Asthma hospitalizations on the decline?

For several years now we RTs have noticed a trend where asthma rates are climbing yet asthma patients are declining. What is the reason for these opposing trends?

This was the topic of my research the past several months, and the subject of my first post over at TherapyTimes.com, " Asthma on the Decline? Where today's statistics stand?" You can read the full article by clicking here.

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Growing up with uncontrolled asthma in the 1970s and 80s caused me to spend too many days in a hospital bed, getting to know many respiratory therapists. When the time came, it seemed a natural decision to become an RT myself. After all, I'd have empathy for all the asthmatic patients.

It sounded like a noble plan except for one thing: asthmatic patients are now few and far between. By the time I became an RT in 1996, there were few little kids, let alone adults, with asthma so bad they needed to visit the emergency room on a regular basis, let alone be admitted. At least this was the observation my co-workers and I have made for hospitals in the region where we live in West Michigan.

I work with two of the RTs who took care of me when I was a child asthmatic (I wrote about this here), and they both tell stories about asthmatics who were what we in the medical world like to refer to as regulars. Regulars, or in this case regular asthmatics, are those asthmatics who visit the hospital so often that RTs get to know them quite well.

Personally, in my 14 years as an RT, I can remember very few regular asthmatics, and only one of them had pure asthma. The rest were former or present smokers who were also diagnosed with COPD, so they probably don’t even count. Likewise, I have gotten to know zero, zilch, nada pediatric regular asthmatics, or those under the age of 18.

It appears that, except for a few exceptions, the regular asthmatic has been replaced by the spot asthmatic. Spot asthmatics are those asthmatics who come to the emergency room (occasionally being admitted), are treated, educated, and discharged. Most are never seen again for one or more of the reasons I list later in this article.

With few regular asthmatics, and a few spot asthmatics thrown in here and there for good measure, I’m still able to empathize with asthmatics, just not on the scale I imagined. And I figured I’d get to know at least a few pediatric regular asthmatics.

While we have plenty of COPD and pneumonia patients to empathize with, the classic asthmatic seems to be the patient of the past. Yet, while my co-workers and I observed the decline in the asthmatic patient, this was difficult to prove, as medical statistics aren’t always easy to come by, and even studies and statistics accumulated are often incomplete due to lack of data. Likewise, when I talk to my RT friends in Detroit, they say they have not noticed a decline in the asthmatic patient.

So would the stats confirm my observation?

According to this report by the Michigan Department of Community Health, the pediatric asthmatic hospitalization rate went from 33 out of every 10,000 residents in 1990 to 17.3 out of every 10,000 residents in 2000. Likewise, the same report notes, “Since 1990 there has been a significant overall decline in asthma hospitalization rates in Michigan for whites 0-4 years, 5-64 years, and 65 years and older.

So far so good. This statistic would explain our observation for the small town hospital we work for, considering the population where I live is mostly white. However, if you look at statistics for Saginaw and Detroit, the asthma hospitalization rate is significantly higher than the rest of the state.

In fact, according to this report with statistics from the Michigan Inpatient Database, “The rate of asthma hospitalizations in Detroit (in 2006) is three times higher than that of Michigan as a whole.” So this confirms what my Detroit friends have noted.

New York City asthma hospitalization rates actually increased from 1988 to 1997 according to this article from the Journal of Urban Health. Studies have similarly shown higher rates of asthma and higher rates of asthma hospitalizations among blacks and the underprivileged, which may help explain the higher rates for Detroit and New York City.

According to the same article, asthma rates overall have actually stabilized since 2000, with about 16-18 asthma hospitalizations of every 10,000 residents for the state of Michigan as a whole, and 51.2 asthma hospitalizations of every 10,000 residents for Detroit.

In the United States as a whole, the asthma hospitalization rate has declined, as you can see by this study originally published in the Journal of Asthma. The study “confirms that both asthma hospitalization and mortality rates decreased (from 1995 to 2002) and the black to white racial disparity in asthma hospitalization has narrowed for children younger than 10 years of age.”

