Oregon Asthma Surveillance Summary Report August 26 Oregon Asthma Program Office of Disease Prevention and Epidemiology Public Health Services Oregon Department of Human Services
Mel Kohn, MD, MPH, State Epidemiologist Oregon Asthma Program Jane Moore, PhD, RD, Manager, Health Promotion and Chronic Disease Prevention Section Karen Main, MPA, Asthma Program Manager Kirsten Aird, MPH, Health Systems Coordinator, Asthma Program Tracy Alexander, MPA, Community Partnerships and Self-Management Coordinator, Asthma Program Mike Emerson, PhD, Epidemiologist, Asthma Program Richard Leman, MD, MPH, Medical Epidemiologist, Health Promotion and Chronic Disease Prevention Section Debi Livengood, Administrative Assistant, Asthma Program Sara Beth Weiner, MSW, MPH, CDC Public Health Prevention Service, Asthma Program For more information contact: Oregon Asthma Program Department of Human Services 8 NE Oregon Street, Suite 73 Portland, OR 97232-2162 Phone: (971) 673-984 Fax: (971) 673-994 Email: asthma.ohd@state.or.us Web site: www.healthoregon.org/asthma This document is in the public domain and may be used and reprinted. The Department of Human Services appreciates citation and notification of use. This project is supported by the Centers for Disease Control and Prevention, Cooperative Agreement #U59/CCU17777. 1
Table of Contents Executive Summary...7 Asthma Prevalence...1 Adult Asthma Prevalence...11 Child and Teen Asthma Prevalence...15 Emergency Department or Urgent Care Visits for Asthma...16 Asthma Hospitalizations...19 Asthma Mortality...22 Asthma Control...25 Asthma Management...29 Risk Factors for Asthma...32 Asthma in the Medicaid Population...35 Prevalence...37 Emergency Department or Urgent Care Visits...38 Asthma Control...39 Asthma Management...4 Risk Factors...41 Appendix A: Data Source Listings, Descriptions, and Limitations...43 2
Table of Tables Table 1 Table 2 Table 3 Table 4 Current asthma prevalence by county, Oregon adults (BRFSS, 2-1 county oversample)...14 Oregon, U.S., and Healthy People 21 target asthma hospitalization rates* (Hospital Discharge Index, 1999-25)...2 Asthma mortality rate per million residents compared to Healthy People 21 targets for asthma (Oregon death certificates, 1999-24)...23 Listing, description, and limitations of data sources...43 3
Table of Figures Figure 1 Lifetime asthma prevalence in adults for Oregon and the U.S. (BRFSS, 21-25)...11 Figure 2 Current asthma prevalence in adults for Oregon and the U.S. (BRFSS, 21-25)...11 Figure 3 Current asthma prevalence by sex, Oregon adults (BRFSS, 25)...11 Figure 4 Current asthma prevalence by race/ethnicity, Oregon adults (BRFSS, 2-1 race/ethnicity over-sample)...12 Figure 5 Current asthma prevalence by age, Oregon adults (BRFSS, 25)...12 Figure 6 Current asthma prevalence by income, Oregon adults (BRFSS, 25)...12 Figure 7 Current asthma prevalence by education level, Oregon adults (BRFSS, 25)...13 Figure 8 Current asthma prevalence by type of health insurance, Oregon adults (BRFSS, 25)...13 Figure 9 Current asthma prevalence by year, Oregon children -17 years of age by adult proxy (BRFSS, 22-4)...15 Figure 1 Current asthma prevalence among Oregon 8 th grade and 11 th grade students (Oregon Healthy Teens, 25)...15 Figure 11 Percentage of Oregon adults with current asthma, by year, who report one or more emergency department or urgent care visits for asthma in the past 12 months (BRFSS, 21 and 23)...17 Figure 12 Percentage of Oregon adults with current asthma, by sex and year, who report one or more emergency department or urgent care visits for asthma in the past 12 months (BRFSS, 21 and 23)...17 Figure 13 Percentage of Oregon adults with current asthma, by type of insurance and year, who report one or more emergency department or urgent care visits for asthma in the past 12 months (BRFSS, 21 and 23)...17 Figure 14 Percentage of health plan members age 4-55 with asthma, by plan type and year, who had one or more emergency department visits for asthma in the past 12 months (ADWG, 21-4)...18 Figure 15 Percentage of health plan members age 4-55 with asthma, by plan type and year, who had a follow-up outpatient visit within 3 days of an emergency department visit for asthma (ADWG, 21-4)...18 Figure 16 Age-adjusted hospitalization rate per 1, residents in which asthma was the primary discharge code (Hospital Discharge Index, 1997-25)...2 Figure 17 Hospitalization rate (per 1, residents), by sex and age group, with asthma as the primary discharge code (Hospital Discharge Index, 25)...2 Figure 18 Number of hospitalizations due to asthma by month in 25 (Hospital Discharge Index, 25)...21 Figure 19 Age-adjusted mortality rate per million residents in which asthma was the primary cause of death (Oregon death certificates, 1999-24)...23 Figure 2 Age-adjusted mortality rate per million residents by sex in which asthma was the primary discharge code (Oregon death certificates, 1999-24)...23 Figure 21 Age-adjusted mortality rate per million residents from 1999-24 by race/ethnicity in which asthma was the primary cause of death (Oregon death certificates, aggregated from 1999-24)...24 Figure 22 Percentage of adults with current asthma, by sex, who missed one or more days of activities because of asthma in the past three months (BRFSS, 23)...26 Figure 23 Number of days in the past 12 months adults with asthma were unable to work or carry out their usual activities because of asthma (NAS, 25 preliminary results)...26 Figure 24 Percentage of adults with current asthma, by income, who missed one or more days of activities because of asthma in the past three months (BRFSS, 23)...26 4
