 |
|
In the United States, Blacks and Asian/Pacific Islanders Are More Likely Than Whites to Seek Medical Care for Atopic Dermatitis
Shirisha R. Janumpally, MD;
Steven R. Feldman, MD, PhD;
Aditya K. Gupta, MD, FRCP;
Alan B. Fleischer, Jr, MD
Arch Dermatol. 2002;138:634-637.
ABSTRACT
| |
Background There have been population-based studies conducted in England and the
United States that suggest an increase in prevalence of atopic dermatitis
among black and/or Asian children.
Objective To assess whether health care utilization for atopic dermatitis differs
among different ethnic groups in the United States.
Design Weighted data on representative office visits by whites, blacks, and
Asian/Pacific Islanders were analyzed using a cross-sectional study, the National
Ambulatory Medical Care Survey (NAMCS), from 1990 through 1998 using statistical
software.
Setting The NAMCS is an ongoing data collection effort by the Division of Health
Care Statistics, National Center for Health Statistics, Centers for Disease
Control and Prevention. The survey samples representative visits to US office-based
physicians during a representative week of practice.
Patients All outpatient visits were analyzed and compared with those for patients
diagnosed as having atopic dermatitis (International Classification
of Diseases, Ninth Revision, Clinical Modification, code 691.80).
Main Outcome Measure Diagnosis of atopic dermatitis by race.
Results Of 570 million estimated visits for skin conditions, 7.9 million were
for atopic dermatitis. The numbers of per capita visits for atopic dermatitis
among blacks and Asian/Pacific Islanders were 2-fold and 6-fold higher, respectively,
than among whites. The odds ratios (95% confidence intervals) for atopic dermatitis
visits by blacks and Asian/Pacific Islanders relative to whites were 3.4 (2.5-4.7)
and 6.7 (4.8-9.5), respectively.
Conclusions Blacks and Asian/Pacific Islanders are much more likely to visit physicians
for atopic dermatitis than are whites and may benefit from education and early
intervention efforts concerning the disease.
INTRODUCTION
SEVERAL POPULATION-BASED studies suggest that atopic dermatitis is common
in black and Asian/Pacific Islander children. Williams et al1
reported a 2-fold difference in the prevalence of atopic dermatitis between
black Caribbean children and white children born in London, England. Similarly,
a local US study found an increased prevalence of atopic dermatitis in black
patients.2 Another British study suggested
similar findings in infants of West Indian origin living in South East London.3
The aforementioned studies are prevalence studies, and one might predict
differential health care utilization among different ethnic groups if the
prevalence differences are significant. A retrospective analysis of 5912 patients
in a Kaiser Permanente pediatric practice based in San Diego, Calif, suggests
there is an increase in health care utilization for atopic dermatitis in patients
of Asian origin, the highest levels being in Filipino patients.4
Even though prior studies have suggested an increase in prevalence of
atopic dermatitis among blacks and Asian/Pacific Islanders compared with whites,
an analysis at a national level in any country of a representative sample
of patients has never been conducted. Therefore, we sought to assess the relative
disparity between the number of visits for atopic dermatitis among blacks
and Asian/ Pacific Islanders compared with whites using the data from the
National Ambulatory Medical Care Survey (NAMCS).5
Although health utilization information is not analogous to incidence or prevalence,
it has significance for both.
METHODS
Data were compiled from the US NAMCS from 1990 through 1998. The NAMCS
is conducted by the Division of Health Care Statistics, National Center for
Health Statistics, Centers for Disease Control and Prevention.5
The survey samples representative visits to US office-based physicians during
a representative week of practice. The sample of physicians includes both
dermatologists and nondermatologists. Government-run practices (such as Veterans
Affairs facilities) are not included. The survey does not attempt to follow
up with individual patients over multiple visits. The data are weighted to
produce national estimates that describe the utilization of ambulatory medical
care services in the United States.
