The Office of Minority Health estimates that in 2018, non-Hispanic Black individuals were 40% more likely to have asthma than non-Hispanic white individuals, and that in 2019, non-Hispanic Black people were almost three times more likely than non-Hispanic white people to die from asthma-related causes. Similarly, OMH estimates that Hispanic individuals are twice as likely to visit the ER for asthma than non-Hispanic white individuals, and that Hispanic children are 40% more likely to die from asthma than non-Hispanic white children.
Based in part on these health disparities, researchers with the AAFP National Research Network and other organizations participated in the Person Empowered Asthma Relief trial to determine whether adding new approaches to traditional asthma care could improve outcomes in these populations. Their research, published recently in the New England Journal of Medicine, indicates that adding an easy-to-use, low-cost intervention to usual asthma care can reduce symptoms and improve quality of life in these populations, creating a practical and equitable treatment option that family physicians can provide to their patients with asthma.
“In the past, effective interventions in Black and Latinx groups have generally required intensive work to deliver and have been difficult to sustain,” said Jennifer Carroll, M.D., M.P.H., a research professor and associate vice chair for research in the Department of Family Medicine at the University of Colorado School of Medicine, Denver, and Wilson Pace, M.D., chief medical officer and chief technology officer at the DARTNet Institute in Aurora, Colo. “This intervention is simple to implement and the medications are well known to family physicians, just used in a novel approach. This approach should be considered in all individuals with poorly controlled asthma or those with ongoing exacerbations, especially in Blacks and Latinx individuals.”
Carroll and Pace are both former directors of the AAFP NRN and served as co-investigators and co-authors on the study.
The study population consisted of adults ages 18 to 75 years in the continental United States and Puerto Rico who self-identified as Black or Latinx and had moderate-to-severe asthma as diagnosed by a clinician. At baseline, all participants were being prescribed daily inhaled glucocorticoids (with or without long-acting beta agonists) and either had uncontrolled asthma (based on an Asthma Control Test score of 19 or lower) or had experienced at least one asthma exacerbation in the previous year that was serious enough to require systemic glucocorticoids or overnight hospitalization.
In the study, 1,201 individuals were randomly assigned into two groups. One group continued to receive usual care for their asthma from their clinician. Participants in the intervention group also continued to receive usual care, but additionally were given an open-label inhaler that administered a metered dose of glucocorticoids, received in-person training on how to use the inhaler, and watched an instructional video. The authors referred to this additional protocol as a patient-activated, reliever-triggered inhaled glucocorticoid strategy, or PARTICS.
Participants in the intervention group who had been using a nebulized quick-relief inhaler received an additional inhaler to place with their nebulizer. They were instructed to take one puff of inhaled glucocorticoids for each puff of quick-relief inhaler and five puffs of inhaled glucocorticoids with each quick-reliever nebulization.
Participants were followed for up to 15 months via monthly surveys. They were compensated for their visit and for completing surveys, and inhaler refills were provided free of charge. Study outcomes included number of asthma exacerbations (in particular severe asthma exacerbations as defined by the American Thoracic Society), quality of life and missed days of work, school or usual activities.
Among participants in the intervention group, more than three-quarters reported using inhaled glucocorticoids with quick-reliever metered-dose inhalers or quick-reliever nebulization all or most of the time.
Analysis of the participant surveys found that the annualized rate of severe asthma exacerbations among participants in the intervention group was 13% lower (0.69/year) than participants in the usual care group (0.82/year). This difference was consistent throughout the trial duration.
In addition, patients in the intervention group reported fewer days missed of work, school and usual activities (13.4) compared with patients in the usual care group (16.8).
The researchers also found that Asthma Control Test scores increased by 3.4 points for participants in the intervention group compared with 2.5 points for participants who received usual care only, and that quality of life (as measured by the Asthma Symptom Utility Index) increased by 0.12 points for those in the intervention group versus 0.08 points for those who received usual care only.
Serious adverse events occurred in slightly more than 12% of the trial participants, with an even distribution across patient groups.
“Reducing disparities in asthma morbidity in Black and Latinx populations has been difficult,” the study authors concluded. “In this trial involving an ethnically diverse population of Black and Latinx patients with moderate-to-severe asthma and multiple coexisting conditions, the provision of inhaled glucocorticoid with instructions for use triggered by quick-reliever use (PARTICS), added to existing usual care, led to a lower risk of severe asthma exacerbations. The outcome was observed after a single visit and appeared to be durable. Such a strategy may be easy to implement in populations with disproportionate asthma morbidity as we continue to assess the effectiveness of additional interventions in diverse populations.”
In an email to AAFP News, Carroll and Pace expanded on the study’s findings and said they could impact the way family physicians care for patients from the studied populations who have asthma, pointing to updated guidelines from the National Asthma Education and Prevention Program and recommendations from the Global Initiative for Asthma that allow for greater flexibility in the use of inhaled corticosteroids.
“Single maintenance and reliever therapy, or SMART, represents a cornerstone to the newer recommendations, as is the approach we used in this study,” they wrote. “PARTICS is easier to prescribe, likely to have better insurance coverage, uses less expensive medications and has a similar impact to SMART. Thus, it should be included in family physicians’ treatment options.”
Pace and Carroll added that they would add the PARTICS approach to all patients, regardless of race or ethnicity, if their asthma was poorly controlled or they continued to experience exacerbations in any two-year period.
They noted that some clinicians and patients who are not accustomed to using inhaled corticosteroids as rescue therapy may have concerns about the PARTICS approach, although these barriers could be overcome by promptly addressing concerns and responding to questions, and being persistent.
“Family physicians are experts at tailoring their treatment recommendations to their patients’ needs and abilities,” Pace and Carroll wrote. “PARTICS offers a familiar therapy that is easy to initiate, easy for patients to use, insurance-covered and patient-centered. It must be included in all family physicians’ asthma treatment toolbox.”