Figure 25 Number of self-reported sleep disturbances per month due to asthma among adults with asthma (BRFSS, 23)...27 Figure 26 Degree of self-reported limitations of usual activities among adults with asthma (BRFSS, 23)...27 Figure 27 Frequency of asthma symptoms in past four weeks among adults with asthma (BRFSS, 23)...27 Figure 28 Perceived health status among adults with or without asthma (BRFSS, 24)...28 Figure 29 Percentage of adults with asthma who report ever receiving an asthma action plan from their healthcare provider (NAS, 25, unweighted)...3 Figure 3 Percentage of adults with asthma who have taken a course or class on how to manage their asthma (NAS, 25, unweighted)...3 Figure 31 Percentage of adults with asthma who use inhaled beta 2 -agonist or corticosteroid prescription inhalers (NAS, 25, unweighted)...3 Figure 32 Age-adjusted percentage of Oregonians with asthma in 24, by type of insurance, who received at least one prescription for an anti-inflammatory asthma medication (ADWG, 24)...31 Figure 33 Age-adjusted percentage of Oregonians with asthma in 24, by type of insurance, who received six or more dispensings for a short-acting beta 2 -agonist rescue medication in the past year (ADWG, 24)...31 Figure 34 Current asthma prevalence by smoking status, Oregon adults (BRFSS, 24)...33 Figure 35 Percentage of Oregon adults who currently smoke, by current asthma status (BRFSS, 24)...33 Figure 36 Current asthma prevalence by secondhand smoke exposure in a typical week (excluding current smokers), Oregon adults (BRFSS, 24)...33 Figure 37 Percentage of Oregon adults with secondhand smoke exposure in a typical week (excludes current smokers), by current asthma status (BRFSS, 24)...34 Figure 38 Current asthma prevalence by body mass index, Oregon adults (BRFSS, 24)...34 Figure 39 Distribution of Oregon adults, with and without current asthma, by body mass index (BRFSS, 24)...34 Figure 4 Current asthma prevalence by sex among Oregon adults served by Medicaid (HRHSS, 24)...37 Figure 41 Current asthma prevalence by age group among Oregon adults served by Medicaid (HRHSS, 24)...37 Figure 42 Current asthma prevalence by education level among Oregon adults served by Medicaid (HRHSS, 24)...37 Figure 43 Number of visits to an emergency department or urgent care center in the past 12 months due to asthma among Oregon adults with asthma who are served by Medicaid (HRHSS, 24)...38 Figure 44 Number of visits to an emergency department in the past 12 months due to asthma, Oregonians aged 4-55 with asthma who are served by Medicaid (OMAP-QPI, 23-4)...38 Figure 45 Percentage of Medicaid members age 4-55 with asthma, by year, who had a follow-up outpatient visit within 3 days of an emergency department visit for asthma (OMAP- QPI, 23-4)...38 Figure 46 Frequency of asthma symptoms in past four weeks among Oregon adults served by Medicaid (HRHSS, 24)...39 Figure 47 Degree of self-reported limitations of usual activities among Oregon adults with asthma who are served by Medicaid (HRHSS, 24)...39 5
Figure 48 Figure 49 Figure 5 Figure 51 Figure 52 Figure 53 Figure 54 Figure 55 Figure 56 Figure 57 Number of days of work, school, or other daily activities missed in the last three months because of asthma among Oregon adults with asthma who are served by Medicaid (HRHSS, 24)...39 Perceived health status by asthma status among Oregon adults served by Medicaid (HRHSS, 24)...4 Number of visits to a healthcare professional in the past 12 months for routine treatment of asthma among Oregon adults with asthma who are served by Medicaid (HRHSS, 24)...4 Percentage of Oregon adults with asthma served by Medicaid who report their healthcare provider gave them information on how to avoid making asthma worse, explained how to recognize early signs of an asthma episode, or provided written instructions on how to take asthma medicine (HRHSS, 24)...4 Percentage of Medicaid members age 4-55 with asthma, by year, who received at least one anti-inflammatory medication in the past 12 months (OMAP-QPI, 23-4)...41 Percentage of Medicaid members age 4-55 with asthma, by year, who received six or more rescue medication dispensings in the past 12 months (OMAP-QPI, 23-4)...41 Current asthma prevalence by smoking status among Oregon adults served by Medicaid (HRHSS, 24)...41 Percentage of Oregon adults who currently smoke, by current asthma status, among Oregon adults served by Medicaid (HRHSS, 24)...42 Current asthma prevalence by secondhand smoke exposure in a typical week (excluding current smokers) among Oregon adults who are served by Medicaid (HRHSS, 24)...42 Percentage of Oregon adults with secondhand smoke exposure in a typical week (excludes current smokers), by current asthma status, among Oregon adults who are served by Medicaid (HRHSS, 24)...42 6
Executive Summary This report provides information on the impact of asthma in Oregon and compares Oregon to the United States and Healthy People 21 objectives. The primary topics include asthma prevalence, asthma emergency department (ED) or urgent care visits, asthma hospitalizations, asthma mortality, control indicators for asthma, asthma management, risk factors associated with asthma, and asthma in the Medicaid population. The main findings for these topics are summarized in each section and highlighted below. Additional data from one of our primary sources, the Behavioral Risk Factor Surveillance System (BRFSS), are available on the Oregon Asthma Program website at http://www.oregon.gov/dhs/ph/asthma/datareport/index.shtml. Listings, descriptions, and limitations of the primary data sources for this report are available in Appendix A. Asthma Prevalence The prevalence of current asthma in Oregon continues to rise and is considerably higher than the U.S. average. Current asthma prevalence was 9.9% in Oregon adults aged 18 or older in 25 and 6.9% in Oregon children less than 18 years of age in 24. These prevalence estimates mean that approximately 333, Oregon adults and children currently have asthma. Asthma prevalence in Oregon differs by demographic factors. For example, in 25 the prevalence of current asthma was higher in women (12.4%) than men (7.4%). Similarly, asthma prevalence estimates from 2-1 also varied by race/ethnicity with the highest prevalence in American Indians or Alaska Natives (12.8%), similar prevalence among Whites (8.9%) and Blacks (9.7%), and lower prevalence in Hispanics (5.5%) and Asians or Pacific Islanders (5.9%). Asthma prevalence in Oregon also differs by socioeconomic factors. For example, in 25 current asthma prevalence was higher for those who earned less than $25, per year than people who earned more than that amount. In addition, in 25 the prevalence of current asthma in the Medicaid population (2.7%) was more than double that of people who had private or Medicare insurance (9.2%) or who had no health insurance (9.4%). Emergency Department or Urgent Care Visits for Asthma