Asthma Hospitalizations in the NCR

ASTHMA HOSPITALIZATIONS IN THE NATIONAL CAPITAL REGION, 2004-2006

A Report created collaboratively by the National Capital Region Asthma Partnership

May 2010

Acknowledgments

National Capital Region Asthma Partnership Agencies DC Control Asthma Now (DC CAN) Staff

Anjali Talwalkar, MD, MPH Deputy Director of Policy and Programs Principal Investigator Edwina V. Davis-Robinson, MS, CHES Asthma Program Manager

LaVerne Hawkins Jones, MPH Asthma Program Epidemiologist

Maryland Asthma Control Program Staff

Cheryl De Pinto, MD, MPH Medical Director, Child, Adolescent, and School Health Principal Investigator Yvette McEachern, MA Director, Federal-State MCH Partnerships Asthma Program Manager Rachel Hess-Mutinda, MSW Asthma Program Coordinator Linda Nwachukwu, MPH Asthma Epidemiologist

Authors

Linda Nwachukwu, MPH Epidemiologist, DHMH

LaVerne Hawkins Jones, MPH Epidemiologist, DOH

District of Columbia Department of Health (DOH)

Community Health Administration (CHA) Adrian M. Fenty, Mayor

Pierre Vigilance, MD, MPH, Director, DOH

LaQuandra S. Nesbitt, MD, MPH, Senior Deputy Director, CHA

Maryland Department of Health and Mental Hygiene (DHMH) Family Health Administration (FHA)

Martin O’Malley, Governor

Anthony G. Brown, Lieutenant Governor

John M. Colmers, Secretary, DHMH

Russell W. Moy, MD, MPH, Director, FHA

Background

National Capital Region Asthma Partnership

Asthma Hospitalizations in the National Capital Region

Asthma Overview

Asthma is a common, yet complex, chronic disease characterized by hyper responsiveness of the airways to certain triggers resulting in inflammation of the airways, reversible airway constriction, and excess mucus secretion. The resulting airway narrowing causes the clinical symptoms of wheezing, coughing, tightness of the chest, and difficulty breathing. Common asthma triggers include allergens, irritants, respiratory infections, physical exercise, or stress. Triggers, symptoms, and episodes of asthma exacerbation vary from person to person.

In 2007, asthma affected 24.4 million adults and 9.6 million children,1 and accounted for about 444,000 hospitalizations nationwide.2 The hospitalization rate, a population-level marker of asthma severity, remains high and generates nearly one-half of all US health care costs for asthma.3

Despite the publication of national consensus guidelines for asthma diagnosis and management, there is considerable variation in the hospitalization rates for asthma within and between jurisdictions in the National Capital Region. The identification of the determinants of variation in hospitalization rates may be used to guide the development of strategic interventions to improve asthma outcomes, including improved self-management and reduced hospital-based health care utilization.

National Capital Region Overview

For this report, the National Capital Region (NCR) is defined as the District of Columbia (District) and neighboring Maryland jurisdictions. At the time of publication, data was not available for Virginia. This region is home to over two million residents who routinely cross jurisdictional lines to work, attend school, participate in recreational activities, patronize local business and a variety of other services, including health care. Shared natu-ral resources like water and air serve the needs of its citizens. They also share the burden of elevated chronic disease rates, including asthma.

Government agencies, non-profit organizations, and businesses have a long track record of partnering to address the environmental health and human services needs of the NCR. Recognizing the epidemic of asthma and its impact on each respective jurisdiction, the DC Department of Health, Community Health Administration, Asthma Control Program, DC Control Asthma Now (DC CAN), and the Maryland Department of Health and Mental Hygiene’s Family Health Administration, Center for Maternal and Child Health, Asthma Control Program (MACP) resolved to establish a regional partnership to identify strategies to address cross-cutting public health and environmental issues that increase the burden of asthma.

This study was designed and conducted collaboratively by DC CAN and MACP to (1) document the presence and magnitude of regional differences in hospitalization rates for asthma in the National Capital Region; (2) examine factors associated with the hospitalization rate variations; (3) provide insights into the social and economic structure of the populations that cross jurisdictions to access health care services; and (4) enable the region to explore opportunities for collaborative interventions such as improved indoor air quality through healthy homes, increased public awareness of the importance of asthma self-management, and expanded implementation of national consensus guidelines for asthma diagnosis, and management by health care providers.

