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* From the Channing Laboratory (Drs. Cohen, Celedón, Ramsey, and Weiss), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; Albert Einstein College of Medicine (Ms. Hinckson), Bronx, NY; and the Department of Pediatrics (Ms. Wakefield and Dr. Cloutier), University of Connecticut Health Center, Farmington, CT.
Correspondence to: Robyn T. Cohen, MD, Channing Laboratory, 181 Longwood Ave, Boston, MA 02115; e-mail: robyn.cohen{at}channing.harvard.edu
Abstract
Study objectives: To compare the rates of emergency department (ED) visits, hospitalizations, hospital days, and outpatient clinic visits for asthma among children in two ethnic minority groups that are disproportionately affected by asthma (Puerto Ricans and African Americans).
Study design: This cross-sectional study was part of an asthma intervention program in Hartford, CT, in which 6,554 children were screened for asthma by primary care providers using a parental survey. Medicaid and the supplementary State Children’s Health Insurance Plan data about health-care utilization for asthma were obtained for each child for the 12 months preceding completion of the screening survey.
Results: Among 2,304 children in whom asthma had been diagnosed, Puerto Ricans had more severe asthma than African Americans. In analyses adjusted for asthma severity and other potential confounders, Puerto Rican children had more clinic visits for asthma (rate ratio [RR], 1.31; 95% confidence interval [CI], 1.12 to 1.53) but spent fewer days in the hospital for asthma (RR, 0.36; 95% CI, 0.24 to 0.53) than African-American children. There were no differences in the rates of ED visits or hospitalizations between the two groups.
Conclusions: Puerto Rican children had more severe asthma but were less likely than African-American children to have prolonged hospitalizations for asthma. This finding may be due to the frequent clinic visits for asthma made by Puerto Rican children. Further research is needed to understand the cultural factors that contribute to different approaches to health-care utilization among ethnic minorities.
Key Words: African Americans • asthma • ethnicity • health-care utilization • Puerto Ricans
Asthma prevalence, morbidity, and mortality increased in the United States between 1980 and 1995, with racial/ethnic minorities disproportionately affected.1234 Racial and ethnic differences in health-care use for asthma by whites and blacks are well-documented; however, few studies have reported on health-care use by Hispanics.5 Brahan and Bauchner5 reviewed all original articles about pediatric asthma published in five major print journals from 2000 through 2002, and found that outcomes for whites and blacks were reported in 79% and 89% of the articles, respectively, but that Hispanic ethnicity was reported in only 55%.
Limited information exists about the burden of asthma among specific Hispanic subgroups in the United States, including Puerto Ricans. The prevalence of asthma in Puerto Ricans is higher than that in other ethnic groups in the United States.6 Data from the 2002 Behavioral Risk Factor Surveillance System for adults in the United States showed that the prevalence of asthma is higher in individuals living in Puerto Rico (11.6%) than in members of other ethnic groups who live in other states and territories of the United States.1 The Second National Health and Nutrition Examination Survey and the Hispanic Health and Nutrition Examination Survey found that, among children in the mainland United States, the prevalence of childhood asthma was higher in Puerto Ricans (20.1%) than in African Americans (9.1%), Mexican Americans (4.5%), and non-Hispanic whites (6.4%).7 This difference is not likely to be due exclusively to differences in socioeconomic status (SES). Ledogar at al8 found that the prevalence of asthma was higher in Puerto Ricans than in Dominicans or "other Latinos" living in the same streets and in the same buildings in Brooklyn, NY (odds ratio, 2.7; 95% confidence interval [CI], 2.0 to 3.6).
Current evidence also suggests that Puerto Ricans have greater morbidity and mortality from asthma than members of other ethnic groups.6 Among individuals living in New York City, Carr et al9 found significantly higher rates of hospitalization and death from asthma in both Hispanics (most of whom were Puerto Rican) and blacks than in whites. After reviewing US vital statistics data from 1990 to 1995, Homa et al4 found that Puerto Ricans, especially those living in the northeastern United States, had the highest overall asthma-related mortality rate of all racial and ethnic groups in the mainland United States. While several studies2910 have shown higher rates of health-care utilization for asthma in African Americans and Hispanics than in whites, few studies have examined the rates of health-care utilization in specific Hispanic subgroups such as Puerto Ricans. In a study of 1,319 children in East Harlem, Findley et al11 found that Puerto Rican children had higher rates of asthma symptoms and asthma-related school absences but fewer emergency department (ED) visits for asthma than children belonging to other ethnic groups. In contrast, Burchard et al12 compared Puerto Rican and Mexican children and adults with asthma, and found that Puerto Ricans were more likely to have visited the ED or been hospitalized in the past year than individuals of Mexican origin, even after adjusting for asthma severity.
