Asthma 2009: Overview of Asthma Prevalence & Mortality

Karen Meyerson, MSN, RN, FNP-C, AE-C

Asthma Network of West MichiganApril 21, 2009

Prevalence of Asthma Among Michigan Children (<18 Years), 2007

11.3

7.7

10.6

16.8

11.6

8.1

9.5

0 2 4 6 8 10 12 14 16 18 20

Male

Female

Hispanic

NH Other

NH Black

NH White

Total

Percent

MI BRFS, 2007

Prevalence of Asthma Among Michigan Adults (18 Years), 2007

7.9

11.0

14.5

11.1

12.9

8.7

9.5

0 2 4 6 8 10 12 14 16

Male

Female

Hispanic

NH Other

NH Black

NH White

Total

Percent

MI BRFS, 2007

Prevalence of Asthma for Adults (18 Years) by Indicators of Socioeconomic Status, Michigan, 2007

10.5 11.0 9.3 8.40

4

8

12

16

20

Per

cen

t

< High SchoolHigh School GraduateSome CollegeCollege Graduate

MI BRFS, 2007

8.6 9.9 7.1 8.913.30

4

8

12

16

20

Perc

en

t

<20,00020,000-34,99935,000-49,99950,000-74,99975,000+

Education Income

Prevalence of Asthma Among Michigan

Adults (18 Years) by County, 2005

MI BRFS, 2005

Percent of Children with Persistent

Asthma by County of Residence, Medicaid,

Michigan, 2005

1. Source: Data Warehouse, 2005, MDCH

2. Persistent asthma and asthma medications defined according to NCQA HEDIS

3. Age-adjusted to 2000 US Std Population

4. Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months) in Medicaid with full coverage and no other insurance.

Rates of Hospitalization due to Asthma by Sex, by Race and by Age Group, Michigan, 2004-2006

*Age adjusted to the 2000 US standard population. Sources: 2004-2006 Michigan Inpatient Database & 2005 MI population estimates, MDCH

13.4

19.3

11.3

46.9

45.6

15.3

7.3

16.2

24.1

16.6

0 10 20 30 40 50

Male*

Female*

White*

Black*

0 to 4

5 to 14

15 to 34

35 to 64

65+

Total*

Rate per 1,000,000

Rates* of Hospitalization due to Asthma by Race and Income, Michigan, 2000-2002

34.7

15.3

56.3

13.6 11.3

36.1

8.4 8.4

19.6

0

10

20

30

40

50

60

Total White Black

Low Income

Middle Income

High Income

*Uses 2000 MI population and is age adjusted to the 2000 US standard population.Source: 2000-2002 Michigan Inpatient Database, MDCH

Rate

per

10,0

00

Asthma Hospitalization Rates* by Age-Race Group and Year, All Ages, Michigan, 1990-2006

0

20

40

60

80

100

90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06

White, Child White, Adult

Black, Child Black, Adult

*Uses MI population estimates, 1990-2006 and is age adjusted to the 2000 US standard population. Source: 1990-2006 Michigan Inpatient Database, MDCH.

Ra

te p

er

10

,00

0

*Insufficient data to compute a stable rate, 20 Events or < 5000 Population**Uses 2005 MI population estimates and is age adjusted to the 2000 US standard population. Source: 2004-2006 Michigan Inpatient Database, MDCH

White Black

Asthma Hospitalization Rates** by Race and County of Residence, All Ages, Michigan, 2004-2006

Emergency Department Reliance

Methodological Notes:All asthma outpatient visits (office, urgent

care, and Emergency Department), ICD-CM-9 493.xx

Among these, the percent of asthma visits that occurred in the emergency department

Interpretation of the IndicatorX% of outpatient asthma visits that occurred

in the emergency department for children in Medicaid with persistent asthma

Percent Reliance on Emergency Department by Race among Children with Persistent Asthma,

Medicaid, Michigan, 2001-2005

10

20

30

40

50

2001 2002 2003 2004 2005

Total Black White

1. Source: Data Warehouse, 2001-2005, MDCH2. Persistent asthma and asthma medications defined according to NCQA HEDIS 3. Age-adjusted to 2000 US Std Population4. Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months)

in Medicaid with full coverage and no other insurance.

