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Article
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Pharmacy Practice in Focus: Health Systems
Pharmacists can help address the significant asthma health disparities among racial, ethnic, and socioeconomic groups to help improve outcomes.
Précis
Pharmacists can help address the significant asthma health disparities among racial, ethnic, and socioeconomic groups to help improve outcomes.
Introduction
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In 2021, 7.7% of individuals in the US (nearly 25 million people) had a diagnosis of asthma, including 8.0% of adults, according to CDC data.1 By 2023, the percentage of adults in the US with asthma had risen to 8.9%.2 The disease burden on the US health system is significant, with asthma health care costs exceeding $81 billion each year and more than 3500 deaths annually.3
Furthermore, there are health disparities present among racial and ethnic minority groups in relation to asthma disease burden and impact,1 with asthma prevalence and mortality rates highest among minority groups. For example, Puerto Rican individuals, when compared with White individuals, are 200% more likely to develop asthma, and Black individuals are 150% more likely to develop asthma than White individuals.4 In 2021, the CDC reported asthma death rates per million as being nearly 3.5 times higher in Black individuals than White individuals.1 This marked difference occurred amid a similar prevalence (approximately 40%) of asthma attacks among any race or ethnicity (Table).1
*Asthma attack: At least 1 asthma attack in the past year among those with asthma.
Additionally, asthma prevalence has increased in low-income communities (Figure).1 When asthma is stratified by household income, its prevalence is significantly higher among patients below the federal poverty threshold when compared with patients at or above the federal poverty threshold (Figure).1
Furthermore, asthma medication therapy often requires use of a daily maintenance inhaler, yet literature suggests a trend toward decreased medication adherence rates among minority groups. This has been shown to stem from a multitude of social determinants of health (SDOH), including socioeconomic barriers and low health literacy.5 Moreover, racial and ethnic minority groups may also be disadvantaged by structural factors, including poor housing, education, employment, and overall health care, demonstrating the necessity for culturally versed strategies to ensure all patients have the access, understanding, and motivation to utilize available resources to improve their quality of life and asthma control.2
Socioeconomic Barriers to Asthma Progression and Proper Care
Healthy People 2030, a 10-year plan launched by the US Department of Health and Human Services to improve the health and well-being of individuals in the US, defines health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.”6 In a review published in the Journal of Allergy and Clinical Immunology, the authors explain that the most important health disparity impacting patients with asthma is healthy housing, citing an estimated 39% decrease in the prevalence of asthma in the US if all residential risk factors were eliminated.7,8
Additional barriers to adequate asthma management include the financial burden of addressing indoor asthma triggers (eg, mold, dust, pests), limited autonomy for home improvement in rental properties, and inadequate housing maintenance among short-term tenants.7 These barriers have a significant impact on the development and severity of asthma in children who become sensitized to several allergens in substandard housing.7
Healthy People 2030 is also working toward several objectives that influence SDOH for patients with asthma, such as the goal of smoke-free homes, which has almost been reached.6 However, the proportion of people who live in poverty has shown minimal detectable change.6
There are several goals community pharmacists can specifically target to address 2030 objectives, including assessing whether adequate health literacy and comprehension were attained following an interaction with a provider.6 For pharmacists, aiding in the education and administration of targeted respiratory vaccines or offering financial resources for medication assistance are simple steps that can yield a significant impact in reducing asthma burden and exacerbations.
Exposure to asthma triggers, such as secondhand smoke, is higher among people with low income or minimal education.9 CDC data show that tobacco smoke prevalence among adults is nearly 3 times higher in those with low income (18.3%) vs high income (6.7%).9 Further, smoking frequency was higher among those with a General Educational Development diploma (30.7%) than those with an associate (13.7%) or bachelor’s (5.3%) degree.9 Secondhand smoke has also been found to increase wheeze and asthma incidence in children, and the 2023 Global Initiative for Asthma (GINA) clinical practice guidelines note that secondhand smoke is a major risk factor for asthma exacerbations.10,11
Asthma has been documented as the fourth leading cause of work absences, as well as a primary cause of school absence in children; asthma has also been shown to be related to reduced adult productivity at work.12 Moreover, a chronic disease such as asthma requires frequent monitoring and follow-up, yet low-income patients who lack employment benefits often have to face risking admonishment from supervisors for leaving work to visit a primary care provider or to rely on an emergency department (ED) that is open 24 hours a day and 7 days a week.4 Supporting this finding, a study conducted by Redmond et al identified an association between lower socioeconomic status and increased ED visits, hospitalizations, and readmissions among patients with asthma.13
Systemic Racism
Psychosocial Stressors and Asthma Disease Burden
The American Psychological Association defines implicit bias as “a negative attitude, of which one is not consciously aware, against a specific social group.”14 Implicit bias is thought to be shaped by an individual’s personal experience and based on learned associations among particular qualities and social categories, such as race, ethnicity, sex, and gender. Individuals’ perceptions and behaviors can also be influenced by the implicit biases they hold, even if they are unaware of these biases.14
In a retrospective cohort study assessing children with equal health care access, investigators found evidence of racial and ethnic disparities in relation to asthma care and positive outcomes.15 They discovered that the likelihood of patients with asthma visiting an asthma specialist was much higher in White children (12.9%) than Black (9.6%) or Hispanic (9.6%) children (P < .001).15 This suggests that despite perceived equal health care access, racial and ethnic disparities still are substantial barriers to optimal asthma management.
