The burden of asthma in the United States varies

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1 Supplement ELIMINATING ASTHMA DISPARITIES A Review of Potential State and Local Policies To Reduce Asthma Disparities* Sarah K. Lyon-Callo, MA, MS; Leslie P. Boss, MPH, PhD ; and Marielena Lara, MD, MPH Although policies promoting asthma-friendly communities should reduce asthma disparities, not much is known about the status of policy implementation or effectiveness. We review the efforts of state and local agencies to identify and target asthma disparities for reduction, as evidenced by written laws and policy documents and use of funding. Policies targeting health care, homes, schools, and workplaces hold promise for creating asthma-friendly communities; however, the scope and reach of these activities must be increased to have statewide or national impact. In addition, there is a general lack of systematic review of evidence about the institutionalization of successful demonstration programs into policy. (CHEST 2007; 132:840S 852S) Key words: asthma; disparities; health policy; inequality; minority groups; public policy; socioeconomic factors The burden of asthma in the United States varies by age, race and ethnicity, gender, income, geographic residence, primary language, education, and literacy. 1 4 Even with recent reductions in rates of severe asthma events, disparities continue. 1 4 State and local municipalities can act to reduce asthma disparities through their multiple roles as regulators in health care, education, and environmental arenas; promoters of public health awareness and intervention activities; sources of funding and quality assurance for Medicaid and safety net systems; and purchasers of health care for governmental employees. Nongovernmental organizations, such as professional organizations *From the Bureau of Epidemiology (Ms. Lyon-Callo), Michigan Department of Community Health, Lansing, MI; and the RAND Corporation (Dr. Lara), Santa Monica, CA. Retired. This work was performed at the Michigan Department of Community Health and the RAND Corporation. The authors have no conflicts of interest to disclose. Manuscript received December 20, 2006; revision accepted August 2, Reproduction of this article is prohibited without written permission from the American College of Chest Physicians ( org/misc/reprints.shtml). Correspondence to: Sarah Lyon-Callo, MA, MS, Section Manager, Chronic Disease Epidemiology Section, Epidemiology Services Division, Bureau of Epidemiology, Michigan Department of Community Health, 201 Capitol View, Fourth Floor, Lansing, MI 48909; lyoncallos@michigan.gov DOI: /chest and foundations, play a role in reducing health disparities through advocacy, policy development, funding, and implementation of programs. Policies to promote asthma-friendly communities, that is, communities in which people with asthma receive a quick and accurate diagnosis, receive appropriate treatment, and are safe from physical and social environmental risks that exacerbate asthma, 5 have been proposed at the national level. Although integration of policy activities at the national, state, and local levels is important to reach the goal of asthma-friendly communities for all, the purpose of this review is to describe the specific role that state and local policies can have in reducing asthma disparities. Materials and Methods In this review, asthma disparities are defined as differences in outcomes and management by race and ethnicity, gender, income, geography, language, literacy, and/or insurance status. Policy was defined broadly as... purposeful action by an organization or institution to address an identified problem or issue through executive, legislative or administrative means. 6 We conducted a literature review of articles on asthma policies using PubMed, with an emphasis on disparities. The bibliographies of relevant papers were also examined to identify other references. Additional online searches of state and local associations addressing health policies were conducted using World Wide Web search engines and following links from identified Web sites. The facilitator and members of the State and Local 840S Eliminating Asthma Disparities

2 Policy Workgroup of the National Workshop to Reduce Asthma Disparities provided review and comment on the results of the literature and Web search and a set of preliminary conclusions. Results National, state, and local governments have increased attention to health disparities in recent years. 5,7 22 A number of federal agencies and national foundations are funding activities that have the potential to reduce asthma disparities at state, county, city, and health-care provider levels Three reports deserve specific mention: (1) Improving Childhood Asthma Outcomes in the United States: a Blueprint for Policy Action 5 provides a framework for developing asthma-friendly communities and 11 specific recommendations for improving health-care delivery and financing and for strengthening the public health infrastructure; (2) Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care 18 contains recommendations to improve legal, regulatory and policy arenas and health systems; provide patient education and empowerment; provide cross-cultural education in the health professions; improve data collection and monitoring; and address research needs; and (3) State Policy Agenda To Eliminate Racial and Ethnic Health Disparities 9 provides state policy makers with a menu of interventions to address minority health disparities, including interventions in addressing asthma. A consolidation of the recommendations in these policy documents 5,9,18 provides a model policy framework (Table 1) to explore the potential for state and local policies to reduce asthma disparities. The policy framework encompasses the following: (1) health-care access and financing; (2) quality of health-care delivery; (3) health-care workforce diversity and cultural competency; (4) data collection and surveillance; (5) public health infrastructure; and (6) the development of asthma-friendly environments in homes, schools, and workplaces. For five of these areas, we provide examples of existing state and local policies or programs that may reduce asthma disparities (Table 2). The policy framework recommendations regarding the diversity and cultural competencies of health-care professionals are covered in depth by Cabana (see page 810S) in this volume and will not be discussed here. The majority of activities and policy initiatives described below are in early stages of implementation and/or conducted in isolated