The NAMCS identifies 4 racial classifications: whites, blacks, Asian/Pacific
Islanders, and American Indian/Eskimo/Aleuts. We excluded the data for American
Indian, Eskimo, and Aleuts because their total number of atopic dermatitis
visits (approximately 11 000) was not reliably estimated using this survey.
Similarly, we did not analyze proportions of the population identified as
being Hispanic since there were only an estimated 74 500 atopic dermatitis
visits among Hispanics, also below the threshold for reliable estimation.
Dermatologic or skin condition visits were operationally defined as those
having International Classification of Diseases, Ninth Revision,
Clinical Modification codes as listed in Table 1. Data from the 1994 US Census6
(midpoint between 1990 and 1998) were used to calculate per capita inferences.
Data manipulation and analyses were performed using SAS (Cary, NC) and STATA
(College Station, Tex) systems. Categorical analysis and logistic regression
procedures that take into account sampling variability were used to calculate
the estimates.
|
|
|
|
Table 1. International Classification of Diseases,
Ninth Revision, Clinical Modification Skin Condition Diagnoses
|
|
|
RESULTS
From 1990 through 1998, there was an estimated total of 6.6 billion
office visits for all conditions, cutaneous and otherwise: 5.7 billion (86.4%)
among whites, 630 million (9.6%) among blacks, and 220 million (3.4%) among
Asian/Pacific Islanders (Table 2). Of approximately 570 million estimated skin visits, 500 million (87.6%) were
by whites, 47 million (8.2%) by blacks, and 20 million (3.5%) by Asian/Pacific
Islanders. Blacks and Asian/Pacific Islanders accounted for 20.1% and 16.1%
of visits for atopic dermatitis, respectively.
|
|
|
|
Table 2. National Ambulatory Medical Care Survey 1990-1998 Estimates
of Physician Office Visits for 3 Racial Groups*
|
|
|
Table 2 presents per capita
estimates of numbers of visits for all skin conditions and several individual
skin conditions. While the per capita number of office visits for all medical
conditions and all skin conditions were highest for whites, blacks and Asian/Pacific
Islanders had higher per capita numbers of visits for atopic dermatitis (Table 2; Figure 1).
|
|
|
|
Figure 1. Proportion of visits in each race.
Error bars represent 95% confidence intervals.
|
|
|
We performed logistic regression using the total number of estimated
visits for all conditions and the estimated number of atopic dermatitis visits
for blacks and Asian/Pacific Islanders compared with whites. The calculated
odds ratios (95% confidence intervals) for visits of blacks vs whites was
3.4 (2.5-4.7; P<.001), whereas for Asian/Pacific
Islanders vs whites it was 6.7 (4.8-9.5; P<.001).
Female patients accounted for a greater proportion of estimated atopic
dermatitis visits than male patients in all 3 groups. Among whites, 50.8%
of atopic dermatitis visits were by female and 49.2% by male patients. Among
blacks, female patients accounted for 62.9% of visits compared with 37.1%
male. Finally, among Asian/Pacific Islanders, 55.9% of atopic dermatitis visits
were by female patients, whereas 44.1% of visits were by male patients.
To further assess the variation in atopic dermatitis visits in different
ethnic groups, we examined the relative number of visits for other diagnoses—including
actinic keratosis, acne, psoriasis, and common warts—as controls (Table 2; Figure 2). For these common dermatologic conditions, whites had
greater numbers of per capita visits than blacks and Asian/Pacific Islanders
for all conditions, with the only exception of more acne visits by Asian/Pacific
Islanders.
|
|
|
|
Figure 2. Per capita annual visits by dermatologic
condition.
|
|
|
COMMENT
Blacks and Asian/Pacific Islanders were more likely to make office visits
for atopic dermatitis than whites. Blacks are 3 times more likely and Asian/Pacific
Islanders almost 7 times more likely than whites to make office visits at
which atopic dermatitis is diagnosed. These differences are clearly not due
to greater health care utilization in general by blacks or Asian/Pacific Islanders.
