Access to Asthma Care

Vol. 17 •Issue 4 • Page 16
Access to Asthma Care

Disparities Mean Inner-City Poor Hit Hardest by Disease

Asthma care’s future has never been brighter. Over the next few decades, therapies targeting the link between allergies and asthma will finally give medicine the upper hand on this disease, experts assert. In time, new vaccines might even be able to eliminate the allergic antibody altogether, effectively undercutting the disease process.

But therapies that don’t reach the people who need it most are imperfect at best, said allergy specialist Bob Lanier, MD, past president of the American College of Allergy, Asthma & Immunology (ACAAI), a professional association of 4,000 allergists/immunologists dedicated to improving the quality of patient care in allergy and immunology.

“Even if we come up with a cure, it’s still a problem getting it out there,” he explained, speaking as part of a panel of asthma experts at the ACAAI’s annual meeting in New Orleans. “And so for the foreseeable future, what we’re stuck with, unfortunately, is the day-by-day asthma treatment.”

Many people are left with even less than that. According to the Centers for Disease Control and Prevention (CDC), asthma rates have more than doubled since 1980, and the disease is hitting the inner-city poor at disproportionately higher rates.

Each year, it is estimated about 5,000 people die from asthma-related causes, according to William Berger, MD, MBA, president of the ACAAI. “The statistics, unfortunately, are the same year after year, so I know them by heart at this point,” he added.

Moreover asthma is estimated to cause half a million hospitalizations and 2 million emergency room visits annually in the U.S.

This problem is compounded by the restricted access many lower-income patients have to critical acute care medication. In fact, a recent national poll conducted by the ACAAI showed nine out of 10 allergists objected to a new policy requiring prior authorization for many of these drugs.


“Inner-city asthma is not different from regular asthma, but it is different to the extent that its management and diagnosis are complicated by a host of environmental and socioeconomic issues,” said Michael Foggs, MD, vice chairman of the executive committee of the Allergy & Immunology Section of the National Medical Association (NMA). The NMA serves as a collective voice of physicians of African-American descent and is a leading force for parity in medicine, elimination of health disparities and promotion of optimal health.

Although African-Americans represent only a minority of the nation’s population, “they account for more than 24 percent of all asthma related deaths,” he said. “The lifetime prevalence rate for asthma is 15 percent higher among African-Americans than among white Americans.”

Additionally, the asthma attack prevalence is 22 percent higher among African-Americans than it is for white Americans. “African-Americans are three to four times more likely to require emergency department treatment for asthma or to be hospitalized for asthma,” he said.

These disparities are no coincidence. Asthma in inner cities remains frequently under-diagnosed and inappropriately treated. Often patients in these locations heavily rely on quick-relief therapies like bronchodilators.

He said the lack of diagnosis takes preventive measures out of the equation. If a patient believes a cough is related to the common cold, the diagnosis is simply written off as cold or chest congestion.

“As a result, there’s increased morbidity or expression of the disease as it goes on to present itself with decline in lung function and inflammation being unchecked,” he explained. “This condition can be devastating, and those patients do end up in the emergency departments.”


Prescribing quick-relief medicines does not substitute for disease management, Foggs said. “This treatment is very effective, suppressing the acute symptoms of asthma’s expression. It unfortunately does not have the ability to control the chronic inflammation that is present in those who have persistent asthma.”

Caregivers must “raise the bar with regard to the early diagnosis of asthma and have intervention with the best medications available so that there are no formulary restrictions so that certain individuals in our society have less access to the best medications available,” he added.

Education remains an issue in the African-American community, where asthma is seen as an event rather than a chronic lung disease, and “this must be changed,” he asserted. “We are in the midst of an asthma epidemic, and this indeed constitutes a public health care crisis in the inner city.”

Another expert offered his own first-hand experience. A long-time allergist in Fort Worth, Texas, Bob Lanier, MD, past president of the ACAAI, said that as asthma medications have improved, burdening patients with fewer side effects, often access to these next generation drugs is restricted.

