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Trends in Childhood Asthma: Prevalence, Health Care Utilization, and Mortality Lara J. Akinbami and Kenneth C. Schoendorf  Pediatrics 2002;110;315

 

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2002 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Trends in Childhood Asthma: Prevalence, Health Care Utilization, and Mortality Lara J. Akinbami, MD, and Kenneth C. Schoendorf, MD, MPH ABSTRACT.   Objectives.   Our objective objective was to use national data to produce a comprehensive description of trends in childhood asthma prevalence, health care utilization, zatio n, and mortality mortality to assess changes in the disease burden among US children.  Methods.   Five data sources sources from the National National Center for Hea Health lth Sta Statis tistic ticss wer were e use used d to des descri cribe be tre trend ndss in asthma for children aged 0 to 17 years from 1980 to the most recent year for which data were available. These included the National Health Interview Survey (NHIS), the National Ambulatory Medical Care Survey, the Nationall Hosp tiona Hospital ital Ambu Ambulator latory y Medi Medical cal Care Survey, the National Hospital Discharge Survey, and the Mortality Component of the National Vital Statistics System. Results.   Asthma prevalence prevalence increased by an average of 4.3% per year from 1980 to 1996, from 3.6% to 6.2%. The peak prevalence was 7.5% in 1995. In 1997, asthma attack prevalence was 5.4%, but changes in the NHIS design in 1997 comparison previous Asthma attackpreclude prevalence remainedtolevel from estimates. 1997 to 2000. After a decrease between 1980 and 1989, the asthma office visit rate increased by an average of 3.8% per year from 1989 to 1999. The asthma hospitalization rate grew by 1.4% per yearr fro yea from m 198 1980 0 to 199 1999. 9. Alt Althou hough gh chi childh ldhood ood ast asthm hma a deaths are rare, the asthma death rate increased by 3.4% per year from 1980 to 1998. Children aged 0 to 4 years had the largest increase in prevalence and had greater health care use, but adolescents had the highest mortality. The asthma burden was borne disproportionately by black children throughout the period. Racial disparities were largest for asthma hospitalizations and mortality: compared with white children, in 1998–1999, black children were   >3 times as likely to be hospitalized and in 1997– 1998 >4 times as likely to die from asthma. Conclusions.   Rec Recent ent dat data a sug sugges gestt tha thatt the burden burden from childhood asthma may have recently plateaued after several years of increasing, although additional years of data collection are necessary to confirm a change in trend. tre nd. Rac Racial ial and eth ethnic nic dis dispar pariti ities es rem remain ain lar large ge for asthma health care utilization and mortality.   Pediatrics 2002;110:315–322; asthma, child, prevalence, office visits, hospitalization, mortality. ABBREVIATION ABBREVIA TIONS. S. NHIS NHIS,, Natio National nal Healt Health h Inter Interview view Sur Survey; vey; NCHS, National Center for Health Statistics; NAMCS, National Ambulatory Medical Care Survey; NHDS, National Hospital Discharge Survey; NHAMCS, National Hospital Ambulatory Medical

From the Infan Infantt and Child Healt Health h Stud Studies ies Branch, National National Cent Center er for Health Healt h Stat Statistic istics, s, Cent Centers ers for Disea Disease se Cont Control rol and Preve Preventio ntion, n, Beth Bethesda, esda, Maryland. Received for publication Aug 20, 2001; accepted Feb 4, 2002. Reprint requests to (L.J.A.) National Center for Health Statistics, 6525 Belcrest Rd, Rm 790, Hyattsville, MD 20782. E-mail: [email protected] PEDIATRICS (ISSN 0031 4005). Copyright © 2002 by the American Academy of Pediatrics.

Care Survey; SE, standard error; ICD, error;  ICD, International Classification of  emergenc gency y depar department tment;; OPD, outpatient outpatient depar departtDiseases;; ED, emer Diseases ment.

A

s a leading chronic childhood illness in the United States,1 asthma places a large burden on affected children and their families. Although asthma is a major cause of childhood disability2,3 an and d in ra rare re ca case sess ca caus uses es pre prema matu ture re de deat ath, h, asthma morbidity and mortality are largely preventable when patients and their families are adequately educated about the disease and have access to highquality qualit y healt health h care.4 – 6 That is, poor outcomes for chil ch ildh dhoo ood d as asth thma ma,, su such ch as ho hosp spita italiz lizat atio ions ns an and d deaths, are at least partially sensitive to the quality of  ambulatory health care.5,7 Thus, it is important to simult sim ultane aneous ously ly mon monito itorr tre trends nds in ast asthma hma prev prevaalence, health care utilization, and mortality to estimate the burden of disease and to help assess the impact of asthma prevention programs and changes in health care quality. Although local data may be optimal for program evaluation and resource allocation tio n dec decisio isions, ns, nat nation ional al dat dataa are pre presen sented ted in thi thiss analysis because population-based data for the entire spectrum of measures are not consistently available in local areas. National data on asthma prevalence, office visits, emergency department visits, hospitalizations, and mortality mortal ity were publis published hed recen recently, tly,8  but the analysis did not focus on children; the burden of asthma is larger for children than for the rest of the population.8,9 This report presents trends in asthma prevalence, health utilization, and mortality for race/ ethnicity andcare age groups in the pediatric population. In particular, patterns among different race and ethnicity nic ity gro groups ups are impo importa rtant nt bec becaus ausee elim elimina inatin ting g health disparities among different segments of the population is 1 of the 2 overarching goals of  Healthy of  Healthy 10 People Peo ple 201 20100. Alth Althoug ough h dis discus cussed sed in det detail ail els elseewhere,11,12 another purpose of this report is to highlight the effect of the 1997 redesign of the National Health Interview Survey (NHIS) on asthma prevalence estimates. The NHIS is the principal means of  measuring national asthma prevalence, and the 1997 redesign redes ign created a break in the time series trend and therefore complicates assessment of recent trends in asthma prevalence. METHODS

