587 - Poverty significantly amplifies the effect of small differences in asthma management on racial disparities in childhood asthma

Though asthma is the most prevalent childhood illness, its severity is distributed unevenly across socioeconomic and racial cohorts. Despite general acknowledgement that multiple risk factors contribute to differences in asthma outcomes, how the interaction of specific variables leads to disparities in asthma remains unclear.

Objective: To test the hypothesis that poverty significantly amplifies the impact of small differences in asthma management on racial disparities in childhood asthma.

Design/Methods: We performed a retrospective cohort study using health data extracted from the Healthcare Map® (Komodo Health, Inc.) and linked to population data from the American Community Survey (ACS) and US Census. Patients < 18 years of age with ≥ 2 encounters with an asthma diagnosis in 2017 – 2019 were included in this study. The main outcomes are asthma exacerbations, where uncontrolled asthma is defined as ≥ 1 asthma exacerbation during the study timeframe. Severe and the most severe cases of asthma were defined as ≥ 2 or ≥ 3 asthma exacerbations, respectively. Adjusted odds ratios (OR) were used to assess the extent to which asthma management is associated with racial disparities in asthma and how poverty affects this relationship.

Results: The study included 485,264 children (56% White, 44% Black) with a mean age of 9.5 years. Black children were 16% less likely to have seen an asthma specialist and approximately 2 – 13% less likely to be prescribed asthma controller medications. After adjusting for demographics, insurance and urban status, Black children were 44% more likely to have uncontrolled asthma (odds ratio [OR], 1.440; 95% confidence interval [CI], 1.414 - 1.465), 84% more likely to have severe uncontrolled asthma (OR, 1.843; 95% CI, 1.785 - 1.902) and 212% more likely to have the most severe asthma (OR, 2.115; 95% CI, 2.008 - 2.226). Underprescribing of controller medications accounted for 5 – 7.7% of these disparities, an influence that was intensified 174 – 292% when poverty was considered.

Conclusion(s): Black children are more than twice as likely to have the most severe asthma than White children. Though underprescribing of controller medications accounts for a small part (≤ 7.7%) of the disparity, the impact of underprescribing on the disparity intensifies as much as 3-fold when poverty is considered. These findings highlight the degree to which poverty amplifies the effect of provider behaviors on racial disparities in childhood asthma, and suggest small improvements in disease management can have a large effect on decreasing racial disparities, particularly in the setting of poverty.