1Pleis JR, Lethbridge-Çejku M. Summary health statistics for U.S. adults: National Health Interview Survey, 2007. National Center for Health Statistics. Vital Health Stat 10(240). 2009. 2DeFrances CJ, Lucas CA, Buie VC, Golosinskiy A. 2006 National Hospital Discharge Survey. National health statistics reports; no 5. Hyattsville, MD: National Center for Health Statistics. 2008. 3Smith, D. H., D. C. Malone, K. A. Lawson, L. J. Okamoto, C. Battista, and W. B. Saunders. 1997. A national estimate of the economic costs of asthma. Am. J. Respir. Crit. Care Med. 156: 787-793.

Methods

Page 4



Data presented in this report represents hospitalizations or hospital discharges of District and Maryland residents from 2000 through 2006 from the District of Columbia State Health Planning and Development Agency (SHPDA), Maryland Health Services Cost Review Commission (HSCRC), and Maryland Health Care Commission (MHCC), respectively. Hospitalization data was collected for billing and other administrative purposes, rather than surveillance purposes. As a result, there is the potential for incorrect diagnoses, inconsistent coding, and misclassification of information such as race. While these data exist for billing and other administrative purposes, they are valuable resources for health research containing a host of information. These hospital discharge collection systems compile information from non-federal, short stay, acute care hospitals regarding patient information including demographics (age, gender, race), patient residen-tial geographic information, admission and discharge dates, diagnostic and procedure codes, payer source, and some measure of monetary expenditure for the stay.

For this report, the unit of analysis was the discharge event, not the patient. All discharges with asthma as a principal diagnosis were selected based on the ninth revision of the International Classification of Diseases (ICD-9), codes 493.0-493.9. It is important to note that hospitalizations were expressed as numbers of discharges, not as unduplicated patients; as a result a single person with multiple hospitalizations can be counted more than once. Patient identifiers have been removed from these databases to preclude identification of individual patients.

Furthermore, some of the variables that would be of interest for surveillance such as education level or income, are not collected. Data on ethnicity are not available for hospitalization records in the District and are therefore excluded from analysis.

Three years of data were averaged to provide more stable estimates. The reference period is 2004 – 2006. A national reference point in the form of equivalent data for the United States as a whole is also included. The U.S. data are for 2005, the midpoint of the three-year period for data included in this report.

Asthma hospitalization rate trends are described for a seven-year period from 2000 to 2006 for the District, Baltimore City, the State of Maryland, and the United States. Though Baltimore City is not included in the National Capital Region, it is included in Figures 1 and 5 to allow for comparison of the District’s hospitalization rates with an urban area with similar demographic characteristics.

Unless stated otherwise, only hospitalizations for District residents who were admitted to District hospitals are included in the District residents only category and only hospitalizations for Maryland residents who were admitted to Maryland hospitals are included in the Maryland resident only category. For this report, the National Capital Region includes hospitalizations from the District and parts of the State of Maryland, specifically Prince George’s and Montgomery counties. These regions were included in this definition primarily due to their proximity. The National Capital Region category includes hospitalizations for District and Maryland residents who were admitted to either the specified counties in Maryland or District hospitals.

Hospitalization rates were calculated by gender, race, and age using three-year average population estimates from the National Center for Health Statistics Vintage 2006 population files, and are age-adjusted to the 2000 U.S. Census population.

Source: SHPDA, HSCRC; MHCC; National Hospital Discharge Survey

In 2006, there were approximately 1,383 hospitalizations due to asthma in the District and 9,674 hospitalizations due to asthma in Maryland. In the District, the age-adjusted hospitalization rate per 10,000 District residents decreased from 26.7 in 2000 to 25.7 in 2006. In Maryland, the age-adjusted hospitalization rate per 10,000 Maryland residents increased from 14.3 in 2000 to 17.2 in 2006.

Maryland asthma hospitalization rates were lower that U.S. rates from 2000 through 2004. All other regions were higher than the national rate (Figure 1). Maryland and national rates have been relatively steady from 2000 to 2006, while the District and Baltimore City experienced fluctuating rates for the same time span.1

Results



Figure 1: Asthma Hospitalization Rates, District of Columbia, Baltimore City, Maryland vs.

