Interventions to Improve Outcomes for Minority Adultswith Asthma: A Systematic Review

Valerie G. Press, MD, MPH1, Andrea A. Pappalardo, MD2, Walter D. Conwell, MD3,Amber T. Pincavage, MD4, Meryl H. Prochaska, BA5, and Vineet M. Arora, MD, MAPP4

1Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA; 2Comer Children’s Hospital, Department ofPediatrics, University of Chicago, Chicago, IL, USA; 3Division of Pulmonary/Critical Care, Department of Medicine, University of Colorado,Denver, CO, USA; 4Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA; 5School of Law,Loyola University Chicago, Chicago, IL, USA.

OBJECTIVES: To systematically review the literature tocharacterize interventions with potential to improveoutcomes for minority patients with asthma.DATA SOURCES: Medline, PsycINFO, CINAHL,Cochrane Trial Databases, expert review, referencereview, meeting abstracts.STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, ANDINTEVENTIONS: Medical Subject Heading (MeSH)terms related to asthma were combined with terms toidentify intervention studies focused on minority pop-ulations. Inclusion criteria: adult population; interven-tion studies with majority of non-White participants.STUDY APPRAISAL AND SYNTHESIS OF METHODS:Study quality was assessed using Downs and Black(DB) checklists. We examined heterogeneity of studiesthrough comparing study population, study design,intervention characteristics, and outcomes.RESULTS: Twenty-four articles met inclusion criteria.Mean quality score was 21.0. Study populations targetedprimarily African American (n=14), followed by Latino/a(n=4), Asian Americans (n=1), or a combination of theabove (n=5). The most commonly reported post-inter-vention outcome was use of health care resources,followed by symptom control and self-managementskills. The most common intervention-type studied waspatient education. Although less-than half were cultur-ally tailored, language-appropriate education appearedparticularly successful. Several system–level interven-tions focused on specialty clinics with promising find-ings, although health disparities collaboratives did nothave similarly promising results.LIMITATIONS: Publication bias may limit our findings;we were unable to perform a meta-analysis limiting thereview’s quantitative evaluation.CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS:Overall, education delivered by health care professionalsappeared effective in improving outcomes for minoritypatients with asthma. Few were culturally tailored andone included a comparison group, limiting the conclu-sions that can be drawn from cultural tailoring. System-redesign showed great promise, particularly the use ofteam-based specialty clinics and long-term follow-upafter acute care visits. Future research should evaluatethe role of tailoring educational strategies, focus on

patient-centered education, and incorporate outpatientfollow-up and/or a team-based approach.

KEY WORDS: asthma; disparities; interventions; culturally tailored.

J Gen Intern Med 27(8):1001–15

DOI: 10.1007/s11606-012-2058-9

© Society of General Internal Medicine 2012

INTRODUCTION

Despite increasing national efforts over several decades, healthdisparities are widening for numerous illnesses and chronicdiseases. The Healthy People initiative began in 1979 with theSurgeon General’s Report, followed by Healthy People 2000and 2010, with Healthy People 2020 currently underdevelopment.1 Although the goal of Healthy People 2010was to challenge “individuals, communities, and professio-nals…to take specific steps to ensure that good health, as wellas long life, are enjoyed by all,”1 this need has not been metfor minority patients with asthma in the United States (US).Currently, almost 20 million Americans have asthma, and

by the year 2020, asthma is expected to affect 1-in-14Americans.2 Asthma is responsible for a substantial propor-tion of health care utilization, including outpatient visits(over 10 million),3 emergency department (ED) visits (over1.5 million)4 and hospitalizations (over 400,000 annually)nationally.5 This care is costly, with greater than $30 billionspent annually in the US.6 Besides direct costs of treatingasthma, missed work days are also non-trivial, with greaterthan 14 million days missed annually.7

Minority patients, however, assume a greater proportionof burden from asthma. African Americans with asthmasuffer greater morbidity and mortality, with higher ratescompared to whites of ED visits (350 %), hospitalizations(240 %), and mortality (200 %).7 Also, within ethnicpopulations, disparities exist. For instance, the Puerto Ricanpopulation has higher prevalence than any other racial orethnic group, including African Americans.7,8 Canino et al.has attributed the root cause of these disparities to amultitude of factors, including individual, environmental,

1001

provider and health system components that may all play aninter-related role.9

It has been well documented that a disproportionate numberof minority patients have low health literacy, placing them athigher risk for poor health outcomes.1 Further, environmentalfactors, such as neighborhood context, pollution and aller-gens have also been implicated.9 At the provider and healthcare system-levels, access to care, provider beliefs, andcultural sensitivity may all play a role. All of these inter-related components are also affected by the policy context inwhich they exist. For instance, patient-centered medicalhomes (PCMH) have been a recent area of interest by bothpolicy makers and medical professionals and may play anincreasingly important role in addressing disparities.10

Because of the multitude of factors that may play a role inperpetuating health disparities for minority patients withasthma, it is important to critically evaluate the scope andtarget of interventions that aim to improve care for thispopulation. Although hundreds of studies have evaluatedindividual components of asthma management includingeducational and system-level approaches to improving healthoutcomes related to asthma, there is a dearth of studies that areculturally tailored, or that even include a majority of non-White study participants. Through a systematic review of whatlimited literature exists, clinicians, health care organizations,communities, patients, and policymakers can understandwhich interventions are likely to be successful in addressingand decreasing health disparities and will identify what gapsremain for future work in this area. Therefore, the aim of thisreview is to systematically review the literature to answer thefollowing question: what interventions work best to improveoutcomes for minority adult Americans with asthma?

METHODS

Initial Search

In consultation with a biomedical librarian, we conducted anelectronic search of the English literature in Medline from1950 to Fall 2010 by exploding Medical Subject Heading(MeSH) terms related to asthma (e.g., respiratory inhalers,anti-asthmatic agents) combined with terms to identify studiesfocused on minority populations (e.g. MeSH “MinorityGroups” and keyword “dispari*mp”) and with terms toidentify intervention studies. [Text Box 1] Please refer to thetechnical web appendix in the introductory paper by Chin etal. for recommended search strategies for interventions toreduce racial and ethnic disparities in health care.11 Weconducted parallel searches in PsycINFO and CINAHL. Toidentify additional studies that may not have been included inthese search results, we reviewed the Cochrane database ofinterventions and all references from included studies. Finally,an expert reviewer evaluated the included references to ensurekey articles were not inadvertently missed. To explorepublication bias, we reviewed meeting abstracts from 2009

and 2010: American Thoracic Society, American Academy ofAllergy, Asthma and Immunology, and the Society of GeneralInternal Medicine, for studies that may not have yet beenpublished or were not published due to negative findings.

