Disparities in allergy testing and health outcomes among
urban children with asthma
Jeanette A. Stingone, MPH, and Luz Claudio, PhD
New York, NY
Background: Previous research has found that treating allergies
and reducing exposure to allergens can reduce asthma
Objective: We sought to examine whether urban asthmatic
children were receiving care for allergies as part of a
comprehensive asthma management plan.
Methods: A cross-sectional study, consisting of a parent-
reported questionnaire, was conducted in 26 randomly selected
New York City public elementary schools during the 2002-2003
Results: In a sample of 5250 children aged 5 to 12 years, 13.0%
were found to have current asthma. The prevalence of allergy
diagnosis was 21.0%. Less than half (47.3%) of the subjects with
current asthma reported a physician’s diagnosis of allergies.
The frequency of a reported allergy diagnosis varied with race/
ethnicity, ranging from 14.4% in Mexican American children to
67.9% in white children. Only 54.9% of asthmatic children with
an allergy diagnosis reported allergy testing. Children from
lower-/middle-income households and children with public
forms of health insurance were the least likely to report testing
(adjusted odds ratios, 0.18 and 0.46). Higher frequencies of
reported allergy testing were associated with education on
allergen avoidance, use of allergy medications, lower
exposure to household allergens, and lower prevalence
Conclusions: Many children do not receive comprehensive
asthma treatment that includes management of allergies and
education on avoidance of household allergens. Lower reported
allergy testing might indicate lower access to medical care
among middle-income families who are ineligible for public
programs but who do not have the income to access higher-
quality care. Interventions aimed at improving medical care
and adherence to treatment guidelines are necessary to
decrease asthma morbidity. (J Allergy Clin Immunol
Key words: Allergies, medical care, asthma management, health
disparities, minority children
Comprehensive treatment of childhood asthma is complex,
involving medication for both active treatment and prevention of
symptoms. It should also include a plan for avoidance of known
triggers that can contribute to exacerbations. For a majority of
asthmatic children, triggers include environmental allergens that
Childhood Inner-City Asthma Study, a multicenter inner-city
study of more than 1000 asthmatic children, found that 77% had
at least 1 positive skin test response after undergoing allergy
testing, and almost half were sensitized to at least 3 allergens.1
Similarly, the global International Study of Allergies and Asthma
in Childhood study found significant associations between aller-
gic sensitization and asthma symptoms in almost all affluent na-
tions among children ages 8 to 12 years.2Allergic sensitization
has also been found to be associated with increased medication
use for asthma, both b-agonists and controllers.3
Avoiding exposure to allergens can directly prevent asthma
exacerbations and symptoms in the lower airways among allergic
asthmatic subjects. In addition, previous research suggests that
treating inflammation and symptoms in the upper airways asso-
on asthma control.4-6The converse is also true: failure to treat
symptoms of the upper airways can have a negative effect on
health outcomes and contribute to the onset of asthma exacerba-
tions, strengthening the rationale for including allergy evaluation
and treatment in asthma management plans.
The current guidelines issued by the National Heart, Lung, and
of severitylevel,to be asked about their exposure to allergensand
informed of ways to reduce or eliminate exposure. Subjects with
persistent asthma should be more thoroughly evaluated for
allergies, including conducting skin or in vitro tests to determine
uation and associated treatments.8,9In a study conducted in
London, Bobb and Ritz9demonstrated that adult asthmatic pa-
tients benefited from a structured allergy evaluation, although
the benefits of allergy skin testing were unclear in their study.
gen immunotherapy as a treatment for asthma and concluded that
treatment of allergies through immunotherapy reduced asthma
prove both upper and lower airway inflammation.5Interventions
aimed at reducing allergen exposures in the home environment
have also been found to improve clinical outcomes among asth-
From the Department of Community and Preventive Medicine, Mount Sinai School of
Medicine, New York, NY.
to the Mount Sinai Center for Children’s Environmental Health and Disease
Prevention (EPA Region 2, grant R827039).
Disclosure of potential conflict of interest: The authors have declared that they have no
conflict of interest.
