Factors associated with asthma control among adults in five New England states, 2006-2007.

Abstract

Despite the National Asthma Education and Prevention Program (NAEPP) guidelines that specify the goals of asthma control and management strategies, the number of patients with uncontrolled asthma remains high, and factors associated with uncontrolled asthma are unknown.
The aim was to examine the relationship between asthma control and socio-demographic characteristics, health-care access and use, asthma education, and medication use among adults with active asthma residing in New England.
Data from the 2006-2007 Behavior Risk Factor Surveillance System Adult Asthma Call-Back Survey were analyzed using multinomial logistic regression. Asthma control was categorized as "well controlled," "not well controlled," or "very poorly controlled" according to the NAEPP guidelines.
Of the respondents (n = 3079), 30% met the criteria for well-controlled asthma, 46% for not well-controlled asthma, and 24% for very poorly controlled asthma. Being of Hispanic ethnicity (odds ratio [OR] = 4.0; 95% confidence interval [CI] = 1.2-13.7), unemployed or unable to work (OR = 17.9; 95% CI = 6.0-53.4), high school educated or less (OR = 2.8; 95% CI = 1.6-4.7), current smokers (OR = 2.5; 95% CI = 1.3-5.1), or being unable to see a doctor or specialist for asthma care or unable to buy medication for asthma because of cost (OR = 7.6; 95% CI = 3.4-17.1) were associated with very poorly controlled asthma. In addition, having Coronary Obstructive Pulmonary Disease (COPD) (OR = 2.6; 95% CI = 1.5-4.5), two or more routine checkups for asthma (OR = 4.5; 95% CI = 2.3-8.9), or an emergency department visit, urgent care facility visit, and hospitalization in the past year (OR = 3.9; 95% CI = 2.1-7.3) were also associated with having very poorly controlled asthma. Using controller medication in the past year (OR = 2.6; 95% CI = 1.6-4.2) and taking a course on how to manage asthma (OR = 3.0; 95% CI = 1.2-7.8) were significantly associated with poor asthma control.
The high prevalence (70%) of not well-controlled asthma and poorly controlled asthma in this study emphasizes the need to identify factors associated with poor asthma control for development of targeted intervention. A health policy of increasing asthma education, health-care access, and smoking cessation may be effective and result in better asthma control and management.

Full text

Page 1

Journal of Asthma, Early Online, 1–8, 2011
Copyright © 2011 Informa Healthcare USA, Inc.
ISSN: 0277-0903 print/1532-4303 online
DOI: 10.3109/02770903.2011.576744
Factors Associated with Asthma Control among Adults in Five New
England States, 2006–2007
KIMBERLY NGUYEN, M.S., M.P.H.,1,∗HATICE ZAHRAN, M.D., M.P.H.,2SHAHED IQBAL, M.B.B.S., PH.D.,2
JUSTIN PENG, M.P.H.,1AND EILEEN BOULAY, R.N., B.S.N.1
1Asthma Program, Health Education Management and Surveillance Section, Connecticut Department of Public Health,
Hartford, CT, USA.
2Air Pollution and Respiratory Health Branch, National Center for Environmental Health, Centers for Disease Control
and Prevention, Atlanta, GA, USA.
Background. Despite the National Asthma Education and Prevention Program (NAEPP) guidelines that specify the goals of asthma control
and management strategies, the number of patients with uncontrolled asthma remains high, and factors associated with uncontrolled asthma
are unknown. Objective. The aim was to examine the relationship between asthma control and socio-demographic characteristics, health-care
access and use, asthma education, and medication use among adults with active asthma residing in New England. Methods. Data from the
2006–2007 Behavior Risk Factor Surveillance System Adult Asthma Call-Back Survey were analyzed using multinomial logistic regression.
Asthma control was categorized as “well controlled,” “not well controlled,” or “very poorly controlled” according to the NAEPP guidelines.