United States, 2000-2006

0

10

20

30

40

50

2000 2001 2002 2003 2004 2005 2006

Rate

per

10,

000

DC Baltimore City MD US

Between 2004 and 2006, Maryland residents hospitalized for asthma spent a total of 26,847 days in the hospital, with an average of 3.0 days per hospital stay. District residents hospitalized for asthma spent a total of 4,617 days in the hospital, with an average of 3.9 days per hospital stay. Per admission, children under the age of 5 years spent an average of 1.8 days in Maryland hospitals and 2.4 days in District hospitals, while adults age 65 and older spent, on average, 4.5 days in Maryland hospitals and 5.7 days in District hospitals for asthma.

1Though Baltimore City is not included in the National Capital Region, it allows for comparison of the District’s hospitalization rates with an urban area with similar demographic characteristics.

Tab

le 1

: A

ge-A

djus

ted

Ast

hma

Hos

pita

lizat

ion

Rat

es b

y D

emog

raph

ic C

hara

cter

istic

s of t

he N

atio

nal C

apita

l Reg

ion

and

Are

a Ju

risd

ictio

ns, 2

004-

2006

Page

6

Mar

ylan

d C

ount

ies

U

S‡ N

atio

nal

Cap

ital

Reg

ion†

Dis

trict

of C

olum

bia

All

Cou

ntie

s M

ontg

omer

y Pr

ince

Geo

rge’

s

D

istri

ct

Res

iden

ts

Onl

y

Non

-D

istri

ct

Res

iden

ts

Mar

ylan

d R

esid

ents

O

nly

Non

-M

aryl

and

Res

iden

ts

Mon

tgom

ery

Res

iden

ts O

nly

Mon

tgom

ery

R

esid

ents

seen

in

the

Dis

trict

Prin

ce G

eorg

e’s

R

esid

ents

Onl

y Pr

ince

Geo

rge’

s R

esid

ents

seen

in

the

Dis

trict

Num

ber

of

Hos

pita

lizat

ions

48

9,00

0 9,

929

3,58

4 1,

899

27,2

57

1,34

0 2,

264

218

2,57

9 1,

077

Rat

e pe

r 10,

000

16.6

14

.2

21.6

12

.4

16.3

0.

8 8.

1 2.

0 10

.8

7.2

Age

±

0

– 4

year

s old

--

32

.2

37.2

45

.7

37.4

1.

6 29

.7

6.7

11.8

26

.3

5

– 14

yea

rs o

ld

--

18.9

23

.4

31.5

14

.9

0.4

10.8

3.

1 4.

4 21

.5

15

– 34

yea

rs o

ld

--

4.9

5.7

2.9

6.7

0.4

2.9

0.2

4.5

1.3

35

– 64

yea

rs o

ld

--

14.0

26

.3

7.2

16.2

0.

9 5.

1 0.

5 12

.8

3.8

> 6

5 ye

ars o

ld

30.5

24

.8

31.9

8.

6 28

.5

1.6

14.0

2.

0 26

.3

3.5

Gen

der

Mal

e 13

.3

33.7

17

.9

13.9

13

.0

1.0

7.4

1.4

6.5

8.3

Fem

ale

19.7

48

.1

25.0

11

.0

19.3

0.

6 8.

7 1.

4 14

.7

6.2

Rac

e

Whi

te

--

38.0

2.

9 5.

5 11

.2

0.7

5.6

1.5

6.0

1.2

Bla

ck

--

45.7

27

.3

14.1

26

.9

1.0

15.4

0.

9 11

.2

9.6

Oth

er**

--

28

.3

85.1

88

.6

14.6

0.

2 11

.7

17.4

15

.1

41.4

So

urce

: H

SCR

C; M

HC

C; V

HI;

2005

Nat

iona

l Hos

pita

l Dis

char

ge S

urve

y.