Received for publication November 20, 2007; revised July 31, 2008; accepted for publi-
cation August 4, 2008.
Reprint requests: Luz Claudio, PhD, One Gustave Levy Place, Box 1057, New York, NY
10029. E-mail: Luz.Claudio@mssm.edu.
? 2008 American Academy of Allergy, Asthma & Immunology
NHLBI: National Heart, Lung, and Blood Institute
Allergy testingforasthmatic patientsis relevant inurbanareas,
where aspects of both the indoor and outdoor environment have
strong effects on allergic asthmatic subjects. Previous research
has found that cockroach exposure and sensitivity are more
prevalent intheinner-citiesoftheNortheastUnitedStates, andits
effect on asthma morbidity can be greater than other household
allergens, such as dust mite or pet dander.12In terms of the out-
door environment, the odds of having allergic asthma are greater
in areas with higher levels of airborne particulate matter.13Stud-
ies with animal models have found that exposure to diesel parti-
cles increase airway hypersensitivity and exacerbate the allergic
New York City, a large urban center, has high levels of
childhood asthma prevalence and morbidity.16,17The objective
of this study was to determine whether urban children with
asthmawere being evaluated for allergies as part of a comprehen-
sive asthma management plan. Based on previous research, the
authors hypothesized that children with reported allergy care
would have better asthma outcomes than those without allergy
care and that allergy care would differ based on race/ethnicity
ences could be partially attributed to differences in access to care,
such as insurance coverage and source of usual care. Therefore
this study sought to examine the sociodemographic factors asso-
ciated with receiving allergy care among an ethnically and eco-
nomically diverse sample of urban asthmatic children, with the
aim of providing empiric information on populations that might
not receive asthma care as recommended by current clinical
Data were collected as part of a cross-sectional study of asthma
prevalence during the 2002-2003 school year.16The project was reviewed
and approved by the Mount Sinai Institutional Review Board, the Mount Si-
nai Health Insurance Portability and Accountability Act Office, and the New
York City Department of Education’s Division of Assessment and
Methodology for this study has been reported in previous publica-
tions.16,17Briefly, New York City ZIP Codes were ranked and grouped ac-
cording to their childhood asthma hospitalization rate. To obtain an
accurate representation of distinct New York City populations, the 3 groups
with the highest, median, and lowest asthma hospitalization rates were eligi-
ble to be included in the study. Within these 3 strata, one public elementary
school per ZIP Code was randomly selected, with probability proportional to
size. A total of 26 schools were selected, 8 within each strata and 2 additional
schools in the area of low asthma hospitalization to compensate for the lower
expected prevalence. Schools from each of the 3 groups were assessed con-
currently during overlapping 2-week periods to control for seasonality of
asthma symptoms. These 2-week periods were scheduled so that equal num-
bers of schools were assessed during the fall, winter, and spring seasons. This
sampling strategy allowed for control of seasonal symptom variability among
Within each school, questionnaires were distributed in 2 randomly
selected classrooms per grade level, kindergarten through fifth grade, and
up to 2 self-contained special education classrooms, where available.
Children were instructed to bring the questionnaire home to their parent/
guardian and return the completed form within 2 weeks. Both children and
teachers weregiven nominal incentives, such as school supplies, to encourage
The parental questionnaire, containing standardized items on demograph-
ics, household environment, asthma diagnosis and symptoms, allergy diag-
nosis and testing, medication use, and healthcare use, was adapted from a
previous study of childhood asthma.18The questionnaire was available in En-
a physician. Current asthma was defined as having a physician’s diagnosis of
asthma and wheezing in the previous 12 months. Parents were also asked to
report their child’s demographic information, including race/ethnicity, house-
hold income of the child’s primary residence, and type of health insurance.
The presence of allergies among all respondents was assessed by using the
following question: ‘‘Have you or your child ever been told by a doctor or
nurse that he/she has allergies?’’ The prevalence of allergy testing among
asthmatic children was assessed by using the following question: ‘‘Has your
child ever been tested for allergies?’’