Percent Reliance on Emergency

Department by Race among Children with Persistent Asthma, Medicaid, Michigan,

2005

1. Source: Data Warehouse, 2005, MDCH

2. Persistent asthma and asthma medications defined according to NCQA HEDIS

3. Age-adjusted to 2000 US Std Population

4. Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months) in Medicaid with full coverage and no other insurance.

Proportion with Overuse of SABA Medication

Methodological Notes:SABA medications defined by NCQA HEDIS list

of asthma medicationsOveruse defined as >6 filled prescriptions of

SABA filled in 12 months

Interpretation of the IndicatorX% of children in Medicaid with persistent

asthma filled >6 prescriptions for SABA medication

Percent of Overuse of Short-Acting -Agonist Medication among Children with Persistent

Asthma, Medicaid, Michigan, 2001-2005

10

13

16

2001 2002 2003 2004 2005

Total Black White

1. Source: Data Warehouse, 2001-2005, MDCH2. Persistent asthma and asthma medications defined according to NCQA HEDIS 3. Age-adjusted to 2000 US Std Population4. Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months)

in Medicaid with full coverage and no other insurance.

Proportion taking Inhaled Corticosteroid Medication

Methodological Notes: Inhaled corticosteroid (ICS) medications defined by

NCQA HEDIS list of asthma medications ICS use defined as 1 filled prescriptions of ICS filled in

12 months ICS includes bronchodilator combination therapy

Interpretation of the Indicator X% of children in Medicaid with persistent asthma filled

1 prescriptions for ICS medication

Percent of Children with Persistent Asthma with 1 Inhaled Corticosteroid or Bronchodilator Combination

by Race, Medicaid, Michigan, 2001-2005

40

50

60

2001 2002 2003 2004 2005

Total Black White

1. Source: Data Warehouse, 2001-2005, MDCH2. Persistent asthma and asthma medications defined according to NCQA HEDIS 3. Age-adjusted to 2000 US Std Population4. Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months)

in Medicaid with full coverage and no other insurance.

Rates of Mortality due to Asthma by Sex, by Race and by Age Group, Michigan, 2004-2006

*Age adjusted to the 2000 US standard population.Data Source: Michigan Resident Death Files & 2005 MI population estimates, MDCH.

10.3

14.3

9.7

28.7

5.6

6.7

12.4

42.9

12.6

0 10 20 30 40 50

Male*

Female*

White*

Black*

5 to 14

15 to 34

35 to 64

65+

Total*

Rate per 1,000,000

Thirty-Two Deaths from Asthma in Michigan 2002, Age 2 - 34

Demographics

Age <19 38% Male 59% African-American 56% High School Graduate 70% Wayne County 44% Pronounced Dead Prior to Hospitalization 84% Medical Insurance 78%

Thirty-Two Deaths from Asthma in Michigan 2002, Age 2 - 34

Tox/Alcohol Screen 0%

Steroids 50%

Prior Intubation 13%

Prior Hospitalization 48%

Treated in ED 80%

Allergist 38%

Pulmonologist 40%

PFTs 33%

Peak Flow Meter 63% Used Regularly 13%

Asthma Management Plan 0%

BMI > 30 37%

Type 2 – 18%

Medical History

Causal Factors Based on 18 Deaths Reviewed for Adults (ages 19-34), Michigan 2002

Doctor

Inadequate prescription of steroids 11

Needed referral or inadequate diagnosis for high risk patients 5

Patient

Compliance 9

Inadequate use of steroids 7

Obesity 3

Lack of prior diagnosis 2

Depression 1

Allergic reaction 1

Aspirin sensitivity 1

Society

Lack of insurance 5

Health insurance would not pay for referral 1

Job/heat 1

Suggested Intervention Based on 18 Deaths Reviewed for Adults (ages 19-34), Michigan 2002

Educate Health Care Providers Steroids 8 Referrals 3 Pulmonary function tests 2Educate Patients Steroids 6 Provide education in ED 3 Aspirin 1Society Case manager 5 Insurance 5 Public awareness 2 Regulation insurance companies on referrals Labeling aspirin products 1Medical Examiners Criteria for asthma deaths 4

