|Bay Window : Children and Asthma: Q&A with Dr. Shannon Thyne of the San Francisco General Hospital Asthma Clinic
Is it true that asthma rates among children have doubled over the last 20 years?
If you look at the rates of asthma, somewhere between 5 and 12 percent of kids have this disease. If you look at specific populations, that rate can be higher. For instance, in San Francisco, the African-American community is at a higher risk for asthma. There was a great asthma prevalence survey that was conducted in the Bay View district [of San Francisco], and they found a 15 percent prevalence, which I believe actually may have been higher. But it is a challenge to measure actual numbers. Asthma is clearly on the rise, and we still have a long way to go.
Why do you think that children who live in neighborhoods like Bay View have higher rates of asthma? Is it environmental?
I think that the environment is certainly a factor in asthma. If you consider the environmental triggers which lead to asthma, many are found in greater level in economically disadvantaged areas, such as the presence of more heavily polluting companies. Also, residents often have less control over their living conditions and the types of things that exist in their homes, such as mold and dust, and they often do not have the option to choose things such as hardwood floors versus carpeting, and blinds versus drapes, etc., to help control their symptoms.
Additionally, if you don't have access to good primary healthcare, you will not have good asthma management. Itís clear that people who are from socially disadvantaged neighborhoods, regardless of race, use the emergency room for their care and not primary care for their treatment. I think that theses two factors are important.
Do you see a lack of education about asthma to be an issue?
I think that there has been a lot of publicity about the environmental problems in Bay View, so the community has done a great job of educating itself about environmental conditions and asthma. This doesn't mean that everyone understands the nitty-gritty of it, but they know that asthma is a problem. But I think we still have a lot of work to help people better understand the best ways to manage asthma and to prevent asthma triggers.
I also think that access to medication is a big issue, since the drugs can be quite expensive. We write a lot of prescriptions for asthma medication, but at our asthma clinic we know which health plan covers which medication, so we have judicious prescribing practices. However, a lot of emergency rooms and primary care clinics don't know the cost of asthma medications, so a lot of patients don't pick up their medication because of the prohibitive cost.
Do you find that there is a problem with undocumented families not seeking asthma treatment?
I think undocumented families have a harder time accessing primary care. They shouldn't in California, because of the [publicly funded] "Healthy Families" and "Medi-Cal" programs. Most of the kids we see were born here, so they are eligible for these programs. However, getting this information to families is another issue. We find that undocumented and uninsured families use the emergency room more because they come only when they have to and assume they will have to pay. And sometimes they come to the ER and realize that they can sign up for primary care, but because of this, the kids are often late to get the asthma treatment they need and the symptoms have become worse. There is outreach to tell the community about these health insurance programs, but outreach is difficult to a community that is concerned about privacy issues, especially when it comes to documentation status. It's not a new problem.
How does the clinic work? What kind of research are you conducting at the clinic?
At the asthma clinic, we see new and follow-up patients every week, where they get a full evaluation by a doctor, resident, medical student or a nurse practitioner. We make a treatment plan and arrange for a consultation with an allergist. Once skin tests and lung function tests are done, the allergist and the person who did the evaluation discuss the plan with the patient. Then an asthma educator discusses that treatment program and gives further information.
Currently, I am doing a study to see how home care will impact asthma management. It's expensive to send people out to a house, so we are evaluating whether the care and equipment that people get at the asthma clinic is enough or if a home visit in addition to the clinic visit is more effective. The ultimate question is whether home visits improve quality of life and decrease asthma symptoms. We are also writing a paper showing that the kids who come to the asthma clinic have fewer ER visits and fewer hospital visits.
Can you speak about the strain this puts on emergency rooms?
I think that the burden on the ER is tremendous and admission to the hospital costs a lot of money. Luckily, this is a rare event for an asthmatic, but it shouldn't have to happen. There is a general guide that is used to see if someone has intermittent or persistent asthma, persistent asthma being the most worrisome, which says that if you have more than two ER visits in a year, you need better treatment. We have many kids who come to our ER and who have up to nine visits per year for respiratory symptoms. There is a huge problem with over-utilizing the ER. Most people donít go to the ER for a cold, but asthmatics do, because the cold often triggers their asthma symptoms. Asthma is definitely the number-one diagnosis in our ER.
What is the most effective strategy in fighting asthma?
Continued education and culturally competent outreach efforts are both key in increasing awareness of the disease and improving the lives of children and families coping with asthma. Weíll continue working to help people live more healthy and productive lives by better managing this chronic illness.