Understanding the reasons for poor asthma outcomes in ethnic minorities: welcome progress, but important questions remain

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.

Ethnic variations in asthma hospital admission, readmission and death: a retrospective, national cohort study of 4.62 million people in Scotland

BACKGROUND

Our previous meta-analysis found that South Asians and Blacks in the UK were at a substantially increased risk of hospital admission from asthma. These estimates were, however, derived from pooling data from a limited number of now dated studies, confined to only three very broad ethnic groups (i.e. Whites, South Asians and Blacks) and failed to take account of possible sex-related differences in outcomes within these ethnic groups. We undertook the first study investigating ethnic variations in asthma outcomes across an entire population.

METHODS

This retrospective 9-year cohort study linked Scotland's hospitalisation/death records on asthma to the 2001 census (providing ethnic group). We calculated age, country of birth and Scottish Index of Multiple Deprivation adjusted incident rate ratios (IRRs) for hospitalisation or death by sex for the period May 2001-2010. We calculated hazard ratios (HRs) for asthma readmission and subsequent asthma death.

RESULTS

We were able to link data on 4.62 million people (91.8% of the Scottish population), yielding over 38 million patient-years of data, 1,845 asthma deaths, 113,795 first asthma admissions, and 107,710 readmissions (40,075 of which were for asthma). There were substantial ethnic variations in the rate of hospitalisation/death in both males and females. When compared to the reference Scottish White population, the highest age-adjusted rates were in Pakistani males (IRR = 1.59; 95% CI, 1.30-1.94) and females (IRR = 1.50; 95% CI, 1.06-2.11) and Indian males (IRR = 1.34; 95% CI, 1.16-1.54), and the lowest were seen in Chinese males (IRR = 0.62; 95% CI, 0.41-0.94) and females (IRR = 0.49; 95% CI, 0.39-0.61).

CONCLUSION

There are very substantial ethnic variations in hospital admission/deaths from asthma in Scotland, with Pakistanis having the worst and Chinese having the best outcomes. Cultural factors, including self-management and health seeking behaviours, and variations in the quality of primary care provision are the most likely explanations for these differences and these now need to be formally investigated.

Inhaled corticosteroid adherence in paediatric patients: the PACMAN cohort study

AIMS

Poor adherence with inhaled corticosteroids (ICSs) has been reported frequently and may be associated with uncontrolled asthma. A better understanding of factors influencing adherence may help to achieve higher adherence rates for a larger part of the population, which will eventually lead to better asthma control. The aim of this study was to investigate factors associated with adherence in paediatric ICS users.

METHODS

We included 527 children using ICSs who participated in the Pharmacogenetics of Asthma Medication in Children: Medication with Anti-inflammatory Effects (PACMAN) cohort study. The outcome, a parent-reported adherence, was assessed by using the Medication Adherence Report Scale. Four categories of determinants were studied: child characteristics, family characteristics, medication use (parental beliefs towards medication; using Beliefs about Medicines Questionnaire) and environmental factors.

RESULTS

Good adherence was observed in 302 children (57%). Increased fractional exhaled nitric oxide values (indication for airway inflammation) were associated with a lower chance of good adherence (OR = 0.25, 95%CI = 0.15-0.41). Parental necessity beliefs about medication were associated with higher adherence (OR = 2.32, 95%CI = 1.59-3.39). Dutch origin was also associated with higher adherence rates (OR = 2.11, 95%CI = 1.09-4.07). Furthermore, younger age (< 6 years) was associated with better adherence (OR = 1.62, 95%CI = 1.02-2.59).

CONCLUSIONS

Increased airway inflammation was associated with lower ICS adherence, which underlines the need of good adherence to reach disease control. Our results suggest that by improving knowledge, especially in ethnic minorities, and by stimulating positive parental perception towards the nature of the disease, the characteristics of the prescribed drugs and the use of medications, better adherence and as a result better asthma control could be reached.

The role of income in reducing racial and ethnic disparities in emergency room and urgent care center visits for asthma-United States, 2001-2009

OBJECTIVE

To examine racial/ethnic disparities and associated factors in asthma-related emergency room (ER) and urgent care center (UCC) visits among US adults and determine whether disparities vary across increasing income strata.

METHODS

We analyzed data from 238,678 adult respondents from the 2001 to 2009 National Health Interview Survey and calculated the weighted annual prevalence of an ER/UCC visit for persons with current asthma. We used logistic regression to calculate adjusted odds ratios (AORs) for asthma-related ER/UCC visits by race/ethnicity and income, adjusting for demographics, socioeconomic, and other health-related factors.

RESULTS

The average annual prevalence of asthma-related ER/UCC visits among adults with current asthma was highest for Puerto Ricans (24.8%, 95% confidence interval [CI]: 20.3-29.9) followed by non-Hispanic American Indian/Alaskan Natives (22.1%, 95% CI: 14.4-32.4), non-Hispanic blacks (20.4%, 95% CI: 18.5-22.4), other Hispanics (17.3%, 95% CI: 15.0-19.9), Asians (11.0%, 95% CI: 7.8-15.4), and non-Hispanic whites (10.1%, 95% CI: 9.4-10.9). Puerto Ricans (AOR: 2.01; 95% CI: 1.54-2.62), non-Hispanic blacks (AOR: 1.72; 95% CI: 1.46-2.03), and other Hispanics (AOR: 1.55; 95% CI: 1.25-1.92) with current asthma had significantly higher odds of an asthma-related ER/UCC visit than non-Hispanic whites. Lower socioeconomic status, obesity, and serious psychological distress were also associated with higher odds of asthma-related ER/UCC visits. Puerto Ricans with the lowest income (AOR: 3.52; 95% CI: 2.27-5.47), non-Hispanic American Indian/Alaskan Natives with the highest income (AOR: 5.71; 95% CI: 1.48-22.13), and non-Hispanic blacks in every income stratum had significantly higher odds of asthma-related ER/UCC visits compared to non-Hispanic whites in the highest income stratum.

CONCLUSIONS

Racial/ethnic disparities in asthma-related ER/UCC visits persist after accounting for income and other socioeconomic factors. Further research is needed to identify modifiable risk factors directly associated to race/ethnicity to decrease the asthma burden on minority populations.

Promoting recruitment of minority ethnic groups into research: qualitative study exploring the views of South Asian people with asthma

BACKGROUND

We sought to understand the barriers and facilitators to participation in research from the perspectives of South Asian people with asthma.

METHODS

Eight focus groups were conducted in the preferred language of participants. Sampling was purposeful to ensure inclusion of males and females from differing ethnic, linguistic and religious backgrounds.

RESULTS

The forming of trusting relationships was described as pivotal to the successful recruitment of minority ethnic groups into research; personalized approaches were likely to be better received than more impersonal written approaches. Notable barriers to participation included: the stigma of being labelled with asthma; concerns surrounding participation in pharmaceutical trials; major time or travel commitments and a failure to show respect by not making information available in minority ethnic languages. Flexibility, in terms of timing, location and respecting of cultural and religious sensitivities around gender segregation, together with the offer of incentives, were highlighted as key factors to promote participation.

CONCLUSIONS

The barriers to recruitment are largely surmountable, but these will necessitate the use of resource intensive and more personalized approaches than are commonly employed for the White European origin population. Our proposed model to enhance recruitment is likely to have transferability beyond the field of asthma.