areas or sites across the nation. Access to Health Care The policy framework recommends extending continuous health-care coverage to all uninsured children and addressing coverage for adults and immigrant populations. Shields in this volume (see page 818S) provides an excellent review of private and public health-care trends, including the benefits of the expansion in Medicaid, the State Children s Health Insurance Program, and federal qualified community health centers, and the potential of pay-for-performance, disease management, and information technology efforts to reduce disparities. We will not duplicate her work here; rather focus on state or local initiatives that particularly deal with increasing the likelihood that people with asthma have health coverage. Some states, counties, and cities are promoting and implementing policies to increase the number of people with chronic diseases, including asthma, who have health care coverage and access ,21,25 Seven states have included asthma in their definitions of medically fragile or disability, 7 increasing the likelihood that children with severe asthma can obtain health-care coverage or services. Some states have passed specific laws or regulations (Table 2) trying to reduce barriers (such as copayments) to obtaining asthma services or medications for children, the elderly, and economically disadvantaged populations. 7 Other states and local communities fund programs to bring quality asthma care directly to children in areas of highest need, focusing on school-based health centers 19,25,26 or mobile clinics such as the Breathmobiles 23 (Table 2), to provide asthma diagnostic, clinical, and education services to students on a routine basis. For example, a New Mexico Medicaid program is funding pediatric pulmonary clinics in outlying areas experiencing highest asthma rates. 7 Hawaii is conducting a childhood asthma project using rural community health centers 11 (Table 2). Texas law mandates implementation of Medicaid disease management programs for asthma in counties with a high pediatric asthma incidence and rates of emergency department visits. 7 All of these policies and programs are meant to increase access to quality asthma care for populations of greatest need. Quality of Asthma Care Delivery Promoting the consistency and equity of health care using evidence-based guidelines, including the use of performance measures for asthma care and disparities, is a theme common to all three policy documents. State and local policies can drive health systems changes by setting standards of care and performance measurement; funding improvements in processes of care; and/or requiring various levels of disease management for people with asthma receiving state-funded health care. A number of initiatives at the national, 19 21,24 state and county 7,16 18,25,27 28 levels promote reimbursewww.chestjournal.org CHEST / 132 / 5/ NOVEMBER, 2007 SUPPLEMENT 841S

3 Table 1 Summary of Policy Recommendations for Reducing Disparities and Developing Asthma Friendly Communities Policy Area Improving Childhood Asthma Outcomes* Unequal Treatment State Policy Agenda Health-care access and financing Quality of health care Health-care workforce diversity and cultural competency Data collection and surveillance Public health infrastructure and leadership Extend continuous health insurance coverage to all uninsured children Develop model benefit packages for essential asthma services Educate purchasers about asthma benefits Develop and implement performance measures for asthma care Teach patients with persistent asthma selfmanagement skills Provide case management to highrisk patients Develop a national asthma surveillance system Establish public health grants to foster asthma-friendly communities Avoid fragmentation of health plans along socioeconomic lines Equal protections for publicly funded and private health maintenance organization enrollees Payment systems structure ensures adequate supply of services to minority patients Provide financial incentives for practices to encourage evidence-based practice Strengthen stability of patient/provider relationships in publicly funded plans Promote consistency and equity of care through use of evidence-based guidelines Support use of interpretation services Support use of community health workers Implement multidisciplinary care teams Increase providers awareness of disparities Increase proportion of underrepresented US racial and ethnic minorities among health professionals Integrate cross-cultural education into training of all health professionals Collect and report data on health-care access and utilization by patients race, ethnicity, socioeconomic status, and primary language Include measures of racial and ethnic disparities in performance measurement Monitor progress toward elimination of health-care disparities Report racial and ethnic data by Office of Management and Budget categories, but use subpopulation groups where possible Increase awareness of racial and ethnic disparities in health care among the general public and stakeholders Ensure adequate levels of elderly services, focusing long-term care use and Medicaid coverage in low-income and minority elderly populations Address insurance issues in Medicaid and State Children s Health Insurance Program programs as well as coverage for adults and immigrant populations Expand the number of community health centers Establish standardization of care through statewide implementation of National Heart, Lung, and Blood Institute guidelines Develop and support formal collaborations between school nurses, patients, and physicians Increase cultural/linguistic competencies of health institutions and work force Improve data collection for subpopulations to monitor racial/ethnic disparities, conduct quality improvement initiatives, and target program development Alter purchasing contracts to require plans to report performance measures by race and ethnicity Use regulatory approaches to collect data on minority access and utilization to expand health resources Follow disease rates in different locations or populations to target services and programs; help evaluate effectiveness; and identify risk factors Monitor environmental exposures and impact on illness Understand disparities in asthma rates, including environmental, socioeconomic, cultural, and genetic factors Increase cultural/linguistic competencies of public health institutions and work force 842S Eliminating Asthma Disparities

