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Asthma among older adults in Massachusetts: Using surveillance data
to prompt action Kathleen Fitzsimmons, MPH
Asthma Prevention and Control ProgramMassachusetts Department of Public Health
2011 CSTE Annual ConferencePittsburgh, PA
June 2011
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Overview
• Background– Asthma – Older Adults – Priority population in MA
• Data Analysis– Purpose– Findings
• Taking Action– Potential Partners– Next Steps
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Asthma
• Chronic inflammatory disease of the airways– Symptoms: wheezing, shortness of breath, chest tightness, cough– Cause of individual cases usually unknown– No cure exists, but can be controlled
• Affects all ages– US (2008): 7.3% of adults (16.4 mil), 9.4% of children (7.0 mil)– Of adults with asthma, 15.9% aged 65+
• Estimated $20.7 billion annual healthcare expenditures (NHLBI, 2009)
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Asthma Prevention and Control Program
Our Mission: To improve the quality of life for all MA residents with asthma and to reduce disparities in asthma outcomes.
Selected Key Activities:• Asthma Surveillance• Partnering to implement the state asthma plan and
coordinate asthma prevention and control activities throughout the state, region and country
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Surveillance:Burden of Asthma in Massachusetts
• Asthma prevalence in Massachusetts is among the highest in the nation –approximately 10% of adults and children have asthma.
• Disparities in poor asthma outcomes exist. – Children aged 0-4– Adults aged 65 and older– Black, Non-Hispanics and
Hispanics
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Population of Adults Aged ≥ 65, United States, 1900-2050
Source: Federal Interagency Forum on Aging-Related Statistics, http://www.agingstats.gov
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Background - Older Adults and Asthma
• Asthma in older adults is under-diagnosed and under-treated (Stupka E & deShazo, 2009)
• Diagnosis and management of asthma in older adults may pose unique challenges (NAEPP, 1996)
• Considerable knowledge gaps – epidemiology and effectiveness of interventions (NAEPP, 1996)
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Partnering: Strategic Plan for Asthma in Massachusetts
GOAL 1 – Enhance Surveillance
GOAL 2 – Improve Asthma Management for Massachusetts Residents
•Identify specific “priority” populationsthat have significant disparate outcomes
• Prepare data bulletins to explain and document the burden of asthma among priority populations, such as older adults
• Asthma and Allergy Foundation of America –New England Chapter and MDPH will facilitate the development of state-specific recommendations for public health and healthcare institutions to improve asthma outcomes for older adults
• MDPH will promote and support dissemination of the recommendations
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Special Topic Data Bulletin:Highlights
• Prevalence
• Characteristics of Older Adults with Asthma
• Asthma Treatment Guidelines
• Hospitalizations
• Mortality
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Asthma PrevalenceData Source: Behavioral Risk Factor Surveillance System (BRFSS)
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BRFSS: Lifetime and Current Asthma
• “Have you ever been told by a doctor, nurse, or other health professional that you had asthma?”
• “Do you still have asthma?”
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Prevalence of Current Asthma among Adults Aged ≥ 65 , MA and US, 2000-2009
0.0
2.0
4.0
6.0
8.0
10.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
Prev
alen
ce (%
)
US Curr
MA Curr
Data Source: Behavioral Risk Factor Surveillance System, 2000-2009
7.5
8.4
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Current Asthma Prevalence among Adults Aged ≥ 65 in Massachusetts
Data Source: MA Behavioral Risk Factor Surveillance System, 2007-2009
Compared to…Higher among…
Those not (6.2% & 7.2%, respectively)
Those overweight (10.0%) or obese (13.5%)
Those without (6.5%)Those with a disability (14.1%)
Those with household incomes of $75,000+ (7.4%)
Those with household incomes of < $25,000 (10.4%)
Those with 4+ years of college (6.9%)
Those with < high school degree (11.4%)
White, Non-Hispanics (8.4%)Hispanics (12.6%)
Males (6.4%)Females (10.2%)
Those aged 80+ (6.5%)Those aged 65-79 (9.5%)
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Characteristics of Older Adults with Asthma
Data Source: BRFSS Adult Asthma Call-back Survey
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Asthma Call-Back Survey
Methodology:• Eligible: ‘Yes’ in BRFSS to
ever diagnosed with asthma
• Asked if willing to participate in a follow-up interview
• Called within 2 weeks & administered the Asthma Call-Back Survey
Content:• History of asthma symptoms• Health care utilization• Asthma education• Home environment• Medications• Access to care• Workplace• Co-morbid conditions• Complimentary and
alternative therapy
http://www.cdc.gov/asthma/questions.htm#callback
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37.7
58.4 63.1
19.5
75.9
25.3
56.0
29.9
82.6
0.010.020.030.040.050.060.070.080.090.0
Very poor contro
l
Symptoms, past
mo.
