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CDC asks for more state data on asthma control

The disease has been on the rise for 20 years, and now the public health emphasis shifts away from prevention strategies toward tracking asthma care.

By Victoria Stagg Elliott, amednews staff. May 26, 2003.

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For the first time, the Centers for Disease Control and Prevention has included state-specific data related to control of asthma's symptoms in its annual asthma prevalence report published in Morbidity and Mortality Weekly Report.

For years, the agency has tracked the increasing prevalence of asthma through its Behavioral Risk Factor Surveillance System and various other surveys, but only analysis of national and regional hospitalization data has provided the occasional insight into the care of those individuals who already have the condition.

For the 2001 data published earlier this month, however, eight states included questions about factors related to disease control, including emergency department visits, activity limitations and sleep disturbance. In the 2002 survey, which will be available next year, that number increased to 22. The CDC also is planning a National Asthma Survey in upcoming months that will delve even further into asthma health care and quality-of-life issues.

According to the CDC, the inclusion of these questions and the new survey represent a fundamental shift in the public health philosophy regarding the disease. Tracking the prevalence is important because asthma has dramatically increased. But in the absence of effective prevention strategies, public health officials say that there is little they can do with these data.

"You really can't control how many people have asthma because we don't have a primary prevention program," said David Mannino, MD, one of the authors of the paper and a medical epidemiologist for the CDC's National Center for Environmental Health.

There are also many asthma experts who say the prevalence numbers are not reliable because they depend on self-reporting and assessment rather than control factors that are easier to measure, such as emergency department utilization. Mississippi, for example, reported one of the lower prevalence rates at 5.5%.

"I don't believe those data," said Richard deShazo, MD, director of the division of allergy and immunology at the University of Mississippi Medical Center in Jackson. "I've worked all over the United States, and I don't think that our asthma prevalence is low. It's probably underreported."

Much more is known, though, about how to actually control asthma, and the data regarding these efforts give the public health system much more to work with.

"It's easier to tackle than prevention," Dr. Mannino said. "A person diagnosed with asthma and taking appropriate medications should be well-controlled and should not be limited in their activities."

Who does best and why?

Asthma experts praised the shift as a possible means of saving health system dollars.

"That's absolutely appropriate," said William E. Berger, MD, president of the American College of Allergy, Asthma and Immunology. "At least half of the cost of providing care to asthma patients is tied in emergency room visits and hospitalizations."

The agency will not just collect data measuring asthma control. It also will attempt to provide an explanation as to why some states perform better than others, although there is abundant speculation already for some disparities that came up in the early information from the first eight states reporting.

Experts suggest that differences may be due to a wide variety of factors ranging from physician practice to access to care and health insurance.

"In some states, there may be more systemic problems than in other states," Dr. Mannino said.

Most asthmatics in Washington state, for example, appear to have their disease well-controlled, with just over 12% reporting to an emergency room for care in 2001 and only a quarter needing urgent care visits. Public health officials speculated that it had more to do with state economics than with any asthma-specific program.

"It's nothing that we as a state health department have been doing," said Juliet VanEenyk, PhD, epidemiologist for noninfectious conditions for the Washington State Dept. of Health. "But our insurance coverage is a little bit better than the United States as a whole. If people have good primary care, their asthma can be kept under control."

Mississippi didn't do quite as well, with about a third of asthmatics presenting to the emergency department and about 35% needing urgent care services. That state consistently ranks low on many health indicators and is one of the poorest in the nation.

"Controlling the disease requires medication, a lot of care and education," said Alan Penman, MD, MPH, chronic disease epidemiologist at the Mississippi State Health Dept. "We don't have good access to primary care here. We have problems with low education and lack of insurance, and the ED is being used as a source of primary care."

Despite the fact that the CDC would like to see reduced emphasis on prevalence rates and more attention paid to control issues, there is some good news regarding prevalence. The asthma rate did not change from 2000 to 2001, adding to the growing body of evidence and hope that asthma, after years on the increase, may have peaked. Many public health officials, though, still say it's too soon to say that definitively.

"We've had drops before only to have it go up the following year, but we really can't control asthma prevalence," Dr. Mannino said. "I'd be much more pleased if over the next couple years, we see that asthma is better controlled."

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