Abstract

Objective

The purposes of this study are to describe and develop preliminary models of the burden of diagnosed asthma and symptoms of possible undiagnosed asthma in a large, citywide, ethnically and socioeconomically diverse sample of Chicago elementary schoolchildren. We hypothesized that considering possible asthma would give a more complete picture of race/ethnic disparities in pediatric asthma.

Methods

We studied 35583 students aged 6 to 12 years attending Chicago Public and Archdiocese elementary schools for the Chicago Initiative to Raise Asthma Health Equity (CHIRAH) study. The full enrollments of 105 schools were surveyed for asthma and possible undiagnosed asthma by the Brief Pediatric Asthma Screen Plus (BPAS+) respiratory symptoms. The child had to be 6 to 12 years old, the valid age range for the BPAS+. Questionnaires included the BPAS+, basic demographic information, and household asthma information; they were sent home with each schoolchild for completion by the parent and returned to school for collection and scoring.

Results

Overall, 13.9% of students had diagnosed asthma. For children aged 6 to 12 years, rates of diagnosed asthma varied from 13.1% to 14.5%, whereas the rates of possible undiagnosed asthma varied from 14.8% to 10.9%. The rate of diagnosed asthma was 21.2% for African Americans, 9.7% for whites, 11.8% for Hispanics, with similar rates of possible undiagnosed asthma. By multinomial logistic regression, African Americans were more than twice as likely and Hispanics were 1.57 times more likely than whites to have diagnosed asthma at all school district income levels and controlling for other household members with asthma, type of school, age of the child, gender, and language preference. The odds of African Americans being diagnosed with asthma rather than having possible asthma were 76% higher and for Hispanics were 46% higher compared with whites, at all school district income levels and controlling for other household members with asthma, type of school, age of the child, gender, and language preference.

Conclusions

Our study confirms national disparities in diagnosed asthma by race/ethnicity. Respiratory symptoms consistent with possible undiagnosed asthma increase the total potential burden of asthma overall to more than one-quarter of the school enrollees. Among students with respiratory symptoms, African Americans, Hispanics (controlling for language), and families where another person has asthma are more likely to have diagnosed rather than possible asthma. Improved knowledge about asthma, recognition of symptoms, and access to high-quality care are necessary to ascertain how much of the possible undiagnosed asthma represents additional cases of asthma requiring treatment.

Up to one-third of patients receiving a clinical diagnosis of COPD or asthma have been shown to lack evidence of disease in subsequent lung-function studies. 

https://cdn-uat.mdedge.com/files/s3fs-public/JFP06803076.PDF

Abstract

Single maintenance and reliever therapy (SMART) is an asthma treatment approach that utilizes combined inhaled corticosteroids and long-acting β-agonists for maintenance and quick relief therapy. Despite the evidence for its benefits in asthma treatment and its adoption into American and international asthma guidelines and recommendations, SMART remains a practice of some debate. This article reviews the available evidence for SMART and offers guidance for its integration into comprehensive asthma management. Overall, short-acting β-agonist-only asthma therapy regimens should be avoided, regardless of condition severity (SOR A Recommendation). Family medicine clinicians should start SMART for patients requiring either GINA Step 3 or 4 therapy, especially if they have signs of poor adherence (SOR B Recommendation). Finally, use budesonide-formoterol over other inhaled corticosteroid/long-acting β-agonist combinations when implementing SMART (SOR B Recommendation).

Keywords: Anti-Asthmatic Agents; Asthma; Evidence-Based Medicine; Pharmacotherapy; Primary Health Care; Single Maintenance and Reliever Therapy (SMART).

Self-reported food allergies (FAs) affect approximately 8% of the US pediatric and approximately 10% of the adult population, which reflects potentially disproportionate increases among ethnically and racially minoritized groups. Multiple gaps and unmet needs exist regarding FA disparities. There is reported evidence of disparities in FA outcomes, and the FA burden may also be disproportionate in low-income families. Low family income has been associated with higher emergency care spending and insecure access to allergen-free food. Pharmacoinequity arises in part as a result of structural racism still experienced by historically marginalized populations today. Historically redlined communities continue to experience greater rates of neighborhood-level air pollution and indoor allergen exposure, lack of transportation to medical appointments, poverty, and lower prescription rates of necessary medications. Clinical research needs racially and ethnically diverse participation to ensure generalizability of research findings and equitable access to medical advances, but race reporting in clinical trials has been historically poor. Addressing health disparities in FA is a priority of clinical care, with professional organizations such as the American Academy of Allergy, Asthma & Immunology having a prominent role to play in mitigating the challenges faced by these individuals. In this position statement we recommend some key steps to address this important issue.

