Asthma burden in the United States: results of the 2009 Asthma Insight and Management survey

Updated guidelines and new treatments for asthma have become available since the last major survey of asthma management in the United States was completed ～11 years ago. The Asthma Insight and Management (AIM) survey was conducted to assess the current status of asthma burden in the United States. A geographically stratified screening of 60,682 households provided a national sample of 2500 patients with current asthma (2186 adults aged ≥18 years; 314 adolescents aged 12-17 years). A national sample of 1004 adults without current asthma was interviewed for comparison with the adult asthma population, and 309 asthma health care providers were surveyed for their opinions about the burden of asthma. Asthma prevalence in the United States was estimated at 8%. Twice as many adult asthma patients rated their health as "only fair," "poor," or "very poor," or experienced limitations in activity because of health problems, compared with the general population. Asthma also frequently caused negative emotional symptoms in patients. Most patients experienced asthma throughout the year (63%) and symptoms within the 4 weeks before the summer survey (68%). Overall, 41% of patients responded that asthma interfered with their/their child's life "some" or "a lot". During the year before the survey, 69% of patients experienced at least one severe asthma episode. Asthma burden in the United States remains high despite the availability of updated treatment guidelines and new therapies. Asthma care in the United States remains suboptimal, indicating the need for continued improvements in patient management.     

Patient and physician asthma deterioration terminology: results from the 2009 Asthma Insight and Management survey

Long-term achievement of asthma control is dependent in part on the use of mutually understandable asthma terminology in all verbal and written patient-physician communications. Using data from the Asthma Insight and Management (AIM) survey, the objective of this analysis is to provide a contemporary depiction of asthma deterioration terminology as used by current asthma patients and physicians in the United States. As part of the 2009 AIM survey, current asthma patients (≥12 years of age; weighted n = 2499) and physicians (n = 309) were queried about their recognition, understanding, and/or use of the terms "asthma attack," "asthma flare-up," and "asthma exacerbation" in telephone interviews. Nearly all patients had heard the term "asthma attack" (97%), but relatively few had heard the term "asthma exacerbation" (24%); 71% had heard "asthma flare-up." In contrast, physicians reported using the term "asthma attack" least (65%) and the term "asthma exacerbation" most (77%) when discussing asthma with their patients; 70% reported using "asthma flare-up." Among patients familiar with "asthma flare-up" and "asthma exacerbation" (n = 502), only 38% said that the terms mean the same thing; nearly all physicians (94%) said that the terms mean the same thing. Collectively, data from the AIM survey suggest that patients and physicians use different asthma deterioration terminology and, more importantly, that they do not necessarily understand each other's terms. Standardizing asthma deterioration terminology may help optimize asthma patient-physician communication to improve patient understanding of written asthma action plans and therefore, enhance patient outcomes.     

Endoscopic sedation in the United States: results from a nationwide survey

OBJECTIVES: The introduction of new sedative agents as well as a desire for improved patient satisfaction and greater efficiency has changed the practice of endoscopic sedation. This survey was designed to provide national and regional data on endoscopic sedation and monitoring practices within the United States. METHODS: A 22-item survey regarding current practices of endoscopy and sedation was mailed to 5,000 American College of Gastroenterology physician members nationwide. RESULTS: A total of 1,353 questionnaires (27.1%) were returned. Respondents performed an average of 12.3 esophagogastroduodenoscopies (EGDs) and 22.3 colonoscopies per wk. Endoscopic procedures were performed within a hospital setting (55.2) more often than at an ambulatory center (35.8%) or private office (8.8%). The vast majority of EGDs and colonoscopies (>98%) were performed with endoscopic sedation. Almost three quarters (74.3%) of the respondents used a narcotic and benzodiazepine for sedation, while propofol was preferred by 25.7%. Sedation practices varied considerably within different geographic regions of the United States. Respondents routinely monitored vital signs and pulse oximetry (99.2% and 98.6%, respectively), and supplemental oxygen was administered to all patients during EGD by 72.7% of endoscopists. Endoscopist satisfaction with sedation was greater among those using propofol than conventional sedation (10 vs 8, p < 0.0001). CONCLUSIONS: During the past 15 yr, the volume of procedures performed by endoscopists in the United States has increased two- to fourfold. Propofol is currently being used for sedation in approximately one quarter of all endoscopies in the United States. The findings from this survey may help in the formulation of updated policies and practice guidelines pertaining to endoscopic sedation.     

