Objective: To examine the prescribed asthma medications for inner-city children with severe asthma as an indicator of the quality of asthma care. Design:Multi-center cross-sectional survey. Data were collected by in-person interview of the child's caretaker. Setting: Eight study sites in seven major metropolitan U.S. inner cities. Participants: Asthmatic children ages 4 to 9 years and their caretakers. Subjects resided in census tracts in which at least 30% of the households were at or below the 1993 federal guidelines for poverty. Results: Severe asthma was defined as reported use of 2 or more asthma medications simultaneously, any hospitalizations, or two or more emergency visits in the past year. Of the 1376 children with physician diagnosed asthma, 284 (22%) met the study definition of severe asthma. Subjects were predominantly African-American(73.9%) or Hispanic (19.5%). Seventy-four percent reported Medicaid, 7% had no insurance, and the remainder had private or HMO coverage. Nearly all subjects reported having access to a usual site of acute (95.6%) and routine (96.7%) asthma care. The ED was the reported site of acute care for significantly more children with severe asthma(84.3%) compared to those with non-severe asthma (63%) (p< 0.01). Over 98% of those with severe asthma used oral or inhaled β -agonists; for 14% it was the only medication used. Less than half (47.5%) used anti-inflammatory medications (cromolyn or inhaled steroids). Only 18% used a peak flow meter, and 53% of those prescribed an MDI also reported using a spacer device. Among the non-severe patients, only 1.4% used anti-inflammatory medications. There was no significant difference in medication use by insurance status. Conclusion: Despite good access to health care, children with severe asthma do not receive chronic preventative medications or devices considered necessary for adequate medical management. Inadequate treatment may contribute to morbidity among these children.funded by National Institute of Allergy and Infectious Diseases, NIH