Acute Asthma Among Adults Presenting

to the Emergency Department*

The Role of Race/Ethnicity and Socioeconomic
Status
Edwin D. Boudreaux, PhD; Stephen D. Emond, MD; Sunday Clark, MPH; and
Carlos A. Camargo, Jr, MD, DrPH, FCCP
Objectives: To investigate racial/ethnic differences in acute asthma among adults presenting
to the emergency department (ED), and to determine whether observed differences are
attributable to socioeconomic status (SES).
Design: Prospective cohort studies performed during 1996 to 1998 by the Multicenter Airway
Research Collaboration. Using a standardized protocol, researchers provided 24-h coverage
for a median duration of 2 weeks per year. Adults with acute asthma were interviewed in the
ED and by telephone 2 weeks after hospital discharge.
Participants: Sixty-four North American EDs.
Results: A total of 1,847 patients were enrolled into the study. Black and Hispanic asthma
patients had a history of more hospitalizations than did whites (ever-hospitalized patients:
black, 66%; Hispanic, 63%; white, 54%; p < 0.001; patients hospitalized in the past year:
black, 31%; Hispanic, 33%; white, 25%; p < 0.05) and more frequent ED use (median use in
past year: black, three visits; Hispanic, three visits; white, one visit; p < 0.001). The mean
initial peak expiratory flow rate (PEFR) was lower in blacks and Hispanics (black, 47%;
Hispanic, 47%; white, 52%; p < 0.001). For most factors, ED management did not differ
based on race/ethnicity. After accounting for several confounding variables, blacks and
Hispanics were twice as likely to be admitted to the hospital. Blacks and Hispanics also were
more likely to report continued severe symptoms 2 weeks after hospital discharge (blacks,
24%; Hispanic, 31%; white, 19%; p < 0.01). After adjusting for sociodemographic factors,
the race/ethnicity differences in initial PEFR and posthospital discharge symptoms were
markedly reduced.
Conclusion: Despite significant racial/ethnic differences in chronic asthma severity, initial
PEFR at ED presentation, and posthospital discharge outcome, ED management during the
index visit was fairly similar for all racial groups. SES appears to account for most of the
observed acute asthma differences, although hospital admission rates were higher among
black and Hispanic patients after adjustment for confounding factors. Despite asthma
treatment advances, race/ethnicity-based deficiencies persist. Health-care providers and
policymakers might specifically target the ED as a place to initiate interventions designed to
reduce race-based disparities in health. (CHEST 2003; 124:803812)
Key words: adults; asthma; ethnicity; quality of care; race; socioeconomic status
Abbreviations: CI confidence interval; EDemergency department; IQR interquartile range; MARCMulticenter
Airway Research Collaboration; OR odds ratio; PCP primary care provider; PEFR peak expiratory flow rate;
SES socioeconomic status
I
n the United States, asthma does not affect all
racial/ethnic groups equally. Population studies
have repeatedly found higher asthma prevalence
among blacks compared to whites.
17
Black patients
with asthma also experience greater morbidity
818
and mortality.
1923
Hispanic patients, especially
those of Puerto Rican descent, likewise bear a
greater asthma burden than whites.
5,9,10,2426
The reasons for racial/ethnic differences in asthma
prevalence, morbidity, and mortality remain unclear.
While evidence for the genetic basis of asthma (or
asthma susceptibility) is clear,
27,28
information about
the contribution of genetic factors to race/ethnicity
differences in asthma is lacking.
2,2932
Rather, other
nongenetic factors have been implicated, such as
lower socioeconomic status (SES) and its correlates,
including greater allergen and irritant exposure and
poor access to and compliance with state-of-the-art
medical management.
28,12,13,17,18,3341
Most published studies on emergency department
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(ED) utilization by asthmatic adults of different
racial/ethnic backgrounds have used retrospective
reviews of archived or billing data.
18,33
This restricts
the range of variables that can be examined and leads
to an incomplete picture of what actually happens to
patients while they are in the ED. To further
examine the role of race/ethnicity in asthma among
adults presenting to the ED, we examined prospec-
tive data from the Multicenter Airway Research
Collaboration (MARC). Based on previous research,
we hypothesized that black and Hispanic asthma
patients would be (1) in more severe respiratory
distress on arrival to the ED, (2) more likely to
receive substandard care while in the ED, (3) hos-
pitalized more often during their index ED visit, and
(4) more likely to relapse or have continued symp-
toms during the 2 weeks after hospital discharge. We
further hypothesized that, after statistically control-
ling for factors thought to be confounders of the
relation between race/ethnicity and illness severity
(ie, education level, income, insurance status, and
access to a primary care provider [PCP]), the ob-
served racial/ethnic differences either would disap-
pear or be dramatically reduced.
