title: Conundrums in childhood asthma severity, control, and health care use: Puerto Rico versus Rhode Island.
abstract: BACKGROUND
  The lifetime prevalence of self-reported asthma among Puerto Ricans is very high, with increased asthma hospitalizations, emergency department visits, and mortality rates. Differences in asthma severity between the mainland and island, however, remain largely unknown.
  
  
  OBJECTIVE
  We sought to characterize differences in asthma severity and control among 4 groups: (1) Island Puerto Ricans, (2) Rhode Island (RI) Puerto Ricans, (3) RI Dominicans, and (4) RI whites.
  
  
  METHODS
  Eight hundred five children aged 7 to 15 years completed a diagnostic clinic session, including a formal interview, physical examination, spirometry, and allergy testing. Using a visual grid adapted from the Global Initiative for Asthma, asthma specialists practicing in each site determined an asthma severity rating. A corresponding level of asthma control was determined by using a computer algorithm.
  
  
  RESULTS
  Island Puerto Ricans had significantly milder asthma severity compared with RI Puerto Ricans, Dominicans, and whites (P < .001). Island Puerto Ricans were not significantly different from RI whites in asthma control. RI Puerto Ricans showed a trend toward less control compared with island Puerto Ricans (P = .061). RI Dominicans had the lowest rate of controlled asthma. Paradoxically, island Puerto Ricans had more emergency department visits in the past 12 months (P < .001) compared with the 3 RI groups.
  
  
  CONCLUSIONS
  Potential explanations for the paradoxic finding of milder asthma in island Puerto Ricans in the face of high health care use are discussed. Difficulties in determining guideline-based composite ratings for severity versus control are explored in the context of disparate groups.
authors.affiliation: Department of Pediatrics, Division of Allergy and Immunology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA. Cesteban@Lifespan.org
authors.forename: Cynthia A
authors.initials: CA
authors.lastname: Esteban
authors.forename: Robert B
authors.initials: RB
authors.lastname: Klein
authors.forename: Elizabeth L
authors.initials: EL
authors.lastname: McQuaid
authors.forename: Gregory K
authors.initials: GK
authors.lastname: Fritz
authors.forename: Ronald
authors.initials: R
authors.lastname: Seifer
authors.forename: Sheryl J
authors.initials: SJ
authors.lastname: Kopel
authors.forename: Jose Rodriguez
authors.initials: JR
authors.lastname: Santana
authors.forename: Angel
authors.initials: A
authors.lastname: Colon
authors.forename: Maria
authors.initials: M
authors.lastname: Alvarez
authors.forename: Daphne
authors.initials: D
authors.lastname: Koinis-Mitchell
authors.forename: Alexander N
authors.initials: AN
authors.lastname: Ortega
authors.forename: Brenda
authors.initials: B
authors.lastname: Martinez-Nieves
authors.forename: Glorisa
authors.initials: G
authors.lastname: Canino
mesh_terms: D000293:Adolescent; D018927:Anti-Asthmatic Agents / Q000627:therapeutic use; D001249:Asthma / Q000188:drug therapy / Q000453:epidemiology* / Q000503:physiopathology; D002648:Child; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D044382:Population Groups / Q000208:ethnology / Q000706:statistics & numerical data; D011647:Puerto Rico / Q000453:epidemiology; D012237:Rhode Island / Q000453:epidemiology; D012720:Severity of Illness Index; D012959:Socioeconomic Factors
chemical_list: D018927:Anti-Asthmatic Agents