4 Table 1 Continued Policy Area Improving Childhood Asthma Outcomes* Unequal Treatment State Policy Agenda Develop asthmafriendly environments Promote asthma-friendly schools and school based-asthma programs Develop and implement national agenda for asthma prevention research Increase public awareness and knowledge of asthma Promote asthma-safe home environments Ensure asthma-friendly schools Develop state minority health infrastructure anchored in statute or regulation with adequate financial and data resources, inclusive membership, and clear performance measures Evaluate outreach and education programs to ensure addressing health disparities Alter purchasing contracts to require plans to develop interventions targeted at needs of racial and ethnic groups Support comprehensive environmental interventions to reduce indoor allergens Improve public housing and address poor housing Promote asthma education for personnel in schools, workplaces, public housing, child-care and youth programs, and other community institutions *Adapted from Lara M, Rosenbaum S, Rachelefsky G, et al. Improving childhood asthma outcomes in the United States: a blueprint for policy action. Pediatrics 2002; 109: Adapted from Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: confronting racial and ethnic disparities in health care. Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Board on Health Sciences Policy, Institute of Medicine, 2004; Adapted from McDonough JE, Gibbs BK, Scott-Harris JL, et al. A state policy agenda to eliminate racial and ethnic health disparities Commonwealth Fund ment systems that provide adequate funding for quality asthma care, as part of an overall effort to improve primary care for chronic diseases. For example, California 27 is using an 1115 Medicaid Waiver to restructure the health-care delivery system in Los Angeles County to rely more on primary preventive care than acute care. This waiver includes resources to restructure levels of reimbursement and performance measurement, provide health services to indigent populations, and provide reimbursements to clinics that are participating in the demonstration. Some state and local agencies are forming public/ private partnerships to determine quality and performance standards for asthma care (Table 2). 11,25,27,28 For example, Oregon is developing and implementing performance measures to promote consistency and equity of care in state health plans, with an emphasis on high-risk asthma patients (Table 2). Certification standards for asthma management and education standards can also be developed, similar to those in some states for diabetes care and education. 29 Numerous asthma interventions 11,25,28,30 involving both clinical and community components are targeted and tailored for low-income and disadvantaged populations. Yes We Can of San Francisco (Table 2) targets low-income children through changes in primary care clinics, provider education, clinical care coordination for high-risk children, and high-risk case finding with aggressive follow-up. A number of state minority health programs 7 target asthma funding to programs already serving low-income and minority children (Table 2). Data Collection, Surveillance, and Assessment Recommendations from national organizations 19,22,31 emphasize the need to collect and report data on health-care access and utilization by race, ethnicity, socioeconomic status, and primary language, as well as to monitor environmental exposures and their impact on asthma. These data are essential to raise awareness of disparities, to develop interventions and target health services and programs, and to evaluate program effectiveness. The policy framework recommends state governments alter purchasing contracts and certification processes to require plans and health-care providers to collect needed demographic data. The most sophisticated surveillance systems measure asthma prevalence, mortality, hospitalizations, CHEST / 132 / 5/ NOVEMBER, 2007 SUPPLEMENT 843S

5 844S Eliminating Asthma Disparities Table 2 Selected Examples of State and Local Policies and Activities That Could Reduce Asthma Disparities Policy Area Recommendation Policy Example Health-care access and financing Quality of health care Extend continuous health insurance coverage to all uninsured children; address insurance issues and coverage for adults and immigrant populations Expand the number of community health centers Promote consistency and equity of care through use of evidence-based guidelines States are using State Children s Health Insurance Program and Medicaid dollars to extend continuous health insurance coverage to uninsured children (Shields, this volume, see page 818S). For example, New York State advertises its Child Health Plus and Family Health Plus insurance programs in its asthma activities. The Child Health Plus program provides critical primary and preventive services to children who were previously uninsured. Family Health Plus is a public health insurance program for adults between the ages of 19 and 64 yr who do not have health insurance but have incomes too high to qualify for Medicaid. The program is available to adults with limited income who are residents of New York State and are US citizens or fall under one of many immigration categories. 25 As of 2002, seven states 7 have included asthma in their definitions of medically fragile or disability, increasing the likelihood that children with severe asthma can obtain health-care coverage or services. 7 A few states have passed specific laws or regulations trying to reduce barriers to obtaining asthma services or medications for children, the elderly, and economically disadvantaged populations, 7 including: Georgia requires that no copayment will be charged for children 6 yr old for asthma-related conditions. 7 As part of the Healthy Maine Prescription Program, the Department of Human Services may conduct a program to provide lowcost asthma prescription drugs, medication and medical supplies to disadvantaged, elderly, and disabled individuals. 7 A 2002 California Senate Bill (No. 842) lays out the conditions under which co-payments and formularies for Medicaid managed care enrollees will be handled 7 ( Community health centers have been crucial in improving access to and quality of asthma care for low income areas (Shields, this volume, see page 818S). 19 A few examples of different state and city efforts to expand asthma services through community clinics and school outreach are as follows: New York State is investing $20 million in state funds in school-based health centers that play a critical role in helping children manage their asthma on a daily basis. These centers also are located in areas with highest incidences of asthma in the state. 