Results. Of the respondents (n = 3079), 30% met the criteria for well-controlled asthma, 46% for not well-controlled asthma, and 24% for very
poorly controlled asthma. Being of Hispanic ethnicity (odds ratio [OR] = 4.0; 95% confidence interval [CI] = 1.2–13.7), unemployed or unable
to work (OR = 17.9; 95% CI = 6.0–53.4), high school educated or less (OR = 2.8; 95% CI = 1.6–4.7), current smokers (OR = 2.5; 95% CI =
1.3–5.1), or being unable to see a doctor or specialist for asthma care or unable to buy medication for asthma because of cost (OR = 7.6; 95%
CI = 3.4–17.1) were associated with very poorly controlled asthma. In addition, having Coronary Obstructive Pulmonary Disease (COPD) (OR
= 2.6; 95% CI = 1.5–4.5), two or more routine checkups for asthma (OR = 4.5; 95% CI = 2.3–8.9), or an emergency department visit, urgent
care facility visit, and hospitalization in the past year (OR = 3.9; 95% CI = 2.1–7.3) were also associated with having very poorly controlled
asthma. Using controller medication in the past year (OR = 2.6; 95% CI = 1.6–4.2) and taking a course on how to manage asthma (OR =
3.0; 95% CI = 1.2–7.8) were significantly associated with poor asthma control. Conclusion. The high prevalence (70%) of not well-controlled
asthma and poorly controlled asthma in this study emphasizes the need to identify factors associated with poor asthma control for development
of targeted intervention. A health policy of increasing asthma education, health-care access, and smoking cessation may be effective and result
in better asthma control and management.
Keywords
access to health care, asthma, cross-sectional study, education, socio-demographic factors
INTRODUCTION
Asthma is one of the most common chronic conditions in
the United States. It affects more than 20 million people
in the United States, including 7.1 million children (1).
In 2007, an estimated 8.3% of US adults were told by
a physician that they “currently have asthma”; 13.1%
had been told at some point in their life that they “have
asthma” (2). Asthma was responsible for approximately
14 million physician office visits, 1.4 million hospital
outpatient discharges, 2 million emergency department
visits, 450,000 asthma hospitalizations, and 3500 deaths
in 2007 (3–5). The total cost for asthma was estimated
at $56 billion due to medical and productivity losses
in 2007 (6). Uncontrolled asthma contributes to an
increase in asthma symptoms, medication use, physician
office visits and ED visits, and missed days of school
and work (7). Most asthma costs can be attributed to
∗Corresponding author: Kimberly Nguyen, M.S., M.P.H., Centers for
Disease Control and Prevention, Atlanta, GA, USA. Tel: 404-639-2051;
E-mail: KNguyen2@cdc.gov
uncontrolled asthma symptoms, with 80% of the direct
costs distributed among approximately 20% of patients
with difficult-to-control asthma (8, 9). The estimated
annual cost for patients with difficult-to-control asthma
was more than $2500 per patient, while the cost was only
$140 per patient for other asthma patients (9).
The 2007 National Asthma Education and Prevention
Program(NAEPP)guidelinesdefineasthmacontrolbased
on current impairment (e.g., symptoms, sleep distur-
bances, limitation of daily activities, and use of rescue
medication) and future risk (e.g., asthma exacerbations,
progressive decline in lung function in adults or reduced
lung growth in children, or treatment-related adverse
effects) (10). Despite the NAEPP guidelines that specify
the goals of asthma control and asthma management
strategies, previous studies have shown that asthma is not
well controlled in most patients (11, 12).
Several studies have examined the factors associated
with asthma control. While Schatz et al. (13) found that
health-care access and use was associated with poorer
asthma control, Vogt et al. (14) and Bloomberg et al.
(15) identified socio-economic factors (e.g., low income
1
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2K. NGUYEN ET AL.
and Medicaid insurance) as important variables. Overall,
epidemiologic studies suggest that health-care access and
use, smoking status, poor adherence to doctor’s advice,
critical errors in inhaler use, oral corticosteroid use,
and lack of regular specialist care are significant factors
associated with poor asthma control (16–20). Having
Coronary Obstructive Pulmonary Disease (COPD) a
higher body mass index (BMI), gastroesophageal reflux,
low income, and other than Caucasian ancestry are also
significant factors associated with poor asthma control
(16–20). However, most of these studies were conducted
among patients with a high prevalence of poor control and
may not be representative of the total asthma population.
While previous studies suggest that patient character-
istics may be significant predictors of control, no study
has examined these factors among the general population
using NAEPP guidelines for asthma control. Previous
studies were conducted in high-risk groups, such as
those in an intervention program to reduce asthma, in
specialty practice, in a Medicaid plan, or in randomized
controlled trials (13–21). In addition, previous studies
were inconsistent in their definitions of asthma control
and did not necessarily follow NAEPP guidelines
(13–21). A literature gap exists on factors and patient
characteristics (e.g., socio-economic status, ethnicity,
health insurance status, presence of comorbidities, and
current smoking) that could predict individual responses
to asthma therapies among the general population and
therefore asthma-related health outcomes.