This analysis used data from 1980 through the most recent year for which data were available from 4 National Center for Health Statistics (NCHS) data systems: the NHIS, the National Ambula-

PEDIATRICS Vol. 110 No. 2 August 2002   315

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tory Medical Care Survey (NAMCS), the National Hospital Discharge Survey (NHDS), and the Mortality Component of the National Vital Statistics System. A fifth NCHS data set, the National Hospital Ambulatory Medical Care Survey (NHAMCS), provided data on ambulatory care in hospitals beginning in 1992. Children aged 0 to 17 years were included, and the sample from each data source was stratified by age group (0 – 4 years, 5– 5–10 years, and 11––17 year 11 years) s) and by race race/ethn /ethnicity icity when possible (white nonHispanic, black non-Hispanic, and Hispanic). The NHIS is a continuing household survey of a representative sample of the US civilian noninstitutionalized population1 and the primary source of national asthma prevalence estimates. In 1997, the NHIS was redesigned to improve data quality, simplify the survey, surv ey, and redu reduce ce the ques questionn tionnaire aire leng length. th.12 Info Informati rmation on to estimate asthma prevalence from 1980 to 1996 was obtained by the following question: question: “  “During During the redesign past 12 months, your child have asthma? asthma?” ”   After the survey in 1997, did information to estimate asthma attack prevalence was obtained from the following questions: “ questions: “Has Has a doctor or other health professional ever told you that you yourr chi child ld had ast asthma hma??”   and,   “Dur During ing the pas pastt 12 months, has your child had an episode of asthma or an asthma attack?”” National estimates were calculated using survey weights. attack? Standard errors (SEs) were calculated using SUDAAN software (Research Triangle Institute, Research Triangle Park, NC). The NAMCS was administered in 1980, 1981, 1985, and annually since 1989 and coll collects ects information information on ambu ambulator latory y patie patient nt visits to private physician offices. 13 National estimates for asthma visits were calculated using survey sample weights for visits for which asthma (Internationa (Internationall Classification of Diseases, Ninth Revision, Clinical Modification [ Modification  [ICD-9-CM ICD-9-CM], ], code 493) was listed as the first diagnosis. SEs for 1980 to 1985 were estimated using relative SE tables produced by the NCHS14,15 and with SUDAAN for 1990 to 1999. The NHAMCS has been administered annually since 1992 and gathers information about health care provided by hospital emerg em ergenc ency y dep depart artme ments nts (ED (EDs) s) and out outpat patien ientt dep depart artmen ments ts (OPDs).16,17 National estimates and SEs for visits to sample hospital pit al EDs and OP OPDs Ds for which which ast asthma hma was lis listed ted as the first diagnosis (ICD-9-CM (ICD-9-CM,, code 493) were calculated using SUDAAN. We used US Census Bureau estimates for the US civilian noninstitutionalized population as denominators for asthma ED and OPD visit rates.18,19 For the approximately 9% of records missing data on race, NCHS imputed the information by assigning the same race from patient record forms with similar characterischaracteristics.13,16,17 A larger percentage of records were missing Hispanic ethnicity data (15%– (15%–20%), and NCHS stopped imputing ethnicity  beginning in 1997. Therefore, the analysis of ambulatory visits by race was conducted without consideration of ethnicity. The NHDS is an annual national survey of nonfederal general and short-stay specialty hospitals.20 Estimates for asthma hospitalizations were calculated using hospitalizations for which the primary discharge diagnosis was asthma (ICD-9-CM ( ICD-9-CM,, code 493). The 5% to 22% of records missing data on race were excluded from race-specific rates because there was no imputation for race performed on NHDS records. We performed a sensitivity analysis assuming that records with missing race represented hospitalizations for children of white race. This approach was taken because an analysis of race underreporting in the NHDS suggested that most records with missing race represent white patients 21 and  because it produces the most conservative estimate of a racial disparity in hospitalization. SEs for NHDS estimates from 1980 to 1986 were calculated using NCHS relative SE tables, 22,23 and from 1990 to 1999 using SUDAAN. We used US Census Bureau estimates for the US civilian population as denominators for asthma hospitalization rates.18,19 To estimate asthma mortality, mortality, we used the Mort Mortality ality Component of the National Vital Statistics System.24 Deaths identified among children younger than 18 years for which asthma was the underlying cause of death (ICD-9 (ICD-9,, code 493) were included. We calculated SEs (the square root of the inverse of the number of  deaths) because the number of asthma deaths is small and annual rates are subject to random variation.24 We used US Census Bureau estimates for the US residential population as denominators for asthma mortality rates.18,19 Beginning in 1999, the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10 (ICD-10)) replaced the   ICD-9  ICD-9   for death certificates. Because Beca use 1999 death rates are not comparable comparable to earli earlier er years, mortality rates from 1980 to 1998 are presented.