25 The New Mexico Department of Health Children s Medical Services is funding pediatric pulmonary clinics in rural areas where such services are not available ( Breathmobiles is a school-based mobile asthma treatment, education and research program developed by the Southern California Chapter of the Asthma and Allergy Foundation of America, Los Angeles County, and University of Southern California Medical Center. Allergists, nurses, and respiratory therapists provide comprehensive asthma services on each Breathmobile. Inbetween visits; patients and school nurses have access to the Breathmobile by telephone and to all services available through the program. Patient and parent education focuses on the proper use of devices and medications and environmental control measures. In addition to improving pediatric asthma care and management, the program provides health providers with an intensive educational experience related to treatment of asthma in a high-risk minority population ( Many areas are experimenting with provider education and system redesign using evidence-based guidelines. For example: California is using an 1115 Medicaid Waiver to restructure the Los Angeles County health-care delivery system to rely more on primary care than acute care. This waiver includes dollars to restructure the system, provide health services to indigent populations, and provide reimbursements to clinics that are participating in the demonstration. 27 The New York State Medicaid Program is promoting disease-management interventions in the treatment of asthma for Medicaid recipients through practitioner/patient education and ensuring the delivery of quality care. The Island Peer Review Organization conducts an asthma quality improvement initiative in select Community Health Centers in the greater New York City region to identify both outstanding performances by health-care providers, as well as areas of concern. 25

6 CHEST / 132 / 5/ NOVEMBER, 2007 SUPPLEMENT 845S Table 2 Continued Policy Area Recommendation Policy Example Develop and implement performance measures for asthma care Teach patients with persistent asthma selfmanagement skills; provide casemanagement to highrisk patients; support the use of community health workers The Hawaii Health Department and Primary Care Association are undertaking a Childhood Rural Asthma Project to focus on improving the health, quality of life, and functional status of low-income children in rural areas. The project builds upon the capacity of five rural community health centers to effectively identify, treat, and educate pediatric asthma sufferers and their caregivers/families. The program expands asthma outreach to additional sites in schools, early childhood education programs, and community-based sites; provides follow-up clinical staff training in pediatric asthma guidelines and practices; and strengthens systems focused on identifying, referring, educating, treating and providing case management services for asthma patients at all sites ( A number of states are developing and reporting on performance measures for asthma. A few examples include: Michigan Quality Improvement Consortium is a collaborative effort of the Michigan health plans and insurers along with the state department of health, the state medial and osteopathic associations, and the Peer Review Organization. Michigan Quality Improvement Consortium establishes and implements a core set of clinical practice guidelines and performance measures, including for asthma. Quality improvement interventions are implemented at the discretion of individual plans, but guidelines, performance goals, measurement, and reporting are standardized ( Minnesota Community Measurement is a collaboration among Minnesota nonprofit health plans, provider groups, Stratis Health, and the National Committee for Quality Assurance to improve the quality of patient care in Minnesota. Quality measures based on billing data are tabulated at the provider group level and compared to the physician-designed standards recommended by the Institute of Clinical Systems Improvement. The site contains reporting and tools in formats useful for consumers, employers, providers, and policy makers ( The state of Oregon is investing in a public/private collaborative developing and measuring performance measures to promote consistency and equity of care in state health plans, with an emphasis on high-risk asthma patients. Oregon s surveillance system monitors both asthma burden and asthma management indicators in publicly and commercially insured populations ( gov/dhs/ph/asthma/pubs.shtml). The Washington State Department of Health is investing in health collaboratives to improve chronic and preventive care among adults. 28 The Chronic Disease Electronic Management System, a software application developed by the Washington State Diabetes Prevention and Control Program, is designed to assist medical providers and management in tracking the care of patients with chronic health conditions. Chronic Disease Electronic Management System is precoded to track diabetes and adult preventive health but is customizable for monitoring other chronic conditions. Printed progress notes, patient lists, and summary reports generated from the registry database can alter the way services are delivered and measure quality improvement efforts ( There are a number of evaluated and field-translated patient education and case-management programs for asthma ( and The program must fit with the communities need. Here is an example of three programs, specifically targeting people with asthma from low-income families or areas: Yes We Can of San Francisco makes use of a community-focused team approach to address both the social and the medical challenges of good asthma management. The program uses a primary care team consisting of a clinician, a nurse care coordinator, and a community health worker from the child s own community to build cultural and linguistic competence into the heart of health care. The program incorporates clinic visits and home visits. The Centers for Disease Control and Prevention is funding the implementation of two scientifically evaluated asthma interventions shown to decrease acute care visits, decrease hospitalizations, and increase use of asthma action plans: The Asthma and Allergy Foundation of America s Asthma Care Training for Kids (grantees in Illinois two sites, New Jersey, New York, Pennsylvania, Texas, and Washington); goals are to increase asthma control compliance behaviors and to decrease emergency department visits and number of days spent in the hospital.

