Asthma self-assessment in a Medicaid population

Health Disparities: Interventions for Pulmonary Disease - A Narrative Review

There is expansive literature documenting the presence of health disparities, but there are disproportionately few studies describing interventions to reduce disparity. In this narrative review, we categorize interventions to reduce health disparity in pulmonary disease within the US health care system to support future initiatives to reduce disparity. We identified 211 articles describing interventions to reduce disparity in pulmonary disease related to race, income, or sex. We grouped the studies into the following four categories: biologic, educational, behavioral, and structural. We identified the following five main themes: (1) there were few interventional trials compared with the breadth of studies describing health disparities, and trials involving patients with asthma who were Black, low income, and living in an urban setting were overrepresented; (2) race or socioeconomic status was not an effective marker of individual pharmacologic treatment response; (3) telehealth enabled scaling of care, but more work is needed to understand how to leverage telehealth to improve outcomes in marginalized communities; (4) future interventions must explicitly target societal drivers of disparity, rather than focusing on individual behavior alone; and (5) individual interventions will only be maximally effective when specifically tailored to local needs. Much work has been done to catalog health disparities in pulmonary disease. Notable gaps in the identified literature include few interventional trials, the need for research in diseases outside of asthma, the need for high quality effectiveness trials, and an understanding of how to implement proven interventions balancing fidelity to the original protocol and the need to adapt to local barriers to care.

Impact of psychiatric illness upon asthma patients' health care utilization and illness control. Are all psychiatric comorbidities created equal?

The impact of psychiatric illnesses upon asthma patients' functioning is not well understood. This study examined the impact of psychiatric comorbidity upon illness management in asthma patients using empirically-derived psychiatric comorbidity groups. Participants were a clinic sample of Greek-speaking asthma patients (N = 212) assessed using the Patient Health Questionnaire (PHQ) Somatoform, Depression, Panic Disorder (PD), Other Anxiety Disorder, Eating Disorder (ED) and Alcohol sub-scales. The associations between sub-scales were examined using multiway frequency analysis. The following groups were derived: Somatoform disorder and/or Any Depressive disorder (n = 63), Somatoform disorder and/or Other Anxiety disorder (n = 51), Somatoform disorder and/or Any ED (n = 60), and Any Anxiety group including PD and/or Other Anxiety disorder (n = 24). Across all groups, psychiatric illness was associated with significantly worse asthma control (p < .01). Participants in Any Anxiety group, OR = 4.61, 95% CI [1.90, 11.15], Somatoform and/or Any Depressive disorder, OR = 2.06, 95% CI [1.04, 4.09] and Somatoform and/or Other Anxiety disorder, OR = 2.75, 95% CI [1.35, 5.60] were at higher risk for asthma-related Emergency Room (ER) visits compared to controls. However only Somatoform and/or Any Depressive disorder, OR = 3.67, 95% CI [1.60, 8.72], Somatoform and/or Other Anxiety disorder, OR = 5.50, 95% CI [2.34, 12.74], and Somatoform and/or Any ED, OR = 4.98, 95% CI [2.14, 11.60] group membership were risk factors for asthma-related hospitalizations. Results suggest that while comorbid psychiatric disorders generally negatively impact asthma illness management, different psychiatric comorbidities appear to have disparate effects upon illness management outcomes.

"No other choice": reasons for emergency department utilization among urban adults with acute asthma

OBJECTIVES

Asthma is considered "ambulatory care-sensitive," yet emergency department (ED) visits remain common. Few studies have examined how ED asthma patients choose their sites of urgent care. The authors explored reasons for asthma-related ED use among adults.

METHODS

From May to September 2012, semistructured qualitative interviews were conducted with a convenience sample of patients visiting a high-volume urban ED for asthma. A piloted interview guide was used; it had open-ended questions derived from clinical experience and a focus group of asthmatic adults who frequently use the ED for care. Interviews were conducted until theme saturation was reached. Interview transcripts and field notes were entered into NVivo 10 and double-coded, using an iterative process to identify patterns of responses, ensure reliability, examine discrepancies, and achieve consensus through content analysis.

RESULTS

Patients view their asthma symptoms in two categories: those they can manage at home and those requiring a provider's attention. Preferred site of acute asthma care varied, but most patients felt that they had little choice for acute exacerbations. Specific reasons for ED visits included wait times, acuity, insurance status, ED resources/expertise, lack of symptom improvement, lack of asthma medication, inability to access outpatient provider, referral by outpatient provider, and referral by friend or family member.

CONCLUSIONS

Barriers to urgent outpatient care may contribute to ED use for asthma. Additionally, patients with asthma exacerbations may not recognize a need for provider attention until the need is urgent. Efforts to identify patients with acute asthma early and to increase access to urgent outpatient care may reduce asthma-related ED visits.