Parents of asthmatic children were further queried to determine whether
their child had received an asthma plan containing information on ways to
prescription allergy medications. The questionnaire included a table of
commonly prescribed medications used to treat asthma or allergies, which
allowed respondents to indicate which asthma medications, allergy medica-
parents could include medications not listed. Allergy medications were
defined as oral antihistamines, nasal corticosteroids, and nasal anti-inflam-
matory agents. Asthma medications included short-term b-agonists, long-
term b-agonists, inhaled corticosteroids, and cromolyn.
Data were weighted to represent the number of children attending public
elementary schools within their respective ZIP Codes. Missing data were
excluded from calculations of percentages and statistical tests. All data
analyses were conducted with the Surveymeans and Surveyfreq procedures
in SAS version 9.1 (SAS Institute, Inc, Cary, NC). These methods account for
the clustering by school and stratification by neighborhood asthma hospital-
ization rate in the sampling design. A flow chart indicating the number of
children in each primary analysis group is shown in Fig 1. The prevalence es-
timatesofthedifferent disease-relatedsubgroupsareweightedandthus donot
match the percentages obtained by means of simple division of the numbers
included in Fig 1.
Descriptive statistics of the sample’s demographic characteristics were
calculated, as were the prevalence of asthma, allergies, and allergy testing
among demographically defined subgroups. To determine the socioeconomic
factors that predict allergy testing, a multivariate model was computed by
using logistic regression procedures in SAS to calculate odds ratios and
FIG 1. Flow chart illustrating the number of unweighted respondents in
each of the primary analysis groups.
J ALLERGY CLIN IMMUNOL
VOLUME 122, NUMBER 4
STINGONE AND CLAUDIO 749
corresponding 95% CIs. Demographic characteristics, including ethnicity,
household income, medical insurance, usual source of asthma care, language
in which the survey was completed, and sex, were included as indicator
variables. Age was entered as a continuous variable. The model was
constructed by using backward elimination, and significance was determined
at a P value of .05.
on removing asthma triggers, or both was compared between the 2 groups by
using corrected x2tests to measure the association to determinewhether asth-
matic subjects who reported both an allergy diagnosis and allergy testing re-
ceived different care than those who only reported an allergy diagnosis.
Respondents were queried about the presence of common household sources
of allergensand irritantsto determinewhethertherewasa significant relation-
ship between allergy testing and the household environment, and results were
compared by using corrected x2tests in SAS. Additionally, the percentage of
respondents reporting wheezing symptoms in the previous 2 weeks were cal-
ing was associated with health outcomes.
Description of the population
Overall, 5250 children returned a questionnaire, yielding an
absence-adjusted response rate of 76.9%. As described in previ-
New York City public elementary school population, as well as
the populations of the surrounding ZIP Codes.16,17The demo-
graphic profiles of the study respondents are highly correlated
with the Department of Education’s enrollment figures on student
race/ethnicity of the individual schools. This is evidenced by
Spearman correlation coefficients for white, black, Hispanic,
and Asian subjects of0.957, 0.945,0.972,and 0.931, respectively
was significantly correlated with the overall 5- to 12-year-old
population of the surrounding ZIP Codes, as reported by the US
Census Bureau. The Spearman correlation coefficients obtained
in this analysis for white, black, Latino, and Asian subjects
were 0.847, 0.738, 0.902, and 0.905, respectively (P <.001).
The average age of the sample was 8.11 years (SD, 1.81), and
46.8% were male. Approximately 39% of the sample was Latino,
22.3% was African American, 15.2% was white, and 12.3% was
Asian. Six percent classified themselves as ‘‘other,’’ which
included multiracial children. Forty-one percent had household
greater than $75,000.
