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Coordinated Federal Actions Are Needed to Reduce Racial and Ethnic Disparities in Childhood Asthma

Ashley, Peter J. DrPH, MPH; Freemer, Michelle MD, MPH; Garbe, Paul DVM, MPH; Rowson, David MS

Journal of Public Health Management & Practice: March/April 2017 - Volume 23 - Issue 2 - p 207–209
doi: 10.1097/PHH.0000000000000541
Special Section: Evaluating the Impact of the New York State Healthy Neighborhoods Program: Commentary

US Department of Housing and Urban Development, Washington, District of Columbia (Dr Ashley); National Heart, Lung, and Blood Institute, Bethesda, Maryland (Dr Freemer); Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Garbe); and US Environmental Protection Agency, Washington, District of Columbia (Mr Rowson).

Correspondence: Peter J. Ashley, DrPH, MPH, US Department of Housing and Urban Development, 451 7th St, SW, Room 8236, Washington, DC 20410 (Peter.J.Ashley@hud.gov).

The authors declare no conflicts of interest.

The New York State Healthy Neighborhoods Program, as described in the accompanying articles, is an innovative program that addresses a number of the priority actions identified in the Coordinated Federal Action Plan to Reduce Racial and Ethnic Asthma Disparities (Action Plan), which was released in May 2012.1 The Action Plan was developed by a federal interagency working group under the auspices of the President's Task Force on Environmental Health Risks and Safety Risks to Children. The objective of the task force is to identify priority issues within its purview that, at the federal level, can more effectively be addressed through coordinated interagency efforts, recommend and implement interagency actions, and communicate information to protect children from risks. Because of the relevance of environmental exposures and the importance of asthma as a childhood illness, the task force selected asthma as one of its focus areas.

Disparities in childhood asthma are evidenced by a disproportionate rate of disease, worse asthma outcomes, and higher needs for acute medical care in some racial and ethnic minority populations. The prevalence of asthma among US children is 8.6%; however, the prevalence among black, non-Hispanic children is 13.4%.2 Children living in poverty also have a higher asthma prevalence at 10.4%. Furthermore, black children have a higher risk of mortality and a higher rate of emergency department visits for asthma than white or Hispanic children. Asthma is also a leading cause of missed school days, thus presenting a significant barrier to children's successful achievement of academic milestones.

The Action Plan is founded on the following principles, aimed at aligning federal efforts to address asthma disparities:

* Collaborating across federal agencies, other levels of government, and community partners.

* Utilizing federal resources and optimizing their impact through synergies.

* Emphasizing activities that address the preventive factors that impact asthma disparities.

An important focus of the Action Plan is to prioritize actions that will help ensure greater availability of evidence-based, comprehensive asthma care to ethnic and racial minority children. The Action Plan is grounded on the 4 key components of comprehensive care identified in the National Asthma Education and Prevention Program (NAEPP) Guidelines for the Management of Asthma3: assessment and monitoring of disease, education to allow patients to participate as partners in care, control of environmental exposures that worsen asthma, and pharmacologic treatment.

Of the 4 components of comprehensive care identified in the NAEPP Guidelines, reduction in environmental exposures can be a significant challenge because this aspect of care does not occur in the medical setting. Drawing attention to the need for sustainable ways to support and increase the availability of asthma care that occurs in the home and community settings has become a priority area for federal partners engaged in implementing the Action Plan.

Interventions in the home and community often include both education on disease management and assistance in the identification and control of asthma triggers, consistent with the services provided by many of the Healthy Neighborhood Program grantees. Because of their focus on housing and the environment, both the US Environmental Protection Agency (EPA) and the US Department of Housing and Urban Development (HUD) have focused their attention on this issue. The HUD, in coordination with the EPA and the Centers for Disease Control and Prevention (CDC), has sponsored 8 “asthma summits” throughout the United States to promote the concept of in-home interventions for children with poorly controlled asthma. The summits brought together payers, local and state health departments, health care providers, and other key stakeholders to discuss in-home interventions, learn about successful program models, and facilitate the creation and support of local programs.

