Epidemiology of Asthma in Michigan Chapter 8: Hospitalization for Asthma

Transcription

1 Contributors: Elizabeth Wasilevich, PhD, MPH Sarah Lyon-Callo, MA, MS Marcus Wasilevich, PhD Introduction: Asthma hospitalizations are particularly useful in understanding the asthma burden for a population and targeting or evaluating asthma intervention efforts. They are extremely severe events that increase the risk of asthma mortality. Additionally, asthma hospitalizations are considered preventable - people with asthma can stay out of the hospital if their disease is managed well. The following chapter provides an in depth review of asthma hospitalizations in Michigan, highlighting the observed disparities and trends. Key Findings: The annual asthma hospitalization rate in Michigan, all ages, is 16.6 per 10,000. ( ) The rate of asthma hospitalizations for black persons is at least four times the rate for white persons, regardless of age group. The degree of disparity in asthma hospitalization rates between black persons and white persons has remained unchanged over recent years. Between 2000 and 2006, rates of asthma hospitalization for adults age years and adults age 65 years and older are significantly increasing. In 2006, the average length of stay for an asthma hospitalization was 3.3 days. This has been significantly increasing over recent years. Michigan counties with rates of asthma hospitalization significantly higher than the rate for the state as a whole are Bay, Ingham, Saginaw, and Wayne Counties. Genesee County, with a historically high asthma burden, is no longer significantly higher than the state rate for asthma hospitalizations. Key Recommendations: Michigan should develop projects aimed to understand the reasons for the dramatic racial and geographic disparities in asthma hospitalization rates. This knowledge could be used to develop programs that effectively address these disparities. Michigan should focus efforts to reduce the asthma burden to those communities or populations with the highest asthma hospitalization rates. Data Michigan Inpatient Database Population Estimates Michigan Department of Community Health Healthcare Cost and Utilization Project (HCUP) Agency for Healthcare Research and Quality Methods: An asthma hospitalization is defined as a inpatient stay with a primary discharge diagnosis of asthma (ICD-9 -CM=493.XX). These data represent the number of hospitalizations for asthma, not the number of persons with a hospitalization for asthma. Age-adjusted asthma hospitalization rates are calculated using the direct standardization method and presented per 10,000 population. Rates are age-adjusted, using the 2000 US standard population, so that valid comparisons can be made between populations of different age distributions. 95% confidence intervals accompany all hospitalization rates. In addition to asthma hospitalization rates, the average length of stay for an asthma hospitalization is included in this report. Hospitalization rates for demographic units with a small number of events (20 or less) or a small population size (less than 5,000) are not calculated due to statistical instability. Additionally, counts less than 5 are not presented to protect the identity of those who have been hospitalized. Asthma hospitalization rates are calculated for various subgroups, including county of residence, age, race, sex, and month of admission, to identify disparities and patterns. Maps generated using geographic information system (GIS) tools are used for visual display of the data and to identify areas of high burden. (ArcGIS, Environmental Systems Research Institute) Overall monotonic trend in asthma hospitalization rates between 2000 and 2006 is statistically evaluated using the Spearman Correlation Coefficient and its accompanying Rank Correlation Test. A p-value of <0.05 for this test is considered statistically significant. (SPSS 15.0 for Windows, SPSS Inc.) The data source for these analyses is the Michigan Inpatient Database, which includes virtually all acute hospital discharges that occur in Michigan during the study period. Analyses presented in this report are inclusive of nonresidents of Michigan who were hospitalized in Michigan, unless otherwise noted. The Asthma Initiative of Michigan (AIM) AIM is a collaborative effort involving multiple partners from public and private sectors across the state and is committed to reducing the burden of asthma documented in this report. For information about AIM s priorities and interventions, please review the strategic plan for the initiative: Asthma in Michigan 2010: A Blueprint for Action. ( reports.asp)

