Detroit: The Current Status of The Asthma Burden

Detroit:
TheCurrentStatusoftheAsthmaBurden
PeterDeGuire,BinxinCao,LaurenWisnieski,DougStrane,RobertWahl,
SarahLyonCallo,ErikaGarcia,
MichiganDepartmentofHealthandHumanServices
BureauofDiseaseControl,PreventionandEpidemiology
March2016
www.michigan.gov/asthma
ThisreportwassupportedbytheCooperativeAgreementNumberU59EH000525,fundedbytheCentersforDiseaseControlandPrevention.Its
contentsaresolelytheresponsibilityoftheauthorsanddonotnecessarilyrepresenttheofficialviewsoftheCentersforDiseaseControland
PreventionorthedepartmentofHealthandHumanServices
WhatisAsthma?
Asthmaisachroniclungdiseasethatinflamesand
narrowstheairways.Asthmacausesrecurringperiodsof
wheezing,chesttightness,shortnessofbreath,and
coughing.Thecoughingoftenoccursatnightorearlyin
themorning.
Asthmahasnocure.However,withtoday'sknowledge
andtreatments,mostpeoplewhohaveasthmaareable
tomanagethedisease.
Michiganseffortstoaddressasthmawerecoordinated
throughtheAsthmaInitiativeofMichigan(AIM).
DataNotes:
1.
Source:http://www.nhlbi.nih.gov/health/health
topics/topics/asthma/
Introduction
Detroitexperiencessomeofthehighestasthmaburdenin
Michigan,particularlyamongchildren.
HereisMarcosstory:
MarcoisanAfricanAmericanfirstgraderwholivesinDetroitwithhismomand
youngersister.Hehasmissedseveraldaysofschoolmostweeksbecauseofasthma.In
thelastyearhehasbeentotheemergencydepartmentfivetimes,andhashadmany
urgentdoctorvisits.Hehashadsixsteroidburstsinthelastyeartotrytogaincontrol
overhisasthma,whichleavehimsleepless,jittery,andbreathingbetterforonlyashort
time.Mostdays,hetakesnebulizertreatmentsandhisrescueinhalereverythreeto
fourhourstoquiethiswheezeandcough.Hismotherdoesntknowwhattriggershis
asthma,butsheknowsitsworsewhenheplaysoutside,soheisnolongerallowedto
beoutsidefortoolongortoplaytoohard.Hespendsmostofhistimeinfrontofthe
TV.Hismotherisfrightenedforhim,butresignedtothefactthatthisisMarcos,and
theirfamilys,normal.
Introduction
Thisreportdetailstheasthmaburdenin
Detroitacrossmanydatasets:
Surveys
Hospitalizations
Medicaidclaims
Mortality
KeyFindings
TheasthmaburdeninDetroitwasfoundtobegreaterthantheoverallasthmaburdenin
Michigan.
Nationwide,inrecentyears,asthmaprevalencehasceasedtoincreasesignificantlyamong
children,andtheracialdisparitybetweenblackandwhitechildrenhasplateaued. 1 Still,
largedisparitiesinadverseasthmaeventsexistandmustbeaddressed.
TheprevalenceofcurrentasthmaamongDetroitadultswas29%higherthanin
Michiganasawhole.
TherateofhospitalizationsforasthmawasmorethanthreetimesgreaterforDetroit
residentsthanforMichiganresidentsasawhole.
TherateofasthmahospitalizationsforwhitepersonsinDetroitwasabout35%less
thantherateamongblackpersonsinDetroit.
TherateofemergencydepartmentvisitsamongchildrencoveredbyMichiganMedicaid
wastwiceashighinDetroitastherateforthestateasawhole.
Relianceontheemergencydepartmentforasthmacarewas50%higherforchildren
enrolledinMedicaidwithpersistentasthmainDetroitascomparedwiththeir
counterpartsinthestateasawhole.
1.AkinbamiLJ,SimonAE,RossenLM.ChangingTrendsinAsthmaPrevalenceAmongChildren.Pediatrics.2016;137(1):e20152354
1.PopulationDemographics1 ofDetroit,Michigan,2014
Measure
Detroit Population
Estimate
Totalpopulation
680,250
%lessthan18years
26.7%
%black
82.7%
%ofthose25yearsandolder
withlessthanhighschool
diploma
22.2%
Persons withouthealth
insurance,underage65years
21.4%
Medianhouseholdincome
ThetotalresidentpopulationofDetroit,
Michigan,in2010exceeded600,000;
83.0%ofthispopulationwereblack.
$26,095
%inpoverty
39.8%
%ofhousingunitsthatwere
vacant
49.3%
In2014,themedianhouseholdincome
was$26,095,with39.8%ofthe
populationlivinginpoverty.
Ofthepopulation<65yearsofage
21.4%didnothavehealthinsurancein
2014.
Amongthepopulation25yearsofage,
22.2%hadnotearnedahighschool
diplomain2014.
Theprevalenceofvacanthousingunits
was49.3%in2014.
DataNotes:
1.
Source:AmericanCommunitySurvey,20102014
2.PrevalenceofCurrentAsthma1 forAdults(18Years),
DetroitandMichigan,20122014
20
18
In20122014,15.5%ofDetroitadults
and11.0%ofMichiganadults
currentlyhadasthma.
CurrentasthmaprevalenceinDetroit
was significantlyhigherthan
Michiganasawhole.
16
Percent
14
12
10
8
15.5
11.0
4
2
0
Detroit
Michigan
DataNotes:
1.
Source:20122014MichiganBehavioralRisk
FactorSurveys,MDHHS.
3.PrevalenceofCurrentAsthma1 forChildren
(<18Years),DetroitandMichigan,20122014
16
In20122014,11.3%ofDetroit
childrenand9.7%ofMichigan
children currentlyhadasthma.
Currentasthmaprevalencefor
Detroitchildrenwasnotsignificantly
differentfromtheprevalencefor
Michiganchildren.
14
12
Percent
10
8
6
11.3
9.7
4
2
0
Detroit
Michigan
DataNotes:
1.
Source:20122014MichiganBehavioralRisk
FactorSurveys,MDHHS
4.Rates1 ofAsthmaHospitalization2,Detroitand
Michigan,20082013
In2013,24%ofallasthma
hospitalizationsinMichigan
residentsoccurredinresidentsof
Detroit(3,082and12,837asthma
hospitalizationsinDetroitand
Michiganresidents,respectively).
70
60
Rateper10,000
50
40
Michigan
30
Detroit
Therateofasthmahospitalizations
inDetroitresidentsin2013was
43.3per10,000population.
20
Theasthmahospitalizationratein
Detroitin2013was3.5timesthe
rateinMichiganasawhole.
10
0
2008
2009
2010
2011
DataNotes:
Source:MichiganInpatientDatabase,20082013,MDHHS
1. Ageadjustedtothe2000USStandardPopulation
2. Asthmaasprimarydiagnosis,ICD9CM:493.XX
2012
2013
Between2008and2013,therates
ofasthmahospitalizationinDetroit
andMichigandecreasedby15.3and
3.9asthmahospitalizationsper
10,000population,whichisa
decreaseof24%and26%,
respectively.
5.Rates1 ofAsthmaHospitalization2 bySex,

