white gap in asthma hospitalizations and mortality

Original articles The widening black/white gap in asthma hospitalizations and mortality Ruchi S. Gupta, MD, MPH,a,b Violeta Carrio´n-Carire, MA,a,c and Kevin B. Weiss, MD, MPHa,c,d Chicago and Hines, Ill

Key words: Asthma, disparities, hospitalizations, mortality

From athe Institute for Healthcare Studies and cthe Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago; bSmith Child Health Research Program, Children’s Memorial Hospital, Chicago; and dMidwest Center for Health Services and Policy Research, US Department of Veterans Affairs, Edward Hines, Jr. VA Hospital, Hines. Supported by Health Resources and Services Administration (HRSA) training grant #T32HS00078-07. Received for publication August 22, 2005; revised November 17, 2005; accepted for publication November 29, 2005. Reprint requests: Ruchi Gupta, MD, MPH, Institute for Healthcare Studies and Children’s Memorial Hospital, 339 E Chicago Ave, Room 712, Chicago, IL 60611-3071. E-mail: [email protected]. 0091-6749/$32.00 Ó 2006 American Academy of Allergy, Asthma and Immunology doi:10.1016/j.jaci.2005.11.047

Abbreviations used B/W: Black/white ED: Emergency department ICD-9: International Classification of Disease, Ninth Revision ICD-10: International Classification of Disease, Tenth Revision NAEPP: National Asthma Education and Prevention Program NCHS: National Center for Health Statistics NHDS: National Hospital Discharge Survey

Health disparities are pervasive and have recently been receiving much attention.1-3 Asthma, a leading cause of chronic illness in children and young adults,4,5 is a health condition characterized by substantial racial disparities. Differences in US asthma hospitalizations and mortality were described during the 1970s6 and more recently since 1995.7 African Americans have a higher prevalence of asthma and are 4 times more likely to be hospitalized and 5 times more likely to die of asthma than nonAfrican Americans.6,8-12 It is generally believed that asthma morbidity and mortality are largely preventable, especially when patients are well educated about their disease and have access to quality health care.13,14 In 1991, the National Heart, Lung, and Blood Institute established the National Asthma Education and Prevention Program (NAEPP). The first major task of the NAEPP was to develop national guidelines to help improve the quality of treatment of asthma.15 There have also been a number of large-scale national studies to improve inner-city asthma,16,17 programs at the Centers for Disease Control and Prevention,18 and national support of local and regional asthma coalitions.19 Asthma morbidity has even had the attention of the White House in developing health policy to improve care and reduce morbidity.20 Multiple strategies have been described and shown to be cost-effective in decreasing asthma symptoms and reducing disparities.20-22 With much attention on improving asthma care and asthma disparities, a 2003 Institute of Medicine report still identified asthma treatment quality as one of 20 priority areas for national action.23 Priorities in research to reduce asthma disparities by the National Heart, Lung, and Blood Institute were published in 2002.24 351

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Background: Large racial differences in asthma morbidity and mortality have prompted research on new interventions, public awareness, and health policy efforts in the past decade. Objective: We sought to characterize recent trends in US asthma hospitalization and mortality for black and white children and adults during the period from 1980 through 2002. Methods: We conducted a successive representative national cohort study of US residents ages 5 to 34 years using data from the National Hospital Discharge Survey and the US vital statistics system. Outcome measures included black/white (B/W) asthma hospitalization and mortality rates, rate ratios, and rate differences. Results: For asthma hospitalizations from 1980 through 2002, children ages 5 to 18 years had a 50% increase in the B/W rate ratio, and the rate difference increased from 22.8 to 28.3 hospitalizations per 10,000 population. For young adults ages 19 to 34 years, the B/W rate ratio increased from 2.3 to 2.8, and the rate difference decreased from 9.6 to 7.9 hospitalizations per 10,000 population. For asthma mortality from 1980 through 2001, children ages 5 to 19 years had a large increase in the B/W rate ratio from 4.5 to 5.6 and in the rate difference from 5.6 to 8.1 deaths per 1,000,000 population. There did not appear to be a significant change in the B/W differences for adults ages 20 to 34 years. Conclusions: For children, there have been notable increases in asthma B/W differences in hospitalizations and mortality since 1980, whereas for adults the increase has been smaller. National efforts to improve asthma care over the past decade do not appear to have reduced this B/W gap. When treating children with asthma, it is important to consider the racial-ethnic factors that might lead to avoidable hospitalizations and premature mortality. (J Allergy Clin Immunol 2006;117:351-8.)

