Asthma in Iwa A Plan t Imprve the Health f Iwans with Asthma 2010-2015 May 2010
Table f Cntents What is Asthma?...4 Purpse and Use f the Plan.......................................... 6 Histry f Asthma Prgramming in Iwa....7 The Scpe f Asthma in Iwa....9 The Planning Prcess............................................... 20 A Strategic Plan fr Addressing Asthma in Iwa, 2010-2015... 23 Asthma Planning Wrkgrup Members................................. 38 Appendices....................................................... 39 A. 2006 Revised Iwa State Plan.... 40 B. Emergency Department (ED) Visits Due t Asthma in Iwa, 2003-2008.. 45 C. Wrk-related Asthma in Iwa: 2006-2008 BRFSS Adult Asthma Call-back Survey...50 2
Fr questins related t this dcument, please cntact: Jill Heins Nesvld, MS Directr f Respiratry Health American Lung Assciatin in Iwa, Minnesta, Nrth Dakta, and Suth Dakta 651-223-9578 jill.heins@lungmn.rg Fr questins related t the Iwa Asthma Calitin, please cntact: Janelle Thier, CHES American Lung Assciatin in Iwa 515-309-9507 janelle.thier@lungia.rg Iwa Department f Public Health. 2010. A Plan t Imprve the Health f Iwans with Asthma, 2010-2015. Iwa Department f Public Health Chrnic Disease Preventin and Management Bureau. The develpment f this state plan was supprted by Cperative Agreement 5U59EH000202-03. Its cntents are slely the respnsibility f the authrs and d nt necessarily represent the fficial views f the Centers fr Disease Preventin and Cntrl (CDC). 3
What is Asthma? Asthma is a chrnic inflammatry disrder f the airways that causes three primary changes in the lungs: Inflammatin (swelling) f the lining f the airways Nrmal Lung Tissue Brnchcnstrictin (tightening f the bands f smth muscles surrunding the airways) which reduces the width f the airways Excess mucus prductin that further narrws the airways Asthma Asthma is an bstructive disease that may cause permanent changes (remdeling) if nt prperly treated. Asthma is a disease that cannt be cured but can be cntrlled. Diagnsis f Asthma A diagnsis f asthma can be made by a health care prfessinal thrugh assessment f symptms, medical histry, physical examinatin and spirmetry a simple breathing test. Diagnsing asthma in infants is ften difficult, yet under-diagnsis and undertreatment are key prblems in this age grup. A detailed histry f symptms and a physical exam is a vital and imprtant part f diagnsing asthma at any age. 4 Symptms Althugh symptms may vary fr each persn with asthma, the primary symptms f an asthma episde may include: Wheeze Cugh Shrtness f breath Chest tightness Retractins Remember, all symptms shuld be taken seriusly. Please nte that cugh may be the nly symptm. Sme peple with asthma may never wheeze.
Classificatin f Asthma Part f managing asthma includes assessing the severity f a persn s asthma. This includes assessing night and daytime symptms, plus a breathing test (spirmetry). A persn with asthma may be assessed at ne f several different levels. The severity level then determines the type, dsage, and frequency f medicatins prescribed. Health care prviders can step-up r step-dwn therapy based n the respnse t medicatins. Gals f Medicatin Therapy Cntrl chrnic and nighttime symptms. Maintain nrmal activity levels, including exercise. Maintain near-nrmal pulmnary functin. Prevent acute episdes f asthma. Minimize emergency department visits and hspitalizatins. Reduce schl r wrk absenses due t asthma. Avid adverse effects f asthma medicatins. Medicatins Asthma medicatins are essential t asthma management. They are imprtant in bth preventing an asthma episde frm ccurring and in treating an asthma episde already underway. A variety f medicatins are prescribed in the management f asthma. Sme medicatins reduce inflammatin and prevent episdes. These are cntrller medicatins. They are taken n a daily basis, even when felling well. Side effects can include a harse vice and yeast infectin in the muth but can be prevented by using a hlding chamber and rinsing yur muth after medicatin use. Cntrller medicatins will nt help during an asthma episde r in emergencies. Other medicatins relieve brnchcnstrictin (narrwing f the airways) and are designed fr quick relief during an asthma episde. These are called quick relief medicatins. Quick relief medicatins relax the airway muscles and shuld be used when asthma symptms first appear and/r befre exercise, as indicated by a health care prvider. Quick relief medicatins are taken n an as-needed basis t relieve symptms. Oral sterids (taken in pill r liquid frm by muth) are taken shrt-term (3 t 10 days) t treat severe asthma episdes. An ral sterid (like prednisne) begins t wrk in 6 t 24 hurs t decrease swelling in the lungs. This ral sterid is safe when taken shrt-term. It is nt the same medicatin that athletes take t increase their muscle mass. 5
Purpse and Use f the Plan The Iwa Asthma Plan is a tl that will allw rganizatins acrss Iwa and the regin t identify the tp pririties and strategies fr asthma management in Iwa. This plan can: Be used as a tl by a variety f rganizatins acrss Iwa t guide asthma-related activities Be referenced fr legislative and plicy decisins related t asthma in Iwa Be used as a recruitment tl f new members/rganizatins t the Iwa Asthma Calitin Be used by the Iwa Health Care Refrm Preventin and Chrnic Care Management Advisry Cuncil as a reference tl fr key pririties and strategies fr addressing asthma in Iwa Be used fr reference by rganizatins applying fr funding shwing the need, pririty, and justificatin fr the activities Accmpany a cmpetitive, federal applicatin prcess t shw that Iwa has develped a statewide asthma plan and that pririties have been identified shuld asthma-related funding be granted Shw the asthma-related accmplishments and need fr additinal resurces, if the Iwa Asthma Plan pririties are reprted upn n an annual basis. 6
Histry f Asthma Prgramming in Iwa Asthma management and cntrl frmally began in Iwa in 2000 with a grant frm the Centers fr Disease Preventin and Cntrl (CDC) t the Iwa Department f Public Health (IDPH). Thrugh this CDC funding, IDPH was able t establish an asthma surveillance system, statewide asthma plan, and several interventins. In 2003, IDPH prvided a grant t the American Lung Assciatin in Iwa (ALA) t lead the Iwa Asthma Calitin. The rle f the Iwa Asthma Calitin (IAC) is t develp a partnership f agencies, academic institutins, health care and insurance prviders, and cnsumers t build awareness and educatin arund asthma. Gals f the calitin include: facilitate cmmunicatin and netwrking amng persns and rganizatins, update the Iwa State Plan every five years, and implement interventins. The fllwing highlights are examples f asthma prgrams that have been implemented since 2007 in Iwa. 1. The University f Iwa Asthma Center launched their University f Iwa Asthma Center Cnference in 2005. This annual cnference educates practicing healthcare prfessinals n the newest develpments in the diagnsis and treatment f asthma. 2. Linn Cunty Asthma Reductin Calitin had the pprtunity, thrugh a grant with the Envirnmental Prtectin Agency (EPA) t cnduct in-hme asthma educatin and assessments. Children s Hme Asthma Management Prgram (CHAMP) delivered in-hme asthma educatin t ver 50 Linn Cunty families with asthma between Octber 1, 2007 and September 30, 2008. Thrugh additinal funding, September 1, 2008 and August 30, 2009, anther 15 children with asthma participated in a multi-visit educatinal curriculum. Linn Cunty Public Health staff als used the Iwa Asthma Cntrl Prgram s Asthma Actin Plan and Using Yur Asthma Actin Plan brchure in the prgram. 3. The Asthma Outcmes Prject trained physicians and nurses n the updated Natinal Heart, Lung, and Bld Institute s Asthma Guidelines. Over 50 health care prfessinals were reached at a respiratry therapist cnference and three primary care medical clinics acrss Iwa between September 1, 2008 and August 31, 2009. 7
4. One Life t Breathe was develped and implemented, between September 1, 2008 and August 31, 2009, with the Senir Educatin Prgram (SE*ED) and Grinnell Reginal Medical Center (GRMC). Prgrams were prvided t senir adults wh had been referred t the prgram by their physician. Mre than 75 senirs were prvided the educatin they needed t manage their asthma. 5. Organizatins including IDPH, Visiting Nurse Services (VNS), ALA, Child Care Resurce and Referral Agency (CCR&R), GlaxcSmithKline and the IAC develped an asthma management training curriculum fr child care prviders, schl nurses, and health care cnsultants. Between September 1, 2008 and March 31, 2010, train-the-trainer curses were held fr 236 nursing students, schl nurses, and schl health assistants representing 90 f Iwa s 99 cunties t implement the Yung and the Breathless Prgram in their wn cmmunities. A dcumented 1,162 childcare prviders have received training using the Yung and the Breathless curriculum. 6. Between September 1, 2008 and August 31, 2009, Athletes & Asthma, a tw-hur training fr caches, athletic trainers, schl persnnel, and nurses was delivered t 18 individuals. A secnd training was given t ver 70 caches and athletic persnnel at a Caches Training Physitherapy Assciates Cnference. 7. IDPH Tbacc Use Preventin and Cntrl Divisin and the Iwa Asthma Cntrl Prgram partnered t implement a secndhand smke and asthma media campaign using billbards and bus advertisements in majr Iwa cities (Des Mines, Cedar Rapids, Siux City, and Waterl). Between Nvember 2008 and February 2009, this campaign resulted in ver 13 millin impressins n Iwans. 8. ALA hlds an annual week-lng, residential camp fr children, 8-14 year f age, with persistent asthma. This asthma camp prvides intensive asthma educatin in a fun and medical safe camp setting. 9. Beginning in 2008, ALA has trained facilitatrs and implemented training sessins using their Asthma 101: What Yu Need t Knw curriculum fr childcare prvider, caches, schl persnnel, and thers. 8