New England has a higher asthma prevalence rate
(9.7%) than the other regions of the United States
combined (8.1%), after controlling for gender, age,
race/ethnicity, income, education, and marital, over-
weight, and smoking status (22). The reasons for these
higher prevalence rates remain unknown, which further
emphasizes the need for understanding asthma risk factor
roles in this region. A better understanding of modifiable
risk factors can help improve asthma management
and prevent asthma exacerbations. We examined the
relationship between different factors and asthma control
in a sample of adults with active asthma among New
England residents using the 2006–2007 Behavioral Risk
Factor Surveillance System (BRFSS) Asthma Call-Back
Survey (ACBS) data.
METHODS
BRFSS Survey Design
The BRFSS is the largest ongoing telephone survey in the
world that has been conducted by the Centers for Disease
Control and Prevention and state health departments
since 1984. This nationally representative survey is
administered in all 50 states, the District of Columbia,
and US territories. The survey collects information about
modifiable risk factors for chronic diseases and other
leading causes of death among the non-institutionalized
US population aged ≥18 years annually. The BRFSS uses
a disproportionate, stratified sampling plan for selecting a
nationally representative sample (2). This survey design
has been detailed elsewhere (23). Estimates from the
BRFSS have been found to be reliable and valid (24, 25);
BRFSS data are widely analyzed by researchers and the
results are published in peer-reviewed journals (26).
Data Collection
Interviewers undergo standard training, follow uniform
procedures for data collection, and receive refresher
training courses on an annual basis (27). Supervisors
are responsible for ensuring that interviewers conduct
quality interviews, adhere to protocol oversee, and
accurately collect data (27). Two weeks after the annual
BRFSS survey was conducted, a follow-up ACBS was
administered to respondents who responded “yes” to the
question “Have you ever been told by a doctor, nurse,
or other health professional that you had asthma?” The
ACBS contains questions that cover a wide range of
topics including detailed information about demographic
factors, health-care use, asthma self-education and
management, medication, symptoms, quality of life, and
other factors associated with asthma (28). A complete
list of the questions is available online (28). Many of
the questions in the ACBS have been used in national
surveys (e.g., The National Asthma Survey and The
National Health Interview Survey) (29). Definitions for
asthma cases in questionnaires have been validated in
previous studies by testing the questionnaire in relation
to a clinical physiologic investigation, comparing the
answers from the questionnaire with a clinical diagnosis
of asthma and comparing a new questionnaire with an old
one (25). Because of the repeated use of asthma-related
measures in national surveys, general agreement among
researchers and the logical relations among several
questions demonstrate face and construct validity (30).
Following the guidelines in the NAEPP Expert Panel
Report 3 (10), we classified asthma control as well
controlled, not well controlled, and very poorly controlled
by using four parameters: daytime symptoms, nighttime
symptoms, interference with normal activity, and use
of short-acting β2-agonists (SABA) (Table 1). This is a
modified version of the 2007 NAEEP guidelines because
it does not include pulmonary function measures. Symp-
toms were defined as recurrent episodes of coughing,
TABLE 1.—Classification of asthma control modified from the National
Asthma Education and Prevention Program Expert Panel Report 3
guidelines.
ImpairmentWell controlled
Not well
controlled
Very poorly
controlled
Symptoms
≤2 days/week
>2 days/week Throughout
the day
≥4/week Nighttime
awakenings
Interference with
normal activity
Short-acting
β2-agonists
≤2/month1–3/week
NoneSome limitationExtremely
limited
Several
times/day
≤2 days/week
>2 days/week
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FACTORS ASSOCIATED WITH ASTHMA CONTROL3
wheezing, shortness of breath, or chest tightness. Some
limitations to physical activity were defined as “a little” or
“a moderate amount” of activity limitations due to asthma
(i.e., exercise, other physical activity, and attendance at
work or school). Cost as a barrier is defined as being
unable to see a doctor or specialist for asthma care or
unable to buy medication for asthma in the past year
because of cost.