2 List of Figures: Rate of Asthma Hospitalization, Michigan 1. Total and By Sex, Total and By Sex, Annual By Race, By Race, Annual By Age Group, By Age Group, Annual By Age and Sex-Race Groups, Rate Ratios Comparing Black versus White by Age Group, Asthma Hospitalization by Month of Admission, Michigan 9. Count, Rate, Count By Age Group, Rate by Age Group, Average Length of Stay for Asthma Hospitalization, Michigan 13. Total, By Age Group, Rate of Asthma Hospitalization by County of Residence 15. Total, Total, Map, Child, Child, Map, Adult, Adult, Map, White Persons, White Persons, Map, Black Persons, Black Persons, Map, Rate Ratio for Black Persons Versus White Persons, Map, Suggested Citation: Wasilevich EA, Lyon-Callo S, Wasilevich MJ. Hospitalization for Asthma. Epidemiology of Asthma in Michigan. Bureau of Epidemiology, Michigan Department of Community Health, For more information about the Asthma Initiative of Michigan, visit: or call EZLUNGS ( ). This surveillance publication was supported by Cooperative Agreement Number U59/CCU from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

3 1. Rate 1,2 of Asthma Hospitalization 3 by Sex, Michigan, The average number of hospitalizations due to asthma per year in Michigan is 16,743. The asthma hospitalization rate in Michigan is 16.6 per 10,000. The average charge for an asthma hospitalization in Michigan is $11, The asthma hospitalization rate for females is significantly higher than that for males 19.3 per 10,000 versus 13.6 per 10,000, respectively. In 2006, the average charge for an asthma hospitalization for females is $13,042 and for males is $9, Annual Rate 1,2 of Asthma Hospitalization 3 by Sex, Michigan, Between 2000 and 2006, the rates of asthma hospitalization for the total population in Michigan are consistent over time, with no distinguishable trend. (p>0.05) 5 Between 2000 and 2006, the rates of asthma hospitalization for both males and females in Michigan are consistent over time. (p>0.05 for each) 5 Since 2001, the average charge for an asthma hospitalization has steadily increased, from $7,001 in 2001 to $11,671 in Population Data, MDCH: 2005 Michigan population for 3-year rates; corresponding annual Michigan population data for annual rates. 2. Age-adjusted to the 2000 US Standard Population. 3. Asthma as primary diagnosis, ICD-9-CM:493.xx. 4. Source: Healthcare Cost and Utilization Project (HCUP), AHRQ, Spearman s correlation and rank correlation test.

4 3. Rate 1,2 of Asthma Hospitalization 3 by Race 4, Michigan, In Michigan, the average number of hospitalizations due to asthma per year for white persons is 9,355, and for black persons is 6,966. However, the asthma hospitalization rate for white persons in Michigan is 11.1 per 10,000. The rate for black persons in Michigan is 47.5 per 10,000. The asthma hospitalization rate for black persons is 4.3 times higher than that for white persons a statistically significant difference. In 2006, the average charge for an asthma hospitalization for white persons is $10,549 and for black persons is $11, Annual Rate 1,2 of Asthma Hospitalization 3 by Race 4, Michigan, Between 2000 and 2006, the rates of asthma hospitalization for white and black persons in Michigan are not significantly changing. (p>0.05 for each) 6 1. Population Data, MDCH: 2005 Michigan population for 3-year rates; corresponding annual Michigan population data for annual rates. 2. Age-adjusted to the 2000 US Standard Population. 3. Asthma as primary diagnosis, ICD-9-CM:493.xx. 4. Where information regarding race is missing from the record, race is imputed based on the 1990 Census ( ) or on the hospitalized population for that year ( ). 5. Source: Healthcare Cost and Utilization Project (HCUP), AHRQ, Spearman s correlation and rank correlation test.

5 5. Rate of Asthma Hospitalization 1 by Age Group, Michigan, The highest age-specific asthma hospitalization rate in Michigan is for children, 0-4 years. (45.6 per 10,000) The lowest age-specific asthma hospitalization rate in Michigan is for young adults, years. (7.3 per 10,000) Asthma hospitalization rates increase with age group after age group years. The pattern in asthma hospitalization rates by age group is not similarly observed for asthma mortality rates, where rates increase with age. Children 0-4 years have the lowest asthma mortality rates and adults 65 years and older have the highest rates. (Data not shown.) 6. Annual Rate of Asthma Hospitalization 1 by Age Group, Michigan, Between 2000 and 2006, the rates of asthma hospitalization for age groups less than 35 years in Michigan are not demonstrating a significant overall trend. (p>0.05 for each) 2 Between 2000 and 2006, the rates of asthma hospitalization for adults age years and age 65 years and older in Michigan are significantly increasing. (p<0.05 for each) 2 Population Data, MDCH: 2005 Michigan population for 3- year rates; corresponding annual Michigan population data for annual rates. 1. Asthma as primary diagnosis, ICD-9-CM:493.xx. 2. Spearman s correlation and rank correlation test.