Another report confirmed a decline in hospitalizations in Berkley, California, where the Health and Human Services noted that “over the entire 17 year period reviewed (from 1990 to 2006), asthma hospitalization rates declined an average of 2 percent per year.”

So, based on the statistics I have obtained, I think it’s safe to surmise that with the exception of some geographic regions, the overall asthma hospitalization rate in the U.S. has dropped since the mid 1980s. Yet, while we have made this observation, other statistics show the number of asthmatics is rising and will continue to rise.

According to the American Academy of Allergy, Asthma and Immunology (AAAAI.org), asthma rates increased 75 percent between 1980 and 1994. They also note, “It is estimated that the number of people with asthma will grow by more than 100 million by 2025."

Another interesting statistic of note is that up until about 1997, the asthma death rate in the U.S. steadily increased, and since then it has been steadily decreasing to it’s present level of less than 3,400. AAAAI statistics note there are about 34.1 million asthmatics in the U.S. Thus, the risk of someone dying from asthma is as low as 0.01 percent.

One would think more asthmatics would translate into more asthma hospitalizations as the statistics for Detroit and New York City confirm. Although that doesn't seem to be the case for the rest of the country, or at least the region of Michigan where I live. Obviously the asthma experts are doing something right – they are, after all, keeping an increasing number of asthmatics healthy and out of hospitals.

But How?

The truth is, nobody really knows for sure why asthma-related hospital visits are declining despite an increasing number of people diagnosed with the disease. I propose some viable theories.

1. Improved Asthma Wisdom: I remember my asthma doctor prescribing Vanceril when I was a regular asthmatic and then telling me to only use it when I was having trouble breathing. Any asthma expert today would wince at that prescription, but doctors didn't know any better back then. So instead of the Vanceril controlling my asthma, there were many hospital visits. This was the same for many asthmatics. Today, we know that inhaled corticosteroids are safe, and if used every day can actually prevent asthma from occurring.

Likewise, new asthma wisdom has proven there are two main components of asthma: bronchospasm that occurs during an acute attack, and chronic inflammation. This has lead to better ways of treating asthma.

2. Emphasis on Prevention: While the old emphasis was to treat acute asthma symptoms, the new emphasis is on preventing asthma attacks altogether. Asthma experts have learned that inhaled corticosteroids work best to control this inflammation, and are now a top line therapy for controlling asthma. The most common way of receiving inhaled steroids is in combination with long-acting beta agonists (LABAs) in medicines like Advair and Symbicort.

3. Better Asthma Medicines: Studies like this have proven medicines like Advair and Symbicort improve asthma and have reduced the need for ER visits and hospitalizations. These meds work best to control both components of asthma, and are therefore top of the line asthma medicines. Singulair is another medicine that has done wonders for asthmatics by controlling allergies and controlling exercise induced bronchospasm. While it may take some trial and error, with a good asthma doctor and good compliance by the patient, most asthmatics can easily prevent asthma from occurring altogether.

4. Improved Asthma Compliance: In 1985, I had to take some medicine about every two hours throughout the day. My Azmacort was four puffs four times a day, Theo-Dur one tablet every six hours, and throw in Q4 hour breathing treatments and I was inhaling asthma meds all day. Needless to say, there were many puffs, and many pills that were never taken.

Thank God for new medicines. Both Advair and Symbicort are only taken twice a day, and Singulair is a once a day pill. So, basically an asthmatic takes his medicine when he brushes his teeth in the morning, and again when he brushes his teeth in the evening. Since these meds work well to control asthma, bronchodilators are needed less often. The result here is much improved compliance with asthma medicines.