352 Gupta, Carrio´n-Carire, and Weiss

To date, there has been no study to explore whether the research, education, and health policy actions taken in the 1990s have had an effect on asthma disparities. The purpose of this study is to characterize the trends in asthma hospitalization and mortality rates in the United States by race for children and young adults between 1980 and 2002.

METHODS Study population This study examines national reports of hospitalizations (hospital discharges) and deaths (mortality data) that occurred among US residents ages 5 to 34 years between January 1, 1980, and December 31, 2002. Hospitalization data were stratified into data on children (ages 5-18 years) and data on adults (ages 19-34 years). Mortality data were also stratified into data on children (ages 5-19 years) and data on adults (ages 20-34 years). These age groups were used to minimize misclassification of asthma caused by diagnostic uncertainty that occurs in younger children (age <5 years) and the potential for misclassification of asthma with chronic obstructive pulmonary disease in older adults.10,25

Hospitalization data

Health care education, delivery, and quality

Information on hospitalizations was obtained from public files from the National Hospital Discharge Survey (NHDS). These data sets are a series of nationally representative cross-sectional surveys of all discharges from short-stay, acute-care hospitals exclusive of military and Veterans Administrations facilities.26 The NHDS’s information is abstracted from information found on the face sheet of the patient’s medical record. This information includes date of birth, date of admission, date of discharge, age, race, sex, marital status, medical diagnoses and surgical operations, and expected source of payment. Approximately 7% of hospitals in the United States were included in the sample. Hospitals for this survey were chosen from a stratified sample based on geographic location, bed size, and type of ownership-management. The sample discharges from each participating hospital were then randomly selected each day. The individual sample discharges were subsequently weighted to produce a US estimate. Categories for the desired age, race, and year categories were determined and used as subpopulations for further analysis.

Mortality data Data on asthma mortality were obtained from the Centers for Disease Control and Prevention US vital statistics system. Each year, more than 2 million death certificates are filed, providing information on the decedent’s medical diseases; demographic characteristics; date, time, and place of death; and performance of an autopsy. For each death, an underlying cause of death is selected from the list of conditions on the death certificate by the use of the classification structure and selection and modification rules contained in the International Classification of Diseases. From 1979 through 1998, the cause-of-death statistics published by the National Center for Health Statistics (NCHS) have been classified according to the International Classification of Disease, Ninth Revision (ICD-9).27 The International Classification of Disease, Tenth Revision (ICD10), was implemented in the United States effective with deaths occurring in 1999 through 2002.28

Case definition For the hospitalization and mortality data, asthma-specific cases were selected on the basis of the 3-digit ICD-9 diagnostic code 493.

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For the mortality data, the period of 1980 through 1998 was based on the ICD-9 diagnostic code, and the period of 1999 through 2002 was based on ICD-10 diagnostic codes J45 through J46. The number of deaths is reported from counts of underlying causes of death. Hospitalizations were reported from first-listed discharge diagnosis.

Race classification Racial classifications used in this report are based on those used by the NCHS during the study time period. From the available race classifications for hospitalization data, ‘‘white’’ and ‘‘black/African American’’ were selected for further analysis. From the mortality data, ‘‘white’’ and ‘‘black’’ classifications were selected. For simplicity, we will report our results using the classification of black/ white (B/W).

Statistical considerations Crude hospitalization and mortality rates were calculated by using annual population estimates by age, race, and year provided by the NCHS hospitalization data. Estimates of hospitalization and mortality rates were estimated to reflect the ratio per 10,000 US population. The ratios of crude rates were calculated as the rate of hospitalizations or mortality for black subjects for a given year over the rate of hospitalizations or mortality for white subjects. Similarly, the rate difference was estimated by subtracting the white rate from the black rate for a given time period. SEs of the hospitalization discharge crude rates were estimated with STATA 8.2 (StataCorp LP, College Station, Tex) survey data analysis procedures for the subpopulation of interest by age, race, and year. SEs for the hospitalization discharge crude rates were adjusted to reflect per 10,000 US population rates. SEs of the hospitalization crude rate estimates were used to approximate the SEs of the hospitalization rates ratios and rate differences by using the delta method of variance estimation. The delta method of variance approximation is based on Taylor series approximation methods and assumes zero covariance between the black and white rates. Therefore SEs of these rate ratios and rate differences are expected to underestimate the true values of such standard errors. The mortality data in this report are based on complete counts of death certificates and are therefore not subject to sampling error. These numbers are, however, subject to random variation. Simple linear regression fits to the data across years was done with STATA 8.2. Crude rate averages for selected time periods were grouped by using bins ranging from 3 to 5 years. Tables I and II include P values for the test of the slope of the linear fit being significantly different than zero for the 21- or 22-year period. Crude rates of asthma hospitalization discharges and mortality are also depicted across years (Figs 1 and 2).