6 7. Rate of Asthma Hospitalization 1 by Age and Sex-Race 2 Groups, Michigan, For children 0-14 years, male children have higher asthma hospitalization rates than female children, regardless of race. For persons 15 years and older, females have higher asthma hospitalization rates than males, regardless of race. Black persons have the highest asthma hospitalization rates, regardless of age group or sex. 1. Asthma as primary diagnosis, ICD-9-CM:493.xx. 2. Where information regarding race is missing from the record, race is imputed based on the hospitalized population for that year.

7 8. Ratio of Asthma Hospitalization 1 Rates 2 Comparing Black 3 versus White 3, by Age Group and Year, Michigan, The rate of asthma hospitalizations for black persons is at least four times the rate for white persons, regardless of age group. The degree of disparity in asthma hospitalization rates between black persons and white persons has remained unchanged over recent years. 4 4 Annual Population Data, MDCH. 1. Asthma as primary diagnosis, ICD-9-CM:493.xx. 2. Age-adjusted to the 2000 US Standard Population. 3. Where information regarding race is missing from the record, race is imputed based on the 1990 Census ( ) or on the hospitalized population for that year ( ). 4. The presented rate ratios are calculated by dividing the asthma hospitalization rate for black persons by that for white persons. A rate ratio whose 95% confidence interval does not include the value of 1.0 indicates a statistically significant relationship between race and asthma hospitalization.

8 9. Count of Asthma Hospitalizations 1 by Month of Admission, Michigan, The fewest number of asthma hospitalizations occur during the summer months. Asthma hospitalizations are most frequent during the fall months. 10. Rate 2 of Asthma Hospitalization 1 by Month of Admission, Michigan, The highest asthma hospitalization rates occur in September and October. The lowest rates occur during July and August. 1. Asthma as primary diagnosis, ICD-9-CM:493.xx. 2. Age-adjusted to the 2000 US Standard Population.

9 11. Count of Asthma Hospitalizations 1 by Month of Admission and Age Group, Michigan, The most pronounced seasonal variation in the number of asthma hospitalizations is observed for children less than 18 years ( ). In this age group, there are dramatically high peaks during the fall months and smaller peaks during the month of April. The number of hospitalizations is the lowest during the month of July. For adults age 18 through 64 years ( ), there are peaks in the number of asthma hospitalizations during the months of October and January/February. Hospitalization counts are generally lowest among adults age 65 years and older. This age group experiences a peak in asthma hospitalizations during January through March. ( ) Source: 1. Asthma as primary diagnosis, ICD-9-CM:493.xx.

10 12. Rate 1 of Asthma Hospitalization 2 by Month of Admission and Age Group, Michigan, For children less than 18 years, peaks in the rate of asthma hospitalization occur during May and September. The lowest asthma hospitalization rate for this age group is observed during July. For adults age 18 to 64 years, the highest asthma hospitalization rate occurs during October and the lowest rate occurs during July/August. For adults age 65 years and older, the highest asthma hospitalization rate is observed during March. This age group does not demonstrate a peak in the rate of asthma hospitalizations during the fall months. 1. Age-adjusted to the 2000 US Standard Population. 2. Asthma as primary diagnosis, ICD-9-CM:493.xx.

11 13. Average Length of Stay for an Asthma Hospitalization 1, Michigan, In 2006, the average length of stay for an asthma hospitalization was 3.3 days. Between 2000 and 2006, the average length of stay for an asthma hospitalization is significantly increasing. (p<0.05) 2 For asthma-related hospital stays in 2006, there were an additional 5,451 hospital days compared to asthma-related hospital stays in Average Length of Stay for an Asthma Hospitalization 1 by Age Group, Michigan, Average length of stay for an asthma hospitalization increases with age group. In 2006, the average length of stay ranged from 1.9 days for children less than 18 years and 4.9 days for adults 65 years an older. Between 2000 and 2006, the average length of stay for an asthma hospitalization is significantly decreasing for children less than 18 years. (p<0.05) 2 Between 2000 and 2006, the average length of stay for an asthma hospitalization is significantly increasing for adults age 18 to 64 years. (p<0.05) 2 Source: 1. Asthma as primary diagnosis, ICD-9-CM:493.xx. 2. Spearman s correlation and rank correlation test.