The Scpe f Asthma in Iwa There is a variety f data that describes the scpe f asthma in Iwa. The Iwa Department f Public Health released several asthma surveillance reprts, which can be accessed via the web at www.idph.state.ia.us/hpcdp/asthma.asp. The fllwing summary highlights the mrtality, prevalence, and health care utilizatin f asthma in Iwa and asthma s cnnectin t tbacc use. Mrtality data 1 While asthma is nt a leading cause f death in Iwa, it is a prevalent chrnic cnditin, with a rate f arund 10% in adults. Fr each year between 1979 and 2006, asthma was the primary cause f death fr fewer than 80 Iwans. During the 28 years shwn belw, the number f deaths frm asthma peaked during the 1980s and 1990s (N=35 deaths in 2006). Deaths frm Asthma, Iwa Residents, 1979-2006 9
Deaths frm Asthma, by Gender, Iwa Residents, Age-adjusted Rates and Cunts, 1979-2005 Females accunt fr the majrity f asthma deaths in Iwa arund 60% f asthma deaths during the perid frm 2003-2005. During this time, 5% f asthma deaths ccurred amng children and yuth; 60% amng Iwans age 65 years and lder. On average, Iwans wh die frm asthma are yunger than Iwans wh die frm ther causes. Between 1999 and 2005, 94% f asthma-related deaths ccurred amng Caucasians, 5% amng African-Americans, and 1% amng Iwans f ther races. Prevalence data Accrding t the 2009 Iwa Behaviral Risk Factr Surveillance Survey 2, an annual telephne survey f Iwans t help mnitr the prevalence f health cnditins and behavirs, 10.3% f adult Iwans reprted they had ever been tld that they had asthma by a dctr. This percentage increased 1.8% since 2000 (8.5%). 10.3% f Iwa adults reprt they have asthma. 10
Percent f Iwa Adults with Asthma 2000-2009 Bahaviral Risk Factr Surveillance Survey In 2009, 6.7% reprted that their child had ever been tld they had asthma by their dctr. This was dwn 3.1% frm 2005 (9.8%). Percent f Iwa Children with Asthma 2000-2009 Bahaviral Risk Factr Surveillance Survey 11
The Yuth Risk Behavir Surveillance System is an epidemilgic system established by the U.S. Centers fr Disease Cntrl and Preventin (CDC) t mnitr the prevalence f behavirs that put yuth at risk fr health and scial cnditins. This survey is used by the State f Iwa t mnitr these behavirs amng yuth wh were attending high schls (Grades 9 thrugh 12, traditinal and alternative schls) in Iwa during 2006-07. 3 15.4% f students wh had ever been tld by a dctr r nurse that they had asthma. (1,437) 8.8% f students wh had ever been tld by a dctr r nurse that they had asthma and still have asthma (i.e., current asthma). (1,430) There were n statistically significant differences by gender r grade level n the questins relating t asthma. Prevalence amng farm children 8.8% f Iwa A chrt f rural Sutheast Iwa (Kekuk Cunty) children was studied t students determine the assciatin between farm and ther envirnmental risk reprt they factrs with fur asthma utcmes: dctr-diagnsed asthma, dctrdiagnsed asthma/medicatin fr wheeze, current wheeze, and cugh with currently have asthma. exercise. Dctr-diagnsed asthma prevalence was 12%, but at least ne f these fur health utcmes was fund in mre than a third f the children. There was a high prevalence f asthma health utcmes amng children living n farms that raise swine (44.1%, p = 0.01) and raise swine and add antibitics t feed (55.8%, p = 0.013). 4 12
Hspitalizatins fr asthma Accrding t data frm the Iwa Hspital Assciatin, every year, apprximately 2200 Iwans are hspitalized fr asthma (ICD 493.xx) (2007 N=2188; 2008 N=2190). Females cnsistently have a higher rate f asthma hspitalizatins than males. 5 2007-2008 Iwa Asthma Hspitalizatins Asthma as Primary Diagnsis by Gender The highest rates f hspitalizatin fr asthma ccur in the very yung children and lder Iwans. 13
2007-2008 Iwa Asthma Hspitalizatins Asthma as Primary Diagnsis by Age Grup Emergency department visits (ED) fr asthma Iwa asthma-related ED visits shwed a much lwer rate than natinal and Midwest regin rates. See table belw. Natinal, Midwest, and Iwa Emergency Department Visits Age-adjusted rates per 10,000 2003 2004 Natinal 61.5 63.4 Midwest 47.2 73.8 Iwa 33.6 30.5 ED data als shwed that children under age 15 had the highest ED visit rates due t asthma, especially fr bys under age 5, while the elderly had the lwest rate. Overall, females had 1.3 times higher rate than that f males. Age grups shwed wide differences between gender ratis. Amng them, females aged 35-44, 45-54 and 55-64 had mre than tw times higher rates than that f males. 6 14
The largest difference was fund in Caucasians and African Americans. Overall, African Americans accunted fr 14% f the ttal ED visits due t asthma, but cmprise nly 2.8% f Iwa s ttal ppulatin (2008). The average annual ED visit rate fr African Americans (192 per 10,000) was 8 times higher than that fr Caucasians (24 per 10,000). ED visit rate fr African Americans increased frm 170 in 2003 t 211 per 10,000 in 2008 (crude rate), with an average annual increase f 5%; while Caucasians increased frm 23 t 26 per 10,000 (increased by 3.5% per year). 7 Iwa Asthma Emergency Department Visit Rates by Race, 2003-2008 The average annual rate f ED visits amng African American children (220.7 per 10,000) was 6.6 times higher than that fr Caucasian children (33.2 per 10,000). Fr adults, the rate fr African American ED visits (170.7 per 10,000) was 8.3 times higher than Caucasians (20.5 per 10,000). Out f the 17 Iwa cunties defined as metrplitan areas (ppulatin >50,000), 3 cunties had lwer rates than the state average: Stry Cunty 18.7 (Ames), Jhnsn and Washingtn 24.1 (Iwa City). These tw metrplitan areas are university cities. Des Mines Cunty had the highest ED visit rate due t asthma in 2008. Des Mines Cunty s age-adjusted asthma rate (93 per 10,000) was 2.5 times higher than that f state average (36.5 per 10,000). Fr mre infrmatin abut Iwa ED visits fr asthma, see Emergency Department Visits due t Asthma in Iwa, 2003-2008 in Appendix B. Iwa ranks as having ne f the lwest uninsured rates in the natin at 9%. This represents an imprvement ver the natinal average f 16%. 8 15
Health Care Data The Healthcare Effectiveness Data and Infrmatin Set (HEDIS) is a measurement tl used by mre than 90% f health plans in the US. HEDIS evaluates a health plan s perfrmance fr clinical quality and custmer service. There is ne HEDIS measure fr asthma the use f apprpriate medicatins fr asthma (cntrller medicatins fr individuals with persistent asthma). The fllwing chart shws the results fr the Wellmark Health Plans f Iwa 2009 asthma HEDIS measure (Nte: HEDIS results fr ther Iwa health plans was nt accessible via the web). 9 Use f Apprpriate Meds fr Asthma: 5-9 years 95.74% Use f Apprpriate Meds fr Asthma: 10-17 years 93.50% Use f Apprpriate Meds fr Asthma: 18-56 years 89.21% Use f Apprpriate Meds fr Asthma: 5-56 years 90.58% Tbacc use and asthma The Surgen General reprt, The Health Cnsequences f Invluntary Expsure t Tbacc Smke, cncludes the evidence is sufficient t infer a causal relatinship between parental smking and ever having asthma amng children f schl age. 10 Based n the Iwa Behaviral Risk Factr Surveillance Survey, tbacc use amng Iwans has steady declined since 1997, in 2007, 20.4% f Iwans currently used tbacc; higher than the 19.6% natinal average. 11 In 2007, Iwa increased their cigarette tax by $1.00. The 2008 Iwa Adult Tbacc Survey reprted the prevalence f cigarette smking amng adult Iwans t be 14%. This cntinues the trend f a decrease in cigarette smking prevalence frm 23% in 2002 t 20% in 2004 and then t 18% in 2006. 12 16
Current Tbacc Use, 1997-2007 *Smked 100 cigarettes/lifetime & current tbacc smking every day r sme days Starting in 2004, the Iwa Yuth Tbacc Survey included survey questins abut smking and asthma. T assess whether students wh smked had higher rates f asthma r reprted increased absence frm schl due t illness, students were asked whether they ever had asthma, currently had asthma, hw many asthma episdes r attacks they had, and hw many days f missed schl they had due t illness. While bth smking and having asthma are risk factrs fr having missed at least ne day f schl in the past mnth, middle and high schl yuth wh bth have asthma and smke were at especially high risk f missing multiple days f schl. Cmpared t students wh d nt smke, middle schl and high schl students wh smke are mre likely t have ever have had asthma, t have current asthma, t have had an asthma attack in the past year and t have missed multiple days f schl in the past mnth. The fllwing table and pints are highlights f the 2009 Iwa Yuth Tbacc Survey asthma-related data analysis. 13 2009 Middle and High Schl Yuth Wh Reprt Ever Had Asthma Grade Level Smkers Nn-Smkers Reprt ever had asthma Middle Schl 29% 15% High Schl 21% 17% 1. Asthma prevalence rates were 24% higher amng smking high schl students and 93% higher amng smking middle schl students cmpared t nn-smkers. 17
