Health Policy and Asthma Disparities: What is Needed?

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