Racial and Ethnic Differences in the Management of Childhood Asthma in the United States

Objectives. We examined racial and ethnic differences in the management of childhood asthma in the United States and the extent that care conformed to clinical best practices. Methods. Two years of pooled data from the National Health Interview Survey were analyzed using logistic regression. The sample included all children between ages 2 and 17 years who had asthma currently and had been diagnosed with asthma by a doctor or health professional (n = 1757; 465 African-American, 212 Mexican-American, 190 Puerto Rican and other Hispanic, 806 white, non-Hispanic, and 84 children of other and multiple races and ethnicities). Results. African-American children with asthma were significantly less likely than white, non-Hispanic children to have taken preventive asthma medication, but more likely to have had an asthma management plan. Mexican-American and Puerto Rican and other Hispanic children did not differ significantly from white, non-Hispanic children in either receiving preventive asthma medication or having an asthma management plan. Caregivers of African-American and Puerto Rican and other Hispanic children were more likely to report that they or their child had taken a course or class on how to manage their child’s asthma. We did not find racial or ethnic differences in the extent children used quick-relief asthma medication or received advice about reducing asthma triggers in their home, school, or work environments. Conclusions. This work highlights a need for more research on racial and ethnic differences in asthma management. Implications for public health responses and racial and ethnic disparities in asthma morbidity are discussed.     

Asthma in Hispanics in the United States

The Hispanic population in the United States is diverse in many respects. Although there is marked variation in the prevalence, morbidity, and mortality of asthma among Hispanic subgroups in the United States, these differences are poorly understood. Future stu-dies of asthma should include large samples of Hispanic subgroups that are well characterized in terms of self-reported ethnicity, country of origin, place of birth, area of residence, and indicators of socioeconomic status. Because a significant proportion of Hispanics live in poverty, public health interventions aimed at improving access to health care and housing conditions would have a major impact on reducing asthma morbidity among Hispanics in the United States.     

Asthma control,cost and race: results from a national survey

Abstract

Objective: Although interventions have been shown to alleviate symptoms in most patients suffering from asthma, only one-third of asthma patients have disease that is well-controlled. The purpose of this study is to investigate whether partly and uncontrolled asthmas are associated with increased costs for asthma-related healthcare utilization compared to well-controlled asthma and to determine whether these associations differed across racial groups. Methods: We classified respondents from the Asthma Insights and Management survey into those with well-, partly and uncontrolled asthma and compared utilization of healthcare services and costs among these groups, as well as between whites and non-whites. Results: Respondents categorized as having asthma that was not well-controlled reported lower income levels, higher rates of unemployment and more trouble paying for healthcare; similar results were found in analyses stratified by race. Patients whose asthma was partly or uncontrolled had greater use of asthma-related medications and medical services compared to patients whose asthma was well-controlled. Total unadjusted and adjusted costs were greater in patients whose asthma was classified as partly and uncontrolled. Similar results were found in analyses stratified on race. Across all levels of asthma control, non-whites had higher rates of utilization of emergency rooms and urgent care facilities and had greater rates of hospitalizations compared to whites. Conclusions: Our findings indicate that patients with asthma that is not well-controlled utilized more healthcare resources and had greater medical costs, despite lacking of health insurance which may suggest less access to care.     

Asthma management and inhalation techniques among community pharmacists in 2009: a comparison with the 1999 survey

Objective: In a 1999 survey, community pharmacists from the Alsace region of France had a reasonably good knowledge of asthma treatment and prevention, but their skill in the use of asthma inhalation devices left room for improvement. Since then, health authorities have encouraged the involvement of community pharmacists in patient care and education in order to improve asthma control. The aim of this study was to assess the change in the knowledge of asthma management and inhaler technique skills of community pharmacists in the same geographic area after a 10-year interval. Methods: In 2009, 86 randomly selected community pharmacists from the Alsace region answered a standardized questionnaire about their theoretical knowledge of and practical attitude toward asthma management and inhaled delivery systems, following which their skills in the use of four inhalation devices (pressurized metered-dose inhaler (pMDI) with/without a spacer, breath-actuated pMDI and dry powder inhaler (DPI)) were evaluated. Results: Very few pharmacists were required to manage an acute asthma exacerbation at the pharmacy, but all responded well by administering a short-acting inhaled β2-agonist. Theoretical knowledge of asthma management (criteria of severity of asthma exacerbation, guidelines and drugs triggering asthma exacerbations) was still average. Compared with 1999, they were twice as confident in demonstrating inhaler use, and their skills in using the pMDI, breath-actuated pMDI and DPI had improved significantly (p?Conclusions: Since 1999, pharmacists’ skill in the use of inhalers has improved, but theoretical knowledge of asthma management is still average, pointing to the importance of continuing pharmaceutical education.     