5. Better Educated Doctors: I had a good doctor when I was a child asthmatic, but there came a time when my asthma got so bad he didn't know what to do for me. So he had me shipped out to Denver to a hospital that specialized in asthma. That hospital, which is now known as National Jewish Health, did a great job of finally helping me to control my asthma not because it had better doctors, but because doctors that worked there had the advantage of access to the latest asthma wisdom.

Today all doctors are privy to the latest asthma wisdom. One reason is because asthma research centers like National Jewish hold annual seminars to educate regional asthma doctors. Another reason is because of the National Heart, Lung and Blood Institute's Asthma Guidelines.

6. The Asthma Guidelines: In the late 1980s, a group of the most renowned asthma experts in the world decided that with all the new asthma wisdom and medicines now available, most asthmatics should be able to gain control of their asthma and live normal lives. The catch is that every doctor needs to be up on the latest asthma wisdom, and be on the same page.

That's why in 1991, the Asthma Guidelines were released. These guidelines provide "guidance for selecting treatment based on a patient's individual needs and level of asthma control." Basically, every reason for better controlled asthma I mention in this article is in one way or another related to the asthma guidelines. It has resulted in better asthma wisdom, better educated doctors, better educated patients, and across the board better asthma control.

7. Better Patient Education: So not only do we have better educated asthma doctors we also have better educated asthma patients, asthma moms and dads, grandparents, teachers, day care providers, brothers and sisters, aunts and uncles. Asthmatics and those who take care of asthmatics are educated about asthma triggers and how to avoid them, about how to pick up on the early warning signs of asthma, and asthma action plans so the asthmatic (or those around the asthmatic) know when to take rescue medicine, when to call the doctor, and when to call an ambulance.

8. Asthma Action Plans: The asthma guidelines, along with most asthma experts, recommend the asthmatic (and/or the parents of the asthmatic) work together with the asthma doctor to create a plan so the patient knows exactly what to do when the signs and symptoms of asthma are observed. (To view a sample plan click here.) By observing the early signs of asthma and acting swiftly according to the asthma action plan, the asthmatic may prevent asthma from getting worse, thus eliminating the need for an unscheduled doctor’s office visit, emergency room visit, and hospitalization. Of course this has also helped to reduce the already low (although still too high) asthma death rate.

9. The Internet: I have to admit that since the advent of the Internet, my asthma wisdom has been magnified. Not only do we asthmatics get to share our asthma experiences via blogs and communities like these, we also have access to the latest asthma wisdom from Web sites like the one your on, or Google alerts, MyAsthmaCentral.com, or wherever else you prefer to obtain your wisdom.

10. All of the Above: Most of the studies you'll find on the Internet (such as this), will give credit for improved asthma control and decreased hospital visits to Advair, and occasionally Singulair. While it is true, these new asthma meds can work miracles for many asthmatics, no asthmatic can gain control of his or her asthma without all the other reasons listed above.

Studies show that both blacks and low-income individuals have a greater chance of having uncontrolled asthma, and a greater chance of being admitted for their asthma. One of the main reasons here is lack of access to quality healthcare, lack of education, and lack of opportunity to avoid asthma triggers, such as molds, cockroaches, cigarette smoke, air pollution, and dust mites. These individuals, as was noted in the Detroit study, are also less likely to visit their asthma doctor at least once a year, as the asthma guidelines recommend.

Efforts are ongoing to improve asthma control, and lower hospitalization rates, not just in Detroit and New York City, but across the country.

Thanks to smarter scientists, we have more information for the researchers to assimilate. And thanks to smarter researchers we have smarter asthma experts. Thanks to smarter asthma experts the asthma guidelines have been updated three times since 1991, and most recently in August of 2007. And thanks to the asthma guidelines we have smarter doctors, smarter patients, and so and so down the line.

Rarely do I ever look down at my clipboard and see the diagnosis of asthma listed there. When I do, it’s a spot asthmatic I’ll probably never see again. The reason is because most asthma cases are better controlled these days. And this, as I’m sure you’ll agree, is a good thing.