In2013,therateofasthma
hospitalizationsamongDetroitfemales
was50.8per10,000.Amongmalesin
Detroit,theratewas34.0per10,000.
80
70
Rateper10,000
60
50
Detroit,Male
40
Detroit,Female
Michigan,Male
30
Michigan,Female
20
10
0
2008
2009
2010
2011
DataNotes:
2012
2013
InDetroitin2013,therateofasthma
hospitalizationsamongfemaleswas49%
higherthanamongmales.ForMichigan,
thefemaleratewas57%higherthanthe
malerate.
Sexspecificasthmahospitalizationrates
inDetroitwereoverthreetimestherates
forMichiganasawhole.
Between2008and2013,therateof
asthmahospitalizationsformalesin
DetroitandMichigandecreased,with
decreasesof16.0and3.3per10,000
population,respectively.Forfemalesin
DetroitandMichigan,therates
decreasedby14.6and4.4per10,000
population,respectively.
10
6.Rates1 ofAsthmaHospitalization2 byAgeGroup,

InDetroit,therateofadultasthma
hospitalizationssurpassedtherate
amongchildrenin2010;inMichigan,
adultratesfirstroseabovechildratesin
2011.
80
70
Rateper10.000
60
50
Detroit,Child(<18years)
40
Detroit,Adult(18+years)
hospitalizationsamongDetroitchildren
was33.6per10,000.Amongadults,the
ratewas46.7per10,000.
Michigan,Child(<18years)
30
Michigan,Adult(18+years)
20
10
0
2008
2009
2010
2011
DataNotes:
2012
2013
Theasthmahospitalizationratefor
childreninDetroitwasalmostthree
timestherateinMichiganasawhole.
Theasthmahospitalizationrateforadults
inDetroitwasalmost3.7timestheratein
Michiganasawhole.
Between2008and2013,asthma
hospitalizationratesamongchildrenin
DetroitandinMichigandecreased,with
decreasesof35.6and6.6per10,000,
respectively.Amongadults,theserates
alsodecreasedinDetroitandinMichigan,
withdecreasesof8.2and3.0per10,000,
respectively.
11
7.Rates1 ofAsthmaHospitalization2 bySexAgeGroup,