According to findings from the Behavioral Risk Factor Surveillance System (BRFSS), the percentage of Oregonians with asthma who have visited an ED or urgent care center in the past 12 months decreased from 21 (17.2%) to 23 (12.9%). Similar to current asthma prevalence, there was a noticeable gender difference among people with asthma surveyed in 23 such that females (14.1%) were more likely than males (1.7%) to have an ED or urgent care visit for asthma in the past 12 months. Another source of medical claims data from Oregon s Asthma Data Workgroup (ADWG) indicates that from 21-4, Oregonians with asthma who were covered by Medicaid were twice as likely to have an ED visit for asthma in the past 12 months as people with commercial health insurance. Unfortunately, regardless of whether Oregonians were covered by Medicaid or commercial health insurance, only about 4% of those who had an ED visit for asthma had a follow-up outpatient visit within 3 days of the ED visit. 7
Asthma Hospitalizations In 25, there were 2,446 hospitalizations in Oregon in which asthma was the principal discharge diagnosis. Although this number seems high, the asthma hospitalization rate has generally decreased from 1997 through 25, and the lowest rate of 6.1 hospitalizations per 1, Oregon residents was achieved in 24. This 24 rate represents a 9% decrease compared to 2 and an 18% decrease compared to 1997. Furthermore, despite Oregon s higher asthma prevalence, Oregon asthma hospitalization rates are lower than the U.S. rates and in 25 were lower than the Healthy People 21 targets except in people aged 65 years or older. Asthma Mortality In 24, there were 49 deaths attributed to asthma in Oregon for a rate of 13.3 deaths per million Oregonians. Oregon s asthma mortality rate has decreased 41% from 1999 to 24. Although the mortality rate for females is historically higher than that of males, the difference between the sexes is decreasing and mortality rates were virtually the same for both sexes in 24. Oregon s 22-24 asthma mortality rates are below Healthy People 21 targets for ages 5-14 and 15-34, but our rates are above the targets for ages -4, 35-64, and 65 or older. Asthma Control In 23, 58% of Oregonians with asthma reported having asthma symptoms at least once a week in the past four weeks. About 22% of people also reported three or more sleep disturbances in the past month due to asthma. In 24, people without asthma were about 4% more likely than people with asthma to report very good or excellent health. In 25, about 74% of people with asthma did not report missing any work or usual activities in the past 12 months due to asthma. However, 9% missed 1-3 days, 7% missed 4-1 days, and 1% missed more than 1 days in the past 12 months due to asthma. Asthma Management The National Asthma Survey (NAS) was administered to adult Oregonians with asthma in 25. Preliminary results from the NAS showed that only 18% reported ever receiving an asthma action plan from their healthcare provider and about 7% have taken a course or class on how to manage their asthma. In addition, roughly 38% of adult Oregonians with asthma are taking an inhaled corticosteroid, which helps prevent asthma symptoms and asthma attacks, either alone or in combination with a beta 2 - agonist. However, 57% are only taking a beta 2 -agonist inhaler, which is a rescue medication and does not help prevent future attacks. In addition to the NAS, medical and pharmacological claims data from the ADWG indicates that, of Oregonians with asthma in 24, 8% of those covered by private insurance and 65% of those covered by Medicaid received at least one anti-inflammatory medication in the past year. However, 26% of those covered by private insurance and 42% of those covered by Medicaid received six or more dispensings of a short-acting beta 2 -agonist rescue medication in the past year, which indicates that a quarter to nearly a half of Oregonians with asthma are not effectively managing their asthma. Risk Factors for Asthma Smoking is linked to higher rates of asthma. For example, current asthma prevalence in 24 is highest among current smokers (12.%) followed by former smokers (1.6%) and people who have never smoked (8.5%). People with current asthma in 24 were also 27% more likely to be current smokers than people without current asthma. 8
Obesity is also linked to higher rates of asthma. For example, current asthma prevalence in 24 was similar for people classified as normal (7.8%) or overweight (8.7%) based on the body mass index, whereas prevalence was higher for obese people (13.3%) and higher still in extremely obese people (23.%). Furthermore, the percentage of people termed obese by the body mass index (3 or more) in 24 was higher for those with current asthma than for those without current asthma (34% vs. 21%, respectively). Conversely, the percentage of people with normal body mass index (<25) was lower in those with current asthma than those without current asthma (33% vs. 42%, respectively). Asthma in the Medicaid Population Current asthma prevalence estimates among the Medicaid population range from 17.1-18.8% in 24 and are much higher than a similar estimate in the non-medicaid population (9.2%). In addition, survey self-reports from 24 indicate that 22% of the Medicaid population has been to the ED or an urgent care center for asthma in the past 12 months, whereas medical claims from 23-4 indicate that 13-14% of the Medicaid population has been to the ED for asthma in the past 12 months. Among adults with asthma who were served by Medicaid in 24, 2% reported missing one or more days of work, school, or other activities because of asthma, 78% had asthma symptoms at least once a week in the past four weeks, and 67% reported at least some degree of limitation of their usual activities due to asthma. Medical claims gathered by the Office of Medical Assistance Programs-Quality and Performance Improvement (OMAP-QPI) Workgroup from 23-4 indicate that 64-65% of the Medicaid population received at least one anti-inflammatory asthma medication in the past 12 months. However, similar to findings for people with commercial insurance, 41-42% of the Medicaid population also received six or more short-acting beta 2 -agonist rescue medications in the past 12 months, indicating that their asthma may not be well controlled. Similar to risk factors for the general Oregon adult population, current asthma prevalence among the Medicaid population in 24 was higher for former smokers (21.8%) and current smokers (2.4%) than for people who have never smoked (16.%). Similarly, 24 survey results show that people with asthma are more likely to be current smokers (37.9%) than were people without asthma (34.5%). People with asthma who are served by Medicaid and surveyed in 24 were also more likely to have secondhand smoke exposure (36.1%) than were people without asthma (3.9%). 9