2. Amng high schl students with asthma, 55% reprted being absent at least ne day in the past 30 days, amng middle schl students, 43% reprted being absent at least ne f the past 30 days. Amng students withut asthma, 31% f middle schl and 42% f high schl students missed at least ne f the past 30 days. 3. While bth smking and having asthma are risk factrs fr having missed at least ne day f schl in the past mnth, middle and high schl yuth wh bth have asthma and smke were at especially high risk f missing multiple days f schl. 4. Abut 46% f middle students with asthma and 64% f high students with asthma wh smked missed ne r mre day f schl in the past 30 days. 5. Only abut 43% f middle schl and 52% f high schl yuth with asthma wh were nn-smkers missed any schl in the past mnth. 6. Abut 15% f middle schl and 17% high schl students reprt having ever been diagnsed with asthma. 7. Abut 8% f middle schl and 14% f high schl students reprt having had an asthma attack in the past 12 mnths. 18
REFERENCES 1. Iwa Department f Public Health. 2009. Healthy Iwans: Iwa Chrnic Disease Reprt. Des Mines, IA: Iwa Department f Public Health. 2. Iwa Department f Public Health. 2009. Iwa Behaviral Risk Factr Surveillance Survey 2009. Iwa Department f Public Health Center fr Health Statistics. 3. Iwa Department f Public Health. 2006. Yuth Risk Behaviral Surveillance Survey 2006. Iwa Department f Public Health Center fr Health Statistics. 4. Merchant, JA. Et al. 2005. Asthma and Farm Expsures in a Chrt f Rural Iwa Children. Envirnmental Health Perspectives. 113 (3). 350-356. 5. Hspitalizatin data prvided t the American Lung Assciatin in Iwa by the Iwa Hspital Assciatin. February 2010. 6. Iwa Department f Public Health. 2009. Emergency Department Visits Due t Asthma in Iwa, 2003-2008. Iwa Department f Public Health Center fr Health Statistics. 7. Ibid. 8. www.iwa-health-insurance.rg. Iwa Health Insurance. Accessed May 19, 2010. 9. http://www.wellmark.cm/healthandwellness/chsecare/ dcs/2009hedisresults.pdf. Wellmark Health Plan f Iwa 2009 HEDIS Results. Accessed May 25, 2010. 10. Department f Health and Human Services. The Health Cnsequences f Invluntary Expsure t Tbacc Smke: A Reprt f the Surgen General. U.S. Department f Health and Human Services, Centers fr Disease Cntrl and Preventin, Crdinating Center fr Health Prmtin, Natinal Center fr Chrnic Disease Preventin and Health Prmtin, Office n Smking and Health, 2006. 11. Iwa Department f Public Health. 2009. Healthy Iwans: Iwa Chrnic Disease Reprt. Des Mines, IA: Iwa Department f Public Health. 12. Iwa Department f Public Health: Divisin f Tbacc Use & Cntrl. 2009. 2008 Adult Tbacc Survey, Center fr Scial & Behavir Research, University f Nrthern Iwa. 13. Iwa Department f Public Health. 2009. Iwa Yuth Tbacc Survey 2009. Iwa Department f Public Health Center fr Health Statistics. 19
The Planning Prcess The Iwa Department f Public Health develped the first state asthma plan in 2003 and revised the plan in 2006. In January 2010, the Iwa Department f Public Health cntracted with the American Lung Assciatin in Iwa t facilitate and develp a new 2010-2015 Iwa Asthma Plan. The fllwing details the prcess the American Lung Assciatin in Iwa fllwed t cmplete the 2010-2015 Iwa Asthma Plan. 1. Identify and review all available asthma dcumentatin, including 2003 and 2006 Iwa State Plans, prgram evaluatin summaries, and surveillance reprts (January 2010). 2. Inventry past and current asthma prgrams in Iwa thrugh an electrnic survey (February 2010). 3. Gather and analyze additinal asthma-related mrtality, hspitalizatin, and emergency department data (February-April 2010). 4. Cnduct key infrmant interviews with parents f children with asthma and health care prfessinals (March 2010). 5. Hld Iwa Asthma Summit (March 23, 2010). a. Prir t the Iwa Asthma Summit, participants were asked t review electrnic versins f the agenda, 2006 Iwa Asthma Plan, and Emergency Department (ED) Visits Due t Asthma in Iwa, 2003-2008 reprt. b. During the Iwa Asthma Summit, participants self-selected int ne f eight cmmunity setting discussin grups, including: Advcacy Data and surveillance Envirnment Health care delivery and prfessinal educatin Individuals with asthma and their caregivers (parents and childcare prviders) Infrastructure Schls Wrksite/ccupatinal 20
c. Each grup was charged with creating recmmendatins fr their tpic/fcus/target area. A facilitatr dcumented recmmendatins that were develped by the tpic area grups and walked each thrugh a series f questins fr each. Questins included: What are the recmmendatins t imprve health utcmes fr Iwans with asthma thrugh this tpic? What is the ratinale/need fr this recmmendatin? What is the reach (in scpe r specific ppulatin) f this recmmendatin?. What are the majr barriers t this recmmendatin?. Hw culd this recmmendatin be sustained?. What will indicate success/what are the indicatrs? What is the timeframe required t implement this recmmendatin? Wh are the lead and supprting rganizatins fr this recmmendatin? d. After the tpic area grups cmpleted generating their recmmendatins and prviding supprting infrmatin, participants switched discussin grups and respnded t the draft recmmendatins, strengthening them with additinal perspectives. e. After all tpic area grups ccurred and additinal input was prvided, a brief summary f the recmmendatins was prvided t all Iwa Asthma Summit participants. f. Each recmmendatin was psted n flipchart sheets thrughut the perimeter f the rm. g. Iwa Asthma Summit participants then priritized recmmendatins by dt methd. Each participant was prvided with 10 dts, used t designate the tpic the participant deemed t be a pririty. The dts culd be allcated in any way, except n mre than 5 dts culd be used fr any ne specific recmmendatin. Participants were asked t cnsider the fllwing criteria as they assessed each tpic and priritized recmmendatins: Ability t have an impact Ability t reach thse at greatest risk r very large in scpe Affrdability and/r cst-effectiveness Ability t be linked t an nging effrt r likelihd f being sustained Evidence-based apprach Feasibility 21
Realistic Can be implemented statewide versus a small gegraphic area Plitically feasibility Ptential t change systems at the highest level (public plicy r rganizatinal plicy) Lead rganizatin identified h. Pririties were then ranked int three tiers. The tp third ranked recmmendatins mved frward int the final 2010-2014 Iwa Asthma Plan. The middle and lwest ranked recmmendatins were discussed further by the participants. Many f these recmmendatins were adjusted, imprved upn, and accepted by the participants and added t the plan. Fur recmmendatins were cmpletely eliminated, including indr air quality mnitring at the cunty level, ban pen air burning, statewide registry fr individuals with asthma, and distributing educatinal games t individuals with asthma. 6. Draft Iwa Asthma Plan (April 2010). 7. Seek review and cmment frm key stakehlders acrss Iwa (April and May 2010). 8. Finalize Iwa Asthma Plan (May 2010). 9. Revive the Iwa Asthma Calitin t supprt and implement the 2010-2014 Iwa Asthma Plan (May 2010). A number f ptential recmmendatins were generated during the March 23, 2010 Iwa Asthma Summit, but were nt elevated t a pririty level. Ratinale fr nt including them as a pririty recmmendatin may include lack f plitical feasibility, lack f demnstrated effectiveness, grundwrk nt established t be able t accmplish by 2014. The fllwing lists thse ptential recmmendatins that are nt included in the final Iwa Asthma Plan: 1. Identify and distribute varius games that children, parents, and childcare prviders can use t increase their knwledge abut asthma. 2. Develp a state electrnic registry f peple with asthma. 3. Pass a plicy restricting pen burning, such as garbage r backyard campfires. 4. Prmte ambient air mnitring. 5. Change plicy t mnitr indr air quality at the cunty r lcal level. 6. Develp a cmprehensive asthma management in the emergency department prgram, including a prtcl fr asthma educatin, patient fllw-up, and filling cntrller medicatins prir t discharge. 22