Detroit,20082013
hospitalizationsamongDetroitmale
childrenwas40.6per10,000.Therate
amongfemaleDetroitchildrenwas
26.4per10,000.
100
90
80
Rateper10,000
70
60
MaleChild(<18years)
50
MaleAdult(18+)
40
FemaleChild(<18years)
FemaleAdult(18+)
30
20
10
0
2008
2009
2010
2011
DataNotes:
2012
hospitalizationsamongDetroitmale
adultswas31.7per10,000.Among
Detroitfemaleadults,theratewas
59.3per10,000.
Asthmahospitalizationrateswere
about87%higheramongadultfemales
thanmalesin2013.AmongDetroit
children,thefemaleratewas40%
lowerthanmales.
2013
From2008to2013,theratesof
asthmahospitalizationformaleand
femalechildrendecreased,with
decreasesof43.2and27.7per10,000,
respectively.Amongadultmalesand
females,theratesdecreased6.6and
10.0per10,000,respectively.
12
8.Rates1 ofAsthmaHospitalization2 byRace,

70
60
Rateper10,000
50
Detroit,Black
40
Detroit,White
30
Michigan,Black
20
Michigan,White
10
0
2008
2009
2010
2011
2012
2013
hospitalizationsamongblackpersons
inDetroitwas45.3per10,000.The
rateamongwhitepersonsinDetroit
was29.6per10,000,about35%less
thantherateamongblackpersonsin
Detroit.
In2013,asthmahospitalizationrates
inDetroitwereoverthreetimes
higherthantheratesinMichiganasa
wholeforwhitepersons,butDetroit
vsMichiganrateswereonlyabout
22%higherforblackpersons.
DataNotes:
13
9.Rates1 ofAsthmaHospitalization2 bySexRaceGroup,

Detroit,20082013
80
70
Rateper10,000
60
50
WhiteMale
40
WhiteFemale
BlackMale
30
BlackFemale
20
In2013,therateofasthmahospitalizations
amongwhitemalesinDetroitwas20.9per
10,000.Therateamongwhitefemalesin
Detroitwas39.8per10,000.
In2013,therateofasthmahospitalizations
amongDetroitblackmaleswas36.0per
10,000.AmongDetroitblackfemales,therate
was52.4per10,000.
10
0
2008
2009
2010
2011
2012
2013
DataNotes:
14
10.Rates1 ofAsthmaHospitalization2 byMonthof

Admission,DetroitandMichigan,20112013
Throughouttheyear,ratesofasthma
hospitalizationinDetroitwere
approximatelythreetofourtimes
higherthantheywereinMichiganasa
whole.
60
Rateper10,000
50
40
30
Michigan
20
10
0
Detroit
Theseasonaltrendinasthma
hospitalizationsinDetroitfollowed
similartrendsinMichiganasawhole:
thelowestratesinJulyandAugust
wereimmediatelyfollowedbyincrease
inSeptember.Thehighestratesfor
DetroitwereSeptemberandOctober.
ThehighestratesforMichiganwerein
MarchandSeptember.
DataNotes:
15
11.AverageLengthofStayforAsthmaHospitalization1,
4
In20052013,theaveragelengthof
stayforanasthmahospitalizationin
Detroitwasabout24minutesshorter
thanthatforMichiganasawhole.
3.5
NumberofDays
3
2.5
Michigan
Detroit
1.5
1
0.5
Between2005and2013,theaverage
lengthofstayforanasthma
hospitalizationinMichiganincreased
significantly(p<0.05)2 whilethechange
inlengthofstayinDetroitwasnot
statisticallysignificant.
0
2005
2006
2007
2008
2009
2010
2011
2012
2013
DataNotes:
Source:MichiganInpatientDatabase,20052013,
MDHHS
2. Spearmanscorrelationandrankcorrelationtest
16
12.Rates1 ofAsthmaHospitalization2 byZIPCodeof

Residence,Detroit,20092013
NumberofHospitalizations
per10,000Population
ZIPCodes48201,48202,
and48238incentral
Detroitand48213,48214,
and48215ineastern
Detroithadthehighest
asthmahospitalization
ratesinthecity.
Lowerratesofasthma
hospitalizationtendedto
occurinZIPCodesinthe
westernandsouthwestern
partsofthecity.
DataNotes:
17

ResidenceforChildren(<18Years),Detroit,20092013
per10,000Population
AlloftheZIPCodeswiththe
highestchildasthma
hospitalizationrateswere
locatedinthecentraland
easternpartsofthecity.
Lowerchildasthma
mostlyinZIPCodesinthe
westernandsouthwestern
partsofthecity.
DataNotes:Source:MichiganInpatientDatabase,20092013,MDHHS
3. Suppressedduetohospitalizationcount<5orpopulation<5,000
18