Asthma Prevalence Asthma prevalence is primarily monitored through the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a random-digit-dialed telephone survey that is administered annually to adults 18 years of age or older in each state. In addition to collecting basic demographic information such as age, sex, race/ethnicity, income, and education, the BRFSS includes questions on preventive health practices, health behaviors, and health risks associated with premature morbidity and mortality. Oregon has conducted the BRFSS since 1989 and asthma prevalence has been assessed since 1995; however, the asthma prevalence questions have changed somewhat over the years. The current surveillance definition has been used since 21 and includes the following questions: Have you ever been told by a doctor, nurse, or other health professional that you have asthma? (lifetime asthma) Do you still have asthma? (current asthma) To assess asthma prevalence in children, Oregon relies on two sources: adult proxy on the BRFSS for children in the same household as the respondent, and students in 8 th and 11 th grade who participate in the Oregon Healthy Teens (OHT) survey. Has a doctor or nurse ever told you that you have asthma? (lifetime asthma) Do you still have asthma? (current asthma) Key Findings Adults o Current asthma prevalence in Oregon increased from 21 to 25 and is considerably higher than the U.S. average. o Current asthma prevalence in 25 was higher for women (12.4%) than men (7.4%). o The 2-1 prevalence of current asthma varies by race/ethnicity; however, several of these estimates are unstable due to small numbers of respondents within some of the race/ethnicity categories. o In 25, current asthma prevalence was highest in people aged 18-24 years (13.5%), relatively similar across 1-year age spans for people aged 25-64 years (range 9.4 to 9.8%), and lower in people aged 65 or older (8.2%). o The prevalence of current asthma in 25 was highest among people who reported annual income of less than $25,. o Based on 25 data, the prevalence of current asthma in the Medicaid population (2.7%) was more than double that of people with private or Medicare insurance (9.2%) or no health insurance (9.4%). o The 2-1 prevalence of current asthma differs among Oregon counties from a low of 3.2% in Hood River County to a high of 12.5% in Baker County. Children o Lifetime and current asthma prevalence estimates in Oregon are stable from 22-4. o The 25 prevalence of current asthma is similar for 8 th (1.5%) and 11 th (1.8%) graders. 1
Adult Asthma Prevalence Figure 1 Lifetime asthma prevalence in adults for Oregon and the U.S. (BRFSS, 21-25) Lifetime Asthma Prevalence (%) 2 18 16 14 12 1 8 6 4 2 14.2 14.2 11. 11.8 11.9 15.4 15.6 13.3 14.8 12.5 21 22 23 24 25 Year Oregon US Figure 2 Current asthma prevalence in adults for Oregon and the U.S. (BRFSS, 21-25) 14 Current Asthma Prevalence (%) 12 1 8 6 4 2 8.2 8.7 9.2 9.7 9.9 7.2 7.5 7.7 8.1 7.9 Oregon US 21 22 23 24 25 Year Figure 3 Current asthma prevalence by sex, Oregon adults (BRFSS, 25) 16 Current Asthma Prevalence (%) 14 12 1 8 6 4 2 7.4 12.4 Male Sex Female 11
Figure 4 Current asthma prevalence by race/ethnicity, Oregon adults (BRFSS, 2-1 race/ethnicity over-sample) Current Asthma Prevalence (%) 18 16 14 12 1 8 6 4 2 8.9 White (non- Hispanic) 9.7 Black (non- Hispanic) 5.9 Asian or Pacific Islander (non- Hispanic) Race/Ethnicity 12.8 American Indian or Alaska Native (non-hispanic) 5.5 Hispanic Figure 5 Current asthma prevalence by age, Oregon adults (BRFSS, 25) Current Asthma Prevalence (%) 18 16 14 12 1 8 6 4 2 13.5 9.4 9.8 9.7 9.8 18-24 25-34 35-44 45-54 55-64 65 and over Age Group 8.2 Figure 6 Current asthma prevalence by income, Oregon adults (BRFSS, 25) Current Asthma Prevalence (%) 2 15 1 5 14.9 12.2 <$15, $15,- 24,999 8.3 8.8 8.2 8.6 $25,- 34,999 Income $35,- 49,999 $5,- 74,999 $75, or more 12
Figure 7 Current asthma prevalence by education level, Oregon adults (BRFSS, 25) Current Asthma Prevalence (%) 16 14 12 1 8 6 4 2 1.9 1. < High school High school graduate or GED 1.9 Some college 8.5 College graduate Education Level Figure 8 Current asthma prevalence by type of health insurance, Oregon adults (BRFSS, 25) Current Asthma Prevalence (%) 25 2 15 1 5 9.4 9.2 2.7 No health insurance Private or Medicare Medicaid Type of Insurance 13
Table 1 Current asthma prevalence by county, Oregon adults (BRFSS, 2-1 county oversample) County Current Asthma Prevalence (%) Baker 12.5% Benton 8.5% Clackamas 7.8% Clatsop 6.3% Columbia 8.3% Coos 12.2% Crook 7.7% Curry 7.% Deschutes 6.1% Douglas 8.9% Grant 4.6% Harney 1.4% Hood River 3.2% Jackson 1.3% Jefferson 7.5% Josephine 8.% Klamath 9.2% Lake 8.2% Lane 9.9% Lincoln 8.9% Linn 8.6% Malheur 9.7% Marion 7.8% Morrow 9.5% Multnomah 8.% Polk 8.5% Tillamook 8.5% Umatilla 11.5% Union 11.% Wallowa 1.% Washington 7.9% Yamhill 11.6% Gilliam/Wheeler 6.6% Sherman/Wasco 7.3% 14
Child and Teen Asthma Prevalence Figure 9 Current asthma prevalence by year, Oregon children -17 years of age by adult proxy (BRFSS, 22-4) Current Asthma Prevalence (%) 16 14 12 1 8 6 4 2 7.2 7.3 6.9 22 23 24 Year Figure 1 Current asthma prevalence among Oregon 8 th grade and 11 th grade students (Oregon Healthy Teens, 25) Current Asthma Prevalence (%) 16 14 12 1 8 6 4 2 1.5 1.8 8th Grade 11th Grade 15
