Respiratory diseases disproportionately affecting minorities. The NHLBI Working Group

Racial and ethnic disparities in antifibrotic therapy in idiopathic pulmonary fibrosis

BACKGROUND AND OBJECTIVE

Racial disparities have been documented in care of many respiratory diseases but little is known about the impact of race on the treatment of interstitial lung diseases. The purpose of this study was to determine how race and ethnicity influence treatment of idiopathic pulmonary fibrosis.

METHODS

Adults with idiopathic pulmonary fibrosis (>18 years) were identified using TriNetX database and paired-wised comparisons were performed for antifibrotic treatment among White, Black, Hispanic and Asian patients. Mortality of treated and untreated IPF patients was compared after propensity score matching for age, sex, nicotine dependence, oxygen dependence and predicted FVC. Additional comparisons were performed in subgroups of IPF patients older than 65 years of age and with lower lung function.

RESULTS

Of 47,184 IPF patients identified, the majority were White (35,082), followed by Hispanic (6079), Black (5245) and Asian (1221). When subgroups were submitted to matched cohort pair-wise comparisons, anti-fibrotic usage was lower among Black patients compared to White (6.2% vs. 11.4%, p-value <0.0001), Hispanic (10.8% vs. 20.2%, p-value <0.0001) and Asian patients (9.6% vs. 14.7%, p-value = 0.0006). Similar treatment differences were noted in Black individuals older than 65 years and those with lower lung function. Mortality among White patients, but not Hispanic, Black, or Asian patients, was lower in patients on antifibrotic therapy versus not on therapy.

CONCLUSION

This study demonstrated that Black IPF patients had lower antifibrotic use compared to White, Hispanic and Asian patients. Our findings suggest that urgent action is needed to understand the reason why racial disparities exist in the treatment of IPF.

Missing out on effective care in idiopathic pulmonary fibrosis: Racial inequality in access to anti-fibrotic therapy

See related article

National Disparities in COVID-19 Outcomes between Black and White Americans

BACKGROUND

There is very limited comprehensive information on disparate outcomes of black and white patients with COVID-19 infection. Reports from cities and states have suggested a discordant impact on black Americans, but no nationwide study has yet been performed. We sought to understand the differential outcomes for black and white Americans infected with COVID-19.

METHODS

We obtained case-level data from the Centers for Disease Control and Prevention on 76,442 white and 48,338 non-Hispanic Black patients diagnosed with COVID-19, ages 0 to >80+, outlining information on hospitalization, ICU admission, ventilation, and death outcomes. Multivariate Poisson regressions were used to estimate the association of race, treating white as the reference group, controlling for sex, age group, and the presence of comorbidities.

RESULTS

Black patients were generally younger than white, were more often female, and had larger numbers of comorbidities. Compared to white patients with COVID-19, black patients had 1.4 times the risk of hospitalization (RR 1.42, p < 0.001), and almost twice the risk of requiring ICU care (RR 1.68, p < 0.001) or ventilatory support (RR 1.81, p < 0.001) after adjusting for covariates. Black patients saw a 1.36 times increased risk of death (RR 1.36, p < 0.001) compared to white. Disparities between black and white outcomes increased with advanced age.

CONCLUSION

Despite the initial descriptions of COVID-19 being a disease that affects all individuals, regardless of station, our data demonstrate the differential racial effects in the United States. This current pandemic reinforces the need to assess the unequal effects of crises on disadvantaged populations to promote population health.

National Trends and Disparities in Health Care Access and Coverage Among Adults With Asthma and COPD: 1997-2018

BACKGROUND

Racial and ethnic as well as economic disparities in access to care among persons with asthma and COPD have been described, but long-term access trends are unclear.

RESEARCH QUESTION

Have health coverage and access to care and medications among adults with airways disease improved, and have disparities narrowed?