ResidenceforAdults(18Years),Detroit,20092013
per10,000Population
NearlyalloftheZIPCodes
withhigheradultasthma
locatedincentralor
easternDetroit.
Lowerratesoccurredina
fewZIPCodesincentral
Detroitbutwere
predominantlyfoundnear
thesouthernandwestern
bordersofthecity.
DataNotes:
19
15.Prevalence1 ofPersistentAsthma2,Children(<18
Years)onMedicaid3,DetroitandMichigan,20052013
Forthefollowinganalyses,theMedicaidstudy
populationofchildren<18yearsisrestrictedto
thosewhoarecontinuouslyenrolledin
Medicaid(11+months)withfullcoverageand
nootherinsurance.
8
7
6
Percent
Detroit
Michigan
3
2
1
0
2005 2006 2007 2008 2009 2010 2011 2012 2013
DataNotes:
Source:Datawarehouse,MDHHS
2. BasedonannualNCQAHEDISdefinition
3. Medicaidpopulationofchildren<18yearsis
restrictedtothosewhoarecontinuouslyenrolled
inMedicaid(11+months)withfullcoverageand
nootherinsurance
Byusingtheserestrictions,thesedata
undercountthenumberofchildrenwith
asthmacoveredbyMedicaid.Notincluded
werechildrenwithasthmawho:1)werenot
enrolledinMedicaidcontinuouslyor2)didnot
haveapaidMedicaidhealthutilizationclaim
from2005through2013.
TheprevalenceofasthmainDetroithasbeen
consistentlyhigherthaninMichiganasa
whole.Thedifferencebetweenprevalencein
DetroitandMichiganasawholeincreased
between2007and2012andthendecreased
slightlyin2013.
Morethan7,300Detroitchildrencoveredby
Medicaidhavehealthcareutilization
consistentwithpersistentasthma.
20
16.Prevalence1 ofPersistentAsthma2 byZIPCodeof

Residence,Children(<18Years)onMedicaid3,
Detroit,2013
Thehighestratesof
persistentasthmawere
amongchildreninZIP
codes48201and48208.
TheZIPCodesoflowest
prevalencewere48209,
48210,and48223.
PercentwithPersistentAsthma
DataNotes:
nootherinsurance
4. Suppressedduetohospitalizationcount<5or
population<5,000
21
17.Rate1 ofAsthma2 Hospitalizations,Children(<18

Years)onMedicaid3,DetroitandMichigan,20052013
90
In2013,thetotalnumberof
hospitalizationsforDetroitchildren
coveredbyMedicaidwasabout440.
Theratewas36.9hospitalizationvisits
per10,000childrenonMedicaidin
Detroit.TherateforMichiganwas
19.5per10,000childrenonMedicaid.
Therewasatotalof1,414
hospitalizationsinMichiganchildren
coveredbyMedicaid.
Therateofasthmahospitalization
visitsforchildreninDetroitin2013
wasabouttwicetherateforchildren
inMichigan.
From2005to2013,thedisparities
betweentheseratesdecreasedfrom
38.3to19.3per10,000childrenon
Medicaid,respectively.
80
Rateper10,000
70
60
50
Detroit
40
Michigan
30
20
10
0
2005 2006 2007 2008 2009 2010 2011 2012 2013
DataNotes:
3. Medicaidpopulationofchildren18yearsis
nootherinsurance
22
18.Rate1 ofAsthma2 EmergencyDepartmentVisits,Children

(<18Years)onMedicaid3,DetroitandMichigan,20052013
500
450
Rateper10,000
400
350
300
250
Detroit
200
Michigan
In2013,thetotalnumberof
emergencydepartment(ED)visits
forDetroitchildrencoveredby
Medicaidwasabout4,600.The
ratesforDetroitandMichigan
were392.5and193.7EDvisits
per10,000childrenonMedicaid,
respectively.
TherateofasthmaEDvisitsfor
childreninDetroitin2013was
abouttwicetherateforchildren
inMichigan.
150
100
50
0
2005 2006 2007 2008 2009 2010 2011 2012 2013
DataNotes:
nootherinsurance
From2005to2013,thedisparity
betweenDetroitandMichiganin
theasthmaemergency
department(ED)visitrate
increased,from171.4to198.9
per10,000.
23
19.Rate1 ofAsthma2 EmergencyDepartmentVisitsbyZIP

CodeofResidence,Children(<18Years)onMedicaid3,
Detroit,2013
Withfewexceptions,ZIP
Codesinthecenterand
easternpartsofDetroit
tendedtohavethehighest
emergencydepartment
ratesforasthmainthecity.
NumberofEDVisitsper
10,000Population
DataNotes:
nootherinsurance
population<5,000
24
Thefollowingasthmastatisticsare
amongchildreninMedicaidwith
asthma,nottheentirechildMedicaid
population.
25
20.Percent1 ofChildren(<18Years)withAsthma2 with2