CHILDHO HOOD OD ASTHMA 316   TRENDS IN CHILD

Annual estimates of each of the above measures are presented in figures, with the exception of hospital ED and OPD visits for which data are available beginning in 1992. For each data series, a trend line was estimated by fitting a linear regression model to the logarithm of the rates from 1980 to 1996 for asthma prevalence, from 1980 to 1999 for asthma office visits and hospitalization, and from 1980 to 1998 for mortality. A logarithmic scale was used  because trends in asthma prevalence, health care utilization, and mortality tend to follow a constant percentage change rather than a constant absolute change.25 On the logarithmic scale, trend lines with similar slopes represent similar rates of change. Furthermore, trends over time can be visually compared for outcomes that have a wide range of absolute rates. Average annual estimates based on combining 2 years of data were calculated for age and race subgroups to decrease sampling error and are presented as tabulated data for selected years. To address the possibility that diagnostic transfer may partially explain the trends observed,26,27 we examined trends in prevalence of chronic bronchitis and health care utilization for bronchitis, bronchiolitis, and pneumonia (information about bronchiolitis and pneumoni pneumoniaa is not availabl availablee in the NHIS). NHIS). For the NH NHIS, IS, prevalence for chronic bronchitis was estimated by positive responses to the question,   “During the past 12 months, did your child have bronchitis?” bronchitis?” and by including those children for whom the conditio condition n was present present for longer longer tha than n 3 mon months ths.. For the NAMCS and NHDS, records for which bronchitis, bronchiolitis, and pneumonia were listed as the primary diagnosis were included (ICD-9-CM (ICD-9-CM codes  codes 466, 480 through 486, 490, and 491). For the NHIS, the log-linear trend for bronchitis was calculated for survey years 1980 to 1996. For NAMCS, a log-linear trend for  bronchitis and bronchiolitis was calculated for years 1989 to 1999 during which the survey was conducted annually. For the NHDS, log-linear trends for pneumonia and for bronchitis and bronchiolitis were calculated for 1980 to 1999. These trends were compared with those calculated for asthma.

RESULTS Asthma Prevalence

Asthma prevalence among 0- to 17-year-old children increased from 36 per 1000 children (SE 3.4) to 75 per 10 1000 00 (SE 5. 5.1) 1) from 19 1980 80 to 19 1995 95 but th then en decreased 17% to 62 per 1000 children (SE 5.9) in 19966 (Fi 199 (Fig g 1). Ast Asthma hma pre preval valenc encee incr increas eased ed by an average of 4.3% per year from 1980 to 1996. The 1997 estimate of childhood asthma attack prevalence from the redesigned questionnaire, 54 per 1000 children, and subsequent estimates cannot be compared directly with previous estimates and should be considered the first points of a new trend. 11 Because the redesigned asthma questions measure asthma attack preval pre valenc encee (in (indiv dividua iduals ls who had prev previous iously ly received a diagnosis of asthma and who had 1 or more asthma attacks in the past 12 months) as opposed to asthma prevalence in the past 12 months, it is not surpris sur prising ing tha thatt the pos post-1 t-1997 997 est estima imates tes are low lower er than previous estimates. Asthma attack prevalence from 1997 to 2000 remained level with no statistically significant difference between estimates during this time period (SEs not shown). Table 1 shows childhood asthma prevalence for selected years by race/ ethnicity and age group. The gap between black and white non-Hispanic children widened progressively during the period, from 15% higher asthma prevalence among black non-Hispanic children in 1980 – 1981 to 26% higher in 1995– 1995–1996. In 2000, black nonHispanic had asthma attack prevalence ratee 44% children rat higher tha higher than n an that tha t of whi white te non non-Hi -Hispa spanic nic childre chi ldren. n. Fro From m 198 1985/1 5/1986 986 to 199 1995/1 5/1996 996,, ast asthma hma prevalence increased dramatically among Hispanic

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Fig 1.  Trends in childhood asthma prevalence, hospitalizations, office visits to private physicians, and mortality, age

18 years.



TABLE 1.   Average Annual Asthma Asthma Prevalence (per (per 1000), 1980 to 1996 and and Asthma Attack Prevalence Prevalence (per 1000), 1997 to 2000 During the Previous 12 Months Among Children Younger than 18 Years, United States*† States* †

Asthma Prevalence

Overall prevalence Race/ethnicity Whit Wh itee no nonn-H His ispa pani nicc Blac Bl ack k non on--His ispa pani nicc Hispanic Age 0–4 y 5–10 y 11––17 y 11

Asthma Attack Prevalence

1980––1981 1980

1985–1986

1990–1991

1995–1996

1997

1998

1999

2000

36.8

49.4

60.1

68.6

54.4

53.1

52.7

55.3

51.0 59.8 31.5

59.6 72.6 51.2

65.3 82.1 76.1

52.2 67.5 51.3

52.1 68.1 47.4

49.9 74.1 44.5

53.4 76.8 42.1

31.9 54.5 58.0

43.0 62.7 71.4

50.3 74.3 77.4

41.2 58.5 60.4

46.5 53.0 58.0

42.1 57.2 56.2

43.5 57.5 61.5

36.4‡ 36. 41..9‡ 41 n/a‡ 29.4 49.0 32.1

     