STUDY DESIGN AND METHODS

Using the 1997 through 2018 National Health Interview Survey, we examined time trends in health coverage and the affordability of medical care and prescription drugs for adults with asthma and COPD, overall and by income and by race and ethnicity. We performed multivariate linear probability regressions comparing coverage and access in 2018 with that in 1997.

RESULTS

Our sample included 76,843 adults with asthma and 30,548 adults with COPD. Among adults with asthma, lack of insurance rose in the first decade of the twenty-first century, peaking with the Great Recession, but fell after implementation of the Affordable Care Act (ACA). From 1997 through 2018, the uninsured rate among adults with asthma decreased from 19.4% to 9.6% (adjusted 9.27 percentage points; 95% CI, 7.1%-11.5%). However, the proportions delaying or foregoing medical care because of cost or going without medications did not improve. Racial and ethnic as well as economic disparities present in 1997 persisted over the study period. Trends and disparities among those with COPD were similar, although the proportion going without needed medications worsened, rising by an adjusted 7.8 percentage points.

INTERPRETATION

Coverage losses among persons with airways disease in the first decade of the twenty-first century were reversed by the ACA, but neither care affordability nor disparities improved. Further reform is needed to close these gaps.

Persistent differences in asthma self-efficacy by race, ethnicity, and income in adults with asthma

OBJECTIVE

The objective of this population-based study was to determine if and to what extent there are differences in asthma self-efficacy by race/ethnicity and income, and whether health status, levels of acculturation, and health care factors may explain these differences.

METHODS

We conducted a secondary data analysis of asthma self-efficacy using the 2009 and 2011-2012 California Health Interview Survey, in adults with asthma (n=7874). In order to examine if and how the effect of race/ethnicity and income on asthma self-efficacy may have been altered by health status, acculturation, and health care factors, we used staged multivariable logistic regression models. We conducted mediation analyses to evaluate which of these factors might mediate disparities in self-efficacy by race/ethnicity and income.

RESULTS

69.8% of adults reported having high asthma self-efficacy. Latinos (OR 0.66; 95% CI 0.51-0.86), African-Americans (OR 0.50; 95% CI 0.29-0.83), American Indian/Alaskan Natives (OR 0.55; 95% CI 0.31-0.98) and Asian/Pacific Islanders (OR 0.34; 95% CI 0.23-0.52) were less likely to report high self-efficacy compared to Whites. Individuals with income below the federal poverty level (OR 0.56; 95% CI 0.40-0.78) were less likely to report high self-efficacy compared to higher income individuals. The relationship between income and self-efficacy was no longer significant after further adjustment for health care factors; however, the differences in race and ethnicity persisted. Receiving an asthma management plan mediated the relationship in certain subgroups.

CONCLUSIONS

Addressing modifiable health care factors may play an important role in reducing disparities in asthma self-efficacy.

Genetic ancestry-smoking interactions and lung function in African Americans: a cohort study

BACKGROUND

Smoking tobacco reduces lung function. African Americans have both lower lung function and decreased metabolism of tobacco smoke compared to European Americans. African ancestry is also associated with lower pulmonary function in African Americans. We aimed to determine whether African ancestry modifies the association between smoking and lung function and its rate of decline in African Americans.

METHODOLOGY/PRINCIPAL FINDINGS

We evaluated a prospective ongoing cohort of 1,281 African Americans participating in the Health, Aging, and Body Composition (Health ABC) Study initiated in 1997. We also examined an ongoing prospective cohort initiated in 1985 of 1,223 African Americans in the Coronary Artery Disease in Young Adults (CARDIA) Study. Pulmonary function and tobacco smoking exposure were measured at baseline and repeatedly over the follow-up period. Individual genetic ancestry proportions were estimated using ancestry informative markers selected to distinguish European and West African ancestry. African Americans with a high proportion of African ancestry had lower baseline forced expiratory volume in one second (FEV₁) per pack-year of smoking (-5.7 ml FEV₁/ smoking pack-year) compared with smokers with lower African ancestry (-4.6 ml in FEV₁/ smoking pack-year) (interaction P value  = 0.17). Longitudinal analyses revealed a suggestive interaction between smoking, and African ancestry on the rate of FEV(1) decline in Health ABC and independently replicated in CARDIA.