Materials and Methods
We analyzed data from three prospective cohort studies
performed from 1996 to 1998 as part of the MARC (http://
healthcare.partners.org/marc). The purpose of the MARC was to
try to define the characteristics of patients presenting to the ED
for acute asthma, to describe their management and outcome,
and to follow their course after hospital discharge. Using a
standardized protocol, researchers at 64 EDs in 21 US states and
4 Canadian provinces provided 24-h coverage for a median
duration of 2 weeks and consecutively enrolled adult patients.
The following criteria were used to determine eligibility: (1)
physician-diagnosed asthma (including new diagnoses by the ED
physician or patient reported history); (2) current ED visit was
due to an exacerbation; (3) age 18 to 54 years (truncated at 54 in
order to help rule out COPD); and (4) the ability to give informed
consent. Repeat visits by individual patients were excluded. All
patients were managed at the discretion of the treating physician.
The site investigators were not informed that we intended to
compare presentation/management/outcome by race/ethnicity.
Therefore, they were blinded to the specific hypotheses studied
in this investigation. The institutional review board at each
hospital approved the study.
Public hospitals constituted 36% of sites. The remainder of the
sites were private or not-for-profit hospitals. The median number
of annual hospital admissions was 23,427, the median number of
annual ED visits was 54,000, and the median number of annual
visits for asthma was 1,500.
Data Collection
The ED interview assessed patients sociodemographic char-
acteristics, asthma history, and details of their current asthma
exacerbation. Data on ED management, disposition, and hospital
discharge medications were obtained by chart review. Follow-up
data were collected by telephone interview 2 weeks later. Re-
search personnel used best numbers and best times solicited
during the ED interview to guide their calls. A minimum of five
attempts to reach the patient were made, spaced across at least
3 days. All forms were reviewed for accuracy, completeness, and
legibility by site investigators before submission to the MARC
Coordinating Center in Boston, MA, where they underwent
further review by trained personnel. Incomplete, contradictory,
or illegible data were returned to the site investigator for
reconciliation. The data were double-entered.
Sociodemographic Factors: Age, sex, level of education, and
insurance status were recorded. Consistent with other literature
in this area,
10,11,13,17,18,33,38
the median family income was esti-
mated using patients home ZIP codes.
42
Race/ethnicity was
assigned by self-report to standard US Census categories. For the
purpose of this analysis, mutually exclusive categories were
determined as follows: black (ie, African American or non-
Hispanic); Hispanic; or white (ie, non-Hispanic). Patients desig-
nated as Asian or other ethnicity were excluded due to small
numbers. While the limitations of self-report have been discussed
in the literature,
4346
it remains the most common and efficient
manner by which to classify patients race/ethnicity. Patients were
asked whether they had a PCP.
Chronic Asthma History: We also assessed patients asthma
medication use, including oral corticosteroids, rescue inhalers,
and inhaled corticosteroids. We measured health-care utilization
via hospitalization history (ever hospitalized and hospitalized in
the past year), the number of ED visits made in the past year, and
the source of their primary asthma care and prescriptions.
Smoking status also was assessed. To examine further disease
self-management, we assessed whether the patient owned a
spacer device, peak flowmeter, and a written action plan. Finally,
we recorded whether a comorbid medical condition was present
(eg, congestive heart failure or COPD).
ED Course: We collected both subjective and objective mea-
sures of acute asthma severity. Severe symptoms was assigned to
patients who reported asthma symptoms most of the time or
had experienced severe discomfort and distress due to their
asthma during the past 24 h. Peak expiratory flow rate (PEFR)
was expressed as the percentage of the patients predicted value,
based on race, age, sex, and height.
47
Initial measurement and
change in PEFR were recorded. The number of inhaled -
agonist treatments received prior to arrival in the ED, the
number of treatments received during the ED visit (ie, within the
*From the Department of Emergency Medicine (Dr. Boud-
reaux), Cooper Hospital and University of Medicine and Den-
tistry of New Jersey-Robert Wood Johnson Medical School,
Camden, NJ; Emergency Department (Dr. Emond), Kaiser
Permanente, Santa Clara Medical Center, Santa Clara, CA;
and Department of Emergency Medicine (Mr. Clark and
Dr. Camargo), Massachusetts General Hospital and Channing
Laboratory, Boston, MA.
A complete list of the MARC investigators is located in the
Appendix.
Dr. Camargo is supported by grant HL-63841 from the National
Institutes of Health (Bethesda, MD). The Multicenter Airway
Research Collaboration was supported by grant HL-63253 from
the National Institutes of Health, and by unrestricted grants from
GlaxoSmithKline Inc (Research Triangle Park, NC) and Mon-
aghan Medical Corporation (Syracuse, NY).
Manuscript received August 1, 2002; revision accepted March 13,
2003.
Reproduction of this article is prohibited without written permis-
sion from the American College of Chest Physicians (e-mail:
permissions@chestnet.org).