Text Box 1: Medline search strategy

Inclusion criteria were: 1) adult population (age 18 or older);2) intervention studies with greater than 50 % minorityparticipants or with a subset analysis of minority patients byrace/ethnicity were included; and 3) intervention studiesaffiliated with a health care delivery setting (i.e., outpatientclinic, ED, hospital). We limited our search to adultpopulations because the Finding Answers program haspreviously published on interventions to address disparitiesfor care of minority children with asthma.12 While communityinterventions are an important part of an overall disparitiesreduction strategy, the current paper focuses on interventionsthat occur in or have a sustained linkage to a health caredelivery setting. Only studies that took place in the UnitedStates and published in English language were included. Allstudy designs were included.

Article Selection

Following the initial searches, duplicates were eliminatedand a title and abstract review was performed whereby each

1002 Press et al.: Minority Patients with Asthma: A Systematic Review JGIM

article was independently reviewed for exclusion by two co-authors (authors VGP, VMA, AAP, WDC, AAP). Articleswere excluded based on title and abstract review if thearticle focused on a topic other than asthma, did not includeadult patients, was not an intervention-based study, did nothave a focus on, or inclusion of, minority patients, or didnot have an affiliation with a health care delivery setting.For any titles or abstracts that were unclear, the authorserred on the side of including for full article review. Thistitle/abstract review was followed by an article extractionreview. To ensure reviewers were consistent across articleextraction, all reviewers participated in a training process.Two articles were then selected at random and werereviewed by all reviewers to ensure the training wassuccessful and definitions were being applied appropriately.All discrepancies were resolved by consensus. Followingthis training, all articles were extracted onto a uniformextraction form first by one author (AAP, WDC, ATP, orVGP), with all articles then undergoing a second indepen-dent extraction by a different author for verification (VMA,VGP, or MHP); a weighted k was calculated to determineinter-rater agreement. The standardized extraction formfocused on identifying the following elements for eachstudy: intervention type (education-based or system-level),study design (RCT, Pre/Post, Cohort, Case control), studypopulation (White, African American, Latino/a, Asian,American Indian, other), setting (community [if linked toa health care delivery setting], outpatient, inpatient), thestudies’ outcome measures, the assigned study quality score(DB score).

Data Analysis and Synthesis. Authors examinedheterogeneity of studies qualitatively through comparingstudy population, study design, intervention characteristics(setting, target), and outcomes.13 Then the studies werebroken down into education-based or systems-levelinterventions. The education-based studies were identifiedas culturally tailored education (CTE) if either the authorsof the study being reviewed self-defined their interventionas culturally tailored, or our review of the interventionindicated that it had at least one foci of cultural tailoring(language appropriate education or use of focus groups forthe target population in the development of theintervention). A structured data abstraction form inMicrosoft Access facilitated collection of these dataelements. Any articles not meeting inclusion criteria wereexcluded. Added to the final included studies were thosemeeting inclusion criteria found from reference mining,meeting review and expert opinion.

Quality and Bias Assessment

This review conforms to the Preferred Reporting Items forSystematic Reviews and Meta-Analyses (PRISMA) standards.

However, because the interventions and outcomes evaluatedby, and reported on, in the included studies in this reviewvaried and did not have a unified methodology or healthoutcome, our systematic review did not meet current guide-lines for submission to a systematic review protocol registry.14

To assess study quality, the previously validated Downs andBlack (DB) checklist was used.15 The original DB score iscalculated by rating each study across a variety of domainsincluding external validity (3 items), bias (7 items), con-founding (6 items), and power (1 item). Instead of using afive-point range for scoring the power item,15 we simplifiedthe scoring to a binary system of granting a point (1) foradequate power calculations, or no points (0) if power wasnot adequately addressed. Additionally, we have added oneitem from the Cochrane tool for bias16 that was not capturedwith the DB tool, for a total maximum modified DB score of29.15 The average DB quality score (out of a maximum of 27points; they did not include the power item or additional biasitem) from a prior set of systematic reviews performed by theFinding Answers team is 17.65 (213 studies total).17 Theinter-rater agreement for data abstraction using the modifiedDB tool was adequate (k=0.67).18 To describe the risk ofmethodological bias for each study, the Cochrane Collabo-ration tool was used, and was captured in the overallmodified DB quality score as above.16 We used the DBscore, rather than other methods for assessing quality, for thefollowing reasons. First, this tool was used in the priorsystematic reviews of health disparities interventions by theFinding Answers team.17 Therefore, the benefit of using itfor our review is to have a benchmark by which to comparethe DB quality scores for studies in our review across otherreviews in this supplement and to prior large systematicreviews of health disparities interventions. Second, the DBchecklist is particularly useful for intervention studies as itassesses the quality of the study method for both RCTs andnon-randomized designs. Finally, it also provides an over-view of the paper, highlighting the strengths and weakness ofeach study.15

RESULTS

From 1637 studies, 24 were eligible for review (Figure 1).Excluded studies did not study asthma (n=821), were notintervention-based (n=526), not an adult population (n=119),not US-based (n=83), did not have sufficient minoritypopulation (n=22), were pharmacologic-based (n=16), dupli-cates (n=14) or were not affiliated with a health care setting(n=12). Meeting abstracts were reviewed (n=1219); three metinclusion criteria, none resulted in mansucripts.19–21 Ulti-mately, 15 educational22–36 and 9 system-level studies wereincluded.37–45 (Table 1) The education-based interventionsprimarily targeted patients while the system-level interventionstargeted providers and/or health systems.

1003Press et al.: Minority Patients with Asthma: A Systematic ReviewJGIM

Study Quality

Study quality ranged from 12 to 26, with a mean of 21.0.Using a previously published categorization of DB scores,46

16 (67 %) were in the very good range (≥20), 6 (25 %) in

the good range (15–19), 2 (8 %) in the fair range (10–14),and none (0 %) were rated as poor (<10). The tenrandomized clinical trials were the most highly rated (range16–26, mean 22.1), following by the six pre/post designstudies (range 17–24, mean 21.7), the two case-control

Total Title/Abstracts Reviewed

1637

Medline 984 PsycINFO 438 CINAHL 215

Articles Included

24 Medline 18 PsycINFO 0 CINAHL 1 Other 5

Education

15

Culturally tailored Education: 5

Systems Interventions

9

Specialty clinics 4

Community health center collaborative 2

Articles identified in other ways

5 Cochrane 0 Review of

Reference/Review articles: 4

Expert review: 1 Abstract review: 0

Excluded (1613)

Not Asthma: 821 Not Intervention: 526

Not Adults: 119 Non-US:83

Did not meet minority criteria: 22

Pharmacologic study: 16

Duplicate: 14 Not affiliated with

health care center: 12

Figure 1. Flow diagram.