A Strategic Plan fr Addressing Asthma in Iwa, 2010-2015 As this statewide strategic plan mves frward, it is vital that an evaluatin and sustainability plan is develped and fllwed. Gal #1: An infrastructure exists t implement the Iwa Asthma Plan. Objective A: Integrate asthma management and cntrl strategies int the existing effrts f the Iwa Department f Public Health. 1. Ensure Iwa Health Care Refrm and the Preventin and Chrnic Care Management Advisry Cuncil is aware f and cnnected t the impact f asthma n Iwans. The purpse f the Preventin and Chrnic Care Management Advisry Cuncil is t advise and assist the Iwa Department f Public Health t develp a state initiative fr preventin and chrnic care management as utlined in Iwa Huse File 2539. 2. Ensure asthma, asthma triggers, and trigger reductin remain part f the Iwa Department f Public Health Healthy Hmes Initiative. 3. Maintain the Iwa Department f Public Health s Iwa Asthma Prgram website with up-t-date resurces and/r partner links. 4. Ensure Tbacc Cmmunity Partnerships, funded thrugh Iwa Department f Public Health, and ther tbacc preventin and cntrl effrts understand the relatinship between envirnmental tbacc smke and asthma and are prepared t educate the public abut envirnmental tbacc smke as an asthma trigger fr many individuals with asthma. 5. Cllabrate with Iwa Health Care Refrm and the Preventin and Chrnic Care Management Advisry Cuncil recmmend that health care prviders fllw the Natinal Heart, Lung, and Bld Institutes 2007 Asthma Guidelines when prviding care and educatin t individuals with asthma (als see Gal 4, Obj. A). Partners: Iwa Department f Public Health, Iwa Health Care Refrm, Preventin and Chrnic Care Management Advisry Cuncil, Iwa Department f Public Health Healthy Hmes Initiative Indicatrs: Recmmendatin develped by the Preventin and Chrnic Care Management Advisry Cuncil. Asthma educatin and trigger reductin is included in the Iwa Department f Public Health Healthy Hmes Initiative. 23
Objective B: Revive the Iwa Asthma Calitin t supprt and implement the 2010-2015 Iwa Asthma Plan. 1. Develp a partnership between American Lung Assciatin in Iwa, Iwa Department f Public Health, and University f Iwa Asthma Center t mbilize the Iwa Asthma Calitin. 2. Identify and recruit Iwa Asthma Calitin chair r c-chairs. 3. Develp a distributin list t prvide timely cmmunicatin, netwrking, and sharing amng members f the Iwa Asthma Calitin. 4. Hst quarterly, in-persn Iwa Asthma Calitin meetings and prvide a cnference call/webinar ptin fr Greater Iwa. Meetings shuld include an educatinal ffering, netwrking/sharing time, plicy updates, and Iwa Asthma Calitin business discussin. 5. Develp an annual summary f the Iwa Asthma Calitin s activities, gals, prgress tward gals, successes/challenges, and the scpe f asthma in Iwa that will be shared with plicymakers, rganizatins wrking t decrease the effects f asthma in Iwa, and ptential funding surces. 6. Invite the fllwing grups t jin the Iwa Asthma Calitin: physicians, physician assistants, all levels f nursing, respiratry therapists, pharmacists, health plans, industry, public health, schl nurses, schl administratrs, academic educatrs and researchers, ccupatinal health, parents, childcare prviders, secndary educatinal prgrams, wrksites, at-risk ppulatins, husing/envirnmental services, prfessinal assciatins, indr air quality, and representatin frm varius unins, including nurses and husekeeping/janitrial. Partners: Iwa Department f Public Health, American Lung Assciatin in Iwa, University f Iwa Asthma Center Indicatrs: C-chairs are identified fr the Iwa Asthma Calitin. Iwa Asthma Calitin quarterly meetings are held. Annual summary f Calitin activity is prepared and disseminated. 24
Gal #2: A statewide asthma surveillance system meets the needs f diverse stakehlders, is multi-methd, and increases data utility. Objective A: Frm an Iwa Asthma Calitin Data and Surveillance Wrkgrup t guide the statewide asthma surveillance system. Objective B: Mnitr trends in asthma mrtality amng Iwa residents utilizing Iwa death recrds fr which the underlying cause f death was asthma. Objective C: Mnitr trends in asthma prevalence amng Iwa residents. 1. Track asthma prevalence using the Behaviral Risk Factr Surveillance System (BRFSS) survey and Iwa Yuth Tbacc Survey 2. Analyze asthma prevalence in subppulatins, such as Medicaid enrllees, migrant farm wrkers, and immigrant grups, and by race/ethnicity. 3. Mnitr Iwa Yuth Tbacc Survey t ensure asthma questins cntinue t be included. Objective D: Mnitr trends in asthma-related health care utilizatin amng Iwa residents. 1. Analyze asthma-related hspitalizatin and emergency department data. 2. Gather HEDIS (Healthcare Effectiveness Data and Infrmatin Set) data. Objective E: Make available and peridically update the Wrk-related Asthma in Iwa 2006-8 Behaviral Risk Factr Surveillance System Adult Asthma Call-Back Survey. Objective F: Explre data surces t cnnect asthma t indr and utdr air pllutants. Objective G: Mnitr the impact f asthma n Iwans thrugh reprts shwing asthma-related hspitalizatin rates and prevalence amng the ppulatin. 1. Cllabrate with the Iwa Department f Public Health Bureau f Chrnic Disease Preventin n the develpment f asthma-specific reprts. 2. Identify the type f reprts t generate and a mechanism fr publishing and disseminating reprt findings. 25
Objective H: Use asthma surveillance data t infrm and respnd t plicymakers, lcal public health agencies, state agencies, and the general public. 1. Make data available thrugh surveillance reprts, fact sheets, Iwa Department f Public Health web site, Iwa Asthma Calitin web site, newsletters, and ther frmats. 2. Develp a Snapsht f Asthma in Iwa reprt every 3 years. 3. Utilize available data t better target asthma interventins t specific cmmunities, age grups, ppulatins, and thse at greatest risk. Partners: Iwa Department f Public Health, Iwa Asthma Calitin, American Lung Assciatin in Iwa, Wellmark BlueCrss BlueShield f Iwa, Principal Financial Grup, United Healthcare, and ther health plans that ensure Iwans Indicatrs: Iwa Asthma Calitin Data and Surveillance Wrkgrup is frmed. A Snapsht f Asthma in Iwa reprt, cntaining mrtality, prevalence, health care utilizatin, and practice pattern data, is develped every three years. Outreach materials were created, disseminated r made available t stakehlders and the public Supprting Evidence: Infrmatin reprted by the University f Iwa Cllege f Public Health indicates that n-farm expsure t swine prductin is assciated with asthma amng children living n these farms and that swine prductin cntinues t the higher prevalence f asthma utcmes in this livestck-intensive rural cmmunity. 1 It is imprtant t cntinue t gather surveillance data n children with asthma in rural Iwa and t identify cmmunities at greatest-risk. In additin, Chrischilles (2004) reprts that using a standardized questinnaire with a high respnse rate in this large, rural, ppulatin-based study, asthma prevalence rivaled that in large Midwestern cities. 2 26
Gal #3: Public plicy supprts asthma prgramming and individuals with asthma. Objective A: Request that the Iwa legislature apprpriate funding fr statewide asthma surveillance and prgramming. Objective B: Expand Iwa s existing self-carry inhaler law (Iwa Cde 280.16) fr students t allw students t carry their reliever medicatin during all schl-related activities n and ff site. 1. Advcate fr and educate individuals and grups n the need fr the revised legislatin. 2. Identify a legislatr champin t authr self-carry inhaler language. 3. Prvide educatin abut hw t effectively implement this bill in schl districts acrss Iwa. Partners: Iwa Bard f Health, Iwa Bard f Educatin, Iwa Schl Nurse Assciatin, Iwa Asthma Calitin Indicatrs: Funding is apprpriated t supprt asthma in Iwa. Iwa s self-carry inhaler law is expanded. 27
Gal #4: All health care prfessinals wh treat peple with asthma utilize the Natinal Asthma Educatin Preventin Prgram asthma guidelines and best practice methds. Objective A: Cllabrate with Iwa Health Care Refrm and Preventin and the Chrnic Care Management Advisry Cuncil t recmmend that all health care prviders fllw the Natinal Heart, Lung, and Bld Institutes 2007 Expert Review Panel 3 used fr all educatin abut asthma, including patients, parents/ caregivers, health care prfessinals, and the public (als see Gal 1, Obj. A). Objective B: Frm an Iwa Asthma Calitin Health Care Delivery Wrkgrup t lead the wrk f healthcare prfessinal educatin. Objective C: All Iwa secndary institutins that train health care prfessinals will incrprate the Natinal Asthma Educatin Preventin Prgram guidelines and best practice methds int their respiratry disease/asthma curriculum. 1. Develp an Iwa Asthma Calitin Health Care Delivery Wrkgrup t develp key cmpnents that shuld be included in asthma curriculum in secndary institutins. These key cmpnents shuld be cnsistent with NHLBI guidelines. 2. Assess current secndary educatin curricula arund asthma. 3. Curriculum is incrprated int health care prfessinal educatin training prgrams. Partners: Iwa Asthma Calitin, American Lung Assciatin in Iwa, Drake University Cllege f Pharmacy, Des Mines Area Cmmunity Cllege, Nrtheast Iwa Cmmunity Cllege, Hawkeye Cmmunity Cllege, Sutheastern Cmmunity Cllege, Kirkwd Cmmunity Cllege, St. Luke s Cllege, Des Mines University, University f Iwa Cllege f Medicine, University f Iwa Cllege f Pharmacy, Drake University Cllege f Pharmacy, and Iwa s 28 nursing schls Objective D: Increase health care prviders assessment f asthma cntrl, use f cntrller medicatins, and cmpletin f asthma actin plans. 1. Incrprate asthma cntinuing medical educatin curses int existing prfessinal venues. 2. Incrprate asthma cntinuing educatin curses thrugh existing health care prfessinal venues. 3. Incrprate asthma cntinuing pharmacy educatin curses thrugh existing pharmacist prfessinal venues. 28