12 15. Rates 1 of Asthma Hospitalization 2 by County of Residence, Michigan, Epidemiology of Asthma in Michigan 1.Age-adjusted to the 2000 US Standard Population. 2.Asthma as primary diagnosis, ICD-9-CM:493.xx. *Insufficient Data: Count of events <20 or population <5,000.

13 16. Rates 1 of Asthma Hospitalization 2 by County of Residence, Michigan, Significantly Higher than State Rate [16.6 (95% CI: )] Michigan counties with rates of asthma hospitalization significantly higher than the rate for the state as a whole [16.6 per 10,000 (95% CI: )] are: Bay County Ingham County Saginaw County Wayne County 1.Age-adjusted to the 2000 US Standard Population 2.Asthma as primary diagnosis, ICD-9-CM:493.xx. *Insufficient Data: Count of events <20 or population <5,000.

14 17. Rates 1 of Asthma Hospitalization 2 by County of Residence, Michigan, Age <18 Years, Age-adjusted to the 2000 US Standard Population 2.Asthma as primary diagnosis, ICD-9-CM:493.xx. *Insufficient Data: Count of events <20 or population <5,000.

15 18. Rates 1 of Asthma Hospitalization 2 by County of Residence, Michigan, Age <18 Years, Significantly Higher than State Rate [22.1 (95% CI: )] Michigan counties with rates of asthma hospitalization for children that are significantly higher than the rate for the state as a whole [22.1 per 10,000 (95% CI: )] are: Eaton County Gratiot County Ingham County Isabella County Jackson County Saginaw County Wayne County 1.Age-adjusted to the 2000 US Standard Population 2.Asthma as primary diagnosis, ICD-9-CM:493.xx. *Insufficient Data: Count of events <20 or population <5,000.

16 19. Rates 1 of Asthma Hospitalization 2 by County of Residence, Michigan, Age 18 Years, Age-adjusted to the 2000 US Standard Population. 2.Asthma as primary diagnosis, ICD-9-CM:493.xx. *Insufficient Data: Count of events <20 or population <5,000.

17 20. Rates 1 of Asthma Hospitalization 2 by County of Residence, Michigan, Age 18 Years, Significantly Higher than State Rate [14.7 (95% CI: )] Michigan counties with rates of asthma hospitalization for adults that are significantly higher than the rate for the state as a whole [14.7 per 10,000 (95% CI: )] are: Bay County Ingham County Saginaw County Wayne County 1.Age-adjusted to the 2000 US Standard Population. 2.Asthma as primary diagnosis, ICD-9-CM:493.xx.

18 21. Rates 1 of Asthma Hospitalization 2 by County of Residence for White Persons 3, Michigan, Age-adjusted to the 2000 US Standard Population. 2. Asthma as primary diagnosis, ICD-9-CM:493.xx. 3. Where information regarding race is missing from the record, race is imputed based on the hospitalized population for that year. *Insufficient Data: Count of events <20 or population <5,000.

19 22. Rates 1 of Asthma Hospitalization 2 by County of Residence for White Persons 3, Michigan, Significantly Higher than State Rate [11.1 (95% CI: )] Michigan counties with rates of asthma hospitalization for white persons that are significantly higher than the rate for the state as a whole [11.1 per 10,000 (95% CI: )] are: Baraga County Gratiot County Monroe County Bay County Ingham County Saginaw County Branch County Iosco County St. Clair County Clare County Isabella County St. Joseph County Eaton County Jackson County Wayne County Genesee County Lenawee County Gladwin County Macomb County 1. Age-adjusted to the 2000 US Standard Population. 2. Asthma as primary diagnosis, ICD-9-CM:493.xx. 3. Where information regarding race is missing from the record, race is imputed based on the hospitalized population for that year. *Insufficient Data: Count of events <20 or population <5,000.

20 23. Rates 1 of Asthma Hospitalization 2 by County of Residence for Black Persons 3, Michigan, Age-adjusted to the 2000 US Standard Population. 2. Asthma as primary diagnosis, ICD-9-CM:493.xx. 3. Where information regarding race is missing from the record, race is imputed based on the hospitalized population for that year. *Insufficient Data: Count of events <20 or population <5,000.