Correspondence to: Edwin D. Boudreaux, PhD, Emergency
Medicine Residency Program, Cooper Hospital, One Cooper
Plaza, Camden, NJ 08103-1489; e-mail: boudreaux-edwin@
cooperhealth.edu
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first hour and the total number), and whether the patient
received oral corticosteroids were abstracted from the chart. We
calculated ED length of stay and recorded ED disposition.
Hospital discharge medications were recorded, including sys-
temic and inhaled corticosteroids. However, prescription for
inhaled corticosteroids at hospital discharge was systematically
collected for only two of the three cohorts (566 patients).
Two-Week Follow-up: All patients were called 2 weeks after
their discharge from the ED. Relapse was defined as any urgent
visit to an ED or clinic for worsening of asthma during the
2-week follow-up period. The number of days between discharge
from the ED and the date of relapse was recorded. An ongoing
exacerbation classification was assigned to patients who reported
severe symptoms during the 24-h period preceding the phone
call on any one of two questions (ie, asthma symptoms most of
the time or severe discomfort and distress due to their asthma)
or to those who stated that their asthma was about the same or
worse than at the time of their ED presentation.
Statistical Analysis
All statistical analyses were performed using a statistical soft-
ware package (STATA, version 7.0; StataCorp; College Station,
TX). The data are presented as proportions, means (with SD), or
medians (with interquartile range [IQR]). The association be-
tween race/ethnicity and other factors was examined using
2
test, analysis of variance, and Kruskal-Wallis test, as appropriate.
Three multivariate models were derived to predict the initial
PEFR, hospitalization, and posthospital discharge outcome. Each
of these final models included the following variables: age; sex;
education; median household income; insurance status; PCP
status; and recent inhaled corticosteroid use. Other salient
variables then were added based on the particular dependent
variable (eg, initial PEFR and change in PEFR were used to
predict hospitalization). The race/ethnicity variable was added to
the three models as one variable. All interpretations of the odds
ratios (ORs) for blacks and Hispanics were based on the refer-
ence group (whites). The possibility of a period effect was
examined by adjusting for the period of enrollment, but this did
not materially affect any of the results that follow (data not
shown). All ORs are presented with 95% confidence intervals
(CIs). All p values are two-sided. Considering the large sample
size and the risk of multiple testing error, p 0.01 was consid-
ered to be statistically significant.
Results
Among the eligible patients, 588 refused study
entry, were missed, or were not enrolled for another
reason, and 1,847 were enrolled into the study.
Three patients were excluded because race/ethnicity
data were missing. Patients identified as Asian or
other race/ethnicity (44 patients) were excluded,
since the purpose of the study was to investigate
blacks and Hispanics. Patients who were enrolled did
not differ from those who were not enrolled accord-
ing to demographic factors, available chronic asthma
factors, ED course (except for the administration of
steroids in the ED, which was more likely among
those who were enrolled in the study [68% vs 62%,
respectively; p 0.01]), or disposition.
Among the 1,800 patients used in these analyses, 935
(52%) were black, 411 (23%) were Hispanic, and 454
(25%) were white. Since the US sites had a high
proportion of black and Hispanic patients and the
Canadian sites had a high proportion of white patients,
we re-ran all the analyses excluding the Canadian sites.
We found no significant differences in the results.
Sociodemographics
Sociodemographic characteristics by race/ethnicity
are presented in Table 1. Trends show that black and
Hispanic asthma patients were from lower SES
households and were less likely to have a PCP.
Chronic Asthma History
Chronic asthma history by race/ethnicity also is
presented in Table 2. Black and Hispanic patients
were more likely to have a history of hospitalization
and reported a greater number of ED visits. They
were more likely to state that they used the ED as
their primary source of asthma care and prescrip-
tions. The three groups were equally likely to have
recently used systemic corticosteroids and inhaled
bronchodilators, but black and Hispanic patients
were less likely to have used inhaled corticosteroids.
Black patients and, especially, Hispanic patients
were less likely to own a spacer and a peak flow-
meter, while action plans were low across all three
Table 1Demographic Characteristics of Adults with Acute Asthma According to Race/Ethnicity*
Characteristics Black (n 935) Hispanic (n 411) White (n 454) p Value
Age, yr 35 10 35 10 34 10 0.80
Female 62 66 71 0.002
High school graduate 68 53 81 0.001
Estimated household income 26,288 (18,99934,487) 25,185 (17,36432,849) 35,336 (27,19043,291) 0.001
Insurance status 0.001
Private 26 21 40
Medicaid 29 41 14
Other public 10 10 24
None 35 29 21
Primary care provider 61 62 77 0.001
*Values given as %, unless otherwise indicated.
Values given as mean SD.
Values given as median (IQR).
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groups. Comorbid medical conditions were equally
likely (blacks, 9%; Hispanics, 4%; whites, 8%;
p 0.03).