Partners: Iwa Academy f Family Practice, Iwa Nurse Practitiner Cnference, Iwa Physician Assistant Cnference, Iwa Sciety f Respiratry Care Cnference, Iwa Pharmacists Assciatin, Iwa Nurse Cnference, Iwa Public Health Assciatin Cnference, Iwa Schl Nurse Organizatin Cnference, and ther lcal and statewide rganizatins. Objective E: Prvide cntinuing medical educatin training fr primary care prviders and clinic staff within the setting where they practice. 1. Make the American Lung Assciatin s Asthma 101: fr clinic staff training available t clinics. 2. Identify and make available ther apprpriate standardized trainings, such as PACE (Prvider Asthma Care Educatin) and the Asthma Educatr Institute. 3. Deliver trainings t primary care prviders statewide. Objective F: Ensure health care prfessinals have the tls and resurces t prvide asthma educatin t patients and their families. Partners: Iwa Asthma Calitin Indicatrs: Iwa Asthma Calitin Health Care Delivery Wrkgrup is develped. A recmmendatin is develped by the Iwa Health Care Refrm and Preventin and Chrnic Care Management Advisry Cuncil. An assessment f secndary institutins asthma curriculum is cnducted. Number f cntinuing medical educatin and cntinuing educatin prgrams ffered. Supprting Evidence: PACE (Prvider Asthma Care Educatin) is a furhur prven prgram develped by the University f Michigan Schls f Public Health and Medicine. PACE aims t imprve physician awareness, attitudes, ability and applicatin f cmmunicatin and therapeutic skills fr asthma care. The three bjectives f the PACE prgram are t: 1) increase knwledge in diagnsing asthma, 2) imprve skills in managing the cnditin, and 3) facilitate effective educatin and cmmunicatin with patients and their families. 3,4,5,6 The Asthma Educatr Institute is a natinally standardized curriculum f the American Lung Assciatin. 29
Gal #5: Iwans are aware f and understand envirnmental triggers and decrease expsure t asthma envirnmental triggers fr peple with asthma. Objective A: Expand upn the Iwa state law t include tbacc-free wrksite and cllege campuses, which wuld discurage use f all frms f tbacc. 1. Prmte initiatives that supprt tbacc-free envirnments, such as yuth recreatin facilities, cmmunity parks and ther grunds, and rental husing. 2. Increase availability and awareness f health, prperty, and car insurance incentives ffered t nn-smkers. 3. Prmte infrmatin that clearly states tbacc affects asthma. Objective B: Prevent and reduce expsure t indr envirnmental triggers. 1. Identify r develp materials abut indr envirnmental triggers. 2. Prvide educatin t individuals with asthma and their caregivers abut triggers (bth allergens and irritants). 3. Assess the living envirnments f individuals with asthma fr envirnmental triggers. 4. Prvide educatin arund lw-cst mdificatins that can be made t the living envirnments t reduce envirnmental triggers. 5. Build the capacity f prfessinals wh cnduct hme visits t understand asthma, assess the hme envirnment fr triggers, and prvide educatin/assistance n lw-cst mdificatins t reduce the triggers. 6. Wrk with Iwa-based health plans t prvide cverage fr envirnmental assessments fr individuals with asthma. Partners: American Lung Assciatin in Iwa; Iwa Department f Public Health Healthy Hmes Initiative; Linn Cunty s existing asthma prgramming, including Children s Hme Asthma Management Prgram (CHAMP); Visiting Nurse Service, Envirnmental Prtectin Agency Indicatrs: Existence f tbacc-free plicies. Inclusin f asthma educatin and trigger assessments in hme visiting prgrams. 30
Supprting Evidence: Airbrne allergens in the hme envirnment have been implicated in the rise f asthma prevalence and exacerbatin rates. These include bilgical surces (dust mite, cckrach, and ther pest infestatins; mld, mildew), mechanical surces (heating, ventilatin), cking practices, dmestic pets, and chemical air pllutants (tbacc smke, cmmn husehld cleaning agents, vlatile rganic cmpunds fund in rm fresheners). 7,8 Envirnmental factrs have lng been recgnized as cntributrs t bth pathgenesis and acute exacerbatins f asthma. The Natinal Heart, Lung, Bld Institute Expert Panel Reprt Guidelines fr the Diagnsis and Management f Asthma gives equal weight t clinical management and the cntrl f envirnmental factrs that lead t asthma exacerbatins. 9 Crdinated imprvements in the scial and physical envirnments, in cnjunctin with medical management, shuld benefit health mst effectively, particularly amng high-risk ppulatins. 10 The Natinal Center fr Healthy Husing and the Centers fr Disease Cntrl and Preventin (CDC) Task Frce n Cmmunity Preventive Services have recmmended multi-faceted, in-hme asthma interventins tailred t the individual. 11 Numerus studies supprt these recmmendatins. 12,13,14,15 31
Gal #6: Parents/guardians are able t manage their child s asthma. Objective A: Prvide a standardized curriculum and key messages fr parents/ guardians f children with asthma. 1. Train health care prfessinals, schl health nurses, asthma educatrs, and thers t implement the Yung and the Breathless, American Lung Assciatin s Asthma 101: What Yu Need t Knw curriculum, r ther standardized curriculum. 2. Ensure trained prgram facilitatrs have the curriculum and participant take-hme materials t deliver asthma educatin in the cmmunity. 3. Ensure asthma educatin materials are available in multiple languages and are culturally apprpriate. Partners: Iwa Asthma Calitin, American Lung Assciatin in Iwa, trained facilitatrs statewide, Prteus, Inc., Iwa/Nebraska Primary Care Assciatin, Latin Service Prvider Calitin, Urban Dreams Indicatrs: Number f trained facilitatrs Number f asthma educatinal prgrams prvided statewide Decrease in percentage/number f asthma-related hspitalizatins Supprting Evidence: The American Lung Assciatin s Asthma 101: What Yu Need t Knw curriculum is based n the Minneaplis/St. Paul s Cntrlling Asthma in American Cities Prject, a seven-year CDC funded pediatric asthma management prgram, Caring fr Kids with Asthma. This curriculum shwed a statistically significant (p > 0.05) increase in retained asthma knwledge frm baseline t eight weeks pst-training. Currently, 34% f Hispanics in Iwa speak English as their primary and nly language. 16 32
Gal #7: Schls have the capacity t identify, manage, and respnd t students with asthma and create an asthma-friendly envirnment. Objective A: Enhance schl health ffice staff capacity t manage students asthma. 1. Train schl persnnel, such as teachers, maintenance, and ther staff n basic training n asthma signs and symptms, when t use reliever medicatins, hw t recgnize respiratry distress, and what t d in an emergency using Asthma 101: What Yu Need t Knw r ther standardized curriculum. 2. Train physical educatin teachers and caches n basic training n asthma signs and symptms, when t use reliever medicatins, hw t recgnize respiratry distress, what t d in an emergency, and hw t help the perfrmance f their athletes with asthma using Asthma 101: What Yu Need t Knw, Caches Clipbard, r ther standardized curriculum. Objective B: Build awareness f and access t the Envirnmental Prtectin Agency s Tls fr Schls indr air quality prgram. Objective C: Expand Iwa s existing self-carry inhaler law fr students t allw students t carry their reliever medicatin during all schl-related activities n and ff site. (Als see Gal #3, Obj. B). Partners: Greater Des Mines Independent Schl District and ther large schl districts in Iwa, Iwa Department f Educatin, Iwa Schl Nurse Organizatin, Iwa Asthma Calitin, Childcare Resurce and Referral Agency Indicatrs: Iwa s self-carry inhaler law is expanded. Number f schls with an asthma-friendly schls initiative. Number f trainings fr licensed schl nurses, physical educatin teachers, caches, and ther schl persnnel. Supprting Evidence: A framewrk fr building the capacity f the schl health ffice t address students asthma is utlined by the Healthy Learners Asthma Initiative. 17,18,19 33
Gal #8: Childcare prviders and befre and after schl care prviders DELIVER quality care fr children with asthma. Objective A: Build the capacity f childcare prviders in managing childhd asthma. 1. Utilize the Yung and the Breathless, American Lung Assciatin s Asthma 101: What Yu Need t Knw curriculum, r ther standardized curriculum fr childcare prviders. 2. Prvide childcare prviders with a checklist t identify envirnmental triggers in their childcare facility. 3. Prvide educatinal tls n lw-cst slutins t remve asthma triggers in childcare envirnments. 4. Prvide childcare prviders with an asthma resurce packet which they can share with parents. Partners: Iwa Asthma Calitin, Childcare Resurce & Referral, Iwa Department f Public Health Childcare Nurse Cnsultants Indicatr: Number f childcare prviders trained in asthma management. Supprting Evidence: The American Lung Assciatin s Asthma 101: What Yu Need t Knw curriculum is based n the Minneaplis/St. Paul s Cntrlling Asthma in American Cities Prject s, a seven-year CDC funded pediatric asthma management prgram, Caring fr Kids with Asthma. The evaluatin findings frm Caring fr Kids with Asthma curriculum, delivered t 237 childcare prviders during 19 training sessins, indicated a statistically significant increase and retentin f asthma knwledge frm pre-training test t 8 week pst-training fllw-up test (p > 0.05). 34