21 24. Rates 1 of Asthma Hospitalization 2 by County of Residence for Black Persons 3, Michigan, Significantly Higher than State Rate [47.5 (95% CI: )] Michigan counties with rates of asthma hospitalization for black persons that are significantly higher than the rate for the state as a whole [47.5 per 10,000 (95% CI: )] are: Ingham County Saginaw County Wayne County 1. Age-adjusted to the 2000 US Standard Population. 2. Asthma as primary diagnosis, ICD-9-CM:493.xx. 3. Where information regarding race is missing from the record, race is imputed based on the hospitalized population for that year. *Insufficient Data: Count of events <20 or population <5,000.

22 25. Difference in Rates 1 of Asthma Hospitalization 2 for Black Persons 3 Versus White Persons 3 by County of Residence, Michigan, The difference in rates of asthma hospitalization for black persons versus white persons demonstrates a dramatic disparity for all counties with sufficient data for the comparison. Depending on county of residence, there are between 15.9 and 48.4 additional asthma hospitalizations per 10,000 people per year for black persons compared to white persons. 1. Age-adjusted to the 2000 US Standard Population. 2. Asthma as primary diagnosis, ICD-9-CM:493.xx. 3. Where information regarding race is missing from the record, race is imputed based on the hospitalized population for that year. *Insufficient Data: Count of events <20 or population <5,000.

23 Rate of Asthma Hospitalizations 1 (per 10,000), Michigan, Count Rate Total 2 [Figure 1] Sex 2 [Figure 1] Race 2,3 [Figure 3] Age [Figure 5] 50, ( ) Male 19, ( ) Female 30, ( ) White 28, ( ) Black 20, ( ) 0-4 Years 8, ( ) 5-14 Years 6, ( ) Years 6, ( ) Years 19, ( ) 65 Years 9, ( ) Age & Sex-Race 3 [Figure 7] 0-4 Years White Male 2, ( ) White Female 1, ( ) Black Male 2, ( ) Black Female 1, ( ) 5-14 Years White Male 1, ( ) White Female 1, ( ) Black Male 2, ( ) Black Female 1, ( ) Years White Male ( ) White Female 2, ( ) Black Male 1, ( ) Black Female 1, ( ) Years White Male 2, ( ) White Female 8, ( ) Black Male 2, ( ) Black Female 5, ( ) 65 Years White Male 1, ( ) White Female 4, ( ) Black Male ( ) Black Female 1, ( ) 1. Asthma as primary diagnosis, ICD-9-CM: 493.xx. 2. Age-adjusted to the 2000 US Standard Population. 3. Where information regarding race is missing from the record, race is imputed based on the hospitalized population for that year.