HUD is also taking actions that will reduce exposure to indoor asthma triggers in federally assisted housing, including the promotion of smoke-free policies in multifamily housing starting in 2009. This initiative is expected to benefit residents whose asthma symptoms are worsened by tobacco smoke. In December, 2016, HUD took an additional step, publishing a rule to prohibit the smoking of lit tobacco products in and adjacent to federally assisted public housing properties. HUD also promotes the adoption of integrated pest management practices in federally assisted housing, provides grants to support interventions to mitigate lead and other health hazards in low-income, privately owned housing, and supports research and evaluation efforts on “healthy homes” issues (eg, funding of the cooperative agreement that supported the evaluation of the New York State Healthy Neighborhoods Program).

In support of the Action Plan, a primary aim of the EPA's asthma program is to equip communities to identify viable options for sustainably financing in-home interventions, particularly health insurer coverage, to ensure long-term access to in-home interventions as part of comprehensive asthma care. For example, the EPA developed the National Environmental Leadership Award in Asthma Management to recognize best practice approaches from community-based programs, health care providers, and health plans that effectively integrate environmental asthma management within comprehensive care. These 38 award-winning programs—including the Healthy Neighborhoods Program (award received in 2011)—integrate in-home asthma care services using innovative approaches to finance this care component. The EPA also sponsors the AsthmaCommunityNetwork.org Web site, providing a robust, central resource for the more than 1000 enrolled community-based programs. Among other content, the Web site features best practices through webinars and podcasts, archives documents from the asthma summits, and incorporates a “Financing In-Home Asthma Care” microsite. This microsite allows users to explore new opportunities and program components for financing evidence-based in-home asthma care.

The EPA is also sponsoring the development of a technical assistance program by the National Center for Healthy Housing. The program incorporates mentorship opportunities and e-learning modules tailored to equip organizations with the knowledge and skills needed to secure and scale up sustainable financing for in-home asthma interventions at the state level, with a particular focus on state Medicaid programs. Finally, the EPA promotes payer coverage through a cooperative agreement with America's Health Insurance Plans by identifying the current landscape of health plans that incorporate tailored environmental interventions into asthma management programs, exploring new and emerging payment and delivery models, disseminating best practice approaches, and building a community of health plan leaders committed to expanding access to comprehensive asthma care, including in-home services.

The CDC remains actively committed to improve asthma surveillance across communities and promote the use of comprehensive, guidelines-based care. To maximize surveillance efforts and assess progress, the CDC developed suggested standardized measures to track racial disparities in childhood asthma.4 To maximize adherence to guidelines-based care, the CDC is working with its federal partners to update an EPA checklist to assess homes for asthma triggers. The CDC's National Asthma Control Program (NACP) supports 25 state health departments that work with local government and nongovernmental organizations to improve surveillance of asthma, to coordinate asthma activities across the state, and to create and support the infrastructure to both improve the quality of asthma clinical care and expand home, community, and school-based services. The goal of the NACP is to improve asthma outcomes for children, beginning with ensuring the availability of and access to guidelines-based medical management and pharmacotherapy for all people with asthma. For children whose asthma remains poorly controlled, additional steps to provide or link them with progressively more individualized services (eg, intensive self-management education, home-based trigger reduction services, and other environmental management strategies) are implemented. The NACP expects to reduce disparities in asthma outcomes by increasing the provision of and coverage for comprehensive asthma control services and improving the coordination of health care and public health services. In the long-term, these efforts are expected to expand the development and use of practice-based evidence at the population level.

The CDC also focuses on asthma as one of 6 common and costly health conditions in its 6|18 initiative, which involves partnering with health care purchasers, payers, and providers to improve health and control health care costs. The CDC provides these partners with rigorous evidence about high-burden health conditions and associated interventions to inform their decisions to have the greatest health and cost impact. For asthma, one of the suggested interventions is to expand access to home visits by licensed professionals or qualified lay health workers to improve self-management education and reduce home asthma triggers for children with uncontrolled asthma.