‡ Data for ethnicity are unavailable for 1980-81. White and black prevalence estimates include Hispanic ethnicity. Adapted from Centers for Disease Control and Prevention. Measuring childhood asthma prevalence before and after the 1997 redesign of the National Health Interview Survey– Survey –United States. MMWR States.  MMWR Morb Mortal Wkly Rep. 2000;49:908 Rep.  2000;49:908 –911. † The space between 1995– 1995–1996 and 1997 indicates a trend break due to redesign of the 1997 NHIS. * All relative SEs for estim estimates ates are below 30%.

children. However, from 1997 to 2000, asthma attack prevalence among Hispanic children remained be-

1995/1996. 1995/199 6. From 1997 to 2000 2000,, asthm asthmaa attac attack k preva preva-lence remained fairly level among all age groups.

low that for white non-Hispanic children. Within ther 3 ped pediat iatric ric age gro groups ups,, pre preval valenc ence e inc increa reased sed ove over time. Children aged 0 to 4 years had the most rapid growth gro wth in ast asthma hma pre preval valenc encee fro from m 198 1980/1 0/1981 981 to

Ambulatory Health Care Utilization

The rate for annual visits to private physician offices for childhood asthma followed an increasing ARTICLES   317

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TABLE 2.   Average Annual Office Office Visits for Asthma (per (per 1000) Among Children Children Younger Younger Than 18 Years, Selected Selected Years 1980 to 1999, United States*

Office Visits to Private Physician Offices

Hospital ED Visits

Hospital OPD Visits

Total Ambulatory Asthma Visits

1980––19 1980 1981 81 19 1985 85 19 1990 90––199 19911 199 19955–199 19966 199 19988–199 19999 199 19955–199 19966 199 19988–199 19999 199 19955–199 19966 199 19988–199 19999 199 19955–199 19966 199 19988–1999 Overall 38.1 Race White††   39.1 White Black††   35.2 Black Age 0–4 y 36.4 5–10 y 50.4 11––17 y 11 3300.0

 

36.1

41.7

48.7

61.4

10.4

11.4

6.7

7.7

65.7

80.5

3377.8 ‡  

4400.2 45.5

48.1 55.1

59.3 71.7

7.5 25.8

9.0 26.2

4.7 17.4

5.5 19.3

60.3 98.2

73.9 117.1

31.2 61.3 19.3

38.2 49.2 37.5

54.9 50.8 42.2

67.0 71.4 48.5

14.8 11.4 6.2

15.6 12.0 8.0

7.7 8.7 4.0

10.9 7.2 5.9

77.4 70.9 52.4

93.5 90.6 62.4

Source: Medicaland Care Survey, National Hospital Ambulatory Medical Care Survey, National Center for Health Statistics,National CentersAmbulatory for Disease Control Prevention. * All relative SEs for estimates are below 30% unless indicated. † Hispanic origin not reported because of insufficient data. Race categories include persons of Hispanic origin. ‡ The relative SE is 30%. The estimate is unreliable.

trend during 1989 to 1999, the period for which annual data are available, and rose by an average of  3.8% per year (Fig 1). However, before this period, the asthma office visit rate declined by a total of 27% during the 9-year period from 1980 to 1989. Compared with white children, the asthma office visit rate in 1998 –1999 for black children was 1.2 times high hi gher er (T (Tab able le 2) 2).. As Asth thma ma of offi fice ce vi visi sitt ra rate tess we were re high hi gher er in yo youn unge gerr ch chil ildre dren n an and d al almo most st do doub uble led d among children 0 to 4 years of age between 1980/ 19811 and 199 198 1998/1 8/1999 999 com compar pared ed wit with h mor moree mod modest est increa inc reases ses amo among ng old older er chi childre ldren. n. Dat Dataa for vis visits its to hospital EDs and OPDs are shown in Table 2 for 1995 to 199 1999. 9. Bla Black ck chi childre ldren n had visit rat rates es to hos hospita pitall OPDs and EDs approximately 3 times higher than thos th osee fo forr wh whit itee ch child ildre ren n in 19 1998 98––199 1999. 9. Whe When n all sources of data for ambulatory visits for asthma are combined (shown in the far right columns in Table 2), black children had a visit rate 1.6 times higher than tha n whi white te chi childr ldren en in 199 19988 –199 1999. 9. As with office office visits to private physician offices, rates of hospital ED and OPD visits in 1995– 1995–1999 were higher among younger children compared with those aged 11 to 17 years. Hospitalizations

The childh childhood ood asth asthma ma hospit hospitaliza alization tion rate grew slowly from 1980 to 1999, by an average of 1.4% per year. yea r. How Howeve ever, r, the hos hospit pitaliz alizati ation on rat ratee see seems ms to have plateaued since the mid-1990s (Fig 1). Asthma hospitalization rates increased to a much greater extent among black children than white children. In 1998 –1999 1999,, the asthm asthmaa hospit hospitaliza alization tion rate among  black children was 3.6 times the rate for white children (Table 3). The results of a sensitivity analysis show that if hospit hospitaliza alizations tions with unkno unknown wn race are assumed to be for children of white race, then the hospitalization rate for black children in 1998 –1999 was 3.2 times that for white children and hospitalization rates for black and white children increased 25% and 11%, respectively, from 1980/1981 to 1998/ 1999 (data not shown). prevalence was lowest among the Although youngest asthma children, hospitalization rates were substantially higher among 0- to 4-year-old 4-ye ar-oldss and increa increased sed more rapidly compared CHILDHO HOOD OD ASTHMA 318   TRENDS IN CHILD

with older children. After 1995– 1995 –1996, asthma hospitalization rates plateaued among all age groups. Mortality