CONCLUSIONS/SIGNIFICANCE

African American individuals with a high proportion of African ancestry are at greater risk for losing lung function while smoking.

Antimicrobial resistance in Hispanic patients hospitalized in San Antonio, TX with community-acquired pneumonia

Limited information is available on the antimicrobial resistance of patients with community-acquired pneumonia (CAP) depending on their ethnicity. Our aim was to compare the clinical characteristics, etiology, and microbiological resistance of Hispanic versus non-Hispanic white patients. A retrospective cohort of 601 patients with a diagnosis of CAP included 288 non-Hispanic whites and 313 Hispanics. Penicillin-resistant Streptococcus pneumoniae was more common among Hispanic patients (21.7% vs 0%; P=0.03) but there were no significant differences in macrolide-resistant S pneumoniae, drug-resistant S pneumoniae, or potential or actual multidrug-resistant pathogens (eg, drug-resistant S pneumoniae, methicillin-resistant Staphylococcus aureus, Pseudomonas spp., and Acinetobacter spp.). There were no differences among groups in length of hospital stay, intensive care unit (ICU) admission, or 30-day mortality. This study suggests that Hispanic patients with CAP have a higher rate of penicillin-resistant S pneumoniae, but no differences in antimicrobial resistance, 30-day mortality, ICU admission, or length of stay when compared with non-Hispanic white patients.

The built environment, climate change, and health: opportunities for co-benefits

The earth's climate is changing, due largely to greenhouse gas emissions resulting from human activity. These human-generated gases derive in part from aspects of the built environment such as transportation systems and infrastructure, building construction and operation, and land-use planning. Transportation, the largest end-use consumer of energy, affects human health directly through air pollution and subsequent respiratory effects, as well as indirectly through physical activity behavior. Buildings contribute to climate change, influence transportation, and affect health through the materials utilized, decisions about sites, electricity and water usage, and landscape surroundings. Land use, forestry, and agriculture also contribute to climate change and affect health by increasing atmospheric levels of carbon dioxide, shaping the infrastructures for both transportation and buildings, and affecting access to green spaces. Vulnerable populations are disproportionately affected with regard to transportation, buildings, and land use, and are most at risk for experiencing the effects of climate change. Working across sectors to incorporate a health promotion approach in the design and development of built environment components may mitigate climate change, promote adaptation, and improve public health.

Asthma prevalence among US children in underrepresented minority populations: American Indian/Alaska Native, Chinese, Filipino, and Asian Indian

OBJECTIVES

The purpose of this work was to estimate asthma prevalence among US children in racial minority subgroups who have been historically underrepresented in the pediatric asthma literature. These subgroups include American Indian/Alaska Native, Chinese, Filipino, and Asian Indian children. We also explored the association between these race categories and asthma after adjusting for demographic and sociodemographic characteristics and explored the effect of place of birth as it relates to current asthma.

PATIENTS AND METHODS

Data on all 51944 children aged 2 to 17 years from the 2001-2005 National Health Interview Survey were aggregated and analyzed to estimate the prevalence of current asthma, lifetime asthma, and asthma attacks according to race and place of birth. Logistic regression was used to determine adjusted odds ratios for current asthma according to race and place of birth while controlling for other demographic and sociodemographic variables.

RESULTS

National estimates of current asthma prevalence among the children in the selected minority subgroups ranged from 4.4% in Asian Indian children to 13.0% in American Indian/Alaska Native children. Overall, children born in the United States had greater adjusted odds of reporting current asthma than did children born outside of the United States.

CONCLUSIONS

Smaller racial and ethnic minority groups are often excluded from asthma studies. This study reveals that, among children from different Asian American subgroups, wide variation may occur in asthma prevalence. We also found that children born in the United States were more likely than children born outside of the United States to have current asthma.