https://www.jacionline.org/article/S0091-6749(24)01065-0/fulltext

Findings from the 2017-2021 Medicare Current Beneficiary Surveys (MCBS)

Recent national data indicates that 8% of adults ages 18 and older in the United States have current asthma (Centers for Disease Control and Prevention, 2023). However, those rates vary based on sex, race, ethnicity, and age. Among U.S. adults, asthma is more prevalent in females (9.7%) compared to males (6.2%). In terms of race and ethnicity, asthma is most prevalent in non-Hispanic American Indian/Alaskan Natives (13.3%), followed by non-Hispanic Blacks (10.7%), and non-Hispanic Whites (8.0%). It is least prevalent among Hispanics (6.7%) and non-Hispanic Asians (4.2%).

When looking more specifically at older adults (ages 65 and older), 7.2% have current asthma nationally, accounting for approximately 20% of individuals with asthma in the United States (Centers for Disease Control and Prevention, 2023). However, asthma prevalence is likely higher among older adults, as it is widely understood to be underdiagnosed in the older population (Gibson et al., 2010). This is attributed to a combination of factors unique to older adults, including changes in lung structure and function (Dunn et al., 2017), challenges administering and interpreting pulmonary functioning tests used for diagnosis (Battaglia et al., 2016), an increase in comorbidities such as chronic obstructive pulmonary disease (COPD) (Tzortzaki et al., 2011), and complications related to polypharmacy (Battaglia et al., 2016). Additionally, asthma tends to be less controlled in older adults when compared to younger age groups, and mortality rates tend to be higher (Tsai et al., 2012; Talreja & Baptist, 2011). For example, asthma mortality rates in 2021 increased throughout the lifespan, with rates as low as 1.4 per million among those 0-4 years old, 2.4 per million among those 5-11, 2.0 per million among those 12-17, 3.8 per million among those 18-24, 6.4 per million among those 25-34, 11.5 per million among those 35-64, and 27.1 per million among those 65 and older (Centers for Disease Control and Prevention, 2023). The underdiagnoses, in conjunction with high mortality rates and a lack of literature on the disease among older adults, indicate a need for further investigation.

https://publish.illinois.edu/geigerevallab/medicare-current-beneficiary-survey-mcbs/

For children with asthma, access to quick-relief medications is critical to minimizing morbidity and mortality. An innovative and practical approach to ensure access at school is to maintain a supply of stock albuterol that can be used by any student who experiences respiratory distress. To make this possible, state laws allowing for stock albuterol are needed to improve medication access.

https://web.archive.org/web/20240420124321/https://www.atsjournals.org/doi/10.1164/rccm.202106-1550ST

Treatments for long-term control of asthma have improved and include a promising but expensive class of biologic therapies. However, the clinical trials evaluating these and other novel treatments have used a variety of different outcomes to evaluate efficacy. The evolution of asthma care calls for a re-examination of outcomes that are most important to patients and other stakeholders.

https://www.annallergy.org/article/S1081-1206(21)00256-8/abstract

Severe asthma is a subtype of asthma that can be hard to control, resulting in an exceptional impact on an individual's quality of life. The aim of this review article is to explore the misalignment of perceptions of severe asthma among different stakeholders to identify how to reduce burden and improve delivery of care.

https://www.worldallergyorganizationjournal.org/article/S1939-4551(20)30403-8/fulltext

Severe asthma is a debilitating, life-threatening disease associated with substantial global morbidity, mortality, and health care resource utilization. Patients may not receive guideline-directed medical care for severe asthma. Moreover, viable precision-based assessment tools and newer preventive therapies that can reduce the frequency of exacerbations and associated functional impact are underused. As a result, high rates of poorly controlled severe asthma persist, and patient health-related quality of life suffers.

https://link.springer.com/article/10.1007/s12325-020-01450-7

Hispanic/Latinx (HL) ethnicity incorporates many subgroups from diverse racial and cultural backgrounds. Studies suggest that Puerto Ricans (PR) have a greater asthma prevalence and asthma-related morbidity relative to White and Mexican counterparts. However, these studies were in children or limited in clinical and phenotypic characterization. Our purpose was to determine whether clinical, phenotypic differences, and disparities in asthma-related morbidity exist across adult HL subgroups. Considering the shared heritage between PR and other Caribbean HL (Cubans and Dominicans, C&D), we hypothesized that Caribbean HL (CHL; PR and C&D) adults would have greater asthma morbidity compared to other HLs (OHL; Mexicans, Spaniards, Central/South Americans).

https://journal.chestnet.org/article/S0012-3692(21)01523-3/fulltext