Noreen M. Clark, Ph.D.

Myron E. Wegman Distinguished University Professor

Director, Center for Managing Chronic Disease
University of Michigan

Health Policy and Asthma

Disparities: What is
Needed?
American Thoracic Society International Conference
New Orleans, Louisiana
May 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 Professor
Director, Center for Managing Chronic Disease
University of Michigan

Intervention
Example of raising both same amount
 Noreen M. Clark, Ph.D.
Myron E. Wegman Distinguished University Professor
Director, Center for Managing Chronic Disease
University of Michigan

Intervention
Example of raising
Brown et al, 2004, botheducation
Physician asthma sameprogram
amount
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,
death
versus 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 children
4. Extend Continuous health insurance coverage to all uninsured children
5. Develop model-benefit packages for essential childhood asthma services
6. 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 programs
9. 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
 In addition, adherence by clinicians to
guidelines are very poor in low income
communities
Preteens with Asthma and a
Prescription
Type of asthma Well Not well Very poorly p value
medication used Controlled Controlled controlled

Controller + Reliever 28% 37% 43% 0.004

Controller only 2% 1% 4%
Reliever only 70% 61% 53%
Number of meds, 1.8 (0.8) 2.1 (1.0) 2.2 (0.9) 0.0002
mean (SD)
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 29% 35% 35% 0.64
time
Sometimes/hardly ever 21% 21% 18%
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
Patient Self Management
Family Involvement
Clinical Expertise
Work/School Support

Community Awareness
Support & Action
Community-Wide
Environmental Control
Measures

Policies needed within each

 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
Noreen M. Clark, PhD

1) Personal financial relationships with commercial

interests relevant to medicine, within past 3 years:

No relationships to disclose
 Presenter Disclosures

Noreen M. Clark

2) Personal financial support from a non-commercial

source relevant to medicine, within past 3 years:

No relationships to disclose
 Presenter Disclosures
Noreen M. Clark

3) Personal relationships with tobacco

industry entities within the past 3 years:

No relationships to disclose.
 Presenter Disclosures
Noreen M. Clark

Off-Label Disclosure:
My presentation will include discussion of “off-label” use
of the following:

No relationships to disclose