Disparities in Guideline Recommended Care among Women with Asthma

Research Article

Chronic Dis Int. 2014;1(1): 6..

Disparities in Guideline Recommended Care among Women with Asthma

Minal R Patel1*, Georgiana M Sanders2, Ye Yang3, Randall W Brown1,4 and Kausar Hafeez4

1Department of Health Behavior & Health Education, University of Michigan, USA

2Department of Internal Medicine, University of Michigan, USA

3Department of Biostatistics, University of Michigan, USA

4Center for Managing Chronic Disease, University of Michigan, USA

*Corresponding author: Minal R Patel, Department of Health Behavior and Health Education, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA

Received: August 08, 2014; Accepted: August 25, 2014; Published: August 25, 2014


Purpose: To examine racial differences in the provision of guideline recommended care among women with asthma, and whether disparities in outcomes are evident despite guideline recommended care.

Methods: Data came from African American and White participants from baseline assessments of two randomized controlled trials for women with persistent asthma (n=724). Participants reported demographic and clinical information, and asthma-related outcomes.

Results: More White than African American women (67% vs. 36%, p<0.001) reported seeing a specialist for their asthma. African Americans were significantly more likely to have received an asthma action plan (OR, 2.93; 95% CI, 2.0-4.28, P<.01), prescription of a controller medication (OR, 4.06; 95% CI, 2.74-6.01, P<.001), and were more likely to ask their doctor questions about asthma (OR, 1.83; 95% CI, 1.26-2.65, P<.001) compared to Whites when adjusted for asthma control, income, education, and specialty care. African Americans experienced more emergency department visits for asthma (RR 1.44; 95% CI (1.07 to 1.95), p<0.01), and worsening asthma control (OR, 2.27; 95% CI, 1.57-3.29, P<.001), compared to Whites when adjusted for four aspects of guideline recommended care (asthma action plan, ownership of a peak flow meter, talking with a physician, receipt of controller medication for persistent asthma), income, educational attainment, and specialty care.

Conclusion: Fewer African American women reported seeing a specialist compared to White women, but received more guideline recommended care. Despite this, asthma outcomes for African American women were worse than Whites. Greater attention is needed to support the self-management efforts of high-risk groups.

Keywords: Asthma; Self-management; Women; Clinical guidelines; Outcomes; Disparities


NAEEP: National Asthma Education and Prevention Program


Asthma affects 8% of U.S. adults, with prevalence higher in women compared to men (9.5% vs. 7%) [1]. Despite over two decades of advancements in the diagnosis, treatment, and management of asthma, disparities in outcomes and asthma-related health care costs remain high in the United States [1]. Two such disparities of particular concern are the higher prevalence and worse outcomes in adult women and minority communities. African-American populations bear a significantly greater prevalence of asthma and burden of disease as demonstrated by higher emergency department rates, hospitalizations, and deaths attributable to asthma compared to Whites [1]. Contributing to these data may be that African-American patients report less use of anti-inflammatory medicines, especially inhaled corticosteroids [2-5]. Other reasons for differences between African-American and other populations have been discussed, including lack of access to quality medical care, lack of asthma education and support, social environment, economic status, cultural influences, racial discrimination, and underestimation of patients’ asthma severity [6-9].

Disparities in asthma outcomes in women merit particular attention because they get worse with age. Older asthmatic women have higher mortality rates due to asthma compared to men and use more urgent care services [10 -13]. These outcomes are particularly worse for African American women [12]. Given greater awareness and efforts over the past decade to reduce health disparities through dissemination of the National Asthma Education and Prevention Program (NAEEP) clinical asthma guidelines, and providing training in culturally sensitive care, we sought to examine whether racial differences in provision of guideline recommended care among women with asthma persist, and whether disparities in outcomes persist between African American and White women despite guideline recommended care. These findings may provide more nuanced information of where greater efforts are needed to reduce disparities in asthma outcomes, particularly among African American women.



Data came from baseline assessment of two self-managementinterventions for women with asthma conducted at the University of Michigan Health System (subsequently referred to as cohort 1 and cohort 2). Details of the self-management interventions are described elsewhere [14,15]. The protocols for both studies were approved by the Institutional Review Board at the University of Michigan Medical School.