“We found if some of the newer, improved medications were used, we could shorten the hospital stay significantly,” he said. “But some of the newer medications we use in the emergency room and hospital are not necessarily the ones that are approved. Part of that has to do with the fact that a lot of times, people who control pharmacy costs are not the same people who look at global costs.”

Cost containment is often studied in segments, he explained. For example, if a new medication costs a dollar more than the older medications, a patient would see that as a nominal cost. Knowing the benefits of the next-generation drug, they would opt for the more expensive medication.

But a pharmacy-benefits manager at a large hospital, which administers hundreds of thousands of doses each month, would likely opt for the less expensive drug. Even a dollar more on this larger scale represents a huge increase when multiplied across several thousand patients.

What the manager doesn’t count into the cost of a single dose of a drug is the cost of a longer hospital stay, Lanier asserted. “The least expensive medication can be sweet initially yet a bitter pill to swallow in the long run.”

When bean counters study the cost of a drug versus the cost of a hospital stay in a global fashion, they begin understand the issues more in depth, he said. To avoid this issue, hospitals need to have a knowledge and compassionate hospital administration. Also, they should have a good plan and the ability to sort out the total health care picture.


As messages like that get out, asthma care in both inner cities and rural areas will dramatically progress, according to the asthma expert. “I’m looking forward in the next couple of years to seeing some really big improvements in the management of asthma, because this is really a family issue more than an individual issue,” Lanier said. “This affects Mom being able to sleep at night and go to work the next day.”

Sandra Fusco-Walker, a vocal national patient advocate and director of Outreach Services at the Allergy and Asthma Network Mothers of Asthmatics (AANMA) in Fairfax, Va., agreed that asthma patients’ quality of life remains a big concern. Founded in 1985, AANMA is a national non-profit network of families whose desire is to overcome, not cope with, allergies and asthma.

“It wears many different faces for different people,” she said. “And it begs a comprehensive treatment plan which investigates all possible causes, triggers, treatments and options possible.”

That is why a comprehensive treatment plan, focusing on managing asthma, is essential. She said most often the team would consist of an allergist and a primary care physician. Ideally, they would provide patient education too, ultimately empowering asthmatics to own their own disease.

“This is the most cost-effective and humane approach,” Fusco-Walker asserted. “People, whether they live in the inner city, the countryside or somewhere in between, just want to breathe well enough to get on with the business of life.”

But that goal is not as easy as it sounds. Asthma care is still a struggle for families the AANMA has studied. “We found that access to care, challenges with medications and their unwanted side effects and environmental factors were the important issues for both rural and urban families,” she said. “Their quest to resolve these issues is often complicated by factors beyond their control.”

Asthma is a treatable condition, and patients everywhere should have access to effective care, she asserted. In reality, care often falls short of this goal. And in the end, that momentum will have to be broken before patients will see significant improvements.

“Unless we find some way to entertain dialogue and protect the sanctity of the patient and physician relationship, we’re all headed the wrong way on a one way road,” said Fusco-Walker.

For more information on ACAAI, visit the organization’s Web site at For more information on AANMA, visit the organization’s Web site at or call 800-878-4403.

You can reach Shawn Proctor at [email protected].

Do Patients Know What’s Left in Their MDIs?

Two-thirds of asthma patients believe that their pressurized metered dose inhaler (MDI) contains lifesaving medication until absolutely no spray comes out. This belief has dire consequences for asthma patients both young and old according to one AANMA national survey.

“MDI package inserts caution patients to discard the device after using the labeled number of doses, even though contents remain in the canister,” according to Bradley Chipps, MD, medical director at the Capital Allergy & Respiratory Disease Center in Sacramento, Calif., who co-authored the study. “After that point, the quality of each puff cannot be assured.”

The consequences of not following that directive can be frightening, misleading or even deadly in time of need, said Nancy Sander, AANMA president. “Most respondents said they’d never been informed to keep track of doses,” she explained. But the next question is how to do it. Like driving a car with no gas gauge, MDI users have no indicator they are running on empty.

“I think this work gives added weight to the guidance FDA has recently provided, encouraging manufacturers to make dose counters or indicators a part of their new MDI development plans,” said Robert J. Meyer, MD, director of the FDA’s Office of Drug Evaluation II.