1004 Press et al.: Minority Patients with Asthma: A Systematic Review JGIM

Tab

le1.

AsthmaIntervention

san

dOutcom

es

Reference

Design

Setting

N,Pop

ulation

%Intervention

Typ

eLengthof

Followup

Outcom

esResults

Quality

score

Martin

2009

24

RCTa

Cb

42;AAc10

0%

African

American

adultsrecruitedfrom

prim

arycare

clinicsreceived

4grou

peducationalsessions

ledby

acommun

itysocial

workeralon

gwith

6ho

mevisitsby

commun

ityhealth

workers;education

includ

edgeneralasthmainform

ation,

medicationinform

ationinclud

ing

controllermedication,

inhalertechniqu

e,andspacer

use,

andsymptom

mon

itoring

andavoidance[trigg

ers].Tho

sein

the

controlgrou

pweremailedasthma

educationmaterials.

CTEd

6mon

ths

SFe

NSi :daytim

esymptom

s;no

cturnal

symptom

s24

SM

fNS:Receipt

ofactio

nplansfrom

doctor:

trendtowardsigat

3mon

ths;NSat

6mon

ths

NS:inhaledcorticosteroid

use;

useof

aspacer

A-Q

OLg

12%

absoluteim

prov

ement(4.2

vs.3

.7,

p=0.00

2)in

interventio

ngrou

pat

6mon

thfollo

w-up

Kh

NS:Asthm

akn

owledg

e

Sob

el20

0923

Pre/Po

stC

130;

AA

100%

Ahealth

literacyfocusededucationalp

rogram

thatrecruitedparticipantsfrom

aninternal

medicineclinic,churchor

adulteducatio

ncenter,w

howereprovided

aneducational

videoto

prom

oteself-careconcepts

includingbasicasthmainform

ation,

avoiding

triggers,m

edicationeducationand

self-m

onito

ring

ofcontrol,vialaptop.

CTE

Immediately

post

interventio

n

K>60

%absolute

increase

inmean

posttestkn

owledg

escore(4.2

to6.8,

p<0.00

1)

17

Odegard

2004

26

Pre/Post

C,Oj

32;SAk10

0%

Pharm

acistsor

pharmacystud

entsprov

ided

oral

andwritteneducationin

the

participants’prim

arylang

uage,usingin-

person

,grou

psessions

that

includ

edvideotapes

andwritteninform

ationon

pathop

hysiolog

y,triggers,therapies,inh

aler

techniqu

e,anduseof

PFM

l s.

CTE

6mon

ths

Um

78%

absolute

decrease

inmeanclinic

visitsdecreased(1.8

to0.4,

p<0.00

1)from

6mon

thspriorto

6mon

thspo

stinterventio

n

22

SF

73%

absolute

decrease

inMean#

asthmaattacks(3.7

to1.0,

p<0.00

1)and79

%decrease

inno

cturnal

symptom

s(1.4

to0.3,

p<0.00

1)SM

44%

absolute

increase

inuseof

cham

bers

(22to

56%;p<0.00

1)and

41%

PFM

use(3

to44

%,p<0.00

2)Tatis 2005

25

Coh

ort

O19

8;Ln91

%Patientswereseen

byaspecialist

(pulmonologisto

rallergist)andwere

provided

care

andeducationfirstb

ythe

physicianfollo

wed

byareview

with

atrained

asthmaeducator

usinglung

modelsto

teach

aboutairway

inflam

mation,controller

therapy,inhalertechnique

andtriggercontrol;

bookletsatthe3rdgradereadinglevelwere

provided

inEnglishor

Spanish;interventio

ngroupcomparedto

matched

controls.

CTE

6mon

ths

U28

%absolute

redu

ctionin

EDpvisits

(from

3.9to

2.8,

p=0.00

05);41

%redu

ctionin

hospitaladmission

(from

1.65

to0.97

,p<0.00

1)in

interventio

ngrou

p(interventiongrou

phadhigh

erstartin

gED

visitsthan

matched

controlsby

gend

erandagewith

in10

yearswho

declined

theinterventio

n)

18

QOLo

20%

absolute

improv

ement(for

those

who

completed

four

questio

nnaires)

KNS:Asthm

akn

owledg

eGalbreath

2008

29

RCT

C,O

429;

L51

%,W

r

31%,A

A/other,

18%

Telephonediseasemanagem

ent(6–7calls)

[DM]thatprovided

individualized

education

andan

actionplan

bytrainedrespiratory

nurses;and

[ADM]–thatalsoincluded

telephoneplus

4homevisitsfrom

respiratory

therapistswho

provided

hands-on

equipm

ent

instructionandahome-environm

ent

evaluation;

comparedto

traditionalcare.

Es

1year

UNS:urgent

office

visits;ED

visits;

Inpatient

admission

s24

SF

NS:tim

eto

firstevent

A-Q

OL

14%

absolute

improv

ementin

ADM

t

(4.2

to4.9,

p=0.04

)

1005Press et al.: Minority Patients with Asthma: A Systematic ReviewJGIM

Table

1.(c

ontinue

d)

Reference

Design

Setting

N,Pop

ulation

%Intervention

Typ

eLengthof

Followup

Outcom

esResults

Quality

score

Stiegler

2003

31

Pre/Post

O,I

17;AA

100%

Pharm

acistprov

ided

30minuteintensive

coun

selin

gon

asthmainform

ation,

triggers,

PFM,medications,inhalerandspacer

use

andside

effectsof

therapy,

forpatients

hospitalized

with

acuteexacerbatio

nsof

asthma,

follo

wed

byou

tpatient

teleph

one

follo

w-upat

1weekpo

stdischargeto

reinforceeducationandansw

erqu

estio

nsand5weeks

postdischargeto

reinforce

educationandassess

adherence

E6mon

ths

U78

%absolute

decrease

inho

spital

admission

sandED

visits(from

1.58

to0.35

,p=0.00

16)

24

SM

41%

absolute

improv

ementin

medicationrefill(from

22%

to63

%,

p=0.01

75)

George

1999

30

RCT

O,I

77;AA

Majority

Inpatient

educationby

anasthmanu

rse

educator

ondiseaseinform

ation,

medication

inform

ation,

inhalertechniqu

e,symptom

mon

itoring

andan

actio

nplan,bedside

spirom

etry;aph

onecall24

hoursafter

dischargeto

answ

erqu

estio

nson

discharge

instructions,medicationandasthma

symptom

s;follo

w-upin

anasthmaprog

ram

in1weekpo

stdischargeforspirom

etry,

physicianvisitandasthmanu

rseeducation

toreinforcetheho

spital-basededucation;

controlsweregivenusualcare.