Chronic stress also poses a risk to the development of many chronic diseases, including diabetes, hypertension, and obesity.16 It is reported that chronic stress may be a risk factor for 75% to 90% of chronic, noncommunicable conditions.17 Similarly, investigators of several studies have observed a correlation between chronic stress and diminished asthma outcomes, notably in children.17 There is conjecture that activation of the hypothalamic-pituitary axis secondary to chronic stress and subsequent cortisol production may dampen the efficacy of mainstay asthma therapies (ie, inhaled corticosteroids and bronchodilators).15,18 Further, a review was conducted utilizing data from the prospective cohort study known as the Black Women’s Health Study. In this study, investigators observed a trend between daily or lifetime racism and increased incidence of adult-onset asthma among Black women.19 Thus, although additional research is warranted for a definitive causal relationship, evidence suggests that psychosocial stressors pose a significant risk for negative outcomes in patients with asthma.
Racial Inequities in Pulmonary Function Testing
Asthma has been deemed the most racially disparate health condition in the United States.20 For example, interpretations of pulmonary function testing (PFT) utilized in the diagnosis of asthma have been shown to support racial inequities. For instance, it is not certain whether genetic traits related to lung function have an accurate representation within race, despite this being an element of PFT.21
“Globally, race/ethnicity is a social construct that changes across geography and time, making it difficult to envision it as a fixed characteristic of people,” said Nirav R. Bhakta, MD, PhD, during a 2021 American Thoracic Society (ATS) workshop.22 Bhakta is an associate professor and a critical care specialist and pulmonologist at the University of California, San Francisco, School of Medicine.
Bhakta emphasized that recent literature points to a superior race-neutral equation for accurate PFT interpretation.22 The workshop’s panel called for future studies to determine a more precise measurement to reflect biological variables and clearly define race and ethnicity designation when utilized.22
Additionally, the ATS released details regarding the PFT discussion, urging health care professionals to switch to a Global Lung Function Initiative equation in place of the current standard.23 However, the ATS cautioned that a shift toward this equation warrants further research and close evaluation regarding patient-specific confounding variables, specifically when comparing patients with the reference of PFTs.23 Hence, efforts are being made toward more race-neutral procedures to diagnose asthma, and thus improve health outcomes.
The Pharmacist's Role in Mitigating Disparities in Patients With Asthma
Advocate
Pharmacists can increase awareness of disparities by supporting organizations that are working to mitigate asthma disparities. The Asthma and Allergy Foundation of America, for example, released its Asthma Disparities in America report in 2020, which detailed public policy and research and presented a call to action to address asthma disparities.
Similarly, the CDC launched the National Asthma Education and Prevention Program (NAEPP) in 1989 and the National Asthma Control Program (NACP) in 1999.12 Since its launch, the NAEPP has published asthma management guidelines, and the NACP has partnered with several states to improve asthma care quality and educate policy makers about the disease burden. These organizations collectively echo the plea to increase accurate racial and ethnic representation among respective disease states in clinical studies.
Collaborate
Community pharmacists are some of the most accessible health care providers. Patients encounter their community pharmacist almost 12 times more than their primary care provider, and 93% of individuals in the US live within 5 miles of a community pharmacy.24,25 Therefore, community pharmacists have the unique opportunity to discover and address asthma health disparities in their community. This may include connecting patients with local health departments, community health workers, and social workers to address socioeconomic barriers, such as assessing qualifications for patient assistance programs. In addition, pharmacists can enhance continuity of care by reviewing medication refill history and offering medication therapy management services to evaluate any exacerbation risk or negative outcomes of treatment. Subsequently, pharmacists have the responsibility to communicate their findings with providers to augment and improve patient care.
Communicate
Pharmacists can ensure effective communication and patient comprehension by providing thorough, culturally competent patient counseling. Cultural competency entails the “recognition of cultural influence and interactivity that creates a trusting and respectful exchange.”26 Culturally competent patient counseling may involve working with an interpreter and/or providing health literacy materials appropriate for the demographics of the local community. In addition, the GINA clinical practice guidelines offer strategies to improve education in patients with low health literacy, such as presenting information in order of priority level.11 In addition, it is encouraged to establish a psychologically safe environment so that patients feel comfortable asking questions.11
Educate
Asthma education is essential for patients and caregivers to improve overall quality of life and understand how to control the disease. Although there is controversial evidence regarding the efficacy of asthma action plans, it is well documented that proper and consistent asthma education is beneficial.27 For example, the CDC launched the Controlling Asthma in American Cities Project, an inner-city initiative that successfully educated parents of children with asthma. The program encouraged using a patient diary to track asthma symptoms and the correlation of rescue or controller medications, which was shown to decrease the dependence on rescue medications.12 Similarly, evidence has demonstrated the frequency of poor inhaler technique deteriorating over time due to lack of follow-up.28 With their accessibility to patients, community pharmacists can incorporate these simple strategies aimed to promote asthma education and ensure optimization and confidence in one’s asthma regimen.
Rachel Winters, PharmD, is a PGY-1 ambulatory care pharmacy resident at Prisma Health Richland in Columbia, South Carolina. At the time of writing, she was a final-year pharmacy student at Cedarville University School of Pharmacy in Cedarville, Ohio.
Rachel Chandra, PharmD, MPH, FASHP, is a clinical pharmacist practitioner and PGY-1 residency program director at the Dayton Veterans Affairs Medical Center in Ohio; and pharmacoequity lead in the Office of Health Equity.
Conclusion
Asthma affects individuals across a wide array of ages, races, and socioeconomic statuses. Further, health disparities continue to be substantial barriers to optimal health outcomes among patients with asthma. For this reason, a progressive approach to asthma management may be necessary, which may include assessing slightly unconventional variables such as exposure to substandard housing, chronic stress, and racial inequities to minimize gaps in care.
Additionally, expanding awareness of health disparities is a great strategy to improve health outcomes among those with asthma. Therefore, prioritizing a holistic view of asthma management is a strategy pharmacists can use to mitigate health disparities for patients with this disease.
REFERENCES