24 Annual Number of Asthma Hospitalizations 1, Michigan, Total 15,878 15,363 14,696 16,572 16,567 17,423 16,238 Sex Male 6,741 6,271 5,971 6,788 6,669 6,841 6,353 Female 9,137 9,092 8,725 9,784 9,898 10,582 9,885 Race 2 White 8,773 8,541 8,133 9,367 8,933 10,015 9,116 Black 6,888 6,518 6,279 6,788 7,142 7,125 6,631 Age 0-4 Years 3,256 3,341 3,039 3,312 3,245 3,055 2, Years 3,006 2,363 2,002 2,311 2,209 2,363 1, Years 2,500 2,253 2,104 2,269 1,935 2,116 1, Years 5,263 5,383 5,317 6,112 6,319 6,776 6, Years 1,853 2,023 2,234 2,568 2,859 3,113 3,143 Age-Race Years, White 3,277 2,905 2,572 2,841 2,524 2,765 2, Years, Black 3,316 3,032 2,653 2,907 2,962 2,824 2, Years, Black 5,496 5,636 5,561 6,526 6,409 7,250 6, Years, Black 3,572 3,486 3,626 3,881 4,180 4,301 4,363 Annual Rate of Asthma Hospitalization 1 (per 10,000), Michigan, Total 3 [Figure 2] Sex 3 [Figure 2] Race 2,3 [Figure 4] Age [Figure 6] 16.0 ( ) 15.5 ( ) 14.7 ( ) 16.6 ( ) 16.5 ( ) 17.3 ( ) 16.1 ( ) Male 13.7 ( ) 12.8 ( ) 12.2 ( ) 14.0 ( ) 13.7 ( ) 14.0 ( ) 13.2 ( ) Female 18.0 ( ) 17.8 ( ) 16.9 ( ) 18.9 ( ) 18.9 ( ) 20.2 ( ) 18.8 ( ) White 10.8 ( ) 10.5 ( ) 9.9 ( ) 11.4 ( ) 10.7 ( ) 12.0 ( ) 10.8 ( ) Black 45.2 ( ) 43.2 ( ) 42.0 ( ) 45.2 ( ) 48.5 ( ) 48.4 ( ) 45.9 ( ) 0-4 Years 48.8 ( ) 50.5 ( ) 45.8 ( ) 51.1 ( ) 49.9 ( ) 47.0 ( ) 40.6 ( ) 5-14 Years 20.3 ( ) 16.0 ( ) 13.7 ( ) 15.9 ( ) 15.4 ( ) 16.7 ( ) 13.9 ( ) Years 9.1 ( ) 8.2 ( ) 7.7 ( ) 8.3 ( ) 7.0 ( ) 7.7 ( ) 7.3 ( ) Years 13.6 ( ) 13.8 ( ) 13.5 ( ) 15.3 ( ) 15.7 ( ) 16.7 ( ) 16.1 ( ) 65 Years 15.2 ( ) 16.5 ( ) 18.1 ( ) 20.8 ( ) 22.9 ( ) 24.7 ( ) 24.9 ( ) Age Race 2, Years, White 16.6 ( ) 14.9 ( ) 13.2 ( ) 14.9 ( ) 13.2 ( ) 14.5 ( ) 12.2 ( ) 0-17 Years, Black 68.4 ( ) 63.0 ( ) 55.1 ( ) 61.2 ( ) 63.2 ( ) 60.5 ( ) 49.9 ( ) 18 Years, White 8.8 ( ) 8.9 ( ) 8.7 ( ) 10.1 ( ) 9.8 ( ) 11.1 ( ) 10.4 ( ) 18 Years, Black 37.1 ( ) ( ) 37.5 ( ) 39.7 ( ) 43.4 ( ) 44.1 ( ) 44.6 ( ) Annual Rate 3 Ratios of Asthma Hospitalization 1,2 (per 10,000) for Black Persons versus White Persons by Age Group, Michigan, [Figure 8] Years 4.1 ( ) 4.2 ( ) 4.2 ( ) 4.1 ( ) 4.8 ( ) 4.2 ( ) 4.1 ( ) 18 Years 4.2 ( ) 4.1 ( ) 4.3 ( ) 3.9 ( ) 4.4 ( ) 4.0 ( ) 4.3 ( ) Annual Population Data, MDCH. 1. Asthma as primary diagnosis, ICD-9-CM: 493.xx. 2. Where information regarding race is missing from the record, race is imputed based on the 1990 Census ( ) or on the hospitalized population for that year ( ). 3. Age-adjusted to the 2000 US Standard Population.

25 Annual Count of Asthma Hospitalizations 1 by Month of Admission, Michigan, Total [Figure 9] <18 Years [Figure 11] Years [Figure 11] 65 Years [Figure 11] January 1,309 1,711 1, February 1,347 1,737 1, March 1,474 1,497 1, April 1,364 1,535 1, May 1,536 1,548 1, June 1,236 1, July August 1, September 1,663 1,838 1, October 1,715 1,957 1, November 1,428 1,438 1, December 1,539 1,140 1, Rate 2 of Asthma Hospitalization 1 (per 10,000) by Month of Admission, Michigan, Total [Figure 10] <18 Years [Figure 12] Years [Figure 12] 65 Years [Figure 12] Count Rate Count Rate Count Rate Count Rate January 4, ( ) 1, ( ) 2, ( ) ( ) February 4, ( ) 1, ( ) 2, ( ) ( ) March 4, ( ) 1, ( ) 2, ( ) 1, ( ) April 4, ( ) 1, ( ) 2, ( ) ( ) May 4, ( ) 1, ( ) 2, ( ) ( ) June 3, ( ) ( ) 1, ( ) ( ) July 2, ( ) ( ) 1, ( ) ( ) August 2, ( ) ( ) 1, ( ) ( ) September 5, ( ) 2, ( ) 2, ( ) ( ) October 5, ( ) 2, ( ) 2, ( ) ( ) November 4, ( ) 1, ( ) 2, ( ) ( ) December 4, ( ) 1, ( ) 2, ( ) ( ) Average Length of Stay for Asthma Hospitalization 1 (per 10,000), Michigan, Total [Figure 13] Age [Figure 14] <18 Years Years Years Asthma as primary diagnosis, ICD-9-CM: 493.xx. 2. Age-adjusted to the 2000 US Standard Population.

