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  1. 1. Determinants of Asthma Morbidity Among Inner-City Populations Juan P. Wisnivesky, MD, MPH Divisions of General Internal Medicine and Pulmonary, Critical Care, and Sleep Medicine Mount Sinai School of Medicine
  2. 2. Inner-City Asthma Asthma is a chronic disease affecting 15 to 17 million Americans Minority inner-city populations are disproportionately affected by asthma African Americans and Hispanics have 2 to 3 times greater rates of death due to asthma when compared to whites New York City has asthma mortality rates 10 times the national average
  3. 3. Determinants of Morbidity Among Inner-City Asthmatics Study Goal: to evaluate the role of patient, provider, and environmental factors on outcomes of inner-city asthmatics
  4. 4. Baseline Survey Mount Sinai Hospital Rutgers University Pulmonary function tests Blood for IgE, serum, DNA Chart review 1st Telephone Follow-up 2nd Telephone Follow-up 0 Time (months) 1231 Electronic measure of adherence Demographics Asthma regimen Medication beliefs Disease beliefs Communication Adherence Asthma control Resource utilization Quality of life 3rd Telephone Follow-up Study Outline Physician Survey Mount Sinai Hospital Metropolitan Hospital North General Hospital Local health centers Rutgers University
  5. 5. Physician Factors Knowledge Attitudes Communication Language Behavioral Processes Adherence to controller meds Adherence Self-regulation of meds Self-monitoring Trigger avoidance Outcomes Symptoms Quality of life Airway function Resource utilization System Factors Access to care Pt education capacity Gatekeeping Insurance Transportation Cognitive/Emotional Processes Self Regulation beliefs Knowledge Self efficacy Depression/anxiety Clinical Factors Genetics Asthma history Sensitization Smoking PATIENT Environmental Factors Housing conditions Passive smoking Aeroallergens Air Pollution Potential Determinants of Asthma Morbidity in Inner-City Populations Sociodemographics Age, sex, race, ethnicity Language, Culture, Education, Income
  6. 6. Characteristics of Study Population (N=326) Age (yrs), mean+SD 48+13 Female (%) 83 Race/Ethnicity (%) Hispanic 56 African-American 28 White 12 Others 4 Insurance (%) Medicaid 62 Medicare 18 Commercial 17 Uninsured 3 Income <$15,000/yr (%) 62 Asthma History Age Onset (yrs), mean+SD 26+15 ED visit last year (%) 52 Hospitalized last year (%) 23 ValueCharacteristic Controller Medication (%) 87 Comorbid Conditions (%) Eczema 19 Chronic sinusitis 23 Diabetes 25 Hypertension 46 Environmental Exposure (%) Second hand smoking 25 Cat 23 Cockroach 44 Dampness/Mold 51 Rodents 40 ValueCharacteristic
  7. 7. Disease Beliefs and Asthma Self-Management Self-management is critical for long-term asthma control "Do you think you have asthma all of the time or only when you are having symptoms?" Responses: I have it all of the time Most of the time Some of the time Only when I am having symptoms 53% of patients were classified as having the no symptoms- no asthma, acute episodic disease belief Halm EA, et al. No Symptoms, No Asthma. The Acute Episodic Disease Belief Is Associated With Poor Self-Management Among Inner-City Adults With Persistent Asthma. Chest, 2006.