The purpose of this study was to compare the patterns of health-care utilization for asthma among children in two ethnic minority groups known to bear a disproportionate burden of asthma morbidity (ie, Puerto Ricans and African Americans). Our specific aims were to examine whether ethnicity is associated with indicators of health-care use for asthma (rates of ED visits, hospitalizations, hospital days, and outpatient clinic visits) among Puerto Rican and African-American children with asthma in an inner-city community in Hartford, CT, and to examine the factors that predict utilization of health-care services for asthma within each ethnic group.
Materials and Methods
Study participants were children aged 6 months to 17 years who were screened for asthma as part of the Easy Breathing asthma care program in Hartford between June 8, 1998, and August 13, 2002. All children were eligible for Medicaid or the State Children’s Health Insurance Program (S-CHIP) for part of the year prior to completion of the screening questionnaire. The Easy Breathing program was designed to improve asthma diagnosis and treatment by primary care providers and has been described in detail elsewhere.13 Informed consent was obtained from the parents of participating children. The study was approved by the Institutional Review Board of the University of Connecticut Health Center and the Connecticut Children’s Medical Center.
Parents were asked to complete the Easy Breathing Survey when their children presented for care for any reason to any of the six primary care clinics in Hartford. The Easy Breathing Survey, which is a validated instrument14 in English and Spanish based on the asthma section of the International Union Against Tuberculosis and Lung Disease respiratory questionnaire,15 is composed of 25 questions about asthma symptoms, symptom triggers, family history of asthma, history of allergy and eczema, home and school environmental exposures, and demographics. The child’s ethnicity was classified according to parental report using the 2000 US Census categories. Trained clinic health-care providers diagnosed asthma using parental responses to the survey questions and available clinical information from medical records. A diagnosis of asthma was based on a history of at least two episodes (including one in the past 12 months) of cough, wheeze, and/or shortness of breath in response to known triggers; response to asthma therapy; and (when available) pulmonary function data. For children who received a diagnosis of asthma, health-care providers determined asthma severity using a separate written instrument that was modeled after the guidelines of the National Asthma Education and Prevention Program.16
The utilization rates for ED visits, outpatient clinic visits, hospitalizations, and the total number of inpatient hospital days with a primary diagnosis of asthma (International Classification of Diseases, ninth revision, code 493.0) were obtained from Medicaid, as were S-CHIP claims data for each child for the duration of eligibility during the 12-month period prior to completion of the Easy Breathing Survey. The number of prescriptions filled per subject for bronchodilators, oral steroids, inhaled corticosteroids, and nonsteroidal antiinflammatory asthma medications (ie, leukotriene modifiers and cromolyn) were obtained from the National Drug Code during the same time period.
Frequency data and 
2 tests were used for descriptive analyses of racial/ethnic differences within the study population. The relative risks of health-care utilization were determined by calculating incident rate ratios (RRs). We used Poisson regression for bivariate predictors of health-care utilization, adjusting for the duration of time each participant had been eligible for Medicaid or S-CHIP benefits in the 12 months prior to completion of the Easy Breathing Survey. Multivariable Poisson regression models were constructed by entering all univariate predictors with a p value of 
20. Ethnicity remained in all multivariable models, except those constructed for analyses stratified by ethnicity. Covariates were retained in the final multivariable models if they were statistically significant (p < 0.05) or if they satisfied a change-in-estimate criterion (ie, 
10% change in the RR). All analyses were performed with a statistical software package (SAS, version 8.0; SAS Institute; Cary, NC).
Results
During the study period, 6,554 children were screened for asthma. The ethnic distribution of these children was 3,357 Puerto Rican children (51.2%), 1,600 African-American children (24.4%), 78 white children (1.2%), 606 non-Puerto Rican Hispanic children (9.3%), and 913 children (13.9%) of other or mixed ethnicities. Of these 6,554 children, 2,959 (45%) received a diagnosis of asthma and an asthma severity classification from a trained clinic health-care provider (all children in whom asthma had been diagnosed received a severity classification). Of these 2,959 children with asthma, 2,304 (77.9%) were Puerto Rican (1,697 children; 74%) or African American (607 children; 26%) and were thus included in the current study. In these children, the mean duration of eligibility for Medicaid and/or S-CHIP was 9.8 months.
The characteristics of the study population are shown in Table 1 . Puerto Rican children had more severe asthma than did African-American children, with 21% of Puerto Rican children having moderate or severe persistent asthma compared with 14% of African-American children (p < 0.0001). Puerto Rican children were also more likely to have a maternal history of asthma and to have been more frequently exposed to cockroaches than African-American children (p < 0.005 in both instances). African-American children were more often exposed to environmental tobacco smoke in the household than were Puerto Rican children (p < 0.0005). Although Puerto Rican and African-American children had similar rates of filling prescriptions for bronchodilators, Puerto Rican children were more likely than African-American children to have at least one prescription for oral steroids (p = 0.03).