Asthma death rat Asthma rates es inc increa reased sed by an av avera erage ge of  3.4% per year from 1980 to 1998 (Fig 1 and Table 4). After reaching reaching a peak of 3.8 per 1 000 000 children children in 1996, the childhood asthma death rate declined 18% in 19 1997 97 to 3. 3.11 pe perr 1 00 0000 00 0000 ch child ildre ren. n. Ho Howe weve ver, r, asth as thma ma mo mort rtal alit ity y ro rose se ag agai ain n in 19 1998 98 to 3. 3.55 pe perr 1 000 000 children. Black non-H non-Hispan ispanic ic childre children n had the highest asthma death rates and the greatest increase over time. In 1985– 1985 –1986, the death rate among  black non-Hispanic children was 4.1 times higher than the death rate for white non-Hispanic children and an d in 19 1997 97––199 19988 was 4.6 tim times es hig higher her.. His Hispan panic ic children had asthma death rates similar to those of  white whi te non non-Hi -Hispa spanic nic chi childre ldren. n. Ast Asthma hma mor mortal tality ity trends over time were generally similar among all agee gr ag grou oups ps,, bu butt 11 11-- to 17 17-y -yea earr-ol old d ch child ildre ren n ha had d asthma ast hma dea death th rat rates es app approx roxima imatel tely y twic twicee tho those se of  younger children. Diagnostic Transfer

A possible explanation for increasing asthma prevalence and health care utilization is diagnostic transfer––an increasing tendency over time of respiratory fer TABLE 3.   Aver Average age Annual Asthma Asthma Hospitalizatio Hospitalizations ns (per 10 000) Among Children Younger Than 18 Years, Selected Years 1980 to 1999, United States* States*

Overall Race White††   White Black††   Black Age 0–4 y 5–10 y 11––17 y 11

1980– 1980– 1981

1985– 1985– 1986

1990– 1990– 1991

1995– 1995– 1996

1998– 1998– 1999

21.6

26.3

29.5

31.7

26.9

16.0 16 4455.5

19.0 48.0

16.7 57.6

16.5 71.0

15.5 56.9

38.0 21.2 11.6

48.9 21.6 13.8

55.7 22.8 14.8

59.7 27.4 14.8

51.4 24.2 12.1

Source: National Hospital Discharge Survey, National Center for Health Statistics, Centers for Disease Control and Prevention. * All relative SEs for estimates are below 30%. † Hispanic origin not available. Race categories include persons of  Hispanic origin.

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TABLE 4.   Average Annual Annual Asthma Mortality Mortality (per 1 000 000) Among Children Children Younger Younger Than 18 Years, Selected Years 1980 to 1998, United States*

1980––1981 1980

1985–1986

1990–1991

1995–1996

1997–1998

1.8

2.7

3.1

3.8

3.3

1.0 4.1 4. ‡

2.0 8.5 1.9

2.4 11.7 2.0

2.2 10.1 1.6

2.2 2.3 4.4

2.7 2.7 5.6

2.5 2.7 4.4

Overall mortality Race/ethnicity Whit Wh itee no non n-H -His ispa pan nic Black non-Hispanic Hispanic Age 0–4 y 5–10 y 11––17 y 11

1.2† 1.2 5.3† NA† 1.2 1.6 2.4

   

1.6 2.0 4.1

 

NA indicates not applicable. Source: Mortality File, National Center for Health Statistics, Centers for Disease Control and Prevention. * All relative SEs for estim estimates ates are below 30%. † Data for ethnicity not available for 1980 –1981. Rates for white and black children include those of  Hispanic ethnicity for 1980 –1981. ‡ The estimate is statistically unreliable because there were fewer than 20 deaths.

conditions to be labeled as asthma rather than as other conditions.26,27 If the increase in asthma prevalence and health care utilization was mirrored by a declinee in that for other respira declin respiratory tory conditions, conditions, then diagnostic transfer may be a plausible explanation for the tren trends ds obs observ erved ed sin since ce 198 1980. 0. We ass assess essed ed trends for bronchitis, bronchiolitis, and pneumonia  because these conditions may be confused with asthma. From 1980 to 1996, the prevalence of chronic  bronchitis increased by 2.3% per year on average compared with 4.3% per year for asthma prevalence. Although this pattern does not suggest diagnostic transfer, the pre-1997 NHIS data are based on parental report and not necessarily on physician diagnosis. From 1989 to 1999, the office visit rate for bronchitis and bronchiolitis decreased by 6.3% per year and for pneu pn eumo moni niaa by 9. 9.9% 9% pe perr ye year ar,, wh wher erea eass th that at fo forr asthma rose 3.8% per year. However, from 1980 to 1989, a period for which annual data are not available, the visit rate to private physician offices for  bronchitis and bronchiolitis increased by a total of  81% during the 9- year period and for pneumonia by 91%, whereas the asthma visit rate decreased by 27%. The hospitalization rate for bronchitis and bronchiolitis increased by 0.7% per year from 1980 to 1999, whereas that for asthma increased by 1.4%. However, the pneumonia hospitalization rate decreased  by 1.3% per year during this same period. Thus, there is an inverse relationship between trends in asthma office visits and hospitalizations and those for pneumo pneumonia, nia, bronch bronchitis, itis, and bronch bronchiolitis iolitis..