The association between childhood asthma and community violence, Los Angeles County, 2000

OBJECTIVE

This study's objective is to determine if there is an association between rates of violence and rates of childhood asthma in Los Angeles County communities.

METHODS

Rates of hospitalization for assault and for asthma were calculated for each ZIP Code and city in Los Angeles County. Linear regression was used to determine the effect of assault rates on asthma rates while controlling for potential confounders such as poverty and racial/ethnic distribution. At the city level, crime rates were included in the model as additional measures of community violence.

RESULTS

Hospitalization rates for childhood asthma and assaults were significantly correlated at both the city (r = 0.80) and the ZIP Code (r = 0.54) levels. The association remained significant when controlling for poverty and racial/ethnic distribution with linear regression (p < 0.0001). At the city level, the variables measuring the crime rate were not significant predictors of asthma hospitalizations.

CONCLUSIONS

Community violence as measured by the rate of assault hospi; talizations is associated with childhood asthma in Los Angeles County. Health care providers should consider their asthmatic patients' social environments when devising treatment plans.

Racial and ethnic disparities in sarcoidosis: from genetics to socioeconomics

Sarcoidosis is a multisystem granulomatous disease of unknown cause that occurs worldwide. The clinical expression of sarcoidosis varies by race. These racial differences may be the result of genetic and socioeconomic factors. Many of these genetic associations are race-specific in that they are found in either African Americans or whites but not both. Socioeconomic differences may also explain the racial disparities between African American and white patients with sarcoidosis. Finally, the phenotypic differences be-tween races may relate to an interaction between genetics and socioeconomic factors. The influences of genetics and socioeconomic status on the development and phenotypic expression of sarcoidosis will be better understood as the mechanisms of disease development are uncovered.

Disparities in Lung Cancer: Focus on Asian Americans and Pacific Islanders, American Indians and Alaska Natives, and Hispanics and Latinos

Significant population changes in the United States are expected over the next few decades. The changing demographics inclusive of native and newly native individuals will significantly impact health care because racial and ethnic groups vary widely in their risks for disease and approach to medical care. For lung cancer specifically, racial and ethnic groups differ in smoking habits, metabolism of nicotine, presentation, stage at diagnosis, treatment received, and outcomes. This article summarizes current information on lung cancer for American and Pacific Islanders, American Indians and Alaska natives,and Hispanics and Latinos with an emphasis on tobacco use, epidemiologic issues sur-rounding acculturation and assimilation, genetic epidemiology, and disparities in treatment outcomes.

Racial variations in processes of care for patients with community-acquired pneumonia

BACKGROUND

Patients hospitalized with community acquired pneumonia (CAP) have a substantial risk of death, but there is evidence that adherence to certain processes of care, including antibiotic administration within 8 hours, can decrease this risk. Although national mortality data shows blacks have a substantially increased odds of death due to pneumonia as compared to whites previous studies of short-term mortality have found decreased mortality for blacks. Therefore we examined pneumonia-related processes of care and short-term mortality in a population of patients hospitalized with CAP.

METHODS

We reviewed the records of all identified Medicare beneficiaries hospitalized for pneumonia between 10/1/1998 and 9/30/1999 at one of 101 Pennsylvania hospitals, and randomly selected 60 patients at each hospital for inclusion. We reviewed the medical records to gather process measures of quality, pneumonia severity and demographics. We used Medicare administrative data to identify 30-day mortality. Because only a small proportion of the study population was black, we included all 240 black patients and randomly selected 720 white patients matched on age and gender. We performed a resampling of the white patients 10 times.

RESULTS

Males were 43% of the cohort, and the median age was 76 years. After controlling for potential confounders, blacks were less likely to receive antibiotics within 8 hours (odds ratio with 95% confidence interval 0.6, 0.4-0.97), but were as likely as whites to have blood cultures obtained prior to receiving antibiotics (0.7, 0.3-1.5), to have oxygenation assessed within 24 hours of presentation (1.6, 0.9-3.0), and to receive guideline concordant antibiotics (OR 0.9, 0.6-1.7). Black patients had a trend towards decreased 30-day mortality (0.4, 0.2 to 1.0).

