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Noreen M. Clark, Ph.D.Myron E. Wegman Distinguished University ProfessorDirector, Center for Managing Chronic DiseaseUniversity of Michigan
Health Policy and Asthma Disparities: What is
Needed? American Thoracic Society International Conference
New Orleans, LouisianaMay 14-19, 2010
Many new or reformed policies in the U.S. could improve outcomes for people with asthma, but we must consider changes in light of how they would reduce disparities. Asthma prevalence remains highest in low income and racial/minority groups.
In all countries, sub-groups are likely to have disparate asthma outcomes.
One could argue:
Policies with equal effect on all people could raise all boats, but not repair inequities.
Noreen M. Clark, Ph.D.Myron E. Wegman Distinguished University ProfessorDirector, Center for Managing Chronic DiseaseUniversity of Michigan
Example of raising both same amount part 1
Intervention
Noreen M. Clark, Ph.D.Myron E. Wegman Distinguished University ProfessorDirector, Center for Managing Chronic DiseaseUniversity of Michigan
Example of raising both same amount part 1
InterventionBrown et al, 2004, Physician asthma education program improves outcomes for children of low income families
But burden of disease is another way to think about asthma and asthma disparities.
So, as relates to asthma control and disparities we might focus policies on:
• Burden: emergency department, hospitalization, deathversus simply prevalence of disease.
Societal factors associated with disparities in asthma:
• Income (Gold & Wright, 2005)
• Race/ ethnicity (McDaniel et al, 2006)
• Education, age, sex (Eagan et al, 2004;
Sondik, 2008; Gold et al, 1993)
• Stress, depression, violence
(Adler & Conner Snibbe, 2003; Kashani et al, 1988; Wright et al, 2004)
• Physical environment (Williams et al,
2009; Gold & Wright, 2005).
• Obesity (Valerio et al, 2009)
These factors are challenges that require at least two levels of change:
• Behavioral (individuals, families, clinicians)
• Structural (community wide systems, cultures, practices)
• Both can be affected by policy.
Elements of the blueprint for policy action (Lara et al. 2002)
*1.Develop and implement primary care performance measures for childhood asthma care
*2. Teach all children with persistent asthma and their families a specific set of self-management skills
*3. Provide care management to high risk children4. Extend Continuous health insurance coverage to all uninsured children5. Develop model-benefit packages for essential childhood asthma
services6. Educate health care purchasers about asthma benefits*7. Establish public health grants to foster asthma friendly communities
and home environments*8. Promote asthma friendly schools and school-based asthma programs9. Launch a national asthma public education campaign*10. Develop a national asthma surveillance system 11. Develop and implement national agenda for asthma research
* = Targeting sub-populations make these especially amenable to reducing disparities
Global disparities can be counter to conventional wisdom and deserve attention
• Asthma prevalence in children– Detroit: 24%– Beijing: 7.3%
Clark et al, 2005, A trial of asthma self-management in Beijing schools; Clark et al, 2005, Influences on childhood asthma in low-income communities in China and the United States
In addition, adherence by clinicians to guidelines are very poor in low income
communitiesPreteens with Asthma and a Prescription
Type of asthma medication used
Well Controlled
Not well Controlled
Very poorly controlled
p value
Controller + Reliever 28% 37% 43% 0.004
Controller only 2% 1% 4%
Reliever only 70% 61% 53%
Number of meds, mean (SD)
1.8 (0.8) 2.1 (1.0) 2.2 (0.9) 0.0002
Uses an inhaler 76% 85% 89% 0.001
Uses a nebulizer 41% 49% 53% 0.003
Spacer use, among inhaler users
Always/most of the time
29% 35% 35% 0.64
Sometimes/hardly ever
21% 21% 18%
Never 50% 44% 47%
Clark et al, 2010, A current picture of asthma diagnosis, severity, and control in a low-income minority preteen population
Twin management problems
• Provider capacity (includes health care organization)
• Patient capacity
Give rise to needed policy focus:• Provided related• Patient related
Growing recognition that clinical systems are not prepared nor able to provide all services needed to reduce asthma disparities
Failure to acknowledge the real asthma managers: individuals and families and build their capacity to manage
Policy needs to target the interface between clinical and community settings and efforts.
Circles of Influence on Disease Control
Community-Wide Environmental Control Measures
Community Awareness Support & Action
Work/School Support
Clinical Expertise
Family Involvement
Patient Self Management
Policies needed within each circle
Effective disparities policy would:
• Directly aim to increase equity in health care (raise all boats, but sub-groups more)
• Target special patient/family capacity building efforts in asthma management for groups experiencing disparities
• Reward providers for reducing disparities in their patient population
Potential policy focus (especially in the U.S.)
• Establishment of organization/state/province surveillance
• Adequate insurance coverage for low income patients (including devices)
• Coverage/support for community health workers (Krieger et al, 2006)
• Environmental controls (Institute of Medicine, 2000)
Potential policy focus (especially in the U.S.) cont’d
• Reimbursement/support for evidence based self management programs (medical home, accountability organizations)
• Realignment of incentives to clinicians to reduce disparities
In the U.S., there is potential for furthering these policies under health care reform
• Shared savings• Community benefit• Getting viable options onto
state Medicaid agendas
A global goal is requiring that policy makers at all levels examine each policy proposal for its actual ability to promote equity and eliminate disparities.
Presenter Disclosures
1) Personal financial relationships with commercial interests relevant to medicine, within past 3 years:
Noreen M. Clark, PhD
No relationships to disclose
Presenter Disclosures
2) Personal financial support from a non-commercial source relevant to medicine, within past 3 years:
Noreen M. Clark
No relationships to disclose
Presenter Disclosures
3) Personal relationships with tobaccoindustry entities within the past 3 years:
Noreen M. Clark
No relationships to disclose.
Presenter Disclosures
Off-Label Disclosure:
My presentation will include discussion of “off-label” use of the following:
Noreen M. Clark
No relationships to disclose