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Reconcilable Differences^*

A Cross-sectional Study of the Relationship Between Socioeconomic Status and the Magnitude of Short-Acting ß-Agonist Use in Asthma

^* From the Faculty of Pharmaceutical Sciences (Dr. Lynd), and the Department of Health Care and Epidemiology (Dr. Anis), University of British Columbia, Vancouver, BC, Canada; iCAPTURE Centre (Drs. Sandford, Parè, and Bai, and Ms. Kelly), Providence Health Care, Vancouver, BC, Canada; and the Centre for Clinical Epidemiology and Evaluation (Dr. FitzGerald), Vancouver General Hospital, Vancouver, BC, Canada.

Correspondence to: Aslam H. Anis, PhD, Centre for Health Evaluation and Outcome Sciences, 620–1081 Burrard St, Vancouver, BC, Canada; e-mail: aslam.anis{at}ubc.ca

Study objective: To assess the association between socioeconomic status (SES) and short-acting (SA) ß-agonist use, controlling for asthma severity.

Design: Cross-sectional study.

Setting: Vancouver, BC, Canada.

Participants: Two hundred two asthmatics between 19 years and 50 years of age and residing in the greater Vancouver regional district.

Measurements: The quantity of SA ß-agonist used in the previous year was collected by self-report; pulmonary function and ß-receptor genotype were measured on each participant. SES was measured at both the individual and population levels. Five methods of adjustment for asthma severity were used, as follows: the Canadian Asthma Consensus Guidelines, three previously developed asthma-severity scores, and forward stepwise multiple regression modeling. Polychotomous logistic regression was used to assess all relationships.

Results: Independent of the method used to measure SES or adjust for asthma severity, lower SES was consistently and significantly associated with the use of greater amounts of SA ß-agonist. Adjusting for severity using the multivariate model explained the most variance of SA ß-agonist use (R² adjusted, 0.35 to 0.37). In this model, social assistance recipients were more likely to use greater amounts of SA ß-agonist (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.7 to 6.5). An inverse relationship between SA ß-agonist use and both annual household income (> $50,000; OR, 0.28; 95% CI, 0.13 to 0.60; and $20,000 to $50,000; OR, 0.44; 95% CI, 0.21 to 0.96; relative to <$20,000) and education (completing a bachelor’s degree vs no formal education; OR, 0.25; 95% CI, 0.14 to 0.71). Participants living in a neighborhood with higher median household income (OR, 0.91; 95% CI, 0.84 to 0.98 per $1,000 increase) or a higher prevalence of having attainted a bachelor’s degree (OR, 0.96; 95% CI, 0.84 to 0.98 per 1% increase) were also less likely use greater amounts of SA ß-agonist. Results were consistent for neighborhood unemployment rate.

Conclusions: The social gradient in asthma-related outcomes may be at least partially attributable to poorer asthma control in lower-SES asthmatics.

Key Words: adrenergic ß-agonists • asthma • severity of illness index • social class

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