7 846S Eliminating Asthma Disparities Table 2 Continued Policy Area Recommendation Policy Example Data collection and surveillance Public health infrastructure and leadership Collect and report data on health care access and utilization by patients race, ethnicity, socioeconomic status, and primary language; monitor progress toward the elimination of health-care disparities Establish public health grants to foster asthmafriendly communities The American Lung Association s Open Airways for Schools (grantees in California two sites, Colorado, Illinois, New Jersey, and New York); goals are to increase school performance and self-management behaviors and to decrease the number of asthma episodes. States report data on asthma care and utilization through their asthma programs, minority health programs, and Medicaid quality assurance activities. 7 A few examples: California Department of Health Services programs are required to keep asthma data concerning ethnic and racial statistics, strategies, and programs that address multicultural health issues. 7 The Connecticut annual asthma surveillance report documents differences in asthma prevalence and outcomes by sex, race, education, household income, and payer. This report includes asthma utilization prevalence in pediatric Medicaid population The Michigan Asthma Prevention and Control Program and Health Disparities Reduction Program have developed two asthma disparities fact sheets documenting disparities in asthma prevalence, utilization, and outcomes by age, sex, race, education, and income, including information on pediatric Medicaid utilization for asthma. One version of the fact sheet was developed for providers and public health professionals (available from and one for more general audiences. Michigan also provides local asthma coalitions with county and zip code level asthma statistics to better target and evaluate intervention efforts. Nebraska provides data on asthma mortality, hospitalization, outpatient utilization, and prevalence at the city and county level to help a local coalition better understand and address high rates of asthma mortality in the area ( asthma_report.pdf#search omaha%20lung ). Many state policy documents and laws indicate an intention to reduce asthma disparities: Illinois state law stipulates that public health must implement an asthma information program targeted at, but not limited to, African Americans, Hispanics, the elderly, children, those exposed to environmental factors associated with high risk of asthma, and those with a family history of asthma. 7 The New Jersey Office on Minority and Multicultural Health is funding local agencies to conduct innovative projects to reduce dramatic differences in asthma rates between white and minority populations. 7 Asthma was identified as priority health issue for disparity reduction in executive order forming Oregon s Racial and Ethnic Health Task Force 7 ( A goal of the California state asthma plan is to advocate and support policies that promote asthma friendly communities, especially those that eliminate the disproportionate burden of asthma for people living in poverty and people of color ( Wisconsin state asthma plan objectives for reducing disparities include providing asthma education and outreach; increasing awareness of asthma disparities; increasing the proportion of minority health-care providers; reducing rates of acute events in racial and ethnic minority populations; increasing primary care health service utilization for Medicaid-enrolled children and adults; and increasing the percent of household who had management of environmental triggers( pdf/wapcomplete.pdf). National, state, and local policies are also evidenced as targeting of funding and efforts: Through Allies Against Asthma, the Robert Wood Johnson Foundation targeted the development of asthma control efforts in order to reach children under the age of 18 years, especially those seen under publicly financed systems of care; those targeted by safety net providers; and by other systems designed to serve inner-city or other populations that experience difficulties in securing care (

8 CHEST / 132 / 5/ NOVEMBER, 2007 SUPPLEMENT 847S Table 2 Continued Policy Area Recommendation Policy Example Develop asthma friendly environments Increase public awareness and knowledge of asthma Promote asthma-safe home environments Ensure asthma-friendly schools To decrease asthma-related morbidity, the Centers for Disease Control and Prevention funded grantees in seven urban communities (Chicago, Minneapolis/St. Paul, New York City, Oakland, Philadelphia, Richmond, St. Louis) to use innovative collaborative approaches to improve overall asthma management among urban children up to 18 years of age 11 ( Using state and federal funds, Michigan targets its development and technical assistance to asthma coalitions in areas with highest hospitalization rates. The Michigan 2010 asthma plan ( emphasizes the need to target state and coalition activity to populations with highest burden. In addition, the Michigan Health Disparity Reduction Program has targeted part of its 2005 local grant funding to addressing asthma in areas with high rates of asthma hospitalizations in young African- American children ( Nebraska laws require the health department to establish and fund Offices of Minority Health in each congressional district that will target asthma. 7 In New York, seven regional coalitions formed across the state using state and federal funding provide asthma education to improve asthma care coordination and to develop data systems necessary to track disease and measure program effectiveness. The major objectives of this initiative are to decrease asthma-related visits to emergency departments and to decrease asthma-related school days lost. Specific coalition activities include asthma education and training for schools through the American Lung Association Open Airways program; asthma education for families, communities, schools and day care; asthma education for health-care professionals; asthma care coordination for high-risk children; and data systems development 25 ( ny.us/nysdoh/asthma/coalitions.htm). New York State is conducting a statewide media campaign to promote asthma awareness and management. Beginning in 2002, two 30-s television advertisements are targeted to parents aged 25 to 49 yr and are running on channels popular with this demographic group. 