CONCLUSION

Although blacks were less likely to receive optimal care, our findings are consistent with other studies that suggest better risk-adjusted survival among blacks than among whites. Further study is needed to determine why this is the case.

Prevalence of asthma and chronic respiratory symptoms among Alaska Native children

STUDY OBJECTIVES

To quantify the prevalence and impact of chronic respiratory symptoms among predominantly Alaska Native (AN)/American Indian (AI) middle school students.

DESIGN

School-based prevalence assessment using the International Study of Asthma and Allergy in Children survey, with supplemental video material and added questions about productive cough, exposure to tobacco smoke, and the functional impact of symptoms.

SETTING

The Yukon-Kuskokwim delta region of western Alaska.

PARTICIPANTS

A total of 466 children in the sixth to ninth grades, 81% of whom are AN/AI (377 children).

INTERVENTIONS

No study intervention.

RESULTS

Among the 377 AN/AI children, 40% reported one of the following three categories of chronic respiratory disease: physician-diagnosed asthma, 7.4%; asthma-like symptoms (ALS) without an asthma diagnosis, 11.4%; and chronic productive cough (CPC) without asthma diagnosis or symptoms, 21.5%. Symptom prevalence differed substantially between the largest town in the region and rural villages. After an adjustment for demographic factors, exposure to environmental tobacco smoke, active tobacco smoking, and self-report of atopy, village residents were 63% less likely to have ALS (p = 0.009), and had a twofold greater risk of CPC (p < 0.001) compared to children living in the town. Children with respiratory symptoms experienced sleep disturbances and accessed clinic visits for respiratory problems more often than did asymptomatic children.

CONCLUSIONS

Chronic respiratory symptoms are very common among AN children. CPC is an important nonasthmatic respiratory condition in this population. The differing patterns of respiratory illness within this region may help to elucidate the specific risk factors for asthma and chronic bronchitis in children.

Risk factors for asthma in US adults: results from the 2000 Behavioral Risk Factor Surveillance System

BACKGROUND

Identifying populations at risk for having asthma is an essential step toward appropriately allocating resources and reducing the burden of this disease. To date, the impact of demographic and social factors on asthma prevalence has not been assessed in a nationally representative sample of U.S. adults.

METHODS

We conducted weighted analyses using data from a random digit-dialed telephone survey of non-institutionalized persons > or = 18 years of age in 50 states, Puerto Rico, and the District of Columbia to assess risk factors for asthma prevalence.

RESULTS

We found that women were more likely than men to report current asthma [odds/ratio (OR): 1.91, 95% confidence interval (CI): 1.77-2.06]; adults aged 35-64 and >65 were less likely than adults aged 18-34 to report current asthma (OR: 0.79, 95% CI: 0.73-0.85 and OR: 0.65, 95% CI: 0.58-0.72, respectively); persons from the lower socioeconomic status (SES) were more likely to report current asthma than those in other SES (OR: 1.36, 95% CI: 1.25-1.49); overweight and obese people were more likely to report current asthma than were those of normal weight (OR: 1.10, 95% CI: 1.02-1.20 and OR: 1.65, 95% CI: 1.51-1.80, respectively); and current and former smokers were more likely than never smokers to report current asthma (OR: 1.28, 95% CI: 1.18-1.39 and OR: 1.36, 95% CI: 1.24-1.48, respectively).

CONCLUSIONS

While several important sociodemographic risk factors were associated with increased asthma prevalence in U.S. adults, the impact of generally modifiable risk factors such as elevated body mass index and cigarette smoking is of specific concern. These findings further underscore the need to target and diminish these risk factors among U.S. adults.

Acute asthma among adults presenting to the emergency department: the role of race/ethnicity and socioeconomic status

OBJECTIVES

To investigate racial/ethnic differences in acute asthma among adults presenting to the emergency department (ED), and to determine whether observed differences are attributable to socioeconomic status (SES).