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In our study, Puerto Rican children had more severe asthma than did African-American children. Puerto Rican children had more outpatient visits for asthma than did African Americans, but African-American children spent three times as many days in the hospital as Puerto Rican children. Perhaps because Puerto Ricans were more likely to see a physician for an asthma clinic visit than were African Americans, Puerto Rican children were less likely to have a severe asthma exacerbation and thus to spend extended time in the hospital.
Boudreaux and colleagues17 examined whether black and Hispanic children who presented to the ED for an asthma exacerbation had more severe symptoms than white children and therefore a higher likelihood of a hospital admission. In that study, the parents of black and Hispanic children reported a history of higher rates of hospitalization and ED visits for asthma than did the parents of white children. Consistent with our findings in Puerto Rican children, Hispanic children had a history of a greater number of urgent clinic visits in the year preceding their study than did white children. However, there were no differences in asthma severity, duration of ED stay, rate of hospitalization, or duration of hospital stay on presentation to the ED among black, Hispanic, and white children with asthma.17 Those findings have to be interpreted with caution because of the potential inclusion of members of Hispanic subgroups known to differ with regard to asthma severity and asthma morbidity (eg, Mexican Americans and Puerto Ricans) in the study population.
The observed difference in outpatient clinic visits between Puerto Rican children with asthma and African-American children with asthma may reflect cultural differences in the approach of Puerto Ricans and African Americans to medical care in general and asthma care in particular. In a study of 99,268 children, the average number of physician visits per year was higher in Puerto Rican children (regardless of an asthma diagnosis) than in children of other ethnic groups (ie, blacks, whites, and other Hispanic subgroups).18 Among children with asthma who were enrolled in Washington State Medicaid, African-American children had the highest rates of ED visits and hospitalizations of all ethnic groups. In agreement with our findings, African-American children were only half as likely as white children to have made an office visit for asthma.2 Using National Health Interview Survey Data, Akinbami et al19 found that the ratio of physician visits to asthma "bed days" was lower among poor black children than that in white children and nonpoor black children, suggesting an underuse of ambulatory care by black children of low SES. African-American adults of low SES have been shown to place more emphasis on the treatment of asthma symptoms than on preventive treatment, thus leading to a delay in seeking preventive asthma care.20 Mansour et al21 examined barriers to asthma care among urban black children with asthma. In addition to concerns about issues of trust and a desire for a more holistic approach by primary care providers, many parents reported a preference for seeking care in the ED than in the clinic because they believed that it provided the best care, and that because asthma is a breathing disorder, it should be treated as an emergency.
Although ethnicity was a significant predictor of the number of outpatient visits and hospital days, the best predictor of all health-care utilization outcomes in this study was asthma severity. This is most evident in the clear dose-response relationship between asthma severity, and hospitalizations and hospital days. Although approximately 50% of children in whom asthma was diagnosed were classified as having persistent mild-to-severe asthma, only 10% of these children had taken inhaled corticosteroids or other preventive medications during the year before completion of the Easy Breathing Survey. Of note, the assessment of asthma severity was made at the time of enrollment into the Easy Breathing Program and before any standardized therapeutic intervention. Thus, this study is relatively unusual in that we were able to examine the relationship between asthma severity and health-care use for asthma in a population of children with asthma who rarely or never used preventive treatment.
Although antiinflammatory medications such as inhaled corticosteroids are effective therapy for persistent asthma, they are underutilized in children who belong to ethnic minority groups.22 For example, the current evidence suggests that health insurance coverage, the inability to speak English, patterns of asthma management, the cultural competency of health-care providers, and as yet unexplained cultural reasons influence the use of inhaled corticosteroids by Hispanic children.6 Findings from a study in Hartford suggest that a program to improve asthma management by primary health-care providers results in the increased use of antiinflammatory medications and reduced rates of asthma exacerbations in inner-city children.23 Although further research on factors that impact asthma management in minority children are needed, this should not serve as an excuse for inaction. The implementation of measures to broaden adequate health insurance coverage, improve housing conditions, and positively impact asthma management by primary health-care providers are likely to significantly reduce asthma morbidity in Puerto Rican and African-American children with asthma.
In the analysis stratified by ethnicity, asthma severity remained a predictor of health-care utilization outcomes for both ethnic groups. Not surprisingly, bronchodilator prescriptions were also a significant predictor of all health-care utilization outcomes in both ethnic groups, suggesting that an increasing use of bronchodilators is a marker for having more asthma symptoms requiring medical care.