The prevalence of ever having received an asthma diagnosis
was found to be 20.1% (95% CI, 17.2-23.0), whereas the
prevalence of current asthma (having had symptoms within the
of parent-reported physician- or nurse-diagnosed allergies (re-
gardless of asthma status) in the sample was 20.1% (95% CI,
15.7-24.5). The prevalence of allergies was greatest among
subjects with current asthma because 47.3% of them indicated a
physician’s diagnosis of allergies compared with 30.4% among
asthmatic subjects with no current symptoms and 14.9% of
Sociodemographic characteristics of the asthmatic
There were marked racial/ethnic disparities in reported allergy
diagnosis among subjects with current asthma (Table I). White
subjects had the highest level of codiagnosis of asthma and aller-
gies at 67.9%. The lowest prevalence of comorbidity was among
Mexican American children, for whom the prevalence was
14.4%. In general, asthmatic children with Spanish-speaking par-
ents were less likely to report a diagnosis of allergies when com-
pared with children from English-speaking households. Subjects
with current asthma and private health insurance had a greater
prevalence of codiagnosed allergies than children with public in-
surance. Although the prevalence of reported/diagnosed allergies
was greatest among those without insurance coverage, the num-
ber of children in that category was small (n 5 10). The preva-
lence of allergy diagnosis was dependent on a child’s usual
source of care (Table I). Classifications for usual sources of
offices, and community clinics/hospital outpatient clinics, as well
as not having a usual source of care. No differentiation was made
between primary care and specialists. Allergy diagnosis preva-
lence was highest among children who used a physician’s office
and lowest among children who identified the emergency depart-
ment as their usual source of care.
Approximately half of the subjects with current asthma who
reported an allergy diagnosis indicated that they underwent
allergy testing (54.9%). Because the NHLBI guidelines recom-
mend that all subjects with persistent asthma be tested for
TABLE I. Prevalence of reported allergy diagnosis among sub-
jects with current asthma (n 5 540) by demographic subgroup
Demographics (total no. of
children within each category)*
reporting an allergy
Male (n 5 306)
Female (n 5 232)
Latino (n 5 232)
Dominican (n 5 44)
Mexican (n 5 21)
Puerto Rican (n 5 104)
Other Latino (n 5 63)
African American (n 5 107)
White (n 5 76)
Asian (n 5 52)
Other (n 5 53)
<$20,000 (n 5 218)
$20,000-$39,999 (n 5 143)
$40,000-$74,999 (n 5 72)
>$75,000 (n 5 33)
Language of survey
English (n 5 456)
Spanish (n 5 75)
No insurance (n 5 10)
Public insurance (n 5 286)
Private (n 5 172)
Other (n 5 43)
Usual source of care
Physician’s office (n 5 205)
Community or hospital clinic (n 5 149)
Emergency department (n 5 69)
Other/no usual source of care (n 5 92)
*Includes nonresponders, and therefore not all subgroups total 540.
J ALLERGY CLIN IMMUNOL
750 STINGONE AND CLAUDIO
allergies, we examined the 23.4% of subjects with current asthma
who reported having 1 or more nighttime symptoms per week,
classifying them as having moderate or severe persistent asthma.
Of these, only 59.5% indicated that they underwent allergy
testing. Because such a large proportion of children with a
codiagnosis of asthma and allergies did not report allergy testing,
we sought to determine which demographic factors, access-to-
care factors, or both were associated with allergy testing (Table
II). Univariate and multivariate analyses were similar, and there-
fore only multivariate analyses are presented in Table II.
Allergy testing was less frequent among children living in
middle-income households when compared with upper-income
children because children living in a household with an annual
children living in a household with an annual income of greater
than $75,000 to report allergy testing. Children with no insurance
or receiving public insurance, such as Medicaid or supplemental
state-funded insurance, were significantly less likely to report
allergy testing than children with private health insurance (odds
ratios, 0.13 and 0.46, respectively). The association between
allergy testing and the usual source of care was found not to be
statistically significant in the multivariate analysis, and thus this
variable was removed from the final model.
recent symptoms; greater prevalence of allergy education and
treatment; and lower reported exposure to common sources of
sis of asthma and allergies, we found that children who reported
allergy testing were less likely to respond that they had a wheez-
ing episode in the previous 2-week period than children who did
not report allergy testing (41.2% vs 55.9%). More than 80% of
subjects with current asthma and allergy testing indicated
tion from their physician compared with 63% of thosewithout al-
lergy testing (P <.001). Children with allergy testing were also
twice as likely as those without testing to receive both education
Children who responded that they received allergy testing were
significantly less likely to report the presence of wall-to-wall
carpets, cats, visible mold, and water leaks in their household.