‡ 20

05 d

ata

refe

rs to

the

mid

poin

t of t

he 3

-yea

r per

iod

cove

red

by o

ur lo

cal d

ata

year

. † H

ospi

taliz

atio

ns in

the

Nat

iona

l Cap

ital R

egio

n in

clud

e ho

spita

lizat

ions

from

the

Dis

trict

and

par

ts o

f the

Sta

te o

f Mar

ylan

d, sp

ecifi

cally

Prin

ce G

eorg

e’s a

nd M

ontg

omer

y co

untie

s.

± Age

gro

ups a

re n

ot a

ge-a

djus

ted

to th

e 20

00 U

.S. p

opul

atio

n.

**O

ther

race

cat

egor

y in

clud

es th

e ca

tego

ries A

sian

/Pac

ific

Isla

nder

s and

Nat

ive

Am

eric

ans/

Ala

skan

Nat

ives

Results - Continued

Page 7

Maryland National Capital Region Asthma Partnership


Figure 2: Asthma Hospitalization Rate, National Capital Region†, 2004-2006

0102030405060

White

Black

Other

Male

Female

0-4 yr

s

5-14 y

rs

15-34

yrs

35-64

yrs

65+ yr

sTota

l

Rat

e pe

r 10,

000

Asthma-related hospitalization rates for the NCR are highest at both ends of the age spectrum with the highest rate (32.2 per 10,000) among 0-4 year olds and the second highest rate (24.8 per 10,000) among persons 65 and older. Young adults 15-34 years old had the lowest rate of 4.9 per 10,000. Hospital discharge rates for asthma are approximately 30% higher among females (48.1 per 10,000) compared to males (33.7 per 10,000). Blacks experience asthma-related hospitalization rates 20% and 38% higher than whites and others, respectively.

Source: SHPDA, HSCRC, MHCC. † Hospitalizations in the National Capital Region include hospitalizations from the District and parts of the State of Maryland, specifically Prince George’s and Montgomery counties.

Between 2004 and 2006, a total of 10,865 days, with an average of 3.3 days, were spent in the NCR hospitals due to asthma. While children under the age of 5 years spent an average of 2.0 days, adults age 65 and older spent, on average, 4.9 days in the NCR hospitals for asthma.

In 2005, the midpoint for the study period, the asthma hospitalization rate for the nation as a whole was 16.6 per 10,000. Between 2004 and 2006, the rate of hospitalizations due to asthma in the National Capital Region was 14.2 per 10,000, a rate lower than the rate in the District alone (21.6 per 10,000), Maryland alone (16.3 per 10,000), and the nation as a whole. In contrast, asthma hospitalization rates for Prince George’s and Montgomery County residents are lower than the NCR hospitalization rate.

When comparing hospitalization rates occurring among patients seen within their home jurisdiction to rates for patients seen in neighboring jurisdictions, the rates were lower for both Prince George’s and Montgomery County residents seen in the District compared to rates for residents seen in their home jurisdictions (Table 1).

The hospitalization rates varied for both men and women, across five age groups, and for whites and blacks, as shown in Table 1. Children under the age of 5 years had the highest asthma hospitalization rates when compared to other age groups. with the exception of Prince George’s county residents seen in their home jurisdiction. Across all jurisdictions, adults age 65 and older also have relatively high rates of hospitalization due to asthma.

Women generally have higher rates of hospitalization due to asthma, except for hospitalizations outside of their home jurisdictions. For example, non-resident District hospitalizations and Prince George’s County resident hospitalizations in the District are higher among males.

Blacks across the NCR had an asthma hospitalization rate 20% higher than whites. This pattern is consistent across the region except among Montgomery County residents seen in the District.

Source: SHPDA, HSCRC, MHCC.

Results - Continued

Page 8



Source: SHPDA, HSCRC, MHCC.

Between 2004 and 2006, about 95% of hospitalizations due to asthma in Maryland were state residents. Montgomery and Prince George’s county residents made up 9.0% and 7.9% of those hospitalizations, respectively.

Less than 1% of hospitalizations seen in Maryland were District residents, the majority of which were seen in Prince George’s and Montgomery counties.

District residents were hospitalized in Maryland hospitals for 241 days, an average of 3.5 days per admission.