25 Healthy homes initiatives, using funding from the US Department of Housing and Urban Development ( lead/leadgrantees.cfm), are underway in numerous cities across the country. 41,43 A few examples include the following: Healthy Homes Program in Boston provides in home assessment and education to low-income families of color with a child with asthma. The City of Milwaukee is documenting the level of environmental allergens in 75 homes of children with moderate-to-severe asthma. The target area is comprised of 10 high-risk zip codes in Milwaukee with pre-1950 housing. The 75 homes receiving environmental assessment and housing interventions will be upgraded as a part of this project. The New York Healthy Neighborhoods Program targets New York City and seven high-risk counties with in-home asthma trigger assessment, education, and remediation activities. 25 The Seattle Healthy Homes Initiative 40,43 is decreasing children s exposure to multiple household hazards through remediation and empowerment of residents to take additional actions. This initiative targets low-income households in the Seattle metropolitan area that include a child, aged 2 to 17 yr, with asthma. Housing units are a mix of publicly owned Seattle Housing Authority units, privately owned Section 8 units, and privately owned with no rent subsidy. Thirty-three states have laws allowing access to inhalers and other asthma devices at school, although content and enforcement vary 8 ( A number of states have developed asthma manuals for kindergarten-to-grade 12 schools and/or day-care settings, most of which provide information for different types of staff and faculty. 8 For example: The Missouri asthma school manual contains educational materials and tools for administrators, teachers, custodians, and parents designed to improve all aspects of asthma management in schools, as well as video training ( asthma/publications.html).

9 Table 2 Continued Policy Area Recommendation Policy Example Minnesota is providing a 6- to 8-h training program formatted to provide a comprehensive overview of asthma, the school nurse s role when providing care to a child who has asthma, and what resources and processes should be considered when providing health-care services. The Minnesota manual contains tools, policies, and educational materials that nurses can use in training administrators, all health staff, secretaries, teachers, counselors, coaches, custodial, nutrition services, playground assistants, and bus drivers. Minnesota is mapping completed nurse training by school district ( New York City Asthma Initiative provides training to staff of community-based organizations, schools, day-care centers, shelters, and others. In addition, the New York City Asthma Initiative provides ongoing training for several community contractors to provide community level asthma self-management support, and asthma workshops. Workshops include a discussion of the asthma, symptoms, medications, triggers, and tools for self-management. The New York City Asthma Initiative also implements Open Airways through a public/private partnership ( The National Institute of Occupational Safety and Health has been funding several states to conduct the Sentinel Events Notification of Occupational Risk program ( The Michigan program identifies sentinel cases of work-related asthma through the reporting of index patients. Follow-up with reported patients may lead to the identification of other employees from the same facility who are at risk for asthma or who have similar breathing problems. Michigan has also conducted training workshops on work-related asthma to the state industrial safety and health staff. The workshops were developed to increase awareness of asthma, including its causes and triggers in the workplace so that field staff can evaluate the potential for exposures at the facilities they inspect and offer work-related asthma prevention recommendations to those companies. Plans are underway to present similar workshops on work-related asthma to employers whose workers use occupational allergens ( Promote asthma education for personnel in workplaces and emergency department visits; survey asthma management, trigger exposure, and quality of life; and review clinical and pharmacy utilization for Medicaid and health plan members. 11 Most states are unable to collect or obtain data in the geographic and demographic detail needed to adequately monitor asthma disparities. 32 In addition, the incompatibility of the collection of race and ethnicity in the 2000 Census and in health data systems has complicated the calculation of health statistics by race and ethnicity and limited the value of these health statistics in understanding disparities at the local level over time. 33 A few states have disparity reporting efforts underway that can also raise awareness of the need for improved data collection for identifying and monitoring asthma disparities. 16 Many health service delivery systems do not collect racial and ethnic data 34 due to concerns over antidiscrimination obligations, perceived legal barriers, and confidentiality. State regulations on data collection by health management organizations vary from requiring to prohibiting collection of race/ ethnicity or primary language. 