In addition to the asthma control questions, the
BRFSS included questions on age, sex, race, Hispanic
ethnicity, BMI, metropolitan area residence, educational
level, employment status, smoking status, depression, and
comorbidities such as COPD. All of the six New England
states except Rhode Island conducted the ACBS in 2006
and 2007.
Statistical Analysis
BMIs (kg/m2) were categorized as <25.0 (underweight or
normal), 25.0–29.9 (overweight), and ≥30.0 (obese) (2).
An urban area was classified as a metropolitan statistical
area according to the U.S. Census (31). Education
was categorized as high school (HS) graduate or less,
some college or technical school, or college gradu-
ate. Employment status was categorized as employed,
homemaker/student, retired, or unable to work. Current
smokers were defined as persons who had smoked at
least 100 cigarettes in their lifetime and currently smoked,
either occasionally or every day. Measured comorbidities
included COPD and physician-diagnosed depression.
Health-care access and use were determined by
whether respondents were covered by health insurance
and had seen a doctor within the past year because of
their asthma. These doctor visits for asthma could include
a routine checkup, an ED visit, a doctor visit for an
urgent asthma attack or worsening asthma symptoms, or
an overnight stay in a hospital. Cost of care was assessed
by whether the respondents had ever been unable to see
a doctor or buy medication for their asthma because
of cost. Receiving asthma self-management education
was determined if the respondent was ever taught by
a health-care professional how to recognize early signs
or symptoms of an asthma attack, what to do during
an asthma attack, or how to use a peak flow meter to
adjust their daily medications. Respondents also were
asked whether they had ever been given a written asthma
action plan and whether they had ever taken a course
on how to manage asthma. Medications included any
controller medication use in the past 3 months. Controller
medication variable was created if respondents reported
using any prescription long-term control medications
(e.g., corticosteroids, cromolyn sodium and nedocromil,
long-acting beta agonist, leukotriene receptor antagonists,
immunomodulators, and methylxanthines) in the past 3
months (10).
Based on the Council of State and Territorial Epidemi-
ologists’ (CSTE) recommendation of “probable” case
definition of asthma for surveillance, respondents were
considered to have active asthma if they reported in
the past 12 months any of the following: having seeing
a doctor or other health-care provider about asthma,
taken any asthma medications, or experienced any asthma
symptoms (32–34). For the rest of this article, the word
“respondents” refers to survey respondents who met the
criteria for active asthma.
Weighted analyses were conducted using SAS version
9.2 (SAS Institute, Inc., Cary, NC, USA) to account
for the complex sampling design to represent adult
population in the corresponding New England states (35).
Factors considered in the weighing process included
the probability of selection of a telephone number, the
number of adults in a household, and the number of tele-
phones in a household. Non-response and non-coverage
of households without telephones were also adjusted for
in the final post-stratification.
Descriptive statistics (e.g., means and percentages)
were performed with PROC SURVEYMEANS and
PROC SURVEYFREQ. Chi-square tests were used to
evaluate any differences in demographic characteristics
(e.g., age, sex, race/ethnicity, education, employment
status, BMI, residence in metropolitan area), COPD,
depression, and smoking status. Also evaluated were
health-care access and use (e.g., health insurance, routine
checkup for asthma, ED visit, urgent care facility visit,
hospitalization, cost as a barrier), knowledge of asthma
self-management, and medications used for asthma
control. Variables that were found to be significant
(p < .05) factors of asthma control in a bivariate analysis
were included in the multinomial logistic regression
model. Although age and race were not significant factors
of asthma control in univariate analysis, we included
those variables in the model because they are known
confounders.
Relative standard error [RSE] (RSE = SE/prevalence
estimate) and sample size of 50 for denominator
(requirement for BRFSS data) were used to test the
reliability of our findings (36, 37). If the RSE was
less than 0.30, estimates were considered to be reliable.
None of the estimates in our analysis were found to be
unreliable according to the RSEs.
RESULTS
Sample Population Characteristics
Of the 3079 respondents in New England, 30% met
the criteria for well-controlled asthma, 46% for not
well-controlled asthma, and 24% for very poorly
controlled asthma (Table 2). Most of the respondents
were of non-Hispanic white ancestry (86%); 65% of
the respondents were female. Forty-three percent were
college graduates, 59% were employed, and the average
age was 44 years. The respondents’ BMIs were almost
equally distributed among the three BMI categories:
underweight or normal (35%), overweight (31%), and
obese (34%). More than 80% of the respondents lived in a
metropolitan area. Sixteen percent were current smokers,
27% had COPD, and 34% had depression.