Acute Presentation and ED Course
Data on acute asthma presentation and ED course
are presented in Table 3. Black and Hispanic pa-
tients exhibited more severe objective airway ob-
struction (based on PEFR), but blacks reported
slightly less severe subjective distress. Black and
Hispanic patients received more inhaled bronchodi-
lator doses during the first hour following triage, and
black patients were most likely to have received
systemic corticosteroid treatment. All race/ethnicity
groups were equally likely to be discharged from the
ED with a prescription for inhaled corticosteroids
(566 patients; black, 39%; Hispanic, 37%; white,
48%; p 0.15). When the sample was restricted to
Table 2Chronic Asthma Characteristics of Adults with Acute Asthma According to Race/Ethnicity*
Characteristics
Black
(n 935)
Hispanic
(n 411)
White
(n 454) p Value
Ever taken steroid medicine for asthma 74 68 74 0.09
Ever hospitalized for asthma 66 63 54 0.001
Ever intubated for asthma 18 17 12 0.02
Recent use of home nebulizer 27 38 25 0.001
Hay fever 58 59 74 0.001
Current smoker 34 31 41 0.01
Inhaled -agonist during past 4 wk 85 86 87 0.59
Inhaled corticosteroid during past 4 wk 42 39 53 0.001
Other asthma medication during past 4 wk 35 33 39 0.11
ED visits in past year 3 (15) 3 (05) 1 (03) 0.001
Owns a spacer 38 30 43 0.001
Owns a peak flowmeter 42 30 45 0.001
Has a written action plan 29 32 33 0.42
Admitted for asthma in past year 31 33 25 0.02
ED usual site of care for asthma problems 79 78 61 0.001
ED usual source of asthma prescriptions 52 54 25 0.001
*Values given as %, unless otherwise indicated.
Limited to two cohorts (1,281 patients).
Values given as median (IQR).
Table 3Acute Asthma Presentation and ED Course According to Race/Ethnicity*
Black
(n 935)
Hispanic
(n 411)
White
(n 454) p Value
Presentation
Duration of symptoms 24 h 53 56 56 0.52
Severe symptoms 71 77 79 0.002
ED course
Initial PEFR, % predicted 47 21 47 18 52 21 0.001
Initial PEFR 0.02
50% 59 62 51
5079% 33 33 39
80% 8 5 10
Inhaled -agonist doses in first hour, No. 1.8 0.9 1.9 1.0 1.6 0.9 0.001
Inhaled -agonist doses over ED stay, No. 3.3 1.9 3.1 1.7 3.1 2.4 0.42
Given steroid treatment 72 64 66 0.008
Received other asthma treatments in the ED 27 25 35 0.003
Final PEFR, % predicted 72 23 73 22 75 23 0.12
Change in PEFR, % predicted 25 19 26 19 22 20 0.06
ED length of stay, min 182 (128262) 187 (125270) 180 (134256) 0.97
Sent home on systemic corticosteroids 70 61 65 0.02
Admitted 20 21 19 0.77
*Values given as %, mean SD, or median (IQR), unless otherwise indicated.
See Materials and Methods section for details.
Restricted to patients sent home from ED (1,442 patients).
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only those patients who were not already receiving
inhaled corticosteroids, we again found no differ-
ences (black, 12%; Hispanic, 11%; white, 13%;
p 0.86). After controlling for seven factors (ie, age,
sex, education, estimated household income, insur-
ance status, PCP status, and recent use of inhaled
steroids) using multiple linear regression analysis, we
found that the initial PEFR no longer differed
significantly by race/ethnicity (black vs white: differ-
ence, 0.03; 95% CI, 0.06 to 0.004; p 0.05;
Hispanic vs white: difference, 0.03; 95% CI, 0.07
to 0.001; p 0.05).
At the univariate level, hospitalization did not
differ by race/ethnicity. However, the logistic regres-
sion model predicting hospitalization demonstrated
that, all things being equal, black and Hispanic
patients were more likely to be admitted to the
hospital (black vs white: OR, 2.1; 95% CI, 1.2 to 3.6;
p 0.005; Hispanic vs white: OR, 2.6; 95% CI, 1.4
to 4.7; p 0.002).
Two-Week Follow-up
A total of 1,308 patients (71% of total) were
reached for telephone follow-up. Blacks were the
least likely to be reached (likelihood: black, 66%;
Hispanic, 72%; white, 80%; p 0.001). Univariate
results are presented in Table 4. Race/ethnicity was
not related to the likelihood of short-term relapse,
although time to relapse among those who did
relapse appeared to be longer for blacks. Blacks and,
especially, Hispanics were the most likely to have
ongoing symptoms at the univariate level. However,
when the data were controlled for several factors (ie,
age, sex, education, estimated household income,
insurance status, PCP status, recent use of inhaled
steroids, ED steroid treatment, and final PEFR),
there was no statistically significant difference ac-
cording to race/ethnicity (black vs white: OR, 1.3;
95% CI, 0.9 to 1.9; p 0.17; Hispanic vs white: OR,
0.8; 95% CI, 0.5 to 1.2; p 0.24). Approximately
33% of adults reported a relapse event or an ongoing
exacerbation.
