1.	Title – Addressing Asthma in Massachusetts 
John Auerbach
Commissioner
Massachusetts Department of Public Health
May 2009

2.	Background
Asthma is a significant and growing public health problem in the US and Massachusetts.

Two efforts coordinated by the MDPH Asthma Prevention and Control Program to address this problem:
The Burden of Asthma in Massachusetts
A Strategic Plan for Asthma in Massachusetts, 2009-2014

3.	Asthma Burden Document

4.	MDPH Collaborators 
Bureau of Environmental Health
Essential School Health Services
Health Survey Program
Occupational Health Surveillance Program
Office of Statistics and Evaluation

5.	Data Sources in Massachusetts
MA Department of Public Health
Behavioral Risk Factor Surveillance System (BRFSS)
Asthma Call-back Survey (Adult and Child)
Pediatric Asthma Surveillance (Grades K-8)
Youth Health Survey (Grades 6-12)
Essential School Health Services program data
SENSOR: Work-related Asthma
Registry of Vital Records and Statistics

MA Division of Health Care Finance and Policy
Acute Care Hospital (Inpatient Hospitalizations, Observation Stays, Emergency Department Visits)

6.	Prevalence of Asthma 

7.	Prevalence of Lifetime and Current Asthma among Adults in MA and US, 2000-2007 (line graph) – From 2000 through 2007, the prevalence of lifetime asthma among adults in Massachusetts increased 29.4% and current asthma increased 16.5%.  Nationally, during this same time frame, the prevalence of current asthma among adults increased 13.7%.  The prevalence of lifetime and current asthma among adults was higher in Massachusetts than the US for each year examined.  From 2000 through 2007, the prevalence of current asthma increased 19.8% among female adults and 44% among adults ages 65+ years. 

8.	Prevalence of Current Asthma among Massachusetts Adults and Children by Gender (bar graph) – The prevalence of current asthma varies by gender and patterns by gender are different for adults and children in Massachusetts. 

9.	Factors Associated with Asthma Management

10.	Measures of Impairment among Massachusetts Adults with Current Asthma
Among MA adults with current asthma: 
Almost 7 out of 10 (67.5%) experienced symptoms of asthma at least once in the past 30 days
About 6 in 10 (62.5%) reported having activity limitations because of their asthma in the past year
Over half (52.9%) had an asthma attack or episode in the past year
About one-quarter (24.0%) reported having sleep disruption because of their asthma in the past 30 days

11.	Level of Asthma Control among Massachusetts Adults with Current Asthma, 2006-2007 (pie chart)
Among adults with current asthma, about three-quarters (75.7%) do not have good control of their asthma. 

12.	Level of Asthma Control among Massachusetts Adults with Current Asthma by Cost as a Barrier to Care, 2006-2007 (bar graph)
Of those that reported cost was a barrier to care, only about 4% had well controlled asthma.  Of those that reported cost was not a barrier to care, about 27% had well controlled asthma. 

13.	Asthma Self-Management Education among Massachusetts Adults and Children with Current Asthma, 2006-2007 (table)
Massachusetts is demonstrating progress towards meeting Health People 2010 (HP2010) targets for asthma self-management education for both adults and children. 
97.6% of adults and 97.2% of children with asthma received instructions on how to use a prescription inhaler properly (HP2010 target 98.8%)
79.8% of adults and 89.3% of children with asthma were taught how to respond to an asthma attack or episode (HP2010 target 71%)
33.4% of adults and 45.0% of children with asthma received an asthma action plan from their health care provider (HP2010 target 38%)

14.	Prevalence of Environmental Triggers and Modifications in the Home among Massachusetts Adults with Current Asthma, 2006-2007 (bar graph)
Massachusetts adults with current asthma are exposed to a variety of potential triggers in the home: 58.5% reported being exposed to carpeting or rugs in the bedroom, 18% exposed to tobacco smoke and 16% exposed to mold.  The estimates for cockroaches (3.7%) may be underestimates due to social desirability issues.  Just under one-third of adults with current asthma reported use of mattress (32.6%) and pillow covers (29.4%).

15.	Work-Related Asthma
Work-related asthma (WRA) is asthma that is caused or made worse by conditions or substances in the workplace. 