E1week

U89

%relativ

edecrease

inED

visitsand

88%

relativ

edecrease

inho

spital

admission

sin

interventio

n(27to

3,p=

0.04

;26

to3,

p=0.04

)vs.control(17

to15

,NS;14

to12

,NS)

22

LOSu:NS

Castro

2003

32

RCT

O,I

96;AA

78–8

6%

Multi-facetededucationalprog

ram

includ

ing

review

ofregimen,adaily

‘asthm

acare’

flow

sheet,educationtailo

redto

patient

prov

ided

byasthmanu

rsespecialist,

psycho

social

supp

ort,individu

alized

self-

managem

entplan,dischargeplanning

and

outpatient

follo

w-upwith

phon

econtact,

homevisitsandph

ysicianfollo

w-up

appo

intm

entsas

needed.

E6mon

ths

U50

%fewer

hospitalre-adm

ission

s(21

interventio

n;42

control,p=0.04

)and

61%

relativ

edecrease

inLOS(53

total,1.1perpatient

interventio

n;12

9total,2.8perpatient

control;p=0.04

)

24

NS:health

care

prov

ider

visits

A-Q

OL

33%

relativ

eincrease

ininterventio

ngrou

p(2.7

to4.02

;p<0.00

1)and30

%relativ

eincrease

incontrolgrou

p(2.74

to3.9;

p<0.00

1)Blix

en22

RCT

Iq28

;AA

100%

Anu

rse-runasthmaeducationprog

ram

that

prov

ided

31-ho

urindividu

aleducationalsessions

onasthmaself-

managem

entutilizingapreviously

validatedworkb

ookandavideoon

MDItechniqu

eandPFM;controlgrou

preceived

usualcare.

CTE

6mon

ths

A-Q

OL

NS:difference

inasthmaQOLbetween

interventio

nandcontrolat

3or

6mon

ths

25

Press

VG

2011

33

Pre/

Post

I10

0;Non

white

(AA,AIv,ANw,

PIx)89

%

Teach-to-Goalstrategy

provided

byresearch

staffusingcycles

ofassessmentand

demonstrationtoinstructhospitalized

patients

onuseof

MDI's

yandDiskus®

devices.

EIm

mediate

posteducation

SM

100%

mastery

ofMDIandDisku

s®techniqu

ewith

atmost2roun

ds21

Paasche-

Orlow

2005

27

Coh

ort

I73

;AA

84%

One-on-on

e,30

minute,

guideline-based,

writtenandoral

instructions

abou

tasthma

dischargeregimen

andMDItechniqu

eprov

ided

byresearch

assistants.

E2weeks

SM

100%

mastery

ofMDItechniqu

ewith

atmost3roun

dsin

theho

spital

18

21%

absolute

improv

ementin

mean

MDItechniqu

escoreat

follo

w-upvisit

comparedto

dischargevisit(3.8

to4.8,

p<0.00

1)

1006 Press et al.: Minority Patients with Asthma: A Systematic Review JGIM

Table

1.(c

ontinue

d)

Reference

Design

Setting

N,Pop

ulation

%Intervention

Typ

eLengthof

Followup

Outcom

esResults

Quality

score

Ford

1997

28

RCT

I(ED)

537;

AA

72%,

W27

%,Other

1%

The

interventio

ngroupattended

3sm

allgroup

educationsessions

inEDby

health

care

professional,ondisease,complianceand

self-care;thosewho

didnotattend

received

thematerialsinthemail.Those

inthecontrol

groupdidnotreceive

education.

E12

mon

ths

UNS:ED

visits/yearby

race

26SF

NS:differentialeffect

ofinterventio

nby

race

onchange

inlim

itedactiv

itydays

dueto

asthma

KNS:differentialeffect

onkn

owledg

eof

interventio

nby

race

Kelso,

1995

36

Case

Con

tol

I(ED)

52,AA

100%

1-hour

educationsessioninEDby

unspecified

educators(presumablyresearch

staff)on

disease,triggersandself-m

anagem

entw

ithinhalertechniqueinstruction(with

spacer);

PFMswereprovided

with

demonstration;

1wkf/uappt

atfree

clinic.

E1year

U41

%absolutereductionin

EDvisits(4.4

to2.6,p<0.01)and62

%in

hospital

admissions(1.3

to0.5[62%]p<0.01),

forinterventio

ngroup;

NScontrolgroup

19

Bolton

1991

35

Coh

ort

I(ED)

241;

NW

69%,

W31

%The

interventio

ngroupreceived

usualcare

plus

threein-personeducationalg

roup

sessions

over

anunspecifiedtim

e-period,

provided

byan

asthmanurseeducator

onbasicasthmapathophysiologyandself-

mangementinformation(1

stsession);

pharmacologyandinhelrtechnique(2

nd

session);avoidanceof

triggers

(3rdsession).

E12

mon

ths

U59

%absolute

deceased

ED

visitsfor

interventio

ngrou

p(16per10

0person

s)comparedto

controlg

roup

(39

per10

0person

s)in

12mon

thsof

follo

wup

(p=0.00

05);strong

estdu

ring

first4mon

ths(68vs.22

0per10

0person

s;p=0.00

3),bu

tno

tas

strong

during

last4mon

ths(69vs.9

8per10

0person

s;NS)

23

NS:Hospitaladmission

s;consultatio

nswith

health

profession

als:no

dif

SF

30%

fewer

days

oflim

itedactiv

itydu

eto

asthmain

interventio

nvs.control

(622

vs.88

8,p=0.03

)in

first4and

averaged

over

all12

mon

ths(161

vs.

246,

p=0.04

),no

tin

thelast4mon

ths

(939

vs.63

3,NS)

Maiman

1979

34

RCT

I(ED)

245;

AA

92%,

Non

-AA

8%

Asthm

anurseprovided

educationon

preventio

nandcontrolo

fexacerbatio

ns,

medicationcomplianceandself-efficacy

follo

wed

bya6weeks

post-EDdischarge

phonecallto

reinforceED-based

education

E6mon

ths

U20

%relativ

edifference

inpercentage

ofpatientswith

nofurtherEDvisitsin

the

interventio

ngrou

p(asthm

atic

nurse

educationwith

book

let)comparedto

thosein

thecontrolgrou

p(ED

nurse)

(82vs.66

%,p<0.05

)

16

Hicks

2010

40

Pre/Post

O38

87;W

38.4

%,

AA

22.4

%,L

25.8

%,Other

13.4

%

Health

DisparitiesCollabo

rativ

edeveloped

toim

prov

ethecare

ofpatientswith

chronicdiseases

includ

ingasthmaby

dissem

inatingqu

ality

improv

ement

techniqu

esdevelopedby

theInstitu

tefor

Health

care

Improv

ement.