  8. 8. Beliefs and Behaviors Acute Belief, % Chronic Belief, % OR (CI)  I will not always have asthma 31 9 4.49 (1.94–10.42)  My lungs are always inflamed/irritated 43 67 0.36 (0.20–0.66) Medication beliefs  ICS use is important when no  symptoms 56 77 0.38 (0.19–0.74) Medication adherence (ICS)  Use it all/most of the time when no  symptoms 45 70 0.35 (0.19–0.64) Other self-management behaviors  Routine asthma visits when no  symptoms 50 65 0.54 (0.30–0.97)  Use PFM all/most of the days 14 30 0.39 (0.19–0.80)  Use PFM to self-adjust medicines 15 25 0.53 (0.25–1.09) Associations Between the No Symptoms, No Asthma Belief and Other Key Asthma Beliefs and Behaviors
  9. 9. Adherence to Inhaled Corticosteroids (ICS)Adherence to Inhaled Corticosteroids (ICS) ICS are the cornerstone of asthma therapy Adherence to ICS is often suboptimal Medication Adherence Reporting Scale (MARS) 60 patients were given an electronic monitoring  device 53% of prescribed days used ICS, 35% of the  doses prescribed Identify key medication beliefs independently  associated with adherence with ICS MDI Log
  10. 10. Medication Beliefs Associated with ICS Adherence (MARS) Repeated measures regression adjusted for age, sex, prior Repeated measures regression adjusted for age, sex, prior  intubation, and frequency of oral steroid useintubation, and frequency of oral steroid use Medication Belief OR P-value Important to take when  asymptomatic 4.2 <0.001 Confident in ability to use ICS  as prescribed 2.2 <0.001 Worry about side effects 0.5 <0.001 Medication regimen hard to  follow 0.5 0.04
  11. 11. The Relationship Between Language Barriers and Outcomes of Inner-city Asthmatics  11 million people living in the US have no or limited  English-language skills Limited English proficiency can impair access to quality  health care Adequate patient-provider communication is a key  aspect of asthma management The objective of this analysis was to assess how  language barriers affect the outcomes of adult inner- city asthmatics
  12. 12. 1-Month Follow-up 1 2 3 4 AsthmaControlScore 3-Month Follow-up P=0.01 P<0.0001 Non-Hispanics Hispanics, Proficient in English Hispanics, Limited Proficiency Asthma Control in Relationship to English Proficiency Wisnivesky J, et al. Assessing the Relationship between Language Proficiency and  Asthma Morbidity amongst Inner-city Asthmatics. Medical Care, In Press.
  13. 13. Non-Hispanics Hispanics, Proficient in English Hispanics, Limited Proficiency 10 20 30 40 Percentage Outpatient Exacerbations P=0.004 ED Visits- Hospitalizations P=0.007 Resource Utilization in Relationship to English Proficiency
  14. 14. QualityofLifeScore 1-Month Follow-up 3 4 5 6 3-Month Follow-up P=0.002 P=0.0001 Non-Hispanics Hispanics, Proficient in English Hispanics, Limited Proficiency Quality of Life in Relationship to English Proficiency
  15. 15. Medication and Disease Beliefs, Self-Efficacy, and Adherence According to English Proficiency Variable Medication Beliefs (%) Worry Side Effects ICS Worry Addiction to ICS ICS are Controller Meds Disease Beliefs (%) No Symptoms, No Asthma Asthma is Chronic Disease Self-efficacy (%) Confident Control Asthma Confident Use ICS Control Over Future Health P-value 0.002 <0.0001 0.19 0.009 0.02 0.003 0.02 <0.0001 Non- Hispanics n=141 40 24 85 28 72 84 95 86 Hispanic, Proficient n=120 51 31 80 42 62 76 92 76 Hispanics, Limited Proficiency n=57 69 46 73 47 53 56 79 49
  16. 16. The Role of Allergic Sensitization on Asthma Morbidity Inner-city residents are often exposed to high levels of indoor allergens Sensitization to cockroach allergen has been linked to increased asthma morbidity in children Recent data suggest that sensitization to indoor allergens may worsen asthma in elderly patients and pregnant women Objective of the study was to evaluate the role of sensitization to indoor allergens on asthma control among inner-city asthmatics
