In order to assess whether racial differences in patterns of asthma care persist in a managed care environment, where financial barriers to medical care access care are minimized, this cross-sectional analysis compared medication use and health care facility utilization of African-Americans and Caucasians enrolled in a large Detroit metropolitan area health maintenance organization (HMO). A system-wide database was used to gather information on all continuously enrolled Caucasian or African-American HMO members who received any asthma-related outpatient care during 1993. Visits were categorized as primary care clinic, asthma specialty clinic, emergency department, or inpatient. Socioeconomic indicators were obtained for each subject by using street address and geocoding software. Each street address was mapped to a census block group and median household income.

The results indicated that “an ‘average’ African-American HMO member visited a primary care physician for asthma as frequently as an ‘average’ Caucasian member (0.95 +/-1.24 encounters versus 0.93 +/-1.21, p=0.81). However, African-Americans were more frequently seen in the emergency department (0.71 +/- 1.33 encounters versus 0.28 +/- 0.64, p<0.001) and were hospitalized more often (0.08 +/- 0.31 hospitalizations versus 0.03 +/- 0.28, p=0.002), while asthma specialist visits were significantly less frequent (0.32 encounters +/- 0.93 versus 0.5 +/- 1.12, p = 0.002) than Caucasians.” When the sample group was confined to the low-income subgroup and marital status, gender, and age difference were controlled for, African Americans were still more frequently seen in the emergency department and more likely to be hospitalized with asthma.

The patterns of prescription medication usage revealed that “African Americans were more likely to fill prescriptions for oral corticosteroids (p< 0.001) while paradoxically using less inhaled corticosteroids (p =0.038).” The authors state that this “lower rate of inhaled corticosteroids by the low income and African American populations appeared be particularly inappropriate in view of this group’s pattern of high oral steroid use. Because frequent oral corticosteroid “bursts” and inhaled beta-agonist use is likely an indicator of poorly controlled asthma, a similar (and slightly lower) rate of use of inhaled anti-inflammatory medications among these populations suggests that physicians continue to underutilize inhaled anti-inflammatory agents in this high-risk group.” The other commonly used medications were utilized at similar rates by the two ethnic groups; however, use of all medication types was significantly higher in subjects who had at least one visit with an asthma specialist.

The authors conclude, “African American ethnicity is associated with increased asthma morbidity and mortality [therefore] it is logical that this population should be strongly encouraged to seek and employ intensive asthma management strategies including education, aggressive pharmacologic treatment, and asthma specialist consultation.” However, “African Americans in this study had low rates of asthma specialist consultation,” and the “increased rate of hospitalizations and emergency department visits did not trigger a concomitant increase in asthma specialist visits,” thus suggesting that “the population with the most severe asthma have inappropriately low rates of evaluation by physician with the most expertise in treating asthma.”