Issues Not Foundto be ImportantPreviously Reported in Literature

Issues Consistentwith FactorsPreviously Reported in Literature

Substance abuse

Psychological problems

Lack of peak flow meter

African American Low income Lack of steroids

Summary of Risk Factors for Fatal and Near-Fatal Asthma from

Medical Literature

Risk Factors Reportedwith Fatal Asthma

Risk Factors ReportedWith Near-Fatal Asthma

Lack of steroid inhalers Diagnosis of asthma < 5 years African-American Stress Low income Hx intubation Lack of peak flow meter Hx previous hospital

admission Blunted perception of dyspnea Hx allergy and atopy

> 90% on steroids

Blunted perception of dyspnea

Symptoms of wakening at night Air conditioning at home

Risk Factors for Death from Asthma – EPR-3

Asthma History

Previous Severe Exacerbation (i.e., intubation or ICU admission)

2 or more hospitalizations within the past year

3 or more ED visits in the past year

Hospitalization or ED visit in the last month

Using > 2 canisters of SABA in the last month

Poor perception of symptoms or severity of exacerbation

Lack of a written asthma action plan

Sensitivity to Alternaria

Summary

Asthma deaths – relatively rare

Death occurring prior to hospitalization

Generally preventable

MORE INHALED STEROIDS

Questions?

Karen Meyerson, MSN, RN, FNP-C, AE-C

Phone: 616-685-1432 E-mail: meyersok@trinity-health.org Websites:

www.asthmanetworkwm.org

www.GetAsthmaHelp.org

Asthma 2009: Asthma Guidelines and Goals of Therapy

Karen Meyerson, MSN, RN, FNP-C, AE-C

Asthma Network of West Michigan

April 21, 2009

Acknowledgements: LeRoy M. Graham, MD, Atlanta, GA

Allan T. Luskin, MD, Madison, WI

1997…

2002…

Guidelines For The Diagnosis and Management of Asthma (EPR-3)

Expert Panel Report 3

National Heart, Lung and Blood Institute

(NHLBI)

National Asthma Education and Prevention Program

(NAEPP)

August 29, 2007

…2007

Asthma Assessment and Monitoring:Key Differences from 1997 and 2002

Key elements of assessment and monitoringSeverityControlResponsiveness to treatment

Severity emphasized for initiating therapy

Control emphasized for monitoring and adjusting therapy

Severity and control defined by 2 domains:ImpairmentRisk

Severity & Control are assessed based on 2 domains:

Impairment (present) frequency and intensity of symptoms functional limitations (quality of life)

Risk (future) asthma exacerbations (utilization) progressive loss of pulmonary function (lung growth) risk of adverse reaction from medication

NAEPP Draft Report, ERP 2007

EPR-3, p38-80, 277-345

Domain: Impairment

What the patient tells US in terms of frequency and intensity of symptoms.

This is the disruption of their ability to function or current limitations in their lives due to asthma.

Impairment is the burden of illness.

Goals of Asthma TherapyReducing Impairment

Prevent chronic and troublesome symptoms

Require infrequent (<2x/week) use of rescue therapy

Maintain (near) normal lung function

Maintain normal activity levels

Meet patients’ and families’ expectation of and satisfaction with asthma care

Domain: Risk

What we tell PATIENTS

This is the likelihood of asthma exacerbations,

progressive decline in lung function or risk of

adverse effects from medications - examples:

LABA may decrease impairment but may

increase risk

ICS may decrease impairment but also decrease

risk

Goals of Asthma TherapyReducing Risk

Reduce recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations

Prevent progressive loss of lung function; for children, prevent reduction of lung growth

Provide pharmacotherapy with minimal or no adverse effects

Asthma: Establishing and Maintaining ControlPeriodic Assessment and Monitoring

Monitor signs and symptoms of asthma

Monitor pulmonary functionSpirometryPeak Flow Monitoring

Monitoring quality of life

Monitoring history of asthma exacerbations

Monitoring pharmacotherapy for adherence and side effects

Questions?

Download the Guidelines at:

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

Download the Summary Report at:

http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf