This well-designed study sought to examine whether racial disparities persist in primary care for children with asthma, a chronic yet highly treatable condition, across a clinically and demographically comparable population with the same health insurance coverage. It also sought to determine if the guidelines set by the NIH to assist clinicians with the diagnosis and treatment of asthma were adhered to in the delivery of care, specifically, the recommended guidelines for follow-up visits subsequent to hospitalizations.

The authors identified a sample of 500 Medicaid-enrolled children (207 African American, 293 white) who had been hospitalized for asthma. All lived in an urban area of Massachusetts and thus shared similar socioeconomic status and environmental barriers to care. Using this study sample, the investigators were able to control for the commonly stated risk factors for asthma hospitalization and death – i.e. poverty, urban residence, and health insurance coverage. Claims data for the six-month period after hospitalization were analyzed to determine the number of asthma-related and non-asthma-related primary care visits, emergency room visits and hospitalizations. The number of visits was examined at two weeks, four weeks, and six months after hospitalization.

There were no statistically significant differences in the socio-demographic characteristics of African-Americans and whites at the 0.05 level. Regarding the NIH recommended guidelines for follow-up visits within two weeks of hospitalization, the study found that, in that time period, 90 percent of the 500 Medicaid children had not seen a physician for asthma. “Asthma management guidelines also recommend that children have regular contact with a clinician to monitor their condition.” However, “in the Medicaid sample, by six months post-discharge, 81 percent of the children still had not received a follow up visit for asthma; about one in five children (21 percent) had not seen a physician at all.”

When results were stratified by race, there were significant differences in rates of post-hospital care. In the two weeks after hospitalization, 94 percent of African American children versus 87 percent of white children had not seen a physician for asthma. “African American children were half as likely to have received follow-up care for asthma compared with their white counterparts (6 and 13 percent, respectively).” After four weeks, 85 percent of white children and 93 percent of African American children had not see a physician for asthma. At six months, “the racial disparity in asthma-related physician visits persisted; 87 percent of African American children and 77 percent of white children still had not seen a physician for asthma.” These differences were all statistically significant at the 0.05 level. Emergency room visits and hospitalizations did not differ significantly by race; however, the use of emergency services for both groups suggests “that asthma is a persistent and serious problem for this population.” Furthermore, the lack of significant differences in hospital readmission and ER visit rates between African American and white children indicate that African American children “were not making up for [the] utilization deficit by having more urgent care.”

The authors conclude “that the vast majority of the 500 children studied experienced follow-up care well below the recommended level.” More disturbing is the finding that “within this population of children generally receiving suboptimal care, African American children fared even worse.”

Given the makeup of this study population, the authors were able to dismiss “underlying racial differences in poverty and other environmental or social conditions” as possible explanations for these disparities. A possible explanation proposed is African Americans’ “deep-seated distrust of the health care system.” As a potential solution, the investigators suggest that “culturally sensitive providers are needed to offer appropriate medical advice but also to understand the day to day difficulties associated with living in the patient’s home, school, and work environments.” They state, “the inability of providers to relate to minority patients on a more personal level may act as a barrier to appropriate care-seeking behavior” and contend that the “impact of racism on patterns of health services utilization deserves further consideration.”