Asthma Care Quality, Language, and Ethnicity in a Multi-State Network of Low-income Children

John Heintzman, MD, MPH; Jorge Kaufmann, ND, MS; Jennifer Lucas, PhD; Shakira Suglia, PhD; Arvin Garg, MD; Jon Puro, MS; Sophia Giebultowicz, MA; David Ezekiel-Herrera, MS; Andrew Bazemore, MD; Miguel Marino, PhD


J Am Board Fam Med. 2020;33(5):707-715. 

In This Article


This analysis of care quality measures for asthma in Latino and non-Hispanic white children is novel in its sample size, use of longitudinal EHR data, and ability to consider language while accounting for numerous clinical and sociodemographic features. Spanish-speaking Latino children were less likely than our other cohorts to have the diagnosis of asthma recorded on their problem list on the same day it was first noted in the chart, but the diagnosis of asthma was recorded more quickly after the first day. This pattern could represent an initial language-related barrier to the documentation of asthma as a chronic problem, but a more rapid follow up—possibly initiated by family or provider—that leads to problem list documentation. Providers should continue to be cognizant of the need for rapid documentation/communication of asthma as a chronic problem once diagnosed. The documentation of asthma severity was equitable between the cohorts. This is crucial as asthma severity guides appropriate medication therapy, and equity in medication therapy depends on the appropriate documentation of asthma diagnosis.

Our analyses revealed the surprising finding that Spanish-speaking children had almost double the odds of having been prescribed albuterol and were more likely to have ever been prescribed inhaled or oral corticosteroids as well. In addition, among children prescribed medication, Spanish-speaking Latino children had higher rates of albuterol prescriptions, and when diagnosed with mild persistent asthma, had higher rates of inhaled and lower rates of oral corticosteroids. Overall, it is encouraging, that in this CHC population with established asthma diagnoses, Latino children (English and Spanish preferring) did not experience reduced prescription rates for common asthma medications. This suggests that any asthma disparities experienced by this population may occur at other stages of care (medication filling, initial diagnosis) rather than at the stage of appropriate prescribing to match asthma diagnosis/severity. We were not able to measure specific symptoms, presentations, or other factors which may bring about prescriptions, so it is uncertain whether Spanish-speaking children received more prescriptions because their asthma was somehow worse, although we did stratify by asthma severity when that documentation was appropriate. However, the specific pattern in Spanish-preferring children with mild persistent asthma of increased inhaled steroid prescriptions and decreased oral steroid prescriptions is consistent with more guideline concordant care. Spanish-preferring children may have more family, cultural, or community resources/support that aid in the management and followup of this chronic condition; however, our analysis was unable to measure these factors, and we could not assess overdiagnosis or over prescribing as a response to uncertainty in communication because of language barriers. Given the known high prevalence of asthma among Latino children and the documented barriers to medication use, CHC providers may be especially attentive to this condition in this population, and have a low threshold for the prescription of these medications, as literature does show that limited English proficiency can be a barrier to asthma medication use.[31] Future studies can delve into the individual and provider factors (including language ability) that might have resulted in these findings in these children.

While previously observed findings by Kharat,[3] Crocker,[6] and Kit[8] showed less inhaled steroid prescriptions in Latino children, our analysis was conducted using a much larger sample across 21 states, observed over a longer period of time, controlled for more covariates, examined a low-income population (which is therefore especially vulnerable to inequity) in objective EHR data, and stratified by asthma severity. Spanish- and English-speaking Latino children, with varying levels of overall health care utilization, health insurance, and socioeconomic status, received equitable asthma care—once diagnosed—on numerous asthma care indicators. Our findings may suggest that CHCs in our nation's safety net may provide a worthwhile template for reducing some disparities in asthma care. This has been shown in other disease processes in Latino patients.[32] However, understanding the role and potential mechanisms CHCs play and how they can be utilized in reducing disparities requires further study.