Limite
d usual
activitie
s, past
yr.
Sleep disr
upted, past
mo.
Rescue m
eds, p
ast 3 m
os.
Unsched
uled office v
isit, p
ast yr.
COPD diagnosis
Depressi
on diagnosisDiag
nosed as a
dult
Characteristic
Perc
ent (
%)
Characteristics of Massachusetts Adults Aged
≥ 65 with Asthma
Data Source: 2006-2008 BRFSS Adult Asthma Call-Back Survey
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Asthma Treatment GuidelinesData Sources: BRFSS & BRFSS Adult Asthma Call-back Survey
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NAEPP Guidelines
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Persons with asthma should have 2 + visits/yr with their healthcare provider (HCP) for routine
asthma care.
In Massachusetts
• 47.3% of older adults with asthma reported having the recommended number of routine visits in past year.
• 14.6% reported one visit.
• 38.1% reported no visits.
– HP2020: None (Developmental)
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Persons with asthma should have an Asthma Action Plan.
In Massachusetts
• 24.6% of older adults with asthma reported ever having been given an Asthma Action Plan by a HCP.
– HP2020: 36.8%
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Older adults with asthma should receive influenza vaccination annually and pneumococcal vaccination per recommended schedule.
In Massachusetts
• 81.1% of older adults with asthma reported having influenza vaccination in past year.
– HP2020 (all adults ≥ 65): 90%
• 84.1%% reported ever having pneumococcal vaccination.
– HP2020 (all adults ≥ 65): 90%
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Persons with asthma should receive education about appropriate response to an asthma episode, including recognizing early signs
and symptoms or monitoring peak flow results.
In Massachusetts
• 58.0% of older adults were taught how to recognize early signs and symptoms of an attack.
• 69.1% were taught by a HCP what to do in response to an asthma attack.
• 46.7% were taught how to use a peak flow meter to adjust daily medications
– HP2020(combined): 68.5%
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Persons with asthma should have a discussion with their HCP about environmental exposures
at home and work.
In Massachusetts
• 33.7% of older adults with asthma advised by HCP to change aspects of home or work to improve asthma.
– HP2020: 54.5%
• 31.0% reported believed their asthma was caused or made worse by any job they’d ever had, but only 7.7% reported discussing it with a HCP.
– HP2020: None (Developmental)
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Smoking or exposure to tobacco smoke should be avoided.
In Massachusetts
• 6.2% of older adults with asthma were characterized as current smokers.
– HP2020 (all adults): 12.0%
• In addition, 7.4% of never or former smokers reported exposure to environmental tobacco smoke at home in the past week.