We found that whites had a greater number of per capita visits for all medical
conditions and all skin conditions. Given the overall lower health care utilization
among blacks and Asian/Pacific Islanders, the observed higher utilization
for atopic dermatitis is striking.
Genetic, cultural, and physical factors contribute to the incidence
and prevalence of atopic dermatitis.1, 7-9
The factors that have been mentioned include increased susceptibility to the
irritant effects of repeated washing, increased sensitivity to antigens such
as house dust mites, early infant feeding practices, differences in access
to medical care, and differences in staphylococcal colonizations predisposing
children of black or related descent and Asian descent to atopic dermatitis.
The lack of familiarity of Asian/Pacific Islanders with atopic dermatitis
could also contribute to increased visits.10
Environmental factors may play a role as well. Studies conducted in
Hawaii11 and New Zealand12
claim that migrant populations there have shown large increases in atopic
dermatitis compared with people of similar genetic groups in their country
of origin. These studies suggest that exposure to new or a larger pool of
allergens, or other factors associated with urbanization, could cause such
differences between the groups. However, Williams et al1
note that the prevalence of atopic dermatitis is increased in black Caribbean
residents born in England.
Differences in health care utilization do not necessarily imply differences
in disease prevalence. Previously, increased consultation rates for atopic
dermatitis were identified in Asian children, but the prevalence of atopic
dermatitis in this population was similar to that of other ethnic groups.10 The International Classification
of Diseases, Ninth Revision, Clinical Modification coding used in the
NAMCS does not provide information on the severity and duration of atopic
dermatitis, and these factors could affect health care utilization. Differences
in postinflammatory pigment changes might also affect health care utilization
in the different groups. This study is dependent on the diagnosis made by
the physician, and we do not know whether physicians diagnose atopic dermatitis
differently in these different populations.
In general, there is lower health care utilization among blacks than
other groups at least partly because of insurance status. In 1999, among Americans
younger than 65 years, 21% of blacks were uninsured compared with 14% of whites.13 Because of insurance status, blacks are more likely
to go to emergency departments for most of their medical care rather than
use office-based care.14-15 Therefore,
blacks may be even more likely to make visits for atopic dermatitis than the
estimated proportions if they used emergency department care more often.
At least 1 published report suggests that Asian/Pacific Islanders have
fewer per capita physician office visits than whites.16
We did not confirm this conclusion, finding that the relative proportions
of all medical and all skin visits were roughly comparable to the population
projections in these 2 groups. Nevertheless, general health care utilization
patterns did not explain the greater per capita number of atopic dermatitis
visits in the Asian/Pacific Islander group.
An important limitation of this study that we cannot overemphasize is
the limited specificity of ethnic background in the NAMCS. There may be major
differences within the limited ethnic categories used by the NAMCS (for example,
the Asian/Pacific Islander group includes Chinese, Indian, Korean, Filipino,
and many others). Differences between different subgroups could have opposing
effects on health care utilization. While we recognize that this is a major
limitation of this study, the NAMCS does not include more specific ethnic
information.
The findings of the present study have implications for differences
in incidence, prevalence, and/or severity of atopic dermatitis among different
ethnic groups. The results also suggest potential target populations for information
and perhaps early intervention efforts regarding atopic dermatitis. We hope
the implications of this study promote further investigation into the genetic
and behavioral factors that underlie the differences we have observed.
AUTHOR INFORMATION
Accepted for publication August 2, 2001.
This study would not have been possible without the guidance and support
of Joseph L. Jorizzo, MD, and his long-standing commitment to advanced research
computing.
Corresponding author: Alan B. Fleischer, Jr, MD, Department of Dermatology,
Wake Forest University School of Medicine, Winston-Salem, NC 27157 (e-mail: afleisch{at}wfubmc.edu).
From the Bristol-Myers Squibb Center for Dermatology Research and Department
of Dermatology, Wake Forest University School of Medicine, Winston-Salem,
NC (Drs Janumpally, Feldman, and Fleischer); Division of Dermatology, Department
of Medicine, Sunnybrook and Womens' College Health Sciences Center, University
of Toronto, Toronto, Ontario (Dr Gupta).