OfficeVisitsforAsthma3 onMedicaid4,
35
30
Percent
25
20
Detroit
15
Michigan
10
5
0
2005 2006 2007 2008 2009 2010 2011 2012 2013
Accordingtonationalguidelines,persons
withasthmashouldvisittheirprimary
careproviderforroutineasthmacareat
leasttwiceperyear.
In2013,justover28%ofDetroitchildren
coveredbyMedicaidandabout30%of
Michiganchildrenwithpersistentasthma
hadatleasttwoofficevisitsforasthma.
TheproportionofDetroitchildren
coveredbyMedicaidwithpersistent
asthmawithatleasttwoofficevisitsfor
asthmawassignificantlylowerthanthat
forthestateasawhole.
DataNotes:
2. BasedonNCQAHEDISDefinition
4. Medicaidpopulationofchildren<18yearsisrestrictedtothose
whoarecontinuouslyenrolledinMedicaid(11+months)with
fullcoverageandnootherinsurance.
26
21.PercentofRelianceonEmergencyDepartmentforPrimary
Care1 amongChildren(<18Years)withAsthma2 onMedicaid3,
Relianceontheemergencydepartmentfor
primarycareisameasureofthe
proportionofalloutpatientvisitsfor
asthmathatareemergencydepartment
visits.
60
50
Percent
40
Detroit
30
Michigan
20
10
0
2005 2006 2007 2008 2009 2010 2011 2012 2013
DataNotes:
1. Proportionofalloutpatientvisitsforasthmathatareemergency
departmentvisits(Asthmaasprimarydiagnosis, ICD9CM:
493.XX),ageadjustedtothe2000USStandardPopulation
3. MedicaidPopulationofchildren<18yearsisrestrictedtothose
In2013,theproportionofoutpatientvisits
forasthmathatoccurredintheemergency
departmentforDetroitandMichigan
childrencoveredbyMedicaidwith
persistentasthmawas40.6%and27.0%,
respectively.
Emergencydepartmentreliancefor
primarycarewasabout51%higheramong
childreninDetroitcomparedtothestate
asawholein2013.
From2005to2013,emergency
departmentreliancedroppedinDetroit
andMichigan,by11.4%and4.8%,
respectively.
27

EmergencyDepartmentVisitsforAsthma3,Medicaid4,Detroit
andMichigan,20052013
Itisa goalofasthmatherapythatpersons
withasthmaexperienceminimalorno
emergencydepartmentvisitsforasthma.5
60
50
Percent
40
Detroit
30
Michigan
20
10
0
2005 2006 2007 2008 2009 2010 2011 2012 2013
DataNotes:
5. NationalHeart,Lung,andBloodInstitute.Guidelinesforthe
DiagnosisandManagementofAsthma:ExpertPanelReport3.
NationalInstitutesofHealthPublicationNumber095846.
October2007.
In2013,43.2%ofDetroitchildrenand
27.5%ofMichiganchildrenenrolledin
Medicaidwithpersistentasthmahadone
ormoreemergencydepartmentvisitsfor
asthma.
TheproportionofDetroitchildren
coveredbyMedicaidwithpersistent
asthmawithatleastoneemergency
departmentvisitforasthmain2013was
57%higherthanthatforMichiganasa
whole.
From2005to2013,thedisparity
betweenDetroitandMichigandecreased
slightly,from19.9%to15.9%.
28

EmergencyDepartmentVisitsforAsthma3 byZIPCodeof
Residence,Medicaid4,2013
ResidentsofZIPcodes48202,
48206,48208,48213,48215,
48217,and48224hadthe
highestpercentofchildren
withasthmausingemergency
departments.
PercentofChildrenwithAsthmaUsingED
DataNotes:
4. MedicaidPopulationofchildren<18yearsisrestrictedtothosewho
arecontinuouslyenrolledinMedicaid(11+months)withfull
coverageandnootherinsurance.
5. Suppressedduetohospitalizationcount<5orpopulation<5,000.
29
24.Percent1 ofOveruseofShortActingAgonist(SABA)
MedicationamongChildren(<18Years)withAsthma2,
Medicaid3,DetroitandMichigan,20052013
18
16
14
Percent
12
10
Detroit
Michigan
6
4
2
0
2005 2006 2007 2008 2009 2010 2011 2012 2013
Agoalofasthmatherapyisthattherebe
minimaluseofshortactingagonist
medication4 lessthanonecanisterper
month.Forthisindicator,overuseis
definedasfilling7 ormoreprescriptions
forshortactingagonist(SABA)ina
year.
In2013,prevalenceofSABAoveruse
amongDetroitchildrenandMichigan
childrencoveredbyMedicaidwith
asthmawas15.2%and13.7%,
respectively.TheDetroitratewas11%
higherthantherateforMichiganasa
whole.
DataNotes:
October2007.
30
25.Percent1 ofOveruseofShortActingAgonist(SABA)
MedicationamongChildren(<18Years)withAsthma2 byZip
CodeofResidence,Medicaid3,Detroit,2013
ResidentsofZIPcodes48205,
48209,48210,48211,48212,
48216,48219and48224hadthe
highestratesofSABAoveruse.
TheZIPcodeswiththelowest
ratesofSABAoverusewere
48202,48208,48214,and48215.
PercentSABAOveruse
DataNotes:
4. Suppressedduetohospitalizationcount<5orpopulation<
5,000.
31
26.Percent1ofChildren(<18Years)withAsthma2 with
1InhaledCorticosteroidFills,Medicaid3,Detroitand
Michigan,2013
80
Longtermasthmacontrol
medications,suchasinhaled
corticosteroids,are
recommendedforchildrenwith
persistentasthma.4
67%ofDetroitchildrenon
Medicaidin2013filleda
prescriptionforinhaled
corticosteroids,asignificantly
lowerpercentcomparedwith
childrenonMedicaidstatewide.
70
60
Percent
50
40
70.9
30
66.7
20
10
0
Michigan
DataNotes:
October2007.
Detroit
32
27.Percent1ofChildren(<18Years)withAsthma2 with
1InhaledCorticosteroidFills byZIPCodeofResidence,
Medicaid3 Detroit,2013
ZIPCodeswiththe
lowestpercentof
childrenfillinginhaled
corticosteroids(ICS)
tendedtobelocatedin
thenorthwesternand
easternareasofDetroit.
PercentChildrenwithPersistent
AsthmaandICSMedication
DataNotes:
3. MedicaidPopulationofchildren<18yearsis
restrictedtothosewhoarecontinuouslyenrolledin
Medicaid(11+months)withfullcoverageandno
otherinsurance.
4. NationalHeart,Lung,andBloodInstitute.Guidelines
fortheDiagnosisandManagementofAsthma:
ExpertPanelReport3.NationalInstitutesofHealth
PublicationNumber095846.October2007.
population<5,000.
33
28.Rates1 ofAsthmaMortality2 bySex,Detroitand