Discussion
It is widely recognized that black and Hispanic
asthma patients receive substandard outpatient care,
visit the ED more frequently, and are hospitalized at
greater rates than are whites.
818,48
However, little is
known about whether racial/ethnic differences exist
during the course and treatment of exacerbations
while in the ED or whether racial/ethnic differences
exist in relapse and outcome after discharge from the
ED. Because we prospectively enrolled patients
during their ED visit and observed them after their
ED discharge, rather than using archival or billing
data, our study helps to answer these questions.
Table 4Two-Week Follow-up According to Race/Ethnicity*
Variables Black Hispanic White p Value
Hospital length of stay, d 2 (15) 3 (24) 2 (13) 0.30
Relapse within 2 wk of ED visit 13 17 15 0.31
Days to relapse 7 (411) 2 (210) 3 (18) 0.001
Ongoing exacerbation 24 31 19 0.003
Relapse or ongoing exacerbation 31 40 31 0.008
*Values given as median (IQR) or %, unless otherwise indicated; n 1,308.
Relapse event based on patient reporting a worsening of asthma symptoms that led to an urgent care visit.
See Materials and Methods section for details.
Table 5Relation of Black or Hispanic (vs White) Race/Ethnicity to Risk of Hospital Admission Among Adults With
Acute Asthma
Variables
Black Hispanic
OR 95% CI p Value OR 95% CI p Value
Model 1 (adjusted for age sex) 1.1 0.81.5 0.53 1.1 0.81.6 0.43
Model 2 (adjusted for above education, median
income, insurance status)
1.2 0.91.7 0.22 1.1 0.81.7 0.49
Model 3 (adjusted for above PCP status) 1.3 0.91.8 0.14 1.2 0.81.8 0.37
Model 4 (adjusted for above recent inhaled
steroid use)
1.3 0.91.8 0.11 1.2 0.81.8 0.30
Model 5 (adjusted for above initial PEFR) 1.5 1.02.3 0.05 1.4 0.92.3 0.16
Model 6 (adjusted for above change in PEFR) 2.1 1.23.6 0.005 2.6 1.44.7 0.002
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Racial/Ethnic Differences in Asthma on
Presentation to the ED
We hypothesized that black and Hispanic patients
would present to the ED in more severe respiratory
distress than white patients. Consistent with this
hypothesis, black and Hispanic patients in our sam-
ple presented to the ED with an average PEFR of
47% of the predicted value, compared to 52% for
white patients. Our analyses indicate that this differ-
ence is not likely due to chance. Moreover, if an
individual improved from 47 to 52%, this would
represent a 10% change in the patients PEFR,
which generally is considered clinically significant.
Arguably, using the mean PEFR may have blurred
very sick and very mild cases together, potentially
hiding a trend for a continued greater rate of mild
cases among black and Hispanic patients. To help
explore this possibility, we further subdivided the
PEFR into three groups based on National Asthma
Education and Prevention Program guidelines. This
distribution showed that white patients, rather than
black and Hispanic patients, tended to be more likely
to present with mild exacerbations.
Our multivariate analyses indicated that adjusting
for demographic factors and SES markedly reduced
the size of the discrepancy in severity of acute
asthma by race/ethnicity. The extant literature is
contradictory regarding the role that SES plays in the
race/ethnic disparities observed in asthma severity,
morbidity, and management. Some have found
33
results similar to ours, with all or most of the
race/ethnicity-based disparities being accounted for
by SES. Most others have found that race/ethnicity-
based differences persist even after adjusting for
SES indicators, such as annual income,
11,17,18
urban
nature of residence,
9,10
and insurance status.
18
How-
ever, to conclude that SES is not an important
mediator of race/ethnicity-based asthma disparities
based on these later studies alone would be to
oversimplify a very complex issue. Many of these
studies found that SES was substantially related to at
least some of the disparities noted, and none con-
cluded that SES was unrelated to race-based dispar-
ities or was unimportant in understanding why such
disparities occur. They simply concluded that SES
was not the only factor accounting for racial/ethnic
disparities.
The persisting race/ethnicity differences in mor-
bidity and mortality, even after controlling for SES,
possibly can be explained by cultural differences in
the tendency to use a short-term treatment approach
rather than preventive treatment approaches. How-
ever, to date, convincing data for this hypothesis
have not been published in the asthma literature.
Furthermore, it is clear that, by focusing on only one
indicator such as insurance status or annual income,
many studies simply did not sufficiently account for
SES, which is a multifaceted construct. Kaufman and
colleagues
49
have cautioned that residual confound-
ing can be a significant problem when studying the
health correlates of SES. For example, Zoratti and
colleagues
18
found that, even among members of the
same managed care organization, blacks still earned
less than whites. When they isolated their sample to
include only those patients who had low incomes,
many (but not all) of their race/ethnicity-based dis-
crepancies in health-care utilization and prescription
medication usage disappeared or were markedly
attenuated.