DESIGN

Prospective cohort studies performed during 1996 to 1998 by the Multicenter Airway Research Collaboration. Using a standardized protocol, researchers provided 24-h coverage for a median duration of 2 weeks per year. Adults with acute asthma were interviewed in the ED and by telephone 2 weeks after hospital discharge.

PARTICIPANTS

Sixty-four North American EDs.

RESULTS

A total of 1,847 patients were enrolled into the study. Black and Hispanic asthma patients had a history of more hospitalizations than did whites (ever-hospitalized patients: black, 66%; Hispanic, 63%; white, 54%; p < 0.001; patients hospitalized in the past year: black, 31%; Hispanic, 33%; white, 25%; p < 0.05) and more frequent ED use (median use in past year: black, three visits; Hispanic, three visits; white, one visit; p < 0.001). The mean initial peak expiratory flow rate (PEFR) was lower in blacks and Hispanics (black, 47%; Hispanic, 47%; white, 52%; p < 0.001). For most factors, ED management did not differ based on race/ethnicity. After accounting for several confounding variables, blacks and Hispanics were twice as likely to be admitted to the hospital. Blacks and Hispanics also were more likely to report continued severe symptoms 2 weeks after hospital discharge (blacks, 24%; Hispanic, 31%; white, 19%; p < 0.01). After adjusting for sociodemographic factors, the race/ethnicity differences in initial PEFR and posthospital discharge symptoms were markedly reduced.

CONCLUSION

Despite significant racial/ethnic differences in chronic asthma severity, initial PEFR at ED presentation, and posthospital discharge outcome, ED management during the index visit was fairly similar for all racial groups. SES appears to account for most of the observed acute asthma differences, although hospital admission rates were higher among black and Hispanic patients after adjustment for confounding factors. Despite asthma treatment advances, race/ethnicity-based deficiencies persist. Health-care providers and policymakers might specifically target the ED as a place to initiate interventions designed to reduce race-based disparities in health.

Identifying underserved ethnic populations within a community: the first step in eliminating health care disparities among racial and ethnic minorities

As set forth by the United States Department of Health and Human Services in Healthy People 2010, the primary goal of the national health promotion and disease prevention plan is to eliminate the health care disparities among racial and ethnic groups. This disparity is due, in part, to unequal health access. However, equal access to health care alone would not eliminate the difference. The health care provided must be culturally competent to be effective. Before providers can effectively begin strategizing ways to provide culturally sensitive health care for the people they serve, they first need to identify the groups of people in their service areas. A clinical example will be used to demonstrate public health nursing's role in accessing and advocating for uncounted populations as a fundamental beginning for eliminating disparity in health care delivery.

Rate and place of death from asthma among different ethnic groups in Israel: national trends 1980 to 1997

STUDY OBJECTIVES

To compare the trends of asthma mortality and place of death in young patients (ages 5 to 34 years) from different major population groups in Israel.

DESIGN

Retrospective study.

PATIENTS AND PARTICIPANTS

Patients who died from asthma between the years 1980 and 1997 according to the death record of the National Israeli Health Registry.

RESULTS

During the period studied, 100 asthma mortality cases were reported, which yields a mean mortality rate of 0.226 per 100,000 population. There were no significant changes in the mortality rates over the years. The mean (+/- SD) age of death was 23 +/- 7 years. Of this population, 84.5% were Jews and 15.5% were Arabs, which is proportionate to the general Israeli population. In 52% of the cases, the patients died outside a hospital. There was no significant difference in the place of death between Jews and Arabs. Significantly more men (62.5%) than women (40%) died outside the hospital (p = 0.025).

CONCLUSIONS

The asthma mortality rate in Israel during the years 1980 to 1997 was low and stable. Most of the patients still died outside the hospital. There was no difference in the asthma death rate and place of death between Jews and Arabs, suggesting that in our population genetic predisposition is not likely to be a risk factor for mortality.