Sz

1year

QOL

NS:qu

ality

improv

ementscore

22M

13%

absolute

improv

ementin

disparity

score(39.3to

45.4,p<0.05

)

Lando

n20

0741

Pre/

Post

O33

92;W

41.4

%,

AA

21.3

%,L

23.7

%,Other

13.7

%

Health

DisparitiesCollabo

rativ

edeveloped

toim

prov

ethecare

ofpatientswith

chronicdiseases

includ

ingasthmaby

dissem

inatingqu

ality

improv

ement

techniqu

esdevelopedby

theInstitu

tefor

Health

care

Improv

ement.

S1year

SM

70%

absolute

increase

inuseof

asthma

managem

entplan

(from

8to

27%,

p<0.00

1)

24

QOL

25%

absolute

increase

inscore(from

38.7

to51

.7,p<0.00

1)

1007Press et al.: Minority Patients with Asthma: A Systematic ReviewJGIM

Table

1.(c

ontinue

d)

Reference

Design

Setting

N,Pop

ulation

%Intervention

Typ

eLengthof

Followup

Outcom

esResults

Quality

score

Keslo

1996

44

RCT

O39;W

39.7%,

AA31.8

%,L

17.1%,O

ther

25.7%

Com

prehensive

long

-term

managem

ent

prog

ram

ataun

iversity-based

clinic

with

a1-hou

rph

armacistprov

ided

education

ontriggercontrol,PFM

use,

asthma

educationandmedication;

tailored

pharmacolog

ictreatm

entand

emph

asis

onthepartnershipbetw

eenclinic

and

patient.

S2years

U74

%absolutedecrease

inEDvisitsin

interventiongroup(2.3to

0.6,p=

0.0001);notin

controlgroup(2.6

to2.0,

NS)

16

83%

absolute

decrease

inho

spital

admissionsforinterventio

ngroup(from

0.6to0.1;p=0.002)

and54

%in

control

group(from

1.3to

0.6;

p=0.004)

SF

39%

absolute

improv

ementforsleep

loss

score(3.50to

2.13

,p=0.00

)and

44%

fornigh

tsaw

akened

(4.28to

2.44

,p=0.01

)SM

48%

absolute

improv

ementin

inhaler

techniqu

e(52to

100%);

86%

increaseduseof

spacer

device

(14to

100%);

100%

increaseduseof

homePFMs(0

to10

0%);

52%

increaseduseof

dailyIC

Sβ(48to

100%)

QOL

Significant

absolute

improv

ementsfor6

of8do

mains

(allexcept

physical

functio

nandbo

dily

pain),change

from

baselin

eto

2years:

23%

forhealth

perception

(44.86

to57

.99,

p=0.04

);98

%forph

ysical

limitations

(11.53

to63

.81,

p=0.00

);47

%forem

otionallimitations

(42.22

to80

,p=0.01

);32

%forsocial

function

ing(55.81

to82

.50,

p=0.00

);20

%formentalhealth

(62.57

to78

.29,

p=0.4);and49

%forenergy

/fatigu

e(38.75

to61

.85,

p=0.2)

A-Q

OL

23–4

2%

decrease

inscores

forthe

asthmabo

ther

profileforthe12

of15

statisticallysign

ificantdo

mains

(NS:em

baressmentof

taking

asthma

medication;

worry

abou

tasthma

attack

innew

place;

worry

catch

acold)

K10

0%

improv

ementin

asthma

know

ledg

ewith

regard

todifference

inICSandbeta

agon

ist(0

to10

0%)and

self-m

anagem

entandcrisisprednisone

(0to

100%)

1008 Press et al.: Minority Patients with Asthma: A Systematic Review JGIM

Table

1.(c

ontinue

d)

Reference

Design

Setting

N,Pop

ulation

%Intervention

Typ

eLengthof

Followup

Outcom

esResults

Quality

score

Pauley

1995

45

Case

Con

trol

O25

;AA

76%

Participantsattend

edaspecialasthma

clinic

that

prov

ided

grou

p-based

educationabou

tasthmatriggers

and

prop

eruseof

asthmamedications,

teleph

onecontactwithph

armacistand

anop

en-doo

rclinic

policy.

S6mon

ths

U87

%relativ

edecrease

inmeanper

patient

ED

visit(1.88to

0.24

,p=

0.00

6)whencomparing

controlperiod

tothestud

yperiod

(1year

interval

betweenthetwo)

21

Sperber

1995

42

Coh

ort

O84

;PRaa48

%,

M/C

bb27

%,A

A24

%

All

patients

inon

eclinic

referred

toasthmaspecialist

(allergist/

immun

olog

ist);thosewho

wentwere

“interventiongrou

p”andreceived

educationon

useof

inhalers,triggers,

PFM

use;

controlgrou

pwas

seen

bygeneralpractition

er.

S2years

U63

%relative

decrease

inclinic

walk-

invisits

(73vs.27

,p<

0.00

1),83

%fewer

ED

visits

(30

vs.5,p<0.00

1)and88

%fewer

hospital

admission

s(16vs.2,

p<

0.00

1)in

theintervention

grou

pcomparedto

theno

n-intervention

grou

p;NSchangesexcept

for68

%increasedED

visits

(7vs.22

,p<0.05

)

12

Mayo

1990

43

RCT

O10

4;L80

%,AA

15%,W

4%

Anintensivetreatm

entprog

ram

consisting

oftw

o1-

hour

clinic

visits

onpathop

hysicology

andself-

managem

entstrategies,follow

edby

asneeded

½ho

urfollow

-upvisits

prov

ided

byph

ysicianor

nursepractition

erwas

comparedto

routineclinic,forpatients

withmultiplepriorho

spitalizations

for

asthmaexacerbation

s.

S32

mon

ths

U67

%absolute

decrease

inho

spital

readmission

s(0.4

vs.1.2per

patient,p=<0.00

4)and54

%shorterLOS(3.1

perpatient

days

vs6.7;

p<0.02

)

22

Mayo

1996

39

Coh

ort

O,I

126;

L79

%,W

10%

AA

9%

Ateam

intervention

whereby

hospitalized

patients

who

didno

thave

aprivateph

ysicianwereevaluated

andtaug

htpathop

hysiolog

y,MDI

techniqu

e,andspacer

and

PFM

use,

byanu

rse;

housestaff

andattend

ingwerealso

taug

ht.The

nurseprov

ided

one-on

-one

education

andleft

adetailed

note

forho

usestaff

team

.Atdischarge,

patientwas

prov

ided

aon

e-weekfollow

-up

appo

intm

ent.

