As a physician, it helps when I know if someone may have a higher risk for asthma. It also helps to know why a person with asthma ends up in the emergency room more frequently. Is it because the medications are not controlling asthma episodes, is it because instigating triggers have increased, or is it because there is poor compliance with therapy? If it’s because of poor compliance, then I need to know if the person misunderstands the treatment prescribed, lacks commitment and motivation (and the reason why), or if acute episodes of asthma are occurring because the patient can’t afford the medication I prescribed. Sometimes these different factors can converge and set a person up for failure.
Access to Asthma Care
A January 2019 study published in The Journal of Allergy and Clinical Immunology (JACI) suggests that despite great progress in the diagnosis and treatment of asthma, there seems to be a divide between African-American (black) and Caucasian (white) patients when it comes to emergency room visits and asthma control. What’s interesting about the study is that the researchers’ initial suspicions and observations, in terms of racial disparity issues, actually changed after additional data analysis.
The researchers from the National Heart, Lung and Blood Institute’s (NHLBI) Severe Asthma Research program (SARP) decided to analyze differences in how black and white people with asthma access healthcare. The data that was analyzed over a one-year period was self-reported by the 579 participants, ages six years of age or older. The researchers focused first on how many times each participant went to the emergency room during the year. Initially they noted that the self-reporting of the black people suggested twice as many visits compared to the white people. But when the statistics were weighted and balanced for community and family socio-economic factors and environmental exposures, the racial differences decreased dramatically.
What the researchers did observe from the remaining differences in the data, however, was that black people were 43 percent less likely to seek regular medical care in the outpatient setting for their asthma care.
That essentially means that black people ended up in the emergency room “more” because they were not getting regular care from a doctor or healthcare worker. The result seems to be that they end up having more episodes that “get treated” in the emergency room or they have more visits to the emergency room because of less optimal, less consistent asthma therapy.
Disparities in Asthma Care
So, this study that highlights racial disparity in asthma, is really highlighting disparity in asthma care. Seeing a doctor regularly when you have a condition like asthma is crucial to managing the disease and minimizing emergency room visits. The disease requires prevention of acute episodes with maintenance drugs, and immediate intervention when there’s an acute episode.
The patients that I see regularly let me know if the medication regimen they are on is working or not. They let me know if their insurance has changed and if the current inhalers or medications they take are no longer covered. They tell me if any new triggers seem to be causing asthma exacerbations. They share any acute or new health conditions that may have developed since the last office visit. These interactions are critical to managing asthma and limiting emergency room visits.
The researchers suggest that issues exist with the current healthcare model. People from lower socio-economic levels may not have the kind of educational interactions needed for them to understand the seriousness of asthma. You can die from an untreated acute attack and you can also experience increased lung damage due to uncontrolled inflammation. A lack of education may play a role if you don’t understand the serious nature of asthma, if you aren’t clear on your triggers, and if you can’t easily manage those triggers. If you don’t see a doctor regularly, the emergency room might become your go-to place for intervention and treatment.
Costs, Insurance, and Compliance Are Barriers
There are clearly financial challenges at play – if you don’t have insurance, if your coverage is limited and has a high deductible, if you can’t afford your medications, if you live in an area where healthcare is not readily available – then a chronic disease like asthma will not be well-managed.
As a pulmonologist (lung doctor), I am frequently challenged by these issues that my patients face. I sometimes offer people inhaler samples because the newer ones are very expensive and often not covered by insurance. I know that it’s also easy to lose track of someone's asthma management – I see them in the office and make recommendations and suggest when I need to see them again. But then the burden lies on them to follow through and get their medications, take the medications as instructed, and see me for the next appointment. If any of those steps fall apart, then my patient may end up in the emergency room.
If we can’t find solutions for the roadblocks that people encounter, then the emergency room will continue to be utilized instead of the office and outpatient setting, especially by financially challenged people. That adds to the healthcare cost burden and also means there is not continuity of care for many asthma patients. This study clearly raises issues that we have yet to face and solve.