26 Rate 1 of Asthma Hospitalization 2 (per 10,000) by County of Residence and Age Group, Michigan, Total [Figures 15 & 16] <18 Years [Figures 17 & 18] 18 Years [Figures 19 & 20] County Count Rate Count Rate Count Rate Alcona ( ) 10 * ( ) Alger ( ) 7 * 18 * Allegan ( ) ( ) ( ) Alpena ( ) 19 * ( ) Antrim ( ) 13 * ( ) Arenac ( ) 10 * ( ) Baraga ( ) 12 * ( ) Barry ( ) ( ) ( ) Bay ( ) ( ) ( ) Benzie ( ) 17 * ( ) Berrien ( ) ( ) ( ) Branch ( ) ( ) ( ) Calhoun ( ) ( ) ( ) Cass ( ) ( ) ( ) Charlevoix ( ) 13 * ( ) Cheboygan ( ) ( ) ( ) Chippewa ( ) 12 * ( ) Clare ( ) ( ) ( ) Clinton ( ) ( ) ( ) Crawford ( ) 11 * ( ) Delta ( ) ( ) ( ) Dickinson ( ) 16 * ( ) Eaton ( ) ( ) ( ) Emmet ( ) ( ) ( ) Genesee 2, ( ) ( ) 1, ( ) Gladwin ( ) ( ) ( ) Gogebic ( ) 15 * ( ) Grand Traverse ( ) ( ) ( ) Gratiot ( ) ( ) ( ) Hillsdale ( ) ( ) ( ) Houghton ( ) ( ) ( ) Huron ( ) ( ) ( ) Ingham 1, ( ) ( ) ( ) Ionia ( ) ( ) ( ) Iosco ( ) ( ) ( ) Iron 19 * 5 * 14 * Isabella ( ) ( ) ( ) Jackson ( ) ( ) ( ) Kalamazoo ( ) ( ) ( ) Kalkaska ( ) 11 * ( ) Kent 1, ( ) ( ) 1, ( ) Keweenaw 6 * * 5 * 1. Age-adjusted to the 2000 US Standard Population. 2. Asthma as primary diagnosis, ICD-9-CM: 493.xx. Number of events >0 but <5. *Number of events 20 or population <5,000.

27 Rate 1 of Asthma Hospitalization 2 (per 10,000) by County of Residence and Age Group, Michigan, , Continued Total [Figures 15 & 16] <18 Years [Figures 17 & 18] 18 Years [Figures 19 & 20] County Count Rate Count Rate Count Rate Lake ( ) 10 * ( ) Lapeer ( ) ( ) ( ) Leelanau ( ) 12 * ( ) Lenawee ( ) ( ) ( ) Livingston ( ) ( ) ( ) Luce ( ) 5 * ( ) Mackinac 20 * 5 * 15 * Macomb 3, ( ) ( ) 2, ( ) Manistee ( ) 16 * ( ) Marquette ( ) ( ) ( ) Mason ( ) 15 * ( ) Mecosta ( ) ( ) ( ) Menominee ( ) ( ) ( ) Midland ( ) ( ) ( ) Missaukee ( ) ( ) ( ) Monroe ( ) ( ) ( ) Montcalm ( ) ( ) ( ) Montmorency ( ) 13 * 16 * Muskegon ( ) ( ) ( ) Newaygo ( ) ( ) ( ) Oakland 5, ( ) 1, ( ) 3, ( ) Oceana ( ) 16 * ( ) Ogemaw ( ) 10 * ( ) Ontonagon ( ) * ( ) Osceola ( ) ( ) ( ) Oscoda ( ) 5 * ( ) Otsego ( ) 18 * ( ) Ottawa ( ) ( ) ( ) Presque Isle ( ) 9 * 16 * Roscommon ( ) ( ) ( ) Saginaw 1, ( ) ( ) 1, ( ) St. Clair ( ) ( ) ( ) St. Joseph ( ) ( ) ( ) Sanilac ( ) 19 * ( ) Schoolcraft 12 * * 10 * Shiawassee ( ) ( ) ( ) Tuscola ( ) ( ) ( ) Van Buren ( ) ( ) ( ) Washtenaw ( ) ( ) ( ) Wayne 18, ( ) 6, ( ) 12, ( ) Wexford ( ) ( ) ( ) Michigan 50, ( ) 16, ( ) 33, ( ) 1. Age-adjusted to the 2000 US Standard Population. 2. Asthma as primary diagnosis, ICD-9-CM: 493.xx. Number of events >0 but <5. *Number of events 20 or population <5,000.