In addition to the efforts by the HUD, the EPA, and the CDC, the National Heart, Lung, and Blood Institute (NHLBI) continues to advance the research needed to address disparities and lead the update to the asthma guidelines (NAEPP's Expert Panel Report-3 [EPR-3]). The NAEPP's EPR-3 has served to provide the evidence base for asthma care since 2007, and the NHLBI is now leading efforts to update the evidence on the most effective comprehensive care. Having begun the process with a public “Request for Information” to learn from stakeholders which areas of the guidelines require updates, the NHLBI will continue to oversee the reorganization of the NAEPP as a Federal Advisory Committee and appoint a new Working Group subcommittee to update the guidelines.

The National Institutes of Health (NIH, including the NHLBI) has a robust program to support investigator-initiated research, and, as a direct result of the strategies and priority actions for federal agencies articulated in the Action Plan, the NHLBI has published 2 Funding Opportunity Announcements to promote the creation of comprehensive programs of asthma care to reduce disparities. The 2 announcements comprise the “Asthma Empowerment” program (https://grants.nih.gov/grants/guide/rfa-files/RFA-HL-15-028.html and https://grants.nih.gov/grants/guide/rfa-files/RFA-HL-17-001.html). The first phase of the program (9 grants awarded in 2015) supported community needs assessments to allow investigators to understand stakeholders' perspectives about providing comprehensive, integrated care for children at high risk of poor asthma outcomes. Investigators were encouraged to establish collaborations to create an “asthma care implementation program” (ACIP) that addresses comprehensive asthma management including interventions to improve children's care in the medical setting, within the family, the home, and the community. By creating such programs, investigators have the opportunity to leverage and integrate the resources created through the activities or support of the NHLBI's federal partners. In the second component of the Asthma Empowerment program, with applications due in November 2016, investigators can propose clinical trials to assess the effectiveness of the ACIP designed to meet the community's needs. Moreover, the participating sites will develop a set of best practices to define how to sustain such comprehensive care and implement it more broadly.

In summary, federal agencies continue to implement the Action Plan in a variety of ways, ranging from asthma summits to creating a Web site of resources to supporting community-based care and state asthma control programs and providing funding to support the development of new programs to promote comprehensive care and reduce disparities. Regular communication and coordination by agency representatives in implementing the Action Plan have resulted in the leveraging of individual agency programs and resources to achieve synergies. The Healthy Neighborhoods Program is one example of a successful collaboration between state and local governments that created an effective program to deliver in-home services and improve asthma outcomes. We look forward to continued federal agency efforts to achieve the long-term goal of ending asthma disparities through our individual and collective actions.

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References

1. President's Task Force on Environmental Health Risks and Safety Risks to Children. Coordinated Federal Action Plan to Reduce Racial and Ethnic Asthma Disparities. https://http://www.epa.gov/sites/production/files/2014-08/documents/federal_asthma_disparities_action_plan.pdf. Published May 2012. Accessed October 15, 2016.
2. Centers for Disease Control and Prevention. Most recent asthma data. National current asthma prevalence (2014). http://http://www.cdc.gov/asthma/most_recent_data.htm. Accessed October 15, 2016.
3. National Heart, Lung, and Blood Institute. National Asthma education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Washington, DC: US Department of Health and Human Services; 2007.
4. Centers for Disease Control and Prevention. Measures to track racial disparities in childhood asthma: Asthma Disparities Workgroup Subcommittee recommendations. Standards Subcommittee of the Asthma Disparities Workgroup. http://http://www.cdc.gov/asthma/pdfs/Racial_Disparities_in_Childhood_Asthma.pdf. Published April 2016. Accessed October 17, 2016.
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