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4 K. NGUYEN ET AL.
TABLE 2.—Socio-economic and demographic characteristics and health conditions by level of asthma control.
Level of asthma control
Characteristics
n (%)
Well
controlled
Not well
controlled
Very poorly
controlled
Total
Age (years)
18–24
25–34
35–44
45–54
55–64
≥65
Gender
Male
Female
Race/ethnicity
Non-Hispanic white
Non-Hispanic black
Hispanic
Other
Employment∗∗
Employed for wages/self-employed
Homemaker/student
Retired
Unemployed/unable to work
Education∗∗
High school graduate or less
Some college or technical school
College graduate
Metropolitan area
Yes
No
Body mass index∗
Normal/underweight
Overweight
Obese
Have COPD∗∗
Current smoking∗∗
Yes
No
Depression∗
Yes
No
3079 (100.0)819 (30.4%)1369 (45.6%) 891 (23.9%)
102 (12.3)
279 (21.0)
483 (16.7)
731 (20.9)
748 (14.9)
715 (14.5)
24.7
31.2
35.2
30.7
31.6
26.5
53.8
48.5
47.4
44.5
37.8
42.6
21.5
20.4
17.4
24.7
30.6
30.8
813 (34.7)
2266 (65.3)
33.8
28.7
41.4
47.9
24.8
23.5
2737 (85.7)
52 (2.0)
135 (8.5)
122 (3.8)
32.6
11.2
17.1
20.5
44.3
71.8
50.5
54.7
23.1
17.0
32.4
24.8
1608 (58.5)
223 (11.4)
641 (13.0)
603 (17.1)
36.1
30.9
29.4
12.2
44.9
61.3
39.9
40.6
18.9
7.9
30.7
47.2
1034 (31.7)
788 (24.8)
1256 (43.4)
17.6
25.2
42.8
46.3
49.9
42.7
36.2
24.9
14.5
1841 (83.8)
1238 (16.2)
30.0
32.8
46.3
42.2
23.7
25.0
906 (34.7)
917(31.1)
1108 (34.2)
1124 (26.9)
31.3
36.8
25.3
15.6
47.6
43.8
44.8
39.9
21.1
19.4
29.9
44.5
542 (15.9)
2520 (84.1)
14.2
33.7
47.7
45.4
38.2
20.9
1119 (33.8)
1915 (66.2)
23.5
33.7
46.6
45.2
29.9
21.1
Notes: Percentages are weighted. Percentages may not add to 100 due to rounding.
P-values:∗p < .05;∗∗p < 0.001.
Mostrespondentshadhealthinsurancecoverage(91%)
(Table 3). However, 41% had no annual routine checkups
for asthma, and 13% were unable to see a doctor or
specialist for asthma care or buy medication for asthma in
the past year because of cost. More than one-fourth (27%)
of the respondents reported having an ED visit, urgent
care facility visit, or hospitalization in the past year.
Almost 40% of the respondents reported using controller
medications in the past 3 months.
Seventy-nine percent of the respondents had been
taught what to do during an asthma attack and 66% had
been taught early signs or symptoms of an asthma attack.
Forty-eight percent of the respondents had been taught
how to use a peak flow meter to adjust daily medications;
29% had been given a written asthma action plan; and
6% had taken a course on how to manage asthma.
Overall, 89% of the respondents reported receiving any
self-management education.
Bivariate and Multivariate Results
The respondents’ levels of asthma control were sig-
nificantly (p < .05) associated with their employment,
education, BMI, smoking status, COPD, and depression
(Table 2). In addition, asthma control was signifi-
cantly (p < .05) associated with all factors related
to health-care access and use (Table 3). Respondents
who had been taught how to use a peak flow meter
to adjust daily medications, had been given a written
asthma action plan, or had taken a course on how
to manage asthma compared with those who had not
reported a higher percentage in very poorly controlled
asthma. In addition, respondents who used controller
medications in the past year compared with those who
had not used controller medications in the past year
reported a higher percentage in very poorly controlled
asthma.
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FACTORS ASSOCIATED WITH ASTHMA CONTROL5
TABLE 3.—Health-care access and use, self-management education, and medication use according to asthma control.
