Does Asthma Care Quality Differ for
Children with Minority-Serving Providers?
Alison Galbraith, Lauren Smith, Barbara Bokhour, Irina Miroshnik, Gregory
Sawicki, James Glauber, Katherine Hohman, Charlene Gay, Tracy Lieu
Center for Child Health Care Studies, Department of Ambulatory Care and Prevention,
Harvard Medical School/Harvard Pilgrim Health Care; Massachusetts Department of
Public Health; Boston University School of Public Health and ENRM Veterans Hospital;
Children's Hospital Boston; Neighborhood Health Plan
AcademyHealth Annual Research Meeting
June 28, 2009
Supported by NICHD (R01 HD044070)
Background
• Health care for minority patients is
concentrated in a sub-set of providers
• Minority-serving providers may not be able
to provide same quality of care
• Few studies on children, or on asthma
care, where racial/ethnic disparities are
well-documented
Objective
• To compare asthma care quality for
children with and without minority-serving
providers
Methods
• Design: Cross-sectional telephone survey of
parents, linked with a mailed survey of children’s
providers
• Setting: A Medicaid-predominant health plan
and a multispecialty provider group in
Massachusetts
• Population: Children aged 2-12 years with
persistent asthma identified from claims and
encounter data
Methods
• Primary Outcomes: parent report of whether the
child had:
– ever received inhaled steroids or had them
recommended
– received influenza vaccination in past season
– received asthma action plan in past year
• Primary Predictor Variable: whether the child’s
provider was minority-serving (>25% of patients
black or Latino)
Analyses
• Chi square and Fisher’s exact tests for bivariate
analyses
• Generalized linear mixed models
– Began with unadjusted models including only
child’s race/ethnicity
– Added child, then provider-level variables
• Except for minority-serving provider, co-variates
included only if significantly associated with
outcome in bivariate analyses
Results
• Response rate:
– Parent survey: 72%
– Provider survey: 73%
• Linked parent and provider surveys
available for 563 children and 138 providers
Study Population
% (n=563 children)
Child’s race/ethnicity
White
Black
Latino
Multi/Other
44.9
22.4
19.2
13.5
Child’s age in years
<5
5-9
10-13
24.0
51.2
24.9
Income
<100% FPL
100-199% FPL
> 200% FPL
21.4
18.1
60.5
Parent education < high school
25.3
Medicaid insurance
27.4
Provider Characteristics
for Study Children
% (n=563 children)
Minority-serving provider
50.1
Provider race/ethnicity
White
Black
Latino
Asian
75.8
8.0
6.2
10.0
Provider years in practice
<10
10-20
>20
4.2
20.4
75.5
Provider practice type
Health center
Hospital clinic
Multi-specialty group
Single-specialty/solo practice
13.2
3.6
72.6
10.6
Asthma Care Quality Outcomes
% Not Receiving (n=563)
Inhaled
steroids
Influenza
vaccination
Action Plan
Child’s race/ethnicity
White
Black
Latino
Multi/Other
9.9
10.5
22.6
19.7
29.6
30.2
30.6
29.0
48.7
40.2
51.5
56.9
Minority-serving provider
Yes
No
16.9
10.7
29.4
30.3
46.1
50.8
p <0.05 in pink
Characteristics associated with not
receiving inhaled steroids
OR (95% CI)
Race/ethnicity
White
Black
Latino
Multi/other
Unadjusted model
Final model
ref
1.10 (0.53-2.29)
2.64 (1.42-4.94)
2.28 (1.12-4.62)
ref
1.07 (0.43-2.66)
1.76 (0.74-4.18)
1.62 (0.66-3.99)
Parental education ≤ high school
2.30 (1.18- 4.84)
Minority-serving provider
1.29 (0.63-2.64)
Practice type
Health center
Hospital clinic
Single-specialty/solo practice
Multi-specialty group
4.88 (1.70-14.02)
4.53 (1.09-18.92)
1.23 (0.46-3.29)
ref
Adjusted model controls for variables listed, plus income, insurance type, and bronchodilator and systemic
steroid fills.
Characteristics associated with not
receiving influenza vaccination
OR (95% CI)
Race/ethnicity
White
Black
Latino
Multi/other
ref
1.16 (0.66-2.02)
1.30 (0.74-2.27)
1.03 (0.55-1.90)
Child’s age in years
<5
5-9
10-13
0.33 (0.19-0.58)
0.44 (0.28-0.69)
ref
Minority-serving provider
0.86 (0.56-1.32)
Adjusted model controls for variables listed, plus single parent household and systemic steroid fills.
Characteristics associated with not
receiving asthma action plan
OR (95% CI)
Race/ethnicity
White
Black
Latino
Multi/other
ref
0.70 (0.40-1.22)
0.97 (0.56-1.69)
1.21 (0.66-2.21)
Child’s age in years
<5
5-9
10-13
1.71 (0.99-2.96)
1.72 (1.08-2.76)
ref
Medicaid insurance (vs. private)
1.73 (1.09-2.74)
Minority-serving provider
0.80 (0.49-1.30)
Adjusted model controls for variables listed, plus bronchodilator fills.
Limitations
• Generalizability
• Unmeasured patient and provider factors
• Self-reported data
Conclusions
• Children with persistent asthma were less
likely to receive inhaled steroids if they
received care in community health centers
or hospital clinics
• Practice setting mediated initially-observed
disparities in inhaled steroid use by Latino
children and those with minority-serving
providers
Conclusions
• No differences by race/ethnicity or
minority-serving provider for influenza
vaccinations and asthma action plans
Implications
• Findings do not support the hypothesis that
minority-serving providers deliver lower-quality
asthma care
• Quality improvement efforts should consider
focusing on community health centers and
hospital clinics, which disproportionately serve
minority children
Implications
• Policies promoting pay-for-performance
and public reporting of quality measures
should consider effects on providers in
practices serving minority children