Racial/Ethnic Differences in ED Course and
Management
Many of our results on ED course and manage-
ment ran counter to the trends noted in outpatient
settings. Black and Hispanic patients received more
doses of inhaled -agonists within the first hour of
presentation, and black patients were more likely to
receive oral corticosteroids than were white patients.
This more aggressive treatment possibly reflects an
appropriate response to the aforementioned greater
severity on presentation and worse chronic history of
asthma among minorities. These trends, combined
with the fact that the total number of inhaled
-agonist treatments, the final PEFR, change in
PEFR, ED length of stay, and ED discharge medi-
cations did not differ among racial/ethnic groups,
indicates that patients received similar care and
achieved comparable resolution of symptoms while
in the ED. Other studies
50,51
have shown that the
quality of ED asthma care frequently diverges from
national guidelines. However, these studies did not
specifically investigate whether ED care for minori-
ties diverged to a greater degree than that of whites,
making it difficult to integrate our results. Impor-
tantly, our results affirm the common perception
that the ED is a safety net for individuals with
asthma, regardless of race/ethnicity.
Racial/Ethnic Differences in Hospitalization During
the Index ED Visit
Studies
911,14,17,18,38
have found that hospitaliza-
tion rates among minorities are three to five times
that for whites during a given period. However, we
could not identify any published studies that actually
have investigated racial/ethnic differences in hospital
admission rates during an index ED visit. We ex-
pected moderate-to-large racial/ethnic differences in
hospitalization at the index visit. To the contrary, we
found almost identical rates, in absolute terms,
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among all three groups. Approximately 20% of all
blacks, Hispanics, and whites were hospitalized dur-
ing their index visit.
The discrepancy between hospitalization point
incidence (ie, at the index ED visit) and period
incidence (ie, 1 year) is difficult to explain. It seems
likely that it is due, at least in part, to a base-rate
effect. Even though black and Hispanic patients
have the same risk of being hospitalized during a
given ED visit, they may have a markedly greater
incidence of hospitalization over a given period,
because they experience severe exacerbations war-
ranting emergency care more frequently. This can be
conceptualized in probabilistic terms. The chance of
rolling a six on any roll of a die is identical. Never-
theless, one has a better chance of rolling at least one
six during a given period of time if allowed to roll the
die three times instead of only once. Even though a
black patient has a similar probability of being
admitted to the hospital at a given visit, if that patient
presents three times over the course of a year and a
white patient presents only once, the black patient
will be more likely to be admitted to the hospital
during that year.
Although the absolute rates of hospitalization were
roughly equivalent, our multivariate analyses re-
vealed an interesting trend. Once all sociodemo-
graphic factors, initial PEFR, and change in PEFR
were controlled for, black and Hispanic patients
were more than twice as likely to have been admitted
to the hospital. The inclusion of PEFR indexes in the
last step of the model appeared to have the largest
impact on the race/ethnicity-hospitalization relation-
ship. This finding seems to suggest that, at equivalent
levels of symptom resolution, black and Hispanic
patients are more likely to be admitted to the
hospital than whites. The reasons for this association
are difficult to determine and await further empirical
validation.
The Role of Race/Ethnicity and Posthospital
Discharge Outcome
The posthospital discharge outcomes present a
mixed picture. Blacks and Hispanics sought urgent
medical care within the 2 weeks after hospital discharge
at approximately the same rate as whites (approximate-
ly 15%), although blacks appeared to have a longer
delay before seeking such care. Whether this is due to
a delay in seeking treatment or a delay in experiencing
an exacerbation severe enough to warrant treatment is
not clear. Our relapse rates were comparable to those
reported by other single-center studies.
5254
Treatment
failure, defined by the continued self-report of severe
symptoms, occurred more frequently in minorities,
particularly Hispanics. As with the racial/ethnic differ-
ences noted in initial PEFR on presentation to the ED,
the race-based discrepancy in treatment failure appears
to be associated primarily with racial/ethnic differences
in sociodemographic factors, including SES.
Potential Limitations
In evaluating our results, several potential limita-
tions should be considered. First, we recognize that
the race/ethnicity designation, though ubiquitous in
epidemiologic research, may be misleading, and that
standard census classification is simplistic. Neverthe-
less, our designations are consistent with those used
in prior studies cited throughout our article. Such
research remains common and is important in order
to further understand and eventually to modify the
reasons why such differences exist. The fact that
race/ethnicity is difficult to operationalize does not
mean we should not study it. Research such as ours
is important in raising public awareness and may
help providers to counteract any implicit racism that
may be present.