  17. 17. Prevalence of Sensitization to Indoor Allergens Among Inner-city Asthmatics PercentSensitized 10 20 40 0 30 50 Wisnivesky J, et al. Association between indoor allergen sensitization and asthma morbidity in inner-city asthmatics. JACI, 2007. Dust Mites Cockroach MouseCat Molds
  18. 18. Sensitized Not sensitized 0 1 3 1 2 3 4 AsthmaControlScore Time (months) Cockroach Sensitization 0 1 3 1 2 3 4 AsthmaControlScore Time (months) Cat Sensitization p >0.4 p >0.15 0 1 3 1 2 3 4 AsthmaControlScore Time (months) Mouse Sensitization 0 1 3 1 2 3 4 AsthmaControlScore Time (months) Mold Sensitization p >0.2 p >0.6 Sensitized Not sensitized Sensitized Not sensitized Sensitized Not sensitized Asthma Control According to Sensitization Status
  19. 19. Steroid Use 0 10 20 30 Percentage Cockroach Sensitization Cat Sensitization Mouse Sensitization Mold Sensitization Resource Utilization According to Sensitization Status ED Visit Steroid Use ED Visit 0 10 20 30 Percentage 0 10 20 30 Percentage 0 10 20 30 Percentage Steroid Use ED Visit Steroid Use ED Visit Sensitized Not sensitized Sensitized Not sensitized Sensitized Not sensitized **P=0.06
  20. 20. Attitudes BehaviorKnowledge Lack of Familiarity • volume • time • accessibility Lack of Awareness • volume • time • accessibility Lack of Agreement • specific items • guidelines in general Lack of Outcome Expectancy Lack of Self- efficacy Lack of Motivation/ Inertia External Barriers • patient factors • guideline factors • environmental factors Adapted from Cabana MD, et al. Why don’t physicians follow clinical practice guidelines? a framework for improvement. JAMA 1999. Barriers to Adherence to Asthma Management Guidelines among Primary Care Providers
  21. 21. ICS 0 40 80 ProviderAdherence(%) Peak Flow Monitoring 20 60 100 Action Plan Allergy Testing Influenza Vaccination Primary Care Provider Adherence to NHLBI Asthma Guideline Recommendations
  22. 22. Multivariate Predictors of Adherence to the NHLBI Guideline Components Barrier Familiarity Expect Patient Adherence Self-Efficacy Insufficient Time OR 1.4 1.2 2.8 0.43 P-value 0.34 0.87 0.03 0.07 OR 1.1 3.3 2.3 0.68 P-value 0.75 0.03 0.05 0.25 ICS Use PF Monitoring
  23. 23. Multivariate Predictors of Adherence to the NHLBI Guideline Components Barrier Familiarity Expect Patient Adherence Self-Efficacy Insufficient Time OR 1.8 1.0 4.9 1.3 P-value 0.31 0.99 0.03 0.62 Action Plan OR 5.5 - 1.3 0.6 P-value 0.02 - 0.46 0.46 All Testing OR 2.0 3.5 3.5 1.2 P-value 0.05 0.01 0.05 0.83 Vaccination
  24. 24. Limitations May not be generalizable to other inner-city populations Used self-reported measures of adherence Unable to directly observe patient-provider encounters Used self-reported data on provider adherence to the guidelines
  25. 25. Conclusions Outcomes of inner-city asthmatics remain poor Problem appears to be multifactorial Suboptimal disease and medication beliefs are associated with poor asthma self-management Language barriers may also explain the increased levels of asthma morbidity among inner-city Hispanics The role of allergic sensitization appears to be more important among children than adults with asthma Familiarity and adherence to key treatment recommendations remains suboptimal amongst providers who take care of a large number of inner-city asthmatics
  26. 26. Acknowledgments Department of Medicine Ethan A. Halm, MD, MPH Stephen Berns, MD Thomas McGinn, MD, MPH Jessica Lorenzo, MPH Michael Iannuzzi, MD Julian Baez Diego Ponieman, MD Jessica Segni Department of Pediatrics Hugh Sampson, MD Michelle Mishoe Department of Geriatrics Albert Siu, MD, MSPH Rutgers University Tamara Musumeci, PhD Howard Leventhal, PhD Columbia University David Evans, PhD Mayer Kattan, MD These studies were funded by AHRQ and NYC Department of Health