ASTHMA HOSPITALIZATIONS IN THE NATIONAL CAPITAL REGION, 2004-2006

A Report created collaboratively by the National Capital Region Asthma Partnership

May 2010

Acknowledgments
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 OMalley, Governor Anthony G. Brown, Lieutenant Governor John M. Colmers, Secretary, DHMH Russell W. Moy, MD, MPH, Director, FHA

Authors
LaVerne Hawkins Jones, MPH
Epidemiologist, DOH

Linda Nwachukwu, MPH

Epidemiologist, DHMH

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

Maryland Asthma Control Program Staff

Cheryl De Pinto, MD, MPH
Medical Director, Child, Adolescent, and School Health Principal Investigator

Edwina V. Davis-Robinson, MS, CHES

Asthma Program Manager

Yvette McEachern, MA
Director, Federal-State MCH Partnerships Asthma Program Manager

LaVerne Hawkins Jones, MPH

Asthma Program Epidemiologist

Rachel Hess-Mutinda, MSW

Asthma Program Coordinator

Linda Nwachukwu, MPH

Asthma Epidemiologist

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National Capital Region Asthma Partnership

Asthma Hospitalizations in the National Capital Region Background

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 natural 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 Hygienes Family Health Administration, Center for Maternal and Child Health, Asthma Control Program (MACP) resolved to establish a regional partnership to identify strategies to address crosscutting 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.

Pleis JR, Lethbridge-ejku M. Summary health statistics for U.S. adults: National Health Interview Survey, 2007. National Center for Health Statistics. Vital Health Stat 10(240). 2009. DeFrances 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. Smith, 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.

National Capital Region Asthma Partnership

Asthma Hospitalizations in the National Capital Region Methods

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 residential 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 493.0493.9. 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 Districts 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 Georges 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.

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National Capital Region Asthma Partnership

Asthma Hospitalizations in the National Capital Region Results

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 ageadjusted 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
Figure 1: Asthma Hospitalization Rates, District of Columbia, Baltimore City, Maryland vs. United States, 2000-2006
50 Rate per 10,000 40 30 20 10 0 2000 2001 DC 2002 2003 2004 MD 2005 US 2006

Baltimore City

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

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.

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

Table 1: Age-Adjusted Asthma Hospitalization Rates by Demographic Characteristics of the National Capital Region and Area Jurisdictions, 2004-2006
Maryland Counties

US District of Columbia District Residents Only 9,929 3,584 1,899 27,257 1,340 2,264 218 NonDistrict Residents Maryland Residents Only NonMaryland Residents Montgomery Residents Only Montgomery Residents seen in the District Prince Georges Residents Only 2,579 All Counties Montgomery

National Capital Region Prince Georges

Prince Georges Residents seen in the District 1,077

Number of Hospitalizations 14.2 21.6 12.4 16.3 0.8 8.1 2.0

489,000

Rate per 10,000

16.6

10.8

7.2

Age 32.2 18.9 4.9 14.0 24.8 31.9 8.6 28.5 1.6 26.3 7.2 16.2 0.9 5.7 2.9 6.7 0.4 2.9 5.1 14.0 23.4 31.5 14.9 0.4 10.8 37.2 45.7 37.4 1.6 29.7 6.7 3.1 0.2 0.5 2.0 11.8 4.4 4.5 12.8 26.3 26.3 21.5 1.3 3.8 3.5

0 4 years old

--

5 14 years old

--

15 34 years old

--

35 64 years old

--

> 65 years old

30.5

Gender 33.7 48.1 25.0 11.0 19.3 17.9 13.9 13.0 1.0 0.6 7.4 8.7 1.4 1.4 6.5 14.7 8.3 6.2

Male

13.3

Female

19.7

Race 38.0 45.7 28.3 85.1 27.3 14.1 88.6 2.9 5.5 11.2 26.9 14.6 0.7 1.0 0.2 5.6 15.4 11.7 1.5 0.9 17.4 6.0 11.2 15.1 1.2 9.6 41.4

White

--

Black

--

Other**

--

Source: HSCRC; MHCC; VHI; 2005 National Hospital Discharge Survey. 2005 data refers to the midpoint of the 3-year period covered by our local data year. Hospitalizations in the National Capital Region include hospitalizations from the District and parts of the State of Maryland, specifically Prince Georges and Montgomery counties. Age groups are not age-adjusted to the 2000 U.S. population. **Other race category includes the categories Asian/Pacific Islanders and Native Americans/Alaskan Natives

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Maryland National Capital Region Asthma Partnership

Asthma Hospitalizations in the National Capital Region Results - Continued

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 Georges 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 Georges 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 Georges 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 Georges 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. 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.
Figure 2: Asthma Hospitalization Rate, National Capital Region , 2004-2006
60 50 40 30 20 10 0
M al e Fe m al e W hi te Bl ac k O th er yr s 514 yr s 15 -3 4 yr s 35 -6 4 yr s 65 + yr s 04 To ta l

Source: SHPDA, HSCRC, MHCC. Hospitalizations in the National Capital Region include hospitalizations from the District and parts of the State of Maryland, specifically Prince Georges 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.

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Rate per 10,000

Maryland National Capital Region Asthma Partnership

Asthma Hospitalizations in the National Capital Region Results - Continued

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

8.3% 2.7%
District Residents Montgomery County Residents Prince George's County Residents

19.6%

4.0%

65.4%

Other Maryland Residents Non-District & NonMaryland Residents

Source: SHPDA, HSCRC, MHCC.

Between 2004 and 2006, about 95% of hospitalizations due to asthma in Maryland were state residents. Montgomery and Prince Georges 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 Georges 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

4.0% 0.7%

7.9% 9.0%
Prince George's County Residents Montgomery County Residents Other Maryland Residents District Residents Non-District & NonMaryland Residents

78.4%
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Source: SHPDA, HSCRC, MHCC.

Maryland National Capital Region Asthma Partnership

Asthma Hospitalizations in the National Capital Region Results - Continued

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 asthmarelated hospitalizations.
Percent

Figure 5: Proportion of Hospitalizations by Payor, National Capital Region, District of Columbia, Baltimore City, and Maryland, 2004-2006
80 70 60 50 40 30 20 10 0 61.4 37.8 39.3 27.3 27.3 19.0 69.7 57.2 Public Private

NCR

DC

Baltimore City

MD

Source: SHPDA, HSCRC, MHCC, VHI Includes hospitalizations from the District, and parts of the State of Maryland, specifically Prince Georges 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 Georges 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 guidelines 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.
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Department of Health and Mental Hygiene Family Health Administration Center for Maternal and Child Health

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