Household Smoking and Childhood Asthma in the United States: A State-Level Analysis

Background. The reason for the substantial geographic variation in the prevalence of childhood asthma is not known. Objective. To investigate the association between exposure to cigarette smoking in the home and childhood asthma at the state-level, toward improving current understanding of geographic variation in childhood asthma rates. Methods. Data were drawn from the National Children's Health Survey (NCHS, 2003), a representative sample (n = 102, 000) of youth 0 to 17 years of age in the United States. Household smoking and asthma in children were reported by parents. Air quality for each state was obtained from Environmental Protection Act (EPA) reports, and state-level poverty reports were obtained from the US Department of Agriculture. Results. Household smoking was associated with a statistically significant increase in risk of asthma among children at the state level (p = 0.026). This association did not appear to be influenced by outdoor air quality at the state level or socioeconomic position. Conclusions. These results are the first to show a link between cigarette smoking in the home and childhood asthma at a state-level in the United States.     

Recent Trends in Asthma Hospitalization and Mortality in the United States

Objective. To study the recent trends in asthma hospitalization and mortality rates by age, gender, and race categories in the United States. Methods. The National Hospital Discharge Survey Database for the years 1995 to 2002 was used to examine trends in asthma hospitalization. An International Classification of Diseases Ninth Revision, Clinical Modification (ICD-9-CM) code of 493.0 was used to identify primary hospitalization for asthma. Hospitalization rates were estimated using U.S. Census Bureau population estimates as denominators. Mortality data was obtained from the Center for Disease Control and Prevention Mortality Database. Death from asthma was identified using ICD-9-CM codes (493.0) for the years between 1995 and 1998 and ICD-10 codes (J45–J45.9) for 1999 and afterwards. Asthma hospitalization and mortality rates were estimated per 10,000 and per 100,000 populations, respectively. Crude relative risks (RR) were estimated to compare risks between various groups. Results. During the study period the age-adjusted asthma hospitalization rate decreased by 16.3% among white females (from 13.4/10,000 in 1995–1996 to 11.2/10,000 in 2001–2002), and by 7% (from 8.14/10,000 in 1995–1996 to 7.56/10,000 in 2001–2002) among white males. Among blacks the decrease in hospitalization rate was by 13.9% (from 38.18/10,000 in 1995–1996 to 32.86/10,000 in 2001–2002) in males and by 14.4% (from 40.21/10,000 in 1995–1996 to 34.42/10,000 in 2001–2002) in females. A narrowing of the black to white disparity in asthma hospitalization rate was noted for children younger than 10 years of age. On the other hand, the racial disparity among subjects 10 years and older narrowed until 2000 but has started to widen since then. The overall decrease in asthma mortality rate was evident for the age group ≥ 5, but remained unchanged for the age group less than five. The age adjusted asthma mortality rate has also decreased by 22.2% in blacks (from 3.33/100,000 in 1995 to 2.59/100,000 in 2001) and by 38.4% in whites (from 1.26/100,000 in 1995 to 0.78/100,000 in 2001). Conclusion. This study confirms that both asthma hospitalization and mortality rates decreased during the study period and the black to white racial disparity in asthma hospitalization has narrowed for children younger than 10 years of age. For those subjects 10 years and older the racial disparity in hospitalizations narrowed until 2000 but started to widen since then. The widening racial gap in adults is disconcerting and needs further observation to assess its persistence.     

Screening for hepatocellular carcinoma in patients with cirrhosis in the United States: results of a national survey

OBJECTIVE: Hepatocellular carcinoma (HCC) is one of the dreaded complications of cirrhosis. Although there are no randomized controlled studies showing improved survival with screening, patients with cirrhosis are screened for HCC. Little is known about the practice of HCC screening in the United States. Our aim was to describe the practice of HCC screening in patients with cirrhosis in the United States. METHODS: In March 1998, we mailed a standard questionnaire to 1021 physician members of the American Association of Study for Liver Diseases and the same questionnaire was re-sent to nonrespondents 4 weeks later. RESULTS: We received a response from 554 members (54%). After excluding those not involved in active adult patient care, 473 responses were eligible for analysis. Eighty-four percent of the respondents routinely screened patients with cirrhosis for HCC (screening respondents). Nearly half of the screening respondents limited the HCC screening to patients with high-risk etiologies such as hepatitis B or C or hemochromatosis. Although alpha-fetoprotein (99.7%) and ultrasound (93%) were the two most frequently used screening methods, a sizable proportion of the screening respondents (25%) used abdominal computed tomography for routine screening. On multivariate analysis, the following variables predicted screening for HCC by the respondents: seeing more than one new cirrhotic per week (odds ratio [OR]: 5.4, 95% confidence interval [CI]: 2.5-11.7); practicing for < 10 yr (OR: 4.0, 95% CI: 1.2-13.4); an opinion that screening is cost-effective (OR: 6.4, 95% CI: 1.6-25); an opinion that screening prolongs survival (OR: 5.7, 95% CI: 1.8-17.9); and an opinion that not screening poses malpractice liability (OR: 9.3, 95% CI: 4.2-20.8). CONCLUSIONS: The majority of respondents routinely screen patients with cirrhosis for HCC. Approximately half of the screening respondents limit their screening to only patients with high-risk etiologies. On multivariate analysis, several variables predicted screening for HCC by the respondents.     

