**8. Management**

school and work is hard to measure. The added cost of overutilization of healthcare facilities and emergency department adds to the financial implications of this phenomenon. Overcon‐ sumption of pharmaceutical agents and other supportive agents and procedures further increases the overall cost. Finally, the impact on the general health of the individuals, stunted growth, and development of long-term respiratory impairment adds to the overall societal

The factors contributing to the high prevalence of asthma among inner city residents are varied. Cohen et al. [45] suggest that a key factor in this regard is the poor access to healthcare that patients in urban environments experience. This may be related to a limited number of physicians and healthcare facilities as well as limited availability of safe transportation. Limited access to care has a negative impact on most clinical conditions including the availa‐ bility of effective prenatal care. Another major predisposing factor which increases the prevalence of asthma in residents of inner cities is exposure to tobacco smoke [45]. Tobacco smoke is known to affect the rate of lung growth, clearance of secretions, and defense mech‐

Studies have shown that children living in urban environments have a higher rate of emer‐ gency room visits and lower use of inhaled corticosteroids [46]. This may be related to lower rates of diagnosis as shown by the 1999 National Health Interview Study [34]. Specific factors that have been examined include poverty with reduced access to and quality of care [47]. The resultant additional health issues such as prematurity [48, 49] and obesity [29, 50] further confound the problem. In addition, poor housing [51] with exposure to indoor pollutants and environmental tobacco [52] plays a significant role in aggravating the condition. Finally, the psychological impact of the disease in the setting of poor resources worsens the perception among patients, impacts coping, and results in further deterioration in symptomatology [53,

In general, inner city asthma has a higher index of severity, is associated with increased morbidity, and has a higher mortality rate than asthma outside the inner city milieu [29]. Several criteria may be used to evaluate the level of acuity. These include, among others, emergency room visits, hospitalizations, office visits, time lost from work, and absenteeism from school. Research shows that inner city asthma is associated with increased morbidity in each of these criteria. The national database report of 2006 indicated that around 3.5 million visits to physician offices, half a million visits to hospital outpatient departments, an equivalent number of visits to an emergency department, and over 150,000 hospitalizations were related

impact.

54].

**7. Morbidity and mortality**

to asthma in this population [55].

**6. Predisposing factors**

194 Asthma - From Childhood Asthma to ACOS Phenotypes

anisms against particulate matter and infectious agents.

Management of inner city asthma places additional demands on patients and healthcare providers alike. Patients need to be maintained on the usual asthma medications including short-acting and long-acting bronchodilators, inhaled corticosteroids, leukotriene antagonists, and possibly methyl xanthines. In addition, one has to focus on eliminating or minimizing the effect of the predisposing factors listed in the previous paragraphs. Specifically, dealing with poor housing, indoor pollutants, and environmental tobacco makes it necessary for patients and their families to invest in home improvement projects that are costly and demanding. Since this may be beyond the capabilities of several patients, this poses a significant burden on the public health and social safety networks in various cities. These services are already oversub‐ scribed and have limited resources.

Several interventions have focused on the fact that patient and family education are critical to the process of managing and controlling inner city asthma. Patients and their families need to learn the components of quality care so that they can participate in their own care. An important component of this strategy is making sure patients, and their families have the requisite knowledge to reach healthcare providers in a timely and structured manner. Therefore, efforts should focus on educating patients to improve their ability to acquire the knowledge needed to navigate the healthcare system. A family-based intervention performed by a trained counselor has been shown to improve care and decrease morbidity [56]. Schoolbased asthma education is also effective [57]. Emphasis should also be placed on reducing environmental triggers such as the use of pest control [58] services and reduction of exposure to tobacco smoke [59] and weatherizing homes to decrease mold and moisture [60, 61] Good management of inner city asthma requires the same kind of proactive care that has been shown to be effective in other situations. These include guidelines-driven care and assured access to the appropriate controller medication [62] and the addition of a biologic such as omalizumab in selected cases [63].