Gal #9: Wrksites thrughut Iwa are free f expsures that increase symptms fr peple with asthma. Objective A: Increase awareness amng health care prfessinals, emplyers, and the general public f wrk-related asthma. 1. Identify an ccupatinal health representative t champin this effrt. 2. Frm an Iwa Asthma Calitin Wrksite Wrkgrup t address this issue. 3. Cntinue t cllect Behaviral Risk Factr Surveillance Survey data t identify the extent f the prblem. 4. Identify standards and best practices fr reducing aasthma expsures in the wrkplace. 5. Build awareness f wrk-related asthma amng health care prfessinals. 6. Build awareness f wrk-related asthma amng emplyers. 7. Build awareness f wrk-related asthma amng general public. Partners: Iwa Assciatin f Occupatinal Nurses, Iwa Asthma Calitin, Iwa Department f Wrkfrce Develpment Divisin f Labr Services, Iwa s 32 labr unins, Envirnmental Prtectin Agency, University f Iwa Occupatinal Medicine, Institute f Rural Envirnmental Medicine, Farm Bureau, Quaker Oats, Rckwell-Cllins, and ther larger emplyers Indicatrs: Iwa Asthma Calitin Wrksite Wrkgrup is frmed. Wrk-related Asthma standards and best practices are identified. Supprting Evidence: A survey f emplyees with asthma, cnducted by the Iwa Department f Public Health, indicated that 22% reprted their asthma was caused by r made wrse by a current jb and 12% f adults with asthma have discussed that there asthma was wrk-related with their primary care prvider. 20 35
REFERENCES 1. Merchant, JA. Et al. 2005. Asthma and Farm Expsures in a Chrt f Rural Iwa Children. Envirnmental Health Perspectives. 113 (3). 350-356. 2. Chrischilles, E. et al. 2004. Asthma Prevalence and Mrbidity amng Rural Iwa Schlchildren. Jurnal f Allergy and Clinical Immunlgy. 113 (3). 391. 3. Clark, NM, et al. 1998. Impact f Educatin fr Physicians r Patient Outcmes. Pediatrics. 101(5). 831-836. 4. Cabana, MD, et al. 1999. Why Dn t Physicians Fllw Clinical Practice Guidelines? A Framewrk fr Imprvement. Jurnal f the American Medical Assciatin. 282 (15). 1458-1465. 5. Clark, NM, et al. 2000. Lng-term Effects f Asthma Educatin fr Physicians n Patient Satisfactin and use f Health Services. Eurpean Jurnal. 16. 15-21. 6. Cabana, MD. 2000. Barriers Pediatricians Face When Using Asthma Practice Guidelines. Archives f Pediatric Adlescent Medicine. 154. 685-693. 7. Phipatanakul, W. 2006. Envirnmental factrs and childhd asthma. Pediatric Annals. 35(9). 646-656. 8. Matsui EC, Hansel NN, McCrmack MC, Rusher R, Breysse PN, Diette GB. 2008. Asthma in the inner city and the indr envirnment. Immunl Allergy Clinical Nrth America. 28(3). 665-686. 9. Natinal Heart, Lung and Bld Institute. Expert Panel Reprt 3 (EPR3): Guidelines fr the Diagnsis and Management f Asthma. 2007. 10. Levy JI, Brugge D, Peters JL, Clugherty JE, Saddler SS. 2006. A cmmunity-based participatry research study f multifaceted in-hme envirnment interventins fr pediatric asthmatics in public husing. Sc Sci Med. 63. 2191-2203. 11. Natinal Center fr Healthy Husing. Husing Interventins and Health: A Review f the Evidence. January 2009. Accessed April 30, 2009. Available at www.asthmareginalcuncil.rg/dcuments/husing_interventins_and_ Health_000.pdf 12. Arlian L, Neal J, Mrgan M, Vyszenski-Mher D, Rapp C, Alexander A. 2001. Reducing relative humidity is a practical way t cntrl dust mites and their allergens in hmes in temperate climates. J Allergy Clinical Immunlgy. 107(1). 99-104. 13. Egglestn PA, Butz A, Rand C, Curtin-Brsnan J, Kanchanaraksa S, Swartz L, et al. 2005. Hme envirnmental interventin in inner-city asthma: A randmized cntrlled clinical trial. Annals f Allergy Asthma Immunlgy. 95(6). 518-524. 14. Krieger JW, Takar TK, Sng L, Weaver M. 2005. The Seattle-King Cunty Healthy Hmes Prject: A randmized, cntrlled trial f a cmmunity health wrker interventin t decrease expsure t indr asthma triggers. American Jurnal f Public Health. 95(4). 652-659. 36
15. Parker EA, Israel BA, Rbins TG, Mentz G, Lin XH, Brakefield-Caldwell W, et al. 2008. Evaluatin fr cmmunity actin against asthma: A cmmunity health wrker interventin t imprve children s asthma-related health by reducing husehld envirnmental triggers fr asthma. Health Educatin & Behavir. 35(3). 376-395. 16. www.iwahealthdisparities.rg/dcuments/hispanics-fact2003.pdf. Hispanics in Iwa. Accessed 5-3-10. 17. Splett, PL, Ericksn, CE, Belseth, SB, and Jensen, C. 2006. Evaluatin and Sustainability f the Healthy Learners Asthma Initiative. Jurnal f Schl Health. 76(6). 276-282. 18. Ericksn, CE, Splett, PL, Mullett, SS, and Heiman, MB. 2006. The Healthy Learner Mdel fr Student Chrnic Cnditin Management. Jurnal f Schl Nursing. 22(6). 310-318. 19. Ericksn, CD, Splett, PL, Mullett, SS, Belseth, SS, and Jensen C. 2006. The Healthy Learner Mdel fr Student Chrnic Cnditin Management Part II: The Asthma Initiative. Jurnal f Schl Nursing. 22(6). 319-329. 20. Iwa Department f Public Health. Wrk-related Asthma in Iwa: 2006-2008 BRFSS Adult Asthma Call-Back Survey. 37
Asthma Planning Wrkgrup Members Suellen Carmdy-Menzer, BBA, RRT-NPS, AE-C Laura Delaney, PA-C, MPAS Bev Faber Jenkins, RN, BSN Anne Marie Gldhrn, CPS Randy Grres, RRT, RCP, MS Kathleen Gradville, MA, CPNP Jill Heins Nesvld, MS Sutheastern Cmmunity Cllege Des Mines University Cnsultant Pathways Behaviral Services Iwa Health Des Mines Blank Children s Hspital American Lung Assciatin f Upper Midwest Mary Kinsey, RRT, AE-C Jel Kline, MD, MSc Matt Lazear Kathy Leinenkugel, MPA, REHS, MLS Maggie Murphy, PharmD Jill Myers Geadelmann, BS, RN Ruby Perin Debra Pfab, RN, BA, CCRC Sandy Reed, RN, MA, MSN, CCRC Barb Reutter, RN, MPH Micki Sandquist Janelle Thier, CHES Mari Thulin Mindy Uhle, BA, HHS, MPH University f Iwa Asthma Center Merck and C., Inc. Iwa Department f Public Health AstraZeneca Pharmaceuticals Iwa Department f Public Health Linn Cunty Public Health University f Iwa University f Iwa Asthma Center GlaxSmithKline American Lung Assciatin in Iwa American Lung Assciatin in Iwa Parent Iwa Department f Public Health 38
Appendices A. 2006 Revised Iwa State Plan B. Emergency Department (ED) Visits Due t Asthma in Iwa, 2003-2008 C. Wrk-related Asthma in Iwa: 2006-2008 BRFSS Adult Asthma Call-back Survey 39
A. 2006 Revised Iwa State Plan Gals and Strategies Gal 1. The health care wrkfrce and ther helping prfessins are a practive and prgressive impetus in enhancing the verall health and well-being f peple wh have asthma. Strategy Measure Time Frame Required 1.1 Educate healthcare prviders abut effective early interventin measures t reduce the number f asthma related exacerbatins. 1.2 Prmte the use f current Natinal Institutes f Health guidelines fr the diagnsis and management f asthma. 1.3 Training fr health care prfessinals will include infrmatin n indr triggers and what can be dne t reduce the triggers. This shuld include hmes, schls, wrkplaces, and ther large buildings. 1.4 Increase the accuracy f diagnsing asthma in the pediatric and adult ppulatin by educating physicians abut methds and criteria fr diagnsis. 1.5 Prmte and supprt cultural fluency and cultural cmpetence amng health care prviders and students. 1.6 Address prfessinal barriers t access f treatment, i.e., infrmatin n medical prfessins, specializatin, treatment ptins, financial assistance and insurance issues. 1.7 Eliminate disparities in asthma diagnsis, management, and utcme amng uninsured and racial/ethnic ppulatin subgrups by prviding educatin and referral ptins t the traditinal prviders f these underserved subgrups Curriculum ffered in degree prgrams and CME/CEU prgrams. Number f health care prfessinals trained in Yung and the Breathless. Annual educatinal pprtunity t update trained health care prfessinals. Insurers t encurage physicians with high frequency f acute asthma care visits t attend educatinal prgram. Include infrmatin n guidelines in curriculum fr degree prgrams and CME/CEU/ther prgrams. IAC t develp educatinal plan t target pediatricians and family practice. Physicians invlvement t prmte t academy f physicians. Number f trainings that include infrmatin n indr triggers. Number f health care prfessinals trained. Educatin planning cmmittee f IAC includes physicians frm IAC, Blank s pediatric residency prgram, and UIHC. Educatinal prgram t be delivered t participants f residency prgrams. Wrk with cmmunity advcacy grups in prviding training t health care prfessinals, health care students, and ccupatinal nurses. IAC t create resurce directry including infrmatin n insurance prviders, Hawk-I, cmmunity clinics, etc. Wrk with cmmunity advcacy grups in educating traditinal prviders (i.e., cllege campus nurses, ccupatinal health nurses, schl nurses, child care prviders, etc.) Three years Three years Three years Three years Three years Tw years Three years 40