RESULTS Asthma hospitalizations During the 1980 through 2002 time period, there was an average annual 438,700 6 11,400 hospitalizations, averaging 20 6 0.5 hospital discharges per 10,000 population. The national trends for asthma hospitalizations for black and white individuals ages 5 to 34 years are shown in Fig 1. Table I presents the actual number of discharges per 10,000 population for each time period, along with B/W rate ratios and rate differences. The rate of hospitalizations for white subjects decreased from 9.0 to 6.1 per 10,000 population between 1980 and 1984 and 2000 and 2002, respectively. Asthma hospitalizations rates for black

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TABLE I. Trends in US asthma hospitalizations among persons ages 5 to 34 years from 1989 through 2002 1980-1984

Ages 5-34 y Rate per 10,000 population White Black B/W rate ratio B/W rate difference Ages 5-18 y Rate per 10,000 population White Black B/W rate ratio B/W rate difference Ages 19-34 y Rate per 10,000 population White Black B/W rate ratio B/W rate difference

1985-1989

1990-1994

1995-1999

2000-2002

Rate

SE

Rate

SE

Rate

SE

Rate

SE

Rate

SE

P value

9.0 25.2 2.8 16.3

0.22 0.89 0.12* 0.91*

8.4 26.3 3.1 17.9

0.24 0.90 0.14* 0.94*

6.9 26.4 3.8 19.4

0.22 0.91 0.18* 0.94*

8.0 27.6 3.4 19.6

0.2 0.8 0.15* 0.85*

6.1 24.6 4.0 18.5

0.3 1.0 0.27* 1.08*

<.001 .34 <.001 .04

11.5 34.3 3.0 22.8

0.37 1.49 0.16* 1.54*

11.3 33.4 3.0 22.1

0.42 1.47 0.17* 1.53*

8.8 35.9 4.1 27.1

0.36 1.45 0.23* 1.49*

10.3 40.6 3.9 30.3

0.4 1.3 0.20* 1.35*

8.1 36.5 4.5 28.3

0.5 1.7 0.37* 1.79*

.01 .03 <.001 <.001

7.1 16.6 2.3 9.6

0.26 0.99 0.16* 1.02*

6.3 20.0 3.2 13.7

0.27 1.09 0.22* 1.12*

5.5 17.6 3.2 12.1

0.27 1.11 0.26* 1.14*

5.9 14.4 2.4 8.4

0.3 1.0 0.20* 1.02*

4.3 12.3 2.8 7.9

0.4 1.1 0.36* 1.20*

<.001 .05 .55 .28

*Approximation using the delta method of variance estimation.

Ages 5-34 y Rate per million White Black B/W rate ratio B/W rate difference Ages 5-19 y Rate per million White Black B/W rate ratio B/W rate difference Ages 20-34 y Rate per million White Black B/W rate ratio B/W rate difference

1980-1984

1985-1989

1990-1994

1995-1999

2000-2001

P value

2.1 9.9 4.7 7.8

2.8 12.5 4.5 9.7

3.1 13.8 4.4 10.6

3.4 15.6 4.6 12.2

2.6 13.2 5.0 10.6

.001 <.001 .93 <.001

1.6 7.2 4.5 5.6

2.2 9.5 4.4 7.4

2.3 10.4 4.5 8.1

2.4 11.4 4.7 8.9

1.8 9.8 5.6 8.1

.02 .002 .20 .002

2.5 12.7 5.1 10.2

3.2 15.4 4.8 12.2

3.8 17.7 4.7 13.9

4.4 20.8 4.7 16.4

3.6 18.4 5.1 14.7

<.001 <.001 .37 <.001

subjects did not change significantly between the 1980 through 1984 time period (25.2 discharges per 10,000 population) and the 2000 through 2002 time period (24.6 discharges per 10,000 population). The B/W rate ratio for asthma hospitalizations increased from 2.8 to 4 from 1980 through 2002, and the B/W rate difference increased from 16.3 to 18.5 discharges per 10,000 population. Most of the increase between black and white rates was seen in children (ages 5-18 years). Asthma hospitalizations for white children decreased from 11.5 to 8.1 discharges per 10,000 population between 1980 and 1984 and 2000 and 2002, respectively, whereas rates for black children