Emergency Department or Urgent Care Visits for Asthma The percentage of Oregonians with asthma who have visited an emergency department (ED) or an urgent care center for asthma in the past year is assessed through the Behavioral Risk Factor Surveillance System (BRFSS). This question is worded as follows on the BRFSS: During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma? We also monitor ED visits through the Asthma Data Workgroup (ADWG). The ADWG is a collaboration between the Oregon Asthma Program (OAP) and several of Oregon s largest commercial and Medicaid health plans. Through this collaboration, we are able to measure and report asthma data consistently across health plans. The aggregate data are derived from the claims and encounter records of more than one million insured Oregonians aged 4-55 from six different health plans who had at least six months of continuous enrollment in a participating health plan. As such, these data represent nearly 3% of the Oregon population. Key Findings Behavioral Risk Factor Surveillance System (BRFSS) o The percentage of Oregonians with asthma who have visited an ED or urgent care center in the past 12 months decreased from 21 (17.2%) to 23 (12.9%). o In 23, among those with asthma, females (14.1%) were more likely than males (1.7%) to have an ED or urgent care visit for asthma in the past 12 months. o In 23, Oregonians with asthma who were covered by Medicaid (23.6%) were more likely than people with no health insurance (5.1%) or people with private or Medicare insurance (13.1%) to have an ED or urgent care visit for asthma in the past 12 months. Asthma Data Workgroup (ADWG) o From 21-4, the percentage of people with asthma who had an ED visit for asthma in the past 12 months is stable or decreasing. o From 21-4, Oregonians with asthma who were covered by Medicaid were twice as likely to have an ED visit for asthma in the past 12 months as people with commercial health insurance. o Of Oregonians with asthma covered by Medicaid or commercial health insurance, about 4% of those who had an ED visit for asthma had a follow-up outpatient visit within 3 days of the ED visit. 16
Figure 11 Percentage of Oregon adults with current asthma, by year, who report one or more emergency department or urgent care visits for asthma in the past 12 months (BRFSS, 21 and 23) ED or Urgent Care Visit (%) 25 2 15 1 5 17.2 12.9 21 23 Year Figure 12 Percentage of Oregon adults with current asthma, by sex and year, who report one or more emergency department or urgent care visits for asthma in the past 12 months (BRFSS, 21 and 23) ED or Urgent Care Visit (%) 25 2 15 1 5 15. 18.3 1.7 21 23 Year 14.1 Male Female Figure 13 Percentage of Oregon adults with current asthma, by type of insurance and year, who report one or more emergency department or urgent care visits for asthma in the past 12 months (BRFSS, 21 and 23) 5 ED or Urgent Care Visit (%) 4 3 2 1 15.3 35.3 13.7 13.1 5.1 23.6 No health insurance Private or Medicare Medicaid 21 23 Year 17
Figure 14 Percentage of health plan members age 4-55 with asthma, by plan type and year, who had one or more emergency department visits for asthma in the past 12 months (ADWG, 21-4) 25 ED Visit (%) 2 15 1 5 15.7 15.8 7.1 7.1 7.4 13.4 13.1 21 22 23 24 Year 6.5 Medicaid Commercial Figure 15 Percentage of health plan members age 4-55 with asthma, by plan type and year, who had a follow-up outpatient visit within 3 days of an emergency department visit for asthma (ADWG, 21-4) 6 Followup Visit (%) 5 4 3 2 1 41.3 4.2 36.6 37.5 43.6 4.3 42.6 34.5 Commercial Medicaid 21 22 23 24 Year 18
Asthma Hospitalizations The rate of asthma hospitalizations per 1, Oregon residents is monitored through the Oregon Hospital Discharge Index, which is provided by the Oregon Association of Hospitals and Health Systems. Data from 1997-24 have been analyzed and the results are provided below. The Hospital Discharge Index provides information on hospital discharges from all acute care hospitals in Oregon except two Veterans Administration hospitals. The dataset includes information on the dates of admission and discharge, principal and additional diagnosis and procedure codes, financial charges, primary payer, and limited patient demographic information (e.g., includes gender but not race/ethnicity). Unique identifiers are not available in this dataset; therefore, we can monitor the number of asthma hospitalizations that occur but not the number of people who are hospitalized for asthma. An asthma hospitalization is defined as having a primary diagnosis with an International Classification Disease 9 th Revision (ICD-9) code of 493. When possible, the hospitalization rates presented below have been age-adjusted to the U.S. 2 standard population. Key Findings In 24, there were 2,149 asthma hospitalizations in Oregon. Asthma hospitalizations in Oregon cost approximately $19.3 million in 24. The Oregon asthma hospitalization rate varies by year but is decreasing from 1997-24. The lowest rate occurred in 24 (6.1 hospitalizations per 1, residents). Despite Oregon s higher asthma prevalence, Oregon asthma hospitalization rates are lower than the U.S. rate and in 24 were lower than the Healthy People 21 targets. Oregon asthma hospitalization rates in 24 differ by age with the highest rates in children <5 years old and adults 8 years old. The rate of asthma hospitalizations is higher for females than males except in children <15 years old. Females accounted for 61.5% of asthma hospitalizations and males accounted for the remaining 38.5% of asthma hospitalizations. The number of asthma hospitalizations varies by season with more in the winter months and fewer in the summer months. 19
Figure 16 Age-adjusted hospitalization rate per 1, residents in which asthma was the primary discharge code (Hospital Discharge Index, 1997-25) 9 Hospitalizations per 1, 8 7 6 7.4 7. 6.9 6.7 6.5 7.3 7. 6.1 6.8 5 1997 1998 1999 2 21 22 23 24 25 Year Table 2 Oregon, U.S., and Healthy People 21 target asthma hospitalization rates* (Hospital Discharge Index, 1999-25) U.S., 1998 (Hospitalizations per 1,) Oregon, 1997 (Hospitalizations per 1,) Oregon, 25 (Hospitalizations per 1,) Healthy People 21 (Hospitalizations per 1,) Age Group (years) -4 45.6 19.8 15.1 25. 5-64* 12.5 5.7 4.8 7.7 65 and older* 17.7 11.8 14.5 11. * Age-adjusted rates for age groups of 5-64 years and 65 years or older. Figure 17 Hospitalization rate (per 1, residents), by sex and age group, with asthma as the primary discharge code (Hospital Discharge Index, 25) Hospitalizations per 1, 3 25 2 15 1 5 Total Female Male -4 5-9 1-14 15-19 2-24 25-29 3-34 35-39 4-44 45-49 5-54 55-59 6-64 65-69 7-74 75-79 8-84 85+ Age Group 2
