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Most Marginalized Children with Uncontrolled Asthma Miss Specialist Care
In an interview, investigators Emily Aman, MPH, and Rachel White highlight why marginalized children with uncontrolled asthma rarely see specialists.
Children in marginalized communities with poorly controlled asthma rarely receive guideline-recommended specialist care, with fewer than 2 in 10 seeing a pulmonologist or allergist in the prior year despite meeting clear criteria for referral.
“I think there could be room for more education on the role of specialists and their expertise in managing this condition,” said investigator Emily Aman, MPH, from the University of Rochester Medical Center, in an interview with HCPLive. “A lot of it also goes back to communication and health literacy as well.”
Aman and colleagues conducted a sub-analysis of the Telemedicine Enhanced Asthma Management–Uniting Providers (TEAM-UP) trial, which had enrolled children from Rochester, New York, with uncontrolled asthma. Among 325 children aged 4 to 12 years, only 37% had ever seen an asthma specialist, and just 16% had done so within the previous 12 months.
The cohort was predominantly publicly insured (80%), with 58% identifying as Black and 35% as Hispanic. Although Black children made up more than half of the overall sample, they accounted for only 39% of those who had ever received specialist care, highlighting a clear racial disparity in access.
Children who received pulmonology or allergy care were more likely to come from households with higher income (≥ $35,000 annually), greater caregiver education levels, and married or partnered caregivers. These children were also younger and more frequently identified as Hispanic. Insurance status alone did not appear to overcome these structural factors.
Caregiver awareness of a referral from a primary care clinician substantially increased the likelihood that a child had seen a specialist in the past year. However, only 23% of caregivers reported that their child had been referred at all. The findings also point to gaps in communication, health literacy, and follow-through between primary care, families, and specialty services.
Environmental and comorbid factors further contextualized unmet need. Among children who had not seen a specialist, 38% had caregiver-reported allergic rhinitis and 42% had smoke exposure in the home, both well-established contributors to poor asthma control. These characteristics were also common among children who did receive specialty care, reinforcing that all children in the cohort met guideline thresholds for referral regardless of comorbidity burden.
The data highlight a mismatch between evidence-based recommendations and real-world practice, suggesting that improving referral processes, caregiver education, and system-level support may be as essential as expanding specialist capacity to reduce inequities in pediatric asthma outcomes.
“What's important is that these are not only national but also global guidelines that they all of these children should have equal access to seeing a specialist,” investigator Rachel White, from the University of Rochester Medical Center, told HCPLive. “There shouldn't be any priority based on whether or not you also have allergic rhinitis or how much smoke…you have in the home. All of these children… should be able to see an asthma specialist.”
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