Michigan,20112013
Between2011and2013,55Detroit
residentsdiedduetoasthma.Therateof
asthmamortalityamongDetroitresidents
was24.1per1,000,000population.
45
40
Rateper1,000,000
35
30
25
Detroit
20
Michigan
30.8
15
10
5
TherateofasthmamortalityinDetroitin
20112013was2.4timeshigherthanthe
Michiganrate.
24.1
18.8
10.1
8.2
11.5
Between2011and2013,therateof
asthmamortalityamongDetroitmaleswas
30.8 per1,000,000andtherateforDetroit
femaleswas18.8per1,000,000.
Total
Male
Female
TheratesofasthmamortalityforDetroit
malesandfemaleswerenotsignificantly
differentduringthistimeperiod.
DataNotes:
Source:MichiganDeathFile,MDHHS
2. Asthmaastheunderlyingcauseofdeath,ICD
10:J45J46
34
29.Rates1 ofAsthmaMortality2 byAgeGroup,

Therateofasthmamortalityfor
Detroitchildrenbetween2011and
2013was10.0per1,000,000.
40
35
Rateper1,000,000
30
25
Detroit
20
15
Michigan
28.6
10
5
10
3.3
10.9
Children
DataNotes:
Source:MichiganDeathFile,MDHHS
2. Asthmaasprimarycauseofdeath,ICD10:J45J46
Adults
AmongDetroitadults,therateof
asthmamortalitybetween2011and
2013was28.6per1,000,000
Therateofasthmamortalityamong
childreninDetroitwasnot
significantlydifferentthanratesfor
childreninMichigan,butwasalmost
threetimeshigher.
Therateofasthmamortalityfor
Detroitadultswas3.3timeshigher
thantherateforadultsinMichigan.
35
KeyRecommendation
The disparity in the asthma burden in Detroit
warrants continued attention. Public health
efforts should continue to be directed to
persons with asthma in Detroit to improve
asthma control and prevent severe outcomes.
36
DataSources
AmericanCommunitySurvey,UnitedStates
CensusBureau
MichiganBehavioralRiskFactorSurvey(MIBRFS),
MichiganDepartmentofHealthandHuman
Services(MDHHS)
MichiganInpatientDatabase,MDHHS/Michigan
HealthandHospitalAssociation
MichiganDataWarehouse,MDHHS
MichiganDeathFiles,MDHHS
37
Methods
PrevalenceofAsthma
Michiganprevalenceestimatesforasthmawerebasedonselfreportingfrom the
MichiganBehavioralRiskFactorSurvey(MiBRFS)usingtwoquestions:
1. Haveyoueverbeentoldbyadoctor,nurse,orhealthprofessionalthatyouhad
asthma?(lifetimeasthma)
2. Doyoustillhaveasthma?(currentasthma)
Lifetimeasthmaprevalencewasthepercentageofrespondentswhoreported
yestoquestion#1.Currentasthmaprevalencewasthepercentageof
respondentswhoreportedyestobothquestions#1and#2.
MiBRFSdatawerecollectedbytelephoneinterviewofasamplefrombothcell
phoneandlandlinetelephonenumbers(see
http://www.michigan.gov/documents/mdch/2014_MiBRFS_Standard_Tables_FINAL_5
00159_7.pdf,page3formoreinformation).Allmeasuresofasthmaprevalencewere
accompaniedby95%confidenceintervals.
Annualestimatesofasthmaprevalenceforadults(18years)wereprovidedby
20122014MiBRFS,bysex,race/ethnicity,education,andhouseholdincome.The
MiBRFSwasalsothesourceforestimatesofprevalenceofasthmaamongchildren
(<18years)byaskingtheadultrespondenttoactastheproxyforaselectedchildin
thehousehold.Annualestimatesofprevalenceforchildrenwereprovidedfor2012
2014bysex,race/ethnicity,proxyseducation,andhouseholdincome.
38
Methodscontinued
AsthmaHospitalization
Anasthmahospitalizationwasdefinedasaninpatientstaywithaprimarydischargediagnosisof
asthma(ICD9CM=493.XX).Thesedatarepresentthenumberofhospitalizationsforasthma,notthe
numberofpersonswithahospitalizationforasthma.
Ageadjustedasthmahospitalizationrateswerecalculatedandpresentedper10,000population.
Rateswereageadjusted,usingthe2000USstandardpopulation,sothatvalidcomparisonscouldbe
madebetweenpopulationsofdifferentagedistributions.Allhospitalizationrateswereaccompaniedby
95%confidenceintervals.Inadditiontoasthmahospitalizationrates,theaveragelengthofstayand
hospitalizationratesbymonthofadmissionwerecalculated.
Asthmahospitalizationrateswerecalculatedfordemographicandgeographicsubgroups,
includingZIPCodesofresidence(forDetroit),age,race,sex,andmonthofadmission,toidentify
disparitiesandpatterns.Mapsgeneratedusinggeographicinformationsystems(GIS;ArcGISTM,
EnvironmentalSystemsResearchInstitute)wereusedtovisuallydisplaythedataandtoidentifyareasof
highburden.Censusdatafrom2010wereusedtocalculatetheDetroithospitalizationrates.Yearly
bridgedracepopulationestimatedprovidedbytheNationalVitalStatisticsSystemmaintainedbythe
CentersforDiseaseControlandPreventionwereusedtocalculateMichigansrates.
Temporaltrends inasthmahospitalizationrateswerestatisticallyevaluatedusingtheSpearman
correlationcoefficientanditsaccompanyingrankcorrelationtest.Apvalueof <0.05forthistestwas
consideredstatisticallysignificant.
ThedatasourcefortheseanalyseswastheMichiganInpatientDatabase,whichincludesvirtually
allhospitaldischargesforMichiganresidentsduringthestudyperiod.
39
Methodscontinued
AsthmaManagementforChildrenCoveredbyMedicaid
FromtheMichiganMedicaidbeneficiaryandadministrativeclaimsdata(20052013),thestudy
populationwasidentifiedbythefollowingparameterswithineachyear:children17yearsofageand
youngerwhohadcontinuousMedicaidenrollment(11+months),fullMedicaidcoverage,andnoother