Figure 18 Number of hospitalizations due to asthma by month in 25 (Hospital Discharge Index, 25) 4 Hospitalizations 3 2 1 254 34 279 24 22 175 114 97 182 217 185 179 January February March April May June July Month of 24 August September October November December 21
Asthma Mortality Compared to hospitalizations, there are very few deaths due to asthma each year. Asthma mortality is monitored through Oregon s Death Certificate Statistical File, which contains information about all deaths occurring in Oregon and deaths occurring out-of-state among Oregon residents. An asthma death is defined as having asthma listed as the underlying (principal) cause of death. When possible, the mortality rates presented below have been age-adjusted to the U.S. 2 standard population. For comparability, state and national age-adjusted rates may be obtained from the Centers for Disease Control and Prevention (CDC) Wonder data system at http://wonder.cdc.gov. Key Findings In 24, there were 49 deaths (13.3 per million) attributed to asthma in Oregon. Overall, Oregon s asthma mortality rate has decreased 41% from 1999 to 24. The mortality rate for females is historically higher than that of males; however, the gap is decreasing and mortality rates were virtually the same for both sexes in 24. Despite Oregon s higher asthma prevalence, Oregon asthma mortality rates are lower than the U.S. rate except in people 65 years or older. Comparing asthma mortality rates from 1999-21 to 22-24, the Oregon rate decreased in all age groups except children <5 years old; there were no deaths in this age group from 1999-23 whereas a single death occurred in a child <5 in 24. Oregon s 22-24 asthma mortality rates are below Healthy People 21 targets for ages 5-14 ( per million) and 15-34 (1.7 per million), but our rates are above the targets for ages -4 (1.5 per million), 35-64 (12.5 per million), and 65 or older (84.9 per million). Mortality rates combined from 1999-24 differ somewhat by race/ethnicity; however, these rates are unstable and should be interpreted with caution due to the small number of deaths in non-white races/ethnicities (<1 in each group) that occurred during this time. 22
Figure 19 Age-adjusted mortality rate per million residents in which asthma was the primary cause of death (Oregon death certificates, 1999-24) 3 Deaths per million 25 2 15 1 5 22.5 16.9 18. 18.9 15. 13.3 1999 2 21 22 23 24 Year Table 3 Age Group (years) Asthma mortality rate per million residents compared to Healthy People 21 targets for asthma (Oregon death certificates, 1999-24) Oregon, 1999-21 (per million) Oregon, 22-24 (per million) Healthy People 21 (per million) U.S., 22 (per million) -4 1.5 2.4 1. 5-14.7. 3. 1. 15-34 2.5 1.7 5. 2. 35-64 14. 12.5 14.5 9. 65+ 14.9 84.9 58.1 6. Figure 2 Age-adjusted mortality rate per million residents by sex in which asthma was the primary discharge code (Oregon death certificates, 1999-24) Deaths per million 35 3 25 2 15 1 5 29 18.2 15.2 14.9 23.8 23.2 16.8 13 12.1 9.7 13.2 13.2 Female Male 1999 2 21 22 23 24 Year 23
Figure 21 Age-adjusted mortality rate per million residents from 1999-24 by race/ethnicity in which asthma was the primary cause of death (Oregon death certificates, aggregated from 1999-24) 3 Deaths per million 25 2 15 1 5 17.1 23.6 8.9 18.9 6.2 White Black Asian/Pacific Islander Race/Ethnicity American Indian/Alaska Native Hispanic 24
Asthma Control The extent to which people have control of their asthma and asthma symptoms is monitored through Oregon-added questions on the BRFSS and through the National Asthma Survey (NAS). The standard version of the BRFSS administered by all states only asks the lifetime and current asthma prevalence questions discussed in the Asthma Prevalence section. In Oregon, however, we have included additional asthma questions to assess asthma control every two years, beginning in 21. In addition to the BRFSS, Oregon is one of only three states to pilot the NAS in 25. This is an additional call-back survey on asthma administered to people who indicated on the BRFSS that they have asthma. The NAS is very detailed and asks many questions related to asthma such as healthcare utilization, knowledge of asthma, asthma management, asthma medications, environmental factors, costs of asthma care, work-related asthma, co-morbid conditions, and complementary and alternative medicines. At the time of this report, we have examined preliminary data from the NAS but have not yet finalized the analyses because additional steps are necessary to ensure the data are representative of Oregon s population. For this reason, results from the NAS presented below should be treated as preliminary and interpreted with caution. Key Findings Behavioral Risk Factor Surveillance System (BRFSS) o In 23, more females (15.3%) than males (8.6%) reported missing one or more days of activities in the past three months due to asthma. o In 23, people with asthma who made less than $25, a year were more likely than those with higher incomes to report missing one or more days of activities in the past three months due to asthma. o About 22% of people with asthma in 23 reported three or more sleep disturbances in the past month due to asthma. o In 23, nearly 39% of people with asthma reported some or a moderate degree of limitation of their activities due to asthma. Only 3% reported severe limitations on their activities. o Nearly 58% of people with asthma in 23 reported having asthma symptoms at least once a week in the past four weeks. o In 24, people without asthma were about 4% more likely than people with asthma to report very good or excellent health. National Asthma Survey (NAS) o In 25, about 74% of people with asthma did not report missing any work or usual activities in the past 12 months due to asthma. However, 9% missed 1-3 days, 7% missed 4-1 days, and 1% missed more than 1 days in the past 12 months due to asthma. 25