REFERENCES
| |
1. Williams HC, Pembroke AC, Forsdyke H, Boodoo G, Hay RJ, Burney PG. London-born black Caribbean children are at increased risk of atopic
dermatitis. J Am Acad Dermatol. 1995;32:212-217.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
2. Schachner L, Ling LS, Press S. A statistical analysis of a pediatric dermatology clinic. Pediatr Dermatol. 1983;1:157-164.
PUBMED
3. Davis LR, Marten RH, Sarkany I. Atopic eczema in European and Negro West Indian infants in London. Br J Dermatol. 1961;73:410-414.
PUBMED
4. Baker RP. Incidence of atopic dermatitis and eczema by ethnic group seen within
a general pediatric practice. Available at:
http://www.kaiserpermanente.org/medicine/permjournal/winter99pj/winter99pjatopic.html. Accessed February 15, 2002.
5. Division of Health Care Statistics, National Center for Health Statistics,
Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey (NAMCS). Available at:
ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NAMCS/. See doc93.exe through doc98.exe. Accessed February 15, 2002.
6. US Census Bureau. Resident population estimates of the United States by sex, race, and
Hispanic origin. Available at:
http://eire.census.gov/popest/archives/national/nation3/intfile3-1.txt. Accessed February 15, 2002.
7. Palacios JJ, Sachno R, Blaylock WK. Inheritance patterns in patients with asthma, allergic rhinitis, and
eczema. South Med J. 1968;61:1172-1174.
PUBMED
8. Noble WC. Carriage of Staphylococcus aureus and beta
hemolytic streptococci in relation to race. Acta Derm Venereol. 1974;54:403-405.
WEB OF SCIENCE
| PUBMED
9. Bowker NC, Cross KW, Fairburn EA, Wall M. Sociological implications of an epidemiological study of eczema in
the city of Birmingham. Br J Dermatol. 1976;95:137-144.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
10. George S, Berth-Jones J, Graham-Brown RA. A possible explanation for increased referral of atopic dermatitis
from the Asian community in Leicester. Br J Dermatol. 1997;136:494-497.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
11. Worth RM. Atopic dermatitis among Chinese infants in Honolulu and San Francisco. Hawaii Med J. 1962;22:31-35.
12. Waite DA, Eyles EF, Tonkin SL, et al. Asthma prevalence in Tokelauan children in two environments. Clin Allergy. 1980;10:71-75.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
13. Medical Expenditure Panel. Medical Expenditure Panel Survey: The Uninsured in
America—1999. Available at: http://www.meps.ahrq.gov/papers/hl13_010023/hl13.pdf. Accessed February 15, 2002.
14. Neighbors HW, Jackson JS. Barriers to medical care among adult blacks: what happens to the uninsured? J Natl Med Assoc. 1987;79:489-493.
PUBMED
15. American Medical Association. Report on racial and ethnic disparities in health care. Available at: www.ama-assn.org/ama/downloads/minority/html/263.html. Accessed February 7, 2002.
16. Yu ES, Cypress BK. Visits to physicians by Asian/Pacific Americans. Med Care. 1982;20:809-820.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
RELATED ARTICLE
Have You Ever Seen an Asian/Pacific Islander?
Hywel C. Williams
Arch Dermatol. 2002;138(5):673-674.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Atopic Dermatitis in Children in the United States, 1997 2004: Visit Trends, Patient and Provider Characteristics, and Prescribing Patterns
Horii et al.
Pediatrics 2007;120:e527-e534.
ABSTRACT
| FULL TEXT
Perinatal Predictors of Atopic Dermatitis Occurring in the First Six Months of Life
Moore et al.
Pediatrics 2004;113:468-474.
ABSTRACT
| FULL TEXT
Have You Ever Seen an Asian/Pacific Islander?
Williams
Arch Dermatol 2002;138:673-674.
FULL TEXT
|