Analytic sample

Survey data from both cohort 1 and cohort 2 were pooled in the current analysis to increase the sample size and reliability of estimates to examine differences between African American and White women on outcomes of interest. For cohort 1, of the 2,336 women who were initially approached for the study, 997 consented to participate. Ultimately, 808 women returned the completed consent forms by mail, and provided baseline data. For cohort 2, a total of 1,315 women were initially approached. Of those, 843 women were successfully reached via telephone and mail, and a total of 444 (53%) women consented to participate. Ultimately, 422 of those who consented to participate provided baseline data. The pooling of the sample between cohort 1 and cohort 2 resulted in 1,230 women with asthma. The analytic sample comprised women with the following inclusion criteria 1) 18 years of age older; 2) physician diagnosis of persistent asthma; 2) not pregnant; 3) access to a telephone; and 4) self-identify as White or African American. The final analytic sample of individuals who met inclusion criteria was 724 women (White = 303; African American = 421).


Asthma action plan

Asthma Action Plan (AAP) was defined as a written treatment plan for asthma. To assess whether participants had an AAP, weasked them the following question on a binary (yes/no) scale: “Do you have a treatment plan or asthma care plan that you and your doctor worked out together for you to adjust your medication use when symptoms change?”

Owning a peak flow meter

To assess whether participants owned a peak flow meter to monitor their asthma symptoms, we asked the following question on a binary (yes/no) scale: “Do you own a peak flow meter?”

Initiating discussion about asthma with their physician

To assess whether participants initiated discussion about their asthma with their physician, we asked the following question: “Would you say that you asked the doctor questions about asthma often, sometimes, rarely, or never?” Based on the distribution of responses, responses were collapsed into yes/no.

Asthma medications

The participant was asked to assemble medicines to refer to during the interview. We assessed which asthma medications, bothcontroller and quick relief forms, were prescribed to the participant by obtaining the names of medications through open-ended responses. Medicines were then categorized as controller or reliever.

Asthma-related health services use

We assessed frequency of asthma-related urgent health care use (ED visits, hospitalizations) in the past 12 months through self-report and verified these data with medical records.

Asthma control and frequency of asthma symptoms

Asthma control and symptom frequency were assessed based on self-report of the presence of daytime and nighttime symptoms in the previous month, as recommended by the NAEPP guidelines for the diagnosis and management of asthma [16]. Asthma control was calculated by the worst impairment category of daytime or nighttime symptoms, and was classified into three categories: poorly controlled, not well controlled, or well controlled. The NAEPP guidelines were used to classify the symptom frequency reported by participants into four categories: ≤ 1 day per week, 2 days per week, ≥3 days per week, and throughout the day.

Social support

We measured social support for asthma, using 5 items with responses on a 5-point Liker scale that identify the frequency with which social support is perceived. The items were organized to cover five dimensions of social support: material, affective, positive social interaction, emotional and informational. All items were summed with a higher score indicating greater perception of social support.

Demographic and clinical data from participants were also collected. All data were collected through one-hour long telephone interviews by trained interviewers.

Data analysis

Data were analyzed in SAS 9.3. Descriptive statistics were computed for all demographic and clinical characteristics of the sample as well as the outcome variables of interest. Frequencies were computed for all categorical variables, and means and standard deviations were computed for all continuous variables. Estimates for differences between white and African Americans on demographic, clinical, and outcome variables were assessed using Student’s t test or chi-square tests.

Four multiple variable logistic regression models adjusted for education, income, age, specialty care, and asthma control were used to examine differences between white and African American women in the odds of receiving aspects of guideline recommended asthma care (asthma action plan, ownership of a peak flow meter, collaborating with a physician in self-management, receipt of controller medication).

Three multiple variable regression models adjusted for aspects of guideline recommended care (asthma action plan, ownership of a peak flow meter, collaborating with a physician in self-management, receipt of controller medication), education, income, age, and specialty care to examine differences between White and African American women in asthma-related emergency department visits (Poisson regression), hospitalizations (Poisson regression), and asthma control (cumulative logistic regression).


Sample characteristics

Demographic and clinical characteristics of the analytic sample are provided in Table 1. Forty-two percent of the sample (n= 303) were White and 58% (n= 421) were African American. The mean age of participants was 44.7(SD=14.15). Forty-five percent (n=321) reported being married, 39% (n=281) had a college education or higher, 65% (n=468) were employed, and 51% (n=358) reported an annual household income of $40,000 or less. The sample reported moderate levels of social support (mean 2.66 (SD=1.03)). Compared to White women, African American women were younger in age (p<0.001), and fewer were married (p<0.001) and attained a college degree or higher (p<0.001). African American women reported lower income (p<0.01), but reported higher levels of social support (p<0.01) compared to Whites.