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Asthma HospitalizationsData Source: Massachusetts Inpatient Hospitalization Discharge Database
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Asthma Hospitalizations among Older Adults in Massachusetts
• 23.2% of the ~9,725 asthma hospitalizations each year among aged ≥ 65
• 44% occurred January-April
• Compared to adults aged 18-64:– Longer avg. length of stay (4.6 vs. 3.5 days)– Higher mean total charge ($12,745 vs. $10,368)
• Medicare expected payer for 90%
Data Source: MA: 2006-2008 Massachusetts Inpatient Hospital Discharge Database
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17.6 17.3 18.0
22.1 23.326.2 26.2
24.527.6
0.0
5.0
10.0
15.0
20.0
25.0
30.0
2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Hos
pita
lizat
ions
per
10,
000
Res
iden
ts
MA
Rate of Hospitalization for Asthma among Adults Aged ≥ 65 , MA, 2000-2008
Data Source: MA: 2000-2008 Massachusetts Inpatient Hospital Discharge Database; US: 2000-2006 National Hospital Discharge Survey
HP2020 (20.3)
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Rate of Hospitalization for Asthma among Adults Aged ≥ 65 by Sex, MA, 2000-2008
11.2 10.2 11.014.6 16.0
17.5 18.9 18.121.421.8 22.1 22.7
27.2 28.3
32.1 31.328.8
31.8
0
5
10
15
20
25
30
35
2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Hos
pita
lizat
ions
per
10,
000
Res
iden
ts
Males Females
Data Source: MA: 2000-2008 Massachusetts Inpatient Hospital Discharge Database
HP2020
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Asthma MortalityData Source: Massachusetts Registry of Vital Records and Statistics
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Asthma Mortality Rate by Age, MA, 2000-2007
6.6
4.54.9
4.3
5.3 5.4
3.6 3.5
0.9 0.8 0.8 0.7 0.6 0.7 0.4 0.3
0
1
2
3
4
5
6
7
2000 2001 2002 2003 2004 2005 2006 2007
Year
Dea
ths
per 1
00,0
00 R
esid
ents
0-64 65+
Data Source: 2000-2007 Massachusetts Registry of Vital Records and Statistics.
HP2020 (2.3)
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Summary
• Asthma prevalence among adults aged ≥ 65 - increasing nationally & in MA.
• Asthma hospitalization rate among older MA adults – 2nd highest of any age group & increasing; the rate for younger adults has been consistently lower & stable.
• 327 older MA adults died from asthma between 2000-2007; accounted for over half of the asthma deaths during this time.
• Asthma mortality rate for older MA adults has consistently been higher than the rate for younger ages.
• Among older MA adults, females and Hispanics bear a disproportionate asthma burden.
• MA has not yet reached HP2020 targets for asthma management or outcomes in this age group.
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Taking Action – Potential Partners
• MDPH Office of Healthy Aging • MDPH Chronic Disease Self Management Program • State/Local Councils On Aging & Senior Centers• State/Local Elder Affairs Offices• Healthcare Providers• MCPHS Pharmacy Outreach Program• AARP• Home Care Alliance of Mass.• LeadingAge Mass. • Mass. Assisted Living Facilities Association• Mass. Council for Home Care Aide Services • Mass. Senior Action Council, Inc. • LGBT Aging Project
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Taking Action – Next Steps
• Share findings
• Convene Task Force– Identify & evaluate effective interventions for addressing
asthma in older adults– Identify areas where more research is needed
• Develop recommendations
• Disseminate recommendations
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Acknowledgements
• Jean Zotter• Carrie Huisingh• Tish Davis• Maria McKenna• Kathleen Grattan• Vivian Pun• Elise Pechter• James West• Jamie Wilkins
• Cheryl Bartlett• Jewel Mullen• MDPH Internal Asthma
Working Group• Joshua Nyambose• Sheila Erimez• Elaine Rosenberg• David Callahan• Kathie Sunnarborg
*This work was supported by the CDC Cooperative Agreement #5U59EH000502-02. Contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.
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Contact Info
Kathleen Fitzsimmons, MPH
Epidemiologist
(617) 624-5624
Asthma Prevention and Control Program
Massachusetts Department of Public Health
250 Washington Street
Boston, MA 02108
http://www.mass.gov/dph/asthma
Jean Zotter, JD
Director
(617) 994-9807