16.	Work-related Asthma among Massachusetts Adults
Among MA adults with current asthma:
40.2% reported that their asthma was either caused or made worse by exposures at any job they had ever had (13.9% current job)
10.0% reported discussing relation to work with health care provider
5.1% reported changing or quitting jobs because of their work-related asthma

17.	Hospital Treatment for Asthma
Most asthma hospitalizations are preventable with proper disease management and regular health care. 

18.	Magnitude and Trends in Massachusetts
On an average day in Massachusetts, asthma was associated with:
102 emergency department visits (57.8 per 10,000 residents; n= 36,146 in 2005)
25 hospitalizations (14.7 per 10,000 residents; n=9,457 in 2006)
8 observation stays (3.4 per 10,000 residents; n=2,101 in 2005)

Annual age-adjusted rates for asthma remained:
Stable for emergency department visits (2002-2005)
Stable for hospitalization (2000-2006)
Decreased 35% for observation stays (2000-2005)

19.	Age-Specific Rate of Hospitalization due to Asthma in Massachusetts, 2000 and 2006 (bar graph)
From 2000 through 2006, the Massachusetts age-specific rates of hospitalization due to asthma were highest among children ages 0-4 years and adults ages 65 years and older.  Within the age group of adults ages 65 years and older, the rate increased 49.4% from 2000 through 2006. 

20.	Age-adjusted Rate of Hospitalization for Asthma by Race/Ethnicity in Massachusetts, 2000-2006 (line graph)
In 2006, compared with White, non-Hispanics, the age-adjusted rate of hospitalization for asthma among Black, non-Hispanic was 3.1 times higher and among Hispanics, the rate was 2.7 times higher. This pattern is relatively consistent over time. 

21.	Average Annual Age-adjusted Rate of Hospitalization for Asthma by Geography, 2004-2006 (map)
The average annual age-adjusted rate of hospitalization for asthma in Massachusetts was 14.1 hospitalizations per 10,000 residents.
Compared to the statewide rate, the Community Health Network Area with a higher rate of hospitalization for asthma were around
Fall River (29.5 hospitalizations per 10,000 residents)
New Bedford (23.5 hospitalizations per 10,000 residents)
Boston (23.1 hospitalizations per 10,000 residents)
Brockton (18.8 hospitalizations per 10,000 residents)
Worcester (16.5 hospitalizations per 10,000 residents)
Springfield (16.1 hospitalizations per 10,000 residents)
Southern Worcester County (16.0 hospitalizations per 10,000 residents)

22.	Total Charges for Hospitalization for Asthma in Massachusetts
In 2006, total charges for hospitalizations for asthma were over $88 million. This does not include lost productivity or other indirect measures.

Public insurance (including Free Care, Medicare, and Medicaid) was the expected payer for 62.6% of hospitalizations for asthma in 2006. 

23.	Asthma Mortality
Asthma deaths are preventable with appropriate diagnosis, management and treatment. 

24.	Asthma Deaths are Rare but Disparities Exist in Massachusetts
In 2006, 52 deaths from asthma occurred among Massachusetts residents  From 2000 through 2006, the annual Massachusetts asthma death rate decreased 50.9% from 16.5 to 8.1 per 1,000,000 residents  Average annual age-specific asthma death rate (2002-2006) was highest among adults ages 65 years and older (46.9 per 1,000,000 residents).  

Compared with White, non-Hispanics (8.8 per 1,000,000 residents), the average annual age-adjusted asthma death rate (2002-2006)
among Black, non-Hispanics was 3.4 times higher (29.8 per 1,000,000 residents)
among Hispanics was 2.7 times higher (23.5 per 1,000,000 residents)

25.	Summary
Asthma prevalence is higher in MA than the US and is increasing.  Poorly controlled asthma is associated with cost barriers to care in Massachusetts.  Exposures in the workplace may be important contributing factors to asthma among MA adults.  Disparities exist in asthma hospitalizations and mortality (e.g. age, race/ethnicity, geography)

26.	Strategic Plan for Asthma in Massachusetts 2009 – 2014

27.	Purpose of the State Asthma Plan
Improve the quality of life for all people with asthma
Reduce disparities in asthma outcomes