insurance.Bothfeeforserviceandmanagedcarebeneficiarieswereincluded,butTitleVbeneficiaries
wereexcluded.
Byusingtheserestrictions,thesedataundercountthenumberofchildrenwithasthmacoveredby
Medicaid.Notincludedwerechildrenwithasthmawho:1)werenotenrolledinMedicaidcontinuously
or2)didnothaveapaidMedicaidhealthutilizationclaimfrom2005through2013.
Withinthispopulation,thefollowingindicatorsoftotalasthmaburdenweremeasured:
Persistentasthmaprevalence:Utilizationconsistentwiththediagnosisofasthmawasdefined
accordingtoHEDISspecifications;intheyearoftheprevalencemeasurement,having(1)4
asthmamedicationdispensingeventsOR(2)1emergencydepartmentvisitsforasthmaOR(3)1
hospitalizationforasthmaOR(4)4outpatientvisitsforasthmaand2asthmamedication
dispensingevents (NationalCommitteeforQualityAssurance.AppropriateMedicationsforPeople
withAsthma.HEDIS 2003,Volume2:TechnicalSpecifications. Washington,DC;2003).Prevalence
ofpersistentasthmawasthepercentageofbeneficiariesinthestudypopulationwhomeetthe
HEDIS definitionofpersistentasthma.
Rateofasthmaemergencydepartmentvisits:Anasthmaemergencydepartmentvisitwasdefined
asavisitoccurringinahospitalemergencydepartmentwithaprimarydiagnosisofasthma(ICD9
CM=493.XX).Thesedatarepresentthenumberofpersonsvisitingtheemergencydepartmentfor
asthma.Thenumberofasthmaemergencydepartmentvisits,dividedbythestudypopulation then
multipliedby10,000,generatedthismeasure.
40
Methodscontinued
AsthmaManagementforChildrenCoveredbyMedicaid,continued
Childrenwithutilizationconsistentwithpersistentasthma,asdefinedabove,formedtheannual
studypopulationuponwhichindicatorsofasthmamanagementaremeasuredwithinthatyear,
including:
Percentagewithanofficevisit:ThepercentageofchildrenwithpersistentasthmainMedicaidwith
oneormoreannualasthmaofficevisits.Thisincludesvisitsinaphysician'soffice,butsomehome
andurgentcarevisitsmayalsobeincludedinthismeasure(ICD9CM=493.XX).
Percentagewithanemergencydepartmentvisit:ThepercentageofchildrencoveredbyMedicaid
withpersistentasthmawhohavehadoneormoreannualasthmaemergencyvisits(ICD9
CM=493.XX).
Emergencydepartmentreliance:Thepercentageofallambulatoryasthmavisits(ICD9CM=493.XX,
outpatientandemergencydepartment)amongchildrencoveredbyMedicaidwithpersistent
asthmathatoccurintheemergencydepartment.Itestimatestherelianceontheemergency
departmentforprimarycare.
Shortactingagonistoveruse:ThepercentageofchildrenwithpersistentasthmainMedicaidwho
havefilledsevenormoreprescriptionsforshortactingagonistsinayear anindicatorof
overuseofthismedication.
Proportionusinganinhaledcorticosteroidmedication:Theproportionofchildrenwithpersistent
asthmainMedicaidwhofilledoneormoreprescriptionsforaninhaledcorticosteroidmedication
inayear inhaledcorticosteroidsarethepreferred,firstlinemedicationrecommendedfor
personswithpersistentasthma.Forthismetric,inhaledcorticosteroidmedicationincludes
bronchodilatorcombinationtherapy.
41
Methodscontinued
AsthmaManagementforChildrenCoveredbyMedicaid,continued
Foralloftheabove,indicatorswereageadjustedusingthe2000USstandard
populationandwereaccompaniedbya95%confidenceinterval.Bothgeographic(ZIP
Code)anddemographic(age,race,andsex)subpopulationanalysiswereconductedto
identifydisparities.Mapsgeneratedusinggeographicinformation(GIS;ArcGISTM,
EnvironmentalSystemsResearchInstitute)systemswereusedforvisualdisplayofthe
dataandtoidentifyareasofhighburden.
AsthmaDeath
Anasthmadeathwasdefinedbytheunderlying causeofdeath(ICD10=J45or
J46).Asthmamortalityrateswerecalculatedforthethreeyearperiod20112013and
werepresentedper1,000,000population.Rateswereageadjusted,usingthe2000US
standardpopulation,sothatvalidcomparisonscouldbemadebetweenpopulations
ofdifferentagedistributions.Rateswerecalculatedbyage,race,andsex,toidentify
disparitiesandpatterns.Allmortalityrateswereaccompaniedby95%confidence
intervals.
ThedatasourcefortheseanalyseswastheMichiganDeathFiles,whichincluded
alldeathsforMichiganresidentsduringthestudyperiod.
42
Methodscontinued
DefiningDetroit
ThedefinitionofDetroitwasslightlydifferentforeachdatatype
presentedinthisreport.Thedefinitionswereasfollows:
Currentasthmaprevalencefromsurvey:OntheMiBRFS,
Detroitadultswereidentifiedbytheiraffirmativeresponseto
thequestion,DoyouliveinthecityofDetroit?
HospitalizationandMedicaiddata:Detroitwasdefinedby ZIP
Codetabulationareas(ZCTAs)forthecity.Theseareas
included HighlandParkandHamtramck.
Mortality:DetroitwasdefinedbytheDetroitminorcivil
division,whichexcluded HighlandParkandHamtramck.
43
TheAsthmaInitiativeofMichigan
TheAsthmaInitiativeofMichigan(AIM)isa
collaborativeeffortinvolvingmultiplepartnersfrom
publicandprivatesectorsacrossthestateandis
committedtoreducingtheburdenofasthma
documentedinthereport.ForinformationaboutAIMs
prioritiesandinterventions,pleasereviewthestrategic
planfortheinitiative:AsthmainMichigan:ABlueprint
forAction,StrategicPlan2014 2017,FourthEdition
athttp://www.getasthmahelp.org/reports.aspx.
44

