title: Quality and access to care among a cohort of inner-city adults with asthma: who gets guideline concordant care?
abstract: OBJECTIVE
  Asthma morbidity is highest among inner-city populations. This study measured whether quality and access to care over time was concordant with National Asthma Education and Prevention Program (NAEPP) guidelines. It also identified factors associated with NAEPP guideline-concordant care.
  
  
  METHODS
  A prospective, observational cohort study.
  
  
  METHODS
  An urban academic medical center.
  
  
  METHODS
  A consecutive cohort of 198 inner-city adults hospitalized for asthma.
  
  
  METHODS
  Detailed information about sociodemographics, asthma history, access to care, history of the current exacerbation, prescription and use of inhaled corticosteroids (ICS) and beta-agonists, and other elements of NAEPP-concordant care (spacers, metered-dose inhaler [MDI] technique, peak flow meters, and action plans) was collected during the index admission and 1 month and 6 months after discharge.
  
  
  RESULTS
  In this predominantly low-income, nonwhite cohort, while 92% of patients had insurance and 80% had a usual source of care, 73% reported delays in seeking care. ICS were prescribed for 77% of patients prior to hospital admission, 83% at 1 month, and 67% at 6 months. Adherence with other NAEPP recommendations were 89% for receipt of MDI instruction, 68% for spacers, 80% for peak flow meters, 31% for written action plans for worsening, and 22% for written plans for attacks. In multivariate analysis, greater asthma severity and having a usual source of care increased the odds of receiving ICS, spacers, and peak flow meters. Care by a specialist increased the odds of receiving action plans. Patients who spoke mostly Spanish were less likely to be given spacers or action plans.
  
  
  CONCLUSIONS
  Baseline problems with quality and access to care persisted over time. Better systems of care are needed to ensure that high-risk patients receive an appropriate step-up in the quality of ongoing asthma care.
authors.affiliation: Division of General Internal Medicine, Department of Medicine, Mount Sinai School of Medicine, Box 1087, One Gustave L. Levy Place, New York, NY 10029, USA. ethan.halm@mountsinai.org
authors.forename: Ethan A
authors.initials: EA
authors.lastname: Halm
authors.forename: Juan P
authors.initials: JP
authors.lastname: Wisnivesky
authors.forename: Howard
authors.initials: H
authors.lastname: Leventhal
mesh_terms: D000328:Adult; D017668:Age of Onset; D000368:Aged; D000369:Aged, 80 and over; D001249:Asthma / Q000628:therapy*; D005006:Ethnicity; D005260:Female; D017408:Guidelines as Topic; D006801:Humans; D007348:Insurance, Health; D008297:Male; D008875:Middle Aged; D009515:New Jersey; D009519:New York City; D010342:Patient Acceptance of Health Care; D018579:Patient Selection; D011785:Quality Assurance, Health Care; D014505:Urban Population