A paternal history, but not a maternal history, of asthma was associated with significantly more days spent in the hospital for both Puerto Ricans and African Americans. This finding is consistent with findings from the Childhood Asthma Management Program Study24 in which paternal history of asthma was associated with increased airway responsiveness (a determinant of asthma severity) among children with asthma. We found that a maternal history of asthma was inversely associated with spending days in the hospital in African-American children, and that a sibling history of asthma was inversely associated with outpatient clinic and ED visits in Puerto Rican children. These findings likely indicate that mothers who were familiar with managing asthma in themselves and/or their children were better equipped to manage asthma in study participants.
Among Puerto Rican children, the number of prescriptions for inhaled corticosteroids was associated with an increased number of clinic visits and days spent in the hospital for asthma, and the number of prescriptions for nonsteroidal antiinflammatory medications (ie, leukotriene modifiers) was associated with more outpatient clinic and ED visits for asthma. In contrast to these findings, the number of prescriptions for inhaled corticosteroids was inversely associated with the number of days hospitalized among African-American children. A plausible explanation for this difference is that African-American children who actually present for preventive care may be more likely to use their inhaled steroids once the prescription is filled than are Puerto Rican children, thus reducing their need for hospitalizations for asthma. In addition, there may have been residual confounding by an indication among Puerto Rican children with asthma (eg, those who were prescribed preventive medications had the most severe asthma), resulting in an increasing likelihood of health-care use for asthma.
A limitation of this study is its cross-sectional nature. While we were able to report and explain significant associations between several covariates of interest and health-care utilization outcomes, we are unable to draw conclusions regarding causality. For example, we found that among Puerto Rican children having a pet cat was inversely associated with the number of days spent in the hospital. This inverse association may reflect a deliberate avoidance of environmental triggers by mothers of children with severe asthma. A second limitation of this study is that we were only able to obtain information about the number of prescriptions filled, not the actual medication use or adherence with prescribed regimens. Additional limitations to this study included our limited information on SES. However, all of the children lived in the city of Hartford and were eligible for Medicaid or the S-CHIP program. Hartford is the poorest city in Connecticut and the fourth poorest medium-sized city in the United States, with a per capita income of $13,428 in 2000.25 Most likely, this population was relatively homogenous with regard to SES. In addition, our measures of environmental exposures are based on parental report instead of objective measurements. Reporting exposure to indoor allergens has high specificity but limited sensitivity; in other words, reported allergens are often present in increased concentrations, but detectable allergen levels are often present in the absence of reported exposure.2627 Finally, the diagnosis of asthma in children is difficult, particularly in children < 3 years of age. The instrument used for diagnosing asthma (the Easy Breathing Survey) was validated in primary care clinics in Hartford.13 The sensitivity and specificity of the Easy Breathing Survey for a diagnosis of asthma were 94.8% and 60%, respectively. In our study, a diagnosis of asthma was based on parental responses to the Easy Breathing Survey and available information from medical records (including pulmonary function data, when available). To further reduce the potential misclassification of children with transient wheezing as having asthma, we repeated the analysis including only children 3 years of age (n = 1,850) and obtained similar results (data not shown).
To our knowledge, this is the first study to compare the rates of health-care utilization of children in two ethnic minority groups that reside side by side in one small (17 square miles) community that bear a disproportionate burden of asthma morbidity (Puerto Rican children and African-American children). Although Puerto Rican children had more severe asthma and higher rates of outpatient clinic visits for asthma, African-American children spent three times as many days in the hospital for asthma exacerbations. There were no significant differences between the rates of ED visits or hospitalizations in these two ethnic groups when controlling for asthma severity. Further research is needed to help explain the sociocultural factors that contribute to differences in the patterns of seeking asthma care in Puerto Ricans and African Americans.
Acknowledgements
We thank the clinicians and office staff of Asylum Hill Family Practice Center, Burgdorf/Fleet Health Center, Community Health Services, Family Health Center, St. Francis Hospital/Pediatrics Ambulatory Care, and Connecticut Children’s Medical Center/Primary Care Center for their dedication to patient care and their willingness to participate in the Easy Breathing program.
Footnotes
Abbreviations: CI = confidence interval; ED = emergency department; RR = rate ratio; S-CHIP = State Children’s Health Insurance Program; SES = socioeconomic status
This research was funded by the Patrick and Catherine Weldon Donaghue Medical Research Foundation (to Dr. Cloutier), the National Institutes of Health/National Heart Lung Blood Institute (grants No. HL 70785–01 [to Dr. Cloutier], 5 T32 HL07424 [to Dr. Cohen], and HL04370 [to Dr. Celedón]). Ms. Hinckson participated in the study in partial fulfillment of the requirements for the degree of Master of Public Health.
The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Received for publication December 13, 2005. Accepted for publication January 23, 2006.
References
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