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The Philadelphia Story

David M. Lang, MD; Michael S. Sherman, MD; Marcia Polansky, ScD

Arch Intern Med. 1997;157(11):1193-1200.

Abstract
Background
Guidelines from the National Heart, Lung, and Blood Institute, Bethesda, Md, have encouraged more frequent use of inhaled steroids in asthma management.

Objectives
To determine (1) whether prescription rates for inhaled steroids have increased compared with prescriptions for bronchodilators and (2) significant associations of demographic factors with bronchodilator— inhaled steroid prescription ratios and with rates of inhaled steroid prescriptions.

Design
Cross-sectional analysis of monthly bronchodilator and inhaled steroid prescription rates, numbers and types of asthma care providers, and demographic factors.

Setting
Philadelphia, Pa.

Measurements
Using univariate and multivariate analyses, bronchodilator and inhaled steroid prescription rates were determined for 45 ZIP codes and studied for associations with race and ethnicity, poverty, educational attainment, marital status, gender, total numbers of asthma drug prescriptions, and numbers and types of asthma care providers.

Results
Monthly bronchodilator-inhaled steroid prescription ratios increased from July 1991 to June 1993 (P<.001). Prescription rates for inhaled steroids and inhaled bronchodilators declined, but rates for oral bronchodilators (β-agonists and theophylline) increased. By stepwise multiple regression, higher bronchodilator-inhaled steroid prescription ratios and lower inhaled steroid prescription rates were each significantly associated with ZIP codes in which greater proportions of residents lacked a high school diploma (P<.001); associations that approached statistical significance were found for higher bronchodilator-inhaled steroid ratios and fewer asthma care providers (P=.05) and for lower inhaled steroid prescription rates and lower proportions of asthma specialists (P=.04).

Conclusions
In Philadelphia, a gap exists between optimal asthma drug prescribing and actual prescribing patterns that has widened from July 1991 to June 1993. Underuse of inhaled steroids is most closely associated with lower educational attainment, suggesting that interventions that include addressing the special asthma care needs of a low-literacy population will be required to achieve the goals of the National Asthma Education Program.

Arch Intern Med. 1997;157:1193-1200

Author Affiliations
From the Department of Medicine, Division of Allergy and Immunology (Dr Lang), Division of Pulmonary and Critical Care Medicine (Dr Sherman), and School of Public Health (Dr Polansky), Allegheny University of the Health Sciences, Philadelphia, Pa.

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