increased slightly, from 34.3 to 36.5 discharges per 10,000 population. The B/W rate ratio of asthma hospitalizations for children increased from 3.0 to 4.5 (50%), and the rate difference increased from 22.8 to 28.3 discharges per 10,000 population. The length of hospital stay for both black and white children similarly decreased: 3.7 to 2.4 days for black children and 3.8 to 2.3 days for white children between 1980 and 2002, respectively. For adults, there was a trend toward decreasing hospitalization rates. Rates for white adults decreased from 7.1 to 4.3 discharges per 10,000 population and for black adults from 16.6 to 12.3 discharges per 10,000 population between 1980 and 1984 and 2000 and 2002,

Health care education, delivery, and quality

TABLE II. Trends in US asthma mortality for persons ages 5 to 34 years from 1980 through 2001

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Health care education, delivery, and quality FIG 1. Trends in asthma hospitalization rates and rate ratios for children ages 5 to 18 years and adults ages 19 to 34 years from 1980 through 2002. Blue lines, Black subjects; yellow lines, white subjects. Crude rates of asthma hospitalization discharges are depicted across years. Simple linear regression fits to the data across years were done by estimating trend.

respectively. The B/W rate ratio and rate difference for adult asthma hospitalizations has not substantially varied, with the most recent (2000-2002) rate ratio of 2.8 and rate difference of 7.9 discharges per 10,000 population. The average length of stay for white adults decreased from 4.8 days to 2.8 days and for black

adults decreased from 4.4 days to 2.3 days between 1980 and 2002.

Asthma mortality Between 1980 and 2001, there were an average annual 218 deaths from asthma in the United States in the 5- to

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FIG 2. Trends in asthma mortality rates and rate ratios for children ages 5 to 19 years and adults ages 19 to 34 years from 1980 through 2002. Blue lines, Black subjects; orange lines, white subjects. Crude rates of asthma mortality are depicted across years. Simple linear regression fits to the data were done by estimating trends.

34-year age group, or 1.31 deaths per 1,000,000 population. Asthma mortality trends for persons ages 5 to 34 years during this time period are presented in Table II and displayed in Fig 2. Unlike hospitalization, overall asthma mortality for white subjects increased from the 1980 through 1984 time period to 2000 through 2001, from

2.1 to 2.6 deaths per 1,000,000 population. For black subjects, asthma mortality also increased during the same time period from 9.9 to 13.2 deaths per 1,000,000 population. The B/W rate ratio for asthma mortality during this time period increased from 4.7 to 5.0, and the rate difference increased from 7.8 to 10.6 deaths per 1,000,000 population.

356 Gupta, Carrio´n-Carire, and Weiss

Childhood asthma mortality for both black and white children increased noticeably from 1980 through 2001. Mortality rates for white children increased from 1.6 in 1980 through 1984 to 1.8 in 2000 through 2001. Mortality rates for black children increased from 7.2 to 9.8 deaths per 1,000,000 population between 1980 and 1984 to 2000 through 2001, respectively. During the same time period, the B/W rate ratio and rate difference for childhood asthma increased from 4.5 to 5.6 and 5.6 to 8.1, respectively. This means an additional 12 deaths per year caused by asthma for white children and an additional 46 deaths per year caused by asthma for black children in 2000 through 2001 compared with 1980 through 1984. Mortality for both black and white adults increased steadily from 1980 through 1999, with a decrease seen in the 2000 through 2001 time period. White adults had a mortality rate increase from 2.5 to 3.6 deaths per 1,000,000 population between 1980 and 1984 and 2000 and 2001. During the same time period, black adults also had an increase in mortality from 12.7 to 18.4 deaths per 1,000,000 population. For young adults in the 2000 through 2001 time period, the B/W rate ratio was 5.1, and the rate difference was 14.7 deaths per 1,000,000 population.