Figure 22 Percentage of adults with current asthma, by sex, who missed one or more days of activities because of asthma in the past three months (BRFSS, 23) 25 Missed 1+ Days of Activities (%) 2 15 1 5 15.3 13. 8.6 Male Female All Adults Figure 23 Number of days in the past 12 months adults with asthma were unable to work or carry out their usual activities because of asthma (NAS, 25 preliminary results) Percent 1 8 6 4 2 73.9 8.5 7.2 1.4 None 1-3 4-1 >1 Number of Days Unable to Work or Carry out Usual Activities in Past 12 Months Figure 24 Percentage of adults with current asthma, by income, who missed one or more days of activities because of asthma in the past three months (BRFSS, 23) Missed 1+ Days of Activities (%) 4 35 3 25 2 15 1 5 18.7 25.9 <$15, $15,- 24,999 14.9 $25,- $34,999 Income 7.1 $35,- 49,999 4.7 $5, or more 26
Figure 25 Number of self-reported sleep disturbances per month due to asthma among adults with asthma (BRFSS, 23) Percent 8 7 6 5 4 3 2 1 56 22 22 None 1-2 nights 3 or more nights Sleep Disturbances per Month Figure 26 Degree of self-reported limitations of usual activities among adults with asthma (BRFSS, 23) Percent 8 7 6 5 4 3 2 1 58 39 3 Not at all Some/moderate limitation Severe limitation Degree of Limitations on Usual Activities Figure 27 Frequency of asthma symptoms in past four weeks among adults with asthma (BRFSS, 23) 6 5 43 Percent 4 3 2 36 22 1 Less than once a week Once to <7 times a week Symptoms every day Frequency of Asthma Symptoms 27
Figure 28 Perceived health status among adults with or without asthma (BRFSS, 24) 7 6 56 Percent 5 4 3 2 1 4 29 3 31 13 Asthma No asthma Excellent or very good Good Fair or poor Perceived Health Status 28
Asthma Management Asthma management refers primarily to the education, instruction, and medical or pharmacological care received by people with asthma. Like asthma control indicators, asthma management indicators are monitored through the National Asthma Survey (NAS), which is a BRFSS call-back survey for people with asthma. As mentioned in the previous section, the NAS is very detailed and asks many questions related to asthma such as healthcare utilization, knowledge of asthma, asthma management, asthma medications, environmental factors, costs of asthma care, work-related asthma, co-morbid conditions, and complementary and alternative medicines. At the time of this report, we have examined preliminary data from the NAS but have not yet finalized the analyses because additional steps are necessary to ensure the data are representative of Oregon s population. For this reason, results from the 25 NAS presented below should be treated as preliminary and interpreted with caution. Asthma management is also monitored through the Asthma Data Workgroup (ADWG), which collects medical and pharmaceutical claims data for more than one million Oregonians with health insurance. Key Findings National Asthma Survey (NAS) o Only 18% of adult Oregonians with asthma reported ever receiving an asthma action plan from their healthcare provider. o About 7% of adult Oregonians with asthma have taken a course or class on how to manage their asthma. o According to the NAS, roughly 38% of adult Oregonians with asthma are taking an inhaled corticosteroid, which helps prevent asthma symptoms and asthma attacks, either alone or in combination with a beta 2 -agonist. However, 57% are only taking a beta 2 - agonist inhaler, which is a rescue medication and does not help prevent future attacks. o Inhaler spacers, which are used to improve the efficacy of inhaled medications and reduce the amount of medication in the mouth or throat, are used by about 47% of adult Oregonians with asthma who use an inhaled medication. Asthma Data Workgroup (ADWG) o Of Oregonians with asthma in 24, 8% of those covered by private insurance and 65% of those covered by Medicaid received at least one anti-inflammatory controller medication in the past year. o Of Oregonians with asthma in 24, 26% of those covered by private insurance and 42% of those covered by Medicaid received six or more dispensings of a short-acting beta 2 - agonist rescue medication in the past year. 29
Figure 29 Percentage of adults with asthma who report ever receiving an asthma action plan from their healthcare provider (NAS, 25, unweighted) Percent 1 9 8 7 6 5 4 3 2 1 18 8 Yes No Don't know Ever Received Asthma Action Plan 2 Figure 3 Percentage of adults with asthma who have taken a course or class on how to manage their asthma (NAS, 25, unweighted) Percent 1 9 8 7 6 5 4 3 2 1 7 Yes 93 No Taken Asthma Management Course or Class Figure 31 Percentage of adults with asthma who use inhaled beta 2 -agonist or corticosteroid prescription inhalers (NAS, 25, unweighted) Percent 8 7 6 5 4 3 2 1 57 Beta-agonist only 15 Corticosteroid only 23 Beta-agonist and corticosteroid 5 Other or don't know Prescription Inhalers Used 3 No medications
Figure 32 Age-adjusted percentage of Oregonians with asthma in 24, by type of insurance, who received at least one prescription for an anti-inflammatory asthma medication (ADWG, 24) Received 1+ Antiinflammatory Meds (%) 1 8 6 4 2 8 Private Type of Insurance 65 Medicaid Figure 33 Age-adjusted percentage of Oregonians with asthma in 24, by type of insurance, who received six or more dispensings for a short-acting beta 2 -agonist rescue medication in the past year (ADWG, 24) Received 6+ Rescue Meds (%) 6 5 4 3 2 1 26 Private 42 Medicaid Type of Insurance 31
Risk Factors for Asthma Risk factors for asthma are monitored through the Behavioral Risk Factor Surveillance System (BRFSS). The risk factors analyzed in this report include smoking, secondhand smoke exposure, and obesity as measured by body mass index. Key Findings Asthma prevalence in 24 is highest among current smokers (12.%) followed by former smokers (1.6%) and people who have never smoked (8.5%). In 24, people with asthma were 27% more likely to be current smokers than people without asthma. Asthma prevalence in 24 is unrelated to secondhand smoke exposure. In 24, people with asthma were no more likely to have secondhand smoke exposure in a typical week than people without asthma. Asthma prevalence in 24 was similar for those with a body mass index of <25 kg/m 2 (7.8%) and those who were overweight (8.7%). However, prevalence was higher for obese people (13.3%) and higher still in extremely obese people (23.%). In 24, the percentage of obese people was higher for those with asthma than for those without asthma (34% vs. 21%, respectively). Conversely, the percentage of people with body mass index <25 kg/m 2 was lower in those with asthma than those without asthma (33% vs. 42%, respectively). 32