The demographics of the United States haemophilia treatment centre social workers: the results of a national survey

Social Workers (SWs) are vital members of the multidisciplinary health care teams at Hemophilia Treatment Centers (HTCs) across the US. However, little research has been done to identify the demographics and qualifications of HTC SWs. In response to this lack of data, a subcommittee from the Social Work Working Group sponsored by the National Hemophilia Foundation conducted a national online survey in 2010. The authors attempted to ascertain the demographics and characteristics of SWs who work at HTCs across the country. The purpose of this article is to report the results of this online survey and evaluate the parameters of SW demographics in HTCs. Electronic surveys were sent to 143 HTC SWs. Ten were excluded and 100 were completed and returned, yielding a 75% response rate. The great majority of HTC SWs are women and almost half are middle‐aged (aged 40–59). They represent a highly educated, very experienced group of professionals. When asked why respondents stayed in their positions at the HTCs, answers appeared to highly correlate to factors related to the HTC multidisciplinary team model. The high survey response rate of 75% reflects the interest of HTC SWs in obtaining data that describe and quantify their qualifications. This information may serve as validation of the haemophilia SW role in times of funding cuts. It may also give a basis for the recruitment and retention of SWs in the haemophilia field.     

Improved hypertension management and control: results from the health survey for England 1998

A survey in 1994 showed that among the 20% of the adult English population who were identified as hypertensive, approximately 30% had their blood pressures controlled to <160 mm Hg systolic and <95 mm Hg diastolic. The 1998 Health Survey for England data update the 1994 findings in light of new thresholds and targets for treatment outlined in recent national and international guidelines. This cross-sectional survey is analyzed to describe the prevalence, awareness, treatment, and control of hypertension in a random, nationally representative sample of 11 529 English adults (>/=16 years) living in noninstitutional households in 1998 and to compare these rates with those from 1994. In 1998, 20% and 37% of adults were hypertensive according to the old (systolic >/=160 mm Hg or diastolic >/=95 mm Hg) and new (systolic >/=140 mm Hg or diastolic >/=90 mm Hg) definitions, respectively. Corresponding values in 1994 were 20% and 38%. Treatment and control rates among hypertensive adults (new definition) improved from 26% to 32% and from 6% to 9%, respectively, although 60% of those on treatment received only 1 antihypertensive drug in both years. Among persons with controlled hypertension, 59% reported having received nonpharmacological advice from their physicians in 1998 compared with 30% in 1994. Rates of hypertension treatment and control have increased significantly (P=0.05 and P<0.01, respectively) since 1994 but remain low by international standards. The 1998 data suggest that improved detection, greater use of nonpharmacological measures, and increased use of >1 antihypertensive agent per patient would produce greater success in achieving target levels. This could lead to major reductions in fatal and nonfatal cardiovascular events.     

Treatment trends for haemophilia A and haemophilia B in the United States: results from the 2010 practice patterns survey

Frequent evaluation of haemophilia treatment is necessary to improve patient care. The 2010 Practice Patterns Survey (PPS) investigated current trends in haemophilia treatment in the United States, as reported by nurses. The aim was to document practice patterns for haemophilia A and haemophilia B Survey questionnaires were sent to nurses at haemophilia treatment centres (HTCs) across the United States. Seventy-one of 126 HTCs (56%) responded to the survey. Factor dosage across treatment modalities ranged from 20 to 50 IU kg(-1) for severe haemophilia A. Dosage for severe haemophilia B was more variable (<40 to >100 IU kg(-1)). On-demand dosing regimens were inconsistent for haemophilia A and more so for haemophilia B. Rates of adherence to prescribed treatment were similar for both haemophilia types (～80%). The main barrier to adherence was identified as inconvenience. More bleeding episodes occurred in adults (16.6 bleeding episodes per year) with severe haemophilia A than in younger patients (11.3 bleeding episodes per year) before switching patients to prophylaxis. For both haemophilia types, most patients who switched from prophylaxis to on-demand treatment were aged 13-24 years; these patients also had the lowest adherence (60-71%). More paediatric patients with severe haemophilia A and inhibitors (53%) received prophylactic bypassing therapy than their haemophilia B counterparts (38%). Adults with severe haemophilia A faced challenges in relation to co-morbidities and long-term care. This PPS provides insights into previously unexplored aspects of haemophilia care that will serve to increase awareness and promote discussion of current issues affecting haemophilia patient care.     