Second, our sample size was large, which enabled
us to detect small differences that were not neces-
sarily clinically meaningful. We were sensitive to this
fact, however, and emphasized only those trends that
appeared clinically significant, noting in the text
when such a problem might exist.
Third, the EDs that comprised our sample are
predominantly urban, academically affiliated hospi-
tals. This may make our results less generalizable to
community hospitals without academic affiliation.
Future studies need to address this issue.
Fourth, we noted a paradoxical trend in initial
severity. Despite presenting with worse PEFR, black
patients reported slightly less severe symptoms than
whites. The reason for this is unclear. The differ-
ences were not likely due to chance, but the magni-
tude was small and may not be clinically meaningful.
The observation awaits validation by other studies. It
is a potentially important area, since blunted percep-
tion of dyspnea has been associated with the in-
creased risk of near-fatal asthma.
55,56
Finally, we found that hospital discharge medica-
tions did not differ based on race. However, since
black and Hispanic patients had more severe chronic
asthma, the fact that the ED discharge rates were
equal for inhaled corticosteroids is somewhat discon-
certing. Under these conditions, one would logically
expect that the ED discharge rates for inhaled
corticosteroids should be greater for blacks and
Hispanic patients. Consequently, the equal rates of
ED discharge on inhaled corticosteroids may actu-
ally be interpreted to mean that blacks and Hispanics
were undertreated on ED discharge.
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Integration
The associations among race/ethnicity, SES, and
various measures of asthma severity and morbidity
are complex. We found marked racial/ethnic differ-
ences in chronic asthma management. Black and
Hispanic asthma patients lacked PCPs more often,
reported a greater likelihood of lifetime hospitaliza-
tion, and reported more numerous ED visits in the
past year. Importantly, they also were less likely to
use inhaled corticosteroids and less frequently
owned a spacer and a peak flowmeter. Not only do
they present to the ED more often, but also our data
show that they presented to the ED with somewhat
more severe exacerbations. However, their course
and treatment during the ED visit did not seem to
differ dramatically, they were not hospitalized during
their index ED visit at greater rates than whites
(except when controlling for confounding factors),
and they did not seek urgent medical care within the
2 weeks after hospital discharge more frequently
than whites. As mentioned earlier, the reason that
minorities exhibit such deficient chronic asthma
management is probably, at least in part, due to SES
and the substandard health care that accompanies
lower SES. Other environmental factors associated
with low SES may lead to deficient chronic disease
management, such as increased risk of respiratory
infections due to overcrowding, and greater exposure
to allergens and irritants,
13,35,38,41
but these were not
assessed in our study. Although we found that most
differences were attributable to differences in SES,
other research
49
suggests that residual race/ethnicity
differences may still be present even after adjusting
for SES. This implicates other sociocultural and
psychological factors. Some authors have speculated
that racial/ethnic discrimination among health-care
providers is a possible cause for the inequities ob-
served in health care,
43,57
although it is probably not
conscious or deliberate.
58
Several other explanations
have been mentioned in the literature but have not
been researched well enough to form conclusions. At
best they offer direction for future research. These
include race-based differences in health beliefs and
practices emphasizing rescue rather than preventive
strategies,
18,59,60
impaired illness perception and
judgment of disease severity,
13,6163
lower self-
efficacy regarding asthma management,
6467
and
greater comorbid psychopathology, such as depres-
sion, anxiety, and panic disorders.
64,65
The elimination of health disparities by race/
ethnicity is an overarching goal of Healthy People
2010. Although race-based disparities are trenchant
and difficult to address, they can and should be
eliminated. Evidence
68
has shown that the deficient
asthma care in economically disadvantaged health-
care facilities can be rectified with education and
supportive programs. The necessary changes are
unlikely to occur on a broad scale, however, without
massive, coordinated, and sustained effort by all
concerned parties, including the federal govern-
ment, health-care providers and organizations, the
pharmaceutical industry, community and civic asso-
ciations, patient-advocacy groups, and the patients
themselves.
Appendix: MARC
Emergency Medicine Network Steering Committee
Edwin D. Boudreaux, PhD; Barry E. Brenner, MD, PhD;
Carlos A. Camargo, Jr, MD (Chair); Rita K. Cydulka, MD;
Theodore J. Gaeta, DO, MPH; and Michael S. Radeos, MD,
MPH.
Emergency Medicine Network Coordinating Center
Keith Brinkley, MA; Carlos A. Camargo, Jr, MD (Director);
Sunday Clark, MPH; Jennifer A. Emond, MS; Jessica L. Hohr-
mann, MPH; Sunghye Kim, MD (all at Massachusetts General
Hospital, Boston, MA).
Principal Investigators at the 64 Participating Sites
F.C. Baker, III (Maine Medical Center, Portland, ME); J.M.