SHospital

Discharge

U17

%absolutedecrease

inLOS(4.8

to4,

p<0.00

1)23

NS:Hospitalreadmission

SM

36%

increasedPFM

byresidents(42to

77%,p<0.00

1)and55

%increased

useof

spacersby

patients(38to

85%,

p<0.00

1)K

57%

increasedpatient

education(31to

72%,p<0.00

1)and34

%increased

resident

education(0

to34

%,

p<0.00

1)

Akerm

an19

9938

Coh

ort

I(ED)

200;

AA

88%,L

8%,W

0.7%,

Other

3.3%

Acontinuo

usqu

alityim

prov

ementproject

toim

prov

easthmacare

andou

tcom

esin

aninner-city

ED

implem

enting

asthma

treatm

entgu

idelines.

S2years

U20

%absolute

decrease

ofadmission

s(4.85to

3.90

per10

0ED

visits,

p<0.05

)

14

SF

36%

decrease

inrelapse(from

12.18to

7.83

,p<0.00

1)

1009Press et al.: Minority Patients with Asthma: A Systematic ReviewJGIM

Table

1.(c

ontinue

d)

Reference

Design

Setting

N,Pop

ulation

%Intervention

Typ

eLengthof

Followup

Outcom

esResults

Quality

score

Ryd

man

1998

37

RCT

I(ED)

113;

AA

74%,

Other

74%

Patientsrecruitedfrom

ED

after3ho

ursof

therapythen

rand

omized

toEDob

servation

unitor

controlgrou

pwhich

received

inpatient

admission

.

S8weeks

SF

NS:PEFRcc;Relapse

22QOL

sign

ificantim

prov

ementfor5of

8do

mains

(interventionvs.control):

19%

physical

functio

n(72vs.58

,p=

0.011);42

%em

otionalfunctio

nrole

(78vs.45

,p=0.00

1);15

%social

functio

n(80vs.68

,p=0.02

1);14%

mentalhealth

(78vs.67

,p=0.00

8);

20%

vitality(59vs.4

7,p=0.01

6);N

S:

physical

functio

ning

role,bo

dily

pain,

generalhealth

perceptio

ns

aRCT:

Ran

domized

Con

trolledTrial

bC:Com

mun

ityc AA:African

American

dCTE:Culturally

Tailo

redEdu

catio

ne SF:Symptom

frequency

f SM:Self-man

agem

entbeha

viors

gAQOL:Asthm

a-relatedQOL

hK:Kno

wledg

ei NS:

Not

sign

ificant

j O:Outpa

tient

k SA:So

uthAsian

l PFM:PeakFlowMeter

mU:Health

care

utilizatio

nnL:Latino

oQOL:Qua

lityof

Life

pED:EmergencyDepartment

qI:Inpa

tient

r W:White

s E:Edu

catio

nt ADM:Aug

mentDisease

Man

agem

ent

uLOS:

Lengthof

Stay

v AI:American

Indian

wAN:Alaskan

Native

x PI:PacificIsland

ery M

DI:Metered-D

oseInha

ler

z S:System

Level

Interventio

naaPR:PuertoRican

bbM/C:Mexican

/Colum

bian

ccPEFR:PeekExpiratoryFlow

Rate

1010 Press et al.: Minority Patients with Asthma: A Systematic Review JGIM

studies (range 19–21, mean 20), and the six cohort studies(range 12–23, mean 18).

Race/Ethnicity

The majority of studies included participants from severalrace/ethnicity populations; studies focusing on AfricanAmericans predominated. Five studies focused entirely onone race/ethnicity; four on African Americans; one onAsian Americans. There were an additional ten studieswhere the majority of participants were African American,and four where the majority were Latinos.

Intervention Sub-TypesEducation-Based Interventions (N=15; Mean StudyQuality Score (DB) 21.5). The majority of theinterventions were education-based (n=15);five wereculturally tailored; three defined by the studies’authors22,23,25 and two by our review.24,26 None of theCTE studies included a comparison group. Three focusedon the African American population,22–24 one on the Latinocommunity,25 and one used language-appropriate educationfor different Asian populations.26 Four CTE interventionsdemonstrated improved outcomes.23–26 The remaining teneducational interventions were not specifically culturallytailored, but did include a majority of non-whiteparticipants; most included a majority of AfricanAmerican participants, though one included a majority ofLatino/a participants. Of these ten interventions, all but onetook place at least partially in the hospital setting,29 incontrast to the CTE interventions that were primarilyoutpatient-based.

System-Level Interventions (N=9, Mean Study QualityScore (DB=19.6). Nine system-level studies met criteria forthis review. The setting was primarily outpatient;40–45 threewere inpatient-based.37–39 Two utilized health disparitiescollaboratives to introduce quality improvementinterventions.40,41

Intervention Outcomes

Almost all of the interventions had at least one successfulcomponent; several studies reported on similar outcomes(e.g., ED visits, hospitalizations). However, a meta-analysiswas not performed as the interventions themselves were tooheterogeneous to provide a valid conclusion. The interven-tions varied in their setting, design, and follow-up. Forexample, some studies utilized pharmacists while othersutilized nurses or asthma educators, and some utilizedmultiple education sessions, sometimes in different settings.Several lessons can still be learned by comparing, when

possible, across the studies’ measured elements. A summa-ry by the most commonly reported outcome measuresfollows. (Table 1)

Health Care Utilization. The most common outcomemeasured among the 24 studies was health care utilization(16/24, 67 %). There was not, however, a unifying item thatcould be compared across studies, as the specific utilizationcomponent(s) differed among the studies.Among the education-based interventions two-thirds (10/15)

followed utilization; eight evaluated ED visits,25,28–31,34–36 7followed hospital admissions,25,29–32,35,36 3 followed outpa-tient visits,26,29,32 and 2 followed length of stay (LOS).30,32

The education provided by these interventions was multi-faceted and included in varying degrees: basic diseaseinformation, self-management skills, medication informationand trigger control. The education was provided in theoutpatient,25,26 inpatient,30–32 ED28,29,34–36 or communitysetting.29 Of note, all three inpatient studies30–32 and 2/4 EDbased interventions34,36 included an outpatient follow-upcomponent (phone call or visit). The education was providedby a range of trained clinical or research staff, includinghealth care professionals,28 pharmacists,26,31 asthma edu-cators,25 asthma nurse educators,29,30,32,34,35 respiratorytherapists (RT) 29 or research staff.36 All of the educationwas provided to the individual participant except for twoof the ED-based interventions28,35 and an outpatientpharmacist based intervention that utilized group ses-sions.26 Several provided more than one session, includingGalbreath’s telephone plus home visit intervention,29 allthree inpatient interventions,30–32 and all but one of theED studies.36