7,34 The variation in data collection among states may be a barrier to disparity reduction approaches driven by performance measurements and quality improvement techniques. As described above, some states and collaboratives are developing performance measurement systems to help identify and target disparities in asthma care (Table 2). Public Health Infrastructure The policy framework recommends improvements to the public health infrastructure, including public health grants fostering asthma-friendly communities, home environments, and schools. The policy framework also recommends increasing cultural and linguistic competencies of public health institutions and work force, and developing state minority health infrastructure. Since the late 1990s, federal, state, and local public health agencies have been developing plans for addressing asthma and funding public health activities and partnerships, 10 11,13 many of which directly address reduction of asthma disparities. A number of state legislatures 7 have directed health departments to develop asthma programs that target asthma activities to populations with highest needs. All published State Asthma Plans aim to reduce asthma disparities by targeting activities to high risk or vulnerable populations. 11 Some other states have institutionalized asthma outreach into existing disparity reduction programs. 7,16 Nebraska laws require the health department to establish and fund Offices of Minority Health in each congressional district that 848S Eliminating Asthma Disparities

10 will target asthma (Table 2). New Jersey s Office on Minority and Multicultural Health is to develop innovative projects to reduce dramatic differences in asthma rates between white and minority populations (Table 2). Federal, state, and local asthma funding is also often targeted at populations experiencing disparities. Federal agencies and national foundations have funded efforts to develop asthma-friendly communities in urban areas that should determine if the community coalition approach can reduce disparities. 11,15,35 37 Some state and local governments, health systems, and foundations are targeting funding for local asthma coalitions to areas of highest asthma burden. 7,18,25,36,37 The challenge is to maintain the programs once the grant or foundation funding is gone. Reducing Asthma Disparities in Homes, Schools, and Workplaces Barriers to self-management, including environmental exposures that can exacerbate asthma, differ by race, ethnicity, and socioeconomic status. Changes to and enforcement of state and local housing codes and landlord/tenant laws may help to address asthma disparities. 16,36,38 42 Some states and cities are developing collaboratives between public health, housing, and construction departments to address housing codes content and enforcement. 40 In-home assessment and remediation activities ( Healthy Homes initiatives) are also underway. 16,25,36,40,42 44 These programs tend to be grant or foundation funded and institutionalizing functions into existing public health activities will probably be a challenge. Policies addressing tobacco use and secondhand smoke exposure reduce asthma exacerbations in people of all ages The Institute of Medicine 38 has identified the need to reduce exposure to secondhand smoke, particularly in children at greatest risk for adverse asthma outcomes. The number of policies reducing exposure to secondhand smoke has increased at the state and local levels, although preemption efforts are also underway. 45 Thirty-nine states have policies addressing tobacco use in school buildings or on school property, including four states whose policies explicitly prohibit use of tobacco by students, staff members, and school visitors. 8 States have also been implementing awareness campaigns, tailoring and targeting asthma and secondhand smoke messages to specific populations. For example, some states and cities are working with the Environmental Protection Agency smoke-free homes campaigns to raise awareness of the relationship between asthma and secondhand smoke, including tailoring these campaigns to particular communities. 11,36,44 Federal agencies and national associations 8,11,42,44,47 have developed guidance documents outlining policies and procedures for asthma-friendly schools. A number of state legislatures and boards of education have passed a variety of asthma policies. 8 As of December 2004, 33 states have policies that allow students to carry and self-administer medications in schools. Twenty-eight states require that individual education or health plans incorporate accommodations and medical instructions for students with chronic health conditions. Eleven states mention asthma awareness or education in their policy related to school health curricula. No state has a written policy requiring professional development for school staff on asthma awareness, management, or emergency response. Twenty-three states have policies addressing indoor air quality and 24 states have policies on pesticide use on school grounds. 8 The Environmental Protection Agency is promoting changes to school policies on bus driving/loading procedures to reduce exposure to diesel exhaust 44 (Table 2). Reducing the proximity of housing, schools, and day-care facilities to highly trafficked roadways and point sources of ambient air pollutants known to exacerbate asthma 36,42,48 is another important policy area. Antisprawl and outdoor air quality initiatives could help to decrease exposure to allergens/irritants. For example, California fuel economy standards cite the relationship of asthma to outdoor air pollutants. 7,23 Additional research is needed on the impact of these policies on reducing asthma rates in communities most affected by pollution. 36 Workplace exposures can also cause asthma or exacerbate existing asthma. 49 The National Institutes for Occupational Safety and Health is funding four states to conduct case identification, exposure reduction, and education activities with workers and employers that can reduce asthma disparities by preventing occupational asthma. 50 For example, the Michigan system reports on the incidence of occupational asthma by sex, race, smoking status, and county of employment. 50 These data are used to initiate investigations of workplaces, targeting industries and occupational groups with the highest rates of disease and exposures. In addition to federal funding, state law 50 requiring reporting of occupational disease makes this system possible. Discussion The purpose of this review was to identify policies that have been shown to or have the potential to reduce asthma disparities, as well as discuss a number of activities or interventions that could lead to CHEST / 132 / 5/ NOVEMBER, 2007 SUPPLEMENT 849S