Basior (Buffalo General Hospital, Buffalo, NY); C.A. Bethel
(Mercy Hospital, Philadelphia, PA); L. Bielory (University Hos-
pital, Newark, NJ); M.P. Blanda (Summa Health System, Akron,
OH); D. Bond (Gray Nuns Community Hospital, Edmonton,
AB, Canada); G.W. Bota (Sudbury General Hospital, Sudbury,
BC, Canada); E.D. Boudreaux (Earl K. Long Memorial Hospital,
Baton Rouge, LA); B.E. Brenner (The Brooklyn Hospital Center,
Brooklyn, NY); J. Brown (Misericordia Community Hospital,
Edmonton, AB, Canada); C.A. Camargo, Jr (Massachusetts Gen-
eral Hospital, Boston, MA); F.L. Counselman (Sentara Norfolk
General Hospital, Norfolk, VA); G. Ramalanjaona (Newark Beth
Israel Hospital, Newark, NJ); R.K. Cydulka (MetroHealth Med-
ical Center, Cleveland, OH); D.J. Dire (University of Oklahoma
Medical Center, Oklahoma City, OK); N. El Sanadi (Broward
General Hospital, Ft. Lauderdale, FL); S.D. Emond (St. Lukes/
Roosevelt Hospital Center, NY, NY); T.J. Gaeta (Methodist
Hospital, Brooklyn, NY); T.J. Gaeta (St. Barnabas Hospital,
Bronx, NY); M.A. Gibbs (Carolinas Medical Center, Charlotte,
NC); T.E. Glynn (Brooke Army Medical Center, Fort Sam
Houston, TX); L.G. Graff IV (New Britain General Hospital,
New Britain, CT); R.O. Gray (Hennepin County Medical Center,
Minneapolis, MN); S.K. Griswold (Thomas Jefferson University
Hospital, Philadelphia, PA); A. Guttman (Sir Mortimer B. Davis
Jewish General Hospital, Montreal, QC, Canada); J.P. Hanrahan
(Beth Israel Hospital, Boston, MA); F. Harchelroad (Allegheny
General Hospital, Pittsburgh, PA); R. Harrigan (Temple Univer-
sity Hospital, Philadelphia, PA); S.E. Hughes (Albany Medical
College, Albany, NY); A.H. Idris (University of Florida Health
Center, Gainesville, FL); G.D. Innes (St. Pauls Hospital, Van-
couver, BC, Canada); M.E. Johnson (Jackson Memorial Hospital,
Miami, FL); D.M. Joyce (University Hospital, SUNY HSC,
Syracuse, NY); L.W. Kreplick (Christ Hospital & Medical Cen-
ter, Oak Lawn, IL); E.C. Leibner (Detroit Receiving Hospital,
Detroit, MI); J. Li (Charity Hospital, New Orleans, LA); L.F.
810 Clinical Investigations
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Lobon (Beth Israel Medical Center, New York, NY); A. Man-
gione (Albert Einstein Medical Center, Philadelphia, PA); M.F.
McDermott (Cook County Hospital, Chicago, IL); J.S. Myslinski
(Richland Memorial Hospital, Columbia, SC); E.S. Nadel
(Brigham and Womens Hospital, Boston, MA); R.M. Nowak
(Henry Ford Hospital, Detroit, MI); C.V. Pollack, Jr (Maricopa
Medical Center, Phoenix, AZ); M.S. Radeos (Lincoln Medical
Center, Bronx, NY); D.J. Robinson (University of Maryland
Medical Center, Baltimore, MD); R.M. Rodriguez (Southwest-
ern Medical Center, Dallas, TX); B.H. Rowe (University of
Alberta Hospital, Edmonton, AB, Canada); G. Rudnitsky (Allegh-
eny University-MCP Division, Philadelphia, PA); R.E. Sapien
(University of New Mexico Health Sciences Center, Albuquer-
que, NM); D. Schreiber (Stanford University Medical Center,
Stanford, CA); R.A. Silverman (Long Island Jewish Medical
Center, New Hyde Park, NY); H. Smithline (Baystate Medical
Center, Springfield, MA); S. Stahmer (Hospital of the University
of Pennsylvania, Philadelphia, PA); D. Stewart (Bronson Medical
Center, Kalamazoo, MI); A. Sucov (University of Rochester
Hospital, Rochester, NY); D.M. Taylor (University of Pittsburgh
Medical Center, Pittsburgh, PA); C.A. Terregino (Cooper Hos-
pital/University Medical Center, Camden, NJ); J.L. Larson (Uni-
versity of North Carolina Hospitals, Chapel Hill, NC); A. Walker
(Royal Alexandria Hospital, Edmonton, AB, Canada); J. Walter
(University of Chicago Hospital, Chicago, IL); E.J. Weber (Uni-
versity of California San Francisco Medical Center, San Fran-
cisco, CA); L. White (Akron General Medical Center, Akron,
OH); and J.L. Zimmerman (Ben Taub General Hospital, Hous-
ton, TX).
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