They were also less likely to indicate exposure to cockroaches, a
major source of allergen in the US urban environment,19although
these results did not reach statistical significance. There was also
no significant difference in the presence of mice or rats among
the observed relationship between exposures and allergy testing.
This study shows that manyurban children with asthma are not
receiving diagnoses or care for allergies that could improve their
asthma outcomes. In this study less than half of subjects with
current asthma reported an allergy diagnosis, with marked racial/
ethnic disparities in the frequency of this diagnosis, although not
in the odds of allergy testing, after adjusting for factors such as
insurance and household income. Although some of these
disparities are consistent with previous research, the prevalence
of allergy diagnosis in our sample is lower than the prevalence
that 77% had positive allergy skin test responses,1which is
TABLE II. Demographic factors associated with allergy testing
among subjects with current asthma who reported an allergy
diagnosis (n 5 270)*
Odds ratio95% CI
*Model adjusted for age, race/ethnicity, insurance, and median household income.
?Unstable estimate because of low n value (n 5 4).
TABLE III. Differences among subjects with current asthma with
and without allergy testing (n 5 257)*
(n 5 113)
(n 5 144)
Percentage with at least
1 d with wheezing
symptoms in the past 2 wk
Use of preventive strategies (%)
Have both an asthma plan
with trigger avoidance and
taking an allergy medication
Have an asthma plan including
trigger avoidance only
Currently taking an allergy
Household exposures (%)
*Thirteen respondents with current asthma and allergies did not specify an answer to
the allergy test question.
J ALLERGY CLIN IMMUNOL
VOLUME 122, NUMBER 4
STINGONE AND CLAUDIO 751
markedly greater than the 47.3% of diagnoses in our sample.
These results suggest that many children are not having their al-
lergies diagnosed, potentially hindering their ability to success-
fully manage their asthma.
Disparities in allergy diagnoses and lack of testing
This disparityin diagnosis ismore pronouncedamongminority
populations. For example, research done by Recio-Vega et al20in
showed that less than 15% of Mexican American children had re-
ceived an allergy diagnosis, despite research that shows Mexican
Americans have a higher prevalence of both asthma and hay fever
than their counterparts living in Mexico.21Our results show chil-
dren who used a physician’s office as their usual source of care
weremorelikelytorespondthat they weregivenadiagnosisofal-
lergy than children using other sources of care. It is possible that
racial/ethnic groups can explain some of our results. For example,
parents might be more likely to report an allergy diagnosis if they
have consistent contact with their child’s health care provider and
have been told about their child’s allergies on multiple occasions.
Of those who did receive an allergy diagnosis, a significant
percentage reported not having undergone allergy testing to
determine the specific allergens relevant to the child and to
confirm whether the allergy diagnosis was indeed accurate.
According to NHLBI guidelines, all subjects with persistent
asthma should undergo allergy testing,7but more than 40% of the
subjects with persistent asthma in our sample reported that they
were never tested. Our findings are consistent with other research
diatric asthma care and the standardized national guidelines.22,23
These results illustrate the need for the implementation of inter-
ventions aimed at improving clinical compliance with the na-
tional guidelines. Previous work by Cabana et al24has shown
that physician education on asthma management can improve
both physician knowledge and patient health outcomes in a num-
ber of communities throughout the United States.
Allergy testing as a marker for other aspects of care
The need for education of physicians and patients on the
importance of allergies in the overall management of asthma is
supported by the results of this study that found a higher
prevalence of treatment and education, as well as better health
There are a number of potential mechanisms that could explain
whyallergytesting wasassociatedwith positivehealthoutcomes.