Gal 2. Peple wh have asthma and their families are empwered, knwledgeable, and capable f taking respnsibility fr their wn health utcmes. Strategy Measure Time Frame Required 2.1 Increase the number f frmal utpatient Number f prgrams ffered. Three years asthma educatin prgrams within the state. IAC t gather data n utpatient services bring prvided. Offer Yung and the Breathless n DVD, as web-based training, r thrugh ICN. 2.2 Educate and engage the media at state and lcal levels abut asthma and its effects n Iwans. 2.3 Patients and families have mre access t infrmatin n indr asthma triggers and what can be dne. 2.4 Patient educatin materials are available t any individual with asthma that meets cultural expectatins and literacy needs. 2.5 Families will be able t find and access adequate medical management fr their asthma. 2.6 Families will have access t evidence-based prgrams that will develp asthma selfmanagement cnfidence and skills. 2.7 Each individual with asthma will have a written asthma actin plan that supprts management f his/her disease. Evidence-based curriculum ffered. Educatinal materials targeted at media. IAC t create media packets fr members t distribute t media surces in their cmmunities. Media packets include infrmatin t use fr pen air spts. IAC Surveillance Cmmittee t include Iwa-specific stats in media packets. Surces f infrmatin available and prgrams ffered. Incrprate allergy skin testing infrmatin in literature t ensure that families are made aware f what the child/persn with asthma is allergic t. Family resurce packets distributed t families thrugh child care prvider and schl trainings. Wmen resurce packets distributed t wmen thrugh lcal Breast and Cervical Cancer prgrams. Patient educatin materials available. Cultural cmpetence is demnstrated in the materials. Family resurce packets available. Wmen resurce packets available. Managed maintenance and urgent care use. Prvide infrmatin t clinics and urgent care. Train the trainer, Yung and the Breathless, ffered in cmmunities. Family resurce packets distributed thrugh trainings. Plans in place. Discuss with physicians n IAC. Prmted thrugh all trainings. Three years Tw years Tw years Three years Tw years Tw years 41
Gal 3. Cmmunity and interested rganizatins will fcus n prviding resurces and educatin abut asthma and its triggers. Strategy Measure Time Frame Required 3.1 Implement apprpriate effrts in a cllabrative apprach f public, private, and nnprfit entities. 3.2 Develp and cnduct nging educatin sessins fr schl administratrs and staff relating t asthma management. 3.3 Prfessinal and cmmunity rganizatins will ffer culturally apprpriate prgrams t help individuals and families develp asthma selfmanagement skills. 3.4 Raise cmmunity awareness f envirnmental expsure t particulate matter and txins emitted frm leaf, slid waste, and ther frms f pen burning. 3.5 Cmmunity rganizatins are prvided with infrmatin n indr asthma triggers and what can be dne. 3.6 Ensure cmmunity educatin and resurces include an emphasis n the impacts f secndhand smke and hw t eliminate this as a trigger. Cllabrative prjects. One year and nging Number f trainings prvided statewide. Encurage schls t adpt and implement effrts cnsistent with the CDC guide, Strategies fr Addressing Asthma within a Crdinated Schl Health Prgram. Prvide infrmatin t schlbased rganizatins thrugh newsletters, mailings, etc. Number f educatinal initiatives. Wrk with cmmunity advcacy grup t distribute culturally apprpriate materials and educatinal pprtunities in areas with diverse ppulatins. Advcacy with lcal Iwa cmmunities t assist in setting plicy. Distributin f educatinal literature t cmmunity leaders and health prfessinals. Educate media thrugh press releases in Lung Health Mnth in Octber and Asthma Awareness Mnth and Clean Air Mnth in May. Number f wrkshps/ presentatins. Number f peple participating. Infrmatin prvided at exhibits, health fairs, cnferences and trainings. Materials prvided t educate n impact f secndhand smke. Tw years Tw years Tw years Tw years Tw years 42
Gal 4. Decisins and actins regarding asthma are based n needs and pririties that are measured and dcumented with sund methds. * Strategy Measure Time Frame Required 4.1 Establish an nging surveillance system fr Iwa that will prvide high quality and timely infrmatin t plicy makers, practitiners, and the public, including peple with asthma. 4.2 Rutinely update the Iwa strategic plan fr asthma. Taking int accunt the limitatin f funding surces and evidence fr effectiveness, the strategic plan will define reasnable pririties fr actin. Pririties will be based n brad public input and examinatin f: Iwa asthma surveillance system data Peer-reviewed literature State, lcal, and natinal level pririties, prgrams, and plans 4.3 Using Iwa asthma surveillance system data, pririties fr asthma cntrl fund in the state plan, and ther findings abut prgram effectiveness and cst-reasnableness, systematically plan, implement, and evaluate asthma cntrl interventins. 4.4 Using Iwa asthma surveillance system and ther surces, develp ptential hyptheses fr asthma research. The system will rutinely lk at: Health utcmes and the burden f asthma (e.g. frequency, severity, ethnic and ther sci-demgraphic variability, csts ver time). Cmmn risk factrs which are clsely linked t asthma utcme (e.g. persnal, health care, schl and physical envirnment, scial systems, envirnmental). Data analyzed and published frm surces listed belw (See Appendix fr mre detail n relevant databases): Wrk-related asthma Adult ppulatin: urban/rural, lw incme, uninsured, smking, etc. Children age 0 4 yrs. Schl-age children Medical services Deaths Envirnmental data Reprtable diseases Published literature reviewed fr effective interventins and plicies: Childhd YBRFSS Tbacc BRFSS Call-back Iwa Child and Family Husehld Health Lcal, state, and natinal prgrams and plicies rutinely reviewed. Prgrams, plicies, services implemented. Evaluatins f interventins cmpleted. Three years Tw years One year and nging Hyptheses generated, tested. Three t five years * See nte in Appendix: Surveillance 43
Gal 5. Public plicy at all levels supprts a healthy citizenry and a reductin in the incidence and severity f asthma in Iwa. Strategy Measure Time Frame Required 5.1 Eliminate bias and discriminatin that may be assciated with the diagnsis f asthma. 5.2 Increase the number f cmmunities that ban pen-air burning, a knwn trigger f asthma. 5.3 Increase actins taken by lcal, reginal, r state public plicy makers (e.g., city cuncils, schl bards, bards f supervisrs, state legislature) t address indr air issues in the schls, wrkplaces, and public places. 5.4 Increase the number f cmmunities adpting smke-free rdinances. 5.5 Children with asthma shall nt be restricted frm pssessing and using prescribed asthma medicatins in schl r day care r during schl-related activities, prvided basic dcumentatin and safeguards are met. The percentage f asthma diagnses per pediatric patient ppulatin. Cllabrate with IDNR t distribute infrmatinal packets n pen-air burning. Make available t 20 t 25 f the heaviest ppulated Iwa cmmunities cntinuing t pen-air burn. Prvide supprt t lcal cmmunities in implementing pen-air burn bans. Recmmendatins made r requirements in place. Number f public plicy entities addressing schl, wrkplaces, and public places indr air issues. Schls and wrkplaces t implement smke free envirnments. Number f smke free rdinances in frce. Cntinue t educate schls n inhaler legislatin. Legislatin allwing schlaged children t carry and selfadminister inhalers at befre and after-schl child care. Three years Three years Three years Three years One year and nging 44
B. Emergency Department (ED) Visits due t Asthma in Iwa, 2003-2008 Outpatient/ED Visits Data Outpatient/Emergency Department Visits (ED) database cntains infrmatin n patient characteristics, the nature f the ED visits and gegraphic regin. The database prvides infrmatin n treat and release ED visits, as well as ED visits in which the patient was admitted t hspital fr further care. Each year, abut 13% f asthma related ED visits in Iwa were admitted t hspital. All asthma related ED visits were included in this reprt. Since 2003 Iwa Hspital Assciatin (IHA) started a new database fr utpatients, the number befre 2003 is nt cmparable t the years after 2003. In this asthma related ED visits reprt, we used primary diagnsis t identify ED visits due t asthma (ICD 9 CM cde 493). Patients wh were treated in emergency rm were included. Only Iwa residents treated within the state were included in rder t calculate state ageadjusted rate, which enables cmparisn t ther states rates with different age distributins in its ppulatin. All f the age adjusted rates are per 10,000 Iwa ppulatin and are age adjusted t the 2000 US standard ppulatin using the direct methd applied t 11 age grups. ED Visits due t Asthma On average, abut 9,800 ED visits due t asthma incurred during 2003 2008, r 34 ED visits per 10,000 residents (age adjusted rate). Like inpatient asthma data, Iwan ED visits due t asthma were much lwer than the natinal average (62 per 10,000) and Midwest regin (60 per 10,000) 1. But, unlike inpatient data, the age adjusted ED visit rate due t asthma was up frm 33.6 in 2003 t 36.5 per 10,000 in 2008, with an average increase f 2% during the six years. Fig. 1 Age adjusted Rates f ED Visits due t Asthma in Iwa, 2003 2008 1 Surce: Natinal Surveillance fr Asthma US, 1980 2004, MMWR, Oct. 19, 2007. The natinal and Midwest regin average included in this reprt was the average f 2003 2004. 45