Figure 4: Proportion of Hospitalizations in Maryland due to Asthma, 2004-2006

78.4%

0.7%4.0% 7.9%

9.0%Prince George's CountyResidents

Montgomery CountyResidents

Other MarylandResidents

District Residents

Non-District & Non-Maryland Residents

Figure 3: Proportion of Hospitalizations in the District of Columbia due to Asthma, 2004-2006

65.4%4.0%

19.6%

2.7%8.3%

District Residents

Montgomery CountyResidents

Prince George's CountyResidents

Other MarylandResidents

Non-District & Non-Maryland Residents

Between 2004 and 2006, about 65% of hospitalizations in District hospitals were District residents. Over 25% of hospitalizations occurring in District hospitals were among Maryland residents. Of these, 64.5% were children under the age of 15.

Prince George’s County residents are the largest proportion of Maryland residents seen in the District, followed by Montgomery County residents.

Maryland residents were hospitalized in District hospitals for approximately 1,378 days, an average of 2.9 days per admission.

Figure 5: Proportion of Hospitalizations by Payor, National Capital Region†, District of Columbia,

Baltimore City, and Maryland, 2004-2006

39.337.8

57.2

69.761.4

19.027.327.3

01020304050607080

NCR DC Baltimore City MD

Perc

ent

Public

Private

Between 2004 and 2006, a larger percentage of asthma hospitalizations were covered by public insurance, including Medicare and Medicaid, in the District and in Maryland.

In the National Capital Region, public insurance was the source of payment for approximately 38% of asthma-related hospitalizations.

Results - Continued

Page 9



Source: SHPDA, HSCRC, MHCC, VHI † Includes hospitalizations from the District, and parts of the State of Maryland, specifically Prince George’s and Montgomery counties.

Discussion & Conclusions Asthma is a chronic disease affecting residents of all ages across the NCR, therefore, considerable healthcare resources are required to address this persistent public health problem. During the period from 2004-2006, asthma hospitalization rates for the District (21.6 per 10,000) exceeded national rates (16.6 per 10,000) by approximately 30%. For the same timeframe, statewide Maryland (16.3 per 10,000), NCR (14.2 per 10,000) and NCR Maryland county rates (10.8 and 8.1 per 10,000) were each progressively lower compared to rates for the United States. District and Maryland residents were hospitalized for over 30,000 days in local hospitals with asthma-related diagnoses for average lengths of stay of three or more days, thus suggesting that asthma management needs improvement for those residents.

Some residents experience a disproportionately high burden of asthma in the NCR. A relatively large proportion of young children (0-4 years) and older adults (65+ years) are hospitalized for asthma. Likewise, blacks and women have higher asthma-related hospitalization rates than their counterparts.

Many people cross state and county jurisdictional lines to receive hospital-based asthma treatment. More than one quarter of hospitalizations due to asthma occurring in District hospitals were Maryland residents, most of whom were Prince George’s and Montgomery county residents. Fewer than 1% of Maryland hospitalizations due to asthma were District residents. Publicly funded insurance pays for more than half of hospitalizations for asthma in both the District and Maryland.

Policies and programs to reduce the burden of asthma in the NCR are potentially beneficial to the citizens of each jurisdiction. In light of the scope of asthma as a common problem in the region, partnerships to identify common challenges and implement shared strategies can provide key resources for decreasing the rate of hospitalizations for asthma. One such strategy is the establishment of interventions designed to promote consistent use of consensus guide-lines for asthma diagnosis and management among health care professionals that serve patients who obtain health care within the NCR. Another is the shared use of media resources to promote awareness of asthma and its self-management in the region. Coordinated initiatives to address environmental concerns including healthy homes and improved outdoor air quality may also contribute to the reduction of asthma-related hospitalizations. High rates among children and youth speak to the need to target programs to childcare providers and school nurses who provide direct care for this vulnerable population. Through collaborative strategies, children, older adults, women, Blacks and other at risk groups and those who serve them will likely experience improved health outcomes, including reduced hospitalization in the NCR.

Produced by: DC Control Asthma Now Program & Maryland Asthma Control Program

www.dcasthmapartnership.org

www.marylandasthmacontrol.org

May 2010

This publication was supported by Cooperative Agreement Numbers 1U59EH000517-01 and 1U59EH000497-01 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

Revised 05/01/10

Department of Health and Mental Hygiene Family Health Administration Center for Maternal and Child Health

Asthma Hospitalizations in the NCR

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