The burden of asth asthma ma on the pediatric population population as meas measured ured by asthm asthmaa preva prevalence, lence, ambulatory ambulatory visits, and mortality increased dramatically during the past 2 decades. The childhood asthma hospitalization rate increased more slowly but was still rising during a period when pediatric hospitalization rates for other causes were declining.28 –30 The factors be-

nosis may be more difficult, raises the question of  changes in diagnosis over time. The majority of episodes of wheezing in infants are related to transitory conditions and are not associated with increased risk of asthma later in life. 31 It is possible that over time, asthma was more likely to be diagnosed in infants during these transient episodes because of greater awareness of the diagnosis and treatment of asthma among parents and health professionals. However, it is unlikely that changes in diagnostic awareness in younge you ngerr chi childre ldren n com complet pletely ely acc accoun ountt for the sus sus-tained increase in asthma prevalence in older age groups as measured by the NHIS, especially because the NHIS focused on asthma in the 12 months before the survey. Diagnostic transfer is another possible change in labelin lab eling g of res respira piratory tory con condit dition ionss in chi childre ldren n tha thatt could contribute to the increase in asthma prevalence and health care utilization. Our analysis of trends in  bronchitis prevalence cannot be used to definitively support or refute the theory that an increasing tendenc de ncy y to tr tran ansf sfer er di diag agno nose sess fr from om br bron onch chiti itiss to asthma over time has resulted in increased asthma prevalence. In contrast, trends in health care utilization show that rising asthma office visit rates from 1989 to 1999 were roughly mirrored by decreases in those for bronchitis, bronchiolitis, and pneumonia, and inc increa reasin sing g ast asthma hma hos hospita pitaliz lizati ation on rat rates es fro from m 1980 to 1999 by decreasing pneumonia hospitalization tio n rat rates. es. The These se pat patter terns ns sug sugges gestt tha thatt dia diagno gnosti sticc transfer has contributed to the increasing trend in asthma health care utilization. However, more detailed investigation is necessary to examine the influence of other factors that could also contribute to these patterns. For example, efforts to reduce hospitalizations for pneumonia and bronchitis may have  been more successful than those to reduce asthma hospitalizations. Anot An othe herr po poss ssib ible le ex expla plana natio tion n fo forr in incr crea easi sing ng asthma prevalence and morbidity is changing environmental exposure.27 Some have hypothesized that

hind increasing increa sing asthma burden remain n unclea unclear. r. Thethe dispro dis proport portion ionate ate inc increa rease se inremai asthma ast hma prevapre valence, health care utilization, and mortality for children younger than 5 years, for whom accurate diag-

urbanization leads tothat multiple exposures indoors and outdoors) increase the risk (both of devel26,32–35 oping asthma. However, evidence in this area is mixed; 1 study demonstrated that both urban and

DISCUSSION Dramatic Increases in Childhood Asthma

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rura rurall popu populat lation ionss und underwe erwent nt sim simila ilarr inc increa reases ses in asthma prevalence during the 1980s.36 Research to elucidate elucida te the causes of asthm asthmaa contin continues. ues. Recent Trends Suggest That the Asthma Burden Has Plateaued

 Just as puzzling as the prolonged increase in asthma prevalence, health care utilization, and mortality is the recent plateauing of some indicators and the app appare arent nt dec decrea rease se of ast asthma hma pre preval valenc encee aft after er 1995. The interpretation of trends in asthma prevalence has been complicated by the redesign of the NHIS in 1997. Although the redesign will improve the validity of asthma surveillance by requiring a diagnosis by a health professional, it created a break in the trend of asthma prevalence 11 and generated unce un cert rtai aint nty y ab abou outt ho how w to int inter erpr pret et th thee dr drop op in asthma ast hma pre preval valenc encee in 19 1996. 96. The 199 19966 sam sample ple was reduced by 40% as a result of pilot testing of the 1997 redesigned survey, and the impact of this decreased sample size on prevalence estimates is unclear. Although asthma hospitalizations and mortality have plateaued since 1995, these recent trends cannot be used to “ to  “confirm confirm””  a change in the prevalence trends  because multiple factors affect asthma morbidity and mortality. morta lity. For examp example, le, chang changes es in hospit hospitaliza alization tion rates may also reflect changes in medical practice, asthma ast hma the therap rapy, y, and acc access ess to and util utiliza ization tion of  5,26,28,37 care. Mortality Mortal ity may reflec reflectt avai availabili lability ty and utilization of health care, access to and correct use of  medication and prevention strategies, and severity of  disease.7,38 The Theref refore ore,, add additio itional nal yea years rs of dat dataa are necessary to determine whether the pattern of increasi cre asing ng ast asthma hma pre preval valenc encee duri during ng the pas pastt 2 de11 cades has changed. One possible reason for the recent plateauing of  hospitalizations and deaths may be the impact of  clinical and public health intervention and prevention efforts. Although it is difficult to evaluate the efficacy of specific or local prevention programs with national data, the impact of nationwide programs, such as the State Children’ Children’s Health Insurance Program that was passed as part of the Balanced Budget Act of 1997, may be discerned. A large nationwide increase in enrollment of children in insurance programs (2 684 300 children were enrolled by Septem ber 1998)39 may be partly responsible for the large  jump in asthma office visits in 1998. Another recent nationwide natio nwide development development is the dissemination dissemination of the National Asthma Education and Prevention Program Guidelines in 1997.6 It has been theorized that adoption of these guidelines by medical practitioners was responsible for the recent decline in asthma mortality among all ages in the United States in 1997. 7 Disparities in Asthma Burden Among Children