By Age and Gender Als like inpatients, the ttal female ED visits rate (38 per 10,000) was higher than the male s (30 per 10,000, see the table belw), but varied widely by age grups. Females aged 35 44, 45 54 and 55 64 had mre than tw times higher rates than the males. In teens (15 24), yung adults (25 34) and elderly grup (65 74), the female/male rati was 1.6, 1.8 and 1.8, respectively. By cntrast, children had an ppsite gender rati: males yunger than 15 had the highest rates (70.3 per 10,000), nearly duble that fr females under age 15 (39.7 per 10,000). Male children at age 1 4 and 5 14 had 1.9 and 1.6 times higher rate than the female children, respectively. Overall, children under 15 had the highest ED visit rates (55.4 per 10,000). Amng them, newbrn babies <1 year had the highest rate (128 per 10,000), fllwed by 1 4 (63 per 10,000) and 5 14 (45 per 10,000). ED rates due t asthma decreased quickly as peple aged. Fig. 2 Average Annual Age Specific ED Visit Rate due t Asthma, 2003 2008 Male Rate Female Rate Ttal M/F rati F/M rati <1 yr 175.1 79.4 128.5 2.2 0.5 1-4 81.7 43.5 63.0 1.9 0.5 5-14 55.2 34.2 45.0 1.6 0.6 Subttal <15 70.3 39.7 55.4 1.8 0.6 15-24 30.9 50.7 40.5 0.6 1.6 25-34 29.9 55.4 42.4 0.5 1.9 35-44 19.8 45.7 32.6 0.4 2.3 45-54 12.7 29.4 21.0 0.4 2.3 55-64 9.3 18.7 14.1 0.5 2.0 65-74 8.1 14.5 11.6 0.6 1.8 75-84 11.0 13.1 12.2 0.8 1.2 85+ 10.6 12.9 12.2 0.8 1.2 Ttal 2 30.2 37.8 34.0 0.8 1.3 2 Age adjusted rate 46
By Race Like inpatient data, abut 17% f ED visit data n race is missing. Amng the remaining, 68% were Caucasian (annual number 6,600), 14% were African American (1,400). Native American and Asian/Pacific Islander were 0.4% and 0.5%, respectively. The average annual ED visits rate fr African Americans (crude rate 192 per 10,000) was 8 times higher than that fr Caucasians (24 per 10,000). The rate fr African Americans increased by 5% annually (average) vs. Caucasians by 3.5%. African American adults (>17 years) had an average annual increase rate at 7.4% vs. Caucasian adults at 4.5% (nt shwn in the chart). The average annual changes fr children (0 17) fr bth races were lwer: Caucasian children increased by 2% and African American children by 1%. Fig. 3 ED Visit Rates (Crude Rate) due t Asthma by Race, 2003 2008 The average annual rate f ED amng African American children (220.7 per 10,000) was 6.6 times higher than that fr Caucasian children (33.2). Fr adult grup, rate fr African American ED visits (170.7 per 10,000) was 8.3 times higher than Caucasians (20.5). Fig. 4 Average Annual ED Visit Rate (Crude Rate) due t Asthma, by Race and Age, 2003 2008 47
By Cunty Every year many Iwa residents seek medical treatments in ther states, especially, fr the residents n the brdering cunties. Their medical recrds are nt included in Iwa state hspital data. Therefre, we excluded these brdering cunties in this sectin. The ED visit rates due t asthma by cunty were nt evenly distributed acrss the state. In 2008, the verall state ED rate due t asthma was 35 per 10,000 residents (crude rate). The average rate f the cunties with ppulatin mre than 20,000 was higher than the statewide, while the average rate f cunties with ppulatin less than 20,000 was lwer than the state average. Amng the cunties with cmplete data, Des Mines Cunty had the highest rate (85 per 10,000), fllwed by Sctt (61), Wapell (60), and Lee 3 (57). Five f the tp cunties are all lcated at the suth side f the state. Fig. 5 ED Visit Rates (Crude Rate) due t Asthma by Cunty, 2008 Lyn Siux Oscela O'Brien Dickinsn Clay Emmet Pal Alt 35.3 Kssuth Winnebag Hancck 44.0 Wrth Cerr Grd 47.5 Mitchell Flyd 28.4 Hward Chickasaw 27.2 Winneshiek Allamakee Plymuth 10.7 Cherkee 13.0 Buena Vista 28.4 Pcahntas 27.8 Humbldt 36.8 Wright 29.5 Franklin 21.0 Butler 23.2 Bremer 37.8 Fayette 34.5 Claytn Rate per 10,000 10.7-13.0 13.1-26.0 26.1-34.6 34.7-49.5 49.6-85.2 Wdbury 35.3 Mnna Harrisn Mills Crawfrd Pttawattamie Fremnt Ida 32.1 Shelby Page Sac 22.3 Mntgmery Audubn Cass Carrll 11.9 Calhun 35.4 Adams Taylr Guthrie 37.6 Greene 49.5 Adair 29.3 Webster 46.7 Unin 46.5 Ringgld 19.4 Dallas 37.6 Bne 39.1 Madisn 37.6 Hamiltn 37.1 Clarke 50.9 Decatur 23.8 Plk 37.6 Stry 18.7 Warren 37.6 Hardin 38.0 Lucas 40.9 Wayne 51.2 Marshall 31.9 Jasper 32.8 Marin 25.5 Grundy 37.8 Mnre 27.7 Appanse 45.9 Tama 30.0 Pweshiek 22.6 Mahaska 36.3 Black Hawk 37.8 Wapell 60.0 Davis 19.8 Kekuk 29.0 Bentn 36.2 Iwa 23.3 Buchanan 30.9 Jeffersn 38.8 Van Buren 39.1 Linn 36.2 Jhnsn 24.1 Washingtn 24.1 Henry 34.6 Delaware 26.0 Lee 57.0 Jnes 36.2 Luisa 22.2 Cedar 12.2 Dubuque 37.4 Muscatine 25.6 Des Mines 85.2 Jacksn 23.0 Clintn 47.2 Sctt 61.1 3 State inpatient asthma reprt shwed that Des Mines and Lee cunties were all in the tp 25% f the distributin f cunty rates (2000 2004). 48
Discussin This reprt is the first state ED visits summary n the burden f asthma. As with inpatient reprt, this reprt includes cunts and ppulatin based rates fr asthmas related ED visits. The data in this reprt indicate that asthma related ED visits increased in bth cunts and rate since year 2006, and the average annual increase rate was 2% during the six years (2003 2008). There has been a small increase in ED visits while hspitalizatins have decreased. The reasn fr the increase in ED visits is nt clear. Outpatient/ED visits data culd nt prvide real cunts and rates f individual asthma related ED visits, fr there is a pssibility that the same patient may be treated multiple times fr the same asthma event. Hwever, the stable asthma prevalence rate in Iwa, as dcumented by Behaviral Risk Factr Surveillance Survey (BRFSS) data, may be attributed t increased educatin and preventive care effrts. Like inpatient asthma data, Iwa asthma related ED visits shwed a much lwer rate than the natinal and Midwest regin rates. The natinal average age adjusted rate fr ED visit due t asthma was 61.5 and 63.4 per 10,000 in 2003 and 2004, respectively (the latest data available); the rates were fr the Midwest was 47.2 and 73.8 per 10,000. In Iwa, the rate was 33.6 and 30.5 per 10,000 in 2003 and 2004. ED data als shwed that children under age 15 had the highest ED visit rates due t asthma, especially fr bys under age 5, while the elderly had the lwest rate. Overall, females had 1.3 times higher rate than that f male. Age grups shwed wide differences between gender ratis. Amng them, female aged 35 44, 45 54 and 55 64 had mre than tw times higher rates than that f males. The mst striking difference was fund, like inpatient data, in races f Caucasians and African Americans. Overall, African Americans accunted fr 14% f the ttal ED visits due t asthma, but cmprise nly 2.8% f Iwa s ttal ppulatin (2008). The average annual ED visits rate fr African Americans (192 per 10,000) was 8 times higher than that fr Caucasians (24 per 10,000). ED visit rate fr African Americans increased frm 170 in 2003 t 211 per 10,000 in 2008 (crude rate), with an average annual increase 5%; while Caucasians increased frm 23 t 26 per 10,000 (increased by 3.5% per year). Out f the 17 cunties defined as metrplitan areas (ppulatin >50,000), 3 cunties had lwer rates than the state average: Stry cunty 18.7 (Ames), Jhnsn and Washingtn 24.1 (Iwa City). These tw metrplitan areas are all university cities. Since Des Mines Cunty had the highest ED visit rate due t asthma in 2008, we cmpared its age specific rates t that f statewide. All f its age specific rates were higher than that f state s crrespnding age grups. Its age adjusted rate (93 per 10,000) was 2.5 times higher than that f state average (36.5 in 2008). In the future, we culd lk int ther risk factrs fr asthma, like race/ethnicity. 49
C. Wrk-related Asthma in Iwa: 2006-2008 BRFSS Adult Asthma Call-back Survey Based n respnses received frm Iwans frm 2006-2008, apprximately 233,000 adults aged 18 and lder reprted having asthma at sme time in their life, with 162,000 reprting they currently had asthma: 22% reprted their asthma was caused by r made wrse by a current jb while 29% reprted their asthma was caused by r made wrse by a prir jb; 23% f adults reprted their asthma was caused by wrk, while 47% reprted their asthma that was made wrse by wrk; 8 % reprted they were tld by a healthcare prvider (HCP) that their asthma was wrk-related while 9.4% said they tld a HCP their asthma was wrk-related (self assessment); verall, 12% had talked t a healthcare prvider abut their asthma being wrk-related. 52% f the survey respndents (three year average) answered Yes t ne r mre f the seven wrk-related asthma questins included in the call-back survey. During 2006-2008, a ttal f 894 adults (aged 18 and lder) with asthma in Iwa respnded t the BRFSS Call-back survey, an average f 300 per year. Because f the expected small sample size, a cmplex survey design was used t get unbiased (r nearly unbiased) estimates fr the asthma ppulatin. All percentages were weighted based n the prbability that an individual wuld be selected t participate in the survey by age, gender and race. Of the apprximately 233,000 adults wh had ever had asthma in Iwa, an annual average f 162,000 reprted currently having asthma. Fr the first time, the call-back survey prvided detailed infrmatin n their recent asthma histry and symptms. Fr adults wh currently had asthma, the survey fund that thse with WRA rutinely reprted mre prblems than thse whse asthma was nn-wrk related. 1 Behaviral Risk Factr Surveillance System 2 In 2006, Iwa participated CDC's newly designed annual Asthma Call-back Survey administered as part f BRFSS. Adults (aged 18 and lder) wh are identified in the BRFSS as having lifetime asthma are invited t participate in a detailed asthma survey. The questins included asthma symptms, medicatins, activity limitatin, envirnmental expsures and wrk-related asthma. Wrk related status f asthma was measured by self-reprt whether asthma was wrk related. 50