Ethnic comparisons of disease severity in children hospitalized with pneumonia in New Zealand

OBJECTIVE

To determine if there are ethnic differences in disease severity in children hospitalized with pneumonia in New Zealand.

METHODOLOGY

A population based audit of children hospitalized in Auckland with pneumonia over 12 months from 1 November 1994 to 31 October 1995. The study population was children aged from 0 to 14 years with a discharge diagnosis of pneumonia. The sample was stratified by ethnicity and included 151 Pacific, 85 Mäori and 151 European children. Measurements were made of demographics and prehospital care; vital signs and therapy received in the emergency department and inpatient wards and laboratory investigations performed. Comparisons between the three ethnic groups were adjusted for age, weight, gender, socio-economic status and relationship with primary care.

RESULTS

A larger proportion of Pacific (15%) and Mäori (22%) children than European children (8%) had a respiratory rate elevated for > or = 2 days, odds ratio (OR) (95% CI): Pacific versus European 2.7 (1.1, 6.8), Mäori versus European 4.3 (1.7, 11.6). A larger proportion of Pacific (15%) and Mäori (15%) children than European children (< 1%) had a heart rate elevated for > or = 2 days, OR Pacific versus European 17.2 (3.2, 320), Mäori versus European 26.1 (4.4, 508). Compared with European children, a larger proportion of Pacific and Mäori children received intravenous fluids and antibiotics. A larger proportion of Pacific (29%) and Mäori (27%) children than European children (11%) received oxygen for > = 2 days, OR Pacific versus European 3.2 (1.6, 6.6), Mäori versus Europeans 2.6 (1.2, 6.2).

CONCLUSIONS

Based on the comparisons of vital signs and intensity of therapy, Pacific and Mäori children hospitalized with pneumonia have more severe pneumonia than European children.

Importance of beta(2)adrenergic receptor genotype, gender and race on albuterol-evoked bronchodilation in asthmatics

To determine whether race and gender affect beta(2)receptor-stimulated bronchodilation, we quantified FEV(1)and plasma concentrations of albuterol at various times following the oral administration of a single 8-mg dose of albuterol in 15 black and 15 white male and female asthmatics. No important racial or gender differences in albuterol-evoked FEV(1)or percent-predicted FEV(1)were evident, although females tended to be more sensitive compared to males. Pharmacodynamic (PD) models were fitted to data in 19 patients (63%); FEV(1)was too erratic to fit in three, and a clockwise hysteresis in the FEV(1)vs. albuterol concentration relationship was observed in eight asthmatics. Mean +/- SD baseline (E(0)), maximal FEV(1)(E(max)) and C(50)were: 3.18 + 1.03 l, 4.00 +/- 1.12 l, 7.84 +/- 10.2 microg/l, respectively. beta(2)receptor genotype was determined in 16 patients. All Arg 16 homozygotes exhibited proportional FEV(1)response vs. plasma albuterol concentration relationships, and thus were fitted by PD models. All those having a poor FEV(1)vs. albuterol concentration relationship carried the Gly 16 allele. We conclude that receptor genotype, but not race or gender, is an important determinant of albuterol pharmacodynamics.

Asthma mortality in U.S. Hispanics of Mexican, Puerto Rican, and Cuban heritage, 1990-1995

We used national vital statistics data for 1990 through 1995 to examine both national and regional age-adjusted asthma mortality rates for U.S. Hispanics of Mexican, Cuban, and Puerto Rican heritage, as well as for non-Hispanic whites and non-Hispanic blacks. Nationally, Puerto Ricans had an age-adjusted annual asthma mortality rate of 40.9 per million, followed by Cuban-Americans (15. 8 per million) and Mexican-Americans (9.2 per million). In comparison, non-Hispanic whites had an age-adjusted annual asthma mortality rate of 14.7 per million and non-Hispanic blacks had a rate of 38.1 per million. Age-adjusted asthma mortality for Puerto Ricans was highest in the Northeast (47.8 per million); this region accounted for 81% of all asthma deaths among Puerto Ricans in the United States. In the U.S., Puerto Ricans had the highest asthma mortality rates among Hispanics, followed by Cuban-Americans and Mexican-Americans. In addition, among Hispanic national groups, mortality rates were consistently higher in the Northeast than the Midwest, South, or West regions. These results further support that Hispanics do not represent a uniform, discrete group in terms of health outcomes, and that further public health research and interventions should take Hispanic national origin into account.