Of the 8 studies that followed ED visits, all buttwo28,29 demonstrated absolute reductions post-education(22–89 %)25,31,36 or relative reductions compared tocontrol (16–59 %).30,34,35 The most successful interven-tions (≥50 % reduction) included two inpatient-basedstudies provided by a pharmacist31 or asthma nurse30 andBolton’s ED multiple-group session intervention.35 Tatis’specialty clinic with asthma educator intervention25 andthree of four ED-based interventions showed slightly less-impressive reductions.28,34,36 The two interventions withnon-significant findings, included Galbreath’s respiratorynurse telephone education +/- home visits by RTs29 andFord’s ED, multiple-session, group-based education.28

Of the seven studies that followed hospital admissions,all but two29,35 demonstrated absolute25,31,36 or relative30,32

reductions (41–88 %). All but Tatis’ asthma educatorstrategy25 showed reductions of ≥50 %, including the threeinpatient interventions,30–32 and Kelso’s one-hour ED-basedintervention.36 The three studies that followed outpatientvisits included Odegard’s language-appropriate pharmacist-based, Galbreath’s telephone, and Castro’s nurse-specialistinpatient, education.26,29,32 However, only Odegard’s

1011Press et al.: Minority Patients with Asthma: A Systematic ReviewJGIM

showed a significant absolute decrease (78 %) in visits.26

Finally, only two inpatient-based education interventions,both provided by asthma nurses, followed LOS.30,32 Theresults were split: Castro found 59 % relative fewer days forthe intervention group compared to the control group,32

while George did not find a relative decrease in LOS.30

Because only one CTE study evaluated ED visits,25 hospitaladmissions,25 and outpatient visits,26 and none evaluatedLOS, conclusions based on the effectiveness of CTE onreducing utilization cannot be made from this data.Two-thirds (6/9) of system-based studies evaluated

utilization post-intervention. Half followed ED visits.42,44,45

These interventions were similar in that they were clinic-based and utilized experts, including pharmacists44,45 andspecialty-based clinics (e.g., allergists).42,45 All three founda relative42,45 or absolute44 decrease between 63–87 %; thecontrol group in one study actually had increased ED visitsby 71 %.42 These three studies, along with another clinic-based intervention that used multiple sessions and ahospital-based nurse-led intervention, both by Mayo,followed hospital admissions.39,43 All but Mayo’s hospital-based study39 found an absolute decrease by 20–88 % inpost-intervention admissions. LOS decreased in both ofMayo’s studies (17 %, inpatient; 54 %, outpatient).39,43

Sperber found a relative decrease in urgent outpatient clinicvisits of 63 %.42

Symptom Control and Self-Management. The next mostcommonly measured items fell under the topics of symptomcontrol/asthma severity (8/24; 33 %) and self-managementtools (6/24; 24 %). However, as with the general topic of‘health care utilization,’ these topic areas were also diverseand varied. For instance, with respect to asthma control,some studies specifically measured the frequency of day/night symptoms, while others used symptom scales, limitedactivity days, etc. Similarly, with respect to measuring self-management, these ranged from the use of spacers or peak-flow meters PFM], to action plans, to respiratory inhalertechnique.Of the five education-based studies that followed

symptoms,24,26,28,29,35 only two found improvements.26,35

Odegard’s language-appropriate pharmacist-based educa-tion demonstrated a 73 % absolute reduction in asthmaattacks and a 79 % absolute reduction in nocturnalsymptoms.26 Bolton’s asthma nurse inpatient educationdemonstrated a 30 % relative decrease in number of daysof limited activity (intervention group vs. control group).35

The three studies that did not find a reduction in symptomsincluded Martin’s social-work led group educational ses-sions with community health workers home visits,24

Galbreath’s telephone +/- RT home visits,29 and Ford’smulti-session ED-based intervention.28 The results for self-management (5/15) were more favorable;24,26,27,31,33 all butone24 found improvements in participants’ self-management

skills. Two pharmacist-based education interventions26,31

showed absolute improvement of chambers (34 %),26

PFMs (41 %),26 and/or medication refills (41 %).31 Simi-larly, two inpatient interventions that used repeated roundsof inhaler technique instruction demonstrated 100 % mas-tery after two or three rounds.27,33 The only study that didnot demonstrate improvements in self-management wasMartin’s community-based intervention.24 Again, few CTEstudies evaluated symptoms and self-management;24,26

therefore conclusions based on the effectiveness of culturaltailoring on improving patient self-care or symptoms cannotbe made.One-third (3/9) of system-based interventions evalu-

ated symptoms.37,38,44 Kelso’s comprehensive long-termmanagement program decreased sleep loss by 63 % andnight awakenings by 43 %.44 Akerman’s continuousquality improvement program at an inner-city ED36

decreased absolute relapse rates by 83 %. However,Rydman’s ED observation unit37 did not show a relativedecrease in relapse rates. Of the three studies thatfollowed self-management, Landon’s use of qualityimprovement collaborative at community health centers41

demonstrated a 19 % absolute increase in use of self-management plans. Both Pauley and Mayo found arelative increase in spacers use (47–86 %) and PFMs(35–100 %).39,45 Pauley also demonstrated relative im-proved inhaler technique (48 %) and use of inhaledcorticosteroids (52 %).45

Overall Health Status and Asthma Quality of Life. Aboutone-third (8/24) of the studies evaluated some aspect ofquality of life (QOL). Some measured overall QOL (n=4),25,40,41,44 while others used asthma-related QOLinstruments (A-QOL, n=5).22,24,29,32,44

Of the five education-based studies that measured QOL,all but one25 looked at A-QOL.22,24,25,29,32 All but onedemonstrated a relative32or absolute24,29 improvement inQOL of 12–33 % (scores of 0.5 to 1.32) post-intervention.Blixen’s inpatient asthma-nurse education did not find arelative improvement in A-QOL.22 Tatis’ was the onlystudy25to evaluate improvement in overall QOL scores andfound a 20 % absolute improvement for those completingthe four rounds of questionnaires. Three CTE studiesevaluated QOL (2 A-QOL, 1 QOL);22,24,25 there is notenough data to make any conclusive role on culturaltailoring and improvements in QOL.Four system-based studies evaluated QOL,37,40,41,44

one of which also studied A-QOL.44 Hicks and Landonboth studied health disparities collaborative.40,41 WhileLandon demonstrated a 25 % absolute improvement in hisoverall quality improvement score,41 Hicks did not findsignificant absolute improvement in QOL.40 Kelso’scomprehensive community clinic and Rydman’s ED-basedobservation unit showed absolute and relative improve-

1012 Press et al.: Minority Patients with Asthma: A Systematic Review JGIM

ments, respectively, of 14–98 % in the majority of SF-36domains they studied (6/8 and 5/8, respectively).37,44

Neither study found significant results for the bodily paindomain. Kelso also evaluated A-QOL using the asthmabother profile and found that 12/15 domains decreasedsignificantly by 23 to 42 %.