28.	State Asthma Plan Goals
Enhance asthma surveillance to inform asthma prevention and control efforts in Massachusetts
Improve asthma management for Massachusetts residents
Reduce exposure to environmental factors that cause and/or exacerbate asthma in Massachusetts
Develop a roadmap for better understanding the causes of asthma and the role of primary prevention
Increase capacity of the statewide and local partnerships to implement the plan 
Evaluate Massachusetts’ progress on the plan 

29.	Collaborators to the Plan
Massachusetts Asthma Advocacy Partnership
Over 78 other parents, community groups, health care providers, school officials, day care providers, housing agencies, environmental groups, state agencies, local governments, and others

30.	Action Steps

31.	Enhance Asthma Surveillance
Selected highlights:
Include questions about occupation and industry on the BRFSS to better understand work-related asthma
Explore the utility of a new database (e.g. Health Care Claims Database) to understand primary care office visits and prescriptions filled for asthma among the managed care population
Prepare bulletins to explore the burden of asthma among priority populations, such as older adults

32.	Reduce Asthma Disparities
Selected highlights:
Use asthma surveillance data to identify priority populations
Promote best practices to reduce disparities
Support coalition efforts to address the social and environmental factors

33.	Improve Standards of Care
Selected highlights:
Develop at least one standard of care measure and track it over time
Improve the diagnosis and assessment of asthma
Improve care coordination between hospitals and ambulatory care settings
increase asthma knowledge and competency of health care professionals 

34.	Increase the number of health care providers that address the environmental factors related to asthma 
Selected highlights:
Increase home visits for asthma
Increase flu vaccination
Promote smoking cessation
Increase number of providers that assess the role of work environment in adult asthma

35.	Improve the asthma self-management of Massachusetts residents 
Selected highlights:
Increase the # of people who receive asthma self-management education in the clinic
Increase the # of people who attend chronic disease self-management courses
Expand multi-media campaign Kids with Asthma Can! across the state

36.	Increase sustainability of  asthma care 
Selected highlights:
Promote coverage of asthma care recommended in the national guidelines

37.	Improve the integration of care outside the health care setting with schools and child care settings 
Selected highlights:
Improve linkages between school nurses and primary care providers
Increase the capacity of early education and child care settings to manage asthma

38.	Reduce exposure to specific outdoor air pollutants linked to asthma 
Selected highlights:
Decrease vehicle idling
Reduce pollution caused by diesel transportation sources 
Continue to implement and develop potential strategies to reduce air pollution from mobile and stationary sources 
Make environmental and public health data accessible to the public
Use environmental and public health data to inform community planning 

39.	Reduce Exposures to Factors that Cause and/or Exacerbate Asthma in School, Child Care and Child Recreational Settings
Selected Highlights:
Renewed focused on school environment and asthma through a multi-agency and community taskforce
Training for school staff on preventing and addressing triggers
Increase use of green cleaners in schools
Increase number of child care settings that have indoor air quality policies

40.	Reduce Exposures to Factors that Cause and/or Exacerbate Asthma in Home Setting 
Selected Highlights:
Increase multi-unit properties that have smoke-free home rules
Build the capacity of at least 5 boards of health on addressing asthma triggers in the home
Enhance regulations and guidance documents that focus on reducing exposures in the home
increase the use of integrated pest management for eliminating/reducing pest problems in homes 

41.	Reduce Exposures to Factors that Cause and/or Exacerbate Asthma in the Work Place
Selected Highlights:
Investigate and facilitate changes for WRA in response to case reported to MDPH
Raise worker and employer awareness of WRA and promote safe work practices 
Advance (or implement) policy initiatives to decrease exposures to hazardous products in worksites 

42.	Additional Goals and Objectives
Promote safer alternatives to chemicals
Develop a roadmap for primary prevention
Increase the capacity of statewide and local partnership to implement the state asthma plan
Evaluate our progress

43.	Resources
View www.mass.gov/dph/asthma
The Strategic Plan for Asthma In Massachusetts, 2009-2014
Burden of Asthma in Massachusetts

Jean Zotter
jean.zotter@state.ma.us 
617-944-9807

Carrie Huisingh
carrie.huisingh@state.ma.us 
617-624-5489

Kathleen Fitzsimmons
Kathleen.fitzsimmons@state.ma.us
617-624-5624