talization and mortality has been found to be correlated with minority race and living in poverty.25,27,33,42,48 Al Alth thoug ough h mo most st po poor or ch chil ildre dren n have access to a source of asthma care,41,49,50 poor and minority children with asthma are less likely to receive care in a high-quality setting with continuity of care41,49,50 and less likely to be prescribed or to use maximally effective preventive therapy.33,49,51,52 Furthermore, some studies suggest that after adjusting for severity of disea disease, se, even great greater er discre discrepanci pancies es in health care utilization exist between poor and nonpoorr chi poo childre ldren n and between between bla black ck and white chi chill41 dren (L. J. Akinbami and K. C. Schoendorf, Nation ti onal al Ce Cent nter er fo forr He Heal alth th St Stat atis isti tics cs,, un unpub publis lishe hed d manuscript). Such differences in utilization of and access to health care are likely to contribute to the racial rac ial and inc income ome dis dispar pariti ities es in ast asthma hma mor morbid bidity ity and mortality that have been widely described in the literature. Strategies to Expand Childhood Asthma Surveillance

There are regional and local variations in asthma prevalence, preva lence, hospitalization, hospitalization, and mortal mortality ity that nationall data do not reveal.8,9,42,53 As demonstrated by tiona studie stu diess foc focusi using ng on reg region ional al va variat riation ionss in ast asthma hma hospitalization trends,5,28 examining smaller population groups exposes important differences in practices and outcomes and facilitates translating surveillance findings into policy. Strategies to increase local surveillance surve illance include analyzing analyzing existi existing ng data on hospital discharges or billing information and standardized household surveys.8 The Behavioral Risk Factor Surveillance Surveil lance System is a rando random-digi m-digit-dia t-dialed led telephone survey operated in all 50 states, the District of  Columbia, and Puerto Rico. The Behavioral Risk Factor Surv Surveil eillan lance ce Sys System tem has cor coree ques questio tions ns abo about ut health conditions (including asthma) and an optional standardized module beginning in 2001 that states may use to gat gather her more det detaile ailed d inf informa ormatio tion n on asthma, including childhood prevalence. Although asthma ast hma pre preval valenc encee dat dataa fro from m the core survey are collected only for adults, some states added questions about childhood asthma. However, the questions were not standardized between states. A standardi da rdize zed d as asth thma ma mo modu dule le to me meas asur uree ch chil ildh dhoo ood d asthma prevalence may be available for states to use in the future (J. Moorman, National National Cente Centerr for Environmental Health, Centers for Disease Control and Preven Pre vention tion,, per person sonal al com commun munica ication tion,, Jan Januar uary y 16, 2001). The NCHS is also launching an asthma survey in th thee St Stat atee an and d Lo Loca call Ar Area ea In Inte tegr grat ated ed Sur Surve vey, y, a telephone survey that will use a uniform questionnaire nai re for all sta states tes and will prov provide ide sta statete-spe specif cific ic information inform ation about asth asthma ma for childr children en and adults. Limitations

9,29,34,38,40 – 47

As do docum cumen ente ted d in se seve vera rall st studi udies es,, preval pre valenc ence, e, mor morbid bidity ity,, and mor mortal tality ity are hig higher her among black children compared with white children. Although much has been made of racial disparities

It is not possible using NCHS data to detect multiple hospitalizations and office visits for each patient. Therefore, the extent to which changes over time reflect the changes in the frequency of recurrent

in prevalence, much46larger forasthma morbidity and mortality (L. J.disparities Akinbamiexist and K. C. Schoendorf, National Center for Health Statistics, unpublished manuscript). Risk of asthma hospi-

asthma office visits or hospitalthat readmissions is unknown. It is unlikely, however, readmissions are primari prim arily ly res respon ponsib sible le for obs observ erved ed tre trends nds giv given en 54 asthmaa readm asthm readmission ission rates report reported ed elsew elsewhere. here. In

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addition, it is unclear how readmissions may affect the observed racial disparity. That is, it is unknown whet wh ethe herr ch child ildre ren n of di diff ffer eren entt ra race ce/e /eth thni nicc ba back ck-grounds have a different level of risk for readmission. Missing race data are an important limitation for the NAMCS, NHAMCS, and NHDS. Race for all of  these surveys is obtained from medical records, in contrast to the NHIS for which race is self-reported. Forr th Fo thee ap appr prox oxim imat atel ely y 9% of th thee NA NAMC MCS S an and d NHAMCS records missing race, NCHS imputed this information.13,16,17 Given the limitations in the data collected on race, the analysis by race for asthma ambulatory visits must be interpreted with caution. For the NHDS, the 5% to 22% of hospital discharge records with missing race data are most likely to represent white patients.21 There is no ideal solution to adjust for underreporting of race in the NHDS; therefore, data by race should be interpreted cautiousl tio usly. y. How Howeve ever, r, the there re is evi eviden dence ce tha thatt a siz sizabl ablee racial rac ial dis dispar parity ity in ast asthma hma hos hospita pitaliz lizati ations ons exi exists sts given the robustness of the disparity in the sensitivity analysis for unreported race in the NHDS and the raciall dispa racia disparities rities reported in sever several al other studies 28,30,33,42 using different data sources. CONCLUSION

The burden of pediatric has increased substantially during the pastasthma 2 decades and has been  borne disproportionately by black children. Although tho ugh rec recent ent dat dataa sug sugges gestt tha thatt the bur burden den fro from m childhood asthma may have recently plateaued after several years of increasing, additional years of data collection are necessary to confirm a change in trend.