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Detroit:

5.Rates1 ofAsthmaHospitalization2 bySex,

6.Rates1 ofAsthmaHospitalization2 byAgeGroup,

7.Rates1 ofAsthmaHospitalization2 bySexAgeGroup,

8.Rates1 ofAsthmaHospitalization2 byRace,

9.Rates1 ofAsthmaHospitalization2 bySexRaceGroup,

10.Rates1 ofAsthmaHospitalization2 byMonthof

12.Rates1 ofAsthmaHospitalization2 byZIPCodeof

13.Rates1 ofAsthmaHospitalization2 byZIPCodeof

14.Rates1 ofAsthmaHospitalization2 byZIPCodeof

16.Prevalence1 ofPersistentAsthma2 byZIPCodeof

17.Rate1 ofAsthma2 Hospitalizations,Children(<18

18.Rate1 ofAsthma2 EmergencyDepartmentVisits,Children

19.Rate1 ofAsthma2 EmergencyDepartmentVisitsbyZIP

20.Percent1 ofChildren(<18Years)withAsthma2 with2

2005 2006 2007 2008 2009 2010 2011 2012 2013

2005 2006 2007 2008 2009 2010 2011 2012 2013

22.Percent1 ofChildren(<18Years)withAsthma2 with1

23.Percent1 ofChildren(<18Years)withAsthma2 with1

28.Rates1 ofAsthmaMortality2 bySex,Detroitand

29.Rates1 ofAsthmaMortality2 byAgeGroup,

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