Socioeconomic Variation in Asthma Hospitalization: Excess Utilization or Greater Need?

To the Editor. I read with interest the article entitled “Socioeconomic Variation in Asthma Hospitalization” in the June 1999 issue ofPediatrics electronics pages (URL:http://www.pediatrics.org/cgi/content/full/103/6/e75).It has occurred to me that the patients who fare best with severe asthma in my practice are those with college-educated parents with a science background, a strong sense of cause-and-effect, and compulsive tendencies. In other words, people much like us physicians.As the current “decision tree” for asthma care is laid out, people who think like us and attend to details like us clearly do the best, and those, for social or cultural reasons, who deal with problems differently than those who embrace the “cult of science” do less well.This is, I fear, a trap of our own making. By developing “guidelines” (that health maintenance organizations enforce with draconian economic penalties for “outlying” physicians who deviate from them in patient management), we have, by our cultural bias, set up parents, who attack problems and manage their lives by rules other than our own, for failure.I ought to be able to manage an asthmatic child without using 3 to 4 drugs in a decision tree scheme based on the ability of a frightened, possibly hypoxic child to exhale on demand into a flow meter and inhale on demand a foul-tasting aerosol. Certainly all parents are not equally capable of managing a child in such a situation. In view of the inflexibility of the “guidelines” to be modified to suit the parents' and child's abilities and their cultural norms of dealing with stressful situations, it is not surprising we see socioeconomic variables in hospitalizations.Meanwhile, the health maintenance organizations apply the “guidelines” without thought and penalize the physicians who deal with a population more likely to need hospitalization, while rewarding the physicians most likely to follow the “guidelines” and keep their well-heeled, suburban, college-educated, practice population out of the hospital.The bean counters have won, and the article just shows us the proof.In Reply. We appreciate Dr Gerbasi's interest in our manuscript. We expect he is correct in assuming that families of lower socioeconomic status have greater difficulty in following recommended guidelines for prevention or treatment of acute asthma exacerbations. Simpler and more effective asthma treatment would benefit children with asthma across the socioeconomic spectrum. Evidence that health maintenance organizations have applied economic penalties to providers for failure to adhere to such guidelines has not come to our attention. Published studies have not examined whether use of peak flow meters to guide management has a clinically important effect on asthma-related morbidity burden for any socioeconomic group.For several reasons, we doubt that differences in health care alone can account for the large differences in hospitalization rates among socioeconomic areas that were observed in our community. Some of these reasons have already been discussed in the manuscript (page 6 of 8) and will not be repeated. Among additional reasons, the greatest observed differences by far occurred among preschool children. Management for these children is simpler than for older children, because use of peak flow meters is not involved. If adherence to complex treatment regimens is worse among lower socioeconomic groups, then socioeconomic differences would be greater among older children because management in these children is made more complex through use of peak flow meters.Furthermore, although some children are hospitalized repeatedly for asthma, relatively few children ever hospitalized for asthma are hospitalized more than once. Observations in our 5-year study strongly support this (see section on Asthma-Patient Hospitalized Rates, page 5 of 8). The mean number of asthma hospitalizations was only slightly greater for inner-city children than for suburban children. If differences in health care accounted for a large proportion of the hospitalization rate differences, then large differences in repeat hospitalization rates might be expected. Environmental differences provide a more plausible explanation for the large differences in hospitalization rates among socioeconomic groups.It's not clear to us why Dr Gerbasi believes “the bean counters have won. …” A primary objective in publishing this analysis was to demonstrate that variations in asthma hospitalization rates (counting beans) among different populations cannot, by themselves, justify penalties to providers for children with higher rates. This objective has been achieved. We have shown that differences in rates that are associated with differences in socioeconomic status are expected; they result from differences in morbidity burden, not merely differences in hospitalization decision making. To win the “asthma game,” patients, parents, providers, and payers all need to know why tremendous socioeconomic disparities in asthma morbidity burden exist and how to intervene.