Allergy testing can lead to a more tailored form of care because
take medications, or both designed to prevent symptoms in the
upper airways, which can help prevent exacerbations in the lower
derwent allergy testing went on to receive immunotherapy as
effects of immunotherapy on health outcomes.8,25It is also likely
includes awareness and treatment of allergies as a way to reduce
asthma symptoms and exacerbations. Health care providers who
refer patients for allergy testing might be more likely to follow
other aspects of the NHLBI guidelines, including patient educa-
tion, appropriate medication use, and adequate follow-up visits.
It is also possible that some children might have been referred
for allergy testing but did not receive it because of barriers to
follow-up care. Although adjusting for insurance and household
quality communication with the provider, and other potential
recommendation for allergy testing.26This could contribute to
ing an allergy diagnosis.
Although our study did not find differences in allergy care
associated with a patient’s usual source of care, previous research
has shown that children who are treated by specialists, such as
health maintenance organization. They found that those who re-
ported an allergist as their usual source of care had better scores
on health symptom and quality-of-life scales, as well as a lower
risk of hospitalizations and unscheduled office visits compared
with patients visiting only a primary care provider.27Work in
adults conducted by Frieri et al28found similar results, including
differences in care received by patients who are treated by aller-
gists compared with those who receive care exclusively from
itiveskin test response fordust mite, Callahan et al29documented
nificantly more knowledgeable of techniques to reduce exposure
to dust mite allergen than those who did not see an allergist.
Relationship between allergy testing and health
Previous research also shows that children with public health
insurance are less likely to receive specialty care for asthma,24
health insurance were among the least likely to report having re-
ceived allergy testing. Yoon et al30found that Medicaid patients
wereless likely to attendscheduled visitswith asthma specialists,
such as allergists, when compared with patients with private in-
surance, whereas Valerio et al26suggested that difficulty in main-
taining continuity of care because of turnover in physicians
participating in Medicaid programs can contribute to the differ-
ences in asthma outcomes experienced by patients with public
Our study also shows an income-related disparity in allergy
testing, with the middle-income groups having lower odds of
reporting allergy testing when compared with both the lowestand
highest income levels. The boundary between the middle-income
groups in our sample ($40,000) lies between the 2000 US Census
median household income levels for New York City ($38,293)
and the overall US population ($41,994), illustrating that this
range of household income accurately represents middle-income
families. The lower prevalence reported of allergy testing among
these households could be related to differences in insurance
coverage that were not captured in our study. Previous research
has documented differences in access to specialists depending on
the child’s type of health care–delivery plan.31The public
J ALLERGY CLIN IMMUNOL
752 STINGONE AND CLAUDIO
insurance plans in New York City are managed care plans, which
offer consistent coverage,32whereas private insurance plans can
be managed care or fee-for-service, with differences in coverage,
copayments, and other factors that could affect access to special-
ists among the less affluent.
bias and limitations related to self-report data. Additionally,
differences in educational attainment and health literacy can play
a role in reporting health outcomes and compliance.33,34Previous
work in hypertensive adults found that agreement between self-
report of medication use and the medical record was lower in
patients with lower measured levels of health literacy.34We at-
tempted to minimize the chance of these problems affecting our
results by pilot testing the questionnaire multiple times for clarity
and understanding. Additionally, we found no association be-
tween parental educational level and reporting allergy testing
after adjusting for race/ethnicity and household income level.
This study shows that many urban children do not receive
comprehensive asthma treatment that includes diagnosis and
management of associated allergies and education on avoidance
of common household allergens. These study results are gener-
as to children living in other US urban environments that share
similar demographic profiles, insurance coverage, and asthma
prevalence. Additionally, this study raises the possibility that
with asthma, a finding with the potential for international
relevance. Interventions aimed at improving medical care and
adherence to treatment guidelines in regardto themanagement of
allergies among asthmatic subjects, especially among children
morbidity in urban areas.
We thank Michelle DePass of the Ford Foundation for support.
Clinical implications: Successful asthma management includes
proper diagnosis of allergies and allergy testing. Allergy testing
can be used to tailor allergen avoidance instruction and treat-
ment and to guide patients to reduce exposure to allergens
that can trigger asthma exacerbations.
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