Asthma-Related Knowledge. Only six of the studiesmeasured knowledge related to asthma such as disease-related information, triggers, and medication post-intervention.23–25,28,39,44 Four education-based studiesevaluated asthma-knowledge;23–25,28 of these, only Sobel’seducational video promoting self-care concepts increasedknowledge (>60 %).23 The others included Martin’s multi-session social-work intervention, Tatis’ outpatient specialty-clinic, and Ford’s multi-session ED-based study.24,25,28

Only two system-based studies evaluated knowledge.39,44

Kelso’s comprehensive clinic improved participants’understanding of medications and self-managementknowledge from 0–100 %.44 Mayo’s hospital-basededucation increased patient and resident education (41 %,34 %).39

DISCUSSION

This review demonstrates that, first and foremost, asurprising dearth of intervention studies exist that addressthe health disparities of racial and/or ethnic minority adultswith asthma in the US. Since these disparities overwhelm-ingly affect African Americans and Puerto Ricans, it is notsurprising that the majority of studies focused on these twopopulations. Unfortunately, few studies utilized adequatecontrol groups, limiting our ability to endorse interventionsthat would specifically address racial disparities for patientswith asthma.However, our review still provides guidance for clini-

cians and health care systems about what modalities havebeen tried and successfully implemented. For instance, weare unable to determine which educational intervention ismost likely to reduce disparities for minority patients withasthma, but we can report that a variety of educationalmodalities appeared effective at improving outcomes forminority patients with asthma, including point-of-careeducation by health-care professionals (e.g., pharmacists,asthma nurses) or technological approaches (e.g., videos).Further, although our review is unable to definitivelyconclude CTE interventions are superior due to limitationsin study design, despite prior documented success with CTEinterventions,47 it is still noteworthy that education thatincluded language-appropriate materials (e.g., Spanish,Chinese, health literacy focus) for the patient seemed toplay an important role in the majority of the CTEinterventions.

When looking at specific outcomes, group-based educa-tion appeared less-successful in reducing health careutilization, as 1/3 found non-significant reductions in EDvisits and 2/3 in admissions. Neither symptoms norknowledge improved across most of the education-basedstudies; there was no unifying theme that directs thesuccess or lack thereof. Self-management was oftenimproved when education was provided by pharmacists(~40 %) and/or was inpatient skill-based education (100 %mastery). Studies that measured Asthma-related QOLfound improvements of up to 33 %. Finally, educationalstrategies that began in the hospital but continued withoutpatient follow-up demonstrated some of the morepromising findings with greater than 50 % reductions inhealth care utilization.22 Clinicians should recognize thatreproducible educational programs that target health-disparities for sub-populations of the US need to befurther developed and implemented and the role of culturaltailoring should be further explored.We found that specialty clinics, especially for “high risk”

patients, consistently demonstrated decreased utilizationand improved symptoms, self-management, knowledgeand QOL. Similarly, inpatient-based interventions werenearly uniformly successful across the various outcomesstudied. However, despite the promising nature of healthdisparities collaboratives, results to date have not shownexpected improved outcomes. Therefore, efforts to furtherevaluate and possibly combine the most successful strate-gies should be explored.There are several limitations of this review. Although we

reviewed recent abstracts from key scientific meetings inthe field of asthma and allergy, publication bias may limitour findings. Also, the interpretation of results may beaffected due to the high proportion of data from the studiesbeing at high risk of bias.16 Further, community-basedstudies without a health center affiliation were excluded.Future reviews may seek to understand how they mayimprove outcomes for patients with asthma. Finally, wewere unable to perform a meta-analysis limiting thequantitative evaluation of this review.

CONCLUSION

Overall, education delivered by healthcare professionals(nurses, pharmacists, community health workers or eventechnology) appeared effective in improving processes andoutcomes for minority patients with asthma. Because fewstudies were culturally tailored and lacked adequatecontrol groups, it is currently unclear whether this is asuperior approach for reducing health disparities. Systemredesign showed great promise, particularly the use ofteam-based specialty clinics and long-term follow up afteracute care visits. High-priority future areas of research

1013Press et al.: Minority Patients with Asthma: A Systematic ReviewJGIM

should evaluate the role of tailoring educational strategies,focus on patient-centered education, and incorporateoutpatient follow-up and/or a team-based approach.

Acknowledgements:Contributors: We would like to thank Dr. Jerry Krishnan, MD,PhD, Professor of Medicine and Public Health, Director of Popula-tion Health Sciences, Associate Vice President, Office of the VicePresident for Health Affairs, University of Illinois at Chicago, forproviding an expert review of the included references for thissystematic review. We would also like to thank Deb Werner for theexpertise she provided in developing our literature search. We alsowould like to thank Kathy Fletcher, Darcy Reed and Jack Litrell fortheir expertise in performing systematic reviews. Finally, we wouldlike to thank Morgen Alexander-Young for her assistance early inthe project and Nicole Babuskow for her assistance with theproject.

Funding Source: Support for this publication was provided by agrant from the Robert Wood Johnson Foundation’s Finding Answers:Disparities Research for Change Program. The funding source had norole in the design and conduct of the study; collection, management,analysis, and interpretation of the data; and preparation, review,approval, or decision to submit the manuscript for publication.

Prior Presentations: This work has been presented at the 2011University of Illinois at Chicago 3rd annual Minority Health in theMidwest Conference, the 2011 University of Chicago Pediatrics’Resident Research Day, and the 2011 Society of General InternalMedicine Meeting.

Conflict of Interest: The authors declare that they do not have anyconflicts of interest with this work. Dr. Press reports receivingfunding from the National Cancer Institute (KM1CA156717) andthe Robert Wood Johnson Foundation’s Finding Answers: Dispar-ities Research for Change Program. None of the other authors havefunding to report.

Corresponding Author: Valerie G. Press, MD, MPH; Section ofHospital Medicine, Department of Medicine, University of Chicago,5841 S. Maryland Ave, MC 5000, W305, Chicago, IL 60637, USA(e-mail: vpress@medicine.bsd.uchicago.edu).

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