler devices correctly, which may compromise asthma treatment. To ensure that patients use their inhaler devices appropriately, the choice of inhaler should be matched to each individual patient's capabilities and preferences. Thorough patient education regarding the effective use of the selected inhaler, repeated demonstrations on proper inhalation technique, and frequent patient follow-up is necessary to ensure that inhalers are operated correctly. Patient adherence to therapy, which traditionally has been poor, is another factor that may negatively affect asthma control. Patient attitudes and perceptions regarding the effectiveness of therapy, the risks of inadequate asthma control, and the need for daily controller medications all influence compliance. Consequently, effective education regarding the benefits of treatment and the risks of nonadherence is critical to enhancing patient adherence, self-care skills, and, potentially, asthma control.

The value of care algorithms

The use of protocols or care algorithms in medical facilities has increased in the managed care environment. The definition and application of care algorithms, with a particular focus on the treatment of acute bronchospasm, are explored in this review. The benefits and goals of using protocols, especially in the treatment of asthma, to standardize patient care based on clinical guidelines and evidence-based medicine are explained. Ideally, evidence-based protocols should translate research findings into best medical practices that would serve to better educate patients and their medical providers who are administering these protocols. Protocols should include evaluation components that can monitor, through some mechanism of quality assurance, the success and failure of the instrument so that modifications can be made as necessary. The development and design of an asthma care algorithm can be accomplished by using a four-phase approach: phase 1, identifying demographics, outcomes, and measurement tools; phase 2, reviewing, negotiating, and standardizing best practice; phase 3, testing and implementing the instrument and collecting data; and phase 4, analyzing the data and identifying areas of improvement and future research. The experiences of one medical institution that implemented an asthma care algorithm in the treatment of pediatric asthma are described. Their care algorithms served as tools for decision makers to provide optimal asthma treatment in children. In addition, the studies that used the asthma care algorithm to determine the efficacy and safety of ipratropium bromide and levalbuterol in children with asthma are described.

Asthma prevention in urbanites

OBJECTIVES

The purpose of this intervention was to evaluate the efficacy of low-literacy asthma education and the provision of free asthma controller medications to persons living in the urban inner-city.

METHODS

The intervention was conducted as a series of three studies. A health educator from the Johnson Health Center (JHC) performed chart reviews in the first two studies to identify urban asthma patients with frequent emergency department (ED) visits. The third study evaluated participants from the community-at-large who came to the ED for episodic asthma care. Free controller medications and education were provided to participants in all three studies.

RESULTS

Emergency department utilization, inpatient admissions, and consumer medical costs were greatly reduced in all three studies during the 5-year intervention period. Lung function improved, and participants reported an improved quality of life.

CONCLUSION

The provision of free asthma controller medications resulted in greatly improved asthma management and reduced costs. There was no evidence that an asthma education component per se produced any of the changes.

Predictors of asthma control in children from different ethnic origins living in Amsterdam

To identify factors associated with asthma control in a multi-ethnic paediatric population. We interviewed 278 children with paediatrician diagnosed asthma (aged 7-17 years) and one of their parents. Asthma control was assessed with the Asthma Control Questionnaire (ACQ). Detailed information about sociodemographic variables, asthma medication, knowledge of asthma, inhalation technique and environmental factors were collected. Turkish and Moroccan parents were interviewed in their language of choice. Logistic regression analyses were used to identify correlates of asthma control. Of the 278 children, 85 (30.6%) were Dutch, 84 (30.2%) were Moroccan, 58 (20.9%) were Turkish and 51 (18.3%) were Surinamese. Overall, almost 60% had a status of well-controlled asthma, as indicated by the ACQ. Only 51 of the 142 (35.9%) Moroccan and Turkish parents had a good comprehension of the Dutch language. In logistic regression analyses the risk of having uncontrolled asthma was significantly higher among Surinamese children (OR 2.3; 95% CI 1.06-4.83), respondents with insufficient comprehension of the Dutch language (OR 2.3; 95% CI 1.08-4.78), children using woollen blankets (OR 9.8; 95% CI 1.52-63.42), and significantly lower among male (OR 0.5; 95% CI 0.31-0.91) and non-daily users of inhaled corticosteroids (OR 0.6; 95% CI 0.38-1.07). In conclusion, ethnicity as well as insufficient comprehension of the Dutch language appeared to be independent risk factors for uncontrolled asthma. Special attention should be given to children from immigrants groups for example by calling in an interpreter by physicians when comprehension is insufficient.