11 policies in the future. There are promising examples. Some states and local communities are attempting to target limited health dollars and public health resources to areas with greatest need. School policies may improve asthma management, educate students about asthma, and improve the indoor environment. Similarly, ordinances ensuring smoke-free work places, schools, and public places hold great promise for reducing asthma triggers. Although several activities across public and private sectors have the potential to reduce asthma disparities, we found a general lack of peer-reviewed, published evidence-based programs or policies. The implementation of these policies remains sketchy at best, related perhaps, to lack of education and political will resulting in inadequate funding of recommendations. There are also obvious gaps in policy activity. For example, comprehensive data systems, including information on race/ethnicity, socioeconomic status, literacy, primary language and geography, are needed to monitor trends in asthma management, outcomes and trigger exposure. A number of state and local collaboratives are developing systems that routinely measure asthma management and react accordingly. However, policies need to support the inclusion of detailed sociodemographic information in the systems and provide for the routine examination of data to identify disparities in asthma management. Policies on educating and training school staff about asthma are also lacking, as is evidence of policies improving asthma management and environments in the child-care setting. Similarly, although housing code enforcement efforts may be institutionalized into existing public health activities, there is currently no source of funding for in-home remediation of asthma triggers. The case needs to be developed for making asthma education, management devices, and materials for reducing in-home triggers (eg, mite-impermeable bed covers) a reimbursable part of case management services. The Community Health Worker model for environmental control of asthma triggers and improvement of coordination of asthma services also hold much promise. 36 Evaluation of the feasibility and impact of these activities should continue. In addition, much more work is needed on the impact of planning policy on reducing proximity of homes, schools, and day cares to high traffic roadways. Asthma policies are relatively new, and variation in policies across states and localities is a cross cutting theme of this review. While the definition of asthmafriendly community should be consistent, some variation in policy is to be expected, as different areas will have different policy needs. This variation provides many natural experiments into which policies may be effective in particular situations. However, policies promoting the development of asthmafriendly communities hold promise for reducing disparities only if policies and interventions appropriately address all subpopulations. The results of these natural experiments always should be evaluated. Following continued evaluation, success or failure of implementation strategies of existing policies need to be shared widely with other state and local communities and organizations. Another theme in this review was the important role that federal resources and guidance play in development and evaluation of asthma activities at the state and local levels. Federal dollars and flexibility in funding guidelines allow states and local areas the opportunity to innovate. For example, reducing asthma disparities in the health-care system requires funding for system level changes, including setting quality standards, measuring performance, and altering reimbursement to provide for adequate asthma management. To date, state and local agencies rely heavily on federal resources from agencies such as the Centers for Medicaid and Medicare Services, Health Resources and Services Administration, and Agency for Healthcare Research and Quality to implement system changes. Expanding and maintaining health system changes will require investment. In the absence of additional funding, state and local governments and health-care providers will only be able to make this investment if long-term cost neutrality or savings are documented. Areas with fewest resources will have the most difficult time making such an investment, thereby potentially increasing disparities in access and quality of care. The lack of information on the health impact of asthma policy was a critical limitation of this review. Many of the activities described regard newly implemented policies or statements of intention to act, rather than describing published evaluations of implemented policies. Only a sampling of policies and activities are presented here, not an exhaustive compendium of state and local activities. Even for those activities or policies with demonstrable efficacy, there is limited information on their effectiveness over time. Furthermore, the existing information on local level activities is not routinely summarized for use by public health. Asthma is a relatively recent addition to state and local public health activities, and determining what activities and policies are most effective will take time. Evaluation of the impact of these policy activities would be beneficial before other states and localities institute asthma policies. All these findings point to the need for a routine, systematic review of the impact of community and policy interventions, combined with a method for disseminating those findings to communities across 850S Eliminating Asthma Disparities