Health Interview Survey– Survey–United States. MMWR States.  MMWR Morb Mortal Wkly Rep. Rep . 2000;49:908––911 2000;49:908 12. National Center for Health Statistics. Statistics. Health Measures in the New 1997 Redesigned Redes igned National National Healt Health h Inter Interview view Survey (NHIS (NHIS). ). Avail Available able at: www.cdc.gov/nchs/about/major/nhi www.cdc.gov/nchs/ about/major/nhis/hisdesgn.htm s/hisdesgn.htm 13. Woodwell DA. DA. National  National Ambulatory Medical Care Survey: 1998 Summary. Summary . Hyattsville, MD: National Center for Health Statistics; 2000 (Advance data from vital and health statistics, statistics, no. 315) (DHHS Publ. No. [PHS [PHS]] 2000-1250) 14.. Natio 14 National nal Cent Center er for Heal Health th Sta Statist tistics. ics. Public use data tape document docu mentatio ation: n: 1981 Nati National onal Ambu Ambulato latory ry Medic Medical al Care Surv Survey. ey. Hyattsville, MD: US Department of Health and Human Services, Public Health Service, National Center for Health Statistics; 1983 15.. Natio 15 National nal Cent Center er for Heal Health th Sta Statist tistics. ics. Public use data tape document docu mentatio ation: n: 1985 Nati National onal Ambu Ambulato latory ry Medic Medical al Care Surv Survey. ey. Hyattsville, MD: US Department of Health and Human Services, Public Health Service, National Center for Health Statistics; 1987 16. McCaig LF. National LF. National Hospital Ambulatory Medical Care Survey: 1998 Emer gency Department Summary. Summary . Hyattsville, MD: National Center for Health Statistics; 2000 (Advance data from vital and health statistics, no. 313) (DHHS Publ. No. [PHS] 2000-1250) 17. Slusarcick AL, McCaig LF.  National Hospital Ambulatory Medical Care Survey: 1998 Outpatient Department Summary. Summary . Hyattsville, MD: National Center for Health Statistics; 2000 (Advance data from vital and health statistics, no. 317) (DHHS Publ. No. [PHS] 2000-1250) 18. US Census Bureau, Population Division, Division, Population Projections Projections Branch. National Estimates Quarterly Population Estimates, 1980 to 1990. Available at: eire.census.gov/ eire.census.gov/popest/archives/ popest/archives/national/nat_80s_de national/nat_80s_detail.php tail.php 19. US Census Bureau, Popula Population tion Divisio Division, n, Popula Population tion Project Projections ions Branch.. Natio Branch National nal Estim Estimates ates Mont Monthly hly Popu Populatio lation n Estim Estimates, ates, 1990 to 2000. Available at: eire.cens eire.census.gov/p us.gov/popest/arc opest/archives/na hives/national/ tional/ nat_90s_detail/nat_90s_3.php 20. Hall MJ, Popovic JR. 1998 JR.  1998 Summary: National Hospital Discharge Survey. Survey. Hyattsville, MD: National Center for Health Statistics; 2000 (Advance data from vital and health statistics, statistics, no. 316) (DHHS Publ. No. [PHS [PHS]]

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LAW REVISES STANDARDS FOR SCIENTIFIC STUDY

“It does not even take effect until next October 1, but a little-noticed law called the Data Quality Act, signed in the waning days of the Clinton administration, has set off a fierce debate over how best to weigh health and environmental risks. The law— law—supported, and largely written, by industry-backed groups— groups —requires the government for the first time to set standards for the quality of scientific informa inf ormatio tion n and sta statis tistics tics dis dissem semina inated ted by fed federa erall age agenci ncies. es. It woul would d cre create ate a system in every government agency under which anyone could point out errors in documents and regulations. . . The Data Quality Act was quietly enacted in December 2000 as 27 lines in a giant budget bill. . . .  ‘ ‘This This is the biggest sleeper there is in the regulatory area and will have an impact so far beyond anything people can imagine,’’  said William L. Kovacs, the vice president for environment, technology imagine, and regulatory affairs of the US Chamber of Commerce.   ‘This is the first time where, if the data are not good, you can actually begin challenging the agency,’ agency, ’ Mr. Kovacs Kova cs said. . .The more influe influential ntial the data are likely to be, the higher the quality standard they must meet, the guidelines say. In some cases, the guidelines state even studies published in respected peer-reviewed journals will require further confirmation. . .Views remain mixed on whether the benefits of the law will outweigh the potential harm.” harm.”

Revkin AC. New AC.  New York Times. March Times.  March 21, 2002

Noted by JFL, MD

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Trends in Childhood Asthma: Prevalence, Health Care Utilization, and Mortality Lara J. Akinbami and Kenneth C. Schoendorf  Pediatrics 2002;110;315 Updated Information & Services

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