DISCUSSION

Health care education, delivery, and quality

From this analysis, it appears that B/W differences in asthma hospitalizations and mortality in the United States for children and young adults have either remained stable or increased during the 1980 through 2002 time period. For children ages 5 to 18 years, these differences have increased for both hospitalization and mortality. For young adults, there appears to be a smaller increase in B/W differences for hospitalizations and mortality. With the B/W differences increasing more for children compared with adults, it is unlikely that there is a single explanation for what underlies these trends. Common factors thought to be associated with disparities include differences in prevalence of disease, access to care, quality of care and treatment, patient education, and personal health beliefs and behaviors. Pediatric asthma prevalence for both black and white children increased from 1980 through 1996 but then decreased and stabilized by 2000.29 From 1980 through 1999, asthma prevalence, morbidity, and mortality increased among all US adults.8 Yet there are few data to suggest that during the 1980 through 2002 time period, asthma prevalence increased more disproportionately for black children or adults compared with white children or adults to explain these findings. Access to quality medical care is to a large extent governed by access to health insurance. Recent increases in health care access and use among children, especially among minorities, has been demonstrated because of the State Children’s Health Insurance Program.30-32 In contrast, more than 15 million adults without insurance

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have a chronic health problem, including asthma,33 and the number of uninsured adults is increasing. Therefore it is likely that lack of access to insurance for adults could be contributing to this gap. Beyond insurance, perhaps the largest factor associated with quality in asthma management is the medication used to treat asthma. In a survey of parents of Medicaid-insured children with asthma, black children had worse asthma status and less use of preventive medication than white children.34 In private practice black children received fewer controller and reliever medications than white children.35 Similar to children, fewer black adults reported care consistent with recommendations for medication use than white adults.36,37 Additionally there, might be differences in treatment effect by race. Most notable is the genetic variability in the b-receptor that might be related to how black subjects have different responsiveness to this class of medications.38 Improving asthma treatment quality is one of 20 priority areas for national action23 and could be a significant factor underlying the lack of improvement in the B/W gap seen in this study. Asthma knowledge, health beliefs, and behaviors also influence the appropriate use of treatment and medications. When parents were asked about barriers to asthma medication use for their children, the majority reported personal health beliefs, mainly misperceptions about asthma, asthma medications, and their use.39 Fewer black adults reported receiving asthma self-management education.36 Asthma management education and skills training are vital for improved treatment and prevention of asthma.40,41 Some factors shown to be associated with improved asthma care include having a primary care physician, an asthma specialist, a written action plan, and a follow-up visit42 and believing the benefits of a treatment outweigh the risks. Evidence-based asthma guidelines, such as those of the NAEPP,15 can be a powerful tool for reducing racial disparities because they consist of strict explicit protocols based on symptoms and not race and ethnicity.43 When the NAEPP guidelines are adhered to, a reduction in hospitalizations, emergency department (ED) visits, and outpatient asthma visits has been demonstrated.44 Although these guidelines, along with other interventions, might be contributing to the overall decrease in hospitalization seen in our study, it is not apparent how this would affect the B/W gap. A recent study looking at asthma health disparities since 1995 found a reduction in the disparities gap between black and white adults and children.7 The study looked at a narrower time frame, men and women separately, and patients from less than 1 to 74 years old. Discrepancies in the diagnosis of asthma are known to exist for children less than 5 years of age because of misdiagnosis and confusion with transient early wheezing25 and with adults greater than 35 years of age because of misclassification of asthma with chronic obstructive pulmonary disease in older adults.10 The differences in the study age categories and years analyzed might account for the differences in our results.

There are, as with all studies, limitations to the design that need to be highlighted. The NHDS, unlike the vital records, describe events and person-based experience. Also, the source of the data on race for both hospitalization and mortality data is not known. For example, it is not possible with the hospital data to know whether the patient, family, nurse, administrator, or physician recorded the patient’s race and, ultimately, whether it was determined by self-report or observation. We were also unable to detect repeat hospitalizations by the same patient, and the race variable was missing in 18.51% of the NHDS database. Although the NHDS hospital sample is designed to provide national estimates of inpatient hospital use, it is potentially feasible that ED practices, such as 23-hour ED short stays (observation units), might not be uniformly deployed at all hospitals and therefore might not be optimally represented in the NHDS hospital sample. For mortality records, the origin of race data is also not well characterized. On the basis of the recent trends in asthma hospitalization and mortality, reducing disparities in asthma care should be a national priority for research, health policy, and community action.2,20,24 Black and white children ages 5 to 18 years had the largest increases in differences for both asthma hospitalizations and mortality over the past 2 decades, with adults having a slight increase or stabilization. Different issues might be driving the relatively large increase in asthma disparities for children compared with adults. Further understanding of the reasons for these differences and strategies to eliminate them might start to close this unacceptable B/W gap. We thank Ramon A. Durazo-Arvizu, PhD, and Christopher S. Lyttle, MA, for their statistical expertise in this study.

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