Level of asthma control
n (%)
Well
controlled
Not well
controlled
Very
poorly
controlled
Health-care access and use
Health insurance∗
Routine checkup for asthma∗∗
None
One
Two or more
ER visit, urgent care facility visit, or hospitalization in
the past year∗∗
Cost as a barrier∗∗
Self-management education
Taught signs or symptoms of an asthma episode
Taught what to do during an asthma episode
Taught how to use a peak flow meter to adjust daily
medications∗∗
Been given an asthma action plan∗∗
Taken a course on how to manage asthma∗∗
Any self-management education
Medication use
Controller medication use∗∗
2882(91.4)31.646.5 21.9
1239(41.4)
758(29.8)
1037(28.8)
857(26.7)
38.8
34.0
14.7
15.2
48.3
41.6
45.8
42.9
12.9
24.4
39.5
41.9
402(12.7)5.444.7 49.9
1946(66.4)
2349(79.3)
1396(47.7)
28.4
29.4
24.6
47.8
45.3
46.6
23.7
25.3
28.8
850(29.1)
265(6.3)
2689(89.1)
19.3
14.1
28.8
48.8
41.7
46.7
31.9
44.2
24.5
1420(39.6)20.547.132.3
Notes: Percentages are weighted. Percentages may not add to 100 due to rounding.
P-values:∗p < .05;∗∗p < .0001.
In a multinomial logistic model, socio-demographic
factors, health-care access and use, self-management
education, and medication use were associated with
poor asthma control (Table 4). Hispanic ethnicity was
associated with very poorly controlled asthma (OR =
4.0; 95% CI = 1.2–13.7). Compared with homemakers
and students, retired respondents were 3.8 times more
likely (95% CI = 1.2–11.8) to have very poorly controlled
asthma; employed respondents were 4.5 times more likely
(95% CI = 1.7–12.4); and unemployed or unable to
work respondents were 17.9 times more likely (95%
CI = 6.0–53.4). Compared with college graduates, HS
graduate respondents were 1.8 times more likely (95%
CI = 1.1–3.1) to have not well-controlled asthma and
were 2.8 times more likely (95% CI = 1.6–4.7) to have
very poorly controlled asthma. Current smokers were 2.5
times more likely (95% CI = 1.3–5.1) than non-smokers
to have very poorly controlled asthma; respondents with
COPD were 2.6 times more likely (95% CI = 1.5, 4.5)
than respondents without these conditions to have very
poorly controlled asthma.
Having two or more routine checkups for asthma
in the past year was significantly associated with not
well-controlled asthma (OR = 2.3; 95% CI = 1.2–4.2)
and very poorly controlled asthma (OR = 4.5; 95% CI =
2.3–8.9). Having an ED visit, urgent care facility visit,
or hospitalization in the past year was associated with
very poorly controlled asthma (OR = 3.9; 95% CI =
2.1–7.3). Being unable to see a doctor or specialist for
asthma care or buy medication for asthma because of cost
was associated with not well-controlled asthma (OR =
4.7;95%CI=2.3–9.5)andverypoorlycontrolledasthma
(OR = 7.6; 95% CI = 3.4–17.1). Having taken a course
on how to manage asthma was significantly associated
with very poorly controlled asthma (OR = 3.0; 95% CI
= 1.2–7.8). Respondents who used controller medication
in the past year were 1.7 times more likely (95% CI
= 1.1–2.5) to have not well-controlled asthma, and 2.6
times more likely (95% CI = 1.6–4.2) to have very poorly
controlled asthma compared with respondents who had
not used controller medications.
DISCUSSION
The purpose of this population-based study was to assess
asthma control status and identify potential risk factors
for suboptimal asthma control among respondents with
active asthma in New England. Similar to a report by
the Asthma Regional Council (22), this study showed
that 70% of the respondents with active asthma had
very poorly controlled/not well-controlled asthma. Also
consistent with previous study findings (23), smoking and
having less than a HS education were associated with
poor asthma control. Similar to results by Williams et al.
(19) and Adams et al. (20), this study showed that the
level of health-care access and use and self-management
education were reflected in the degree of asthma control.
In particular, poor asthma control was associated with
an increase in ED visits or hospitalization in the
past year. Although 91% of the population reported
having insurance, underinsurance may be contributing
to poor asthma control as evidenced by our finding
that 13% of our respondents reported cost as a barrier
to seeking health care. Similar to previous studies,
respondents who reported an economic barrier to seeing
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