Preliminary results of 2009 pandemic influenza surveillance in the United States using the Aggregate Hospitalization and Death Reporting Activity

Please cite this paper as: Jhung et al. (2011) Preliminary results of 2009 pandemic influenza surveillance in the United States using the Aggregate Hospitalization and Death Reporting Activity. Influenza and Other Respiratory Viruses 5(5), 321–327. Background To augment established influenza surveillance systems in the United States, the Centers for Disease Control and Prevention and the Council of State and Territorial Epidemiologists implemented the Aggregate Hospitalization and Death Reporting Activity (AHDRA) in August 2009. The AHDRA was designed to meet increased demands for timely and detailed information describing illness severity during the 2009 H1N1 influenza A (pH1N1) pandemic response. Objectives We describe the implementation of AHDRA and provide preliminary results from this new surveillance activity. Methods All 50 US states were asked to report influenza‐associated hospitalizations and deaths to AHDRA each week using either a laboratory‐confirmed or syndromic surveillance definition. Aggregate counts were used to calculate age‐specific weekly and cumulative rates per 100 000, and laboratory‐confirmed reports were used to estimate the age distribution of pH1N1 influenza‐associated hospitalizations and deaths. Results From August 30, 2009, through April 6, 2010, AHDRA identified 41 689 laboratory‐confirmed influenza‐associated hospitalizations and 2096 laboratory‐confirmed influenza‐associated deaths. Aggregate Hospitalization and Death Reporting Activity rates peaked earlier than hospitalization and death rates seen in previous influenza seasons with other surveillance systems, and the age distribution of cases revealed a tendency for hospitalizations and deaths to occur in persons <65 years for age. Conclusions Aggregate Hospitalization and Death Reporting Activity laboratory‐confirmed reports provided important information during the 2009 pandemic response. Aggregate Hospitalization and Death Reporting Activity syndromic reports were marked by low representativeness and specificity and were therefore less useful. The AHDRA was implemented quickly and may be a useful surveillance system to monitor severe illness during future influenza pandemics.     

Influences on Childhood Asthma in Low-Income Communities in China and the United States

For comparison of childhood asthma, the same case-finding survey and parent interview questionnaires were used to collect data from 639 children with asthma in 21 elementary schools in Beijing and 835 children with asthma in 14 elementary schools in Detroit, Michigan. Asthma prevalence in Beijing (7.3%) was more than three times lower than in Detroit (24%) despite a high level of smoking among Chinese parents. Body mass index (BMI; weight in kilograms divided by height in meters squared) levels were higher in Detroit but were not associated with persistent asthma in either country. Higher levels of past infection in Beijing and household allergens in Detroit were noted and may be associated with differences in prevalence. Despite less severe disease observed in Beijing, hospitalizations and office visits did not differ from Detroit. This may be partially associated with less use of anti-inflammatory medicine and lower levels of parental asthma management in China.     

Prevalence of obesity: a comparative survey in France, the United Kingdom and the United States.

We investigated the differences in the prevalence of obesity between France, the United Kingdom and the United States in 1988. The analysis was made on a total sample of 5580 subjects, representative of the population aged 16-50 years in the three countries. The same questionnaire was used in all three countries. Body mass index (kg/m2) was used to assess corpulence. Significant differences in the prevalence of obesity were observed among the three countries: 7% of the population in France was obese, 9% in the UK and 15% in the USA (P less than 0.001). There was a strikingly high percentage of very obese women (more than 50% overweight) in the USA (8% of the population) as compared to the two European countries (2% in France and 3% in the UK). In all three countries, obesity was related to sex, age, level of education, marital status, physical exercise and smoking. An inverse association was found between obesity and alcohol consumption in the USA, but not in France nor in the UK. In men, prevalence of obesity remained significantly higher in the USA than in France or in the UK when adjusting for the obesity-related factors. In women, differences in prevalence of obesity between the three countries varied according to the level of exercise, income and alcohol consumption.