Race, income, urbanicity, and asthma hospitalization in California: a small area analysis

STUDY OBJECTIVES

To explicate the interrelationship between asthma hospitalization and race/ethnicity and income.

DESIGN

Small area ecologic analysis using census and administrative data.

SETTING AND PARTICIPANTS

All asthma hospitalizations in California were identified using the 1993 California Hospital Discharge file. Small area analyses of Los Angeles (LA) were compared with published rates in New York City (NYC).

RESULTS

In 1993, the age-adjusted asthma hospitalization rate in California for nonelderly blacks was 42.5/10,000-approximately four times higher than other populations. Black rates remained fourfold higher after stratification by age, income, and urbanicity. Multivariate analyses suggest that the association between black race and asthma hospitalization is independent of income. Regardless of race, children and persons living in poverty were at increased risk for asthma hospitalization. Urbanicity was not a predictor for asthma hospitalization. Overall, asthma hospitalization rates in NYC were 2.8 times higher compared with rates in LA; while rates were similar among blacks (60 vs 40/10,000, respectively), Puerto Rican Hispanics in NYC had dramatically higher rates compared with Mexican Hispanics in LA (63 vs 14/10,000, respectively).

CONCLUSIONS

After controlling for socioeconomic status, notable differences in asthma hospitalization by race and ethnicity persist. The reasons for the significantly elevated risk of asthma morbidity among blacks remain unclear.

Variations in hospitalization rates for asthma among black and minority ethnic communities

In response to the introduction of ethnic monitoring within the U.K. hospital inpatient data set, this study investigates the variations in secondary healthcare utilization by Black and minority ethnic communities whose cause of admission is related to asthma. The study examines all residents of the West Midlands: over 5 million people, of whom 8.5% are from Black and minority ethnic groups. A retrospective study of 15,921 asthma-related hospital admissions, from 1 April 1995 to 31 March 1996, was carried out. Age-standardized admission rates were higher in all Black and minority ethnic groups studied than in the White group. There were elevated rates in Black children aged 5-14 years, and particular differences were observed for Indian and Bangladeshi men and women aged 65 years or over. Emergency admissions to hospital for asthma were strongly associated with patients' socioeconomic background but this was largely observed for Black and minority ethnic groups that also generally experience high levels of deprivation. The findings support previous studies which suggest that hospital utilization rates for asthma among people from Black and minority ethnic groups are high compared with the White group, despite little evidence in measured prevalence. This study suggests that ethnic background is more important in asthma admissions than deprivation, which raises serious concerns on the appropriateness and quality of asthma care for these patient groups within our society. Future studies need to examine pathways to care, that is the health-seeking behaviour of Black and minority ethnic groups, the type of treatment received at the primary care level and referral patterns to secondary care.

Adherence to tuberculosis preventive therapy among Latino immigrants

Tuberculosis infects someone in the world every second. Although TB is preventable and curable, it has resurfaced as a significant health problem in the U.S., particularly among Latino immigrant groups. In this study of 65 Latino immigrants primarily from Central America, we examined adherence to appointments and medication taking during the six months of preventive therapy for latent TB infection. Findings indicated that the Latinos' adherence to appointment keeping ranged from 81% on the first visit to 59% by the sixth monthly visit. Similarly, medication adherence dropped from 89% in the first month to 64% at six months. Demographic factors, self-assessment of health, other support and presence of side effects were examined in the analysis. Implications for public health nursing are discussed.