28 Rate 1 of Asthma Hospitalization 2 (per 10,000) by County of Residence and Race 3, Michigan, White [Figures 21 & 22] Black [Figures 23 & 24] Rate Difference [Figure 25] County Count Rate Count Rate Rate Alcona ( ) 0 * * Alger ( ) 0 * * Allegan ( ) 9 * * Alpena ( ) 0 * * Antrim ( ) 0 * * Arenac ( ) * * Baraga ( ) 0 * * Barry ( ) * * Bay ( ) ( ) 48.4 Benzie ( ) * * Berrien ( ) ( ) 22.6 Branch ( ) 7 * * Calhoun ( ) ( ) 16.7 Cass ( ) ( ) 34.1 Charlevoix ( ) * * Cheboygan ( ) 0 * * Chippewa ( ) 0 * * Clare ( ) 0 * * Clinton ( ) 29 * * Crawford ( ) 0 * * Delta ( ) * * Dickinson ( ) 0 * * Eaton ( ) ( ) 24.3 Emmet ( ) 0 * * Genesee 1, ( ) 1, ( ) 24.9 Gladwin ( ) * * Gogebic ( ) 0 * * Grand Traverse ( ) * * Gratiot ( ) 9 * * Hillsdale ( ) 0 * * Houghton ( ) * * Huron ( ) * * Ingham ( ) ( ) 39.0 Ionia ( ) * * Iosco ( ) * * Iron 19 * 0 * * Isabella ( ) 8 * * Jackson ( ) ( ) 15.9 Kalamazoo ( ) ( ) 26.9 Kalkaska ( ) 0 * * Kent 1, ( ) ( ) 18.4 Keweenaw 5 * 0 * * 1. Age-adjusted to the 2000 US Standard Population. 2. Asthma as primary diagnosis, ICD-9-CM: 493.xx. 3. Where information regarding race is missing from the record, race is imputed based on the hospitalized population for that year. Number of events >0 but <5. *Number of events 20 or population <5,000.

29 Rate 1 of Asthma Hospitalization 2 (per 10,000) by County of Residence and Race 3, Michigan, , Continued White [Figures 21 & 22] Black [Figures 23 & 24] Rate Difference [Figure 25] County Count Rate Count Rate Rate Lake ( ) 11 * * Lapeer ( ) * * Leelanau ( ) 0 * * Lenawee ( ) 16 * * Livingston ( ) 6 * * Luce ( ) 0 * * Mackinac 19 * 0 * * Macomb 3, ( ) ( ) 19.2 Manistee ( ) 0 * * Marquette ( ) 6 * * Mason ( ) 0 * * Mecosta ( ) * * Menominee ( ) 0 * * Midland ( ) * * Missaukee ( ) 0 * * Monroe ( ) ( ) 24.7 Montcalm ( ) 7 * * Montmorency ( ) 0 * * Muskegon ( ) ( ) 18.3 Newaygo ( ) * * Oakland 3, ( ) 1, ( ) 28.3 Oceana ( ) 0 * * Ogemaw ( ) * * Ontonagon ( ) 0 * * Osceola ( ) 0 * * Oscoda ( ) 0 * * Otsego ( ) * * Ottawa ( ) ( ) 25.5 Presque Isle ( ) 0 * * Roscommon ( ) 0 * * Saginaw ( ) ( ) 41.2 St. Clair ( ) ( ) 32.8 St. Joseph ( ) 16 * * Sanilac ( ) * * Schoolcraft 12 * 0 * * Shiawassee ( ) * * Tuscola ( ) * * Van Buren ( ) ( ) 24.0 Washtenaw ( ) ( ) 30.4 Wayne 4, ( ) 14, ( ) 42.4 Wexford ( ) 0 * * Michigan 28, ( ) 20, ( ) Age-adjusted to the 2000 US Standard Population. 2. Asthma as primary diagnosis, ICD-9-CM: 493.xx. 3. Where information regarding race is missing from the record, race is imputed based on the hospitalized population for that year. Number of events >0 but <5. *Number of events 20 or population <5,000.