Figure 34 Current asthma prevalence by smoking status, Oregon adults (BRFSS, 24) Current Asthma Prevalence (%) 16 14 12 1 8 6 4 2 12. 1.6 8.5 Never smoked Former smoker Current smoker Smoking Status Figure 35 Percentage of Oregon adults who currently smoke, by current asthma status (BRFSS, 24) Current Smoker Prevalence (%) 3 25 2 15 1 5 24.2 19.1 Current asthma No current asthma Asthma Status Figure 36 Current asthma prevalence by secondhand smoke exposure in a typical week (excluding current smokers), Oregon adults (BRFSS, 24) Percent 16 14 12 1 8 6 4 2 9.3 9.6 Some exposure No exposure Secondhand Smoke Exposure in Typical Week 33
Figure 37 Percentage of Oregon adults with secondhand smoke exposure in a typical week (excludes current smokers), by current asthma status (BRFSS, 24) Secondhand Smoke Exposure (%) 6 5 4 3 2 1 35.2 Current asthma Asthma Status 35.9 No current asthma Figure 38 Current asthma prevalence by body mass index, Oregon adults (BRFSS, 24) 3 Current Asthma Prevalence (%) 25 2 15 1 5 7.8 8.7 13.3 23. <25 (normal or underweight) 25 to <3 (overweight) Body Mass Index (BMI) 3 to <4 (obese) 4 or more (extremely obese) Figure 39 Distribution of Oregon adults, with and without current asthma, by body mass index (BRFSS, 24) Percent 6 5 4 3 2 1 33 42 Normal (<25) 37 33 34 Overweight (25 to <3) Body Mass Index 21 Obese (>3) Current asthma No asthma 34
Asthma in the Medicaid Population Although information on Oregonians with Medicaid health insurance from the BRFSS are interspersed throughout this report, we also include this separate section on the Medicaid population. This section includes findings from the Oregon Medicaid Health Risk and Health Status Survey (HRHSS) and from analysis of medical claims data gathered by the Office of Medical Assistance Programs-Quality and Performance Improvement (OMAP-QPI) workgroup. The HRHSS was conducted in 24 by the Oregon Department of Human Services, Health Services, Office of Medical Assistance Programs to measure the health risk and health status of adult Oregon Health Plan (OHP) clients. This telephone survey was conducted in English and Spanish from August through October 24, and the survey was designed to assess health risk behaviors, clinical preventive health practices, and healthcare access, mainly related to chronic diseases. The eligible population included adults age 18 or older who were enrolled in the Oregon Health Plan (OHP) for at least 137 days during the period of July 1, 23-June 3, 24. Continuous enrollment was not required. The sample was random and stratified by six race/ethnicity categories: White, African American, Hispanic, Native American, Asian, and Other. A total of 11,921 adult enrollees were included in the survey sample and 2,995 completed the survey. As a random sample, these results should be interpreted as estimates of behaviors and practices with inherent variability rather than as precise prevalence percentages. Our second source of Medicaid-related asthma data comes from the OMAP-QPI workgroup. Through this workgroup we are able to measure and compare five asthma indicators across all Medicaid clients in Oregon, which makes Oregon the only state to have full availability to asthma data for the Medicaid population of the entire state. The indicators are derived from medical and pharmacy claims for Oregonians served by Medicaid who are between the ages of 4-55 and who have at least six months of continuous enrollment. Key Findings Prevalence o In 24, current asthma prevalence was 18.8% among adult Medicaid recipients as assessed by the HRHSS. This is similar to the 25 BRFSS finding for people served by Medicaid and is more than twice the prevalence seen in the non-medicaid population. o Current asthma prevalence in 24 increases with age through age 45-54 and then decreases. Emergency department (ED) and urgent care visits o In 24, self-reports indicate that 22% of the Medicaid population have been to the ED or an urgent care center for asthma in the past 12 months. o Medical claims from 23-4 indicate that 13-14% of the Medicaid population has been to the ED for asthma in the past 12 months. o Among Medicaid recipients who visited an ED for asthma in the past 12 months, 34-4% had a follow-up outpatient visit within 3 days of the ED visit. Asthma control o In 24, 78% of adults with asthma served by Medicaid had asthma symptoms at least once a week in the past four weeks and 67% reported at least some degree of limitation of their usual activities due to asthma. o Of adults with asthma served by Medicaid in 24, in the past three months 8% missed 1-3 days and 12% missed four or more days of work, school, or other daily activities. 35
o Among adults served by Medicaid in 24, compared to people without asthma, people with asthma were less likely to rate their health as excellent or very good (15% vs. 27%, respectively) and more likely to rate their health as fair or poor (65% vs. 43%, respectively). Asthma management o According to self-reports from 24, 52% of the adult Medicaid population did not visit a healthcare professional in the past 12 months for routine treatment of asthma. o Medical claims from 23-4 indicate that 64-65% of the Medicaid population has received at least one anti-inflammatory asthma medication in the past 12 months. However, 41-42% of the Medicaid population also received six or more short-acting beta 2 -agonist rescue medications in the past 12 months, indicating that their asthma may not be well controlled. Risk factors o Of adults served by Medicaid, current asthma prevalence in 24 was higher for former smokers (21.8%) and current smokers (2.4%) than for people who have never smoked (16.%). o In 24, among the adult Medicaid population, people with asthma are more likely to be current smokers (37.9%) than were people without asthma (34.5%). o Among non-smoking adults served by Medicaid, current asthma prevalence in 24 was higher for people with secondhand smoke exposure (2.9%) than for people with no exposure (17.2%). o In 24, among the adult, non-smoking Medicaid population, people with asthma are more likely to have secondhand smoke exposure (36.1%) than were people without asthma (3.9%). 36